A decade of experience with dorsalis pedis artery bypass: analysis of outcome in more than 1000 cases

OBJECTIVE: The purpose of this study was to review our experience over the last decade with the dorsalis pedis bypass for ischemic limb salvage in patients with diabetes mellitus. METHODS: The study was a retrospective analysis of a computerized vascular registry and chart review. From January 10, 1990 to January 11, 2000, 1032 bypasses to the dorsalis pedis artery were performed in 865 patients (27.6% of the 3731 lower extremity arterial bypass procedures performed in that time period). Five hundred ninety-seven patients (69%) were male, with a mean age of 66.8 years. Ninety-two percent had diabetes mellitus. All procedures were done for limb salvage. Conduits included 317 nonreversed saphenous vein (30.7%), 273 in situ (26.4%), 235 reversed vein (22.8%), 170 arm vein (16.5%), 35 other vein (3.4%), and two polytetrafluoroethylene (0.2%) grafts. The inflow arteries were as follows: 294 common femoral (28.5%), 550 popliteal (53.2%), 114 superficial femoral (11%), and 74 other (7.2%). RESULTS: The mortality rate within 1 month of surgery was 0.9%, and 42 grafts (4.2%) failed in the same interval, although 13 were successfully revised. In a follow-up period that ranged from 1 to 120 months (mean, 23.6 months), primary patency, secondary patency, limb salvage, and patient survival rates were 56.8%, 62.7%, 78.2%, and 48.6%, respectively at 5 years and 37.7%, 41.7%, 57.7%, and 23.8% at 10 years. Both polytetrafluoroethylene grafts failed in less than 1 year. Primary graft patency was worse in female patients (46.5% female versus 61.6% male at 5 years; P <.009) but better in patients with diabetes (65.9% diabetes mellitus versus 56.3% non-diabetes mellitus at 4 years; P <.04). Saphenous vein grafts performed better than all other conduits with a secondary patency rate of 67.6% versus 46.3% at 5 years (P <.0001). Multivariate analysis showed that length of stay greater than 10 days and dorsalis pedis bypass for the surgical indication of previous graft occlusion were independently predictive of worse graft patency at 1 year and use of saphenous vein as conduit was predictive of better patency. CONCLUSION: Dorsalis pedis bypass is durable with a high likelihood of ischemic foot salvage over many years. Saphenous vein is the preferred conduit when available. Short vein grafts from distal inflow sites are possible in more than 50% of cases. These results justify the routine use of pedal arterial reconstruction for patients with diabetes with ischemic foot complications.     

Gastrointestinal symptoms secondary to implanted spinal cord stimulators

IMPLICATIONS: We report severe gastrointestinal symptoms in two patients who had implanted spinal cord stimulators. These side effects were severe enough to require cessation of the stimulation, even though the patients reported significantly improved analgesia. It is important for clinicians caring for patients with these devices to be aware of these potentially severe side effects.     

Insulin-like growth factor-1 induces adhesion and migration in human multiple myeloma cells via activation of beta1-integrin and phosphatidylinositol 3'-kinase/AKT signaling

Insulin-like growth factor-1 (IGF-I) is a growth and survival factor in human multiple myeloma (MM) cells. Here we examine the effect of IGF-I on MM cell adhesion and migration, and define the role of beta1 integrin in these processes. IGF-I increases adhesion of MM.1S and OPM6 MM cells to fibronectin (FN) in a time- and dose-dependent manner, as a consequence of IGF-IR activation. Conversely, blocking anti-beta1 integrin monoclonal antibody, RGD peptide, and cytochalasin D inhibit IGF-I-induced cell adhesion to FN. IGF-I rapidly and transiently induces association of IGF-IR and beta1 integrin, with phosphorylation of IGF-IR, IRS-1, and p85(PI3-K). IGF-I also triggers phosphorylation of AKT and ERK significantly. Both IGF-IR and beta1 integrin colocalize to lipid rafts on the plasma membrane after IGF-I stimulation. In addition, IGF-I triggers polymerization of F-actin, induces phosphorylation of p125(FAK) and paxillin, and enhances beta1 integrin interaction with these focal adhesion proteins. Importantly, using pharmacological inhibitors of phosphatidylinositol 3'-kinase (PI3-K) (LY294002 and wortmannin) and extracellular signal-regulated kinase (PD98059), we demonstrate that IGF-I-induced MM cell adhesion to FN is achieved only when PI3-K/AKT is activated. IGF-I induces a 1.7-2.2 (MM.1S) and 2-2.5-fold (OPM6) increase in migration, whereas blocking anti-IGF-I and anti-beta1 integrin monoclonal antibodies, PI3-K inhibitors, as well as cytochalasin D abrogate IGF-I-induced MM cell transmigration. Finally, IGF-I induces adhesion of CD138+ patient MM cells. Therefore, these studies suggest a role for IGF-I in trafficking and localization of MM cells in the bone marrow microenvironment. Moreover, they define the functional association of IGF-IR and beta1 integrin in mediating MM cell homing, providing the preclinical rationale for novel treatment strategies targeting IGF-I/IGF-IR in MM.     

Low Birth Weight Across Generations

Objectives: This study sought to determine the relationship between maternal birth weight, prenatal care usage, and infant birth weight. Methods: Stratified and logistic regression analyses were performed on a dataset of computerized Illinois vital records of White (N = 187,074) and African-American (N = 58,856) infants born between 1989 and 1991 and their mothers born between 1956 and 1975. Results: Among White mothers who received adequate prenatal care, the low birth weight (<2500 g) rate was 4% for infants of former low birth weight mothers (N = 5230) compared to 2.1% for infants of former nonlow birth weight mothers (N = 93,011), relative risk equaled 1.9(1.7–2.2); the population attributable risk of maternal low birth weight was 4.1%. Among African American mothers who received adequate prenatal care, the low birth weight rate was 15% for infants of former low birth weight mothers (N = 2196) compared to 7.2% for infants of former nonlow birth weight mothers (N = 14,607), relative risk equaled 2.1(1.9–2.4); the population attributable risk of maternal low birth weight was 10.9%. The maternal–infant birth weight associations were consistent across all maternal age, education, marital status, and prenatal care categories. Conclusions: Maternal low birth weight is a risk factor for infant low birth weight independent of risk status during the current pregnancy. A greater percentage of low birth weight African American (compared to White) infants are attributable to maternal low birth weight.     

Preproenkephalin mRNA expression in rat dorsal striatum induced by selective activation of metabotropic glutamate receptor subtype-5

Group I metabotropic glutamate receptors (mGluR1 and mGluR5 subtypes) are positively coupled to phosphoinositide hydrolysis through G-proteins and are densely expressed in medium-sized projection neurons of striatum. Selective activation of Group I mGluRs upregulates preproenkephalin (PPE) mRNA expression in the rat dorsal striatum. This study investigated the role of one subtype of Group I receptors, mGluR5, in the regulation of PPE mRNA expression in the rat dorsal striatum using quantitative in situ hybridization. Unilateral injection of the mGluR5 selective agonist (RS)-2-Chloro-5-hydroxyphenylglycine (CHPG) into the dorsal striatum (caudoputamen) of chronically cannulated rats at doses of 50 and 200 nmol elevated basal levels of PPE mRNA in the injected dorsal striatum. The induction of PPE mRNA was evident at 1 h, remained at 3 h, and returned to normal level 6 h after CHPG injection. Pretreatment with an mGluR5 selective antagonist 2-methyl-6-(phenylethynyl) pyridine hydrochloride (MPEP) at a dose of 10 mg/kg (i.p.) blocked CHPG-stimulated PPE expression. MPEP also attenuated PPE expression induced by dopamine D(2) receptor blockade with eticlopride (0.5 mg/kg, i.p.). Administration of MPEP alone had no significant effects on basal levels of PPE mRNA in the striatum. The results from the present study demonstrate that glutamatergic tone on mGluR5 possesses the ability to positively regulate PPE gene expression in striatal neurons in vivo. Moreover, activation of mGluR5 participates in the mediation of D(2) antagonist-induced PPE expression.     

Replacement-fed infants born to HIV-infected mothers in India have a high early postpartum rate of hospitalization

Access to safe breast-feeding alternatives for HIV-infected mothers and their infants in many settings is limited. We compared the rates of early postpartum hospitalization of infants born to HIV-infected mothers using different infant-feeding practices in a large government hospital in Pune, India. From March 1, 2000 to November 30, 2001, infants born to HIV-infected mothers were followed in a postpartum clinic. All mothers had received a standard short course of antenatal zidovudine. Infant-feeding practices were assessed within 3 d of delivery, prior to postpartum hospital discharge. Sixty-two of 148 mothers (42%) were breast-feeding their infants. Eighty-six of the mothers (58%) were providing replacement feeding, primarily diluted cow, goat or buffalo milk (top feeding). Twenty-one of the 148 participating infants (14.2%) born during the study period required hospitalization within the 1st 6 mo of life and 6 infants required repeat hospitalization. All hospitalized infants were receiving replacement feeding with a rate of 0.093 hospitalizations per 100 person-days (95% CI, 0.062 to 0.136). The reasons for hospitalization included acute gastroenteritis (48.1%), pneumonia (18.5%), septicemia (11.1%) and jaundice (11.1%). A high risk for early postpartum hospitalization was seen in replacement-fed infants born to HIV-infected mothers in Pune, India. In settings such as India, where access to safe replacement feeding is limited, interventions making exclusive breast-feeding safer for HIV-infected mothers and infants are needed. Such interventions would be valuable additions to the very effective national prevention programs that currently rely on the provision of short-course zidovudine and nevirapine.     

Project Muskan: Social responsibility of the plastic surgeon

Although exact statistics are not available, Indian plastic surgeons see around 7,00,000–8,00,000 burn admissions annually with around 10,00,000 cleft patients yet to be operated. In spite of this voluminous load, India does not have national health programs for the various deformities Indian plastic surgeons typically treat. As Plastic Surgeons, it is our social responsibility to treat these patients and bring ‘muskan’ (smile in Hindi) back into their lives. Project Muskan was initiated as an innovative model for targeting these patients and is probably one of its kind in the field of plastic surgery in our country. It is unique because it is a perfect collaboration of government institutions, a Non Government Organization (NGO), and cooperative sectors providing free health care at the doorstep. Identification of the patients was done with the help of the extensive milk dairy network in the state of Gujarat. Provision of transport and other facilities was done by the NGOs and quality health care provision was taken care of by the government hospital. Project Muskan started from a single village but now covers around 3000 villages and tribal areas of Gujarat. It is a system that can be easily reproducible in all hospitals and has reestablished the faith of the common man in government institutes.     

Peak Bone Mineral Density of Physically Active Healthy Indian Men With Adequate Nutrition and No Known Current Constraints to Bone Mineralization

We undertook this study to characterize peak bone density and evaluate its determinants in a healthy cohort of young adult male paramilitary personnel. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry in 473 healthy men aged 21–40 yr. The effect of anthropometry and biochemical parameters on BMD was determined. Mean BMD values of L1–L4, forearm, total hip, and femoral neck were 1.170 ± 0.137, 0.755 ± 0.089, 1.129 ± 0.130, and 1.115 ± 0.133 g/cm², respectively. BMD values for 31- to 40-yr age group were lower than those of 20- to 30-yr age group except for forearm, which was higher in the former. Significant positive correlation was observed between height, weight, and body mass index with BMD. On multivariate regression analysis, weight was the most consistent contributor to variance in the BMD. Compared with age-matched US males, BMD of total hip and femoral neck were higher for Indian paramilitary personnel by 3.58% and 4.2%, whereas lumbar spine BMD was lower by 4.1%. In conclusion, peak BMD in healthy Indian males was achieved by 30 yr of age at lumbar spine and hip, with weight being the most consistent contributor to variance in BMD. Peak BMD in this population was comparable to that reported in white US males.     

The prevalence and break down of narrow anterior chamber angle pathology presenting to a general ophthalmology clinic

To approximate the breakdown of narrow anterior chamber angle conditions, on general ophthalmology clinics, in the predominantly white population of the South East Kent region in the United Kingdom.A review was done of all patients attending a secondary care ophthalmology general clinic over a 3-year period. Patients were assessed with: slitlamp biomicroscopy with indentation gonioscopy; SD optical coherence tomography, Humphrey visual field analyzer, and high frequency ultrasound and categorized into various narrow angle conditions. These were: narrow Van Herrick but open angle; primary narrow angle but nonoccludable; primary angle closure suspect; primary angle closure; chronic narrow angle glaucoma; plateau iris configuration; plateau iris syndrome, and phacomorphic narrow angle.A total of 14,520 patients were referred to the clinic, of those 10,491 attended and were analyzed. Six hundred seventy four (6.4%) of the patients had some form of narrow angle condition in at least 1 eye. The majority of these patients were at relative low risk of pathology such as nonoccludable narrow angles (359/53.3%) and narrow Van Herrick but open angles (93/13.8%). 8.8% of all the narrow angle patients had primary angle closure suspect or primary angle closure. Plateau iris pathology was seen in 68 (10.1%) of patients with 18 (26%) having confirmed plateau iris syndrome after peripheral iridotomy. Phacomorphic pathology was confirmed in 75 (11.1%) patients.Narrow angle patients form a significant proportion (6.4%) of those attending general ophthalmology clinic in the predominantly white population in the South East Kent Region of the United Kingdom. The majority of these (67.1%) are at a relatively low risk of developing acute or chronic angle closure glaucoma. Of the remaining patients 8.8% have primary angle closure suspect or primary angle closure and 2.9% have already progressed to chronic narrow angle closure glaucoma. Plateau iris pathology and phacomorphic glaucoma account for the remainder of the presentations.