A prospective randomized double blinded placebo controlled trial to study the effect of diuretics on shock wave lithotripsy treatment of renal and upper ureteric calculi

INTRODUCTION: The introduction of shock wave lithotripsy (SWL) treatment for renal and ureteric calculi in 1983 rapidly replaced open surgery for smaller stones. Over time the indications and techniques have been constantly redefined in pursuit of a better outcome. With the arrival of minimally invasive surgical procedures like ureterorenoscopy (URS), percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) the status of SWL has become all the more threatened. But, the unique stature of SWL as a practically ‘no touch’ approach in the treatment of urolithiasis scores over these minimally invasive techniques. It is therefore imperative, that a continuous effort is made to identify novel methods that can improve the treatment outcome of SWL. One such method proposed is to provide diuresis during the shock wave session to enhance the fragmentation and clearance. This is a prospective randomized double blinded placebo controlled trial that aims to analyse the effect of diuretics on SWL treatment of renal and upper ureteric calculi. MATERIAL AND METHODS: Design and location - This hospital based prospective randomized double blinded placebo controlled trial was conducted at the Department of Urology, Christian Medical College, Vellore. Duration - Between June 2011 and December 2012. Patients - Patients with renal and upper ureteric calculi who satisfied the following inclusion and exclusion criteria were included; Inclusion criteria: Age: adults > 18 years, Non obstructive radio opaque renal and upper ureteric calculi up to 1.5 cm (obstruction – no contrast seen beyond the calculus up to the 1 hour film on intravenous urogram) Sterile or treated urine culture, Normal renal function (creatinine up to 1.4 mg%). Exclusion criteria: Anatomical abnormality, Distal obstruction, Morbid obesity (body mass index > 40), Pregnancy, Coagulopathy, History of any previous intervention on the same side, Significant cardiac history. RESULTS: During the study period from June 2011 to December 2012, a total of 96 patients were included. These comprised both renal and upper ureteric calculi as per inclusion criteria. They were randomised into two groups; Group A: Placebo arm, Group B: 40 mg Furosemide iv arm. The mean age in group A was 39.45 years and group B was 38.56 years. The female to male ratio was almost similar in both groups. There were 30 men and 18 women in group A, whereas in group B it was 31 men and 17 women. The mean weight of the patients in group A was 61.16 kg and in group B was 61.39 kg. The mean calculus size in group A was 9.26 mm and group B was 9.41 mm. CONCLUSIONS: The use of diuretics along with SWL treatment of renal and upper ureteric calculi results in higher fragmentation and clearance rates along with a requirement of lower number of shocks and sessions, though not statistically significant

Acute HIV infection detection and immediate treatment estimated to reduce transmission by 89% among men who have sex with men in Bangkok

Published 28 June 2017Introduction: Antiretroviral treatment (ART) reduces HIV transmission. Despite increased ART coverage, incidence remains high among men who have sex with men (MSM) in many places. Acute HIV infection (AHI) is characterized by high viral replication and increased infectiousness. We estimated the feasible reduction in transmission by targeting MSM with AHI for early ART. Methods: We recruited a cohort of 88 MSM with AHI in Bangkok, Thailand, who initiated ART immediately. A risk calculator based on viral load and reported behaviour, calibrated to Thai epidemiological data, was applied to estimate the number of onwards transmissions. This was compared with the expected number without early interventions. Results: Forty of the MSM were in 4th-generation AHI stages 1 and 2 (4thG stage 1, HIV nucleic acid testing (NAT)+/4thG immunoassay (IA)-/3rdG IA–; 4thG stage 2, NAT+/4thG IA+/3rdG IA–) while 48 tested positive on third-generation IA but had negative or indeterminate western blot (4thG stage 3). Mean plasma HIV RNA was 5.62 log¹⁰ copies/ml. Any condomless sex in the four months preceding the study was reported by 83.7%, but decreased to 21.2% by 24 weeks on ART. After ART, 48/ 88 (54.6%) attained HIV RNA <50 copies/ml by week 8, increasing to 78/87 (89.7%), and 64/66 (97%) at weeks 24 and 48, respectively. The estimated number of onwards transmissions in the first year of infection would have been 27.3 (95% credible interval: 21.7–35.3) with no intervention, 8.3 (6.4–11.2) with post-diagnosis behaviour change only, 5.9 (4.4–7.9) with viral load reduction only and 3.1 (2.4–4.3) with both. The latter was associated with an 88.7% (83.8–91.1%) reduction in transmission. Conclusions: Disproportionate HIV transmission occurs during AHI. Diagnosis of AHI with early ART initiation can substantially reduce onwards transmission.Eugène D.M.B. Kroon, Nittaya Phanuphak, Andrew J. Shattock, James L.K. Fletcher, Suteeraporn Pinyakorn, Nitiya Chomchey, Siriwat Akapirat, Mark S. de Souza, Merlin L. Robb, Jerome H. Kim, Frits van Griensven, Jintanat Ananworanich, and David P. Wilson on behalf of the RV254/SEARCH 010 Study Grou

Bilateral vesical inguinal hernia: A perineal ′Mickey mouse′

Bladder being a content of inguinal hernias is a rare event and it being the sole component is extremely uncommon. Usually, elderly obese males are affected and symptomatology depends on the extent of bladder involvement. However, recognition of this entity is important in the treatment of LUTS as well as to avoid inadvertent bladder injury during hernia repair

Primary renal angiosarcoma

Primary angiosarcoma of the kidney is a rare tumor with only a few case reports in the literature. Management is not standardized and the prognosis is poor. However, clinicians need to be aware of this uncommon entity

A prospective randomised double-blind placebo-controlled trial to assess the effect of diuretics on shockwave lithotripsy of calculi

Objective: To assess the effect of diuretics with shockwave lithotripsy (SWL) on the treatment of renal and upper ureteric calculi. Patients and methods: Adult patients with a solitary non-obstructive radio-opaque renal or upper ureteric calculus with normal renal function were included. They were prospectively randomised to receive either SWL with placebo or SWL with diuretics (40 mg parenteral furosemide) in a double-blind manner with a sample size of 48 patients in each arm. The primary outcomes were the SWL success and failure rates. The secondary outcomes were the number of shocks and sessions. Results: Complete fragmentation was achieved in 89.6% of the patients in the furosemide arm as compared to 81.3% in the placebo arm. Clearance was achieved in 77.1% of the patients in the furosemide arm as compared to 70.8% in the placebo arm. The number of shocks and the number of sessions were higher in the placebo arm. These differences were not statistically significant. Conclusion: The use of diuretics along with SWL treatment of renal and upper ureteric calculi does not show a statistically significant improvement in fragmentation or clearance. Keywords: Diuretics, Renal calculi, Shockwave lithotripsy, Ureteric calcul

A novel computer based stent registry to prevent retained stents: Will patient directed automated short message service and letter generator help?

Objective: The objective of this study was to evaluate the feasibility of a computer based stent registry with patient directed automated information system to prevent retained double J stents. Materials and Methods: A stent registry system was developed in collaboration with our Computerized Hospital Information Processing Service Department. This computer based stent registry with patient directed automated information system was integrated with the existing clinical work station. We reviewed the records retrospectively and assessed the feasibility of the system in reminding clinicians and patients regarding the stent and its date of removal. Results: In a short run at our department, this new system appeared feasible, with patients promptly responding to the short message service and letter alerts. Conclusions: Computer based stent registry with patient directed automated information system is feasible in a clinical setting. A prospective study is needed for evaluation of its efficacy in preventing retained stents