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This series reports the outcomes and significant complications associated with the rectus myocutaneous flap when used for pelvic or inguinal reconstruction in patients with gynecologic cancers. Perioperative variables were retrospectively reviewed to identify social and medical risk factors as well as intraoperative and postoperative complications that predisposed to rectus flap failure. Fifteen patients with gynecologic malignancies underwent reconstructive procedures using a vertically oriented rectus abdominis myocutaneous flap for either vaginal (n = 14) or inguinal (n = 1) reconstruction. The patients' primary cancers were cervical (n = 11), rectal (n = 1), ovarian (n = 1), vulvar (n = 1), and vaginal (n = 1). The median age was 50 years. The median follow-up was 17 months. All flaps were mobilized in conjunction with a radical salvage operation. There were no cases of vaginal prolapse and no abdominal wound infections. However, 4 patients (27%) had major postoperative morbidity in this small series. There was one wound dehiscence and three episodes of necrosis of the subcutaneous and cutaneous portions of the flap. All 4 of these patients required additional operative intervention or debridement. Eleven patients had complete healing of the flap. The rectus abdominis myocutaneous flap is a valuable option for gynecologic reconstructive procedures. Perioperative strategies for improving flap viability include the identification of risk factors that may compromise flap perfusions such as prior abdominal incisions, peripheral vascular disease, and obesity. Meticulous surgical technique is required to preserve the vascular pedicle. These strategies may be useful in preoperative counseling, the perioperative evaluation, and the intraoperative management.
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PMID:Gynecologic reconstruction with a rectus abdominis myocutaneous flap: an update. 864 16

To examine the characteristic features of risk factors for macroangiopathy (MA) in nonobese Japanese NIDDM patients, 899 NIDDM patients with and without MA were registered from 40 facilities. Of these, 386 subjects were identified as having any form of MA (total MA); these included 211 with ischemic heart disease (IHD), 163 with cerebrovascular disease (CVD), and 77 with peripheral vascular disease (PVD). Univariate analyses revealed the following common risk factors for total MA, IHD, CVD, and PVD: age, hypertension, systolic blood pressure (sBP) or diastolic blood pressure (dBP), duration of diabetes, diabetic microangiopathy (retinopathy, nephropathy, and neuropathy), low HDL cholesterol level, and higher LDL cholesterol/HDL cholesterol ratio. Additional significant risk factors for specific conditions were also identified, respectively, as male sex for total MA, IHD, and PVD, smoking for IHD and PVD, and high fasting plasma glucose level for total MA and CVD. With stepwise multivariate logistic regression analysis, older age, duration of diabetes, smoking, and low LDL cholesterol/HDL cholesterol ratio were identified as significant and independent risk factors for total MA, IHD, CVD, and PVD. Other risk factors identified were high dBP for IHD, CVD, and PVD, high sBP for total MA, and low BMI for PVD. These results clearly demonstrated that duration of diabetes, smoking, hypertension, and dyslipidemia are major risk factors for MA in NIDDM patients. Since the mean BMI was similar for both groups (approximately 23 kg/m2) and there were no significant differences in immunoreactive insulin levels before and after 75-g oral glucose challenge testing, obesity and hyperinsulinism at the time of the analyses were not considered to play an important role for the pathogenesis of MA in Japanese NIDDM patients. By using the chi 2 test, cutoff points were determined for six of the most commonly measured risk factors. The cutoff point was the level beyond which a significantly higher prevalence of MA occurred. The cutoff points (rounded slightly upward in some cases) for fasting plasma glucose, sBP, dBP, serum total cholesterol level, serum triglyceride level, and BMI were 140 mg/dl, 140 mmHg, 80 mmHg, 180 mg/dl, 120 mg/dl, and 23 kg/m2, respectively. When these cutoff points were used as control criteria, the prevalence of MA was significantly lower in subjects whose risk factor measurements remained under the proposed control criteria for four or more of the six variables. In conclusion, in nonobese NIDDM patients, age, hypertension, and dyslipidemia were found to be risk factors for MA. Duration of diabetes was also demonstrated as an independent risk factor, indicating the close association of deranged glucose metabolism with the pathogenesis of MA in NIDDM patients. It seems to be crucial to control these risk factors for the prevention of MA in NIDDM patients.
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PMID:Risk factor analyses for macrovascular complication in nonobese NIDDM patients. Multiclinical Study for Diabetic Macroangiopathy (MSDM). 867 83

Glycosylated haemoglobins and weights were recorded for 200 consecutive diabetic clinic attenders seen yearly for 5 years, 76 of whom were also seen up to 10 years from diagnosis of type 2 diabetes, representing 1380 patient years. Weight fluctuation (> 3 kg) was associated with increased final prevalence of hypertension, macroalbuminaemia and a raised creatinine (P < 0.002) but this relationship was abolished by correction for higher initial weight. Average glycaemia over 5/10 years [itself related to initial weight in women on tablets (N = 53) but not others, and to waist but not waist/hip ratio], correlated with prevalence and severity of retinopathy (N = 200; r = 0.38, P < 0.0006) seen also in the subgroup of patients on tablets (N = 145, P < 0.006). At HbA1 levels > 10.5% an increased prevalence of retinopathy was seen in those on insulin (N = 37, P < 0.001) and an increased prevalence of peripheral vascular disease was seen in men but not women (x2 = 2.87, P < 0.01) as well as in the prevalence of neuropathy. These findings suggest that good glycaemic control is of value in type 2 diabetes and less easily achieved in obesity.
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PMID:Dependence of retinopathy (and other complications) on glycaemic control and on weight over 5/10 years from diagnosis of type II diabetes. 870 79

One of the characteristics of peripheral vascular disease in diabetic patients is that it occurs at the time of detection of diabetes mellitus. As one of the possible pathogenic mechanisms, in non-smokers, is the sol-called metabolic syndrome (obesity, disorders in regard to metabolism of lipids and carbohydrates and hypertension). Lipoprotein Lp(a) is the most atherogenic among lipoproteins. While data on coronary arterial disease exist, although contradictory, there is a small number of those which document the same for peripheral vascular occlusive disease in diabetics. Two patients, non-smokers, with characteristic constellation of risk factors, are described as possible models for further epidemiologic examinations.
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PMID:[The metabolic syndrome and hyper-Lp(a)-lipoproteinemia in peripheral obliterative atherosclerosis: 2 case reports]. 892 51

The prevention of coronary artery disease is based on the control of several factors associated with a disease or clinical condition and suspected to play a pathogenetic role, defined as 'risk factors'. Smoking is a powerful risk factor for coronary artery disease, with risk of events increasing in relation to the number of cigarettes smoked daily. Smoking cessation is associated within 3-4 years, with a significant reduction in cardiovascular risk. Hyperlipidaemia is a powerful predictor of coronary disease with a strong, independent, continuous and graded positive association between cholesterol levels and risk of coronary events. Several large studies have shown the benefit of cholesterol reduction, and there is clear evidence of the efficacy of statins in the reduction of events in primary and secondary prevention. Hypertension is a significant, strong and independent risk factor for coronary artery disease morbidity and mortality and the reduction of events and mortality by antihypertensive treatment is well documented. Obesity is associated with an increase in all-cause mortality and cardiovascular mortality, with a particularly high risk for subjects with central obesity. Central obesity is also part of the so-called 'metabolic X syndrome' including insulin resistance, which appears to be associated with a particularly high risk of coronary artery disease. Type 1 and type 2 diabetes mellitus are associated with an increased risk of cardiovascular disease, especially in women. Several studies have shown that good metabolic control and multifactorial risk factor reduction significantly lower the coronary risk in these patients. Recent evidence is accumulating that some clotting factors (fibrinogen, factor VII, von Willebrand factor) and fibrinolytic factors (t-PA and PAI-1) are associated with an increased risk of coronary artery disease. The European Concerted Action on Thrombosis (ECAT) showed that the levels of fibrinogen, von Willebrand factor antigen, and t-PA antigen are independent predictors of subsequent coronary syndromes in patients with angina pectoris, and that low fibrinogen is associated with a low risk of events despite high cholesterol levels. Post-menopausal status is associated with increased risk of coronary artery disease, particularly when menopause is premature (before the age of 45) or abrupt (surgical). There is strong, thought not yet completely definite evidence that post-menopausal hormone replacement therapy may significantly reduce the risk of events and improve survival. Hyperhomocysteinaemia is an emerging risk factor independently associated with an increased risk of coronary artery disease, cerebral vascular disease, and peripheral vascular disease. The administration of vitamin B6, B12 or folate seems to be useful and is currently under further evaluation. Recently, attention has been focused on the correlation between coronary artery disease and genetic factors, such as ACE gene polymorphism or the gene polymorphism for the IIIa-moiety of the platelet fibrinogen receptor IIb-IIIa. In primary prevention, control of the major risk factors mainly in patients with clustered factors will substantially reduce the risk of ischaemic events. Secondary prevention of CHD is based on: aggressive behavioural advice, blood pressure reduction in hypertensives, good metabolic control of diabetes, and cholesterol reduction. Aspirin, beta-blockers, ACE inhibitors, and oral anticoagulants, may be useful in selected patients.
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PMID:Classical risk factors and emerging elements in the risk profile for coronary artery disease. 951 44

Results obtained with intra-aortic balloon pumps (IABPs) at Harbor-UCLA Medical Center from 1990 to 1995 were reviewed to analyze the indications for its use as well as the incidence and types of vascular complications that occurred. Of 86 patients (53 men and 33 women) in whom pumps were used, 66 underwent coronary bypass, 14 underwent valve replacement, and 6 underwent both coronary bypass/valve replacement. Thirteen (15%) deaths occurred (8 coronary bypass patients, 4 valve replacement patients, and 1 coronary bypass/valve replacement patient). The indications for IABP were broadly classified as prophylactic or inability to wean. Prophylactic IABP placement preoperatively occurred in 35 (41%) patients for profound ventricular dysfunction (27 patients), compelling coronary anatomy including critical left main disease (7 patients), and unstable angina (1 patient). Inability to wean occurred in 51 (59%) patients. Three patients (3.5%) developed major vascular complications resulting in limb ischemia. All three underwent thrombectomies, fasciotomies, and above-knee amputations; two patients subsequently died. Vascular reconstruction was performed in two patients as a direct result of their vascular process. All three vascular complications occurred in women. Besides gender, there was no difference between IABP patients with or without vascular complications in terms of age or presence of diabetes, hypertension, smoking history, obesity, or known peripheral vascular disease. These results indicate that IABPs are effective both prophylactically and intraoperatively in patients who would not otherwise survive cardiac surgery.
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PMID:Intra-aortic balloon pump: indications and complications. 954 76

Microalbuminuria is associated with increased morbidity and early mortality in non-insulin-dependent diabetes mellitus (NIDDM), mostly due to cardiovascular disease. This association may be due to a higher prevalence of known cardiovascular risk factors in those with microalbuminuria. We examined the relationship of microalbuminuria to components of the metabolic syndrome in 98 NIDDM patients with elevated urinary albumin excretion rate (UAER) (> 10.5 micrograms/min) (high UAER) and 102 normoalbuminuric NIDDM patients. Patients with high UAER were older than normoalbuminuric patients (P < 0.05), but they did not differ with respect to duration of diabetes, total cholesterol, body mass index (BMI) or the prevalence of smoking. A total of 58 (60%) patients with elevated UAER had two or more of hypertension, ischaemic heart disease (IHD), hypertriglyceridaemia and obesity compared with 41 (40%) in the normoalbuminuric group, (P < 0.05). Only nine (9.2%) high UAER patients had none of the above risk factors compared with 26 (25.5%) in the normoalbuminuric group (P < 0.01). The prevalence of hypertension (blood pressure (BP) > 160/95) was significantly higher in high UAER patients; 61/98 (62%) versus 39/102 (38%) in normoalbuminuric group, (P < 0.05). Elevated UAER was also associated with a higher risk of macrovascular disease (P < 0.01). The high UAER group included 50 Caucasian, 30 Asian and 18 Afro-Caribbean. The three groups did not differ with respect to total cholesterol, glycosylated haemoglobin (HbA1c) or prevalence of smoking. Asians had a lower BMI, a lower BP and a lower prevalence of peripheral vascular disease (PVD), but had a higher serum triglyceride (P < 0.01 for all) compared with Caucasian. Patients of Afro-Caribbean origin had a lower prevalence of IHD (0%) compared with both Asians (16%) and Caucasians (22%). Elevated UAER in NIDDM is closely associated with components of the metabolic syndrome and an increased risk of IHD and PVD. There are however, significant ethnic differences in this association.
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PMID:Relationship of elevated urinary albumin excretion to components of the metabolic syndrome in non-insulin-dependent diabetes mellitus. 959 78

Diabetes mellitus and particularly non-insulin-dependent diabetes mellitus (NIDDM) increases the risk for all manifestations of: (a) atherosclerotic vascular disease; (b) coronary heart disease (CHD); (c) cerebrovascular disease; and (d) peripheral vascular disease. NIDDM is known to be associated with several adverse cardiovascular risk factors, including: (i) hypertension; (ii) obesity; (iii) central obesity; (iv) hyperinsulinemia; and (v) serum lipid and lipoprotein abnormalities, characterized mainly by elevated serum total triglycerides and low high-density lipoprotein cholesterol. This review will discuss the prevalence of hypertension in NIDDM, the role of hypertension to increase the risk for macrovascular complications in NIDDM and finally trial evidence for the beneficial effect of blood pressure lowering in patients with NIDDM.
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PMID:Hypertension and macrovascular disease--the killing fields of NIDDM. 964 57

Diabetes mellitus is a strong risk factor for all manifestations of atherosclerotic vascular disease, coronary heart disease (CHD), cerebrovascular disease and peripheral vascular disease. Diabetes can be classified into two main subtypes, insulin-dependent diabetes mellitus and non-insulin-dependent diabetes mellitus (NIDDM). This review focuses only on NIDDM. Also, in impaired glucose tolerance (IGT), a precursor stage of diabetes, the risk of macrovascular disease is substantially increased. NIDDM and IGT are known to be associated with several adverse cardiovascular risk factors, including hypertension, obesity, central obesity, hyperinsulinemia and serum lipid and lipoprotein abnormalities, characterized mainly by elevated serum total triglycerides and low high-density lipoprotein cholesterol. Practically no information is available on the role of different cardiovascular risk factors to predict macrovascular complications in subjects with IGT. The role of different cardiovascular risk factors with respect to the risk of CHD, stroke and peripheral vascular disease will be discussed.
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PMID:Epidemiology of risk factors for cardiovascular disease in diabetes and impaired glucose tolerance. 969 44

We screened 597 newly-diagnosed diabetic patients (201 women) mean +/- SD age 42.3 +/- 6.2 years to determine the prevalence of diabetic complications; 22% presented because of symptoms of diabetes, 27% were diagnosed when hyperglycaemia was discovered at a health screening, and 36% were diagnosed while being treated for intercurrent illness. Neuropathy was present in 25.1%, nephropathy in 29%, retinopathy in 15%, coronary vascular disease in 21%, stroke in 5.6%, peripheral vascular disease in 4.8%, hypertension in 23%, obesity in 16%, central obesity in 21.3%, hypercholesterolaemia in 11%, hypertriglyceridaemia in 14%, and low high-density lipoprotein cholesterol in 12%. The prevalence of coronary vascular disease, hypertension, stroke, neuropathy and retinopathy at the time of diagnosis were higher in our patients than in Caucasian and Indo-Asian patients in the UK. Both a genetic predisposition to develop complications, and exposure to a longer duration of asymptomatic hyperglycaemia due to poor access to adequate health care, may contribute to the high frequency of complications at diagnosis. Since complications are already present at diagnosis, there is a case for implementing primary prevention programmes combined with screening for diabetes in high-risk groups.
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PMID:Long-term complications in newly diagnosed Sri Lankan patients with type 2 diabetes mellitus. 970 62


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