2/03/2017

Many people ask about our pathology. For a long time, Danny Milner, MD, at Harvard/Brigham and Women's Hospital. performed all our pathology on the specimens I brought home with me. This was a really great situation which, unfortunately, ended when Danny left the Brigham to become the Chief Medical Officer at the American Society for Clinical Pathology. After an appeal on my Blog Site (www.earthwidesurgicalfoundation.blogspot.com), I received many gracious offers for pathology help from around the world. 
 
Fortunately, we met Dr. Chidi Onwuka from the Department of Histopathology at the University of Uyo Teaching Hospital. He graduated from the University of Nigeria, Nsukka and did his pathology training at the National Postgraduate Medical College of Nigeria. His group now does all our pathology work. Chidi is a very pleasant chap and comes every week to pick up our specimens and his turn around time is 1 week!

1/31/2017

FIBROUS DYSPLASIA WITH ECTOPIC TEETH

This 12 year old girl came in with a swollen Cheel. She obviosly had fibrous dysplasia-Fibrous dysplasia is an uncommon bone disorder in which scar-like (fibrous) tissue develops in place of normal bone. This can weaken the affected bone and cause it to deform or fracture. In most cases, fibrous dysplasia affects only a single bone — most commonly the skull or a long bone in the arms or legs. We operated and found massive fibrous tissue requiring a chisel for revoval of the entire maxilla. During removal we found several ectopic teeth-perhaps the stimulus for her problem. 

The orbital floor was gone and the eye drooped down into the sinus when we were done. We used a polypropylene mesh sling to support the eye-which is onlevel with the other eye after surgery. She is healing well.
 


1/29/2017

CONGENTIAL URINARY INCONTINENCE

This 13 year old girl was incontinent of urine from birth. Its a a long story so I won't tell it all. We repaired the problem. She ended up with 3 ureters reimplanted into the bladder. Her pants are dry now.


TRA FLAP FOR FUNGATING BREAST CANCER


This Lady came in with a fungating breast cancer that was constantly bleeding. We felt it ws best to remove the cancer before giving her chem/XRT. We used a TRAM FLAP for reconstruction



1/26/2017


This 18 year old female came with a large left upper quadrant mass which had been growing for 1.5 years. Based on CT results, we thought we were dealing with a giant liver cyst. We were wrong. The patient had a giant retroperitoneal cyst of some type with the stomach, duodenum, pancreas and colon firmly attached to it. With careful dissection, we were able to dissect the cyst free.
Right upper quadrant mass
Apparent liver cyst
Cyst with stomach adherent
Stomach,  duodenum, pancreas, and colon dissected free
Dr. Uche Nkeonye
Ebere Erundo, surgical assistant
Retroperitoneal cyst
Specimen opened



1/24/2017

A PICTURE IS WORTH A THOUSAND WORDS


CHEST WALL RESECTION

Yesterday we operated on a 48 year old lady with a right flank/chest wall mass. The lady has neurofibromatosis which is benign but occasionally becomes malignant. The mass invaded ribs 9-12. Resection would require resection the mass and ribs and reconstruction of the chest wall. 



We resected the mass/ribs, transfered the diaphragm to the 8th rib and reconstructed the resulting defect with mesh. Everything came back together great and the patient did well overnight. We are awaiting her pathology


Resection of mass

Mass prior to removal

Mass removed and chest and abdomen opened with lung to right
Diaphragm reattached with PTFE patch

Defect reconstructed with mesh

Final result

YOU DON'T WANT THIS!

This 39 year old lady came in with a prolapsing uterine fibroid-a intrauterine fibroid that became so big that the body tries to eject it through the cervix like a baby. The fibroid in on a long stalk and usually is bleeding. In a pinch, you can clamp the stalk and stop the bleeding. We did a definitive procedure-a total abdominal hysterectomy. The lady did fine.



1/23/2017

CHAOS

MONDAY IS CHAOS

17 patients waiting for surgery
2 operating tables working full blast
6 MDs, 3 nurse anethetists, 3 nurse anethetist students, 5 technicians
42 surgical patients waiting to be seen

Use your mouse to pan the picture


MORE WORK

Malaria is endemic in Nigeria so you can expect to get sick when you visit. There is malaria prophylaxis but in my experience it is not very effective so I stopped using prophylaxis several years ago. I usually get a case every trip but it is very mild and responds to treatment. Unfortunately, my current case has been recalcitrant to the normal treatments including two courses of Fansidar and one course of P-Alaxin. I am recovering now.



During the last few days I have not blogged but we have been working hard. We have done 18 cases in the last 3 days including:

1. Inguinal hernia repair
2. Giant scrotal hernia repair
3. Excision of thrombophlebitis secondary to chemo infiltration
4. Six total thyroidectomies for goiter
5. Two total thyroidectomies for toxic goiter
6. TruCut biopsy of the neck fot a large mass
7. Laparotomy for SBO
8. TruCut biopsy of breast mass
9. Excision of breast mass
10. Radical hysterectomy for cervical cancer including resection of the rectum and left iliac lymph node dissection
11. Excision of premaxillary cyst
12. Exploratory laparotomy for strangulated cecum in a ventral hernia requiring right hemicolectomy, and venral hernia repair


 
This is the man with the premaxillary cyst


This lady had a similar cyst which was repaired several years ago with good result



There are 13 cases waiting for surgery and many more coming. There is always a big rush at the end of trips, especially on Mondays



1/19/2017

GET IT WHILE YOU CAN


INTERESTING ITEMS

Yesterday a lady came for consultation. She had an ameloblastoma removed from her right maxillary sinus and noticed new progresive swelling. We obtained a CT which showed a recurrence in the right maxillary sinus. We will operate this week.




Another lady came in with a goiter that had been growing fro 20 years. Hopefully this will not be cancer. We will also operate on her this week.



Uche Nkeonye, Md,  arrived yesterday. He had been to NCH many times and now has his own private practice in Abuja. We are glad he is here.


1/18/2017

TOXIC GOITER

Most people don't realize that untreated or improperly treated toxic goiter is a lethal disease. Patients are in a hypermetabolic state and slowly waste away. In the end stages of the disease, you can close your index finger and thumb around the biceps of these patients.They waste away and then one day a breeze comes along and they are gone. They suffer from high output cardiac failure among many other disorders. Occasionally, they will suffer thyroid storm , sometimes called thyroid crisis.Thyroid storm, also referred to as thyrotoxic crisis, is an acute, life-threatening, hypermetabolic state induced by excessive release of thyroid hormones (THs) in individuals with thyrotoxicosis. Thyroid storm may be the initial presentation of thyrotoxicosis in undiagnosed children, particularly in neonates. The clinical presentation includes fever, tachycardia, hypertension, and neurological and GI abnormalities. Hypertension may be followed by congestive heart failure that is associated with hypotension and shock. Because thyroid storm is almost invariably fatal if left untreated, rapid diagnosis and aggressive treatment are critical. Death can occur rapidly-even in minutes. Thyroid storm can occur before, during or after thyroid surgery. Just recently we admitted a patient with toxic goiter. We went to the ward, sat on her bed and dropped dead. Fortunately, we have a medical regimen that has drastically cut down on these issues which includes carbimazol, prednisone, iodine, inderal and lithium. In the USA, these patients are often treated with radioactive iodine but surgery is more common in the third world.



 


 

PALM OIL

Palm oil

From Wikipedia, the free encyclopedia
Palm oil block showing the lighter color that results from boiling
Palm oil (also known as dendĂȘ oil, from Portuguese) is an edible vegetable oil derived from the mesocarp (reddish pulp) of the fruit of the oil palms, primarily the African oil palm Elaeis guineensis,[1] and to a lesser extent from the American oil palm Elaeis oleifera and the maripa palm Attalea maripa.
Palm oil is naturally reddish in color because of a high beta-carotene content. It is not to be confused with palm kernel oil derived from the kernel of the same fruit,[2] or coconut oil derived from the kernel of the coconut palm (Cocos nucifera). The differences are in color (raw palm kernel oil lacks carotenoids and is not red), and in saturated fat content: palm mesocarp oil is 41% saturated, while palm kernel oil and coconut oil are 81% and 86% saturated fats, respectively.
Along with coconut oil, palm oil is one of the few highly saturated vegetable fats and is semisolid at room temperature.[3]
Palm oil is a common cooking ingredient in the tropical belt of AfricaSoutheast Asia and parts of Brazil. Its use in the commercial food industry in other parts of the world is widespread because of its lower cost[4] and the high oxidative stability (saturation) of the refined product when used for frying.[5][6]
The use of palm oil in food products has attracted the concern of environmental activist groups; the high oil yield of the trees has encouraged wider cultivation, leading to the clearing of forests in parts of Indonesia and Malaysia to make space for oil-palm monoculture.[7] This has resulted in significant acreage losses of the natural habitat of the orangutan, of which both species are endangered; one species in particular, the Sumatran orangutan, has been listed as critically endangered.[8] In 2004, an industry group called the Roundtable on Sustainable Palm Oil was formed to work with the palm oil industry to address these concerns.[9] Additionally, in 1992, in response to concerns about deforestation, the Government of Malaysia pledged to limit the expansion of palm oil plantations by retaining a minimum of half the nation's land as forest cover.[10][11]

History[edit]

Oil palms (Elaeis guineensis)
Human use of oil palms may date as far back as 5,000 years; in the late 1800s, archaeologists discovered a substance that they concluded was originally palm oil in a tomb at Abydos dating back to 3,000 BCE.[12] It is believed that Arab traders brought the oil palm to Egypt.[13] Some argue that it is not possible that Arab traders could have brought the oil palm to ancient Egypt, as the Arabs did not settle in Africa until the 8th century CE. It is more likely that the oil palm was brought to Ancient Egypt (Kemet) by its founding peoples who migrated from other regions of the African continent.[14]
Palm oil from E. guineensiss has long been recognized in West and Central African countries, and is widely used as a cooking oil. European merchants trading with West Africa occasionally purchased palm oil for use as a cooking oil in Europe.
Palm oil became a highly sought-after commodity by British traders, for use as an industrial lubricant for machinery during Britain's Industrial Revolution.[15]
Palm oil formed the basis of soap products, such as Lever Brothers' (now Unilever) "Sunlight" soap, and the American Palmolivebrand.[16]
By around 1870, palm oil constituted the primary export of some West African countries, such as Ghana and Nigeria, although this was overtaken by cocoa in the 1880s.[citation needed]

Composition[edit]

Fatty acids[edit]

Main article: Fatty acid
Palm oil, like all fats, is composed of fatty acidsesterified with glycerol. Palm oil has an especially high concentration of saturated fat, specifically, of the 16-carbon saturated fatty acid palmitic acid, to which it gives its name. Monounsaturated oleic acid is also a major constituent of palm oil. Unrefined palm oil is a significant source of tocotrienol, part of the vitamin E family.[17][18]
The approximate concentration of fatty acids in palm oil is:[19]
Fatty acid content of palm oil
Type of fatty acidpct
Myristic saturated C14
  
1.0%
Palmitic saturated C16
  
43.5%
Stearic saturated C18
  
4.3%
Oleic monounsaturated C18
  
36.6%
Linoleic polyunsaturated C18
  
9.1%
Other/Unknown
  
5.5%
black: Saturated; grey: Monounsaturated; blue: Polyunsaturated

Carotenes[edit]

Red palm oil is rich in carotenes, such as alpha-carotenebeta-carotene and lycopene, which give it a characteristic dark red color.[18][20]

Processing and use[edit]

Many processed foods either contain palm oil or various ingredients derived from it.[21]

Refining[edit]

After milling, various palm oil products are made using refining processes. First is fractionation, with crystallization and separation processes to obtain solid (stearin), and liquid (olein) fractions.[22] Then melting and degumming removes impurities. Then the oil is filtered and bleached. Physical refining[clarification needed] removes smells and coloration to produce "refined, bleached and deodorized palm oil" (RBDPO) and free sheer fatty acids,[clarification needed] which are used in the manufacture of soapswashing powder and other products. RBDPO is the basic palm oil product sold on the world's commodity markets. Many companies fractionate it further to produce palm olein for cooking oil, or process it into other products.[22]

Red palm oil[edit]

Since the mid-1990s, red palm oil has been cold-pressed and bottled for use as cooking oil, and blended into mayonnaise and salad oil.[23]

Butter and trans fat substitute[edit]

The highly saturated nature of palm oil renders it solid at room temperature in temperate regions, making it a cheap substitute for butteror trans fats in uses where solid fat is desirable, such as the making of pastry dough and baked goods. A recent rise in the use of palm oil in the food industry has partly come from changed labelling requirements that have caused a switch away from using trans fats.[24]Palm oil has been found to be a reasonable replacement for trans fats;[25] however, a small study conducted in 2009 found that palm oil may not be a good substitute for trans fats for individuals with already-elevated LDL levels.[26] The USDA agricultural research service states that palm oil is not a healthy substitute for trans fats.[27]

Biomass and bioenergy[edit]

Palm oil is used to produce both methyl ester and hydrodeoxygenated biodiesel.[28] Palm oil methyl ester is created through a process called transesterification. Palm oil biodiesel is often blended with other fuels to create palm oil biodiesel blends.[29] Palm oil biodiesel meets the European EN 14214 standard for biodiesels.[28] Hydrodeoxygenated biodiesel is produced by direct hydrogenolysis of the fat into alkanes and propane. The world's largest palm oil biodiesel plant is the Finnish-operated Neste Oil biodiesel plant in Singapore, which opened in 2011 and produces hydrodeoxygenated NEXBTL biodiesel.[30]
The organic waste matter that is produced when processing oil palm, including oil palm shells and oil palm fruit bunches, can also be used to produce energy. This waste material can be converted into pellets that can be used as a biofuel.[31] Additionally, palm oil that has been used to fry foods can be converted into methyl esters for biodiesel. The used cooking oil is chemically treated to create a biodiesel similar to petroleum diesel.[32]

Nutrition and health[edit]

Palm oil is an important source of calories and a food staple in poor communities.[57][58][59]
Much of the palm oil that is consumed as food is cooking oil, to some degree oxidized rather than in the fresh state, and this oxidation appears to be responsible for the health risk associated with consuming palm oil.[60]

Palmitic acid[edit]

According to studies reported on by the Center for Science in the Public Interest (CSPI), excessive intake of palmitic acid, which makes up 44 percent of palm oil, increases blood cholesterol levels and may contribute to heart disease.[61] The CSPI also reported that the World Health Organization and the US National Heart, Lung and Blood Institute have encouraged consumers to limit the consumption of palmitic acid and foods high in saturated fat.[57][61] According to the World Health Organization, evidence is convincing that consumption of palmitic acid increases risk of developing cardiovascular diseases, placing it in the same evidence category as trans fatty acids.[62]

Comparison to trans fats[edit]

In response to negative reports on palm oil many food manufacturers transitioned to using hydrogenated vegetable oils in their products, which have also come under scrutiny for the impact these oils have on health.[63] A 2006 study supported by the National Institutes of Health and the USDA Agricultural Research Service concluded that palm oil is not a safe substitute for partially hydrogenated fats (trans fats) in the food industry, because palm oil results in adverse changes in the blood concentrations of LDL cholesterol and apolipoprotein B just as trans fat does.[26][64] However, according to two reports published in 2010 by the Journal of the American College of Nutrition palm oil is again an accepted replacement for hydrogenated vegetable oils[63] and a natural replacement for partially hydrogenated vegetable oils, which are a significant source of trans fats.[65]

Comparison with animal saturated fat[edit]

Not all saturated fats have equally cholesterolemic effects.[66] Studies have indicated that consumption of palm olein (which is more unsaturated) reduces blood cholesterol when compared to sources of saturated fats like coconut oil, dairy and animal fats.[66][67]

Acrolein[edit]

A 2009 study[68] tested the emission rates of acrolein, a toxic and malodorous breakdown product from glycerol, from the deep-frying of potatoes in red palm, olive, and polyunsaturated sunflower oils. The study found higher acrolein emission rates from the polyunsaturated sunflower oil (the scientists characterized red palm oil as "mono-unsaturated") and lower rates from both palm and olive oils. The World Health Organization established a tolerable oral acrolein intake of 7.5 mg/day per kilogram of body weight. Although acrolein occurs in French fries, the levels are only a few micrograms per kilogram. A 2011 study concluded a health risk from acrolein in food is unlikely.[69]

Social and environmental impacts[edit]

Social[edit]

In Borneo, the forest (F), is being replaced by oil palm plantations (G). These changes are irreversible for all practical purposes (H).
The palm oil industry has had both positive and negative impacts on workers, indigenous peoples and residents of palm oil-producing communities. Palm oil production provides employment opportunities, and has been shown to improve infrastructure, social services and reduce poverty.[70][71][72] However, in some cases, oil palm plantations have developed lands without consultation or compensation of the indigenous people occupying the land, resulting in social conflict.[73][74][75] The use of illegal immigrants in Malaysia has also raised concerns about working conditions within the palm oil industry.[76][77][78]
Some social initiatives use palm oil cultivation as part of poverty alleviation strategies. Examples include the UN Food and Agriculture Organisation's hybrid oil palm project in Western Kenya, which improves incomes and diets of local populations,[79] and Malaysia's Federal Land Development Authority and Federal Land Consolidation and Rehabilitation Authority, which both support rural development.[80]

Food vs. fuel[edit]

Main article: Food vs. fuel
The use of palm oil in the production of biodiesel has led to concerns that the need for fuel is being placed ahead of the need for food, leading to malnourishment in developing nations. This is known as the food versus fuel debate. According to a 2008 report published in the Renewable and Sustainable Energy Reviews, palm oil was determined to be a sustainable source of both food and biofuel. The production of palm oil biodiesel does not pose a threat to edible palm oil supplies.[81] According to a 2009 study published in the Environmental Science and Policy journal, palm oil biodiesel might increase the demand for palm oil in the future, resulting in the expansion of palm oil production, and therefore an increased supply of food.[82]

Environmental[edit]

Palm oil cultivation has been criticized for impacts on the natural environment,[83][84]including deforestation, loss of natural habitats,[85] which has threatened critically endangered species such as the orangutan[86][87] and Sumatran tiger,[88] and increased greenhouse gas emissions.[84][89] Many palm oil plantations are built on top of existing peat bogs, and clearing the land for palm oil cultivation contributes to rising greenhouse gas emissions.[89][90]
Efforts to portray palm oil cultivation as sustainable have been made by organizations including the Roundtable on Sustainable Palm Oil,[91] an industry group, and the Malaysian government, which has committed to preserve 50 percent of its total land area as forest.[10]According to research conducted by the Tropical Peat Research Laboratory, a group studying palm oil cultivation in support of the industry,[92] oil palm plantations act as carbon sinks, converting carbon dioxide into oxygen[93] and, according to Malaysia's Second National Communication to the United Nations Framework Convention on Climate Change, the plantations contribute to Malaysia's status as a net carbon sink.[94]
Environmental groups such as Greenpeace and Friends of the Earth oppose the use of palm oil biofuels, claiming that the deforestationcaused by oil palm plantations is more damaging for the climate than the benefits gained by switching to biofuel and utilizing the palms as carbon sinks.[90][95][96]
While only 5 percent of the world's vegetable oil farmland is used for palm plantations, palm cultivation produces 38 percent of the world's total vegetable oil supply.[97] In terms of oil yield, a palm plantation is 10 times more productive than soya bean and rapeseed cultivation because the palm fruit and kernel both provide usable oil.[97]