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Biomedical subjects

J H Stevenson

Publications and source records attributed to J H Stevenson.

At least 19 recordsLinked to original sources

Skin excision and groin lymphadenectomy: techniques and outcomes.

A 10-year retrospective review of 25 patients undergoing groin lymphadenectomy for cutaneous malignancy in the Tayside region of the UK was conducted. Comparison was made between patients undergoing the procedure with an elliptical incision orientated as a long oblique of at least 4cm width (group 1) and those undergoing a similarly oriented incision with no skin excision (group 2). Outcome measures including survival, postoperative complications, operative time and hospital stay were analyzed. Patients in group I suffered significantly fewer complications (p < 0.004) and shorter hospital stay (p < 0.008). Elliptical excision of at least 4cm width is our preferred technique for groin lymphadenectomy in the treatment of cutaneous malignancy of the lower limb.

Adult↗

The anatomical and neurophysiological basis of the sensate free TRAM and DIEP flaps.

Recent developments in autogenous breast reconstruction using the rectus abdominis myocutaneous free flap include attempts to reinnervate the flap tissue. We have carried out anatomical studies to determine the nature of abdominal-wall cutaneous innervation, with particular emphasis on the harvesting of sensate flaps. Dissections were performed on four embalmed and 12 fresh human cadavers (32 sides). The lowest five intercostal nerve trunks were identified and traced to the lateral border of the rectus sheath. A detailed dissection of the intramuscular course of the nerves and associated vasculature was performed. The relationship of the nerves to the vascular perforators used for rectus abdominis myocutaneous flaps was determined visually, and confirmed histologically. In contrast to previous studies, we show that nerves supplying cutaneous sensation can travel with both medial and lateral vascular perforators. In order to confirm clinically useful innervation, the abdominal flap skin of five patients undergoing TRAM flap reconstruction was stimulated electrically, and sensory recordings were made directly from the related intercostal nerve just prior to flap harvest. These studies represent, to our knowledge, the first clinical application of neurophysiological techniques to outline the perforator neurosomes of flaps based on the deep inferior epigastric vascular axis. We provide the first comprehensive study of abdominal-wall innervation with regard to sensate free-flap harvest. Our dissections show complex patterns of abdominal skin innervation that have not been previously described. The implications for sensate free TRAM and DIEP flap reconstructions, as well as the potential for more accurate inclusion of innervated flap skin, are discussed.

Abdominal Muscles↗

Immediate versus delayed free TRAM breast reconstruction: an analysis of perioperative factors and complications.

Immediate breast reconstruction provides superior psychological benefit to the patient compared with delayed reconstruction, and has a financial advantage. Smokers undergoing immediate free TRAM breast reconstruction have a higher incidence of flap necrosis than smokers undergoing delayed free TRAM reconstruction. Whereas the differences in psychological benefit, effects of smoking and cost are well addressed in the literature, the differences in morbidity between immediate and delayed free TRAM breast reconstruction are still unknown. Knowledge of any differences would help to determine the best timing for reconstruction, and would support surgical decision making and preoperative patient advice. We present a retrospective review of 105 consecutive free TRAM breast reconstructions performed in 97 patients (89 unilateral and eight bilateral reconstructions). There were 48 immediate reconstructions and 57 delayed reconstructions. In the immediate-reconstruction group six flaps required revision of the anastomosis, and three flaps (6%) were lost. In the delayed-reconstruction group five flaps required revision of the anastomosis, and only one flap (2%) could not be salvaged. Delayed healing of the chest-wall skin flaps only occurred in immediate reconstructions (16%, P = 0.017).

Adult↗

An evaluation of Polaroid photographic imaging for cutaneous-lesion referrals to an outpatient clinic: a pilot study.

A pilot study consisted of 65 patient referrals to a Regional Plastic Surgery Department in which the referral letter, accompanied by a high-quality Polaroid photograph, was assessed by four consultants. The diagnosis, degree of urgency of treatment, grade of surgeon (to undertake the operation) and anticipated time for the procedure were recorded. The results were statistically analysed. Our aim was to evaluate the diagnostic accuracy and consistency of the four observers. The majority of malignant skin lesions were detected accurately; those that were missed received urgent attention due to a high degree of suspicion. This study supports the view that 'triage' of referrals using high-quality photographic images in association with an accurate referral letter can offer a significant reduction in pressure on waiting time and inconvenience for patients by avoiding an additional outpatient visit. Advantages to purchasers in terms of cost savings on outpatient visits and travelling reimbursement can result from this initiative.

Algorithms↗

Mitochondrial malic enzyme activity is much higher in mitochondria from cortical synaptic terminals compared with mitochondria from primary cultures of cortical neurons or cerebellar granule cells.

Most of the malic enzyme activity in the brain is found in the mitochondria. This isozyme may have a key role in the pyruvate recycling pathway which utilizes dicarboxylic acids and substrates such as glutamine to provide pyruvate to maintain TCA cycle activity when glucose and lactate are low. In the present study we determined the activity and kinetics of malic enzyme in two subfractions of mitochondria isolated from cortical synaptic terminals, as well as the activity and kinetics in mitochondria isolated from primary cultures of cortical neurons and cerebellar granule cells. The synaptic mitochondrial fractions had very high mitochondrial malic enzyme (mME) activity with a Km and a Vmax of 0.37 mM and 32.6 nmol/min/mg protein and 0.29 mM and 22.4 nmol/min mg protein, for the SM2 and SM1 fractions, respectively. The Km and Vmax for malic enzyme activity in mitochondria isolated from cortical neurons was 0.10 mM and 1.4 nmol/min/mg protein and from cerebellar granule cells was 0.16 mM and 5.2 nmol/min/mg protein. These data show that mME activity is highly enriched in cortical synaptic mitochondria compared to mitochondria from cultured cortical neurons. The activity of mME in cerebellar granule cells is of the same magnitude as astrocyte mitochondria. The extremely high activity of mME in synaptic mitochondria is consistent with a role for mME in the pyruvate recycling pathway, and a function in maintaining the intramitochondrial reduced glutathione in synaptic terminals.

Animals↗

The establishment of a burns unit in a developing country--a collaborative venture in Malawi.

In September 1993, the recently completed 32-bedded Burns Unit in the Queen Elizabeth Central Hospital, Blantyre, Malawi, was officially opened. This represented the culmination of 3 years' planning and construction; this paper presents our experience in developing this type of project, and an analysis of the early results of treatment in the unit. The widespread neglect of this common injury in developing countries is highlighted and the importance of input from specialists in this field working in collaboration with local medical and nursing staff is emphasized. The potential for making a significant impact in reducing the morbidity and mortality in burn injuries is highlighted.

Adolescent↗

Lactate transport by cortical synaptosomes from adult rat brain: characterization of kinetics and inhibitor specificity.

Since lactate released by glial cells may be a key substrate for energy in neurons, the kinetics for the uptake of L-[U-14C]lactate by cortical synaptic terminals from 7- to 8-week-old rat brain were determined. Lactate uptake was temperature-dependent, and increased by 64.9% at pH 6.2, and decreased by 43.4% at pH 8.2 relative to uptake at pH 7.3. Uptake of monocarboxylic acids was saturable with increasing substrate concentration. Eadie-Hofstee plots of the data gave evidence of two carrier-mediated uptake mechanisms with a high-affinity Km of 0.66 mM and Vmax of 3.66 mM for pyruvate, and a low-affinity system with a Km of 9.9 mM for both lactate and pyruvate and Vmax values of 16.6 and 23.1 nmol/30 s/mg protein for lactate and pyruvate, respectively. Saturable uptake was seen in the presence of 10 mM alpha-cyano-4-hydroxycinnamate. Lactate transport by synaptic terminals was much more sensitive to inhibition by sulfhydryl reagents than transport in astrocytes. Addition of 0.5 and 2 mM mersalyl decreased the uptake of 1 mM lactate by synaptic terminals by 59.3 and 66.37%, respectively. Pyruvate moderately decreased lactate transport, whereas 3-hydroxybutyrate had little effect. Quercetin, an inhibitor of lactate release, had little effect on the content of 14C lactate in synaptic terminals, supporting the concept that the majority of lactate produced within brain is from glial cells. Oxidation of L-[U-14C]lactate by synaptosomes was saturable, and yielded a Km of 1.23 mM and a Vmax of 116 nmol/h/mg protein. Overall the studies show that synaptic terminals from adult brain have a high capacity for transport and oxidation of lactate, consistent with the proposed role for this compound in metabolic trafficking in brain. Furthermore, the data provide kinetic evidence of two carrier-mediated mechanisms for monocarboxylic acid transport by synaptosomes and demonstrate that uptake of lactate by synaptic terminals is regulated differently than transport by astrocytes. Uptake of lactate by synaptic terminals also has differences from the systems described for neurons.

Animals↗

The modified B-mammoplasty incision: an alternative skin-conserving technique for mastectomy with immediate breast reconstruction.

A modification of the B-mammoplasty incision (originally described by Regnault for reduction mammoplasty) is presented for patients undergoing skin-conserving mastectomy and reconstruction. This approach has several advantages; not only does it facilitate good exposure for the oncological surgeon to carry out the mastectomy, but it can easily be extended into the axilla to allow nodal clearance and microvascular access. It creates a suitable pocket into which a flap can be tailored or implant/expander inserted, and further adjustment of the breast size or shape can be undertaken easily. Most importantly, the scar is confined to the infralateral aspect of the breast, leaving the aesthetically important upper and medial breast skin scar free.

Adult↗

Overexpression of p53 in normal oral mucosa of oral cancer patients does not necessarily predict further malignant disease.

Recent reports of p53 positivity in the normal mucosa of some head and neck cancer patients have been taken as evidence for field cancerization and hence a likelihood of the development of further tumours, yet few papers report the clinical significance of this finding through long-term follow-up. The immunohistochemical detection of p53 expression in clinically and histopathologically normal oral mucosa taken from the wound margin following excision of oral cancer was assessed using the polyclonal antibody CM1. Fresh frozen biopsies of normal oral mucosa and the corresponding tumour from 21 oral cancer patients and of normal mucosa from 25 non-cancer patients were assessed for p53 overexpression. The 'normal' mucosa was positive in 12 of the oral cancer patients and one of the non-cancer patients. Second malignant tumours were seen in patients from whom p53-positive 'normals' and p53-negative 'normals' were recorded. In five of the p53-positive 'normals', the corresponding cancer was p53-negative. In one case, where 'normal' mucosa was available from more than one site, one region was positive, whilst the other was negative. No obvious difference in age, tobacco use, or recurrence rate was seen between positive and negative cases. All patients who were still alive were reviewed for a minimum of 5 years. Using Fisher's exact test, no statistically significant difference was found for the rate of second malignant tumours occurring in patients with p53-positive compared with p53-negative normal mucosa. Thus, the detection of p53 in normal mucosa did not necessarily predict a further tumour.

Aged↗

Burns in prisoners: an assessment of problems in handling prisoners in a burns unit.

All burns units look after members of the prison population at times. This can cause anxiety among the staff and unique problems with management. Four cases-were reviewed from Her Majesty's Prison (HMP) Perth, Scotland, all of whom required resuscitation, and a survey undertaken of the nursing staff in our unit to assess attitudes to caring for burns prisoners in particular. Despite a careful search of the literature, no reference to the problems of managing prisoners in a burns unit could be found. However, it was found that the handling of violent offenders can be a significant cause of anxiety for nursing staff, and the presence of prison officers a reassurance rather than a hindrance in the management of burned prisoners. It is therefore recommended that prison officers be present at all times while managing burned prisoners.

Adolescent↗

A modified Bretteville technique for hypospadias.

A modified Bretteville technique for hypospadias repair is presented. This is a two-stage repair, utilising a preputial skin flap. The modification reduces the second stage to a day-case procedure. 40 cases are reported with good early functional and aesthetic results. The only major complications were two fistulae. There were no strictures.

Follow-Up Studies↗

The deltoid muscle flap: anatomical studies and case reports.

Anatomical studies of the deltoid muscle were performed on 16 cadaver shoulders. The anatomy of the axillary nerve, the vascular pedicles, and the musculocutaneous perforators was assessed. These studies confirmed that part of the deltoid muscle can be used as a vascularised flap to cover defects of the shoulder while leaving some viable functioning muscle intact. We report the use of hemideltoid flaps to treat chronic radionecrotic ulcers involving the shoulders of two patients. In the first, the posterior part of the muscle was used as a local muscle flap. In the second, the anterior part of the muscle was raised with overlying skin to form a musculocutaneous flap. The flaps remained healed at one year follow-up. These soft tissue radionecrotic defects over the shoulder are an uncommon late complication of radiotherapy for breast cancer. Pedicled or free flaps are now recognised as the preferred methods of treatment.

Aged↗

New insights into the compartmentation of glutamate and glutamine in cultured rat brain astrocytes.

Studies from several groups have provided evidence that glutamate and glutamine are metabolized in different compartments in astrocytes. In the present study we measured the rates of 14CO2 production from U-[14C]glutamate and U-[14C]glutamine, and utilized both substrate competition experiments and the transaminase inhibitor aminooxyacetic acid (AOAA) to obtain more information about the compartmentation of these substrates in cultured rat brain astrocytes. The rates of oxidation of 1 mM glutamine and glutamate were 26.4 +/- 1.4 and 63.0 +/- 7.4 nmol/h/mg protein, respectively. The addition of 1 mM glutamate decreased the rate of oxidation of glutamine to 26.3% of the control rate, demonstrating that glutamate can effectively compete with the oxidation of glutamine by astrocytes. In contrast, the addition of 1 mM glutamine had little or no effect on the rate of oxidation of glutamate by astrocytes, demonstrating that the glutamate produced intracellularly from exogenous glutamine does not dilute the glutamate taken up from the media. The addition of 5 mM AOAA decreased the rate of 14CO2 production from glutamine to 29.2% of the control rate, consistent with earlier studies by our group. The addition of 5 mM AOAA decreased the rate of oxidation of concentrations of glutamate < or = 0.1 mM by approximately 50%, but decreased the oxidation of 0.5-1 mM glutamate by only approximately 20%, demonstrating that a substantial portion of glutamate enters the tricarboxylic acid (TCA) cycle via glutamate dehydrogenase (GDH) rather than transamination, and that as the concentration of glutamate increases the relative proportion entering the TCA cycle via GDH also increases. To determine if the presence of an amino group acceptor (i.e. a ketoacid) would increase the rate of metabolism of glutamate, pyruvate was added in some experiments. Addition of 1 mM pyruvate increased the rate of oxidation of glutamate, and the increase was inhibited by AOAA, consistent with enhanced entry of glutamate into the TCA cycle via transamination in the presence of pyruvate. Enzymatic studies showed that pyruvate increased the activity of mitochondrial aspartate aminotransferase (AAT). Overall, the data demonstrate that glutamate formed intracellularly from glutamine enters the TCA cycle primarily via transamination, but does not enter the same TCA cycle compartment as glutamate taken up from the extracellular milieu. In contrast, extracellular glutamate enters the TCA cycle in astrocytes via both transamination and GDH, and can compete with, or dilute, the oxidation of glutamate produced intracellularly from glutamine.

Aminooxyacetic Acid↗

Regulation of mitochondrial and cytosolic malic enzymes from cultured rat brain astrocytes.

Malate has a number of key roles in the brain, including its function as a tricarboxylic acid (TCA) cycle intermediate, and as a participant in the malate-aspartate shuttle. In addition, malate is converted to pyruvate and CO2 via malic enzyme and may participate in metabolic trafficking between astrocytes and neurons. We have previously demonstrated that malate is metabolized in at least two compartments of TCA cycle activity in astrocytes. Since malic enzyme contributes to the overall regulation of malate metabolism, we determined the activity and kinetics of the mitochondrial and cytosolic forms of this enzyme from cultured astrocytes. Malic enzyme activity measured at 37 degrees C in the presence of 0.5 mM malate was 4.15 +/- 0.47 and 11.61 +/- 0.98 nmol/min/mg protein, in mitochondria and cytosol, respectively (mean +/- SEM, n = 18-19). Malic enzyme activity was also measured in the presence of several endogenous compounds, which have been shown to alter intracellular malate metabolism in astrocytes, to determine if these compounds affected malic enzyme activity. Lactate inhibited cytosolic malic enzyme by a noncompetitive mechanism, but had no effect on the mitochondrial enzyme. alpha-Ketoglutarate inhibited both cytosolic and mitochondrial malic enzymes by a partial noncompetitive mechanism. Citrate inhibited cytosolic malic enzyme competitively and inhibited mitochondrial malic enzyme noncompetitively at low concentrations of malate, but competitively at high concentrations of malate. Both glutamate and aspartate decreased the activity of mitochondrial malic enzyme, but also increased the affinity of the enzyme for malate. The results demonstrate that mitochondrial and cytosolic malic enzymes have different kinetic parameters and are regulated differently by endogenous compounds previously shown to alter malate metabolism in astrocytes. We propose that malic enzyme in brain has an important role in the complete oxidation of anaplerotic compounds for energy.

Animals↗

Transport of 3-hydroxybutyrate by cultured rat brain astrocytes.

It is well established that 3-hydroxybutyrate can serve as an energy source for the brain. Since substrate utilization may be regulated in part by transport across the cellular membrane, we investigated the uptake of 3-hydroxybutyrate by primary cultures of rat brain astrocytes. Measurement of the net uptake indicated a saturable system and a Lineweaver-Burke type plot was consistent with a single carrier-mediated mechanism with a Km of 6.03 mM and a Vmax of 32.7 nmol/30 seconds/mg protein. The rate of uptake at pH 6.2 was more than ten times the rate at pH 8.2, with the rate at pH 7.4 being intermediate between these values, suggesting the possibility of cotransport with H+ or exchange with OH- (antiport). Mersalyl had only a slight effect on the transport of 3-hydroxybutyrate, suggesting that sulfhydryl groups are not involved in the transport of this monocarboxylic acid. Phenylpyruvate and alpha-ketoisocaproate also attenuated the transport, but lactate had only a marginal effect. These results suggest that the utilization of 3-hydroxybutyrate as an energy source by astrocytes is regulated in part by carrier-mediated transport and that the uptake system is different from the lactate transport system.

3-Hydroxybutyric Acid↗

Scald burns in children caused by hot drinks--the importance of the type of cup.

A prospective study of 36 consecutive scald injuries in children caused by hot beverages is reported. Almost a third of these were deep dermal or full skin thickness and the highest percentage resulted in injury to the upper chest region. The study further investigates the cooling characteristics in four different types of cup. These studies clearly show the potential for significant disfigurement from this type of injury for up to 11 min from the time the drink is poured. The need for greater public awareness in relation to hot drinks is highlighted.

Accidents, Home↗