FAQ: Understanding Kidney Stones (Part II)

In a previous post, I wrote about: What are kidney stones, how common are kidney stones, kidney stones composition and risk factors for kidney stones disease.

  • A first-time kidney stone (urolithiasis) former is at risk of having another episode?

Yes. First-time stone formers have a 50% risk for recurrence within the sub­sequent 10 years.

  • Which patients need metabolic evaluation (work-up)?

Those that are recurrent stone formers, who have a strong family history of stones, those with chronic diarrhea or with history of pathologic fractures, osteoporosis, urinary tract infection (UTI) with calculi, gout, solitary kidney, urological anatomic abnormalities, renal insufficiency or those with stones composed of struvite, uric acid or cystine.

  • What are the general conservative recommendations for all patients who have had kidney stones (urolithiasis)?

Consume enough fluids to produce at least 2 liters of urine per day. Soda beverages flavored with phosphoric acid may increase stone risk, whereas those with citric acid may decrease risk. Regarding diet, studies have shown a great advantage of a diet with reduced animal protein (meat) intake. Dietary sodium restriction. Have a diet high in fruits and vegetables. Calcium restriction INCREASES stone recurrence risk and calcium supplements should be taken with meals.



FAQ: Understanding Kidney Stones (Part I)


  • What are kidney stones?

Are small (at the beginning), hard mineral deposits that form in the kidney. Urine contains dissolved salts and minerals. If the urine has high levels of this deposits, you can form kidney stones. Stones can stay in the kidney, but eventually can travel down to the ureter, bladder and urethra. If the stone blocks the ureter, it also blocks the urinary flow and can cause excruciating pain.

  • How common are kidney stones?

The lifetime prevalence of having kidney stones is estimated at 1% to 15%. It varies according to race, age, gender and geographic location. Specifically, 114.3 per 100,000 people will have an episode of kidney stones. It is estimated that more than 500,000 people visit emergency departments for kidney stone disease.

  • What are kidney stones made of?

Calcium stones (calcium oxalate by far is the most common) in 80% of cases.  Uric acid stones 5-10%. Struvite 10% mostly related to urinary tract infections. Cystine less than 1% of cases.

  • What are the risk factors for kidney stones?

Men are affected 2-3 times more than women. It is more common in whites, followed by hispanics, asians, and african-americans. It is uncommon before age 20 but peaks in the fourth to sixth decades of life. It has a higher prevalence in hot, arid, or dry climates (mountains, desert, or tropical areas). However, genetic factors and diet may influence this disease. Heat exposure and dehydration are occupational risk factors for kidney stone disease. Also overweight and high body mass index are directed related to kidney stone disease. Despite this risk factors, the most important risk factor is dehydration, so a high fluid intake can prevent urolithiasis.



Don’t miss PART II of this FAQ.


Recto-Vesical Fistula


Recto-vesical fistula is an anomalous communication (fistulous tract) between the bladder and the rectum. The common etiologies are diverticulitis, Crohn’s disease, irradiation, traumatic, bladder or colo-rectal cancer and tuberculosis.

Common symptoms of presentation are fecaluria (presence of feces in the urine), pneumaturia (passage of gas in the urine), hematuria (presence of blood or clots in the urine), intestinal symptoms, abdominal pain, and fever/chills.

Evaluation: urine test (urinalysis) shows food fibers, fecal particles, bacteria, white blood cells and red blood cells.

Cystography shows fistulous tract and bladder inflammation, as seen in this picture, which is a diagnostic/evaluation method barely used because of availability of CT scans.

Later I will give you the fast facts about treatment of this condition.

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.


  • 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.


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


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


  • 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.


image under Creative Commons license

Top 10 Fattest Countries

According to the World Health Organization there are currently 1.6 billion overweight adults in the world and that number is projected to grow by 40% over the next 10 years.

  • Naruru (94.5%)
  • Micronesia (91.1%)
  • Cook Islands (90.9%)
  • Tonga (90.8%)
  • Niue (81.7%
  • Samoa (80.4%)
  • Palau (78.4%)
  • Kuwait (74.2%)
  • United States (74.1%)
  • Kiribati (73.6%)

The list reflects the percentage of overweight adults aged 15 and over. These are individuals who have individual body mass indexes, which measures weight relative to height, greater than or equal to 25. Obese is defined as having a BMI greater than or equal to 30.

Why don’t you calculate your Body Mass Index right here?


Mesothelioma brief review

This is a paid review

Mesothelioma Aid

Mesothelioma Aid is a site for practical living with malignant mesothelioma. In addition to medical information, mesothelioma patients, their families, and their caregivers need support with real life and mesothelioma caregiving issues. Mesothelioma Aid’s focus is on providing answers to your questions and helping you best cope with what is ahead.

Fast Facts
Mesothelioma is an insidious neoplasm arising from the mesothelial surfaces of the pleural and peritoneal cavities, tunica vaginalis, or pericardium. 80 percent of this cases are from pleural origin. The major risk factor for malignant mesothelioma is inhalation of asbestos.

Since asbestos inhalation is the main risk factor, it’s considered as an occupational disease. The incidence in the U.S. is estimated to be 2,200 cases per year.

Asbestos is valued in industry for its resistance to heat and combustion and it’s still used in cement, ceiling and pool tiles, automobile brake linings, and in shipbuilding.

As many as eight million living persons in the U.S. have been occupationally exposed to asbestos over the past 50 years. Those workers in contact with asbestos are at significant risk for the development of both non malignant and malignant pulmonary disease.

  • Approximately 8 percent of asbestos workers will die of respiratory failure secondary to asbestosis.
  • The vast majority of cancers in asbestos workers involve the lung (mesothelioma for example).
  • The lifetime risk of developing mesothelioma among asbestos workers is thought to be as high as 10%.
  • There is a long latency of approximately 30 to 40 years from the time of asbestos exposure to the development of mesothelioma.
  • There appears to be a dose – response relationship between asbestos exposure and mesothelioma.
  • Asbestos exposure acts synergistically with cigarette smoking to increase the risk of developing lung cancer 60 times.
  • Clinical Presentation
    Malignant pleural mesothelioma most commonly presents in the 5th to 7th decades of life. A large proportion of patients diagnosed at an earlier age have a history of childhood exposure to asbestos.

    The most frequent presenting symptoms of pleural mesothelioma are dyspnea (difficulty in breathing) and nonpleuritic chest pain. Rarely, asymptomatic patients present with a unilateral pleural effusion that is found incidentally on routine chest radiograph.

    Common physical findings at the time of diagnosis include unilateral dullness to percussion at the lung base, palpable chest wall masses, and scoliosis towards the side of the malignancy.

    Clinical course
    This neoplasia exerts its morbidity and mortality via inexorable local invasion. Patients typically develop shortness of breath and chest pain as the tumor gradually obliterates the pleural space and replaces any pleural fluid. Local invasion of crucial thoracic structures can result in one or more of the following complications:

  • Dysphagia
  • Hoarseness
  • Cord compression
  • Brachial plexopathy
  • Horner’s syndrome
  • Superior vena cava syndrome
  • The survival of patients with mesothelioma is between 6 and 18 months, and is not significantly affected by currently available therapeutic interventions.

    With a brief review of this disease we can see that this isn’t a benign disease, that’s why I strongly recommend patients, their families, and their caregivers to visit Mesothelioma Aid for questions and support.

    Volkmanns ischemic contracture

    The brachial artery is the major artery that transverses the antecubital fossa; injury to the brachial artery will cause radiating pain, decreased skin temperature, decreased pulses, and pallor of the distal arm and may result in Volkmann contracture.

    The Volmann’s ischemic contracture is a contracture of the flexor muscles and median and ulnar nerve palsies. a long-term sequelae of compartimental syndrome and posterior elbow dislocation.

    It could be prevented by early microvascular repair of brachial artery injuries.