Urgent ureteroscopies in acute ureteric colic requiring intervention

Background: Urolithiasis, in general, constitutes a significant volume of the daily clinical activities in our institution

Objective: To evaluate the outcome of ureteroscopies performed in patients admitted acutely with symptomatic ureteric calculi compared with elective ureteroscopies

Design: A retrospective review

Setting: Department of Urology, King Hamad University Hospital, Bahrain

Method: All ureteroscopy [URS] procedures performed for symptomatic ureteric calculi between 1 January 2013 to 31 December 2013 were reviewed. These procedures were divided into two groups: urgent URS and elective URS group. Both groups were comparable in personal and stone characteristics

Result: One hundred ninety-five procedures were performed on 167 patients. One hundred twenty-seven [65.1%] procedures were urgent and 68 [34.9%] were elective. The cohort included 131 males and 36 females with a mean age of 41.5 years, a range of 19 to 74. One hundred fortynine [76.4%] procedures were performed on male patients, while 46 [23.5%] were performed on female patients. The mean stone size for patients undergoing urgent URS was 7.7 mm and 8.3 mm for elective procedures; approximately one-third of patients had more than one stone. Eighty-one stones in the urgent group were distally located; fifty-seven were in the elective group. The most common indication for urgent URS was pain refractory to injectable analgesia. LASER was used in 182 [93.3%] procedures, 179 [91.7%] procedures were urgent. Seventeen [8.7%] complications were documented for urgent URS and 8 [4.1%] for elective cases, no statistical significance, P value = 0.74

Conclusion: Urgent URS procedure is a safe and cost effective option compared with Elective URS. It should be the preferred option when resources and expertise are available

Leiomyoma of the ureter: a conservative approach

We present a case of bladder leiomyoma and concurrent left lower ureteric leiomyoma in a sixty-two year old Bahraini male without any other comorbid conditions. He had infrequent hematuria for the last two years; it was associated with burning and discomfort during urination, frequency and urgency. Urine culture did not reveal any growth. Contrast CT abdomen revealed a mass in the bladder and lower ureteral narrowing with hydronephrosis. Histopathology of both lesions revealed leiomyoma. Limited resection with subsequent stenting saved patient from having major surgery. The patient was followed up after removal of left ureteric stent. He had MAG3 [Mercapto Acetyl Triglycine] scan, which was satisfactory with no restriction to drainage

Non-culture-based diagnostic methods for the diagnosis of invasive candidiasis: are they helpful to clinicians?

Invasive candidiasis in immune-compromised patients is associated with high attributable mortality. Early detection of candidemia and accurate identification of Candida species are essential pre-requisites for improved prognosis. Since clinical presentation is non-specific and blood culture-based methods lack sensitivity, detection of immunological and molecular markers has provided an alternative for early diagnosis of invasive candidiasis. Serial estimations of these biomarkers have also proved useful to initiate pre-emptive therapy in suspected patients before clinical signs appear and to monitor response to therapy. Antigen-based methods include detection of beta-D-glucan [panfungal marker] and Candida mannan [genus-specific marker]. Detection of both, Candida mannan and anti-mannan antibodies has higher sensitivity. While false positive / negative results remain a problem, these markers provide a useful adjunct to the diagnosis if performed in select patient population. Recent advances have also been made in nucleic acid-based detection methods. A commercial real-time PCR assay [Light Cycler Septi Fast] for detection of clinically important Candida spp. in blood specimens within six hours is now available. Molecular methods have also resulted in speciesspecific identification of yeast isolates within an hour. While these advances aid in early and specific diagnosis of candidemia and invasive candidiasis, further evaluation of these approaches in different clinical settings is also needed

Neoatal candidiasis

Invasive candidiasis has become a significant problem of preterm, low birth weight infants. Candida albicans is the most frequent cause, but other species of Candida, such as C. parapsilosis, C. tropicalis and C. glabrata are being increasingly reported. Early acquisition of the Candida sp. occurs from the mother's genital tract during delivery, while colonization thereafter is acquired mostly through caretakers. The major risk factors are low birth weight, prolonged use of central venous catheter or other lines, hyperalimentation therapy, prolonged use of broad spectrum antibiotics, and an extended period of endotracheal intubation. Colonization of skin or gut with Candida species may precede bloodstream infection, and this could be facilitated by slight trauma to fragile integument. The clinical features of neonatal candidiasis are non-specific and include deteriorating respiratory function, abdominal distention, and temperature instability. An apparently septic preterm neonate who deteriorates, despite adequate antibiotic treatment, should be considered to have systemic candidiasis, particularly if other risk factors are present. In the disseminated disease, meningitis, skin lesions, endophthalmitis or involvement of renal/genitourinary tract are not uncommon. Affected neonates may exhibit neutropenia or neutrophilia, thrombocytopenia, glucose intolerance and oliguria. At present, no single laboratory test can reliably diagnose systemic candidiasis. Blood cultures, preferably by lysis centrifugation method, microscopic examination of buffy coat smears, culture and microscopic examinations of urine samples collected by suprapubic aspiration, serial measurements of C-reactive protein, and the determination of Candida antigen levels may provide useful diagnostic information. Fundoscopic examination of the retina for fluffy white lesions, and ultrasound scans for cardiac, hepato-splenic and renal involvement, should be routinely performed. Once candidiasis is diagnosed, treatment should be started promptly. The removal of central lines and stoppage of broad-spectrum antibiotics are initial important steps and should be considered. Amphotericin B remains the drug of choice. Nephrotoxicity is minimal if the dose is kept under 1 mg/kg in preterm infants. Although amphotericin B can be used alone, combination with flucytosine [100 mg/kg] may be needed to treat neonates with severe central nervous system involvement. The duration of antifungal therapy depends upon the severity of infection and response to therapy, and therefore must be individualized. In absence of any consensus on the duration of therapy, it should be continued for 7-14 days after the first negative blood culture and/or when the signs or symptoms of the disease have completely disappeared. Fluconazole has been used successfully in some studies with minimal side-effects. A dose of 6 mg/kg every three days in the first week of life, followed by 6 mg/kg every two days in subsequent weeks, has been suggested. Likewise, liposomal amphotericin B has been successfully used in a few studies with a dose of 3 mg/kg in most of the cases. Despite sporadic reports of the therapeutic efficacy and safety of both these drugs, additional evaluation is needed to develop a consensus administration protocol. Until such information is available, fluconazole and liposomal amphotericin B may be used selectively in neonates who are either unable to tolerate conventional amphotericin B or who have failed the treatment by it