A simple position to provide better imaging of upper ureteral stones close to the crista iliaca during extracorporeal shock wave lithotripsy using the Siemens Lithostar

OBJECTIVE: The fluoroscopic image from the second plan (oblique) tube of an upper ureteral stone close to the crista iliaca may be superimposed on the pelvic bones during SWL using the Siemens Lithostar with the patient in the prone position. This creates difficulty in imaging and targeting of the stone and can necessitate using ureteral catheters before treatment and/or intravenous contrast injection during SWL. We describe a very simple, yet effective method for easier visualization of the stone under this circumstance. METHODS: Between March 1992 and February 2003, we treated 1561 patients with ureteral stones by SWL with the Siemens Lithostar. The stones were localized in the upper ureter in 841. The image of the stone from the second plan (oblique) tube was superimposed on the pelvic bones in 221 in whom visualization of the stone was hardly possible with the standard prone position. By simply rotating the patient 180 degrees on the table, the superimposition of the image of the stone on the pelvic bone was obviated. This resulted in easier and better imaging of the stone during SWL. It also allowed for a clear and superior image to the treating physician during SWL. The energy and shock waves, utilization of anesthesia, number of treatment sessions, auxiliary measures, and complications were noted. Stone load was recorded in square centimeters (cm(2)). Patients were evaluated by intravenous urogram or KUB and ultrasonography when stone-free or CIRF (nonobstructive and noninfectious insignificant fragments < or =4mm) status was noted at the fluoroscopic control 2 to 4 weeks after the last session. Final CIRF decision was made 10-12 weeks after the last session. SWL was regarded as failure if no fragmentation was noted after the 3rd session. Therapy was continued if fragmentation was noted. RESULTS: The median age was 40 (range 5-85). The mean stone burden was 0.8 (range 0.24-2.9) cm(2). No indwelling ureteral stents were placed in any patients before and during treatment. The mean number of shock waves and energy used for the entire patient population was 2007 and 17.5kV, respectively. The median and average treatment session was 1 and 1.7, respectively. A total of 196 patients (89%) were rendered stone-free. Clinically insignificant residual fragments were present in 18 (8%). SWL was unsuccessful in 7 (3%) patients. These stones were removed by ureterorenoscopy. Intravenous contrast administration was not used to facilitate stone targeting during SWL. Anesthesia, in the form of analgesic sedation, was used in 7 (3%) patients. We did not observe any complications and adverse effects. CONCLUSIONS: The technique described hereby does not have an affect on coupling; it only provides a superior image of the stone to the treating physician. We advocate its application in all patients with upper ureteral stones close to the crista iliaca when the fluoroscopic image of the stone from the second plan (oblique) tube is superimposed on pelvic bones during SWL in prone position.     

Colonic interposition vs. gastric pull-up after total esophagectomy

Gastric pull-up is the most frequent reconstruction after esophagectomy. In this report we aimed to compare gastric pull-up with colonic interposition in terms of graft function and patient satisfaction. Of 62 patients undergoing esophagectomy, reconstruction was performed by colonic interposition in 11 and gastric pull-up in 51 (without pyloric drainage in 44 and with pyloric drainage in 7). All esophagectomies were performed transhiatally. Patient follow-up ranged from 6 to 132 months (median 14 months). Follow-up examinations were performed 1, 9, 15, and 24 months postoperatively. The following factors were evaluated: time to the start of oral liquid and solid nutrients without vomiting, frequency of regurgitation, presence of pillow staining (night regurgitation), postprandial fullness, and degree of satisfaction during and after eating compared between groups undergoing colonic interposition and gastric pull-up with or without pyloric drainage. Among patients undergoing gastric pull-up, regurgitation was observed in 22% to 27% during follow-up. None of the patients with colonic interposition had reflux or regurgitation. Twenty-five percent of patients with gastric pull-up without drainage and 66% of patients with gastric pull-up plus drainage had reflux esophagitis at 15 months. No esophagitis was observed in patients with colonic interposition during the same period. Overall satisfaction was superior in patients undergoing colonic interposition followed by gastric pull-up with no drainage. Colonic interposition after esophageal resection is a viable option. Our study suggests that function of the replacement is better in this group of patients.     

Diffuse idiopathic skeletal hyperostosis of the cervical spine: an underestimated cause of dysphagia and airway obstruction

Background context

Diffuse idiopathic skeletal hyperostosis (DISH) is a common but underdiagnosed condition relating to ossification of spinal ligaments that can cause compression of the esophagus and trachea. According to case reports, dysphagia or airway obstruction resulting from DISH is a rare occurrence.

Purpose

This study was intended to identify all published cases of dysphagia and/or airway obstruction resulting from DISH to increase the epidemiologic/clinical knowledge of these related conditions.

Study design

A systematic review of the literature was performed.

Methods

The articles resulting from the systematic PubMed/EMBASE search of the literature were closely read, and predefined parameters were scored.

Results

The search yielded a total of 118 articles (95 case reports and 23 case series) describing 204 patients with dysphagia and/or airway obstruction resulting from DISH. The number of cases demonstrated a steady increase from 1980 to 2009. This might be a real effect not ascribable to publication bias or expansion of the medical literature alone.

Conclusions

Diffuse idiopathic skeletal hyperostosis as a cause of dysphagia and/or airway obstruction may be an increasing and underappreciated phenomenon. Diffuse idiopathic skeletal hyperostosis should be included in the differential diagnosis of dysphagia and airway obstruction.     

Esophageal Calibration with Soft Orogasrtric Tube During Laparoscopic Nissen Fundoplication may Reduce Postoperative Transient Dysphagia

Gastroesophageal reflux is the most common benign disorder of the esophagus and laparoscopic Nissen fundoplication has become the standard surgical treatment for its treatment. In our area, where the use of bougie calibration is debatable, postoperative dysphagia is encountered often after this surgery although it is usually not permanent. The aim of this study was to investigate the effect of using a soft silicone tube 39 F in diameter for esophageal calibration during laparoscopic Nissen fundoplication on the incidence of postoperative dysphagia. We divided cases scheduled to undergo laparoscopic Nissen fundoplication between January 2009 and November 2010 into two groups, each consisting 25 patients. Esophageal calibration with a 39 F silicone orogastric tube was used for the first group while there was no operative calibration in the second group. The surgical duration was recorded; the presence and severity of the postoperative dysphagia was calculated by using a dysphagia severity scoring system during the 1-year postoperative follow-up. The dysphagia severity scores were significantly lower in group 1 than group 2 on the postoperative second day and at the end of the first week and first month. We did not find a significant difference at the end of the 6-month and first year. There was also no significant difference regarding surgery duration. The use of a soft orogastric tube 39 F in diameter for esophagus calibration during laparoscopic Nissen fundoplication has significantly decreased the incidence of postoperative transient dysphagia without affecting the duration of surgery. Although dysphagia gradually resolves in the majority of patients, a safe and easy calibration method for its prevention is worth developing, and we believe that the use of our method in larger series could be beneficial.     

Serum S100B Protein Levels in Patients with Panic Disorder: Effect of Treatment with Selective Serotonine Reuptake Inhibitors

ObjectiveAltered serum S100B protein levels have been shown in several psychiatric disorders. Our aim was to investigate whether plasma S100B is different in patients with panic disorder (PD) when compared with controls. Our second aim was to investigate whether treatment with SSRIs have an effect on S100B levels in patients with PD.MethodsThe sample included 32 patients diagnosed with PD (21 women, 11 men) per DSM-IV criteria and 21 healthy controls (11 women, 10 men). S100B levels were measured with BioVendor Human S100B ELISA (Enzyme Linked Immunosorbent Assay) kit.Results14 patients were not on drug treatment (43.8%) while 18 patients were taking various SSRIs. Median S100B value was 151.7 pg/mL (minimum-maximum: 120.4-164.7 pg/mL) in the control group, 147.4 pg/mL (minimum-maximum: 138.8-154.1 pg/mL) in the drug free group and 153.0 pg/mL (minimum-maximum: 137.9-164.7 pg/mL) in the treatment group. Kruskal-Wallis analysis showed a significant diffrerence among the three groups (z=9.9, df=2, p=0.007). Follow up Mann-Whitney-U tests indicated that while the control and the patients with treatment were not significantly different (z=-0.05, p=0.96), there were significant differences between the control group and untreated patients (z=-2.6, p=0.009) and treated and untreated patients (z=-3.0, p=0.003).ConclusionOur results suggested that, serum S100B protein level might be decreased in untreated PD patients and that patients who were treated with SSRIs had similar S100B level to healthy controls.     

Chronic bilateral hearing loss in an immunocompetent patient: An atypical course of tuberculous meningitis

Congenital, infectious, toxic, and demyelinating disorders are common etiological causes of deafness. Tuberculous meningitis, as one of the infectious causes, should be considered in the differential diagnosis since tuberculosis represents an endemic public health problem in developing countries. Multiple cranial nerve palsies can be expected due to basal meningitis; however, presentation with bilateral hearing loss is quite rare. Early diagnosis and treatment are crucial to prevent mortality and residual neurologic deficits. The focus of this discussion is a 42-year-old female presenting with bilateral hearing loss and nonspecific complaints who was finally diagnosed with chronic tuberculous meningitis. We also demonstrate the characteristic radiological and histopathological findings.Congenital, infectious, toxic, vascular, tumoral, and demyelinating disorders are common etiologic factors that can result in deafness. Acoustic trauma, endolymphatic hydrops, and senility are relatively rare causes that should also be taken into account. Bilateral hearing loss is an unusual clinical presentation, resulting from any one of these conditions. Among the infectious causes, tuberculosis still represents an endemic public health problem in developing countries and tuberculous meningitis, which is the most common form of CNS involvement, accounts for 1-2% of these cases.1 Sufferers generally describe constitutional symptoms including fever and night sweats or various complaints arising from basal meningitis like headache, nausea, and/or vomiting; however, presentation with bilateral hearing loss is quite rare. The objective of this case presentation is to include tuberculous meningitis in the differential diagnosis of progressive bilateral hearing loss, and emphasize the importance of early diagnosis and treatment to prevent morbidity and mortality.     

Cranial computed tomography in purulent meningitis of childhood

The cranial computed tomography (CT) findings of 48 children with purulent meningitis were examined, prospectively, to determine the importance of cranial CT findings on the prognosis of childhood meningitis, in a developing country. The age of children ranged from 2 months to 13 years. Of 48 patients, 29 (60.5%) survived without sequelae, 13 (27%) survived with sequelae, and six (12.5%) died. Cranial CT was normal in 21 (43%) patients of 48 children with meningitis at admission. Abnormal CT findings were detected in 10, 11, and 6 children in the groups of survived without sequelae, survived with sequelae, and deaths, respectively, at admission (p <.05) We found that CT scan results were correlated with neurological signs (p <.05). At least one or more cranial CTs were was re-taken in children in whom the first CT revealed abnormal findings; we did not find a statistically significant difference for the follow-up CT findings between the groups (p >.05). Hydrocephalus and subdural effusion were the commonest abnormal CT findings. In conclusion, our findings showed that cranial CT may safely be used to detect intracranial complications of meningitis in childhood and the ratio of sequelae and death were more common in children with abnormal cranial CT than those of normal cranial CT findings. Additionally, there was a positive correlation between CT scan results and neurological signs.     

Psychotic disorder in a case with Hallervorden-Spatz disease

OBJECTIVE: Hallervorden-Spatz disease is a rare autosomal recessive condition, with early onset of predominantly extrapyramidal dysfunction. The symptoms of the disease are dystonia, rigidity, choreoathetosis, pyramidal signs, and intellectual decline. Recent genetic studies mapped the disease to chromosome 20p12.3-p13, and identified mutations in the pantothenate kinase gene. This report describes a childhood onset case of Hallervorden-Spatz disease with schizophreniform psychotic symptoms. Former reports about the psychiatric comorbidity generally included depressive disorder. METHOD: A single case report. RESULTS: A 14-year-old boy with Hallervorden-Spatz disease presented a psychotic episode with prominent auditory hallucinations. Symptoms were relieved after neuroleptic treatment. CONCLUSION: To the authors' knowledge, this is the first published report of the disease with psychotic symptoms. The contribution of basal ganglia, with their wide projections, to the emergence of psychotic symptoms was discussed.