Pickering syndrome is an under recognised cardio-renal syndrome where life threatening flash pulmonary edema develops in the setting of diastolic dysfunction of the heart. Renal artery stenosis induced activation of sympathetic nervous system and renin-angiotensin-aldosterone system result in fluid retention; such fluid retention in the setting of diastolic dysfunction results in flash pulmonary edema. Most patients who present with pickering syndrome have normal coronary circulation and left ventricular systolic function. We here present a case of pickering syndrome that was precipitated by initiation of angiotensin converting enzyme inhibitor therapy in a patient with undiagnosed unilateral renal artery stenosis. The incidence of flash pulmonary edema decreases on revascularization of renal artery stenosis. Underlying renal artery stenosis should be suspected in a patient with recurrent flash pulmonary edema as such patients merit from revascularization of renal artery stenosis. To the best of our knowledge we are the first to report angiotensin converting enzyme inhibitors as a precipitator of pickering syndrome.
To identify clinicopathological or radiological factors that may predict a diagnosis of upper urinary tract urothelial cell carcinoma (UTUC) to inform which patients can proceed directly to radical nephroureterectomy (RNU) without the delay for diagnostic ureteroscopy (URS).All consecutive patients investigated for suspected UTUC in a high-volume UK centre between 2011 and 2017 were identified through retrospective analysis of surgical logbooks and a prospectively maintained pathology database. Details on clinical presentation, radiological findings, and URS/RNU histopathology results were evaluated. Multivariate regression analysis was performed to evaluate predictors of a final diagnosis of UTUC.In all, 260 patients were investigated, of whom 230 (89.2%) underwent URS. RNU was performed in 131 patients (50.4%), of whom 25 (9.6%) proceeded directly without URS - all of whom had a final histopathological diagnosis of UTUC - and 15 (11.5%) underwent RNU after URS despite no conclusive histopathological confirmation of UTUC. Major surgery was avoided in 77 patients (33.5%) where a benign or alternative diagnosis was made on URS, and 14 patients (6.1%) underwent nephron-sparing surgery. Overall, 178 patients (68.5%) had a final diagnosis of UTUC confirmed on URS/RNU histopathology. On multivariate logistic regression analysis, a presenting complaint of visible haematuria (hazard ratio [HR] 5.17, confidence interval [CI] 1.91-14.0; P = 0.001), a solid lesion reported on imaging (HR 37.8, CI = 11.7-122.1; P < 0.001) and a history of smoking (HR 3.07, CI 1.35-6.97; P = 0.007), were predictive of a final diagnosis of UTUC. From this cohort, 51 (96.2%) of 53 smokers who presented with visible haematuria and who had a solid lesion on computed tomography urogram had UTUC on final histopathology.We identified specific factors which may assist clinicians in selecting which patients may reliably proceed to RNU without the delay of diagnostic URS. These findings may inform a prospective multicentre analysis including additional variables such as urinary cytology.
Acne vulgaris is commonly treated with topical antibacterials. We evaluated lincomycin gel, a new topical formulation for mild to moderate acne. A multicentric, randomized, double blind, placebo controlled, clinical trial was conducted with lincomycin hydrochloride in 2% gel form in 200 patients with grade II and grade III acne. The severity of acne lesions was noted at baseline and after 4 weeks. About 70% cases in the study group showed a good to excellent response, which was significantly more as compared to 23% in the placebo group. The frequency and severity of adverse reactions in the two groups were similar. Lincomycin hydrochloride gel is an effective and safe treatment option for mild to moderate acne vulgaris.
Objectives: To assess the association of skin-to-stone distance (SSD) and stone-free rates following extracorporeal shockwave lithotripsy (SWL) using two statistical methods: logistic regression and a matched-pair analysis approach. Patients and Methods: Patients with a solitary radio-opaque upper ureteral calculus diagnosed on noncontrast computed tomography were included. Patients were treated with a Sonolith I-Sys Lithotripter (focal depth 17 cm). Stone treatment success was defined as stone free (fragments ≤3 mm) at 3 months. Failure was defined as persistent fragments beyond 3 months or requirement for intervention with ureteroscopy. The outcome was assessed by a plain kidney, ureter, and bladder radiograph (KUB) at 2 weeks. Logistic regression was used to determine association of patient and stone factors with treatment failure. The patient cohort was divided into tertiles by SSD, and matched-pair analysis was undertaken between individuals from the top and bottom tertiles (SSD ≤12 cm and SSD ≥14 cm). Matching criteria consisted of age, sex, maximum stone diameter (±2 mm), and stone density (±250 HU). Results: From a database of 2849 patients who underwent SWL, 397 patients were identified who had treatment of a single upper ureteral stone. Age (odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.01–1.04, p = 0.007), SSD (OR: 1.16, 95% CI: 1.03–1.32, p = 0.02), stone side (OR: 1.65, 95% CI 1.01–2.73, p = 0.05), stone diameter (OR: 1.09, 95% CI: 1.00–1.19, p = 0.05), and multiple sessions (OR: 4.65, 95% CI: 2.61–8.29, p < 0.001) were significantly associated with treatment failure by logistic regression univariable analysis. Multiple sessions was the only factor significantly associated with treatment failure on multivariable analysis (OR: 4.03, 95% CI: 2.18–7.42, p < 0.001). From a cohort of 141 patients with SSD ≥14 cm and 174 patients with a SSD ≤12 cm, 66 matches were identified (132 patients). Forty-nine patients (74.2%) with SSD ≥14 cm were deemed stone free at follow-up vs 51 patients (77.3%) with SSD ≤12 cm (p = 0.85). Conclusion: This study demonstrates by two statistical methods that SWL can provide efficacious treatment of upper ureteral stones in obese patients and that the upper threshold of SSD for SWL with Sonolith I-SYS could be revised to allow these patients the benefits of SWL.
Abstract Funding Acknowledgements Type of funding sources: None. Introduction With widespread awareness about the harmful effects of traditional smoking, many people are considering the use of an e-cigarette. However, there are many studies which have shown e-cigarettes is not entirely harmless and it’s use has been implication in causing major adverse cardiovascular events. Methodology This systemic review strictly adhered to the PRISMA checklist. An electronic search was conducted comprehensively through five databases to find the relevant articles. The odds ratio (OR) was used for comparing groups. Meta-analysis was conducted using R statistical software version 3.4.3. A random-effect model was used. Results A total of 4 studies were included in the analysis incorporating data on 585,306 subjects. In these, 19,435 were e-cigarettes users, while 1693 used only traditional cigarette users, and 553,095 were non-e-cigarette users. A total of 7.0% of e-cigarette users suffered an MI in their lifetime, while only 6.5% of non-e-cigarette users have had MI. The OR of getting an MI in e-cigarettes users was 1.30 (95% CI = 1.23-1.38, p-value < 0.01) in comparison to non e-cigarette users. While it is 0.61 (95% CI = 0.40 – 0.93, p-value 0.02) when compared with traditional smoking. Conclusion Those using e-cigarettes have a higher odds of suffering from an MI in comparison to not using e-cigarettes. However, using e-cigarettes reduces the risk of MI by half in comparison to traditional smoking. Abstract Figure. Forest plot
