Surgical anatomy for endoscopic subfascial division of perforating veins

PURPOSE: This study was undertaken to define the surgical anatomy of the medial perforating veins (PVs) of the leg and to provide information on how to gain access to all medial PVs from the superficial posterior compartment during a subfascial endoscopic procedure. METHODS: The venous anatomy of 40 limbs (from 23 cadavers) were studied. Medial PVs located between the ankle and the tibial tuberosity were dissected. None of the subjects had pathologic evidence of venous disease. Each PV's type (direct or indirect), size (< 1 mm, 1 to 2 mm, > 2 mm), location (distances from ankle [D1], and tibia [D2]), and accessibility from the superficial posterior compartment were recorded. RESULTS: Five hundred fifty-two PVs were identified (mean, 13.8; range, 7 to 22). Two hundred eighty-seven PVs (52%) directly connected the superficial with the deep systems, 228 (41%) were indirect muscle perforators, and 37 PVs (7%) were undetermined. One hundred thirty-seven PVs (25%) were > 2 mm. Sixty-three percent of PVs were accessible from the superficial posterior compartment. In the distal half of the leg, two groups of direct PVs could be identified (Cockett II: D1, 7 to 9 cm; Cockett III: D1, 10 to 12 cm). In the proximal half of the leg, paratibial direct PVs (D2 < or = 1 cm) were found clustered in three groups (D1, 18 to 22 cm; D1, 23 to 27 cm; D1, 28 to 32 cm). CONCLUSIONS: Our study confirmed the presence of the Cockett II and III PVs and three groups of proximal paratibial PVs, including the "24-cm" perforators. Two thirds of the medial direct PVs are accessible for endoscopic division from the superficial posterior compartment. To divide paratibial PVs, however, incision of the paratibial deep fascia is frequently required.     

Iterative optimization of high-affinity proteases inhibitors using phage display. 1. Plasmin

We generated a series of libraries having variants of the first Kunitz domain of human lipoprotein-associated coagulation inhibitor (LACI-D1, also known as tissue-factor pathway inhibitor-I) displayed on bacteriophage M13 as pIII-fusions. We varied LACI-DI iteratively in two regions: the P1 region (positions 10-21) and the "second loop", (positions 31-39), which together form one end of the domain. Display-phage library Lib#1 allows 31 200 amino-acid sequences in P1 region (residues 13, 16-19). Preliminary, we screened Lib#1 against human plasmin (PLA, EC 3.4.21.7) immobolized on agarose to enrich for phage displaying variants with PLA affinity. We introduced a 1600-fold increase in second-loop diversity (residues 31, 32, 34, 39) into the population of selectants from Lib#1, yielding Lib#2. Lib#2 (allowing approximately 50 million amino-acid sequences) was screened against PLA-agarose to isolate highest affinity binders. Protein EPI-P211, derived from the best isolate of Lib#2, inhibits PLA with Ki = 2 nM (at least 500-fold better than LACI-D1) and with high specificity. We used amino-acid sequences of PLA-binding selectants to design a PLA-biased library (Lib#3) which we screened against PLA. The protein EPI-P302 (derived from the best binder obtained from Lib#3) has Ki for PLA inhibition of 87 pM, which is 25-fold better than the first-round best binder and > or = 12 500-fold better than LACI-D1. EPI-P302 also shows very high specificity for PLA vs other human proteases and is resistant to inactivation by oxidants and extremes of temperature or pH. Thus, one can use selectants from one library to design target-tailored combinatorial libraries and obtain quite stable, highly specific, very high-affinity binding molecules while maintaining an essentially human framework.     

Perinuclear antineutrophil cytoplasmic antibodies in patients with Crohn's disease define a clinical subgroup

BACKGROUND & AIMS: Antineutrophil cytoplasmic antibodies (ANCA) have been consistently detected in a subgroup of patients with Crohn's disease (CD). This study was designed to determine whether serum ANCA expression in patients with CD characterizes an identifiable clinical subgroup. METHODS: The study population consisted of 69 consecutive patients with an established diagnosis of CD as determined by a combination of characteristic clinical, radiographic, endoscopic, and histopathologic criteria. Sera from the patients were analyzed for the presence of ANCAs using the fixed neutrophil enzyme-linked immunosorbent assay (ELISA) assay. Perinuclear ANCA (pANCA)-positive and cytoplasmic ANCA (cANCA)-positive results by ELISA were confirmed by indirect immunofluorescence staining. Clinical profiles of the ANCA-positive patients with CD were compared with those of patients with CD not expressing ANCA (ANCA-negative). RESULTS: pANCA-positive patients with CD have endoscopically and/or histopathologically documented left-sided colitis and symptoms of left-sided colonic inflammation, clinically reflected by rectal bleeding and mucus discharge, urgency, and treatment with topical agents. One hundred percent of patients with CD expressing pANCA had "UC-like" features. CONCLUSIONS: In patients with CD, serum pANCA expression characterizes a UC-like clinical phenotype. Stratification of CD by serum pANCA provides evidence of heterogeneity within CD and suggests a common intestinal mucosal inflammatory process among a definable subgroup of patients with CD and UC expressing this marker.     

A neutron diffraction investigation of some β′-sialons

Neutron diffraction measurements have been made on -sialons having chemical compositions Si₆-zAlzOzN₈-z, where Z=2.0, 2.9 and 4.0. The powder diffraction patterns have been recorded for sample temperatures of 300 K and 4.2 K, and the profile refinement method has been used in the data analysis. The unit-cell dimensions and the atomic co-ordinates were found to vary in a regular way with composition. The values of scattering amplitude per atomic site obtained using the refinement method provide evidence of a preferential replacement of nitrogen by oxygen on specific crystallographic sites, and an indication of a small vacancy concentration on the metal-atom sites.     

EFFECT OF TIME AND TEMPERATURE ON ACCELERATED CHEMICAL DURABILITY TESTS MADE ON COMMERCIAL GLASS BOTTLES*

Chemical durability results obtained by tests on crushed samples and bottle surfaces on a variety of commercial glass-bottle compositions show the difficulties encountered in attempting to correlate accelerated tests with the actual performance of the bottles toward various solutions under service conditions. The results obtained thus far indicate that the value of accelerated tests conducted with distilled water as a leaching medium is questionable as an aid in predicting resistance of various glass compositions to neutral solutions at room temperature.     

Anisotropy of point defect diffusion in alpha-zirconium

Two types of intrinsic defect, i.e., vacancy and self-interstitial atom (SIA), are formed in metals during irradiation with energetic particles. The evolution of defect population leads to significant changes in microstructure and causes a number of radiation-induced property changes. Some phenomena, such as radiation growth of anisotropic materials, are due to anisotropy in the atomic mass transport by point defects. Detailed information on atomic-scale mechanisms is, therefore, necessary to understand such phenomena. In this article, we present results of a computer simulation study of mass transport via point defects in alpha-zirconium. The matrix of self-diffusion coefficients and activation energies for vacancy and SIA defects have been obtained, and different methods of treatment of diffusion have been tested. Molecular dynamics (MD) shows that vacancy diffusion is approximately isotropic in the temperature range studied (1050 to 1650 K), although some preference for basalplane diffusion was observed at the lower end of the range. The mechanism of interstitial diffusion changes from one-dimensional (1-D) in a 〈11 0〉 direction at low temperature (<300 K) to two-dimensional (2-D) in the basal plane and, then, three-dimensional (3-D) at higher temperatures. This article is based on a presentation made in the symposium entitled “Defect Properties and Mechanical Behavior of HCP Metals and Alloys” at the TMS Annual Meeting, February 11–15, 2001, in New Orleans, Louisiana, under the auspices of the following ASM committees: Materials Science Critical Technology Sector, Structural Materials Division, Electronic, Magnetic & Photonic Materials Division, Chemistry & Physics of Materials Committee, Joint Nuclear Materials Committee, and Titanium Committee.     

Anisotropy of point defect diffusion in alpha-zirconium

Two types of intrinsic defect, i.e., vacancy and self-interstitial atom (SIA), are formed in metals during irradiation with energetic particles. The evolution of defect population leads to significant changes in microstructure and causes a number of radiation-induced property changes. Some phenomena, such as radiation growth of anisotropic materials, are due to anisotropy in the atomic mass transport by point defects. Detailed information on atomic-scale mechanisms is, therefore, necessary to understand such phenomena. In this article, we present results of a computer simulation study of mass transport via point defects in alpha-zirconium. The matrix of self-diffusion coefficients and activation energies for vacancy and SIA defects have been obtained, and different methods of treatment of diffusion have been tested. Molecular dynamics (MD) shows that vacancy diffusion is approximately isotropic in the temperature range studied (1050 to 1650 K), although some preference for basal-plane diffusion was observed at the lower end of the range. The mechanism of interstitial diffusion changes from one-dimensional (1-D) in a direction at low temperature (<300 K) to two-dimensional (2-D) in the basal plane and, then, three-dimensional (3-D) at higher temperatures. This article is based on a presentation made in the symposium entitled “Defect Properties and Mechanical Behavior of HCP Metals and Alloys” at the TMS Annual Meeting, February 11–15, 2001, in New Orleans, Louisiana, under the auspices of the following ASM committees: Materials Science Critical Technology Sector, Structural Materials Division, Electronic, Magnetic & Photonic Materials Division, Chemistry & Physics of Materials Committee, Joint Nuclear Materials Committee, and Titanium Committee.     

Factors associated with implementation of preventive care measures in patients with diabetes mellitus

BACKGROUND: There is only limited information on the extent to which physicians' characteristics affect the level of care and implementation of guidelines in patients with diabetes mellitus. OBJECTIVE: To identify physician characteristics associated with implementation of measures for preventive care in patients with diabetes mellitus and the distribution of implementation of these measures among them. PATIENTS AND METHODS: A retrospective chart audit of 519 patients eligible for health maintenance organization insurance on December 31, 1994, representing patients with diabetes receiving care from 22 primary care physician-providers of a managed care medical group in suburban North Los Angeles, Calif, and seen by physicians between January 1993 and December 1994. A short retroactive questionnaire for participating physicians was also used. The outcome measures were (1) measurement of serum high-density lipoprotein cholesterol; (2) urinalysis for the detection of proteinuria; and (3) ophthalmology referral for dilated fundus examination. RESULTS: Over a period of 2 years 78% of the patients had a high-density lipoprotein cholesterol determination, 80% had a test for proteinuria, and 62% were referred to an ophthalmologist. After adjustment for patient pool differences, physicians who were perceived by the administration of the medical group as "fast," based on a blinded evaluation of their number of patient encounters per unit time, had an odds ratio of 0.60 (95% confidence interval [CI], 0.37-0.95; P=.03) to obtain a high-density lipoprotein cholesterol determination in their patients and an odds ratio of 0.53 (95% CI, 0.32-0.87; P=.01) to test their patients for proteinuria. In patients requiring insulin, of fast physicians, the odds ratio for a referral for ophthalmology screening was 0.25 (95% CI, 0.07-0.85; P= .03). Duration of time in practice of over 15 years and disagreement with practice guidelines were associated with better outcomes. There was no association between physician sex, internal medicine training, or number of patients with diabetes in the practice and the implementation of outcomes. There was a highly significant association between the implementation of an outcome and the implementation of the other 2, resulting in a nonhomogeneous distribution of health care delivery. Physicians' estimate of their rate of implementation of outcomes, as assessed by the questionnaires, overestimated their actual performance while being in proportion with the documented rates. Most physicians took responsibility for the nonimplementation, accepting that it was an oversight on their part as opposed to an encounter with patient resistance. CONCLUSIONS: Most physicians believe that the lack of implementation of the measures for preventive care in patients with diabetes mellitus is an oversight. The oversight is more prevalent in the practices of busy physicians. The result is a nonhomogeneous distribution of health care. Computer reminders might be the solution.     

Comparison of systematic search and database methods for constructing segments of protein structure

Two principal methods of determining the conformation of shortpieces of polypeptide backbone in proteins have been developed:using a database of known structures and systematicallygeneratingall conformations. In this paper, we compare the effectivenessof these two techniques. The completeness of the database forsegments of different lengths is examined and it is found tocontain most conformations for segments seven residues long,but to deteriorate rapidly for longer regions. When the databasesegment is to be incorporated into the rest of a structure,at least seven residues are required to build four new residues,because of the need to positionthe segment relative to the restof the structure.It is found that such positioning using flankingresidues results in large errors in the inserted region. Weconclude that the database method is currently not effectivefor comparative modeling, even for short segments. The systematicsearchprocedure is found to generate almost all structures of shortsegments found in proteinsIn contrast to the database method,low root mean square error structures are obtained for a setof trial segments embedded in the rest of a protein structure.Thus, it should be considered the method of choice.