Bypass graft to the midpopliteal artery with a combined anterior and posterior approach.

PURPOSE: The medial supragenicular and infragenicular approaches to the popliteal artery were introduced almost 50 years ago and replaced the posterior approach to the popliteal artery for distal graft implantation. We review a contemporary series of bypass grafts to the midpopliteal artery by use of a combined anterior and posterior approach to evaluate its potential clinical benefits. TECHNIQUE: After the proximal graft anastomosis is constructed, an incision is made in the popliteal fossa to access the midpopliteal artery, the graft is passed into that incision, and all but the popliteal incision is closed. The patient is turned, the midpopliteal artery dissection is completed, and the graft is anastomosed distally. METHODS: Fifty-seven bypass grafts, implanted distally on the midpopliteal artery by this technique over a 13-year period, chosen in preference to an infragenicular bypass graft in selected patients when a supragenicular bypass was not feasible, were assessed in terms of indications for surgery, conduit type, complications, length of postoperative hospitalization, and graft patency. RESULTS: Bypass grafting originated from the axillary artery in two cases, the common iliac artery in one case, and the femoral artery in 54 cases. The procedure was performed in five patients with a popliteal trifurcation anomaly, nine patients with a blind popliteal segment, 20 patients with limited length of autologous vein, and five patients with an above-knee graft infection requiring an alternate path for revascularization. Autologous vein was used in 35 and polytetrafluoroethylene (PTFE) in 19 bypass grafts. Three other patients had a composite sequential femoral-popliteal-tibial bypass graft, with PTFE and autologous vein. Postoperative (30 day) complications include one death (composite sequential), one stroke (PTFE), and one graft thrombosis (saphenous vein). The mean postoperative hospitalization for the last 31 patients was 4.2 +/- 3.7 days. In the autologous vein group, the 1-year primary patency rate was 87%, and the primary assisted patency rate was 94%. In the PTFE group, the 1-year primary patency rate was 72%. Two composite sequential grafts remained patent at 1 year. CONCLUSIONS: Bypass grafting to the midpopliteal artery with a combined anterior and posterior approach offers a safe and effective option to below-knee bypass grafting when an above-knee bypass grafting is not feasible. Compared with the medial infragenicular incision, the posterior incision results in reduced morbidity rates, rapid mobilization, and early hospital discharge.

Delinquency and mortality: A 50-year follow-up study of 1,000 delinquent and nondelinquent boys.

OBJECTIVE: It is well established that until age 40 years, delinquent individuals have roughly twice the mortality of nondelinquent individuals and that the excess deaths are largely due to accidents, violence, and substance abuse. The present study examined if the increased mortality of delinquent subjects continues until age 65 years and, if so, why. METHOD: The authors followed 475 delinquent and 456 matched nondelinquent comparison boys from age 14 years until age 65 years. RESULTS: Thirteen percent (N=62) of the delinquent and only 6% (N=28) of the nondelinquent subjects died unnatural deaths. By age 65 years, 29% (N=139) of the delinquent and 21% (N=95) of the nondelinquent subjects had died from natural causes. In a univariate analysis, frequency of delinquency, abuse of alcohol, adult crime, dysfunctional home environment, and poor education were significantly related to death, especially to unnatural death. However, when delinquency and alcohol abuse were controlled by logistic regression, education, dysfunctional upbringing, and adult criminality made no further contributions to mortality. CONCLUSIONS: Although delinquency is strongly associated with premature mortality, the etiological links remain unclear. Alcohol abuse and poor self-care in adulthood (e.g., infections or accidents) account for most of the modest variance in mortality that could be accounted for.

Dicationic 2-fluorenonylcarbapenems: potent anti-MRS agents with improved solubility and pharmacokinetic properties.

The synthesis and biological evaluation of a series of dicationic-substituted 2-fluorenonylcarbapenems is described. This class of compounds showed enhanced water solubility while maintaining potent activity against MRS. Introduction of a 1-beta-methyl substituent was found to improve pharmacokinetics.

The synthesis and anti-MRSA activity of amidinium-substituted 2-dibenzofuranylcarbapenems.

A series of amidinium-substituted 2-dibenzofuranylcarbapenems with potent activity against MRSA has been synthesized via a Stille cross-coupling reaction. These new carbapenems show reduced serum protein binding and improved in vivo efficacy as a consequence of the positively charged amidinium substituent.

Inhibition of IMP-1 metallo-beta-lactamase and sensitization of IMP-1-producing bacteria by thioester derivatives.

IMP-1 metallo-beta-lactamase is a transferable carbapenem-hydrolyzing enzyme found in some clinical isolates of Pseudomonas aeruginosa, Serratia marcescens and Klebsiella pneumoniae. Bacteria that express IMP-1 show significantly reduced sensitivity to carbapenems and other beta-lactam antibiotics. A series of thioester derivatives has been shown to competitively inhibit purified IMP-1. As substrates for IMP-1, the thioesters yielded thiol hydrolysis products which themselves were reversible competitive inhibitors. The thioesters also increased sensitivity to the carbapenem L-742,728 in an IMP-1-producing laboratory stain of Escherichia coli, but will need further modification to improve their activity in less permeable organisms such as Pseudomonas and Serratia. Nonetheless, the thioester IMP-1 inhibitors offer an encouraging start to overcoming metallo-beta-lactamase-mediated resistance in bacteria.

Synthesis and SAR of thioester and thiol inhibitors of IMP-1 metallo-beta-lactamase.

Potent thioester and thiol inhibitors of IMP-1 metallo-beta-lactamase have been synthesized employing a solid-phase Mitsunobu reaction as the key step.

Urban poverty and the family context of delinquency: a new look at structure and process in a classic study.

This paper reanalyzes data from the Gluecks classic study of 500 delinquents and 500 nondelinquents reared in low-income neighborhoods of central Boston. Based on a general theory of informal social control, we propose a 2-step hypothesis that links structure and process: family poverty inhibits family processes of informal social control, in turn increasing the likelihood of juvenile delinquency. The results support the theory by showing that (1) erratic, threatening, and harsh discipline, (2) low supervision, and (3) weak parent-child attachment mediate the effects of poverty and other structural factors on delinquency. We also address the potential confounding role of parental and childhood disposition. Although difficult children who display early antisocial tendencies do disrupt family management, as do antisocial and unstable parents, mediating processes of informal social control still explain a large share of variance in adolescent delinquency. Overall, the results underscore the indirect effects of structural contexts like family poverty on adolescent delinquency within disadvantaged populations. We note implications for current debates on race, crime, and the "underclass" in urban America.

Violent criminal behavior over the life course: a review of the longitudinal and comparative research.

In this paper we review the existing longitudinal research on violent criminal behavior. Although interested in comparative research on this topic, we found that virtually all of the longitudinal studies comprised individuals from Western societies. The primary issue we examine concerns the extent to which there are universal patterns of violent behavior over the life course. Based on the available evidence, our best guess is that universal patterns do not exist. It cannot be answered definitively, however, to what extent sociocultural variations in violence reflect differences in opportunity structures or differences in developmental trajectories and transitions over the life course. In order to address these issues, specific recommendations for future research, both within countries and cross-nationally, are presented and discussed.

Conventional and delinquent activities: implications for the prevention of violent victimization among adolescents.

While age is one of the most important correlates of an individual's risk of violent victimization, research regarding the victimization of adolescents is relatively meager. Using two well-known national data sources and an analytical framework guided by lifestyle/routine activities theories, we describe the relationships between activity involvement and the risk of assault and robbery victimization among adolescents in the United States. Several findings relevant to victimization prevention emerge. First, we find that certain adolescent activities are related to risk of violence. Youth who engage in delinquent activities experience the highest risk of assault and robbery victimization. Second, we find very few conventional activities which protect adolescents from victimization net of background factors (e.g., gender, race, family structure) or offending levels. We discuss the implications of these findings for programs directed at reducing violent victimization among adolescents and for lifestyle/routine activities theories of victimization.

Failure of pentoxifylline for end-stage peripheral vascular disease.

In this trial of pentoxifylline, 15 patients with end-stage peripheral vascular disease had symptoms severe enough to warrant operation, but surgery was contraindicated because of anatomically noncorrectable disease, serious medical problems, or refusal. Their mean age was sixty-six years. Each patient received oral pentoxifylline, 400 mg tid, for twelve weeks. Pentoxifylline had no measurable clinical benefit in 14 of the patients. In addition, the authors noted an increased incidence of symptomatic coronary artery insufficiency during the trial period that may or may not have been drug related.

Atraumatic extracranial vertebral artery aneurysm: case report and review of the literature.

A case of atherosclerotic aneurysm of the extracranial vertebral artery in a 31-year-old woman is reported. The lesion was excised after distal and proximal ligation of the vessel. Review of the literature showed that atraumatic extracranial vertebral artery aneurysm unrelated to systemic illness is rare. Analysis of the reported cases of such lesions disclosed only one comparable case in a 73-year-old man.