Preferred strategies for secondary infrainguinal bypass: lessons learned from 300 consecutive reoperations

PURPOSE: To determine the optimal surgical strategies in reoperative infrainguinal bypass, we reviewed our results in 300 consecutive secondary bypasses in 251 patients operated on between Jan. 1, 1975, and Nov. 1, 1993. METHODS: There were 168 men (67%) and 83 women (33%), with a mean age of 64.8 years and a typical distribution of risk factors including smoking (76.4%), diabetes (33.7%), and coronary artery disease (47.1%). The indications for surgery were limb-threatening ischemia in 83.5% and severe claudication in 16.5% of patients. The majority of conduits (n = 213) were autogenous vein and were composed of a single segment of greater saphenous vein in 121 bypasses (57%) and various alternative veins including composite, arm, and lesser saphenous vein in 92 bypasses (43%). Prosthetic conduits included 69 polytetrafluoroethylene, 16 umbilical vein, and two Dacron grafts. RESULTS: There was one perioperative death (0.3%) and a 25% total morbidity rate including a 1.7% myocardial infarction rate. There was a 28.6% early (< 30 days) graft failure and 10.7% early amputation rate for prosthetic bypass grafts compared with 13.6% early graft failure and 5.6% early amputation rates for vein grafts. Autogenous vein bypasses had higher 5-year secondary patency rates than had prosthetic grafts (51.5% +/- 4.6% vs 27.4% +/- 6.1%, p < 0.001). Results with autogenous vein bypass improved significantly from the 1975 to 1984 to the 1985 to 1993 interval with 5-year secondary patency rates increasing from 38.3% +/- 6.9% to 59.1% +/- 5.8% (p = 0.017) and 5-year limb-salvage rates increasing from 40.4% +/- 7.6% to 72.4% +/- 6.6% (p < 0.001). Vein grafts to the popliteal and tibial outflow levels had equivalent long-term results. Vein grafts completed for claudication demonstrated results superior to those for limb salvage, with a 5-year secondary patency rate of 75.8% +/- 8.1% versus 52.3% +/- 7.9% (p = 0.048). Secondary autogenous vein bypass grafting performed after early primary graft failure (< 3 months) did particularly poorly, with only a 27.2% +/- 7.7% 4-year secondary patency rate. Greater saphenous veins tended to perform better than alternative vein bypasses, with a 5-year secondary patency rate of 68.5% +/- 6.0% compared with 48.3% +/- 10.5% (p = 0.09) and a 5-year limb-salvage rate of 77.8% +/- 7.4% versus 54.2% +/- 11.8% (p = 0.046). CONCLUSIONS: When patients suffer a recurrence of limb-threatening ischemia at the time of infrainguinal graft failure, aggressive attempts at secondary revascularization with autogenous vein are warranted based on the low surgical morbidity and mortality rates and the improved patency and limb salvage rates that are currently attainable.     

Role of child and maternal processes in the psychological adjustment of children with sickle cell disease.

In this study, 64% of children aged 7–12 yrs with sickle cell disease were found to have a parent-reported behavior problem, and 50% met the criteria for a Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) diagnosis based on a structured clinical interview of the child. Internalizing types of behavior problems and diagnoses were the most frequent. Support was provided for a transactional stress and coping model in delineating the processes associated with child adjustment. In particular, maternal anxiety accounted for 16–33% of the variance in mother-reported internalizing and externalizing behavior problems, respectively, and child pain-coping strategies accounted for 21% of the variance in child-reported adjustment problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The introduction of alkyl,ester, carboxylate,amino, hydroxyl,and phosphate functional groups to the surface of polyethylene

The surface of polyethylene was derivatized with ester, carboxylate, amino, hydroxyl, and phosphate functional groups. α, ω bifunctional alkanes, containing on one end a primary amine, were coupled to oxidized polyethylene through an amide linkage. Polyethylene was first oxidized with chromic acid, the carboxylate groups were converted to the acyl chloride with phosphorus pentachloride, and then reacted with a primary amine to give the covalently bound amide. The copposing ends of the bifunctional alkanes were the methyl, tertiary amine, ester, and hydroxyl groups. The ester was converted to the carboxylate by acid cleavage and the hydroxyl group converted to the phosphate by treatment first with phosphorus oxychloride and then aqueous base. Attenuated total reflection FTIR, XPS, and pH-dependent contact angle wetting were used to characterize the surfaces. The FTIR data were used to confirm the formation of the amide and to detect an undesired carboxylate/ammonium ion complex formed in the presence of trace amounts of water. XPS data were used to confirm expected changes in elemental composition and to provide quantitative estimates of the yields. Oxidation of the polyethylene introduced 5 × 10¹⁴ carboxylate groups/cm² in the 25 Å XPS sampling depth. Of these, up to 98% could be converted to the amide. The advancing contact angle data confirmed the acid/base behavior of the functional groups.     

The costs and benefits of tonal centers for chord processing.

Harmonic priming studies have shown that a musical context, with its established tonal center, influences target chord processing. This study investigated costs and benefits of priming tonal centers for target processing by adding a baseline condition (sequences without a specific tonal center). Results confirmed harmonic priming, with faster processing for related than for unrelated and less related targets (tonic chord, out-of-key chord, subdominant chord). Comparing targets in baseline contexts with targets in sequences with well-established tonal centers revealed a benefit of processing for related targets but a cost of processing for unrelated and less related targets. Findings are discussed in terms of tonal knowledge activation and suggest that an activated tonal center gives rise to strong expectations for the tonic. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ethics of practice: The beliefs and behaviors of psychologists as therapists.

There is an absence of comprehensive, systematically gathered data concerning psychologists' beliefs about and compliance with ethical principles. Furthermore, we know little about which resources are valued as effective in guiding appropriate behavior. Survey data were collected from 456 APA Division 29 members regarding the degree to which they engaged in each of 83 behaviors and the degree to which they considered each behavior to be ethical. These data were categorized and examined in terms of five principles derived from the Hippocratic oath (avoiding harm, competence, avoiding exploitation, respect, and confidentiality) as well as two additional principles (informed consent; social equity and justice). Twelve of the behaviors were very difficult for participants to evaluate on the basis of ethics. Seven of the 83 behaviors were practiced by over 90% of the participants; 16 by fewer than 10%. Colleagues, the APA Ethical Principles, and internship training were rated as the most helpful resources in guiding behavior; state and federal laws, published research, and local ethics committees were rated least helpful. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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Diffusion with simultaneous immobilization in polymer–dye systems. I. Diffusion of the cationic dye anilana red BL in the anionically modified polyester fiber dilana

The diffusion coefficient of the cationic dye Anilana Red BL in the anionically modified polyester fiber Dilana has been calculated regarding a general diffusion-immobilization model. In the model the mobile species are distinguished from the immobilized ones. In computations of Sand's equation and experimentally determined sorption isotherm of the dye in the fiber, the rate-of-dyeing curve and the concentration profiles of the dye in the same fiber were employed. The diffusion coefficient of the mobile species of Anilana Red BL in the fiber is two orders of magnitude higher than the average diffusion coefficient obtained from Hill's equation and the apparent diffusion coefficient calculated by the Boltzmann–Matano method.     

Testing the Ortega hypothesis: Facts and artifacts

We examine the assumptions and data base used by researchers who have tested the Ortega hypothesis. We find that the assumptions are not supported by the data and that the data are faulty. We conclude that the results are artifactual. We recommend that any policy implemented on the basis of this research be suspended.     

Privileged communication in the psychologist–client relationship.

Determining the status of privileged communications between psychologists and clients is a complex task. There is considerable variation across states with respect to the scope of psychologist–client privilege, and several sections of state codes directly and indirectly influence its status. An analysis of state laws related to privileged communication in the psychologist–client relationship is presented and prevalent legal exceptions and trends related to client privilege are discussed. Implications for practice to assist psychologists in balancing their ethical and legal obligations also are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychological adjustment of children with sickle cell disease: Stability and change over a 10-month period.

Rates of poor psychological adjustment of children with sickle cell disease remained relatively constant over initial and follow-up assessment points. 50 children (aged 7–12 yrs) and their mothers completed the initial protocol. 30 children completed the follow-up plus 5 additional children and their mothers. These Ss were aged 7–24 yrs at follow-up. With initial levels of adjustment controlled, children's strategies for coping with pain accounted for a significant increment in child-reported symptoms and mother-reported internalizing behavior problems at follow-up beyond the contribution of illness and demographic parameters and follow-up interval. (PsycINFO Database Record (c) 2010 APA, all rights reserved)