Tentorial Venous Anatomy: Variation in the Healthy Population.

BACKGROUND AND PURPOSE: A new transtentorial venous system consisting of medial, intermediate, and lateral tentorial veins, connecting infra- and supratentorial compartments, was recently shown in 2 cadaver dissections and 2 patient scans. We sought to characterize the venous patterns within the tentorium and their relation to measures of skull development in a cohort of healthy adults. MATERIALS AND METHODS: We retrospectively reviewed tentorial venous anatomy of the head using CTA/CTV performed for routine care or research purposes in 238 patients. Included studies had adequate contrast opacification of venous structures and a section thickness of ≤2 mm; we excluded cases with space-occupying lesions and vascular pathologies. Tentorial angle, dural sinus configurations, and measures of skull base development were assessed as predictors of tentorial venous anatomy variation via Cramér V association, the binary encoded Pearson correlation, and nearest-point algorithm with the Euclidean distance metric for clustering. RESULTS: Tentorial vein development was related to the ringed configuration of the tentorial sinuses (P < .005). There were 3 configurations. Groups 1A and 1B (n = 50/238) had ringed configuration, while group 2 did not (n = 188/238). Group 1A (n = 38/50) had a medialized ringed configuration, and group 1B had a lateralized ringed configuration (n = 12/50). Measurements of skull base development were predictive of these groups. The ringed configuration of group 1 was related to the presence of a split confluens, which correlated with a decreased internal auditory canal-petroclival fissure angle. Configuration 1A was related to the degree of petrous apex pneumatization (P value = .010). CONCLUSIONS: Variations in the transtentorial venous system directly correlate with cranial development.

Sphenoid sinusitis caused by Clostridium perfringens.

Anaerobic bacterial infections in chronic sinusitis are well described in literature. We present what is believed to be the first reported case of Clostridium perfringens presenting as the causative pathogen in paranasal sinusitis. This patient presented with severe headaches and, with CT and MRI findings of unilateral sphenoid sinus opacification, with bone demineralization and intrasinus calcification. This patient responded to endoscopic debridement and long-term antibiotics without sequelae.

Combined transcervical transmastoid approach to giant parotid pleomorphic adenoma: a case report.

Although rare, giant major salivary gland pleomorphic adenomas are among the most astonishing patient presentations. Patients may ignore these slow-growing, benign lesions until significant functional impairment occurs. Complete tumor excision and facial nerve preservation in these cases are challenging requirements and are greatly aided by combined transcervical and transmastoid approaches to these lesions. In the presented case, facial nerve monitoring accurately identified the collateralization between the upper and lower divisions of the facial nerve and allowed the required sacrifice of the lower division without the need for facial nerve grafting or reconstruction. The patient recovered full function of all branches.

Evaluation of a collagen-alginate wound dressing in the management of diabetic foot ulcers.

Efficacy and safety of a collagen-alginate topical wound dressing (FIBRACOL Collagen-Alginate Wound Dressing) in the treatment of diabetic foot ulcers was compared with that of regular gauze moistened with normal saline. Seventy-five patients with foot ulcers were assigned randomly in a 2:1 ratio to the collagen-alginate test dressing or the gauze dressing. At the end of the study, the mean percent reduction of the wound area was 80.6% +/- 6% in the collagen-alginate dressing group and 61.1% +/- 26% in the gauze dressing group (p = .4692). Thirty-nine (78%) patients treated with the collagen-alginate dressing achieved > or = 75% wound area reduction, compared with 15 (60%) of gauze-treated patients. Complete healing was achieved in 24 (48%) of the collagen-alginate dressing group and 9 (36%) of the gauze dressing group. Wound size, when averaged over the 8-week period and with the duration of the ulcer taken into account, was reduced significantly in the collagen-alginate dressing group, as compared with the gauze dressing group (df = 1, p = .0049). It is concluded that the collagen-alginate test dressing is as or more effective and safe as the currently used treatment.

Genotyping of forensic short tandem repeat (STR) systems based on sizing precision in a capillary electrophoresis instrument.

Automated fluorescence analysis of polymerase chain reaction (PCR)-amplified short tandem repeat (STR) systems by capillary electrophoresis (CE) is becoming an established tool both in forensic casework and in the implementation of both state and national convicted offender DNA databases. A new capillary electrophoresis instrument, the ABI Prism 310 Genetic Analyzer, along with the Performance Optimized Polymer 4 (POP-4) provides an automated and precise method for simultaneously analyzing ten fluorescently labeled STR loci from a single PCR amplification kit, which provides a power of discrimination of approximately one in five billion from a single PCR amplification. Data are presented on sizing precision, sizing accuracy, and resolution for the STR loci in the AmpFlSTR Profiler kit. Sizing accuracy is highly dependent on the electrophoresis system, and therefore the reporting of alleles based on the nucleotide size obtained from an electrophoresis system is not recommended for forensic work. The precision of the 310 capillary electrophoresis system, coupled with software developed for automated genotyping of alleles based on the use of an allelic ladder, allows for accurate genotyping of STR loci. Sizing precision of < or = 0.16 nucleotide standard deviation was obtained with this system, thus allowing for accurate genotyping of length variants that differ in length by a single nucleotide.

High-precision genotyping by denaturing capillary electrophoresis.

Genotyping, as applied to linkage mapping, human identification, or mapping of genetic traits, mandates electrophoretic separation systems that enable a user to identify alleles with high precision to obtain a correct genotype. For 2-bp microsatellites or short tandem repeats (STRs), standard deviations of +/-0.3 nucleotide are required to ensure with 99.7% probability the identity or dissimilarity of tested alleles. A complete system, consisting of commercially available laser-induced fluorescence capillary electrophoresis (ABI PRISM 310) and performance optimized polymer 4 (POP-4), was evaluated for microsatellite separations. POP-4 is a low viscosity polymer for use in uncoated fused microbore silica capillaries. It separates DNA fragments that differ in size by 1 nucleotide up to 250 nucleotides and that differ in size by 2 nucleotides for fragments up to at least 350 nucleotides in length in about 30 min. The presence of denaturants and, more importantly, operation at 60 degrees C was mandatory for high-precision and high-resolution sizing operation. Reproducible separation performance was achieved in excess of 100 injections per capillary with resulting standard deviations in the range of 0.04 to 0.17 nucleotide. Comparative sizing of known CEPH (Centre d'Etudes du Polymorphisme Humaine) samples performed at 22 independent test sites showed the usefulness of the system for genotyping with standard deviations of 0.24 nucleotide, or better.

Neuropathic ulcerations plantar to the lateral column in patients with Charcot foot deformity: a flexible approach to limb salvage.

Neuroarthropathy of the midfoot may lead to a structural deformity that predisposes the diabetic patient to skin breakdown and ulceration. In some cases, conservative management is not adequate, making surgical intervention necessary. The authors performed a retrospective study to look at those patients who required surgical intervention for a specific pattern of neuroarthropathy. Over a 2 1/2-year period, 32 feet (31 patients) underwent surgical procedures for treatment of nonhealing neuropathic ulcerations beneath the lateral column of Charcot feet. All feet underwent exostectomy with 17 undergoing excision of the ulcer with primary closure, 8 closure via rotational fasciocutaneous flap with transpositional intrinsic muscle flap, and 6 through an incision placed adjacent to the ulcer. One patient whose ulcer was healed at the time of surgery had the incision placed directly over the prominence. Overall, 29 of 32 feet maintained functional limb salvage. This included eight patients who required revisional surgery, either by resection of more bone or creation of a local flap for coverage. Life-table analysis resulted in an 89% overall success rate. The results show that a flexible approach to skin and soft tissue coverage is necessary to heal these patients, provided attention is directed to the underlying bony prominence.

Improved single-strand DNA sizing accuracy in capillary electrophoresis.

Interpolation algorithms can be developed to size unknown single-stranded (ss) DNA fragments based on their electrophoretic mobilities, when they are compared with the mobilities of standard fragments of known sizes; however, sequence-specific anomalous electrophoretic migration can affect the accuracy and precision of the called sizes of the fragments. We used the anomalous migration of ssDNA fragments to optimize denaturation conditions for capillary electrophoresis. The capillary electrophoretic system uses a refillable polymer that both coats the capillary wall to suppress electro-osmotic flow and acts as the sieving matrix. The addition of 8 M urea to the polymer solution, as in slab gel electrophoresis, is insufficient to fully denature some anomalously migrating ssDNA fragments in this capillary electrophoresis system. The sizing accuracy of these fragments is significantly improved by the addition of 2-pyrrolidinone, or increased capillary temperature (60 degrees C). the effect of these two denaturing strategies is additive, and the best accuracy and precision in sizing results are obtained with a combination of chemical and thermal denaturation.

New energy transfer dyes for DNA sequencing.

We have synthesized a set of four energy transfer dyes and demonstrated their use in automated DNA sequencing. The donor dyes are the 5- or 6-carboxy isomers of 4'-aminomethylfluorescein and the acceptor dyes are a novel set of four 4,7-dichloro-substituted rhodamine dyes which have narrower emission spectra than the standard, unsubstituted rhodamines. A rigid amino acid linker, 4-aminomethylbenzoic acid, was used to separate the dyes. The brightness of each dye in an automated sequencing instrument equipped with a dual line argon ion laser (488 and 514 nm excitation) was 2-2.5 times greater than the standard dye-primers with a 2 times reduction in multicomponent noise. The overall improvement in signal-to-noise was 4- to 5-fold. The utility of the new dye set was demonstrated by sequencing of a BAC DNA with an 80 kb insert. Measurement of the extinction coefficients and the relative quantum yields of the dichlororhodamine components of the energy transfer dyes showed their values were reduced by 20-25% compared with the dichlororhodamine dyes alone.

New dye-labeled terminators for improved DNA sequencing patterns.

We have used two new dye sets for automated dye-labeled terminator DNA sequencing. One set consists of four, 4,7-dichlororhodamine dyes (d-rhodamines). The second set consists of energy-transfer dyes that use the 5-carboxy-d-rhodamine dyes as acceptor dyes and the 5- or 6-carboxy isomers of 4'-aminomethylfluorescein as the donor dye. Both dye sets utilize a new linker between the dye and the nucleotide, and both provide more even peak heights in terminator sequencing than the dye-terminators consisting of unsubstituted rhodamine dyes. The unsubstituted rhodamine terminators produced electropherograms in which weak G peaks are observed after A peaks and occasionally C peaks. The number of weak G peaks has been reduced or eliminated with the new dye terminators. The general improvement in peak evenness improves accuracy for the automated base-calling software. The improved signal-to-noise ratio of the energy-transfer dye-labeled terminators combined with more even peak heights results in successful sequencing of high molecular weight DNA templates such as bacterial artificial chromosome DNA.

Differences in joint mobility and foot pressures between black and white diabetic patients.

Limited joint mobility is common in diabetes and is related to high foot pressures and foot ulceration. We have examined the differences in joint mobility and foot pressures in four groups matched for age, sex, and duration of diabetes: 31 white diabetic, 33 white non-diabetic, 24 black diabetic, and 22 non-diabetic black subjects. Joint mobility was assessed using a goniometer at the fifth metacarpal, first metatarsal, and subtalar joints. In-shoe and without shoes foot pressures were measured using an F-Scan system. Neuropathy was evaluated using clinical symptoms (Neuropathy Symptom Score), signs (Neuropathy Disability Score), and Vibration Perception Threshold. There was no difference between white and black diabetic patients in Neuropathy Symptom Score, Neuropathy Disability Score, and Vibration Perception Threshold. Subtalar joint mobility was significantly reduced in white diabetic patients (22 +/- 7 degrees) compared to white controls (26 +/- 4 degrees, black diabetic patients (25 +/- 5 degrees), and black controls (29 +/- 7 degrees), and increased in black controls compared to white controls and black diabetic patients (level of statistical significance p < 0.05). Without shoes foot pressures were higher in white diabetic patients (8.31 +/- 400 kg cm-2) compared to white controls (6.81 +/- 2.31 kg cma2), black diabetic patients (6.2 +/- 2.53 kg cm-2) and black controls (5.00 +/- 1.24 kg cm-2) and lower in black controls compared to white and black diabetic patients (p < 0.05 in all cases). We conclude that racial differences exist in joint mobility and foot pressures between black and white subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Variability in function measurements of three sensory foot nerves in neuropathic diabetic patients.

We have examined the variability in function measurements of three sensory foot nerves in neuropathic diabetic patients and have compared them to measurements from healthy non-diabetic subjects. Sixty-six healthy, non-diabetic subjects (30 (45%) males, mean age 56 years (range, 21-84 years)) and 61 age and sex matched diabetic patients (33 (54%) males, mean age 55 years (range, 34-78 years) Type 1 diabetes mellitus (DM), mean duration of DM 24 years (range, 2-48 years)) were tested. Current perception threshold (CPT) at 250 Hz was employed to test the sensory function of three nerves: superficial peroneal, sural and posterior tibial. The vibration perception threshold, (VPT) and the cutaneous perception threshold (CCPT) were also assessed at the great toe. According to the results of the neuropathy disability score (NDS), mild neuropathy was present in 8 (13%) patients, moderate in 33 (54%) and severe in 20 (33%). In both groups the CPT of the posterior tibial nerve was higher than the other two nerves (P < 0.0001) while no difference was found between the superficial peroneal and sural nerves (P = NS). CPT was different between the two feet at the superficial peroneal nerve in 39 (64%) diabetic patients and 34 (52%) controls (P = NS), at the sural nerve in 40 (65%) and 45 (68%) (P = NS), and at the posterior tibial in 36 (59%) and 33 (50%), respectively (P = NS). VPT was different by more than 10% at the great toes in 26 (43%) diabetic subjects and CCPT in 21 (34%). We conclude that although there is variation in sensory nerve function tests in diabetic patients this is similar to that noticed in healthy subjects. The great variability of all quantitative sensory testing indicates that more than one site should be tested.

The role of foot surgery in patients with diabetes.

In conclusion, surgery on the diabetic foot should be looked upon as a required addition to quality conservative care. The success that can be gained from proper performance of these procedures can be rewarding and often improves the ability to salvage limbs that may have otherwise been lost because of ulceration, infection, instability, or pain.

Preventing loss of the great toe with the hallux interphalangeal joint arthroplasty.

Chronic ulcerations of the hallux may result in amputation if infection becomes uncontrolled. Salvage of the hallux often requires surgical intervention when conservative measures fail. Many authors have described various procedures to prevent recurrent ulceration and the potential for loss of the great toe. The authors have reviewed their experience with the hallux interphalangeal joint arthroplasty for chronic neuropathic ulcers of the great toe. Between August 1988 and July 1991, the authors performed 46 hallux interphalangeal joint arthroplasties on 40 patients (22 males, 18 females). Of the 40 original patients, one patient was lost to follow-up in the immediate postoperative period, leaving 45 procedures on 39 patients. Thirty-six feet were noted to heal both the procedure and ulceration uneventfully (80%). There were five minor complications (11%). Four cases were deemed failures (9%). Overall, 41 feet (91%) healed and had no evidence of recurrence in the follow-up period. Follow-up was an average of 23.6 months (range 4-44 months). The hallux interphalangeal joint arthroplasty has been a valuable procedure for chronic ulcerations of the hallux. By allowing these ulcers to heal, loss of the great toe has been avoided. Function and structure of the foot has been maintained.

In-shoe foot pressure measurements in diabetic patients with at-risk feet and in healthy subjects.

OBJECTIVE: To measure in-shoe foot pressures in diabetic patients and healthy subjects and compare them with the foot pressures when they walked without their shoes. RESEARCH DESIGN AND METHODS: Forty-four diabetic patients at risk of foot ulceration and 65 healthy subjects were matched for age, sex, race, and weight. Neuropathy was evaluated clinically, and the F-Scan program was used to measure the foot pressures. Foot pressures were measured with the sensors placed in the shoes (S measurements), between the foot and the sock with shoes (H measurements) or with their socks alone (B measurements). RESULTS: In the control group, significant differences were found between S (4.77 +/- 1.87 kg/cm2) and H measurements (5.12 +/- 1.87 kg/cm2, P < 0.001), between S and B (7.23 +/- 2.95 kg/cm2, P < 0.0001), and between H and B (P < 0.0001). In the diabetic group, no difference was found between S and H measurements (5.28 +/- 2.22 vs. 5.27 +/- 2.39 kg/cm2, NS). In contrast, the B pressure was significantly higher when compared with both (8.77 +/- 4.67 kg/cm2, P < 0.02). When compared with the control group, the S and H pressures did not differ significantly, but the B pressure in the diabetic group was significantly higher (P < 0.02). The peak S pressure was above the normal limit in 24 (27%) diabetic and 21 (16%) control feet (P < 0.05), the H pressure in 17 (19%) diabetic feet and 22 (17%) control feet (NS), and the B pressure in 24 (27%) diabetic and 21 (16%) control feet (P < 0.05). CONCLUSIONS: In-shoe foot pressure measurements are significantly lower than the ones measured when walking with the socks only in both diabetic patients and healthy subjects. The shoes of diabetic patients provided a higher pressure reduction than did those of the control group, but the number of feet with abnormally high pressures did not change. The F-Scan system may be particularly helpful in designing footwear suitable for diabetic patients with at-risk feet.

Maximizing foot salvage by a combined approach to foot ischemia and neuropathic ulceration in patients with diabetes. A 5-year experience.

OBJECTIVE: The combination of peripheral neuropathy and arterial insufficiency in patients with diabetes frequently results in chronic non-healing foot ulcers. These patients often have a protracted course that commonly ends in limb amputation. RESEARCH DESIGN AND METHODS: Since 1987, 39 diabetic patients presented with 42 neuropathic ulcerations beneath the lesser metatarsal heads, complicated by severe arterial insufficiency. A variety of vascular reconstructions were performed to improve circulation to the foot. After successful vascular reconstruction, 14 patients with deep ulcers underwent resection of the involved bone or joint through a plantar elliptical incision with excision of the ulcer and primary closure (33%). Five patients required a simultaneous panmetatarsal head resection (12%). For fifteen superficial ulcers, metatarsal osteotomy through a dorsal approach was performed (36%). Eight patients underwent a fifth metatarsal head resection through a dorsal approach (19%). RESULTS: In follow-up of 2-64 months (mean 21.2 months), 35 extremities with patent bypass grafts achieved and maintained primary healing of their local foot procedure (83%). Two feet required subsequent revision but ultimately healed (5%). Three feet (7%) developed a new plantar ulceration adjacent to the original one. In two extremities, the foot remained healed in spite of thrombosis of their grafts (5%). One patient with a thrombosed graft required a below-knee amputation. One patient died before the foot healed with a patent bypass graft. Overall, 40 of 42 extremities (95%) ultimately healed over the course of the follow-up period. CONCLUSIONS: We conclude that complex neuropathic ulcers in diabetic patients can be successfully treated by an aggressive surgical approach that removes infected bone and ulcers and corrects underlying structural abnormalities provided arterial insufficiency is corrected first.

Use of ampicillin/sulbactam versus imipenem/cilastatin in the treatment of limb-threatening foot infections in diabetic patients.

In a double-blind randomized trial, imipenem/cilastatin (I/C; 500 mg every 6 hours) and ampicillin/sulbactam (A/S; 3 g every 6 hours) were compared in regard to their efficacy for initial empirical and definitive parenteral treatment of limb-threatening pedal infection in diabetic patients. The major endpoints of treatment were cure (resolution of soft-tissue infection), failure (inadequate improvement, necessitating a change in antibiotic therapy), and eradication (clearance of all pathogens from the wound and any bone cultures). Patients in the two treatment groups were similar in regard to the severity of diabetes; presence of neuropathy and peripheral vascular disease; site and severity of infection; pathogen isolated; and frequency of osteomyelitis (associated with 68% of the 48 A/S-treated infections and 56% of the 48 I/C-treated infections). After 5 days of empirical treatment, improvement was noted in 94% of the A/S and 98% of the I/C recipients. At the end of definitive treatment (days' duration [mean +/- SD]: 13 +/- 6.5 [A/S], 14.8 +/- 8.6 [I/C]), outcomes were similar: cure, 81% (A/S) vs. 85% (I/C); failure, 17% (A/S) vs. 13% (I/C); and eradication, 67% (A/S) vs. 75% (I/C). Treatment failures were associated with the presence of antibiotic-resistant pathogens and possible nosocomial acquisition of infections. The number of adverse events among patients in the two treatment groups was similar: 7 in the A/S group (4 had diarrhea and 3 had rash) and 9 in the I/C group (5 had diarrhea, 2 had severe nausea, 1 had rash, and 1 had seizure). Efficacy of A/S and I/C is similar for initial empirical and definitive treatment of limb-threatening pedal infection in patients with diabetes.

A historical look at the transmetatarsal amputation and its changing indications.

In March 1949, McKittrick described the use of the transmetatarsal amputation for the diabetic foot, along with specific indications. Infection, ischemia, and neuropathic ulcerations of the toes and forefoot were all treated with this procedure. In the past 30 years, however, advances in the management of these problems have led to a decrease in the number of transmetatarsal amputations performed at the New England Deaconess Hospital. With these advances, the current approach to the transmetatarsal amputation has changed, leading to significant modifications in the basic indications for this procedure.

Panmetatarsal head resection. A viable alternative to the transmetatarsal amputation.

While the transmetatarsal amputation has resulted in the salvage of numerous diabetic limbs, it remains an ablative procedure with both short- and long-term complications. The authors reviewed their experience with the panmetatarsal head resection as an alternative to the transmetatarsal amputation. A retrospective review was performed of all patients having undergone this procedure between May 1986 and November 1991. Thirty-seven procedures were performed; of these, 34 were evaluated. The average follow-up period was 20.9 months. Thirty-two feet showed primary healing while one showed delayed healing. One patient had local recurrence of the original ulceration. Primary healing was 94% while overall success was 97%. No patient required amputation of any kind. The authors conclude that the panmetatarsal head resection is a viable alternative to the transmetatarsal amputation in properly selected patients because it avoids many of the structural and biomechanical pitfalls of the transmetatarsal amputation.