Steroid induced ocular complications in idiopathic nephrotic syndrome: a cross sectional single center study.

Objective: To screen children receiving steroids to identify ocular complications and their prevalence. METHODS: The cross-sectional study was conducted at the Paediatric Nephrology and Ophthalmology departments of the Sindh Institute of Urology and Transplantation, Karachi, from May to October 2022, and comprised patients who received at least 1500mg cumulative steroid dose for a minimum of 3 months. They were screened for steroidsensitive or steroid-resistant nephrotic syndrome. Ocular examinations, including visual acuity, intraocular pressure, slit-lamp biomicroscopy, lens examination and fundus evaluation, were performed. Data was analysed using SPSS 22. RESULTS: Of the 124 subjects with mean age 8.15±2.03 years (range: 6-12 years), 64(51.6%) were boys. Steroidsensitive nephrotic syndrome was present in 97(78%) cases. The mean cumulative steroid dose was 3999.31±1564.22mg. Overall, 36(29%) children developed ocular complications. Blood pressure, number of relapses and the duration of treatment were significantly associated (p<0.05). Conclusion: Refractive errors were the most frequent side effects/complication seen among children with nephrotic syndrome who received prolonged corticosteroids.

Proteinuria in Asymptomatic Siblings of Children with Steroid Resistant Nephrotic Syndrome: A Screening Using Urinary Dipstick.

OBJECTIVE: To screen asymptomatic siblings of steroid-resistant nephrotic syndrome patients for proteinuria using the urinary dipstick method to determine the involvement of siblings in the familial and likely genetic cause of the steroid-resistant nephrotic syndrome. METHODS: This cross-sectional study was performed at the outpatient department of Sindh Institute of Urology and Transplantation (SIUT) from May to July 2021. RESULTS: Out of 104 patients with steroid-resistant nephrotic syndrome, siblings of 66 patients were enrolled. Mean age of primary patients with steroid resistant nephrotic syndrome was 8.7±4.3 years. Most common histopathological diagnosis was focal segmental glomerulosclerosis in 25 (37.9%) children followed by minimal change disease in 17(25.8%) of them. The majority, 48 (72.7%) patients were on immunosuppressive treatment, while 4 (6.1%) had progressed to chronic kidney disease (CKD). A total of 178 siblings were recruited in the study. There were 99(55.6%) boys and 79(44.4%) girls. Their mean age was 10.67±6.2 years. Consanguinity was high in our study population i.e. 56(84%) families. Positive proteinuria on dipstick was detected in only 5(7.5%) enrolled SRNS families. One family refused further testing. Two of the five affected siblings had nephrotic range proteinuria. Renal biopsy of one of them showed membranous nephropathy while the second showed mesangiocapillary glomerulonephritis. Both had normal renal functions. CONCLUSIONS: The frequency of proteinuria in asymptomatic siblings of children with steroid-resistant syndrome is low in our population despite a high prevalence of consanguineous marriages. Hence, familial involvement of nephrotic syndrome is low and further genetic testing for monogenic causes is required in steroid-resistant nephrotic syndrome cases.

Rapidly progressive glomerulonephritis in children.

Rapidly progressive glomerulonephritis (RPGN), characterized by a rapid development of nephritis with loss of kidney function in days or weeks, is typically associated histologically, with crescents in most glomeruli; and is a challenging problem, particularly in low resource settings. RPGN is a diagnostic and therapeutic emergency requiring prompt evaluation and treatment to prevent poor outcomes. Histopathologically, RPGN consists of four major categories, anti-glomerular basement membrane (GBM) disease, immune complex mediated, pauci-immune disorders and idiopathic /overlap disorders. Clinical manifestations include gross hematuria, proteinuria, oliguria, hypertension and edema. Diagnostic evaluation, including renal function tests, electrolytes, urinalysis/microscopy and serology including (anti GBM antibody, antineutrophil cytoplasmic antibody (ANCA)) starts simultaneously with management. An urgent renal biopsy is required to allow specific pathologic diagnosis as well as to assess disease activity and chronicity to guide specific treatment. The current guidelines for management of pediatric RPGN are adopted from adult experience and consist of induction and maintenance therapy. Aggressive combination immunosuppression has markedly improved outcomes, however, nephrotic syndrome, severe acute kidney injury requiring dialysis, presence of fibrous crescents and chronicity are predictors of poor renal survival. RPGN associated post infectious glomerulonephritis (PIGN) usually has good prognosis in children without immunosuppression whereas immune-complex-mediated GN and lupus nephritis (LN) are associated with poor prognosis with development of end stage kidney disease (ESKD) in more than 50% and 30% respectively. Given the need for prompt diagnosis and urgent treatment to avoid devastating outcomes, we conducted a review of the latest evidence in RPGN management to help formulate clinical practice guidance for children in our setting. Information sources and search strategy: The search strategy was performed in the digital databases of PubMed, Cochrane Library, google scholar, from their inception dates to December 2020. Three investigators independently performed a systematic search using the following search terms "Rapidly progressive glomerulonephritis" "children" "crescentic glomerulonephritis" "management" at the same time, backtracking search for references of related literature.

Prevalence of Cardiac Abnormalities in Children with Chronic Kidney Disease: A Cross-sectional Study from a Developing Country.

Improved therapeutic modalities in chronic kidney diseases (CKD) children and consequent extension of life expectancy, draws more attention towards secondary complications. Cardiovascular adaptations precipitating such terminal events, begin in pre-dialysis CKD. Hence, it's imperative to identify modifiable risk factors to direct care and resources in haltering CKD progression, evade long-term dialysis and anticipate kidney transplantation to avert cardiac complications in predialysis period. One hundred and six pre-dialysis patients aged one year to 15 years, with estimated glomerular filtration rate of <90 mL/min/1.73 m2 and proteinuria were included. Patient's history, weight, height and blood pressures (BPs) performed. Left ventricular mass index (LVMI) calculated to correct for patient height to determine raised values of >38.6 g/m2.7 and of left ventricular hypertrophy (LVH) >55 g/m2.7. Shortening fraction and ejection fraction measured to assess systolic function. Diastolic function assessed by Doppler measuring the mitral inflow (e/a) ratio. Hemoglobin, calcium phosphorous product, parathyroid hormone and hypertension measured to assess cardiac risk factor. The total prevalence of cardiac abnormality was found in 66.9% (95% confidence interval [CI] 57.6%-75.2%. Raised LVMI was seen in 64%, among which 34.9% had LVH. Diastolic and systolic dysfunction was found in 12.2% and 11.3% respectively. The cardiac abnormality was more prevalent in CKD grade IV and V. The independent risk factors were anemia and abnormal diastolic BP index which increase the risk for LVH by 3-fold and 5-fold respectively. Proportion of cardiac abnormalities were more prevalent in CKD IV and V. Anemia and diastolic hypertension were independent risk factors for LVH.

Obturator hernia: a case report.

BACKGROUND: Obturator hernia is rare and accounts for less than 1% of all abdominal wall hernias. It represents a diagnostic challenge due to its nonspecific signs and symptoms. CASE PRESENTATION: We present a case of an 89-year-old caucasian female with a 12-hour history of right medial thigh pain. Computed tomography scan revealed a right obturator hernia with small bowel obstruction. The hernia was successfully repaired laparoscopically without any need for small bowel resection. She was discharged on postoperative day 2 with an uneventful recovery and zero complications. CONCLUSION: This case report highlights the importance of rapid diagnosis and repair of obturator hernia even in the setting of an improving clinical picture. It also demonstrates the safety of laparoscopic repair in this setting.

Clinicopathologic Features and the Association with Short-Term Outcome of Primary Membranous Nephropathy in Children: A Single-Center Study from Pakistan.

Membranous nephropathy (MN) is an uncommon cause of steroid-resistant nephrotic syndrome in children. Our study aimed to determine the clinicopathologic features of primary MN in children and their association with short-term outcome. This observational study was conducted from January 2009 to June 2017 at the Pediatric Nephrology Department. A total of 50 children were diagnosed with primary MN. Their clinical, laboratory, and histopathological findings on renal biopsy were recorded. The minimum follow-up was for six months. Clinicopathologic features were correlated with the outcome at the last follow-up. Data analysis was done using IBM SPSS Statistics for Windows software version 20.0. The mean age at onset was 10.92 ± 3.08 years (range: 4-17 years). The male-to-female ratio was 3:1. The serum albumin of ≤2.5 g/dL was seen in 40 patients (80%), hypertension was present in 38 (76%), and heavy proteinuria was seen in 32 children (70%). The mean estimated glomerular filtration rate (eGFR) at presentation was 178.71 ± 0.78 mL/min/1.73 m2. At the initial visit, nine children (18.4%) were in chronic kidney disease stage 2 and one (2%) in stage 4. Phospholipase A2 receptor antibody was present in five (15%) of 32 children tested. At the last follow-up (28 interquartile range: 25.5 months), 11 children (26%) were in complete remission and 25 (66%) had achieved partial remission. The mean eGFR had reduced to 145.84 ± 78.05 mL/min/1.73 m2. Patients with normal initial eGFR were more likely to go into remission (P = 0.001). The short-term outcome of childhood primary MN is relatively good in our setup. A multicenter collaborative study is required to determine prognostic factors and to standardize treatment in this uncommon nephropathy.

Perioperative Antibiotic Selection and Surgical Site Infection in Elective Colon Surgery.

OBJECTIVES: The highest rates of surgical site infections (SSIs) are associated with colorectal operations (up to 30%). A sentinel paper showed that the use of intravenous (IV) cefazolin and metronidazole was associated with decreased rates of SSI compared with cefoxitin (6% vs 13%). We reviewed the association of SSI with prophylactic antibiotic choice. We specifically investigated the regimens of ceftriaxone and metronidazole IV, cefoxitin IV, or ertapenem. METHODS: We conducted a retrospective review of 532 colon surgeries between 2016 and 2018. Inclusion criteria were patients 18-89 years of age undergoing elective colon surgery who received ceftriaxone/metronidazole, cefoxitin, or ertapenem for prophylaxis. All emergent cases were excluded. This resulted in 241 elective colon cases for review. The primary endpoint was to determine if the use of ceftriaxone/metronidazole decreased the rate of SSI. RESULTS: In total, there were 241 elective colon cases with 21 SSI. We compared SSI rates in the ceftriaxone/metronidazole group to those patients receiving either cefoxitin or ertapenem (4.5% vs 12.2%; P = .035). We then compared SSI in ceftriaxone/metronidazole to SSI in cefoxitin (4.5% vs 10%; P = .13). Finally, we compared SSI in the ceftriaxone/metronidazole group to SSI in the ertapenem group (4.5% vs 14%; P = .03). Comorbidities and underlying factors were similar across all antibiotic groups. CONCLUSION: In our experience, the use of ceftriaxone/metronidazole is associated with a decreased SSI rate. Furthermore, ceftriaxone/metronidazole use is superior to the use of ertapenem, with a trend toward superiority over cefoxitin. Based on this study, we recommend ceftriaxone/metronidazole as antibiotic prophylaxis for elective colon surgery.

Ameliorative Effects and Cellular Aspects of Phytoconstituents in Atherosclerosis.

Atherosclerosis is a cardiovascular disease that involves vessels through the development of fatty streaks and plaques. Plant-based compounds can help treat or prevent atherosclerosis by affecting various factors that are involved in the disease. The present review discusses our current knowledge of the major cellular and molecular mechanisms of phytotherapeutics for the treatment of atherosclerosis. Numerous studies have evaluated the antiatherosclerotic activity of phytoconstituents to provide preliminary evidence of efficacy, but only a few studies have delineated the underlying molecular mechanisms. Plant-derived phytotherapeutics primarily targets abnormal levels of lipoproteins, endothelial dysfunction, smooth muscle cell migration, foam cell development, and atheromatous plaque formation. Nonetheless, the principal mechanisms that are responsible for their therapeutic actions remain unclear. Further pharmacological studies are needed to elucidate the underlying molecular mechanisms of the antiatherosclerotic response to these phytoconstituents.

Phytochemical analysis and hypotensive potential of Teucrium stocksianum Boiss.

Teucrium stocksianum Boiss. is an aromatic perennial herb. It has long been used traditionally in the treatment of hypertension in northern areas of Pakistan. The aim of this study was to evaluate its folkloric claim as hypotensive plant, phytochemical analysis and to predict potential phytoconstituent through in-silico studies. Hypotensive effect was investigated in anesthetized normotensive Sprague-Dawley rats. Recording of chronotropic and inotropic effect of plant extract in isolated right atria was done using tissue organ bath technique. Further, phytochemical characterization was performed through LC-MS. Whereas docking studies were carried out against M2 mAchR and Ca2+ Channel receptor. Dose dependent reduction in systolic, diastolic, mean arterial pressure and heart rate was observed. Pretreatment with atropine and amlodipine significantly (p<0.001) reduced the hypotensive and negative chronotropic and inotropic effect. Phytochemical studies revealed the presence of twenty active compounds including Luteolin, Sarmentosin epoxide and Quinic acid. Docking studies showed pronounced interactions of majority of these phytochemicals with M2 mAch receptor in agonistic way and Ca2+ Channel receptor in antagonistic way. Results speculate that dose dependent hypotensive and bradycardia effect of Teucrium stocksianum are mediated through muscarinic pathway and Ca2+antagonism and is also well predicted by in-silico studies.

The Use of Robotic and Laparoscopic Surgical Stapling Devices During Minimally Invasive Colon and Rectal Surgery: A Comparison.

PURPOSE: To date there exists no published study examining the safety and efficacy of the EndoWrist 45 (Intuitive Surgical, Inc.) robotic stapler. We compared outcomes between the robotic and comparable laparoscopic stapler in robotic-assisted colorectal procedures. MATERIALS AND METHODS: We conducted a retrospective review of 93 patients who underwent robotic-assisted colorectal surgery at our institution from 2012 to 2014. Surgeries included left, sigmoid, subtotal and total colectomies, and low anterior rectal resections. Indications were malignancy and diverticular and inflammatory bowel disease. Preoperative demographics, intraoperative data, and postoperative outcomes were examined. Student's t-test and Fischer's exact used were appropriate. RESULTS: Forty-five millimeters laparoscopic staplers were used in 58 cases, while the 45 mm robotic stapler was used in 35 cases. There was no difference in age (P = .651), gender (P = .832), or body mass index (P = .204) between groups. There was no difference in estimated blood loss (P = .524), operative time (P = .769), length of stay (P = .895), or complication rate (P = .778). The robotic stapler group had one anastomotic leak, while the laparoscopic stapler group had six (P = .705). There were more laparoscopic stapler fires (2.69) per patient than robotic stapler fires (1.86) (P = .001). The cost per patient for the laparoscopic group was $631.45 versus $473.28 for the robotic group (P = .001). CONCLUSION: This is the first study to evaluate the robotic stapler. Advantages of the robotic stapler include large range of motion and 90° of articulation, which may provide a benefit when using the stapler in difficult areas like the pelvis. The robotic stapler has a comparable level of safety as a 45 mm laparoscopic stapler and is more cost effective.