Two decades of research on etiology and genetic factors in the abdominal aortic aneurysm (AAA)--with a glimpse into the 21st century

Long gone are the days when the question of "etiology" of the abdominal aortic aneurysm (AAA) required a simplistic response. AAA is caused by an interplay of environmental and genetic factors, each of which may modify the expression of the other. A low penetrance, an insidious onset, and a wide distribution have forced scientists to rely on complex approaches to elucidate the pathophysiology of AAA. Hypotheses over the last twenty years have evaluated several components of connective tissue structure, function, and regulation. Although there has been considerable overlap in the many genetic approaches undertaken to explain aneurysm development, research recently has focused on reverse-engineering techniques. While earlier investigations using a "forward" or "candidate gene approach" have provided many insights in the understanding of AAA disease, advances in statistical modeling, new techniques in molecular biology, and gross computing power have now made more feasible the development of a reverse approach. New hope lies with the development of biochemical and computing tools which have paralleled information's vast dissemination in this rapidly widening field. Aortic inflammation and the upregulation of proteases and dysfunctional tissue-turnover are receiving more attention. No doubt, the interplay of all of these technologies will occupy investigators with an interest in AAA etiology for many years to come.     

Things you never thought of that make a difference: personal goals, common sense, and good behavior in practice

There are many aspects of your practice that you never think of when you first get into your new practice environment. You have spent the better part of your life training in a rigorous surgical residency and possibly fellowship. You have worked hard to get to this station in life. Because of your training and the obvious fact that you are a hard-driving individual, there are certain subtleties to a successful practice that you might have overlooked or never thought about during your training years. In many ways, it is the "little things" that you never learned or never thought of that will affect your overall long-term practice success, personal happiness, and relationships the most. This article reviews aspects of practice that at first glance are merely good common sense.     

Cervicomental "Turkey Gobbler": A New Source for Full-Thickness Grafts

A LARGE NUMBER of sources for full-thickness grafts have been described. The concepts of adapting liposuction techniques from cosmetic surgery to reconstructive surgery, especially with flap reconstructions, have been well documented by this author and others in many forums over many years. ^1–7 However, obtaining the excess skin of the lower neck in those patients with "turkey gobbler" deformities utilizing liposuction aspiration and dissection techniques has not been previously documented. This same approach might at times be valuable in very obese necks with excessively redundant skin as well.     

Xenotransplantation: the good,the bad,and the ugly or how far are we to clinical application?

On the way to successful clinical XTP many obstacles have to be overcome, and new difficulties might still arise. For clinical XTP all "players of the concert" have to harmonize. It is not enough if one molecule is recognized by its receptor. A chain is only as strong as its weakest link; this is also true for xenogeneic immunology, physiology, and pharmacology. The phylogeneic distance between man and pig comprises 180 million years. This tremendous distance has to be bridged by new and still unknown methods to outwit evolution.     

Controlled tissue expansion in reconstructive surgery

Controlled soft tissue expansion by encouraging the development of tissues which are ideally matched in colour, texture and hair-bearing qualities to a given donor defect, offers a new, safe and widely applicable technique in reconstructive surgery. Over the past four years we have used this technique to reconstruct "difficult" defects in many parts of the body. When necessary, synthetic implants or bone grafts have been successfully implanted beneath the expanded tissues.     

Stem cell characteristics of human trabecular bone-derived cells

Human trabecular bone-derived cells (HTBs) have been used for many years as osteoblast progenitors. In this study we tested whether HTBs have stem cell characteristics; that is, whether they are pluripotent and able to self-renew. We show that HTBs readily differentiate into osteoblasts, chondrocytes, and adipocytes if subjected to the appropriate differentiating conditions. Importantly, differentiation into these three lineages is maintained in single cell clones derived by limiting dilution, following expansion over more than 20 cumulative population doublings. We conclude that cultures of HTBs are equivalent to cultures of "mesenchymal stem cells" (MSCs) isolated from bone marrow.     

Adrenaline: isolated 111 years ago by an energetic Japanese scientist, Jokichi Takamine

Adrenaline is one of the most commonly used drugs in anesthesia, intensive care and pain medicine. This organic substance was first isolated by a Japanese scientist, Jokichi Takamine, with an ingenious technical assistance by Keizo Uenaka. Although 111 years have passed from their success, the brightness of this achievement has never faded. Also, conflicts provoked after the invention suggest many fundamental issues regarding scientific invention and business. Anesthesiologists, who take big benefits of adrenaline, should correctly understand how this useful drug became available widely in the world and why the name was fluctuated between "adrenaline" and "epinephrine".     

Restrict or enforce the preoperative clear liquid intake?: preface and comments

Restriction of preoperative clear liquid intake causes thirst in many patients but is followed traditionally for many years in the preoperative order by an anesthesiologist in charge. Although many anesthesiologists doubted long the efficacy of this tradition, no one has stopped. In 1999, the ASA guideline on restriction of preoperative clear liquid intake was published. However, this guideline was not yet followed in many institutes and hospitals in Japan. In 2005, the report from north European countries was published and introduced the new idea "Enhanced Recovery after Surgery, ERAS" which consists of many factors. Among these factors, the enforcement of preoperative clear liquid intake was reviewed in this volume.     

Problems with the intraurethral spiral]

In the last decade numerous attempts have been undertaken in non-surgical treatment of benign prostatic hyperplasia in order to enable the patient to void his bladder under control, without residual urine and without surgical resection. For the time being, attempts with drug therapy, as well as the more invasive methods with thermic or dilating effect on the prostatogenic infravesical obstruction are based on empiric studies. For many patients transurethral or suprapubic long-term catheterisation is, after all, the only solution. In this respect the "urologic spiral" represents a conservative alternative. In 1980 Fabian was the first to report on the successful clinical application of the intraprostatic "partial catheter" in 2 patients. 4 years later Fabian's remarkably good results in 48 patients are promising. However, what strikes first as an efficient innovation may also have its shortcomings and complications, as it was our experience in the first applications.     

Living Unrelated Kidney Transplantation

The use of living donors, particularly if unrelated, in kidney transplantation is still not recommended although many transplant centers have come to accept the procedure. Usually the main argument against this approach is ethical. Acknowledging this problem, we accept biologically unrelated donors only if they have an emotional closeness to the recipient. From November 1982 to November 1997, 527 kidney allografts from living donors were performed at our institution. Of these 302 living donors were first-degree relatives of the recipient and shared one haplotype (LRD) and 172 were unrelated(LURD). Among the LURD group 146 donors were "emotionally related"--wife to husband 110 cases and husband to wife 35 cases and 1 case from a nun to a friar. Statistical analysis of the results was performed with the chi(2) method. Actuarial graft survival rates in the LRD and LURD groups were 91% and 87% at 1 year, 77% and 79% at 5 years, and 66% and 69% at 9 years (P =n.s.). In conclusion kidney transplantation between unrelated donors and recipients may be a valid alternative in view of the cadaver organ shortage. It is a procedure that can be performed successfully and that provides a "gift of life" for both the patient and the family.     

The Pierre Robin syndrome reassessed in the light of recent research

For many years clinicians have known the coincidental presentation of micrognathia, glossoptosis and cleft palate as the Pierre Robin syndrome. In conferences in 1974 and 1975 the term "Anomalad" was introduced which by definition is a primary malformation with superimposed secondary structural changes and the Pierre Robin syndrome became known as the Robin Anomalad. The concept was based on experimental observations available at that time. However, since that date further studies have demonstrated that administration of drugs to pregnant female rodents can produce coincidental failure of normal development of both mandible and palate. In the light of this work a critical review is made of the evidence upon which the mechanistic view of the condition evolved and an alternative hypothesis developed. From animal experimentation it can be argued that the nature of the condition is not mechanical and is more likely to be metabolic. Indeed, confirmatory evidence in man has recently been presented from Finland. If this is the case it may be erroneous to consider the Robin malformations as an "Anomalad" and mandibular maxillary agenesis would probably be a more accurate term.     

Long-term high-flow priapism. Case review and proposal of diagnostic algorithm and treatment

High-flow priapism is an infrequent pathology in Urology, specially long-term cases as the one we present. Literature is scarce and both diagnostic methods and treatment have remained unchanged for many years We present a high flow priapism case that has lasted for 30 years, but which is well tolerated and even desired by the "patient". Furthermore, we propose a new diagnostic algorithm and treatment.     

Breast implant materials: sense and safety.

Cosmetic breast augmentation, and post-mastectomy breast reconstruction surgery using synthetic implants, have become established in surgical practice over more than 20 years. The operative technique for implant placement have changed somewhat during this time, as many different implant presentations have become available, but the same basic materials have remained in use. We have reviewed the present state of knowledge about breast implant materials with particular reference to the possible connection between polydimethylsiloxane and polyurethane to the so-called "Human Adjuvant Disease", and to carcinogenesis. Problems related to capsular contracture and mammography are also discussed.     

A young surgeon's perspective on alternate surgical training pathways

Most residents in training today are in focused on their training, and the thoughts of changing the structure of residencies and fellowships is something that they are ambivalent about or have never heard anything about. The small minority who are vocal on these issues represent an activist group supporting change. This group is very vocal and raises many of the excellent questions we have examined. In discussion with residents, some feel that shortened training will help with the financial issues facing residents. However, many people today add additional years to their training with research years or "super" fellowships. The residents demonstrate that they want to get the skill sets that they desire despite the added length of training. This is unlikely to change even if the minimum number of years of training changes with the evolution of tracked training programs. Medical students, in the Resident and Associate Society of the American College of Surgeons survey, did not indicate that shortened training would have an affect on decision to pursue or not pursue a surgical career. If the focus of these changes is to encourage medical students to pursue a residency in surgical specialties, we may need to look at other options to increase medical student interest. Medical students indicated that lifestyle issues, types of clinical problems, stress-related concerns, and interactions with the surgical faculty were far more important in their decision to enter a surgical specialty than work hours or duration of training. If we are to make a difference in the quality and quantity of applicants for surgical residencies, then changes in the structure of residencies do not seem to be the most effective way to accomplish this. We should possibly focus more on faculty and medical student interaction and the development of positive role models for medical students to see surgeons with attractive practices that minimize some of the traditionally perceived negative stereotypes. Residents in general surgery training programs often do not make decisions on the type of fellowship that they will pursue until late in their residency. Many residents are apprehensive about these types of tracked training programs because it will accelerate the timeline for choosing a track. Changes in the structure of residency and fellowships would result in residents having to decide and "match" in their second or third postgraduate years of training instead of the fourth or fifth postgraduate year time frame. Many residents will not have been exposed to all of the types of tracks by their third postgraduate year and many voice concerns over being ready to make this decision that early in their training. Acceptance and enthusiasm about this concept among all residents will likely depend on the final version of any planned changes. A wholesale rewrite of surgical training in the United States would likely not be well received. However, the addition of alternate pathways, on a limited scale and under close scrutiny and supervision, could evaluate interest and ease into this type of program. Before embarking on massive changes in surgical training, scientific, statistically valid research determining the interest of residents in these types of programs will target changes to make these programs successful.     

Burn care costing: the Welsh experience

It has been accepted for many years that the cost of care for the burn-injured patient is high. There is, however, little published data to show how "expensive" it is. At the Welsh Centre for burns we have undertaken a costing exercise in an attempt to define the true cost to the treatment of burns. Using our current cost base and activity, we established a cost per health related group (HRG) for burns and also prospectively calculated costs for three inpatients to determine whether HRG-based burn tariffs accurately represent these costs. The NHS is under increasing pressure to provide evidence to support budgetary requirements; we feel this paper offers a framework for burn care costing upon which calculations could be based.     

Changes in arterial pressure during mechanical ventilation

Mechanical ventilation induces cyclic changes in vena cava blood flow, pulmonary artery blood flow, and aortic blood flow. At the bedside, respiratory changes in aortic blood flow are reflected by "swings" in blood pressure whose magnitude is highly dependent on volume status. During the past few years, many studies have demonstrated that arterial pressure variation is neither an indicator of blood volume nor a marker of cardiac preload but a predictor of fluid responsiveness. That is, these studies have demonstrated the value of this physical sign in answering one of the most common clinical questions, Can we use fluid to improve hemodynamics?, while static indicators of cardiac preload (cardiac filling pressures but also cardiac dimensions) are frequently unable to correctly answer this crucial question. The reliable analysis of respiratory changes in arterial pressure is possible in most patients undergoing surgery and in critically ill patients who are sedated and mechanically ventilated with conventional tidal volumes.     

A method for protecting the anastomosis in deep inferior epigastric artery perforator flap breast reconstruction

In cases of microvascular breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps, many authors often express concern about possible trauma to the microanastomosis from the suction drain routinely placed in the wound at the end of the case. The senior author has devised and practiced for many years a novel technique to protect the anastomosis from this potential trauma in breast reconstructions. This technique involves harvesting a "sleeve" of scarpa's fascia in the direction of the planned orientation and inset of the flap pedicle. In our experience, this technique is effective and robust, and we would like to recommend this to others for use in their DIEP flap reconstructions.     

Partial Left Ventriculectomy: Have Well-Succeeded Cases and Innovations in the Procedure Been Observed in the Last 12 Years?

OBJECTIVE

In 1996, the Brazilian cardiovascular surgeon, Dr. Randas Batista, introduced a surgical technique called partial left ventriculectomy, where he admitted the possibility of reducing the diameter of the left ventricle through the sectioning of one section of its wall. After the publication of this study, thousands of case reports and procedure analysis have been published, and due to several disappointing results, many doctors and institutions failed to execute it. As the main objective of this study, stands out the search for success cases of ventriculectomy in the last 12 years and if during this period it was achieved some significant development in this procedure that allows obtaining lower mortality rate postoperatively.

METHODS

Systematic review of indexed scientific literature over the past 12 years and the term "Partial Left Ventriculectomy".

RESULTS

There has been a considerable number of reported successful cases and highly significant findings in regard to determining the most suitable region for the section, proper selection of the patients indicated to the procedure, including the influence of the coronary artery anatomy in the nomination procedure and the need for preservation of ventricular geometry to ensure better quality of ventricular contractions after the sectioning.

CONCLUSION

This surgical procedure has been successfully performed, mainly in Japan, improvements in its efficiency were found and the need for a mathematical modeling of the slice to be severed is a prominent factor in many studies.     

Patellofemoral arthroplasty in the treatment of patellofemoral arthritis: rationale and outcomes in younger patients

Patellofemoral degenerative disease encompasses a spectrum of articular wear from severe chondrosis to advanced arthrosis. The rationale and timing for many operative approaches currently advocated for the relief of symptomatic patellofemoral degeneration can be the subject of intense surgical debate in any one patient. Unfortunately, the limited efficacy of many commonly advocated operative procedures has left a legacy of patellofemoral disability in many younger individuals. While total knee arthroplasty has an established role in the treatment of advanced patellofemoral arthritis in the older patient (age >60 years), the performance of what some have called "a knee joint amputation" in younger patients (age <45 years) remains controversial and less acceptable to patients. The Avon patellofemoral prosthesis is a second-generation knee joint-conserving device that has consistently achieved good to excellent results in both the primary treatment and salvage of patellofemoral degenerative disease in younger patients. In addition, patellofemoral arthroplasty has demonstrated success as a unique functional, tibial-femoral joint-conserving solution in a variety of other patellofemoral extensor mechanism problems.     

Living kidney transplantation between spouses: Results in 100 cases

Abstract The use of unrelated living donors in kidney transplantation is still controversial but many transplant centres have accepted this procedure. The main argument against this approach is usually an ethical one. Because of this, at our institution we accept biologically unrelated donors only if they have an emotional closeness to the recipient. From January 1983 to October 1993, out of 654 kidney transplantations we performed at our institution, 364 kidney allografts were from living donors. Of these living donors, 245 were first-degree relatives of the recipient (LRD) while 119 were unrelated (LURD); 100 cases were spouses-wife to husband in 76 cases and husband to wife in 24 cases Statistical analysis of the results (chisquare) revealed actuarial patient and graft survival rates of 89.8% and 86.8% at 1 year, 82.9% and 72.3% at 5 years and 12.3% and 60.3% at 9 years, respectively. In our series, the result of living donor kidney transplantation in this group were similar to those obtained in the LRD group, while they were significantly better than those from cadaver donors (P = 0.003). In conclusion, cadaver organs given the shortage of kidney transplantation between spouses may be a good alternative and can be performed successfully, providing a "gift of life" for both the patient and the family.