[Silica-containing urinary stones--clinical issues to keep in mind]. / Silikathaltige Harnsteine im Klinikalltag. Was gibt es zu beachten?

Formation of calculi in efferent urinary passages is always due to supersaturation of urinary calculi substances and associated increased crystallization. Apart from the typical calculi, consisting of calcium oxalate, inorganic phosphates, uric acid or cystine, there are occasional signs of rare substance classes. Although more than 50 silicate stones have already been reported internationally, this stone entity remains relatively unknown. In particular, the occurrence of silicate stones in the absence of magnesium trisilicate abuse is extremely rare. A medium-sized left-sided ureterolith was removed from a 54-year-old male patient using a ureteroscope. X-ray diffraction showed it to be a compound stone consisting of 40% silicate. The patient, who in 1986 was living close to the nuclear reactor accident in Chernobyl, showed no signs of a constant uptake of magnesium trisilicate. However, he had undergone partial (2/3) gastrectomy 4 months before for a drug-refractory gastric ulcer, which had been diagnosed at the end of the 1980s and treated with excessive dosages of a magnesium trisilicate antacid preparation until the time of the operation. The patient had also been suffering from unstable angina pectoris since 1986 and treated with Pentalong (pentaerythrityltetranitrate) for 17 years. We were also able to detect silicium dioxide in components of this drug using X-ray diffraction. Silicate uroliths are extremely rare but they can be clearly identified by X-ray diffraction or infrared spectroscopy and distinguished from artifacts or quartz pebbles. Formation of calculi can be prevented by increasing diuresis as well as switching to a different drug and reducing the dosage.

[An unusual complication of extracorporeal shock wave lithotripsy: rupture of the kidney with consecutive nephrectomy]. / Eine seltene Komplikation der Extrakorporalen Stosswellenlithotripsie: Nierenruptur mit nachfolgender Nephrektomie.

INTRODUCTION: Extracorporeal shockwave lithotripsy (ESWL) plays a major role in the treatment of urolithiasis. It has a high success rate, and spectrum and incidence of treatment-related morbidity are low. CASE REPORT: A 66-year-old male patient underwent ESWL treatment for an 8 mm medium-sized stone in the left kidney. During the subsequent post-interventional phase he experienced persistent flank pain, macrohematuria and protracted hemodynamic instability. An acute CT scan displayed a massive kidney rupture. Emergency lumbar exploration of the left kidney revealed multiple lacerations in the renal parenchyma and a nephrectomy was carried out. CONCLUSION: This is the second internationally reported case study in which nephrectomy was necessitated after ESWL treatment due to multiple ruptures of the kidney. In view of the increasing use of ESWL in outpatient care, it is important that this potential complication is recognized and its clinical aspects appropriately assessed. The conclusion of the report comprises a concise review of the most severe complications in the immediate period after ESWL.

[Liposarcoma of the spermatic cord--report of one new case and review of the literature]. / Liposarkom des Samenstrangs--Darstellung eines Falls.

Liposarcoma of the spermatic cord is a rare entity. Although most liposarcomas of the spermatic cord are well-differentiated, the propensity for local recurrence is high. Preferential treatment of spermatic cord liposarcoma is radical orchiectomy with high ligation of the cord. Radiation therapy is recommended in addition to surgery in cases with evidence of more aggressive tumour behavior (i.e., high-grade tumour, lymphatic invasion, inadequate margin, or recurrence). A 39-year-old-male presented with a 4-year history of a mass in the left scrotum. Radical orchiectomy was performed. Pathological analysis demonstrated a well-differentiated liposarcoma with tumour detection in the surgical margin. In view of the incomplete surgical removal of the tumour a retroperitoneal reoperation of the testicular vessels and vas deferent with R0-resection was conducted. Without any postoperative adjuvant therapy in evidence of recurrence or metastasis was noted during the 12-month follow-up period. The current literature on management of malignant tumours of the spermatic cord is reviewed. Paratesticular liposarcomas are most commonly well-differentiated and lipoma-like and have a prolonged clinical course. Radical orchiectomy with wide local excision of the mass is the recommended therapy, while adjuvant radiotherapy may be considered in high-grade tumours and in recurrent liposarcomas. Retroperitoneal lymphadenectomy does not offer any additional therapeutic benefit, and the role of chemotherapy is not well defined. Regardless of initial therapy, the risk of local recurrence always necessitates long-term followup.

[Bilateral testicular masses in the scope of adrenogenital syndrome]. / Beidseitige testikuläre Raumforderungen im Rahmen des adrenogenitalen Syndroms.

Testicular masses in male individuals with the adrenogenital syndrome (AGS) are a clinical and pathological diagnostic dilemma. The major differential diagnosis of gonadal nodules in this setting includes interstitial Leydig cell tumors and secondary benign tumors possibly of adrenal origin. We report a case of adrenogenital syndrome occurring in a 14-year-old boy. Examinations to clarify the cause of his dwarfism and bilateral testicular masses revealed 21-hydroxylase deficiency. The testes were not tender and were firm and nodular on palpation. The serum levels of adrenocorticotrophic hormone (ACTH), 17 alpha-hydroxyprogesterone (17-alpha-OHP), testosterone, and aldosterone were found to be elevated. Under corticosteroid therapy the serum marker abnormalities were corrected and there was gradual regression of the tumor lesions in both testes. Testicular tumors with adrenogenital syndrome are typically bilateral and develop in untreated or inadequately treated males with AGS.

[Superior vena cava syndrome with bilateral jugular and subclavian vein thrombosis. Paraneoplastic manifestion of renal cell carcinoma]. / V. -cava-superior-Syndrom mit beidseitiger Jugularis- und SubklaviavenenthromboseParaneoplastische Manifestation eines Nierenzellkarzinoms.

At present thrombosis of the superior vena cava is an uncommon event that is now more frequently associated with diagnostic or therapeutic catheterization. If an apparent spontaneous thrombosis occurs, malignancy should be considered in the differential diagnosis. One case of clinically symptomatic thrombosis of the internal jugular, subclavian, and superior vena cava is presented. We detected an asymptomatic left renal cell carcinoma in a 54-year-old patient and nephrectomy was performed. Increased blood coagulability as part of a paraneoplastic syndrome was considered to be the possible etiology. In patients with otherwise unexplained superior vena cava thrombosis, examination not only of the head and neck but also of the abdomen, retroperitoneum, and pelvis should be pursued. A review of the literature pertinent to this rare case is provided.

[Outlet of a megaureter with aplastic kidney into a seminal vesicle cyst. Case report of laparoscopic intervention]. / Mündung eines Megaureters mit aplastischer Niere in eine Samenblasenzyste. Fallbericht einer laparoskopischen Intervention.

Unilateral cyst of the seminal vesicle, ipsilateral ectopic ureter, and ipsilateral renal aplasia are the components of a rare congenital abnormality affecting the male urogenital tract. The clinical picture is characterized by a retrovesical cystic tumor, which may cause nonspecific symptoms. Differential diagnosis includes cysts of the müllerian duct, the urogenital sinus/ejaculatory duct, and the prostate. We report a case of a left seminal vesicle cyst associated with aplasia of the left kidney in a 14-year-old boy. Preoperatively, an ipsilateral renal agenesis was suspected, but a renal aplasia with an ectopic urinary megaureter into the seminal vesicle was found intraoperatively. An 8-cm cystic left seminal vesicle and an ipsilateral renal aplasia was successfully removed by operative laparoscopy. The advantages of the laparoscopic approach over open surgery include excellent exposure of the deep pelvic structures, a short hospitalization, and a rapid recovery for the patient. We searched the literature to review the clinical presentation, diagnostic procedures, differential diagnosis, and therapeutic treatment options for this anomaly.

[Solitary renal cell carcinoma metastasis to the thyroid gland--a paradigm of metastasectomy?]. / Die solitäre Nierenzellkarzinommetastase in der Schilddrüse. Ein Paradigma der Metastasenchirurgie?

We investigated the usefulness of thyroidectomy for solitary metastases from renal cell carcinomas in ten patients. In the absence of postoperative morbidity and mortality, a mean survival time of 3.4 years was observed. Subsequently, four patients developed intracerebral metastases. Swelling of the neck and the discovery of a nodule in the thyroid of patients who have undergone nephrectomy for renal cell carcinoma should raise suspicion of a metastasis, possibly after a long latency period. With the aid of modern immunohistochemical methods, renal cell carcinoma metastasis can now be identified unequivocally, with differentiation from a primary follicular carcinoma of the thyroid rendered possible by a combination of TTF-1, thyroglobulin, and CD 10. In the event of a solitary lesion with no extrathyroidal tumour manifestation, an R0 resection of the metastasis should always be attempted. If tumour dissemination has occurred, palliative measures and endoscopic intervention (e.g. placement of an endotracheal stent) with the aim of improving quality of life by preventing obstruction of the airways are justified.

[Angiomyolipoma of the kidneys as a rare cause of retroperitoneal hemorrhage. Two case reports with tuberous sclerosis Bourneville-Pringle]. / Renale Angiomyolipome assoziiert mit tuberöser Hirnsklerose als seltene Ursache einer abundanten retroperitonealen Blutung. Report von 2 Fällen.

Tuberous sclerosis (Bourneville-Pringle-disease, TSC) is an autosomal dominant disorder characterized by seizures, mental retardation and hamartomatous tumours in multiple organs, including subependymal giant cell astrocytomas, cardiac rhabdomyomas and renal angiomyolipomas. Recent population-based studies suggest a prevalence of 1 case per 25,000 individuals. Renal angiomyolipomas, which may be found sporadically or associated with TSC, become evident as an acute retroperitoneal haemorrhage or by symptoms of a flank mass. Ultrasound and computed tomography provide clear evidence of lipomatous formation while, in rare instances, angiography can demonstrate the existence of multiple vascular tumour compartments. In view of two cases which were admitted with the clinical picture of an acute abdomen on the basis of retroperitoneal haemorrhage, the therapeutic strategies for TSC patients with renal angiomyolipomas are discussed, paying regard to the literature in this field.

Classification of haemorrhage following tonsillectomy.

To date there exists no sensible way of classifying the intensity of haemorrhage following tonsillectomy, though this is a prerequisite when comparing the results presented in literature. We evaluated the incidence of post-operative haemorrhage according to our classification in 602 patients who underwent tonsillectomy at our department in 1999. In 21 patients a grade 1 (spontaneous cessation) bleeding occurred. One patient had a grade 2 (infiltration anaesthesia), 14 patients had a grade 3 bleeding (treatment under general anaesthesia) with one patient receiving a blood transfusion. Two patients had a grade 4 bleeding (ligature of the external carotid artery). There was no patient with grade 5 bleeding (lethal outcome). Grades 1 and 3 had the same incidence rates. Primary haemorrhage (<24 hours) can be expected in the majority of patients undergoing tonsillectomy. Secondary haemorrhage is rare and can be life-threatening.

Correlates of resilience in homeless adolescents.

PURPOSES: To (a) describe reasons adolescents give for their homelessness, (b) explore relationships among resilience and selected risk and protective factors, (c) identify differences in risk and protective factors by gender and sexual orientation, and (d) determine best predictors of resilience. DESIGN: A descriptive and exploratory correlational design was used to collect and analyze data from a convenience sample of 59 homeless adolescents who sought health and social services from a community street-outreach project in central Texas in 1998. METHODS: A paper and pencil survey consisting of valid measures (Resilience Scale, UCLA-Revised Loneliness Scale, Beck Hopelessness Scale, Social Connectedness Scale, and Death-Related Attitude Schedule) was administered in a street-outreach setting. FINDINGS: Nearly half the sample (47%) reported a history of sexual abuse and 36% self-identified as gay, lesbian, or bisexual in orientation. Over half (51%) were thrown out of their homes by their parents, 37% left home because their parents disapproved of their alcohol or drug use, and nearly one-third left home because parents sexually abused them. Lack of resilience was significantly related to hopelessness, loneliness, life-threatening behaviors, and connectedness, but not to gender or sexual orientation. Hopelessness and connectedness explained 50% of the variance in resilience. CONCLUSIONS: Participants who perceived themselves as resilient, although disconnected from other people, were less lonely, less hopeless, and engaged in fewer life-threatening behaviors than were those who perceived themselves as not being resilient. They survived by adapting to street life and by becoming overly self-reliant. Findings may be useful in planning interventions to promote health and well-being in this vulnerable population.

Sexual abuse, alcohol and other drug use, and suicidal behaviors in homeless adolescents.

Previous research has shown that homeless youth have high rates of suicidal ideation, sexual abuse, and abuse of alcohol and other drugs. However, little is known about how these rates differ by gender and ethnicity. Our objective was to describe patterns of sexual abuse, alcohol and other drug use, and indicators of suicidal behaviors in homeless adolescents and to determine gender and ethnic differences in these factors. We used secondary data analysis of data from surveys completed by 96 homeless youth whose average age was 17.9 years. Over 60% of the sample reported a history of sexual abuse; the majority were under the age of 12 years when they first tried alcohol, marijuana, and cocaine; 56.3% had injected drugs, and 46.9% had tried inhalants. During the past 12 months, 35.1% had seriously considered suicide and 12.3% had actually attempted suicide at least once. Significantly more Hispanics than Whites had considered suicide (chi 2 = 4.31, p = .038). A disproportionate number of Hispanics (95% of the sample) reported a history of sexual abuse. Participants with a history of sexual abuse were significantly more likely than those who did not have a history of sexual abuse to have used alcohol and/or marijuana (chi 2 = 9.93, p < .01) and to have considered suicide in the past 12 months (F = 14.93, p < .001). We found that sexual abuse history is greater in this sample than in the general population and is particularly prevalent among Hispanic/Latino subjects. As in other studies, sexual abuse was more common among females than among males. High prevalence of sexual abuse, alcohol and other drug use, and suicidal behaviors in this sample of homeless youth underscores the need to develop and test community-based interventions to improve their health status.

Without parental consent: conducting research with homeless adolescents.

ISSUES AND PURPOSE: To identify the ethical and legal implications of conducting research with homeless adolescents and to discuss guidelines for conducting research without parental consent. CONCLUSIONS: Ethical principles of capacity, risk, postponement, and truthful disclosure within the context of the rights of minors to consent to healthcare treatment form the basis of the argument for allowing adolescents to consent to participate in research without parental consent when there is minimal risk or when such consent could place them at increased risk for harm. PRACTICE IMPLICATIONS: Adolescents who are the target population for clinical research or who are intended recipients of nursing care should be involved in setting priorities, purposes, and protocols. Parents and other adults from their communities should be included in developing strategies to protect their confidentiality and privacy while helping them achieve autonomy in making informed health-related decisions.

Risky sexual behavior among adolescent women.

ISSUES AND PURPOSE: To review the epidemiology and etiology of risky sexual behavior in adolescent women, and to discuss implications for primary prevention. CONCLUSION: Adolescent women who participate in risky sexual behavior are at risk for sexually transmitted infections, including HIV. Black, Hispanic, and out-of-home adolescent women, however, are at greatest risk. Factors contributing to risky sexual behavior include early initiation of sexual intercourse, inconsistent use of condoms and other barrier contraception, and unprotected sexual intercourse. Identified protective factors for early initiation of sexual activity include the development of healthy sexuality, family and school connectedness, and the presence of caring adults. PRACTICE IMPLICATIONS: Effective clinical interventions target high-risk adolescent women; incorporate environmental and cognitive-behavioral components; use social learning theories; address differences in regards to culture, developmental stage, and sexual experience; and support family and school involvement.

Nurse-physician collaboration.

The literature indicates that collaboration between nurses and physicians has become more sophisticated as these relationships have become collegial in nature and as nurses have become assertive, autonomous, and accountable. On an individual level, physicians and nurses now entering collaborative relationships are successful at minimizing the obstacles of turf and territoriality as well as at managing practice boundaries. However, both need to consciously examine their patterns of communication in order to effect clinical interaction styles that maintain unequal or hierarchical relationships. Studies of interprofessional communication, including style of clinical interaction, conflict resolution, use of humor, and negotiation, contribute support for nurses and physicians in collaborative relationships (Balzer, 1993; Campbell, Mauksch, Neikirk, & Hosokawa, 1990; Feiger & Schmitt, 1979; Lenkman & Gribbins, 1994; Pike, 1991). Research on differences in health outcomes of patients cared for in the traditional and collaborative models of health care delivery, identification of the unique product of collaborative practice models, and further identification of the type of attitudinal climate in which collaborative relationships can be nurtured should be undertaken if the elusive nature of collaboration is to be captured (Siegler, Whitney, & Schmitt, 1994). Providing collaborative, interdisciplinary clinical experiences for students, as well as role modeling of collaborative relationships in nurse-physician faculty practice, can contribute to a greater understanding and acceptance of each professional's role in health care delivery (Campbell, 1993; Forbes & Fitzsimons, 1993; Larson, 1995). Tradition and professionalism and progressive concern about practice boundaries continue to be obstacles to collaborative practice. These need to be addressed by medical and nursing professionals on the institutional level and in the political arena. Collaboration between nurses and physicians need not remain only a researchable issue; its viability and vitality are crucial to the changing health care scene. Understanding the issues that affect collaboration, as well as the historical background in which it has developed, can help nurses and physicians in their joint effort to improve health care delivery.