Objective: Patients undergoing hemodialysis are repeatedly exposed to stress and pain from approximately 300 punctures per year to their arteriovenous fistula. This study was designed to measure pain associated with venepuncture during AVF cannulation and to compare the effectiveness of ethyl chloride vapocoolant spray, topical eutectic mixture of local anesthetics (EMLA) cream and placebo in controlling pain caused by venepuncture of arteriovenous fistula patients undergoing chronic hemodialysis.Methods: This randomized, placebo-controlled, crossover study, included 41 patients undergoing conventional hemodialysis three times a week. First intervention was conducted as baseline pain assessment (control). In the three consecutive dialysis sessions, every patient randomly received 1) ethyl chloride vapocoolant spray, 2) EMLA, or 3) placebo cream before venepuncture. Pain perception was recorded by patients immediately after cannulation on a 0-100 mm visual analogue scale (VAS). p<0.05 was considered as significant.Results: VAS scores presented a marked inter-individual variation during venepuncture. EMLA application resulted in significantly lower total pain scores compared to control and all other interventions (p<0.05). No patient experienced severe pain with EMLA or vapocoolant. The patients reported less moderate and severe pain with EMLA, and vapocoolant spray compared to control and placebo interventions. Moderate and severe pain scores were similar between EMLA and vapocoolant spray (p>0.05).Conclusion: Venipuncture for AVF cannulation causes mild to moderate pain in hemodialysis patients. Although local application of EMLA is more effective than in preventing venepuncture pain, ethyl chloride vapocoolant is as effective as EMLA for preventing mild to moderate puncture pain in patients undergoing hemodialysis.

Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder with characteristic vascular malformations of the skin, gastrointestinal system, and, less often, other organ systems. The characteristic cutaneous lesions consist of deep-blue, soft, rubbery blebs, which are easily compressible. The most serious complication is abundant gastrointestinal bleeding. We describe the case of an 8-year-old girl with diagnosed BRBNS who had multiple venous malformations all over her body, importantly, throughout the gastrointestinal tract, mouth, esophagus, stomach, small bowel, and colon. She presented with recurrent massive gastrointestinal bleeding and soft tissue hematoma despite prednisolone and α-interferon therapy. We started low-dose sirolimus as an antiangiogenic agent. The vascular masses were reduced rapidly and there was no gastrointestinal bleeding and muscular hematoma after sirolimus therapy. There was no drug adverse reaction at 20-month follow-up. To the best of our knowledge, this is the first report related to the use of sirolimus in a patient with BRBNS.

SummaryBackground and objectives Malnutrition, inflammation, atherosclerosis/calcification (MIAC) and endothelial dysfunction are the most commonly encountered risk factors in the pathogenesis of cardiovascular disease in ESRD patients. Epicardial adipose tissue (EAT) is the true visceral fat depot of the heart. The relationship between CAD and EAT was shown in patients with high risk of coronary artery disease. In this study, we aimed to investigate the relationship between EAT and MIAC syndrome in ESRD patients.Design, setting, participants, & measurements Eighty ESRD patients and 27 healthy subjects enrolled in this cross-sectional study. EAT and coronary artery calcification score were measured by a multidetector computed tomography (MDCT) scanner. Patients with serum albumin Ͻ3.5 mg/dl were defined as patients with malnutrition; those with serum C-reactive protein level Ͼ10 ng/dl (normal range, 0 -5 ng/dl) had inflammation; and those with CACS Ͼ10 had atheroscleosis/calcification.Results Total CACS and EAT measurements were significantly higher in ESRD patients when compared with healthy subjects. There was a statistically significant relationship between EAT and CACS in ESRD patients (r ϭ 0.48). EAT measurements were higher in PD patients than HD patients. Twenty-four of the patients had no component, 31 had one component, 17 had two components, and nine had all of the MIAC components. EAT was found to be significantly increased when the presence of MIAC components increased. EAT was positively correlated with age, body mass index, and presence of MIAC. These parameters were also found as independent predictors of increased EAT.Conclusions We found a relationship between EAT and components of MIAC syndrome in ESRD patients.

Background: Plantar fasciitis often leads to disability. Optimal treatment for this clinical condition is still unknown. Objective: To compare the effectiveness of wearing a full-length silicone insole with ultrasound-guided corticosteroid injection in the management of plantar fasciitis. Study design: Randomized clinical trial. Methods: Forty-two patients with chronic unilateral plantar fasciitis were allocated randomly to have an ultrasound-guided corticosteroid injection or wear a full-length silicone insole. Data were collected before the procedure and 1 month after. The primary outcome measures included first-step heel pain via Visual Analogue Scale and Heel Tenderness Index. Other outcome measures were the Foot and Ankle Outcome Score and ultrasonographic thickness of the plantar fascia. Results: After 1 month, a significant improvement was shown in Visual Analogue Scale, Heel Tenderness Index, Foot and Ankle Outcome Score, and ultrasonographic thickness of plantar fascia in both groups. Visual Analogue Scale scores, Foot and Ankle Outcome Score pain, Foot and Ankle Outcome Score for activities of daily living, Foot and Ankle Outcome Score for sport and recreation function, and plantar fascia thickness were better in injection group than in insole group (p < 0.05). Conclusions: Although both ultrasound-guided corticosteroid injection and wearing a full-length silicone insole were effective in the conservative treatment of plantar fasciitis, we recommend the use of silicone insoles as a first line of treatment for persons with plantar fasciitis. Clinical relevanceSilicone insole may be considered as a first-line treatment option in patients with plantar fasciitis.

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