Safety and efficacy of percutaneous nephrolithotomy for the treatment of paediatric urolithiasis.

INTRODUCTION: Paediatric percutaneous nephrolithotomy (PCNL) has revolutionised the treatment of paediatric nephrolithiasis. Paediatric PCNL has been performed using both adult and paediatric instruments. Stone clearance rates and complications vary according to the technique used and surgeon experience. We present our experience with PCNL using adult instruments and a 28Fr access tract for large renal calculi in children under 18 years. METHODS: All patients undergoing PCNL at our institution between 2000 and 2009 were reviewed. Demographics, surgical details and post-operative follow-up information were obtained to identify stone clearance rates and complications. RESULTS: PCNL was performed in 32 renal units in 31 patients (mean age: 10.8 years). The mean stone diameter was 19mm (range: 5-40mm). Twenty-six cases required single puncture and six required multiple tracts. Overall, 11 staghorn stones, 10 multiple calyceal stones and 11 single stones were treated. Twenty-seven patients (84%) were completely stone free following initial PCNL. Two cases had extracorporeal shock wave lithotripsy for residual fragments, giving an overall stone free rate of 91% following treatment. There was no significant bleeding or sepsis encountered either during the operation or in the post-operative setting. No patient required or received a blood transfusion. CONCLUSIONS: Paediatric PCNL can be performed safely with minimal morbidity using adult instruments for large stone burden, enabling rapid and complete stone clearance.

What impact will shortened training have on urological service delivery?

INTRODUCTION: Modernisation of Medical Careers dictates a shortening of the training required to achieve consultant status. Precisely what type of work these consultants could be expected to accomplish, and be trained to do, is not clear. The objective of this study was to demonstrate a method of stratifying urological workload so as to determine what a urological trainee, undergoing shortened training, might be expected to do as a consultant and to use this stratification to help manpower planning within the specialty. PATIENTS AND METHODS: A cohort study of all urological activity undertaken over a 3-year period in a single teaching hospital in the UK was performed. All out-patient, in-patient or day-case activity within the urological department was analysed in the years 2000-2002. Urological activity was stratified according to the absolute numbers of patients presenting for different types of out-patient consultation, the grade of complexity of any surgical intervention undertaken, and the theatre resource consumed by the study population. RESULTS: Utilising prospectively collected data, it was possible to aggregate information about the contributions generalist and sub-specialty activity made to the overall workload of a urological unit. Whilst the majority of out-patient activity, and almost 88% of the surgical workload, could be accomplished by consultants undergoing shortened training, 11.9% of specialised urological activity, consuming nearly 43% of the available theatre resource, was outwith the remit of such a specialist. CONCLUSIONS: Shortened training seems able to satisfy the service delivery needs of the majority of out-patient and day-case urological activity. It will not, however, fulfil the need for subspecialty-based training required to cope with the large minority of patients necessitating complex surgical intervention. Specialist training programmes, promoting advanced operative skills, need to be evolved in parallel to shortened training so as to ensure global urological service provision for the future.

Experience with non-cycled artificial urinary sphincters.

OBJECTIVE: To report our experience in children and adolescents with a non-cycled artificial urinary sphincter. While some children with the AUS can void, others require clean intermittent catheterization (CIC) through the sphincter or an alternative site for catheterization; in some of the latter we have either not cycled (pumped) an activated AUS or the AUS has failed, and there is concern about ischaemia in some adults with a non-cycled AUS. PATIENTS AND METHODS: In all, 143 patients who had an AUS placed between 1980 and 2002 were reviewed retrospectively; 15 (10 boys and five girls) no longer cycled (pumped) their AUS. The mean age at AUS insertion was 11 years and the mean (range) follow-up after insertion was 10.4 (1.64-22.2) years. The diagnoses included myelomeningocele in 11, sacral agenesis in three and cloaca in one. Nine patients have an activated functioning AUS and in six the AUS does not function; in the first nine the sphincter has not routinely been cycled (pumped) for a mean (range) of 1.6 (0.6-2.9) years. In the other six with a nonfunctioning AUS the mean (range) observation period is 6.4 (1.5-10) years since the system has not functioned. RESULTS: All patients were completely continent, including the six with a nonfunctioning AUS. After inserting the AUS, two patients voided in combination with CIC (one each urethral and abdominal stoma) and 13 emptied by CIC (nine abdominal stoma, four urethral). There was a mechanical complication in eight patients; three had the AUS repaired and are dry, and five are dry with no repair. In one patient the AUS was never activated. To date there has been no erosion of the cuff in any of the 15 patients with a non-cycled AUS. CONCLUSION: The AUS remains an extremely reliable procedure to achieve continence in children and young adults. It is versatile and can be combined with other procedures that provide an alternative means for catheterization. While some have noted the need to routinely cycle the AUS to prevent erosion, this has not been our experience in these 15 patients.

Duplicated inferior vena cava and crossed renal ectopia with abdominal aortic aneurysm: preoperative anatomic studies facilitate surgery.

Abdominal aortic aneurysm in association with duplication of the inferior vena cava and crossed renal ectopia is described for the first time. Preoperative imaging with computer-aided tomography provided good visualization of the local anatomy, allowing the surgical approach to be adapted for the best access to the surgical site. A retroperitoneal approach was successfully used for repair of the abdominal aortic aneurysm.

The results of subintimal angioplasty in a district general hospital.

OBJECTIVES AND DESIGN: we report a prospective study to determine if subintimal angioplasty can be performed in non-teaching centres and to establish its learning curve. MATERIALS AND METHODS: subintimal angioplasty was performed on 50 limbs in 46 patients (34 male) with a median age of 72 years (range 45-93 years). Indication was critical limb ischaemia (27 limbs) or intermittent claudication (23 limbs). Occlusions were located in the superficial femoral artery in 44 limbs, popliteal artery in 4 limbs and the peroneal artery in two limbs. At a median of 7.9 months patients had colour duplex imaging of the vessels that underwent angioplasty to assess vessel patency. RESULTS: primary technical success was achieved in 39 cases (78%). Primary technical success was greater in the second group of 25 consecutive limbs to undergo angioplasty at 92% (23 cases) compared with the first 25 consecutive limbs at 64% (16 cases). At 6 months the overall vessel patency rate on duplex imaging was 57%, improving to 64% in the group having a primarily successful procedure. The equivalent rate of symptomatic improvement was 59 and 66% respectively. Complications occurred in five procedures, most were minor, but a single fatality was directly attributable to the procedure. CONCLUSION: subintimal angioplasty can reasonably be performed outside major teaching institutions. There is a short learning curve associated with the procedure.

Experimental Manufacture of Paper for War Maps.

Early in World War II, a new map paper was developed that greatly improved the quality and performance of war maps. The National Bureau of Standards cooperated in the development and, subsequently, determined by experimental manufacture how to make the paper from commercially available raw materials. The best results were obtained in experimental manufacture by using fiber furnishes of 100-percent strong bleached sulfate pulps with the addition of melamine-formaldehyde resin to increase the wet strength and titanium dioxide to produce the desired capacity. It was essential that the beating be very carefully controlled to preserve the maximum fiber strength. The most critical requirements from a manufacturing standpoint were very high resistance to tear, high wet tensile strength, high opacity, and good smoothness. A moderate degree of wildness was not objectionable. The data obtained by experiments were applied to initiate the commercial production of the new paper to meet unprecedented tonnage requirements.

Aural pain resulting from acoustic reflex.

We present an unusual case of physical discomfort, as opposed to objective or subjective tinnitus, caused by a unilateral acoustic reflex. The cause of the discomfort was identified audiologically by the use of acoustic impedance audiometry. The dull pain that was elicited upon contraction and relaxation of the stapedius muscle was eliminated with sectioning of the stapedial tendon. No explanation of the mechanism for the pain is suggested at present.

Xantogranuloma juvenil. / Juvenile xanthogranuloma

Se presentan cuatro casos de xantogranuloma juvenil, dos de ellos con lesiones unicas, uno de los cuales afecta a un adulto.Se senalan las caracteristicas clinicas e histopatologicas, la falta de compromiso sistemico y sus posibles asociaciones. Se destaca la involucion espontanea de esta dermatosis, lo que hace innecesario su tratamiento

Xantogranuloma juvenil. / Juvenile xanthogranuloma

Se presentan cuatro casos de xantogranuloma juvenil, dos de ellos con lesiones unicas, uno de los cuales afecta a un adulto.Se senalan las caracteristicas clinicas e histopatologicas, la falta de compromiso sistemico y sus posibles asociaciones. Se destaca la involucion espontanea de esta dermatosis, lo que hace innecesario su tratamiento

Modification of the response to 8 MeV electrons of auxotrophic strains of Escherichia coli by amino-acid deprivation and rifampicin.

An investigation has been made of the possibility that the accumulation of RNA enriched in messenger can influence the survival of bacteria after exposure to 8 MeV electrons. The multiple amino-acid auxotroph E. coli CP79 RCrel accumulates RNA during inhibition of protein synthesis, and the proportion of RNA present as messenger increases by a factor of 3 during a 2-hour period of amino-acid deprivation. Amino-acid withdrawal led to changes in the shape of the survival curve, which also occurred in strain CP78 RCstr, which synthesizes very little RNA when deprived of amino acids. We conclude that accumulation of RNA enriched in messenger plays little or no part in modification of the survival of irradiated bacteria. We show that rifampicin, an inhibitor of RNA synthesis, increases the sensitivity of both strains equally.