Repeated use of the same myocutaneous flap in difficult second operations of the head and neck.

We have found that the pectoralis major myocutaneous flap is so reliable a flap that in seven selected patients we completely re-elevated, isolated, and transposed it to a new reconstructive site in the head and neck. This may be accomplished safely, despite full courses of external-beam radiation therapy to the flap. We discuss the principles of this and propose that it can be extended and applied to other island, pedicle, or free flaps. The manner in which the flap can be reused and integrated with microvascular transfer or other regional pedicle flaps in complex secondary operations must be determined by the individual reconstructive surgeon on the basis of the requirements of the reconstruction. This technique will make one more tool available to the surgeon for reconstruction.

Rose Questionnaire angina among United States black, white, and Mexican-American women and men. Prevalence and correlates from The Second National and Hispanic Health and Nutrition Examination Surveys.

The prevalence of Rose Questionnaire angina and its association with coronary heart disease risk factors and manifestations were investigated in representative samples of the US population. The study populations included 1,135 black and 8,323 white subjects aged 25-74 years examined in the Second National Health and Nutrition Examination Survey, 1976-1980, and 2,775 Mexican-American subjects aged 25-74 years examined in the Hispanic Health and Nutrition Examination Survey, Mexican-American portion, 1982-1983. Age-adjusted prevalence rates of Rose angina were similar among black, white, and Mexican-American women (6.8%, 6.3%, and 5.4%, respectively). An excess in the prevalence of Rose angina was observed in women compared with men for white and Mexican-American persons under age 55 years, but not for those over age 55. Electrocardiographic evidence of myocardial infarction and self-reported heart attack were strongly associated with prevalent Rose angina among white men and women aged 55 years and over, but not among those below age 55. Serum cholesterol, body mass index (weight (kg)/height (m)2), current cigarette smoking, and dyspnea were independently associated with an increased risk of prevalent angina in multivariate logistic models for white women, excluding those with a prior heart attack. Because many younger women with chest pain who may consult physicians are likely to have elevations in cardiovascular risk factors, their self-reported chest pain can be used as an opportunity to intervene and reduce their future risk of cardiovascular disease.

Urban-rural differences in 12 year coronary heart disease mortality: the Puerto Rico Heart Health Program.

Preliminary observations of the Puerto Rican population in 1965 indicated that the coronary heart disease mortality rate was lower than in the U.S., and that the rate in rural areas might be less than urban ones because of lower levels of cardiovascular risk factors. This prompted a prospective investigation of 8793 urban and rural men, aged 45-64 years. A 12-year mortality study has been completed with almost total follow-up. After excluding those with known coronary heart disease at baseline, age-adjusted rates for coronary heart disease, sudden, and stroke death are 19-37% higher in urban than rural men. Urban men had higher average blood pressure, cholesterol, glucose, and heart rate and were less physically active than rural men. When urban-rural differences for the known risk factors, including education and alcohol intake, are adjusted for by multivariate logistic regression analysis, no remaining significant urban-rural coronary heart disease mortality differential is present. Thus, it appears that variation in identified risk factors could explain the difference in mortality within Puerto Rico. The presence of unidentified protective factors cannot be excluded.

Milk consumption, calcium intake, and decreased hypertension in Puerto Rico. Puerto Rico Heart Health Program study.

The baseline observations in the Puerto Rico Heart Health Program during 1965-1968 involved blood pressure determinations, other measurements, and a 24-hour dietary recall in 7932 men aged 45-64 years. This extensive data base provided an opportunity to test the hypothesis that low calcium intake is related to increased blood pressure level. Among men without baseline coronary heart disease and not taking antihypertensive medication, there was an inverse relationship between milk consumption and definite hypertension in urban Puerto Rican men and older rural men. When data from all age and area groups had been averaged, a twofold increase in hypertension was found in subgroups who drank no milk compared to those who consumed over 1 quart of milk a day. Similar trends were found when an estimate of total calcium intake from food, principally from milk, was used. With multivariate analysis while known correlates of blood pressure were simultaneously considered, an independent effect persisted between milk consumption and blood pressure. These results appeared to confirm an inverse association between calcium and hypertension. It was still not possible to ascribe a causal relationship between calcium and blood pressure, however, due to the intricate network of covarying food intakes, the factors related to absorption or lack of absorption of calcium, and the possible role that unmeasured social and cultural factors may play in the observed relations.

Juvenile hypertension: highlights of a workshop.

The workshop was successful in achieving its two major goals: (1) the scientific updating of research issues in pediatric blood pressure determinants and in pediatric hypertension, and (2) the delineation of future research objectives. These objectives are itemized at the end of the workshop proceedings and, in brief, center around the need for better definitions of normal and abnormal blood pressures in youth, the identification of variables in childhood capable of indicating which children are at risk for developing hypertension as adults, and finally, a thoughtful list of additional research issues germane to the explanation of primary and secondary forms of hypertension.

Abnormal blood glucose and coronary heart disease: the Puerto Rico Heart Health Program.

The presence of abnormal blood glucose (ABG) was determined for participants in the Puerto Rico Heart Health Program, a prospective epidemiological study of cardiovascular disease. Subjects were considered to have ABG at baseline if they were receiving treatment for diabetes (diet, oral hypoglycemics, or insulin), or if the blood glucose level was 140 mg/dl or more. Urban-rural comparisons of the prevalence of ABG were made in this cohort of 2585 rural and 6208 urban men aged 45-64 yr. The prevalence of ABG in the urban population was more than double that in the rural. This population has been followed up for coronary heart disease (CHD) over an 8 1/4-yr period. ABG at baseline is significantly associated with CHD death in urban men. When the relationship is controlled for smoking, systolic blood pressure, cholesterol, and relative weight, the relationship remains significant. The association with total CHD is similar. Either by adjusting for diabetes (i.e., when treated diabetes was excluded from analysis) or by entering both blood glucose and diabetes under treatment into the model, blood glucose was no longer statistically significant. This suggests that ABG, rather than blood glucose alone, is the important variable associated with CHD.

Alcohol and coronary heart disease in Puerto Rico.

The relationship of alcohol consumption, measured in 1965-1968 by the 24-hour recall method, to incident coronary heart disease morbidity at eight years and mortality at 12 years of follow-up was investigated in a cohort of 9150 Puerto Rican males 35-79 years of age. After adjustment for age, cigarettes, exercise, urban/rural status, and income, there was clear evidence of a "U-shaped" relationship between alcohol and total mortality, and also the suggestion of a "J-shaped" relationship for angina pectoris, nonfatal myocardial infarction, and nonsudden coronary heart disease death. There was no association of alcohol with sudden cardiac death. The adjusted odds ratio for drinkers versus nondrinkers was 0.6 for angina pectoris (p less than 0.05), 0.7 for nonfatal myocardial infarction (p less than 0.1), and 0.7 for nonsudden coronary heart disease death (p less than 0.05). The inverse association of alcohol consumption to nonsudden coronary heart disease death was found to be dependent on age and income: the adjusted odds ratio for subjects under age 60 (0.4) or over the median income (0.3) strongly favored drinkers, while there was no evidence for a "protective effect" of alcohol consumption in the older and poorer segments of the population. It is concluded that available evidence does not justify the assertion that the inverse association between moderate alcohol intake and coronary heart disease risk is a causal one.

Increased physical activity: a protective factor against heart attacks in Puerto Rico.

The incidence and potential risk factors of coronary heart disease were assessed in 2,585 rural and 6,208 urban men, aged 45 to 64 years, participating in the Puerto Rico Heart Health Program, a prospective epidemiologic study of coronary heart disease initiated in 1965. An index of daily physical activity and a metabolic equivalent of heaviest activity were estimated from each individual history. Rural men had higher mean levels of overall activity as well as higher levels of heavy activity than urban men. An 8 1/4 year follow-up study for coronary heart disease other than angina pectoris was analyzed for relationships with physical activity. Significant inverse associations were found for both urban and rural men. Metabolic equivalent of heaviest activity showed similar results. Although the physical activity index was inversely associated with most known coronary risk factors, multivariate analyses indicated that a significant independent inverse relationship existed with the incidence of coronary heart disease. In Puerto Rico, increased physical activity appears to be a separate protective factor against heart attacks.

An apparent inverse relationship between serum cholesterol and cancer mortality in Puerto Rico.

In the Puerto Rico Heart Health Program, a prospective epidemiologic study, 9824 men living in defined urban and rural areas of Puerto Rico have been followed for approximately eight years. Periodic examinations have been used to assess potential cardiovascular risk factors and to monitor coronary heart disease events. Although the emphasis of the study has been oriented to cardiovascular disease, all causes of death have been closely monitored. During the observation period, 179 deaths from cancer have occurred in the age group 45--64 years. The distribution of cancer deaths varies from that of the mainland, with a greater percentage being oral, pharyngeal and stomach, and a lesser frequency being lung. Serum cholesterol measured at the first examination in 1965 was found to vary inversely with subsequent mortality from cancer. This trend was significant overall for the rural area and in the age group 45--54 years in the urban area. Multivariate analysis with other covariables did not eliminate the cholesterol relationship in the rural men, although relative weight, ventricular rate, hematocrit and cigarette smoking made independent contributions in certain age groups in both locations. The association between serum cholesterol and cancer mortality in the rural area and in the young urban area suggests that further investigation is needed to determine whether the relationship is causal, a secondary association to some other unidentified set of primary factors, or merely a physiological reaction to early and undiagnosed stages of the cancer process.

The relation of antemortem factors to atherosclerosis at autopsy. The Puerto Rico Heart Health Program.

Among 9824 Puerto Rican men, aged 35-79, participating in a prospective study of cardiovascular risk factors, there were 970 deaths during the period 1965-1977. About 14%, or 139, of these deaths had a protocol autopsy following the procedures of the International Atherosclerosis Project. The percentage of involvement with raised atherosclerotic lesions in the coronary arteries was higher in the urban deceased than in the rural. The coronary heart disease death rate was also found to be higher in urban than in rural men in this population. Serum cholesterol and systolic blood pressure measured from up to 8 years before death were related both to raised lesions in the coronary arteries and in the aorta. Age and previous smoking status were associated with lesions only in the aorta. These results lend support for an etiologic relationship between serum cholesterol and blood pressure and the atherosclerotic process.

Hematocrit and risk of coronary heart disease: the Puerto Rico Health Program.

Hematocrit was determined in 2555 rural and 6151 urban men age 45 to 64 years participating in the Puerto Rico Health Program, a prospective epidemiologic study of coronary artery disease (CAD). These participants were reexamined three additional times and mortality by cause and coronary heart disease (CHD) morbidity were carefully documented for 8 years of follow-up. Since hematocrit (Hct) is an indirect measure of blood viscosity, its value an an independent risk factor of CHD was evaluated. Within the Puerto Rican cohort, Hct is slightly lower in older age groups, and appears slightly lower in the rural than in the urban area. In the rural area 4.6% had Hct values below 40%; in the urban area 3.0% were below 40%. A higher Hct level was associated with cigarette smoking, higher relative weight, higher blood pressure, and higher serum cholesterol. An elevated Hct level was also associated with an increased risk of myocardial infarction (MI), coronary insufficiency or CHD death in the urban area. Incidence of MI, coronary insufficiency, or CHD death was more than double in the high hematocrit group (Hct greater than 49%) compared to the low group (Hct less than 42%). Using a multivariate logistic function, the relationship remained statistically significant after adjustment for the above mentioned risk factors. These results provide further insight concerning the issue of the potential impact of elevated Hct as an independent risk factor contributing to the incidence of CHD mortality and morbidity.