Predicting calyceal access for percutaneous nephrolithotomy with computed tomography multiplanar reconstruction

OBJECTIVES:

Objective parameters in computed tomography (CT) scans that could predict calyceal access during percutaneous nephrolithotomy have not been evaluated. These parameters could improve access planning for percutaneous nephrolithotomy. We aimed to determine which parameters extracted from a preoperative multiplanar reconstructed CT could predict renal calyceal access during a percutaneous nephrolithotomy.

METHODS:

From January 2009 through April 2011, 230 patients underwent 284 percutaneous nephrolithotomies at our institution. Sixteen patients presented with complete staghorn calculi, and 11 patients (13 renal units) were analyzed. Five parameters were extracted from a preoperative reconstructed CT and compared with the surgical results of percutaneous nephrolithotomy.

RESULTS:

Fifty-eight calyces were studied, with an average of 4.4 calyces per procedure. A rigid nephroscope was used to access a particular calyx, and a univariate analysis showed that the entrance calyx had a smaller length (2.7 vs. 3.98 cm, p = 0.018). The particular calyx to be accessed should have a smaller length (2.22 vs. 3.19 cm, p = 0.012), larger angles (117.6 vs. 67.96, p<0.001) and larger infundibula (0.86 vs. 0.61 cm, p = 0.002). In the multivariate analysis, the only independent predictive factor for accessing a particular calyx was the angle between the entrance calyx and the calyx to be reached (OR 1.15, 95% confidence interval [CI], 1.053–1.256, p = 0.002).

CONCLUSION:

The angle between calyces obtained by multiplanar CT reconstruction is the only predictor of calyx access.     

A comparative study of complications and long term outcomes of Surgical Tracheostomy and two techniques of Percutaneous Tracheostomy

Context:

The operative technique for surgical tracheostomy has remained unchanged, but different techniques for percutaneous tracheostomy have evolved due to interest in minimally invasive procedures for the critically ill patient.

Aims:

To compare the periprocedural complications and long term outcomes of bedside surgical tracheostomy (ST) with two percutaneous tracheostomy (PCT) techniques, namely serial guide wire dilating forceps (GWDF) and PercuTwist (PT).

Settings and Design:

This prospective observational study was carried out in ICU of a tertiary referral centre over three year period on adult intubated patients needing elective tracheostomy.

Materials and Methods:

Patients with anticipated difficult neck anatomy were assigned for ST based on discretion of intensivist. Patients included for PCT were randomly assigned to the GWDT and PT technique. 90 patients underwent either bedside ST (n = 30), PCT by GWDF technique (n = 30) or PCT with PercuTwist (n = 30) and were followed up with fibreoptic bronchoscopy monthly for 06 months.

Statistical Analysis Used:

Data was analyzed by applying chi square tests for categorical variables.

Results:

Periprocedural complications during PCT included major bleeding (>100ml) in two patients in GWDF group which required conversion to ST. Periprocedural bleeding was also the main complication in ST. Increased incidence of granulation tissue and tracheal narrowing in long term was seen in both ST and PCT groups. All of the P values analysed for the intra operative, post operative complications or long term outcomes were >0.05.

Conclusions:

There was no statistically significant difference in incidence of complications of ST and two techniques of PCT. Proper case selection makes PCT as safe as ST.     

Evaluation of risk of nephrotoxicity with high dose,extended-interval colistin administration

Aim:

The aim was to evaluate the risk of nephrotoxicity with high-dose, extended-interval regimen of colistin administration in critical ill patients.

Materials and Methods:

This prospective study was conducted on patients suffering from sepsis due to Gram-negative infection susceptible only to colistin. The dosing schedule for colistin was 9 million units stat followed by 4.5 million units at 12 hourly interval (adjusted as per body weight and renal functions). The serum creatinine and creatinine clearance were estimated at the start of therapy and daily during therapy.

Results:

Thirty-one patients suffering ventilator associated pneumonia (61.29%), blood stream infections (29.03%) and urinary tract infections (9.67%) due to Gram-negative multiple drug resistance organisms were assessed. Most commonly isolated organism were Acinetobacter baumannii (54.83%), Klebsiella pneumonia (16.12%) and Pseudomonas (29.03%). Five patients (16.12%) developed acute kidney injury within 4-5 days of start of therapy and returned to baseline after 6 days with no patient requiring renal replacement therapy or discontinuation of colistin.

Conclusion:

Our study showed that high-dose, extended-interval colistin can be given to critically ill patients without any significant risk of nephrotoxicity.     

Evaluation of obstetric admissions to intensive care unit of a tertiary referral center in coastal India

Background and Aim:

To evaluate the occurrence, indications, course, interventions, and outcome of obstetric patients admitted to the intensive care unit (ICU).

Design:

Retrospective study.

Setting:

ICU of a Medical College Hospital.

Materials and Methods:

The data collected were age, parity, obstetric status, primary diagnosis, interventions, and outcome of obstetric patients admitted to the ICU from Jan 2005 to June 2011.

Results:

Total deliveries were 16,804 in 6.5 years. Obstetric admissions to the ICU were (n = 65) which constitutes 0.39% of deliveries. Majority of the admissions were in the postpartum period (n = 46, 70.8%). The two common indications for admission were obstetric hemorrhage (n = 18, 27.7%) and pregnancy related hypertension with its complications (n = 17, 26.2%). The most common intervention was artificial ventilation (n = 41, 63%). The mortality among obstetric admissions in the ICU was (33.8% (22/65)). The patients appropriate for High Dependency Unit (HDU) care was (32.3% (21/65)). The statistical analysis was done by fractional percentage and Chi-square test.

Conclusions:

Hemorrhage and pregnancy-related hypertension with its complications are the two common indications for ICU admissions. The need for a HDU should be considered.     

Clinical observation of childhood urinary stones induced by melamine-tainted infant formula in Anhui province,China

Introduction

The current report detailed an investigation of melamine-linked urinary stones in children exposed to contaminated formula.

Material and methods

A total of 1062 children fed with melamine-contaminated infant formula were screened for urinary stones. Sixty healthy children without melamine exposure were recruited as a control group. Ultrasonography of the urinary tract system was performed. Urinalysis, renal function, liver status, and serum electrolytes were determined.

Results

We encountered 49 affected children from the 1062 screened ones, at a rate of 4.6% per ultrasound performed. Thirty-two were male, and 17 were female. The affected children ranged in age from 1 month to 96 months, with a mean of 25 months. Duration of exposure was from 1.3 months to 84 months, with a mean of 19.5 months. The melamine contents in serum were between 12 mg/kg and 2563 mg/kg, with mean concentration of 1295.3 mg/kg. Most affected children were asymptomatic with no urinary findings. Patients with urinary stones exhibited lower urine pH and serum HCO₃ ^– than those in the healthy children, whereas for serum uric acid, alanine aminotransferase, aspartate aminotransferase, and anion gap the opposite trends were observed. The stone diameter ranged from 2 mm to 18 mm with a median of 6.5 mm. Multiple stones were noted in all patients. After 1 week of conservative management, stone diameters of 38 cases (77.6%) were significantly decreased. Among them, urinary stones were discharged completely in 21 affected children (42.9%).

Conclusions

The short-term outcome of melamine-linked urinary stones is satisfactory.     

Intraoperative blood loss during surgical treatment of low-rectal cancer by abdominosacral resection is higher than during extra-levator abdominosacral amputation of the rectum

Introduction

Abdominosacral resection (ASR) usually required blood transfusions, which are virtually no longer in use in the modified abdominosacral amputation of the rectum (ASAR). The aim of this study was to compare the intra-operative bleeding in low-rectal patients subjected to ASR or ASAR.

Material and methods

The study included low-rectal cancer patients subjected to ASR (n = 114) or ASAR (n = 46) who were retrospectively compared in terms of: 1) the frequency of blood transfusions during surgery and up to 24 h thereafter; 2) the volume of intraoperative blood loss (ml of blood transfused) during surgery and up to 24 h thereafter; 3) hemoglobin concentrations (Hb) 1, 3 and 5 days after surgery; 4) the duration of hospitalization.

Results

Blood transfusions were necessary in 107 ASR patients but in none of those subjected to ASAR (p < 0.001). Median blood loss in the ASR group was 800 ml (range: 100–4500 ml). The differences between the groups in median Hb determined 1, 3 and 5 days following surgery were insignificant. The proportions of patients with abnormal values of Hb, however, were significantly higher in the ASR group on postoperative days 1 and 3 (day 1: 71.9% vs. 19.6% in the ASAR group, p = 0.025; day 3: 57.% vs. 13.0%, p = 0.009). Average postoperative hospitalization in ASR patients was 13 days compared to 9 days in the ASAR group (p = 0.031).

Conclusions

Abdominosacral amputation of the rectum predominates over ASR in terms of the prevention of intra- and postoperative bleeding due to the properly defined surgical plane in low-rectal cancer patients.     

Risk factors for hospital-acquired hypernatremia among critically ill medical patients in a setting utilizing a preventive free water protocol: Do we need to do more?

Context:

Hospital-acquired hypernatremia (HAH) is a frequent concern in critical care, which carries high mortality.

Aims:

To study the risk factors for HAH in settings that practice a preventive protocol.

Settings and Design:

Two tertiary-care hospitals. Prospective observational study design.

Materials and Methods:

Patients aged >18 years admitted for an acute medical illness with normal serum sodium and need for intensive care >48 h formed the study population. Details of the basic panel of investigations on admission, daily electrolytes and renal function test, sodium content of all intake, free water intake (oral, enteral and intravenous) and fluid balance every 24 h were recorded. Individuals with serum Na 140-142 meq/l received 500 ml of free water every 24 h, and those with 143-145 meq/l received 1000 ml free water every 24 h.

Statistical Analysis Used:

Risk factors associated with HAH was analysed by multiple logistic regression.

Results:

Among 670 study participants, 64 (9.5%) developed HAH. The median duration of hypernatremia was 3 days. A total 60 of 64 participants with HAH had features of renal concentrating defect during hypernatremia. Age >60 years (P = 0.02), acute kidney injury (AKI) on admission (P = 0.01), mechanical ventilation (P = 0.01), need for ionotropes (P = 0.03), worsening Sequential Organ Failure Assessment (SOFA) score after admission (P < 0.001), enteral tube feeds (P = 0.002), negative fluid balance (P = 0.02) and mannitol use (P < 0.001) were the risk factors for HAH. Mortality rate was 34.3% among hypernatremic patients.

Conclusions:

The study suggests that administration of free water to prevent HAH should be more meticulously complied with in patients who are elderly, present with AKI, suffer multi-organ dysfunction, require mechanical ventilation, receive enteral feeds and drugs like mannitol or ionotropes.     

Meta-analysis of randomized trials on access site selection for percutaneous coronary intervention in ST-segment elevation myocardial infarction

Introduction

Superior outcomes with transradial (TRPCI) versus transfemoral coronary intervention (TFPCI) in the setting of acute ST-segment elevation myocardial infarction (STEMI) have been suggested by earlier studies. However, this effect was not evident in randomized controlled trials (RCTs), suggesting a possible allocation bias in observational studies. Since important studies with heterogeneous results regarding mortality have been published recently, we aimed to perform an updated review and meta-analysis on the safety and efficacy of TRPCI compared to TFPCI in the setting of STEMI.

Material and methods

Electronic databases were searched for relevant studies from January 1993 to November 2012. Outcome parameters of RCTs were pooled with the DerSimonian-Laird random-effects model.

Results

Twelve RCTs involving 5,124 patients were identified. According to the pooled analysis, TRPCI was associated with a significant reduction in major bleeding (odds ratio (OR): 0.52 (95% confidence interval (CI) 0.38–0.71, p < 0.0001)). The risk of mortality and major adverse events was significantly lower after TRPCI (OR = 0.58 (95% CI: 0.43–0.79), p = 0.0005 and OR = 0.67 (95% CI: 0.52–0.86), p = 0.002 respectively).

Conclusions

Robust data from randomized clinical studies indicate that TRPCI reduces both ischemic and bleeding complications in STEMI. These findings support the preferential use of radial access for primary PCI.     

Detection of heart disease by open access echocardiography: a retrospective analysis of general practice referrals

Background

Heart disease is difficult to detect clinically and it has been suggested that echocardiography should be available to all patients with possible cardiac symptoms or signs.

Aim

To analyse the results of 2 years of open access echocardiography for the frequency of structural heart disease according to request.

Design and setting

Retrospective database analysis in a teaching hospital open access echocardiography service.

Method

Reports of all open access transthoracic echocardiograms between January 2011 and December 2012 were categorised as normal, having minor abnormalities, or significant abnormalities according to the indication.

Results

There were 2343 open access echocardiograms performed and there were significant abnormalities in 29%, predominantly valve disease (n = 304, 13%), LV systolic dysfunction (n = 179, 8%), aortic dilatation (n = 80, 3%), or pulmonary hypertension (n = 91, 4%). If echocardiography had been targeted at a high-risk group, 267 with valve disease would have been detected (compared to 127 with murmur alone) and 139 with LV systolic dysfunction (compared to 91 with suspected heart failure alone). Most GP practices requested fewer than 10 studies, but 6 practices requested over 70 studies.

Conclusion

Open access echocardiograms are often abnormal but structural disease may not be suspected from the clinical request. Uptake by individual practices is patchy. A targeted expansion of echocardiography in patients with a high likelihood of disease is therefore likely to increase the detection of clinically important pathology.     

Propofol versus flunitrazepam for inducing and maintaining sleep in postoperative ICU patients

Context:

Sleep deprivation is a common problem on intensive care units (ICUs) influencing not only cognition, but also cellular functions. An appropriate sleep-wake cycle should therefore be maintained to improve patients’ outcome. Multiple disruptive factors on ICUs necessitate the administration of sedating and sleep-promoting drugs for patients who are not analgo-sedated.

Aims:

The objective of the present study was to evaluate sleep quantity and sleep quality in ICU patients receiving either propofol or flunitrazepam.

Settings and Design:

Monocentric, randomized, double-blinded trial.

Materials and Methods:

A total of 66 ICU patients were enrolled in the study (flunitrazepam n = 32, propofol n = 34). Propofol was injected continuously (2 mg/kg/h), flunitrazepam as a bolus dose (0.015 mg/kg). Differences between groups were evaluated using a standardized sleep diary and the bispectral index (BIS).

Statistical Analysis Used:

Group comparisons were performed by Mann-Whitney U-Test. P < 0.05 was considered to be statistically significant.

Results:

Sleep quality and the frequency of awakenings were significantly better in the propofol group (Pg). In the same group lower BIS values were recorded (median BIS propofol 74.05, flunitrazepam 78.7 [P = 0.016]). BIS values had to be classified predominantly to slow-wave sleep under propofol and light sleep after administration of flunitrazepam. Sleep quality improved in the Pg with decreasing frequency of awakenings and in the flunitrazepam group with increasing sleep duration.

Conclusions:

Continuous low-dose injection of propofol for promoting and maintaining night sleep in ICU patients who are not analgo-sedated was superior to flunitrazepam regarding sleep quality and sleep structure.     

Impact of preoperative mild renal dysfunction on short term outcome in isolated Coronary Artery Bypass (CABG) patients

Background and Aim:

It is well known that dialysis dependent renal failure increases the likelihood of poor outcome following cardiac surgery. But the results of CABG in patients with mild renal dysfunction are not clearly established. The aim of the study is to analyze the risk of preoperative mild renal dysfunction on outcome after isolated coronary surgery.

Materials and Methods:

We reviewed prospectively collected data between June 2006-Nov 2006 in 488 patients who underwent isolated CABG. We separated the data into two groups. Control group having normal renal function and study group having mild renal dysfunction (serum creatinine 1.4 mg-2.2 mg%). Among 488 patients, 412 patients were in control group and 76 patients were in the study group.

Results:

Analysis of data showed significant postoperative complications in the mild renal dysfunction group, like increased operative mortality (7.5% vs 1.6%), increased requirement of postoperative renal replacement therapy (10% vs 1.2%), increased incidence of new onset atrial fibrillation (20% vs 4.2%) and prolonged duration of ICU stay. Multivariate analysis adjusting for known risk factors confirmed preoperative mild renal dysfunction (S.creat.1.4-2.2 mg/dl) is an independent risk factor for postoperative morbidity and mortality. (Adj. OR: 4.47; 95% CI: 1.41-14.16; P=0.010).

Conclusion:

Mild renal dysfunction is an important independent predictor of outcome in terms of in-hospital mortality and morbidity in patients undergoing CABG.     

Mortality patterns among critically ill children in a Pediatric Intensive Care Unit of a developing country

Background and Aim:

Advances in biomedical technology have made medical treatment to be continued beyond a point, at which it does not confer an advantage but may increase the suffering of patients. In such cases, continuation of care may not always be useful, and this has given rise to the concept of limitation of life-sustaining treatment. Our aim was to study mortality patterns over a 6-year period in a Pediatric Intensive Care Unit (PICU) in a developing country and to compare the results with published data from other countries.

Materials and Methods:

Retrospective cohort study was conducted in a PICU of a tertiary care hospital in Pakistan. Data were drawn from the medical records of children aged 1-month – 16 years of age who died in PICU, from January 2007 to December 2012.

Results:

A total of 248 (from an admitted number of 1919) patients died over a period of 6 years with a mortality rate 12.9%. The median age of children who died was 2.8 years, of which 60.5% (n = 150) were males. The most common source of admission was from the emergency room (57.5%, n = 143). The most common cause of death was limitation of life-sustaining treatment (63.7%, n = 158) followed by failed cardiopulmonary resuscitation (28.2%, n = 70) and brain death (8.1%, n = 20). We also found an increasing trend of limitation of life-sustaining treatment do-not-resuscitate (DNR) over the 6-year reporting period.

Conclusion:

We found limitation of life support treatment (DNR + Withdrawal of Life support Treatment) to be the most common cause of death, and parents were always involved in the end-of-life care decision-making.     

Strain of experimental animals and modulation of nitric oxide pathway: their influence on development of renal failure in an experimental model of hepatorenal syndrome

Introduction

Pathomechanism of HRS is still poorly understood. The aim of our study was: (1) to test whether different strains of rats could develop typical HRS, and (2) to estimate the influence of activation and inhibition of nitric oxide for development of renal failure in course of HRS.

Material and methods

First, we used 16 of Wistar and 16 of Sprague-Dawley rats in galactosamine model of HRS. Next, we used 48 of SDR rats, which received saline, N-nitro-L-arginine or L-arginine before and after liver damage. Twenty four hours urine and blood samples were collected 48 h after saline or Ga1N injection. Biochemical parameters were determined in serum or urine and then creatinine clearance and osmolality clearance were calculated. Liver and kidney tissues were collected for histopathological examination.

Results

Liver failure developed in all tested groups with significant increase of bilirubin (p < 0.001), ALT (p < 0.001) and ammonia (p < 0.001). Nevertheless we did not achieve any evidence of renal failure in Wistar, but we found typical renal failure in Sprague-Dawley group with significant decrease in creatinine clearance (p < 0.0012) and increase in concentration of creatinine and urea (p < 0.001) and (p < 0.001) respectively. Inhibition of NOS prevented development of renal failure with significant improvement of GFR both before (p < 0.0017) and after (p < 0.003) Ga1N injection. Injection of L-arginine after Ga1N injection did not caused significant improvement of GFR.

Conclusions

Our study showed, that genetic factors might be responsible for development of renal failure in course of HRS and nitric oxide play important role in acute model of this syndrome.     

Case Review of Impacted Bile Duct Stone at Duodenal Papilla: Detection and Endoscopic Treatment

Purpose

A bile duct stone impacted at the duodenal papilla is an urgent condition that can rapidly lead to either suppurative cholangitis or acute pancreatitis due to almost complete obstruction of the bilio-pancreatic outflow. This study evaluated the clinical characteristics and results of endoscopic treatment for a bile duct stone impacted at the duodenal papilla.

Materials and Methods

Forty-six patients who had been diagnosed with an impacted papillary stone were retrospectively reviewed.

Results

The typical features of acute cholangitis (Charcot''s triad) and pancreatitis were only observed only in 10 patients (21.7%) and 17 patients (37.0%), respectively. After the endoscopic retrograde cholangiopancreatography, 30 patients (65.2%) were found to have a solitary stone impacting the duodenal papilla and 16 patients had one or more stones in the bile duct. On the radiological studies, the former patients were associated more commonly with no visible stone or no bile duct dilatation (p < 0.05). All impacted papillary stones were successfully removed by endoscopic sphincterotomy: 23 by a needle knife and 23 by a pull type papillotome. The procedure-related complications (n = 7, 4 bleeding, 3 pancreatitis) were not serious and did not differ, based on endoscopic findings and the procedure used.

Conclusion

A bile duct stone impacted at the duodenal papilla requires both clinical and radiographic evidence to support the diagnosis. Endoscopic sphincterotomy, either with a needle knife or a pull type papillotome, was safe and effective for removing the impacted papillary stone.     

Continuous versus intermittent administration of piperacillin�Ctazobactam in intensive care unit patients with ventilator-associated pneumonia

Background and Aims:

Ventilator-associated pneumonia (VAP) is one of the most common Intensive Care Unit (ICU)-acquired infection. The aim of this study was to compare the clinical outcome of continuous and intermittent administration of piperacillin–tazobactam by serial measurements of the Clinical Pulmonary Infection Score (CPIS).

Subjects and Methods:

Groups were designed as parallel and the study was designed as quasi-experimental and conducted at a semi-closed ICU between September 2008 and May 2010. Patients received 3.375 g (piperacillin 3 g/tazobactam 0.375 g) either through intermittent infusion every 6 h for 30 min [Intermittent Infusion (II) group; n = 30] or through continuous infusion every 8 h for 4 h [Continuous Infusion (CI) group; n = 31]. CPIS was used to assess the clinical diagnosis and outcome of VAP patients.

Results:

Sex, age, Acute Physiology and Chronic Health Evaluation II II score on ICU admission, diagnosis and underlying disease of VAP patients were not significantly different in the CI (n = 31) and II (n = 30) groups. Duration of mechanical ventilation, length of stay, total number of antibiotics used per patient and duration of piperacillin/tazobactam treatment were similar in both groups. Mortality rates of VAP patients were similar between both groups during hospitalization.

Conclusion:

There was no significant difference in clinical outcomes of patients receiving piperacillin–tazobactam via CI or II when measured by serial CPIS score.     

Prevalence of angiotensin converting enzyme (ACE) gene insertion/deletion polymorphism in South Indian population with hypertension and chronic kidney disease

Context:

Chronic Kidney Disease (CKD) is associated with a high risk of developing further severe complications such as, cardiovascular disease and eventually End Stage Renal Disease (ESRD) leading to death. Hypertension plays a key role in the progression of renal failure and is also a chief risk factor for the occurrence of End Stage Renal Disease (ESRD).

Aim:

This study investigates the possible association of insertion (I) and deletion (D) polymorphism of ACE gene in patients of Chronic Kidney Disease (CKD) with and without hypertension (HT).

Settings and Design:

Total 120 participants with 30 members in each group (Control, HT, CKD and CKD-HT) were chosen followed by informed consent.

Materials and Methods:

Blood samples were collected and subjected to biochemical analyses and nested PCR amplification was performed to genotype the DNA, for ACE I/D using specific primers.

Statistical Analysis:

Statistical analyses were performed using SPSS version 13. Allele and genotypic frequency was calculated by direct gene counting method. Comparison of the different genotypes was done by using Chi square test. Odd''s ratios were calculated with a 95% confidence interval limit.

Results:

The ACE genotype were distributed as II, 27 (90%); DD, 2 (6.67%) and ID, 1 (3.33%) in control, II, 1 (3.33%); DD, 5 (16.67%) and ID, 24 (80%) in HT, II, 4 (13.33%); DD, 24 (80%) and ID, 2 (6.67%) in CKD and II, 0 (0%); DD, 2 (6.67%) and ID, 28 (93.33%) in CKD-HT group.

Conclusions:

D allele of ACE gene confers a greater role in genetic variations underlying CKD and hypertension. This result suggest that CKD patients should be offered analysis for defects in ACE I/D polymorphisms, especially if they are hypertensive.KEY WORDS: Allele, chronic kidney disease, hypertension, PCR, polymorphism of ACE gene     

Laparoscopic nephrectomy for xanthogranulomatous pyelonephritis – Are there predictive factors for success?

OBJECTIVES:

Laparoscopic nephrectomy for xanthogranulomatous pyelonephritis is currently associated with great operative difficulty and surgical complications. Herein, we report on our single-center experience and describe predictive factors for successfully accomplishing this procedure.

METHOD:

Between March 1998 and April 2010, 66 patients (27 men and 39 women) underwent laparoscopic nephrectomy for the treatment of a unilateral nonfunctioning kidney. These patients had previous diagnoses of renal chronic inflammation associated with calculi and previous pyonephrosis. All of the nephrectomies were performed using the transperitoneal approach, and a similar technique was used for radical nephrectomy.

RESULTS:

Laparoscopic nephrectomy for the treatment of renal chronic inflammation was successful in 58/66 cases (87.9%). Eight cases were converted to the open technique because of difficulty in progression, which was related to the discovery of dense adhesions in the hilar or perirenal region. One major (colonic lesion) and two minor (wound infection) complications occurred in the conversion group. A diagnosis of xanthogranulomatous pyelonephritis was confirmed pathologically for all of the specimens. Of the factors examined, a longitudinal renal length greater than 12 cm (laparoscopy group - 7.2±1.8 cm, versus open group - 13.6±1.5 cm; p<0.05) and time to access the renal vessels (laparoscopy group - 32±18 min, versus open group - 91±11 min; p<0.05) were associated with a higher conversion rate. Although the number of patients in the conversion group was small, the majority of these patients received right-sided nephrectomy.

CONCLUSIONS:

Laparoscopic nephrectomy for the treatment of xanthogranulomatous pyelonephritis is feasible and associated with low levels of morbidity. Factors including the time required to control the renal vessels, renal length and right-sided nephrectomy were associated with higher chances of conversion into an open procedure.     

Laboratory Measures of Postural Control During the Star Excursion Balance Test After Acute First-Time Lateral Ankle Sprain

Context

No researchers, to our knowledge, have investigated the immediate postinjury-movement strategies associated with acute first-time lateral ankle sprain (LAS) as quantified by center of pressure (COP) and kinematic analyses during performance of the Star Excursion Balance Test (SEBT).

Objective

To analyze the kinematic and COP patterns of a group with acute first-time LAS and a noninjured control group during performance of the SEBT.

Design

Case-control study.

Setting

University biomechanics laboratory.

Patients or Other Participants

A total of 81 participants with acute first-time LAS (53 men, 28 women; age = 23.22 ± 4.93 years, height = 1.73 ± 0.09 m, mass = 75.72 ± 13.86 kg) and 19 noninjured controls (15 men, 4 women; age = 22.53 ± 1.68 years, height = 1.74 ± 0.08 m, mass = 71.55 ± 11.31 kg).

Intervention

Participants performed the anterior (ANT), posterolateral (PL), and posteromedial (PM) reach directions of the SEBT.

Main Outcome Measure(s)

We assessed 3-dimensional kinematics of the lower extremity joints and associated fractal dimension (FD) of the COP path during performance of the SEBT.

Results

The LAS group had decreased normalized reach distances in the ANT, PL, and PM directions when compared with the control group on their injured (ANT: 58.16% ± 6.86% versus 64.86% ± 5.99%; PL: 85.64% ± 10.62% versus 101.14% ± 8.39%; PM: 94.89% ± 9.26% versus 107.29 ± 6.02%) and noninjured (ANT: 60.98% ± 6.74% versus 64.76% ± 5.02%; PL: 88.95% ± 11.45% versus 102.36% ± 8.53%; PM: 97.13% ± 8.76% versus 106.62% ± 5.78%) limbs (P < .01). This observation was associated with altered temporal sagittal-plane kinematic profiles throughout each reach attempt and at the point of maximum reach (P < .05). This result was associated with a reduced FD of the COP path for each reach direction on the injured limb only (P < .05).

Conclusions

Acute first-time LAS was associated with bilateral deficits in postural control, as evidenced by the bilateral reduction in angular displacement of the lower extremity joints and reduced reach distances and FD of the COP path on the injured limb during performance of the SEBT.Key Words: ankle joint, biomechanics, kinematics, kinetics, postural balance

Key Points

• Individuals with acute, first-time lateral ankle sprain injuries exhibited bilateral deficits in dynamic postural control as assessed using the reach distances achieved during the anterior, posterolateral, and posteromedial directions of the Star Excursion Balance Test.
• These deficits are underpinned by both local and global modifications in the movement patterns adopted at the point of maximum reach by the joints of the lower extremity.
• A trend toward reduced sagittal-plane range-of-motion displacement was also noted at the hip, knee, and ankle joints throughout each reach attempt in the injured group.
• These deficits were associated with an apparently reduced capacity to exploit the available base of support, as illustrated by a reduced fractal dimension of the stance-limb center-of-pressure path of the injured limb.
• Researchers need to determine if some deficits observed in the acute phase of lateral ankle sprain precede or predispose an athlete to the initial injury and to clarify whether these deficits are central to the onset of chronic injury.

In a recent meta-analysis, we¹ elucidated that ankle sprain is an injury risk for participants of all ages during a wide variety of activity types. Decreased physical activity,² the potential for the development of posttraumatic ankle arthritis,³ and medical costs⁴ are immediate concerns associated with the acute ankle-joint injury, which has substantial potential for recurrence.⁵Investigators^6,7 have hypothesized that the chronic sequelae associated with ankle-sprain injury result from the emergence of inappropriate postinjury-movement strategies. The success or failure of these strategies depends on a process of sensorimotor reorganization, whereby structurally different components of the neurobiological system, known as degeneracies, combine toward a common motor output. These degeneracies in available degrees of freedom at affected joints are exploited to satisfy the demands of morphologic and task constraints.⁸ An acute lateral ankle sprain (LAS) injury can be conceptualized as a morphologic constraint that challenges the human sensorimotor system to optimally organize altered peripheral sensorimotor inputs and the influence of higher brain centers.⁹Clinicians frequently use postural-control assessments to evaluate the movement deficits associated with injury. Dynamic postural-control tasks seek to mimic the demands of physical activity by dictating movement around the supporting base.¹⁰ The Star Excursion Balance Test (SEBT) is a dynamic postural-control task that has gained attention in clinical and research settings.¹⁰ Whereas the primary outcome variable during SEBT performance in the clinical setting is the magnitude of the achieved reach distance, the movement patterns associated with this distance have also been evaluated in the laboratory.^11–13 With regard to the SEBT, instrumented analysis enhances the assessment of reach-distance magnitude in isolation. In particular, 3-dimensional kinematic analyses, combined with measures of force-plate stabilometry, provide insight into the causative mechanisms underpinning the test outcome, thus allowing the movement insufficiencies linked with acute injury, such as LAS, to be identified.Analysis of center of pressure (COP) is a branch of stabilometry that has been combined with kinematic assessment in ankle-sprain research.¹⁴ A newly applied measure called fractal dimension (FD) characterizes the complexity of a given COP signal by describing its shape with a discrete value ranging from 1 (straight line) to 2 (line so convoluted that it fills the plane it occupies).^15,16 A larger FD of the COP path has been associated with greater activity of the sensorimotor system in fulfilling the demands of balance. However, FD scores do not indicate on a linear scale where more or less is better or worse; an FD that is too large may reflect an inability of the sensorimotor system to synergistically modulate sensory afferents in producing an appropriate efferent response,¹⁷ and an FD that is too small may reflect a deficit in using the base of support available^16,18 secondary to the demands of morphologic and task constraints.¹⁹Previous researchers^7,20 have revealed contrasting movement patterns during dynamic postural-control tasks in groups presenting with chronic injury and full recovery in the months after an ankle sprain. Investigations^21–23 of acute LAS cohorts have typically been restricted to the evaluation of COP measures during static postural-control tasks. To our knowledge, no one has assessed the immediate postinjury-movement strategies associated with LAS using combined COP and kinematic analyses during a dynamic postural-control task. Therefore, the purpose of our study was to examine the movement-pattern characteristics of participants with acute LAS and noninjured participants serving as a control group during the performance of the SEBT using instrumented 3-dimensional kinematic and COP analyses. We hypothesized that the group with acute LAS (1) would report reduced function secondary to injury, (2) would display bilateral impairment of dynamic balance as assessed using SEBT reach-distance scores compared with the control group, and (3) would exhibit altered kinematic and COP measures during performance of selected reach directions of the SEBT compared with the control group.     

Hypofractionated radiotherapy as local hemostatic agent in advanced cancer

Purpose:

Tumor bleeding continues to remain a challenge in an oncological setting, and radiotherapy has been studied as a local hemostatic agent. We studied the role of local radiotherapy in controlling bleeding at our center.

Materials and Methods:

We reviewed 25 treated cases (cancer urinary bladder: 12, lung cancer: 5, cervical cancer: 4, uterine cancer: 1, rectal cancer: 2, schwanoma: 1) at our center from March 2008 to December 2010. All patients had either an advanced or recurrent disease. Radiotherapy schedule was either 20 Gray in 5 fractions or 15 Gray in 5 fractions and was delivered with Cobalt 60.

Results and Conclusion:

Of 25 patients, 22 (88%) responded, and there was complete cessation of bleeding. Both 15 Gray and 20 Gray dose schedule had equal efficacy. Treatment was well tolerated without any intermission. Radiotherapy is a safe and effective option in controlling tumor bleeding.     

Identifying patients with suspected renal tract cancer in primary care: derivation and validation of an algorithm

Background

Earlier diagnosis of renal tract cancer could help improve survival so better tools are needed to help this.

Aim

To derive and validate an algorithm to estimate the absolute risk of renal tract cancer in patients with and without symptoms in primary care.

Design

Cohort study using data from 375 UK QResearch® general practices for development and 189 for validation.

Method

Included patients were aged 30–84 years free at baseline of a diagnosis of renal tract cancer (bladder, kidney, ureter, or urethra) and without haematuria, abdominal pain, appetite loss, or weight loss in previous 12 months. The primary outcome was incident diagnosis of renal tract cancer recorded in the next 2 years. Risk factors examined were age, body mass index, smoking, alcohol, deprivation, treated hypertension, renal stones, structural kidney problems, diabetes, previous diagnosis of cancer apart from renal tract cancer, haematuria, abdominal pain, appetite loss, weight loss, diarrhoea, constipation, tiredness, and anaemia. Cox proportional hazards models were used to develop separate risk equations in males and females. Measures of calibration and discrimination assessed performance in the validation cohort.

Results

There were 2878 incident cases of renal tract cancer from 4.1 million person-years in the derivation cohort. Independent predictors in both males and females were age, smoking status, haematuria, abdominal pain, weight loss, and anaemia. A history of prior cancer other than renal tract cancer, and appetite loss were predictors for females only. On validation, the algorithms explained 75% of the variation in females and 76% in males. The receiver operating curve statistics were 0.91 (females) and 0.95 (males). The D statistic was 3.53 (females) and 3.60 (males). The 10% of patients with the highest predicted risks contained 87% of all renal tract cancers diagnosed over the next 2 years.

Conclusion

The algorithm has good discrimination and calibration and could potentially be used to identify those at highest risk of renal tract cancer, to facilitate more timely referral and investigation.