Percutaneous nephrolithotomy in children before school age: experience of a Pakistani centre

OBJECTIVE: To review our experience of percutaneous nephrolithotomy (PCNL) in children before school age, and determine its efficacy and safety in this age group. PATIENTS AND METHODS: The records of children aged < or = 5 years undergoing PCNL were reviewed. Variables assessed included stone number, size, location and type. The PCNL puncture site and number were also recorded. We reviewed stone clearance with PCNL, ancillary procedures used, complication rates and follow-up status of the children. RESULTS: There were 30 renal units in 29 children (median age 3.8 years, range 1.4-5). Because of poor growth the mean (SD) body weight of the children was only 12.2 (2.8) kg, which is near the 50th percentile for children of mean age 3.5 years. The median (range) stone burden was 2.35 (1.3-6) cm; 60% of the patients had single stones while 28% had more than five. There were five staghorn stones. All PCNL was primary and with one puncture, using a 17 F angled nephroscope; stones were fragmented using a pneumatic lithoclast. After PCNL stones were completely cleared in 60% of the renal units, which increased to 100% after combining it with extracorporeal shockwave lithotripsy. The median (range) follow-up was 24.9 (4-51) months; the overall complication rate was 6%. In the long follow-up hypertension was not detected in any child and isotopic renograms in 17 kidneys detected no new scarring or loss of renal function. CONCLUSION: PCNL is a safe and effective for treating renal stones in very young children.     

Quality of life and survival prediction in terminal cancer patients: a multicenter study

BACKGROUND: It remains unclear whether health-related quality of life (HRQoL) measurements from patients and staff can be combined with medical data to predict survival in patients with terminal cancer. METHODS: The correlations between survival and potential health-related quality-of-life (HRQoL) prognostic variables were explored in 2 independent cohorts of patients with terminal cancer (248 patients in Cohort 1 and 756 patients in Cohort 2) after adjusting for clinical and demographics variables using Cox regression models. RESULTS: At the onset of the terminal phase (Cohort 1), the hazards of dying increased by 28% in the presence of dyspnea and by 68% in the presence of nausea/emesis; however, the most important predictors of worse survival were the presence of liver metastases (hazard ratio [HR], 2.5; 95% confidence interval [95% CI], 1.8-3.8), lung tumor (HR, 2.4; 95% CI, 1.7-3.4), and tumor burden (HR, 2.0; 95% CI, 1.4-2.7). In contrast, for patients who were seen in later stages of their terminal disease (Cohort 2), dyspnea (HR, 1.5; 95% CI, 1.1-1.9) and the coexistence of weakness with a diagnosis of digestive tumors (HR, 5.2; 95% CI, 1.2-21.8), breast tumors (HR, 3.1; 95% CI, 1.6-6.2), and genitourinary tumors (HR, 3.5; 95% CI, 1.6-7.8) were more predictive of survival than the type of tumor primary. Emotional functioning along with anxiety, spiritual distress, and lack of insight were not associated consistently with survival in both cohorts. CONCLUSIONS: Health care professionals should focus on physical HRQoL indicators, such as nausea and emesis, dyspnea, and weakness, to gather prognostic clues in patients with terminal cancer. These symptoms may reflect consequences of cancer cachexia and the progress of patients toward this terminal syndrome. Psychosocial distress did not appear to be associated consistently with survival; however, future studies should clarify further the prognostic significance of "positive attitudes", such as hope and optimism, in patients with advanced cancer.     

Usefulness of compensatory hyperkinesis in the noninfarcted left ventricular wall in separating single from multivessel coronary artery disease in patients with initial ST-elevation acute myocardial infarction

We assessed the contractility of the contralateral wall on 2-dimensional echocardiography in 50 patients with an initial ST-elevation acute myocardial infarction who underwent coronary angiography. Compensatory hyperkinesis, which we defined as a fractional thickening of >/=60% in the contralateral wall, was a strong predictor of single-vessel coronary artery disease, with a positive predictive value of 85%.     

Rhabdomyolysis and compartment syndrome with coadministration of risperidone and simvastatin

We report a case of rhabdomyolysis and acute compartment syndrome of the lower extremity in a schizophrenic patient taking risperidone following the addition of simvastatin to treat hyperlipidemia. We suspect that disrupted drug metabolism, resulting from interactions with cytochrome P450 enzymes, rapidly elevated drug plasma levels, which then led to muscle toxicity. Clinicians who pharmacologically treat medical comorbidities in patients receiving atypical antipsychotics must be proactive in anticipating potential drug-drug interactions.     

Cost of delivering child immunization services in urban Bangladesh: a study based on facility-level surveys

This facility-based study estimated the costs of providing child immunization services in Dhaka, Bangladesh, from the perspective of healthcare providers. About a quarter of all immunization (EPI) delivery sites in Dhaka city were surveyed during 1999. The EPI services in urban Dhaka are delivered through a partnership of the Government of Bangladesh (GoB) and non-governmental organizations (NGOs). About 77% of the EPI delivery sites in Dhaka were under the management of NGOs, and 62% of all vaccinations were provided through these sites. The outreach facilities (both GoB and NGO) provided immunization services at a much lower cost than the permanent static facilities. The average cost per measles-vaccinated child (MVC), an indirect measure of number of children fully immunized (FIC-the number of children immunized by first year of life), was 11.61 U.S. dollars. If all the immunization doses delivered by the facilities were administered to children who were supposed to be immunized (FVC), the cost per child would have been 6.91 U.S. dollars. The wide gap between the cost per MVC and the cost per FVC implies that the cost of immunizing children can be reduced significantly through better targeting of children. The incremental cost of adding new services or interventions with current EPI was quite low, not significantly higher than the actual cost of new vaccines or drugs to be added. NGOs in Dhaka mobilized about 15,000 U.S. dollars from the local community to support the immunization activities. Involving local community with EPI activities not only will improve the sustainability of the programme but will also increase the immunization coverage.     

Quantitative comparison of three different types of anterior cruciate ligament reconstruction methods: laxity and 3-D kinematic measurements

In this project, we compared knee laxity and 3-D knee kinematics after ACL reconstruction on cadaver knees using (1) bone-patellar tendon-bone two-tunnel; (2) synthetic ligament two-tunnel; and (3) synthetic ligament "over-the-top" technique. We used a computer assisted system, based on the acquisition of the knee's movement with magnetic sensors (Polhemus, Vermont, USA). The use of personalised three-dimensional (3D) models of the bones enabled us to ensure a reproducible measurement of three-dimensional kinematic and laxity parameters. Our results showed that even when knee laxity was restored to normal, 3D kinematic measurements revealed that the reconstructions tended to under or over-constrain the knee's movement. This study shows that 3D kinematics is a complementary measurement that can be useful to get a better comprehension of the knee's function after ligament reconstruction.     

Hepatitis e virus infection in fulminant hepatitis patients and an apparently healthy population in Bangladesh

This is the first study comparing hepatitis E virus (HEV) infection in Bangladesh in fulminant hepatitis (FH) patients presumed to have a viral cause and in the apparently healthy population. Sera from 22 FH patients were analyzed for antibodies to hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C and D viruses, and HEV and for hepatitis B surface antigen (HBsAg). Anti-HEV immunoglobulin M (IgM) was detected in the sera of 63.6% of patients, whereas 35.7% were positive for HBsAg. A high prevalence of HEV infection (83.3%) was noted in the HBV carriers. Serum samples from 273 apparently healthy individuals were tested for antibodies to HAV and HEV. Anti-HEV IgM was detected in 7.3% of the samples. The seroprevalence of HAV differed from that of HEV in the same population because all samples were negative for anti-HAV IgM. These data indicate that HEV infection is highly endemic in Bangladesh.