Dysfunctional uterine bleeding is a common presentation of women in the emergency department. We describe the case of a 33-year-old female who presented with intermittent spotting due to an acquired uterine AVF. The patient underwent a transvaginal pelvic ultrasound as well as a CT angiogram. The patient was treated conservatively and elected to undergo uterine artery embolization in an effort to preserve fertility. She successfully delivered a healthy baby boy at 39-week gestation via an emergent caesarian section due to a prolapsed umbilical cord 17 months after undergoing the uterine artery embolization.

Background: The best way to reduce the occurrence of arrhythmias that generally occur after an open heart surgery is to improve the quality of myocardial protection against reperfusion damage during the cross-clamp time. In this regard, different cardioplegic solutions play a key role. Differences in the types and contents of cardioplegic solutions may lead to different results of effective protection of the myocardium. The purpose of this study was to compare the effects of the newly introduced procaine hydrochloride (PHC) containing cardioplegic solution (Shahid Ghazi Pharmaceutical Co. Tabriz, Iran) and lidocaine (L) in cardioplegic solution on post aortic clamp arrhythmia in coronary artery bypass graft surgery.

Background: Although the TAVI technique has been widespread in Europe and America, concerns have emerged regarding the associated complications, mainly paravalvular leakage, vascular complications, stroke, post-operative pacemaker implantation due to complete AV block, optimal access sites, long-term valve durability, and economic sustainability, therefore controversy remains about the ideal treatment of high-risk operable patients. Sutureless tissue valves like Perceval S may be a good option for these high risk operable patients. We will present the clinical outcomes of first cases of Perceval S in Iranian patients. Methods: From July 2015 to August 2016, 11 patients (8 male, 3 female) with severe aortic stenosis who were candidates for aortic valve replacement were included in this study. The mean age of patients was 73 ± 8 ranged from 65 to 86 years. The most common presenting symptom was dyspnea and three of the patients had coronary artery disease in need for concomitant revascularization. Preoperative peak gradient across the aortic valve ranged from 72 to 135 mmHg (mean = 97 ± 25). All patients were followed up from 3 to 20 months with a median of 13 months. Results: Dramatic reduction of trans-aortic peak gradients was seen in all patient (mean postoperative gradient = 29 ± 8 mmHg). Small degrees of transvalvular and paravalvular leakage were seen in intraoperative echocardiographies but only one patient had small asymptomatic paravalvular leakage during midterm follow up. Two patients need for transient pace maker; however we had no case of complete heart block. Mean post-operative mediastinal bleeding was 480 ± 150 mL and no patient needed re-exploration for bleeding or tamponade management. ICU stay time was 3 ± 1.54 days, and there was no in-hospital mortality. All patients were discharged in good status and there was no mortality during follow-up period. Conclusions: Preliminary clinical results of the first experience was encouraging; however we need to continue the study with more study volume, more follow up period and more high risk or complicated patients.

INTRODUCTION: Cushing Syndrome (CS) is a condition of hypercortisolism due to adrenal disease or an ACTH secreting tumor. Associated hypercoagulability and immunosuppression create the potential for venous thromboembolism and opportunistic infection, respectively. CASE PRESENTATION:We present a case of a 47-year-old man with hypertension and diabetes who presented with encephalopathy. MRI showed pituitary macroadenoma. He was diagnosed with Cushing's disease and underwent successful resection of this mass. However, post-operative cortisol levels did not fall as expected thus bilateral adrenalectomy was performed.His hospital course was complicated by acute pulmonary embolism and left sided pleural effusion of unclear etiology leading to respiratory compromise. He subsequently developed a spontaneous hydropneumothorax which did not resolve despite placement of multiple pigtail chest tubes. CT chest showed cavitary pneumonia, and the pneumothorax and associated empyema were attributed to rupture of this infected area. Pleural fluid culture data revealed Nocardia pseudobrasiliensis and a new MRI brain showed cerebritis and left temporal lobe abscess.The patient received meropenem and trimethoprim-sulfamethoxazole (TMP-SMX) and ultimately required left thoracotomy with left lower lobectomy. He improved and was discharged to acute rehabilitation.DISCUSSION: Cushing's disease describes CS due to an ACTH producing pituitary tumor. Manifestations include insulin resistance, hypertension, and cushingoid appearance. It also causes hypercoagulability and immunosuppression by increasing production of clotting factors, decreasing fibrinolysis, and impairing neutrophil and macrophage recruitment to infection sites (1, 2). Nocardia infection typically occurs in immunocompromised patients, such as those with HIV, malignancy, and CS (3). Pulmonary Nocardiosis is typically due to direct inhalation of the organism and often associated with cavitary lung lesions. Extrapulmonary Nocardia is characterized by abscess formation with the central nervous system (CNS) being the most common extrapulmonary site. CNS imaging is recommended in all patients diagnosed with Nocardia pneumonia, especially in those with neurologic symptoms (3). For patients with CNS involvement, antibiotic duration is at least one year and should include TMP-SMX with a carbapenem or ceftriaxone, to be de-escalated to TMP-SMX monotherapy after clinical improvement. Secondary prophylaxis with daily TMP-SMX is recommended (3). CONCLUSIONS:Nocardiosis is an important opportunistic infection to consider in immunocompromised patients. Pulmonary infection commonly involves cavitary lesions and the possibility of CNS involvement must be considered in every case of Nocardiosis.