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PubMed2003

Extremity soft tissue sarcoma patient follow-up: tumor grade and size affect surveillance strategies after potentially curative surgery.

A large recent survey disclosed considerable variation in the intensity of follow-up after potentially curative surgery for extremity soft tissue sarcoma among highly credentialed clinicians. The source of the variation is not known. The survey was reanalyzed to investigate whether tumor grade and size account for the variation. The 1,592 members of the Society of Surgical Oncology were surveyed to measure their follow-up practices for 10 years after initial therapy for extremity sarcoma. Repeated-measures analysis of variance was used to measure the relationship among follow-up practice patterns and tumor grade, tumor size, and years after surgery. The 318 respondents who performed surgery and also carried out long-term follow-up for their patients with extremity soft tissue sarcoma were considered evaluable; 94% were general surgeons and 5% were orthopedic surgeons. Office visit, complete blood count, liver function tests, chest X-ray, chest computed tomography, extremity computed tomography, and extremity magnetic resonance imaging were ordered significantly more frequently with increasing tumor grade and size. Tumor grade and size significantly impacted physician practice patterns in post-treatment follow-up, although the degree of variation attributable to these variables was modest. These data permit rational design of a randomized clinical trial of two alternative follow-up plans.

Delivery of Health Care↗
PubMed1992

[A case of thalamo-subthalamic hemorrhage presenting monoballism in the contralateral lower extremity].

We report a 62-year-old man with ballism confined to the right leg, so-called monoballism. He was admitted to our hospital complaining of gait disturbance due to violent involuntary movements in the right lower extremity which had developed seven days before. He had a ten-years' history of hypertension and at age 57 had been diagnosed as having asymptomatic multiple cerebral infarcts. Until admission, he was taking antiplatelet drugs for the purpose of preventing thrombotic stroke. On neurological examination, he showed mild impairment of higher brain function, Horner's sign in the left eye, and typical ballism in the right lower extremity. Involuntary movements were never observed in the face and the other extremities. Surface electromyography also showed reciprocal burst discharges at about 1 Hz related to the ballistic movements in the right lower extremity. CT scan revealed a high density lesion surrounded by a low density in the left subthalamic area. MRI examination demonstrated a dumbbell shaped hemorrhage extending from the left subthalamic nucleus to the dorsomedial nucleus of the ipsilateral thalamus. Adding to the hemorrhage, many ischemic lesions were observed in the bilateral basal ganglia and thalamus including the left pallidum. The causal end of the hemorrhage apparently located in the anterior dorsomedial portion of the subthalamic nucleus. There were few reports concerning monoballism, especially monoballism limited to the lower extremity. Recent researches indicate that a subthalamic lesion reduces the excitatory control from the subthalamus to the internal segment of the globus pallidus, which leads to a disinhibition of the thalamus and gives rise to ballism.(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebral Hemorrhage↗
PubMed1992

The relationship of visual acuity, tactile sensitivity, and mobility of the upper extremities to proficient breast self-examination in women 65 and older.

The purpose of this study was to describe the relationship of visual acuity, tactile sensitivity, and mobility of the upper extremities to the performance of proficient breast self-examination (BSE) in women 65 and older. A convenience sample of 32 women, ages 66-89, met with the investigator to have their visual acuity, tactile sensitivity, and upper extremity mobility tested. Their ability to perform the visual, tactile, and upper extremity components of proficient BSE also was tested by using simulated breast models (SBMs). Thirty of the women had adequate visual acuity (< or = 20/40 Snellen equivalent) but were unable to visually detect the abnormalities on the SBM. Thirty of the women had tactile sensitivity of 10 mm (1 cm) or better on the static two-point discrimination test of the second, third, and fourth digits of each hand. Yet, only 13 of these women were able to locate the 1 cm lump; only 12 were able to locate the 5 mm lumps; and none were able to locate the 3 mm lump. The subjects' ability to pass the upper extremity mobility component of proficient BSE was significantly related to their ability to pass the upper extremity range of motion criteria. Limitations and deficits, mostly of the hands and shoulders, were revealed. When teaching BSE to older women, nurses are responsible for assessing limitations and deficits in their ability to perform proficient BSE and, if necessary, for intervening with alternatives. The need for further research in this area is indicated to improve assessment and education of older women regarding the use of proficient BSE for early detection of breast cancer.

Age Factors↗
PubMed2003

Postnatal adaptation of cerebral blood flow using near infrared spectroscopy in extremely preterm infants undergoing high-frequency oscillatory ventilation.

AIM: To determine cerebral blood flow using near infrared spectroscopy in extremely preterm infants undergoing high-frequency oscillatory ventilation during the first three days of life. Low cerebral blood flow has been associated with both intra-ventricular haemorrhage and periventricular leucomalacia. It is well established that cerebral blood flow increases over the first three days of life in extremely preterm infants who are conventionally ventilated with intermittent positive pressure ventilation. However, there is no information about cerebral blood flow in preterm babies undergoing high-frequency oscillatory ventilation. In addition, there are concerns that high-frequency oscillatory ventilation may be associated with an increased incidence of intra-ventricular haemorrhage in premature infants. METHODS: Thirteen appropriately grown, preterm infants of less than 28 wk gestation who were admitted to the neonatal unit at University College Hospital, London were studied using near infrared spectroscopy. Left ventricular output and right ventricular output were assessed echocardiographically. RESULTS: Extremely preterm infants undergoing high-frequency oscillatory ventilation have remarkably low cerebral blood flow in the first 12 h of life, median 6.7 (range 4.4-11) mls. 100 g(-1) min(-1) followed by an increase over the subsequent three days. Left ventricular output also increased over the first three days of life, whereas right ventricular output showed no clear relationship with time. Despite low cerebral blood flow only one infant had evidence of major cerebral injury. CONCLUSION: Cerebral blood flow is extremely low in this group of preterm babies. Despite this extremely low cerebral blood flow, the clinical outcome is good. There was an increase in cerebral blood flow and a corresponding increase in left ventricular output over the first few days of life.

Adaptation, Physiological↗
PubMed1992

[Laser puncture in the treatment of diabetic angiopathies of the lower extremities].

Laseropuncture in patients with diabetes mellitus associated with angiopathies of the lower extremities (grade II and III) produced a pronounced clinical effect which was manifested by removing the pain syndrome, improvement of the peripheral circulation and extremity function and function of the lower extremities, improvement of thermographic values. But this positive dynamics was more pronounced in angiopathies of the lower extremities of the stage of functional disorders than obliterating atherosclerosis of the legs. Sterility of the laser beam, possibility of local effect on biologically active points, non-painful procedure, absence of age limits and side effects allow to widely recommend this method for the treatment of Diabetes mellitus associated with angiopathies of the lower extremities.

Acupuncture Points↗
PubMed1992

[Extreme results in electrolyte determination].

Besides statistical quality control, quality control based on patient specimens is an important tool for quality enhancement and thus for an increased diagnostic certainty in laboratory medicine. One of three possibilities of plausibility judgement is the control of extreme results, that is alert and absurd value check. The aim of our study was to look for extremely high or low findings of the most frequently examined clinical-chemical parameters, to scrutinize their validity according to clearly defined criteria and to find out the underlying actual clinical situations and diseases. In this publication only the results for the electrolytes are discussed. Retrospectively the most extreme values of all results for serum sodium, potassium and chloride concentrations of a 21-month interval were extracted in a large university hospital. The clinical situation was then evaluated by reading the medical reports of these patients. The validity of the findings was judged by previously defined criteria and rated as confirmed, questionable and not confirmed. In all cases the survival time was determined. The most extreme confirmed results were for sodium 191 and 100 mmol/l, for potassium 9.0 and 1.3 mmol/l and for chloride 138 and 65 mmol/l. All these findings were compatible with life, at least for several hours. Even if it is probably impossible to give generally valid extreme ranges. Nevertheless our results should certainly have practical importance in absurd and alert value check.

Chlorides↗
PubMed2004

[Doppler ultrasound diagnosis of lower extremity deep vein insufficiency: Valsalva maneuver or pneumatic cuff?].

PURPOSE: To compare the efficacy of Valsalva maneuver and pneumatic compression techniques in detecting lower extremity deep venous and saphenofemoral insufficiency. MATERIALS AND METHODS: Eighty-one extremities evaluated in 43 patients who had undergone Doppler ultrasound examination of the lower extremity venous system were included in the study. Valsalva maneuver and pneumatic cuff techniques were used to elicit reflux in the standing position. Reflux was investigated with spectral Doppler in the superficial femoral vein, popliteal vein, the proximal segment of the great saphenous vein close to its junction with the femoral vein and in its caudal segment at the medial aspect of the knee. The same measurements were repeated after rapid deflation of the pneumatic cuff, which was applied to the calf and was initially inflated to 200 mmHg. Retrograde flow exceeding 1000 msec was regarded as insufficiency. The results of the two techniques at each venous segment were compared with the McNemar test. RESULTS: Deep venous and/or saphenofemoral insufficiency were detected in 61 of the 81 extremities. The cuff deflation technique was superior at the popliteal vein and caudal segment of the great saphenous vein. The Valsalva maneuver was superior at the superficial femoral vein. The statistical results did not change when the McNemar test was repeated for reflux exceeding 2000 msec. CONCLUSION: Combined application of Valsalva maneuver and pneumatic cuff techniques will lead to more accurate evaluation and increased detection of lower extremity venous insufficiency.

Adolescent↗
PubMed2004

Spatial analysis of extreme precipitation in Sweden 1961-2000.

Extreme daily precipitation in Sweden for the years 1961-2000 is analyzed with respect to spatial scale, regional variations and associated weather types. Correlograms based on a lag distance of 30 km estimated the spatial scale of variation of the annual mean precipitation, the 99th percentile of daily precipitation and the average of annual maximum daily precipitation to 100 km, 60-100 km and 40-70 km, respectively. Regions of correlation with respect to precipitation at 82 stations during days of extreme events are identified through Maximum-Likelihood Factor Analysis. Eleven factors are found to provide the optimum factor solution. Weather types for the days of extreme events are determined by an objective classification scheme, based on daily sea level pressure, which is modified by subjective inclusion of fronts. In total, 63% of the extreme events occurred during cyclonic weather types, 32% during frontal, 3% during directional and 2% during anticyclonic types. The frequency of the weather types during extreme events varied between the regions however.

Climate↗
PubMed1992

Prevalence of lower extremity arterial disease among elderly people in the community.

To estimate the prevalence of lower extremity arterial disease, all patients aged over 65 years registered with a rural general practice near Cambridge were invited to attend for examination of the circulation to the lower extremities; 265 subjects (80%) accepted. Three methods were used to investigate the presence of lower extremity arterial disease - enquiring about symptoms of intermittent claudication; clinical examination (and particularly the detection of arterial bruits); and pressure index calculations from measurements of the ankle and brachial systolic blood pressure using a Doppler ultrasound probe. When examining the legs, the presence of a bruit was taken as stronger evidence of disease than inability to palpate the pulses which may be difficult or impossible to detect for a number of reasons. Forty seven of the 264 patients examined (18%) showed evidence of lower extremity arterial disease. Seven patients showed unequivocal evidence of lower extremity arterial disease as demonstrated by all three criteria, 12 by two criteria and 28 patients on one criterion alone. While the pressure index followed a normal distribution curve, there was a tendency for it to decline with age. Other risk factors which showed a correlation with evidence of disease including current, but not previous, cigarette smoking, and a history of stroke. The significance of the findings is discussed in the context of some degree of arterial pathology in many British subjects in this age group.

Age Factors↗
PubMed2005

Differences in lower extremity alignment between males and females. Potential predisposing factors for knee injury.

AIM: The goal of this study was to compare measures of lower extremity alignment between males and females, which may account for gender differences in anterior cruciate ligament injury rates. Static lower extremity alignment has been implicated as predisposing individuals to anterior cruciate ligament injury and may vary between males and females. An initial step in identifying relevant risk factors for injury is to determine those factors that vary between genders. METHODS: Thirty male and 27 female college aged individuals with no history of lower extremity injury participated. Three indices of lower extremity alignment were measured on each subject: quadriceps angle, thigh foot angle, and subtalar joint range of motion ratio. RESULTS: Q-angles in females exceeded values for males by 4.4 degrees (p<0.001). Thigh foot angle for females was 3.6 degrees greater than for males (p=0.020). Subtalar joint movement ratio did not vary between genders (p=0.573). CONCLUSION: Previous research suggests that abnormal alignment may predispose individuals to anterior cruciate ligament injury. The present findings may help to explain the difference in anterior cruciate ligament injury rates between males and females. Any tangible links between lower extremity alignment and anterior cruciate ligament injury rates must be confirmed with prospective studies.

Ankle Joint↗
PubMed1991

Lower extremity replantation.

Replantation of the traumatically amputated lower extremity is a technically feasible surgical undertaking. Successful outcome must be judged by functional achievements of the patient toward returning to the preinjury level. Appropriate patient selection significantly increases the potential for obtaining a satisfactory outcome. Patients in whom peripheral nerve injury precludes return of sensation in the extremity or in whom severe joint destruction will yield an immobile extremity will have marginal results. The risks of replantation, including blood transfusions, sepsis, and prolonged hospitalization, must be weighted heavily against prosthetic substitution as an alternative. If the lower extremity can be successfully replanted, however, this provides a superior functional and aesthetic result for the patient. Salvage replantation to preserve maximal functional length and durability of an extremity must always be considered when assessing a patient with a traumatic amputation. Free-tissue transfer to salvage a threatened replanted limb must be similarly a part of the armamentarium of the replantation surgeon. Although lower limb replantation may continue to be controversial, improved surgical techniques and increasing experience make it an excellent alternative to prosthetic substitution. In the well-motivated patient, an excellent result may be achieved.

Adult↗
PubMed1991

Angiographic yield in penetrating extremity trauma.

Indications for angiography in the evaluation of penetrating extremity trauma remain controversial. Our experience was reviewed to determine the yield of angiography in penetrating extremity trauma and to correlate clinical findings with angiographic results. During an 81-month period from 1983 through 1989, 284 extremity arteriograms were carried out in 268 patients. The angiographic yield in patients with abnormal clinical findings was 51%. The angiographic yield in patients when proximity of the injury to major vessels was the only indication was 6% (7% with gunshot wounds and 0% with stab wounds). Neurologic deficit alone as an indication for angiography accounted for 55% of the angiograms interpreted as "negative" and none of those interpreted as "positive". We conclude that the use of angiography in patients with gunshot wounds to the extremity with "proximity injuries" to major vessels should continue, its use is not warranted in extremity stab wounds when proximity is the sole indication, and abnormal neurologic findings in the absence of other findings are a poor predictor of vascular injury.

Adolescent↗
PubMed1990

Limb salvage versus amputation. Preliminary results of the Mangled Extremity Severity Score.

Objective criteria can predict amputation after lower-extremity trauma. The authors examined the hypothesis that objective data, available early in the evaluation of patients with severe skeletal/soft-tissue injuries of the lower extremity with vascular compromise, might discriminate the salvageable from the unsalvageable limbs. The Mangled Extremity Severity Score (MESS) was developed by reviewing 25 trauma victims with 26 severe lower-extremity open fractures with vascular compromise. The four significant criteria (with increasing points for worsening prognosis) were skeletal/soft-tissue injury, limb ischemia, shock, and patient age. (There was a significant difference in the mean MESS scores; 4.88 in 17 limbs salvaged and 9.11 in nine limbs amputated; p less than 0.01). This scoring system was then prospectively evaluated in 26 lower-extremity open fractures with vascular injury over a 12-month period at two trauma centers. Again, there was a significant difference in the mean MESS scores; 4.00 for the 14 salvaged limbs and 8.83 for the 12 amputated limbs (p less than 0.01). In both the prospective and retrospective studies, a MESS score of greater than or equal to 7 had a 100% predictable value for amputation. This relatively simple, readily available scoring system of objective criteria was highly accurate in acutely discriminating between limbs that were salvageable and those that were unsalvageable and better managed by primary amputation.

Adult↗
PubMed1990

[Pre-amputation freezing of the extremity in acute ischemic gangrene].

When preparing for amputation in 153 patients with acute ischemic gangrene of a lower extremity, the tourniquet-cold isolation was used. In 137 patients, the damaged extremity was freezed by means of a special portable freezing chamber, which can be used in any surgical in-patient department. The duration of cooling ranged from 18 hrs to 14 days. The state improved in 136 patients, the amputation of the extremity was performed in them. The use of freezing of the damaged extremity permitted to reduce the postoperative lethality from 41 to 19.1%. A high effectiveness of the method in gangrene of the extremity against the background of diabetes mellitus was noted.

Adult↗
PubMed1990

Cerebral palsy of the upper extremity.

The care of patients with spastic cerebral palsy requires the dedicated attention of a surgeon who is interested in the upper extremity, in association with therapists and other medical personnel who have a similar interest. The difficult problems of the upper extremity have often been overlooked by concerns related to the other skeletal manifestations in the spine and lower extremities. However, a pessimistic view of surgical results in the upper extremity is unwarranted, as even small gains in severely affected patients often result in an improved life. The surgical concepts related to this complex neurologic problem must be kept rather simple, and include principally the release of spastic deforming muscles, and, secondly, the use of augmentation tendon transfers to maintain an improved functional position. In order to allow the augmentation tendon transfers to function with minimal postoperative muscle re-education, tendon transfers that use muscles that contribute to the deformity are preferred; in the transferred position, these will function to correct the deformity and fire in phase without extensive postoperative training. Such muscle transfers are usually available to correct the more common pattern of spastic deformities. The most important aspect of surgical planning is to determine whether or not the individual is attempting to voluntarily use the upper extremity. In such cases, surgical procedures can reposition the deformed limb and enable the individual to function more effectively. On the other hand, it is most important to realize that an operative procedure will not stimulate an individual to begin to use a previously functionless limb.

Arm↗
PubMed1990

[Impedance plethysmographic evaluation of sympathetic activity to lower extremity].

Impedance plethysmographic analysis was performed in two cases of late cortical cerebellar atrophy (LCCA) and two cases of Shy-Drager syndrome. Blood pressure, heart rate and peripheral hemodynamics (arterial blood flow and vascular resistance of lower extremity) were measured during head-up tilting. In cases of LCCA, there was no decrease of blood pressure by tilting up. Impedance plethysmography showed significant increase in vascular resistance of lower extremity and heart rate was also increased. In cases of Shy-Drager syndrome, however, marked decrease of blood pressure was shown during tilting up, while there was no significant change in heart rate and vascular resistance of lower extremity was decreased. Therefore, in cases of Shy-Drager syndrome, decrease of peripheral sympathetic activity to lower extremity was suggested. Impedance plethysmography of lower extremity is simple, non-invasive and useful method to assess the status of peripheral sympathetic activity.

Aged↗
PubMed1989

The extremal quotient in small-area variation analysis.

This article reviews the current small-area variation analysis (SAVA) approach to population-based rates of surgery, and describes a new method for ascertaining variance based on the beta-binomial probability distribution of small-area rates. The critical review of the current SAVA approach focuses (1) on how incidence rates are calculated, and (2) on how the significance of the observed magnitude between the largest and smallest rates (i.e., the external quotient) is ascertained. While reducing the problems of calculating rates by considering only certain operative procedures, the new method addresses the current inadequacies of ascertaining significant differences among small areas. Not only does it correctly assess likelihood of an extermal quotient, it also can determine the particular area's rate, producing an unlikely extermal quotient. The method evaluates the probability that the observed magnitude of the extremal quotient is due solely to chance and study design effects, and tables of these probabilities are available for the method's application. A mathematical model, based on a combination of the binomial and beta distributions, uses (1) the sample size, (2) the average of the areas' rates, (3) the variance among the rates, and (4) a specific quotient level to determine the probability of observing the quotient by chance. After computerizing this calculation, probability tables for reasonable values of these four parameters are generated. In addition to looking at just one quotient for each sample, the probability tables facilitate the easy examination of intermediate quotients when the extremal quotient is unlikely due to chance. By alternatively ignoring the highest and lowest rates, two new quotients can be produced and tested. Given that one of these two quotients is likely due to chance, the excluded rate (i.e., producing the unlikely extremal quotient) can be classified as an outliner, and the associated small area should be the focus of more detailed investigation. The probability tables reveal that the external quotient is not the appropriate statistic to be applied in studies where many small areas are to be included. The probability of seeing even a "large" extremal quotient simply by chance rapidly approaches one as the sample size increases. However, an extremal quotient modeled from a beta-binomial distribution can be useful for studies with small sample sizes (e.g., six counties). The use of this beta-binomial model for small-area rates provides a new method of designing and evaluating small-area studies where costs or domain limit the number of areas under consideration.(ABSTRACT TRUNCATED AT 400 WORDS)

Analysis of Variance↗
PubMed1988

Incomplete palmar fracture of the proximal extremity of the third metacarpal bone in horses: ten cases (1981-1986).

In 4 adult horses, simple, nondisplaced, incomplete fracture of the proximal extremity of the third metacarpal bone (MC3) was identified radiographically only on the dorsopalmar projection. Lameness was slight to moderate. Although nerve blocks of the foot and fetlock did not alter the lameness, high palmar regional nerve block improved the gait in 1 of the 2 horses on which it was performed. Pain on palpation or swollen distal accessory (inferior check) ligament, flexor tendons, and suspensory ligament were not found in any horse. The fracture was localized to the palmar surface of the proximal extremity of the MC3 on the basis of the intense uptake of radiopharmaceutical (99MTc-labeled sodium medronate) observed in that area during the soft tissue and delayed bone phases of a nuclear scintigraphic examination (nuclear scan) performed concurrently with radiography. Of 4 horses evaluated 6 months after the initial diagnosis, 3 had medullary sclerosis without radiographic evidence of fracture; results of follow-up nuclear scintigraphy performed in one of these horses at the same time were normal. Incomplete fracture also was suspected in another 6 adult horses with clinical lameness referable to the proximal extremity of the MC3. Although a fracture line could not be seen radiographically, trabecular hypertrophy and/or medullary sclerosis of the proximal extremity of the MC3 were detected on the dorsopalmar projection. Further, during nuclear scintigraphy, an intense uptake of the radiopharmaceutical was observed on the palmar aspect of the proximal extremity of the MC3 in all 6 horses.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗