Study objectives: We evaluate pain during the reduction procedure of an anterior dislocation of shoulder. Artl technique, which consisted of a scapular rotation and traction on the humerus, was performed without analgesia. Methods: An open prospective study over an 18-month period included patients presenting with anterior dislocation of the shoulder. We recorded the duration of dislocation, recurrence rate, position of dislocated humeral head, time of traction needed to reduce the dislocation, and complications. The patient was seated athwart the chair, and the axilla of dislocated shoulder rested on the back of a seat padded with drapes. Pain was evaluated at arrival, after placing and resting the shoulder astride the back of the chair, and at postreduction using a visual analogic ruler. Standard shoulder radiographs were taken pre- and postreduction. Results: Reduction was attempted on 43 consecutive patients, 29 men and 14 women aged 42±23 years. Dislocation lasted 110±73 minutes, except 3 that lasted 10, 19, and 26 hours. Thirty-four dislocations were inaugural. Humeral head locations were 26 subcoracoid, 15 subglenoid, and 2 erecta. Associated fractures were 7 trochanter, 3 trochanter and Bankart, 3 trochanter and surgical neck of humerus, and 13 Hill Sachs notches. None received analgesia before reduction, with patient agreement. Pain on arrival peaked at 85±15 mm, it dropped to less than 30 mm after resting of the patient's axilla astride the back of the seat and during reduction. After reduction, pain reached 0 to 10 mm. Reduction was successful with 96% of patients in 27±23 seconds and in less than 10 seconds with 52% of patients. Success rate was 98%. We recorded 1 episode of prereduction circumflex nerve hypoesthesia and 1 failed reduction of a subcoracoid dislocation that had lasted 26 hours and was treated under general anesthesia. Conclusion: This technique alleviates pain on resting the dislocated shoulder on the back of a seat without the use of analgesics. Rate of success is high (98%) even with associated fracture, inaugural dislocation, or prolonged dislocation time beyond 110 minutes. Study objectives: We evaluate pain during the reduction procedure of an anterior dislocation of shoulder. Artl technique, which consisted of a scapular rotation and traction on the humerus, was performed without analgesia. Methods: An open prospective study over an 18-month period included patients presenting with anterior dislocation of the shoulder. We recorded the duration of dislocation, recurrence rate, position of dislocated humeral head, time of traction needed to reduce the dislocation, and complications. The patient was seated athwart the chair, and the axilla of dislocated shoulder rested on the back of a seat padded with drapes. Pain was evaluated at arrival, after placing and resting the shoulder astride the back of the chair, and at postreduction using a visual analogic ruler. Standard shoulder radiographs were taken pre- and postreduction. Results: Reduction was attempted on 43 consecutive patients, 29 men and 14 women aged 42±23 years. Dislocation lasted 110±73 minutes, except 3 that lasted 10, 19, and 26 hours. Thirty-four dislocations were inaugural. Humeral head locations were 26 subcoracoid, 15 subglenoid, and 2 erecta. Associated fractures were 7 trochanter, 3 trochanter and Bankart, 3 trochanter and surgical neck of humerus, and 13 Hill Sachs notches. None received analgesia before reduction, with patient agreement. Pain on arrival peaked at 85±15 mm, it dropped to less than 30 mm after resting of the patient's axilla astride the back of the seat and during reduction. After reduction, pain reached 0 to 10 mm. Reduction was successful with 96% of patients in 27±23 seconds and in less than 10 seconds with 52% of patients. Success rate was 98%. We recorded 1 episode of prereduction circumflex nerve hypoesthesia and 1 failed reduction of a subcoracoid dislocation that had lasted 26 hours and was treated under general anesthesia. Conclusion: This technique alleviates pain on resting the dislocated shoulder on the back of a seat without the use of analgesics. Rate of success is high (98%) even with associated fracture, inaugural dislocation, or prolonged dislocation time beyond 110 minutes.

Endoscopic surgery was first carried out in 1807 by Bozzini, who developed the first endoscopic instruments. European surgeons continued to develop this technique, especially Dubois in France, who performed the first laparoscopic cholecystectomy in 1987.1 Bruhat and Mouret first used laparoscopic techniques in gynaecological surgery. This decade has seen endoscopic techniques used for thoracic surgery, particularly video-assisted thoracic surgery (VATS). This technique was developed by Regan 2'3 and Mack 4 in the USA and by RosenthaP in Germany. However, it was not until the beginning of this century that thoracoscopy was first used diagnostically by Jacobaeus 6 in the treatment of tuberculosis.

The beta-oxidation of unsaturated fatty acids with odd-numbered double bonds proceeds by reduction of the double bond (reductase-dependent pathway) in addition to the well established isomerization of the double bond (isomerase-dependent pathway). The metabolic significance of the reductase-dependent pathway was assessed with 2-trans-5-cis-octadienoyl-CoA (2,5-octadienoyl-CoA) and its products, all of which are metabolites of alpha-linolenic acid, A kinetic evaluation of beta-oxidation enzymes revealed that the presence of a 5-cis double bond in the substrate most adversely affected the activity of 3-ketoacyl-CoA thiolase although not enough to become rate-limiting, Concentration dependent and time-dependent measurements indicated that most (80%) of 2,5-octadienoyl-CoA is metabolized via the isomerase-dependent pathway, The reason for the greater flux through the isomerase-dependent pathway is the higher activity of L-3-hydroxyacyl-CoA dehydrogenase as compared with Delta(3),Delta(2)-enoyl-CoA isomerase. These two enzymes catalyze the rate-limiting steps in the isomerase-dependent and reductase-dependent pathways, respectively, Once 2,5-octadienoyl-CoA is converted to 3,5-octadienoyl-CoA (perhaps fortuitously because of the presence of Delta(3),Delta(2)-enoyl-CoA isomerase), the only effective route for its degradation is via the reductase-dependent pathway, It is concluded that the reductase-dependent pathway assures the degradation of 3,5-dienoyl-CoA intermediates, thereby preventing the depletion of free coenzyme A and a likely impairment of mitochondrial oxidative function.

The presence of Δ3,5,Δ2,4-dienoyl-CoA isomerase in peroxisomes was demonstrated by determining the subcellular distribution of this enzyme in rat liver. The peroxisomal and mitochondrial forms of the isomerase exhibit similar chain length specificities and they are homologous as indicated by the recognition of the peroxisomal 66-kDa enzyme by an antiserum raised against the mitochondrial 32-kDa isomerase. This report demonstrates that peroxisomes contain all enzymes required for the β oxidation of unsaturated fatty acids with odd-numbered double bonds by a novel pathway in which double bonds are reductively removed by the NADPH-dependent 2,4-dienoyl-CoA reductase.

Mitochondrial delta 3,5, delta 2,4-dienoyl-CoA isomerase, which catalyzes the conversion of 3,5-octadienoyl-CoA to 2,4-octadienoyl-CoA, was purified from rat liver 370-fold at almost 30% yield by a six-step purification procedure. The final preparation appeared to be homogeneous as judged by gel electrophoresis. The molecular weights of the native enzyme and its subunit(s) were estimated to be 126,000 and 32,000, respectively. The purification of delta 3,5, delta 2,4-dienoyl-CoA isomerase completes the characterization of the enzymes functioning in the NADPH-dependent pathway for the beta-oxidation of unsaturated fatty acids with double bonds extending from odd-numbered carbon atoms. This novel pathway may not be operative in peroxisomes because delta 3,5, delta 2,4-dienoyl-CoA isomerase was only detected in mitochondria. Substrates of this pathway are 2,5-dienoyl-CoAs formed from 5-enoyl-CoAs by acyl-CoA dehydrogenase. Two sequential isomerization reactions catalyzed by delta 3, delta 2-enoyl-CoAs isomerase and delta 3,5, delta 2,4-dienoyl-CoA isomerase, respectively, convert 2,5-dienoyl-CoAs to 2,4-dienoyl-CoAs, which are reduced by NADPH-dependent 2,4-dienoyl-CoA reductase (EC 1.3.1.34) before reentering the beta-oxidation spiral.