Cross-sectional area of the abdomen predicts complication incidence in patients undergoing sternal reconstruction

Background

Sternal reconstruction with vascularized flaps is central to the management of sternal wound infections and mediastinitis but carries a high risk of complications. There is a need to identify reliable predictors of complication risk to help inform patients and clinicians in preparation for surgery. Unfortunately, body mass index and serum albumin may not be reliable predictors of complication rates. Analytic morphomics provides a robust quantitative method to measure patients' obesity as it pertains to their risk of complications in undergoing sternal reconstruction.

Methods

We identified 34 patients with preoperative computed tomography scans of the abdomen from a cohort of sternal reconstructions performed between 1997 and 2010. Using semiautomated analytic morphomics, we identified the patients' skin and fascia layers between the ninth and 12th thoracic spine levels; from these landmarks, we calculated morphomic measurements of the patients' abdomens, including their total body cross sectional area and the cross sectional area of their subcutaneous fat. We obtained the incidence of complications from chart review and correlated the incidence of complications (including seroma, hematoma, recurrent wounds, mediastinitis, tracheostomy, and death) with patients' morphomic measurements.

Results

Sixty-two percent of patients (n = 21) suffered complications after their operation. Those who suffered from complications, relative to those who did not have complications, had increased visceral fat area (12,547.2 mm²versus 6569.9 mm², P = 0.0080), subcutaneous fat area (16,520.2 mm²versus 8020.1 mm², P = 0.0036), total body area (91,028.6 mm²versus 67,506.5 mm², P = 0.0022), fascia area (69,238.4 mm²versus 56,730.9 mm², P = 0.0118), total body circumference (1101.8 mm versus 950.2 mm, P = 0.0017), and fascia circumference (967.5 mm versus 868.1 mm, P = 0.0077). We also demonstrated a significant positive correlation between the previously mentioned morphomic measurements and the incidence of complications in multivariate logistic regression models, with odds ratios ranging from 1.19–3.10 (P values ranging from 0.010–0.022).

Conclusions

Increases in abdominal morphomic measurements correlate strongly with the incidence of complications in patients undergoing sternal reconstruction. This finding may influence preoperative risk stratification and surgical decision making in this patient population.     

Isolation and characterization of fifteen microsatellite loci for the giant clam Hippopus hippopus (family Tridacnidae)

Fifteen polymorphic microsatellite markers were developed for Hippopus hippopus in order to assess the effectiveness of population replenishment within marine protected areas in New Caledonia. Number of alleles varied from 2 to 11 per locus, observed and expected heterozygosities ranged from 0.300 to 0.866 and 0.495 to 0.858 respectively. Significant deviations from HWE were detected in two loci. Cross-amplifications were tested in four other species of Tridacnidae.     

Identification of the 11-cis-specific retinyl-ester synthase in retinal Müller cells as multifunctional O-acyltransferase (MFAT)

Absorption of a photon by a rhodopsin or cone-opsin pigment isomerizes its 11-cis-retinaldehyde (11-cis-RAL) chromophore to all-trans-retinaldehyde (all-trans-RAL), which dissociates after a brief period of activation. Light sensitivity is restored to the resulting apo-opsin when it recombines with another 11-cis-RAL. Conversion of all-trans-RAL to 11-cis-RAL is carried out by an enzyme pathway called the visual cycle in cells of the retinal pigment epithelium. A second visual cycle is present in Müller cells of the retina. The retinol isomerase for this noncanonical pathway is dihydroceramide desaturase (DES1), which catalyzes equilibrium isomerization of retinol. Because 11-cis-retinol (11-cis-ROL) constitutes only a small fraction of total retinols in an equilibrium mixture, a subsequent step involving selective removal of 11-cis-ROL is required to drive synthesis of 11-cis-retinoids for production of visual chromophore. Selective esterification of 11-cis-ROL is one possibility. Crude homogenates of chicken retinas rapidly convert all-trans-ROL to 11-cis-retinyl esters (11-cis-REs) with minimal formation of other retinyl-ester isomers. This enzymatic activity implies the existence of an 11-cis-specific retinyl-ester synthase in Müller cells. Here, we evaluated multifunctional O-acyltransferase (MFAT) as a candidate for this 11-cis-RE-synthase. MFAT exhibited much higher catalytic efficiency as a synthase of 11-cis-REs versus other retinyl-ester isomers. Further, we show that MFAT is expressed in Müller cells. Finally, homogenates of cells coexpressing DES1 and MFAT catalyzed the conversion of all-trans-ROL to 11-cis-RP, similar to what we observed with chicken-retina homogenates. MFAT is therefore an excellent candidate for the retinyl-ester synthase that cooperates with DES1 to drive synthesis of 11-cis-retinoids by mass action.Light perception begins with the absorption of a photon by an opsin pigment in the membranous outer segment (OS) of a rod or cone photoreceptor cell. The light-absorbing chromophore in most vertebrate opsins is 11-cis-retinaldehyde (11-cis-RAL). Photon capture isomerizes the 11-cis-RAL to all-trans-retinaldehyde (all-trans-RAL), inducing conformational changes in the protein that lead to its active meta-II state. After a brief period of signaling through the transduction cascade, meta II decays to yield apo-opsin and free all-trans-RAL. Light sensitivity is restored to the apo-opsin when it combines with 11-cis-RAL to regenerate the pigment. Conversion of all-trans-RAL to 11-cis-RAL is carried out by a multistep enzyme pathway called the visual cycle, located in cells of the retinal pigment epithelium (RPE) (1, 2). The retinoid isomerase in this pathway is Rpe65, which converts an all-trans-retinyl ester (all-trans-RE), such as all-trans-retinyl palmitate (all-trans-RP), to 11-cis-retinol (11-cis-ROL) and a free fatty acid (3–5). Retinyl esters are synthesized in RPE cells by lecithin:retinol acyl transferase (LRAT), which transfers a fatty acid from phosphatidylcholine to retinol (6, 7). LRAT converts both all-trans-ROL and 11-cis-ROL to their cognate esters with similar catalytic efficiency (8).A second visual cycle is present in Müller cells of the retina, providing 11-cis-ROL to cones (9–11). Cones, but not rods, can use 11-cis-ROL as a chromophore precursor to regenerate bleached opsin pigments (10, 12, 13). The isomerase in the noncanonical pathway is dihydroceramide desaturase (DES1) (11). DES1 catalyzes rapid equilibrium isomerization of retinol (11). At equilibrium, 11-cis-ROL is much less abundant than all-trans-ROL, due to the 4.1 kcal/mole difference in free energy between these isomers (14). Accordingly, a secondary source of energy is required to drive the conversion of all-trans-ROL to 11-cis-ROL by DES1. Retinas from cone-dominant species contain 11-cis-retinyl esters (11-cis-REs), whereas retinyl esters are much less abundant in retinas from rod-dominant species (11, 13, 15). Homogenates from cone-dominant chicken and ground-squirrel retinas convert all-trans-ROL predominantly to 11-cis-REs in the presence of palmitoyl CoA (palm CoA) (13, 16, 17). These observations suggest that selective esterification of 11-cis-ROL may be the driving force for 11-cis-retinoid formation. In the current work, we sought to identify the protein responsible for the 11-cis-RE-synthase activity in Müller cells. We evaluated multifunctional O-acyltransferase (MFAT) as a candidate for this synthase. MFAT, also called acyl-CoA wax-alcohol acyltransferase-2 (AWAT2), catalyzes palm CoA-dependent synthesis of triglycerides, wax monoesters, and retinyl esters (18). It is present in the endoplasmic reticulum and predominantly expressed in skin (18). The retinol-isomer specificity of MFAT, and its expression in ocular tissues, has not been studied.     

Deoxygenation of the Baltic Sea during the last century

Deoxygenation is a global problem in coastal and open regions of the ocean, and has led to expanding areas of oxygen minimum zones and coastal hypoxia. The recent expansion of hypoxia in coastal ecosystems has been primarily attributed to global warming and enhanced nutrient input from land and atmosphere. The largest anthropogenically induced hypoxic area in the world is the Baltic Sea, where the relative importance of physical forcing versus eutrophication is still debated. We have analyzed water column oxygen and salinity profiles to reconstruct oxygen and stratification conditions over the last 115 y and compare the influence of both climate and anthropogenic forcing on hypoxia. We report a 10-fold increase of hypoxia in the Baltic Sea and show that this is primarily linked to increased inputs of nutrients from land, although increased respiration from higher temperatures during the last two decades has contributed to worsening oxygen conditions. Although shifts in climate and physical circulation are important factors modulating the extent of hypoxia, further nutrient reductions in the Baltic Sea will be necessary to reduce the ecosystems impacts of deoxygenation.Dead zones are hypoxic (low-oxygen) areas unable to support most marine life, and over the past 50 y they have spread rapidly in the open ocean (1) as well as in coastal ecosystems (2). Global warming is thought to be a major driver for these changes (3), although biogeochemical factors have also been recognized, especially in coastal marine ecosystems (4, 5). In the Baltic Sea, the present spread of hypoxia is the combined result of climate changes influencing deepwater oxygenation (6) and increased eutrophication (7, 8), resulting in a hypoxic area ranging between 12,000 and 70,000 km² with an average of 49,000 km² over the time period 1961–2000 (7). Here, we separate the effects of the two factors on oxygen conditions.Physical factors are an important consideration in whether an ecosystem will experience hypoxia. The Baltic Sea is naturally prone to hypoxia due to a restricted water exchange with the ocean and a long residence time above 30 y (9, 10). Saltier, denser water from the North Atlantic flows over a series of shallow sills in the Danish Straits to ventilate waters below the permanent halocline and are governed by meteorological-induced variations in sea levels (11), displaying variations at decadal scales (12, 13). The dense saltwater inflows bring new supplies of oxygen to bottom waters, but at the same time enhance stratification, creating larger bottom areas that experience hypoxia (14). In particular, the ventilation of the deeper waters is attributed to events of larger inflows of high-saline water (>17), termed Major Baltic Inflows (MBIs), that have been less frequent in the last three decades (6).Climate warming decreases oxygen solubility due to higher water temperature, increases stratification, and enhances respiration processes (15). Climate warming is likely to be accompanied by increased precipitation and inflows of freshwater and nutrients to coastal waters in many areas of the globe. Increasing nutrient inputs from land stimulates primary production and export of organic material to the deep waters, thereby disrupting the subtle natural balance between oxygen supply from physical processes and oxygen demand from consumption of organic material. However, the importance of decreasing oxygenation versus increasing nutrient inputs for explaining the recent spread of hypoxia is not known (6, 7).Water column measurements of dissolved oxygen concentrations began around 1900 with more regularly spaced measurements commencing in the 1960s (Fig. S1), allowing a more consistent assessment of the spatial extent of hypoxia (7, 14). The sparse temporal and spatial resolution of oxygen data before 1960 allowed only assessing hypoxia at specific locations (16) or specific years (17). To our knowledge, our study is the first to report basin-wide trends of stratification and oxygen conditions from 1898 to present, and here we will focus on the two basins that have perennial hypoxia—the Bornholm Basin and the Gotland Basin (Fig. S2). These two basins are connected via a channel with a sill depth of 60 m.