Association between malnutrition-inflammation score and risk of subsequent self-reported bone fractures in prevalent kidney transplant recipients.

Chronic inflammation and protein energy wasting (PEW) syndrome are common in kidney transplant recipients (KTR). The presence of inflammation and PEW syndrome can directly affect bone resorption and bone formation, leading to bone loss and fractures. We showed PEW is independently associated with new clinically detected bone fractures in prevalent KTR. INTRODUCTION: Kidney transplant recipients (KTR) have a 4-fold higher risk of fracture compared to the general population. Chronic inflammation and PEW syndrome are common in KTR and are associated with poor outcomes. We hypothesized that the Malnutrition-Inflammation Score (MIS), a validated measure of PEW, is associated with higher risk of bone fractures in KTR. METHODS: This prospective cohort study included 839 prevalent KTR from a Central European academic center. MIS, a semiquantitative instrument of PEW, was calculated at the study entry. Self-reported history of fractures was recorded during the 2-year follow-up period. The association between MIS and bone fractures was examined in logistic regression analyses with adjustment for age, gender, eGFR, smoking habits, history of pre-transplant bone fractures, and acute rejection. RESULTS: Mean age was 51 ± 13 years, and 56% of patients were males with median (interquartile range) transplant vintage 69 (38-112) months, estimated glomerular filtration rate 55 ± 21 ml/min/1.73 m2, and calculated MIS 3 (2-4) at enrollment. Fifty-five (7%) patients experienced self-reported bone fractures during the 2-year follow-up period. Higher MIS score showed linear association with increased risk of fracture. Each one-point higher MIS was associated with 23% higher risk of bone fractures (odds ratio (OR) and 95% CI 1.23, 1.12-1.34), which remained significant after multivariable adjustments (OR 1.17, 95% CI 1.06-1.29). CONCLUSION: The MIS is independently associated with new clinically detected bone fractures in prevalent KTR.

Low free to total PSA ratio is not a good discriminator of chronic prostatitis and prostate cancer: An Indian experience.

Aims: To find out the utility of free to total PSA ratio in discriminating chronic prostatitis and prostate cancer. Setting and design: The patients visited urology clinics at Batra Hospital and Medical Research Center, New Delhi. Background: The use of serum free to total PSA as a diagnostic tool for prostate cancer has led to early detection of prostate cancer; however, the effect of inflammation on f/t PSA ratio restricts its use in early detection of cancer. Materials and Methods: The study was conducted in age related 101 patients which include 27 carcinoma patients (group I), 34 BPH patients (group II) and 40 chronic prostatitis patients (group III). Serum total PSA (tPSA) and free PSA (fPSA) were analyzed on Elecsys 2010. These were compared with histological reports of biopsy specimen. Other biochemistry tests were done on Randox Imola. P Value was calculated using one way ANOVA with posthoc Bonferroni analysis. Results: Serum total PSA levels were comparable in group I and III and were higher than group II (P < 0.049). Serum fPSA in group I was not significantly different from group II and III, However, group II has higher levels than group III (P < 0.035). Difference was significant for f/t PSA ratio in group I and II (P < 0.00) and group II and III (P < 0.000).Group I and III were with comparable levels (P < 0.807). Conclusions: f/t PSA ratio is not a good discriminator for malignancy and chronic prostatitis. This limitation of f/t PSA ratio must be taken into consideration while interpreting the results clinically.

Biodegradation of organophosphate pesticide quinalphos by Ochrobactrum sp. strain HZM.

AIMS: Isolation and identification of bacteria capable of degrading organophosphate pesticide quinalphos and elucidation of its biodegradative pathway. METHODS AND RESULTS: A bacterium capable of degrading organophosphate pesticides was isolated from the pesticide-contaminated soil samples by selective enrichment on quinalphos (QP) as a sole source of carbon and energy. The bacterial strain was identified as Ochrobactrum sp. strain HZM on the basis of its morphological and biochemical characteristics and by phylogenetic analysis based on 16S rRNA gene sequences. The organism utilized various organophosphate pesticides such as quinalphos, profenofos, parathion-methyl and chlorpyrifos as growth substrates. Response surface methodology (RSM) showed optimum conditions for quinalphos degradation at pH 7 and 27°C. 2-Hydroxyquinoxaline and diethyl phosphate were identified as metabolites of quinalphos degradation by HPLC and GC-MS analysis. Cell-free extract of Ochrobactrum sp. strain HZM grown on quinalphos contained the quinalphos hydrolase activity. CONCLUSIONS: A bacterial strain capable of degrading quinalphos was isolated and identified as Ochrobactrum sp. strain HZM. The organism utilized organophosphate pesticides quinalphos, profenofos, parathion-methyl and chlorpyrifos as carbon sources. The organism degraded quinalphos by hydrolysis to yield 2-hydroxyquinoxaline and diethyl phosphate which were further utilized as carbon sources. SIGNIFICANCE AND IMPACT OF THE STUDY: The isolated bacterium Ochrobactrum sp. strain HZM was versatile in degrading various organophosphate pesticides. There was complete mineralization of quinalphos by Ochrobactrum sp. This strain could potentially be useful in the bioremediation of soil and water contaminated with toxic organophosphate pesticides.

Utility of free/total prostate specific antigen (f/t PSA) ratio in diagnosis of prostate carcinoma.

The discovery that PSA exists in serum in both free and complexed forms led to development of immunoassays specific for different PSA forms. This helped in measuring free PSA in the presence of PSA-ACT (PSA-alpha antichymotrypsin), hence it was possible to calculate the percent free PSA or free to total PSA ratio, measurement of which was helpful in reducing the number of unnecessary biopsies significantly, while maintaining a high clinical sensitivity for detection of cancer. The study was performed on 103 consecutive male patients (mean age 68 +/- 10.8 years SD) comprising of 90 patients with benign disease (87%) and 13 prostate carcinoma patients (13%), who had histologically proven prostate cancer. Patients with total PSA between 2-25 ng/ml were included in the study. 30 normal healthy males with age 58 +/- 10 years, served as control. Serum total PSA and free PSA were analyzed using streptavidin biotin EIA method (M/s Roche Diagnostics, Germany). The mean total PSA in normal healthy control subjects was 1.86 +/- 1.07 ng/ml. It was increased significantly in diseased condition. Its mean concentration in carcinoma patients was 12.6 +/- 5.3 ng/ml and in benign patients it was 6.3 +/- 4.6 ng/ml. The free to total PSA ratio in all the three groups was significantly different (p < 0.004) from each other. In carcinoma patients, mean f/t PSA ratio was 0.12 +/- 0.06 as compared to 0.21 +/- 0.11 and 0.28 +/- 0.17 in benign patients and in control respectively. The sensitivity and specificity of the test was calculated at different f/t PSA ratio cutoff. At 0.1 cutoff value, sensitivity of the test was 54% and specificity was 83%. The positive predictive value (ppv) was 32% and negative predictive value (npv) was 92%. From cutoff value of 0.12 to 0.16, sensitivity was increased from 54% to 85% but specificity was reduced from 78% to 67%. The ppv did not show much change and npv was increased from 92% to 97%. Increasing the cut off value thereafter showed no change in sensitivity but specificity was further reduced to 40%, therefore in this patient series, f/t PSA ratio cutoff of 0.16 was found to be the appropriate cutoff value. Combination of this ratio cutoff with other parameters like serum total PSA, DRE and TRUS helped in increasing the sensitivity of the test and this also helped in reducing the number of unnecessary biopsies. In 103 men who were biopsied, 13 (12.6%) prostatic carcinoma were identified. Among these 13 cancer patients, 9 patients had abnormal findings in DRE.7 individuals out of these 9, also had free to total PSA ratio lower than 0.16 and would have been biopsied and diagnosed anyway. If we use only f/t PSA ratio less than 0.16, to decide whom to biopsy, we would have biopsied and diagnosed 11/13 cases i.e. sensitivity of 85% but If we decide to biopsy those patients who had abnormal DRE and those who had low f/t PSA ratio, we could identify 13/13 carcinoma i.e. 100% sensitivity. Combining the f/t PSA ratio with total PSA, DRE and TRUS findings could help in reducing the number of unnecessary biopsies. 37 patients who were negative for malignancy having total PSA in the range of 5-20 ng/ml, normal DRE and TRUS findings, have been biopsied but with combination of total PSA in the range of 5-20 ng/ml, normal findings in digital rectal examination and TRUS and f/t PSA ratio more than 0.16 (cutoff), we could have avoided 16 biopsies which were unnecessary that means there was 43% reduction in unnecessary biopsies.

Transurethral resection versus open surgery for leiomyoma of urinary bladder--a report of 2 cases.

The authors describe two patients with leiomyoma of the bladder who presented with bladder outlet obstruction. The results of magnetic resonance imaging are presented and their management discussed. Complete resection was curative in both patients, by enucleation in the first case and by transurethral resection in the second.

Stone necklace of urinary tract presenting as renal failure: one stage management.

We describe three cases with bilateral extensive involvement of both upper and lower urinary tract with calculi presenting in renal failure. The management of these patients in a single operative session and rendering them stone free is discussed. Modern endourologic techniques have made it possible to treat patients with such an extensive involvement of the urinary tract with stone disease with minimum morbidity.

Laparoscopic removal of a gigantic non-functioning kidney via retroperitoneal access.

Hugely dilated kidneys can sometimes present as abdominal masses. These kidneys are invariably non-functioning and are managed by nephrectomy. We describe a case of massive kidney containing 12.5 litres on fluid which was managed by retroperitoneoscopic nephrectomy. The patient was a 24-year-old male who presented with a huge abdominal mass, anorexia and weight loss. Laparoscopic surgery for such a large kidney has not been previously reported. We discuss salient features of the procedure and elaborate on the modifications required in the case of significantly enlarged kidneys.

Endoscopic management of prolapsing intravesical ureterocele in an adult female--a case report.

The authors present a case of intravesical ureterocele in a female which prolapsed out of the external urethral meatus causing urinary obstruction, and was managed by reduction into the bladder followed by endoincision.

Concomitant renal and prostatic aspergillosis.

Aspergillosis limited to the urinary tract is a rare disease seen most often in patients with altered immune status. Only 19 cases of renal aspergillosis including 3 with AIDS and 4 cases of isolated prostatic aspergillosis have been reported. We report the first case of concomitant renal and prostatic aspergillosis in a non-immunocompromised patient who presented with pyrexia of unknown origin and with dysuria. The diagnosis was based on the demonstration of characteristic hyphal elements on direct microscopy and isolation of the fungus in the culture of pus from the kidney. In view of obstructive prostatic enlargement and left non-functioning renal mass, transurethral resection of the prostate and left nephrectomy were performed in a single session with successful outcome. The aetiopathogenesis and brief review of the literature are discussed.

Retroperitoneoscopic nephrectomy for benign diseases of the kidney: prospective nonrandomized comparison with open surgical nephrectomy.

PURPOSE: To describe, define, and evaluate the efficacy of retroperitoneoscopic nephrectomy (RPN) for benign diseases of the kidney and to compare it with open surgical nephrectomy (OSN) via a flank approach. PATIENTS AND METHODS: From August 1995 to November 1997, 29 men and 14 women (mean age 33 years) with severely damaged kidneys underwent RPN. Among these, 11 patients had undergone prior surgery, 3 had chronic renal failure, and 8 patients had a percutaneous nephrostomy. The RPN was performed via three or four ports, with the kidneys being removed intact from the retroperitoneal working space. During the same period, 43 patients underwent OSN through a flank approach (extrapleural and extraperitoneal) for nonfunctioning or poorly functioning kidneys. RESULTS: In the RPN group, two patients required conversion to OSN. The operative time and estimated blood loss ranged from 40 to 210 minutes (mean 114 minutes) and 50 to 450 mL (mean 127 mL), respectively. In the OSN group, the corresponding values were 60 to 100 minutes (mean 104 minutes) and 70 to 600 mL (mean 266 mL), respectively. The mean length of hospitalization after RPN was considerably shorter--2 to 7 days (mean 3.4 days)--than after conventional open surgery--4 to 16 days (mean 8.6 days). The incidences of minor and major complications were 21% and 5%, respectively, in the RPN group and 33% and 2% in the OSN group. The postoperative analgesic requirement was significantly less (P < 0.001) in RPN group. The interval to return to normal activity ranged from 7 to 30 days (mean 20.3 days) and 20 to 60 days (mean 32.9 days) in the RPN and OSN group, respectively, with superior performance status, cosmesis, and quality of life observed in the former group. CONCLUSION: Retroperitoneoscopic nephrectomy is as effective as open nephrectomy for benign kidney diseases with less postoperative pain, a shorter hospital stay, earlier recuperation, and excellent cosmesis. This procedure can also be performed in patients who have undergone abdominal operations previously, in those with chronic renal failure, and in those with a percutaneous nephrostomy. The operation has become our first line of approach for benign diseases of the kidney.

Coarctation of the aorta: tailoring the surgical approach.

OBJECTIVE: To employ a flexible approach for repairing coarctation of the aorta in an attempt to minimize residual coarctation and avoid the use of synthetic material. DESIGN: Retrospective study of consecutive children undergoing surgical repair of coarctation of the aorta. SETTING: Walter C Mackenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta. PATIENTS: Children presenting with coarctation of the aorta between June 1993 and October 1996 (n = 42), treated by one surgeon. INTERVENTIONS: Children had repair by one of three methods: subclavian flap angioplasty for discrete juxtaductal coarctation, 17 (40%); resection and end-to-end anastomosis, 13 (31%); and resection with extended transverse arch repair, 12 (29%). MAIN RESULTS: Follow-up was 22 +/- 2 months. The preoperative mean arm-leg gradient was 23 +/- 3 mmHg and postoperatively was 4 +/- 2 mmHg (P < 0.001). In late follow-up, five children developed a significant gradient (end-to-end anastomosis, one; transverse arch repair, two; subclavian flap angioplasty, two) necessitating balloon dilation, one of whom (subclavian flap angioplasty) eventually required end-to-end repair. Another child, who had a subclavian flap angioplasty, underwent transverse arch repair at the time of complete cardiac repair. There was one perioperative death in a child who was in extremis preoperatively and three late deaths in children with additional complex intracardiac anomalies. CONCLUSIONS: A flexible surgical approach with avoidance of synthetic material and low threshold for extended repair has yielded good early and intermediate term results.

Blunt cardiac injury: a 10 year institutional review.

A 10 year review of all blunt cardiac injuries (N = 70) at a single trauma institution was conducted. The majority of patients were diagnosed on the basis of elevated myocardial band fraction of creatine kinase (CK-MB), ST/T wave changes or arrhythmias. The presence of CK-MB elevation was not predictive of arrhythmias, cardiac complications, inotrope requirement, or mortality. The presence of ECG abnormalities or arrhythmias was also not predictive of inotrope requirement or mortality. Cardia complications requiring treatment occurred in 26 per cent (N = 18) of patients. Patients requiring inotropes (N = 12, 17 per cent) had higher Injury Severity Scores (ISS), longer times from injury to emergency, and higher mortality rates, than those not requiring them. Patients who died (N = 10) had a higher ISS, lower Revised Trauma Score, and a more frequent need for inotropes. Only three deaths were directly attributable to the cardiac injury. Myocardial contusion is an injury often of little clinical importance. Patients present with injuries of little or no consequence, severe injuries where the diagnosis is readily apparent, or as a confounding variable in a multiply injured patient. Early use of transthoracic echocardiography is advocated.

The effect of a synthetic analogue of prostaglandin E2 on wound healing in rats.

This was a prospective, randomized, double-blind experimental study to assess the effect of a long-acting prostaglandin (PG) analogue on wound healing in rats. Eight-cm long, dorsal midline skin incisions were made on rats (n = 44) and immediately resutured. The treatment group (n = 22) received daily intraperitoneal injections of 16,16-dimethyl prostaglandin E2-methyl ester (di-MPGE2) for 7 days, whereas the controls (n = 22) received normal saline. The rats were sacrificed in groups of 11 at 7 and 14 days, respectively. The wounds were excised and analyzed. Histology showed that there was increased fibrosis (p < 0.03) and a decreased number of macrophages (p < 0.02) in the PG group at 7 days. Tensile strength and hydroxyproline content also increased but did not attain significant levels. The differences between the PG and control groups at 14 days similarly did not attain statistical significance. The results suggest that in wound healing, the administration of di-MPGE2 may be beneficial during the early stages of inflammation, rather than during the later stages of remodelling.

Traumatic rupture of the thoracic aorta during the second trimester of pregnancy.

A 36-year-old woman in the second trimester of pregnancy underwent emergent operative repair of a traumatic aortic disruption caused by a motor vehicle accident. Left atrial-to-femoral artery bypass was used to maintain fetal circulation during the cross-clamp period. Her healthy, full-term child was subsequently delivered 3 months later by normal vaginal delivery.

Cardiopulmonary bypass for resuscitation after penetrating cardiac trauma.

Cardiopulmonary bypass is only occasionally required acutely in the management of penetrating cardiac injuries, usually to allow coronary grafting. We describe a case of penetrating trauma in which cardiopulmonary bypass was used to resuscitate a patient whose cardiac lacerations were controlled in the emergency department.

Ureterovaginal fistula following laparoscopic-assisted vaginal hysterectomy--a case report with review of literature.

The authors present a case of ureterovaginal fistula following laparoscopy-assisted vaginal hysterectomy, which was successfully managed by ureteroneocystostomy with bladder psoas hitch.

Primary adenocarcinoma of the urinary bladder--a case report with review of literature.

Primary adenocarcinoma of the urinary bladder is a rare neoplasm. We present the clinicopathological and immunohistochemical analysis of a case in a 50 year old male. The histogenesis of the tumour and a review of literature is also discussed.

Fine needle aspiration cytology of a lipoblastoma.

A lipoblastoma, an uncommon tumor of childhood that can be mistaken for a liposarcoma, was preoperatively diagnosed by fine needle aspiration cytology. The characteristic features on the cytologic smears were the presence of immature fat cells in the form of spindle-shaped cells, stellate cells and vacuolated lipoblasts along with lipocytes. The cytologic diagnosis was confirmed by histologic study of the excised tumor.