Common adiponectin gene variants show different effects on risk of cardiovascular disease and type 2 diabetes in European subjects.

Alterations in the secretion of adipokines may explain the link between obesity, type 2 diabetes (T2DM) and coronary artery disease (CAD). These conditions have been associated with variation in the adiponectin gene, although evidence for this relationship has been variable, with differences found even in similar samples. This study aims to clarify these inconsistencies by determining the impact of identified adiponectin gene (ADIPOQ) variants (-11391G>A,-1377C>G[promoter] and +45T>G[exon 2] and +276G>T[intron 2]) on the prospective risk of CAD and T2DM in healthy men, and on adverse metabolic markers, in myocardial infarct survivors and controls from different parts of Europe. The hazard ratio for cardiovascular disease varied across the -11391GG/GA/AA(p = 0.03) and -11371CC/CG/GG(p = 0.05) genotypes only. In contrast, only the +45T>G variant (3.80[1.76-8.24]) was associated with T2DM, while two haplotypes GCTT/GCGG (p < 0.05) and +276G>T(p = 0.01) increased risk in interaction with obesity. The variants were associated with a number of biomarkers in Southern but not Northern Europe (p = 0.01), despite no significant differences in allele or haplotype frequencies (p > 0.44). A risk haplotype could not be identified in either sample. Adiponectin gene variants are hence currently poor markers for the development of T2DM and CAD. Their influence on risk depends significantly on interactions that are not currently understood with either genetic variation elsewhere or the environment of the sample studied.

Adiponectin and its gene variants as risk factors for insulin resistance, the metabolic syndrome and cardiovascular disease.

The increasing prevalence of obesity and metabolic syndrome/insulin resistance has attracted considerable interest due to their identification as risk factors for cardiovascular disease and, hence, targets for cardiovascular disease prevention. This review focuses on adiponectin, the most profusely secreted protein from adipose tissue, which itself is being increasingly recognised as an important and very active endocrine organ, secreting a wide range of biologically active substances known as adipokines or adipocytokines. Adiponectin has been demonstrated to have insulin sensitising effects, and secretion of adiponectin is reduced as adipose tissue mass increases. Adiponectin has also been demonstrated to have anti-inflammatory and anti-atherogenic properties, and is independently associated with cardiovascular disease. The evidence that suggests adiponectin plays a role in the relationship between obesity and insulin resistance, and also insulin resistance and cardiovascular disease, is examined. Variation in the adiponectin gene is one tool to determine whether this relationship is causal. The association of identified variants with human disease, specifically obesity and its consequences, type 2 diabetes and cardiovascular disease is reviewed. This data may enable patients at greater risk of the adverse effects of obesity to be identified and, as such, benefit from more targeted therapy of its consequences.

Bovine pericardial patch angioplasty in carotid endarterectomy.

Patch angioplasty during carotid endarterectomy (CEA) has been shown to reduce the incidence of both early and late complications. Controversy continues, however, over the ideal patch material. Bovine pericardium (Vascu-Guard Biovascular Inc., Saint Paul, MN) offers an attractive alternative to other patch materials because of its handling and suturing characteristics that are similar to that of autogenous material. This study examines the perioperative and midterm results of bovine pericardial patch angioplasty during CEA. We studied 112 patients who underwent 129 CEAs with bovine pericardial patch angioplasty during an 18-month period. Data were collected regarding demographics, operative indications, perioperative complications, and the occurrence of late adverse outcomes based primarily on follow-up arterial duplex studies. Among this group there were 63 male (56%) and 49 female (44%) patients whose mean age was 71.8 +/- 9.1 years. In these patients there was the typical distribution of atherosclerotic risk factors. Seventy-four patients (66%) had symptomatic disease preoperatively and the remaining 38 patients (34%) were asymptomatic. Temporary cranial nerve palsy occurred in three patients (2%). There were no perioperative strokes, acute occlusions, bleeding episodes requiring reoperation, or deaths. The patients were followed up to 54 months postoperatively with a mean follow-up time of 41.7 +/- 4.4 months. During this period two patients (2%) developed three significant restenoses (70-99%). All required reoperation. There were no asymptomatic occlusions, infections, aneurysms, or rupture. These data demonstrate that bovine pericardial patch angioplasty during CEA is associated with a low incidence of both perioperative and midterm adverse outcomes.

Thoracoscopy in the management of posttraumatic persistent pneumothorax.

BACKGROUND: Persistent posttraumatic pneumothorax (PPP) is an uncommon complication of traumatic injuries of the chest, usually managed with suction drainage and involving prolonged hospital stays. This study was conducted to assess the advantages of using video-assisted thoracoscopic surgery (VATS) in the management of patients with PPP. STUDY DESIGN: Eleven patients with PPP underwent VATS for diagnosis and for definitive treatment. RESULTS: Before VATS was done, all patients had undergone multiple attempts to resolve the PPP; the hospital stay before VATS was 10 days (range, 4-14 days). In 10 patients, the cause of the PPP was identified and a segmental stapled resection was performed, with complete success in resolving the air leak and obtaining pleural synthesis. In another patient, the source of the air leak was not identified and a thoracoscopically assisted chemical pleurodesis was performed, with immediate cessation of the air leak. All chest tubes were removed within 48 hours of the procedure; 9 patients were discharged within 72 hours of VATS. Preoperative computed tomography of the chest was useful in 2 patients, but bronchoscopy did not disclose any major airway injury. CONCLUSIONS: Videothoracoscopy is an accurate, safe, and reliable alternative to an open thoracotomy in the management of patients with PPP. In the patients in whom the procedure was completed, excellent results were obtained and the hospital stay was reduced. We believe that VATS should be used earlier and more frequently after failure of conservative management in such patients.

Blunt popliteal artery injury: is physical examination alone enough for evaluation?

Failure to recognize popliteal artery injury and restore vessel continuity of flow after blunt trauma is a major cause of lower-extremity amputation and morbidity. A high index of suspicion and early recognition of the injury are paramount for limb salvage, especially with posterior knee dislocation. Traditionally, arteriography has been the test most widely used to ensure an expedient diagnosis and institution of appropriate treatment. More recently, some authors have tried to move away from routine arteriography and rely on physical examination alone without arterial evaluation to guide them on their course of treatment. Based on our experience, the presence of arterial pulses after blunt trauma and dislocation of the knee is not an absolutely reliable indicator to exclude an arterial injury. The high morbidity of a missed popliteal artery injury mandates arterial evaluation of the popliteal artery either by arteriography or ultrasonography. A patient is presented with multiple injuries including a posterior knee dislocation. He had completely normal lower-extremity pulses on initial examination and at the time of discharge, but was required to have emergency reoperation with a ruptured popliteal artery pseudoaneurysm 5 weeks later.

Surgical implications of hypercoagulable syndromes.

The advent of improved diagnostic tests for primary hypercoagulability has led to increased recognition of this entity as a problem in surgical patients. We treated 20 patients with documented evidence of increased coagulability from 1975 to 1995. Clinical presentations included venous (16) and arterial (4) thrombosis. Symptoms usually occurred early in life (mean age, 38 years) and developed spontaneously without a secondary inciting event or factor. Deficiencies in naturally occurring anticoagulant proteins including antithrombin III (n = 7), protein C (n = 3), and protein S (n = 1) were seen, as were problems with lupus anticoagulant (n = 2) and anticardiolipin antibody (n = 4) deficiencies. Treatment of these patients is difficult, and results are often suboptimal. A total of 12 vascular reconstructions were required in 5 of the 20 patients; 11 eventually failed. Patients with primary venous thrombosis were often successfully treated with anticoagulant therapy in the short term but fared less well in the long term. There were three deaths directly related to thrombotic complications. Surgeons may encounter patients with primary hypercoagulable syndromes. The diagnosis should be expected in patients with unusual patterns of vascular disease or arterial or venous thrombosis without cause or at an early age, or in patients with recurrent or migratory clotting. Evaluation of this population, although expensive, is indicated. Treatment with chronic anticoagulation is also generally indicated. Arterial reconstruction in this subset of patients usually leads to a poor outcome.

The rationale for esophagectomy as the optimal therapy for Barrett's esophagus with high-grade dysplasia.

OBJECTIVE: The authors determined the incidence of invasive adenocarcinoma after esophagectomy in patients endoscopically diagnosed as having Barrett's esophagus with high-grade dysplasia. SUMMARY BACKGROUND DATA: Barrett's esophagus is a well-recognized premalignant condition. There is controversy with regard to the optimal treatment of high-grade dysplasia in Barrett's esophagus. Recognizing the morbidity and mortality associated with esophagectomy, some recommend a selective approach, reserving esophagectomy only for evidence of invasive cancer identified through endoscopic surveillance. Other advocate esophagectomy for all suitable operative candidates. METHODS: The authors reviewed their experience between 1985 and 1995 with 11 patients with high-grade dysplasia arising in Barrett's esophagus diagnosed by endoscopic biopsy and treated by esophagectomy. RESULTS: All patients were white men ranging in age from 47 to 70 years. Ten patients underwent esophagectomy by the Ivor Lewis technique; one had a transhiatal resection. Eight patients (73%) had invasive adenocarcinoma identified after esophagectomy; two (18%) had positive lymph nodes; one required a prolonged hospital stay for an anastomotic leak; two (18%) temporarily suffered delayed gastric emptying. The authors' review identified 85 additional patients previously reported during the same period. Including the current series, 39 patients (41%) had invasive adenocarcinoma identified in the resected specimen. A preponderance of early, potentially curable carcinomas are characteristically found in these patients. CONCLUSION: A high incidence of endoscopically undetected invasive carcinoma strongly supports esophagectomy as the preferred approach for suitable operative candidates with high-grade dysplasia in Barrett's esophagus.