Readers comment on response to chest tube instillation question

The place of philosophical medical ethics in medical education and clinical practice has recently been questioned. Although partially valid, the criticisms do not warrant abandoning the enterprise. Instead a reappraised model, based on Aristotelean concepts of intellectual and moral virtue is suggested.     

Percutaneous cystolithotomy with endotracheal tube tract dilation after urinary tract reconstruction

PURPOSE: The effectiveness of a percutaneous approach to intact removal of large calculi from the urinary reservoir after urinary tract reconstruction was reviewed. MATERIALS AND METHODS: The original site of the reservoir drainage tube was used for percutaneous access. After dilation of the tract to 34F a number 10 endotracheal tube was advanced through the tract, and the balloon (diameter up to 43 mm.) was inflated. The rigid nephroscope was then passed through the tract and calculi were removed intact without the need for ultrasonic or electrohydraulic lithotripsy. RESULTS: Removal of single or multiple reservoir calculi attempted in 4 patients was successful in 3. Patients were discharged home within 2 days. CONCLUSIONS: The technique of over dilation of the percutaneous tract allows removal of multiple large calculi in select patients without the need for lithotripsy.     

Simple reinforcement for thin nephrostomy catheters

PURPOSE: Nephrostomy catheters are prone to kinking or damage because the thin, flexible silicone tube is too vulnerable against mechanical stress even when the proximal end is carefully fixed. We developed a simple method to reinforce the outside part of a thin catheter protruding from the skin. MATERIALS AND METHODS: We treated 7 children with nephrostomy catheters or ureteral stents with a diameter of 8F or smaller. After insertion a large plastic tube was wrapped around the small catheter, and fixed to the skin and to the peripheral collection system with adhesive tape. RESULTS: Handling of the catheters improved and there was less need for re-fixation. CONCLUSIONS: Thin nephrostomy catheters can be effectively protected by wrapping them into a larger, outer tube after insertion.     

Upper digestive tract dyspepsia and early gastric cancer

AIM: The study of the frequency and evolution of upper digestive tract dyspepsia in a group of patients operated for early gastric cancer (EGC) and to perform a strategy of diagnosis for the patients with long term upper digestive tract dyspepsia. METHODS: Clinical data of 35 patients operated for EGC were retrospectively evaluated. The frequency, characteristics and evolution time of upper digestive tract dyspepsia, main when it began more than 6 months before surgery, were analyzed. Radiologic and endoscopic exams carried out for diagnosis were also evaluated. Histological diagnosis of surgical specimens were considered, looking for the presence of chronic atrophic gastritis, intestinal metaplasia, and peptic gastric ulcer. RESULTS: Long-term upper digestive tract dyspepsia was present in 27 patients (mean evolution time of 43.4 months). Clinical changes of previous symptoms that suggested gastric carcinoma were not found in 15 patients. Concurrent peptic gastric carcinoma were not found in 15 patients. Concurrent peptic gastric ulcer along with EGC was diagnosed by histology in 11 patients, and chronic atrophic gastritis and intestinal metaplasia were both present in the non-tumoral gastric mucosa in all cases. CONCLUSIONS: 1) Unspecific upper digestive tract dyspepsia is frequently found in patients with EGC. 2) Endoscopy should be the first exam performed in patients with upper digestive tract dyspepsia. 3) The patients with gastric ulcer, chronic atrophic gastritis or intestinal metaplasia must be submitted to sequential endoscopic follow-up.     

Percutaneous nephrostomy in utero for bilateral foetal hydronephrosis

Left percutaneous nephrostomy was performed in a 30-week foetus with bilateral hydronephrosis due to abnormal pyelo-ureteral junction. Puncture of the pelvis and insertion of a 5 cm long F8 Malecot catheter were carried out under ultrasonography. The end of the catheter was left free in the amniotic fluid. Drainage was perfect during 3 weeks, until the skin of the foetus grew over the end of the catheter. At 34 weeks, a much longer catheter was introduced, but it was dislodged from the kidney within 48 hours. Vaginal delivery was induced at 37 weeks, giving birth to a normal male child. On the 4th day after birth the catheter was removed and resection-anastomosis of the left pyelo-ureteral junction was performed.     

Upper respiratory tract disease and mycoplasmosis in desert tortoises from Nevada

A population of desert tortoises (Gopherus agassizii) at Yucca Mountain (Nevada, USA) was monitored during four sampling periods using enzyme-linked immunosorbent assays (ELISA) to determine the percentage of individuals that had been exposed to Mycoplasma agassizii, a causative agent of upper respiratory tract disease. Respiratory tract disease has been considered a significant factor in the decline of desert tortoise populations in the Mojave Desert (USA). Few differences between sexes in ELISA values or percentages testing positive were noted. From 15 to 23% of samples per period tested positive for exposure to the mycoplasma. However, we noted few clinical signs of upper respiratory tract disease. This is in contrast to an earlier study which reported a similar proportion of seropositive tortoises as well as a high percentage of tortoises with clinical signs. However, our results are consistent with that study's conclusion that seropositivity for M. agassizii was a poor predictor of the likelihood to exhibit clinical signs of upper respiratory tract disease. Earlier reported epizootics of mycoplasma-associated respiratory disease occurred mainly during times of drought. Our samples were collected during a period of average to above-average rainfall, suggesting that manifestation of clinical signs of the disease may depend upon the physiological condition of tortoises which, in turn, is related to environmental conditions.     

Intraarterial urokinase for acute native arterial occlusion of the limbs

Since 1988, 49 limbs of 47 patients underwent intraarterial urokinase infusion for acute native artery occlusion. The time from the onset of ischemic symptoms ranged from 1 to 45 days (mean = 17.5). The arterial sectors involved were femoropopliteal in 32 cases, followed by aortoiliac in 13 cases, distal in three cases, and subclavian in one case. Treatment consisted of placing a catheter in the clot and the infusion of 4400 U/kg in 20', followed by a series of 4400 U/kg weight/hour during 6 hours. Clinical evaluation, hemodynamic and coagulation parameters, and angiographical changes were assessed periodically. Infusion time ranged from 6 to 24 hours (mean = 13.2 hours). Improvement of ischemic was achieved in 43 (87.75%) patients. In five patients (12.25%) there was no improvement. Total immediate lysis was achieved in 35 cases (71.5%), and among them, 13 patients (26%) required no associated treatment, 16 (48%) underwent PTA, and four (12%) had surgery of underlying peripheral aneurysms revealed after thrombolysis. Partial lysis was achieved in 13 cases (26.5%), that was enough in four of them, but the remaining nine required further treatment (four PTA, and five arterial surgery). In one case no lysis was achieved, and arterial surgery was carried out. No mortality was recorded, and major complications included one upper gastrointestinal bleeding, and one cerebral hematoma. Late follow-up of successfully treated patients who did not require further surgery shows a cumulative patency rate of 81% at 24 months.     

Hysterosalpingographic evaluation of tubal patency in women treated for anovulatory infertility

During therapy of anovulatory infertility, percentage of pregnancies is lower than the ovulation rate. Cause of this phenomenon is connected as well with the inadequate corpus luteum as others anomalies of the genital tract. Hysterosalpingography was performed in 120 infertile women in whom pregnancy did not occur in spite of effective induction of ovulation. Patency of both tubes was observed in 79 percent of patients. Occlusion of right tube has occurred in 8 percent, left tube in 5 percent, and both tubes in 8 percent of women. Authors suggest that laparoscopy should be obligatory as diagnostic and therapeutic procedure in woman with concomitant ovarian failure and abnormal HSG results.     

Warfarin sodium (Coumadin) anticoagulant therapy for vascular access patency

The increase of geriatric and diabetic patients with poor vasculature brings about a corresponding increase in the use of synthetic vascular access grafts. Synthetic vascular accesses are plagued with numerous problems in maintaining patency. As a result, many practitioners use warfarin sodium. Coumadin, because of its predictability and bioavailability to interrupt the coagulation cascade to prevent thrombus formation. This article includes actions, interactions, monitoring, and adverse effects of this drug.     

Feeding tubes for tube feeding

Several techniques are available for the provision of enteral nutritional support. Nasal tubes, gastrostomy tubes and jejunostomy tubes can be distinguised. Nasal tubes are used for short-term support, gastrostomy tubes (preferably via a percutaneous endoscopic gastrostomy) for long-term support (over 4 to 6 weeks), while (needle catheter) jejunostomy tubes are most often used to provide early enteral nutrition immediately after operations on the proximal gastrointestinal tract. The most frequent complications are: with the nasal tube dislodging, clogging and aspiration, with the gastrostomy tube peristomal infection and with the jejunostomy tube, obstruction. It should further be noted that the quantity of enteral nutrition prescribed and that actually administered may differ substantially so that patients with a feeding device may even become malnourished. With proper patient selection and secure control of the energy balance, feeding tubes are simple (temporary) devices that improve the patient's health and quality of life.