Xanthogranulomatous pyelonephritis mimicking malignant disease: is preservation of the kidney possible?

Xanthogranulomatous pyelonephritis (XGP) is an uncommon form of pyelonephritis rarely seen in children. It is characterized by destruction of the renal parenchyma and invasion of adjacent tissues, mimicking renal tumors. Preoperative diagnosis is very difficult. Two children with XGP are presented. One underwent nephrectomy and the other drainage of a renal abscess with kidney preservation. Although surgery is considered the only effective treatment, a high index of suspicion and renal biopsy may prevent radical nephrectomy.     

Health and Nutritional Status of Vegetarian Candidates for Bariatric Surgery and Practical Recommendations

Introduction

Data on vegetarianism and bariatric surgery (BS) are scarce. We herein describe the health and nutritional status of vegetarian patients who plan to undergo BS and propose combined recommendations for vegetarian patients who undergo BS, based on our clinical experience and current scientific literature in both nutrition fields.

Methods

Cross-sectional analysis of a prospectively maintained database of all primary laparoscopic sleeve gastrectomies (LSG) performed at a bariatric center of excellence between January 2014 and November 2016 was carried out querying patients who declared a vegetarian or vegan lifestyle before surgery. Preoperative data collected included demographics, anthropometrics, dietary patterns, supplementation use, physical activity, smoking habits, co-morbidities, and blood tests. Each vegetarian was matched to five different omnivores based on age, gender, and BMI.

Results

During the study period, 1470 patients underwent primary LSG surgery (63.7% females). Twenty-one declared a vegetarian or vegan lifestyle (1.4%) pre-surgery. Most were classified as lacto-ovo (57.1%) and were driven from ethical reasons (85.7%). No differences were found between vegetarian and omnivore LSG candidates regarding co-morbidities and nutritional deficiencies, except for lower prevalence of impaired fasting glucose (14.3 vs. 47.1%;P = 0.007), lower ferritin levels (54.3 ± 50.5 vs. 96.8 ± 121.8 ng/ml; P = 0.052) and higher transferrin levels (313.9 ± 42.7 vs. 278.4 ± 40.4 mg/dl; P = 0.009) among the vegetarian cohort. Preoperative use of vitamin B12 and iron supplementation was higher among vegetarian LSG candidates than their omnivore counterparts (57.1 vs. 6.7%;P < 0.001 and 23.8 vs. 6.7%; P = 0.015, respectively).

Conclusions

Vegetarians have comparable health status and nutritional deficiencies, lower iron stores, and higher supplementation use before surgery compared to omnivore LSG candidates.

     

Incidence and Risk Factors for Mortality Following Bariatric Surgery: a Nationwide Registry Study

Background

Although bariatric surgery (BS) is considered safe, concern remains regarding severe post-operative adverse events and mortality. Using a national BS registry, the aim of this study was to assess the incidence, etiologies, and risk factors for mortality following BS.

Methods

Prospective data from the National Registry of Bariatric Surgery in Israel (NRBS) including age, gender, BMI, comorbidities, and surgical procedure information were collected for all patients who underwent BS in Israel between June 2013 and June 2016. The primary study outcome was the 3.5-year post-BS mortality rate, obtained by cross-referencing with the Israel population registry.

Results

Of the 28,755 patients analyzed (67.3% females, mean age 42.0?±?12.5 years, and preoperative BMI 42.14?±?5.21 kg/m²), 76% underwent sleeve gastrectomy (SG), 99.1% of the surgeries were performed laparoscopically, and 50.8% of the surgeries were performed in private medical centers. Overall, 95 deaths occurred during the study period (146.9/100,000 person years). The 30-day rate of post-operative mortality was 0.04% (n =?12). Male gender (HR?=?1.94, 95%CI 1.16–3.25), age (HR?=?1.06, 95%CI 1.04–1.09), BMI (HR?=?1.08, 95%CI 1.05–1.11), and depression (HR?=?2.38, 95%CI 1.25–4.52) were independently associated with an increased risk of all-cause 3.5-year mortality, while married status (HR?=?0.43, 95%CI 0.26–0.71) was associated with a decreased risk.

Conclusion

Mortality after BS is low. Nevertheless, a variety of risk factors including male gender, advanced age, unmarried status, higher BMI, and preoperative depressive disorder were associated with higher mortality rates. Special attention should be given to these “at-risk” BS patients.

     

Experience with focused abdominal sonography for trauma (FAST) in 313 pediatric patients

PURPOSE: The use of focused abdominal sonography for trauma (FAST), which detects free fluid in the abdomen and pelvis, for the assessment of blunt abdominal trauma is gaining acceptance worldwide and has been described extensively in the general medical literature. The precise application of this technique in pediatric patients, however, has yet to be established. The aim of this study was to assess the utility of FAST in pediatric trauma patients by comparing the results of this technique with those of CT and explorative laparotomy (ELAP). METHODS: We retrospectively reviewed the medical records and sonographic examinations of pediatric patients who had sustained multiple traumatic injuries for which they were treated at our hospital during a 20-month period. For all patients, FAST had been the initial screening examination for blunt abdominal trauma. We compared the FAST findings, which had been recorded as positive or negative, with the findings on CT or ELAP, which were considered definitive. RESULTS: A total of 313 patients (204 boys and 109 girls) with a mean age of 7.1 years were included in the study. The FAST finding had been negative in 274 patients, of whom 201 had had no clinical signs of abdominal injury and had been managed conservatively without complications. CT had been performed in 109 patients and ELAP in 11. FAST had yielded 3 false-negative and 2 false-positive results. The sensitivity, specificity, and accuracy of FAST were 92.5%, 97.2%, and 95.5%, respectively. CONCLUSIONS: FAST is an effective tool in screening pediatric trauma patients for blunt abdominal trauma.     

Laparoscopic Sleeve Gastrectomy for Morbid Obesity in 3003 Patients: Results at a High-Volume Bariatric Center

Background

Laparoscopic sleeve gastrectomy (LSG) is gaining wide acceptance as a single surgical treatment for obesity. The reported morbidity and mortality rates are low. We herein report the results of LSG performed in a high-volume center by an experienced team.

Methods

Retrospective analysis of a prospectively maintained database of all bariatric surgery (BS) was performed between May 2006 and December 2014. Data inspected included operative time, length of hospital stay (LOS), comorbidity resolution, re-operation, percent excess weight loss (%EWL), and 30-day morbidity and mortality.

Results

In the study period, 3003 patients underwent BS (1901 (63 %) female). Mean age and body mass index (BMI) were 43 years (range 14–73) and 42.8 kg/m² (range 35–73), respectively. %EWL at 1 year was 72 % (n?=?937; 57 % follow-up rate). There was 1 perioperative mortality due to bleeding (0.03 %). Comorbidity improvement and resolution were 98 % for obstructive sleep apnea, 79 % for diabetes mellitus, 87 % for dyslipidemia, and 85 % for hypertension. Mean operative time and LOS were 50 min (range 32–94) and 2.2 days (range 1–38), respectively. Of the patients, 132 had complications (4.4 %), 25 leaks (0.83 %), 63 bleeding (2.1 %), 1 intra-abdominal abscesses (0.03 %), 3 sleeve strictures (0.1 %), 2 mesenteric vein thromboses (0.06 %), 10 trocar site hernias (0.3 %), and 78 symptomatic cholelithiasis (2.6 %). Re-operation was needed in 13 patients (0.43 %).

Conclusion

In a high-volume center with an experienced team, LSG can be performed with low morbidity and mortality.

     

Screening for depressive symptoms

Question Several of my female patients of reproductive age seem to be depressed. Is there a simple tool I can use to screen them?Answer Motherisk is using the Edinburgh Postnatal Depression Scale to screen for depression. This simple questionnaire is filled out by women while in the waiting room. Using this tool has helped us identify large numbers of women who are at risk of, but have not been diagnosed with, depression. We believe family physicians should use this screening tool extensively with women of reproductive age.     

Effect of seminal plasma application to the vaginal vault in in vitro fertilization or intracytoplasmic sperm injection treatment cycles—a double-blind, placebo-controlled, randomized study

Purpose

To study whether intravaginal application of seminal plasma after follicle aspiration has the potential to increase implantation and clinical pregnancy rates after IVF-ET.

Methods

We conducted a prospective, double-blind, placebo-controlled randomized study of 230 patients undergoing IVF-ET cycles. 500 μL of Fresh seminal plasma from the patient’s partner or culture medium (placebo) were injected in the vaginal vault just after follicle aspiration. The main outcome measured was ongoing clinical-pregnancy rate.

Results

After ET cancellation in ten patients due to lack of fertilization or embryo cleavage, 220 embryo transfers (103 and 117 in the study and control groups) resulted in a clinical pregnancy rate of 36.9 % and 29.1 % for the study and control groups, corresponding to a relative increase of 26.8 %. After an early pregnancy loss of 13.1 % (5/38) and 23.5 % (8/34) in the study and control groups respectively an ongoing pregnancy rate of 32.0 % (33/103) and 22.2 % (26/117) was achieved corresponding to a relative increase of 44.1 %. Multivariate logistic regression analysis adjusted for study group, age, infertility, and cycle characteristics did not demonstrate any parameter that could predict occurrence of clinical pregnancy rates after IVF-ET.

Conclusions

Patients who underwent SP intravaginal insemination after oocyte pick-up reached higher implantation and clinical pregnancy rates following ET compared to controls, although the difference did not reach statistical significance. More studies and variable methodologies may clarify the potential clinical effect of SP in improving live birth rates after ART.