Spontaneous kidney rupture after delivery due to an urothelial carcinoma

The case of a spontaneous kidney rupture due to an urothelial carcinoma one week after delivery is presented. Diagnosis was made during operation. In comparison to the carcinoma, which is diagnosed and treated in time, the prognosis is poor. The patient deserved continuous gynecological follow-up and showed the classic symptoms of an urothelial carcinoma for six months. In spite of regular sonographic controls during pregnancy the tumor was not diagnosed. Diagnosis and management of renal carcinomas during pregnancy are discussed.     

Changes in bone structure after augmentation cystoplasty in chronic uraemic rats

OBJECTIVE: To investigate the effect of urinary diversion using several types of intestinal segments on cortical and cancellous bone structure of growing rats with renal insufficiency. MATERIAL AND METHODS: In all, 110 female Sprague-Dawley rats (8 weeks old) had either a two-stage subtotal nephrectomy by removing five-sixths of the renal mass, or a sham operation. Except for a uraemic control group, all uraemic rats then had an enterocystoplasty using stomach, ileum or colon (20 animals per group). An additional group with colic augmentation received the bisphosphonate ibandronate. After 12 weeks, the left tibia was assessed using peripheral quantitative computed tomography and bone histomorphometry. RESULTS: After subtotal nephrectomy all groups had approximately 30% less endogenous creatinine clearance. Renal failure alone or in association with gastric or colic augmentation induced only negligible changes in the mass and structure of cortical and cancellous tibial bone. In contrast, rats after ileal augmentation and renal failure had a significant reduction in cancellous bone mineral density (P < 0.05) whereas the reduction in trabecular bone area and volume was not statistically significant. Furthermore, ileocystoplasty caused a decrease in trabecular number and perimeter, increased trabecular separation and enlarged bone marrow space, whereas ileocystoplasty had no effect on cortical bone. The changes were not associated with alterations in serum pH. Ibandronate treatment in the colonic cystoplasty group increased trabecular bone mass and structural variables over the untreated colonic cystoplasty group. CONCLUSIONS: These results suggest that cystoplasty using an ileal segment causes a decrease in bone mass and architecture in growing rats with mild uraemia. It remains open to question whether the results obtained from experimental animals can be directly extrapolated to the clinical situation.     

Mutation in exon 7 of PTCH deregulates SHH/PTCH/SMO signaling: possible linkage to WNT

The novel PTCH mutation and clinical manifestations within Gorlin syndrome family links PTCH haploinsufficiency and aberrant activation of the Wnt pathway. We report a family case with Gorlin syndrome, characterized by the usual phenotype features such as widespread basocellular tumors and craniofacial and bone malformations, but also including a less common appearance of craniopharyngioma. These clinical manifestations might be associated with a novel constitutional mutation of the PTCH gene, 1047insAGAA, which we found in exon 7. It changes the normal amino acid sequence leading to termination of the PTCH protein at exon 9. The analyzed tumors of the family show extensive loss of heterozygosity in the PTCH region, both basocellular and in particular craniopharyngioma, and in the latter a high expression of beta-catenin was detected. Our findings suggest involvement of the SHH/PTCH/SMO pathway in pathogenesis of the analyzed disorders, including its possible contribution to aberrant activation of the Wnt pathway in craniopharyngioma.     

Additive prognostic value of the SYNTAX score over GRACE, TIMI, ZWOLLE, CADILLAC and PAMI risk scores in patients with acute ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention

This study evaluated additive prognostic value of the SYNTAX score over GRACE, TIMI, ZWOLLE, CADILLAC and PAMI risk scores in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). All six scores were calculated in 209 consecutive STEMI patients undergoing pPCI. Primary end-point was the major adverse cardiovascular event (MACE—composite of cardiovascular mortality, non-fatal myocardial infarction and stroke); secondary end point was cardiovascular mortality. Patients were stratified according to the SYNTAX score tertiles (≤12; between 12 and 19.5; >19.5). The median follow-up was 20 months. Rates of MACE and cardiovascular mortality were highest in the upper tertile of the SYNTAX score (p < 0.001 and p = 0.003, respectively). SYNTAX score was independent multivariable predictor of MACE and cardiovascular mortality when added to GRACE, TIMI, ZWOLLE, and PAMI risk scores. However, the SYNTAX score did not improve the Cox regression models of MACE and cardiovascular mortality when added to the CADILLAC score. The SYNTAX score has predictive value for MACE and cardiovascular mortality in patients with STEMI undergoing primary PCI. Furthermore, SYNTAX score improves prognostic performance of well-established GRACE, TIMI, ZWOLLE and PAMI clinical scores, but not the CADILLAC risk score. Therefore, long-term survival in patients after STEMI depends less on detailed angiographical characterization of coronary lesions, but more on clinical characteristics, myocardial function and basic angiographic findings as provided by the CADILLAC score.     

Role of color-coded Doppler sonography in the assessment of internal ureteral stent patency.

OBJECTIVE: To evaluate the role of color-coded Doppler sonography (CCDS) in the assessment of internal ureteral stent patency. PATIENTS AND METHODS: We compared micturating cystography (MC) and CCDS in 48 patients with internal ureteral stents. Forty-five of these patients had pyelocaliectasis on renal sonography. RESULTS: In all of the 48 patients, the distal end of the internal ureteral stent could be seen sonographically in the bladder. The color images of 30 patients showed typical flow from the distal holes of the stent. Micturating cystography demonstrated patency of the stents in 36 patients. The two procedures showed the same results in 42 of 48 patients. Six patients had no detectable flow by CCDS, but the MCs showed patency of the stents. CONCLUSION: The CCDS is a valid noninvasive method for the assessment of internal ureteral stent patency with a sensitivity of 100%, a specificity of 83%, a positive predictive value of 67%, and a negative predictive value of 100%.     

Pain to hospital times after myocardial infarction in patients from Dalmatian mainland and islands, southern Croatia

Aim

To analyze pre-hospital delay in patients with myocardial infarction from mainland and islands of Split-Dalmatian County, southern Croatia.

Methods

The study included all patients with myocardial infarction transported by ambulance to the University Hospital Split in 1999, 2003, and 2005. Pre-hospital delay was analyzed in the following intervals: pain-to-call, call-to-ambulance, ambulance-to-door, and door-to-coronary care unit interval. Patients were categorized according to the location from which they were transported: Split, mainland >15 km from Split, and islands.

Results

There were 1314 patients (62.9% men) transported and hospitalized for myocardial infarction. Total pre-hospital delay (pain-to-hospital) was significantly reduced from 1999 to 2005 (5.2 hours vs 4.3 hours, P = 0.011). Seventy-five patients (5.7%) were admitted to the coronary care unit within the recommended time-frame of less than 90 minutes, none of which was from the islands, while 248 patients (18.9%) were admitted more than 12 hours from the onset of pain.

Conclusion

Pre-hospital delay in patients with myocardial infarction in southern Croatia is still too long, especially in patients coming from outside of Split. Prognosis and survival of such patients may be improved by introducing changes to the health care system in remote areas, such as out-of-hospital thrombolysis, greater use of telemedicine, training of lay persons and paramedics in defibrillation, introduction of quality assessment mechanisms, and improved patient transport.Coronary or ischemic heart disease (CHD), manifesting as stable or unstable angina pectoris, acute myocardial infarction (AMI), functional heart impairment, cardiac arrest, or sudden heart failure, is the leading cause of death around the world. It affects approximately 17 million people worldwide, including 5 million a year in Europe (1).In Croatia, it was the leading cause of death in 2008, causing one-fifth of all deaths in both women and men (2). From 1979 to 2001, AMI mortality in the capital city of Zagreb was very high: 50% of all patients with AMI died, with 31% being out-of-hospital deaths (3). In the Split-Dalmatia county, primary health care institutions reported 1022 patients with AMI in 2002, and only 391 (38%) of them (249 men and 142 women) were admitted to University Hospital Split (4). We may conclude that 62% of patients did not receive adequate care, a reason for which may be the existence of only one general hospital in Split-Dalmatia County, which is also the only one with a coronary care unit (CCU).The mortality rate of AMI in the first 30 days after the onset of disease ranges from 30-50%, with about half of deaths occurring within the first 2 hours (5,6). In-hospital mortality of AMI in North America has decreased from 25-30% to 7-10% in the past 30 years. This decrease can be attributed to the introduction of CCUs, administration of beta blockers, and introduction of fibrinolytic therapy and percutaneous coronary intervention (PCI) (5,6).The greatest barrier to optimal treatment is the delay between the onset of symptoms and initiation of therapy. This delay is of interest given the time-dependent benefits associated with early use of coronary reperfusion therapy (7). In order to treat AMI effectively, the time span from the onset of the first symptoms to administration of fibrinolytic therapy or PCI, known as pain-to-needle time, should be shorter than 90 minutes (8,9). According to the second Euro Heart Survey on acute coronary syndromes, conducted in 190 medical centers in 32 countries, the median time from symptom onset to arrival to the emergency department in 2004 was 2.8 hours (range, 1.3-7 hours), while median pain-to-call time was 1.75 hours (range, 0.7-5.1 hours) (10).In Split, the average time interval from the onset of myocardial infarction symptoms to arrival to the coronary unit from 1981 to 1987 was 14.8 ± 11.6 hours (range, 2-72 hours). The authors of the study concluded that this interval should be substantially reduced in order to decrease the mortality associated with CHD (11).Pre-hospital delay assessment takes into consideration several intervals: pain-to-call, call-to-ambulance, ambulance-to-door, and door-to-CCU time. Pain-to-call time accounts for the greatest part of pre-hospital delay in urban areas, while the other intervals, which depend on the health care system, are more responsible for pre-hospital delay in rural and remote areas (12).The aim of this study was to analyze pain-to-door time in patients with myocardial infarction from mainland and islands of Split-Dalmatian County, compare it with previous studies, and provide recommendations for more effective practice.