How to manage complications in CAS?

The different types of complications which might occur during CAS are described. Recommendations are given how to avoid and how to handle complications.     

How to treat refractory arthritis in lupus?

Arthritis in systemic lupus erythematosus (SLE) is episodic and self-limited in most patients. However, in some cases, refractory joint problems occur and may be poorly controlled by NSAIDs and other treatments. Damage to joints and to other organs must be considered when making any decision to prescribe such other treatments. In the context of new and potent biodrugs, we have reviewed and analysed here all Medline published data on arthritis treatment in SLE, as well as the French recommendations (Protocol national de diagnostic et de soins [PNDS] and Club Rhumatismes et Inflammation [CRI]). In SLE patients with isolated, intermittent joint symptoms, short courses of NSAIDs should be used as the first-line treatment. If joint symptoms are more severe or recurrent, a combination of low-dose corticosteroids (≤ 10 mg/day) and antimalarial drugs is recommended. Corticosteroid infiltrations may be useful on occasions, in cases of persistent localised arthritis. If joint symptoms persist, treatment indications depend on the other organs affected. In joint forms that are refractory to treatment or corticodependent and requiring an unacceptable dose of prednisone in a patient with confirmed compliance with treatment, methotrexate should be proposed initially, in combination with antimalarial drugs. In cases of treatment failure or intolerance, mycophenolate mofetil or even azathioprine may be considered as an alternative treatment. As a last resort, after having weighed up the individual benefit-risk ratio, leflunomide, belimumab, rituximab or abatacept may be considered, on a case-by-case basis, and anti-TNF antibodies may be considered in exceptional cases.     

How to reduce osteopenia in total knee arthroplasty?

European Journal of Orthopaedic Surgery & Traumatology - Osteopenia of the front half of the distal femur is a well-known problem after total knee arthroplasty (TKA) with secondary issues after...     

Are we ready to use aliskiren in children?

The objective of this case series was to review the safety and efficacy of aliskiren in combination with losartan in pediatric chronic kidney disease (CKD) patients. This was a retrospective study in which the medical files of all patients who had received aliskiren were reviewed. Four patients were identified between 5 and 18 years of age who had received aliskiren and losartan for the reduction of refractory proteinuria. While proteinuria was reduced in all four of these patients by 45, 96, 53, and 64%, respectively, three patients experienced side effects requiring changes in the aliskiren dose. A significant side effect occurred in the patient with CKD stage 3 who suffered accelerated loss of kidney function leading to dialysis after only a short course of therapy. The data from this preliminary trial strongly suggest that clinicians should exercise caution when prescribing aliskiren in combination with losartan until appropriate pediatric trials establish dosing, efficacy, and safety.     

Does homocysteine contribute to bone disease in hyperparathyroidism?

BACKGROUND: Osteoporosis is a complication of hyperparathyroidism (HPT). Hyperhomocysteinemia (HHCy) is an independent risk factor for osteoporotic fractures. We hypothesize that HHCy correlates with bone disease in HPT. METHODS: A prospectively collected database of 250 patients treated for HPT was reviewed. Patients were categorized into 3 groups: group I, normal renal function; group 2, mild renal insufficiency; and group 3, secondary HPT with end-stage renal disease on dialysis. Serum homocysteine levels, markers of bone metabolism, and bone density studies were examined. RESULTS: The prevalence of HHCy in group 1 (208 patients) was 5%, in group 2 (23 patients), 82%, and in group 3 (19 patients), 78%. Mean (+/-SD) preoperative homocysteinemia (HCy) levels in groups 1, 2, and 3 were 9.3 +/- 4.0, 20 +/- 10.2, and 20.6 +/- 12.3 micromol/L, respectively. Elevated serum markers of bone metabolism increased significantly with decreasing renal function. CONCLUSIONS: Prevalence of HHCy is low in HPT patients with normal renal function. It is significantly greater in those with dialysis-independent and -dependent renal insufficiency. HHCy correlates with other serum markers of bone metabolism in HPT and may be useful for monitoring progression or improvement.     

Screening for prostate cancer--how to manage in 2006?

National Societies usually recommend screening for Prostate Cancer (PC) with Serum Prostate Specific Antigen (PSA) and digital rectal examination annually beginning at age 50. In high risk population including men with a family history of PC or African population screening should start at age of 45 years. PSA has been widely used to detect PC despite the fact that PSA is not specific for PC. Over the years serum PSA level of greater than 4.0 ng/ml was considered the treshold to perform prostate biopsy, searching for PC. In 2005 the Prostate Cancer Prevention Trial (PCPT) demonstrated that the cut-off of 4.0 ng/ml for PSA is not anymore adapted due to the fact that this survey found in 15% of men with PSA < or = 4.0 ng/ml a prostate cancer on sextant biopsies. Today the value of PSA and the cut-off for Prostate biopsy is questionned suggesting that PSA level higher than 2.6 ng/ml must be the case to propose Prostate Biopsy. Catalona confirms that approximately 25% to 30% of men with PSA 2.6 to 4.0 ng/ml have prostate cancer. Schr?der and Gosselaar assert that screening for PC at low PSA levels (< 4.0 ng/ml) risks to detect clinically insignificant cancers which are no threat to man. So far in the year 2006 screening for PC demonstrates accumulating evidences of efficacy but persistent uncertainty. The major question for an urologist at work when facing a young men searching early diagnosis of PC is: at which level of PSA do we have to perform rectal biopsy?     

The extremes in orthopaedics! Whom to blame?

Traditional medicines especially the herbal paste is routinely prescribed by the herb sellers. The unsupervised combinations and preparations are easily available in our part of world. The demand and supply of such irrational combination is only based on the principle that anything natural is safe. Drugs and preparations made by the people who lack the scientific knowledge of traditional herbal medicines adversely affect the consumer. We put forward few complications that resulted after herbal paste application in those who already had visited the specialist but opted the easily available unsupervised herbal preparations.     

How to operate kidney puncture in percutaneous nephrolithotomy?

Obtaining a precise percutaneous calyceal puncture gave way to the development of percutaneous nephrolithotomy, one of the first micro-invasive techniques described in urology. Both radiologist and urologist can perform puncture, sometimes in a collaborative effort. However, being followed by a true surgical procedure, it should be done in the O.R; perfect knowledge of the procedure is mandatory for every urologist. Standard guidance uses a fluoroscopic C-arm device, only able to guide the needle precisely towards the apex of the chosen calyx. Moving the C-arm with cephalad tilting will provide 3-D imaging. Ultrasound guidance is an alternative, but might be difficult with non dilated upper tract. CT guidance and retrograde puncture are rarely used. The access is to be adapted according to the patient (adult or child), type of stone (single or multiple access), or kidney position (eutopic or ectopic). Direct ad stable puncture entering the apex of the chosen calyx is a pre-requisite for easy and efficient subsequent nephrolithotomy.