Gamma-tocotrienol attenuates high-fat diet-induced obesity and insulin resistance by inhibiting adipose inflammation and M1 macrophage recruitment.

BACKGROUND AND OBJECTIVE: We have previously demonstrated that gamma tocotrienol (γT3) potently inhibits adipocyte hyperplasia in human adipose-derived stem cells (hASCs). In this study, our objective was to investigate the γT3 effects on early-onset obesity, inflammation and insulin resistance in vivo. METHODS: Young C57BL/6J mice were fed a high-fat (HF) diet supplemented with 0.05% γT3 for 4 weeks. The concentrations of γT3 in plasma and adipose tissue were measured using high-performance liquid chromatography. Effects of γT3 on body weight gain, adipose volume, plasma levels of fasting glucose, insulin (enzyme-linked immunosorbent assay (ELISA)), proinflammatory cytokines (mouse cytokine array), insulin signaling (western blotting) and gene expression (quantitative real-time PCR, qPCR) in the liver and adipose tissue were examined. Influences of γT3 on [3H]-2-deoxyglucose uptake and lipopolysaccharide (LPS)-mediated NFκB signaling (western blotting) were assessed in hASCs. Effects of γT3 on macrophage M1/M2 activation were investigated using qPCR in mouse bone marrow-derived macrophages. RESULTS: After a 4-week treatment, γT3 accumulated in adipose tissue and reduced HF diet-induced weight gain in epididymal fat, mesenteric fat and the liver. Compared with HF diet-fed mice, HF+γT3-fed mice were associated with (1) decreased plasma levels of fasting glucose, insulin and proinflammatory cytokines, (2) improved glucose tolerance and (3) enhanced insulin signaling in adipose tissue. There were substantial decreases in macrophage specific markers, and monocyte chemoattractant protein-1, indicating that γT3 reduced the recruitment of adipose tissue macrophages (ATMs). In addition, γT3 treatment in human adipocytes resulted in (1) activation of insulin-stimulated glucose uptake and (2) a significant suppression of MAP kinase and NFκB activation. In parallel, γT3 treatment led to a reduction of LPS-mediated M1 macrophage polarization. CONCLUSION: Our results demonstrated that γT3 ameliorates HF diet-mediated obesity and insulin resistance by inhibiting systemic and adipose inflammation, as well as ATM recruitment.

Not all biologics are equal!

BACKGROUND: Although the efficacy of various biologic meshes in the abdominal reconstruction of complex ventral hernia has been shown, the performance profile of various biologic mesh scaffolds in terms of hernia-specific outcomes such as recurrence, mesh explantation, and mesh infections has not been examined. AIM: To evaluate the clinical outcomes of patients who underwent complex ventral hernia repair with bioprosthetic material. METHODS: This study is a retrospective analysis of the use of bioprosthetic material in complex ventral hernia at an academic institution from January 2002 to December 2007. RESULTS: A total of 58 patients with a mean age of 57.2 years and mean body mass index (BMI) of 33.8 who underwent reconstruction of ventral abdominal defects with a bioprosthetic from January 2002 to February 2009 were included in the study. The study patients had about 4.8 previous surgeries and 43.1% of patients had reconstruction in a setting of enterocutaneous fistula, while 46.6% had a previous mesh infection. Complex ventral hernia was seen in 50 patients, while eight patients had ventral and parastomal hernia. The type of biologic used for reconstruction was human-derived (AlloDerm, 29), porcine cross-linked (CollaMend, 3; Permacol, 2), and non-cross-linked porcine (Surgisis, 16; Strattice, 8). At least one complication was seen in 72.4% of patients. Major complications noted were surgical wound infections (19.0%), seroma (8.6%), and abscess formation (5.2%). The one-year hernia recurrence rate was 27.9% and mesh explantation was needed in 17.2% of patients. AlloDerm was less likely to be explanted (13.8%) or become infected (37.9%) but more likely to recur (28.6%) compared to porcine cross-linked bioprosthesis. Porcine cross-linked biologics were more likely to become infected (60%) and explanted (40%) but less likely to recur (20%) compared to AlloDerm. Non-cross-linked porcine biologics were less likely to be explanted (16.7%) but had higher recurrence (29.4%) compared to cross-linked porcine biologics and a higher infection rate (54.2%) compared to AlloDerm. CONCLUSIONS: The results from this study underscore the difficulty of repairing complex abdominal wall defects in contaminated fields. Cross-linked porcine biologics showed relatively higher infection and explantation rates. Equivalent recurrence and explantation rates were observed for the non-cross-linked porcine biologics and AlloDerm. These data indicate that there is currently no ideal biologic for complex ventral hernia repair.

The team concept in mandibular reconstruction after ablative oncologic surgery.

PURPOSE: This study evaluated the efficiency and cost-effectiveness of using a reconstructive team for mandibular reconstruction. METHODS: An outcome-based retrospective review of 64 patients who had undergone microvascular fibular reconstruction of the mandible was performed. Operating room time, use of blood products, intraoperative fluid replacement, and hospital and intensive care unit stay were evaluated. Patients were divided into 2 groups on a chronologic basis. Group 1 was the first 34 consecutive patients and group 2 was the next 30 consecutive patients. RESULTS: Group 2 had a significantly shorter operating room time (P < .0001), hospital stay (P = .012), and used significantly less blood (P = .002) and colloid (P = .044) than group 1, resulting in significant cost savings, ($5,061.47/patient). Analysis showed no differences between groups demographically or for wound complications. CONCLUSIONS: Experience and the development of a team concept significantly decreased the cost for mandibular reconstruction with free fibula flaps without increasing wound complications.

Microvascular reconstruction of the head and neck after tumor ablation.

Microvascular reconstruction of the head and neck in cancer patients after surgical ablation has significantly improved the quality of life of these patients from both a functional and cosmetic standpoint. Successful management and reconstruction of these patients requires a well-coordinated team approach. Operating room times and hospital stays have significantly decreased with coordination and experience of the team members.

Congenital nasal pyriform aperture stenosis.

Congenital nasal pyriform aperture stenosis is a rare, but increasingly recognized, form of neonatal nasal airway obstruction. The condition may occur as an isolated anomaly or in association with holoprosencephaly. Treatment is determined by the overall prognosis of the infant and the symptomatic severity of the stenosis.

Distal radial artery lesion as a source of digital emboli.

Ischemic changes of the digits caused by emboli are rare. When they do occur, the typical sites of origin include the heart, the proximal subclavian artery, and the thoracic outlet. Dialysis access or iatrogenic injuries may be a more distal source of emboli. Two patients, each with embolization to the thumb and index finger from a lesion in the anatomical snuff-box, were studied. Neither patient had any other atherosclerotic occlusive disease, and both lesions occurred precisely where the extensor pollicis longus crossed the artery and would be expected to compress it against the proximal epiphysis of the first metacarpal when the hand was closed. These lesions were excised, and bypass was performed, with rapid resolution of symptoms. This is an unusual cause of digital embolization that should be considered in patients with emboli to the thumb and index finger.

Use of free fibula flap in patients with prior failed mandibular reconstruction.

PURPOSE: The purpose of this study was to assess the efficacy of the free fibula flap in patients who had failed prior attempts at bony reconstruction. PATIENTS AND METHODS: The records of all patients who had undergone free fibula reconstruction for segmental mandibular resections between 1993 and 1995 were retrospectively reviewed. Patients were divided into group I (14 patients who had failed previous bony reconstruction attempts) and group II (50 patients who had no previous reconstruction), and the two groups were compared. RESULTS: No statistical differences were found between group I and group II for mean age, mean hospital stay, mean intensive care unit stay, mean operating room time, mean intraoperative blood loss, mean colloid usage, or mean blood units transfused. Although group I had a statistically higher proportion of both patients with osteoradionecrosis and those receiving hyperbaric oxygen therapy (HBO), the number with a history of radiation therapy was not different in the two groups. Wound complication rates were not statistically different between groups I and II for all patients, or between those group I patients who did or did not receive HBO therapy. CONCLUSION: There was no increase in wound complications in the patients who had failed prior bony reconstructive attempts who underwent free fibula flaps. The free fibula flap is suggested as the reconstructive method of choice in this patient population.

Laparoscopic gastrostomy versus open gastrostomy in head and neck cancer patients.

Alimentation in the surgically treated head and neck cancer patient frequently requires bypassing the upper aerodigestive tract. The laparoscopic gastrostomy fulfills this criterion. The authors compared 25 laparoscopic gastrostomies (group 1) with 18 open gastrostomies (group 2) performed on head and neck cancer patients. The length of operation, morbidity, mortality, and cost were evaluated. Operative time was significantly shorter in group 1 (40 +/- 2 minutes) than in group 2 (56 +/- 4 minutes), with P=.003. The major complication rate was 9% for group 1 and 11% for group 2. There was no procedure-related mortality in group 1, but 1 patient died in the immediate postoperative period in group 2. The cost was not significantly different. It is concluded that the laparoscopic gastrostomy is a safe and cost-effective alternative to open gastrostomy in this patient group.

Microvascular reconstruction of the head and neck cancer patient.

Surgical resection of cancer of the head and neck often results in significant functional and cosmetic deformity. Reconstruction of these deficits have often been inadequate to reintegrate these patients into daily life. Recent advances in microsurgical techniques, however, have ushered in a new era for reconstruction following head and neck cancer ablative surgery. Microvascular free tissue transfers have made possible the reconstruction of major head and neck defects that previously were not possible as well as markedly improving function and cosmesis. Successful reconstruction requires close cooperation between the head and neck ablative surgeon as well as the reconstructive surgeon. We describe four different microvascular flap techniques which we have used for head and neck cancer reconstruction to illustrate some of the many applications of these microvascular flaps.

Diagnosis and treatment of biliary tract complications after orthotopic liver transplantation.

Biliary tract complications are a continuing source of morbidity after liver transplantation. In a 3.5-year period we performed 264 liver transplants in 226 patients (132 adults, 94 children). Biliary tract reconstruction was via Roux limb choledochojejunostomy (n = 144) or choledochocholedochostomy (n = 118). Fifty (19.1%) biliary complications occurred, and 35 (13.4%) necessitated operative repair. The incidence was similar in adults and children and after each method of reconstruction. Risk factors were vascular thrombosis and reduced-sized transplants. Diagnosis was based on the algorithmic use of multiple modalities with early biliary visualization. Roux limb complications usually occurred in the first month after transplant and necessitated operative intervention, whereas duct-to-duct problems appeared later and were more accessible to percutaneous or endoscopic manipulations. Eight (6.8%) patients required conversion to a Roux limb, whereas 8/15 (53.3%) cases of biliary stricture were successfully managed nonoperatively. Three (1.3%) patients and four (1.5%) grafts were lost as a result of biliary complications. One-year actuarial patient survival is 76.4% with a mean follow-up of 13.2 months. Early recognition of biliary complications and prompt interventional therapy can effectively prevent long-term sequelae. Although choledochocholedochostomy is more physiologic and expeditious, Roux-en-Y choledochojejunostomy remains a safe and versatile alternative and is the preferred method of reconstruction in select cases.

Multiple idiopathic root resorption: diagnostic considerations.

Multiple idiopathic root resorption is a specific entity that must be delineated from all other resorptive processes. We present a case report and discuss the diagnostic possibilities that must be considered before arrival at this diagnosis.

Pseudoankylosis of the mandible after temporal bone attached craniotomy.

Mandibular hypomobility after intracranial surgical procedures is seldom encountered. A case of limited oral opening after temporal bone attached craniotomy is described. The condition is due to fibrosis of the temporalis muscle resulting in a pseudoankylosis of the temporomandibular joint. The appropriate operative intervention is transoral coronoidectomy, which restores normal joint function.

Problems in evaluation of penetrating foreign bodies with computed tomography scans: report of cases.

Computed tomography is the best radiologic modality available in the evaluation of penetrating injuries to the soft tissues. The technique is the best available when the foreign body has a density similar to the surrounding tissues. Limitations of CT scanning include difficulty in identifying small foreign bodies, objects with densities similar to surrounding structures, and detecting vascular injury. Interpretation of postoperative changes is also difficult. Two cases have been presented to illustrate the advantages, and limitations of CT scanning in penetrating soft tissue trauma.

Mesenchymal chondrosarcoma: a case report.

Mesenchymal chondrosarcoma is a rare tumor distinctly different from the more common chondrosarcoma. It shows a predilection for the head and neck in both osseous and extraosseous forms. The prognosis for cure is poor, with a high incidence of local recurrence as well as regional and distant metastasis. Treatment is based on radical surgical excision, although combination chemo-therapy has recently shown promise. Additional experience with this tumor is required to define the most efficacious form of treatment.

Orthognathic surgery in correcting dentofacial defects.

Advances in orthognathic surgery now make it possible to correct most skeletal abnormalities of the face. Simple screening measures can be quickly applied to assess the patient who appears to be a candidate. Cases are carefully planned and coordinated, with the aid of special diagnostic procedures to identify the problem and select the appropriate management. Properly executed, these techniques result in a lifetime of improved function and aesthetics.