Removing staghorn fern from tree

Staghorn ferns (Platycerium spp) are so-called because their leaves resemble the horns of that large herbivore. (If that animal had floppy horns, of course. Ja nee. And so why are they pups and not fawns? Hey, we’re just gardeners).

Moving along:

Staghorns are epiphytic, meaning that they are air plants, deriving moisture and nutrients from the air, while relying for physical support from another plant, generally a tree. They are not parasitic.

In our homes they can be grown on a piece of wood or in a basket, and make wonderful green accents for tree trunks, walls and patios.

To attach a pad to a tree in your garden, pack compost or spaghnum moss between the fern and the trunk of the tree with pantyhose, fishing line or wire (pantyhose can easily be cut away once the plant has adhered, or they will disintegrate in time).

For a wall, use a board as backing (with a hook to hang, like a picture frame), or buy a special slatted wooden mount from a nursery. Bury the staghorn roots in a ball of moistened spaghnum moss and press to the mount. With thin fishing line, tie the wad of spaghnum moss with the embedded fern to the board and staple the fishing line to the board. Fluff out the moss to hide the wire, and later the developing fern fronds will do that for you.

For best growth, partial shade and light watering or spraying is all that is required. A special tip from Suzanne Kilpin (Constantiaberg Garden Club): “From time to time feed with a ‘vrot’ banana. Pack skin and fruit at the back. This supplies the plant with the potassium that it requires.”

Over time the fern will produce pups from the spores under the leaves and will fill up around the trunk of the tree and become quite spectacular. And then you can sell them. Like we plan to!

Come and get your pups at our Open Gardens Constantia plant sale on November 14th and 15th!

Photo: Lyn McCallum. Text: Suzanne Kilpin, Marie Viljoen

Staghorn Kidney Stones

Staghorn Stones

A staghorn kidney stone is a term used to describe a large stone that takes up more than one branch of the collecting system in the renal pelvis of the kidney.

By way of review, the urinary tract begins with the kidneys.

The kidneys, one on each side, sit high in the upper abdomen partially underneath the rib cage. They filter the blood to extract excess waste products and fluid to form the urine. Urine, once formed in the kidneys, is collected in the renal pelvis, the first part of the urinary drainage system. Urine travels through a tube on each side, the ureter, down to the bladder. Urine is constantly being made by the kidneys and transported through the ureters into the bladder. The bladder stores urine until full and then empties to the outside through the urethra. The urinary system is the same in both men and women from the kidneys to the bladder. In men, the urethra is longer and encircled by the prostate which is a gland that is part of the reproductive system.

Staghorn stones form in the renal pelvis.

Some of the risk factors for staghorn stone formation include long standing history of stones, certain unique metabolic defects, and repeated urinary tract infections with particular types of bacteria. If a staghorn stone occurs in association with infection, there may be a pattern of intermittent and recurrent infection which may persist until the staghorn stone is removed.

Recommendations

A patient with a staghorn stone should be treated.

If a staghorn stone is not treated, then renal deterioration occurs in at least 1 out of 4 patients. Over time, an untreated staghorn calculus is likely to destroy the kidney and/or cause life-threatening infections (sepsis). Complete removal of the stone is important in order to eradicate infection, relieve obstruction, prevent further stone growth, and preserve kidney function.

Types of Treatment

Types of treatment include: Percutaneous nephrolithotomy (PNL), combinations of PNL and shock-wave lithotripsy (SWL) (see ESWL newsletter), SWL alone and open surgery.

In some cases the staghorn stone may have already caused significant damage to the affected kidney and the kidney may not contribute much to the overall level of a patient’s kidney functioning. An imaging study called a Lasix renal scan may help determine if the Kidney has any significant function. If the kidney does not work, and there’s chronic infection or pain, then removal of the kidney may be recommended (see nephrectomy newsletter).

Stone-free Rates and Complications

To help decide how to proceed, it is worthwhile to consider the stone-free rates and the potential complications. A useful way to interpret this information is to consider the following: a staghorn stone can pose a significant risk to a patient’s health; what are the types of help that are available; what are the hazards that go along with the efforts to help?

Some technical answers to those questions follow:

The overall estimated stone-free rate following treatment is highest for PNL (78%) and lowest for SWL (54%).

Comparing PNL with combination therapy, stone-free rates are higher with PNL (78% versus 66%, respectively) and PNL requires fewer total procedures (1.9 versus 3.3, respectively). On average, PNL requires 1.9 total procedures while combination therapy and SWL require 3.3 and 3.6 total procedures, respectively.

Complications

Estimated rates for overall significant complications are similar for the four therapeutic modalities and range from 13% to 19%.

For PNL: acute loss of kidney; colon injury; hydrothorax; perforation; pneumothorax; prolonged leak; sepsis; ureteral stone; vascular injury.

For SWL: acute loss of kidney; colic requiring admission; hematoma (significant); obstruction; pyelonephritis; sepsis; steinstrasse; ureteral obstruction.

For combination therapy: any listed for the above plus deep vein thrombosis; fistula; impacted ureteral stones; renal impairment.

Staghorn calculus (kidney)

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Medical Treatment of a Staghorn Calculus: The Ultimate Noninvasive Therapy

Clinical History

A 77-year-old female was referred due to a history of intermittent left flank pain and recurrent urinary-tract infections. Laboratory studies by her physician revealed worsening renal function; subsequently, a CT scan showed bilateral >3-cm renal staghorn calculi involving three renal calyces bilaterally with moderate left hydronephrosis. Hounsfield units on the left stone were 694 and on the right stone were 664. Significant in her medical history was a parathyroidectomy 7 years ago for hyperparathyroidism, discovered following metabolic workup for nephrolithiasis; serum parathyroid hormone and calcium levels returned to normal. Her medical history included hypertension, chronic kidney disease, arthritis, atrial fibrillation, hepatitis B, hyperlipidemia, and anemia. Her prior surgeries included bilateral hip and knee prostheses and oophorectomy. Her medications included prophylactic dose cephalexin, lisinopril, furosemide, valsartan, calcium carbonate, acetaminophen with codeine, colace, amiodarone, warfarin, lovastatin, and iron. Her family history revealed kidney stones in her daughter.

She underwent an MAG-3 renal Lasix scan, which showed split function of 49.3% on the left and 50.7% on the right, with decreased drainage on the left side (T½ of 22.17 minutes on the left vs 5.33 minutes on the right) with associated left hydronephrosis. After a 7-day course of levofloxacin, she underwent an upper pole left percutaneous nephrolithotomy (PCNL) with bridging anticoagulation therapy. A low dose CT scan of the abdomen and pelvis without contrast the following morning revealed resolution of the left collecting system staghorn with persistence of a 4 mm and 8 mm upper and lower pole renal parenchymal calcification, respectively; the right staghorn calculus was unchanged. Stone analysis demonstrated 90% struvite and 10% calcium phosphate, with stone culture positive for Enterococcus faecalis and Proteus mirabilis. She was discharged from the hospital on postoperative day 3. She was scheduled to undergo right PCNL 6 weeks later, but postponed her surgery due to her husband’s poor health and ultimate passing. As such, her surgery was delayed for 9 months.

Physical Examination

Examination revealed an elderly Caucasian female who was 5.0 feet tall with body mass index of 32.5 kg/m2. Her blood pressure was 167/67 with normal remaining vital signs. She had a 2/6 systolic ejection murmur. Abdomen was soft with a well-healed midline abdominal incision. There was no costovertebral tenderness bilaterally. PCNL tract on the left showed a well-healed scar. There was 1+ peripheral edema. The remainder of the examination was unremarkable.

Diagnostic studies urinalysis: Specific gravity 1.012, pH 7.5, protein 100, nitrite positive, leukocyte esterase positive, red blood cell count >182, white blood cell count 176. Urine culture: >100,000 CFU of E. faecalis and 11,000 CFU of P. mirabilis.

Initial CT scan prior to left PCNL (Fig. 1): A left 3.2 cm renal staghorn involving three calyces with HU of 694 and a right 3.4 cm renal staghorn involving three calyces with HU of 664. There are two separate left renal parenchymal calcifications, 4 mm and 8 mm, left mild hydronephrosis, and bilateral parenchymal thinning.

FIG. 1.  CT scan prior to left PCNL: Bilateral staghorn stones, left 3.2 cm renal staghorn involving 3 calyces, HU of 694, and right 3.4 cm renal staghorn involving 3 calyces, HU of 664. There is mild left hydronephrosis, bilateral parenchymal thinning and two left renal parenchymal calcifications (not shown).

CT scan 1 day following left PCNL: Complete resolution of left staghorn stone with persistence of 4 mm and 8 mm left renal parenchymal calcifications and persistence of a 3.4-cm right renal staghorn.

CT scan 9 months later, prior to scheduled right PCNL (Fig. 2): Unchanged left renal parenchymal calcifications, no new left renal stones, improvement of left hydronephrosis and complete resolution of right renal stone.

FIG. 2.  CT scan after 9 months of antibiotic therapy: No new left renal stones, improvement of left hydronephrosis and complete resolution of right renal stone.

Intervention

She was scheduled to undergo PCNL on the right, but the patient delayed surgery due to her husband’s ill health and subsequent death. During this time, she was placed on a 5-month course of prophylactic antibiotics cephalexin 250 mg PO daily and a 1-month prophylactic course of nitrofurantoin 100 mg PO daily, but continued to have symptomatic urinary-tract infections that were positive for E. faecalis, P. mirabilis, Escherichia coli, and Klebsiella pneumonia (Table 1). As such, over the next 9 months, she underwent 17 culture-directed therapeutic courses of antibiotics prescribed by her family physician, often with two antibiotics given concomitantly. The antibiotics included nitrofurantoin, ciprofloxacin, levofloxacin, sulfamethoxazole–trimethoprim (SMX-TMP), and amoxicillin (Table 2).

Table 1. Urine Cultures

Urine source Bacteria Amount (CFU) Susceptible Resistant
Clean midstream Enterococcus faecalis >100,000 Nitrofurantoin, ampicillin Ciprofloxacin
Proteus mirabilis 11,000 SMX-TMP, ciprofloxacin, cephalexin Nitrofurantoin
Cystoscopy E. faecalis >100,000 Nitrofurantoin, ampicillin Ciprofloxacin
Left renal stone E. faecalis 2+ Nitrofurantoin, ampicillin Ciprofloxacin
P. mirabilis Few SMX-TMP, ciprofloxacin, cephalexin Nitrofurantoin
Clean midstream E. faecalis >100,000 Nitrofurantoin, ampicillin Ciprofloxacin
Escherichia coli 4000 Nitrofurantoin, SMX-TMP, cephalexin Ciprofloxacin
Clean midstream E. faecalis >100,000 Nitrofurantoin, ampicillin Ciprofloxacin
Klebsiella pneumonia 1000 Nitrofurantoin, SMX-TMP, cephalexin, ciprofloxacin
E. coli 1000 Nitrofurantoin, SMX-TMP, cephalexin, ciprofloxacin
Clean midstream E. faecalis >100,000 Nitrofurantoin, ampicillin Ciprofloxacin
E. coli 1000 Nitrofurantoin, ciprofloxacin SMX-TMP, cephalexin

SMX-TMP, sulfamethoxazole–trimethoprim.

Table 2. Antibiotics

Dose Duration No. of treatments
Prophylactic antibiotics
 Cephalexin 250 mg daily 5 months
 Nitrofurantoin 100 mg daily 1 month
Therapeutic antibiotics
 Nitrofurantoin 50–100 mg BID 7–14 days 6
 Ciprofloxacin 500 mg BID 7 days 3
 Levofloxacin 250 mg daily 7 days 2
 SMX-TMP 800 mg/160 mg BID 7 days 4
 Amoxicillin 500 mg BID 7 days 2

Outcome

The patient was rendered stone free of renal collecting system stones on the left following the left PCNL, with only a 4 mm and an 8 mm calcification persisting in the renal parenchyma. The patient was found to have complete dissolution of the right renal stone after 9 months of myriad antibiotic therapies.

According to the 2005 AUA guidelines on the management of staghorn calculi, standard of care includes definitive treatment of newly diagnosed otherwise healthy patients with staghorn calculi to render them stone free with intervening procedures.1 Several studies have shown that nonsurgical management of staghorn calculi with antibiotics, urease inhibitors or supportive measures lead to renal deterioration, recurrent urinary-tract infections, sepsis, pain, and increased mortality.2

While antibiotics alone have been shown to be insufficient in the definitive management of struvite stones, they play a clear role for the safe management of planned directed therapy. Both the EUA and AUA recommend antibiotic therapy in the presence of a suspected struvite stones with associated infection; however, while antibiotics are typically given for 1 to 2 weeks prior to the planned surgical procedure, high-level guidelines for specific antibiotic choice, timing, and duration have not been established.1,3 The curious finding of this case is that long-term very aggressive antibiotic therapy in and of itself resulted in complete resolution of a 3-cm presumably struvite stone. This observation may warrant further investigation as to the potential pharmaceutical dissolution of struvite calculi and may warrant obtaining a CT scan prior to PCNL in cases of suspected struvite stone in patients who have had a prolonged course of antibiotic therapy prior to their planned date of surgery.

Disclosure Statement

No competing financial interests exist.

  • 1 Preminger GM, Assimos DG, Lingeman JE, et al. Chapter 1: AUA guidelines on management of staghorn calculi: Diagnosis and treatment recommendations. J Urol 2005;173:1991–2000. Crossref, Medline, Google Scholar
  • 2 Flannigan R, Choy WH, Chew B, et al. Renal struvite stones—Pathogenesis, microbiology, and management strategies. Nat Rev Urol 2014;11:333–341. Crossref, Medline, Google Scholar
  • 3 Türk C, Petřík A, Sarica K et al. EAU Guidelines on Diagnosis and Conservative Management of Urolithiasis. Eur Urol 2015; ; DOI: 10.1016/j.eururo.2015.07.040. Crossref, Google Scholar

Cite this article as: Chamberlin JD and Clayman RV (2015) Medical treatment of a staghorn calculus: the ultimate noninvasive therapy, Journal of Endourology Case Reports 1:1, 21–23, DOI: 10.1089/cren.2015.29003.jdc.

Abbreviations Used

CT

computed tomography

HU

Hounsfield units

PCNL

percutaneous nephrolithotomy

SMX-TMP

sulfamethoxazole–trimethoprim

What Are Staghorn Fern Pups: Should I Remove Staghorn Pups

Staghorn ferns are fascinating specimens. While they reproduce through spores, a much more common method of propagation is through pups, small plantlets that grow off of the mother plant. Keep reading to learn more about removing staghorn fern pups and staghorn fern pup propagation.

What are Staghorn Fern Pups?

Staghorn fern pups are little plantlets that grow off of the parent plant. In nature these pups will eventually grow into new, whole plants. The pups will be attached underneath the brown, dry shield fronds of the plant.

Gardeners have two choices: removing the pups and propagating new plants to give away or allowing them to remain

in place to form the appearance of a much larger, more imposing single fern. The choice is up to you.

What to Do with Staghorn Fern Pups

If you choose not to remove your staghorn fern pups, they will grow bigger and bigger and might even reach the size of the parent plant. They will also keep increasing in number. The result is a very attractive covering of fronds that can span 360 degrees in hanging baskets and 180 degrees on wall mounts.

It’s a spectacular look, but it can also get big and heavy. If you don’t have the space (or your wall or ceiling doesn’t have the strength), you might want to keep your fern more contained by thinning out some pups.

How Should I Remove Staghorn Fern Pups?

Pups are the main source of staghorn fern propagation. Removing staghorn fern pups is easy and has a very high success rate. Wait until the pup is at least 4 inches (10 cm.) across.

Find the spot under the brown shield fronds where the pup is attached and, with a sharp knife, cut the pup away with some roots attached. You can mount the pup just as you would a fully grown staghorn fern.

What’s the difference, anyway?

The staghorn is bigger than the elkhorn. It features a large central rosette of leaves below which pendulous fertile fronds hang down. Elkhorn ferns have multiple small rosettes, or nest leaves, from which slender, pendulous strap-like fronds cascade. Only elkhorns produce pups whereas stags must be propagated from spores.

Gather your supplies

• Staghorn or elkhorn

• Horizontal slats (5) 90 x 22 x 650mm treated pine decking

• Vertical battens (2) 90 x 22 x 450mm treated pine decking

• Galvanised hooks (2)

• Galvanised chain

Note: You may need to adjust the measurements and number of the treated pine battens and slats to suit the size of your fern.

You’ll also need

PVC-coated tie wire; 40mm galvanised screws; galvanised staples; pruning saw; hammer; drill; secateurs; straightedge or ruler; bucket; tape measure; sphagnum moss.

Here’s how…

Step 1

Put vertical battens on a flat surface, about 300mm apart, making sure they’re parallel.

Step 2

Place horizontal slats on battens, leaving a 80mm overhang on each end of slats.

Step 3

Find centre of each batten. Rule a horizontal line through this point, across slats. Using line as a guide, screw slats to battens

Step 4

On middle 3 slats, mark drill holes 10-20mm in from screws on each side – this is for threading the wires so they will evenly hold the weight of the fern. If necessary, adjust spacing to suit your fern. Drill a hole through each marking, all the way through the vertical battens.

Step 5

Position fern on board. Insert 1 wire end into 1 hole and feed through enough wire to reach centre of back of board. Pull other end across fern. Trim wire, ensuring there’s enough excess to tie ends together at back. Feed this end of wire through corresponding hole at opposite end. Repeat twice.

Step 6

Holding fern in place with 1 hand, stand board upright. Pull 2 wire ends so they’re firm, then twist together to secure. Repeat for remaining wire ends. Hammer in staples to secure wire to back of board.

Step 7

If necessary, tidy up your fern by trimming off dead and browning par ts. Soak sphagnum moss in a bucket of water, then grab a handful, squeeze out excess water and use to fill gaps between board and plant. This will help the fern to retain moisture between watering.

Step 8

Standing board upright, predrill and screw galvanised hooks into vertical battens. Attach a chain and hang.

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