Author: Jon Mikel Iñarritu

Uric acid nephrolithiasis

Kidney stones (nephrolithiasis or urolithiasis) affect approximately 12% of men and 5% of women during their lifetime. Nearly half of all first time stone formers will have another stone episode within the next four years.

Stones can form when calcium, oxalate, uric acid or cystine are at high levels in the urine.

Uric acid stones represents 5 – 10% of all kidney stones. But they comprise 40% in areas with hot/arid climates where low urine volume and acid urine pH promote uric acid precipitation.
Prevalence:  In patients with gout without antihyperuricemic treatment is 20%. Hundreds-fold greater than healthy adults.

Risk factors: It primarily occurs in patients without abnormality in uric acid metabolism such as: relatively high serum uric acid levels, comparatively low urinary pH, and low fractional excretion of urate. Clinical gout. Hyperuricosuria, chronic diarrhea (bicarbonate loss and dehydration).  Diabetes, metabolic syndrome and overweight.

How it occurs?:  Two major factors contribute uric acid precipitation

  • a high concentration of uric acid in urine
  • acid urine pH

Diagnosis: Is suggested from the acute onset of flank pain, a positive non-contrast-enhanced CT scan, and history of a predisposing disease (gout, cancer, etc). Plain X-ray is not helpful because these stones are not radiopaque. Confirmation of the diagnosis is best made by chemical analysis of a stone that has been passed.

Treatment:

  • Maintenance of the urine output above 2 L/day to diminish the urine uric acid concentration
  • alkalinization of the urine (increase the urine pH) with potassium bicarbonate or potassium citrate (cytra-k; polycitra-k; urocit-k; citro-k) can be given and this regimen can both dissolve preexisting stones and prevent the formation of new ones.
  • Allopurinol (zyloprim; aloprim; atisuril)
  • Reduction in dietary purine intake (protein)
Image courtesy of: Urocit-K

Effectiveness of vasectomy

Around 42 million couples worldwide rely on vasectomy as a method of family-planning.

Every year 800,000 vasectomies are performed in the US.

Recanalisation: 0.5% of all vasectomies (is defined as the presence of any spermatozoa after one or more previously azoospermic samples were properly collected and documented).

Why are doctors sued following vasectomy?

  1. Failure to be sterile (unwanted pregnancy)
  2. Failure to inform regarding positive semen sample post-operatively
  3. Hematoma/infection
  4. Chronic testicular pain
  5. Atrophy or loss of testicular volume

Vasectomy Failure

Can be due to technical errors, recanalization, or unprotected intercourse before azoospermia is documented

  1. Intraluminal needle cautery (vas not transected, no segment removed): Less than 1%
  2. Cautery both ends and fascial interruption: 1.2 % or less
  3. Cautery (prostatic end) only and fascial interruption (clip): 0.02 to 2.4%
  4. Cautery of both ends and excision of a segment: 4.8% or less
  5. Ligation and fascial interruption: 16.7% or less
  6. Ligation and excision of segment: 1.5 to 29%

To confirm sterility: Obtain a semen analysis 3 months on the postop period; the patient should have had at least 20 ejaculates since the time of vasectomy. Azoospermia in a semen sample is definitive evidence of infertility.

Sokal DC, Labrecque M. Effectiveness of Vasectomy Techniques. Urol Clin N Am 36 (2009) 317–329.

Carcinophobia

Fear from cancer

One not uncommon indication for prophylactic mastectomy is carcinophobia (a.k.a. cancerophobia).

Cancerophobia or carcinophobia is an active behavior of extreme fear of cancer that can lead to repeated medical examination without giving full reassurance to the patient. Denial is a mechanism of defense that usually helps the patient to cope with painful, threatening, overwhelming, or awkward thoughts. When it turns out to be ineffective and pathological, it can cause either delay or avoidance in seeking treatment for symptoms relevant for a true malignancy and will lead inexorably to death if not cured. Most people worry about cancer, but those with cancerophobia are unable to perform their activities of daily living.

For example, cancerophobics believe that a simple headache is a symptom of brain cancer/tumor or dysphagia is a symptom of gastric cancer.  This patients need psychological intervention.

In a female patient cancerophobia with a strong family history of breast cancer and a benign tumor in her breast and if psychological intervention doesn’t help her and she still over-anxious, prophylactic mastectomy is indicated.

2009 Best Hospitals in the US

Flag

The Best U.S. Hospitals for 2009

  1. Johns Hopkins Hospital, Baltimore
  2. Mayo Clinic, Rochester, Minn.
  3. Ronald Reagan UCLA Medical Center, Los Angeles
  4. Cleveland Clinic
  5. Massachusetts General, Boston
  6. New York-Presbyterian University Hospital of Columbia and Cornell
  7. University of California-San Francisco Medical Center
  8. Hospital of the University of Pennsylvania, Philadelphia
  9. Barnes-Jewish Hospital/Washington University, St. Louis
  10. Brigham and Women’s Hospital, Boston &  Duke University Medical Center, Durham, N.C.
  11. University of Washington Medical Center, Seattle
  12. UPMC-University of Pittsburgh Medical Center
  13. University of Michigan Hospitals and Health Centers, Ann Arbor
  14. Stanford Hospital and Clinics, Stanford, Calif.
  15. Vanderbilt University Medical Center, Nashville, Tenn.
  16. New York University Medical Center
  17. Yale-New Haven Hospital, New Haven, Conn.
  18. Mount Sinai Medical Center, New York
  19. Methodist Hospital, Houston
  20. Ohio State University Hospital, Columbus

Top Hospitals by Specialty in the U.S.

  • Cancer: M.D. Anderson Center, University of Texas, Houston
  • Diabetes and endocrine disorders: Mayo Clinic, Rochester, Minn.
  • Digestive disorders: Mayo Clinic
  • Ear, nose, throat: Johns Hopkins Hospital, Baltimore
  • Geriatric care: Ronald Reagan UCLA Medical Center, Los Angeles
  • Gynecology: Brigham and Women’s Hospital, Boston
  • Heart and heart surgery: Cleveland Clinic
  • Kidney disorders: Brigham and Women’s Hospital
  • Neurology and neurosurgery: Mayo Clinic
  • Ophthalmology: Bascon Palmer Eye Institute, University of Miami
  • Orthopaedics: Mayo Clinic
  • Psychiatry: Massachusetts General, Boston
  • Rehabilitation: Rehabilitation Institute of Chicago
  • Respiratory disorders: National Jewish Hospital, Denver
  • Rheumatology: Johns Hopkins Hospital
  • Urology: Johns Hopkins Hospital

REFERENCES:

  • News release, U.S. News & World Report.
  • U.S. News & World Report: “America’s Best Hospitals.”
  • Avery Comarow, health rankings editor, U.S. News & World Report.

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image under Creative Commons license

Rectal Prolapse – NSFW

Rectal prolapse Rectal prolapse Rectal prolapse

As in Marvin L. Corman’s book (Colon & Rectal Surgery) quotes:

Man should always strive to have his intestines relaxed all the days of his life and that bowel function should approximate diarrhea. This is a fundamental principle in medicine, that whenever the stool is withheld or is extruded with difficulty, grave illnesses result.

Maimonides: Mishneh Torah

Rectal prolapse (a.k.a. Procidentia) is one of the most fascinating surgical pathologies because its complexity in treatment. In 1912 Moschcowitz proposed an herniation of Douglas pouch as a cause for rectal prolapse. Another cause was proposed by Broden and Snellman with the help of defecography described a full thickness rectal intussusception.

Rectal prolapse is 6 times more common in females (as males) aged 50 years or older. Many of male patients has a past medical history of psychiatric disorders. Chronic or lifelong constipation with straining is present in more than 50% of patients.

Patients describe a mass or bulge that they have to push back in after defecation. Often, presentation of rectal prolapse can be dramatic when the prolapsed segment becomes incarcerated below the level of the anal sphincter as in this clinical case and emergency surgical therapy was indicated.

More than fifty types of procedures for repair rectal prolapse have been described, but the treatment is always surgical.

Succesful surgery in a Girl with eight limbs

Lakshmi is the hindu goddess of of wealth, fortune, love and beauty, the lotus flower and fertility. She is represented by an icon of a lady with four arms.

Lakshmi Tatma is a girl who is two years old but she was born with 8 limbs, because she is joined at the pelvis to what is, in fact, a headless, undeveloped twin (parasitic twin or to be more specific, ischiopagus cojoined twin).

This is surely an abnormal feature and it has attracted media attention worldwide.

The 24-hour-long surgery to remove the extra limbs of this Indian girl born with four arms and four legs was a success, doctors announced Wednesday.

A team of more than 30 physicians removed Lakshmi’s extra limbs, salvaged her organs, and rebuilt her pelvis area, Dr. Sharan Patil said from a hospital in the southern Indian city of Bangalore, India.

Surgical model

This surgical model is made of glass fiber and has abdominal and thoracic compartments separated. A selective bronchial intubation can be done in this model. It also has a structure that simulates a diaphragm. You can perform both laparoscopy and thoracoscopy.

The organs of a pig are placed within the model.


The model is intubated with an “orotracheal” tube

abdominal view
Abdominal view

thoracic view
Thoracic view

Laparoscopy
Laparoscopy view

Damn Racists

click here

The english organization Marie Stopes International maintains a campaign to alert british citizens on the risks of acquiring venereal diseases or non-wished pregnancies when traveling to Mexico.

“What is more embarrassing, his hat or what he might give you? Make sure don’t come home with any unwanted holiday souvenirs”

This poster is very offensive and annoying. It’s an insult for my Country and it will frighten tourists. MFs, try to think before offend.