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Background: People with chronic diseases of the immune system, such as multiple sclerosis (MS), are at risk for Covid-19 disease. However, more research is needed with long-term follow-up. The aim of the study was to follow up people with MS (PwMS) for up to three months after AstraZeneca vaccination for the recurrence of MS and Covid-19 infection. Method(s): This study was a case study (descriptive-analytical) of follow-up type. The study population was PwMS over 18 years of age in Kermanshah province who received both doses of the AstraZeneca vaccine. This study was conducted from August to November 2021. Sampling was done with existing methods based on the National MS Registry of Iran (NMSRI). Demographic information of patients was extracted from NMSRI. A researcher-made form was used to collect information by telephone three months after vaccination about clinical characteristics, Covid-19 infection, and recurrence of MS. Data were analyzed using SPSS-25 software. Result(s): Study participants were 40 MS patients with a mean (SD) age of 39.27 (8.8) years, including 32 (80.0%) women. A mean of 9.39 (4.6) years had passed since The patients were diagnosed with MS, and 29 (76.4%) had RR type MS. Four patients (10%) relapsed between the second dose and three months later, of whom two (50%) had sensory symptoms, one (25%) had optic nerve involvement, and one (25%) had motor symptoms and pyramidal pathway involvement. The symptoms of Covid-19 were mild in three patients (10%), while severe symptoms developed in one patient (10%) who received rituximab. Among the patients, no cases of thrombosis were observed. Infusion therapy, a leg fracture, and kidney stones were the only hospitalized cases. Conclusion(s): Covid-19 and MS relapse prevalence did not differ significantly in the three months before and after vaccination. There is a need for further studies with a longer follow-up period.Copyright © 2022 Razazian et al. Published by Tehran University of Medical Sciences.
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Objective: A new generation of vaccine technology platform has been developed to combat the COVID- 19 pandemic, the mRNA vaccine. The EMA granted the Pfizer- BioNTech COVID-19 vaccine an emergency use authorization in December 2020 with limited clinical experience, especially in the pediatric population. Method(s): Here, we present a case-report of a 17-yearold girl, who was vaccinated with the mRNA-COVID vaccine in October 2021, and developed a gross hematuria and proteinuria the day after the vaccination. Result(s): The patient presented at our outpatient clinic three days after the vaccination with new-onset hematuria and proteinuria. Up to this date, she had no former known medical conditions and the family history was negative regarding kidney diseases. We excluded nephrolithiasis, autoimmune glomerulonephritis and urinary tract infection as causes. The laboratory chemistry of the kidney was within normal range. The proteinuria dissolved spontaneously, and a microhematuria persisted. One day after the second dose of Cominarty in November 2021, the gross hematuria with proteinuria relapsed. A treatment with an ACE-inhibitor did not have any effect on the proteinuria. At this point, only a few casereports of patients with a comparable clinical course, especially from Japan, were published. In suspicion of a vaccine-triggered nephritis we started a prednisolon therapy which dissolved the proteinuria and induced a regression of the haematuria to a minimal stage. Conclusion(s): Within the last year, the medical community has gained more insights concerning mRNA vaccines. There is growing evidence, that mRNA vaccines can trigger de novo or relapse IgA nephropathy. But more systematic research and long-term evaluation is desirable to elucidate the underling pathophysiology as well as the influence on kidney survival of affected patients in the future. Furthermore, patient education should incorporate the risk of hematuria and proteinuria in children when applying mRNA vaccines.
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Purpose: To evaluate the relationship between the presence of kidney stones and COVID-19. Materials and methods: Patients, who were treated for COVID-19 as outpatients as well as inpatients in the ward and/or ICU of two different secondary and tertiary care centers between July 15, 2020, and December 31, 2020, and aged ≥18 years were retrospectively evaluated. The patients were divided into two subgroups based on the presence of kidney stones, and then the patients with kidney stone were categorized into three groups: those who were treated in an outpatient setting (Group 1), those who were treated in the ward (Group 2), and those who were treated in the intensive care unit (Group 3). Results: The total of 1,335 COVID-19 patients included in the study. Kidney stone was present in 31 (6.9%) of 450 outpatients, 41 (8.9%) of 460 inpatients treated in the ward, and 60 (14.1%) of 425 inpatients treated in the intensive care unit. In Group 1, the duration of COVID-19 treatment was significantly longer in patients with kidney stone than patients without kidney stone (8.1±1.7 vs. 6.8±2.2 days, p=0.01). In Group 2 and in Group 3, the mean hospitalization duration was significantly longer in patients with kidney stone than in those without kidney stone (9.1±3.7 vs. 6.2±2.1 days, p=0.007;19.1±8.1 vs. 11.3±6.2 days, p=0.001, respectively). Conclusion: The duration of COVID-19 treatment was longer and the COVID-19 infection was more severe in those with kidney stones. © 2022, Pamukkale University. All rights reserved.
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INTRODUCTION AND OBJECTIVE: Studies suggest that there is a disproportionately increasing prevalence of kidney stone disease among African American and Hispanic patients in the United States. Furthermore, evidence indicates that disparities exist in the workup, management, and surgical interventions of different diseases based on race, ethnicity and socioeconomic status, among other variables. We sought to explore the potential non-clinical factors that could lead to disparities in the management of patients with symptomatic nephrolithiasis at a tertiary care center serving a mixed urban and non-urban population. METHOD(S): We retrospectively analyzed consecutive nonestablished adult patients presenting with symptomatic unilateral nephrolithiasis requiring definitive ureteroscopic stone extraction at a single institution between October 2019 and September 2021. The primary endpoint was time in days from the date of referral to the date of definitive treatment. Other variables included patient demographics, clinical characteristics, need for preoperative decompression, referral source, treatment date in relation to the COVID-19 pandemic, and Area Deprivation Index (ADI) ranking, a validated measure of neighborhood adversity related to education, employment, housing, and income. RESULT(S): Of 398 included patients, the mean age was 53 years, 55% female and 75% Caucasian. 47% had private insurance, 40% had government assistance and 13% were uninsured. The majority (73%) of referrals were from the emergency department. 10% of patients had a urinary tract infection on presentation. Renal obstruction was present in 77% of patients with 40% requiring preoperative decompression. The overall mean time from referral to surgery was 29 days (IQR 15-36). Factors associated with significantly longer time to surgery included Hispanic identity (40 days IQR 12-68, p=0.0098) compared to other ethnicities, Medicaid insurance (36 days IQR 17-55, p=0.012) compared to other payer groups and patients within the highest tertile ADI (most disadvantaged) ranking (+8 days, p=0.022) compared to those in the lowest tertile (most advantaged). CONCLUSION(S): In our cohort we demonstrated several nonclinical factors that resulted in a delay to definitive treatment in symptomatic kidney stone patients including Hispanic identity, Medicaid insurance, and most disadvantaged ADI ranking. Recognition of such disparities is the first step to help delineate and eliminate the barriers delaying the care of these vulnerable patients.
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INTRODUCTION AND OBJECTIVE: In New York State, March 16, 2020 marked the end of any in-restaurant dining due to the COVID- 19 pandemic. The general population was forced to do more cooking at home and less dining out. Dietary modifications like this are considered first line therapy for calcium stone formers due to an effort to reduce dietary sodium intake which is known to affect lithogenic risk factors including hypernatriuria and hypercalciuria. This study aims to see if dietary changes made during the pandemic changed the risk of stone disease as evidenced in 24-hour urine studies and if these changes ceased after the end of widespread shutdowns. METHOD(S): All patients with nephrolithiasis seen for an outpatient visit from April 1, 2020-December 31, 2020 were queried and included if they had a 24-hour urine study pre-COVID (before March 16, 2020) and during-COVID (March 16, 2020-December 31, 2020);a post- COVID study was included if available (January 1, 2021- October 31, 2022). Values were compared using paired, 2-tailed t-tests. RESULT(S): 93 patients (54 males, 39 females, mean age 60.1) were studied pre-COVID, during-COVID, and post-COVID time periods with 24-hour urine studies. Stone analysis revealed calcium oxalate (61%), calcium phosphate (15%), uric acid (15%), other (9%). The 24-hour urine revealed a significant reduction in urinary sodium (uNa) and urinary calcium (uCa) in these patients. uNa levels decreased from 166.15+/-7.5 mEq/L pre-COVID to 149.09+/-7.6 mEq/L during- COVID (p=0.015) and maintained improved at 138.55+/-6.83 mEq/L post-COVID era (p=0.0035). uCa levels decreased from 214.18+/-13.05 mEq/L pre-COVID to 191.48+/-13.03 mEq/L during- COVID levels (p=0.010) and remained improved at 185.33+/-12.61 mEq/L post-COVID (p=0.012). There were no significant differences in 24-hour urine total volume, magnesium, or citrate levels. CONCLUSION(S): During the COVID-19 lockdown, dietary choices limited to home cooked meals allowed patients to better identify their food choices. This study demonstrates that known urinary risk factors for lithogenesis, such as urinary sodium and calcium, improved during the lockdown and these improvements were maintained even after restrictions in restaurants were lifted. Moving forward, it will be imperative to monitor patient's 24-hour urine to ensure these dietary modifications are continued in the postpandemic era and to see if these improved urinary parameters will impact stone formation in these patients.
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INTRODUCTION AND OBJECTIVE: Patients with acute renal colic due to stones frequently visit the ED. With limited ED resources due to the COVID-19 pandemic, we developed a best practice management pathway within our electronic medical records (EMR) to provide consistent, expeditious and appropriate care for patients with nephrolithiasis. The objective of this study is to describe the development and 1 year outcomes of our EMR Care Pathway for nephrolithiasis. METHOD(S): Our hospital system is composed of many centers. To standardize best practice care, we convened a clinical consensus group, with key stakeholders in emergency medicine, urology, interventional and diagnostic radiology to develop a pathway for the initial work up and management of acute renal colic. AUA guidelines, current literature, and expert consensus across specialties were used to develop the pathway to guide work up and management. Risk assessment tools, and criteria for specific imaging modalities, lab work, and pain protocols were outlined. Criteria for routine discharge with follow-up, including pre-populated links for referrals, indications for urology consult, hospital admission and urgent decompression (stent versus nephrostomy tube) were provided. Data was gathered through the EMR analytics team and descriptive statistics were performed. RESULT(S): The Care Pathway was utilized 944 times from August 3, 2021-September 17, 2022 at 11 different hospitals or care centers (Table 1). Usage increased overtime (r2=0.77). The majority of usage was in the ED (892, 94.4%). A total of 194 providers utilized the Pathway with the majority being residents (64, 33.0%). The pathway included care of 505 unique patients, with 106 primary diagnosis key words triggering pathway use. 139 Urology referrals were placed through the pathway with 124 new 28 day prescriptions of tamsulosin. CONCLUSION(S): An EMR-integrated care pathway has been readily utilized in our system and may augment triage and best practice management of patients presenting with stone disease. Further studies are needed to understand the full impact on outcomes.
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In this study, a computer-assisted kidney stone diagnosis system based on CT images has been proposed. The method is based on a combination of deep training and metaheuristics. The method aims to provide a customized Deep Believe Network (DBN) based on a fractional version of the coronavirus herd immunity enhancer to provide an efficient and reliable kidney stone diagnosis system. The designed method is then authenticated by running a standard benchmark called a "CT kidney dataset". Subsequently, a comparison is made between the results and some other state-of-the-art methods. Simulations show that the recommended DBN/FO-CHIO outperforms the other studied approaches in terms of efficiency with an accuracy of 97.98%. Moreover, the proposed DBN/FO-CHIO recall outperforms others with 92.99%, demonstrating its excellent accuracy compared to other comparison algorithms. Moreover, the higher specificity of the proposed method compared to the other evaluated approaches indicates its advanced event-independent value.Copyright © 2023 Elsevier Ltd
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Limited hospital resources and access to care during the COVID-19 pandemic led us to implement a quality-improvement study investigating the feasibility, safety, and costs of same-day discharge after PCNL. The outcomes of 53 consecutive first-look PCNL patients included in a same-day discharge protocol during COVID-19 were compared to 54 first-look PCNL patients admitted for overnight observation. Control group had a similar comorbidity profile. Demographics, operative details, 30 day outcomes and readmissions, complications, and cost were compared between the two groups. Same-day discharge and one-day admission post-PCNL patients did not have significantly different baseline characteristics. The study group were more likely to have mini-PCNL (81% vs 50%, p < 0.01). Operative characteristics including median pre-operative stone burden (1.4 vs 1.7 cm3, p = 0.47) and post-operative stone burden (0.14 vs 0.18 cm3, p = 0.061) were similar between the two groups. Clavien-Dindo complication rates were lower in the study group compared to controls (0 vs 7%, p = 0.045). Readmission rates (2 vs 4%, p = 0.569) and ED visits (4 vs 6%, p = 0.662) were similar between the two groups. Total cost ($6,648.92 vs $9,466.07, p < 0.01) was significantly lower and operating margin ($4,475.96 vs $1,742.16, p < 0.01) was significantly higher for the same-day discharge group. Percutaneous nephrolithotomy may be performed in select patients without an increase in short-term complications, ED visits, or readmissions. Patients undergoing mini-PCNL are particularly amenable to same-day discharge, however, standard PCNL patients should not be excluded from consideration. Avoiding overnight admission decreases total cost and increased hospital operating margin.
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COVID-19 , Kidney Calculi , Nephrolithotomy, Percutaneous , Nephrostomy, Percutaneous , Humans , Nephrostomy, Percutaneous/adverse effects , Nephrostomy, Percutaneous/methods , Pandemics , COVID-19/epidemiology , COVID-19/etiology , Kidney Calculi/surgery , Kidney Calculi/etiology , Nephrolithotomy, Percutaneous/adverse effects , Nephrolithotomy, Percutaneous/methods , Treatment Outcome , Retrospective StudiesABSTRACT
Background: The novel coronavirus disease (caused by SARS-CoV-2) has become a disaster all over the world. Based on available evidence, the main organ infected by this virus is the respiratory system;however, various other vital systems can also be affected by potential outcomes. One of the critical affected organs is the kidney. Objectives: This study aimed to report and reviewed Risk of Renal Stones in Patients With COVID-19 Infection.
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Introduction &Objective: Infection control practices and public policy in response to the COVID-19 pandemic shifted healthcare practices towards a telemedicine format. Even two years after peak onset of the pandemic, many clinics, including our own institution, maintain a working telehealth option for patient visits. Our objective was to evaluate patient satisfaction with a urologic telehealth program at our institution. Method(s): This was a prospective survey study sent to patients being seen by our institution's urology providers beginning in October 2021. All patients seen via any telemedicine platform were eligible to participate and were contacted via MyChart or email after their visit to complete this survey. We present a sub-analysis comparing patients being seen for kidney stones or pain (n = 52, 17.6%) vs. patients being seen for other benign conditions (Benign-Other: n = 107, 36.1%) or oncology diagnoses and care (Oncology: n = 137, 46.3%). Result(s): Patients were 89.6% Caucasian, 88.9% non-Hispanic, 70.7% male, with a mean Age of 59.7 years (SD = 15.1). 34.4% of patients used phone/audio, 45.0% used video by EPIC/MyChart, and the remaining used Doximity, UpDox, or Other. Kidney stone patients were most likely to use video by EPIC/MyChart (55.8%) compared to other method, and this was also higher compared to Benign-Other and Oncology patients (p = 0.013). Patients were overall very satisfied (M = 6.3/7, p < 0.001 vs. 'neutral') with their telehealth appointment, with kidney stone patients marginally more satisfied p = 0.084). Patients, regardless of diagnosis, indicated they would like to continue using telehealth even after COVID-19 restrictions and thought that their doctor managed their appointment and diagnosis appropriately via telemedicine. Finally, kidney stone patients reported higher satisfaction (p = 0.031) with troubleshooting prompts when an error occurred during their appointment. Conclusion(s): Patients seen via telemedicine for kidney stones and pain at our institution highly satisfied with their telemedicine visits, even as in-person visits could be scheduled, and this held across platform type. This suggest a usable program moving forward, even as social distancing requirements and patient safety concerns during the COVID-19 pandemic are reduced.
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Introduction &Objective: The COVID-19 pandemic and subsequent world-wide quarantine resulted in a major change in individual lifestyles. In New York State, March 16, 2020 marked the end of any in-restaurant dining and the general population reported a shift to more cooking at home. Reducing dietary sodium intake, such as less dining out, is often considered first line dietary therapy for calcium stone formers due to known risk factors of hypernatriuria and hypercalciuria. We investigated the 24-hour urine of our patients with known history of nephrolithiasis to see if these dietary changes during COVID-19 pandemic may have also changed the risk of stone disease. Method(s): Retrospectively, patients with a history of nephrolithiasis seen for an outpatient visit from April 1, 2020-December 31, 2020 were studied. All patients included had a 24-hour urine study pre-COVID, defined as before March 16, 2020 as well as a study during-COVID, March 16, 2020-December 31, 2020;a post-COVID study including January 1, 2021-December 31, 2021 was also included. Mean pre-COVID, during-COVID and post-COVID values were compared using paired, 2-tailed t-tests. Result(s): 94 patients (M = 54, F = 40) with a mean age of 60 years were evaluated. Stone analysis revealed calcium oxalate (61%), calcium phosphate (15%), uric acid (15%), other (9%). The 24-hour urine revealed a significant reduction in urinary sodium (uNa) levels from pre-COVID (165.64 +/- 7.5 mEq/L) compared to during-COVID (149.16 +/- 7.6 mEq/L) (p = 0.018). There was also a significant reduction in urinary calcium (uCa) from pre-COVID (214.18 +/- 13.05mEq/L) compared to during-COVID levels (191.48 +/- 13.03 mEq/L) (p = 0.010). Post-COVID 24-hour urine (N = 59) levels for both post-COVID uNa (137.43 +/- 8.03mEq/L, p = 0.02) and post-COVID uCa (193.07 +/- 13.23, p = 0.035) remained significantly reduced compared to the pre-COVID values, but with no difference compared to during-COVID values. There were no significant differences in 24 hour urine total volume, magnesium, or citrate levels. Conclusion(s): During the COVID-19 lockdown, dietary choices limited to home cooked meals allowed patients to better identify their food choices. This study demonstrates that home cooked meals improved urinary parameters to minimize the lithogenic risk factors for stone formation including hypernatriuria and hypercalciuria. Persistently improved urinary factors during the post-COVID period may be secondary to improved dietary practices combined with continued lockdown as a result of new virus variants.
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Introduction &Objective: High-dose vitamin C therapy is commonly believed to treat or protect against viral illnesses, such as seasonal influenza. However, not only is there a lack of supporting evidence for this practice, but high-dose vitamin C can also carry clinical risks. This includes its metabolic conversion to oxalate and resultant hyperoxaluria, which increases the risk of oxalate-based kidney stones. During the COVID-19 pandemic, there has been new interest in vitamin C therapy. This study aims to characterize public interest in vitamin C therapy and its association with nephrolithiasis. Method(s): The Google Trends platform was queried to assess worldwide searches for vitamin C, influenza, and COVID-19 using multiple related keywords. We analyzed search traffic from 2011 to 2021 for influenza and from 12/2019 to 9/2021 for COVID-19. To assess sources and accuracy of information about vitamin C therapy, we performed Google searches of "vitamin C COVID" and analyzed top results by support for the therapy and discussion of potential risks. Result(s): Online searches for vitamin C and influenza show a yearly chronicity with seasonal fluctuations (Fig. 1A). Online search traffic for vitamin C therapy paralleled interest in COVID (Fig. 1B). Subsequent peaks in COVID searches during the summer 2020, winter 2021, and summer 2021 surges were all associated with increased interest in vitamin C therapy. Among the top results for COVID-related vitamin C queries, most (90%) were medical websites or scientific publications. About a third of results stated without support that vitamin C may have potential benefit in treating COVID. No sources discussed the increased risk of kidney stones due to vitamin C therapy;only 1 source noted "potential adverse effects" but did not specify risks. Consistent with the lack of public information about stone risk, there were no apparent associations in search patterns between vitamin C or COVID and kidney stones (Fig. 1C). Conclusion(s): Online interest in vitamin C therapy reflects surges in COVID-19 incidence. Despite the known association between high-dose vitamin C and oxalate stones, no online sources discussing this therapy for COVID cited this risk. Continued public interest in COVID therapies may have unexpected epidemiological consequences including increased risk of kidney stones.
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Methicillin-resistant Staphylococcus aureus (MRSA) infections are a primary health concern. They are commonly differentiated as hospital-acquired methicillin-resistant Staphylococcus aureus (HA-MRSA) and community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections, based on their epidemiology, susceptibility findings, and molecular typing patterns. Therefore, appropriate contact precautions and isolation measures should be implemented. CA-MRSA mostly causes skin and soft-tissue infections, but the probability and incidence of it causing sepsis and invasive infections have increased dramatically in recent years. In this study, we report a case of CA-MRSA pneumonia with pan-pneumonic effusion in a 59-year-old male diabetic patient with preexisting comorbidities such as diabetic ketoacidosis and non-ST elevated myocardial infarction. The early reporting of the organism's identity and its antimicrobial susceptibility, as well as timely initiation of antibiotic therapy, aided in the successful management and cure of the patient.
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Introduction: Gastrointestinal stromal tumors (GISTs), soft tissue sarcomas of the digestive tract, are associated with oncogenic mutations that led to the approval of tyrosine kinase inhibitors (TKIs) [1-2]. Considering the increased use of TKIs in clinical practice, it may be useful to identify unexpected adverse drug reactions (ADRs). Objective: The aim of this study was to describe better ADRs and to identify unexpected potential safety signals through the analysis of individual case safety reports (ICSRs) among TKIs approved for GIST collected into the European Spontaneous Reporting System (SRS) database. Methods: All ICSRs recorded starting from the drug approval up to 31 December 2021 with one of the following TKIs reported as suspected drug were included: imatinib (IM), sunitinib (SU), avapritinib (AVA), regorafenib (REG), and ripretinib (RIP). A descriptive analysis was conducted to assess all demographic characteristics. Moreover, a disproportionality analysis was performed using the Reporting Odds Ratio (ROR) with the corresponding 95% Confidence Interval (CI) to evaluate the frequency of ADRs for each TKI compared to all other TKIs. Results The number of analyzed ICSRs was 8,512 (Figure 1 Flowchart of ICSRs selection process): the 57.9% were related to IM, followed by SU (24.2%), AVA (13.1%), REG (2.7%), and RIP (2.1%). ICSRs were mainly serious (87.5%), related to males (51.7%), and to adults (44.7%);moreover, the 25.5% were fatal. The disproportionality analysis showed a higher reporting frequency of some unexpected ADRs for each TKI: gait disturbance (ROR 2.86;95% CI 1.90-4.29), hyperhidrosis (2.57;1.06-6.20), and hyperammonemia (3.92;1.05-14.60) for SU;cerebrovascular accident (6.23;2.18-17.84), hemoglobin decreased (2.23;1.08-4.61), and internal haemorrhage (14.44;3.94-52.92) for RIP;gastrointestinal ulcer (10.88;2.98-39.81) for REG;hepatic and lung cancer for IM (12.79;8.04-20.37 and 7.71;3.33-17.84, respectively);hallucination (24.33;9.02-65.68), mood swings (8.02;2.44-26.33), and stress (6.68;1.93-23.11), nephrolithiasis (6.69;2.15-20.77), pollakiuria (3.08;1.17-8.13), and dialysis (6.68;1.67-26.73), sinusitis (3.34;1.14-9.78), cellulitis (4.17;1.36-12.78), and COVID-19 (7.25;3.40-15.45), chills (2.36;1.22-4.58), limb fracture (3.53;1.63-7.60), hernia (9.23;3.71-23.00), diabetes mellitus (5.02;2.11-11.95), hyposideraemia (5.02;2.11-11.95), tinnitus (3.64;1.34-9.87), parosmia (5.00;1.12-22.38), Raynaud's phenomenon (5.00;1.12-22.38), and thyroid function test abnormal (8.90;1.99-39.83) for AVA. Conclusion: This study is largely consistent with results from literature but some unexpected ADRs were shown. Further studies are necessary to increase the awareness about the safety profiles of new TKIs approved for GISTs.
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Aim: To assess how patients presenting with suspected ureteric colic are managed compared to NICE guidance (renal and ureteric stones, QS195 July 2020). Also, to review the incidence of ureteric stones occurring in all referrals received in a hospital where patients are referred prior to imaging confirmation of stones. Method: The dataset was formed by retrospective handover screening during a three-month period in 2019 prior to the impact of COVID-19 with any patient included who was referred to urology with a suspected ureteric calculus, generating 149 cases. Demographic information, imaging modality and treatment were recorded as well as comparisons to five NICE quality statements on the management of ureteric stones. Results: Of the 149 referrals 88 were male with a median age of 45 years. Ureteric stones were found in 61/149 of referrals with 99/149 receiving CT scan first line whilst the remainder were initially imaged using ultrasound. Forty referrals were received for women under the age of 50 with only 3/40 having a ureteric stone. Pick-up rate of ureteric stones was higher in older and male patients. CT within 24 hours of referral was achieved in 82.8% and 69.9% were given appropriate analgesia. In patients in which it was necessary primary treatment occurred within 48 hours in 45.4% of patients. Conclusions: Less than half of referrals received had a ureteric stone with particularly low pick-up rates in young women. A large proportion of patients having ultrasound first line had subsequent CT imaging. Adherence to NICE quality standards was comparable to other centres.
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[...]it’s hard to draw useful conclusions about the value of parathyroidectomy from these data because people treated surgically had higher rates of stone formation before treatment and higher serum calcium concentrations (J Clin Endocrinol Metab doi:10.1210/clinem/dgac193). Art improves life Virtual visits to an art gallery improve the quality of life for older people, according to a trial from Canada. Among 100 participants, all over 65, those randomised to weekly online guided tours of the Montreal Museum of Fine Arts showed improved scores for social isolation, wellbeing, quality of life, and frailty when compared with controls who didn’t participate in cultural activities (Front Med doi:10.3389/fmed.2022.969122/full).
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Introduction: Enhanced recovery after surgery (ERAS) protocols have decreased hospital length of stay (LOS) and increased the rate of same-day discharge in patients undergoing minimally invasive surgery, including in female pelvic medicine and reconstructive surgery (FPMRS). In October of 2019, our hospital implemented an ERAS protocol;however, the onset of the COVID-19 epidemic accelerated the need to adopt a same day discharge policy. Given the rapid implementation of this policy, it was important to determine its effect on FPMRS surgical outcomes in a public teaching hospital serving predominantly uninsured and underinsured patients. Objective: The primary objective of this study was to evaluate perioperative management and postoperative outcomes for FPMRS patients after implementation of an ERAS protocol in a public teaching hospital. Methods: A single-center review was performed of FPMRS patients undergoing surgery prior to introduction of the ERAS protocol from January 2019 to June 2019 compared to those undergoing surgery after its implementation from January 2021 to June 2021. Demographic and surgical details were collected for all patients. A retrospective analysis was performed comparing outcomes, including percentage of outpatient surgery, emergency department visits within 30 days of surgery, and opioid use pre- and post-ERAS implementation Results: 29 patients were included in the pre-implementation group and 19 patients were included in the post-ERAS implementation group. Procedure types and patient demographics are seen in table 1. Ninety-three percent of patients self-described as Hispanic/Latino ethnicity. The percentage of outpatient surgeries increased from 17% to 90% (p < 0.01). Preoperative acetaminophen use increased from 3% to 74% of patients (p < 0.01), while mean perioperative morphine milligram equivalents decreased from 57 mg to 42 mg (p < 0.01). Mean opioid pills prescribed was not different after implementation of ERAS. Thirty-day emergency department (ED) returns increased from 0% to 11% (P = 0.15). These two ED returns included one visit for a urinary tract infection and the other for nephrolithiasis. Conclusions: ERAS implementation for FPMRS patients at a public hospital led to a significant decrease in LOS, inpatient admission, and perioperative morphine milligram equivalents used without a significant increase in 30-day ED returns. While the COVID-19 epidemic resulted in an accelerated adoption of ERAS protocol, it was found to be safe and effective in our underserved FPMRS patient population.
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Diagnosis of a genetic kidney disease can enhance treatment/management, allow patient/family counseling, and enable patient referral to specialists or clinical trials. Here we present a case study describing the use of a >380 gene panel associated with kidney diseases (The RenasightTM test, Natera, Inc.) to diagnose Dent disease 2 in a patient and their family members. A 41-year-old male was referred to Nephrology for evaluation of elevated SCr (4.6 mg/dL) and proteinuria. The patient’s medical history was unremarkable except for glaucoma in infancy. A renal biopsy identified glomerulomegaly. Genetic testing identified a likely pathogenic, hemizygous, frame-shift variant (c.311del;p.Cys104Phefs*2) in exon 5 of OCRL, an X-linked gene, which is associated with Dent disease 2. This genetic diagnosis prompted changes to the patient’s treatment plan, including patient counseling and preparation for renal replacement therapy (RRT). The patient’s 46-year-old brother was hospitalized due to COVID-19 symptoms with a SCr of 19.1 mg/dL. Due to limited medical history, it was unclear if he was presenting with acute kidney injury or chronic kidney disease. Although there was no evidence of nephrolithiasis or renal tubular acidosis typically associated with Dent disease 2, the family history prompted genetic testing that confirmed the presence of the familial variant in this patient. These genetic findings prevented delay in treatment, namely, initiation of RRT. Given the X-linked inheritance of Dent disease 2, the patients’ mother is an obligate carrier of the p.Cys104Phefs*2 variant in OCRL. Therefore, the third brother is an appropriate candidate for genetic testing due to his 50% chance of inheriting the familial variant. In this family, identification of an OCRL variant via broad panel renal genetic testing impacted patient counseling, management, and family testing. Notably, without genetic testing for the proband, his brother’s condition may have gone undiagnosed due to the atypical presentation, demonstrating the variability of OCRL-related conditions. Genetic testing can enable accurate disease diagnosis in individuals with an atypical presentation, syndromic kidney disease and/or a family history.
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CASE: An 80-year-old woman with untreated osteoporosis and suspected primary hyperparathyroidism presents to establish care. Review of systems and physical examination are normal. She has mild hypercalcemia (11.2), and normal albumin and phosphorous. Parathyroid hormone (PTH) is elevated (71). Bone density testing demonstrates osteoporosis at the hip and spine (Tscore -2.9 and -3.0). She reports self-medicating with 12,000 IU of vitamin D daily to prevent COVID-19 infection, which she learned about from a popular news source;she is unvaccinated for COVID-19. Her vitamin D 25-OH level is 172 (normal 30-100). The patient was instructed to stop vitamin D supplementation. Additional work up for hyperparathyroidism was initiated, including 24-hour urine collection for calcium, and she was referred for a parathyroidectomy. IMPACT/DISCUSSION: Adequate vitamin D supplementation has been postulated to reduce the risk and severity of the COVID-19 infection through its immunomodulatory effects that augment the immune cell response, decrease inflammation, and prevent RAAS system dysregulation, which is associated with more severe coronavirus infection. However, trials and metaanalyses have yielded inconclusive data, with most reporting no associations between adequate or high-dose vitamin D supplementation and COVID-19 morbidity and mortality. Nonetheless, popular news sources and social media have called for high-dose vitamin D supplementation, which can result in hypervitaminosis D through patient self-medication. Both hypervitaminosis D and primary hyperparathyroidism present with signs and symptoms of hypercalcemia, including nephrolithiasis, osteoporosis, bone pain, weakness, and neuropsychiatric changes. Hypervitaminosis D is caused by ingestion of too much exogenous vitamin D (normally more than 10,000 IU/day), dysregulation of the vitamin D pathway, or overproduction of vitamin D. Primary hyperparathyroidism is caused by parathyroid adenomas, hyperplasia, and carcinomas. Distinguishing between the two conditions involves a thorough history and physical, laboratory measurements, and occasionally imaging. Hypervitaminosis D patients have suppressed PTH levels, serum 25(OH)D > 150ng/mL, and hyperphosphatemia while primary hyperparathyroidism patients have normal/elevated PTH levels, low/normal 25(OH)D levels, and hypophosphatemia. Primary hyperparathyroidism is the most common cause of hypercalcemia, but this case highlights the importance of screening for and identifying other etiologies of hypercalcemia. This patient's vitamin D toxicity can be treated by stopping vitamin D supplementation. Her primary hyperparathyroidism meets criteria for a parathyroidectomy due to the presence of osteoporosis. CONCLUSION: 1. High dose vitamin D supplementation is ineffective as prophylaxis against the COVID-19 infection. 2. Hypercalcemia secondary to vitamin D toxicity is distinguished from primary hyperparathyroidism by PTH, 25(OH)D, and phosphorus levels.
ABSTRACT
CASE: A 60-year-old woman with past medical history including hypertension, nephrolithiasis, and Covid-19 4 months prior presented to the emergency department with 3 days of substernal chest pain radiating toward the back and shoulders 6 days after receiving her second dose of the BNT162b2 mRNA Covid-19 vaccine (Pfizer/BioNTech) in her left deltoid. The patient tested negative for Covid-19 and denied shortness of breath, cough, fever, or dyspnea on exertion. Her ECG was notable for more pronounced t-wave inversions in III and aVF, but further cardiac workup was unremarkable, and she was discharged the next day. The patient re-presented to care 6 days later with left arm pain, erythema, edema, and warmth. Her left bicep circumference was 31cm versus 28cm on the right. Upper extremity duplex ultrasound (US) was remarkable for deep venous thrombosis (DVT) of the left internal jugular, subclavian, axillary, and basilic veins. MRI angiogram was confirmatory. Other than her occupation as a hairdresser, the patient did not have known risk factors for DVT: no personal or family history of thromboembolism, no tobacco use, took no prescription medications, and had received all ageappropriate cancer screening. Her thrombophilia workup was negative. The patient was discharged on apixaban. Eleven days later, a venogram showed persistent clot burden in the left axillary, mid-subclavian, and brachiocephalic veins. Thrombectomy, overnight tPA infusion, and left subclavian vein stenting were performed and the patient was discharged on daily apixaban and aspirin. IMPACT/DISCUSSION: As of December 10th, 2021, the vaccine adverse event reporting system yielded 464 reports of “thrombosis” after the Pfizer/ BioNTech vaccine in individuals with no reported current illness, 32 of which occurred in the upper extremity. To our knowledge, our patient represents the first report of upper extremity deep venous thrombosis (UEDVT) shortly after receipt of the Pfizer vaccine in an otherwise healthy person. UEDVT is relatively rare: it occurs in about 0.4 to 1 per 10,000 people per year and less than 20% of incidents are idiopathic. Given the scarcity of potential causes, our case may simply reflect expected background incidence. Nevertheless, the literature includes multiple case reports of DVT after mRNA Covid-19 vaccination, including cases of lower extremity DVT and DVT with pulmonary embolism (PE) after the Pfizer vaccine, and cases of lower extremity DVT, PE, and UEDVT after the mRNA-1273 (Moderna) vaccine. Given the similar mechanism of action between the Moderna and Pfizer vaccines, it is possible that the same pathophysiology underlies the reports of DVT in these vaccine recipients. CONCLUSION: Upper extremity deep venous thrombosis after Covid-19 mRNA vaccination should remain on the differential as clinicians assess chest and arm pain following vaccination. There is a possible association between the BNT162b2 mRNA Covid-19 vaccine and upper extremity deep venous thrombosis that requires further research.