Development and content validation of the percutaneous nephrolithotomy assessment score.

OBJECTIVES: To develop and content validate a percutaneous nephrolithotomy assessment score, taking into consideration the procedure-specific risks. METHODS: This prospective international study utilized the Healthcare Failure Mode and Effect Analysis to systematically outline percutaneous nephrolithotomy and failure modes for each step. A total of 25 h was spent observing percutaneous nephrolithotomy carried out by six expert surgeons. Hazard analysis scoring was carried out by 11 experts. It was determined if the steps were single point weaknesses. Single point weaknesses and those assigned a hazard score ≥4 were included in the percutaneous nephrolithotomy assessment score. The tool was then content validated by 16 experts from 10 countries. RESULTS: Application of the Healthcare Failure Mode and Effect Analysis identified 64 failure modes; 37 failure modes had a hazard score ≥4. After adaptations based on expert feedback the final percutaneous nephrolithotomy assessment score was developed containing 10 phases, 21 processes and 47 subprocesses. All participants agreed that the tool contained pertinent procedural steps. CONCLUSIONS: This study has developed and shown the international content validity of a novel percutaneous nephrolithotomy assessment score. The tool can be utilized in modular operating room training to quantify operator progress, and can be used in conjunction with other modules as part of a complete percutaneous nephrolithotomy curriculum for trainees.

Obstructive uropathy due to uretero-inguinal hernia: An uncommon occurrence.

Obstructive uropathy secondary to uretero-inguinal hernia is a rare phenomenon. Two types have been described-the rarer extraperitoneal type is frequently associated with other renal anomalies. Pre-operative diagnosis is essential in order to reduce the risk of ureteric injury intra-operatively. We describe one such case.

Renal cell carcinoma with retro-aortic renal vein thrombus: a case series.

OBJECTIVE: To present three cases of tumour thrombus in the retro-aortic renal vein (RARV) arising from left renal cell carcinomas (RCCs), a very rare event (<1:1000-2000 per case) and to discuss the embryological, radiological and surgical aspects of this anomaly. PATIENTS AND METHODS: Three cases of RCC with RARV thrombus presented in a 1-month period at one institution. RESULTS: All three cases were identified before surgery by computed tomography (CT) urograms and had a successful nephrectomy. CONCLUSION: RCC in the presence of RARVs is rare but can be identified on CT urogram. At nephrectomy, a midline laparotomy or full 'rooftop incision' is recommended, and any attempt to mobilize the kidney before dealing with the renal pedicle should be avoided.

Safety profile of a nicotine lozenge compared with that of nicotine gum in adult smokers with underlying medical conditions: a 12-week, randomized, open-label study.

BACKGROUND: Nicotine polacrilex lozenges deliver 25% to 27% more nicotine compared with equivalent doses of nicotine polacrilex gum. The increased nicotine exposure from the lozenge has raised questions about the relative safety of the lozenge and gum. OBJECTIVE: The objective of this study was to compare the safety profiles of the 4-mg nicotine lozenge and 4-mg nicotine gum in smokers with selected label-restricted diseases. METHODS: This was a multicenter, randomized, open-label study in adult smokers with heart disease, hypertension not controlled by medication, and/or diabetes mellitus. Patients were randomized in a 1:1 ratio to receive the 4-mg nicotine lozenge or 4-mg nicotine gum. Safety assessments were made at baseline and at 2, 4, 6, and 12 weeks after the start of product use. RESULTS: Nine hundred one patients were randomized to treatment, 447 who received the lozenge and 454 who received the gum (safety population). The majority were women (52.7%). Patients' mean age was 53.9 years, their mean weight was 193.9 pounds, and they smoked a mean of 25.2 cigarettes per day at baseline. Five hundred fifty-three patients, 264 taking the lozenge and 289 taking the gum, used the study product for > or =4 days per week during the first 2 weeks (evaluable population). The nicotine lozenge and nicotine gum were equally well tolerated, despite increased nicotine exposure from the lozenge. The incidence of adverse events in the 2 groups was similar during the first 2 weeks of product use (evaluation population: 55.3% lozenge, 54.7% gum), as well as during the entire study (safety population: 63.8% and 58.6%, respectively). Stratification of patients by sex, age, extent of concurrent smoking, extent of product use, and severity of adverse events revealed no clinically significant differences between the lozenge and gum. The most common adverse events were nausea (17.2% and 16.1%; 95% CI, -3.7 to 6.0), hiccups (10.7% and 6.6%; 95% CI, 0.5 to 7.8), and headache (8.7% and 9.9%; 95% Cl, -5.0 to 2.6). Serious adverse events were reported in 11 and 13 patients in the respective groups. Fewer than 6% of patients in either group were considered by the investigator to have a worsening of their overall disease condition during the study. The majority of patients (>60%) experienced no change in their disease status from baseline. CONCLUSION: The 4-mg nicotine lozenge and 4-mg nicotine gum had comparable safety profiles in these patients with label-restricted medical conditions.

Perinephric Collection: Hematoma or Duodenal Perforation?

A 74-year-old man presented with a history of collapse and abdominal pain. Initial imaging showed a left sided preirenal collection. The initial working diagnosis was perirenal hematoma secondary to renal trauma. Subsequent patient deterioration led to further imaging which led to the diagnosis of a duodenal perforation with tracking of duodenal contents into the left perirenal space. This important differential should be a consideration in cases of perinephric collections of unknown etiology.

An overview of the use and implementation of checklists in surgical specialities - a systematic review.

INTRODUCTION: Surgical procedures present an immense risk to patients, and adverse patient outcomes are frequently due to substandard non-technical skills amongst surgical staff. The implementation of a 19-item Surgical Safety Checklist, developed by the World Health Organization, is being enforced in operating theatres globally. The objective is to systematically analyze published literature to assess the use of the WHO Surgical Safety Checklist and their impact in on patient safety. METHODS: An English literature search was carried out using MEDLINE, EMBASE and PsycINFO databases. Relevant information was extracted relating to surgical specialities, compliance with the checklist, effects of checklist use on patient outcomes, and staff perceptions of the checklist. Selection was restricted to articles that used the WHO Surgical Safety Checklist. RESULTS: The literature search found 916 potentially relevant articles, which were narrowed down following an abstract review and a full text review. A final total of 16 studies were identified that observed the use of checklists in various surgical specialties; all surgical specialities (n-10), pediatric surgery (n-2), orthopedic surgery (n-2), otorhinolaryngology surgery (n-2). DISCUSSION: Surgical checklists have been shown to significantly improve patient outcomes subsequent to surgery, and therefore their use is being widely encouraged and accepted. Continual feedback could be given to maintain high checklist compliance, and thus high patient safety. SUMMARY: The recent use of checklists in surgery has shown improvements in patient outcomes post-operatively. A review was conducted to establish the impact of the checklist on different surgical specialities.