Angiosomes of the leg: anatomic study and clinical implications

In 1987, Taylor and Palmer introduced the angiosome concept. This anatomical study defined the three-dimensional vascular territories supplied by source arteries and veins to each tissue layer between the skin and the bone. This report, however, was an overview investigation and did not study each region of the body in fine detail. In 1996, Inoue and Taylor studied the angiosomes of the forearm in much greater detail. They showed, among other findings, that the zone between the angiosomes, formed by reduced caliber (choke) vessels or similar caliber (true) anastomotic arteries, occurred usually within tissues, especially the muscles, not between them. This study focuses on the same region in the lower limb to draw a comparison and to fill certain voids in our knowledge--the leg. Twelve lower limbs from fresh cadavers were investigated over a 2-year period after perfusing each with a mixture containing radio-opaque lead oxide. The anatomy of the arterial supply to the skin, the muscles, and the periosteum of the bones of the leg was examined. The contribution to each tissue was defined by dissection, by metal clip tagging of vessels, by radiography, and by mapping the branches with colored pins, coded to match the respective source arteries. A subtraction technique was used to study the muscles whereby the bones of the limb were replaced with radiolucent balloons to obtain an unobscured picture of the vasculature of the leg. The muscles were then segregated one by one from the muscle mass and x-rayed again. Next, cross-section studies were made in two legs to complete the three-dimensional picture, tracing the branches from the source arteries to each layer. Finally, the contribution to each tissue from the popliteal, sural, anterior tibial, posterior tibial, and peroneal vessels were color coded to match these source arteries, thus defining the angiosomes of the leg. Results, as in the forearm, showed that in most cases the connections between adjacent angiosomes occurred within tissues, not between them. The skin, the bones, and most muscles received branches from two or more angiosomes, thus revealing one of the important anastomotic pathways through which the circulation is reconstituted when a source artery is interrupted by disease or trauma. Notably, however, the muscles of the anterior compartment of the leg were supplied from one angiosome. This finding, coupled with the anatomy of the rigid fascial compartments of the leg, helps explain the variable clinical pictures and syndromes seen in cases in which the circulation is compromised or interrupted. Finally, this anatomical study adds further information to help design or redesign flaps in the leg for local or free transfer. Similarly, the information reveals the pathways through which the supply to the remaining tissues is reconstituted when one of the source arteries is harvested with a free flap, especially when multiple tissues are included in the transplant.     

The angiosomes of the forearm: anatomic study and clinical implications

The angiosome concept was introduced in 1987 by Taylor and Palmer. Their anatomic study correlated the blood supply to the skin from the named segmental or distributing "source" arteries with their supply to the underlying muscles, tendons, nerves, and bones. Although this investigation encompassed the body, there were areas where the supply to individual tissues was not examined in detail. The present study, therefore, examines one of these regions where certain voids in our knowledge still exist--the forearm. Ten upper limbs from fresh cadavers were studied over an 18-month period after perfusing each with a radiopaque lead oxide mixture. The arterial supply to the skin and the bones of the forearm, together with that of a total of 200 muscles, was examined. The contribution to each was defined by dissection, by metal clip tagging of vessels, by radiography, and by mapping the branches with colored pins coded to match the respective source arteries. In the case of the muscles, a subtraction technique was used whereby the bones of the extremity were replaced with radiolucent balloons to obtain an unobscured picture of the forearm vasculature. Then the muscles were removed one by one from the muscle mass and x-rayed again. In this way, the angiosomes in the forearm, provided by the brachial, radial, ulnar, and interosseous arteries, were defined. Similarly, the contribution from each angiosome to the skin, to each muscle, and to the radius and the ulna was identified and the territories were color-coded to match these source arteries. Results showed that in most cases the connections between adjacent angiosomes occurred within tissues, not between them. The skin, the bones, and most muscles received branches from the source arteries of at least two angiosomes, thus revealing one of the important anastomotic pathways by which the circulation is reconstituted in those cases where a source artery is interrupted by disease or trauma. Several muscles, however, were supplied within one angiosome. This helps explain the variable clinical pictures seen in cases where the circulation is interrupted, such as that which occurs in a Volkmann's ischemic contracture. Finally, this anatomic study provides further information to help design various flaps from the forearm for local or free transfer. In the case of muscles, the supply to most from multiple angiosomes allows for refinements whereby a portion only of a muscle can be used. Similarly, this anatomic information reveals the pathway by which the supply to remaining muscle groups is reconstituted when one of the source arteries is harvested with a skin flap, a muscle, or part thereof.     

Positions of dorsal root ganglia in the cervical spine. An anatomic and clinical study

STUDY DESIGN: The authors investigated the positions of dorsal root ganglia and the relation of the location to symptoms and to the effects of nerve root infiltration in the cervical spine anatomically and clinically. OBJECTIVES: To clarify normal variation of positions of dorsal root ganglia and the relation of the location of dorsal root ganglia to symptoms and to the effects of nerve root infiltration. SUMMARY OF BACKGROUND DATA: The dorsal root ganglia of the spinal nerve has attracted much attention as an important structure in the mechanisms of radicular symptoms in the lumbar spine. Although the position of the dorsal root ganglia in the lumbar spine has been classified recently, there are few reports regarding the dorsal root ganglia in the cervical spine. METHODS: The positions of dorsal root ganglia were divided into two types: proximally situated and distally situated. The positions of dorsal root ganglia in the anatomic and clinical cases were compared. The relation of the positions of dorsal root ganglia to symptoms and to the clinical effects of nerve root infiltration were analyzed. RESULTS: There was no statistically significant difference in positions of dorsal root ganglia in C6 nerve roots between anatomic and clinical cases. In addition, there was no relation between symptoms and the positions of dorsal root ganglia in clinical cases. However, there was a significant difference in positions of dorsal root ganglia in C7 nerve roots between anatomic and clinical cases. Nerve root infiltration was significantly more effective in the distally situated type of dorsal root ganglia. CONCLUSIONS: This study defined the normal variation of the positions of dorsal root ganglia. The results strongly suggest that some attention should be paid to the position of dorsal root ganglia in the diagnosis and treatment of cervical radiculopathy.     

Characteristics of adrenoceptors in the human radial artery: clinical implications

OBJECTIVES: The radial artery has been suggested to be spastic. Endogenous and exogenous catecholamines and the use of beta-blockers may be related to radial artery spasm, but the characteristics of adrenoceptors in this artery are unknown. This study was designed to characterize the alpha- and beta-adrenoceptor in the human radial artery. METHODS: Ring segments of the radial artery (n = 59) taken from patients undergoing coronary artery bypass grafting were studied in organ chambers. Alpha-adrenoceptor agonists (norepinephrine, methoxamine, and UK14304) and antagonists (phentolamine hydrochloride [INN: phentolamine], prazosin, and yohimbine) were used to characterize the alpha-adrenoceptor. Beta-adrenoceptor function was studied in U46619-precontracted rings in response to isoproterenol (INN: isoprenaline). RESULTS: Norepinephrine induced 6.9 +/- 0.6 gm (80.6% +/- 6.8% of the contraction by 100 mmol/L KCl), and this was almost fully inhibited by phentolamine hydrochloride (10 micromol/L, p < 0.0001). The contraction force induced by methoxamine (2.9 +/- 0.8 gm) was abolished by 0.5 micromol/L prazosin (p = 0.017). The contraction force induced by UK14304 (1.7 +/- 0.4 gm) was abolished by 1 micromol/L yohimbine. In contrast to the porcine coronary artery used as the control (fully relaxed to isoproterenol), radial artery rings did not have significant relaxation (1.1% +/- 0.8%). CONCLUSIONS: The human radial artery is an alpha-adrenoceptor-dominant artery with little beta-adrenoceptor function. The use of beta-blockers will not likely evoke the spasm of the radial artery. Furthermore, the radial artery has a dominant alpha1-adrenoceptor function, but the postjunctional alpha2-adrenoceptor is also functional. Circulating catecholamines will mainly contract the human radial artery by activation of the alpha1-adrenoceptors and to a lesser extent also by alpha2-adrenoceptors.     

Transchoroidal approach to the third ventricle: an anatomic study of the choroidal fissure and its clinical application

OBJECTIVE: We review the anatomic features of the lateral ventricle, the foramen of Monro, the third ventricle, and the choroidal fissure, and we describe the transchoroidal approach to the third ventricle. This approach consists of opening the taenia fornicis of the choroidal fissure in the body of the lateral ventricle and approaching the third ventricle between the two internal cerebral veins. This route allows further posterior enlargement of the foramen of Monro without sacrificing any neural structures. When necessary, the anterior septal vein can be sacrificed. METHODS: Twenty adult cadaveric brains and four adult cadaveric heads were studied, using a magnification ranging from 3 times to 40 times, after perfusion of the arteries and veins with colored latex. RESULTS: The choroidal fissure is a natural cleft between the thalamus and the fornix, and it is identified by following the choroid plexus in the lateral ventricle. The choroid plexus in the body of the lateral ventricle originates from the tela choroidea of the roof of the third ventricle and is apparently attached to the fornix by the taenia fornicis and to the thalamus by the taenia choroidea. The taenia is actually the ependyma that covers the internal wall of the ventricular cavity and the choroid plexus. CONCLUSION: An understanding of the choroidal fissure is fundamental for use of the transchoroidal approach. Unlike transforaminal, subchoroidal, subforniceal, and interforniceal approaches to the third ventricle, which sacrifice some neural or vascular structures, the transchoroidal approach follows a natural route, and certainly it is one of the options to be considered when entry into the third ventricle is required.     

Variations of the frontal exit of the supraorbital nerve: an anatomic study

Meningeal worm (Parelaphostrongylus tenuis) is a neurotropic nematode of ungulates in eastern North America. Lack of an effective diagnostic test increases the concern of translocating potentially infected ungulates into western North America, where P. tenuis does not occur naturally. In an attempt to identify serodiagnostic molecules, we determined (1) whether elk (Cervus elaphus) experimentally infected with P. tenuis produce antibodies against infective larvae or adult worms, and (2) if sera consistently recognize antigens that distinguish P. tenuis from a common nematode parasite of elk, the lungworm Dictyocaulus viviparus. Each of 10 elk were exposed to 15 or 300 infective P. tenuis larvae. Serum was collected (0, 41, and 83 days post-exposure and at necropsy) and monitored for antibodies using the enzyme-linked immunosorbent assay (ELISA) and immunoblot. When reactivity of sera with larval P. tenuis protein was compared (day 0 versus 83), ELISA values were significantly higher on day 83 for elk exposed to 15 or 300 parasites. Likewise, ELISA values using protein of adult P. tenuis were higher for elk exposed to 300 larvae. Immunoblots showed that sera from elk, with adult worms in the central nervous system, consistently recognized the 25-27, 28-30, and 34-36 kDa antigens of infective larvae after 83 days. However, many D. viviparus molecules were found to cross-react with antibodies formed against meningeal worm antigens. Use of adult worm proteins for serodiagnosis appears limited, because no protein was consistently recognized by sera collected from elk exposed to 15 larvae. We believe that development of a reliable diagnostic test for meningeal worm requires more research addressing cross-reactivity and detection of P. tenuis during the incubation stage.     

Graft-versus-leukemia effect and its clinical implications

Graft-versus-leukemia (GVL) effect is an immunologically important phenomenon which decreases the relapse rate of leukemia after allogeneic bone marrow transplantation. GVL effect is sometimes associated with the occurrence of graft-versus-host disease (GVHD). Analyses of GVL effect and GVHD showed that these two phenomena were separable in some conditions. Although we cannot yet completely control the development of the GVL effect without inducing GVHD in humans, basic analyses using animal models show potential benefits of the GVL effect for clinical applications. Autologous GVHD is another important phenomenon which can help to eradicate minimal residual disease. Interleukin 2 and/or cyclosporin A are extensively used in animal models and in humans to induce autologous GVHD, showing beneficial effects. In the future, cytokine usage and allogeneic stem cell transplantation or leukocyte infusion appear to be promising in the control of minimal residual disease. Further studies on the mechanisms of GVL effects and GVHD may well open a new era for cell transplantation.     

Examination of the lateral antebrachial cutaneous nerve: an anatomic study in human cadavers

Variations in the anatomic course of the cutaneous nerves about the lateral aspect of the elbow are important when surgical exposures and the establishment of arthroscopic portals are considered. The specific anatomic course taken by the lateral antebrachial cutaneous nerve and its relationship to the lateral epicondyle were determined by studying 33 upper extremities in 22 preserved adult cadavers. Considerable anatomic variation was found regarding the location of the lateral antebrachial cutaneous nerve as it crossed the elbow. The nerve pierced the brachial fascia an average of 3.2 cm proximal to the lateral epicondyle and was located an average of 4.5 cm medial to the lateral epicondyle as it crossed the interepicondylar line. In two instances, the nerve passed through the biceps muscle directly, prior to piercing the brachial fascia.     

Multiple schwannomas in the radial nerve

We present a case of multiple schwannomas in the radial nerve. The occurrence of multiple schwannomas in a single major nerve is very rare. Magnetic resonance imaging was useful in detecting the tumours. As schwannomas may be multiple without clinical symptoms, we recommend MR imaging of the entire limb when schwannomas occur in a major nerve in the upper extremity.     

The detailed anatomy of the palmar cutaneous nerves and its clinical implications

We have recently reported that in vitro low dose of ultraviolet B radiation (UVB, 100-200 J per m2) directly impaired the antigen-presenting function of human Langerhans cells. In this study, we analyzed the effect of UVB irradiation on the Langerhans cells expression of several accessory molecules, namely CD54, CD80, and CD86. Langerhans cells phenotype was determined either immediately after UVB exposure (100 J per m2) or after a 2 d culture. No modification in cell surface antigen levels was observed immediately after irradiation. Prior UVB exposure did not modify the levels of CD80 at the Langerhans cells surface after a 2 d culture. In contrast, CD54 and, above all, CD86 expression were significantly decreased. Addition of exogenous anti-CD28 monoclonal antibodies partly restored the allostimulatory property of irradiated Langerhans cells in mixed epidermal cell-lymphocyte reaction, demonstrating that impairment of CD86 upregulation contributes to the UVB-induced immunosuppressive effect. Furthermore, we found that UVB irradiation at 200 J per m2 significantly reduced the number of viable Langerhans cells after 2 d of culture. UVB-induced cytotoxicity was due to apoptotic cell death, as demonstrated by typical morphologic alterations and by DNA fragmentation yielding a classical ladder pattern on gel electrophoresis. Interestingly, interaction of Langerhans cells with CD40-ligand transfected L cells improved the viability of irradiated Langerhans cells, counteracted the inhibition of CD86 expression, and efficiently reduced the number of apoptotic cells after a 2 d culture. Collectively, these results demonstrate that in vitro UVB exposure affects Langerhans cells via at least two distinct pathways: (i) decreased CD86 costimulatory molecule upregulation; and (ii) induction of Langerhans cells apoptosis, a phenomenon partly prevented by CD40 triggering.     

Safe lateral-mass screw lengths in the Roy-Camille and Magerl techniques. An anatomic study

STUDY DESIGN: Investigation of the mean safe lateral-mass screw lengths in the Roy-Camille and Magerl screw techniques in cadaveric cervical specimens. OBJECTIVES: To report the mean screw path length and to evaluate the relation of the screw trajectory to the nerve root in the Roy-Camille and Magerl screw techniques. SUMMARY OF BACKGROUND DATA: Potential injury to the cervical nerve root caused by too long a screw remains a major concern. Few studies regarding proper screw length and its relation to the adjacent nerve root are available. METHODS: Fourteen cervical spines were used for this study. Each lateral mass from C3 to C7 was drilled according to the techniques described by Roy-Camille (right side) and Magerl (left side). The cervical spines were harvested from the cadavers, and the anterior aspect of the lateral mass and spinal nerve were exposed. The screw path length between the dorsal and ventral cortices of the lateral mass were measured. An additional measurement was taken from the ventral aspect of the lateral mass to the nerve root along the screw path. RESULTS: The mean screw path length in the Roy-Camille technique decreased consistently from C3 (15.7 +/- 1.7 mm) to C7 (11.3 +/- 0.8 mm). The mean distance from the ventral cortex to the nerve root ranged from 1.2 to 2.3 mm, and the smallest value was at C7. The mean screw path length in the Magerl technique also decreased from cephelad to caudal, with a range of 15-16 mm at C3-C6 and a mean value of 13.8 mm at C7. CONCLUSIONS: A safe screw length is 14-15 mm in the Roy-Camille technique and 15-16 mm in the Magerl technique at C3-C6. A short screw may be used at C7 if desired.     

An ultrastructural study of the glycine transporter GLYT2 and its association with glycine in the superficial laminae of the rat spinal dorsal horn

The glycine transporter GLYT2 is present in axonal boutons throughout the spinal cord, and its laminar distribution matches that of glycine-enriched axons, which are presumed to be glycinergic. In order to determine whether boutons which possess GLYT2 are glycine-enriched, we have carried out pre-embedding immunocytochemistry with antibody raised against GLYT2, and combined this with post-embedding detection of glycine, in the rat. GLYT2 immunoreactivity was present in boutons which formed symmetrical axodendritic, axosomatic or axoaxonic synapses, and was often seen in peripheral axons of type II synaptic glomeruli. One hundred and fifty GLYT2-immunoreactive boutons were analysed quantitatively, and in 142 (94.6%) of these the density of gold particles representing glycine-like immunoreactivity exceeded the background level (over presumed glutamatergic boutons) by at least a factor of two. Within immunoreactive boutons, the GLYT2 reaction product was associated with the plasma membrane, but often appeared as discrete clumps and was generally excluded from the region of the active sites of synapses. These results confirm that GLYT2 is associated with glycine-enriched axonal boutons in the superficial dorsal horn. They also suggest that GLYT2 is unevenly distributed on the plasma membrane of these boutons, and raise the possibility that it may be excluded from synaptic clefts.     

Finding the self: A behavioral measure and its clinical implications.

Presents a clinical model of the development of self. The model focuses on the early learning responsible for linguistic self-referents such as "I" and "me." This model offers an account for why some patients, such as those with borderline personality disorder (BPD), feel that they "do not know who they are" or that their sense of self is controlled by other people, while other patients have a sense of a secure, stable self that is not prey to the whims of others. The authors administered the Experiencing of Self Scale, which measures the degree to which other people influence the experience of self, along with the Self-Esteem Scale and the Dissociative Experiences Scale to 284 undergraduate students (mean age 19.2 yrs) and 14 BPD patients (mean age 41.1 yrs). Results show that the degree to which other people influence the experience of self depended on the nature and closeness of the people involved, that those in the BPD sample suffered from excessive influence of other people over the experience of self relative to the undergraduates, and that the degree of influence correlated predictably with high dissociation and low self-esteem. Implications for conceptualizing BPD and narcissistic personality disorder are discussed, and clinical applications are suggested. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The anatomic location of the dorsal ramus of the cervical nerve and its relation to the superior articular process of the lateral mass

STUDY DESIGN: This study analyzed the anatomic relation of the dorsal ramus of the cervical spinal nerve to the lateral mass. OBJECTIVES: To determine the location of the dorsal rami of the cervical spinal nerves from C3 to C7 in relation to the superior articular processes of the lateral masses. SUMMARY OF BACKGROUND DATA: The anatomic study of the cervical spinal nerve and its relations to adjacent bony structures have been addressed. No previous anatomic study with regard to the location of its dorsal ramus relative to the lateral mass has been reported. METHODS: Twelve specimens were obtained for study of the dorsal rami of the cervical spinal nerves. All soft tissues surrounding the cervical spinal nerves from C3 to C7 were dissected from the intervertebral foramens until the dorsal rami were clearly exposed. The facet joints in the corresponding levels were then opened by removal of the capsules. Three measurements, including the height of the dorsal ramus, the distance between the dorsal ramus and the tip of the superior articular facet, and the angle of the dorsal ramus relative to the superior articular surface, were taken for each ramus. RESULTS: The results showed that the mean height of the dorsal ramus for both sides decreased progressively from C3 (2.2 +/- 0.6 mm) to C7 (1.2 +/- 0.2 mm). The mean distance between the dorsal ramus and the tip of the superior facet showed an inconsistent change, with the maximum value seen at C5 (7.4 +/- 1.6 mm) and the minimum at C7 (5.5 +/- 2.9 mm). The mean angle of the dorsal ramus relative to the superior articular facet ranged from 23.3 degrees +/- 14.3 degrees to 29.8 degrees +/- 11.2 degrees. CONCLUSIONS: The dorsal ramus of the cervical spinal nerve is closer to the anterolateral corner of the base of the superior articular processes. Lateral mass screws directed to the anterolateral corner of the base of the superior articular process should be avoided.     

An electron microscopic study of the processes of nerve regeneration after lyophilized nerve homografting

The objective of the present study was to investigate the role of the Schwann cell basal lamina in nerve regeneration. To achieve this goal, we observed the process of axonal regeneration within a lyophilized nerve graft, in which only the basal lamina of the Schwann cell persisted. Sciatic nerves were removed from rats and lyophilized to kill the Schwann cells and other components. These grafts were transplanted to rat sciatic nerve defects. The rats were then killed after lapses of time. We observed the processes of axonal regeneration using a transmission electron microscope. Regeneration of axons along the inner surface of the Schwann cell basal lamina was clearly seen. These results suggest that, if tubular basal laminae persist, Schwann cells are not always necessary, and axonal regeneration can be induced in the direction toward the basal lamina.     

Phase I clinical study of the recombinant oncotoxin TP40 in superficial bladder cancer

Many previous studies evaluating various hormone levels in males with subnormal semen analyses were performed when the normal semen parameters were considerably higher than now. This study evaluated sera levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), total testosterone (TET), free TET, and prolactin (PRL) in 60 males with oligospermia and decreased motility according to recent World Health Organization standards. Three separate groups were evaluated: group 1, motile density (MD) < 5 x 10(6)/mL (but not azoospermia); group 2, 5 < or = MD < 10 x 10(6)/mL; group 3, MD > 10 x 10(6)/mL, but % motility < 30%. There were no significant differences in mean FSH levels between groups. Overall FSH was increased in 47.1% of the cases. In contrast, mean LH levels were normal in all three groups. Only 17.3% of the entire group had elevated LH levels. The TET level was below normal in 32.3% of the entire group, with a fairly equal distribution between the three groups. Overall, only 7.8% had elevated PRL levels, with the highest percentage found in group 3 (22.2%). Only a small minority of patients with increased FSH had low TET levels compared to 48.0% of those with normal FSH. These data demonstrate that when using the lower semen parameters, the most common serum hormone abnormality is increased FSH; men with MD < 5 x 10(6)/mL do not have a higher incidence of elevated FSH than those with higher MDs.(ABSTRACT TRUNCATED AT 250 WORDS)     

An anatomical study of the tympanic branch of the glossopharyngeal nerve (nerve of Jacobson)

OBJECTIVE: To examine physician characteristics associated with being a high prescriber of antibiotics for pediatric upper respiratory tract infections (URIs). DESIGN AND SETTING: Analysis of 34624 episodes of care for URIs in children (younger than 18 years) in the Kentucky Medicaid program from July 1, 1995, to June 30, 1996. PARTICIPANTS: Primary care physicians with at least 25 episodes of care (n=205). The proportion of patients with URIs receiving antibiotics stratified the sample into low (< or =25th percentile) and high (> or =75th percentile) antibiotic prescribers. MAIN OUTCOME MEASURES: Bivariate analyses were computed comparing the high and low prescribers. A logistic regression model was computed for likelihood of being a high prescriber by number of URI episodes, proportion of patients receiving antibiotics that were broad spectrum, years since medical school graduation, physician gender, rural/urban practice, and specialty. RESULTS: The high prescriber group (n=52) included data from 11899 episodes of care, with a mean prescribing rate of 80%. The low prescriber group (n=55) included data from 5396 episodes, with a mean prescribing rate of 16%. High prescribers were significantly more years away from medical school graduation (27 vs 19 years; P<.001) and had managed significantly more URI episodes than low prescribers (229 vs 98; P=.001). In the logistic regression, compared with pediatricians, the odds ratios of being a high prescriber were 409 (95% confidence interval [CI], 29-7276) for family practitioners and 318 (95% CI, 17-6125) for other primary care physicians. CONCLUSION: With the rise of antibiotic-resistant bacteria, more focused training regarding treatment of URIs is warranted in residency and in continuing medical education forums.     

Schwannoma of the superficial peroneal nerve presenting as web space pain

A 55-year-old male presented complaining of pain at his right fourth toe and dorsal fourth web space. Physical examination findings pointed to a lesion affecting the superficial peroneal nerve. A schwannoma of the superficial peroneal nerve was subsequently excised, relieving the patient's symptoms. In the differential diagnosis of nontraumatic and/or nonarthritic toe and foot pain, benign tumors, including schwannomas of the tibial and peroneal nerves, should be considered.     

Type II diabetic nephropathy: its clinical course and therapeutic implications

Type II diabetes is responsible for more end-stage renal disease in the United States than any other single condition. Until recently, the majority of research in diabetic nephropathy has focused on patients with type I diabetes despite the fact that type II nephropathy is a more prevalent condition. The notion that there are major differences between the nephropathy of these two types of diabetes is not supported by recent literature. The biggest difference appears to be related to ethnic risk. Histopathologic differences are now being described as well. Clinical interventional trials are few compared to type I diabetes; however, it seems that maneuvers that improve renal prognosis in patients with type I diabetes (blood pressure control, blood glucose control, and the use of angiotensin-converting enzyme inhibitors) apply to the type II population as well. Some of the calcium channel blockers lower proteinuria to a degree that suggests renoprotection and may further improve outcome.