Treating open lower limb fractures successfully; thoughts and current practice on therapy and centralization in The Netherlands.

INTRODUCTION: The British Orthopedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) updated the evidence-based guidelines for the treatment and care of open lower limb fractures (BOAST 4). Following this, a Dutch version has been developed. The main points are multidisciplinary care, planning, and treatment of these injuries. Early osteosynthesis (within 7-14 days) combined with soft-tissue coverage results in more efficient care and less complications. AIM: To study the variation in treatment and thoughts among trauma, orthopedic, and plastic surgeons. MATERIALS AND METHODS: In this cross-sectional study 94 surgeons (57 trauma, 23 plastic, and 14 orthopedic surgeons) working at 46 centers completed an online questionnaire, consisting of 5 demographic, 14 hospital-related, 8 BOAST 4-related, and 2 centralization-related questions. RESULTS: There was a strong agreement among surgeons about the best moment for multidisciplinary consultation, which was before initial debridement, while in practice, this often does not occur. All surgeons agreed that the initial debridement should be performed immediately by any surgeon, but not solely by trainees. Plastic surgeons responded that the definitive stabilization and wound cover should not exceed 7 days, while half of the trauma and orthopedic surgeons agreed that it should not exceed 14 days. Finally, most surgeons agreed that Gustilo 3 fractures should be centralized. However, there was disagreement on the need for centralization of Gustilo 2 fractures. DISCUSSION: Surgeons agree on better and earlier multidisciplinary treatment of open lower limb fractures and the centralization of Gustilo 3 fractures.

Lifetime weight cycling and psychological health in normal-weight and overweight women.

OBJECTIVE: The relationship between weight cycling history and psychological health was studied in a sample of 429 normal-weight and overweight women. METHOD: Participants were from the Healthy Women Study, a longitudinal investigation of biological and psychosocial aspects of menopause. Participants were asked to report retrospectively details on their weight cycling history in terms of the frequency and magnitude of previous weight loss episodes. Data were examined using the total cycle weight lost and the frequency of weight cycles > or = 10 lb. Self-reported measures of depression, stress, anxiety, and anger were used to evaluate psychological health. RESULTS: For both normal-weight and overweight women, the analyses revealed no adverse relationships between weight cycling history and the psychological measures. DISCUSSION: These findings suggest that a history of weight cycling regardless of weight status does not adversely impact psychological health.

Prospective study of the determinants of age at menopause.

The authors prospectively studied the effect of demographic, reproductive, stress-related, and health behavior factors measured at study entry on age of natural menopause in 185 healthy US women. At study entry, women were 42.5-47.5 years old and premenopausal. After a baseline examination (1983-1985), women were followed for 7-9 years, during which time they reported on a monthly basis their menstrual status and whether they were taking hormones. Menopausal age was defined as age at the last menstrual period prior to stopping menstruation for 12 months (and not taking hormones). Estimated median age at menopause was 51.5 years for the whole sample. Median age at menopause was earlier for women who reported irregular menstrual cycles at study entry (50.2 years), were African-American (49.3 years), were smokers (50.6 years), or were currently on a weight reduction diet (50.5 years). Psychosocial stress was predictive of an even earlier median age at menopause in African Americans (48.4 years) and in those with irregular cycles at baseline (49.4 years). Results suggest that premenopausal women in their forties who are experiencing irregular menstrual cycles, are smokers, are dieting, or are African-American are likely to reach menopause earlier than their contemporaries. African-American women may have a different "biological clock" than white women, especially when under stress, or they may experience more stress of longer duration.

Prior to use of estrogen replacement therapy, are users healthier than nonusers?

Observational studies have demonstrated that women who have used postmenopausal estrogen replacement therapy (ERT) are at reduced risk of coronary heart disease. The authors examined whether premenopausal women who subsequently elected to use ERT during menopause had a better cardiovascular risk factor profile prior to use than did nonusers. A total of 541 premenopausal women had their cardiovascular risk factors and psychosocial characteristics evaluated at study entry. After approximately 8 years, 355 women had become postmenopausal, and 157 women reported ERT use during the follow-up period (mean = 93.4 months). The authors compared the premenopausal characteristics of users with those of nonusers. Relative to nonusers, ERT users were better educated (63 vs. 81% with at least some college), and prior to the use of ERT had higher levels of high density lipoprotein (HDL) cholesterol (1.49 vs. 1.59 mmol/liter), HDL2 (0.50 vs. 0.57 mmol/liter), HDL3 (0.98 vs. 1.02 mmol/liter), leisure physical activity (5, 122 vs. 7,158 Kjoules), and alcohol intake (7.5 vs. 9.7 g/day), and lower levels of apolipoprotein B (0.97 vs. 0.90g/liter), systolic blood pressure (112.1 vs. 107.1 mmHg) and diastolic blood pressure (73.8 vs. 71.4 mmHg), weight (68.5 vs. 64.2 kg), and fasting insulin (9.10 vs. 7.66 microU/liter). Prior to use of ERT, in comparison with nonusers, subsequent users reported on standardized questionnaires that they often exhibited Type A behavior, more aware of their feelings, motives, and symptoms, and had more symptoms of stress. Women who elect to use ERT have a better cardiovascular risk factor profile prior to the use of ERT than do women who subsequently do not use this treatment during the menopause, which supports the hypothesis that part of the apparent benefit associated with the use of ERT is due to preexisting characteristics of women who use ERT. This study underscores the widely recognized importance of randomized clinical trials to estimate the direct benefit of postmenopausal ERT for protecting women from cardiovascular disease.

Influence of the perimenopause on cardiovascular risk factors and symptoms of middle-aged healthy women.

OBJECTIVE: To determine the changes in cardiovascular risk factors and psychological and physical symptoms that occur during the perimenopause. DESIGN: Cohort study of 541 healthy middle-aged premenopausal women followed up through the menopause. SETTING: General community. PARTICIPANTS: After a baseline evaluation taken at study entry, 152 women ceased menstruating for 3 months (not due to surgery) and were not using hormone replacement therapy, and were reevaluated in a similar protocol (perimenopausal examination); 105 of the 152 were evaluated a third time when they had ceased menstruating for 12 months and were not using hormone replacement therapy (postmenopausal examination). One hundred nine premenopausal women who were repeatedly tested constituted a comparison group. MAIN OUTCOME MEASURES: Levels of lipids and lipoproteins, triglycerides, fasting glucose and insulin, blood pressure, weight, height, and standardized measures of psychological symptoms. RESULTS: Women who became perimenopausal showed increased levels of cardiovascular risk factors, which were similar in magnitude to those experienced by the comparison group of premenopausal women. Perimenopausal women reported a greater number of symptoms, especially hot flashes, cold sweats, joint pain, aches in the skull and/or neck, and being forgetful; reports of hot flashes at the perimenopausal examination were associated with low concentrations of serum estrogens. Menopausal status was not associated with depressive symptoms. Perimenopausal women who became postmenopausal showed a decline in the level of high-density lipoprotein-2-cholesterol (means, 0.53 to 0.43 mmol/L [20.6 to 16.7 mg/dL]) and a gradual increase in the level of low-density lipoprotein cholesterol (means, 3.14 to 3.33 mmol/L [121.3 to 128.8 mg/dL]), whereas symptom reporting declined. CONCLUSIONS: During mid-life, women experience adverse changes in cardiovascular risk factors and a temporary increase in total number of reported symptoms, with no change in depression. Preventive efforts to reduce the menopause-induced increase in cardiovascular risk factors should begin early in the menopausal transition.

Environmental and familial contributions to insulin levels and change in insulin levels in middle-aged women.

OBJECTIVE: To examine familial and environmental variables associated with elevated insulin levels and changes in insulin levels in healthy, premenopausal women. METHODS: A population-based sample of 518 women (aged 42 to 50 years) completed baseline assessments of weight, cardiovascular risk factors, exercise behaviors, and glucose and insulin levels (fasting and 2 hours after a glucose load); 495 of the women were reevaluated after 3 years. RESULTS: Plasma insulin levels were related to weight, activity level, race, body fat distribution, and weight gain since age 20 years. Parental history of either diabetes or hypertension was also related to elevated insulin levels, independent of body mass index, with the highest insulin levels occurring in those women with a parental history of both diseases. Increases in plasma insulin levels over the years of follow-up were related to weight gain. CONCLUSIONS: This study suggests that importance of using family history to identify women who may have elevated insulin levels and of intervening to prevent weight gain during middle age.

Waist to hip ratio in middle-aged women. Associations with behavioral and psychosocial factors and with changes in cardiovascular risk factors.

Waist to hip ratio (WHR) was measured in 487 middle-aged women participating in the Healthy Women Study. Upper body fat distribution was found to be associated with numerous behaviors that affect cardiovascular risk, including smoking, low exercise levels, weight gain during adulthood, and higher caloric intake. Moreover, WHR was also associated with higher levels of anger, anxiety, and depression and lower levels of perceived social support. Women with upper body fat obesity had higher systolic blood pressure, total cholesterol, low density lipoprotein cholesterol, triglycerides, and apolipoprotein B and lower levels of high density lipoprotein (HDL) and the HDL subfractions 2 and 3. These associations remained significant after adjusting for body mass index. Among 108 women who had repeat measurements of WHR, changes in WHR over a 3-year period were significantly correlated with changes in activity and with decreases in HDL2. Thus, WHR appears to be an integral component of the cardiovascular risk profile. WHR is related to those behaviors and psychosocial attributes that influence cardiovascular risk.

Weight gain at the time of menopause.

We studied prospectively the weight change and the effect of weight change on changes in coronary heart disease risk factors in a population-based sample of 485 middle-aged women. All women were studied first in 1983 to 1984, when they were premenopausal and aged 42 to 50 years, and then restudied in 1987. Women gained an average of 2.25 +/- 4.19 kg during this 3-year period; 20% of women gained 4.5 kg or more, and only 3% lost 4.5 kg or more. There were no significant differences in weight gain of women who remained premenopausal and those who had a natural menopause (+2.07 kg vs +1.35 kg). Weight gain was significantly associated with increases in blood pressure and levels of total cholesterol, low-density lipoprotein cholesterol, triglycerides, and fasting insulin. Weight gain is thus a common occurrence for women at the time of menopause and is related to the changes in coronary heart disease risk factors observed during this period. Efforts to lose weight or to prevent weight gain may help to mitigate the worsening in coronary heart disease risk factors in middle-aged women.

Relationship of endogenous sex steroid hormones to lipids and apoproteins in postmenopausal women.

The relationships between blood levels of estrogen and lipoprotein lipids and apoproteins were evaluated in 120 women early in the climacteric. Among women who were 1-year amenorrheic, not taking hormone replacement therapy, and with follicle-stimulating hormone levels greater than 720 ng/ml, serum estradiol levels were positively related to concentrations of the high density lipoprotein 2 cholesterol (HDL2c) subfraction. There was a substantial decrease in HDL2c and apoprotein (apo) A-I in women whose estradiol levels decreased to less than or equal to 2.5 pg/ml from the first to the second postmenopausal examination. In a sample of women evaluated during the perimenopause (3-months' amenorrheic), those with the highest concentrations of estradiol or estrone showed a (nonsignificantly) higher level of HDL2c and a lower level of low density lipoprotein cholesterol (LDLc) than did those with the lowest concentration of estradiol or estrone. Estradiol levels declined dramatically between the perimenopausal and the postmenopausal examinations, and this was accompanied by a decrease in HDL2c and a nonsignificant increase in LDLc. HDL2c levels fell substantially in those women whose estradiol decreased below the sensitivity of the assay. The change, however, was not statistically significant. Estrone is the primary postmenopausal estrogen, and levels are directly related to obesity, as are levels of insulin. The interrelationship among obesity, conversion of estrone to estradiol at the tissue level, and insulin (or insulin sensitivity) is probably the primary determinant of HDLc concentration among postmenopausal women.

Evaluation of Factors Involved in Antibotulinal Properties of Pasteurized Process Cheese Spreads.

Pasteurized process cheese spreads with various levels of sodium chloride, disodium phosphate, moisture and pH were challenged with spores of Clostridium botulinum types A and B. Response surface methodology was used to design experiments that would yield maximum results with the minimum number of trials. Supplemental experiments were added to further clarify the response and to examine combinations of special interest. A total of 304 treatment combinations (batches) was incubated at 30°C, and five samples from each batch were taken at predetermined intervals up to 42 wk of incubation and tested for botulinal toxin. Sodium chloride and disodium phosphate inhibited botulinal toxin production with similar effectiveness. The inhibitory effect of low pH (<5.7) and low moisture (<54%) levels on botulinal toxin production was as expected, i.e., as either pH or moisture went up, it was necessary to increase sodium chloride and/or phosphate concentrations to compensate. Differences in water activity between cheese spreads with different compositions were observed but they were too small to use for controlling the properties of the products, e.g., a range of 9% in moisture level (51 to 60%) produced only 0.022 variation in water activity. Combinations of the above factors were developed for safe pasteurized process cheese spreads containing up to 60% moisture.

The number of sarcomeres and architecture of the M. gastrocnemius of the rat.

The aim of this study was to investigate the number of sarcomeres of different regions (proximal, intermediate and distal third) of the M. gastrocnemius of the rat and compare them with in vivo measurements of the length of the most proximal and distal muscle bundles. These lengths were measured with the aid of dividers at the muscle resting length. The number of sarcomeres was calculated from the length of fibres (measured at 20 times enlargement) tested from HNO3-treated muscle and the average sarcomere length (determined from 80 microns samples taken along the fibres every 800 microns). Ten fibres were isolated from each of three regions of six muscles. All muscles showed the smallest number of sarcomeres in the proximal region of the muscle and increasingly higher numbers in the intermediate and distal parts. The number of sarcomeres in the proximal region is significantly (p less than 0.01) smaller than that of the distal region. These results agree with the results of in vivo length measurements of the most proximal and distal bundles (resp. 31 and 36% of the muscle resting length), the former being significantly (p less than .01) smaller. As there is no significant difference (p less than 0.01) in the length of the treated fibres of the three regions it is concluded that HNO3 treatment does affect the fibres of the muscle in the different regions in a non uniform fashion.