A prospective randomized comparison of type of nephrostomy drainage following percutaneous nephrostolithotomy: large bore versus small bore versus tubeless

PURPOSE: We compared postoperative outcomes among tubeless, conventional large bore nephrostomy drainage and small bore nephrostomy drainage following percutaneous nephrostolithotomy (PCNL) in a prospective randomized fashion. MATERIALS AND METHODS: Between January and June 2001, 30 patients undergoing PCNL were randomized to receive conventional large bore (20Fr) nephrostomy drainage (group 1, 10 patients), small bore (9Fr) nephrostomy drainage (group 2, 10 patients) or no nephrostomy drainage (group 3, 10 patients). Inclusion criteria included a single subcostal tract, uncomplicated procedure, normal preoperative renal function and complete stone clearance. Factors compared among the 3 groups were postoperative analgesia requirement, urinary extravasation, duration of hematuria, duration of urinary leak, decrease in hematocrit and hospital stay. RESULTS: The postoperative analgesic requirement was significantly higher in group 1 (217 mg) compared to groups 2 (140 mg, p <0.05) and 3 (87.5 mg, p <0.0001). Patients in group 3 had a significantly shorter duration (4.8 hours) of urinary leak through the percutaneous renal tract compared to patients in groups 1 (21.4 hours, p <0.05) and 2 (13.2 hours, p <0.05). Hospital stay was significantly shorter in group 3 (3.4 days) compared to groups 1 (4.4 days, p <0.05) and 2 (4.3 days, p <0.05). All 3 groups were similar in terms of operative time, duration of hematuria and decrease in hematocrit. Postoperative ultrasound did not reveal significant urinary extravasation in any case. CONCLUSIONS: Tubeless PCNL is associated with the least postoperative pain, urinary leakage and hospital stay. Small bore nephrostomy drainage may be a reasonable option in patients in whom the incidence of stent dysuria is likely to be higher.     

Should laparoscopic cholecystectomy be performed in patients with thick-walled gallbladder?

Background/Purpose Laparoscopic cholecystectomy is the procedure of choice for patients with symptomatic cholelithiasis. This procedure is contraindicated in patients with gall-bladder cancer (GBC) because of fear of dissemination of the disease. One of the findings raising the suspicion of GBC is a thick-walled gallbladder (TWGB).Methods A prospective study of patients with TWGB was done over a period of 10 months at a tertiary-level referral hospital in northern India. We studied the clinical profiles, investigations (ultrasound [US] and computerized tomography [CT]) and management plans in these patients.Results A total of 60 patients were included in the study. After cholecystectomy, histopathology of gallbladders showed GBC in 2 (3.3%) patients. The remaining 58 patients had chronic cholecystitis, of whom 28 (48%) had xanthogranulomatous variant chronic cholecystitis. Cholecystectomy by the laparoscopic method was attempted in 46 (77%) patients and by open technique in the remaining 14 (23%) patients. Laparoscopic cholecystectomy was successful in 40 of the 46 (87%) patients in whom it was attempted. Obscure anatomy, suspicion of GBC, and bile duct injury were the causes of conversion, in the remaining 13% (6/46). None of the 11 patients who had a CT examination because of clinical or US suspicion of malignancy turned out to have GBC at final histology. Both the cases of GBC in this study were incidental findings on final histopathology.Conclusions Laparoscopic cholecystectomy can be successfully performed in the majority of patients with diffuse TWGB, with appropriate selection. There is, however, an increased chance of conversion to open cholecystectomy in these patients. If there is an intraoperative suspicion of GBC, early conversion to open cholecystectmy and frozen section/imprint cytology will help to decide the further treatment during surgery.     

Non-invasive assessment of endothelial function by brachial artery flow mediated vasodilatation and its association with coronary artery disease: an Indian perspective

Endothelial dysfunction is the final common pathway through which various coronary risk factors culminate into atherosclerosis and subsequent coronary artery disease (CAD). Endothelial function can be reliably assessed by flow mediated vasodilatation (FMD) in the brachial artery using high-resolution ultrasonography and has been shown to be an excellent surrogate marker for the presence of CAD. Two hundred and forty-one individuals comprising of 101 patients with CAD (angiographically proven, or with history of documented myocardial infarction) and 140 individuals without CAD were included in the study. All subjects underwent clinical evaluation, fasting lipid profile, treadmill test and FMD assessment. Selected individuals underwent coronary angiography too. Brachial artery diameter and Doppler indices (systolic and diastolic velocity time integrals) were recorded using high resolution ultrasonography at baseline, immediately after and at one minute after release of cuff (occlusion time 5 minutes). FMD was calculated as percentage increase in brachial artery diameter at one minute. FMD index was calculated as the ratio of FMD and percentage increase in flow during reactive hyperaemia. Mean FMD was significantly higher in non-CAD group (8.71+/-4.77%) than in CAD group (3.77+/-2.03%; p < 0.0001). The FMD index was also significantly higher in the non-CAD group (0.031 ) than in CAD group (0.021; p=0.0117). On multiple regression analysis, FMD index was found to be significantly associated with presence of CAD (p=0.0015), independent of conventional cardiovascular risk factors. Endothelial function as assessed by FMD is significantly depressed in patients with established CAD and this association is independent of presence of conventional cardiovascular risk factors.     

Anthropometric profile and perinatal outcome of babies born to young women (< 18 years)

This study was conducted to ascertain the sociodemographic profile, maternal characteristics, neonatal anthropometry and perinatal outcome in adolescent pregnancy (18 years or less). 128 consecutive primiparous women more than 18 years of age served as the control group. There were 4556 deliveries during the study period. Young adolescents accounted for 1.25% of total pregnancies. The proportion of shorter (<145 cm), lighter (<45 Kg), and anemic (Hb. <9 g/dL) women was significantly higher in the study group. Incidence of premature delivery in the young adolescents was significantly higher. Mean birth weight, length, head circumference and chest circumference of full-term babies of adolescent mothers were significantly lower.     

Elective abortion as a primary health service in rural India: experience with manual vacuum aspiration

India allows abortion up to 20 weeks of pregnancy but places restrictions on abortion facilities and providers. Abortion services are especially deficient in rural areas. Although vacuum aspiration is safer, sharp curettage continues to be used by providers as they lack relevant training. This paper describes the provision of first trimester abortion services using manual vacuum aspiration (MVA) in a rural clinic in the state of Rajasthan over a four-year period. Non-use of anaesthesia increased safety and allowed women to return early to a normal routine. Of 534 women, none suffered major complications; 16 required repeat evacuation and the procedure failed in two. We recommend that models based on MVA and including medical methods be piloted in rural areas of a number of states of the country, to establish the feasibility of delivering first trimester abortion as a primary health service. Ways to increase access to second trimester procedures are also required. Current requirements for certification of private facilities are excessive and the process of obtaining certification is arduous. The law in India does not extend these norms to government facilities, which remain under-equipped and lack trained providers. We recommend that certification of facilities be liberalized and applied equally to government and private institutions. There is also a need to rapidly increase training capacity across the country.     

Role of RLIP76 in lung cancer doxorubicin resistance: I. The ATPase activity of RLIP76 correlates with doxorubicin and 4-hydroxynonenal resistance in lung cancer cells

RLIP76 functions as an ATP-dependent transporter of amphiphilic chemotherapeutic drugs such as doxorubicin (DOX, adriamycin), as well as of glutathione-conjugates of endogenous electrophilic toxins such as 4-hydroxynonenal (4HNE). RLIP76 couples transport and ATP-hydrolysis with a 1:1 stoichiometry, making the ATPase activity of RLIP76 an excellent surrogate for its transport activity. Present studies were performed to determine the relationship of the RLIP76 ATPase activity with DOX and 4HNE resistance in a panel of 13 native human lung cancer cell lines. RLIP76 was purified from each cell line and homogeneity demonstrated by SDS-PAGE and amino acid composition analysis. Anti-RLIP76 antibodies were shown by Ouchterlony double immunodiffusion tests to be non-cross-reactive with any other proteins including P-glycoprotein (Pgp) or multidrug resistance associated protein (MRP). These antibodies completely immunoprecipitated ATPase activity of purified RLIP76 fractions, further confirming homogeneity of purified RLIP76. RLIP76 ATPase purified from NSCLC cell lines was about 2-fold more active than that from SCLC in the absence of the stimulator dinitrophenyl S-glutathione (206+/-47, n=7 vs. 94+/-22, n=6, nmol/min/mg protein, respectively), or in its presence (340+/-60, n=7 vs. 186+/-32, n=6, nmol/min/mg; p<0.01). Partial tryptic digest revealed a 44 kDa internal fragment of RLIP76 beginning at Thr-294 in NSCLC cell lines. This fragment was absent from all SCLC, suggesting the possibility that the activity of RLIP76 in SCLC and NSCLC is differentially regulated through post-translational modifications. Taken together, these findings suggest that RLIP76 activity is a general determinant of 4HNE and DOX resistance, and that its activity contributes to the drug-resistant phenotype of NSCLC.     

Role of RLIP76 in lung cancer doxorubicin resistance: III. Anti-RLIP76 antibodies trigger apoptosis in lung cancer cells and synergistically increase doxorubicin cytotoxicity

RLIP76 (ral-binding protein, RalBP1) is a non-ABC multi-specific transporter of amphiphilic chemotherapeutic drugs such as doxorubicin (DOX) and glutathione-electrophile conjugates. In the present studies, we used polyclonal rabbit anti-human RLIP76 IgG to inhibit RLIP76 function for determining the role of RLIP76 in DOX resistance of NSCLC cells. Western blot analyses and immunohistochemistry studies showed no recognition of other protein in crude NSCLC cell homogenates by anti-RLIP76, confirming the specificity of anti-RLIP76 IgG. In immunohistochemistry and flow cytometry studies, these antibodies recognized RLIP76 domain(s) on the cell surface. Cells coated with anti-RLIP76 IgG accumulated significantly greater DOX than cells coated with pre-immune IgG. Synergy was calculated using the Chou-Talalay median effect analysis. Herceptin was the positive control, and pre-immune IgG and Rituxan (anti-CD20) were negative controls. The interaction of anti-RLIP76 IgG and DOX were markedly synergistic (CI 0.36+/-0.27). Lesser synergy was observed between Herceptin and DOX (CI 0.75+/-0.49). Interaction between Herceptin and anti-RLIP76 was only additive (CI 1.12+/-0.5). Human IgG, Rituxan, and rabbit pre-immune IgG controls had no effect on DOX toxicity. DNA-laddering confirmed that DOX triggered apoptosis. Anti-RLIP76 IgG alone as well as Herceptin alone also triggered apoptosis in all 6 NSCLC cell lines. Anti-RLIP76 IgG and Herceptin were shown to increase DOX accumulation in NSCLC. These results demonstrated that specific inhibition of the transport function of RLIP by anti-RLIP76 IgG can trigger apoptosis and synergistically increase DOX cytotoxicity in NSCLC.     

Animal bites��should primary reconstruction be the standard treatment?

We present a series of 91 cases caused by both wild and domestic animals over a period of 5?years from 2005?C2009. The objective of the study was to compare the results of primary reconstruction with the traditional method of debridement and secondary healing. A total of 91 patients were studied from January 2005?CDecember 2009. In 54 patients, the injuries were carefully documented, and immediate reconstruction was performed. Thirty-seven patients with contraindications to surgery or who refused to undergo surgery were allowed to heal by secondary intention and were studied as a control group. The patients and their relatives were asked to rate their result and outcome. Among the 54 patients who underwent primary reconstruction, 37 patients were males and 17 were females. Age ranged from 2 to 70?years. Amongst the wild animals, bear was the most common offending animal while dog was the most common street animal. Overall bear bites were the most common presentation to our facility. Four out of 54 cases (7.4%) with primary reconstruction developed infection of the operative site. Of the patients with immediate reconstruction, 57.4% thought that the result was excellent, 35.2% patients were satisfied with the result but wanted further refinement while 7.4% were unhappy and wanted immediate revision. Of the 37 patients who did not undergo primary reconstruction, 16.2% thought that the result was excellent, 45.9% were satisfied and 37.8% wanted immediate revision. We recommend that animal bite wounds should be considered for reconstruction at the earliest to achieve maximal functional and aesthetic results.