Safety of supracostal punctures for percutaneous renal surgery

AIM: Supracostal superior calyceal access has been shown to be the most suitable approach for staghorn calculi, calculi in the upper ureter and complex inferior calyceal calculi, as well as for antegrade endopyelotomy. However, many urologists hesitate in using this approach because of the potential for chest complications. The aim of this study was to analyze one institution's data regarding the safety and efficacy of this approach for percutaneous renal surgery. METHODS: A total of 890 renal units (762 patients) were treated with percutaneous renal surgery (849 percutaneous nephrolithotomy, 41 antegrade endopyelotomy) from July 1998 to July 2004. Supracostal access was obtained in 332 (37.3%) patients. The indications for a supracostal approach were ureteropelvic junction obstruction, staghorn and complex inferior calyceal calculi, and stones in the upper calyx or the upper ureter. All punctures were made by the urologist under C-arm fluoroscopic guidance in the prone position. RESULTS: The interspace between 11th and 12th rib was used in all except four patients in whom the puncture was made above the 11th rib. Eleven patients (3.31%) had a pleural breach presenting with fluid in the chest. Insertion of a chest tube was required in seven patients, while other four were managed conservatively. No patient had injury to the lung or other viscera. Hospital stay was not significantly prolonged as a result of the pleural breach in any patient. Except for staghorn calculi where multiple tracts were a necessity for maximal clearance, a single supracostal superior or middle posterior calyceal access served the purpose in 86% (177/205) of patients who underwent percutaneous surgery for renal or upper ureteric calculi. CONCLUSIONS: The supracostal superior calyceal approach was found to be effective as well as safe, with an acceptably low risk of chest complications.     

CUTANEOUS LEISHMANIASIS: SCHEDULES FOR INTRALESIONAL TREATMENT WITH SODIUM STIBOGLUCONATE

Background. Various therapeutic modalities have been used for treating cutaneous leishmaniasis. Intralesional pentavalent antimonial injection is one of the effective therapeutic modalities. In this study, the efficacy of three different intralesional schedules with sodium stibogluconate have been investigated. Methods. Ninety-six patients with 129 lesions were entered into the study, all with confirmed diagnosis of cutaneous leishmaniasis. The lesions were treated with three different schedules, including daily, alternate day, and weekly interlesional injections of sodium stibogluconate. The clinical response was then compared to arrive at the most effective schedule. Results. The clinical responses (complete and partial cure) were 67%, 97%, and 91% for the daily, alternate-day, and weekly schedules, respectively. Lesions with either partial cure or failure of treatment were injected weekly with the same medication until complete cure had been achieved. The final overall success rate of complete cure was 99.2%. Conclusions. Alternate day or weekly intralesional treatment of cutaneous leishmaniasis with sodium stibogluconate are more effective than daily treatments.     

TWENTY FIVE YEARS OF INTERACTION WITH ESOPHAGEAL ATRESIA AND TRACHEO-ESOPHAGEAL FISTULA

Clinical presentation and management modalities for 585 patients of esophageal atresia and/or tracheo-esophageal fistula reporting to Department of Paediatric Surgery, SMS Medical College, Jaipur over twenty five years (1972–1996) were analyzed in five phases of five years each retrospectively. Over the period of observation, the incidence of new cases as well the number of associated anomalies have shown a steady increase due to availability of modern diagnostic facilities. The operative mortality has shown a progressive decline from 95% early in the series to 40% in last few years. Post-operative anastomotic leaks occurred in 21% of cases, strictures in 8% and recurrent fistula in 1% of cases. The presence of severe associated anomalies, prematurity, pulmonary complications and sepsis still remain the major killers in our setup. Early detection and referral has lead to more infants reaching the specialized centres with less pulmonary complications. In the last decade, the survival rate for infants in Waterston''s risk group A has improved to 86% but there is still a substantial difference in the survival rate reported from developed countries. The various factors resulting in poorer results in our set up have been highlighted.KEY WORDS: Esophageal atresia, Tracheo-esophageal fistula     

VARICOCELE IS ASSOCIATED WITH ELEVATED SPERMATOZOAL REACTIVE OXYGEN SPECIES PRODUCTION AND DIMINISHED SEMINAL PLASMA ANTIOXIDANT CAPACITY

PURPOSE: Because varicocele is seen often in infertile men and oxidative stress has been implicated in sperm dysfunction, we assessed spermatozoal reactive oxygen species and seminal total antioxidant capacity in men with and without varicocele. MATERIALS AND METHODS: Levels of reactive oxygen species and total antioxidant capacity were measured in the semen of 21 infertile men with varicocele, 15 men with incidential varicocele and 17 normal donors without varicocele (controls). Men with leukocytospermia (more than 1 x 10(6) white blood cells per ml.) were excluded from study. Reactive oxygen species were measured in washed spermatozoa with a luminol dependent chemiluminescence assay. Total seminal antioxidant capacity was measured with an enhanced chemiluminescence assay, and the results were expressed as trolox equivalents. Sperm characteristics were assessed with a computer assisted semen analyzer, and sperm morphology was assessed using World Health Organization and Kruger's strict criteria. RESULTS: Patients with varicocele had significantly higher reactive oxygen species levels than controls (p = 0.02). Reactive oxygen species levels did not differ significantly between infertile and men with incidental varicocele. Total antioxidant levels were significantly lower among men with varicocele (p = 0.02) and those with incidental varicocele compared to controls (p = 0.05). Reactive oxygen species and total antioxidant capacity levels did not correlate in any group. CONCLUSIONS: Our results suggest that elevated reactive oxygen species and depressed total antioxidant capacity levels are associated with varicocele. These changes may be related to functional sperm abnormalities and infertility seen commonly in these patients. These findings support a possible rationale for controlled clinical trials of antioxidant supplementation in infertile men with varicocele.     

Clinical Experience with a New Lead Comhining Active Fixation with Steroid Elution

The Medtronic lead engineering model number 10335A represents a new concept in lead design combining active fixation with steroid elution. It aims for immediate stability and low chronic thresholds. Twenty-one leads, 9 atrial and 12 ventricular, were implanted in 13 patients (10 males, mean age 68; range 22–91 years). The atrial leads showed no rise in pulse width threshold at a voltage of 1.6 volts (mean thresholds at implant, 1, and 26 weeks; 0.1 ± 0.09 msec, 0.15 ± 0.04 msec, and 0.1 ± 0.03 msec, respectively). The ventricular leads had a small but significant rise between implant and 1 week at an output of 1.6 volts (0.07 ± 0.03 msec increasing to 0.11 ± 0.04 msec; P < 0.02) but no significant later rise (0.1 ± 0.04 msec at 2 weeks and 0.1 ± 0.05 msec at 6 months). These low chronic thresholds would allow early reprogramming of the unit to low voltages resulting in a battery saving with prolongation of the unit's life. There were no significant changes in the P and R wave amplitudes, but there was a fall in lead impedance in the ventricular leads between implantation and 1 week (P < 0.02) but none subsequently, and there was no significant change in atrial impedance. There were no sensing failures and no lead displacements. Despite impressive pacing characteristics, the study was suspended because of a high level of mechanical complications. Of the 96 patients implanted worldwide with 136 leads there were eight helix deformations, which will require redesign. However, the concept of steroid elution combined with active fixation appears to be an attractive and valid concept and is supported by this data; further studies are planned.     

INTRAPERITONEAL INSTILLATION OF BUPIVACAINE FOR ANALGESIA AFTER LAPAROSCOPIC STERILISATION: A CASE CONTROL STUDY

Efficacy of intraperitoneal instillation of bupivacaine at the time of laparoscopic sterilisation to provide postoperative analgesia was studied. In 40 patients undergoing laparoscopic sterilisation 0.75ml/kg of 0.125% bupivacaine was instilled in the peritoneal cavity (Group-I) and another 40 patients where the topical anaesthetic was not used served as controls (Group-II). Pain scores on Visual Analog Scale (VAS) were studied 1,2,4,6 and 24 hours after surgery in both groups. Mean VAS score was significantly lower in Group-I, 1,2 and 4 hours after surgery (p<0.05). Rescue analgesia was required in 20% patients of Group-I compared to 52.5% in Group-II which is definitely significant (p<0.001). No complications or side effects were noted in the bupivacaine treated group. This simple technique provides excellent analgesia in the immediate postoperative period following laparoscopic sterilisation which will go a long way in enhancing patient satisfaction and motivating other eligible clients to come forward for laparoscopic sterilisation.KEY WORDS: Bupivacaine, Laparoscopic sterilisation, Postoperative analgesia     

Conformation of a biologically active C-terminal hexapeptide analog of the pheromone biosynthesis activating neuropeptide by NMR spectroscopy

The solution conformation of a biologically active C-terminal hexapeptide analog of the pheromone biosynthesis activating neuropeptide Tyr-d -Phe-Ser-Pro-Arg-Leu-NH₂ has been studied by NMR spectroscopy. A β-turn conformation was identified from the NOE connectivities observed for the peptide in a mixed solvent of water and DMSO, indicating that this is the biologically active conformation of the peptide. This study also suggests that the use of such an aqueous-like solvent mixture allows the observation of a preferred conformation for small linear peptides in the presence of conformational averaging.     

Characteristics of Telemetry Interference with Pacemakers Caused by Digital Media Players

Background: Contemporary implantable heart rhythm devices communicate multiple complex data simultaneously using radiofrequency telemetry. Interference in communication can expose them to the risk of potential corruption, leading to adverse clinical consequences. Methods & Results: We studied the characteristics of interference with uplink (real time intracardiac electrograms, marker channel, and stored histograms) and downlink (attempt to program a change in the lower rate limit, the pacing mode, and the ventricular lead configuration) data transmission between the wand and the pacemaker caused by digital media players (iPods—Photo and 3G) in 50 patients. We also measured and characterized worst‐case magnetic field emissions (MFE) from the wand (≤0.4 μT), pacemaker (≤0.004 μT), and iPod (≤0.05 μT) during telemetry to understand the modulation techniques and safety protocols employed during data transmission. Telemetry interference (TI) manifested as high‐frequency spikes (24.4%), blanking (17.7%) and interruption (22.2%), or delay (17.6%) in transmission with warning on programmer's screen. TI occurred in 25.6% of patients when the iPod was “on” and in 13% even with the iPod turned “off.” There were no inaccuracies in downlinked data when the downlink communication was successful. Wanded telemetry utilizes low‐frequency (30–300 kHz) radiowaves and simple digital modulation techniques at relatively slow rates for “sequential” data transmission protected by a continuous “handshake.” Emissions from iPods in that range interrupt the telemetry link but are too weak to cause pacemaker malfunction through corruption of vital data. Conclusion: Low‐power MFE from iPods can produce interference with establishment and maintenance of a telemetry link and can cause TI with transmission of real time data, but because of continuous check protocols, do not corrupt the stored and vital downlink data. (PACE 2010; 33:712–720)