Jamsheer J Talati

Proteins in renal stones and urine of stone formers.

Abstract Knowledge of the essential characteristics of macromolecules constituting the organic matrix of the nidus of urinary stones is required to understand the mechanism of urolithogenesis. The aim of this study was to isolate and characterise those stone nidus proteins. Using an extraction buffer containing SDS and β-mercaptoethanol, we were able to overcome known problems of protein isolation from urinary stone matrix. These proteins were characterised by a strong tendency to aggregate under reducing and denaturing conditions. On SDS-PAGE, their molecular weights range from ≤12 to 66 kDa. Antisera raised against stone matrix proteins showed a cross-reactivity between proteins isolated from different stones irrespective of their origin or mineral composition. Moreover, urinary proteins from stone formers also cross-reacted with these whereas there was no reaction with urinary proteins of non-stone formers. Western blotting confirmed these findings. Given the above summarised properties, it can be safely concluded that these proteins are prevalent in urines of stone formers, that they are selectively incorporated into renal stones of all aetiologies, and that they most likely have a role in nidus and, therefore, early stone formation.

Persistent Müllerian duct syndrome.

Persistent müllerian duct syndrome (PMDS) is a rare form of male pseudohermaphroditism. We present 5 cases with PMDS (2 cases associated with testicular malignancy) and discuss the diagnosis and management. Management strategies of PMDS have changed. Whereas in the past, removal of the müllerian remnants was targeted together with orchidopexy or -ectomy, this is no longer recommended. However, testicles that cannot be descended at an early stage are at a high risk of malignancy and should, therefore, be removed. If this is necessary on both sides, there is the additional problem of lifelong testosterone substitution which requires efficient patient monitoring and good patient compliance. In cases where this cannot be achieved, compromises, such as temporarily delayed orchidectomy, may be considered.

Epidemiology of stone disease across the world

Nephrolithiasis is a highly prevalent disease worldwide with rates ranging from 7 to 13% in North America, 5–9% in Europe, and 1–5% in Asia. Due to high rates of new and recurrent stones, management of stones is expensive and the disease has a high level of acute and chronic morbidity. The goal of this study is to review the epidemiology of stone disease in order to improve patient care. A review of the literature was conducted through a search on Pubmed®, Medline®, and Google Scholar®. This review was presented and peer-reviewed at the 3rd International Consultation on Stone Disease during the 2014 Société Internationale d’Urologie Congress in Glasgow. It represents an update of the 2008 consensus document based on expert opinion of the most relevant studies. There has been a rising incidence in stone disease throughout the world with a narrowing of the gender gap. Increased stone prevalence has been attributed to population growth and increases in obesity and diabetes. General dietary recommendations of increased fluid, decreased salt, and moderate intake of protein have not changed. However, specific recommended values have either changed or are more frequently reported. Geography and environment influenced the likelihood of stone disease and more information is needed regarding stone disease in a large portion of the world including Asia and Africa. Randomized controlled studies are lacking but are necessary to improve recommendations regarding diet and fluid intake. Understanding the impact of associated conditions that are rapidly increasing will improve the prevention of stone disease.

Extracorporeal shock wave lithotripsy for urinary tract stones using MPL 9000 spark gap technology and ultrasound monitoring.

Between November 7, 1988 and December 31, 1989, 881 treatments were given with the MPL 9000 lithotriptor to 513 sites in 510 renal units in 464 patients. Of the stones 447 (87.1%) were in the kidney, 64 (12.5%) in the ureter and 2 (0.4%) in the bladder. Stone size was up to 2 cm. in 58.5% of the cases, greater than 2 to 3 cm. in 25.8% and more than 3 cm. in 15.7%, including complete or partial staghorn, or multiple stones. Of the patients 54.2% received only 1 treatment, 17.6% received 2 treatments and 28.2% received more than 2 treatments (re-treatment was necessary in 45.8%). The number of shocks used varied from 610 to 4,000 at 14 to 24 kv., the usual energy used being 18 kv. Of the stones 30.2% were treated after Double-J stents were inserted. A patient was declared stone-free only when no stone particle was visible on a plain abdominal x-ray (or ultrasound if the stone was radiolucent). X-rays 3 months after extracorporeal shock wave lithotripsy (ESWL) were available for review in 397 patients (79.9%) and 72.8% were stone-free (with the aforementioned criteria) at 6 months (61.5% without ancillary procedures and 11.3% after ancillary procedures). Of a subset of 106 patients 84% were stone-free within 3 months when ESWL was restricted to a smaller stone burden, the number of shock waves administered was increased and energy was restricted to 14 to 18 kv. Over-all, 9.1% of the patients needed ancillary measures, including percutaneous nephrostomy in 1.6%, push-back for ESWL in 1.9%, ureterorenoscopy in 5.4%, percutaneous nephrolithotomy in 0.6% and pyelolithotomy/ureterolithotomy in 2.8%. The MPL 9000 device has the unique combination of electrohydraulic shock wave generation and ultrasound monitoring. The latter attribute has the distinct advantage of avoiding radiation to allow for visualization of nonopaque renal and gallbladder calculi. In addition, because there is continuous stone visualization during fragmentation accurate stone targeting can be maintained. The combination of ultrasound monitoring and spark gap technology allows for effective stone fragmentation.

Is measurement of stone surface area necessary for SWL treatment of nonstaghorn calculi

BACKGROUND AND PURPOSE The size of urinary tract stones is usually assessed by the longest diameter (LD) alone. Logically, however, two-dimensional measurement of the stone surface area (SSA) susceptible to shockwaves would give more useful information for the planning of treatment by extracorporeal shockwave lithotripsy (SWL). This has been shown for staghorn calculi. The aim of this study was to determine for nonstaghorn kidney and ureter stones whether the LD alone identifies as reliably a subgroup of patients with a stone of a certain size as does the SSA. Furthermore, we sought to determine whether the LD alone indicates as reliably the number of patients who would be rendered stone free after one SWL session within a certain subgroup as would the SSA. PATIENTS AND METHODS Retrospectively, SWL treatment and radiographic data of 330 patients who had undergone SWL for a single stone were analyzed. RESULTS Ureteral stones were significantly smaller on average, and ureteral stone patients needed fewer SWL treatment sessions and fewer shockwaves to become stone free. Stratification of both kidney and ureteral stones by either LD or SSA resulted in comparable groups of patients. There were no significant differences in patient, stone, or treatment data. More importantly, the stone-free rates after one treatment did not differ significantly. CONCLUSION The LD does accurately reflect the size of a nonstaghorn kidney or ureteral stones. Therefore, the measurement of LD, as generally practiced, appears clinically sufficient and appropriate for the assessment of stone size prior to SWL in both kidney and ureteral stones.

UNUSUAL PRESENTATIONS OF HYDATID DISEASE OF THE URINARY TRACT

Echinococcosis is an infestation caused in humans by the larval form of tenia echinococcus (E. granulosis). Humans are accidental intermediary hosts. Although the liver and lungs are commonly affected, renal infestation occurs in only 2% to 3% of all cases of hydatid disease. 2 Because of its uncommon occurrence in many parts of the world and infrequent involvement of the urinary tract, genitourinary hydatid disease may cause considerable diagnostic difficulty and management challenges for the radiologist and urologist. We report 3 cases to highlight the unusual presentation of hydatid disease of the urinary tract.

Assessment, surgeon, and society

An increasing public demand to monitor and assure the quality of care provided by physicians and surgeons has been accompanied by a deepening appreciation within the profession of the demands of self-regulation and the need for accountability. To respond to these developments, the public and the profession have turned increasingly to assessment, both to establish initial competence and to ensure that it is maintained throughout a career. Fortunately, this comes at a time when there have been significant advances in the breadth and quality of the assessment tools available. This article provides an overview of the drivers of change in assessment which includes the educational outcomes movement, the development of technology, and advances in assessment. It then outlines the factors that are important in selecting assessment devices as well as a system for classifying the methods that are available. Finally, the drivers of change have spawned a number of trends in the assessment of competence as a surgeon. Three of them are of particular note, simulation, workplace-based assessment, and the assessment of new competences, and each is reviewed with a focus on its potential.

Surgical Training Programs in Pakistan

AbstractThis paper traces the history and describes the status of surgical training in Pakistan. A key revelation is that excellent surgeons are produced through systems which on formal review might appear to lack standards. Personal characteristics of residents modify outcomes in high volume surgical training units; and consequent variation in quality of outputs is noted. Attention needs to be given to (i) develop new educational systems which are not prolonged costly and cumbersome, and which produce the adequate number, types and spread of highly skilled and cognitively developed empathic surgeons for the country; (ii) the improvement of the health systems which currently impede the development of surgeons and (iii) novel wars of tackling rural urban disparities in health delivery.

Reducing the need for surgeons by reducing pollution-derived workload: is there a role for surgeons?

The need for additional surgical workforce personnel is likely to increase dramatically at a rate beyond our capacity to train them. As surgical training programmes cannot be rapidly expanded, this paper explores an alternative solution to the quandary, a reduction of the disease burden by a war on pollution. Highlighting the role of pollutants in increasing the surgical workload, it identifies potential roles for surgeons in the battle against pollution and draws attention to the need to research out agents which could protect humans against their carcinogenic effects.

Fourier transform infrared spectroscopy for analysis of kidney stones

Purpose To compare the results of a chemical method of kidney stone analysis with the results of Fourier transform infrared (FT-IR) spectroscopy. Materials and Methods Kidney stones collected between June and October 2015 were simultaneously analyzed by chemical and FT-IR methods. Results Kidney stones (n=449) were collected from patients from 1 to 81 years old. Most stones were from adults, with only 11.5% from children (aged 3–16 years) and 1.5% from children aged <2 years. The male to female ratio was 4.6. In adults, the calcium oxalate stone type, calcium oxalate monohydrate (COM, n=224), was the most common crystal, followed by uric acid and calcium oxalate dihydrate (COD, n=83). In children, the most frequently occurring type was predominantly COD (n=21), followed by COM (n=11), ammonium urate (n=10), carbonate apatite (n=6), uric acid (n=4), and cystine (n=1). Core composition in 22 stones showed ammonium urate (n=2), COM (n=2), and carbonate apatite (n=1) in five stones, while uric acid crystals were detected (n=13) by FT-IR. While chemical analysis identified 3 stones as uric acid and the rest as calcium oxalate only. Agreement between the two methods was moderate, with a kappa statistic of 0.57 (95% confidence interval, 0.5–0.64). Disagreement was noted in the analysis of 77 stones. Conclusions FT-IR analysis of kidney stones can overcome many limitations associated with chemical analysis.