‘Nephrostomy-Free’ Percutaneous Nephrolithotomy: Experience in a UK District General Hospital

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) is the first-line treatment for large and complex renal calculi. Accepted UK practice is to insert a nephrostomy tube at the end of the procedure to drain the kidney and reduce potential complications. ‘Tubeless’ or ‘nephrostomy-free’ PCNL has been advocated in selected patients as it is thought to reduce length of hospital stay, analgesia requirements and pain experienced. We present our outcomes of a consecutive series (n = 101) of ‘nephrostomy-free’ PCNLs compared to standard PCNL over a 4-year period.

PATIENTS AND METHODS

Between January 2004 and October 2006, we performed 55 standard (with nephrostomy tube) PCNLs (Group 1). From October 2006 onwards, we changed our technique and have performed 46 consecutive ‘nephrostomy-free’ PCNLs (JJ stent inserted), independent of patient and stone factors (Group 2). We have compared the two groups in terms of length of hospital stay (LOS), analgesia requirements, transfusion rates, haemoglobin (Hb) decrease and immediate, early and late complications.

RESULTS

‘Nephrostomy-free’ PCNL significantly reduced the length of hospital stay (2.8 vs 5.1 days; P < 0.001), morphine-based analgesia requirements (23% no morphine required vs 2.8%; P < 0.001), transfusion rate (2.5% vs 7%; P < 0.01) and mean Hb decrease (1.89 g/dl vs 2.25 g/dl; P > 0.05). Overall, no patient experienced a serious complication. All attempted ‘nephrostomy-free’ PCNLs were completed (stone clearance 95%) and no patient needed an unplanned nephrostomy. Only 5% in Group 2 needed their ureteric JJ stent removing earlier than planned secondary to pain. Both groups were comparable in terms of immediate, early and late complications, though three patients in Group 1 developed chronic loin pain and one patient in the ‘nephrostomy-free’ group developed a delayed perirenal haematoma.

CONCLUSIONS

‘Nephrostomy-free’ percutaneous nephrolithotomy is a safe, effective and feasible procedure independent of patient and stone factors. It decreases the length of hospital stay, the pain experienced and the need for morphine-based analgesia; we feel it should be the standard of care for patients undergoing a PCNL.     

Tibiofemoral contact areas and pressures in six high flexion knees

The tibiofemoral articulating interfaces of six high flexion knee designs were examined using a standard testing protocol developed by Harris et al. [J Biomech 32:951-958 (1999)] to investigate the polyethylene insert contact areas and pressures. A load of 3600 N was applied for 10 s at 0, 30, 60, 90, 110, 135 and 155 degrees of flexion. Contact areas and pressures at the femoral-polyethylene insert interface were measured with a I-scan 4000 system. Up to 110 degrees of flexion, the VANGUARD RP HI-FLEX showed the highest contact area and lowest pressure. At the deep flexion angles, contact area decreased and contact pressure increased significantly in all knees. The NexGen series showed a constant contact area throughout the various flexion angles. In general, all high flexion knees could result in almost point contact in an extremely high range of motion.     

Cemented versus non-cemented hemiarthroplasty of the hip as a treatment for a displaced femoral neck fracture: design of a randomised controlled trial

Background  

A discussion is ongoing whether displaced femoral neck fractures in elderly patients should be treated with a non-cemented or a cemented hemiarthroplasty. A recent Cochrane analysis stresses the importance of further research into the relative merits of these techniques. We hypothesise that non-cemented hemiarthroplasty will result in at least the same technical-functional outcome and complication rate, with a shorter operation time.     

Postoperative acetabular retroversion causes posterior osteoarthritis of the hip

We retrospectively reviewed 68 hips in 62 patients with acetabular dysplasia who underwent curved periacetabular osteotomy. Among the 68 hips, 33 had acetabular retroversion (retroversion group) and 35 had anteversion (control group) preoperatively. All hips were evaluated according to the Harris hip score. Radiographic evaluations of acetabular retroversion and posterior wall deficiency were based on the cross-over sign and posterior wall sign, respectively. The clinical scores of the two groups at the final follow-up were similar. In the retroversion group, 12 hips had anteverted acetabulum postoperatively. The posterior wall sign disappeared in these hips, but remained in 21 hips with retroverted acetabulum postoperatively. Among the 21 hips with retroverted acetabulum, posterior osteoarthritis of the hip developed postoperatively in five hips. When performing corrective osteotomy for a dysplastic hip with acetabular retroversion, it is important to correct the acetabular retroversion to prevent posterior osteoarthritis of the hip due to posterior wall deficiency.     

Neuropsychological test profile differences between young and old human immunodeficiency virus-positive individuals

Human immunodeficiency virus (HIV) dementia remains as an important cause of neurological morbidity among HIV-seropositive (HIV+) individuals. Differences in the neuropsychological profiles between older and younger HIV+ individuals have not been examined extensively. The objective of this study was to examine the neuropsychological test performance between old and young HIV+ individuals (a) with and without cognitive impairment (total cohort) and (b) with dementia. One hundred thirty-three older (age >or= 50 years) HIV+ individuals and 121 younger (age 20 to 39 years) HIV+ individuals were evaluated with a standardized neuropsychological test battery. Differences between age groups in the mean z score for each neuropsychological test were determined. The older HIV+ (total) cohort had greater impairment in tests of verbal memory (P = .006), visual memory (P < .002), verbal fluency (P = .001), and psychomotor speed (P < .001) compared to the young HIV+ (total) cohort. After adjusting for differences in education, older HIV+ patients with dementia (n = 31) had a greater deficit in the Trail Making test Part B (P = 0.02) compared to younger HIV+ patients with dementia (n = 15). Age was associated with lower performance in tests of memory, executive functioning, and motor performance in older HIV+ individuals with and without cognitive impairment (total cohort), compared to younger HIV+ individuals. Among HIV+ patients with dementia, age may be associated with greater impairment in a test of executive functioning. These differences could be a result of advanced age itself or age-associated comorbidities such as coexisting cerebrovascular or neurodegenerative disease.     

Long-term upregulation of protein kinase A and adenylate cyclase levels in human smokers

Repeated injections of cocaine and morphine in laboratory rats cause a variety of molecular neuroadaptations in the cAMP signaling pathway in nucleus accumbens and ventral tegmental area. Here we report similar neuroadaptations in postmortem tissue from the brains of human smokers and former smokers. Activity levels of two major components of cAMP signaling, cAMP-dependent protein kinase A (PKA) and adenylate cyclase, were abnormally elevated in nucleus accumbens of smokers and in ventral midbrain dopaminergic region of both smokers and former smokers. Protein levels of the catalytic subunit of PKA were correspondingly higher in the ventral midbrain dopaminergic region of both smokers and former smokers. Protein levels of other candidate neuroadaptations, including glutamate receptor subunits, tyrosine hydroxylase, and other protein kinases, were within normal range. These findings extend our understanding of addiction-related neuroadaptations of cAMP signaling to tobacco smoking in human subjects and suggest that smoking-induced brain neuroadaptations can persist for significant periods in former smokers.     

Epigenetic changes in the DAP-kinase CpG island in pediatric lymphoma

BACKGROUND: Hypermethylation of CpG islands in the promoter region of death-associated protein kinase (DAP-kinase) coupled with the loss of gamma-interferon-induced apoptosis have been reported in B-cell malignancies suggesting a role in pathogenesis or prognosis. Along with B-cell malignancies, pediatric lymphomas also include T-cell non-Hodgkin lymphoma (NHL), anaplastic large cell lymphoma, and Hodgkin disease, each with unique prognoses. The purpose of this study was to elucidate epigenetic changes in the DAP-kinase promoter region of pediatric cases to determine associations with aberrant hypermethylation. PROCEDURES: Thirty-nine cases of different lymphoid pathology [10 Burkitt lymphoma, 1 B-cell NHL; 7 T-cell lymphoblastic lymphoma; 4 anaplastic large cell lymphoma (LCL); 2 B-cell LCL; 14 nodular sclerosing Hodgkin disease (NSHD); and 1 B-cell acute lymphoblastic leukemia (ALL)] had methylation-specific polymerase chain reaction performed on bisulfite-treated DNA, which distinguishes the methylation status of the promoter region, and DAP-kinase mRNA expression assays performed on available specimens. RESULTS: In normal lymphocytes, the CpG islands in the promoter region were unmethylated, as were the T-cell lymphoblastic lymphoma and anaplastic LCL. In contrast, 100% of the Burkitt lymphoma (10/10) and B-cell ALL (1/1) were hypermethylated. Of the specimens with mRNA available, 7/8 Burkitt lymphoma had no DAP-kinase mRNA expression compared to normal expression in 3/3 and 4/4 T-cell lymphoblastic lymphoma and NSHD, respectively. CONCLUSIONS: In these pediatric lymphoid tumors, hypermethylation of the DAP-kinase promoter region with associated loss of DAP-kinase gene expression was associated with B-cell malignancies and thus may be important in the development and/or provide a prognostic tool in B- cell lymphomas.     

Effect of dietary curcumin and dibenzoylmethane on formation of 7,12- dimethylbenz[a]anthracene-induced mammary tumors and lymphomas/leukemias in Sencar mice

Female Sencar mice (6 weeks old) were administered 1 mg of 7,12- dimethylbenz[a]anthracene (DMBA) by oral gavage once a week for 5 weeks. At 20 weeks after the first dose of DMBA, 68% of mice developed mammary tumors (the average 1.08 tumors per mouse) and 45% had lymphomas/leukemias. Feeding 1% dibenzoylmethane (DBM) in AIN 76A diet, starting at 2 weeks before the first dose of DMBA and continuing until the end of the experiment, inhibited both the multiplicity and incidence of DMBA-induced mammary tumor by 97%. The incidence of lymphomas/leukemias was completely inhibited by 1% DBM diet. In contrast, feeding 2% curcumin diet had little or no effect on the incidence of mammary tumors, and the incidence of lymphomas/leukemias was reduced by 53%.      

Altered metabolism of familial Alzheimer's disease-linked amyloid precursor protein variants in yeast artificial chromosome transgenic mice

Missense mutations in the beta-amyloid precursor protein gene (APP) co- segregate with a small subset of autosomal dominant familial Alzheimer's disease (FAD) cases wherein deposition of the 39-43 amino acid beta-amyloid (A beta) peptide and neurodegeneration are principal neuropathological hallmarks. To accurately examine the effect of missense mutations on APP metabolism and A beta production in vivo, we have introduced yeast artificial chromosomes (YACs) containing the entire approximately 400 kbp human APP gene encoding APP harboring either the asparagine for lysine and leucine for methionine FAD substitution at codons 670 and 671 (APP(K670N/M671L)), the isoleucine for valine FAD substitution at codon 717 (APP(V7171)) or a combination of both substitutions into transgenic mice. We demonstrate that, relative to YAC transgenic mice expressing wild-type APP, high levels of A beta peptides are detected in the brains of YAC transgenic mice expressing human APP(K670N/M671L) that is associated with a concomitant diminution in the levels of apha-secretase-generated soluble APP derivatives. Moreover, the levels of longer A beta peptides (species terminating at amino acids 42/43) are elevated in YAC transgenic mice expressing human APP(V7171). These mice should prove valuable for detailed analysis of the in vivo effects of the APP FAD mutations in a variety of tissues and throughout aging and for testing therapeutic agents that specifically alter APP metabolism and A beta production.