When prone position is contraindicated or not preferable, can supine percutaneous nephrolithotomy solve the problem?

PURPOSE: To assess safety and efficacy of supine percutaneous nephrolithotomy in patients for whom prone position or general anesthesia is contraindicated or not preferable due to associated comorbidities, overweight or ipsilateral upper ureteric calculi. MATERIALS AND METHODS: Fifty two patients (37 males and 15 females, mean age 33 ± 10.2 years) were included in this study. Supine position was selected due to anesthetic considerations (preexisting compromised cardiopulmonary status, morbid obesity (body mass index > 40 kg/m²) and/or other associated medical comorbidities), impossible prone position due to bone deformities or associated ipsilateral upper ureteric stone. Regional anesthesia was used in 24 patients while 28 patients underwent general anesthesia. After standard cystoscopy and retrograde ureteropyelography in the dorsal lithotomy position, the position was modified using 3 liters of saline bag below the ipsilateral upper flank. Percutaneous access to the pelvicalyceal system was performed through the posterior axillary line under fluoroscopic guidance. RESULTS: Successful renal puncture was achieved in all cases. Single access via the lower calyx was the most commonly used access (36 cases). Stone-free rate was 92.3%. Postoperative complications classified according to Clavien Dindo classification included bleeding requiring transfusion (3.8%), urinary leakage requiring ureteric stenting (5.8%), prolonged fever (7.7%), deep venous thrombosis (1.9%) [grade III in all] and urinary leakage requiring ureteric stenting (5.8%) [grade IIIa]. CONCLUSIONS: The modified supine position for percutaneous nephrolithotomy is a safe and effective option that offers several advantages with an excellent outcome. It can be performed safely for morbidly obese patients and those with cardiopulmonary compromise

<a name="home"></a>Cyclosporin-A does not affect skeletal muscle mass during disuse and recovery

Cyclosporin-A (CsA) is an immunosuppressive drug that acts as an inhibitor of calcineurin, a calcium phosphatase that has been suggested to play a role in skeletal muscle hypertrophy. The aim of the present study was to determine the effect of CsA administration (25 mg kg-1 day-1) on skeletal muscle mass and phenotype during disuse and recovery. Male Wistar rats received vehicle (N = 8) or CsA (N = 8) during hind limb immobilization (N = 8) and recovery (N = 8). Muscle weight (dry/wet) and cross-sectional area were evaluated to verify the effect of CsA treatment on muscle mass. Muscle phenotype was assessed by histochemistry of myosin ATPase. CsA administration during immobilization and recovery did not change muscle/body weight ratio in the soleus (SOL) or plantaris (PL). Regarding muscle phenotype, we observed a consistent slow-to-fast shift in all experimental groups (immobilized only, receiving CsA only, and immobilized receiving CsA) as compared to control in both SOL and PL (P < 0.05). During recovery, no difference was observed in SOL or PL fiber type composition between the experimental recovered group and recovered group receiving CsA compared to their respective controls. Considering the muscle/body weight ratio, CsA administration does not maximize muscle mass loss induced by immobilization. Our results also indicate that CsA fails to block skeletal muscle regrowth after disuse. The present data suggest that calcineurin inhibition by CsA modulates muscle phenotype rather than muscle mass

The modified Medical Research Council scale for the assessment of dyspnea in daily living in obesity: a pilot study

<p>Abstract</p> <p>Background</p> <p>Dyspnea is very frequent in obese subjects. However, its assessment is complex in clinical practice. The modified Medical Research Council scale (mMRC scale) is largely used in the assessment of dyspnea in chronic respiratory diseases, but has not been validated in obesity. The objectives of this study were to evaluate the use of the mMRC scale in the assessment of dyspnea in obese subjects and to analyze its relationships with the 6-minute walk test (6MWT), lung function and biological parameters.</p> <p>Methods</p> <p>Forty-five obese subjects (17 M/28 F, BMI: 43 ± 9 kg/m²) were included in this pilot study. Dyspnea in daily living was evaluated by the mMRC scale and exertional dyspnea was evaluated by the Borg scale after 6MWT. Pulmonary function tests included spirometry, plethysmography, diffusing capacity of carbon monoxide and arterial blood gases. Fasting blood glucose, total cholesterol, triglyceride, N-terminal pro brain natriuretic peptide, C-reactive protein and hemoglobin levels were analyzed.</p> <p>Results</p> <p>Eighty-four percent of patients had a mMRC ≥ 1 and 40% a mMRC ≥ 2. Compared to subjects with no dyspnea (mMRC = 0), a mMRC ≥ 1 was associated with a higher BMI (44 ± 9 vs 36 ± 5 kg/m², p = 0.01), and a lower expiratory reserve volume (ERV) (50 ± 31 <it>vs</it> 91 ± 32%, p = 0.004), forced expiratory volume in one second (FEV₁) (86 ± 17 <it>vs</it> 101 ± 16%, p = 0.04) and distance covered in 6MWT (401 ± 107 <it>vs</it> 524 ± 72 m, p = 0.007). A mMRC ≥ 2 was associated with a higher Borg score after the 6MWT (4.7 ± 2.5 <it>vs</it> 6.5 ± 1.5, p < 0.05).</p> <p>Conclusion</p> <p>This study confirms that dyspnea is very frequent in obese subjects. The differences between the “dyspneic” and the “non dyspneic” groups assessed by the mMRC scale for BMI, ERV, FEV₁ and distance covered in 6MWT suggests that the mMRC scale might be an useful and easy-to-use tool to assess dyspnea in daily living in obese subjects.</p