Experience with More Than 5,000 Cases in Which Monitored Anesthesia Care Was Used for Liposuction Surgery

Background Conscious sedation using monitored anesthesia care can provide a clinical spectrum from relaxation to moderate anesthesia. This middle ground between general anesthesia and pure tumescent liposuction can help facilitate patient comfort and surgical proficiency during the procedure.Objective To describe a method of liposuction surgery with monitored anesthesia care in which a designated licensed and qualified individual is responsible for administration of supplemental intravenous conscious sedation as well as continuous monitoring of the patient.Methods Conscious sedation is induced with midazolam, and the patient is titrated to level II-V on the Ramsey sedation scale with propofol. The basic surgical technique is that of tumescent liposuction. However, the supplemental conscious sedation allows the tumescent fluid to be infiltrated at higher rates and fat extraction to be completed in a shorter period with minimal or no discomfort.Results In the authors experience with more than 5,000 cases of liposuction surgery using this method, safety and efficacy have been proved. No patients have experienced significant adverse effects.Conclusion Tumescent liposuction surgery with monitored anesthesia care provides a middle ground between general anesthesia and purely tumescent liposuction.     

Vestibulopathy and age effects on head stability during chair rise

It is unknown how vestibular dysfunction and age differentially affect balance control during functional activities. The objective of this study was to gain insight into the effects of age and vestibulopathy on head control when rising from a chair. Head relative to trunk (head-on-trunk) sagittal plane angular and linear control strategies were studied in patients with bilateral vestibular hypofunction (BVH) and in healthy subjects aged 30-80 years. A two-way analysis of variance was used to compare head-on-trunk kinematics by age (young vs elderly) and diagnosis (healthy vs BVH) at the time of liftoff from the seat. Angular control strategies differed with age but not diagnosis: young (healthy and BVH) subjects stabilized head rotations in space while elderly (healthy and BVH) subjects stabilized head rotations on the trunk. In contrast, linear control strategies differed by diagnosis but not age: BVH subjects (young and old) allowed a greater rate of head-on-trunk translation while healthy subjects (young and old) inhibited such translations. Young BVH subjects stabilized head-in-space rotations (as did young healthy subjects) without a functioning vestibular system, suggesting cervicocollic reflex and/or other sensory compensation for vestibular loss. Elderly BVH subjects stabilized head rotation with respect to the trunk, as did healthy elders, but did not stabilize head-on-trunk translations, suggesting a reliance on passive mechanical responses of the neck to sense head movements. We conclude that compensation strategies used by patients with vestibulopathy are age-dependent and appear to be more tractable in the younger BVH patient.     

Dermatologic surgery into the next millennium, part II

This is the second article in a 4-part series on dermatologic surgery. This section provides detailed information about filling agents and botulinus toxin A. The filling agents discussed here are frequently used in our office. It is emphasized that meticulous technique and patient selection predict a good cosmetic result. To select the right agent, patient safety must be a priority.     

Calorie restriction in nonhuman primates: mechanisms of reduced morbidity and mortality

Long term chronic calorie restriction (CR) of adult nonhuman primates significantly reduces morbidity and increases median age of death. The present review is focused upon an ongoing study of sustained adult- onset calorie restriction, which has been underway for 15 years. Monkeys, initially calorie restricted at about 10 years of age, are now approximately 25 years old. The median life span of these restricted monkeys is increasing, now exceeding that of ad libitum (AL)-fed monkeys. In our laboratory, maximum life span for AL-fed monkeys appears to be about 40 years. Thus, whether CR can also increase maximal life span, as it does in rodents, cannot be determined for at least another 15 years. The earliest detectable positive benefit on morbidity in these monkeys was previously reported as the prevention of obesity. Current evidence, as reviewed here, suggests that much obesity- associated morbidity is also mitigated by sustained calorie restraint in nonhuman primates. Furthermore, probably because of the prevention of obesity, diabetes has also been prevented. Recent findings include the identification of extraordinary changes in the glycogen synthesis pathway, and on the phosphorylation of glycogen synthase in response to insulin. This calorie restriction-induced prevention of morbidity does not require excessive leanness, but is clearly present when body fat is within the normal range of 10 to 22%, and this is likely to be true in humans as well.      

Extracellular mutations of protease-activated receptor-1 result in differential activation by thrombin and thrombin receptor agonist peptide

The protease-activated thrombin receptor-1 (PAR-1) can be activated by both the tethered ligand exposed by thrombin cleavage and a synthetic peptide having the tethered ligand sequence (thrombin receptor agonist peptide or TRAP). We conducted a mutational analysis of extracellular residues of the receptor potentially involved in interaction with both the tethered ligand and the soluble peptide agonist. Agonist-stimulated calcium efflux in X. laevis oocytes or inositol phosphate accumulation in COS-7 cells was used to assess receptor activation. We have also examined the binding of a radiolabeled TRAP for the wild-type and mutant PAR-1 receptors. Our results indicated that most of the mutations strongly affected TRAP-induced responses without significantly altering thrombin-induced responses or TRAP binding. Several point mutations and deletion of extracellular domains (DeltaEC3, DeltaNH3) drastically altered the ability of mutant receptors to respond to TRAP, but not to thrombin, and did not affect the affinity for the radiolabeled TRAP by these mutant receptors. Only mutations that disrupted the putative disulfide bond or substitution of multiple acidic residues in the second extracellular loop by alanine had a significant effect on both ligand binding and thrombin activation. These results suggest that although both agonists can activate PAR-1, there are profound differences in the ability of thrombin and TRAP to activate PAR-1. In addition, we have found PAR-1 mutants with the ability to dissociate receptor-specific binding from functional activity.     

Physical and pharmacologic restraint of nursing home patients with dementia. Impact of specialized units

This case-control study of 31 specialized dementia units and 32 traditional units in five states investigated use of physical and pharmacologic restraints among 625 patients with the diagnosis of dementia. Physical restraints were observed in use on 18.1% of dementia unit patients and on 51.6% of comparison unit patients who were out of bed during the day (adjusted odds ratio, 0.283;95% confidence interval, 0.129 to 0.619). Pharmacologic restraints were routinely given to 45.3% of dementia unit patients and 43.4% of comparison unit patients (adjusted odds ratio, 0.950; 95% confidence interval, 0.611 to 1.477). We used multivariate logistic regression to identify residence in a nonspecialized nursing home unit, nonambulatory status, transfer dependency, mental status impairment, hip fracture history, and a high nursing staff-to-patient ratio, which we found to be independent predictors of physical restraint use. Physically abusive behavior, severe mental status impairment, and frequent family visitation were found to be significant predictors of pharmacologic restraint use, while advanced patient age, large nursing home size, and patient nonambulatory status were protective against such use. These results support the conclusion that physical and pharmacologic restraint constitute separate treatment modalities with different risk factors for use, and indicate that specialized dementia units are successful in reducing the use of physical but not pharmacologic restraints.     

Noncardiogenic pulmonary edema caused by decompression sickness: rapid resolution following hyperbaric therapy

Noncardiogenic pulmonary edema is a recognized but uncommon manifestation of type 2 decompression sickness. It typically occurs within 6 hours of a dive. Because the adult respiratory distress syndrome in this setting is believed to be due to microbubbles in the pulmonary vasculature, recompression in a hyperbaric chamber has been recommended as a form of therapy. A patient developed noncardiogenic pulmonary edema following a seawater dive to 75 feet. There was complete radiologic and clinical resolution within 5 hours of hyperbaric therapy.