Eptifibatide-induced profound thrombocytopenia

We report a case of profound thrombocytopenia, 2 hours following eptifibatide therapy which got reversed within 12 hours of discontinuation of eptifibatide.

Correlation of radiological and clinical features of metanephric neoplasms in adults

The main objective was to determine the clinical and radiological features of metanephric neoplasms. The tumors were diagnosed on histopathological examination. The clinical data and imaging features were retrospectively analyzed. Between 1998 and 2003, 3 patients underwent radical nephrectomy for renal masses turning out as metanephric neoplasms on histopathology. Two of these tumors were metanephric adenoma (MA) and one was metanephric adenofibroma (MAF). Clinical and radiological features were reviewed. All patients were adult females who presented with flank pain. Tumor was detected on screening ultrasound as a hyperechoic lesion. In all cases CT showed a hyper-attenuating exophytic lesion with cystic areas that enhanced with IV contrast. Based on combination of clinical and imaging features it may be possible to prospectively identify metanephric neoplasms and thus avoid unnecessary radical nephrectomy in favor of conservative surgery.

Local control of high-grade gliomas with limited volume irradiation versus whole brain irradiation

INTRODUCTION

To evaluate the role of limited field radiation therapy in the management of high-grade gliomas and glioblastoma multiforme (GBM).

MATERIAL AND METHODS

From July '96 to January '98, 50 newly diagnosed patients of high-grade gliomas (Grade III and IV) and glioblastoma multiforme who underwent surgery in the form of partial, sub-total or near-total excision as the primary treatment were enrolled in this study. The patients were randomized to receive two different postoperative external radiation protocols, Study Group A: Localized field external radiotherapy 50 Gy/25#/5 wks followed by Boost 10 Gy/5#/1 wk, Control Group B: Whole brain external radiotherapy 40 Gy/20#/4 wks followed by Boost 20 Gy/10#/2 wks by localized field.

RESULTS

20/25 (80%) patients in the study group and 14/25 (56%) patients in the control group showed improvement in their Karnofsky Performance Status (KPS). Thus a significant difference in the performance status was noted in favor of limited field irradiation. No significant difference in the local response was seen between the two groups after radiotherapy. Six months progression-free survival of the study group was 44% as compared to 26% in the control group. Six months overall survival was 66.67% in the study group and 50.72% in the control group (P<0.01). Maximum recurrences were noticed within 2 cm of the original tumor margin in both the groups.

CONCLUSIONS

Although local control and survival of the patient in both the groups were same, performance status definitely improved in patients treated with localized field irradiation only.

Interferon beta in multiple sclerosis: experience in a British specialist multiple sclerosis centre

BACKGROUND

The efficacy of interferon beta (IFN beta) is well established in relapsing-remitting multiple sclerosis (MS). However, the use of this drug in clinical practice is complex, especially because it is only partially effective, its long term efficacy and side effects are unknown, its efficacy may be abrogated by the development of neutralising antibodies, compliance is variable, and its cost effectiveness is controversial.

OBJECTIVES AND METHODS

Analysis of a prospectively followed up series of 101 MS patients treated with IFN beta was undertaken to: (1) monitor the outcome of IFN beta treatment in clinical practice; (2) compare the immunogenicity of the three commercial IFN beta preparations available; (3) assess the proportion of patients fulfilling the current guidelines of the Association of British Neurologists for stopping IFN beta therapy.

RESULTS

During a median treatment period of 26 months (range 2-85), the relapse rate decreased by 41%. Although the reduction in the relapse rate was similar for all three commercial products, none of the Avonex treated patients were relapse free, compared with 19% of the Betaferon treated and 27% of the Rebif treated patients (p=0.02). Neutralising antibodies were not detected in Avonex treated patients (0 of 18), compared with 12 of 32 (38%) Betaferon treated and 10 of 23 (44%) Rebif treated patients (p=0.02). Forty of 101 (40%) patients satisfied the current (2001) Association of British Neurologists criteria for stopping IFN beta treatment at some stage during their treatment.

CONCLUSION

IFN beta is effective in reducing the relapse rate in patients with relapsing-remitting MS in routine clinical practice. However, after a median treatment duration of 26 months, 40% of initially relapsing-remitting MS patients seem to have ongoing disease activity, presenting as disabling relapses or insidious progression.

Stones associated renal pelvic malignancies

BACKGROUND

The clinico-pathological characteristics of renal pelvic malignancies associated with stones were retrospectively analyzed.

AIMS

The main objective was to define the biological behavior and prognostic factors for these malignancies.

SETTINGS & DESIGN

The tumors were classified according to the pathological types. The clinical data, imaging features and pathological features were analyzed with relation to prognosis.

MATERIAL AND METHODS

Eighteen cases of malignancies associated with stone disease were retrospectively studied. The institute review board permitted the study.

RESULTS

High incidence (15/18) of squamous cell carcinoma (SCC) was noted. The prognosis in this group of patients was uniformly poor. The median survival time was 3.6 months in the SCC group, 7.5 months in the Transitional Cell Carcinoma (TCC) group and 24 months in the Adenocarcinoma (AC) group. Infectious and systemic symptoms were noted in the majority of the patients. Preoperative Imaging techniques revealed tumor in only 2 cases. Both underwent radical extirpation and the median survival is 18 months till date. In the other 16 patients, where the initial diagnosis was made only on histological analysis of incomplete nephrectomy specimens, the survival was 3.56 months. All patients had prolonged history of staghorn stone disease with associated non-functioning kidney. We found that the main prognostic factor was the stage of the disease.

CONCLUSIONS

Malignancies associated with stone disease have insidious onset of clinical symptoms and need a high degree of suspicion to identify them pre-operatively. The grave prognosis associated with incomplete excision makes it imperative to diagnose them earlier.

Atypical herpes type 2 encephalitis associated with normal MRI imaging

We describe a case of chronic atypical herpes simplex type 2 encephalitis in an immunocompromised 68 year old man presenting with headache and cognitive changes without focal neurological or MRI findings. To our knowledge this is the first described case of herpes simplex encephalitis associated with normal MRI brain imaging and non-focal neurological examination. This further expands the range of clinical presentations that may be associated with herpes simplex encephalitis and emphasises the value of PCR for herpes simplex virus in the investigation of encephalitis regardless of imaging findings.

Substitution urethroplasty for anterior urethral strictures: a critical appraisal of various techniques

OBJECTIVE

To retrospectively compare the outcome of various techniques of substitution urethroplasty.

PATIENTS AND METHODS

Between 1989 and 2000, 109 patients (mean age 39.5 years) underwent substitution urethroplasty for recurrent anterior urethral strictures. Between 1989 and 1995 the procedure was by ventral placement of free grafts (bladder mucosa, buccal mucosa, penile skin) or penile skin flaps. From 1995 onwards the flaps and grafts (buccal mucosa) were applied either ventrally or dorsally. Stricture recurrence and the complications associated with each technique were compared.

RESULTS

Ventral onlay repairs were associated with a higher incidence of complications than dorsal repairs, e.g. postvoid dribbling (39% vs 23%, P = 0.01), ejaculatory dysfunction (20% vs 5%, P = 0.03) and flap/graft pseudo-diverticulum or out-pouching (26% vs 2.6%, P = 0.01). Superficial penile skin necrosis was significantly more common with the use of penile skin flaps than with free grafts. There was no significant difference in stricture recurrence, erectile dysfunction and residual penile deformity among the various techniques.

CONCLUSIONS

Dorsal free graft/flap onlay urethroplasty gives better results than ventrally placed free grafts/flaps. Dorsal onlay buccal mucosal urethroplasty is a versatile procedure and associated with fewer complications than other substitution methods.

Prospective evaluation of safety and efficacy of the supracostal approach for percutaneous nephrolithotomy

OBJECTIVE

To prospectively evaluate the safety and efficacy of the supracostal approach for percu-taneous nephrolithotomy (PCNL), as it is usually avoided because of concerns about potential chest complications.

PATIENTS AND METHODS

Between August 1998 and August 2001, 465 patients underwent PCNL. Supracostal access was obtained in 62 patients (63 renal units), comprising 13% of the procedures. The indications for a supracostal approach were staghorn, upper ureteric, superior calyceal stones and high-lying kidneys. The data were analysed for stone clearance, need for additional punctures and the complications associated with supracostal puncture.

RESULTS

The supracostal was the only access in 63% of the PCNL procedures. Additional punctures were required mainly for staghorn stones (15 of 23). Overall, 90% of the patients were rendered stone-free or had clinically insignificant residuals with PCNL alone. In patients with staghorn stones, they were completely cleared in 84% of renal units. Significant chest complications developed in three (5%) patients, which required insertion of a chest tube. One (2%) patient developed haemothorax secondary to injury of the intercostal artery. All the patients recovered uneventfully.

CONCLUSIONS

These results indicate that supracostal access provides high clearance rates with acceptable complications; it should not be avoided for fear of chest complications. A chest X-ray after surgery should be routine, to detect any complication.

Brain metabolite changes in cortical grey and normal-appearing white matter in clinically early relapsing-remitting multiple sclerosis

While much work has concentrated on focal white matter (WM) lesions in multiple sclerosis, there is growing evidence to suggest that normal-appearing WM (NAWM) and grey matter (GM) are also involved in the disease process. This study investigated multiple sclerosis disease effects on NAWM and cortical GM (CGM) metabolite concentrations, and the relationships between these metabolite concentrations and clinical impairment. Proton magnetic resonance spectroscopic imaging ((1)H-MRSI) data acquired using point resolved spectroscopic (PRESS) localization (echo time 30 ms, repetition time 3000 ms, nominal voxel volume 2.3 ml) from 27 relapsing-remitting multiple sclerosis and 29 normal control (NC) subjects were processed using LCModel to estimate metabolite concentrations in millimoles per litre. (1)H-MRSI voxel tissue contents were estimated using SPM99 tissue and semi-automatic lesion segmentations of three-dimensional fast spoiled gradient recall scans acquired during the same scanning session. NAWM and CGM metabolite concentrations estimated were: choline-containing compounds (Cho); creatine and phosphocreatine (Cr); myo-inositol (Ins); N-acetyl-aspartate plus N-acetyl-aspartyl-glutamate (tNAA); and glutamate plus glutamine (Glx). CGM data came from 24 of the multiple sclerosis (mean age 35.2 years, mean disease duration 1.7 years) and 25 of the NC (mean age 34.9 years) subjects. NAWM data came from 25 of the multiple sclerosis (mean age 35.0 years, mean disease duration 1.7 years) and 28 of the NC (mean age 36.7 years) subjects. Metabolite concentrations were compared between multiple sclerosis and NC subjects using multiple (linear) regression models allowing for age, gender, (1)H-MRSI voxel tissue and CSF contents, and brain parenchymal volume. At a significance level of P < 0.05, CGM Cho, CGM and NAWM tNAA, and CGM Glx were all significantly reduced, and NAWM Ins was significantly elevated. Spearman correlations of multiple sclerosis functional composite scores with tissue metabolite concentrations were significant for the following: CGM Cr (r(s) = 0.524, P = 0.009), CGM Glx (r(s) = 0.580, P = 0.003) and NAWM Ins (r(s) = -0.559, P = 0.004). These results indicate that metabolite changes in NAWM and CGM can be detected early in the clinical course of multiple sclerosis, and that some of these changes relate to clinical status. The correlation of clinical impairment with CGM Cr and Glx but not tNAA suggests that it is more closely associated with neuronal metabolic dysfunction rather than loss in clinically early relapsing-remitting multiple sclerosis. The correlation of clinical impairment with a raised NAWM Ins may indicate that glial proliferation also relates to function at this stage of the disease.

Bladder dysfunction in acute transverse myelitis: magnetic resonance imaging and neurophysiological and urodynamic correlations

AIMS

To evaluate micturition abnormalities in acute transverse myelitis and correlate these with evoked potentials, magnetic resonance imaging (MRI), and urodynamic findings.

SETTING

Tertiary care teaching hospital.

PATIENTS

18 patients with acute transverse myelitis, aged 4-50 years; 15 had paraparesis and three quadriparesis.

METHODS

Patients with acute transverse myelitis had a neurological evaluation and tibial somatosensory and motor evoked potential studies in the lower limbs. Spinal MRI was carried out using a 1.5 T scanner. Urodynamic studies were done using Dantec UD 5500 equipment. Neurological outcome was determined on the basis of Barthel index score at six months as poor, partial, or complete. In some patients, urodynamic studies were repeated at six and 12 months.

RESULTS

Spinal MRI in 14 of the 18 patients revealed T2 hyperintense signal changes extending for at least three spinal segments in 13; one patient had normal MRI. In the acute stage, 17 patients had a history of urinary retention and one had urge incontinence. On follow up at six months two patients regained normal voiding, retention persisted in six, and storage symptoms developed in 10, of whom five also had emptying difficulties. Urodynamic studies showed an areflexic or hypocontractile bladder in 10, detrusor hyperreflexia with poor compliance in two, and detrusor sphincter dyssynergia in three. Early abnormal urodynamic findings commonly persisted at the six and 12 months examinations. Persistent abnormalities included detrusor hyperreflexia, dyssynergia, and areflexic bladder. The urodynamic abnormalities correlated with muscle tone and reflex changes but not with sensory or motor evoked potentials, muscle power, MRI signal changes, sensory level, or six months outcome.

CONCLUSIONS

Bladder dysfunction is common in acute transverse myelitis and may be the only sequel. Urodynamic study is helpful in evaluating the bladder dysfunction and also in its management.

Brain atrophy in clinically early relapsing-remitting multiple sclerosis

Brain atrophy measured by MRI is a potentially useful tool for monitoring disease progression in multiple sclerosis. The location, extent and mechanisms of brain atrophy in early disease are not well documented. Using quantitative MRI, this study investigated whole brain, grey and white matter atrophy in clinically early relapsing-remitting multiple sclerosis and its relationship to lesion measures. Data came from 27 normal control subjects (14 females and 13 males, mean age 36.1 years) and 26 subjects with clinically definite multiple sclerosis (18 females and eight males, mean age 35.1 years, mean delay from first symptom to scan 1.8 years, median Expanded Disability Status Scale score 1.0). All had three-dimensional fast spoiled gradient recall (3D FSPGR), T(1)-weighted pre- and post-gadolinium-enhanced and T(2)-weighted scans. The 3D FSPGR images were automatically segmented into grey and white matter and cerebrospinal fluid using SPM99. 3D FSPGR hypo-intense, T(2) hyper-intense, T(1) hypo-intense and T(1) post-gadolinium-enhancing lesion volumes were determined by semi-automatic lesion segmentation. The SPM99 output was combined with the 3D FSPGR lesion segmentations to quantify tissue volumes as fractions of total intracranial volumes, producing values for the brain parenchymal fraction (BPF), white matter fraction (WMF) and grey matter fraction (GMF). Comparing multiple sclerosis with control subjects, BPF, GMF and WMF were significantly reduced (P < 0.001 for all tissue fractions). Using Pearson correlations, T(2) hyper-intense and T(1) hypo-intense lesion volumes were inversely related to BPF (T(2) r = -0.78, P < 0.001; T(1) r = -0.59, P = 0.002) and GMF (T(2) r = -0.73, P < 0.001; T(1) r = -0.53, P = 0.006), but not WMF (T(2) r = -0.30, P = 0.134; T(1) r = -0.26, P = 0.199). T(1) post-gadolinium-enhancing lesion volumes were not correlated with any fractional volumes. These results indicate that significant brain atrophy, affecting both grey and white matter, occurs early in the clinical course of multiple sclerosis. The lack of correlation between lesion load measures and WMF suggests that pathological changes in white matter may occur by mechanisms which are at least partly independent from overt lesion genesis in early multiple sclerosis.

Tc-99m-labeled RBC scintigraphy and splenic hemangioma

PURPOSE

The aim of this study was to assess the diagnostic value of RBC scintigraphy in the evaluation of possible splenic hemangioma.

MATERIALS AND METHODS

RBC scintigraphy was performed on a patient with an incidental finding of a splenic mass on computed tomographic scanning. Early and delayed planar and SPECT images were obtained.

RESULTS

Delayed images revealed blood pooling of the splenic mass. This finding is similar to the characteristics seen in RBC scintigraphy for hepatic hemangioma.

CONCLUSION

RBC scintigraphy may be useful in the evaluation of possible splenic hemangioma.

Efficiency and efficacy of different intracorporeal ultrasonic lithotripsy units on a synthetic stone model

PURPOSE

The efficiency and efficacy of the available intracorporeal ultrasonic lithotripters were compared in a stone model experiment.

MATERIALS AND METHODS

Plaster of Paris (POP) stone phantoms having ratios of 1:1, 1.5:1, and 2:1 with water were fabricated into cubes of various hardnesses weighing an average of 24.6 g. The stones were immersed in water in a plastic container, and continuous irrigation through a rigid nephroscope was used. Ultrasonic lithotripters from ACMI, Olympus, Storz, and Wolf manufacturers were evaluated for efficacy in breaking up the three POP concentrations. Time to complete stone fragmentation, occurrence of probe or tubing occlusion, and probe overheating were evaluated.

RESULTS

Efficiency of fragmentation and time to fragmentation of the Storz lithotripter were significantly different from those of the Wolf (p = 0.01 and p = 0.02, respectively) and ACMI (p = 0.001 and p = 0.02, respectively) lithotripters. Comparison of the efficiency of fragmentation and time to fragmentation of the ACMI and Wolf lithotripters showed significant differences (p = 0.005 and p = 0.03, respectively) in favor of the Wolf device. The Olympus lithotriptor resulted in incomplete fragmentation of phantoms of all POP concentrations.

CONCLUSION

The Storz ultrasonic lithotriptor was found to have the lowest fragmentation time and highest efficiency in the fragmentation of phantom stones.

Endopyelotomy in poorly functioning kidney: is it worthwhile?

BACKGROUND

Endopyelotomy is a minimally invasive surgical alternative for primary ureteropelvic junction (UPJ) obstruction. However, its success in poorly functioning kidneys is controversial.

PATIENTS AND METHODS

In this retrospective study, 34 endopyelotomies performed on poorly functioning kidneys between January 1993 and December 1997 were reviewed. Of these, 13 patients had a glomerular filtration rate (GFR) <15 mL/min (Group I) and 21 had a GFR of 15 to 25 mL/min (Group II). All the patients insisted on endopyelotomy to avoid open surgery. Antegrade endopyelotomy was performed by the twin guidewire rail technique with a cold knife. An indwelling stent was kept for 2 to 6 weeks. Patients were followed up with assessment of symptoms and diuretic renograms at 3, 6, and 12 months postoperatively.

RESULTS

Endopyelotomy was considered successful in 8 of 13 patients (62%) in Group I. Success was achieved in 19 of 21 patients (90%) in Group II.

CONCLUSION

Endopyelotomy can be performed for improvement of symptoms. Stabilization or improvement in GFR is less pronounced in poorly functioning kidneys with primary UPJ obstruction.

Prognostic factors for persistent distal renal tubular acidosis after surgery for posterior urethral valve

Risk factors, including age at presentation, age at surgery, time between presentation and surgery, urodynamic abnormalities, and vesicoureteric reflux, were prospectively studied for the development of distal renal tubular acidosis (DRTA) before surgery and persistent DRTA after surgery in 24 boys with posterior urethral valve (PUV) with normal serum creatinine levels. DRTA was persistent in 11 of 17 boys (65%) at the end of follow-up after intervention. For the development of DRTA before surgery, only a longer time between presentation and surgery (intervening period) turned out to be a significant risk factor on multivariate analysis (beta = -0.13; P = 0.04). Boys with persistent DRTA after surgery had older age at presentation (P = 0.03), older age at surgery (P = 0.001), a longer intervening period (P = 0.0007), and bilateral or severe unilateral reflux (P = 0.04) before surgery. On univariate logistic regression, age at surgery (beta = -0.07; P = 0.04) and intervening period (beta = -0.13; P = 0.02) were found to be significant risk factors for persistent DRTA, but on multivariate analysis, only intervening period was found to be significant (beta = -0.13; P = 0.02). A delay in intervention after noticing voiding symptoms can predict a high incidence of DRTA before intervention and persistent DRTA after surgery in boys with PUV.

Acute urinary retention: defining the need and timing for pressure-flow studies

OBJECTIVE

To investigate the utility of "late" pressure-flow studies in predicting the outcome of prostatectomy for acute urinary retention.

PATIENTS AND METHODS

Fifty-eight patients with acute urinary retention were prospectively assessed using the International Prostate Symptom Score and pressure-flow studies at a median (range) of 24 (13-60) days after the episode of retention, and before transurethral resection of the prostate. Bladder outlet obstruction and bladder contractility were graded using a modified adaptation of Schäfer's passive urethral linear resistance relation.

RESULTS

Fifty-six (97%) patients generated a voluntary detrusor contraction, with a mean (range) detrusor pressure at maximum flow of 72.7 (5-144) cmH2O, and 43 (75%) patients were deemed to be obstructed. Eight (16%) patients failed to void after prostatectomy and required clean intermittent catheterization. There were statistically significant differences between successful and unsuccessful patients in mean (SD) age, at 66.30 (6.9) vs 78.8 (2.6) years (P = 0.001), detrusor instability (49% vs 0%, P = 0.01), inability to void during pressure study (8% vs 75%, P = 0.001), and maximal detrusor pressure in the voiding phase, at 80 (36.0) vs 19 (11.2) cmH2O (P = 0.001).

CONCLUSIONS

In patients with acute urinary retention, pressure-flow studies undertaken after a period of adequate bladder rest (> 3 weeks) are useful in predicting the surgical outcome. Old age, absence of bladder instability, inability to void during the pressure-flow study and a maximal detrusor pressure of < 20 cmH2O are associated with a poor outcome after prostatectomy.