Extracorporeal shock wave lithotripsy for treatment of large pediatric renal pelvic stone burden more than 2 cm.

BACKGROUND: The high recurrence rates in pediatric urolithiasis indicate the need for none invasive or a minimally invasive treatment such as SWL. Therefore, EAU, ESPU and AUA recommend SWL as a first line treatment for renal calculi ≤ 2, and RIRS or PCNL for renal calculi > 2 cm. SWL is superior to RIRS and PCNL as it is inexpensive, outpatient procedure, and it has a high SFR in well selected cases specially pediatrics. On the other hand, SWL therapy has a limited efficacy with a lower SFR, and high retreatment rate and/or additional interventions for treatment of larger and harder renal calculi. OBJECTIVE: We carried out this study to evaluate the efficacy and safety of SWL for treatment of renal stones > 2 cm to extend its indications for pediatric renal calculi. METHODS: Between January 2016 and April 2022, we reviewed the records of patients with renal calculi treated by SWL, mini-PCNL, RIRS and open surgery in our institution. Forty-nine eligible children aged 1-5 years old, presented with renal pelvic and/or calyceal calculi measuring 2-3.9 cm and underwent SWL therapy were picked up and participated in the study. The data of an additional eligible 79 children with the same age and had renal pelvic and/or calyceal calculi > 2 cm up to stag horn calculi and underwent mini-PCNL, RIRS and open renal surgery were also picked up and participated in the study. We retrieved the following preoperative data from the records of the eligible patients; age, gender, weight, length, radiological findings (stone size, side, site, number and radio-density), renal function tests, routine laboratory findings, and urine analysis. The outcomes data in the form of; operative time, fluoroscopy time, hospital stay, SFRs, retreatment rates and complication rates were also retrieved from the records of patients treated with SWL and other techniques. Also, we collected the SWL characteristics in terms of; position, number and frequency of shocks, voltage, time of the session and U/S monitoring to assess stone fragmentation. All SWL procedures were performed according to the institution's standards. RESULTS: The mean age of patients treated with SWL was 3.23 ± 1.19 years old, the mean size of the treated calculi was 2.31 ± 0.49 and the mean length of the SSD was 8.2 ± 1.4 cm. All patients had NCCT scan and the mean radio-density of the treated calculi was 572 ± 169.08 HUs based on NCCT scans Table (1). Single- and two-session SFRs of SWL therapy were 75.5% (37/49 patients) and 93.9% (46/49 patients), respectively. The overall success rate was 95.9% (47/49 patients) after three-session of SWL. Complications experienced by 7 patients (14.3%) in the form of fever (4.1%), vomiting (4.1%), abdominal pain (4/1%), and hematuria (2%). All complications were managed in outpatient settings. Our results were obtained on the basis of preoperative NCCT scans for all patients and postoperative plain KUB films and real-time abdominal U/S. Furthermore, single-session SFRs for SWL, mini-PCNL, RIRS and open surgery were 75.5%, 82.1%, 73.7% and 90.6%, respectively. Two-session SFRs by the same technique were 93.9%, 92.8%, and 89.5% for SWL, mini-PCNL and RIRS, respectively. A lower overall complication rate and higher overall SFR were found with SWL therapy compared to other techniques, Fig. (1). DISCUSSION: Being a non-invasive outpatient procedure with a low complication rate and good spontaneous passage of stone fragments is the main advantage of SWL. In this study, the overall SFR is 93.9% where 46 out of 49 patients were completely rendered stone free after three session of SWL with overall success rate 95.9%. Badawy et al. reported overall success rates of 83.4% for renal stones with a mean stone size of 12.5 ± 7.2 mm. In children with renal stones measuring 18.2 mm, Ramakrishnan et al. reported a 97% SFR in accordance with our results. The high overall success rate (95.9%) and SFR (93.9%) in our research were attributed to the regular use of ramping procedure, low shock wave rate, percussion diuretics inversion (PDI) approach and alpha blocker therapy in all participants and short SSD. The limitations of our study are small sample of patients and its retrospective nature. CONCLUSION: The non-invasive nature and replicability of the SWL procedure, along with the high success and low complication rates, give us a new insight to consider its application for treating pediatric renal calculi > 2 cm over the other more invasive techniques. Short SSD, the use of ramping procedure, low shock wave rate, 2 min break, PDI approach and alpha blockers therapy help better success of SWL. LEVEL OF EVIDENCE: IV.

Factors associated with post traumatic hydrocephalus following decompressive craniectomy: A single-center experience.

Background: A decompressive craniectomy (DC) is a surgical procedure sometimes utilized to manage refractory intracranial hypertension following severe traumatic brain injury (sTBI). The previous studies have established a relationship between DC and post traumatic hydrocephalus (PTH). This study aimed to identify the factors responsible for developing shunt-amenable PTH in patients who underwent DC following sTBI. Methods: A review of a prospectively collected database of all patients admitted with severe TBI in a tertiary neurosurgical center in North-west England between January 2012 and May 2022 was performed. PTH was defined as evidence of progressive ventricular dilatation, clinical deterioration, and/or the eventual need for cerebrospinal fluid diversion (i.e., a ventriculoperitoneal shunt). Statistical analysis was carried out using IBM SPSS versus 28.0.1. Results: Sixty-five patients met the eligibility criteria and were included in the study. The mean age of the PTH group was 31.38 ± 14.67, while the mean age of the non-PTH group was slightly higher at 39.96 ± 14.85. No statistically significant difference was observed between the two groups' mechanisms of traumatic injury (P = 0.945). Of the predictors investigated, cerebellar hematoma (and contusions) was significantly associated with PTH (P = 0.006). Conclusion: This study concludes that cerebellar hematoma (and contusions) are associated with developing PTH in patients undergoing DC.

Decompressive Craniectomy and Shunt-Amenable Post-Traumatic Hydrocephalus: A Single-Center Experience.

Background: Prior studies have shown that decompressive craniectomy may be an independent risk factor for the development of post-traumatic hydrocephalus (PTH). It is upon this background that we chose to conduct our single-center retrospective study to establish the possibility of an association between decompressive craniectomy and PTH. Methods: A retrospective review involving a database of all patients with traumatic brain injury was undertaken. All referrals and admissions with traumatic brain injury, as defined by the Mayo Classification, from January 2012 to May 2022, were included in the subsequent analysis. Statistical analysis was carried out using IBM SPSS version 28.0.1. Results: The mean age of the cohort was 44.91 ± 19.16 with more males (82.3%) than females (17.7%). Vehicle incident/collision was the most common cause of traumatic brain injury. 84% of the cohort was alive at 30 days, 4% were noted to have an intracranial infection, and 3% underwent shunt insertion procedures, while 14% received decompressive craniotomies as part of their clinical management. There was a statistically significant association between undergoing decompressive craniectomy, and the development of PTH (odds ratio, 4.759 [95% confidence interval, 1.290-17.559]; P = 0.019). The presence of intracranial infection and insertion of an external ventricular drain insertion were also independent predictors of developing PTH. Conclusions: This study adds to the growing body of work regarding the immediate and long-term effects of the procedure. Although life-saving, PTH, needing shunt insertion, is one of the possible complications that surgeons and patients should be aware of.

Outcomes and efficiency of managing patients admitted for surgery for spinal metastases.

Background: This study evaluated the current pathways for dealing with patients admitted for surgery to address spinal metastases. Methods: In this retrospective analysis (2016-2021), the following variables were studied admission, demographics, length of stay, critical care admission, hospital costs, primary cancer, and average survival. Results: There were 306 patients admitted from 2016 to 2021; 66 were planned admissions, 203 were emergency admissions, and 37 were day case admission. Patients averaged 65.4 years old. About 75% (203) were emergently admitted, while 25% (66) had planned elective admissions. Their respective lengths of stay were 16.5 versus 5.74 days. Interestingly, nearly half of the emergency admissions (46.3%) did not have surgery during that admission. The most common level for metastatic disease was the thoracic spine in both groups (53% in the elective vs. 62% emergency groups). The most common primary lesions included lung, breast, and prostate in both groups. The average survival in the emergency admission group was 9.1 months and the planned admission group was 13.07 months. Notably, the costs of emergent care were much higher than planned admissions. Conclusion: The pathway for spinal metastases is unique in that though there is a pathway for late-stage disease, there is not one for early disease. As a result, the majority of patients admitted for surgery for spinal metastases come in as an emergency rather than as a planned admission. Yet, close to half do not end up having surgery during that emergency admission to the spinal center. The cost of emergency care is significantly higher versus planned elective care for spinal metastatic disease. A service transformation is suggested to combat these problems with a pathway for managing all spinal metastases, rather than just metastatic spinal cord compression.

Circulating miR-92a, miR-143 and miR-342 in Plasma are Novel Potential Biomarkers for Acute Myeloid Leukemia.

MicroRNAs (miRNAs) are small non-coding RNAs that function as post-transcriptional gene expression regulators. The expression profiling of miRNAs has already entered into cancer clinics as diagnostic and prognostic biomarkers to assess tumor initiation, progression and response to treatment in cancer patients. Recent studies have opened the way for the use of circulating miRNAs as non-invasive diagnosis and prognosis of Acute myeloid leukemia (AML). The aim of this study was to identify plasma miR-92a, miR-143 and miR-342 expression signatures in AML patients to introduce new markers for establishing AML diagnosis and prognosis. Blood samples were collected from 65 AML patients and 50 controls. The expression of three target miRNAs (miR-92a, miR-143 and miR-342) was measured using quantitative real-time PCR method. Plasma levels of miR-92a, miR-143 and miR-342 were significantly lower in AML patients in comparison with control group. Receiver operator characteristic (ROC) analysis revealed that the sensitivity and specificity values of miR-92a were 81.5% and 94%, respectively, with a cut-off value of 0.704. The sensitivity and specificity values of miR-143 were 87.7% and 80%, respectively, with a cut-off value of 0.65. The sensitivity and specificity values of miR-342 were 75.4% and 90%, respectively, with a cut-off value of 0.479. Our findings suggest that plasma miR-92a, miR-143 and miR-342 could be promising novel circulating biomarkers in clinical detection of AML.