An observation of massive lumbar disc prolapse.

BACKGROUND: The aim of this study was to investigate whether massive lumbar disc herniations (LDH) can be managed safely with non-operative treatment. Whilst most LDH are treated successfully with analgesia and physiotherapy, there is little literature regarding the treatment of massive LDH. Their impressive size raises the suspicion that they may cause cauda equina syndrome and are therefore often treated surgically. METHODS: Patients were referred to our tertiary unit by either their general practitioner or the musculoskeletal service. To be included in the study, patients had to have a diagnosis of massive LDH on their initial magnetic resonance imaging (MRI) and opt for non-operative treatment. Seventeen patients with a diagnosis of massive LDH with an average follow-up of 209 days (0 to 1,005 days) were reviewed. RESULTS: One patient was listed for surgery due to persisting radicular pain only. However, they were deemed unfit for surgery and this was therefore cancelled. One patient developed impending cauda equina syndrome and underwent urgent discectomy with no complications. All remaining patients were managed safely non-operatively with no complications. CONCLUSIONS: We conclude that the massive LDH can be safely managed non-operatively, providing patients are examined for cauda equina syndrome and are fully educated on the need to represent urgently should red-flag symptoms develop.

Calciphylaxis after parathyroidectomy.

A 60-year-old African American man with end stage renal disease on hemodialysis (HD) for the past 2.5 years developed severe hyperparathyroidism. Other past medical history included atrial fibrillation, type II diabetes mellitus, hypertension, gout, pericardial effusion needing pericardial window, deep vein thrombosis, mitral insufficiency, and cardiomyopathy with implantable cardioversion device placement. His parathyroid hormone (PTH) level peaked at 4,191 pg/mL despite being on cinacalcet, sevelamer, and paricalcitol. He underwent a subtotal parathyroidectomy in January 2015, after which his PTH levels dropped to 184 pg/mL. Approximately 4 weeks later he developed extensive, painful necrotic skin lesions in both his lower extremities and buttocks, suggestive of calciphylaxis which was confirmed by tissue biopsy. The patient was treated with elaborate wound care, wound debridements, increased dialysis dose, and IV sodium thiosulfate (STS) during hemodialysis. Besides STS, he was treated with narcotics, gabapentin, topical lidocaine on intact skin, and oral steroids for pain control. Even though his lesions improved initially, he deteriorated due to recurrent sepsis, respiratory failure, and prolonged hospitalization which culminated in stopping dialysis before he passed away. Calciphylaxis, or calcific uremic arteriolopathy, is a life-threatening complication of end stage renal disease. Treatment of this condition is multidisciplinary which includes elaborate wound care, increasing dialysis dose, and discontinuing vitamin D supplements and calcium containing phosphate binders. Even though STS has been recommended off-label, several studies have shown promising results with resolution of lesions. Thus, sodium thiosulfate has become the mainstay of treatment. Parathyroidectomy is a recommended modality of treatment in those with high PTH levels. Our case was unique in that calciphylaxis developed after subtotal parathyroidectomy. We believe that this is due to a decreased PTH level and decreasing bone turnover which resulted in more circulating calcium facilitating vascular and soft tissue calcification. The exact mechanism of developing calciphylaxis after parathyroidectomy is unknown. Even though parathyroidectomy is an effective treatment for calciphylaxis, clinicians should be aware that it can rarely present after parathyroidectomy.

Incisional Hernia After Peritoneal Dialysis Catheter Placement in a Patient on Sirolimus.

Hernias and peritoneal dialysis (PD) catheter leaks are frequent complications in patients on PD. Transplant recipients have multiple risk factors for delayed wound healing, such as use of corticosteroids and sirolimus, and the presence of uremia and diabetes mellitus. We report a rare occurrence of incisional hernia attributable to internal wound dehiscence after PD catheter placement in a patient on sirolimus.A 34-year-old Latino American man was started on PD training 4 weeks after placement of a PD catheter. Soon after completing training, he developed a large soft bulge close to the PD catheter, with expansile cough impulse suggestive of an incisional hernia filled with peritoneal dialysate. The size of the bulge would decrease after the dialysate was drained. No external leak of dialysate was evident along the exit site.Because of the size of the hernia and the history of it filling soon after dialysis exchange, the feeling was that wound dehiscence had occurred from the peritoneal side, resulting in a large incisional hernia. Because of the large size of the hernia within few weeks of starting PD, sirolimus was suspected to have induced poor wound healing, contributing to formation of the hernia.Sirolimus was stopped, and the patient underwent PD catheter removal and repair of the hernia. A new PD catheter was placed on the opposite side of the abdomen 10 days later. After another 6 weeks, the patient was started on PD. He has been doing well for the 15 months since then, with no recurrence of the hernia. Because he still had residual renal function, he continued to receive low-dose prednisone and mycophenolate sodium. At 10 months after PD start, he stopped the mycophenolate sodium on his own, and we did not resume it. He is still on low-dose prednisone.In end-stage renal disease resulting from failing renal transplantation or from calcineurin inhibitor nephropathy in solid-organ transplantation, sirolimus is a risk factor for wound dehiscence, development of incisional hernia, and peritoneal dialysate leak.Practical tips: Sirolimus should be stopped several days before PD catheter placement. Sirolimus should also be stopped if a PD catheter leak is detected or if incisional hernia develops soon after initiation of PD. Sirolimus should be held till surgical repair of the hernia and removal and replacement of the catheter.

Bullous Skin Lesions in a Patient with End-Stage Renal Disease and Hepatitis C.

Bullous lesions in patients with end-stage renal disease are uncommon and can pose diagnostic and therapeutic challenges. We present a female patient with end-stage renal disease, bullous skin lesions affecting mainly sun-exposed areas, and high ferritin levels. She also had hepatitis C. Her serum porphyrin panel was suggestive of porphyria cutanea tarda. Skin biopsy excluded inflammatory pathologies. Phlebotomy during each hemodialysis, continuation of darbepoetin, and avoidance of any further doses of intravenous iron, with close monitoring of hemoglobin, resulted in a gradual drop in ferritin level and improvement of the skin lesions.

Treatment of Calciphylaxis: A Case for Oral Sodium Thiosulfate.

Calciphylaxis is a major cause of morbidity and mortality in end-stage renal disease (ESRD). Intravenous sodium thiosulfate (STS) is the mainstay of therapy for calciphylaxis. In peritoneal dialysis (PD) patients with calciphylaxis, intravenous STS poses logistic and financial challenges. Even though pharmacokinetic studies show poor bioavailability of oral STS, we report successful use of oral STS in 2 PD patients with calciphylaxis.A 55-year-old Latina American woman with diabetes was initiated on PD after access failure and chronic hypotension. She developed painful ischemic lesions in the left middle finger and left big toe 4 months later. The ischemia in the left hand progressed, requiring amputation of two fingers. She later developed extensive painful calcific areas in the abdominal wall. She was initially started on oral STS 1500 mg twice daily that was subsequently increased to 3750 mg daily, which resulted in substantial pain relief and a decrease in the size of the calcific plaques.Another diabetic patient with ESRD who was on PD presented with a painful ischemic finger for 2 years. He was treated with oral STS 1500 mg twice daily, resulting in prompt pain relief.Oral STS can be an effective treatment for calciphylaxis.

Reducing peritoneal dialysis-related peritonitis rate.

BACKGROUND: Peritoneal dialysis-related peritonitis is an important negative risk of peritoneal dialysis. Peritonitis results when organisms enter the normally sterile peritoneal space, and the peritoneal immune system is unable to prevent the proliferation of the organisms. METHODS: The process of reducing the rate of peritonitis includes identification of the need for reducing peritonitis, identification of the cause of the high peritonitis rate through root cause analysis, and intervention. RESULTS: Interventions vary depending upon the type of organism causing peritonitis. Nonenterococcal gram-positive peritonitis and Pseudomonas peritonitis are related to contamination and are potentially preventable; enteric peritonitis is difficult to prevent. CONCLUSION: The rate of peritonitis can be reduced through a strong continuous quality improvement team because the majority of peritonitis episodes can be prevented.

Unusual presentation of popliteal soft tissue sarcoma: not every swelling in the knee is a Baker's cyst.

Popliteal soft tissue sarcoma is a rare tumour, but sometimes it does pose clinical, diagnostic and management challenges. We present here a case report which initially presented as Baker's cyst as it is one of the commonest cyst in this region. It posed a diagnostic challenge even with the help of new imaging modalities. But the patient presented herself to the hospital several times with new symptoms often pointing us towards common pathologies like Baker's cyst, deep-vein thrombosis and vascular lesions but diagnosis was established only after histology. Unfortunately, at this stage, disease was so advanced and metastasised, patient reached terminal stage and refused any kind of treatment.

Minimally invasive paratenon release for non-insertional Achilles tendinopathy.

BACKGROUND: Non-insertional Achilles tendinopathy is an increasing, perhaps secondary to an increase in sporting activities. Traditional open surgical procedures have been associated with a significant rate of complications. We describe a minimally invasive technique involving the release of the adherent paratenon with a peritendinous infusion of corticosteroids and present the results in a cohort of patients. MATERIALS AND METHODS: Twenty-nine tendons (26 patients) with non-insertional Achilles tendinopathy were treated with the above technique. Assessments were made prospectively using an adapted classification of Achilles tendon disability and a visual analogue scale for pain. Patients were interviewed in person or by telephone at an average of 14 (range, 6 to 30) months after surgery. RESULTS: The average pain score (VAS) improved from 8.7 to 2.4 (p < 0.001) and the average Puddu level of disability improved from 4.9 to 1.7 (p < 0.001). Seventy-five percent of patients had a good or excellent outcome with 20% having sufficient improvement not to pursue further medical attention for their tendinopathy. There was a 7% rate of minor complications due to delayed wound healing which resolved spontaneously and did not affect the rehabilitation or the recovery of the patients. CONCLUSION: A minimally invasive circumferential paratenon release and peritendinous steroid infusion was a simple method to treat non-insertional Achilles tendinopathy and had low morbidity in our series. This technique has become our preferred primary surgical intervention for this condition.

Anaemia is common after kidney transplantation, especially among African Americans.

BACKGROUND: Anaemia is a major cardiovascular risk factor in renal disease. It might be appropriate to extrapolate this association of anaemia with cardiovascular disease to renal transplant recipients who continue to have a significant cardiovascular risk. There are very few studies addressing the issue of anaemia after renal transplantation. METHODS: We studied 192 consecutive kidney transplant recipients over a 5-year period in a tertiary referral centre in Michigan, USA. Patients who were followed up at the ambulatory transplant clinic for at least 1 year after transplantation were studied. Haemoglobin (Hb) level at 6 months and 1 year after renal transplantation was recorded. Risk factors for anaemia were evaluated using multivariate regression analysis. RESULTS: Significant anaemia (Hb <11 g/dl in females and <12 g/dl in males) was common (19.3% at 6 months, 19.8% at 1 year). Anaemia was more common in African American (AA) than in non-AA patients both at 6 months and 1 year after transplantation. Multivariate analysis showed that serum creatinine was an independent risk factor for anaemia. Female gender was associated with significant anaemia at 1 year. Intriguingly, AA race was also an independent risk factor at 6 months and strong trend for risk at 1 year. CONCLUSIONS: Anaemia is common during the first year after kidney transplantation. AA race as well as high serum creatinine and female gender are independent risk factors for post-transplant anaemia. The importance of anaemia as a risk factor in AA patients after renal transplantation should be more recognised.

Fivefold reduction in peritonitis using a multifaceted continuous quality initiative program.

Despite recent advances in peritoneal dialysis (PD) systems, peritonitis is a significant clinical problem in patients on PD. Risk factors for peritonitis are identifiable and modifiable and require focused intervention. During a baseline period in 1998, we observed consistent differences in peritonitis rates among patients using various PD connection systems. In January 1999, motivated by a need to reduce peritonitis, we initiated a multifaceted continuous quality initiative (CQI) program that included retraining all current patients and all new patients 6 months after initiation and then annually; changing from plastic to titanium adapters between the catheter and the transfer set; and using equipment from a single PD manufacturer for all new patients and for current patients with high peritonitis rates. Furthermore, all patients using HomeChoice cyclers (Baxter Healthcare Corporation, McGaw Park, IL, U.S.A.) were taught to use the Compact Exchange Device II to avoid contamination when spiking solution bags. Peritonitis rates improved from 1 episode per 7.5 patient-months (over 512 patient-months) in 1998 to 1 episode per 36.5 patient-months (over 292 patient-months) as of September 2002. Further analysis also showed a significant difference in peritonitis rates between equipment produced by various manufacturers. There was a statistically significant difference in peritonitis for automated peritoneal dialysis systems. Patients using the Freedom Cycler PD+ (Fresenius Medical Care, Frankfurt, Germany) had an average peritonitis rate of 1 episode per 6.9 patient-months as compared with patients using the HomeChoice cycler (Baxter Healthcare), who experienced 1 episode of peritonitis per 23.9 patient-months on average (p < 0.0001). For continuous ambulatory peritoneal dialysis patients using UltraBag (Baxter Healthcare), the peritonitis rate was 1 episode per 26 patient-months as compared with the Premier Double Bag (Fresenius Medical Care), for which a peritonitis rate of 1 episode per 6.3 patient-months was seen (p < 0.0001). Comparison of the UltraBag (1 episode per 26.0 patient-months) with the Disposable Freedom Set, a single-bag "Y" system (Fresenius Medical Care; 1 episode per 7.5 patient-months) yielded similar results (p < 0.0001). We conclude that ongoing CQI efforts can significantly reduce peritonitis rates. Our efforts included aggressive patient retraining, protocol changes, use of a titanium adapter between the catheter and the transfer set, and careful choice of connectology systems (possible supplier-dependent effect).

Feasibility of adequate solute clearance in obese patients on peritoneal dialysis: a cross-sectional study.

BACKGROUND: It is widely assumed that obese patients are poorly suited for peritoneal dialysis (PD). Mathematical models predicting weight limits to achieve adequate solute clearance in anuric patients on continuous ambulatory PD therapy do not apply to the majority of obese patients on PD therapy. METHODS: To define the extent to which obesity or large body size interferes with successful PD, the feasibility of achieving adequate solute clearance, defined by the Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines, was studied. We reviewed prospectively recorded data for 25 obese patients (body mass index > or = 29) from a group of 58 prevalent PD patients treated in an inner-city ambulatory dialysis center. Adequacy of solute clearances was assessed by comparing weekly Kt/V and weekly creatinine clearance (WCC) with those recommended by the K/DOQI. Adequacy also was examined separately for large patients, defined as those with total-body water (TBW) by the Watson and Watson equation of 48 L or greater. Similar analyses were performed separately for 10 anuric obese patients. RESULTS: Eighty four percent and 88% of the 25 obese patients achieved K/DOQI targets for weekly Kt/V and WCC, respectively. Among the 10 anuric obese patients, 90% and 70% achieved these targets. Only 60% of those with TBW of 48 L or greater met the Kt/V target. CONCLUSION: PD remains a viable option for obese patients with end-stage renal disease. It is possible for the majority of obese patients on PD therapy to achieve solute clearances recommended by the K/DOQI.