Renal metastases: clinicopathologic and radiologic correlation

The clinical and radiologic features of 27 patients with renal metastases arising from eight different types of nonlymphomatous primary malignancies are presented. Renal metastases were generally detected late in the course of the malignancy. In 23 patients there were no symptoms referable to the kidney. Urinalysis was normal in nine patients and showed microscopic hematuria in nine, gross hematuria in four, and proteinuria in four. Radiologically, metastases were usually multifocal; however, metastases arising from colon, lung, and breast carcinoma were sometimes large, solitary, and otherwise indistinguishable from primary renal cell carcinoma. Three of four melanoma metastases and three of seven lung metastases infiltrated the perinephric space. Computed tomography was the most sensitive modality, depicting renal metastases in all 24 cases in which it was employed, followed by ultrasound and intravenous urography. In patients with a history of malignancy, renal metastases outnumbered renal cell carcinomas by approximately 4:1. This study indicates that a new renal lesion in a patient with advanced, noncurable cancer is more likely metastatic than primary and that biopsy in this setting is unlikely to be of aid.     

Augmentation and replacement cystoplasty: sonographic findings

Sonographic evaluation of the urinary tract after bladder augmentation and replacement procedures often reveals unexpected findings that result from incorporation of bowel into the urinary bladder wall. Familiarity with such findings is important to avoid misinterpreting them as abnormalities. The authors reviewed the sonograms of 47 patients. The most common findings were thick or irregularly shaped bladder walls (96%), pseudomasses within the bladder lumen (89%), and fine debris or linear strands (47%). Pseudomasses were potentially the most confusing; they are usually attributable to normal bowel folds, intraluminal mucus collections, or segments of bowel that have been intussuscepted into the bladder to prevent reflux.     

A web-based training program to support chronic kidney disease screening by community pharmacists

Background Community pharmacists’ role in screening of several chronic diseases has been widely explored. The global health burden of chronic kidney disease is high; however, the progression and adverse outcomes can be prevented or delayed by detecting and treating the disease in its initial stages 1–3. Therefore, a web-based training program was developed to enhance pharmacists’ knowledge and skills required to perform a chronic kidney disease screening service in a community setting. Objective The aim of this study was to evaluate the impact of a web-based training program on community pharmacists’ knowledge and skills associated with chronic kidney disease screening. As secondary aim, pharmacists’ satisfaction with the training program was assessed. Setting Community pharmacy practice. Method A web-based training program was developed by four pharmacists and a nephrologist. Quantitative data was collected by employing a self-administered, web-based questionnaire, which comprised a set of five multiple-choice knowledge questions and one clinical vignette to assess skills. A nine-item Likert scale was used to determine pharmacists’ satisfaction with the training program. Main outcome measure Pharmacists’ knowledge and skills scores at pre and post-training, reliability of the Likert scale, and the proportion of responses to the individual nine items of the satisfaction survey. Results Fifty pharmacists participated in the pre-questionnaire and 38 pharmacists completed the web-based training and post-questionnaire. Significant differences were observed in the knowledge scores (p < 0.001) and skills scores (p < 0.001) at pre- and post-training. Cronbach’s alpha for the nine-item satisfaction scale was 0.73 and the majority pharmacists (92.1–100 %) were satisfied with the various aspects of the training program. Conclusion The web-based training program positively enhanced pharmacists’ knowledge and skills associated with chronic kidney disease screening. These findings support further development and widespread implementation of the training program to facilitate health promotion and early identification of chronic kidney disease in a community setting.     

Partner Counselling and Referral Services (PCRS) for HIV in Armed Forces - Visiting a Blind Spot

The Indian armed forces have over 5000 cases of human immunodeficiency virus (HIV) infection since 1990. The spouses of the affected soldiers are at a constant risk of contracting infection if not informed of their husband''s HIV status. The onus of counselling the spouse has been delegated to the commanding officer (CO) of the soldier as per policy. The spouses usually reside at their hometown away from the soldier''s unit and bridging this “geographical discordance” and offering effective counselling becomes a tricky issue for the commanding officer (CO). This article examines the effectiveness of this strategy as practised in Indian armed forces.Key Words: HIV, Partner counseling     

The risks of warfarin use in the elderly

The use of warfarin in the elderly, particularly for stroke prevention in chronic atrial fibrillation, is steadily increasing. Although the benefits of warfarin are greatest in the elderly, so are the risk of adverse outcomes and the difficulties of anticoagulant management. Clinical systems need to improve to counter this therapeutic dilemma, as warfarin is likely to remain the only widely available oral anticoagulant for the foreseeable future. Aspects that require attention are: the careful selection of patients in whom treatment with warfarin is appropriate; initiating therapy in a low dose (e.g., 2.5-5 mg/day); thorough education of patients and carers; close monitoring, especially with any change in the patient's regular drug therapy; involving patients more in the management of their warfarin therapy (self-monitoring/management in suitable patients); and ongoing review of the appropriateness of therapy as circumstances change.     

Lack of acute effects of ascorbic acid on spirometry and airway responsiveness to histamine in subjects with asthma

Sixteen adult subjects with asthma in a clinical steady state were studied. On day 1, after baseline spirometry, they underwent four histamine inhalation tests with functional recovery between each test. The provocative concentration causing a 20% fall in FEV1 (PC20) was obtained after each test. On days 2, 3, and 4, after baseline spirometry, active and placebo ascorbic acid (2 gm) was administered orally, double-blind, according to a 4.3.1 two-treatment crossover study design. One hour later, spirometry was performed, and PC20 was reassessed. We found no significant changes in FEV1 and FVC after ascorbic acid as compared with placebo administration. There was no difference between PC20 on days 2, 3, and 4 and by standardizing for the four PC20 results obtained on day 1. We conclude that ascorbic acid has no acute bronchodilator effect and does not alter bronchial responsiveness to histamine in subjects with asthma.     

Interaction of fibronectin with cultured human endothelial cells: characterization of the specific receptor

In this study we provide a characterization of the fibronectin (FN) binding to endothelial cells (EC), and we identify the FN binding site on these cells. 125I-FN binding to EC in suspension was time dependent and reached a plateau at 4 h. Cold FN inhibited this interaction in a concentration-dependent way, but vitronectin, fibrinogen, and IgG were poorly effective. About 80% of the total FN associated to EC at the equilibrium was specifically bound; of this, 60% was reversibly bound, while 20% appeared to be internalized. The FN binding was saturable and an apparent dissociation constant of about 0.23 x 10(-6) mol/L and a maximal number of binding sites of about 9.8 x 10(5) was estimated from binding isotherms. Autoradiography data showed that EC-associated 125I- FN was all in high mol wt form that did not enter the gel. We then characterize the FN receptor (FNR) in EC. An antiserum to the FNR isolated from human placenta inhibited FN binding to EC by 89%, and using the immunoblotting technique, it recognized two bands in the EC detergent extract of mol wt 125/160 Kd. This antiserum also recognized the EC membrane protein complex eluted from the FN affinity column by an arg-gly-asp (RGD) peptide. When this complex was included into liposomes, it poorly bound to FN. However, the binding was strikingly increased by addition of Mn in the buffer and was specific for FN in respect to other substrata. These data define the FN binding site in EC and indicate that it is functionally and structurally related to that isolated from human placenta.     

Subacute Pain as a Predictor of Long-Term Pain Following Orthopedic Surgery: An Australian Prospective 12 Month Observational Cohort Study

The aim of this study was to document the level of pain and functionality in the 12 months following orthopedic surgery and identify if high pain levels following discharge were associated with pain persisting at 12 months.An observational prospective cohort study was undertaken, following 87 patients (mean age 62.4 years [18–92]; 47.1% male) who required orthopedic surgery at the Royal Hobart Hospital, Australia. Following an initial survey, patients were telephoned at 10 days, 6 weeks, 3 months, and 12 months after discharge.Postdischarge pain levels were high with 97.4% of patients suffering pain at 10 days, 81.2% at 6 weeks and 79.5% at 3 months. Pain affected the ability to undertake activities of daily living (ADLs) for 32.7% and 20.0% of patients at 10 days and 6 weeks, respectively. Twelve months after discharge, 65.5% of patients reported pain persisting at the surgical site, with 29.9% of all patients suffering moderate–severe incidental pain; and nearly one quarter of patients reported pain affected their sleep or ADLs. Average pain levels rated as moderate–severe at 10 days (P = 0.01) and 6 weeks (P = 0.02) and pain of neuropathic origin at 3 months (30.2% vs 10.3% P = 0.03) and 12 months (30.4% vs 4.9% P = 0.01) were associated with persistent pain at 12 months.Pain in the period following discharge from hospital is significant and undermanaged. Previous studies has shown that that acute pain, particularly in the first 48 hours following surgery is a predictor for long-term pain after surgery. This study adds to the current literature by showing that pain in the subacute period, following discharge from hospital is also associated with the pain persisting at 12 months. These findings have important implications for improving quality of life as well as potentially preventing persistent pain with increased follow-up and more intensive management of post-discharge pain.