Performance of the Cockcroft-Gault and MDRD equations in adult Nigerians with chronic kidney disease

Background  Estimation of the glomerular filtration rate (GFR) is required in the assessment of patients with chronic kidney disease (CKD) in order to provide information regarding the functional status of the kidneys. Current guidelines advocate the use of prediction equations, such as the Cockcroft-Gault (CG) formula and the Modification of Diet in Renal Disease (MDRD) study-derived equations, over clearance of endogenous creatinine (Ccr) in achieving this aim. We were interested in knowing the accuracy of these equations in predicting the GFR in adult Nigerians with CKD. Methods  We conducted a review of records of patients who were evaluated for CKD at the Nephrology Clinic of the Jos University Teaching Hospital between 2001 and 2003. We compared the CG and MDRD equations against the Ccr in predicting the GFR in 130 patients (88 males and 42 females) with CKD. Results  The means ± standard deviation (SD) for the measured and predicted GFR by the CG and MDRD equations were similar (17.6 ± 25.8 ml/min, 19.9 ± 24.0 ml/min and 21.5 ± 28.2 ml/min, respectively; analysis of variance [ANOVA], F = 0.68, P = 0.5). The mean difference between CG and Ccr was −2.2 ± 14.8 ml/min, with discordance at Ccr values >25 ml/min. The mean difference between MDRD and Ccr was −3.9 ± 18.1 ml/min, with discordance at Ccr values >40 ml/min. Conclusion  The CG and MDRD equations provide reliable alternatives to measured Ccr in the estimation of the GFR in Nigerian patients with CKD.     

Repeated treatment of vestibular schwannomas after gamma knife radiosurgery

Purpose  When gamma knife radiosurgery (GKS) does not achieve control of the growth of a tumour, the need to repeat treatment is considered. The results and risks of repeat treatment of patients with a vestibular schwannoma were reviewed to assess its efficacy and safety. Methods  Between 1992 and 2001, we treated 351 patients with a vestibular schwannoma by GKS, control of the growth of the tumour was not achieved in 32. 26 patients underwntrepeat GKS and five patients had an open microsurgical operation and one stereotactic aspiration of a tumour cyst. Results  Twenty-four of 26 patients were followed up after the repeat GKS for a median of 43 months. 15 tumours became smaller, seven remained unchanged and two enlarged. After the second GKS one patient’s hearing deteriorated, one developed facial weakness and three facial spasms. One patient required insertion of ventriculo-peritoneal drainage. An operation to radically resect the tumour was performed in five patients after the first GKS and for a subtotal removal in one after repeated GKS. Conclusions  In the small proportion of patients (9%) in whom initial GKS does not control the growth of a vestibular schwannoma, most can be controlled by further GKS with a very low risk of a complications.     

Effect of ischemia/reperfusion on bladder nerve and detrusor cell damage

Ischemia, reperfusion, and subsequent free radical damage have been implicated in many voiding disorders. Our goal was to investigate further the mechanisms of these disorders, with particular emphasis on nerve and mitochondrial function and on detrusor smooth-muscle cells. The effects on contractile responses to various stimulations, citrate synthase, choline acetyltransferase activities, and vesicular acetylcholine transporter were evaluated after ischemia alone and ischemia/reperfusion 2 h, 7 days, and 14 days. Nerve density and detrusor cell apoptosis were also measured. The contractile responses were significantly decreased at both 7 and 14 days reperfusion, although at 14 days some recovery was observed. Similar patterns were seen for the intramural nerves, both nerve cell cytoskeletal structures and cholinergic neurotransmitters. Citrate synthase activity was also depressed by ischemia and 2 h reperfusion, but the activity recovered by 7 days. Detrusor cell apoptosis was not significantly affected by ischemia and 2 h reperfusion; but showed an approximately 14-fold increase at both 7 and 14 days reperfusion. Reperfusion following ischemia resulted in worsening intramural bladder nerve dysfunction, nerve fiber injury, mitochondrial injury, and damaged detrusor muscle cells. However, at 14 days reperfusion, nerve and mitochondrial regeneration occurred and resulted in partial recovery of contractile function.     

Cervical Prevertebral Soft Tissue Swelling in the Traumatized Patient: What is Normality in the Intubated Patient?

Abstract   Interpretation of prevertebral soft tissue swelling is generally thought to be invalid in the presence of an endotracheal tube (ETT). There is however little scientific data to support this. We evaluate the prevertebral soft tissue swelling of 43 traumatized patients that have had an endotracheal tube (ETT) placed in the acute setting. A control group of 92 patients were also evaluated which had been subjected to acute trauma and no ETT. There was a significant increase in soft tissue swelling (p < 0.0001) found in the ETT group at the C2 level compared to the non-tube group. There was no significant difference between the two groups at the C4 and C6 levels. We feel that interpretation of prevertebral swelling in the traumatized patient at the C2 level is invalid in the presence of an ETT, and indeed is significantly increased after intubation despite no injury at this level. However, the interpretation of soft tissue swelling at and below C4 remains a useful tool in the evaluation of an occult cervical injury.     

Non-invasive and minimally invasive staging of regional lymph nodes in penile cancer

Introduction  The management of the regional lymph nodes in penile cancer patients, particularly when these lymph nodes are impalpable, remains controversial. Prophylactic bilateral inguinal lymphadenectomy is associated with high morbidity and is often unnecessary. However, there is no non-invasive or minimally invasive staging technique that can determine the lymph node status of penile cancer patients with 100% accuracy. Methods  We reviewed the current literature to examine the role of non-invasive and minimally invasive techniques for staging regional lymph nodes in penile cancer with particular reference to clinically impalpable disease. Results  Cross-sectional imaging (un-enhanced CT and MRI) modalities have a role in the assessment of patients with palpable inguinal basins and in locating distant metastases, but are unreliable in staging impalpable regional lymph nodes. The spatial resolution of lymphotropic nanoparticle enhanced MRI (LNMRI) and positron emission tomography (PET)/CT are limited to several millimetres and so these modalities cannot reliably detect micro-metastases (<2 mm). Ultrasound (US) and fine-needle aspiration cytology (FNAC) are indicated in staging palpable inguinal basins but are unreliable in isolation in the assessment of impalpable lymph nodes. They are, however, useful as an adjunct to dynamic sentinel lymph node biopsy (DSLNB) in lowering false-negative rates. Conclusions  While we await staging modalities that can equal the results of DSLNB with fewer disadvantages, histological staging in the form of DSLNB remains the best minimally invasive staging modality we can offer at risk patients presenting with clinically node negative groins.     

Surgical Management of Peritoneal Dialysis Peritonitis: The Impact of Peritoneal Sclerosis

Background  Peritonitis is a life-threatening complication of peritoneal dialysis. Peritoneal sclerosis is associated with long-term peritoneal dialysis. The aim of this study was to assess the effect of peritoneal sclerosis on outcomes following laparotomy for peritoneal dialysis peritonitis. Methods  A series of 63 consecutive patients underwent laparotomy for peritoneal dialysis peritonitis. Patients were divided into two groups, those with and those without simple peritoneal sclerosis identified at laparotomy. Medical, anaesthetic, and surgical notes were used for data collection. Patients with known encapsulating peritoneal sclerosis were excluded from the study. Results  Patients with simple peritoneal sclerosis had a statistically significant longer duration of peritoneal dialysis. They also had a significantly higher risk of major complications postoperatively and a greater relative risk for mortality. Conclusions  There is an increased prevalence of simple peritoneal sclerosis with long-term peritoneal dialysis. Patients with simple peritoneal sclerosis have higher incidence of postlaparotomy complications. Patients on long-term peritoneal dialysis should be treated aggressively for peritoneal dialysis peritonitis to reduce complication/mortality rates. Evidence of simple peritoneal sclerosis at laparotomy should preclude further peritoneal dialysis.     

Benefits Versus Risks: A Prospective Audit

Background  The purpose of this prospectively collected database is to evaluate the safety, efficacy, and utility of postoperative jejunostomy feeding in terms of achieving nutritional goals and evaluating gastrointestinal and mechanical complications in patients undergoing esophagectomy. Methods  The study included 204 consecutive patients who underwent esophagectomy for various benign and malignant conditions. All patients underwent Witzel feeding jejunostomy at the time of laparotomy. Patients were followed prospectively to record nutritional intake, type of feed administered, rate progression, tolerance, and complications either mechanical or gastrointestinal. Results  Feeding jejunostomy could be performed in 99.5% patients; 6.0% of the patients had a blocked catheter during the course of feeding. The target calorie requirement could be achieved in 78% of patients by third day. In all, 95% of patients could be successfully fed exclusively by jejunostomy catheter during the postoperative period. Minor gastrointestinal complications developed in 15% of the patients and were managed by slowing the rate of infusion or administering medication. Patients spent a mean of 16.67 ± 22.00 days (range 0–46 days) on jejunostomy feeding after surgery; however, 13% required prolonged jejunostomy feeding beyond 30 days. Altogether, 64% of the patients with an anastomotic leak and 50% of the patients with postoperative complications required catheter jejunostomy feeding beyond 30 days. The mean duration for which jejunostomy tube feeding was used was significantly higher for patients who developed anastomotic disruptions (33.05 ± 16.24 vs. 14.69 ± 19.04 days; p = 0.000) and postoperative complications (26.67 ± 25.56 vs. 14.52 ± 18.64 days; p = 0.000) when compared to those without disruption or complications. There were no serious complications related to the feeding catheter that required reintervention. There was no difference in the mean body weight or weight deficit at the end of 10 days and at 1 month in patients who developed complications or anastomotic disruption when compared to their counterparts. No patient died as a result of a complication related to the feeding jejunostomy. Conclusions  Tube jejunostomy feeding is an effective method for providing nutritional support in patients undergoing esophagectomy, and it allows home support for the subset who fail to thrive. Prolonged tube feeding was continued in patients developing anastomotic disruptions and postoperative complications. Feeding jejunostomy has a definitive role to play in the management of the patients undergoing esophagectomy.     

Long term outcomes following surgical resection of myxopapillary ependymomas

Myxopapillary ependymomas, a specific tumor variant of spinal cord ependymomas, occur most commonly in the lumbosacral region. During the study period, 1,013 patients underwent surgery for spinal cord tumors. Fifty-two of the patients had a myxopapillary ependymoma. Forty-eight of these patients underwent surgery at our institutions. There were four patients who came for consultations only. Fourteen pediatric patients were diagnosed with myxopapillary ependymoma. The overall average age at which a patient was diagnosed was 31.8 years. The average age a child was diagnosed was 12.6 years. The adult mean age was 38.7 years. The clinical presentation was of a slow, indolent course, with average symptom duration of 20.8 months. Overall, the pediatric patients had a much more aggressive clinical course with a much higher rate of local recurrence and dissemination of the tumor within the neural axis (64% versus 32%). The median time to disease recurrence was 88 months for the entire group. The overall survival after 11.5 years of follow-up was 94%. The optimal management of patients harboring myxopapillary ependymomas remains somewhat controversial. Excellent outcomes may be obtained, however, with the use of aggressive surgical techniques. No clear benefit for adjunctive chemotherapy, and radiation therapy was demonstrated. Fred Epstein is deceased.     

Conservative management of thoracolumbar and lumbar spine compression and burst fractures: functional and radiographic outcomes in 136 cases treated by closed reduction and casting

Introduction  Both fractures of the lumbar spine and at the thoracolumbar junction are quite common. The treatment of these fracture types is discussed controversially. Some authors advocate surgical treatment even in fractures without neurologic compromise while other series report good results after non-operative treatment. Materials and methods  Between January 1997 and April 2004, 324 patients with spinal fractures were admitted to our institution. Hundred and thirty-six patients with compression and burst type fractures treated by closed reduction and casting were available for follow-up. Their medical records, radiographs and computer tomography scans were reviewed and their functional status was assessed. Results  94 male (69.1%) and 42 female (30.9%) patients with a mean age of 48.6 years (range 17–81) at time of injury were included. The thoracolumbar junction (T11-L1) was affected in 104 patients (76.5%). 23.5% had lumbar fractures. All of the burst type fractures with involvement of the posterior column affection were type A3.3. fractures according to the Magerl classification. Significant correction of radiographic parameters was achieved in the early postreduction period (P < 0.0001). Reduction could not be maintained at the final follow-up but still showed slight improvement compared to the initial presentation. Reduction could be maintained better in the thoracolumbar region than in the lumbar spine. Neurologic function was restored in all patients with unilateral radicular pain but only one patient recovered fully after cauda equina-syndrome. Patients after lumbar spine indicated a higher level of pain when compared to patients with fractures at the thoracolumbar junction. Discussion  Closed reduction and casting is a safe and effective method for treatment of compression and burst type fractures at the thoracolumbar junction and can restore neurologic function in patients with unilateral radicular pain. It is of limited value in lumbar fractures and in burst type fractures with posterior column involvement.