Percutaneous endourologic procedures in high-risk patients in the lateral decubitus position under regional anesthesia

BACKGROUND AND PURPOSE

The prone position is the most commonly used position for percutaneous endourologic procedures. It is usually combined with a general anesthesia. In high-risk patients, this approach can lead to circulatory and respiratory compromises. Operating on such patients in a full lateral position will minimize the hemodynamic and respiratory risks and-if combined with spinal anesthesia-will allow for increased patient comfort and safety.

PATIENTS AND METHODS

After rigorous preoperative assessment, 27 medical high-risk patients (12 men) with a mean age of 62 years and an American Society of Anesthesiologists score of 3+ were included in this study. The majority (78%) had regional anesthesia and were fully awake and alert during the operation. The procedures consisted of an initial retrograde renal study/filling with contrast medium with the patient in the lithotomy position to aid kidney puncture. The percutaneous procedure was then performed with the patient in the lateral decubitus position, and access was performed under fluoroscopic and/or ultrasonographic guidance.

RESULTS

Twenty-two percutaneous nephrolithotomies (PCNL), 3 anterograde endopyelotomies (AEP), 1 percutaneous resection of renal pelvic transitional-cell carcinoma, and 1 percutaneous renal cyst sclerotization were performed. After PCNL, 11 patients were stone free postoperatively, and a further 8 were stone free after adjuvant shockwave lithotripsy. Two patients needed temporary Double-J stents. One renal access failed. Two procedures were aborted because of hemorrhage. One patient died in the recovery room from uncontrollable renal bleeding. A renal scan after 3 months showed relief of obstruction in the three patients who had undergone AEP. Ultrasonography confirmed complete resolution of the sclerotized renal cyst. Neither of the patients with regional anesthesia needed conversion to general anesthesia. In two patients who experienced moderate pain, a "top-up" with local anesthesia solved the problem.

CONCLUSION

The full lateral position-while necessitating expertise and some learning for renal puncture from an unusual angle-is safe in medical high-risk patients. It can be safely performed using regional anesthesia, avoiding the risks of general anesthesia and allowing for patient-anesthetist communication throughout the procedure. Cardiac and respiratory parameters are improved, stable, and easily controlled. As opposed to the supine position, the awake patient is more comfortable, and morbid obesity is not a problem.

The prevalence of urethral and rectal Mycoplasma genitalium and its associations in men who have sex with men attending a genitourinary medicine clinic

OBJECTIVES

To determine the prevalence of rectal and urethral Mycoplasma genitalium (MG) in men who have sex with men (MSM) attending a genitourinary medicine clinic and to measure its associations with symptoms, clinical signs, sexual behaviour and concomitant sexually transmitted infections (STI).

METHODS

MSM attending for STI screening were tested for MG using a real-time PCR assay that targets the MgPa gene. Data were collected on demographics, sexual behaviour, past STI history and clinical symptoms and signs.

RESULTS

849 first-void urine and rectal specimens were collected from 438 MSM. The overall prevalence of MG in MSM was 6.6% with first-void urine positivity of 2.7% and rectal positivity of 4.4%. MG was significantly associated with HIV positivity (OR 7.6, 95% CI 3.2 to 18.7, p<0.001) in contrast to Chlamydia trachomatis (OR 1.5, 95% CI 0.5 to 4.1, p=0.4) and Neisseria gonorrhoeae (OR 1.7, 95% CI 0.7 to 3.8, p=0.194). MG was more prevalent than C trachomatis (p=0.15) and N gonorrhoeae (p=0.02) in this subgroup of HIV-positive MSM. Urethral infection was associated with dysuria (p<0.001) but there was no association between rectal infection and anorectal symptoms or signs.

CONCLUSION

Rates of MG are much higher in HIV-positive MSM than HIV-negative MSM at both urethral and rectal sites, and MG is more prevalent in HIV-positive MSM than other bacterial STI. Although the subclinical nature of MG in the rectum questions its significance, the high prevalence seen at this site could be a potential source of onward urethral transmission. Future work should assess the need for appropriate screening and treatment of MG infection in MSM, particularly those with HIV infection and high-risk sexual behaviour.

Mycoplasma genitalium in asymptomatic patients: implications for screening

OBJECTIVES

Mycoplasma genitalium is well established as a cause of urethritis and has also been associated with cervicitis, endometritis and pelvic infection. Low rates of infection suggest screening may be inappropriate in the general population, but it remains unclear whether asymptomatic patients attending a sexual-health clinic should be tested routinely. The objective of this study was to measure the positivity rate of M genitalium infection in asymptomatic individuals presenting to a sexual-health clinic to inform the need for screening in this population.

METHODS

Asymptomatic patients were identified using a structured questionnaire and tested for M genitalium from genital swabs or urine using two separate polymerase chain reaction (PCR) assays incorporating different primer sequences.

RESULTS

1304 patients were approached over a 6-month period. 743 (57%) patients were symptomatic, and 168 (13%) refused consent, leaving 394 (30%) patients who entered the study. Residual samples were available for 308 (79%) patients, 168 (54%) men and 140 (46%) women. 14/308 (4.5%, 95% CI 2.2 to 6.9%) asymptomatic patients were infected with M genitalium, and an additional 2 (0.6%, 95% CI 0.2 to 2.3%) patients had discrepant PCR results. No significant associations were found between M genitalium infection and age, gender, ethnicity or isolation site.

CONCLUSION

The positivity rate of M genitalium infection in asymptomatic sexual-health clinic attendees is comparable with that of gonorrhoea or chlamydia, and, if evidence of pathogenicity continues to accumulate, a further assessment of the role of routine screening in this setting would be appropriate.

Rapid assessment of soil erosion in the Rio Lempa Basin, Central America, using the universal soil loss equation and geographic information systems

Soil erosion is a severe problem for many developing regions that lack adequate infrastructure to combat the problem. The authors established a first-order method for prioritizing areas to be examined and remediated using preexisting data and expert knowledge where data are lacking. The Universal Soil Loss Equation was applied to the Rio Lempa Basin in Central America using geographic information systems and remote sensing technologies, and the estimated erosion rates were compared with sediment delivery ratios. Spatial analysis indicates that agriculture on very steep slopes contributes only a small fraction to the total estimated soil erosion, whereas agriculture on gentle and moderately steep slopes contributes a large fraction of the erosion. Although much of the basin is in El Salvador, the greatest estimated amount of erosion is from Honduras. Data quality and availability were impaired by a lack of coordination among agencies and across countries. Several avenues for improving the authors' methods are described.

Chemical incidents: are we ready in the West Midlands? Testing the communication arrangements of on-call public health doctors

Primary care trusts are responsible for handling major chemical hazards. This includes the testing and exercising of plans in a regular and routine manner. The Chemical Hazards and Poisons Division (Birmingham), which provides a 24-h, 365-day resource for the West Midlands region in the UK, undertook an audit to test the out-of-hours communication arrangements of public health doctors. The audit revealed that there is an urgent need to: (1) review contact details within on-call packs; (2) ensure that doctors performing on-call duties know, at the very least, the names of the primary care trusts/local authorities, county councils/other trusts in the area; and (3) ensure a failsafe method for contacting the person on call for public health.

Reflections on the meritocracy debate in Britain: a response to Richard Breen and John Goldthorpe

A paper by Breen and Goldthorpe recently claimed to have exposed 'fatal flaws' in my work on meritocracy in Britain. This paper responds to their criticisms. The results of their re-analysis of the NCDS data set are shown to be consistent with my earlier findings and arguments. Furthermore, re-running some of my earlier models using measures that they favour and a method designed to privilege their position, the results once again demonstrate that, while class origins have some effect on class destinations (in particular, for those born into the middle class), ability and effort exert a much greater effect. Based on these results, the paper identifies three core propositions about meritocracy in Britain on which all parties to this debate should now be able to agree.

Effect of ovariectomy on adipose tissue of mice in the absence of estrogen receptor alpha (ERalpha): a potential role for estrogen receptor beta (ERbeta)

Adipose tissue deposition is highly responsive to estrogen; ovariectomy increases adipose deposition, and estrogen replacement reverses this. Estrogen receptor alpha (ERalpha) plays a major role in adipose tissue. ERalpha knockout (alphaERKO) mice show an increase in adipose tissue of over a 100 % compared to wild-type mice. However, alphaERKO mice undergo a 10-fold increase in 17beta-estradiol (E2), and persistent or even increased signaling through ERbeta could be a factor in obesity of alphaERKO mice. To test the hypothesis that ERbeta plays a role in adipose tissue, adult female alphaERKO mice were ovariectomized or sham-ovariectomized and fed a phytoestrogen-free diet. Ovariectomized mice were treated with vehicle or E2, and bodyweights and food consumption were measured. Mice were killed after 28 days and inguinal and parametrial fat pads collected. Sham-ovariectomized alphaERKO mice had increased body weight, ovariectomized alphaERKO mice showed a 6 % decrease, and E2 replacement restored body weight to sham levels. Fat pads of ovariectomized alphaERKO mice showed 45 % and 16 % decreases in weight and adipocyte circumference, respectively, compared to sham-ovariectomized or E2-replaced ovariectomized alphaERKO mice. Ovariectomized alphaERKO mice showed a trend towards decreased feed consumption that did not reach significance. Blood glucose levels were lower both before and after glucose injection in ovariectomized compared to sham alphaERKO mice, and E2 treatment reversed this. Insulin levels following glucose challenge were lower in ovariectomized compared to sham-ovariectomized alphaERKO mice, indicating that ovariectomy ameliorated the glucose intolerance and insulin resistance in alphaERKO mice. Immunohistochemical analysis revealed strong staining for ERbeta in adipose tissue. These observations indicate that removing E2/ERbeta signaling in alphaERKO mice by ovariectomy decreases body and fat-pad weights and adipocyte size, while improving insulin and glucose metabolism. ERbeta mediated effects on adipose tissue are opposite those of ERalpha, although E2 effects on adipose tissue are predominately through ERalpha.