Predictors of mortality and nephrectomy in emphysematous pyelonephritis: a tertiary care centre study.

INTRODUCTION: Emphysematous pyelonephritis (EPN) is a deadly disease due to its associated morbidity and mortality. Attempts have been made to identify predictors of severity, mortality and need for nephrectomy in EPN with little success. METHODS: We conducted an ambispective study of EPN patients between March 2014 and September 2019. Retrospective data were collected which included age, sex, comorbidities, symptoms, signs, laboratory investigations including imaging, need for dialysis, management and any complications. All patients were then followed prospectively for renal dynamic scan, stone surgery or nephrectomy. Univariate analysis was performed to identify factors affecting mortality and need for elective nephrectomy. RESULTS: In total, 112 patients were included. Mean patient age was 50.01 years, 55% were female and 5% had bilateral involvement. Fever and flank pain were the most common symptoms. Diabetes was seen in 75% of cases and 30% of cases required haemodialysis at initial presentation. About 60% of patients improved with pigtail drainage. Need for nephrectomy was greater in Huang-Tseng stage 3a (14.8%). Huang-Tseng stages 3b and 4 had higher mortality rates (25%) than the other stages (2.2%). Twelve of 99 patients had non functional kidney on follow-up and underwent elective nephrectomy. Low platelet counts, high body mass index, septic shock, dialysis and higher Huang-Tseng stage were found to be predictive of mortality and renal parenchymal thickness on computed tomography scan was predictive of follow-up nephrectomy. CONCLUSIONS: Thrombocytopaenia, high body mass index, septic shock, haemodialysis and higher Huang-Tseng stage are predictors of mortality and renal parenchymal thickness <5mm is a predictor of poor salvage of affected kidney on follow-up.

Protistan epibionts affect prey selectivity patterns and vulnerability to predation in a cyclopoid copepod.

Colonisation of crustacean zooplankton with ciliate epibionts is widespread in freshwater and marine environments. However, the ecology of such association are little studied as yet. The occurrence of ciliate epibionts on copepods and the preference towards this association with different life stages of Mesocyclops were studied from winter to spring. Relative susceptibility of zooplankton species was evaluated by analysing the epibiont colonies and zooids and relate this to the surface area of the host. The maximum epibiont infestation per unit body surface area was recorded on copepodites followed by copepod nauplii rather than other zooplankton species, whereas the rotifer Asplanchna was never affected. Influence of climatic factors such as temperature on the colonisation of epibionts on basibionts was found significant. In winter (November to February) samples, copepods were infested by autotrophic epibionts whereas in late spring and early summer (March-April) heterotrophic protists (peritrichian ciliates) were the sole epibionts on copepods. We conducted experiments in the laboratory on prey selection pattern of predators by direct visual and video-graphic observations of various events (encounter, attack, capture, ingestion, prey escape) during predation by infested and uninfested copepodites and adults of Mesocyclops. Postencounter the attack probability was significantly lower in infested than in uninfested copepods. The present paper reports on substrate preference by epibionts and their impacts in food rich and food scarce environments. Furthermore, major environmental interactions were studied with the reproductive phenology of copepods with respect to epibionts and the cause and effect of long term association of epibionts with copepods need to be addressed.

High rising flames: a sign of complex extraperitoneal bladder rupture.

Extraperitoneal bladder rupture is the most common type of bladder injury following pelvic trauma and is seen in 80-90% of cases. Generally, the contrast extravasation seen on computed tomography (CT) cystography is confined to the perivesical space, giving a characteristic flame-shaped appearance. Occasionally contrast extravasation can extend to the scrotum, thigh or anterior abdominal wall, depending on the extent of injury. Here we report an unusual CT cystogram finding of complex extraperitoneal bladder rupture with associated pelvic fracture urethral distraction defect, showing large-volume contrast extravasation extending beyond the perivesical space to the left perinephric region resembling high rising flames.

High rising flames: a sign of complex extraperitoneal bladder rupture.

Extraperitoneal bladder rupture is the most common type of bladder injury following pelvic trauma and is seen in 80-90% of cases. Generally, the contrast extravasation seen on computed tomography (CT) cystography is confined to the perivesical space, giving a characteristic flame-shaped appearance. Occasionally contrast extravasation can extend to the scrotum, thigh or anterior abdominal wall, depending on the extent of injury. Here we report an unusual CT cystogram finding of complex extraperitoneal bladder rupture with associated pelvic fracture urethral distraction defect, showing large-volume contrast extravasation extending beyond the perivesical space to the left perinephric region resembling high rising flames.

Urinary adenosine triphosphate and nitric oxide levels in patients with underactive bladder: a preliminary study.

INTRODUCTION: Various in vitro and in vivo animal studies have shown that adenosine triphosphate (ATP) has a stimulatory role and nitric oxide (NO) has an inhibitory role in modulating bladder contractility. However, it is not known what happens to the urinary levels of ATP and NO in humans with underactive bladder (UAB). METHODS: In this prospective case-control study, we compared ATP and NO levels in twenty six male patients of UAB with a bladder contractility index (BCI) of < 100 and 18 healthy male volunteers without any lower urinary tract symptoms (LUTS). RESULTS: The mean urinary ATP levels were significantly lower in cases compared to controls (546.1 ± 37.3 pg/µl vs. 610.7 ± 24.9 pg/µl, p value < 0.001) and the mean NO levels were significantly higher in cases compared to controls (1233.4 ± 91.2 pg/µl vs. 1126.3 ± 91.3.4 pg/µl, p value < 0.001). The mean NO/ATP ratio in cases was significantly higher than that of controls (2.26 ± 0.2 vs. 1.84 ± 0.18, p value < 0.000). Using receiver operating curve (ROC) analysis, we noted the area under the curve (AUC) for NO/ATP ratio to be 0.91 in the diagnosis of cases. A cut-off value of 2.06 for NO/ATP ratio had sensitivity, specificity and diagnostic accuracy of 88.5%, 88.9% and 88.6%, respectively, in diagnosing patients with UAB. CONCLUSION: Patients with UAB have significantly higher levels of urinary NO and decreased levels of urinary ATP. Urinary NO/ATP levels can be considered as a noninvasive alternate test for diagnosing bladder underactivity.

A huge ureteric stone in a functionally, metabolically and anatomically normal kidney: an alliance of rarity.

Urinary stones are a common health problem, necessitating frequent outpatient visits and hospital admissions. Ureteric stones demand special attention, given their propensity for upstream hydroureteronephrosis and loss of renal function. They are usually predisposed by diverse anatomical, functional or metabolic abnormalities of the urinary tract and have an early symptomatic presentation. We report an exceptional clinical presentation of a huge ureteric stone yet functional renal moiety with no obvious anatomical or metabolic predilection for urolithiasis, and its minimally invasive management in a young woman. We emphasise that swift salvaging of the renal function is of utmost importance in these cases. Open exploration can be avoided in favour of laparoscopic ureterolithotomy with better cosmesis and early recovery.

Robot-assisted pelvic urologic surgeries: is it feasible to perform under reduced tilt?

To evaluate the feasibility and outcomes of performing robot-assisted pelvic surgery at a reduced angle of Trendelenburg position. This was a prospective case-control study of 67 patients in 2:1 ratio. Controls were operated with steep Trendelenburg position of 30°, whereas cases were operated using a graduated method to achieve minimal optimal angle of operating table. Various body habitus parameters, console time, blood loss, rise in mean arterial pressure (MAP) and end-tidal carbon-dioxide (ET-CO2), duration of ileus, postoperative stay and complications were recorded. All demographic profile and body habitus parameters were comparable among two groups except age which was lower in Reduced-Tilt group. Cases were operated at a mean angle of 20.5 ± 3.1° compared to 30° in control group. Rise in MAP, ET-CO2 and facial swelling were significantly low in Reduced-Tilt group compared to control. Notably blood loss, duration of ileus, postoperative stay and complications were also low in patients with Reduced Tilt. Various body habitus parameters were analysed with multiple regression analysis to predict minimal angle required for performing surgery with Reduced Tilt. BMI, xiphisterno-umbilical distance, umbilical-pubic-symphyseal distance and subcostal angle were found to predict the same. Robot-assisted pelvic surgeries can be performed in reduced Trendelenburg tilt which is associated with less hemodynamic and respiratory stress, complication rates and early postoperative recovery. BMI, subcostal angle, xiphisterno-umbilical distance and umbilical-pubic-symphyseal distance can predict the feasible angle of tilt.

Corrigendum to "P095 - Clinical outcomes of robot-assisted laparoscopic partial nephrectomy: Lessons learnt from 221 cases" [Eur Urol Suppl 2019;18(11);e3528].

[This corrects the article DOI: 10.1016/S1569-9056(19)34675-5.].

Population genetic structure of Indian shad, Tenualosa ilisha inferred from variation in mitochondrial DNA sequences.

Indian shad, Tenualosa ilisha, is a commercially important anadromous fish representing major catch in Indo-pacific region. The present study evaluated partial Cytochrome b (Cyt b) gene sequence of mtDNA in T. ilisha for determining genetic variation from Bay of Bengal and Arabian Sea origins. The genomic DNA extracted from T. ilisha samples representing two distant rivers in the Indian subcontinent, the Bhagirathi (lower stretch of Ganges) and the Tapi was analyzed. Sequencing of 307 bp mtDNA Cytochrome b gene fragment revealed the presence of 5 haplotypes, with high haplotype diversity (Hd) of 0.9048 with variance 0.103 and low nucleotide diversity (π) of 0.14301. Three population specific haplotypes were observed in river Ganga and two haplotypes in river Tapi. Neighbour-joining tree based on Cytochrome b gene sequences of T. ilisha showed that population from Bay of Bengal and Arabian Sea origins belonged to two distinct clusters.

Maturation profile and fecundity of the exotic Oreochromis niloticus in the River Yamuna, India.

The knowledge on the reproductive biology of fish Oreochromis niloticus (Linnaeus, 1758) in riverine condition is meagre in the Indian sub-continent which is necessary for the development of an appropriate fishery management protocols for the rivers. In this context, the gonadal maturation profile and fecundity of 0. niloticus was studied. Mature, spawning and spent females recorded in almost all the months of the year evidenced multiple and prolonged breeding behaviour. An overall sex ratio (M/F) of 1: 1.08 observed was statistically non-significant from expected 1:1 ratio (chi2=6.994219, p=0.8642) indicating that males and females were statistically equal in number. The absolute fecundity ranged from 1192 to 4760 with mean of 2590 eggs from ovary weighing between 1.91 g to 28.89 g. Monthly changes in gonado-somatic index (GSI) revealed that fish bred throughout the year except in July and August, but at peak between October-November and March-June. Size at first maturity of male was estimated as 229.6 mm with confidence limit of 235.9 and 223.6 mm and for female as 238.1 mm with confidence limit of 244.7 and 231.7 mm, respectively.

Amino Acid compositions of 27 food fishes and their importance in clinical nutrition.

Proteins and amino acids are important biomolecules which regulate key metabolic pathways and serve as precursors for synthesis of biologically important substances; moreover, amino acids are building blocks of proteins. Fish is an important dietary source of quality animal proteins and amino acids and play important role in human nutrition. In the present investigation, crude protein content and amino acid compositions of important food fishes from different habitats have been studied. Crude protein content was determined by Kjeldahl method and amino acid composition was analyzed by high performance liquid chromatography and information on 27 food fishes was generated. The analysis showed that the cold water species are rich in lysine and aspartic acid, marine fishes in leucine, small indigenous fishes in histidine, and the carps and catfishes in glutamic acid and glycine. The enriched nutrition knowledge base would enhance the utility of fish as a source of quality animal proteins and amino acids and aid in their inclusion in dietary counseling and patient guidance for specific nutritional needs.

Probiotics in fish and shellfish culture: immunomodulatory and ecophysiological responses.

Aquaculture is emerging as one of the most viable and promising enterprises for keeping pace with the surging need for animal protein, providing nutritional and food security to humans, particularly those residing in regions where livestock is relatively scarce. With every step toward intensification of aquaculture practices, there is an increase in the stress level in the animal as well as the environment. Hence, disease outbreak is being increasingly recognized as one of the most important constraints to aquaculture production in many countries, including India. Conventionally, the disease control in aquaculture has relied on the use of chemical compounds and antibiotics. The development of non-antibiotic and environmentally friendly agents is one of the key factors for health management in aquaculture. Consequently, with the emerging need for environmentally friendly aquaculture, the use of alternatives to antibiotic growth promoters in fish nutrition is now widely accepted. In recent years, probiotics have taken center stage and are being used as an unconventional approach that has numerous beneficial effects in fish and shellfish culture: improved activity of gastrointestinal microbiota and enhanced immune status, disease resistance, survival, feed utilization and growth performance. As natural products, probiotics have much potential to increase the efficiency and sustainability of aquaculture production. Therefore, comprehensive research to fully characterize the intestinal microbiota of prominent fish species, mechanisms of action of probiotics and their effects on the intestinal ecosystem, immunity, fish health and performance is reasonable. This review highlights the classifications and applications of probiotics in aquaculture. The review also summarizes the advancement and research highlights of the probiotic status and mode of action, which are of great significance from an ecofriendly, sustainable, intensive aquaculture point of view.

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.

Prognostic significance of distal renal tubular acidosis in posterior urethral valve.

The prognostic significance of distal renal tubular acidosis (DRTA) in the development of overt nephropathy (ON) in children with posterior urethral valves (PUV) is not clear. This condition was studied prospectively in 22 children with posterior urethral valve (PUV), with normal renal function. Prior to surgery, the children with ON had a higher incidence of bilateral reflux (P=0.006), but the difference was not significant for age at surgery (P=0.31), duration of voiding symptoms prior to surgery (P=0.30), presence of DRTA (P=0.35) and bladder abnormalities (P=0.27), with none of these factors being significant on logistic regression analysis. At the end of the follow-up, after surgery, age at surgery (P < or = 0.0001), duration of voiding symptoms prior to surgery (P < or = 0.0003), persistent DRTA (P=0.0001) and persistent bladder dysfunction (P=0.02) after surgery were significantly higher in children with ON. On univariate logistic regression analysis, age at surgery (P=0.009), duration of voiding symptoms prior to surgery (P=0.01), persistent DRTA (P=0.002) and persistent bladder abnormalities (P=0.03) after surgery were significant for ON after surgery, but on stepwise multivariate logistic regression analysis only persistent DRTA (P=0.002) turned out to be significant. We conclude that persistent DRTA after surgery can predict overt nephropathy in children with PUV after surgery.

Cyclosporin A withdrawal in live related renal transplantation: long-term results.

Cyclosporin A (CsA) withdrawal after 1 yr of stable graft function has been shown to be beneficial in cadaveric renal transplantation. This strategy could be even more suitable for 'immunologically advantaged' grafts as in live related renal transplantation. We report the long-term outcome of patients in a live related transplantation programme undergoing early (between 1989 and 1992) and late (1993 onwards) CsA withdrawal as compared with those on long-term low dose CsA (1993 onwards). Two-hundred and fifty-two patients were divided into three groups based on the following immunosuppressive protocol: group ECyW (n=99), early CsA withdrawal (9 months after transplantation); group LCyW (n=44), late CsA withdrawal (median 16 months, range 13--22 months after transplantation); and group LDCy (n=109), long-term low dose CsA. The median period of follow-up was 66 months after transplantation (range 43--84 months). There was no difference in the actuarial 6-yr patient or graft survival among the three groups. Acute rejection episodes were more frequent in ECyW (54.4%) than in LDCy (31.8%) and LCyW (23.8%) (p=0.001). The risk of developing late (> or =9 months) acute rejection was highest in ECyW 32/99 (32.3%) as compared with LCyW 8/44 (18.4%; p=0.08) and LDCy 8/109 (7.3%; p=0.0001). Of the 32 ECyW patients who developed acute rejection episodes after CsA withdrawal, 13 (40.6%) lost their grafts either due to uncontrolled acute rejection or to chronic rejection. Chronic rejection was higher in ECyW (24%) than in LCyW (11%; p=0.04) and LDCy (17%; p=0.17). Antihypertensive requirement was highest in patients maintained on low dose CsA. Graft function, as measured by serum creatinine levels, was significantly better in LCyW (1.24+/-0.4 mg%) as compared with ECyW (1.49+/-0.5 mg%) and LDCy (1.48+/-0.6 mg%). Early CsA withdrawal after live related renal transplantation is associated with a significant risk of acute rejection and subsequent chronic rejection. Slow withdrawal after 1 yr is safe and more economical than the long-term administration of low dose CsA.

Does serum albumin at start of continuous ambulatory peritoneal dialysis (CAPD) or its drop during CAPD determine patient outcome?

The impact of serum albumin at start of continuous ambulatory peritoneal dialysis (SA1), serum albumin before death (SA2), and change in serum albumin during continuous ambulatory peritoneal dialysis (delta SA) were prospectively studied in 41 continuous ambulatory peritoneal dialysis (CAPD) patients with a follow-up of 19 +/- 11.6 months. For analysis, patients were divided into two groups at each measurement point: SA1 or SA2 > 3.0 g/dL or delta SA < 1.0 g/dL (group I), and SA1 or SA2 < 3.0 g/dL or delta SA > 1.0 g/dL (group II). On log rank test, the mortality rate was significantly higher in group II patients in relation to SA1 (p < or = 0.0001), SA2 (p = 0.0002), and delta SA (p = 0.001). On univariate Cox proportional hazard regression analysis, SA1 (p = 0.0001), SA2 (p = 0.0001), delta SA (p = 0.002), and episodes of peritonitis (p = 0.0001) were significant. On multivariate analysis, SA2 (p = 0.003) was significantly related to patient mortality. SA2 (r = 0.8; p = 0.0001), but not delta SA, was related to SA1. We conclude that SA2 is the best predictor of patient mortality on CAPD. SA2 is strongly related to SA1. Thus protein restriction in the pre-dialysis stage should be advised cautiously to avoid consequent hypoalbuminemia.