Should transplant ureter be stented routinely or not?

OBJECTIVE

To compare early complications in patients with/without stents following renal transplantation and to determine whether routine stenting should be used in all renal transplant patients or not.

PATIENTS AND METHODS

194 patients (108 males, 86 females, mean age: 45.2 ± 13.2 years) who were followed-up at the Division of Nephrology of Istanbul Bilim University between 2006 and 2013 were included in the study. Demographic characteristics, etiologies of renal disease, comorbidities, type of renal transplantation, early complications, delayed graft function were retrospectively recorded. All patients were divided into two groups according to stent replacement. Early complications were compared.

RESULTS

101 patients were inserted double-J(DJ) stent (48 females, mean age 46.5 ± 13.7 years, mean body mass index [BMI] 26.1 ± 4.7 kg/m²) and 93 patients were not inserted stent (38 females, mean age 43.7 ± 12.6 years, mean BMI 24.3 ± 4.2 kg/m²). The rate of early complications of urinary tract infections, lymphocele, urinary leaks, wound infection and perirenal hemorrhage of patients with stent were 28.9%,3.0%,4.0%, 5.1% and 1.3%, respectively, while these rates among patients without stent were 35.5%, 2.2%,3.2%,6.5% and 1.2%,respectively. There was no significant difference between with stent and without stent groups with regard to early complications.

CONCLUSIONS

Routine DJ stenting in all renal transplant patients is not necessary. Prophylactic use of DJ stent has no effect on early complications. Prophylactic DJ stent replacement can be used in obese patients, in patients receiving cadaveric transplants or in patients receiving transplants from unrelated donors.

Calcium and vitamin D intake influence bone mass, but not short-term fracture risk, in Caucasian postmenopausal women from the National Osteoporosis Risk Assessment (NORA) study

The impact of calcium and vitamin D intake on bone density and one-year fracture risk was assessed in 76,507 postmenopausal Caucasian women. Adequate calcium with or without vitamin D significantly reduced the odds of osteoporosis but not the risk of fracture in these Caucasian women.

INTRODUCTION

Calcium and vitamin D intake may be important for bone health; however, studies have produced mixed results.

METHODS

The impact of calcium and vitamin D intake on bone mineral density (BMD) and one-year fracture incidence was assessed in 76,507 postmenopausal Caucasian women who completed a dietary questionnaire that included childhood, adult, and current consumption of dairy products. Current vitamin D intake was calculated from milk, fish, supplements and sunlight exposure. BMD was measured at the forearm, finger or heel. Approximately 3 years later, 36,209 participants returned a questionnaire about new fractures. The impact of calcium and vitamin D on risk of osteoporosis and fracture was evaluated by logistic regression adjusted for multiple covariates.

RESULTS

Higher lifetime calcium intake was associated with reduced odds of osteoporosis (peripheral BMD T-score < or =-2.5; OR = 0.80; 95% CI 0.72, 0.88), as was a higher current calcium (OR = 0.75; (0.68, 0.82)) or vitamin D intake (OR = 0.73; 95% CI 0.0.66, 0.81). Women reported 2,205 new osteoporosis-related fractures. The 3-year risk of any fracture combined or separately was not associated with intake of calcium or vitamin D.

CONCLUSIONS

Thus, higher calcium and vitamin D intakes significantly reduced the odds of osteoporosis but not the 3-year risk of fracture in these Caucasian women.

Thymoma: surgical results of 73 cases

PURPOSE

Thymomas are uncommon tumours; they represent a broad spectrum of morphological and clinical behaviour. The purpose of this study is to identify the factors that influence survival.

METHOD

Seventy-three patients with thymoma who underwent thymectomy between 1980 and 2002 were reviewed. Prognostic factors assessed were: age, sex, presenting symptoms, histological features, stage at diagnosis and extent of surgical resection.

RESULTS

Complete resection was achieved in 67 patients and incomplete in 6. Survival rates of patients in the 1st or 2nd stages were 100% and 92.8% for 10 years, respectively. A high incidence of myasthenia gravis (MG) associated thymomas (80.8%) was found. These patients had better survival rates when compared to non-myasthenic patients. However the mortality rate for malign thymomas was high (65.7%) due to tumoral invasion. The histological types of thymoma did not influence the survival rate.

CONCLUSIONS

The association of MG with thymoma enables earlier detection of tumour, thus higher survival rates were achieved in these patients. Survival was also related to the stage of the tumour at diagnosis and the completeness of resection.

Usefulness of exchange transfusion in acute liver failure due to severe falciparum malaria

Acute hepatic failure is a rare and serious complication of severe falciparum malaria. The management of uncomplicated falciparum malaria comprises of specific antimalarial drugs and supportive therapy. In a few patients who are critically ill because of severe falciparum malaria and heavy parasitaemia, exchange transfusion has been used. We describe a young male Saudi patient who presented with a 2-day history of fever, jaundice, and confusion. On examination he was deeply jaundiced, confused, and irritable. There were no signs of chronic liver disease. His laboratory workup revealed a markedly raised direct hyperbilirubinaemia and transaminases with prolonged prothrombin time. His serology was negative for HbsAg, HBc IgM, anti-HCV, HAV IgM, HEV IgM, and IgG. He was initially treated with parenteral quinine and other supportive treatment, without any improvement of his clinical and laboratory parameters. At this stage he was treated with whole blood exchange transfusion. He slowly improved, with complete normalization of his liver function tests and prothrombin time.

Behçet's disease. An insight from a vascular surgeon's point of view

Behçet's syndrome is a multisystem inflammatory disease with unknown aetiology, vasculitis being its major pathological feature. It runs an undulating course of exacerbations and remissions with a frequency that usually abates with the passage of time. Following its first description in the medical literature in 1937, many clinical manifestations, including recurrent ulcerations, eye and urogenital lesions, pulmonary and vascular involvement with thrombus and aneurysm formation, arthritis and neurological features were reported. Various studies undertaken in two Medical Faculties of Istanbul University showed that more than 5000 patients have fulfilled three or more International Behçet's Disease Study Group Criteria and thus can be diagnosed as Behçet's Disease. A total of 142 cases with pulmonary, 30 cases with arterial (non-pulmonary) and 10 cases with cardiac involvement were demonstrated since 1978. A group of 174 neuro-Behçet's Disease patients (cerebral venous and vena caval thrombosis as the cause of intracranial hypertension, extracranial vertebral artery dissection) was evaluated. Our collected data showed that surgery with special techniques and in highly selected cases may be useful if used with adjuvant medical therapy, but might be fatal or unsuccessful in the majority. No means of aggressive surgical or interventional therapy has a role in altering the course of the pathology itself when used alone and thus medical treatment is crucial to suppress the exacerbations.

Overconfidence: It Depends on How, What, and Whom You Ask

Many studies have reported that the confidence people have in their judgments exceeds their accuracy and that overconfidence increases with the difficulty of the task. However, some common analyses confound systematic psychological effects with statistical effects that are inevitable if judgments are imperfect. We present three experiments using new methods to separate systematic effects from the statistically inevitable. We still find systematic differences between confidence and accuracy, including an overall bias toward overconfidence. However, these effects vary greatly with the type of judgment. There is little general overconfidence with two-choice questions and pronounced overconfidence with subjective confidence intervals. Over- and underconfidence also vary systematically with the domain of questions asked, but not as a function of difficulty. We also find stable individual differences. Determining why some people, some domains, and some types of judgments are more prone to overconfidence will be important to understanding how confidence judgments are made. Copyright 1999 Academic Press.

Survival rates in patients with primary malignant brain tumors stratified by patient age and tumor histological type: an analysis based on Surveillance, Epidemiology, and End Results (SEER) data, 1973-1991

OBJECT

The authors present population-based survival rate estimates for patients with malignant primary brain tumors based on an analysis of 18 years of data obtained from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute.

METHODS

Estimates of survival rates at 2 and 5 years after diagnosis for patients with specific histological tumor types were categorized by patient's age at diagnosis (< or = 20 years, 21-64 years, and 65 years or older) and by the time period in which the patients were diagnosed (1973-1980, 1981-1985, 1986-1991). Where appropriate, survival estimates were adjusted for changing patterns in the mean age at diagnosis.

CONCLUSIONS

The authors observed a pattern of declining survival rates in patients with increasing age of the patient at diagnosis for most histological groups and overall improvements in survival rates of patients across these time periods adjusting for age at diagnosis. There were improvements in 2- and 5-year survival rates over the three time periods for children and adults with medulloblastoma and for adults with astrocytoma and oligodendroglioma. Improvements in survival rates for pediatric patients with medulloblastoma have leveled off in the most recent time period, and gender differences in survival rates for patients with this tumor, which were present in the 1970s, have disappeared. Clinically significant improvements in survival rates were not apparent in patients aged 65 years and older. Changes in diagnostic and treatment procedures since the mid-1970s have resulted in improved survival rates for patients diagnosed as having medulloblastoma, oligodendroglioma, and astrocytoma, controlling for age at diagnosis. Glioblastoma multiforme continues to be the most intractable brain tumor.

Changes in diagnostic decision-making after a computerized decision support consultation based on perceptions of need and helpfulness: a preliminary report

We examined the degree to which attending physicians, residents, and medical students' stated desire for a consultation on difficult-to-diagnose patient cases is related to changes in their diagnostic judgments after a computer consultation, and whether, in fact, their perceptions of the usefulness of these consultations are related to these changes. The decision support system (DSS) used in this study was ILIAD (v4.2). Preliminary findings based on 16 subjects' (6 general internists, 4 second-year residents in internal medicine, and 6 fourth-year medical students) workup of 136 patient cases indicated no significant main effects for 1) level of experience, 2) whether or not subjects indicated they would seek a diagnostic consultation before using the DSS, or 3) whether or not they found the DSS consultation in fact to be helpful in arriving at a diagnosis (p > .49 in all instances). Nor were there any significant interactions. Findings were similar using subjects or cases as the unit of analysis. It is possible that what may appear to be counter-intuitive, and perhaps irrational, may not necessarily be so. We are currently examining potential explanatory hypotheses in our ongoing current, larger study.

HELLP syndrome: Clinical profile of seven patients

HELLP syndrome is a multi-organ disorder unique to pregnancy. It is characterized by hemolysis, elevated liver enzymes, and low platelets in patients with pre-eclampsia or eclampsia. In King Abdulaziz Oncology Center, Jeddah, seven patients with HELLP syndrome were admitted over a period of four years (1991-94). Retrospective analysis of data was done to study the clinical profile of HELLP syndrome. The incidence of HELLP syndrome in our institution was 1 per 2285 deliveries. One patient was Saudi and six were non-Saudis. The age range was 23 to 44 years, with a mean of 29 years. All patients were multipara. The disorder occurred between 24 to 33 weeks of gestational age, the average being 29 weeks. The most commonly encountered clinical feature was right upper quadrant/epigastric pain. Other features included nausea/vomiting, jaundice, hepatic encephalopathy, azotemia, hypotension and grand mal convulsions. All patients had severe pre-eclampsia pr eclampsia. Indirect hyperbilirubinemia was in the range of 2 to 8 mg/dL and elevated transaminases up to 229 U/L (n<40 U/L) were noted. Various degrees of peripheral thrombocytopenia (<150x10(9)/L) were present in seven patients. Four patients had elevated prothrombin and partial thromboplastin time with postive fibrinogen degradation products. Laboratory abnormalities returned to normal within 10 days following delivery. Four patients were delivered by cesarean section and three had vaginal deliveries. We had two maternal deaths (mortality 34%). One died of multi-organ failure and the other with adult respiratory distress syndrome. There was one stillbirth and the second baby died soon after birth due to prematurity (infant perinatal mortality 34%). We conclude that HELLP syndrome is rare among pregnant women in our institution. It should always be suspected in women with pre-eclampsia or eclampsia when they present with upper abdominal pain. Multipara seem to be more afflicted. Subclinical disseminated intravascular coagulation was detected in 55% of the patients. A majority of our patients presented late to the hospital.

Effects of a decision support system on the diagnostic accuracy of users: a preliminary report

OBJECTIVES

To assess the effects of incomplete data upon the output of a computerized diagnostic decision support system (DSS), to assess the effects of using the system upon the diagnostic opinions of users, and to explore if these effects vary as a function of clinical experience.

DESIGN

Experimental pilot study. Four clusters of nine cases each were constructed and equated for case difficulty. Definitive findings were omitted from the case abstracts. Subjects were randomly assigned to one of four clusters and were trained on the DSS prior to use.

SUBJECTS

The study involved 16 physicians at three levels of clinical experience (six general internists, four residents in internal medicine, and six fourth-year medical students), from three academic medical centers.

PROCEDURE

Each subject worked up nine cases, first without and then with ILIAD consultation. They were asked to offer up to six potential diagnoses and to list up to three steps that should be the next items in the diagnostic workup. Effects of DSS consultation were measured by changes in the position of the correct diagnosis in the lists of differential diagnoses, pre- and post-consultation.

RESULTS

The DSS lists of diagnostic possibilities contained the correct diagnosis in 38% of cases, about midway between the levels of accuracy of residents and attending general internists. In over 70% of cases, the DSS output had no effect on the position of the correct diagnosis in the subjects' lists. The system's diagnostic accuracy was unaffected by the clinical experience of the users.

Meningococcal disease: Clinical profile of 99 patients

Ninety-nine patients with meningcoccal disease were admitted to the medical department of King Fahd Hospital, Medina during the Haj season of 1407H. (August 1987G). Neisseria meningitidis group A (Clone III-I) was responsible for this outbreak. This bacteria was brought into the Kingdom of Saudi Arabia by the pilgrims from South Asia who were carriers of the disease. Middle age and elderly seemed to be vulnerable to meningococcal disease. The majority of the patients presented with fever, headache, vomiting, skin rash, and signs of meningeal irritation. Diabetics afflicted with meningococcal disease fared badly; of 13 diabetics in the study, eight died. The mortality rate in our patients was 12.1%, a figure comparing favorably with other studies. The factors which influenced mortality included age above 50, shock, coma, renal failure, DIC, upper gastrointestinal bleeding, female sex and other associated diseases. The outbreak was successfully controlled by mass vaccination with polyvalent vaccine of the pilgrims and local population along with chemoprophylaxis with rifampicin.

[Comparison of the Wright, indirect Coombs and enzyme immunoassay IgG methods for the diagnosis of chronic brucellosis]

Incomplete IgG and IgA class immunoglobulins are formed in chronic brucellosis and these antibodies do not detect with classical Wright agglutination test (WAT). However these antibodies are measured with indirect Coombs and enzyme immune assay (EIA) techniques. In this study 90 patients serum samples were tested with WAT, indirect Coombs and EIA. All of the patients had chronic brucellosis. EIA was used to determine the levels of brucella specific IgG antibodies in 44 patients whose WATs were negative and indirect Coombs assays were positive and 46 patients whose WATs and indirect Coombs tests were negative. Thirty-seven (84.08%) of the 44 patients whose WAT negative and indirect Coombs positive were found positive for EIA IgG. Sixteen (34.7%) of the 46 patients whose WAT and indirect Coombs negative were found positive EIA IgG. The importance of EIA and indirect Coombs tests was discussed at the diagnosis of chronic brucellosis.