trans isomers of oleic and linoleic acids in adipose tissue and sudden cardiac death

trans isomers of unsaturated fatty acids are formed by biological or industrial hydrogenation. A population case-control study of sudden cardiac death in mean was done to test the hypothesis that trans isomers of oleic acid and linoleic acid increase the risk of sudden cardiac death due to coronary artery disease. In adipose tissue obtained at necropsy from 66 cases of sudden cardiac death and taken from 286 healthy age and sex matched controls, the proportions of trans isomers of oleic and linoleic acid were measured by gas-liquid chromatography. In cases, the mean (SE) percentage of total trans fatty acids (C18:1 plus C18:2), expressed as a proportion of all fatty acids, was significantly lower (2.68 [0.08]%) than in healthy controls (2.86 [0.04]%; p < 0.05). trans C18:1 was 2.1 (0.7)% in cases compared with 2.27 (0.04)% (p < 0.05) in controls. The proportion of all trans isomers of linoleic acid was 0.58 (0.02)% in cases compared with 0.59 (0.01)% in controls (p = 0.98). The estimated relative risk for sudden cardiac death of trans C18:1 and C18:2 fatty acids combined did not differ significantly from 1.0 in relation to the distribution of these trans isomers by quintile in the control population. The relative risk (95% CI) of sudden cardiac death in the top quintile was 0.40 (0.15-1.02) for C18:1 and 1.08 (0.48-2.74) for C18:2 compared with the bottom quintiles of their respective control distributions. When these univariate relations for trans fatty acids were adjusted for coronary risk factors, smoking was the only factor that remained independently associated with risk of sudden cardiac death (2.27 [1.23-4.17]). Overall, there was no evidence of a relation between trans isomers of oleic and linoleic acids combined and sudden cardiac death. However, trans oleic acid was negatively associated with risk of sudden cardiac death, whereas no association with trans forms of linoleic acid was seen. This study does not support the hypothesis that trans isomers increase the risk of sudden cardiac death.

Advances in Amputee Care

This self-directed learning module highlights the recent innovations in amputee care. It is part of the study guide on limb deficiency in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This focused review article describes the key elements of a successful comprehensive amputee program, the basic surgical considerations for upper- and lower-extremity amputation, and some of the more recent advances in prosthetic components. Further, an update is given on issues such as hand transplantation and the integration of robotics and artificial muscles for people with limb loss.

OVERALL ARTICLE OBJECTIVE

(a) To discuss current issues and advances in the care of patients with amputation, (b) to describe the key elements in designing a comprehensive amputee care program, and (c) to discuss surgical considerations of limb preservation and amputation levels.

Augmentation of the buttocks by micro fat grafting

BACKGROUND

Requests for buttock augmentation are increasing in the United States because of changes in lifestyle and fashion that emphasize the "gluteal aesthetic unit."

OBJECTIVES

We review the use of micro fat grafting for enhancing the buttocks in a series of 566 patients.

METHODS

Tumescent solution (1 mg epinephrine per 1000 mL saline solution) was infiltrated; for small cases the volume used was less than half the amount of expected fat to be harvested. Harvesting was accomplished either manually with a syringe or with a liposuction pump that allowed precise control of the vacuum. The fat was injected both intramuscularly and subcutaneously into all levels of the desired area for augmentation of the buttocks. The typical augmentation averaged 300 to 400 mL per side but ranged from 175 mL to about 800 mL, depending on the patient's desires and the amount of donor fat available.

RESULTS

Patient and physician satisfaction with the results was high. Approximately 50% to 75% of the fat grafted remains in the long term. Complications included cellulitis (1.9% of cases), which responded promptly to treatment with cephalosporin, and infrequent seromas and hematomas (0.8% of cases).

CONCLUSIONS

Buttock augmentation by micro fat grafting is a safe, simple procedure. Compared with implant placement, the advantages of micro fat grafting include greater flexibility in the size and placement of augmentations, less pain and faster recovery for the patient, and less risk of complications. The technique is limited only by the amount of donor fat available. (Aesthetic Surg J 2001;21:311-319.).

A national Survey of Acute Myocardial Infarction and Ischaemia (SAMII) in the U.K.: characteristics, management and in-hospital outcome in women compared to men in patients under 70 years

AIMS

To assess the clinical characteristics, management and outcome of women compared to men with acute myocardial infarction or ischaemia.

DESIGN

A prospective clinical survey was made in a random sample of 94 District General Hospitals in the U.K. 1064 patients, <70 years of age, comprising six consecutive females and six consecutive males from each hospital, diagnosed on admission as acute coronary syndromes (myocardial infarction or myocardial ischaemia) were studied. Outcome measures included: admission and final diagnosis, time to delivery of care, inpatient management, complications and clinical outcome.

RESULTS

Five hundred and three women and 561 men were admitted with a diagnosis of acute myocardial infarction or myocardial ischaemia. Women were older, waited longer between seeking and receiving advice, and much less likely to have infarction than men. After adjustment for age, diagnosis and past medical history there were no gender differences in initial and subsequent hospital management, in complications (recurrent ischaemia, arrhythmias, temporary pacing, heart failure), any routine procedure or outcome. Of all patients, 3.4% died in a District General Hospital, 12.2% were transferred to Specialist Cardiac Centres and 84.4% discharged home. Prophylactic medication on discharge was similar for men and women.

CONCLUSION

After adjustment for age, diagnosis and past medical history, although women waited longer between seeking and receiving medical advice, in hospital their assessment, management, complications, outcome and follow-up arrangements were the same as for men. In hospital, management and outcomes were mainly influenced by age, diagnosis (infarction or ischaemia), a past history of coronary disease, but not by gender. This large, nationally representative, survey has found no evidence of important gender difference in the hospital management of acute ischaemic syndromes.

Linoleic acid and risk of sudden cardiac death

OBJECTIVE

To test the hypothesis that the essential fatty acid, linoleic acid, measured in adipose tissue as an indicator of long term dietary intake, is inversely related to the risk of sudden cardiac death.

DESIGN

A population case-control study.

SETTING

A regional health district.

SUBJECTS

84 men (age 25-64 years) who died instantaneously or within 24 hours of the onset of symptoms with no history of coronary heart disease or medically treated hyperlipidaemia, and in whom coronary artery disease was diagnosed at postmortem examination as the primary cause of death, were compared with 292 age (to within two years) and sex matched healthy controls and their partners drawn from the general practitioners' records with whom the cases were registered.

MAIN OUTCOME MEASURES

Fatty acid composition of adipose tissue and the risk of sudden cardiac death.

RESULTS

Linoleic acid in adipose tissue was inversely related to the risk of sudden cardiac death. The estimated relative risk (95% CI) of sudden cardiac death was 5.7 (1.8 to 17.9) for the lowest quintile and 4.0 (1.2 to 12.9) for the next quintile of adipose linoleic acid in the control population when compared with the highest quintile. This inverse relation was independent of age, reported smoking habits, history of hypertension, and diabetes, although there was a close association with cigarette smoking. The estimated adjusted proportionate increase in risk (95% CI) of sudden cardiac death was 1.14 (1.03 to 1.23) for every 1% reduction of linoleic acid in adipose tissue.

CONCLUSIONS

The percentage content of linoleic acid in adipose tissue was inversely related to the risk of sudden cardiac death. Populations with a high risk of sudden cardiac death may benefit from increasing their dietary intake of polyunsaturated fatty acid oils, principally from cereals and vegetables.

Limb deficiency and prosthetic management. 1. Decision making in prosthetic prescription and management

This self-directed learning module highlights decision making in prosthetic management in pediatric and adult patients. This chapter reviews classification of congenital limb deficiency and management of congenital pediatric upper-extremity amputees. Differences in management of amputees of various ages from infancy to old age is discussed. Case examples are used to formulate prosthetic prescriptions for transradial limb deficiency as well as knee disarticulation and transtibial level amputations. Common prosthetic gait deviations and anticipated functional levels are evaluated.

OVERALL ARTICLE OBJECTIVE

To discuss prosthetic prescription and management in congenital limb deficiency and acquired amputations for patients of various ages.

The RSVP facelift: a highly vascular flap permitting safe, simultaneous, comprehensive facial rejuvenation in one operative setting

This study describes our effort to develop a reliably safe method for combining currently available treatment modalities in an effort to obtain comprehensive facial rejuvenation in one operative setting. Detailed evaluation of 101 available consecutive patients, their per- and postoperative photos and charts was undertaken. Five groups of patients were studied: (1) traditional facelift with wide subcutaneous undermining and SMAS plication. (2) Similar traditional facelift with regional laser resurfacing. (3) RSVP (rejuvenation with sparing of vascular perforators) facelift. Subcutaneous undermining stops 3 cm lateral to the nasolabial fold to preserve the rich angular/facial arterial supply and venous drainage, still permitting lateral SMASectomy or SMAS plication. Subcutaneous neck undermining is discontinuous, the posterior dissection being limited to that which is necessary for identification of the posterior edge of the platysma and its plication to the mastoid and SCM muscle. The anterior dissection is limited to that necessary for anterior platysmal repair leaving intact a vertical subcutaneous non-undermined zone 4-6 cm in width, preserving the submental perforating artery. If indicated, gentle liposuction with a fine cannula is performed through this area. (4) RSVP facelift and regional laser resurfacing. (5) RSVP facelift with total facial laser resurfacing. Mean follow-up was 13.6 months, minimum 6 months. There were no additional major complications associated with the addition of laser resurfacing or fat grafting to the RSVP group. The patients with laser resurfacing were pleased with their result, and estimated that their apparent age had been reduced by a mean of 10.4 years, compared with 6.6 years for the non-lased group. We conclude that the RSVP flap is a hardy, vascular flap permitting simultaneous laser resurfacing, fat grafting, and other adjunctive procedures without significant fear of flap loss.

In pursuit of optimal rejuvenation of the forehead: endoscopic brow lift with simultaneous carbon dioxide laser resurfacing

Coronal foreheadplasty has long been the traditional method of improving the aesthetic appearance of the forehead, permitting not only repositioning of ptotic tissues but also direct access for modification of the "frown" muscles. However, it was only moderately successful in eliminating vertical corrugator lines or deeply etched transverse wrinkles. The recent advent of the endoscopic brow lift has permitted us to minimize the dysesthesias associated with the coronal approach by making the incisions shorter and radially oriented and by being more precise in the muscle resection. Nonetheless, endoscopic brow lift gives no further improvement in persistent deep vertical and transverse wrinkles. Carbon dioxide laser resurfacing can improve the existing wrinkles but does not eliminate the muscular cause of forehead wrinkles. It seemed reasonable that combining these techniques might yield better results than either procedure alone. To evaluate this possibility, 30 patients with simultaneous endoscopic brow lift and carbon dioxide resurfacing were compared with 24 patients having laser resurfacing only and with 26 patients who had traditional coronal foreheadplasty. Both foreheadplasty groups had corrugator resection. All patients were evaluated at least 4 to 6 months postoperatively. Ratings were based on the percent of wrinkles removed, both vertical and transverse. The ratings were performed with predetermined criteria by a surgeon not involved with the operative procedures nor after care. A rating of "excellent" (> or = 95 percent reduction in wrinkles) was obtained in 50 percent of coronal foreheadplasties; 41.7 percent of carbon dioxide resurfacing alone and 80 percent of endobrow lifts with carbon dioxide laser resurfacing. There was no vascular compromise from this latter combination of procedures, no hypertrophic scars, and no impairment of healing. We conclude that endoscopic brow lift with carbon dioxide laser resurfacing is a safe and perhaps more effective means of aesthetic rejuvenation of the forehead.

Limb deficiency and prosthetic management. 4. Comorbidities associated with limb loss

This self-directed learning module highlights common comorbidities found in people with amputations and their impact on functional outcome. It is part of the study guide on limb deficiency and vascular rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article focuses on prosthetic considerations, functional outcome, and potential complications for a woman with the comorbidities of stroke and diabetes who experiences a dysvascular amputation. Formulation of the differential diagnosis, management of limb pain, and evaluation of the potential psychosocial issues arising after amputation are also discussed.

OVERALL ARTICLE OBJECTIVE

To analyze common comorbidities of people with amputations and to delineate their impact on functional outcome.

A new filtered sump tube for wound drainage

A new filtered sump tube has been designed for drainage of collections of fluids from wounds without the danger of infection by airborne contaminants. A two-staged filter has been attached to the vent lumen that removes particulate matter and bacteria from the air that passes through the filter. A clinical evaluation of this tube confirms the superiority of sump drainage as compared with closed suction drainage in the removal of fluids from wounds or cavities.

Acetyl esterase in Bacillus cereus spores

The paucity of data on esterase activity in intact, dormant spores encouraged further examination of Bacillus cereus spores with more sensitive fluorescent methods. Esterase activities of intact and ballistically ruptured spore preparations against α-naphtyl acetate and fluorescein diacetate in phosphate and carbonate buffers were compared. Enzyme inhibition with toluene and molybdate was also inspected. It was found that intact spores and the supernatant from ruptured spores readily hydrolyzed both acetate substrates. Toluene caused approximately an 80% inhibition, whereas that with molybdate was complete. It was suggested that esterase activity in bacterial spores varies with species.

Lack of adverse effect of silicone implant on sarcoidosis of the breast

Involvement of the breast by sarcoidosis is extremely rare, with only 11 case reports in the literature. The potential adverse interaction between silicone prostheses and this disease process poses an unusual clinical dilemma. However, two patients with sarcoidosis of the breast had silicone breast implants placed without exacerbation of their disease nor unusual periprosthetic complications. We conclude that sarcoidosis of the breast does not appear to be a contraindication to placement of silicone implants.

Lipase and acetyl esterase activities in intact Bacillus coagulans spores

Since data on esterase content of intact dormant spores are meager, a study was carried out with various enzyme substrates and several methods of product detection on intact and ruptured preparations of Bacillus coagulans. Measurement of hydrolysis of triacetin, naphthyl acetates, fluorescein diacetate, ethyl acetate, and ethyl butyrate demonstrated the presence of arylesterase, carboxylesterase, acetyl esterase, and lipase activities in both the intact and ruptured preparations of the non-germinated organism used. It was observed that spore esterase was inhibited by normal and basic copper acetate, eserine, taurocholate, 253.7 mμ ultraviolet light, and temperatures between 50 and 100 °C.

The emerging role of laser resurfacing in combination with traditional aesthetic facial plastic surgery

Traditional aesthetic plastic surgery procedures (facelift, browlift, blepharoplasty, etc.) can make dramatic improvement in the facial appearance by removing excess skin and fat and tightening and repositioning the soft tissues of the face, but make no improvement in the quality of the skin. Laser resurfacing is the safest, most predictable method for improving facial wrinkles and actinic damage. This paper discusses the combination of these techniques in pursuit of optimal rejuvenation of the face.

Women married to men with myocardial infarction are at increased risk of coronary heart disease

AIM

To measure the prevalence of coronary heart disease (CHD) risk factors in the female partners of men with acute myocardial infarction (AMI).

METHOD

Consecutive incident cases of men under 65 years of age with AMI surviving to 3 months, their female partners and female healthy controls matched for age and marital status drawn from the general population were investigated.

RESULTS

One-hundred and seventeen cases of AMI in men under 65 years of age and 89 female partners were identified; 133 age- and sex-matched controls were examined for CHD risk factors. Cigarette smoking was more common among the younger partners (25-44 years of age) compared with controls. A body mass index > 28 kg/m2, systolic blood pressure > 150 mmHg, diastolic blood pressure > 90 mmHg and cholesterol > 6.5 mmol/l were all significantly more common in partners compared with controls. In a logistic regression of age, smoking habit, blood pressure, cholesterol and body mass index, based on 89 female partners and 132 controls with complete data, body mass index > 28 kg/m2 (odds ratio 2, 17, 95% CI 1.11-4.23) and cholesterol > 6.5 mmol/l (odds ratio 2.21, 95% CI 1.08-4.49) were both significantly more common in the female partners compared with controls.

CONCLUSIONS

Women married to men with AMI have a higher frequency of CHD risk factors compared with married women in the general population, consistent with a shared family lifestyle putting both adults at higher risk of CHD. Screening blood relatives in families prematurely affected by CHD is widely advocated; such screening should include partners.

Limb deficiency and prosthetic management. 2. Aging with limb loss

This self-directed learning module highlights the issues faced by people aging with limb loss. It is part of the study guide on limb deficiency and vascular rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the impact that limb loss has on health and physical function throughout the life span. Case examples are used to illustrate what effect limb loss in childhood or young adulthood has on the incidence and management of new impairments or disease processes commonly associated with aging.

OVERALL ARTICLE OBJECTIVE

To discuss the impact of early-life limb loss on the incidence and management of physiologic and functional changes associated with aging.

Limb deficiency and prosthetic management. 3. Complex limb deficiency

This self-directed learning module highlights rehabilitation and prosthetic issues associated with complex limb deficiencies. It is part of the chapter on acquired limb deficiencies in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses rehabilitation and prosthetic management of patients with amputations for complex limb deficiencies secondary to trauma. Mechanisms of injury, prosthetic issues, prosthetic components, and potential problems in prosthetic fitting will be discussed.

OVERALL ARTICLE OBJECTIVE

To evaluate common problems associated with complex limb deficiency.

Maintenance of adequate hemodialysis access. Prevention of neointimal hyperplasia

The maintenance of adequate hemodialysis vascular access is frequently complicated in the patient with polytetrafluoroethylene (PTFE) A-V hemodialysis grafts by venous anastomotic stenosis. This stenosis is caused by neointimal hyperplasia (NIH), a response to vascular injury. In this study, the authors prospectively analyzed the effect of a short-term regimen consisting of administration of two medications, heparin and low molecular weight dextran, on the development of NIH at the venous anastomosis in 79 patients with PTFE A-V hemodialysis grafts. In addition, they evaluated other parameters' effects on the development of NIH. In comparison with control subjects, heparin had some effect in minimizing the development of NIH in the PTFE grafts when evaluated radiologically at 3 months, although this effect was not statistically significant. Low molecular weight dextran, however, had no trend or statistically significant effect on this venous anastomotic narrowing. Interestingly, patient age, use of calcium channel blockers, and presence of diabetes mellitus (DM) all appeared to affect the development of NIH. Increasing age and use of calcium channel blockers was associated with decreased development of NIH; conversely, DM was associated with worsened NIH. In evaluation of access survival (time to first access failure), degree of venous anastomosis stenosis at 3 months was not predictive. Patient time on dialysis pre graft placement was the only measured parameter related to access failure. The method of dialysis pre graft placement (hemodialysis versus peritoneal dialysis) was not a significant factor in early access failure. Pharmacologic treatment of venous anastomotic narrowing in PTFE hemodialysis grafts due to NIH continues to be difficult. Short-term treatment with the tested medication failed to statistically affect NIH. Patient age, use of calcium channel blockers, and presence of DM were all factors in the development of NIH. Of measured parameters, time on dialysis pre graft placement was the only factor correlated with early access failure. In future treatment regimens, one should consider more prolonged treatment. In addition, noted risk factors should be considered when determining type of renal replacement therapy.

Microsurgical two-layer vasovasostomy: laboratory use of vasectomized segments

A microsurgical laboratory model is described which uses optimally preserved human vasectomy segments. These preserved specimens retain their natural appearance and handling qualities, permitting ready availability of material for practice, which is mandatory before clinical performance. If laboratory facilities are not available, the model can be used for practice in a convenient area of the operating suite.

An experimental study of end-to-side microvascular anastomosis

Forty-nine end-to-side arterial anastomoses were carried out in dogs. The saphenous artery was anastomosed to the femoral artery. Variations in technique were made regarding the shape of the aperture in the large artery and in the incident angle of the small artery. Blood flow was measured in the immediate postoperative period with electromagnetic flowmeters on the saphenous and femoral arteries. There was no significant difference in flow between each of the four types of anastomoses studied. In each of the flow was slightly, but not significantly, higher than the preoperative level.