Endoscopic extraction of eroded Marlex mesh in a Kock pouch

We report a case of recurrent calculi in a Kock pouch continent urinary diversion. An open operation was avoided by successfully excising the Marlex mesh and removing it with the associated calculi in an endoscopic fashion.     

Terbutaline and diaphragm function in chronic obstructive pulmonary disease: a double-blind randomized clinical trial

We conducted a double-blind, randomized crossover trial to evaluate whether oral terbutaline (2.5 mg orally three times daily for a week) increased the force of diaphragmatic contraction in normocapnic patients with chronic obstructive pulmonary disease. Ten patients with moderate to severe airway obstruction completed the trail. Compared with placebo, terbutaline produced a mean increase of 5.8 cmH2O in peak inspiratory mouth pressure and a mean increase of 5.0 cmH2O in transdiaphragmatic pressure during a maximal inspiratory manoeuvre. These small changes with terbutaline failed to achieve statistical significance. Also, terbutaline failed to alter flow rates (FEV1, Vmax50) or patients' dyspnoea ratings using two separate clinical scales (Pneumoconiosis Research Unit Score and the Modified Dyspnoea Index). Because all observed changes in respiratory muscle strength were small and because the trial had power to detect small changes in inspiratory mouth pressures, we suggest that oral terbutaline at the dose administered in this study has little noteworthy effect on respiratory muscle strength in normocapnic patients with chronic obstructive pulmonary disease.     

Gastropyeloplasty: a swine model

OBJECTIVES: Struvite calculus formation requires an alkaline urinary pH. An acidic urinary pH will dissolve struvite calculi and prevent recurrent struvite stone formation. Long-term urinary acidification has been unsuccessful. We sought to determine whether a gastric patch (with viable parietal cells) anastomosed to the renal pelvis could create an acidic urinary milieu. METHODS: A vascularized stomach patch (from the greater curvature) was anastomosed to the left renal pelvis in 15 female pigs. The right kidney was used as a control. The first 6 pigs were used to refine the surgical technique. The remaining 9 pigs were subjected to a formal gastropyeloplasty and followed up for 4 weeks. Urine was collected before and after stimulation with pentagastrin. Urine pH was measured from both kidneys in response to gastrin stimulation and oral intake. The kidneys, ureters, and bladders were examined for gross changes and histologic review. RESULTS: The 9 test animals had more acidic urine in the control kidney than in the gastropyeloplasty kidney. Pentagastrin had no significant impact on urinary pH. Hydroureteronephrosis and a concentrating defect were noted in the treated kidney. Histologic review revealed smooth muscle hyperplasia of the left ureter and viable parietal cells in the stomach patch. CONCLUSIONS: An animal model was developed to transfer a gastric patch to the renal pelvis. Hydronephrosis and ureteral dilation were associated with this gastric patch. We were unable to acidify the urine despite viable parietal cells in the transposed stomach segment. Further refinements of this concept may be successful in acidifying urine in the hope of preventing recurrent struvite nephrolithiasis.     

Urolithiasis in renal and combined pancreas/renal transplant recipients

PURPOSE: Urological complications in renal transplant recipients will become more common with increasing numbers of transplantations as well as increased graft survival secondary to improvements in immunosuppression. Urinary stone disease may be one of those complications. We determine the current incidence of urinary stone disease in renal transplant patients based on contemporary immunosuppressive regimens. MATERIALS AND METHODS: We reviewed the records of 1,730 renal and 83 pancreas/renal transplantations performed during the cyclosporine era and identified 8 recipients (0.4%) with urinary stone disease, including 3 with renal pelvic stones, 1 with multiple ureteral stones and 4 with bladder calculi. RESULTS: Treatment ranged from conservative observation to open pyelolithotomy, and included percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. The ureteral stones were removed with antegrade and retrograde ureteroscopy. The 4 bladder stones were treated with cystolithalopaxy. No case had significant permanent graft damage. Mean followup was 68.6 months. Mean serum creatinine was 1.5 mg./dl. (normal 0.5 to 1.3) at baseline and 2.38 after followup. CONCLUSIONS: While the incidence of upper tract urinary stone disease in renal (0.23%) and pancreas/renal (1.2%) transplant recipients is not statistically significant (p <0.45), the latter have significantly higher rates of bladder stones (4.8 versus 0%, p <0.001). The diagnosis of urinary stone disease in transplant recipients can be challenging because of the lack of symptoms but the treatment approach is the same as in the normal population.     

Misallocation of respiratory care services: time for a change

In summary, with increasing scrutiny given to the effectiveness and costs of health care, innovative programs that allocate respiratory care ordering to practitioners based on rigorous, specified appropriateness criteria and/or branching-logic algorithms are a promising solution to respiratory care misallocation. Widespread acceptance and implementation will require staunch medical directors' input and advocacy, therapists' support for new programs and for leaving the comforts of 'traditional' practice, and confirmation of the benefits of Respiratory Therapy Consult Services by more extensive, 'hard-nosed' evaluation.     

Magnetic resonance imaging of renal calculi: an in vitro study

Extracorporeal shock wave lithotripsy (ESWL) has been established as a standard method of urinary stone treatment. Poor fragmentation with an increased rate of complications has been noticed with certain calculi types (calcium oxalate monohydrate and cystine). In devising appropriate pre-operative strategies, it would be useful to know the calculi composition. We have investigated the in vitro utility of using magnetic resonance imaging (MRI) in analyzing urinary calculi. Our in vitro analysis found no difference in signal characteristics between calculi of varying composition. The absence of signal can be understood from a molecular basis. We conclude that MRI will not offer any assistance in characterizing the composition of urinary calculi.