Rhinocerebral mucormycosis causing basilar artery aneurysm with concomitant fungal colonic perforation in renal allograft recipient: a case report.
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Brain Diseases↗
Biomedical subjects
Anant Kumar
Publications and source records attributed to Anant Kumar.
Polymorphism of GSTM1 and GSTT1 genes in bladder cancer: a study from North India.
The present study was conducted (1) to examine whether the GSTT1- and GSTM1-null genotypes are risk factors for bladder cancer, and (2) to study possible association of tobacco usage and age strata with genotype of these patients. This case control study was undertaken over a period of 19 months and included 106 bladder cancer patients and 182 controls; both patients and controls originated from northern part of India. The GSTT1 and GSTM1 genotypes were identified by multiplex PCR in peripheral blood DNA samples. Genotype frequencies among patients and controls were assessed and the association of the genotypes with smoking habits and gender of the patients were statistically determined by the chi(2) test. Frequencies of null genotypes in GSTT1 and GSTM1, were 16% (29/182) and 30% (54/182), respectively, in control individuals. The frequencies of GSTT1- and GSTM1-null genotypes in bladder cancer patients were 26% (28/106) and 40% (42/106), respectively. In conclusion, our study demonstrated that the null genotypes of GSTT1 and GSTM1 were substantially at higher risk for bladder carcinoma compared to the normal healthy controls. The GSTT1- and GSTM1-null genotypes did not show significant association with tobacco usage in bladder cancer patients. However, the null genotypes were statistically significant in female relative to male bladder cancer patients.
Adult↗
Fine-needle aspiration cytology of bilateral renal malakoplakia.
Isolated bilateral renal malakoplakia in the absence of concomitant involvement of the urinary tract is a rare occurrence. We report imaging, cytologic, and histologic findings of such a case diagnosed initially by fine-needle aspiration (FNA) cytology. A 26-yr-old female presented with pain in the left flank, fever, anorexia, and weight loss for the past 2 mo. A left lumbar lump was palpable on physical examination. Imaging studies showed an enlarged nonfunctioning left kidney and a small lesion in the right kidney with preserved function. FNA from both kidneys yielded purulent material positive for E. coli on culture. The smears were inflammatory, with a predominance of neutrophilic polymorphs and numerous histiocytes along with some intracellular and extracellular Michaelis-Guttman bodies, which were highlighted with the use of a PAS stain. Histology of the nephrectomy specimen showed ill-defined nodules, composed of foamy histiocytes intermingled with neutrophils, plasma cells, and many variably sized concentric laminated bodies. The right-side lesion resolved with the use of broad-spectrum antibiotics in conjunction with ascorbic acid and bethanecol. When imaging studies are suggestive of a chronic inflammatory process, renal malakoplakia must always be considered in the differential diagnosis even if aspirated material shows a predominance of polymorphonuclear leukocytes. The use of special stains like PAS, Von Kossa, and Perl's helps in reaching the correct diagnosis.
Adult↗
Is povidone iodine an alternative to silver nitrate for renal pelvic instillation sclerotherapy in chyluria?
OBJECTIVE: To compare the efficacy and toxicity of 1% silver nitrate, 0.2% povidone iodine and 50% dextrose in renal pelvic instillation sclerotherapy (RPIS) for chyluria. PATIENTS AND METHODS: In a prospective randomized comparative study from January 1999 to June 2003, 106 patients (61 males and 45 females; mean age 36 years, sd 12, range 14-65) were randomized to receive 1% silver nitrate, 0.2% povidone iodine or 50% dextrose as RPIS. In all, nine doses were given at 8-h intervals, and patients followed at 6 weeks and then at 3-monthly intervals. Patients with 'persistence' or 'recurrence' of chyluria were treated with second course of RPIS using same sclerosant. RESULTS: The dextrose treatment was discontinued at mid-term because of poor success (one of 21 patients, P < 0.001). Of 85 patients, 44 received silver nitrate and 41 povidone iodine; both groups were well-matched and the mean follow-up was 28.4 and 23.3 months, respectively. 'Immediate clearance' was recorded in 91% and 98%, and recurrence in 21% and 22% of patients after the first course of RPIS, after silver nitrate and povidone, respectively; Kaplan-Meier estimates of 'disease-free duration' in the two groups (23.6 vs 20.1 months) were also similar (P = 0.7906). The cumulative success rate after two courses of RPIS was 82% (silver nitrate) and 83% (povidone; P = 1.0). Five (11%) patients in the silver nitrate and one (2%) in the povidone group had significant flank pain during treatment. CONCLUSIONS: Povidone iodine 0.2% is as effective for RPIS as 1% silver nitrate.
Adolescent↗
Localized primary amyloidosis of the genitourinary tract: does conservatism help?
Primary amyloidosis of the genitourinary tract is a rare clinical entity with an excellent prognosis in most cases. It is of interest to the urologist as it mimics malignancy. The definitive diagnosis is made on histologic examination and by excluding secondary causes of amyloidosis. We present 4 patients with primary localized amyloidosis of the genitourinary tract who were treated with transurethral resections alone with satisfactory outcome.
Adult↗
Outcome of pediatric renal transplants in a developing country.
This study was conducted to evaluate the outcome of pediatric renal transplants at our center. A retrospective analysis was done on 39 pediatric transplants (age at transplant <18 years) done at our center over the last 10 years. The mean age at transplant was 15.6+/-1 years (10-17 years). They comprised 4.2% of all renal transplants done at our center (39/921) over the period. Girls comprised 17.5% of total recipients ( n=7). Two patients had a preemptive transplant. The underlying causes of end stage renal disease were chronic glomerulonephritis ( n=21), chronic interstitial nephritis ( n=17) and Alport syndrome [1]. All the 39 children were initiated on triple drug immunosuppression (cyclosporin A (CsA) azathioprine, prednisolone). All patients received grafts from living related donors. In the first month, three patients had graft loss (serum creatinine, SCr, >5 mg/dl). Of these, two patients died because of septicemia and one had acute cortical necrosis. There was evidence of infection in 16 patients (40%). Acute rejection was seen in 17 patients (45.8%). The 1-year patient and graft survival was 89% and at 3 years 70%. The actuarial graft survival at 5 years was 50%. Twelve children discontinued CsA after 1 year post-transplant and five of these had graft loss. Graft losses were significantly greater in patients who discontinued CsA as compared to those who continued CsA (5/12 vs 2/22). After a mean follow-up of 31.5+/-3.5 months, of the 37 patients, 10 had graft loss and chronic graft dysfunction was observed in another 9 patients. The rest of the 17 (48%) patients had a mean SCr of 1.2 mg/dl. The long-term outcome of pediatric renal transplants in our country remains suboptimal. CsA discontinuation due to financial constraints and/or non-compliance remain the most important reasons for this.
Adolescent↗
Isolated type 1 renal hydatid cyst presenting as a peripelvic cyst.
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Adult↗
Routine stenting after ureteroscopy for distal ureteral calculi is unnecessary: results of a randomized controlled trial.
BACKGROUND AND PURPOSE: Insertion of a ureteral stent is routinely done after ureteroscopy. Recently, several authors have questioned routine stenting after ureteroscopy for distal ureteral stones. We report our results of a randomized study comparing ureteroscopy with and without placement of stents for distal ureteral stones. PATIENTS AND METHODS: A total of 48 patients undergoing ureteroscopy for distal ureteral stones were randomized to a stented group (N = 26) or a nonstented group (N = 22). Ureteroscopy was carried out with Wolf 8.5F semirigid endoscope, and the Swiss Lithoclast was used as the source of energy. Any stent was removed at 3 weeks. Patients were assessed for success, operative time, postoperative pain score, analgesic requirement, stent-related symptoms, and risk of ureteral stricture formation. Baseline variables were not significantly different in the two groups. RESULTS: There was no significant difference in the two treatment groups with regard to need for ureteral dilation, use of intracorporeal lithotripsy, or occurrence of intraoperative and postoperative complications. A successful outcome was achieved in 100% of both groups. The mean pain score on day 0 was 5.23 +/- 0.95 of 10 in the stented group and 4.82 +/- 0.96 in the nonstented group; this difference was not statistically significant. Similarly, the analgesic requirement in the two treatment groups was not significantly different. However, patients with stents had significantly more pain (including flank pain with voiding: P = 0.01), urgency (P = 0.04) and dysuria (P <0.01). Radiologic follow-up was available for 83.33% of the patients at the 3-month visit. None of the patients had evidence of ureteral stricture or residual stone fragments. CONCLUSION: In select patients undergoing ureteroscopy for distal ureteral stones, stents can be safely omitted. Patients without stents have significantly fewer lower-urinary symptoms of pain, urgency, and dysuria and are not at risk of increased complications. Avoiding stents may be particularly cost effective in developing countries.
Adult↗
Is a 2-week duration sufficient for stenting in endopyelotomy?
PURPOSE: Internal stenting is an integral part of endopyelotomy. Studies in animals show good healing after 1 to 2 weeks of ureterotomy. Inherent stent related problems warrant a minimum possible duration of stenting without compromising the results of endopyelotomy. We performed a prospective randomized trial to evaluate the optimum duration of stenting after endopyelotomy. MATERIALS AND METHODS: A total of 57 consecutive patients with primary ureteropelvic junction obstruction were randomized to undergo 7/14Fr internal endopyelotomy stent placement for 2 (group 1) and 4 (group 2) weeks. A symptom based questionnaire was administered to all patients at stent removal. Followup was done with diuretic scanning at 3, 6, 9 and 12 months and then yearly, and thereafter with diuretic renography. RESULTS: In each group 26 patients were available for evaluation. The 2 groups were comparable in terms of age, sex, symptoms and ipsilateral glomerular filtration rate. Mean followup was 22.3 (range 12 to 36) and 21.3 months (range 12 to 35) in groups 1 and 2, respectively. At the end of 1 year 24 group 1 (92.3%) and 23 group 2 (90.3%) patients had an improved drainage pattern. This difference was not significant. Stent related symptoms were present in a good proportion of patients in groups 1 and 2 but there was a significant difference in the incidence of urinary tract infections (11.5% versus 38.1%, p = 0.04). Of the group 2 patients 64% preferred 2 weeks of stenting. CONCLUSIONS: Two weeks seems to be a sufficient duration to allow functional restoration across the ureteropelvic junction after endopyelotomy and decrease stent related complications.
Adolescent↗
Subcostal versus transcostal mini donor nephrectomy: is rib resection responsible for pain related donor morbidity.
PURPOSE: Conventional donor nephrectomy is associated with significant postoperative morbidity. Whether this morbidity is associated with rib resection or a long incision is not clear. We designed a prospective randomized study of subcostal and transcostal mini incision donor nephrectomy and compared the results. MATERIALS AND METHODS: We performed 82 donor nephrectomies in the study period of December 2000 to July 2001. Open donor nephrectomies were randomized to subcostal (25) or transcostal (24) mini incision techniques. Results were compared and analyzed using the independent t test. RESULTS: The subcostal and transcostal groups were comparable in terms of patient age, body mass index, nephrectomy side, number of renal vessels and incision length (9.32 vs 9.72 cm). Patients in the subcostal group had a lesser postoperative analgesic requirement (304 +/- 49.8 vs 487 +/- 74.1 mg, p = 0.0001), shorter hospital stay (2.36 +/- 0.7 vs 3.71 +/- 0.81 days, p = 0.0001) and early convalescence (26.56 +/- 4.06 vs 37.46 +/- 6.05 days) compared with the transcostal group. Warm ischemia time and recipient outcome were similar in the groups. CONCLUSIONS: Rib sparing, subcostal mini incision donor nephrectomy has significantly less morbidity and a shorter hospital stay compared with the rib resection transcostal technique.
Adult↗
Surgical and radiological management of renovascular hypertension in a developing country.
PURPOSE: We determined the long-term outcome of radiological and surgical intervention in young patients with renovascular hypertension. MATERIALS AND METHODS: Between 1989 and 2001, 85 patients with a mean age +/- SD of 21 +/- 10.3 years, including 59 with Takayasu's arteritis (TA) and 26 with fibromuscular dysplasia (FMD), underwent radiological (percutaneous transluminal angioplasty) or surgical treatment for renovascular hypertension due to renal artery stenosis. The technical success, complications and clinical response of each treatment were compared. RESULTS: Of the patients 29 with TA and 20 with FMD underwent a total of 56 balloon angioplasties. Technical success was achieved in 94.58 renal units with a clinical response in 41 patients (83.9%). However, the re-stenosis rate was 24.13% in TA and 10% in FMD cases. A total of 41 surgical procedures were performed in the 28 and 7 patients with TA and FMD, respectively, including aortorenal bypass with vein in 12, and with a polytetrafluoroethylene graft in 4, lienorenal bypass in 4, iliorenal bypass in 2, gastroduodenal bypass in 1, autotransplantation in 1, nephrectomy in 14 and partial nephrectomy in 2. The clinical response rate to renal revascularization procedures was 94.4%, whereas it was only 50.0% for nephrectomy/partial nephrectomy during a median followup of 42 months (range 9 to 96). CONCLUSIONS: Percutaneous transluminal angioplasty and renal revascularization provide comparable long-term results in the management of renal artery stenosis due to TA and FMD. Although it is technically complex, surgery for TA is safe and effective. However, the rate of re-stenosis following angioplasty for TA is higher compared with FMD.
Adolescent↗
Prediction of fragility of urinary calculi by dual X-ray absorptiometry.
PURPOSE: Stone fragility is a key factor for the success of shock wave lithotripsy (SWL). Dual x-ray absorptiometry is the gold standard for measuring bone mineral content and density, which helps in determining bone mass and the fracture risk. The same principle was applied to determine the relationship of stone mineral content (SMC) and density (SMD) to predict the fragility of stone before SWL. MATERIALS AND METHODS: A total of 102 patients with a solitary renal and upper ureteral stone of less than 3 cm treated at a single center with a lithotriptor were included. Prior to SWL all patients underwent dual x-ray absorptiometry evaluation for SMC and SMD. Plain x-ray documented disintegration after SWL. Stone size and site, the number of shock waves and energy levels were recorded. Failure was defined as no fragmentation to a size of less than 4 mm, which would pass unaided, up to a maximum of 3,000 shock waves. RESULTS: Overall 94 patients with renal stones were included. Mean stone size was 16.68 +/- 7 mm (range 5 to 30). Mean and median SMC was 0.63 +/- 0.83 and 0.34 gm (range 0.01 to 5.54), and mean and median SMD was 0.48 +/- 0.19 and 0.46 gm/cm2 (range 0.05 to 1.12), respectively. Overall 67 patients (71%) had successful fragmentation and clearance at a mean of 1,623.58 +/- 658.77 shock waves (range 355 to 3,000). On logistic regression analysis only SMC was the significant factor affecting the outcome in terms of fragmentation. At a SMC of more than 1.27 gm 95% of the stones would not fragment or needed more than 3,000 shock waves. CONCLUSIONS: Patients with high stone mineral content (SMC greater than 1.27 gm) could be directly offered percutaneous nephrolithotomy, thus, avoiding the unnecessary cost of prior SWL.
Absorptiometry, Photon↗
Effect of fibular plate fixation on rotational stability of simulated distal tibial fractures treated with intramedullary nailing.
BACKGROUND: The effect of an intact fibula on rotational stability after a distal tibial fracture has, to the best of our knowledge, not been clearly defined. We designed a cadaver study to clarify our clinical impression that fixation of the fibula with a plate increases rotational stability of distal tibial fractures fixed with a Russell-Taylor intramedullary nail. METHODS: Seven matched pairs of embalmed human cadaveric legs and sixteen fresh-frozen human cadaveric legs, including one matched pair, were tested. To simulate fractures, 5-mm transverse segmental defects were created at the same level in the tibia and fibula, 7 cm proximal to the ankle joint in each bone. The tibia was stabilized with a 9-mm Russell-Taylor intramedullary nail that was statically locked with two proximal and two distal screws. Each specimen was tested without fibular fixation as well as with fibular fixation with a six-hole semitubular plate. A biaxial mechanical testing machine was used in torque control mode with an initial axial load of 53 to 71 N applied to the tibial condyle. Angular displacement was measured in 0.56-N-m torque increments to a maximal torque of 4.52 N-m (40 in-lb). RESULTS: Initially, significantly less displacement (p < or = 0.05) was produced in the specimens with fibular plate fixation than in those without fibular plate fixation. The difference in angular displacement between the specimens treated with and without plate fixation was established at the first torque data point measured but did not increase as the torque was increased. No significant difference in the rotational stiffness was found between the specimens treated with and without plate fixation after measurement of the second torque data point (between 1.68 and 4.48 N-m). CONCLUSIONS: Fibular plate fixation increased the initial rotational stability after distal tibial fracture compared with that provided by tibial intramedullary nailing alone. However, there was no difference in rotational structural stiffness between the specimens treated with and without plate fixation as applied torque was increased.
Aged↗
Urinary interleukin-8 predicts the response of standard and low dose intravesical bacillus Calmette-Guerin (modified Danish 1331 strain) for superficial bladder cancer.
PURPOSE: We determined whether the proinflammatory cytokine interleukin-8 (IL-8) can serve as a predictor for the response to standard (120 mg.) and low (40 mg.) dose intravesical bacillus Calmette-Guerin (BCG) (modified Danish 1331 strain) for managing superficial bladder cancer in patients at risk for recurrence and progression. MATERIALS AND METHODS: We randomized 26 patients with superficial bladder cancer to receive a 6-week course of standard dose 120 mg. or low dose 40 mg. intravesical BCG. Voided urine samples were collected immediately before and after (2 and 4 hours) BCG instillation. Urine samples were centrifuged at 1,500 rpm for 8 minutes and stored at -80C. IL-8 was measured using a commercial enzyme-linked immunosorbent assay. Patients were monitored for recurrence, progression and side effects of BCG treatment at 3-month intervals. RESULTS: At a median followup of 24 months (range 12 to 30), 5 and 6 patients who received a standard and low dose, respectively had disease recurrence and/or progression (nonresponders). At 4 hours after BCG mean Il-8 levels plus or minus SD were significantly higher in responders than in nonresponders (1,099.33 +/- 708.51 versus 261.82 +/- 182.66 pg./ml., p = 0.001). There was no difference at 4 hours in mean IL-8 levels in the standard and low dose groups (596.92 +/- 546 and 893 +/- 798.67 pg./ml., respectively, p = 0.28). In all patients who remained disease-free IL-8 levels were greater than 400 pg./ml. In 9 of the 11 patients with disease recurrence/progression IL-8 levels were less than 400 pg./ml. CONCLUSIONS: IL-8 secretion after the initial intravesical BCG instillation strongly correlates with the possibility of future recurrence/progression. The quantitative IL-8 response to low and standard dose intravesical BCG (Danish 1331) is similar.
BCG Vaccine↗
Laparoscopy-assisted live donor nephrectomy: a modified cost-effective approach for developing countries.
BACKGROUND AND PURPOSE: Because of the prohibitive cost of laparoscopic disposable instruments such as the PneumoSleeve, Endocatch, and vascular staples, laparoscopic live-donor nephrectomy has not gained wide acceptance in many developing countries. To circumvent this problem, we have developed a cost-saving approach, which is described herein and compared with the open method. PATIENTS AND METHODS: Forty-nine patients underwent laparoscopic live-donor nephrectomy at our institute, of which two were performed by the hand-assisted technique, five by the technique described by Fabrizio et al and forty-two by our modified cost-saving laparoscopy-assisted technique (LD). The latter patients were compared with 50 patients who had a standard open donor nephrectomy (OD) through a rib-resecting (12th rib) flank incision. Our technique is similar to the procedure described by Fabrizio et al except for a 6- to 8-cm incision placed in the subcostal region to retrieve the kidney after the renal vessels are cut and ligated as in the open procedure. The costs of the various techniques at our institute were compared. RESULTS: The LD and OD groups were similar in terms of age, weight, side of nephrectomy, and number of renal vessels. The operative time was longer in the LD group than in the OD group (180.7 +/- 18 minutes v 101.5 +/- 10.4 minutes), whereas the mean intraoperative blood loss was less (85.5 +/- 21.35 v 220 +/- 22.5 mL; P < 0.001). Warm ischemia time and recipient outcomes were comparable in the two groups. Patients in the LD group had lower postoperative narcotic (tramadol hydrochloride) requirement (155.3 +/- 53.3 mg v 251.8 +/- 63.1 mg; P < 0.001) and earlier discharge from the hospital (3.14 v 5.7 days; P < 0.001). The mean expense incurred was US$175 v US$160 in the LD and OD groups, respectively. The cost of the hand-assisted and standard laparoscopic techniques was significantly higher than that of our modified technique. CONCLUSIONS: Our modified technique of laparoscopy-assisted live-donor nephrectomy avoids the use of costly disposables yet offers the advantages of lesser morbidity and small incision of LD. It is cost effective and is an alternative to open nephrectomy in the developing world.
Adult↗
Pelvic lipomatosis in a child.
We report a 10-year-old boy with pelvic lipomatosis causing chronic urinary retention. CT scan features, therapy and review of the literature are discussed.
Biopsy, Needle↗
Level of awareness about transplantation, brain death and cadaveric organ donation in hospital staff in India.
A questionnaire was distributed in a group of randomly selected hospital staff to ascertain the level and factors associated with awareness regarding organ transplantation, brain death, and cadaveric organ donation. Between October and December 2000, a total of 166 paramedical (nurses, technologists, medical physicists) and 100 nonmedical (administrative, clerical, engineering, social scientists, and miscellaneous) staff of a tertiary referral academic hospital in northern India received this questionnaire. Ninety-seven percent had good to excellent awareness about transplantation, 17.3% of the hospital staff thought that brain death was a reversible process, and 59.4% had misconceptions about the retrieval of cadaveric organs. A significant positive correlation (r = 0.147, P = .01) was observed between the awareness of transplantation, brain death, and organ donation. A significant association was also observed between the workplace (operating room and intensive care unit vs other areas) and awareness of transplantation (P = .048), and brain death and organ donation (P = .030).
Adult↗
Incidence of contraindications to total disc arthroplasty: a retrospective review of 100 consecutive fusion patients with a specific analysis of facet arthrosis.
BACKGROUND CONTEXT: The role of total disc arthroplasty (TDA) in the treatment of spinal pathology is unclear. TDA has been touted as an alternative to fusion. However, not all back pain is purely discogenic in origin. Contraindications to TDA exist. At Spine Week in Porto, Portugal, Cammisa's group from the Hospital for Special Surgery in New York presented a series of 56 fusions where 100% of patients had one or more of 10 contraindications to TDA. En face, this appears to be an extremely large number. PURPOSE: The purpose of the study was to repeat the Hospital for Special Surgery study in another cohort of fusion patients. STUDY DESIGN/SETTING: This study was an independent, retrospective record review of 100 consecutive lumbar spinal fusions performed at a tertiary care private medical center. PATIENT SAMPLE: All adult patients having primary1-3 level lumbar spinal fusions from January 2003 to May 2004 were assessed. OUTCOME MEASURES: Physiologic measures included imaging, range of motion, and response to facet blocks. METHODS: A retrospective chart review was performed of 100 consecutive patients having primary 1-3 level lumbar fusion by all five active staff spinal surgeons (3 orthopedic and 2 neurosurgeons). The review was performed independently by the doctorate level physiotherapist who serves as the medical center's research coordinator, reporting to the chairman of the Hospital institutional review board. The same 10 contraindications from Cammisa's study were noted. Additional facet arthrosis data were collected, including mention on imaging reports or operating room notes. Clinical notes were reviewed for documentation of range of lumbar motion (ROM) and whether there was restricted or painful extension ROM. Note was made if patients had facet blocks as another clinical indicator of facet arthrosis. RESULTS: All 100 patients had at least one contraindication to TDA. The average was 3.69 (range 1-7). Only one patient had facet arthrosis as their only contraindication. Facet arthrosis was documented on imaging reports or operating room notes in 97/100. Reduced extension was present in 71/75 charts that documented ROM. Facet blocks were performed in 12/100 and gave greater than 50% relief in nine. CONCLUSIONS: Both our study and Cammisa's indicate that all lumbar fusion patients in our two institutions have at least one contraindication to TDA. The average fusion patient does not appear to have isolated discogenic pain. A large proportion of the patients appeared to have facet arthritis. The point where facet arthrosis definitely constitutes a contradiction to TDA will require analysis during long-term arthroplasty follow-up studies. Suitable patients for TDA may not represent a significant cohort presently undergoing lumbar fusion.
Adult↗