The use of percutaneous nephrostomy in patients with ureteric obstruction undergoing renal transplantation

The use of percutaneous nephrostomy with or without placement of a ureteric stent has been of increasing aid in treating both acute and chronic ureteral obstruction in recipients of renal allografts. Eight patients who underwent transplantation, had ureteric obstruction develop and were treated by this means are reported herein. The technique is standard and can be performed in an arteriography suite. Once a catheter is inserted into the allograft collecting system, a nephrostomy tube or a stent, or both, is easily inserted. Three of the patients had acute ureteric obstruction secondary to clot forming after needle biopsy of the transplant kidney. Percutaneous nephrostomy tubes were passed, the renal pelvis and ureter irrigated and the clots lysed. Operation was unnecessary. In five patients with declining renal function secondary to chronic obstruction, percutaneous nephrostomy placement allowed return of renal function to base line levels, while placement of a stent through the ureter into the bladder facilitated location of the ureter at operation for ureteral reimplantation. The technique of percutaneous nephrostomy is simple, convenient and allows patient recovery preoperatively. It has become part of our standard armamentarium in transplant recipients.     

Harvey Cushing and the evolution of a polymath

The remarkable productivity of the later career of Cushing is well known. Energies and drive undiminished throughout his life, he contributed consistently and prolifically to the field of surgical procedures, history, biography and education at the very least. Consorting with the famous, honored over the world, his shadow is still seen. Early factors which influenced his personality and career have been analyzed herein. Many of these, individually or in concert, affected the extraordinary life of this complex man.     

Abdominal aortic aneurysm and gastrointestinal disease: should synchronous surgery be considered?

BACKGROUND: Abdominal aortic aneurysm (AAA) is relatively common in an age group in which other abdominal pathologies have an increasing incidence. The co-existence of an aneurysm with a second intra-abdominal pathology presents a difficult management problem for the surgeon. Synchronous aortic and gastrointestinal surgery is often avoided due to the perceived higher risk of infection of the vascular prosthesis. METHODS: Cases of synchronous AAA repair with a second gastrointestinal/biliary procedure were identified from the operative records of a single vascular surgeon working in a district general hospital. RESULTS: Eight cases were identified over a 10-year period, comprising 3 large bowel resections, 2 cholecystectomies and 3 upper gastrointestinal operations as the second synchronous procedure. No graft infections were recorded in this group and there was one death within 30 days. CONCLUSIONS: From our experience and a review of the available literature we conclude that synchronous aortic and gastrointestinal surgery should be considered when urgent surgery for both conditions is indicated.     

Recipient hypertension potentiates chronic functional and structural injury of rat renal allografts

BACKGROUND: Systemic hypertension affects many allograft recipients, is an important risk factor for chronic graft dysfunction, and is linked to reduced graft survival. The condition may up-regulate the expression of inflammatory host cells and their products. These, in turn, may significantly injure vascular endothelium and other components of allografted kidneys. METHODS: Lewis rats received orthotopic F344 renal allografts, a standard model of chronic rejection. Renovascular hypertension was produced by placing a silver clip (0.25 mm) on the renal artery of the retained contralateral native kidney 4 weeks after transplantation. Sham-clipped rats served as normotensive controls. Four recipient groups (Gp) were studied: Gp 1, rats with an allograft plus a clipped native kidney; Gp 2, those with an allograft and a sham-clipped native kidney; Gp 3, isografted animals with a clipped native kidney; and Gp 4, those bearing an isograft and a sham-clipped native kidney. Systolic blood pressure and proteinuria were measured every 2 weeks for 24 weeks. Grafts were assessed serially for morphologic and immunohistologic changes. RESULTS: Systemic blood pressure rose to hypertensive levels in Gps 1 and 3 within a week of clipping but never increased in Gps 2 and 4. Proteinuria developed in hypertensive animals but remained at baseline in normotensive controls. Intimal thickening of allograft arteries progressed to luminal obliteration with extensive perivascular and interstitial fibrosis by 24 weeks. In contrast, vascular changes in isografts of hypertensive hosts were restricted to medial hypertrophy. Tumor necrosis factor (TNF)-alpha, transforming growth factor (TGF)-beta, platelet derived growth factor (PDGF), endothelin, Il-6, major histocompatibility complex (MHC) class II, and B7 were up-regulated in allografts in hypertensive hosts. Vascular deposition of immunoglobulin (IgG) was increased. These changes were markedly less pronounced in Gp 3 isografts and minimal in the kidneys of the normotensive animals of Gps 2 and 4. CONCLUSIONS: An experimental model is presented that examines the influence of recipient hypertension in the pathogenesis of chronic dysfunction and injury developing in rat renal allografts over time.     

Nasal inflammation and chronic ear disease in Australian Aboriginal children

Objective : Chronic middle ear disease is common in Aboriginal children, and may be linked to nasal inflammation and Eustachian tube dysfunction. The pattern of nasal inflammation is unknown. The study reported here was performed to define the role of allergy and infection in causing nasal inflammation in Aboriginal children with chronic middle ear disease.
Methodology : Thirty-one Aboriginal children aged between 3 and 7 years underwent clinical assessment, audiometry and allergy skin tests. Nasal swabs for bacterial culture and cytology were performed during the winter and again in spring to identify any seasonal variation. A randomized trial of nasal beclomethasone for 8 weeks was conducted in children with abnormal tympanometry to identify the effect of therapy upon nasal cytology.
Results : Twenty-six of the 31 children had abnormal tympanograms. Average hearing levels were reduced in nine children. Pathogenic organisms were isolated from most children: Streptococcus pneumoniae (82%), Haemophilus influenzae (79%), Moraxella catarrhalis (39%) and Staphylococcus aureus (29%). Eight of the 31 children (26%) were atopic. Nasal cytology disclosed a marked neutrophil infiltrate (80% of cells) during the winter, which fell significantly in spring to 52% of cells. Only two subjects had nasal eosinophilia of >10%. There was no effect of beclomethasone on nasal cytology.
Conclusions : Chronic ear disease in Aboriginal children is associated with nasal inflammation, neutrophil infiltration and the presence of bacteria. These features suggest respiratory infection as the main cause of chronic nasal inflammation in Aboriginal children with middle ear disease. There is a seasonal variation in the severity of the nasal infiltrate, consistent with increased infections during winter. Despite a high prevalence of atopy, allergic nasal disease was uncommon.     

Hepatic abscess produced by extension of a perinephric abscess

A case of hepatic abscess resulting from direct extension of a perinephric abscess in a patient with chronic urinary tract infection is presented. Anatomic variation contributing to this disease and its clinical features are discussed. Other causes of hepatic abscess are reviewed briefly.