Super obese behave different from simple and morbid obese patients in the changes of body composition after tailored one anastomosis gastric bypass (BAGUA).

INTRODUCTION: Super obese patients behave different from simple and morbid obese patients when they reach final changes of body composition (BC) after bariatric surgery. This has led us to tailor One Anastomosis Gastric Bypass (BAGUA) to achieve better results in this group of patients. PATIENTS AND METHODS: We studied 83 (37 diabetic and 46 nondiabetic BMI 30 and up) patients who completed all evaluation appointment (preoperative, 10 days, 1, 3, 6 and 12 months) after tailored BAGUA for diabesity. We used the Tanita body composition analyzer BC-420 MA by the method of single frequency impedance to analyze the evolution of BC in patients classified by BMI 30 - 34,9, 35 - 50, and >50. RESULTS: While preoperative excess weight presented dramatic decreases after tailored BAGUA in all the groups, super obese have different final BC. Diabetics retained more fat mass and visceral fat, where super obese have double (14 kg) that simple obese patients (6 kg), they lost more muscle mass, and have higher basal metabolism. The final BC is altered in all parameters if diabetes is added. CONCLUSIONS: The reduction of the preoperative excess weight is motivated largely by the tailored effect of BAGUA. Patients BMI 30-50 behaved homogeneous in BC after surgery while patients BMI >50 behave different. Super obese lose less weight, retained more fat mass, visceral fat, bone mass, and total water. This effect should be treated by more aggressive surgery by measuring the entire small intestine to make a proper exclusion (tailored) to achieve homogeneous effects.

Introducción: Los pacientes súper obesos se comportan de manera distinta a los pacientes con obesidad simple y obesidad mórbida cuando alcanzan los cambios finales de la composición corporal (CC) tras la cirugía bariátrica. Esto nos condujo a individualizar la anastomosis única de derivación gástrica (BAGUA) para conseguir mejores resultados en estos pacientes. Pacientes y métodos: Estudiamos a 83 pacientes (37 diabéticos y 46 no diabéticos, con IMC ≥30) que completaron todos las visitas de evaluación (preoperatorio, 10 días, 1, 3, 6 y 12 meses) tras la cirugía personalizada BAGUA para la obesidad. Empleamos el analizador de la composición corporal Tanita CC-420 MA mediante el método de impedancia de un única frecuencia para analizar la evolución de la CC en pacientes clasificados por el IMC 30 - 34,9, 35 - 50, y > 50. Resultados: Mientras que el exceso de peso preoperatorio mostró unas reducciones drásticas tras la cirugía BAGUA personalizada en todos los grupos, los súper obesos tuvieron una CC final diferente. Los diabéticos retuvieron más masa grasa y grasa visceral, mientras que los súper obesos mostraban el doble (14 kg) que los pacientes con obesidad simple (6 kg), perdieron más masa muscular y tuvieron un mayor metabolismo basal. La CC final se altera en todos sus parámetros si se añade la diabetes. Conclusiones: La reducción del exceso de peso preoperatorio está motivada en gran medida por el efecto de la cirugía BAGUA personalizada. Los pacientes con un IMC entre 30-50 se comportan de forma homogénea en la CC tras la cirugía mientras que los pacientes con un IMC > 50 se comportan diferentemente. Los súper obsesos pierden menos peso, retienen más masa grasa, grasa visceral, masa ósea y agua total. Este efecto debería tratarse con una cirugía más agresiva midiendo todo el intestino delgado para realizar una exclusión adecuada (personalizada) para conseguir unos efectos homogéneos.

Characterization of exopolysaccharides produced by three moderately halophilic bacteria belonging to the family Alteromonadaceae.

AIMS: To study the exopolysaccharides (EPSs) produced by three novel moderately halophilic species belonging to the family Alteromonadaceae to optimize EPS yields, characterize their physical and chemical properties and evaluate possible biotechnological applications for these polymers. METHODS AND RESULTS: EPSs synthesized by Idiomarina fontislapidosi F32(T), Idiomarina ramblicola R22(T) and Alteromonas hispanica F23(T) were collected and analysed under optimum conditions: MY medium supplemented with 7.5% (w/v) salts; 32 degrees C; and 1% (w/v) glucose. Polymers were synthesized mainly during the early stationary growth phase with yields ranging from 1 to 1.5 g l(-1). The Idiomarina species each produced an anionic EPS composed mainly of glucose, mannose and galactose. A. hispanica synthesized an anionic EPS composed mainly of glucose, mannose and xylose. Solutions of all the polymers were low in viscosity and pseudoplastic in their behaviour. They showed emulsifying activity and the capacity to bind some metals. CONCLUSIONS: The Alteromonadaceae species studied in this work produced EPSs with physical and chemical properties different from those produced by other halophilic and nonhalophilic bacteria, suggesting that the wide diversity of micro-organisms being encountered nowadays in hypersaline environments offers enormous potential resources for biotechnological applications. SIGNIFICANCE AND IMPACT OF THE STUDY: We have optimized the EPS production and analysed new biopolymers produced by some recently described, moderately halophilic bacteria. These biopolymers are chemically and physically different from others already in use in biotechnology and offer hopes for new applications, especially in the case of A. hispanica, which may prove to be a viable source of xylo-oligosaccharides.

Muerte súbita como forma de presentación de un Síndrome de Conn / Sudden death as presentation of Conn’s syndrome

Los pacientes con hiperaldosteronismo secundario a adenoma suprarrenal (síndrome de Conn) se suelen encontrar asintomáticos o con escasos síntomas debidos a la hipertensión arterial per se o a hipokaliemia. Presentamos un caso de síndrome de Conn no conocido cuyo comienzo fue una muerte súbita con desarrollo posterior de encefalopatía postanóxica y desenlace fatal (AU)

Patients with hyperaldosteronism secondary to an adrenal adenoma (Conn’s syndrome) are usually asymptomatic or evidence but few symptoms due to arterial hypertension per se or to hypokaliaemia. We present one case of previously undiagnosed Conn’s syndrome presenting as sudden death with ensuing development of post-anoxic encephalopathy and fatal outcome (AU)

Efectos de la optimización del transporte de oxígeno sobre la morbimortalidad en el postoperatorio de cirugía cardíaca / Hemodynamic optimization and morbimortality after heart surgery

Fundamento. La contracción de una deuda de oxígeno se ha asociado con peores resultados clínicos, y se ha hipotetizado que la optimización del transporte de oxígeno (DO2) mejoraría dichos resultados. En el presente estudio optimizamos el DO2 y valoramos su efecto sobre la morbimortalidad y estancia media en la unidad de medicina intensiva (UCI).Métodos. Estudio prospectivo, intervencional, aleatorizado y controlado con 390 enfermos sometidos a cirugía cardíaca con circulación extracorpórea (CEC), ingresados en nuestra UCI: el grupo optimizado (GO) incluía a 181 enfermos y el grupo control (GC) a 209. La optimización del GO se llevó a cabo en las primeras 8 h del postoperatorio inmediato, logrando una saturación venosa mixta de oxígeno (SvO2) 70 por ciento. Todos los enfermos ingresaron con un catéter en la arteria pulmonar y se registraron las mediciones de las variables cardiorrespiratorias a las 0, 4 y 8 h de su ingreso. Resultados. Los pacientes del GO revelaron una SvO2 y un DO2 significativamente mayores que los del GC, a pesar de lo cual no observamos ninguna diferencia significativa en las variables estudiadas, respecto al GC. Los enfermos que fallecieron presentaron -en relación con los que sobrevivieron- menores DO2 y SvO2, con cifras de DO2 cercanas a las del DO2 crítico, y precisaron con más frecuencia fármacos inotrópicos y balón de contrapulsación intraaórtica (BCIA). Conclusiones. La optimización del DO2 en el postoperatorio inmediato de cirugía cardíaca no logró disminuir la morbimortalidad ni la estancia media en la UCI; los pacientes que fallecieron contrajeron una deuda de oxígeno, fundamentalmente por fallo cardíaco de bomba, que les incapacitó para conseguir un DO2 superior al DO2 crítico (AU)

Penetrating trauma to the male external genitalia.

BACKGROUND: We report on 40 patients with penetrating trauma to the external genitalia. Initial evaluation and management, operative findings, and treatment outcomes are reviewed. METHODS: We retrospectively reviewed the medical records of all patients presenting to our facility with penetrating trauma to the external genitalia since 1988. RESULTS: Of the 40 patients reviewed, 22 sustained isolated scrotal trauma, 10 sustained isolated penile trauma, and 8 had both scrotal and penile injuries. Twenty-nine of the 30 men with scrotal injuries underwent surgical exploration, and 21 of these were found to have injuries to the spermatic cord or testes (in 2 patients, bilateral injuries were noted). The testicular salvage rate was 35%. Penile trauma occurred in 18 patients. Eight corporal injuries and four urethral injuries were managed with debridement and primary repair. Erection and normal voiding was present in all men undergoing reconstruction who returned for follow-up. Thirty-eight percent of tested patients were positive for hepatitis B, C, or both. More than 60% of tested patients were legally intoxicated at the time of injury. Injuries separate from genitourinary trauma were identified in 72% of the men. CONCLUSION: Early surgical exploration with conservative debridement and primary repair of injured structures is recommended for most men who sustain penetrating injuries to the external genitalia. Selected patients with superficial injuries can be managed nonoperatively, but delayed wound complications are not uncommon. Although universal precautions are recommended for all patients, the high prevalence of hepatitis B and C in this group reemphasizes their importance. Long-term follow-up in this largely young, mobile, indigent population was poor.

Influence of hepatic function on serum levels of prostate specific antigen.

PURPOSE: Recent studies have suggested that the primary site of metabolism for prostate specific antigen (PSA) is the liver. We evaluated men undergoing liver transplantation to determine whether chronic hepatic insufficiency affected serum PSA levels and whether improved hepatic function altered serum PSA levels. MATERIALS AND METHODS: Ten men with a mean age of 46 years (range 23 to 67) undergoing liver transplantation were evaluated. Liver function tests, including serum bilirubin, serum glutamic-oxaloacetic transaminase and serum glutamic pyruvic transaminase, as well as serum PSA were determined 1 day before and a mean of 12.6 months (range 4 to 18) after transplantation. RESULTS: Serum bilirubin and serum glutamic-oxaloacetic transaminase declined significantly after liver transplantation. There was no difference in mean serum PSA levels before and after liver transplantation. CONCLUSIONS: Our results suggest that severe hepatic dysfunction does not significantly alter the serum concentration of PSA. These data, combined with recent investigations demonstrating an intrahepatic mechanism for PSA elimination, suggest that the liver has a significant reserve to metabolize the relatively small quantities of PSA in the circulation.

Cellular PSA in benign and malignant prostate.

To determine the relationship of carcinoma of the prostate and cellular production of prostate-specific antigen, cytosol levels of PSA were measured in benign and malignant fresh prostate tissue harvested from radical prostatectomy specimens. Wedge biopsies were taken from benign (N = 21) and malignant (N = 74) prostate tissue and were immediately fixed in liquid nitrogen, and then homogenized and differentially centrifuged, and the cytosol fractions extracted. The remaining specimen was sent for routine pathologic assessment. The Hybritech methodology was used to measure the cytosol PSA and standard protein analysis was used for cytosol protein (CP) measurement. There was a significantly greater concentration of PSA in malignant tissue (P = 0.046). Also, when benign and malignant tissue were available from a single prostate (N = 17), these differences in cytosol PSA were even greater (P = 0.002). In addition, there was no significant difference when serum PSAs from the malignant tissue were ranked according to Gleason score and placed into three different histologic grades (i.e., Gleason scores 2-4, 5-6, and 7-10).

Techniques for bypassing and stenting ureteral obstructions.

The advent of current endourological equipment and combined cystoscopic fluoroscopy allows the urologist to divert and/or stent the majority of benign and malignant ureteral obstructions in either a retrograde or antegrade fashion. We report on our recent experience in managing 105 obstructed renal units to formulate a troubleshooting endourological algorithm for bypassing and stenting ureteral obstructions. The methods described allow for safe and successful stent diversion in the majority of patients with ureteral obstruction requiring initial or primary endourological management. The algorithm presents alternative techniques for bypassing and stenting ureteral obstructions.

Evaluation of the current incidence of nodal metastasis from prostate cancer.

To determine the influences of transrectal ultrasonography, prostate-specific antigen (PSA), and heightened public awareness of prostate cancer stage at diagnosis, we prospectively evaluated our most recent 173 patients who had a pelvic lymphadenectomy from 1987 to 1991. All patients had clinically localized prostate cancer and underwent bilateral limited pelvic lymph node dissections (N = 173); 19 (10.7%) were found to have nodal metastasis. Pathologic tumor stage and grade information was available for 168 patients who had a simultaneous radical prostatectomy. Clinical T-stage data revealed that only one patient had a T3 lesion. Pathologic T stage showed 7.1% to be T1a (12/168), 4.1% to be T1b (7/168), 13.7% to be T2a (23/168), 34.5% to be T2b (58/168), and 40.5% to be T3 lesions (68/168). Metastatic nodal involvement was not seen in any T1a, T1b, or T2a lesions. A Gleason's score of less than 5 lesions was predictive of no nodal metastasis. The clinical stage was upstaged pathologically in none of the T1a, 16.7% of the clinical T1b, 75% of the T2a, and 73% of the T2b lesions. With regard to serum PSA, 27% of those patients with a level > 20 ng/ml had nodal metastasis (6/22) in this series. Although an elevated PSA was not predictive of tumor nodal metastasis, no patient with a normal PSA had nodal metastasis. Although the distribution of pathologic T stages is similar to that reported in the literature, our low incidence of nodal metastasis may suggest that prostate cancer is being diagnosed earlier.

Anatomic, functional, and pathologic changes from internal ureteral stent placement.

The anatomic, hydrodynamic, functional, and pathologic changes associated with unilateral internal ureteral stenting were evaluated in 20 female canines. Selective glomerular filtration rates (GFR) were measured with technetium 99m diethylenetriamine pentaacetic acid (DTPA) renal scans (N = 14) prior to and several weeks after unilateral internal stent placement. Cystometry and cystography were done at weekly intervals to determine if reflux occurred and to measure the intravesical pressure to produce this reflux (N = 16). Ureteral lumenal capacities of mid 6-cm ureteral segments of stented and unstented ureters were compared. The mid-ureteral lumenal volumes were three times greater in the stented ureters (p < 0.002). There were no significant differences in the selective GFR before and after stenting. Low-pressure vesicoureteral reflux occurred at a mean intravesical pressure of 13.7 cm of water and was present in 84.6 percent (11/13) of the canines whose stents did not migrate or obstruct from encrustation. There were no significant alterations in serum chemistries or blood counts. Fluoroscopic imaging also showed ineffective ureteral peristalsis. This study confirms that internal ureteral stents cause vesicoureteral reflux and significant lumenal dilation without altering renal function.

Acquired immunodeficiency syndrome manifesting as prostate nodule secondary to cryptococcal infection.

We report the first case of acquired immunodeficiency syndrome (AIDS) presenting as prostate nodularity secondary to mycotic granulomatous prostatitis which mimicked prostatic cancer on digital rectal examination. Transrectal ultrasonography revealed hypoechoic areas in the peripheral zone, which on biopsy specimen were found to represent cryptococcal infection. Subsequent serologic evaluation of the patient confirmed human immunodeficiency virus (HIV) positivity and later AIDS developed in the patient.

Evaluation of a new tumor marker for localized prostate cancer.

Adenocarcinoma associated antigen (ACAA) is a large molecular weight protein that is normally found in low serum levels. Recent data have revealed elevations in patients with adenocarcinomas, including prostate cancer. To evaluate the relationship of ACAA levels with prostate cancer, we measured the cytosol content in malignant and nonmalignant prostate tissue and compared these results to those of the standard markers, prostatic acid phosphatase (PAP) and prostatic specific antigen (PSA). Enzyme solid phase immunoassay was used to quantitate PSA and ACAA levels, and the enzymatic method was used to measure PAP. Wedge resection from the right and left posterior lobes of 50 fresh radical retropubic prostatectomy specimens were used for cytosol analysis. All foci of within each prostate gland were carefully mapped by a single pathologist. When all malignant wedges (N = 74) were compared to all the benign wedges (N = 21), only the PSA levels showed significant elevation (p less than 0.02). However, when benign and malignant tissue from the same prostate were available for comparison, both PSA (N = 17) and ACAA (N = 16) showed significant elevations in the cytosol of the malignant tissue (p less than 0.002 and p less than 0.03, respectively). Although not statistically significant, the cytosol PAP did show a consistent trend to be greater in malignant tissue. It appears that there is an association of increased cytosol ACAA and PSA with prostate cancer.

Ureteral injury in abdominal vascular reconstructive surgery.

Iatrogenic ureteral injuries in vascular reconstructive surgery are rarely reported. We present a case of ureteral transection during repair of an aortic aneurysm in a patient with a previously placed aortobifemoral graft. In reported series of surgical ureteral injuries, 17 of 381 injuries occurred during vascular procedures. A review of the literature and management scheme for ureteral complications in the presence of prosthetic vascular grafts is presented in light of current endourologic materials and techniques.

Ultrasound guided percutaneous renal biopsy using an automatic core biopsy system.

With real-time ultrasound visualization and an automatic core biopsy system 23 percutaneous renal biopsies were performed with the use of local anesthesia in 22 patients. Adequate tissue for diagnosis was obtained in all 23 cases, with 1 patient undergoing bilateral renal biopsy and 1 requiring repeat biopsy. One patient had an asymptomatic perirenal hematoma and 1 experienced a single episode of transient gross hematuria. There were no major complications. The use of an automatic core biopsy system guided by real-time ultrasound is an important technique that may be added to the urological armamentarium.

Penile malignant melanoma in association with squamous cell carcinoma of the penis.

We report a case of malignant melanoma of the penis in association with penile squamous cell cancer. Previous regional lymphadenectomy did not prevent subsequent development of regional recurrence. This clinical presentation and the literature are discussed.

Incidental ileal carcinoid associated with multiple urologic malignancies.

Although associated primary neoplasms frequently occur with carcinoid tumors, associated nonendocrine urologic malignancies are uncommonly encountered. We report the first case of an incidental ileal carcinoid associated with bilateral renal cell carcinoma and prostatic adenocarcinoma.