Is there a role for pentosan polysulfate in the prevention of calcium oxalate stones?

The clinical role for pentosan polysulfate (PPS) in the prevention of calcium oxalate urolithiasis is not known. Crystallization and aggregation are important steps in calcium oxalate stone formation, and PPS has been shown to inhibit these steps, both in vitro and in vivo. In addition, PPS has a role in repairing injured urothelium and inhibiting adhesion to epithelial defects. A randomized double-blind placebo-controlled study appears warranted to assess the utility of PPS in the prevention of recurrent calcium oxalate stones.     

Is there a role for urinary podocyte excretion assessment in lupus nephritis?

Objective To establish the occurrence and intensity of podocyturia and its relation to grade of disease activity, as defined by clinical and laboratory criteria. Methods Prospective, cross-sectional study involving 50 patients with lupus nephritis and 29 controls, which had podocyturia levels determined from random urine samples using an immunofluorescence technique. Disease activity was graded by BILAG (renal criteria) and an additional system used in the service (S2). Results Fifty patients with lupus nephritis (WHO classes III, IV and V), with a median age of 37 years, were evaluated. Of these, 86.5% were female, and 52% were BILAG A. Podocyturia quantification in the lupus nephritis and control groups differed significantly (p?=?0.009). This score was higher in relation to classes III, IV and V. The correlation with C3 consumption was stronger (p?=?0.011) than with C4. The highest levels were found in the most active groups (A and B of BILAG and S2). Lower podocyturia correlated with a lower dose of prednisone. There was no association with the intensity of proteinuria, hematuria or pyuria, serum creatinine levels, among others. Conclusions Podocyturia assessment, which was performed by immunofluorescence in this study, can be used as an indicator of disease activity with the advantage of being a urinary biomarker. The levels proved to be higher in patients with lupus nephritis than in the controls and were particularly higher in class IV.     

Is there a role for surgery in the treatment of mastalgia?

Breast pain is a common condition affecting most women at some stage in their reproductive life. Mastalgia is resistant to treatment in 6% of cyclical and 26% non-cyclical patients. Surgery is not widely used to treat this condition and only considered in patients with severe mastalgia resistant to medication. The aims of this study were to audit the efficacy of surgery in severe treatment resistant mastalgia and to assess patient satisfaction following surgery. This is a retrospective review of the medical records of all patients seen in mastalgia clinic in the University Hospital of Wales, Cardiff since 1973. A postal questionnaire was distributed to all patients who had undergone surgery. Results showed that of the 1054 patients seen in mastalgia clinic, 12 (1.2%) had undergone surgery. Surgery included 8 subcutaneous mastectomies with implants (3 bilateral, 5 unilateral), 1 bilateral simple mastectomy and 3 quadrantectomies (1 having a further simple mastectomy). The median duration of symptoms was 6.5 years (range 2-16 years). Five patients (50%) were pain free following surgery, 3 developed capsular contractures and 2 wound infections with dehiscence. Pain persisted in both patients undergoing quadrantectomy. We conclude that surgery for mastalgia should only be considered in a minority of patients. Patients should be informed of possible complications inherent of reconstructive surgery and warned that in 50% cases their pain will not be improved.     

Is there a role for uric acid in an animal model of calcium phosphate nephrocalcinosis and calcium phosphate crystallization in urine of patients with idiopathic calcium urolithiasis? An orientational study

Uric acid (UA), a waste product of purine metabolism, may be involved in calcium phosphate crystallization and deposition. Rats, which develop nephrocalcinosis on high-fat or magnesium-deficient diets, and patients with idiopathic calcium urolithiasis have hyperproteinuria, especially of nonalbumin protein, and a shift toward elevated serum UA. In rats, an increase in UA precursors and renal UA suggests hypoxemia, which stimulates xanthine oxidase. In patients, a primary increase in renal xanthine oxidase would explain the low urine UA in the presence of an elevated serum concentration. For calcium phosphate deposition (rats) or incorporation into stones (humans) to occur, a crucial factor may be xanthine oxidase-mediated overproduction of free radical species and subsequent tissue damage. Another factor may be whether sufficient UA is synthesized to neutralize these free radicals. Allopurinol use, which inhibits xanthine oxidase and has long been favored for the treatment of idiopathic calcium urolithiasis, may not prevent stones, because it also diminishes the availability of UA. An investigation of the factors that control serum UA homeostasis may be rewarding in research into the etiology of idiopathic calcium urolithiasis.     

Is there a role for surgery in the management of dropped head syndrome?

We present a 50-year-old chronic epileptic man with a long-standing head drop, who fell sustaining multilevel thoracic vertebral body fractures. The antiepileptic medication was thought to be responsible for his osteoporosis and dropped head. We review the aetiology of the dropped head and report on our experience of surgery for this rare and disabling condition.     

Is there a role for interval appendectomy in the management of acute appendicitis?

Interval appendectomy (IA) remains a controversial subject in surgery. To determine its effectiveness we reviewed our results with this approach. From January 1990 through December 1998 a total of 73 patients underwent appendectomy, five (7%) of which were interval in nature. These IA patients had a palpable abdominal mass or delayed presentation that led to CT scan. The decision to delay surgery was determined by two factors: 1) a CT scan that showed advanced inflammatory changes (phlegmon or abscess) associated with acute appendicitis and 2) a rapid response to conservative management. All patients received antibiotics-first intravenous and then oral. Repeat CT scans were performed before surgery and showed a virtual resolution of the inflammatory process. Appendectomy was delayed from 35 to 66 days from the time of diagnosis (average 51 days). There were no preoperative complications, the operations were uneventful, and there were no significant postoperative sequelae. IA appears to convert an unfavorable surgical situation potentially fraught with complications (fistula, abscess, wound infection) to one that is essentially elective in nature. It should be considered for the patient who is found to have an extensive periappendiceal inflammatory process, is clinically stable, and responds favorably to initial nonoperative management.     

Is there a role for PET in the evaluation of subcentimeter pulmonary nodules?

There are little published data available at this time to determine the appropriate role of positron emission tomography (PET) in the evaluation of subcentimeter pulmonary nodules. The sensitivity for malignancy is lower in these smaller lesions, while one would expect the specificity to be higher. Given that the resolution of current generation PET scanners is only 5 to 6 mm, one will be very unlikely to gain useful information from PET for a lesion below 5 mm. For lesions 5 to 10 mm in size, useful information might be gained from PET in those deemed intermediate risk by CT criteria, but this remains to be established. A positive PET in a small, intermediate risk lesion might push one toward biopsy/excision, though a negative PET in such a lesion must be considered to provide no information whatsoever. Even with advances in PET technologies in the future, we feel it is unlikely that PET will evolve a major role in the evaluation of the subcentimeter nodule.     

Is there a role for incomplete resection in the management of retroperitoneal liposarcomas?

Complete surgical resection is the most effective modality for the treatment of retroperitoneal sarcomas. Previous studies of all types of retroperitoneal sarcomas have not shown a survival benefit of incomplete resection over no resection. Because death often occurs as a result of local progression in retroperitoneal liposarcomas (RPLS), it is possible that incomplete resection may be beneficial in this histologic type. In this study we have sought to determine the clinical outcomes in patients with incompletely resected and unresected RPLS with the aim of defining patients who may benefit from palliative resection. From a prospective clinical database 55 patients with incompletely resected (n = 43) or unresected (n = 12) RPLS were identified between 1982 and 1999. Statistical analyses were performed using the log-rank test and Kaplan-Meier estimates with disease-specific survival as the primary end point. Variables studied included age, gender, recurrent versus primary disease, tumor grade, and tumor size. The patient population consisted of 34 men and 21 women with a mean age of 61 +/- 14 (SD) years. The median time to death was 10 months (range 1 to 83 months) with a median followup of 12 months (range 1 to 60 months) for survivors. Partial resection was an independent factor for increased survival as compared with exploration or biopsy only (median survival 26 versus 4 months, p < 0.0001). Of patients who received incomplete resections, locally recurrent presentation (n = 19) versus primary disease (n = 24) was a negative prognostic variable (median survival 17 versus 46 months, p = 0.009). Successful palliation of symptoms was achieved in 24 of 32 patients (75%) with preoperative symptoms. In select patients with unresectable RPLS, incomplete surgical resection can provide prolongation in survival and successful symptom palliation. Most likely to benefit are those patients presenting with primary tumors, suggesting that surgical resection should be attempted in the majority of patients.     

Is an immunoassay available for the measurement of bioactive LH in serum?

An in vitro bioassay for luteinizing hormone (LH) is in our opinion the "gold standard" bioassay. The rodent interstitial cell testosterone assay (RICT) is specific for bioactive LH and very sensitive, accurate, and reproducible. Diverse LH standards consistently display parallel dose-response characteristics. Sera also manifest parallel dose-response characteristics throughout reproductive life, with the exception of basal samples from prepubertal children. This indicates that all known hormones with LH bioactivity have a similar bioactive site. The in vivo bioassays for LH used for calibration of World Health Organization standards are more cumbersome and less precise and accurate than the in vitro bioassay. The ovarian ascorbic acid depletion assay corresponds better than the seminal vesicle weight assay with in vitro bioassay. Variation in the ratio of bioactive to immunoreactive LH (B/I) principally reflects variation in LH immunoassay dose-response characteristics, rather than a change in the bioactive moiety of LH. The varying B/I ratio is due to molecular heterogeneity at multiple levels. Different LH standards contain different proportions of nonbioactive but immunoreactive material. The immunoreactive LH isoforms in serum contain different proportions of bioactive material and the isoform distribution differs with reproductive status. Furthermore, the antibodies comprising the various immunoassay systems detect heterogeneous epitopes on LH, which are not necessarily bioactive. B/I ratio disparities indicate lack of specificity of immunoassays for bioactive LH. Polyclonal antibody-based radioimmunoassay requires the use of purified reagents, including a bioactive tracer, in order to achieve high specificity for bioactive LH. The new generation of monoclonal antibody-based immunometric assays yields results that are lower than, but correlate with, LH measured by the in vitro bioassay. The purest of standards, even a recombinant standard, yields results that differ up to 50% or more from one immunoassay to another. Serum LH levels also differ up to two-fold among assays. The immunometric assays have the advantage of being more sensitive and more specific for low levels of LH in serum than radioimmunoassays, but B/I ratio discrepancies remain great. An immunoassay specific for the bioactive "docking site" of human LH isoforms is still needed.     

Is there a role for surgical resection in the treatment of early-stage pancreatic lymphoma?

BACKGROUND: Pancreatic lymphoma is a rare neoplasm. The role of surgical resection in curing this disease is poorly defined. STUDY DESIGN: From March 1983 to July 1997, eight patients with stage I or II primary pancreatic lymphoma were identified and retrospectively reviewed. All patients received chemotherapy, five patients received radiotherapy, and three patients also underwent surgical resection. A review of the published pancreatic lymphoma experience in the English-language literature was also undertaken. RESULTS: Three patients underwent pancreaticoduodenectomy with successful resection of the lymphoma and are disease free at 64, 62, and 53 months followup. Five patients were treated with nonresectional therapy. Three are disease free at 128, 51, and 24 months. Two patients died of disease at 9 and 37 months. A review of the pancreatic lymphoma experience in the English-language literature identified 122 cases of pancreatic lymphoma. Fifty-eight of these cases represented stage I or II lymphoma, which was treated without surgical resection with a 46% cure rate. Fifteen patients who had surgical resection for localized disease have been reported with a 94% cure rate. CONCLUSIONS: Based on both our single institution experience and the literature, it is suggested that surgical resection may play a beneficial role in the treatment of localized pancreatic lymphoma, although selection factors cannot be absolutely excluded.     

Is there a role for rituximab in the treatment of idiopathic childhood nephrotic syndrome?

We each have nephrotic patients who become steroid dependent and in whom multiple immunosuppressive agents are employed. There is a need to balance possible therapeutic benefits with drug toxicity. This case report describes such a patient, who has suffered from nephrotic syndrome for over 11 years and had become resistant to the usual therapies. He was therefore given a single dose of the anti-CD20 drug rituximab, to which he showed a prompt response, leaving him free of proteinuria for the past 10 months.     

Is there still a role for open surgery in the management of renal stones?

PURPOSE OF REVIEW: In the last few decades, with the improvement in endourological surgery and the invention and evolution of extracorporeal shock-wave lithotripsy, the indications for open surgery in stone disease have become rare, although open surgery still has a role in selected cases. In this review we discuss the current indications of open surgery for the elimination of urinary calculi. RECENT FINDINGS: A MEDLINE and MeSH search was performed to evaluate currently available guidelines on open stone surgery and identify the evidence-based medicine that support the role of open surgery in treating urinary lithiasis. The latest papers published on open stone surgery are reviewed and conclusions are drawn, based on their results. SUMMARY: Open stone surgery should be avoided in most cases, but should be considered for those patients in whom a reasonable number of less invasive procedures would not be useful. The most common indications for open stone surgery include complex stone burden, failure of extracorporeal shock-wave lithotripsy or endourological treatment and anatomical abnormalities (such as ureteropelvic junction obstruction and infundibular stenosis with or without renal caliceal diverticulum). The level of evidence for the currently available guidelines is not adequate, mainly because of lack of properly designed, large prospective randomized trials that compare different treatment options.