Lower polar aberrant renal vein-renal pelvis fistula: a rare cause of haematuria

BACKGROUND

Non traumatic fistula between a lower polar aberrant renal vein and renal pelvis is a very rare condition, which to our knowledge has not been previously reported in the English literature.

OBJECTIVE

To report a rare case of non-traumatic fistula between an aberrant lower polar renal vein and renal pelvis.

CASE REPORT

An 80-year old man presented with six-week history of intermittent haematuria. He was fully assessed clinically in addition to having an intervenous urography, ultrasonography, ureteropyelogram and selective right renal angiography and the venography which confirmed the presence of a fistula between the right renal pelvis and an aberrant tortuous lower polar right renal vein just above the level of the pelviureteric junction. There was no communication with an artery. The fistula was successfully treated by selective angiographic (venographic) embolization using a coil. Immediately after the emboliza-tion the haematuria settled.

CONCLUSION

In our opinion renal veno-pelvis fistulae should be managed in the first place by selective angiography to confirm the diagnosis and then by embolization at the same sitting. If embolization fails, then surgical closure of the fistula may be achieved either through laparoscopic or open surgical approach and the vessel may be ligated or occluded.

Apophysomyces elegans - renal mucormycosis in a healthy host: a case report from south India

Zygomycosis is an opportunistic fungal infection that seldom occurs in individuals with a competent immune system. Isolated involvement of any organ is rare and only a few cases of renal zygomycosis have been reported. We present an unusual case of renal zygomycosis caused by Apophysomyces elegans in a patient with no known predisposing factor. He presented with flakes in the urine and was found to have a poorly functioning right kidney. Ureterorenoscopy was performed, fungal elements removed and pathological confirmation obtained. The patient subsequently underwent nephrectomy after treatment with amphotericin B. He made an uneventful recovery.

Primary HIV-1 infection--a "window of opportunity" for healthcare providers

The diagnosis of primary HIV-1 infection (PHI) is often missed and requires a high index of suspicion and a thorough knowledge of laboratory methods. We report the case of a young promiscuous male who presented with fever, rash and neurological symptoms 8 weeks after unprotected sexual exposure. Clinical and laboratory investigations showed the presence of leucopenia and thrombocytopenia with elevated transaminases, and a normal cerebrospinal fluid analysis, while CNS imaging revealed a vasculitis-like involvement of the corpus callosum. Symptoms resolved spontaneously over 3 weeks. Fourth generation ELISA with p24 antigen assay was positive with high HIV-1 RNA load while Western-Blot was negative, thus confirming the diagnosis of PHI. The patient was subsequently started on antiretroviral therapy (ART) and showed undetectable viral load after 8 weeks of therapy. We present the differential diagnoses which need to be entertained as well as the pros and cons of very early ART intervention.

Retinal examination of diabetic patients: knowledge, attitudes and practices of physicians in Oman

Knowledge, attitudes and practices of 40 randomly selected physicians was assessed in the North Sharqiya region of Oman in 2003. We evaluated non-ophthalmologist physicians' knowledge of techniques of eye examination of diabetic patients, attitudes towards fundus examination and practices of detailed eye examination. Knowledge about different parts of the eye was satisfactory in only 58% of physicians and knowledge about method of fundus examination for diabetic retinopathy was poor in 40%. Attitudes towards eye examination by non-ophthalmologists at primary level were positive. In practice 20 physicians had attempted to use an ophthalmoscope and only 9 could see details of the retina. Our general physicians would need detailed training if they are to be involved in early detection of diabetic retinopathy.

The medical student global health experience: professionalism and ethical implications

Medical student and resident participation in global health experiences (GHEs) has significantly increased over the last decade. In response to growing student interest and the proven impact of such experiences on the education and career decisions of resident physicians, many medical schools have begun to establish programmes dedicated to global health education. For the innumerable benefits of GHEs, it is important to note that medical students have the potential to do more harm than good in these settings when they exceed their actual capabilities as physicians-in-training. While medical training programmes are beginning to provide students with the knowledge to put their GHEs in context, they must remember that they also bear the responsibility of training their students in a framework to approach these experiences in a principled and professional way. It is necessary that these institutions provide adequate and formalised preparation for both clinical and ethical challenges of working in resource-poor settings. This paper outlines potential benefits and risks of GHEs and delineates recommendations to some of the current issues.

18F-FDG uptakes in leptomeningeal metastases from carcinoma of the breast on a positron emission tomography/computerized tomography study

Leptomeningeal metastases (LM) are most commonly observed in hematological malignancies. With prolonged survival in solid tumors, an increased frequency of metastases is noted in these tumors too. Early diagnosis, when the patient has minimal neurological disability, is associated with prolonged survival and improved functional outcome although the therapy is palliative. The diagnosis of LM is difficult, and the demonstration of tumor cells in the cerebrospinal fluid remains the gold standard. This can also be done by definitive neuroimaging. MRI is routinely used in this aspect. We discuss here a case where 18F-FDG PET/CT (Fluoro-de-oxy glucose positron emission tomography/computerized tomography) study helped us in the diagnosis of LM. Whole-body PET/CT imaging could be a useful tool in identifying the possibility of metastases of breast carcinoma in the usual sites and the not-so-usual sites of metastases.

Surgical versus medical treatment with cyclooxygenase inhibitors for symptomatic patent ductus arteriosus in preterm infants

BACKGROUND

Patent ductus arteriosus (PDA) with significant left to right shunt in preterm infants increases morbidity and mortality. Early closure of the ductus arteriosus may be achieved pharmacologically using cyclooxygenase inhibitors or by surgery. The efficacy of both treatment modalities is well established. However, the preferred initial treatment of a symptomatic PDA in a preterm infant, surgical ligation or treatment with indomethacin, has not been well established.

OBJECTIVES

To compare the effect of surgical ligation of PDA vs. medical treatment with cyclooxygenase inhibitors (using indomethacin, ibuprofen, or mefenamic acid), each used as the initial treatment, on neonatal mortality in preterm infants with a symptomatic PDA.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. This included search of electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 - July 2007), CINAHL (1982 - July 2007), EMBASE (1980 - July 2007); and hand search of abstracts of Pediatric Academic Societies annual meetings published in Pediatric Research (1990 - April 2002) or on line from May 2002 -July 2007. No language restrictions were applied.

SELECTION CRITERIA

All trials 1) using randomized or quasi-randomized patient allocation, 2) in preterm infants < 37 weeks gestational age or low-birth-weight infants (< 2500 grams) with symptomatic PDA in the neonatal period (< 28 days) and 3) comparing surgical ligation with medical treatment with cyclooxygenase inhibitors, each used as the initial treatment for closure of PDA.

DATA COLLECTION AND ANALYSIS

Assessment of methodological quality and extraction of data for included trials was undertaken independently by the authors. RevMan 4.1 was used for analysis of the data.

MAIN RESULTS

Only one study, trial B in the report of Gersony 1983, was found eligible. No additional studies were identified in the literature searches performed in July 2007. The trial compared the effect of surgical ligation of PDA vs. medical treatment with indomethacin, each used as the primary treatment. No trials comparing surgery to other cyclooxygenase inhibitors (ibuprofen, mefenamic acid) were found. Trial B of Gersony 1983 enrolled 154 infants. The study found no statistically significant difference between surgical closure and indomethacin treatment in mortality during hospital stay, chronic lung disease, other bleeding, necrotizing enterocolitis, sepsis, creatinine level, or intraventricular hemorrhage. There was a statistically significant increase in the surgical group in incidence of pneumothorax [RR 2.68 (95% CI 1.45, 4.93); RD 0.25 (95% CI 0.11, 0.38); NNH 4 (95% CI 3, 9)] and retinopathy of prematurity stage III and IV [RR 3.80 (95% CI 1.12, 12.93); RD 0.11 (95% CI 0.02, 0.20), NNH 9 (95% CI 5, 50] compared to the indomethacin group. There was as expected a statistically significant decrease in failure of ductal closure rate in the surgical group as compared to the indomethacin group: [RR 0.04 (95% CI 0.01, 0.27); RD -0.32 (95% CI -0.43, -0.21), NNT 3 (95% CI 2, 4)].

AUTHORS' CONCLUSIONS

The data regarding net benefit/harm are insufficient to make a conclusion as to whether surgical ligation or medical treatment with indomethacin is preferred as initial treatment for symptomatic PDA in preterm infants. It should be noted that three recent observational studies indicated an increased risk for one or more of the following outcomes associated with PDA ligation; chronic lung disease, retinopathy of prematurity and neurosensory impairment . It is possible that the duration of the "waiting-time" and transport to another facility with surgical capacity to have the PDA ligated could adversely affect outcomes, as could the perioperative care.

Ibuprofen for the treatment of patent ductus arteriosus in preterm and/or low birth weight infants

BACKGROUND

A patent ductus arteriosus (PDA) complicates the clinical course of preterm infants, increasing their risks of developing chronic lung disease (CLD), necrotizing enterocolitis (NEC), and intraventricular hemorrhage (IVH). Indomethacin is used as standard therapy to close a PDA, but is associated with reduced blood flow to the brain, kidneys and gastrointestinal tract. Ibuprofen, another cyclo-oxygenase inhibitor, may be as effective as indomethacin, with fewer side effects.

OBJECTIVES

To determine the effectiveness and safety of ibuprofen compared to placebo or no intervention for closing a PDA in preterm and/or low birth weight infants. To determine the effectiveness and safety of ibuprofen compared to other cyclo-oxygenase inhibitors (including indomethacin, mefenamic acid) for closing a PDA in preterm and/or low birth weight infants.

SEARCH STRATEGY

Randomized or quasi-randomized controlled trials (RCTs) comparing ibuprofen to placebo or indomethacin or mefenamic acid for therapy of PDA were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2007), MEDLINE (1996 - August 2007), CINAHL (1982 - August 2007), EMBASE (1980 - August 2007), reference lists of published RCTs and abstracts from the Pediatric Academic Societies and the European Society for Pediatric Research meetings published in Pediatric Research (1991 - April 2005) or on their website (to August 2007). No language restrictions were applied.

SELECTION CRITERIA

1) DESIGN: Randomized or quasi-randomized controlled trials2) POPULATION: Preterm (< 37 weeks gestational age) or low birth weight infants (< 2500 g) with a clinically or echocardiographically diagnosed PDA3) INTERVENTION: Administration of ibuprofen (orally or intravenously) for the closure of PDA4) OUTCOMES: At least one of the following outcomes were reported: failure to close a PDA, mortality, surgical ductal ligation, intraventricular haemorrhage (IVH), periventricular leukomalacia (PVL), NEC, decreased urine output, retinopathy of prematurity (ROP), chronic lung disease (CLD), sepsis, pulmonary hemorrhage, pulmonary hypertension, duration of supplementary oxygen, duration of mechanical ventilation, duration of hospital stay, and serum creatinine levels following treatment.

DATA COLLECTION AND ANALYSIS

At least two review authors worked independently at each step of the original review, then compared results and resolved differences. The current update was conducted by one review author (AO). Methodological quality of eligible studies was assessed according to blinding of randomization, of intervention and of outcome assessment, and completeness of follow up. Weighted treatment effects, calculated using RevMan 4.2.10, included typical relative risk (RR), typical risk difference (RD), number needed to treat to benefit (NNT) or harm (NNH), and weighted mean difference (WMD), all with 95% confidence intervals (CI). A fixed effect model was used for meta-analyses. Heterogeneity tests including the I-squared test (I(2)) were performed to assess the appropriateness of pooling the data.

MAIN RESULTS

No studies using mefenamic acid were identified. Sixteen studies enrolling 876 infants were identified. Four additional trials were identified for this update and two studies published as abstracts were now available as full articles. One study compared ibuprofen to placebo, but the results were not reported unblinded to intervention group. Fifteen studies including 740 infants compared the effectiveness of ibuprofen to indomethacin for the closure of a PDA. For the primary outcome (failure of ductal closure), there was no statistically significant difference between ibuprofen and indomethacin groups [typical RR 0.99 (95% CI 0.78, 1.27); typical RD 0.00 (95% CI -0.06, 0.06)]. There were no statistically significant differences in mortality, reopening of the ductus, need for surgical duct ligation, duration of ventilator support, duration of supplementary oxygen, pulmonary hemorrhage, pulmonary hypertension, CLD, IVH, PVL, NEC, intestinal perforation, gastrointestinal bleed, time to full enteral feeds, time to regain birth weight, ROP, sepsis, duration of hospitalization. Ibuprofen treatment was associated with statistically significantly lower serum creatinine levels after treatment (6 trials, 336 infants; WMD - 8.2 (95% CI -13.3, -3.2) mmol/L and lower incidence of 'decreased urine output' [3 trials, 336 infants; typical RR; 0.22 (95% CI 0.09, 0.51); typical RD -0.12 (95% CI -0.18, -0.06); NNT 8 (95% CI 6,17)]. There was moderate heterogeneity of treatment effect for the outcomes 'time to regain birth weight' and 'decreased urine output". Heterogeneity was not noted for other outcomes. For several of these outcomes, the sample size was small and the estimates imprecise. There are not enough data available regarding the effectiveness of oral ibuprofen compared with indomethacin to close a PDA [3 trials, 69 infants; typical RR 1.41 (95% CI 0.68, 2.93); typical RD 0.10 (95% CI -0.10, 0.30)]. Pulmonary hypertension was noted in one infant receiving ibuprofen to close a PDA enrolled in a trial in this review and an additional report of such a case was identified from the literature.

AUTHORS' CONCLUSIONS

No statistically significant difference in the effectiveness of ibuprofen compared to indomethacin in closing a PDA was found. Ibuprofen compared with indomethacin reduces the risk of oliguria and is associated with lower serum creatinine levels following treatment. Pulmonary hypertension has been observed in three infants after prophylactic use of ibuprofen and one infant receiving ibuprofen for treatment in this review developed pulmonary hypertension. One additional case of pulmonary hypertension following treatment with ibuprofen to close a PDA was identified from the literature. The available data support the use of either drug for the treatment of a PDA. As both drugs are equally effective in closing a PDA, the clinician needs to weigh the potential side effects of one drug vs. the other when making a decision which drug to use. The most urgent research question to be answered is whether ibuprofen compared to indomethacin confers an improved rate of intact survival (survival without impairment) at 18 months corrected age and at the age of school entry.

Eating disorders and concurrent psychopathology: a reconceptualisation of clinical need through Rasch analysis

Therapies for anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and eating disorder not otherwise specified (EDNOS) take as their focus, perhaps of necessity, the eating disorder symptomatology. However, there is increasing evidence of comorbidity of psychopathological mechanisms (e.g. perfectionism, depression) with eating disorders which, left untreated, may diminish any therapeutic effects. Thus identifying the extent of comorbidity in an eating disorder population and assessing the relationship between psychopathological mechanisms and the eating disorder is important. Rasch analysis was applied to the findings from questionnaires (EDI-2; SCL90-R) completed by 105 female patients referred to an eating disorder unit. General psychopathology was found to be more indicative of 'caseness' than eating disorder psychopathology. In particular, interpersonal sensitivity, depression and mild interpersonal aspects of psychoticism emerged as important factors across eating disorders. The comorbidity of psychopathological mechanisms needs to be given consideration in the successful treatment of eating disorders.

The polyphenol (-)-epicatechin gallate disrupts the secretion of virulence-related proteins by Staphylococcus aureus

AIM

(-)-epicatechin gallate (ECg) modifies the morphology, cell wall architecture and beta-lactam antibiotic susceptibility of Staphylococcus aureus. As these effects result primarily from intercalation into the bacterial cytoplasmic membrane, the capacity of ECg to modulate the secretion of two key staphylococcal virulence factors, coagulase and alpha-toxin, was examined.

METHODS AND RESULTS

Bioassays were used to determine coagulase and haemolysin activity in culture supernatants of a number of S. aureus isolates grown in the presence and absence of ECg; alpha-toxin secretion was also evaluated by immunoblotting. Growth in ECg reduced the levels of activity of both proteins in culture supernatants; the effects could only be partly explained by ECg-mediated inhibition of bioactivity and by induction of secreted proteases.

CONCLUSION

ECg suppresses the secretion of coagulase and alpha-toxin by clinical isolates of S. aureus.

SIGNIFICANCE AND IMPACT OF THE STUDY

The observation that secretion of key components of staphylococcal virulence can be compromised by a naturally occurring polyphenol supports the notion that ECg and related compounds may have therapeutic utility for the control of infections that are currently difficult to treat due to the propensity of methicillin-resistant S. aureus to accumulate antibiotic resistance genes.