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PubMed1982

[Choice of time for the definitive treatment of injuries of the extremities in persons with multiple injuries].

There are still gradually and even fundamentally different opinions about the most favorable moment for the definitive treatment of lesions of extremities in persons with multiple injuries. The immediate definitive treatment or primary treatment within the first 24 to 48 hours is opposed to a therapy method applying a graduated definitive treatment of the lesions of extremities taking into consideration the individual extent of the injury. During the period from January 1st, 1975 to December 31st, 1979, 321 persons with multiple injuries of degrees 2 and 3 have been treated at the Hospital for Accident Surgery of the University of Frankfurt/Main. 290 fractures were treated in 225 surviving persons with lesions of the extremities. Among 136 fractures of the lower extremities, 118 were operated upon--44 of them immediately and 74 until the end of the fourth week. All femur fractures in surviving persons with multiple injuries were surgically stabilized, with the exception of several cases of isolated fractures of the shank diaphysis who received conservative treatment. Although we consider an early surgical treatment of femur fractures in persons with multiple injuries as the most favorable basis for a continuous and uninterrupted recovery, which we also strive for, the experiences made by us hitherto do not demand a general indication of immediate surgical treatment (within the first 24 hours) of closed femur fractures in persons with multiple injuries. We shall continue to apply a graduated therapy method, considering each individual case, for final treatment of fractures of extremities in persons with multiple injuries.

Adolescent↗
PubMed1998

Effective treatment of lymphedema of the extremities.

OBJECTIVE: To define the immediate and long-term volumetric reduction following complete decongestive physiotherapy (CDP) for lymphedema. DESIGN: Prospective study of consecutively treated patients. SETTING: Freestanding outpatient referral centers. PATIENTS: Two hundred ninety-nine patients referred for evaluation of lymphedema of the upper (2% primary, 98% secondary) or lower (61.3% primary, 38.7% secondary) extremities were treated with CDP for an average duration of 15.7 days. Lymphedema reduction was measured following completion of treatment and at 6- and 12-month follow-up visits. INTERVENTION: Complete decongestive physiotherapy is a 2-phase noninvasive therapeutic regimen. The first phase consists of manual lymphatic massage, multilayered inelastic compression bandaging, remedial exercises, and meticulous skin care. Phase 2 focuses on self-care by means of daytime elastic sleeve or stocking compression, nocturnal wrapping, and continued exercises. MAIN OUTCOME MEASURES: Average limb volumes in milliliters were calculated prior to treatment, at the end of phase 1, and at 6- to 12-month intervals during phase 2 to assess percent volume reduction. RESULTS: Lymphedema reduction averaged 59.1% after upper-extremity CDP and 67.7% after lower-extremity treatment. With an average follow-up of 9 months, this improvement was maintained in compliant patients (86%) at 90% of the initial reduction for upper extremities and lower extremities. Noncompliant patients lost a part (33%) of their initial reduction. The incidence of infections decreased from 1.10 infections per patient per year to 0.65 infections per patient per year after a complete course of CDP. CONCLUSIONS: Complete decongestive physiotherapy is a highly effective treatment for both primary and secondary lymphedema. The initial reductions in volume achieved are maintained in the majority of the treated patients. These patients typically report a significant recovery from their previous cosmetic and functional impairments, and also from the psychosocial limitations they experienced from a physical stigma they felt was often trivialized by the medical and payor communities.

Bandages↗
PubMed1990

Prognosis of thick cutaneous melanoma of the trunk and extremity.

The records of 129 patients with thick cutaneous melanoma of the trunk or extremity treated at Memorial Sloan-Kettering Cancer Center, New York, NY, between 1974 and 1984 were reviewed with the aim of defining prognostic variables. All primary lesions invaded subcutaneous fat, were Clark level V, or of a Breslow thickness of 4.0 mm or greater. Treatment in all cases was by wide excision with or without split-thickness skin graft; all patients underwent regional lymph node dissection. Overall survival rate for the group was 47% at 5 years and 36% at 10 years. Factors independently predictive of survival were pathologic negative nodes (71% at 5 years compared with 28% for pathologic positive nodes) and extremity site (58% at 5 years compared with 33% for truncal site). Patients with node-negative thick cutaneous melanoma of the extremity had a 5-year survival rate of 82%. Patients with node-positive truncal thick cutaneous melanoma had a 5-year survival rate of only 8%. There was no difference between the 5-year survival rate of patients with node-negative truncal thick cutaneous melanoma, 52%, and patients with node-positive thick cutaneous melanoma of the extremity, 42%. Nearly half of the patients with thick cutaneous melanoma of the extremity and trunk present with locoregional disease, at a stage when an aggressive surgical approach is warranted. Prognostic variables of pathologic nodal status and site identify patients at risk for early systemic failure.

Age Factors↗
PubMed1996

Risk factors for lower extremity arterial disease in non-insulin-dependent diabetic persons.

The relationship of lower extremity arterial disease to the different risk factors for atherosclerosis in non-insulin-dependent (Type 2) diabetes mellitus is a matter of continuing investigation. The present study was conducted on a random sample of 193 non-insulin-dependent diabetic patients in order to compare the frequency and severity of some known risk factors for atherosclerosis among such persons with and without indications of lower extremity arterial disease. Conventional risk factors for atherosclerosis (smoking, existence of hypertension, total plasma cholesterol, HDL-cholesterol, and triglycerides) were assessed. In addition body mass index, waist-to-hip ratio, body fat mass, and albumin excretion were determined. Criteria for the presence of lower extremity arterial disease were an ankle brachial pressure index < 0.89 and/or the existence of intermittent claudication. Age, length of diabetes, and waist-to-hip ratio appeared to be factors significantly related to lower extremity arterial disease in most cases. Blood lipids, body mass index, HbA1 (except in males), smoking, and type of antidiabetic treatment were not significantly related to disease. The multivariate analysis confirmed the significant contribution of the duration of diabetes (p = 0.002), and waist-to-hip ratio (p = 0.024) and further showed a significant relation with triglycerides (p = 0.020). Thus, lower extremity arterial disease in non-insulin-dependent diabetes mellitus is significantly related to a long duration of diabetes and to central body fat distribution (but not to body mass index), as well as to triglyceride levels.

Aged↗
PubMed2000

Reliability of physical examination of the upper extremity among keyboard operators.

BACKGROUND: Physical examination is a traditional outcome measure in epidemiological research. Its value as a reliable measure depends, in part, on the prevalence of positive findings. The purpose of this paper is to determine the empirical reliability of physical examination and anthropometry in a field study of upper extremity disorders among keyboard operators. METHODS: Two experienced examiners independently performed common provocative tests and procedures in physical examinations of the neck and upper extremity among 160 keyboard operators. Two additional examiners conducted anthropometric surveys among 137 workers. Inter-examiner reliability was assessed with observed agreement, kappa statistics, and intra-class correlations (ICC). RESULTS: Observed agreement was between 96% and 100% for neck and upper extremity signs, muscle stretch reflexes, and muscle strength, however, with the exception of provocative tests, reliability statistics were unstable. Among the provocative tests, Phalen and Tinel tests had modest agreement after adjusting for chance (kappa range: 0.20-0.43). The carpal compression test had the best reliability (kappa=0.60 and kappa=0.67, left and right side, respectively). The ICCs for anthropometry ranged from 0.36-0.91. CONCLUSIONS: Results from the study showed that statistically, except for the carpal compression test, physical examination contributed minimal reliable information. This was attributed mainly to the low prevalence of positive findings, and generally mild nature of upper extremity disorders in this population. The results are the best estimate of what would be found in a field study with experienced examiners. While it may reduce bias, separating physical examination from medical history may contribute to the poor reliability of findings. With a shift toward reliable measures, resources can be allocated to more effective tools, like questionnaires, in epidemiological research of upper extremity disorders among keyboard operators.

Adult↗
PubMed2000

Fibromatoses of the extremities: clinicopathologic study of 36 cases.

BACKGROUND AND OBJECTIVES: Fibromatoses of the extremities are rare and often recalcitrant to treatment. We evaluated the clinical and pathologic features of a group of extremity fibromatoses treated by surgical excision with or without adjuvant therapy to determine if any clinical or pathologic parameters were predictive of clinical outcome. METHODS: Thirty-six extremity fibromatoses were evaluated. A number of clinical and histologic features were correlated with risk of local recurrence. RESULTS: The cohort included 19 females and 17 males with ages ranging from 11-72 years (mean: 35 years), with 12 tumors of the upper and 24 tumors of the lower extremity. Tumors ranged in size from 1.5-15.5 cm (mean: 7.5 cm).Histologically, 26 were infiltrative, 3 had pushing borders and 7 had both. Mitotic counts ranged from 0-5/50 high-power fields (mean: 0.74). Surgical margins were positive in 22 cases. Seventeen patients were treated with postoperative adjuvant therapy including radiation therapy and tamoxifen. Follow-up information was available in 34 cases (from 1-202 months; mean: 83 months). Nineteen patients (56%) had recurrences, including 11 with multiple recurrences (range to first recurrence: 5-61 months; mean 23 months). Seventy-one percent of patients with a positive surgical margin and clinical follow-up had a local recurrence, compared to 31%with a negative surgical margin (P < 0.05). None of the other clinical or histologic parameters correlated with the risk for local recurrence. CONCLUSIONS: Local control in fibromatoses of the extremities remains problematic. Aside from positive surgical margins, none of the other clinical or histologic parameters evaluated in this study were useful in predicting the risk of local recurrence.

Adolescent↗
PubMed2002

Familial correlates of extreme weight control behaviors among adolescents.

OBJECTIVE: To identify familial factors associated with extreme weight control among adolescents. METHOD: Analysis of a comprehensive 1996 health survey of Connecticut students. Familial factors among extreme dieters who deliberately vomited, took diet pills, laxatives, or diuretics were compared with youth reporting none of these behaviors, using logistic regression controlling for age and body mass index. RESULTS: Nearly 7% of adolescents reported engaging in extreme weight control behaviors. Boys' risk factors included high parental supervision/monitoring and sexual abuse history. Protective factors included high parental expectations, maternal presence, and connectedness with friends and other adults. The only significant risk factor for girls was sexual abuse history. Protective factors included family connectedness, positive family communication, parental supervision/monitoring, and maternal presence. CONCLUSIONS: Extreme dieting appears to be less an expression of body composition than of psychosocial issues. That connectedness to family, other adults, and friends is protective further demonstrates interrelationships of extreme weight control behaviors with family/social issues.

Adolescent↗
PubMed1995

Upper extremity bone mass and osteoarthritis of the knees: data from the Baltimore Longitudinal Study of Aging.

To examine the association of upper extremity bone mass with osteoarthritis (OA) of the knee, bilateral standing knee radiographs, taken between 1985 and 1991, in 430 Caucasian male and 266 Caucasian female subjects aged 40 years and above in the Baltimore Longitudinal Study of Aging, were read by one investigator for grade of OA using Kellgren-Lawrence scales. Several measures of upper extremity bone mass, size, and density, including combined cortical thickness (CCT), total width and percentage of cortical area of the second metacarpal, and bone mineral content (BMC), width, and density of the distal third of the left radius measured with single photon absorptiometry, were assessed at the same visit. In univariate analyses, men and women with definite knee OA were significantly older, men had significantly greater radial width, and women had significantly lower bone mass as measured by both CCT and BMC. After adjustment for age and body weight, however, men with knee OA had significantly higher BMC and radial width while neither of these measures of upper extremity bone mass and size was significantly associated with the presence of definite knee OA in women. Neither measure of upper extremity bone density was significantly associated with definite knee OA in either sex. These data suggest that, although men (but not women) with definite knee OA have significantly higher levels of adjusted radial bone mass and size, subjects with knee OA do not have significantly higher levels of adjusted bone mineral density at either upper extremity site.

Adult↗
PubMed1995

Anorexia nervosa viewed as an extreme weight condition: genetic implications.

In anorexia nervosa, psychopathological features and reduced body weight are inseparable, suggesting a prominent role of behavioral factors in achievement and maintenance of extreme underweight. Due to the considerably higher prevalence of this eating disorder in females, anorexia nervosa contributes to the left end of the distribution of the body mass index, especially in the female sex. By reviewing the relevant literature we examined whether genetic research in anorexia nervosa can profit from considering this disorder as an extreme weight condition. For this purpose we compared genetic studies pertaining to both anorexia nervosa and the heritability of the body mass index. Whereas previous genetic studies in anorexia nervosa have mostly concentrated on the assessment of the familial psychopathology, further studies are warranted that additionally attempt to analyze the complex phenotype body weight in relatives of affected probands. Further insight into pathogenetic mechanisms underlying anorexia nervosa might be gained by contrasting the epidemiological, psychopathological and prognostic factors with those in severe obesity. Thus, epidemiological studies suggest that females are more likely to develop both extreme underweight and extreme obesity. A possible explanation for this phenomenon is that the, on average, higher percentage of total body weight composed of fat mass might predispose females towards the development of both extreme weight conditions.

Anorexia Nervosa↗
PubMed1978

A new surgical approach to extensive arterial occlusion of lower extremity--femoro-popliteal open endarterectomy with arteriovenous shunt.

A revascularized surgery for extensive arterial occlusive lesions of the lower extremities, namely open endarterectomy of the occluded femoro-popliteal artery with arteriovenous shunt, was devised. The procedure is specially indicated to the extensive arterial occlusion of the lower extremity for which the conventional reconstructive vascular surgery is not applicable. The patency of the reconstructed femoro-popliteal arteries are ensured by virture of an arteriovenous shunt and newly developed collaterals from the reopened genicular network is expected to provide effective blood flow to peripheral parts. From 1967 to 1975, this procedure was applied to 59 extremities in 53 patients, all of whom had extensive arterial occlusion from the femoral artery to the periphery with impending ulcer and severe rest pain. Fourty-five out of 59 extremities had remarkable improvement of the ischemic symptoms and signs at the time of discharge. Long-term effectiveness was shown in 34 out of 59 extremities or 58 per cent.

Arterial Occlusive Diseases↗
PubMed2005

[Crossing borders. The motivation of extreme sportsmen].

In his article "Crossing borders -- the motivation of extreme sportsmen" the author gets systematically to the bottom of the question of why extreme sportsmen voluntarily take risks and endanger themselves. Within the scope of a representative sampling 217 extreme sportsmen -- from the fields of mountain biking, trekking and free climbing, canoyning, river rafting and deep sea diving, paragliding, parachuting, bungee jumping and survival training -- give information about their personal motives. What fascinates them? The attraction of risk? The search for sensation? Or the drop out of everyday life? And what comes afterwards? Does in the end the whole life become an extreme sport? Fact is: they live extremely, because they want to move beyond well-trodden paths. To escape the boredom of everyday life they are searching for the kick, the thrill, the no-limit experience. It's about calculated risk between altitude flight and deep sea adventure.

Attitude to Health↗
PubMed2003

[Endoprosthesis management of the extremities of children after resection of primary malignant bone tumors].

In recent years, significant progress has been made in the treatment of primary malignant bone tumors. The surgeon is confronted with increasing demand for limb-sparing surgery by patients and parents alike. In the skeletally immature, resection of the growing physis will ultimately result in leg length discrepancies and functional impairment. An adequate reconstruction therefore calls for the compensation of the expected growth deficit to achieve symmetry and an optimized function of the extremity. Between 1975 and 2000, 55 patients (24 female, 31 male) were referred and treated at our institution. All patients were not older than 10 years (4.2-10, mean: 7.9 years). Histological diagnosis was Ewing's tumors ( n=19) and osteosarcoma ( n=36). Localization in the extremities was predominantly in the lower extremity with 63.6% around the knee joint (distal femur and proximal tibia). Surgical treatment was performed in all patients. Endoprosthetic reconstruction was performed in 34 patients (lower extremity n=30, 29 Howmedica Modular Reconstruction System, HMRS, 1 Pafford prosthesis; upper extremity n=4, 4 HMRS); in another case of humeral tumor involvement a resection replantation procedure was carried out. The other patients received a rotationplasty ( n=7), a biologic reconstruction ( n=6), resection replantation of the humerus ( n=1), no reconstruction ( n=3), or had to be amputated ( n=4). After a mean follow-up of 114 months (24-256 months) 11 patients had died. Even in young children endoprosthetic reconstruction with relatively early mobilization and high quality of life can be a very successful method for limb salvage. Optimal reconstructive results following resection of primary malignant bone tumors in children are reached when indications and limitations of each method are carefully considered on an individual basis taking into account the patients' expectations.

Activities of Daily Living↗
PubMed2005

Continuous and discrete extreme climatic events affecting the dynamics of a high-arctic reindeer population.

Climate at northern latitudes are currently changing both with regard to the mean and the temporal variability at any given site, increasing the frequency of extreme events such as cold and warm spells. Here we use a conceptually new modelling approach with two different dynamic terms of the climatic effects on a Svalbard reindeer population (the Brøggerhalvøya population) which underwent an extreme icing event ("locked pastures") with 80% reduction in population size during one winter (1993/94). One term captures the continuous and linear effect depending upon the Arctic Oscillation and another the discrete (rare) "event" process. The introduction of an "event" parameter describing the discrete extreme winter resulted in a more parsimonious model. Such an approach may be useful in strongly age-structured ungulate populations, with young and very old individuals being particularly prone to mortality factors during adverse conditions (resulting in a population structure that differs before and after extreme climatic events). A simulation study demonstrates that our approach is able to properly detect the ecological effects of such extreme climate events.

Animals↗
PubMed2004

Mortality impact of extreme winter temperatures.

During the last few years great attention has been paid to the evaluation of the impact of extreme temperatures on human health. This paper examines the effect of extreme winter temperature on mortality in Madrid for people older than 65, using ARIMA and GAM models. Data correspond to 1,815 winter days over the period 1986-1997, during which time a total of 133,000 deaths occurred. The daily maximum temperature (T(max)) was shown to be the best thermal indicator of the impact of climate on mortality. When total mortality was considered, the maximum impact occurred 7-8 days after a temperature extreme; for circulatory diseases the lag was between 7 and 14 days. When respiratory causes were considered, two mortality peaks were evident at 4-5 and 11 days. When the impact of winter extreme temperatures was compared with that associated with summer extremes, it was found to occur over a longer term, and appeared to be more indirect.

Aged↗
PubMed2000

Endogenous fibrinolysis in patients with lower extremity ischemia.

To explore the relationship between disorders of endogenous fibrinolysis and thrombosis in patients with lower extremity ischemia, we measured the activity of tissue plasminogen activator (tPAac) and plasminogen activator inhibitor (PAlac) and the antigens of tissue plasminogen activator (tPAa) and inhibitor (PAla) in plasma from 420 patients treated for lower extremity ischemia. Values and ratios observed were compared with those in healthy volunteers. Additionally, values and ratios in the patients were examined with respect to the severity of ischemia and site of atherosclerotic occlusion or stenosis (pelvic compared with femoropopliteal or crural). Patients with lower extremity ischemia had higher plasma concentrations of PAla (p<0.01) and PAlac (p<0.0001) than healthy volunteers. In patients with rest pain or gangrene, the ratio of tPAac to PAlac was higher than in patients with claudication (p<0.05). The elevation of tPAac in patients with the more severe form of lower extremity ischemia is probably the feedback protective reaction on prothrombotic mechanisms of the organism suffered from severe atherosclerosis. Results did not vary according to the site of occlusion or stenosis. Our study found defects in endogenous fibrinolysis in patients with lower extremity ischemia. A defect in fibrinolysis may contribute to the development of thrombosis in native arteries and bypasses.

Adult↗
PubMed2001

Prognostic index for extremity soft tissue sarcomas with isolated local recurrence.

BACKGROUND: Local recurrence occurs in 10% to 20% of patients with extremity soft tissue sarcomas despite optimal treatment. The association of local recurrence with subsequent survival is controversial and conflicting. There is a need for a staging system to predict outcome in this subset of patients and also to plan optimal treatment, including adjuvant systemic therapy. METHODS: Data collected from 110 patients with locally recurrent extremity soft tissue sarcomas were studied. The influence of clinical and pathologic factors on local recurrence, distant metastasis, and disease-specific survival were analyzed by univariate and multivariate techniques. RESULTS: Of the 110 patients who presented with local recurrence, 92 had an isolated local recurrence and 18 had prior or concomitant distant metastases. The 5-year disease-specific survival for all patients was 63% and for those with isolated local recurrence, it was 69%. Histologic grade, malignant fibrous histiocytoma histology, pathologic margins, previous local recurrence, and prior radiotherapy were independent prognostic factors for subsequent local recurrence. Tumor size, histologic grade, and time to local recurrence were independent prognostic factors for distant metastasis and disease-specific survival. A prognostic index was calculated by assigning a score of 1 to 3 for each of the three independent prognostic factors for survival and added to give the prognostic index for each patient. As the prognostic index increased from 3 to 9, there was a progressive increase in the hazard ratios and a corresponding deterioration in survival. The patients were then categorized into three prognostic groups based on the hazard ratios for disease specific survival. The differences in the survival curves were highly statistically significant (P < .0001). CONCLUSIONS: Tumor size, histologic grade, and time to local recurrence are the primary determinants of distant metastases and survival in locally recurrent extremity soft tissue sarcomas. The impact of local recurrence on survival varies considerably. The nature of the local recurrence, rather than its presence per se, is a more useful guide to prognosis. We propose a simple staging system based on size, grade, and time to recurrence that correlates extremely well with prognosis and may serve as a guide to make therapeutic decisions in patients with locally recurrent extremity soft tissue sarcomas.

Adolescent↗
PubMed1985

Lumbar sympathectomy for lower extremity vasospasm.

Ten patients, 8 female and 2 male, with refractory episodic lower extremity vasospasm were encountered during a 15 year period in which over 600 patients with upper extremity vasospasm were studied. Seven patients had associated upper extremity vasospasm. No patient had evidence of autoimmune disease. Lower extremity reserpine Bier block produced symptomatic relief for 1 to 3 days in all patients in whom it was used. Oral medications were ineffectual. A diagnostic toe photoplethysmographic pattern was noted in these patients, consisting of a normally pulsatile tracing after warming and a flat, nonpulsatile or minimally pulsatile tracing after cooling. Each patient underwent lumbar sympathectomy. During follow-up, which averaged 4 years, each patient remained free of episodic vasospasm on the side of surgery. We conclude that lumbar sympathectomy is an effective and durable treatment for lower extremity vasospasm.

Female↗
PubMed1984

The need for replantation surgery after traumatic amputations of the upper extremity--an estimate based upon the epidemiology of Sweden.

Reports in the literature give different views of the frequency of serious amputation injuries of the upper extremity. In Sweden the vast majority of work injuries are registered by the Swedish Labour Market Insurance. All registered serious amputation injuries of the upper extremity in Sweden (8 million inhabitants) during 1979 were investigated in this study. For comparison the frequency of all amputation injuries (work and leisure) of the upper extremity in a county of Sweden (0.4 million inhabitants) during five years (1976-1980) were studied. The overall (work and leisure) incidence in Sweden is fourteen serious amputation injuries of the upper extremity per million inhabitants annually, i.e. a total number in the country of 110 cases per year. The frequency is lower in the areas of the largest cities and substantially higher in regions with sawmills, mechanical industry and/or agriculture. Thus, estimation of the total incidence based upon single counties or smaller regions may be misleading. Replantation would have been technically possible in more than 70% of the cases, but attempts at replantation were only carried out in less than 10% of the serious cases. This study emphasizes the importance of a referral of all patients with a suitable injury of the upper extremity to microsurgically trained handsurgeons.

Accidents, Occupational↗