The Body Mass Index as a Measure of Nutritional Status

The measurement and assessment of nutritional status can be challenging, and there is no single test that can provide a complete picture. However, the body mass index (BMI) is a commonly used measurement in clinical practice. The BMI is calculated by dividing a person’s weight in kilograms by their height in meters squared. This measure is used to assess adiposity and nutritional status, and it is simple and quick to calculate and interpret.

Although the BMI is a convenient measure, it has limitations for assessing obesity in individual patients. It is best used to track trends in an individual patient’s BMI over time. In some cases, the BMI may overestimate fat mass in patients who are very tall or have a high proportion of lean tissue due to an active lifestyle. Additionally, the BMI may not be accurate for athletes and children.

Other measurements, such as skin fold thickness and weight, can also be useful, but the BMI is generally considered the better option. The ponderal index is used specifically for children. It is important to note that albumin is not a reliable marker of nutritional status, as it can also be affected by inflammation.

Overall, the BMI is a widely used measure of nutritional status and is recommended by the World Health Organization. However, it is important to consider its limitations and use it in conjunction with other measurements to obtain a more complete picture of a patient’s nutritional status.

The Importance and Risks of Vitamin A

Vitamin A is an essential nutrient that plays a crucial role in various bodily functions such as growth and development, vision, enzyme signalling pathways, and the maintenance of epithelial membranes. However, excessive intake of vitamin A can lead to toxicity, which can cause several adverse effects. These include raised intracranial pressure resulting in headaches, nausea, vomiting, and visual loss, increased bone resorption leading to osteoporosis and hypercalcaemia, liver damage, hair loss, and skin changes. Moreover, there is a possible increased risk of malignancy, particularly among smokers. Pregnant women are also advised to avoid foods rich in vitamin A, such as liver and fish oils, due to the teratogenicity of vitamin A-derived drugs. Therefore, it is crucial to maintain a balanced intake of vitamin A to avoid the risks associated with its toxicity.

Essential Amino Acids and their Importance in the Diet

There are approximately 20 essential amino acids that are crucial for human health. These amino acids are considered essential because the body cannot produce them on its own and they must be obtained through the diet. While some of these essential amino acids can be used to create other non-essential amino acids, they are still necessary for overall health and wellbeing.

Some examples of essential amino acids include histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine. However, the amount of these essential amino acids can vary depending on the type of dietary protein consumed. Additionally, cooking or preserving proteins can alter the amino acid composition, making them less effective for the body.

In summary, essential amino acids play a vital role in maintaining human health and must be obtained through the diet. the importance of these amino acids and their sources can help individuals make informed decisions about their dietary choices.

The Importance of Essential Fatty Acids in the Diet

Essential fatty acids, such as linoleic and alpha-linolenic acids, are crucial components of a healthy diet. Although they are only required in small amounts, they play several important roles in the body. These fatty acids are necessary for the synthesis of phospholipids, which are essential components of cell membranes. They also help regulate cholesterol transport and synthesis, and serve as precursors for omega-3 fatty acids and arachidonic acid. Additionally, essential fatty acids are important for the synthesis of prostaglandins, leukotrienes, and thromboxanes.

A lack of adequate essential fatty acids in the diet can have negative consequences, particularly for brain growth in infancy. It can also lead to alopecia, dermatitis, and fatty liver. Therefore, it is important to ensure that the diet includes sources of these essential fatty acids, such as certain types of fish, nuts, and seeds. By doing so, individuals can support their overall health and well-being.

The Role of the Nucleus and Nuclear Envelope in Cell Function

The nucleus is a crucial component of eukaryotic cells, serving as the control centre for the cell. It is characterised by a membrane-enclosed structure that contains the cell’s chromosomes and is heavily involved in regulating gene transcription and protein synthesis. The nuclear envelope, which consists of an outer and inner membrane, plays a critical role in regulating the movement of molecules in and out of the nucleus. This is achieved through nuclear pores on the surface of the envelope, which allow the passage of water-soluble molecules. While the incorrect answer options describe minor roles of the nuclear envelope, its primary function is to act as a regulatory barrier for anything that enters or exits the nucleus. Overall, the nucleus and nuclear envelope are essential components of cell function, playing a critical role in regulating gene expression and maintaining cellular homeostasis.

The Structure and Functions of Proteins

Proteins are complex molecules that can vary in structure from single amino acids to large, folded molecules. Amino acids are joined together by peptide bonds to form dipeptides and polypeptides. More complex molecules can also have disulphide bonds and ionic bonds. The primary structure of a protein is a simple amino acid chain, while the secondary structure is a specific shape such as a helix or pleated sheet. The tertiary structure is a more globular shape, arranged by ionic, hydrogen, and disulphide bonds, and hydrophobic interactions. The quaternary structure is a complex protein containing several polypeptide chains held together by interactions.

Proteins have multiple roles within the human body, including as hormones, food substrates, enzymes, receptor molecules, muscles, cell membrane constituents, carrier molecules in blood, and determinants of oncotic/osmotic pressures. However, proteins can be easily damaged by denaturation, which is the loss of the specific three-dimensional shape of a molecule. Denaturation can be caused by heat, salts, heavy metals, solvents, detergents, and extremes of pH.

In summary, proteins are essential molecules with a diverse range of structures and functions within the human body. their structure and potential for denaturation is crucial for maintaining their proper function.

Sources of Vitamin D

Vitamin D is a type of fat-soluble vitamin that can be found in certain foods such as cheese, butter, eggs, and oily fish. However, vegetable sources of vitamin D are limited, although some foods are fortified with this vitamin. For instance, 100 grams of sundried shiitake mushrooms contain 1600 IU of vitamin D, while one egg contains 20 IU. Wild salmon is also a good source of vitamin D, with 100 grams containing 800 IU, while farmed salmon contains 200 IU.

Aside from food sources, sunlight is also a good source of vitamin D. Exposure of arms and legs to sunlight for 10-15 minutes can provide 3000 IU of vitamin D. However, it is difficult to obtain the daily requirement of 25-50 IU of vitamin D through sunlight alone, especially for people living in temperate climates. As a result, many people may have insufficient vitamin D levels. It is important to ensure that we get enough vitamin D through a combination of food sources and sunlight exposure.

The Relationship between Alveolar Size and Surface Tension in Respiratory Physiology

In respiratory physiology, the alveolus is often represented as a perfect sphere to apply Laplace’s law. According to this law, there is an inverse relationship between the size of the alveolus and the surface tension. This means that smaller alveoli experience greater force than larger alveoli for a given surface tension, causing them to collapse first. This phenomenon is similar to what happens when two balloons of different sizes are attached together, with the smaller balloon emptying into the larger one.

In the lungs, this collapse of smaller alveoli can lead to atelectasis and collapse if surfactant is not present. Surfactant is a substance that reduces surface tension, making it easier to expand the alveoli and preventing smaller alveoli from collapsing. this relationship between alveolar size and surface tension is crucial in respiratory physiology, as it helps explain the importance of surfactant in maintaining proper lung function.

The Relationship between Alveolar Size and Surface Tension in Respiratory Physiology

In respiratory physiology, the alveolus is often represented as a perfect sphere to apply Laplace’s law. According to this law, there is an inverse relationship between the size of the alveolus and the surface tension. This means that smaller alveoli experience greater force than larger alveoli for a given surface tension, and they will collapse first. This phenomenon explains why, when two balloons are attached together by their ends, the smaller balloon will empty into the bigger balloon.

In the lungs, this same principle applies to lung units, causing atelectasis and collapse when surfactant is not present. Surfactant is a substance that reduces surface tension, making it easier to expand the alveoli and preventing smaller alveoli from collapsing. Therefore, surfactant plays a crucial role in maintaining the proper functioning of the lungs and preventing respiratory distress. the relationship between alveolar size and surface tension is essential in respiratory physiology and can help in the development of treatments for lung diseases.

Microtubules and Chédiak-Higashi Syndrome

Microtubules are made up of alpha and beta tubulin dimers that are arranged in a helix and can be added or removed to change the length. They are found in structures such as flagella, mitotic spindles, and cilia, where they have a 9+2 arrangement. These structures are important for cell movement and division. Chemotherapy agents, such as taxanes, target microtubules and are used in breast cancer treatment.

Chédiak-Higashi syndrome is a rare inherited immunodeficiency disorder caused by mutations in the LYST gene. This condition is characterized by neutrophil inclusions, albinism, recurrent infections, and peripheral neuropathy. The neutrophil inclusions are thought to be caused by abnormal microtubule function, which affects the immune system’s ability to fight infections. While there is no cure for Chédiak-Higashi syndrome, treatment focuses on managing symptoms and preventing infections.

Homologous Recombination: A Mechanism for DNA Repair and Genetic Variation

Homologous recombination is a process that allows for the exchange of nucleotide sequences between two similar or identical DNA molecules. This occurs during meiosis, specifically during the second phase of prophase I, where sister chromatids swap sequences. The primary purpose of homologous recombination is to accurately repair harmful double-strand DNA breaks. This process results in new combinations of DNA sequences that provide genetic variation in daughter cells and, ultimately, the organism’s offspring.

In prokaryotic organisms such as bacteria and viruses, homologous recombination occurs during horizontal gene transfer. This process involves the exchange of genetic material between different strains and species. Homologous recombination plays a crucial role in the evolution of these organisms by allowing for the acquisition of new traits and adaptations.

Overall, homologous recombination is a vital mechanism for DNA repair and genetic variation. It ensures the accuracy of DNA replication and contributes to the diversity of life on Earth.

Mesenchymal Cells: The Stem Cells of the Human Skeleton

Mesenchymal cells are the primary stem cells of the human skeleton. These multipotent cells originate in the bone marrow and have the ability to differentiate into various cell types. Osteoblasts, responsible for bone formation, chondrocytes, which give rise to cartilage, and adipocytes, specialized in storing energy as fat, are some of the cells that mesenchymal cells can produce. Muscle cells, or myocytes, arise from muscle satellite cells, while skin cells come from epithelial stem cells. Neurons mostly arise from neural stem cells, although some may come from astrocytes. White blood cells, on the other hand, come from hematopoietic stem cells. Mesenchymal cells play a crucial role in the maintenance and repair of the human skeleton, making them an essential area of study in regenerative medicine.

The Five Phases of the Cell Cycle

The cell cycle is a complex process that is divided into five main phases, each with its unique cellular events. The first phase is the G0 phase, which is a resting phase where the cell has stopped dividing and is out of the cell cycle. The second phase is the G1 phase, also known as interphase Gap 1, where cells increase in size, and a checkpoint control mechanism prepares the cell for DNA synthesis.

The third phase is the S phase, where DNA replication occurs. The fourth phase is the G2 phase, also known as Gap 2, which is a gap between DNA synthesis and the onset of mitosis. During this phase, the cell continues to grow until it is ready to enter mitosis. Finally, the fifth phase is the M phase, also known as mitosis, where cell growth stops, and the cell focuses its energy to divide into two daughter cells.

A checkpoint in the middle of mitosis, known as the metaphase checkpoint, ensures that the cell is prepared to complete division. the five phases of the cell cycle is crucial in how cells divide and grow.

Techniques in Biochemistry

Over-the-counter urine pregnancy tests use ELISA to detect beta-HCG in a woman’s urine. The test stick contains antibodies that react with beta-HCG, producing a color change that confirms pregnancy. The urinary pregnancy test is a solid-phase ELISA, where the antibody is immobilized on a specialized filter paper. The fluid travels laterally across the paper to bind with the antibody, and if beta-HCG is present, the line turns blue. Electrophoresis characterizes the electrical charge and size of substances, while PCR identifies specific sequences of DNA or RNA. Radioimmunoassay uses radioactivity to identify specific proteins. Enzymatic degradation breaks down large proteins into smaller subunits for which target antibodies may already exist. This method is used to characterize large proteins for which the structure has not yet been described.

The Stages of Prophase in Eukaryotic Mitosis

Prophase is the first stage of eukaryotic mitosis, except for plant cells which have a preprophase stage. During prophase, the cell’s chromatin, which is made up of DNA and associated proteins, condenses into double rod-shaped structures called chromosomes. This process is facilitated by the condensin protein I and/or II complexes. As the chromosomes form, the nuclear membrane and nucleoli disintegrate and disappear, making the chromatin visible.

Before prophase, the cell’s DNA is replicated during interphase, resulting in identical pairs of chromosomes called chromatids. These chromatids attach to each other at a DNA element called the centromere. DNA and centrosome duplication occur during interphase, while chromosome alignment takes place during metaphase. The nuclear membrane and nucleoli re-form during telophase, and the sister chromatids separate during anaphase.

In summary, prophase is the initial stage of eukaryotic mitosis where chromatin condenses into chromosomes, and the nuclear membrane and nucleoli disappear. Chromosome alignment, DNA and centrosome duplication, and re-formation of the nuclear membrane and nucleoli occur in subsequent stages.

Thiamine: Its Roles, Sources, Deficiency States, and Manifestations

Thiamine is a vital nutrient that plays several roles in the body. It acts as a cofactor to enzymes involved in energy production, metabolism of branched chain amino acids, and regulation of nerve and muscle action potentials. It is found in many foods, including wheat, oats, and yeast-containing products. However, deficiency states can occur in chronic alcohol dependence, renal dialysis, and cultures that mainly consume white rice. The deficiency can manifest as ‘dry’ beriberi, which causes peripheral neuropathy, muscle weakness, fatigue, and reduced concentration, or ‘wet’ beriberi, which also involves heart failure and edema. In severe cases, Wernicke-Korsakoff syndrome can develop, which is an emergency requiring urgent IV replacement of thiamine. If left untreated, it can lead to irreversible amnesia, confabulation, and dementia. Therefore, all patients with alcohol-related admissions should be considered for Pabrinex, a B vitamin infusion.

The Importance of Pyridoxine in the Body

Pyridoxine is a group of B-vitamins that are crucial in various bodily functions. They act as essential cofactors in many reactions, particularly in the metabolism of amino acids and neurotransmitters. Pyridoxine also plays a role in regulating gene transcription and controlling steroid hormones.

The body can produce pyridoxine through bacterial flora in the gut, and it is also present in many dietary sources. However, overheating certain foods can destroy pyridoxine, and some medications can alter its metabolism. Pyridoxine is also used therapeutically to prevent neuropathy in the treatment of tuberculosis.

Deficiency in pyridoxine can lead to sensory neuropathy, skin changes, and damage to mucous membranes. On the other hand, deficiency in vitamin C can cause gingivitis and increased bleeding, while vitamin K deficiency can also lead to bleeding. Sleep disturbance is rarely attributed to vitamin B3 (niacin) deficiency.

In summary, pyridoxine is a vital nutrient that plays a crucial role in various bodily functions. Its deficiency can lead to various health problems, highlighting the importance of maintaining adequate levels of this vitamin in the body.

The Roles of Vitamin K in the Body

Vitamin K plays several important roles in the body. One of its main functions is to modify clotting factors II, VII, IX, and X through a process called carboxylation. This modification allows calcium to bind to the factors, which is necessary for them to participate in the clotting pathway. This principle is used in full blood counts to prevent clotting by adding EDTA, which chelates the calcium. Vitamin K also modifies osteocalcin and matrix proteins in bone, as well as nephrocalcin in the kidney, in a similar way.

In addition to its role in blood clotting and bone health, vitamin K is also important for nervous tissue development and growth. However, vitamin K antagonists such as warfarin are sometimes used as anticoagulants to prevent blood clots. It is important to follow guidelines and instructions carefully when using these medications. Overall, vitamin K plays a crucial role in maintaining the health and function of various systems in the body.

Carbohydrates: Building Blocks of Energy and Storage

Carbohydrates are organic compounds made up of carbon, hydrogen, and oxygen, with a general formula of Cx(H2O)y. They can be classified as either aldehydes or ketones and contain multiple hydroxyl groups. Monosaccharides are the simplest form of carbohydrates, consisting of a single unit. They are categorized based on the number of carbon atoms they contain, with trioses having three, pentoses having five, and hexoses having six carbon atoms. These monosaccharides are essential for energy production and building larger carbohydrate structures.

Disaccharides are formed when two monosaccharides are joined together through a condensation reaction, releasing a water molecule. The most common disaccharides are lactose, maltose, and sucrose. Polysaccharides, on the other hand, are long, branched polymers made up of multiple single units. They serve as convenient storage molecules for energy reserves, such as glycogen in humans and starch in plants.

In summary, carbohydrates are vital building blocks for energy production and storage in living organisms. Monosaccharides, disaccharides, and polysaccharides all play important roles in maintaining the body’s energy balance and overall health.

How MRI Scanners Use Hydrogen Ions to Create Images

MRI scanners use the magnetic properties of hydrogen ions, also known as protons, to create images of the human body. These protons have nuclear spin, which means they have magnetic vectors that can be aligned in an electromagnet. The scanner bombards the protons with radiofrequency radiation, causing them to release energy when they return to their resting state. This energy release is recorded and used to construct the MRI image.

While other nuclei, such as carbon 13, also have net nuclear spin and could be used in MRI imaging, hydrogen ions are much more abundant in human tissues. This makes them the preferred choice for creating images of the body. By using the magnetic properties of hydrogen ions, MRI scanners can create detailed images of internal structures without the use of harmful radiation.

Malnutrition

Malnutrition refers to a state where the dietary intake is insufficient to maintain a healthy state and stable weight. It can be caused by over- or under-nutrition, but it is commonly used to describe under-nutrition. Malnutrition can be defined as a state of nutrition where a deficiency, excess, or imbalance of energy, protein, and other nutrients causes measurable adverse effects on tissue, function, and clinical outcome. Protein malnutrition is the most severe form of malnutrition, causing significant mortality and clinical effects such as kwashiorkor. Carbohydrate malnutrition is less common as carbohydrate sources are widely grown and cheap. Fat malnutrition rarely results in problems if there is adequate dietary protein and carbohydrate. Deficiencies of fat-soluble vitamins can result in various clinical effects. Body size can give some indication of nutritional status, but many obese patients may have nutritional deficiencies due to their faddy diets.

Diffusion and Fick’s Law

Diffusion is a natural process that occurs when molecules move from an area of high concentration to an area of low concentration. This process is passive and random, meaning that it does not require any external energy input. Fick’s Law states that diffusion occurs more quickly across a large, permeable, and thin membrane. For example, in lung disease, the thickening of the alveolar epithelial barrier can lead to a poor carbon monoxide transfer coefficient because the thicker membrane slows down the diffusion process. the principles of diffusion and Fick’s Law can help us better understand how molecules move and interact in various biological and chemical processes. By optimizing the conditions for diffusion, we can improve the efficiency of many natural and artificial systems.

Lysosomes: The Digestive System of the Cell

Lysosomes are organelles that come from the Golgi apparatus and are enclosed by a membrane. They are responsible for breaking down various biological macromolecules such as proteins, nucleic acids, carbohydrates, and lipids. Lysosomes contain acid hydrolases, which are enzymes that cleave chemical bonds by adding water and function at an acidic pH of around 5. They are involved in digesting foreign agents that are internalized by the cell and breaking down other cellular organelles like mitochondria, allowing for their components to be recycled.

The acidic pH within lysosomes is maintained by a proton pump in the lysosomal membrane, which imports protons from the cytosol coupled to ATP hydrolysis. This acidic environment is necessary for the activity of the acid hydrolases. D-amino acid oxidases and peroxidases are not found in lysosomes but in peroxisomes. Alcohol dehydrogenases and ATPases are not involved in digestion but in other cellular functions. Alcohol dehydrogenases catalyze the interconversion between alcohols and aldehydes or ketones with the reduction of NAD+ to NADH, while ATPases catalyze the breakdown of ATP into ADP and a phosphate ion, releasing energy for the cell’s functions.

The Function and Structure of the Mammalian Cell Membrane

The mammalian cell membrane serves as a protective barrier that separates the cytoplasm from the extracellular environment. It also acts as a filter for molecules that move across it. Unlike plant and prokaryotic cells, mammalian cells do not have a cell wall. The main component of the cell membrane is a bilayer of amphipathic lipids, which have a hydrophilic head and a hydrophobic tail. The phospholipids in the bilayer are oriented with their hydrophilic heads facing outward and their hydrophobic tails facing inward. This arrangement allows for the separation of the watery extracellular environment from the watery intracellular compartment.

It is important to note that the cell membrane is not a monolayer and the phospholipids are not linked head-to-tail. This is in contrast to DNA, which has a helical chain formation. Overall, the structure and function of the mammalian cell membrane are crucial for maintaining the integrity and proper functioning of the cell.

Glycolysis: The Energy-Producing Reaction

Glycolysis is a crucial energy-producing reaction that converts glucose into pyruvate while releasing energy to create ATP and NADH+. It is one of the three major carbohydrate reactions, along with the citric acid cycle and the electron transport chain. The reaction involves ten enzymatic steps that provide entry points to glycolysis, allowing for a variety of starting points. The most common starting point is glucose or glycogen, which produces glucose-6-phosphate.

Glycolysis occurs in two phases: the preparatory (or investment) phase and the pay-off phase. In the preparatory phase, ATP is consumed to start the reaction, while in the pay-off phase, ATP is produced. Glycolysis can be either aerobic or anaerobic, but it does not require nor consume oxygen.

Although other molecules are involved in glycolysis at some stage, none of them form its end product. Lactic acid is associated with anaerobic glycolysis. glycolysis is essential for how the body produces energy from carbohydrates.

Lipid Metabolism and Transport in the Body

The breakdown of triglycerides in the small intestine is facilitated by pancreatic lipase. These triglycerides are then transported to the liver and other parts of the body through chylomicrons.

Very low-density lipoprotein (VLDL) is responsible for carrying triglycerides from the liver to peripheral tissues. When there is an overproduction of VLDL in the liver, it can lead to high levels of triglycerides in the body.

Pure hypercholesterolaemia is a condition that arises due to a defect in the process of cholesterol uptake into cells. This process relies on apolipoprotein B-100 binding to LDL receptors and facilitating endocytosis. When this process is disrupted, it can lead to high levels of cholesterol in the body.

Vitamin E and its Functions

Several substances are classified as vitamin E, with alpha-tocopherol being the most common, accounting for 90% of human vitamin E. Alpha-tocopherol is composed of two carbon rings and a long saturated hydrocarbon chain, making it hydrophobic. It has an aromatic ring with an OH- group attached to it. Other substances with vitamin E activity include other tocopherols and tocotrienols, all of which act as antioxidants. Alpha-tocopherol is particularly important in cell membranes, preventing the peroxidation of unsaturated fatty acids by free radicals. It also has other functions, such as regulating gene transcription, inhibiting clotting formation, reducing proliferation of vascular smooth muscle, and playing a role in immunity.

Despite claims that taking vitamin E can reduce the risk of heart disease, cancer, and enhance sexual performance, there is currently no strong evidence to support these claims.

Cellular Processes and Organelles

Metabolic processes in the cell occur in specific locations. Acetyl-CoA production and the Krebs cycle take place in the mitochondrium, while glycolysis occurs in the cytoplasm. The nucleus is the central structure of the cell that contains DNA and is double membrane-bound. The rough endoplasmic reticulum is responsible for packaging and transporting proteins, while the smooth endoplasmic reticulum performs a similar function but lacks ribosomes.

It is important to understand where these processes occur in the cell to better understand their functions and how they contribute to the overall functioning of the cell. The mitochondrium is responsible for producing energy in the form of ATP, while the cytoplasm is where glucose is broken down during glycolysis. The nucleus is where genetic information is stored and replicated, and the endoplasmic reticulum is involved in protein synthesis and transport.

In summary, the cell is a complex system with various organelles that perform specific functions. where these processes occur in the cell is crucial to how they contribute to the overall functioning of the cell.

Chromosome Division during Anaphase

Chromosomes are joined together in an X shape at the centromere. During anaphase, the centromeres break down and the chromosomes divide into two identical pairs called sister chromatids. These sister chromatids then move to opposite sides of the cell along a network of spindle fibres. When the cell divides during telophase, each daughter cell receives one sister chromatid from the parent cell. This ensures the accurate copying and propagation of genes. The process of chromosome division during anaphase is crucial for the proper distribution of genetic material in cells.

Assessing Varicose Vein Site of Incompetence

The Trendelenburg and tourniquet tests are both used to evaluate the site of incompetence in varicose veins at the sapheno-femoral junction. During the Trendelenburg test, the examiner applies pressure with their fingers over the junction site, while in the tourniquet test, a tourniquet is placed just below the junction level.

If the veins fill quickly upon standing, it indicates that the sapheno-femoral junction is not the source of the incompetence. These tests are essential in determining the location of the varicose vein site of incompetence, which is crucial in planning the appropriate treatment. By identifying the site of incompetence, physicians can perform targeted interventions to improve venous function and alleviate symptoms. Therefore, the Trendelenburg and tourniquet tests are valuable tools in the diagnosis and management of varicose veins.