Characterisation of angiogenetic growth factor production in adipose tissue-derived mesenchymal cells.

Optimal vascularisation of the graft site is significant for improving the outcome of fat grafting. Adipose tissue, specifically the stromal vascular fraction (SVF), is known to regulate its own vascular network. In order to assess the production of angiogenetic growth factors, this study investigated the content of insulin growth factor (IGF), vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), leptin, and metallothioneine-9 (MMP-9) in the SVF after incubation in differentiation or proliferation media. The SVF was isolated from human subcutaneous adipose tissue. Cells were either cultured in proliferation medium (PM) or in differentiation medium (DM). The samples were analysed for the respective factors using ELISA after 3 and 6 days. The GF levels showed a distinctive characteristic over time depending on the culture medium. IGF, PDGF, and MMP-9 levels decreased with PM and increased with DM. VEGF levels were increased in both media. Leptin showed a decrease in both media. The differentiation medium was associated with high inter-individual distribution in growth factor production except for PDGF and Leptin. In conclusion, incubation with differentiation medium produces a more reliable increase of selected growth factors than incubation with proliferation medium. Enrichment of fat grafts with growth factor-activated autologous SVF samples could help to enable better ingrowth of the transplanted tissue and a more stable outcome. The scattering of the results could explain the inter-individual differences regarding the outcome.

Moving forwards: the anterior supraclavicular artery perforator (a-SAP) flap: a new pedicled or free perforator flap based on the anterior supraclavicular vessels.

Since the original publication in 1997 the supraclavicular island flap (SIF) has evolved and is now a safe and reliable procedure for head and neck reconstruction. The purpose of this communication is to give an overview of the current indications and outcomes. An analysis of the literature shows documented use in over 400 patients. Flap size is around 10 × 30 cm; in the case of pre-expansion the width can be up to 15 cm. In larger case series the major complication rate is <5%. We have transferred 127 flaps in 79 patients. To unify the widely varying nomenclature and in the light of the new classifications regarding perforator flaps, we propose to rename the flap as the supraclavicular artery perforator (SAP) flap. Furthermore we report our improvements to the original technique that have led to the development a new flap for head and neck reconstruction. We have started to use an anterior supraclavicular pedicle, originating separately from the transverse colli artery. This places the skin island into the deltoideo-pectoral fossa; thus the flap is even more thin and has better colour match to the face. The reliability of this vessel was demonstrated clinically. We have also used the flap as a free flap for hand and foot reconstruction in two patients. Both flaps survived without complications. Shifting the skin island forwards to the thin deltoideo-pectoral tissue and the possibility of transferring it as a free flap expands the possibilities considerably. We propose to name the flap as the anterior supraclavicular artery perforator (a-SAP) flap to distinguish it from other flaps harvested in this area.

The effect of centrifugal forces on viability of adipocytes in centrifuged lipoaspirates.

Standard protocols for autologous fat transfer involve centrifugation of the lipoaspirate for better separation. The effect of the centrifugal forces on cell viability and possible induction of apoptosis is discussed controversially in current literature. We have examined the vitality of adipocytes in lipoaspirates after centrifugation by 8 different accelerations up to 20.000g immediately after the respective centrifugation as well as 4 days later by staining. No significant alterations in the viability of differently centrifuged adipocytes were found. Cultivation of the samples after centrifugation revealed no apoptotic changes. Our results show that centrifugation, as a part of the protocol of lipofilling, has no effect on the survival rate of isolated adipocytes in the purified fat. In contrast, lipoaspirates centrifuged with higher accelerations seem to be better cleansed of oil and cell debris than samples treated with lower centrifugal forces.

A 5-year assessment of safety and aesthetic results after facial soft-tissue augmentation with polyacrylamide hydrogel (Aquamid): a prospective multicenter study of 251 patients.

BACKGROUND: The permanent filler polyacrylamide hydrogel (Aquamid) has been used for soft-tissue augmentation for more than 16 years. To evaluate the safety and efficacy of the material, the manufacturer initiated in 2001 a prospective clinical trial with a follow-up of 5 years. This represents one of the longest running studies on currently used fillers. METHODS: Two hundred fifty-one patients were enrolled in a noncomparative, prospective study and followed at 15 sites in Europe. The follow-up rates were 228 (90.8 percent), 101 (40.2 percent), 81 (32.3 percent), and 116 (46.2 percent) for the 12-, 24-, 36/48-, and 60-month follow-up periods. Patients received an average of 4.3 ml of Aquamid during an average of 2.4 injection sessions. Preferred areas were the nasolabial folds (37 percent) and the lips (28 percent). Study parameters were cosmetic outcome, blood analysis, and recording of local or generalized symptoms, including adverse reactions. RESULTS: Aesthetic outcome was rated as "very good" or "good" by 96.5 percent of patients and by 96.0 percent of investigators at final available follow-up. During the entire study period, a total of 53 adverse events and two serious adverse events were classified as treatment related. Thirteen adverse events were gel indurations and four cases of infection were seen. All had been resolved within the study period. CONCLUSIONS: The study showed a very good aesthetic outcome and few adverse events after injection of polyacrylamide gel for soft-tissue augmentation. Correct application was essential to ensure a favorable result. For patients who desire facial soft-tissue augmentation, Aquamid is an excellent alternative to surgery.

Rectourethral fistula following LDR brachytherapy.

Modern LDR brachytherapy has drastically reduced rectal toxicity and decreased the occurrence of rectourethral fistulas to <0.5% of patients. Therefore, symptoms of late-onset sequelae are often ignored initially. These fistulas cause severe patient morbidity and require interdisciplinary treatment. We report on the occurrence and management of a rectourethral fistula which occurred 4 years after (125)I seed implantation.

Content of the growth factors bFGF, IGF-1, VEGF, and PDGF-BB in freshly harvested lipoaspirate after centrifugation and incubation.

BACKGROUND: In autologous fat transfer, several questions regarding basic biochemical properties of the transplant remain unanswered. Basic fibroblast growth factor (bFGF), insulin-like growth factor (IGF), vascular endothelial growth factor (VEGF), and platelet-derived growth factor (PDGF)-BB have been shown to improve transplantation results. However, no study regarding naturally occurring levels of growth factors in transplanted adipose tissue has yet been performed. In addition, there are no data as to whether intraoperative refinement eliminates or concentrates growth factors. METHODS: The authors investigated the content of bFGF, IGF, VEGF, and PDGF-BB in freshly aspirated adipose tissue and the presence of those factors in the various fractions after centrifugation by means of enzyme-linked immunosorbent assay readings. They also analyzed growth factor content after storage periods of 3 and 5 days and investigated the vitality of freshly centrifuged adipose tissue by staining with Hoechst 33342 and propidium iodide. RESULTS: The authors found significant quantities of bFGF, IGF-1, VEGF, and PDGF-BB (39.9, 113.8, 3.0, and 5.8 pg/mg, respectively) in the lipoaspirate harvested for transplantation. Separation by centrifugation and discarding of the infranatant and supernatant fluid means that most of the growth factors are left in the transplant. The growth factor content in the other fractions was significantly lower. Lipoaspirate can be cultured for several days, with the tissue remaining biologically active and producing significant growth factor levels. CONCLUSION: Knowledge of the naturally occurring range for these growth factor quantities will enable researchers and clinicians to make autologous fat transfer procedures more reliable and safe.

Cryopreservation of mature human adipocytes: in vitro measurement of viability.

Cryopreservation of fat grafts for autologous fat transplantation renders repeated harvesting procedures unnecessary. Anecdotic reports have been published, yet data about adipocyte survival are sparse. The beneficial effect of added cryoprotective agents (CPA) is known from other tissues but has not been investigated in adipocytes. Fat cells were harvested using the Coleman method (n = 24). Tests were done after 0, 2, 7, 14, and 30 days of cooling to -20 degrees C and -80 degrees C and after addition of various CPA. Analysis included cell stains, measurement of metabolic activity by MTT and XTT tests, and measurement of cell stability by assessment of extracellular glycerol-3-phosphate-dehydrogenase enzyme. After freezing, up to 92.7% of metabolic activity was lost, but the addition of CPA led to preservation of up to 54% of baseline activity. Also, lower storage temperature showed more cell destruction but yielded higher viability of the surviving cells. Our results implicate that the widely used practice of simple storage in a freezer leads to reinjection of nonviable tissue. Cell survival can be improved by addition of CPA.

Adaptive soft tissue deformation for a virtual reality surgical trainer.

Real time tissue deformation is an important aspect of interactive virtual reality (VR) environments such as medical trainers. Most approaches in deformable modelling use a fixed space discretization. A surgical trainer requires high plausibility of the deformations especially in the area close to the instrument. As the area of intervention is not known a priori, adaptive techniques have to be applied. We present an approach for real time deformation of soft tissue based on a regular FEM mesh of cube elements as opposed to a mesh of tetrahedral elements used by the majority of soft tissue simulators. A regular mesh structure simplifies the local refinement operation as the elements topology and stiffness are known implicitly. We propose an octree-based adaptive multiresolution extension of our basic approach. The volumetric representation of the deformed object is created automatically from medical images or by voxelization of a surface model. The resolution of the volumetric representation is independent of the surface geometry resolution. The surface is deformed according to the simulation performed on the underlying volumetric mesh.

A tension band technique for stabilisation of sacroiliac separations in cats.

A tension band technique was used in conjunction with a transarticular pin to stabilise 24 sacroiliac separations in 19 cats. The authors suggest that this technique is simpler and safer than the transarticular screw technique, and as effective.

Repeated ozone exposures enhance bronchial allergen responses in subjects with rhinitis or asthma.

BACKGROUND: Single exposures to > 200 p.p.b. of ozone are capable of enhancing the early-phase lung function response to allergen. OBJECTIVE: The aim of the present study was to compare the effect of single vs. repeated exposures to ozone on early and late-phase allergen responses. METHODS: Eleven subjects with allergic asthma and 22 subjects with allergic rhinitis underwent single exposures to filtered air, 125 p.p.b. and 250 p.p.b. ozone, as well as repeated exposures to 125 p.p.b. ozone on four consecutive days. Twenty hours after the (final) exposure, subjects inhaled a single dose of allergen and a sputum induction was performed 6-7 h later. RESULTS: In the subjects with rhinitis, the mean early-phase response of FEV1 and the number of > or = 20% reductions were significantly greater after exposure to 250 or 4 x 125 p.p.b. ozone compared with filtered air. In addition, most of the > or = 15% late-phase responses in FEV1 occurred after exposure to 4 x 125 p.p.b., as well as the strongest effects on sputum parameters. The rise in the number of eosinophils was statistically significant in both groups. Regarding the number of lymphocytes and the concentrations of mast cell tryptase, histamine or LDH, significance was, however, only reached in the asthma group. CONCLUSION: Our data suggest that repeated exposure to ozone, at a peak ambient air level, can enhance both functional and inflammatory responses to inhaled allergen in subjects with pre-existing allergic airway diseases, and that these effects might reach a clinically relevant magnitude.

Flow cytometric analysis of lymphocyte subpopulations in bronchoalveolar lavage fluid after repeated ozone exposure.

As known from studies in animal and human subjects, ozone can exert effects on the immune response including allergic sensitisation and allergen responsiveness. The objective of the present study was to assess the changes in lymphocyte subsets in bronchoalveolar lavage fluid (BALF) after single and repeated ozone exposures. Twenty-three healthy subjects underwent single exposures to 200 ppb ozone or filtered air (FA), as well as repeated exposures to 200 ppb ozone on four consecutive days, each during 4 h of intermittent exercise. Bronchoalveolar lavage was performed 20 h after the single exposure or the last of the repeated exposures. Lymphocytes were identified by sideward scatter and CD45 expression, and their subsets by eight different panels of antibodies. Checksums were calculated to assess the validity of the results. The percentage and the absolute number of lymphocytes, mostly comprising T-lymphocytes (CD2+; overall mean 98.8%), increased after single (P < 0.05; each), but not after repeated ozone exposure, compared with FA (7.4 vs 5.8 vs 6.5%; 680 vs 419 vs 301 x 10(3)). In addition, we observed small but statistically significant changes in the proportions of lymphocyte subpopulations. The percentage of CD4+ lymphocytes increased after single (P < 0.05) and repeated ozone exposure (P < 0.01), whereas the percentage of CD8+ cells decreased after repeated exposure (P < 0.05). The proportion of activated lymphocytes (CD25+) was elevated after repeated, compared with single, ozone exposure (P < 0.01), and the percentages of natural killer (NK) cells were decreased after both single (P < 0.05) and repeated (P < 0.01) exposures. Our data suggest that single but not repeated ozone exposures cause a change in absolute numbers of lymphocytes in BALF, whereas the proportions of lymphocyte subsets are affected by single as well as repeated exposures.

The effect of repeated ozone exposures on inflammatory markers in bronchoalveolar lavage fluid and mucosal biopsies.

The aim of this study was to investigate the cellular and biochemical events associated with repeated exposures to ozone. Twenty-three healthy subjects underwent single exposures to 200 ppb ozone and to filtered air (FA), as well as repeated exposures to 200 ppb ozone on 4 consecutive days, each for 4 h of intermittent exercise. Bronchoalveolar lavage was performed and mucosal biopsies were taken 20 h after the single or the last of the repeated exposures. As compared with FA, the single exposure to ozone caused a decrease in FEV(1), an increase in the percentages of neutrophils and lymphocytes, the concentrations of total protein, IL-6, IL-8, reduced glutathione, urate, and ortho-tyrosine in BAL fluid (BALF), but no changes in the cellular composition of biopsy. After the repeated exposure, the effect on lung function was abolished and differential cell counts in BALF were not significantly different from those after FA. However, the concentrations of total protein, IL-6, IL-8, reduced glutathione, and ortho-tyrosine were still increased. IL-10 could only be detected in BALF after repeated ozone exposures. Furthermore, macroscopic scores for bronchitis, erythema, and hypervulnerability of airway mucosa were increased, as well as numbers of neutrophils in bronchial mucosal biopsies. Our data demonstrate that airway inflammation persists after repeated ozone exposure, despite attenuation of some inflammatory markers in BALF and adaptation of lung function.

Ozone-induced airway inflammatory changes differ between individuals and are reproducible.

To study whether the individual inflammatory response to ozone was reproducible, dose-dependent, and time-dependent, we performed two exposures to 250 ppb ozone, one to 125 ppb and one to filtered air, each for 3 h of intermittent exercise and separated by at least 1 wk. Twenty-one healthy and 15 asthmatic subjects participated in the study. One hour after the two exposures to 250 ppb ozone we observed a mean increase in sputum neutrophils of 17.9 and 17.9% in healthy and of 20.3 and 15.2% in asthmatic subjects (p < 0.05 each). Twenty-four hours after exposure, the respective values were 11.9 and 14.8%, and 9.1 and 16.1% (p < 0.05 each). In the whole group of subjects, individual changes in the percentage of neutrophils were significantly correlated between the two exposure days 1 h (r = 0.87, p < 0.001; intraclass correlation coefficient [Ri] = 0.86) as well as 24 h (r = 0.79, p < 0.001; Ri = 0.71) after exposure. The percentages of lymphocytes were increased 24 h after exposures (all subjects combined: p < 0.05). The decrease in FEV1 in both groups (p < 0.01), was also reproducible (r = 0.77, p < 0.001), but there were no correlations between changes in sputum parameters and lung function. Exposure to 125 ppb ozone caused a small increase (p < 0. 05) in the percentage of neutrophils in asthmatic subjects and in the concentrations of interleukin-8 in both groups combined. Our data demonstrate that inflammatory and lung function responses to ozone differ between individuals and are reproducible but not related to each other. Therefore, these responses appear to represent two independent factors underlying the airway response to ozone.

From slogans to strategy: a workable approach to customer satisfaction and retention.

Too many organizations confuse slogans, good intentions, or mechanical phrases with customer service. Most recognize that the most powerful way to prosper in today's economy is to enhance customer satisfaction and loyalty. But customer service has little to do with mottos, slogans, or mechanical phrases. The real management challenge lies in translating the slogans into employee actions that create customer satisfaction and loyalty--in creating a strategy for ensuring good service intentions and exceptional service results. This article shows a logical, theoretically sound approach to building and implementing what I call an E-Plus Customer Satisfaction strategy. Incidentally, I use the term "customer" throughout this article, but I recognize that we have different terms in various organizations. So feel free to substitute "patient", "guest", "client", or any other synonym. The principles are the same.

Behavior of different suture materials in the urinary bladder of the rabbit with special reference to wound healing, epithelization and crystallization.

Five urinary bladder incisions were performed in 16 rabbits and the defects closed by plain catgut 4-0, chromic catgut 4-0, polypropylene 4-0, polyglactin 910 4-0 and polyglactin 910 8-0 in the form of an all-layer suture, thereby obtaining a total of 80 suture sites. The running sutures in 8 animals were reviewed by light microscopy after 1, 2, 7 and 15 weeks, and in 8 additional animals after 3 days, 1, 2, 7 and 15 weeks by scanning electron microscopy. Moreover, we analyzed and compared the autopsy findings on gross inspection, the urinary sediments and urinary cultures of the individual animals. Scanning electron-microscopic evaluations showed that epithelization of the intraluminal suture portions can be accomplished after 3 days already. Reduced suture strength and rapid absorption of the suture material prevent later postoperative incrustations. Light-microscopic inspection of the segments of the bladder wall bearing this suture material suggests that a minor inflammatory tissue response around the suture material--with polyglactin 910 8-0 in particular--is more likely to enhance regeneration of the tunica muscularis and to prevent formation of cysts than seen with a long-standing highly inflammatory tissue response around the suture site of catgut threads. In the animal experiment, the polyglactin 910 suture has shown sufficient firmness and proved to be superior to any other suture material as regards the reaction to foreign bodies and inclination to incrustation.(ABSTRACT TRUNCATED AT 250 WORDS)