Retroperitoneal laparoscopic pyelolithotomy for staghorn stones.

PURPOSE: To establish the feasibility of the retroperitoneal laparoscopic approach for treatment of patients with staghorn renal calculi who are under consideration for an open pyelolithotomy. PATIENTS AND METHODS: Retroperitoneal laparoscopic pyelolithotomy was performed in three patients with impacted staghorn renal calculi between 22 and 45 mm in largest diameter. One of the patients also had multiple caliceal stones. These patients wanted an open procedure but had agreed to have their stone removal done laparoscopically in view of our experience. The previously described retroperitoneal laparoscopic approach was used, and the handling of some of the specific problems in such patients is described in the text. RESULTS AND CONCLUSION: The stones were removed successfully in all the three patients, and there were no complications. Although no definitive conclusion can be drawn from this small series, the paper shows the feasibility of the retroperitoneal laparoscopic approach in a select group of patients with staghorn renal calculi.

Laparoscopic ureterolithotomy: technical considerations and long-term follow-up.

OBJECTIVE: To analyse the technical details and the long-term results of laparoscopic ureterolithotomy. PATIENTS AND METHODS: Laparoscopic ureterolithotomy was undertaken in 101 patients between 1991 and 2001; in only one patient with retroperitoneal fibrous adhesions was the procedure transperitoneal, being retroperitoneal in all the others, using Gaur's balloon retroperitoneoscopy. The mean (range) stone size was 16 (10-47) mm, and the stones were in the upper ureter in 75, mid-ureter in 11 and lower ureter in 15 patients. Nine patients had more than one stone, the maximum being six, in a megaureter. Most were impacted for > 2 months, the maximum being 240 months. RESULTS: Laparoscopic ureterolithotomy was successful in 93 patients, with the eight failures being mostly early in the series. The mean operative duration was 79 min (66 min when the ureter was left open and 92 min when it was sutured). The overall mean duration of urinary leakage was 5.5 days, which was reduced to 3.2 days by stenting and suturing the ureter. The mean (range) blood loss was 25 (5-100) mL. The overall complication rate was high (31%) because of prolonged urinary leakage in 20 patients. No patient required morphine for pain relief and the mean for oral analgesic use was 2.5 days. The mean hospital stay was 3.5 days and that for resuming work 14 (7-28) days. CONCLUSIONS: Laparoscopic ureterolithotomy by the retroperitoneal approach is a safe and reliable minimally invasive procedure. Although its role as a salvage procedure for failed extracorporeal shock wave lithotripsy and ureteroscopy is undisputed, in selected patients with large chronically impacted ureteric stones and particularly with solitary kidneys, it may be considered the first-line treatment.

Depression of plasma cholesterol in men by consumption of baked products containing soy protein.

The effects of soy-protein consumption with and without soy fiber on plasma lipids in 26 mildly hypercholesterolemic men were studied. Four, 4-wk dietary treatments included 50 g protein and 20 g dietary fiber from soy flour (SF), isolated soy protein/soy cotyledon fiber (ISP/SCF), ISP/cellulose (ISP/C), or nonfat dry milk/C (NFDM/C) in conjunction with a low-fat, low-cholesterol diet. Plasma total cholesterol (TC) concentrations were lowest for both ISP dietary treatments compared with baseline (P < 0.05) and NFDM/C (P < 0.01). SF also led to lower TC compared with NFDM/C (P < 0.05). LDL-cholesterol values were lowest for both ISP treatments compared with NFDM/C (P < 0.01), but lower compared with baseline only with ISP/SCF (P < 0.05). Apolipoprotein B was lowest when ISP/C was fed, compared with baseline, SF, and NFDM (P < 0.05). HDL-cholesterol and total triglycerides (TG) were not affected. Results indicate that 50 g ISP is effective in lowering TC, LDL-C, and apolipoprotein B while maintaining HDL concentrations in mildly hypercholesterolemic men.

Effects of acute ethanol doses or dietary phenobarbitol with carbon tetrachloride exposure on vitamin A status of rats.

Hepatotoxins such as ethanol and CCl4 are known to adversely affect vitamin A metabolism, although the effects of acute exposure to these agents have received less evaluation. The purpose of this study was to determine the effects of vitamin A status after a series of acute ethanol doses or a series of CCl4 inhalation challenges with concurrent phenobarbital exposure in the diet of rats. The depressed hepatic vitamin A seen after one ethanol dose was not sustained after repeated dosings. However, the significantly increased urine and liver radiolabeled vitamin A recovery after three acute ethanol exposure periods suggests adaptive physiologic and metabolic changes after the initial dose. The results of repeated CCl4/phenobarbital dosings on vitamin A status paralleled, for the most part, the ethanol results. Thus, the initial acute exposure of hepatotoxic agents causes metabolic changes that are not fully sustained as the animal adapts to these challenges.

Vitamin A status of alcoholics upon admission and after two weeks of hospitalization.

The purpose of this study was to determine the vitamin A status of alcoholics upon admission and after a brief in-patient stay. Fasting blood was drawn from 28 randomly selected subjects who were presumed to represent a wide range of liver disease severity. Admission laboratory tests revealed hypozincemia in 14.8% of subjects, while serum retinol and retinol-binding protein (RBP) were depressed below normal range in 15 (57.1%) and 7 (25%) of the subjects, respectively. Significant linear correlations were found between serum retinol and RBP (r = 0.90, p < or = 0.0001), serum retinol and albumin (r = 0.76, p < or = 0.0001), serum retinol and serum zinc (r = 0.56, p < or = 0.0003), and serum retinol and serum triglycerides (r = 0.42, p < or = 0.006). All subjects with elevated serum bilirubin levels demonstrated depressed serum retinol levels. However, elevated molar ratios of retinol to RBP suggest that the carrying capacity of RBP was at times exceeded, even with low serum retinol levels. Follow-up of 12 subject after 2 weeks of hospitalization revealed significant individual changes in blood chemistry, but no general trends. Although this study emphasizes the need for individual evaluation and treatment, elevated bilirubin levels may be indicative of low serum retinol levels in the alcoholic. Caution in levels of vitamin A therapy in these cases is advised, and consideration should instead be given to beta-carotene supplementation.

Effects of ethanol and carbon tetrachloride upon vitamin A status of rats.

The effects of ethanol and carbon tetrachloride (CCl4) upon tissue vitamin A, liver lipids, liver cytochrome P450 and hepatic morphology were investigated. It was anticipated that CCl4 treatment would have more severe effects upon vitamin A status because CCl4 provides greater hepatic injury than does ethanol. After a 2-week standardization feeding period, young male rats were divided into four groups. For 5 weeks one group of rats (n = 17) received ethanol in liquid diets (30% of calories) while another (n = 8) was exposed to CCl4 inhalation twice a week along with phenobarbital in the diet. All groups received the National Regulatory Commission recommended level for vitamin A. Comparison of ethanol and its pair-fed control group (n = 17) revealed: decreased hepatic vitamin A, no change in serum vitamin A, increased percentage of liver lipid, and cytochrome P450 with moderate fat accumulation in hepatocytes. Comparison of the CCl4-phenobarbital group with pair-fed controls (n = 8) showed: increased serum vitamin A, decreased hepatic vitamin A, increased cytochrome P450, marked hepatic fat accumulation, hepatic cell necrosis, and early cirrhosis. Thus, CCl4 (with phenobarbitol), which is a more potent hepatotoxin as evidenced by a more elevated cytochrome P450 and distorted liver morphology, not only reduced liver vitamin A, but also increased serum vitamin A. The extent of substrate and/or organ specificity remains to be elucidated.

Evaluation of Chemstrip LN in a male geriatric population.

A dipstick method for bacteriologic screening of urine using a combination of leukocyte esterase and nitrite indicators, Chemstrip LN, was evaluated in a male inpatient geriatric population. Three hundred seventy-five urine samples from 198 symptomatic patients (age range, 45 to 98 years; mean, 69.6) were tested by LN and cultured using standard methods. LN showed 169 negatives, but in 7 of these cases, the culture was positive (greater than or equal to 5 X 10(4) col/mL). Organisms recovered from these cultures were Candida (not albicans), Group B Streptococcus, Staphylococcus aureus, and in four cases, Pseudomonas aeruginosa. In the four cases of missed Pseudomonas the patients were receiving aminoglycoside therapy for 2 to 6 days and/or drugs that dye the urine. Despite the fact that many patients were on medications known to interfere with the test strips, the negative predictive value was still 96.0% showing that the strips may be suitable for use with this population given the understanding that certain antibiotics and/or substances that dye the urine may give false negative results.

Vibrio cholerae non-01 cellulitis.

A 46-year-old man presented with pain and fever and a postphlebitic ulcer on his left leg. The wound was suppurative and open at the margins, but there was little underlying fasciitis and no apparent muscle or blood vessel involvement. Three separate wound cultures were obtained at two-day intervals, and all showed only Vibrio cholerae non-01. The patient was successfully treated with cefazolin sodium. This marks the second documented case of V cholerae non-01 type alone as a causative agent of cellulitis, and the first case where no saltwater origin could be demonstrated.

A case report: Aeromonas sobria gastroenteritis in an adult.

Aeromonas sobria, a member of the Aeromonas hydrophila group, recently has been recognized as a gastrointestinal pathogen in adults. There have been a few documented cases, and these have come from far eastern countries, namely India, Thailand, and Indonesia. The authors have isolated a strain of A. sobria from a 62-year-old male patient suffering from diarrheal disease. He had no history of travel outside of the United States for several decades. He presented with a severe diarrheal disease that closely mimicked cholera, producing large quantities of green "rice water" stool. He was severely dehydrated and was in electrolyte imbalance. No other enteric pathogen could be detected. The organism presumptively was identified as Vibrio cholera (81.5% probability) by the Micro Scan system, but later was identified definitively as A. sobria using the API 20E and ZYM systems. Cell-free extract of this strain contained hemolysins, proteolytic enzymes, and enterotoxin. The strain closely fits the description of Burke and associates (J Clin Microbiol 1982; 15:48-52) for their group A, type 1 (VP positive, arabinose negative, enterotoxin producer). The patient was treated with tetracycline and recovered.

Stability of vitamin B12 in the presence of ascorbic acid in food and serum: restoration by cyanide of apparent loss.

Ascorbic acid in varying amounts was added to food and serum samples and heated at 37 C. Vitamin B12 was then measured by radioimmunoassay and microbiologically using several extraction methods. B12 values in a cottage cheese meal were lower than controls when concentrations of ascorbic acid greater than but not equal or less than 0.5 mg/ml were added and if KCN was not used during extraction, but when 70 micrograms/ml KCN was added after ascorbic acid exposure B12 was quantitatively recovered. Serum B12 was variably decreased by lesser concentrations of ascorbic acid but was also quantitatively restored by increasing KCN concentration during extraction. In the absence of KCN in the extraction step some loss of B12 at 100 C was observed; the loss was greater with added ascorbic acid. Our results indicate that previous reports on B12 loss in the presence of ascorbic acid are artifacts of the methods used. In view of these in vitro findings B12 destruction by ascorbic acid in vivo seems highly improbable.

Ascorbic acid and vitamin B12.

Using extraction procedures in which the extracted vitamin B12 was protected by cyanide or metabisulfite, several investigators found no change in vitamin B12 when meals were incubated in the presence of ascorbic acid for 30 minutes at 37 degrees C. A previous report suggested degradation of vitamin B12 under these conditions, but this was apparently caused by incomplete protection of the extracted vitamin B12 in the assay procedure. If incubation at 37 degrees C for 30 minutes is a laboratory mimic of the gastric environment, one must conclude that high doses of ascorbic acid do not affect the stability of vitamin B12 in vivo.

Stability of vitamin B12 in the presence of ascorbic acid.

Experiments were performed in two independent laboratories, each using their own meal preparations which were exactly similar in composition to the meals described by Herbert and Jacob (J. Am. Med. Assoc. 230:241, 1974), in order to check their report that incubating meals (portions of daily food intake by man) of "modest" or "high" vitamin B12 content with increasing levels of added L-ascorbic acid (vitamin C) produced increasing destruction of vitamin B12. The present studies were performed with standardized and official methods. Vitamin B12 was determined microbiologically and by radioassay method. The results showed that 1) the vitamin B12 contents of these meals were in general agreement with values calculated from the literature for the foods involved, 2) the values obtained were manyfold higher than those reported by Herbert and Jacob, and 3) there was no deleterious effect of added ascorbic acid on the vitamin B12 content of meals, contrary to their published results.