During the last two decades laparoscopic surgery has become a widely practiced procedure. Laparos... more During the last two decades laparoscopic surgery has become a widely practiced procedure. Laparoscopic adrenalectomy for adrenal tumor excision is one of these new applications, The Anaesthesia related implications are critical and noteworthy in the presence of long standing essential hypertension and nephrotic syndrome with poly-pharmacy. OBJECTIVES: To report the first anesthesia for laparoscopic adrenalectomy in Security Forces Hospital in Riyadh. SETTING: Tertiary Care Security Forces Hospital in Riyadh. PATIENT: A 58 years old Saudi woman diagnosed with essential hypertension, nephrotic syndrome, non insulin dependent diabetes mellitus (NIDDM), and right adrenal tumor, with the provisional diagnosis of pheochromocytoma. INTERVENTIONS: General anesthesia, thoracic epidural, control of hypertension with both alpha and beta blockers, and selective Surgical ICU admission for monitoring and pain relief. MEASUREMENT AND THE MAIN RESULTS: Preoperative ultrasound and MRI, MIBG scan of the adrenals, catecholamines serum level, intraoperative direct cardiovascular pressure measurements using Swan-Ganz catheter and arterial line. Pain control was achieved by using epidural narcotics, measurement of blood glucose, blood gases, urea, creatinine and electrolytes. Adequacy of ventilation was monitored by capnography and pulse oximetry. The surgical procedures included right adrenalectomy and cholecystectomy. CONCLUSION: Anaesthesia for laparoscopic adrenalectomy has special problems to be solved specially in relation to pneumoperitonium effect, poly-pharmacy and the current disease state. The use of modern anesthetic agents, cardiovascular monitoring, ventilation and proper analgesia make the hospital stay short, thus ensuring low morbidity and minimal mortality.
An 11-month-old baby girl came to the clinic with a pruritic rash. The rash initially appeared in... more An 11-month-old baby girl came to the clinic with a pruritic rash. The rash initially appeared in her popliteal fossa 2 weeks before the visit. The eruption extended to the right leg, arm, and flank the week before the visit, subsequently spreading to the contralateral flank. Three weeks before to the eruption's appearance, the patient had an upper respiratory infection with a dry nonproductive cough, which resolved spontaneously without antibiotics. The physical examination revealed a healthy-appearing infant girl with excoriated erythematous papules coalescing into plaques on her right flexural arm that continued to the axilla and down the right flank to the flexural aspect of her leg (Figure 1). Her left side was essentially free of any rash (Figure 2). No cervical or axillary lymphadenopathy was noted, and the remainder of her exam was normal. What is your diagnosis? How would you manage this condition?
Twenty-one elderly patients with end-stage renal disease (ESRD) secondary to various etiologies r... more Twenty-one elderly patients with end-stage renal disease (ESRD) secondary to various etiologies received IPD at our unit. It was done manually by trained staff nurses. Each patient received 20-24 one hour exchanges of 2 liters PD solution twice a week through a permanent Tenckhoff catheter. Mean age of patients was 63 years (range 60-96), 12 were male and 9 female. Mean duration of stay on IPD was 23 months (range 18-41). The etiologies of ESRD were: diabetes mellitus (9 patients), unknown etiology (7), hypertension (3), glomerulonephritis and liver cirrhosis (hepatitis C) (2). The peritonitis rate was one episode per 16.3 patient/month. The causative organisms were staphylococcus, coliforms, acinobacter and pseudomonas. Six patients died due to each of the following: 2 septicemia not related to PD; 2 hepatic failure; 2 massive myocardial infarction. Two patients were changed to hemodialysis due to recurrent peritonitis. We observed 7 episodes of catheter exit-site infection; causative organisms were staphylococcus (4), and pseudomonas (3). Staphylococcus cases of exit-site infection responded to local fucidin ointment and oral antibiotic, while in the pseudomonas cases the catheter had to be removed. All patients received erythropoiefin and have maintained good hemoglobin levels (10.1 ± 1.2 gin%). They also had adequate control of their serum creatinine and urea level. As the patients improved, they became less dependent on their relatives. We conclude that IPD is relatively safe and acceptable modality of dialysis treatment in elderly.
Journal of the American Academy of Dermatology, 2005
Reprint requests: Stephen R. Tan, MD, FRCPC, Assistant Professor and Director of the Division of ... more Reprint requests: Stephen R. Tan, MD, FRCPC, Assistant Professor and Director of the Division of Dermatologic Surgery, Indiana University School of Medicine, 550 North University Blvd, UH3240, Indianapolis, IN 46202. ... No abstract is available. To read the body of this ...
REPORT OF A CASE A 69-year-old white man presented with a 4-month history of a rapidly growing no... more REPORT OF A CASE A 69-year-old white man presented with a 4-month history of a rapidly growing nodule on his midforehead area. The lesion was nontender but bled intermittently. The patient denied having any previous radiation exposure or trauma, and his medical history was otherwise unremarkable.
Aim: To analyze the effect of repeated pregnancies on underlying MesGN and see the reciprocal eff... more Aim: To analyze the effect of repeated pregnancies on underlying MesGN and see the reciprocal effect on maternal and fetal outcome. Patients and Methods: Pregnancy records of cases with histological diagnosis of MesGN were reviewed, and past medical histories recorded. Results: Cesarean section (CS). Only two patients developed renal insufficiency after undergoing 5 and 11 pregnancies and follow-up of 9 and 20 years respectively. Conclusion: The outcome of repeated pregnancies in patients with MesGN is comparable to normal deliveries. A higher incidence of pre-eclampsia, LBW babies and CS was noted in the post- compared to the pre-MesGN pregnancies. Repeated pregnancies do not influence the course of the MesGN.
A 23-year-old Saudi female presented with nephrotic syndrome. On renal biopsy she had primary foc... more A 23-year-old Saudi female presented with nephrotic syndrome. On renal biopsy she had primary focal and segmental glomerulosclerosis which was resistant to steroids. Two years later she presented with absent left arm pulses and on investigation a diagnosis of left ventricular thrombosis and thromboembolism of left brachial artery was made. Low antithrombin III, high fibrinogen levels and diuretic therapy were the possible causative factors for hypercoagulable state. On anticoagulation therapy initiated with heparin and continued with warfarin for 8 weeks there was complete dissolution of intraventricular and improvement of left brachial artery thrombosis. An early diagnosis and treatment of this potentially serious complication of nephrotic syndrome are stressed.
The occurrence of hepatitis C virus (HCV) infection amongst chronic renal failure (CRF) patients ... more The occurrence of hepatitis C virus (HCV) infection amongst chronic renal failure (CRF) patients in our Nephrology Unit was investigated over a period of 1 year. A total of 71 patients was studied comprising 26 chronic haemodialysis (CHD) patients, 6 acute haemodialysis patients, 4 peritoneal dialysis patients and 35 CRF patients not on dialysis. Patients were screened before and after haemodialysis, and their baseline and postdialysis values of liver enzymes were determined. Eleven (15.5%) of the total 71 patients were HCV antibody positive. Analysis of the individual patient groups showed that 8 (30.7%) of the 26 CHD patients were positive for HCV. Our data showed a statistically significant relationship between seroconversion and duration of dialysis (p < 0.05). A high statistically significant (p < 0.0001) correlation was observed between the HCV antibodies and CRF. The relative risk of hepatitis C was about 22 times greater for those with CRF compared with the normal controls, which makes CRF an important risk factor. A high proportion of the HCV seroconverters had elevated liver enzyme (serum glutamic pyruvic transaminase). The data presented show a positive correlation between HCV seroconversion, CRF, duration on dialysis and elevated serum liver enzymes.
Bartter's syndrome (BS) is characterized by primary renal tubular hypokal... more Bartter's syndrome (BS) is characterized by primary renal tubular hypokalemic metabolic alkalosis, hyperreninemia, hyperaldosteronism and normal blood pressure. The parents and siblings of a BS patient were evaluated for renal tubular function. The father and all 9 siblings of the patient had biochemical features of BS. His mother, a first cousin of his father, had hypokalemia and hyperkaluria but no other features of BS and could have been a 'carrier'. The mother and all 9 siblings were asymptomatic. Including the patient, hypomagnesemia was present in 8 of 12 family members. Therapy with a combination of potassium chloride and magnesium increased the serum potassium and magnesium levels to within normal limits. The familial occurrence in BS is well known, and reports of the disorder in siblings and the first generation of children of consanguineous marriages and normal parents have been taken to suggest an autosomal recessive inheritance. One affected parent and involvement of all siblings of the patient raise the possibility of an autosomal dominant inheritance in the present family.
During the last two decades laparoscopic surgery has become a widely practiced procedure. Laparos... more During the last two decades laparoscopic surgery has become a widely practiced procedure. Laparoscopic adrenalectomy for adrenal tumor excision is one of these new applications, The Anaesthesia related implications are critical and noteworthy in the presence of long standing essential hypertension and nephrotic syndrome with poly-pharmacy. OBJECTIVES: To report the first anesthesia for laparoscopic adrenalectomy in Security Forces Hospital in Riyadh. SETTING: Tertiary Care Security Forces Hospital in Riyadh. PATIENT: A 58 years old Saudi woman diagnosed with essential hypertension, nephrotic syndrome, non insulin dependent diabetes mellitus (NIDDM), and right adrenal tumor, with the provisional diagnosis of pheochromocytoma. INTERVENTIONS: General anesthesia, thoracic epidural, control of hypertension with both alpha and beta blockers, and selective Surgical ICU admission for monitoring and pain relief. MEASUREMENT AND THE MAIN RESULTS: Preoperative ultrasound and MRI, MIBG scan of the adrenals, catecholamines serum level, intraoperative direct cardiovascular pressure measurements using Swan-Ganz catheter and arterial line. Pain control was achieved by using epidural narcotics, measurement of blood glucose, blood gases, urea, creatinine and electrolytes. Adequacy of ventilation was monitored by capnography and pulse oximetry. The surgical procedures included right adrenalectomy and cholecystectomy. CONCLUSION: Anaesthesia for laparoscopic adrenalectomy has special problems to be solved specially in relation to pneumoperitonium effect, poly-pharmacy and the current disease state. The use of modern anesthetic agents, cardiovascular monitoring, ventilation and proper analgesia make the hospital stay short, thus ensuring low morbidity and minimal mortality.
An 11-month-old baby girl came to the clinic with a pruritic rash. The rash initially appeared in... more An 11-month-old baby girl came to the clinic with a pruritic rash. The rash initially appeared in her popliteal fossa 2 weeks before the visit. The eruption extended to the right leg, arm, and flank the week before the visit, subsequently spreading to the contralateral flank. Three weeks before to the eruption's appearance, the patient had an upper respiratory infection with a dry nonproductive cough, which resolved spontaneously without antibiotics. The physical examination revealed a healthy-appearing infant girl with excoriated erythematous papules coalescing into plaques on her right flexural arm that continued to the axilla and down the right flank to the flexural aspect of her leg (Figure 1). Her left side was essentially free of any rash (Figure 2). No cervical or axillary lymphadenopathy was noted, and the remainder of her exam was normal. What is your diagnosis? How would you manage this condition?
Twenty-one elderly patients with end-stage renal disease (ESRD) secondary to various etiologies r... more Twenty-one elderly patients with end-stage renal disease (ESRD) secondary to various etiologies received IPD at our unit. It was done manually by trained staff nurses. Each patient received 20-24 one hour exchanges of 2 liters PD solution twice a week through a permanent Tenckhoff catheter. Mean age of patients was 63 years (range 60-96), 12 were male and 9 female. Mean duration of stay on IPD was 23 months (range 18-41). The etiologies of ESRD were: diabetes mellitus (9 patients), unknown etiology (7), hypertension (3), glomerulonephritis and liver cirrhosis (hepatitis C) (2). The peritonitis rate was one episode per 16.3 patient/month. The causative organisms were staphylococcus, coliforms, acinobacter and pseudomonas. Six patients died due to each of the following: 2 septicemia not related to PD; 2 hepatic failure; 2 massive myocardial infarction. Two patients were changed to hemodialysis due to recurrent peritonitis. We observed 7 episodes of catheter exit-site infection; causative organisms were staphylococcus (4), and pseudomonas (3). Staphylococcus cases of exit-site infection responded to local fucidin ointment and oral antibiotic, while in the pseudomonas cases the catheter had to be removed. All patients received erythropoiefin and have maintained good hemoglobin levels (10.1 ± 1.2 gin%). They also had adequate control of their serum creatinine and urea level. As the patients improved, they became less dependent on their relatives. We conclude that IPD is relatively safe and acceptable modality of dialysis treatment in elderly.
Journal of the American Academy of Dermatology, 2005
Reprint requests: Stephen R. Tan, MD, FRCPC, Assistant Professor and Director of the Division of ... more Reprint requests: Stephen R. Tan, MD, FRCPC, Assistant Professor and Director of the Division of Dermatologic Surgery, Indiana University School of Medicine, 550 North University Blvd, UH3240, Indianapolis, IN 46202. ... No abstract is available. To read the body of this ...
REPORT OF A CASE A 69-year-old white man presented with a 4-month history of a rapidly growing no... more REPORT OF A CASE A 69-year-old white man presented with a 4-month history of a rapidly growing nodule on his midforehead area. The lesion was nontender but bled intermittently. The patient denied having any previous radiation exposure or trauma, and his medical history was otherwise unremarkable.
Aim: To analyze the effect of repeated pregnancies on underlying MesGN and see the reciprocal eff... more Aim: To analyze the effect of repeated pregnancies on underlying MesGN and see the reciprocal effect on maternal and fetal outcome. Patients and Methods: Pregnancy records of cases with histological diagnosis of MesGN were reviewed, and past medical histories recorded. Results: Cesarean section (CS). Only two patients developed renal insufficiency after undergoing 5 and 11 pregnancies and follow-up of 9 and 20 years respectively. Conclusion: The outcome of repeated pregnancies in patients with MesGN is comparable to normal deliveries. A higher incidence of pre-eclampsia, LBW babies and CS was noted in the post- compared to the pre-MesGN pregnancies. Repeated pregnancies do not influence the course of the MesGN.
A 23-year-old Saudi female presented with nephrotic syndrome. On renal biopsy she had primary foc... more A 23-year-old Saudi female presented with nephrotic syndrome. On renal biopsy she had primary focal and segmental glomerulosclerosis which was resistant to steroids. Two years later she presented with absent left arm pulses and on investigation a diagnosis of left ventricular thrombosis and thromboembolism of left brachial artery was made. Low antithrombin III, high fibrinogen levels and diuretic therapy were the possible causative factors for hypercoagulable state. On anticoagulation therapy initiated with heparin and continued with warfarin for 8 weeks there was complete dissolution of intraventricular and improvement of left brachial artery thrombosis. An early diagnosis and treatment of this potentially serious complication of nephrotic syndrome are stressed.
The occurrence of hepatitis C virus (HCV) infection amongst chronic renal failure (CRF) patients ... more The occurrence of hepatitis C virus (HCV) infection amongst chronic renal failure (CRF) patients in our Nephrology Unit was investigated over a period of 1 year. A total of 71 patients was studied comprising 26 chronic haemodialysis (CHD) patients, 6 acute haemodialysis patients, 4 peritoneal dialysis patients and 35 CRF patients not on dialysis. Patients were screened before and after haemodialysis, and their baseline and postdialysis values of liver enzymes were determined. Eleven (15.5%) of the total 71 patients were HCV antibody positive. Analysis of the individual patient groups showed that 8 (30.7%) of the 26 CHD patients were positive for HCV. Our data showed a statistically significant relationship between seroconversion and duration of dialysis (p < 0.05). A high statistically significant (p < 0.0001) correlation was observed between the HCV antibodies and CRF. The relative risk of hepatitis C was about 22 times greater for those with CRF compared with the normal controls, which makes CRF an important risk factor. A high proportion of the HCV seroconverters had elevated liver enzyme (serum glutamic pyruvic transaminase). The data presented show a positive correlation between HCV seroconversion, CRF, duration on dialysis and elevated serum liver enzymes.
Bartter's syndrome (BS) is characterized by primary renal tubular hypokal... more Bartter's syndrome (BS) is characterized by primary renal tubular hypokalemic metabolic alkalosis, hyperreninemia, hyperaldosteronism and normal blood pressure. The parents and siblings of a BS patient were evaluated for renal tubular function. The father and all 9 siblings of the patient had biochemical features of BS. His mother, a first cousin of his father, had hypokalemia and hyperkaluria but no other features of BS and could have been a 'carrier'. The mother and all 9 siblings were asymptomatic. Including the patient, hypomagnesemia was present in 8 of 12 family members. Therapy with a combination of potassium chloride and magnesium increased the serum potassium and magnesium levels to within normal limits. The familial occurrence in BS is well known, and reports of the disorder in siblings and the first generation of children of consanguineous marriages and normal parents have been taken to suggest an autosomal recessive inheritance. One affected parent and involvement of all siblings of the patient raise the possibility of an autosomal dominant inheritance in the present family.
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