Incidence and prevalence of copper deficiency following roux-en-y gastric bypass surgery.

INTRODUCTION AND OBJECTIVES: The frequency of copper deficiency and clinical manifestations following roux-en-y gastric bypass (RYGB) surgery is not yet clear. Objectives were to determine the prevalence and incidence of copper deficiency in patients who have undergone RYGB. DESIGN AND METHODS: We sought to determine the number of RYGB patients undergoing medical and nutritional follow-up visits at the Emory Bariatric Center who experienced copper deficiency and associated hematological and neurological complaints (n=136). Separately, in patients followed longitudinally before and during 6 and 24 months following RYGB surgery, we obtained measures of copper status (n=16). Systemic blood cell counts and measures of copper, zinc and ceruloplasmin were determined using standardized assays in reference laboratories including atomic absorption spectrometry and immunoassays. RESULTS: Thirteen patients were identified to have copper deficiency suggesting a prevalence of copper deficiency of 9.6%, and the majority of these had concomitant complications including anemia, leukopenia and various neuro-muscular abnormalities. In the longitudinal study, plasma copper concentrations and ceruloplasmin activity decreased over 6 and 24 months following surgery, respectively (P<0.05), but plasma zinc concentrations did not change. A simultaneous decrease in white blood cells was observed (P<0.05). The incidence of copper deficiency in these subjects was determined to be 18.8%. CONCLUSIONS: The prevalence and incidence of copper deficiency following RYGB surgery was determined to be 9.6% and 18.8%, respectively, with many patients experiencing mild-to-moderate symptoms. Given that copper deficiency can lead to serious and irreversible complications if untreated, frequent monitoring of the copper status of RYGB patients is warranted.

Plasma antioxidant status after high-dose chemotherapy: a randomized trial of parenteral nutrition in bone marrow transplantation patients.

BACKGROUND: Chemotherapy and radiation therapy result in increased free radical formation and depletion of tissue antioxidants. It is not known whether parenteral nutrition (PN) administered during bone marrow transplantation (BMT) supports systemic antioxidant status. OBJECTIVE: The aims of the study were to determine 1) whether high-dose chemotherapy decreases concentrations of major circulating antioxidants in patients undergoing BMT and 2) whether administration of standard PN maintains systemic antioxidant concentrations compared with PN containing micronutrients and minimal lipids alone. DESIGN: Twenty-four BMT patients were randomly assigned to receive either standard PN containing conventional amounts of dextrose, amino acids, micronutrients, and lipid (120 kJ/d) or a solution containing only micronutrients (identical to those in standard PN) and a small amount of lipid (12 kJ/d). Plasma antioxidant status was measured before conditioning therapy and serially at days 1, 3, 7, 10, and 14 after BMT. RESULTS: Plasma glutathione (GSH) and alpha- and gamma-tocopherol concentrations decreased and the GSH redox state became more oxidized after conditioning chemotherapy. Plasma cysteine concentrations were unchanged, whereas cystine concentrations increased. Plasma vitamin C and zinc concentrations and GSH peroxidase activity increased over time. Plasma alpha-tocopherol concentrations were lower in patients given standard PN. There were no differences in other plasma antioxidants between groups. CONCLUSIONS: A significant decline in GSH-glutathione disulfide, cysteine-cystine, and vitamin E status occurs after chemotherapy and BMT. Standard PN does not improve antioxidant status compared with administration of micronutrients alone. Further evaluation of PN formulations to support patients undergoing high-dose chemotherapy and BMT are needed.

The prosthetic ureter.

Ureteral replacement has always been a challenge. Two approaches have been explored: in situ augmentation or replacement and extra-anatomic passage of a conduit. An in-situ prosthetic ureter is basically a simple al. loplastic tube connected to the urinary tract by end-to-end sutures or by intubation and closure. Antireflux devices and peristaltic mechanisms are not necessary. Among the in-situ designs, only those composed of silicone and silicone rubber have performed at all well. Tissue engineering and acellular matrix grafts have produced impressive early results. Subcutaneous ureteral replacement with alloplasts, including a coaxial assembly of an inner silicone and outer expanded polytetrafluoroethylene tube, has produced good results. In the future, we are likely to see bioengineered neotissue combined with highly porous and infection-resistant alloplasts to create better and more functional neo-organs.

Tissue-bonding cystostomy: potential alternative for neuropathic bladder dysfunction and potential model for other prostheses.

Neuropathic bladder dysfunction commonly results in urinary retention, incontinence, or both. At present, catheterization is commonly used in these patients to empty the bladder, but bacteriuria is a common result. Construction of a device that combines infection-resistant materials and a closed ecosystem has been attempted, yielding a prototype tissue-bonding cystostomy device. This device and the results of the early trials are described.

The artificial bladder.

An artificial bladder should provide adequate urine storage, allow volitional complete evacuation of urine and preserve renal function. Moreover, its structure has to be biocompatible, resistant to urinary encrustation and tolerant to bacterial infection. Various solutions have been proposed over the years to achieve these multiple requirements. However, most of these solutions and their corresponding prototypes did not advance beyond the stage of a preliminary report of experimental data. This review will bring out the 'proof of principal' in alloplastic prosthetic bladder, including type of alloplast and design concept and the recent development in tissue engineering approaches.

Adjunctive therapies in nutritional support.

The need for new therapeutic approaches to improve the metabolic and clinical efficacy of nutritional therapy has been increasingly emphasized. The field of nutrition support of catabolic, malnourished, or hospitalized patients is rapidly evolving in response to the beneficial effects observed with adjunctive therapies in animal models and in emerging clinical investigations. Enteral nutrition is being increasingly administered, and enteral diets are being tested to improve gut structure and function. Adjunctive therapies in enteral and parenteral nutrition are being actively investigated. These include administration of recombinant growth factors and anabolic steroid hormones (e.g., growth hormone, oxandrolone); conditionally essential amino acids (e.g., arginine, glutamine); novel lipid products (e.g., structured lipids, fish oils); nutrient antioxidants (e.g., vitamins C and E); and combinations of these approaches. It is likely that current methods of enteral and parenteral nutrition support will evolve in response to the results of these research studies.

What happened down there? Fournier's gangrene.

Fournier's gangrene is an uncommon but potentially lethal disease caused by a mixed infection of gram negative and anaerobic bacteria. There are many associated factors that put a man at risk, and an identifiable source can be found in 95% of patients. First symptoms are malaise, fever, and scrotal discomfort, but toxic symptoms can rapidly occur and be differentiated by the original site of infection. Early detection, extensive surgical debridement, intravenous antibiotics, and hemodynamic resuscitation are crucial to survival.

Treatment options in struvite stones.

Urinary calculi have plagued man over the centuries. The epidemiology and pathogenesis of infection have been studied. The curative treatment remains problematic. Without therapy, a vicious cycle of stone formation occurs. This results in renal damage and even death. Multimodality therapy is the key. Nonoperative treatment leads to progressive renal damage. The combination of maximal surgical ablation and medical therapy is synergistic. The combination of PCNL-ESWL has not appeared to produce ill effects. PCNL-ESWL is a less morbid surgical alternative than open surgical procedures. Adjunctive medical therapy, such as culture-specific antibiotics and urease inhibitors, complements surgical ablation by reducing the morbidity with persistent UTIs and stone recurrence. The urologist today must approach struvite staghorns with a vast armamentarium of surgical and medical techniques. Each patient requires a unique solution.

Electromotive drug administration to the urinary bladder: an animal model and preliminary results.

PURPOSE: Electromotive drug delivery (EMDA) is the use of an electrical field to enhance penetration of ionized drugs into local tissues. Intraurinary EMDA may be of value in the treatment of various pathological conditions involving the urinary bladder, prostate gland and urethra. We have developed an animal model to study this hypothesis. MATERIALS AND METHODS: Anesthetized adult mongrel dogs were studied. An intravesical anode was inserted through a Foley catheter into the urinary bladder. Two patch electrodes were positioned on the animals' abdominal skin. Both skin and intravesical electrodes were attached to a direct current generator. The bladder was then distended with an anionic blue dye (methylene blue). Fifteen milliamperes (15 mA) pulsed direct current was applied for 40 minutes. After EMDA, the bladder was surgically removed and representative sections of full thickness bladder wall were immediately frozen in liquid nitrogen. Methylene blue was used to visually demonstrate EMDA-enhanced anion penetration into bladder submucosa and muscularis. RESULT: This experimental model demonstrates significant submucosal and muscularis methylene blue penetration in the presence of the electric field. CONCLUSION: Electromotive drug delivery technology may have applications for treating bladder pathology.

Electromotive administration of intravesical lidocaine in patients with interstitial cystitis.

Six patients with long-standing interstitial cystitis (IC) were treated with intravesical electromotive drug-assisted (EMDA) therapy using lidocaine (1.5%) and 1:100,000 epinephrine in aqueous solution. A stainless-steel silver-coated anode placed through an 18F Foley catheter was positioned in the urinary bladder, and a 5 x 10-cm dispersion electrode (cathode) was placed on the suprapubic skin, which was well lubricated with conductive jelly. The two electrodes were connected to a pulsed DC generator, and electrical current was slowly ramped from 0 to 15 mA while the lidocaine and epinephrine were in the urinary bladder. After 40 minutes of current application, the bladder was hydraulically dilated to maximum tolerance. Significant bladder dilatation was achieved without systemic symptoms. Post-treatment, voiding symptoms decreased, as did suprapubic and perineal pain, and in four patients, the results have been durable.

The role of digital rectal examination, biopsy Gleason sum and prostate-specific antigen in selecting patients who require pelvic lymph node dissections for prostate cancer.

OBJECTIVE: To examine the usefulness of clinical stage, tumour differentiation and prostate-specific antigen (PSA) level, alone and in combination, to predict regional nodal metastases in individual patients with localized prostate cancer. PATIENTS AND METHODS: The usefulness of digital rectal examination (DRE), biopsy Gleason sum and PSA, alone and in combination, to predict nodal metastases in an individual patient was examined. The study included 689 patients who had laparoscopic or open pelvic lymph node dissection for clinical stage T1-3 prostate cancer. The Kruskal-Wallis test, Mantel-Haenszel test, chi-squared test and logistic regression were used for continuous, ordinal, categorical, and multivariate analysis, respectively. RESULTS: Of the 689 patients who underwent radical prostatectomy, 52 (8%) had nodal metastases. Although clinical stage, DRE, pre-operative PSA level and biopsy Gleason sum were significantly related in the univariate analysis, only pre-operative PSA level and biopsy Gleason sum were significant predictors of lymph node status in a multivariate analysis. However, based on a receiver operating characteristic curve, a model with satisfactory sensitivity and specificity could not be obtained. CONCLUSION: Current estimations of primary prostate cancer biology using pre-operative PSA level, clinical stage and biopsy Gleason sum are not sufficiently sensitive to predict nodal metastases, and pelvic lymphadenectomy remains the definitive method of detection.

Laser-welded ureteral anastomoses: experimental studies with three techniques.

Tissue welding with laser energy is a new technique for reconstructive surgery. The potential advantages of laser welding are (a) lack of foreign body reaction, (b) decreased operative time, (c) less tissue manipulation, and (d) effective union of tissues equivalent to sutured anastomoses. We have performed ureteral anastomoses in adult mongrel dogs using a KTP 532 nm laser at an intensity of 1.4 W. Multiple "spot welds" of 1-s duration were utilized in a single layer anastomosis. Laser-welded anastomoses were performed with and without protein solder (33% and 50% human albumin) and were compared to sutured anastomoses. The laser-welded anastomoses required less operative time and provided bursting pressure levels similar to those of traditional sutured anastomoses. There was no advantage or disadvantage to the addition of human albumin as a solder in these experimental studies.

The prosthetic bladder.

Bladder reconstruction may be required in a variety of pathological conditions, including bladder cancer, irradiation cystitis, interstitial cystitis, tuberculosis, and various congenital anomalies. Currently, bladder reconstruction is done with an autogenous bowel segment. Use of a total prosthetic bladder as an intracorporeal urinary reservoir has been an elusive goal for many decades. Many investigational and a few clinical trials have been performed in an attempt to develop a near-normal bladder prosthesis utilizing alloplastic materials. To date the ideal prosthetic bladder has not been developed. However, cumulative experimental studies suggest that many, perhaps all, of the ideal functional characteristics of a total prosthetic bladder are possible. Basically, two different alloplastic models have been investigated.

Retrograde nephrostomy: advantages, disadvantages, and the learning curve.

Establishment of a nephrostomy tract is a prerequisite for many endourologic procedures of the upper urinary tract. We reviewed our initial experience with 31 retrograde nephrostomies to determine the advantages and disadvantages and the learning curve for the procedure. All but one of the attempts were successful, and no complications were attributable to the nephrostomy puncture. The procedure time averaged 21.1 minutes in nondilated collecting systems but 32.0 minutes in hydronephrotic kidneys (P < 0.01). The mean procedure time in our first 10 successful cases was 36.2 minutes, but it decreased to 22.6 minutes in the second 10 successful cases (P < 0.02). Radiation exposure was also minimized early, with a mean fluoroscopy time of 3.5 minutes in our first 10 successful cases and 1.5 minutes in our second 10 successful cases (P < 0.02). Similarly, both procedure and fluoroscopy times decreased further in the most recent 10 successful cases. Retrograde nephrostomy is a safe procedure, is easier in a nondilated collecting system, and can be mastered with a short learning curve with minimal radiation exposure.

The effect of iontophoresis on bacterial growth in urine.

PURPOSE: To determine the effect of iontophoresis (electrical current for therapeutic purposes) on the growth of pathogenic bacteria in human urine. MATERIALS AND METHODS: Pathogenic bacteria were isolated and inoculated into a dynamic in vitro artificial bladder model. Pooled sterile human urine was regulated through the artificial bladder by intravenous tubing and pumps to simulate filling and emptying of the human bladder. The effect of electrical current on bacterial growth in the system was then studied. RESULTS: When iontophoresis is applied at low bacterial concentrations ( < 10(8) colony forming units [CFU]/l.), inhibition of bacterial growth occurs. However, when iontophoresis is applied after fulminant growth of bacteria ( > 10(8) CFU/l.), no inhibition of bacterial growth occurs. Iontophoresis was not found to enhance the antibacterial action of gentamicin to resistant Pseudomonas aeruginosa. CONCLUSIONS: Iontophoresis inhibits bacterial growth at low bacterial concentrations. It does not inhibit bacterial growth after infectious levels have been attained, and it does not potentiate the action of gentamicin on resistant Pseudomonas aeruginosa.

Tissue-bonded iontophoretic cystostomy: conceptual and experimental considerations.

We describe a conceptual model for drainage of the dysfunctional bladder. Experimental data from investigations involving several species of animals are presented to support the hypothesis that mature tissue-bonded alloplastic tubes drain urine effectively and are tolerant and resistant to endogenous and exogenous bacteria. We conclude that preliminary clinical trials of a tissue-bonded cystostomy are warranted. We postulate that success in these trials may offer a new alternative for the management of severe vesical dysfunction.