Simultaneous Assessment of Left Atrial Fibrosis and Epicardial Adipose Tissue Using 3D Late Gadolinium Enhanced Dixon MRI

BACKGROUND

Epicardial adipose tissue (EAT) may induce left atrium (LA) wall inflammation and promote LA fibrosis. Therefore, simultaneous assessment of these two important atrial fibrillation (AF) risk factors would be desirable.

PURPOSE

To perform a comprehensive evaluation of 3D Dixon water-fat separated late gadolinium enhancement (LGE-Dixon) MRI by analysis of repeatability and systematic comparison with reference methods for assessment of fibrosis and fat.

STUDY TYPE

Prospective.

POPULATION

Twenty-eight, 10, and 7 patients, respectively, with clinical indications for cardiac MRI.

FIELD STRENGTH/SEQUENCE

A 1.5-T scanner, inversion recovery multiecho spoiled gradient echo.

ASSESSMENT

Twenty-eight patients (age 58 ± 19 years, 15 males) were scanned using LGE-Dixon. A 5-point Likert-type scale was used to grade the image quality. Another 10 patients (age 46 ± 19 years, 9 males) were scanned using LGE-Dixon and 3D proton density Dixon (PD-Dixon). Finally, seven patients (age 62 ± 14 years, 4 males) were scanned using LGE-Dixon and conventional LGE. The scan time, intraobserver and interobserver variability, and levels of agreement were assessed.

STATISTICAL TESTS

Student's t-test, one-way ANOVA, and Mann-Whitney U-test were used; P < 0.05 was considered significant, intraclass correlation coefficient (ICC).

RESULTS

The scan time (minutes:seconds) for LGE-Dixon (n = 28) was 5:01 ± 1:40. ICC values for intraobserver and interobserver measurements of LA wall fibrosis percentage were 0.98 (95% CI, 0.97-0.99) and 0.97 (95% CI, 0.94-0.99) while of EAT were 0.92 (95% CI, 0.82-0.97) and 0.90 (95% CI, 0.80-0.95). The agreement for LA fibrosis percentage between the LGE-Dixon and the conventional LGE was 0.92 (95% CI, 0.66-0.99) and for EAT volume between the LGE-Dixon and the PD-Dixon was 0.93 (95% CI, 0.72-0.98).

CONCLUSION

LA fibrosis and EAT can be assessed simultaneously using LGE-Dixon. This method allows a high level of intraobserver and interobserver repeatability as well as agreement with reference methods and can be performed in a clinically feasible scan time.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY STAGE: 3.

Turbulent Intensity of Blood Flow in the Healthy Aorta Increases With Dobutamine Stress and is Related to Cardiac Output

Introduction: The blood flow in the normal cardiovascular system is predominately laminar but operates close to the threshold to turbulence. Morphological distortions such as vascular and valvular stenosis can cause transition into turbulent blood flow, which in turn may cause damage to tissues in the cardiovascular system. A growing number of studies have used magnetic resonance imaging (MRI) to estimate the extent and degree of turbulent flow in different cardiovascular diseases. However, the way in which heart rate and inotropy affect turbulent flow has not been investigated. In this study we hypothesized that dobutamine stress would result in higher turbulence intensity in the healthy thoracic aorta.

Method: 4D flow MRI data were acquired in twelve healthy subjects at rest and with dobutamine, which was infused until the heart rate increased by 60% when compared to rest. A semi-automatic segmentation method was used to segment the thoracic aorta in the 4D flow MR images. Subsequently, flow velocity and several turbulent kinetic energy (TKE) parameters were calculated in the ascending aorta, aortic arch, descending aorta and whole thoracic aorta.

Results: With dobutamine infusion there was an increase in heart rate (66 ± 9 vs. 108 ± 13 bpm, p < 0.001) and stroke volume (88 ± 13 vs. 102 ± 25 ml, p < 0.01). Additionally, there was an increase in Peak Average velocity (0.7 ± 0.1 vs. 1.2 ± 0.2 m/s, p < 0.001, Peak Max velocity (1.3 ± 0.1 vs. 2.0 ± 0.2 m/s, p < 0.001), Peak Total TKE (2.9 ± 0.7 vs. 8.0 ± 2.2 mJ, p < 0.001), Peak Median TKE (36 ± 7 vs. 93 ± 24 J/m3, p = 0.002) and Peak Max TKE (176 ± 33 vs. 334 ± 69 J/m3, p < 0.001). The relation between cardiac output and Peak Total TKE in the whole thoracic aorta was very strong (R² = 0.90, p < 0.001).

Conclusion: TKE of blood flow in the healthy thoracic aorta increases with dobutamine stress and is strongly related to cardiac output. Quantification of such turbulence intensity parameters with cardiac stress may serve as a risk assessment of aortic disease development.

Improved Efficiency of Intraventricular Blood Flow Transit Under Cardiac Stress: A 4D Flow Dobutamine CMR Study

Introduction: The effects of heart rate, inotropy, and lusitropy on multidimensional flow patterns and energetics within the human heart remain undefined. Recently, reduced volume and end-diastolic kinetic energy (KE) of the portion of left ventricular (LV) inflow passing directly to outflow, Direct flow (DF), have been shown to reflect inefficient LV pumping and to be a marker of LV dysfunction in heart failure patients. In this study, we hypothesized that increasing heart rate, inotropy, and lusitropy would result in an increased efficiency of intraventricular blood flow transit. Therefore, we sought to investigate LV 4D blood flow patterns and energetics with dobutamine infusion.

Methods: 4D flow and morphological cardiovascular magnetic resonance (CMR) data were acquired in twelve healthy subjects: at rest and with dobutamine infusion to achieve a target heart rate ~60% higher than the resting heart rate. A previously validated method was used for flow analysis: pathlines were emitted from the end-diastolic (ED) LV blood volume and traced forward and backward in time to separate four functional LV flow components. For each flow component, KE/mL blood volume at ED was calculated.

Results: With dobutamine infusion there was an increase in heart rate (64%, p < 0.001), systolic blood pressure (p = 0.02) and stroke volume (p = 0.01). Of the 4D flow parameters, the most efficient flow component (DF), increased its proportion of EDV (p < 0.001). The EDV proportion of Residual volume, the blood residing in the ventricle over at least two cardiac cycles, decreased (p < 0.001). The KE/mL at ED for all flow components increased (p < 0.001). DF had the largest absolute and relative increase while Residual volume had the smallest absolute and relative increase.

Conclusions: This study demonstrates that it is feasible to compare 4D flow patterns within the normal human heart at rest and with stress. At higher heart rate, inotropy and lusitropy, elicited by dobutamine infusion, the efficiency of intraventricular blood flow transit improves, as quantified by an increased relative volume and pre-systolic KE of the most efficient DF component of the LV volume. The change in these markers may allow a novel assessment of LV function and LV dysfunction over a range of stress.

The relationship between faecal-associated and mucosal-associated microbiota in irritable bowel syndrome patients and healthy subjects

BACKGROUND

The faecal-associated microbiota is commonly seen as a surrogate of the mucosal-associated microbiota. However, previous studies indicate that they are different. Furthermore, analyses of the mucosal microbiota are commonly done after standard bowel cleansing, affecting the microbial composition.

AIM

To compare the mucosal-associated microbiota, obtained from unprepared colon, with faecal-associated microbiota in healthy subjects and irritable bowel syndrome (IBS) patients.

METHODS

Faecal and mucosal biopsies were obtained from 33 IBS patients and 16 healthy controls. Of IBS patients, 49% belonged to the diarrhoea-predominant subgroup and 80% suffered from IBS symptoms during at least 5 years. Biopsies were collected from unprepared sigmoid colon and faecal samples a day before colonoscopy. Microbiota analyses were performed with a phylogenetic microarray and redundancy discriminant analysis.

RESULTS

The composition of the mucosal- and the faecal-associated microbiota in unprepared sigmoid colon differs significantly (P = 0.002). Clinical characteristics of IBS did not correlate with this difference. Bacteroidetes dominate the mucosal-associated microbiota. Firmicutes, Actinobacteria and Proteobacteria dominate the faecal-associated microbiota. Healthy subjects had a significantly higher (P < 0.005) abundance (1.9%) of the bacterial group uncultured Clostridiales I in the mucosal-associated microbiota than IBS patients (0.3%). Bacterial diversity was higher in faecal- compared with mucosal-associated microbiota in IBS patients (P < 0.005). No differences were found in healthy subjects.

CONCLUSIONS

Differences in the mucosal-associated microbiota between healthy individuals and IBS patients are minimal (one bacterial group) compared to differences in the faecal microbiota of both groups (53 bacterial groups). Microbial aberrations characterising IBS are more pronounced in the faeces than in the mucosa.

Risk-taking behaviours among UK military reservists

BACKGROUND

Deploying in a combat role negatively impacts risk-taking behaviours, such as drinking, smoking and risky driving in regular UK military personnel. Little is known about the impact of deployment on the risk-taking behaviours of reservists.

AIMS

To explore the impact of deployment on risk-taking behaviours among reservists.

METHODS

This was a cross-sectional study. Hazardous drinking, risky driving, physical violence, smoking and attendance at accident and emergency (A&E) departments as a result of risk-taking behaviours were assessed by self-reported questionnaire.

RESULTS

There were 1710 participants in the study; response rate 51%. The overall prevalence of risk-taking behaviours was: hazardous drinking 46%, smoking 18%, risky driving 11%, attending A&E due to risky behaviours 13% and reporting physical violence 3%. Deployment was significantly associated with risky driving [odds ratio (OR) 1.88, 95% confidence interval (CI) 1.25-2.81], smoking (OR 2.02, 95% CI 1.46-2.78) and physical violence (OR 3.63, 95% CI 1.88-7.02).

CONCLUSIONS

It is important to consider the impact of deployment and military factors on the prevalence of risk-taking behaviours in reservists as greater numbers than ever before will face the prospect of deployment to overseas conflicts.

The prevalence of mental health disorders in (ex-)military personnel with a physical impairment: a systematic review

BACKGROUND

Having a visual, hearing or physical impairment (defined as problems in body function or structure) may adversely influence the mental well-being of military personnel. This paper reviews the existing literature regarding the prevalence of mental health problems among (ex-)military personnel who have a permanent, predominantly, physical impairment.

METHOD

Multiple electronic literature databases were searched for relevant studies (EMBASE (1980-January 2014), MEDLINE (1946-January 2014), PsycINFO (2002-January 2014), Web of Science (1975-January 2014)).

RESULTS

25 papers were included in the review, representing 17 studies. Studies conducted among US military personnel (n=8) were most represented. A range of mental health disorders were investigated; predominately post-traumatic stress disorder (PTSD), but also depression, anxiety disorder (excluding PTSD), psychological distress and alcohol misuse. The findings indicate that mental health disorders including PTSD (range 2-59%), anxiety (range 16.1-35.5%), depression (range 9.7-46.4%) and psychological distress (range 13.4-36%) are frequently found whereby alcohol misuse was least common (range 2.2-26.2%).

CONCLUSIONS

Common mental health disorders were frequently identified among (ex-)military personnel with a physical impairment. Adequate care and support is necessary during the impairment adaptation process to facilitate the psychosocial challenges (ex-)military personnel with an impairment face. Future research should be directed into factors impacting on the mental well-being of (ex-)military personnel with an impairment, how prevalence rates vary across impairment types and to identify and act on specific needs for care and support.

Altered faecal and mucosal microbial composition in post-infectious irritable bowel syndrome patients correlates with mucosal lymphocyte phenotypes and psychological distress

BACKGROUND

A subset of irritable bowel syndrome (IBS) patients, denoted post-infectious IBS (PI-IBS), develop symptoms after an enteric infection. Bacterial dysbiosis and mucosal inflammation have been proposed to be involved in the pathophysiology of this entity.

AIM

To characterise the mucosal and faecal microbiota in PI-IBS, general IBS and healthy controls, and to investigate associations between the microbiota and the mucosal immune system.

METHODS

Mucosal biopsies and faeces were collected from 13 PI-IBS patients, 19 general IBS patients and 16 healthy controls. Global bacterial composition was determined by generating 16S rRNA amplicons that were examined by phylogenetic microarray hybridisation, principal component and redundancy analysis. We correlated previously reported lymphocyte proportions with the microbiota.

RESULTS

Faecal microbiota composition of PI-IBS patients differed significantly from both general IBS patients and healthy controls (P < 0.02). Both mucosal (P < 0.01) and faecal (P = 0.05) microbial diversity were reduced in PI-IBS compared to healthy controls. In the intraepithelial lymphocytes the previously published proportion of CD8(+) CD45RA(+) was negatively correlated with mucosal microbial diversity (P < 0.005). The previously published number of lamina propria lymphocytes was negatively correlated with mucosal microbial diversity (P < 0.05). Faecal microbial diversity was significantly negatively correlated with the Hospital Anxiety and Depression scale (P < 0.05).

CONCLUSIONS

We present data that distinguishes the intestinal microbiota of PI-IBS patients from that of both general IBS patients and HC. The microbial composition is significantly associated with the HADs score and alterations in lymphocyte subsets proportions.

What explains post-traumatic stress disorder (PTSD) in UK service personnel: deployment or something else?

BACKGROUND

In previous studies an association between deployment to Iraq or Afghanistan and an overall increased risk for post-traumatic stress disorder (PTSD) in UK armed forces has not been found. The lack of a deployment effect might be explained by including, in the comparison group, personnel deployed on other operations or who have experienced traumatic stressors unrelated to deployment.

METHODS

The sample comprised 8261 regular UK armed forces personnel who deployed to Iraq, Afghanistan or other operational areas or were not deployed. Participants completed the PTSD CheckList-Civilian Version (PCL-C) and provided information about deployment history, demographic and service factors, serious accidents and childhood experiences.

RESULTS

Deployment to Iraq or Afghanistan [odds ratio (OR) 1.2, 95% confidence interval (CI) 0.6-2.2] or elsewhere (OR 1.1, 95% CI 0.6-2.0) was unrelated to PTSD although holding a combat role was associated with PTSD if deployed to Iraq or Afghanistan (OR 2.7, 95% CI 1.9-3.9). Childhood adversity (OR 3.3, 95% CI 2.1-5.0), having left service (OR 2.7, 95% CI 1.9-4.0) and serious accident (OR 2.1, 95% CI 1.4-3.0) were associated with PTSD whereas higher rank was protective (OR 0.3, 95% CI 0.12-0.76).

CONCLUSIONS

For the majority of UK armed forces personnel, deployment whether to Iraq, Afghanistan or elsewhere confers no greater risk for PTSD than service in the armed forces per se but holding a combat role in those deployed to Iraq or Afghanistan is associated with PTSD. Vulnerability factors such as lower rank, childhood adversity and leaving service, and having had a serious accident, may be at least as important as holding a combat role in predicting PTSD in UK armed forces personnel.

Unit cohesion and mental health in the UK armed forces

BACKGROUND

Unit cohesion is recognized as a potentially modifiable factor in the aetiology of mental illness among military personnel.

AIMS

To examine the association between unit cohesion and probable post-traumatic stress disorder (PTSD), common mental disorder and alcohol misuse, in UK armed forces personnel deployed to Iraq.

METHODS

A sample of 4901 male UK armed forces personnel who had deployed to Iraq was drawn from a cohort of personnel who participated in a cross-sectional postal questionnaire study between June 2004 and March 2006. Information was collected on socio-demographic and military characteristics, deployment experiences and information on current health.

RESULTS

Perceived interest from seniors was associated with less probable PTSD [odds ratio (OR) 0.42, 95% confidence interval (CI) 0.26-0.67] and common mental disorder (OR 0.68, 95% CI 0.53-0.87). Among regular personnel, feeling well informed was associated with less common mental disorder (OR 0.74, 95% CI 0.58-0.95) and comradeship was associated with greater alcohol misuse (OR 1.98, 95% CI 1.19-3.28). Feeling able to talk about personal problems was associated with less alcohol misuse among reserve personnel (OR 0.31, 95% CI 0.16-0.60). The general construct of unit cohesion was predictive of less probable PTSD (OR 0.69, 95% CI 0.58-0.81) and common mental disorder (OR 0.80, 95% CI 0.73-0.87).

CONCLUSIONS

Unit cohesion had a linear association with less probable PTSD and common mental disorder. Of the individual items, perception of leadership was associated with less probable PTSD and common mental disorder. Comradeship was associated with greater alcohol misuse among regular personnel, while feeling able to talk about personal problems was associated with less alcohol misuse for reserve personnel.

Male broad-nosed pipefish Syngnathus typhle do not locate females by smell

Broad-nosed pipefish Syngnathus typhle were used to investigate whether males used scent in their search for mates. When the males in an experiment had access to olfactory cues only, they did not locate females better than they located males. Thus, S. typhle, was less successful in mate search when visual cues were absent.

Straight-nosed pipefish Nerophis ophidion and broad-nosed pipefish Syngnathus typhle avoid eelgrass overgrown with filamentous algae

In a habitat choice experiment straight-nosed pipefish Nerophis ophidion and broad-nosed pipefish Syngnathus typhle avoided eelgrass Zostera marina covered with filamentous algae. Both juveniles as well as brooding adult males of the two species clearly preferred to position themselves in Z. marina without growth of filamentous algae.

Mental health among commando, airborne and other UK infantry personnel

BACKGROUND

Despite having high levels of combat exposure, commando and airborne forces may be at less risk of mental ill-health than other troops.

AIMS

To examine differences in mental health outcomes and occupational risk factors between Royal Marines Commandos (RMCs), paratroopers (PARAs) and other army infantry (INF).

METHODS

Three groups of personnel (275 RMCs, 202 PARAs and 572 INF) were generated from a UK military cohort study of personnel serving at the time of the 2003 Iraq war. Participants completed a questionnaire about their mental health and experiences on deployment. Differences in mental health outcomes between the groups were examined with logistic regression and negative binomial regression analyses.

RESULTS

Both RMCs and PARAs were less likely to have multiple physical symptoms or to be fatigued, and RMCs also had lower levels of general mental health problems and lower scores on the Post-traumatic Checklist than INF personnel. Differences were not explained by the level of unit cohesion.

CONCLUSIONS

The effect of warfare on troops' well-being is not universal across occupational groups. A possible explanation for this difference is that the high level of preparedness in RMCs and PARAs may lessen the psychological impact of war-zone deployment experiences.

PTSD after deployment to Iraq: conflicting rates, conflicting claims

BACKGROUND

Post-traumatic stress disorder (PTSD) has been called one of the signature injuries of the Iraq War. In this review prevalence estimates of PTSD are summarized and discrepancies are discussed in relation to methodological differences between studies.

METHOD

We searched for population-based studies with a minimum sample size of 300. Studies based on help-seeking samples were excluded. We identified 60 possible papers, of which 19 fulfilled the inclusion criteria. Prevalence estimates and study characteristics were examined graphically with forest plots, but because of high levels of heterogeneity between studies, overall estimates of PTSD prevalence were not discussed.

RESULTS

The prevalence of PTSD in personnel deployed to Iraq varied between 1.4% and 31%. Stratifying studies by PTSD measure only slightly reduced the variability in prevalence. Anonymous surveys of line infantry units reported higher levels of PTSD compared to studies that are representative of the entire deployed population. UK studies tend to report lower prevalence of PTSD compared with many US studies; however, when comparisons are restricted to studies with random samples, prevalences are similar. US studies that have assessed personnel more than once since return from deployment have shown that PTSD prevalence increases over the 12 months following deployment.

CONCLUSIONS

Differences in methodologies and samples used should be considered when making comparisons of PTSD prevalence between studies. Further studies based on longitudinal samples are needed to understand how the prevalence of PTSD changes over time.

High yield direct 76Br-bromination of monoclonal antibodies using chloramine-T

Monoclonal antibody (MAb) A33 was labeled with the positron emitter 76Br (T(1/2) = 16.2 h). Direct labeling was done using the conventional chloramine-T method. After optimization of the labeling conditions, a maximum yield (mean +/- max error) of 77 +/- 2% was obtained at pH 6.8. In vitro binding of 76Br-A33 to SW1222 colonic cancer cells showed that the immunoreactivity was retained. Also, the MAbs 38S1 and 3S193 and the peptide hEGF were 76Br-labeled, resulting in labeling yields (mean +/- max error) of 75 +/- 3%, 63 +/- 4%, and 73 +/- 0.1%, respectively. We conclude that antibodies and peptides can be labeled conveniently with 76Br for the purpose of whole-body tumour imaging by positron emission tomography.

Effects of dextranation on the pharmacokinetics of short peptides. A PET study on mEGF

The effects of dextranation on the biodistribution of mouse epidermal growth factor (mEGF, 6 kDa) were assessed. By reductive amination, mEGF was coupled to 13 and 46 kDa dextran. The two dextranated conjugates and free mEGF were labeled with the positron-emitting nuclide (76)Br (T(1/2) = 16 h). After intravenous administration to Sprague Dawley rats, the radioactivity biodistribution was evaluated by positron emission tomography (PET) and by measurements of dissected tissues. The dextranation prolonged the retention time in blood, especially when the dextran chain was long. [(76)Br]mEGF-dextran conjugates were shown to have significantly, more than 5 times, lower kidney accumulation than the nonconjugated [(76)Br]mEGF. In conclusion, dextranation affects the biodistribution of mEGF in vivo giving a prolonged circulation time, a decreased uptake in kidney, and an increased spleen accumulation.

Pharmacokinetics and red cell utilization of iron(III) hydroxide-sucrose complex in anaemic patients: a study using positron emission tomography

The pharmacokinetics of a single intravenous injection of 100 mg iron hydroxide-sucrose complex labelled with a tracer in the form of 52Fe/59Fe was followed in six anaemic patients for a period ranging from 6 to 8 3 h using positron emission tomography (PET). Red cell utilization of the labelled iron was followed for 4 weeks. PET data showed radioactive uptake by the liver, spleen and bone marrow. The uptake by the macrophage-rich spleen demonstrated the reticuloendothelial uptake of this iron preparation, with subsequent effective release of that iron for marrow utilization. Red cell utilization, followed for 4 weeks, ranged from 59% to 97%. The bone marrow influx rate constant was independent of blood iron concentration, indicating non-saturation of the transport system in bone marrow. This implied that higher doses of the iron complex can probably be used in the same setting. A higher influx rate into the marrow compared with the liver seemed to be consistent with higher red cell utilization. This would indicate that early distribution of the injected iron complex may predict the long-term utilization.

Kinetic analysis of 52Fe-labelled iron(III) hydroxide-sucrose complex following bolus administration using positron emission tomography

Kinetic analysis of a single intravenous injection of 100 mg iron(III) hydroxide-sucrose complex (Venofer) mixed with 52Fe(III) hydroxide-sucrose as a tracer was followed for 3-6 h in four generally anaesthetized, artificially ventilated minipigs using positron emission tomography (PET). The amount of injected radioactivity ranged from 30 to 200 MBq. Blood radioactivity, measured by PET in the left ventricle of the heart, displayed a fast clearance phase followed by a slow one. In the liver and bone marrow a fast radioactivity uptake occurred during the first 30 min, followed by a slower steady increase. In the liver a slight decrease in radioactivity uptake was noted by the end of the study. A kinetic analysis using a three-compartment (namely blood pool, reversible and irreversible tissue pools) model showed a fairly high distribution volume in the liver as compared with the bone marrow. In conclusion, the pharmacokinetics of the injected complex was clearly visualized with the PET technique. The organs of particular interest, namely the heart (for blood kinetics), liver and bone marrow could all be viewed by a single setting of a PET tomograph with an axial field of view of 10 cm. The half-life (T1/2) of 52Fe (8.3 h) enables a detailed kinetic study up to 24 h. A novel method was introduced to verify the actual 52Fe contribution to the PET images by removing the interfering radioactive daughter 52mMn positron emissions. The kinetic data fitted the three-compartment model, from which rate constants could be obtained for iron transfer from the blood to a pool of iron in bone marrow or liver to which it was bound during the study period. In addition, there was a reversible tissue pool of iron, which in the liver slowly equilibrated with the blood, to give a net efflux from the liver some hours after i.v. administration. The liver uptake showed a relatively long distribution phase, whereas the injected iron was immediately incorporated into the bone marrow. Various transport mechanisms seem to be involved in the handling of the injected iron complex.

Worlds we have lost and worlds we may regain: Two centuries of changes in the life course in Sweden

"The article seeks to place into historical context the familial changes in ¿post-industrial' Sweden during the past two decades, by comparing them with general characterizations (based on documented life-course experiences) of the traditional Swedish agrarian society (before 1800), the transitional society (c. 1800-1870), and the industrial society (c. 1870-1980). Familial lives in traditional Swedish society tended to be stable. By contrast, during the agrarian-to-industrial society, especially since World War II, stability became once again the hallmark because of general government social policy."

Endoscopy for regional lipectomy

With the advances in endoscopic surgery, reconstructive surgeons search for applications in the field of soft tissue contouring. The improvements in endoscopic surgery in other fields are based on surgery within well-contained spaces that allow insufflation. However, minimally invasive surgery in the soft tissue planes has been limited by the relative inability to control separation of the tissue planes to allow a working space for instrumentation. This animal model shows the ability to open up and elevate any soft tissue space by means of external traction elevation and exact separation of tissue layers to allow endoscopic surgery without the need for insufflation. With the use of endoscopic equipment, the removal of fat from any area of the body becomes a much more precise art because of visualization and illumination and the ability to gain immediate hemostasis while exact contouring through removal of layers of fat can be achieved.

Minimally invasive harvesting of rectus abdominis myofascial flap in the cadaver and porcine models

The rectus abdominis muscle has been used in reconstructive surgery as a superiorly and an inferiorly based pedicle flap as well as free flap. Since flap necrosis is unusual, the primary morbidity of the harvesting is donor-site complications, including infections, seromas, poor cosmesis, and hernias. Minimally invasive surgery has been used in abdominal, thoracic, and urologic surgeries with favorable results. To date, flap harvesting and other soft-tissue surgeries have been considered inaccessible to minimally invasive surgery based on existing techniques. We demonstrate in the (5) cadaver and (5) porcine models the technique of endoscopic harvesting of a superiorly based vertical myofascial pedicle flap. Without insufflation, we create a soft-tissue space to operate within using external skin traction. We demonstrate that this flap harvesting can be performed without the obligatory large skin incision. Donor-site complications may be decreased with less tissue disruption. In our cadaver models, we have tried using the rectus without the anterior fascia based on its superior pedicle for breast reconstruction. For this purpose, we use the endoscissors with cautery to create a tunnel up on the chest wall. The muscle based on its superior pedicle could be rotated up on the chest wall subcutaneously, allowing primary closure of the anterior sheath using the endostapler. If the anterior sheath is sacrificed or cannot be closed primarily, mesh can be used to create a reinforcing layer stapled to the edges of fascia and midline. Endoscopic surgery offers an excellent alternative for soft-tissue reconstruction without compromising the results.

Endoscopy mastectomy and breast reconstruction: endoscopic breast surgery

This article describes a new method of external traction elevation which is applied to the breast in order to perform an oncologically thorough glandular removal and axillary dissection followed by immediate autologous reconstruction while significantly reducing wound morbidity and greatly improving cosmesis.

The social and cultural history of medicine and health in Sweden

The social and cultural history of medicine and health is a growing field of research in Sweden, stimulated by the present political, economic and social concern about health and health care. Since there have never been any chairs in the history of medicine within the medical faculty, the topic has mostly been approached by historians of science and ideas, social historians and anthropologists and sociologists interested in long-term developments. Psychiatry and psychiatric care is one of the most popular subjects. Other fields are professional history and social policy, cultural and local studies on different aspects, epidemics and public health and socio-demographic studies of mortality and morbidity. This report presents some major Swedish contributions and gives a short summary of some of the results. There has, during the recent years, been a trend towards interdisciplinary exchange, for instance through Swedish and Scandinavian networks, and towards an international orientation that has led to comparative studies and exchange of results, a trend that can also be observed in many other countries.

Minimally invasive harvesting of the latissimus dorsi

The latissimus dorsi has been used extensively and dependably in reconstruction surgery. The major complications involve donor-site infections, seromas, and poor cosmesis. Minimally invasive surgery has been used in abdominal, thoracic, and urologic surgeries with favorable results. To date, flap harvesting and other soft-tissue surgeries have been considered poorly accessible to minimally invasive surgery based on existing techniques. We demonstrate in the cavader model the minimally invasive harvesting of a latissimus dorsi myofascial pedicle flap. This is performed with a laparoscope and commercially available instruments through three small incisions. External traction on the skin elevates the underlying subcutaneous tissues, creating a soft-tissue cavity without insufflation. Donor-site complications may be decreased as a result of less tissue disruption.