David T. Mininberg

Atherosclerosis across 4000 years of human history: the Horus study of four ancient populations

BACKGROUNDnAtherosclerosis is thought to be a disease of modern human beings and related to contemporary lifestyles. However, its prevalence before the modern era is unknown. We aimed to evaluate preindustrial populations for atherosclerosis.nnnMETHODSnWe obtained whole body CT scans of 137 mummies from four different geographical regions or populations spanning more than 4000 years. Individuals from ancient Egypt, ancient Peru, the Ancestral Puebloans of southwest America, and the Unangan of the Aleutian Islands were imaged. Atherosclerosis was regarded as definite if a calcified plaque was seen in the wall of an artery and probable if calcifications were seen along the expected course of an artery.nnnFINDINGSnProbable or definite atherosclerosis was noted in 47 (34%) of 137 mummies and in all four geographical populations: 29 (38%) of 76 ancient Egyptians, 13 (25%) of 51 ancient Peruvians, two (40%) of five Ancestral Puebloans, and three (60%) of five Unangan hunter gatherers (p=NS). Atherosclerosis was present in the aorta in 28 (20%) mummies, iliac or femoral arteries in 25 (18%), popliteal or tibial arteries in 25 (18%), carotid arteries in 17 (12%), and coronary arteries in six (4%). Of the five vascular beds examined, atherosclerosis was present in one to two beds in 34 (25%) mummies, in three to four beds in 11 (8%), and in all five vascular beds in two (1%). Age at time of death was positively correlated with atherosclerosis (mean age at death was 43 [SD 10] years for mummies with atherosclerosis vs 32 [15] years for those without; p<0·0001) and with the number of arterial beds involved (mean age was 32 [SD 15] years for mummies with no atherosclerosis, 42 [10] years for those with atherosclerosis in one or two beds, and 44 [8] years for those with atherosclerosis in three to five beds; p<0·0001).nnnINTERPRETATIONnAtherosclerosis was common in four preindustrial populations including preagricultural hunter-gatherers. Although commonly assumed to be a modern disease, the presence of atherosclerosis in premodern human beings raises the possibility of a more basic predisposition to the disease.nnnFUNDINGnNational Endowment for the Humanities, Paleocardiology Foundation, The National Bank of Egypt, Siemens, and St Lukes Hospital Foundation of Kansas City.

Laparoscopic surgery in children with ventriculoperitoneal shunts: Effect of pneumoperitoneum on intracranial pressure—preliminary experience

OBJECTIVESnWe monitored changes in intracranial pressure (ICP) in 2 children with myelodysplasia undergoing laparoscopic bladder autoaugmentation. Both children had ventriculoperitoneal shunts (VPS) secondary to Arnold-Chiari malformations (type II).nnnMETHODSnICP was monitored through a 23-gauge needle placed into the shunt reservoir and connected to a pressure transducer and drainage system. Intraoperative mean arterial pressure, end-tidal CO2 (ETCO2), ICP, abdominal pressure, and cerebral perfusion pressures were all monitored.nnnRESULTSnBoth children demonstrated rapid onset and sustained increases in ICP of greater than 12 mm Hg above baseline to a maximum pressure of 25 mm Hg. The average cerebrospinal fluid removed from each patient was 30 cc, thereby lowering ICP with no adverse neurologic sequela. The pCO2 remained constant throughout the procedures, as measured by ETCO2.nnnCONCLUSIONSnWe believe that intracranial hypertension (IH) results from a Valsalva-like phenomenon, which causes cerebral vascular engorgement. In addition, the pneumoperitoneum may increase the resistance to outflow through the distal peritoneal catheter, causing a partial or complete shunt obstruction. Untreated IH may result in adverse neurologic sequelae from brain herniation in these children with hindbrain anomalies and potentially altered brain compliance. We believe it is prudent to perform intraoperative ICP monitoring in this subgroup of patients undergoing laparoscopic surgery and that IH should be treated by ventricular drainage.

Laparoscopic Laser Assisted Auto-Augmentation of the Pediatric Neurogenic Bladder: Early Experience with Urodynamic Followup

PURPOSEnWe report our initial experience with laparoscopic laser assisted bladder auto-augmentation for treatment of the symptomatic pediatric neurogenic bladder.nnnMATERIALS AND METHODSnLaparoscopic auto-augmentation of the bladder was performed in 2 children with myelodysplasia and high pressure neurogenic bladders unresponsive to medical management. Detrusorotomy was done using the KTP-532 laser. Laser energy was directed to the tissue to evaluate long-term effects of the procedure.nnnRESULTSnLaparoscopic bladder auto-augmentation can be performed easily and with less morbidity compared to open auto-augmentation. Although results at 6 weeks showed improvement, enterocystoplasty was ultimately performed in both cases due to symptomatic recurrence of incontinence associated with increasing peak detrusor pressure and decreasing compliance.nnnCONCLUSIONSnWhile this technique has the potential to offer minimally invasive correction in patients with low capacity, high pressure bladders, further modifications will be required to achieve long-term success.

The Museum's mummies : An inside view

WE APPLIED MEDICAL and scientific methodology in a study of the mummies in the Metropolitan Museum of Art in New York, New York, by computed tomographic scanning and other radiographic methods. These noninvasive procedures allow us to “unwrap” these mummies without unwrapping them. This is, in effect, technology transfer of routine diagnostic techniques used in medicine to Egyptology. After this noninvasive information-gathering procedure, the mummies are preserved intact for possible future investigations that may be more sophisticated and more informative. The data are presented and put into perspective by a review of pertinent literature.

Laser Welding of Pedicled Flap Skin Tubes

The efficacy of the carbon dioxide laser used at high power levels for tissue destruction is well established. This laser at lower power levels has been used to incise and anastomose blood vessels, tendons, nerves, dura, bowel, fallopian tube, vasa deferentia, ureters and skin. Laser welding is faster, reduces surgical manipulation and introduces less foreign material into the wound than conventional suturing techniques. We tested the feasibility of laser welding of pedicled flap skin tubes to determine if there is a potential application in reconstruction, particularly for hypospadias repair.

Epispadias: Contending with continence

Forty-seven patients with epispadias not associated with bladder exstrophy were treated at our institution over the last half decade. There were 8 female and 39 male patients, 37 of whom had retrosymphyseal epispadias. Of the 20 male patients with subsymphyseal epispadias and incontinence 13 had a fair to excellent result. Of the 7 females with retrosymphyseal epispadias and incontinence, all but 1 came to urinary diversion. An analysis of our data suggests that premature operative intervention precludes obtaining maximal functional and cosmetic results. In addition, the discrepancy in our overall success rate utilizing a one-stage technique versus a staged procedure favored by others may support the latter.