Complications of endourological procedures and their treatment.

Endourological treatment for urinary stones and other obstructive urinary tract diseases is minimally invasive but in some cases it involves serious complications. This collection of cases describes some complications of endourological procedures and how they were treated. Case 1: A case of right ultrasound-guided percutaneous nephrostomy found to be misplaced in the inferior vena cava. The case was safely managed, but it showed that ultrasound guidance alone may be insufficient so it is recommended that percutaneous nephrostomy should be always placed under fluoroscopic control, either alone or in combination with ultrasound guidance. Case 2: A case of renal subcapsular hematoma occurring on retrograde intrarenal surgery at high perfusion pressure. The hematoma was drained under combined ultrasonic and radiological guidance. Post treatment recovery was uneventful. Large stone size, severe ipsilateral hydronephrosis, long operation time, higher hydrostatic pressure of the irrigating solution and low ureteral wall compliance are supposed to be risks factors associated with renal subcapsular formation. Management strategy should be tailored to patient's clinical conditions. In hemodynamically stable patients, large hematoma drainage is recommended to prevent further complications and favours early recovery. Case 3: A case of double J stent fracture discovered one month after the insertion to relieve obstruction from a 1 cm stone in the right proximal ureter. The distal fragment of the stent was removed by cystoscopy while the proximal fragment was removed by semirigid ureteroscopy in two sessions due to fever and extensive calcification. Case 4: A mini-invasive technique for transurethral replacement of completely encrusted urinary stents in female patients. This technique allows the interventional radiologist to replace obstructed urinary stents by avoiding more invasive and traumatic urological procedures with sedation.

Lung deposition and systemic bioavailability of different aerosol devices with and without humidification in mechanically ventilated patients.

BACKGROUND: During mechanical ventilation medical aerosol delivery has been reported to be upto two fold greater with dry inhaled gas than with heated humidity. Urine levels at 0.5 h post dose (URSAL0.5%) has been confirmed as an index of lung deposition and 24 h (URSAL24%) as index of systemic absorption. Our aim was to determine the effect of humidification and aerosol device type on drug delivery to ventilated patients using urine levels. METHODS: In a randomized crossover design, 36 (18female) mechanically ventilated patients were assigned to one of three groups. Groups 1 and 2 received 5000 µg salbutamol using vibrating mesh (VM) and jet nebulizers (JN), respectively, while group 3 received 1600 µg (16 puffs) of salbutamol via metered dose inhaler with AeroChamber Vent (MDI-AV). All devices were placed in the inspiratory limb of ventilator downstream from the humidifier. Each subject received aerosol with and without humidity at >24 h intervals with >12 h washout periods between salbutamol doses. Patients voided urine 15 min before each study dose and urine samples were collected at 0.5 h post dosing and pooled for the next 24 h. RESULTS: The MDI-AV and VM resulted in a higher percentage of urinary salbutamol levels compared to the JN (p < 0.05). Urine levels were similar between humidity and dry conditions. CONCLUSIONS: Our findings suggest that in-vitro reports overestimate the impact of dry vs. heated humidified conditions on the delivery of aerosol during invasive mechanical ventilation.

Clinical outcome associated with the use of different inhalation method with and without humidification in asthmatic mechanically ventilated patients.

BACKGROUND: Inhaled-medication delivered during mechanical-ventilation is affected by type of aerosol-generator and humidity-condition. Despite many in-vitro studies related to aerosol-delivery to mechanically-ventilated patients, little has been reported on clinical effects of these variables. The aim of this study was to determine effect of humidification and type of aerosol-generator on clinical status of mechanically ventilated asthmatics. METHOD: 72 (36 females) asthmatic subjects receiving invasive mechanical ventilation were enrolled and assigned randomly to 6 treatment groups of 12 (6 females) subjects each received, as possible, all inhaled medication using their assigned aerosol generator and humidity condition during delivery. Aerosol-generators were placed immediately after humidifier within inspiratory limb of mechanical ventilation circuit. First group used vibrating-mesh-nebulizer (Aerogen Solo; VMN) with humidification; Second used VMN without humidification; Third used metered-dose-inhaler with AeroChamber Vent (MDI-AV) with humidification; Forth used MDI-AV without humidification; Fifth used Oxycare jet-nebulizer (JN) with humidification; Sixth used JN without humidification. Measured parameters included clinical-parameters reflected patient response (CP) and endpoint parameters e.g. length-of-stay in the intensive-care-unit (ICU-days) and mechanical-ventilation days (MV-days). RESULTS: There was no significant difference between studied subjects in the 6 groups in baseline of CP. VMN resulted in trend to shorter ICU-days (∼1.42days) compared to MDI-AV (p = 0.39) and relatively but not significantly shorter ICU-days (∼0.75days) compared JN. Aerosol-delivery with or without humidification did not have any significant effect on any of parameters studied with very light insignificant tendency of delivery at humid condition to decrease MV-days and ICU-days. No significant effect was found of changing humidity during aerosol-delivery to ventilated-patient. CONCLUSIONS: VMN to deliver aerosol in ventilated patient resulted in trend to decreased ICU-days compared to JN and MDI-AV. Aerosol-delivery with or without humidification did not have any significant effect on any of parameters studied. However, we recommend increasing the number of patients studied to corroborate this finding.

Tractography at 3T MRI of Corpus Callosum Tracts Crossing White Matter Hyperintensities.

BACKGROUND AND PURPOSE: The impact of white matter hyperintensities on the diffusion characteristics of crossing tracts is unclear. This study used quantitative tractography at 3T MR imaging to compare, in the same individuals, the diffusion characteristics of corpus callosum tracts that crossed white matter hyperintensities with the diffusion characteristics of corpus callosum tracts that did not pass through white matter hyperintensities. MATERIALS AND METHODS: Brain T2 fluid-attenuated inversion recovery-weighted and diffusion tensor 3T MR imaging scans were acquired in 24 individuals with white matter hyperintensities. Tractography data were generated by the Fiber Assignment by Continuous Tracking method. White matter hyperintensities and corpus callosum tracts were manually segmented. In the corpus callosum, the fractional anisotropy, radial diffusivity, and mean diffusivity of tracts crossing white matter hyperintensities were compared with the fractional anisotropy, radial diffusivity, and mean diffusivity of tracts that did not cross white matter hyperintensities. The cingulum, long association fibers, corticospinal/bulbar tracts, and thalamic projection fibers were included for comparison. RESULTS: Within the corpus callosum, tracts that crossed white matter hyperintensities had decreased fractional anisotropy compared with tracts that did not pass through white matter hyperintensities (P = .002). Within the cingulum, tracts that crossed white matter hyperintensities had increased radial diffusivity compared with tracts that did not pass through white matter hyperintensities (P = .001). CONCLUSIONS: In the corpus callosum and cingulum, tracts had worse diffusion characteristics when they crossed white matter hyperintensities. These results support a role for white matter hyperintensities in the disruption of crossing tracts.

Study of the effect of vitamin D supplementation on glycemic control in type 2 diabetic prevalent hemodialysis patients.

Vitamin D is claimed to have an adjuvant effect on glycemic control by dual action on pancreatic ß-cells and insulin resistance. The aim of this study was to assess the possible effect of short-term alfacalcidol supply on glycemic control in type 2 diabetic hemodialysis (HD) patients. Twenty type 2 diabetic HD patients (using diet and oral drugs but not insulin) were randomly selected from our dialysis unit as well as 20 non-diabetic HD patients as control. A third group of 12 healthy subjects were studied as well. All three groups were similar in age, sex, and body mass index. Oral alfacalcidol therapy was administrated daily as recommended by Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines for 12 weeks guided by monthly serum phosphorus and Cax PO4 product. Corrected total calcium, phosphorus, intact parathyroid hormone, 25-hydroxy vitamin D (25[OH]D), and glucoparameters (fasting blood glucose, glycated hemoglobin [HbA1c%], insulin resistance by homeostatic model assessment, and ß-cell function by HOMA-ß%) were measured under basal conditions and after 3 months of therapy. 25(OH)D was non-significantly lower in diabetic than non-diabetic HD patients, but significantly lower than healthy subjects at the start of the study. However, vitamin D level increased significantly after 3 months of trial, although the levels did not reach normal values. This vitamin D rise was associated with highly significant improvement in concentrations of fasting blood sugar (FBS), fasting insulin, HbA1c%, and HOMA-ß-cell function in diabetic and non-diabetic controls. However, there was a significant rise in insulin resistance after treatment. The percentage of change was evident more in diabetics regarding FBS and 25(OH)D concentration. Adjustment of 25(OH)D level in type 2 diabetic prevalent HD patients may improve, at least with short-term therapy, glycemic control mainly through improving ß-cell function.

Noninvasive investigation of asymmetrically conjoined tripus twins with features of rachipagus, parapagus dicephalus, and cephalopagus.

A hypothetical mechanism for conjoined twinning postulated by Spencer ([2003] Developmental Malformations and Clinical Implications, Baltimore: Johns Hopkins University Press, p 1-476) suggests that, after separation, monovular twins fuse in one of eight predictable homologous sites. The tripus fetal specimen under study embodies characteristics of three types therefore preventing it from classification into a simple variant of any one of the eight twin types described by Spencer. The aim of this study was to reveal internal structural anomalies of the fetal specimen by using magnetic resonance imaging and computerized tomography. Dorsally appended to the primary twin is a secondary head mass (brain tissue and ocular globe) and two spinal columns converging at T4/T5, suggesting rachipagus twinning. The ventral orientation of the secondary twin's (right lateral) lower limb suggests parapagus twinning. The caudal divergence of the spinal columns and the presence of a secondary hemipelvis, separate from the primary pelvis, suggest cephalopagus twinning. Measurements of the long bones indicate a gestational age of ∼20-23 weeks. Secondary malformations of the primary fetal body include anencephaly, cleft palate, renal agenesis, decreased left ventricular outflow, and a prematurely terminating descending aorta. This study demonstrates the possibility of using current imaging techniques to study very old, formalin-preserved human material for documentation and scientific discussion without destroying the specimen, thus keeping it intact for posterity.

Pakistan's fight against poliomyelitis: introducing innovative strategies to address challenges and attain the goal of eradication.

Pakistan, with Nigeria, India and Afghanistan, is one of the four remaining polio endemic countries in the world. Since the start of polio eradication initiative in 1994, the country has succeeded in reducing the number of polio cases from an estimated 20,000 annually to 89 in 2009. Furthermore, persistent transmission is largely localized to three transmission zones in which ten of the fifteen highest risk areas are situated. Insecurity, operational issues, governance lapses, low routineimmunization coverage, inadequate trickle-down of the political commitment existing at the national level to sub-national level and extensive population movement are the main barriers to the process. A robust strategic plan was developed for 2010-2012 encompassing district-specific plans and focused strategy on securitycompromised areas, performance-based payment, independent monitoring, attention to migratory populations, social mobilization, and strategic cooperation with Afghanistan. This will provide Pakistan a strong and imminent opportunity to interrupt polio virus circulation.

Pakistan's fight against poliomyelitis: introducing innovative strategies to address challenges and attain the goal of eradication

Pakistan, with Nigeria, India and Afghanistan, is one of the four remaining polio endemic countries in the world. Since the start of polio eradication initiative in 1994, the country has succeeded in reducing the number of polio cases from an estimated 20,000 annually to 89 in 2009. Furthermore, persistent transmission is largely localized to three transmission zones in which ten of the fifteen highest risk areas are situated. Insecurity, operational issues, governance lapses, low routine immunization coverage, inadequate trickle-down of the political commitment existing at the national level to subnational level and extensive population movement are the main barriers to the process. A robust strategicplan was developed for 2010-2012 encompassing district-specific plans and focused strategy on securitycompromised areas, performance-based payment, independent monitoring, attention to migratory populations, social mobilization, and strategic cooperation with Afghanistan. This will provide Pakistan a strong and imminent opportunity to interrupt polio virus circulation

Development and duration of radiographic signs of bone healing in children.

OBJECTIVE: Few articles report the evaluation of pediatric fracture healing and dating based on radiographic appearance. We established a timetable for expected radiographic changes visible during bone healing in otherwise healthy children. MATERIALS AND METHODS: We examined 707 radiographs of fractured forearms in 141 patients. Each fracture was assessed by a pediatric radiologist who was unaware of the timing of the initial injury. Assessment included the following features: fracture margins, fracture gap, periosteal reaction, callus, bridging, and remodeling. The time interval between injury and the appearance of the radiographic features and the duration of radiographic signs were determined and correlated with age, sex, angulation, displacement, and location. RESULTS: Sclerosis at the fracture margins was evident in 85% of fractures 5 weeks after injury. Widening of the fracture gap was observed in 62% of fractures at 6 weeks. Periosteal reaction was evident on all images by 4 weeks, and after 7 weeks, periosteal reaction was separable from cortex in only 10% of fractures. Fracture callus had a density equal to or greater than that of adjacent cortex 10 weeks after injury in 90% of fractures. CONCLUSION: A wide variation exists in the appearance and duration of the radiographic signs of bone healing. Marginal sclerosis should be an expected radiographic sign of normal bone healing. Applying maximum and minimum time spans to objective radiographic signs may aid in fracture dating.

Characterization of major phosphoproteins in the cGMP-mediated protein phosphorylation system of vascular smooth muscle membranes.

G(0) (215-250 kD) and G(1) (120-140 kD), the unidentified major phosphoproteins in the cGMP-mediated protein phosphorylation system of vascular smooth muscle membranes, were compared for biochemical and immunological properties with the type 1 inositol 1,4, 5-trisphosphate receptor (InsP(3)R, 240 kD) and the myosin-binding subunit (MBS, 138 kD) of myosin phosphatase, both of them substrates for cGMP-dependent protein kinase. Two microsomal proteins that were immunoreactive with antibodies to InsP(3)R and MBS were detected, and comigrated with G(0) and G(1), respectively, on SDS-PAGE. When thiophosphorylated G(0) and G(1) were subjected to immunoprecipitation, MBS antibody induced the precipitation of a 138-kD phosphoprotein, but did not significantly affect the amount of G(1) remaining in the supernatant, while InsP(3)R antibody precipitated G(0) almost completely. Unexpectedly, InsP(3)R antibody coprecipitated a large portion of G(1), which did not cross-react with either antibody to MBS or InsP(3)R. Just like InsP(3)R, G(0) bound to the calmodulin column in a Ca(2+)-dependent manner, and, again, a large portion of G(1) was copurified with G(0). These results suggest that G(0) is identical to InsP(3)R, while G(1) consists of several phosphoproteins, including the 138-kD protein associated with InsP(3)R as a major component. MBS is not G(1) or may represent only a minor component of it.

Cryopreservation of invitro-grown shoot tips of taro (Colocasia esculenta (L.) Schott) by vitrification. 1. Investigation of basic conditions of the vitrification procedure.

Invitro-grown shoot tips of taro (Colocasia esculenta (L.) Schott.) were successfully cryopreserved by vitrification. Excised shoot tips precultured on solidified MS supplemented with 0.3M sucrose and maintained under a 16 h phtoperiod at 25°C for 16 h were loaded with a mixture of 2M glycerol plus 0.4M sucrose for 20 min at 25°C. The shoot tips were then sufficiently dehydrated with a highly concentrated vitrification solution (PVS2) for 20 min at 25°C prior to immersion into liquid nitrogen. Successfully vitrified and warmed shoot tips resumed growth within 7 days and developed shoots directly without intermediate callus formation. The average rate of shoot recovery amounted to around 80%, and the vitrification protocol appeared to be very promising for the cryopreservation of taro germplasm.