Safety and efficacy of the supracostal access for percutaneous nephrolithotomy: our initial experience

The aim of this study was to evaluate the safety and efficacy of the supracostal access for percutaneous nephrolithotomy (PCNL). Between July 2007 and June 2010, 122 patients underwent PCNL, of whom 28 (23%) had supracostal access. All procedures were performed in a single sitting under general anesthesia. The data were analysed for indications, stone clearance rates and the complications associated with supracostal puncture. The indications for a supracostal access were staghorn stones (50%), pelvis stones (28.5%), calyceal stones in high-lying kidney (18%) and upper ureter/ureteric stones (3.5%). All tracts were made in the 11th intercostal space. Single tract access was used in 22 cases (78%), but 6 (22%) required a second tract. Additional punctures were required mainly for staghorn stones (4 out of 14). Overall, 82% of the patients were rendered stone free or had clinically insignificant residual stones with PCNL monotherapy, and this increased to 96% with secondary procedures. In patients with staghorn stones, they were completely cleared in 78%. Overall complication rate was 28% and included hydrothorax in 3 (10%) patients, which required insertion of a chest tube. One (3.5%) patient developed haemothorax secondary to injury of the intercostal artery, pelvic perforation in 1 (3.5%), perinephric collection in 1 (3.5%), infection/sepsis in 2 (7%). Except those patients who had complication, all other patient recovered uneventfully. Postoperative hospital stay ranged from 2 to 9 days. In conclusion, supracostal access gives high clearance rate with acceptable complications and should not be avoided for fear of chest complications.

Abstracting the triad of death, existence and adjustment to death: death and adjustment hypotheses

Viewed from a naturalistic and scientific perspective, death appears to represent the permanent cessation of human existence, contributing to the widespread experience of death anxiety. The present argument attempts to deconstruct this argument on epistemological grounds by analyzing

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Hematology and serum chemistry reference values of stray dogs in Bangladesh

Hematology and serum chemistry values were obtained from 28 male and 22 female stray dogs in Chittagong Metropolitan area, Bangladesh. The goal of the study was to establish reference value for hematology and serum chemistry for these semi wild animals in relation to age, sex, reproductive stage and body condition. No significant differences were found for mean values of hemoglobin, packed cell volume, mean corpuscular hemoglobin concentration, white blood cell, differential leukocyte count, total protein, albumin, glucose, cholesterol, phosphorus and potassium among or between sexes, ages, reproductive states or body conditions. Significant differences were noted for erythrocyte sedimentation rate (p<0.02) between sexes. Among different age groups significant differences were found for total red blood cell count (p<0.001). Different body conditions have significant differences in red blood cell count, mean corpuscular volume and mean corpuscular hemoglobin (p<0.001). Pregnant and non-pregnant females differed significantly in their red blood cell count, mean corpuscular volume and mean corpuscular hemoglobin (p<0.001).

Effect of single dose intravenous zoledronic acid on bone mineral density in post-menopausal osteoporosis of Bangladeshi women

The osteoporosis is a major health threat that affects every third post-menopausal women. Postmenopausal osteoporosis is complicated with vertebral, femoral or radius fracture. This prospective study on post-menopausal osteoporosis was carried out in the Pain Centre, Department of Anaesthesia, Analgesia and Intensive Care Medicine of BSMMU, Dhaka during the period of January 2008 to January 2010. The post-menopausal women with back pain were screened by spinal radiographs and dual-energy X-ray absorptiometry (DXA) of lumbar spine to determine the bone mineral density (BMD). The woman after menopause with a BMD T-score of -2.5 or less with or without evidence of vertebral fracture is considered as post-menopausal osteoporosis. A total of 55 post-menopausal osteoporotic patients were assigned to receive a single dose of IV infusion of zoledronic acid (5 mg) along with dietary calcium and vitamin-D. The spinal radiographs and dual-energy X-ray absorptiometry (DXA) were repeated in all the 55 patients at 12 months following zoledronic acid infusion. The mean BMD of lumbar spine increased significantly from pre-infusion value of 0.75695 g/cm2 to post-infusion of 0.80216 g/cm2. The T-score also increased from pre infusion value of -3.567 +/- 0.77 to -3.158 +/- 0.08 in 12 months following the infusion (P < 0.01). The increase is 5.026% higher than pre infusion values. The spinal radiographs taken before infusion of zoledronic acid, showed 14 fractures. There was no new fracture in any case during the 12 months study period. So, it can be concluded that once yearly IV infusion of zoledronic acid is associated with a significant increase in BMD and decrease in the risk of vertebral fracture.

Current management of isolated sternal fractures in the UK: time for evidence based practice? A cross-sectional survey and review of literature

Routine admission of patients with isolated sternal fractures for observation is still widespread in the UK. However, the evidence appears to suggest that this is unnecessary. We undertook a cross-sectional telephone survey of management of isolated sternal fractures in the UK. We contacted 85 acute admitting units over a three-month period and were able to get a response from 67 units. Most of the hospitals were district general hospitals (52) and situated in England (49). The orthopaedic department was the most common admitting department. 51 units indicated that they regularly admit isolated sternal fractures for observation. Other indications for admission included pain control (33), abnormal cardiac enzymes (28), social circumstances (23), abnormal electrocardiogram (6), and low oxygen saturation (5). Chest X-ray was performed on admission in all hospitals. 57 hospitals performed ECG and cardiac enzyme tests prior to admission and 6 hospitals carried out echocardiogram following admission on a regular basis. Patients were not followed up on discharge. 2 hospitals with on-site cardiothoracic unit followed-up patients on discharge, and 1 hospital advised GP follow-up. A review of the literature indicated that patients with isolated sternal fractures are at low risk of significant cardiac, pulmonary or mediastinal complications and do not need extensive investigations or routine admission. The current practice of management of isolated sternal fractures in the UK does not appear to conform to available evidence. In order to decide on management plans based on more rigorous evidence, there is a need for a prospective double blind randomised study of patients with isolated sternal fractures, comparing those discharged to those admitted over a longer follow-up period.

Wilms tumor in adult

Wilms Tumor (WT) is a very rare malignancy in adults representing 1% of all renal neoplasms. It is however the most common renal tumor of children and adult patients are treated like pediatric cases. Bilateral tumors occur in 5% of adult cases. The typical presenting features are asymptomatic abdominal mass (most common), hematuria, pain, fever, and hypertension. As clinical presentation of WT is similar to that of renal cell carcinoma (RCC), it tends to be an unsuspected pathological diagnosis in most cases. The diagnosis of the tumor needs positive sonographic and computed tomography (CT) findings with histopathological confirmation. Prognosis of adult WT is relatively poor and resistant to chemotherapy. We present a case of wilms tumor in a 68 years old male patient with right sided non tender abdominal mass and occasional flank pain. The patient was normotensive but hematuric and radiological findings suggested right renal mass with enlarged lymph node and histopathological analysis revealed nephroblastoma associated with lymph node metastases.

Subclinical thyroid dysfunction does not affect one-year mortality in elderly patients after hip fracture: a prospective longitudinal study

Mortality after hip fractures in the elderly is one of the most important patient outcome measures. Subclinical thyroid dysfunction is common in the elderly population. This is a prospective study of 131 elderly patients with a mean (SD) age of 82.0 (8.9) years (range: 61-94) admitted consecutively to our trauma unit. The aim of the study was to determine the prevalence of subclinical thyroid dysfunction in an elderly cohort of patients with hip fracture and to determine if this affects the one-year mortality. There were three times more women (n=100) than men (n=31) in this cohort. All patients underwent surgical treatment for the hip fracture. The prevalence of subclinical hypothyroidism (TSH>5.5 mU/L) was 15% (n=20) and of subclinical hyperthyroidism (TSH<0.35 mU/L) was 3% (n=4). Overall 18% (n=24) of patients had a subclinical thyroid dysfunction. The twelve-month mortality was 27% (n=36). Age, gender, heart rate at admission, pre-existing coronary heart disease, ASA grade and presence of overt or subclinical thyroid dysfunction were analysed for association with twelve-month mortality using a forward stepwise logistic regression analysis. Only ASA grade was found to significantly affect mortality at twelve months (chi(2)=3.98, df=1, p=0.046). Independently the presence of subclinical hypo- or hyperthyroidism was not associated with a higher mortality (p=0.477). We conclude that subclinical thyroid dysfunction does not affect the one-year mortality in elderly patients treated surgically for hip fracture.

Lymphocystis disease virus persists in the epidermal tissues of olive flounder, Paralichthys olivaceus (Temminch & Schlegel), at low temperatures

Olive flounder artificially infected with lymphocystis disease virus (LCDV) were reared at 10, 20 and 30 degrees C for 60 days, to compare LCD-incidence. In the fish reared at 20 degrees C, lymphocystis cells appeared on the skin and fins at 35 days post-challenge, and the cumulative LCD-incidence was 80% at 60 days. High levels of LCDV, with a mean polymerase chain reaction (PCR) titre of 10(6) PCR-U mg(-1) tissue, were detected in the fins and skin of LCD-affected fish at 20 degrees C, but were not detected in the spleen, kidney, brain and intestinal tissues of these fish. No LCD clinical signs were observed in the fish reared at 10 degrees C and 30 degrees C; however, a low level of LCDV (10(3) PCR-U mg(-1) tissue) was detected in the fins and skin of these fish. By increasing the rearing temperature from 10 to 20 degrees C, lymphocystis clusters appeared on the skin and fins of the fish with no previous LCD clinical signs within 33 days after the temperature change. It was shown that permissive cells for LCDV infection exist in the epidermis of olive flounder. At low temperatures, small amounts of LCDV were able to persist over a period extended for a further 45 days in the fish epidermis, even though the fish showed no LCD clinical signs. The optimum growth temperature of LCDV is near 20 degrees C.

Tobacco smoke: a critical etiological factor for vascular impairment at the blood-brain barrier

Active and passive tobacco smoke are associated with the dysfunction of endothelial physiology and vascular impairment. Studies correlating the effects of smoking and the brain microvasculature at the blood-brain barrier (BBB) level have been largely limited to few selective compounds that are present in the tobacco smoke (TS) yet the pathophysiology of smoking has not been unveiled. For this purpose, we characterized the physiological response of isolated human brain microvascular endothelial cells (HBMEC) and monocytes to the exposure of whole soluble TS extract. With the use of a well established humanized flow-based in vitro blood-brain barrier model (DIV-BBB) we have also investigated the BBB physiological response to TS under both normal and impaired hemodynamic conditions simulating ischemia. Our results showed that TS selectively decreased endothelial viability only at very high concentrations while not significantly affecting that of astrocytes and monocytes. At lower concentrations, despite the absence of cytotoxicity, TS induced a strong vascular pro-inflammatory response. This included the upregulation of endothelial pro-inflammatory genes, a significant increase of the levels of pro-inflammatory cytokines, activated matrix metalloproteinase, and the differentiation of monocytes into macrophages. When flow-cessation/reperfusion was paired with TS exposure, the inflammatory response and the loss of BBB viability were significantly increased in comparison to sham-smoke condition. In conclusion, TS is a strong vascular inflammatory primer that can facilitate the loss of BBB function and viability in pathological settings involving a local transient loss of cerebral blood flow such as during ischemic insults.