Analysis of 88 nephrectomies in a rural tertiary care center of India

Nephrectomy is not an uncommon surgery in day-to-day practice of urology. Trauma is the most common cause of emergency nephrectomy. On the other hand, elective nephrectomy is done for both benign and malignant diseases of the kidney. This study has been performed to know the different causes of nephrectomy in a rural, tertiary care center of India. In our series, we have studied all the elective nephrectomies done in our hospital during a period of eight years. We have analyzed 88 cases of nephrectomies regarding their age, sex, laterality of disease, and histopathologic report of the nephrectomy specimens. Out of 88 cases, 61 were males and 27 were females. In our series, 62.5% cases of nephrectomies were done for benign causes and 37.5% cases for malignant causes. Among the benign causes, neglected pelviureteric junction obstruction was the leading cause, followed by calculus disease resulting in obstruction. On the other hand, renal cell carcinoma was the most common malignant pathology requiring nephrectomy.     

Estimating the Burden of Maternal and Neonatal Deaths Associated With Jaundice in Bangladesh: Possible Role of Hepatitis E Infection

Objectives. We estimated the population-based incidence of maternal and neonatal mortality associated with hepatitis E virus (HEV) in Bangladesh.Methods. We analyzed verbal autopsy data from 4 population-based studies in Bangladesh to calculate the maternal and neonatal mortality ratios associated with jaundice during pregnancy. We then reviewed the published literature to estimate the proportion of maternal deaths associated with liver disease during pregnancy that were the result of HEV in hospitals.Results. We found that 19% to 25% of all maternal deaths and 7% to 13% of all neonatal deaths in Bangladesh were associated with jaundice in pregnant women. In the published literature, 58% of deaths in pregnant women with acute liver disease in hospitals were associated with HEV.Conclusions. Jaundice is frequently associated with maternal and neonatal deaths in Bangladesh, and the published literature suggests that HEV may cause many of these deaths. HEV is preventable, and studies to estimate the burden of HEV in endemic countries are urgently needed.Hepatitis E virus (HEV) infection is endemic in Asia and many parts of Africa, where it is a leading cause of sporadic and epidemic acute hepatitis.1–3 HEV is primarily transmitted through the fecal–oral route, and outbreaks in endemic areas are typically associated with contaminated drinking water sources.4–13 Clinically, it is indistinguishable from other causes of acute viral hepatitis, and jaundice, the yellowing of the eyes and skin, is the most common clinical feature.14 Jaundice is caused by a buildup of bilirubin, a product of dying red blood cells, in the blood. The healthy liver removes bilirubin from the blood, but when the liver’s ability to process bilirubin is impaired, the buildup occurs. Additional clinical signs and symptoms include anorexia, malaise, fever, dark urine, vomiting, and stomach pain.14 Adults are more likely to have HEV disease and antibodies to HEV than are children in endemic areas, which is unexpected given the young ages at which most people are exposed to other enteric pathogens in low-income countries.15In general, fewer than 1% of patients with clinical HEV die, but case fatality ratios among pregnant women have been reported to be as high as 6% to 20%.12,14,16–18 A high case fatality rate among pregnant women is a characteristic feature of HEV that has not been observed for other etiologies of acute viral hepatitis.19 Pregnant women whose deaths are associated with HEV typically die of hemorrhage or hepatic neuropathy.20,21 The few studies that investigated vertical transmission of HEV noted that neonates born to mothers with HEV infections were frequently infected and often died from complications such as prematurity, liver failure, hypothermia, or hypoglycemia.21–25Hepatitis is not considered to be an important cause of maternal or neonatal mortality globally,26–28 but some data suggest that acute hepatitis might significantly contribute to maternal mortality in HEV endemic countries. A retrospective, community-based study of maternal mortality from southern India reported that 11% of maternal deaths were attributable to infectious hepatitis, resulting in a maternal mortality ratio of 8 per 1000 live births.29 Another record review of maternal mortality from Ethiopia concluded that 15% of maternal deaths were the result of infectious hepatitis.30 An autopsy study from India found that the most common cause of maternal deaths at 1 large hospital was acute viral hepatitis, which accounted for 42% of all maternal deaths.31 Notably, none of these studies provided evidence about the etiology of these hepatitis illnesses, so it is not known if they were caused by HEV. However, given that HEV is a particularly fatal cause of acute hepatitis among pregnant women,19 the possibility that HEV could meaningfully contribute to maternal mortality in these countries should be considered.However, to our knowledge, no studies have attempted to quantify the burden of HEV-associated maternal and neonatal mortality. In low-income countries in Asia and Africa where HEV is commonly found,1–3 population-based estimates of mortality usually come from verbal autopsy studies that use structured questionnaires to interview relatives of the deceased about signs and symptoms of illness before death, and then use coding algorithms to determine cause of death based on the interview data.32 The verbal autopsy questionnaires include questions about new onset of jaundice before death in pregnant women, or new onset of jaundice in the mother as a complication of pregnancy for neonatal deaths. Thus, data from verbal autopsy studies can be used to calculate population-based estimates of maternal and neonatal mortality associated with jaundice. However, the nature of these data precludes conclusions about deaths from specific infectious etiologies, such as HEV. Hospital-based studies can provide important information about etiologic causes of maternal and neonatal deaths associated with jaundice that occur in hospital settings of HEV endemic countries. We investigated the possible contribution of HEV to maternal and neonatal mortality by analyzing data from 4 population-based verbal autopsy studies in Bangladesh and comparing these data with the published literature from hospital-based studies of the etiologic causes of jaundice-associated deaths during pregnancy.     

Interim evaluation of a large scale sanitation, hygiene and water improvement programme on childhood diarrhea and respiratory disease in rural Bangladesh

Started in 2007, the Sanitation Hygiene Education and Water Supply in Bangladesh (SHEWA-B) project aims to improve the hygiene, sanitation and water supply for 20 million people in Bangladesh, and thus reduce disease among this population. This paper assesses the effectiveness of SHEWA-B on changing behaviors and reducing diarrhea and respiratory illness among children < 5 years of age. We assessed behaviors at baseline in 2007 and after 6 months and 18 months by conducting structured observation of handwashing behavior in 500 intervention and 500 control households. In addition we conducted spot checks of water and sanitation facilities in 850 intervention and 850 control households. We also collected monthly data on diarrhea and respiratory illness from 500 intervention and 500 control households from October 2007 to September 2009. Participants washed their hands with soap < 3% of the time around food related events in both intervention and control households at baseline and after 18 months. Washing both hands with soap or ash after cleaning a child's anus increased from 22% to 36%, and no access to a latrine decreased from 10% to 6.8% from baseline to 18 months. The prevalence of diarrhea and respiratory illness, among children <5 years of age were similar in intervention and control communities throughout the study. This large scale sanitation, hygiene and water improvement programme resulted in improvements in a few of its targeted behaviors, but these modest behavior changes have not yet resulted in a measurable reduction in childhood diarrhea and respiratory illness.     

Arthroscopic anterior cruciate ligament reconstruction using the double press-fit technique: An alternative to interference screw fixation

Purpose: Patellar tendon autograft fixation in arthroscopic anterior cruciate ligament reconstruction is commonly accomplished using interference screws. However, improper insertion of the screws may reduce primary stability, injure the posterior femoral cortex, or displace hardware into the joint. Even if placed properly, metallic screws interfere with postoperative magnetic resonance imaging. In case of revision surgery, removing screws may be difficult and leaves bone defects. Type of Study: Retrospective study. Methods: An arthroscopic technique was developed that achieves patellar tendon autograft fixation by press-fit without any supplemental internal fixation. Forty patients were examined clinically and by KT-1000 arthrometer 28.7 months (range, 22 to 40 months) postoperatively. Results: The mean difference in side-to-side laxity was 1.3 mm (SD 2.2) and the results according to the IKDC score were as follows: 7 A, 28 B, 5 C, and 0 D. Conclusions: The double press-fit technique we present avoids all complications related to the use of interference screws and creates an ideal environment for osseous integration of the bone–patellar tendon–bone autograft. Concurrently, it achieves a stable fixation of the autograft and allows early functional rehabilitation. However, fixation strength depends on bone quality and the arthroscopic procedure is demanding.     

Micropigmentation for the treatment of vitiligo

A technique of permanent dermal micropigmentation using a nonallergenic iron oxide pigment to cover recalcitrant areas of vitiligo is described. The areas included in this study were the distal digits, the lips, hands, wrists, axillae, elbows, hairline, perioral area, and lower legs. The immediate postmicropigmentation results invariably showed dramatic aesthetic improvements. There was a moderate degree of fading in the majority of cases, most of which occurred within the first six weeks. The pigment that remained usually persisted with minimal to no further fading. Short- and long-term complications, which were few, mild, and resolved fully, are discussed. No allergic reactions to the pigment or koebnerization of the vitiligo have been noted.