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Dr. Md. Rafiul Islam - MBBS , BCS , Health ,FCPS, New York, NY (2025)

08/09/2025

What causes kidney stones (and what to do)
======================================
May 17, 2019
By Kevin R. Loughlin, MD, MBA, Contributor

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Stone disease has plagued humanity since ancient times. Kidney stones have been identified in Egyptian mummies. The Hippocratic oath describes their treatment: "I will not use the knife, not even verily, on sufferers from stone, but I will give place to such as are craftsmen therein."

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Who gets kidney stones and why ??

The lifetime risk of kidney stones among adults in the US is approximately 9%, and it appears that global warming may be increasing that risk. (As the climate warms, human beings are more likely to get dehydrated, which increases the risk of stone formation.) There are four major types of kidney stones: calcium oxalate/calcium phosphate, uric acid, struvite (magnesium ammonium phosphate), and cystine.

A risk factor for all stones, regardless of type, is dehydration. Anyone who is prone to kidney stones should pay attention to good hydration. A randomized trial has shown that drinking 2 liters of fluid a day reduces the likelihood of stone recurrence by about half. The American Urological Association guideline for medical management of kidney stones recommends that patients who form kidney stones should aim to drink more than 2.5 liters of fluid per day.

Anyone with symptoms of kidney stones should be referred to a urologist. The initial evaluation will often include blood, urine, and imaging studies. Decisions about testing, and ultimately treatment, should be made jointly by the physician and the patient. Let's look at specific risk factors and treatment for each of the major stone types.

Calcium oxalate and calcium phosphate stones
-------------------------------------------------------
Calcium stones are the most common type of kidney stones, and can be either calcium oxalate or calcium phosphate. As mentioned, good hydration is important to prevent calcium stones. It may be surprising, but results of a randomized clinical trial show that people with calcium kidney stones should not cut back on dietary calcium. In fact, they should consume the recommended daily allowance of calcium (1,000 mg/day for women younger than 50 years old and men younger than 70, and 1,200 mg/day for women over 50 and men over 70). Why? Calcium binds to oxalate in the intestine and prevents its absorption through the gut, so there is less in the urine to form stones. Ideally, calcium should come from food. Talk with your doctor before taking calcium supplements, and increasing fluid intake might be beneficial depending on how much calcium you take.

Controlling Your Blood Pressure
--------------------------------------
An alarming one in three American adults has high blood pressure. Known medically as hypertension, many people don't even know they have it, because high blood pressure has no symptoms or warning signs. But when elevated blood pressure is accompanied by abnormal cholesterol and blood sugar levels, the damage to your arteries, kidneys, and heart accelerates exponentially. Fortunately, high blood pressure is easy to detect and treat. In the Special Health Report, Controlling Your Blood Pressure, find out how to keep blood pressure in a healthy range simply by making lifestyle changes, such as losing weight, increasing activity, and eating more healthfully.

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Foods high in oxalates (nuts, spinach, potatoes, tea, and chocolate) can increase the amount of oxalate in the urine. Consume these in moderation.

Calcium phosphate stones are less common than calcium oxalate stones. Causes include hyperparathyroidism (when the body produces too much parathyroid hormone), renal tubular acidosis (a kidney condition that causes a buildup of acid in the body), and urinary tract infections. It is important to understand if one of these conditions is behind the formation of calcium phosphate stones.

Good hydration can help prevent recurrence of calcium stones. In addition, thiazide diuretics such as hydrochlorothiazide can help the kidney absorb more calcium, leaving less of it in the urine where it can form stones. Potassium citrate is another medication that can bind to calcium and help keep calcium oxalate and calcium phosphate in the urine from forming into stones.

Uric acid stones
--------------------
Most patients with uric acid stones don't have too much uric acid. Instead their urine is too acidic. When that happens, normal levels of uric acid dissolve into the urine where it can crystalize into stones. Adjusting the pH of the urine, most commonly with the medication potassium citrate, reduces the risk of uric acid stone formation and can also help dissolve existing stones. Sodium bicarbonate can also be used to alkalinize the urine. Some people with uric acid stones do produce high amounts of uric acid. For these patients, eating less animal protein can help, as can a drug called allopurinol.

Struvite stones
-------------------
Struvite stones are composed of magnesium ammonium phosphate, and form in alkaline urine. The most common cause of struvite stones is a bacterial infection that raises the urine pH to neutral or alkaline. Acetohydroxamic acid (AHA) can reduce urine pH and ammonia levels and help dissolve stones.

Cystine stones (the least common type)
----------------------------------------------
Cystinuria is a genetic condition. It results in high levels of cystine (an amino acid) in the urine, which then forms into kidney stones. Most cystine stones can be managed by increasing hydration and medications that change the pH of the urine. If that isn't enough to control stones, then another medication can be added.

The bottom line
---------------------
All kidney stone sufferers should remember the phrase, "Dilution is the solution to the pollution." Good hydration is a safe and useful therapy for all stone formers. That said, it is important to have a thorough discussion with a urologist about the right approach to evaluation, treatment, and strategies to keep new stones from forming.

References
----------------
Prevalence of Kidney Stones in the United States. European Urology, July 2012.

Climate-related increase in the prevalence of urolithiasis in the United States. Proceedings of the National Academy of Sciences, July 2008.

Urinary volume, water and recurrences in idiopathic calcium nephrolithiasis: a 5-year randomized prospective study. The Journal of Urology, March 1996.

Medical Management of Kidney Stones: AUA Guideline. American Urological Association, August 2014.

Meta-analysis of randomized trials for medical prevention of calcium oxalate nephrolithiasis. Journal of Endourology, November 1999.

Management of cystinuria. The Urologic Clinics of North America, August 2007.

Medical Stone Disease Management, AUA University, last updated September 2017.

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What to Do About Kidney Stones
-----------------------------------------

How and why do kidney stones form? If you need tests or treatment for a stone, what’s involved and what are the risks? Who is likely to develop a first (or second or third) kidney stone, and how can it be prevented? What to Do About Kidney Stones will answer all of these questions. We’ll also bust some myths about why kidney stones hurt so much, and how to reduce your risk.

08/09/2025

Causes of phosphate stone formation and the importance of metaphylaxis by urinary acidification: a review
===========================================

A Hesse 1, D Heimbach

Affiliations + Expand

PMID: 10552150 DOI: 10.1007/s003450050152

Abstract
------------
The most important phosphates involved in urinary stone disease are carbonate apatite, brush*te, and struvite. Overall, phosphate stones account for 12-20% of all stones, with a downward trend for struvite and an increase in carbonate apatite being observed in the last decade. The physicochemical basis for the formation of phosphate calculi is supersaturation. Once the solubility product has been exceeded, a metastable process of supersaturation begins, with slow crystalline growth. If a critical limit of supersaturation is exceeded, large-scale spontaneous precipitation of crystals occurs in a second stage. No urinary tract infection is involved in brush*te stone formation. Although infection is not a prerequisite for the formation of carbonate apatite stones, infective conditions favor carbonate apatite formation. Struvite is the characteristic infection calculus, formed as a result of urinary tract infection with urease-producing bacteria. During the first episode of urinary stone disease a definitive diagnosis of the type of stone involved is very difficult without analysis of the latter by infrared spectroscopy or X-ray diffraction. In recurrent disease, appropriate treatment can be initiated on the basis of the previous stone analysis in the majority of cases. The best means of preventing recurrent disease involving any type of phosphate stone is definitive calculus removal by shock-wave lithotripsy, percutaneous stone removal, or open surgery (especially in children). Chemolysis via acidification of the urine with Suby G solution or hemicidrin supported by oral acidification, achieved by the metabolism of L-methionine, and antibiotic therapy (especially for infectious stones) are important adjuvant modalities of therapy. After therapy of phosphate stones, metaphylaxis involving controlled urinary acidification with L-methionine supports the treatment of infection and, at a pH value of less than 6.2 and urine dilution to 2.5 l/24 h, prevents the crystallization of struvite, brush*te, and carbonate apatite.

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Comment in
Ned Tijdschr Geneeskd. 2000 Jul 22;144(30):1462-3
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Publication types
> Review

MeSH terms
> Acids / chemistry
> Acids / urine*
> Apatites / chemistry
> Apatites / urine
> Calcium Phosphates / chemistry
> Calcium Phosphates / urine*
> Crystallization
> Humans
> Magnesium Compounds / chemistry
> Magnesium Compounds / urine
> Phosphates / chemistry
> Phosphates / urine
> Struvite
> Urinary Calculi / etiology*
> Urinary Calculi / prevention & control*
> Urinary Calculi / urine

Substances
> Acids
> Apatites
> Calcium Phosphates
> Magnesium Compounds
> Phosphates
> carboapatite
> Struvite
> calcium phosphate, dibasic, dihydrate

Related information
MedGen
PubChem Compound (MeSH Keyword)

LinkOut - more resources

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08/09/2025

𝗥𝗮𝗱𝗶𝗮𝗹 𝗮𝗿𝘁𝗲𝗿𝘆 𝗹𝗼𝗼𝗽𝘀
Commonly , a hydrophilic guidewire and
deep inspiration can allow catheter to move into ascending aorta.
• Fact is—Loops and tortuosities are invariably unilateral, so if there is a loop on right side, left radial can be tried.
• Few important tricks can be used before moving to another access:
1. Trick 1: if there is a 360° loop try with an extra support 0.014 PTCA wire to cross. Try to negotiate with JR catheter – if fails, then.
2. Trick 2: Put another wire to act as a buddy wire and try the same – if fails, then.
3. Trick 3: BAT (Balloon assisted tracking) is a technique in which an inflated balloon is placed partially into the catheter and partially outside, deployed at 3—6 atmosphere pressure. For 5F catheter 1.5 × 15 mm and 6F catheter 2 × 15 mm balloon is used usually. Now entire
assembly can be tracked over a 0.014” PTCA wire. It can be used not only in radial loop but also any spasm or tortuosity involving RA/
brachial or subclavian artery.
4. Trick 4: Exchange of wire – if it is difficult to track on the PTCA wire— take a pigtail catheter and push the catheter as far as possible, then try to exchange PTCA wire with either 0.025/0.035 wire and try to track on it. Sometimes the wire can be exchanged with Superstiff wire and that will straighten the loop. Remember Superstiff wires precipitate
radial spasm (see fig. 7).

08/09/2025

4 Types of Kidney Stones and How They're Treated
============================

Kidney stones are hard clusters of minerals that accumulate in your kidneys over time. Kidney stones are not a normal occurrence and can cause a lot of pain. Passing a large kidney stone through urination may be excruciating.

Alex Lesani, MD, an expert urologist in Las Vegas, recommends lifestyle changes to prevent kidney stones or to stop them from recurring. Catching and treating kidney stones early helps you avoid unnecessary pain and possibly serious complications.

All kidney stones begin as minerals normally present in your urine and are regularly excreted when you urinate. However, if you don’t drink enough water or consume too many minerals, your body can’t excrete the minerals completely. Instead, they clump together in your kidneys, creating hard and sharp stones that vary in size from minuscule to as large as a golf ball.

Here’s what you need to know about each of the four main types of kidney stones and how they’re treated. You can, of course, develop more than one type of stone, either simultaneously or over the course of your life.

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1. Calcium oxalate or calcium phosphate stones
Calcium stones — the most common type of kidney stones — are created by an accumulation of calcium, oxalate, phosphate, and other minerals. Calcium oxalate or calcium phosphate stones are sometimes referred to as calcium stones, which may lead you to believe that they’re composed of calcium alone and that you should cut down on eating that mineral.

However, calcium oxalate and phosphate stones aren’t caused by consuming too much calcium. In fact, not eating enough calcium puts you at risk for these stones because dietary calcium binds with dietary oxalates and phosphate in the gastrointestinal tract, so they can more easily leave the body.

Calcium phosphate stones are usually caused by an underlying condition, such as hyperparathyroidism or renal tubular acidosis. They may also be a result of a urinary tract infection (UTI).

You may develop calcium oxalate stones if you don’t drink enough water and consume too much:

> Sugar
> Protein
> Salt
> Oxalates

Oxalates are chemicals found in dark leafy green vegetables, such as kale or spinach, as well as other healthy foods, including beets and nuts. Cooking, fermenting, or sprouting these foods helps reduce the amount of oxalates they contain. You should also eat foods with calcium and oxalate at the same time, to encourage binding in the stomach and intestines.

You can treat calcium oxalate stones by taking a vitamin C supplement, which helps dissolve them. You should also avoid taking calcium supplements, as these could lead you to form more stones.

2. Uric Acid Stones
Uric acid stones occur when your body produces more uric acid than it can excrete. Your body makes uric acid when it breaks down purines, a substance that’s found in many foods, particularly rich foods such as red meat and alcohol. Uric acid crystals can also accumulate in your joints, causing a type of arthritis called gout.

If you have uric acid stones, Dr. Lesani first recommends drinking more water. He also advises you to cut out or minimize foods that are high in purines, such as:

> Shellfish
> Red meat
> Organ meats
> Sardines

Following a gout-friendly diet can help you avoid uric acid stones.

3. Struvite Stones
If you have a UTI, you may develop struvite stones. Bacteria in a UTI excrete urease, which hardens into these painful stones.

Only about 10-15% of kidney stones are struvite stones. Struvite stones are composed of magnesium ammonium phosphate. Dr. Lesani may prescribe urease inhibitors to dissolve struvite stones. Acetohydroxamic acid (AHA) can also reduce the pH of your urine and lower ammonia levels to help dissolve struvite stones.

4. Cystine Stones
Cystine stones tend to be bigger than other types of kidney stones. They’re also rarer.

You may develop cystine stones if you have a medical condition called cystinuria, which causes cystine to leak into your urine. Cystine is an amino acid that’s present in your hair, skin, connective tissues, and digestive enzymes. However, if you have cystinuria, you can’t process cystine, and it leaks into your urine, forming stones.

While dietary changes and drinking more water can prevent most kidney stones, if you currently have a stone, you may need medications or therapies to break up or dissolve the stone so you can pass it and get relief. Dr. Lesani may recommend:

> Extracorporeal shockwave lithotripsy (ESWL)
> Uteroscope noninvasive surgery
> Parathyroid gland surgery

If you think you have kidney stones, call our helpful Las Vegas, Nevada office staff at 702-470-2579 to set up an evaluation. You can also book online.

06/29/2025

Abortion is the loss of an early pregnancy, categorized into several types: complete, incomplete, inevitable, missed, septic, and threatened. 🍼❌

Complete abortion terminates the pregnancy before 20 weeks or with a fetus under 500 g, often occurring before 6 weeks or after 14 weeks. ⏳
Incomplete abortion involves the passage of some but not all pregnancy products. 🩸
Inevitable abortion occurs with cervical dilation and uterine contractions, leading to loss. 🚨
Missed abortion is when a failed pregnancy persists without expulsion. 💤
Septic abortion involves infection, while threatened abortion indicates risk, often with bleeding but no cervical changes. ⚠️🩹
Abortion can begin with fetal death or placental separation, manifesting as vaginal bleeding and contractions. 🩸🤰 Clinically, distinguishing between threatened and inevitable abortions is important for prognosis. 📊

Complete abortion involves expulsion of all products, while incomplete means some remain. 🗑️

Ultrasonography helps confirm embryo presence, and pregnancy tests remain positive until placental tissue is gone. 🔍🧪 However, the presence of a living embryo does not ensure a successful pregnancy outcome. ❓

06/29/2025

🔄 Aortic Arch Essentials

🧠 Easy Trick to Remember
Use the acronym ABC’S to recall the branches of the aortic arch:

* A – Artery: Brachiocephalic trunk
* B – Blood to Left Common Carotid
* C – Connects to Left Subclavian artery
* S – Simple, right?
--
📌 What Is the Aortic Arch?
The aortic arch is the middle part of the thoracic aorta. It begins where the ascending aorta ends—near the sternal angle—and curves backward and leftward, becoming the descending thoracic aorta around the T4 vertebra.
Located in the superior mediastinum, it loops above the heart and behind the major airways.
--
🔍 Path & Position

* Starts behind the right 2nd sternocostal joint
* Arches over the heart, in front of the tracheal bifurcation and left bronchus
* Ends just after the left subclavian artery, near the aortic isthmus, connected to the ligamentum arteriosum

---

🌱 Main Arterial Branches

1. Brachiocephalic trunk → divides into right common carotid & right subclavian
2. Left common carotid artery → supplies left head & neck
3. Left subclavian artery → supplies left upper limb & part of the thorax

🧠 About 75–80% of individuals have this standard branching pattern from the upper curve of the arch.

---

🧭 Anatomical Relations

* Anterior: Manubrium, thymic remnants, left brachiocephalic vein
* Posterior: Trachea, esophagus, thoracic duct
* Inferior: Pulmonary trunk bifurcation, left pulmonary artery, ligamentum arteriosum
---
📐 Size & Variations

* Average diameter: \~30 mm
* Diameter over 38 mm is considered dilated in adults

🌀 Variants may include:

* Bovine arch: common origin of brachiocephalic and left carotid
* Left vertebral artery branching directly from the arch
* Arch types (I–III) classify how high the branches originate relative to the curve
* Curvature angle: \~30°–80°, steeper curves may complicate procedures
-
⚠️ Clinical Importance

* Common issues: aneurysm, dissection, coarctation, atherosclerosis, Takayasu arteritis
* Trauma-prone area: aortic isthmus (site of ligamentum arteriosum)
* Surgical/endovascular planning depends on detailed knowledge of arch anatomy for safe interventions and brain protection

06/29/2025

This image appears to be a handwritten study guide or notes on human anatomy, specifically focusing on the axial skeleton, joints, and muscles of the upper extremity and scapular stabilization.

Here's a breakdown of the content visible:
Top Left: Joints of the Axial Skeleton
* Synarthrotic - Immobile [Synar]:
* Fibrous: Suture (Synostosis), Gomphosis (Synar)
* Diarthrotic - Mobile [Diar]:
* Synovial: (Examples given, but not fully legible)
* Amphiarthrotic - Slightly Mobile [Amph]:
* Cartilaginous: Symphysis (Amphia)
* Specific Joints:
* Atlanto-Occipital: Synovial, Condyloid [Diar]
* Atlanto-Axial: Synovial, Pivot [Diar]
* Intervertebral (Cartilaginous): Symphysis [Amphia]
* Intervertebral (Synovial): Plane [Diar]
* Vertebro-Costal (Synovial): Plane [Diar]
* Sterno-Clavicular (Synovial): Saddle [Diar]
* Sterno-Costal (1st) (Cartilaginous): Synchondrosis [Synar]
* Sterno-Costal (2-7) (Synovial): Plane [Diar]
Bottom Left: Muscles of the Upper Extremity & Scapular Stabilization
* An illustration of the posterior view of the torso, highlighting muscles like:
* Trapezius
* Levator Scapulae
* Rhomboids (Major and Minor)
* Serratus Anterior (partially visible)
* Pectoralis Minor (partially visible)
Right Side: Muscle Overviews
* Trapezius:
* O: Occipital bone, Spinous process of C7 to all thoracic vertebrae
* I: Scapula (acromion/spine), Clavicle
* Action: Stabilizes, rotates, adducts, elevates or depresses scapula, extends (head)
* Levator Scapulae:
* O: C1-C6 (transverse processes)
* I: Vertebral border of scapula
* Action: Elevates scapula
* Rhomboid Minor:
* O: Spinous process of C7-T1
* I: Vertebral border of scapula (superior angle to spine of scapula)
* Action: Adducts scapula (retracts and fixes scapula)
* Rhomboid Major:
* O: Spinous process of T2-T5
* I: Vertebral border of scapula (inferior to spine of scapula)
* Action: Adducts scapula (retracts and fixes scapula to thoracic wall)
* Pectoralis Minor:
* O: Ribs 3-5
* I: Coracoid process of scapula
* Action: Pulls scapula anteriorly & inferiorly, helps with arm movements
* Serratus Anterior:
* O: Upper 8-9 ribs
* I: Medial border of scapula (anterior surface)
* Action: Protracts scapula (e.g., punching), rotates scapula for arm elevation
* Synergists:
* Pectoralis Minor + Serratus Anterior:

Protractors
* Trapezius + Rhomboids: Retractors
* Trapezius + Levator Scapulae: Elevators/Depressors (depending on fiber action)
Middle Right: Muscle Illustration (Lateral View)
* An illustration showing the lateral view of the

torso, highlighting:
* Trapezius
* Levator Scapulae
* Pectoralis Minor
* Serratus Anterior
* Rhomboids (implied behind other muscles)
This appears to be a well-organized and detailed set of notes for studying musculoskeletal anatomy.

05/28/2025

We only see small part of the coronary circulation when we do heart catheterization!..

=======================================

You are absolutely right. While heart catheterization (specifically coronary angiography) is a crucial diagnostic tool for visualizing the larger epicardial coronary arteries, it only provides a limited view of the entire coronary circulation. Here's why and what parts are often not seen:
What Coronary Angiography Shows Well:
* Epicardial Coronary Arteries: These are the large arteries that run on the surface of the heart (e.g., Left Main, LAD, Circumflex, Right Coronary Artery). Angiography excels at identifying blockages (stenoses) or complete occlusions in these vessels.
* Major Branches: It can also visualize the significant branches originating from these main arteries.
* Blood Flow Dynamics (to some extent): By observing the contrast dye flow, cardiologists can get a general sense of how well blood is moving through the visible arteries and if there are significant delays or collateral circulation.
What Coronary Angiography Doesn't Show Well (or at all):
* The Coronary Microcirculation: This is the vast network of tiny blood vessels (arterioles, capillaries, venules) embedded within the heart muscle itself. These vessels are too small to be seen with standard angiography. Problems in the microcirculation, such as microvascular dysfunction or spasm, can lead to symptoms like chest pain even with clear epicardial arteries. This is often referred to as "cardiac syndrome X" or "microvascular angina."
* Plaque Composition and Burden: Angiography primarily visualizes the lumen (the inner space) of the artery. It doesn't directly show the atherosclerotic plaque within the vessel wall unless it significantly protrudes into and narrows the lumen. It can't assess the stability or composition of the plaque (e.g., whether it's fatty, fibrous, or calcified), which is crucial for predicting future events.
* Vessel Wall Remodeling: Arteries can remodel in response to plaque buildup, sometimes expanding outwards to accommodate the plaque without significant luminal narrowing. Angiography might miss such "positive remodeling" if the lumen isn't significantly affected.
* Functional Significance of Blockages: While angiography shows the degree of narrowing, it doesn't always tell you how much that narrowing is impacting blood flow to the heart muscle. A moderate blockage might appear significant on angiography, but it might not be functionally impairing blood flow at rest or during stress. This is why techniques like Fractional Flow Reserve (FFR) or Instantaneous Wave-free Ratio (iFR) are used during catheterization to assess the physiological impact of a stenosis.
* Small, Diffuse Disease: If there's widespread, mild-to-moderate atherosclerosis throughout the coronary tree, but no single significant focal blockage, angiography might not fully capture the overall disease burden.
* 2D Representation of 3D Structures: Angiography provides 2D images of inherently 3D structures. This can lead to foreshortening or overlapping vessels, making it difficult to accurately assess lesion severity in certain views.
Advanced Techniques that Complement Angiography:
To overcome these limitations, other diagnostic tools are often used, sometimes in conjunction with catheterization:
* Intravascular Ultrasound (IVUS): Uses sound waves to create detailed images of the inside of the coronary artery wall, showing plaque burden, composition, and vessel remodeling.
* Optical Coherence Tomography (OCT): Uses light waves to provide even higher-resolution images of the vessel wall and plaque, useful for stent optimization and assessing vulnerable plaque.
* Fractional Flow Reserve (FFR) and Instantaneous Wave-free Ratio (iFR): Measure pressure gradients across a stenosis to assess its functional significance.
* Positron Emission Tomography (PET) and Cardiac Magnetic Resonance Imaging (CMR): Can assess myocardial perfusion (blood flow to the heart muscle) and detect microvascular dysfunction.
So, while cardiac catheterization is an indispensable tool for diagnosing and treating significant epicardial coronary artery disease, it's important to understand its limitations, particularly regarding the microcirculation and the detailed nature of plaque within the vessel walls.

Dr. Md. Rafiul Islam - MBBS , BCS , Health ,FCPS

08/09/2025

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05/28/2025

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