Surgical interventions for pulmonary tuberculosis in Mumbai, India: surgical outcomes and programmatic challenges.

Setting: While surgery for pulmonary tuberculosis (PTB) is considered an important adjunct for specific cases, including drug-resistant tuberculosis, operational evidence on its feasibility and effectiveness is limited. Objective: To describe surgical outcomes and programmatic challenges of providing surgery for PTB in Mumbai, India. Design: A descriptive study of routinely collected data of surgical interventions for PTB from 2010 to 2014 in two Mumbai hospitals, one public, one private. Results: Of 85 patients, 5 (6%) died and 17 (20%) had complications, with wound infection being the most frequent. Repeat operation was required in 12 (14%) patients. Most procedures were performed on an emergency basis, and eligibility was established late in the course of treatment. Median time from admission to surgery was 51 days. Drug susceptibility test (DST) patterns and final treatment outcomes were not systematically collected. Conclusion: In a high-burden setting such as Mumbai, important data on surgery for PTB were surprisingly limited in both the private and public sectors. Eligibility for surgery was established late, culture and DST were not systematically offered, the interval between admission and surgery was long and TB outcomes were not known. Systematic data collection would allow for proper evaluation of surgery as adjunctive therapy for all forms of TB under programmatic conditions.

Contexte : La chirurgie de la tuberculose pulmonaire (TBP) est considérée comme un adjuvant important dans des cas spécifiques, notamment celui de la TB pharmacorésistante ; les preuves opérationnelles de sa faisabilité et de son efficacité sont cependant limitées.Objectif : Décrire les résultats de la chirurgie et les défis programmatiques liés à l'offre de chirurgie à Mumbai, Inde.Schéma : Une étude descriptive de données recueillies en routine relatives aux interventions chirurgicales de TBP de 2010 à 2014 dans deux hôpitaux de Mumbai (un public, un privé).Résultats : Sur 85 patients, 5 (6%) sont décédés, 17 (20%) ont eu des complications, dont la plus fréquente était une infection de la plaie. Une deuxième intervention a été nécessaire dans 12 cas (14%). La majorité des procédures a été réalisée en urgence et l'éligibilité a été établie tardivement au cours du traitement. Le délai médian de l'admission à la chirurgie a été de 51 jours. Les profils de résistance de la TB et le résultat final du traitement n'ont pas été recueillis de façon systématique.Conclusion : Dans un contexte lourdement touché comme Mumbai, des données importantes relatives à la chirurgie de la TBP ont été étonnamment limitées à la fois dans le secteur privé et public. L'éligibilité à la chirurgie a été établie tardivement, la culture et le test de pharmacosensibilité n'ont pas été systématiquement proposés, l'intervalle entre l'admission et la chirurgie a été long et les résultats en matière de TB n'ont pas été notés. Un recueil systématique des données permettrait une évaluation correcte de la chirurgie comme traitement adjuvant de toutes les formes de TB dans des conditions de programme.

Marco de referencia: El tratamiento quirúrgico se considera un complemento importante en el manejo de casos específicos de tuberculosis pulmonar (TBP), como la TB farmacorresistente; sin embargo, las pruebas operativas de su factibilidad y eficacia son escasas.Objetivo: Describir los desenlaces quirúrgicos y las dificultades programáticas de la prestación de opciones quirúrgicas a los casos de TBP en Bombay, en la India.Método: Fue este un estudio descriptivo de los datos recogidos de manera sistemática sobre las intervenciones quirúrgicas por TBP, realizadas del 2010 al 2014 en dos hospitales de Bombay (uno del sector público y otro del sector privado).Resultados: De los 85 pacientes tratados, cinco fallecieron (6%), 17 presentaron complicaciones (20%), de las cuales la infección de la herida fue la más frecuente. Fue necesaria una segunda intervención en 12 pacientes (14%). La mayoría de los procedimientos tuvieron lugar en un contexto de urgencia y los criterios de selección se analizaron tarde en el curso del tratamiento. La mediana del tiempo entre la hospitalización y la cirugía fue 51 días. El tipo de resistencia de la TB y los desenlaces terapéuticos no se registraron de manera sistemática.Conclusión: En un entorno con alta carga de morbilidad por TB como Bombay, los datos importantes sobre la cirugía por TBP son sorprendentemente escasos en el sector público y también en el sector privado de atención. Los criterios de selección para la cirugía se analizan tarde, no se ofrece de manera sistemática el cultivo y las pruebas de sensibilidad a los medicamentos, el intervalo entre la hospitalización y el procedimiento es prolongado y se desconocen los desenlaces clínicos de la tuberculosis. La recogida sistemática de datos facilitaría una evaluación adecuada de la cirugía como tratamiento complementario en todas las formas de TB en un contexto programático.

Technical modification for laparoscopic donor nephrectomy to minimize testicular pain: a complication with significant morbidity.

The laparoscopic approach to donor nephrectomy is becoming increasingly common. While it is felt that the recovery from laparoscopic nephrectomy is quicker and less painful, a number of complications have been reported. A rarely reported on complication in the literature with significant morbidity is ipsilateral orchalgia. From 1998 to 2008, 257 hand-assisted laparoscopic donor nephrectomies were performed at our institution. Eight of 129 (6.2%) men complained of de novo ipsilateral orchalgia postoperatively. The average duration of pain was 402 days. Patients reported significant morbidity related to this complication. None, however, required further treatment. Three patients reported that they would reconsider organ donation as a result of testicular pain. Our technique originally included dissection and ligation of the gonadal vein en bloc with the ureter at the level of the left common iliac artery. Since recognizing this complication, we have adopted a gonadal vein sparing approach so as not to disturb the vessel below its point of ligation at the renal vein. To date, 50 patients have undergone the modified technique without experiencing orchalgia. In conclusion, ipsilateral testicular pan is a relatively frequent complication of laparoscopic donor nephrectomy and may be a source of significant morbidity. Using a modified surgical technique, this complication can be reduced or eradicated.

Open or laparoscopic nephrectomy and extracoroporeal repair of complicated renal artery aneurysms: techniques for renal salvage.

Renal artery aneurysm is an infrequently seen disease. The most feared symptom is rupture, which is often rapidly fatal. Indications for intervention include size, intractable symptoms and pregnancy. Many cases are managed by endovascular techniques; however, very complex cases often are referred to the urologist. We report our experience with the rarely used technique of renal artery aneurysms repair comprised of nephrectomy, extracorporeal vascular reconstruction with aneurysmectomy, and autotransplant.

[Multivisceral organ procurement for transplantation derived mobilization maneouvres: very helpful auxiliary techniques in the excision of large retroperitoneal masses]. / Maniobras de movilización derivadas de la extracción multivisceral para trasplante: técnicas auxiliares de gran ayuda en la exéresis de grandes masas retroperitoneales.

The excision of large retroperitoneal masses poses a challenge for every surgeon. Sometimes the urologist must face situations that do not fit to any conventional approach or technique previously described. Obtaining adequate exposure for safe and oncologically correct management of these masses is based, on many cases, in the mobilization of anatomical adjacent structures to generate a sufficient field in abdominal areas of difficult access. Complex visceral mobilization maneuvers derived from multivisceral transplantation organ procurement surgery provides ancillary techniques that used properly facilitate their successful resolution. The main purpose of this paper is the description of these surgical maneuvers essential to increase both exposure and vascular control in addressing the ever-dreaded high-volume retroperitoneal masses.

Nefrectomía abierta o laparoscópica y reparación extracorpórea de aneurismas de arteria renal complejos: técnicas para la recuperación renal / Open or laparoscopic nephrectomy and extracoroporeal repair of complicated renal artery aneurysms: techniques for renal salvage

El aneurisma de la arteria renal constituye una enfermedad infrecuentemente observada. Su síntoma más temido es la ruptura, que habitualmente suele ser fatal rápidamente. Las indicaciones para realizar su intervención incluyen su tamaño, la refractariedad de su sintomatología y la gestación. Muchos de los casos generalmente se tratan mediante técnicas endovasculares; sin embargo, los casos más complejos a veces se remiten al urólogo para su tratamiento. En este artículo comunicamos nuestra experiencia con la infrecuentemente empleada técnica de reparación de aneurismas que incluye la nefrectomía, la aneurismectomía con reconstrucción vascular extracorpórea y el autotransplante(AU)

Renal artery aneurysm is an infrequently seen disease. The most feared symptom is ruptu-re, which is often rapidly fatal. Indications for interven-tion include size, intractable symptoms and pregnancy. Many cases are managed by endovascular techniques; however, very complex cases often are referred to the urologist. We report our experience with the rarely used technique of renal artery aneurysms repair comprised of nephrectomy, extracorporeal vascular reconstruction with aneurysmectomy, and autotransplant(AU)

Maniobras de movilización derivadas de la extracción multivisceral para trasplante: técnicas auxiliares de gran ayuda en la exéresis de grandes masas retroperitoneales / No disponible

La exéresis de grandes masas retroperitoneales constituye un reto para todo cirujano. En algunas ocasiones el urólogo debe enfrentarse a situaciones que no se ajustan a un abordaje o técnica convencional descrita. La obtención de una adecuada exposición con la que abordar de forma segura y oncológicamente correcta estas masas, se basa en muchos casos en la movilización de las estructuras anatómicas adyacentes para generar un campo suficiente en áreas abdominales de difícil acceso.Las maniobras de movilización visceral complejas derivadas de la cirugía de la extracción multivisceral de órganos para transplante proporciona maniobras accesorias que correctamente empleadas facilitan su resolución exitosa.El propósito principal de este artículo consiste en la descripción de las maniobras quirúrgicas esenciales para aumentar, tanto la exposición, como el control vascular en el abordaje de las siempre temidas masas retroperitoneales de gran volumen(AU)

The excision of large retroperitoneal mas-ses poses a challenge for every surgeon. Sometimes the urologist must face situations that do not fit to any con-ventional approach or technique previously described. Obtaining adequate exposure for safe and oncologi-cally correct management of these masses is based, on many cases, in the mobilization of anatomical adjacent structures to generate a sufficient field in abdominal areas of difficult access.Complex visceral mobilization maneuvers derived from multivisceral transplantation organ procurement surgery provides ancillary techniques that used properly facilita-te their successful resolution.The main purpose of this paper is the description of the-se surgical maneuvers essential to increase both exposu-re and vascular control in addressing the ever-dreaded high-volume retroperitoneal masses(AU)

Self-bougienage: long-term relief of corrosive esophageal strictures.

BACKGROUND: Corrosive esophageal strictures require dilatation at frequent intervals. OBJECTIVE: To determine the efficacy of self-dilatation in treatment of corrosive esophageal strictures. METHODS: Retrospective analysis of data from 51 patients with corrosive esophageal strictures seen in a surgical unit. Eighteen patients underwent per-oral antegrade dilatation of stricture using gum elastic bougies (Group I); 15 patients underwent retrograde dilatation with endless string using an India rubber dilator devised at the authors' institution, followed by per-oral antegrade dilatation (Group II); 15 patients underwent retrograde dilatation followed by antegrade dilatation with endless string through esophagostomy (Group III). In three patients with stricture of the entire esophagus, endless string could not be passed; they were subjected to esophagocoloplasty. All patients were taught self-dilatation with gum elastic bougies as the final step, and were put on a progressive, domiciliary, self-dilatation program. Quarterly follow up was done for one year, to ascertain whether self-bougienage was being performed properly. RESULTS: All patients responded well to treatment, with significant relief of dysphagia and improvement in health and barium study findings. Six patients developed mediastinitis (3, 2 and 1 in Groups I, II and III, respectively) during initial dilatation; all improved with conservative management. Only one patient who failed to carry out self-bougienage had to be readmitted and retrained in the procedure, after which he remained asymptomatic. CONCLUSIONS: Patients with corrosive esophageal strictures can be treated with a long-term self-bougienage program, which avoids the need for frequent hospital admissions for esophageal dilatation.

Negative regulation of the growth-promoting transcription factor E2F-1 by a stably bound cyclin A-dependent protein kinase.

Cyclin A-kinase, an enzyme required for coordinating S phase progression, forms stable in vivo complexes with E2F-1, a growth-promoting transcription factor, which binds to the retinoblastoma gene product and is involved in the timely activation of genes whose products contribute to G1 exit and S phase traversal. Complex formation results in a negative biochemical effect of cyclin A-kinase: the shut-off of E2F-1-dependent DNA binding function in S/G2. Thus, specific and timely cell cycle-dependent interactions of E2F-1 with proteins that inhibit its function (i.e., RB during G1 and cyclin A-kinase during S/G2) may contribute to the periodicity of expression of certain E2F-1-responsive genes at the G1/S transition.

Binding to DNA and the retinoblastoma gene product promoted by complex formation of different E2F family members.

The E2F family of transcription factors functions in the control of the mammalian cell cycle. Here it is shown that two family members, E2F-1 and DP-1, form specific heterodimers in vivo, a process that enhances DNA binding, transactivation, and the binding of the retinoblastoma gene product. These results suggest that heterodimerization regulates E2F function and contributes to cell cycle control.

The transcription factor E2F interacts with the retinoblastoma product and a p107-cyclin A complex in a cell cycle-regulated manner.

E2F is a transcription factor believed to play a role in the activation of genes required for cellular proliferation. Its regulation is likely important for maintenance of G0 and for the initiation of cell growth. The retinoblastoma product (RB) forms a complex with E2F in G1 in primary and established human cells. As these cells enter S, a second E2F-containing complex appears. It contains p107, a nuclear "pocket" protein with similarities in structure and protein-binding properties to RB, and cyclin A, a cyclin believed to play a role in facilitating DNA replication. Hence, the regulation of E2F is carried out differently in G1 or S. The presence of cyclin A and a pocket protein, a possible cell growth regulator, in the same S phase-associated complex suggests a link between the function of E2F and the regulation of the DNA replication process.

Aluminum compounds used as adjuvants in vaccines.

The structure of nine commercially manufactured aluminum-containing adjuvants was investigated by X-ray diffraction, infrared spectroscopy, transmission electron micrography, and energy dispersive spectrometry. Seven samples which were labeled as aluminum hydroxide were identified as boehmite, a crystalline aluminum oxyhydroxide [AlO(OH)]. However, the degree of crystallinity varied between the samples. Two samples which were labeled as aluminum phosphate were found to be amorphous aluminum hydroxyphosphate. Buffer anions and sulfate anions substitute for hydroxyls in the amorphous aluminum hydroxide formed by the in situ alum precipitation method. Finally, the aluminum-containing adjuvant in diphtheria and tetanus toxoid, U.S.P., produced by three manufacturers was characterized.