Bilateral nephrectomy as a rescue therapy for refractory hypertension in an end stage renal disease patient: Brahmastra in hypertension management-A case report.

Refractory hypertension is a challenge in End Stage Renal Disease (ESRD) patients who are on regular hemodialysis, despite the use of novel antihypertensive agents and tailor-made dialysis prescriptions. Bilateral nephrectomy seems to be a forgotten option. We present a case history of 16 year old boy who underwent open bilateral nephrectomy as a rescue therapy for refractory hypertension. This surgical treatment option of blood pressure led to satisfactory control of hitherto refractory hypertension complicated with multiple life-threatening episodes of hypertensive crises.

Surgically managed acute Page kidney following renal biopsy-A case report.

INTRODUCTION AND IMPORTANCE: Renal biopsy performed in native or transplanted kidney is considered a safe procedure. However, as it is an invasive procedure bleeding related complications do occur. Bleeding complications such as macroscopic hematuria, renal hematoma, blood transfusion, and rarely nephrectomy and death have been reported in various studies. Acute Page kidney (APK) is a rare complication of post renal biopsy bleeding. CASE PRESENTATION: In this case report we present a case history of a 46-year-old patient complicated with APK, following a native kidney biopsy. Early surgical exploration and evacuation of large hematoma resulted in a favorable outcome. CLINICAL DISCUSSION: APK results from external compression of kidney and compression of the parenchyma can compromise the intra renal blood flow and cause renal impairment, activation of Renin-Angiotensin-Aldosterone System (RAAS) leads to systemic hypertension. CONCLUSION: Awareness, early recognition and timely intervention in APK, in a post renal biopsy bleeding is necessary to prevent poorer outcomes, especially progressively large hematoma is present and response to medical management inadequate.

Musculoskeletal pain is associated with a long-term increased risk of cancer and cardiovascular-related mortality.

OBJECTIVES: To test the hypothesis that individuals with regional and widespread pain disorders have an increased risk of mortality. METHODS: We conducted a prospective cohort study of 4515 adults. Subjects were an age- and sex-stratified sample who had participated in a population study of pain occurrence during 1996. Based on those reports subjects were classified as having no pain, regional pain or widespread pain. All subjects were identified on the National Health Service Central Register and followed up until April 2005, a total of 8.2 yrs, at which time information was obtained on vital status, and if applicable, date and cause of death. The relationship between pain status and subsequent death is expressed as mortality rate ratios with 95% CIs, adjusted for age, gender, ethnicity and practice. RESULTS: A total of 35.2% reported regional pain and 16.9% satisfied criteria for widespread pain. In comparison with those without pain, there was a 20% and 30% increased risk of dying over the follow-up period among subjects with regional and widespread pain, respectively. The specific causes of death in excess were cancer and cardiovascular disease. In addition, the mortality risk from both cancer and cardiovascular deaths was found to increase as the number of pain sites that subjects reported increased. CONCLUSIONS: This study supports a previous observation that persons with regional and widespread pain are at an increased risk of cancer death. Possible mechanisms should be explored.

Urinary excretion of albumin and retinol binding protein in systemic lupus erythematosus.

We have measured the urinary excretion of total protein, albumin and retinol binding protein (RBP) in random urine specimens obtained from 40 female patients with systemic lupus erythematosus (SLE). Thirty-three of these patients had no clinical evidence of any renal impairment (non-renal SLE); seven had overt renal disease (renal SLE). RBP:creatinine ratios were significantly higher in non-renal SLE patients compared with female controls (P = 0.002). There was no significant difference between urine total protein concentrations, albumin:creatinine or total protein:creatinine ratios in non-renal SLE patients when compared with controls, despite approximately 20% of these patients having elevated excretion of total protein or albumin. All seven renal SLE patients had elevated albumin:creatinine ratios but only four of them had an increased RBP:creatinine ratio. Of 29 non-renal SLE patients who had urinary total protein concentrations below 0.2 g/L, (i.e. approximating to a negative protein dipstick), 14 had increases in either albumin or RBP:creatinine ratios. Only two patients had increases in both. In the absence of clinical evidence of renal disease, increases in urinary albumin or RBP excretion could indicate subclinical nephropathy and measurements may have a role in the early diagnosis and subsequent monitoring of renal disease in SLE.

Syringomyelia as a complication of spinal arachnoiditis.

SUMMARY OF BACKGROUND DATA: The authors report a 46-year-old female patient who was referred to this unit for assessment of chronic postsurgical back pain. She reported severe burning pain in the lumbar region accompanied by burning pain and loss of sensation in the lower limbs. She had previously undergone lumbar spinal surgery on three occasions preceded by myelography. METHODS: Examination revealed generalized weakness and hypertonicity of both lower limbs with loss of all sensory modalities below D7. RESULTS: The MRI scanning of the thoracic spine showed an extensive complex syrinx within the thoracic cord. CONCLUSIONS: She underwent syringopleural shunting, and her condition has remained stable.

Can findings from postal questionnaires be combined with interview results to improve the response rate among ethnic minority populations?

STUDY OBJECTIVE: To maximise the response rate in a community survey among ethnic minorities by combining postal questionnaires and interviews and to evaluate the validity of combining results from these different methods. DESIGN: A cross-sectional community survey of a local population using postal questionnaires with interview questionnaires for non-respondents. Postal questionnaires were in English and interview questionnaires were prepared in South Asian languages. A sub-sample completed both postal and interview questionnaires. SETTING: Two general practices in Tameside, Greater Manchester, UK. PARTICIPANTS: Questionnaires were mailed to 1,267 people. People were included if they defined their ethnicity as Indian, Pakistani, Bangladeshi or a combination of these. Fifty-five people who returned postal questionnaires were also interviewed. MAIN RESULTS: Overall response rate was 75%. Comparison of questionnaire and interview responses produced values of kappa ranging from marginally below zero to one. Equivalence was greater with a shorter time between postal completion and interview and where questions were more objective. CONCLUSIONS: It is possible to achieve a good response rate for an epidemiological study among ethnic minorities by using both postal questionnaires and interviews. Care should be taken when results from these two methods are combined, since equivalence is uncertain.

Keloidal scleroderma.

A 53-year-old woman with systemic sclerosis developed numerous cutaneous nodules, resembling keloids, on her anterior chest wall. The nodules failed to respond to therapy with topical steroid, calcipotriol, or extended photochemotherapy. This is a rare, disfiguring variant of scleroderma, unresponsive to treatment, and poorly understood.

Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation.

BACKGROUND: Epidemiologically-based rheumatology healthcare needs assessment requires an understanding of the incidence and prevalence of musculoskeletal disorders in the community, of the reasons why people consult in primary care, and of the proportion of people who would benefit from referral to secondary care and paramedical services. This paper reports the first phase of such a needs assessment exercise. SPECIFIC OBJECTIVE: To estimate the relative frequency of musculoskeletal pain in different, and multiple, anatomical sites in the adult population. SETTING: Three general practices in the former Tameside and Glossop Health Authority, Greater Manchester, UK, a predominantly urban area. DESIGN: Population survey. METHODS: An age and sex stratified sample of 6000 adults from the three practices was mailed a questionnaire that sought data on demographic factors, musculoskeletal symptoms (pain in the past month lasting for more than a week), and physical disability (using the modified Health Assessment Questionnaire--mHAQ). The areas of pain covered were neck, back, shoulder, elbow, hand, hip, knee, and multiple joints. The Carstairs index was used as a measure of social deprivation of the postcode sector in which the person lived. RESULTS: The response rate after two reminders was 78.5%. Non-responders were more likely to live in areas of high social deprivation. People who lived in more deprived areas were also more likely to report musculoskeletal pain, especially backpain. After adjusting for social deprivation the rates of musculoskeletal pain did not differ between the practices and so their results were combined. After adjustment for social deprivation, the most common site of pain was back (23%; 95% CI 21, 25) followed by knee (19%; 95% CI 18, 21), and shoulder (16%; 95% CI 14, 17). The majority of subjects who reported pain had pain in more than one site. The prevalence of physical disability in the community rose with age. It was highest in those with multiple joint problems but was also high in those with isolated back or knee pain. CONCLUSION: Musculoskeletal pain is common in the community. People who live in socially deprived areas have more musculoskeletal symptoms. Estimates of the overall burden of musculoskeletal pain that combine the results of site specific surveys will be too high, those that do not adjust for socioeconomic factors will be too low.

Musculoskeletal pain is more generalised among people from ethnic minorities than among white people in Greater Manchester.

OBJECTIVE: To assess the prevalence of musculoskeletal symptoms among the major ethnic minority populations of Greater Manchester. METHOD: The study group was a community sample of 2117 adults from the Indian, Pakistani, Bangladeshi, and African Caribbean communities. Questionnaires administered by post and by an interviewer were used to assess the presence of any musculoskeletal pain, pain in specific joints, and the level of physical function. Ethnicity was self assigned. The results were compared with those from a recent study in the local white population using the same methodology. RESULTS: Overall response rate was 75% among the south Asian (Indian, Pakistani, and Bangladeshi community and 47% among the African Caribbean community. The profile of musculoskeletal pain among the ethnic minority groups differed from that in the white population. Although musculoskeletal symptoms were slightly more prevalent among people from ethnic minority groups than among the white population, pain in multiple sites was considerably more common among ethnic minorities. CONCLUSIONS: The finding that musculoskeletal pain is more widespread among ethnic minority communities in the UK has not previously been reported. This may reflect social, cultural, and psychological differences. The cause of the differences in the profile of pain and the health needs that follow need further investigation.