Analysis of 88 nephrectomies in a rural tertiary care center of India

Nephrectomy is not an uncommon surgery in day-to-day practice of urology. Trauma is the most common cause of emergency nephrectomy. On the other hand, elective nephrectomy is done for both benign and malignant diseases of the kidney. This study has been performed to know the different causes of nephrectomy in a rural, tertiary care center of India. In our series, we have studied all the elective nephrectomies done in our hospital during a period of eight years. We have analyzed 88 cases of nephrectomies regarding their age, sex, laterality of disease, and histopathologic report of the nephrectomy specimens. Out of 88 cases, 61 were males and 27 were females. In our series, 62.5% cases of nephrectomies were done for benign causes and 37.5% cases for malignant causes. Among the benign causes, neglected pelviureteric junction obstruction was the leading cause, followed by calculus disease resulting in obstruction. On the other hand, renal cell carcinoma was the most common malignant pathology requiring nephrectomy.     

Bioavailability, pharmacokinetics, and clinical effects of an oral preparation of etoposide

Bioavailability of an oral preparation of the antineoplastic drug etoposide (VP-16) was studied in 13 patients with advanced malignancies. An initial pilot study involving three patients suggested that approximately 50% of an orally administered dose was absorbed. Ten additional patients were randomized to receive either 100 mg/m2/day iv or 200 mg/m2/day orally. Three weeks later, the alternate dose schedule was administered. Plasma samples were assayed for VP-16 using a high-pressure liquid chromatography technique. Comparison of the area under concentration-time curves (C X t) revealed that 17%-72% (mean, 52%) of an orally administered dose was absorbed. Absorption was less than 40% for only one patient. For oral and iv preparations, mean peak plasma VP-16 concentrations were 9.6 and 13.0 micrograms/ml, mean alpha-half-lives were 0.96 and 0.82 hour, mean beta-half-lives were 7.2 and 6.8 hours, mean C X t values were 75.9 and 75.3 mg/L/hour, mean plasma clearances were 1.44 and 1.45 L/hour/m2, and mean extrapolated volumes of distribution were 15.2 and 16.9 L/m2, respectively. The half-life for oral absorption was 0.44 hour and peak plasma concentrations were noted 0.5-3 hours after oral drug administration. Granulocyte count nadirs tended to be lower in patients with high C X t values and low plasma clearance values. Granulocytopenia was dose-limiting. Gastrointestinal toxicity was extremely mild. We recommend doses of oral VP-16 of 800 mg/m2/course over 3-5 days for patients with a moderate amount of prior treatment. It is probable that previously untreated patients will tolerate a higher dose and that heavily pretreated patients will require a lower dose.     

Spontaneous massive gastrointestinal hemorrhage in patients with pancreatitis

Spontaneous massive gastrointestinal hemorrhage occurring in patients with pancreatitis is an uncommon and difficult clinical problem, especially in a tropical third world country where the underlying causes of pancreatitis and facilities for its diagnosis and management are different from those in the developed West. Of 7 such cases seen by us in 3 years, 2 were due to hemosuccus pancreaticus, 2 were due to gastric variceal hemorrhage consequent to splenic vein obstruction, and one each due to contiguous pancreatic inflammation involving the duodenum, an aneurysmal bleed from the left gastric artery and a pseudocyst rupturing into the transverse colon. A fiberoptic endoscopic examination was helpful in all the 7 cases and delineated the cause of bleeding, whereas angiography, performed in 4 patients contributed little to management. The mortality rate was 14%. It is suggested that a timely endoscopic examination during active bleeding, which may be repeated if necessary, is extremely rewarding in the diagnosis and management of such patients and often obviates the necessity of angiography which is a time-consuming and cumbersome investigation in a critically ill patient and facilities for which are usually not available in most third world country hospitals.     

Encephalopathy in patients with extrahepatic obstruction after lienorenal shunts.

Thirty patients with portal hypertension resulting from extrahepatic portal vein obstruction were studied. Evidence of postshunt encephalopathy was sought using neurological and psychometric tests and visual evoked potentials. Eleven patients were studied before and after lienorenal shunt operations and 19 at varying intervals, from 6 to 123 (median 26) months, after the same procedure. All the shunts were patent and none of the patients developed clinical or subclinical encephalopathy. In patients with extrahepatic portal vein obstruction, a lienorenal shunt does not appear to be associated with postshunt encephalopathy.     

Management protocol for acute gastrointestinal bleeding

Gastro-intestinal haemorrhage is not uncommon and is manifested as haematemesis, melaena or haematochezia. The first step is to resuscitate the patient if necessary and then proceed to make a diagnosis as well as divide patients into high and low-risk groups after taking a good history and performing a physical examination especially to detect the presence of an enlarged spleen. Then one should proceed with an endoscopy and other investigations chosen carefully for their usefulness. Control of bleeding is then tailored to the diagnosis and is usually with drugs, endoscopy, angio-embolisation and surgery in that order. The mortality rate for upper GI bleeding varies from 10 to 30% depending on the proportion of patients with variceal haemorrhage included. For lower GI bleeding mortality is in the region of 20% and for obscure GI bleeding outpatient mortality is 12%. The main points to remember are that the management of these patients in India should be different from those described in Western textbooks and suited to their specific needs and the facilities available locally. However, in spite of the widespread lack of complex diagnostic techniques and a shortage of blood for transfusion we believe that by adopting an aggressive step-by-step approach tailored to our own environment we will be able to save most of our patients who are usually young and have few comorbid conditions.     

Mastication and acid secretion

The gastric acid response and the buffer capacity of the stomach were measured in 30 control subjects and 22 duodenal ulcer patients in response to a masticatory (solid) and a non-masticatory (homogenized) meal having the same chemical composition. The peak acid output values were equal after a masticatory and after a non-masticatory diet in control subjects (masticatory 18.1 +/- 1.2, non-masticatory 15.7 +/- 1.3 mmol/hr) as well as in duodenal ulcer patients (masticatory 35.7 +/- 1.5, non-masticatory 33.7 +/- 1.1 mmol/hr). The buffer capacity of the stomach contents 1 hr after the meal was significantly greater after a masticatory diet than a non-masticatory diet in both controls (14.6 +/- 1.4 and 9.0 +/- 1.9 mmol) and in duodenal ulcer patients (9.5 +/- 1.5 and 7.5 +/- 1.2 mmol). Duodenal ulcer patients had a significantly lower buffer capacity compared with controls. Masticatory diets may play a part in protecting individuals from developing duodenal ulcer.     

Routine use of antimicrobials by pregnant Indian women does not improve birth outcome: a randomized controlled trial

Low birth-weight is a leading health problem in developing countries. In a randomized controlled trial, the effect of antimicrobials in pregnant women on improving birth-weight and duration of gestation was evaluated. Two hundred twenty-four pregnant women in their second trimester were randomized to receive metronidazole (200 mg 3 times daily for 7 days) and cephalexin (500 mg twice daily for 5 days) orally by one group. The mean (+/-SD) birth-weights were 2,545 g (+/-374) and 2584 g (+/-358, p=0.51), the low birth-weight rates (<2.5 kg) were 40% and 36% (p = 0.28), and the prematurity rates were 8% and 11% (p = 0.6) in the treated group and the control group respectively. Due to small sample size, it is cautiously concluded that routine antimicrobials for genital and urinary tract infections of pregnant women do not improve birth-weight or duration of gestation. Rather an unexpected observation was the proportion requiring caesarian section or forceps, which was five-fold higher in the treated group (p = 0.001), and given no plausible explanations, this finding needs confirmation. Stunted mothers (<25th centile or 146.4 cm) had two-fold higher risk for low birth-weight (p = 0.04) and assisted delivery (p = 0.1). Low maternal body mass index (<25th centile or 18) had six-fold higher risk for stillbirth or abortion (p = 0.007), and high body mass index (>75th centile or 21.2) had three-fold higher risk for assisted delivery (p = 0.003).