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PubMed1998

Noninvasive diagnosis of upper extremity vascular disease.

The relative rarity of vascular disorders of the arm accounts for unfamiliarity with upper extremity diagnostic testing on the part of even experienced vascular clinicians. Understanding the wide variety of noninvasive tests is imperative if one is to appropriately diagnose and treat these disorders. The diagnosis and localization of arterial occlusive disease is dependent on the use of Doppler-derived arterial pressures, which may be measured serially from the upper arm to the digits. Plethysmographic digital waveforms can be used as an aid in the diagnosis of vasospastic disorders as well as in the assessment of therapy. Similarly, provocative testing with cold stimulation can assist in the diagnosis of Raynaud's and other vasospastic disorders. The use of duplex ultrasonography for venous occlusion, although not as accurate as when used for lower extremity problems, can be a useful aid in the diagnosis of upper extremity venous thrombosis. Symptoms associated with the thoracic outlet syndrome can be evaluated and confirmed noninvasively, measuring Doppler pressures and gauging venous outflow obstruction while the patient performs a variety of positional maneuvers. A thorough knowledge of upper extremity noninvasive tests will provide the clinician with confidence in the objective assessment of upper extremity vascular disease.

Arm↗
PubMed2005

Deep-seated, well differentiated lipomatous tumors of the chest wall and extremities: the role of cytogenetics in classification and prognostication.

BACKGROUND: Intramuscular lipomas and atypical lipomatous tumors (ALT) are common deep-seated lipomatous tumors of the chest wall and extremities. Distinguishing between these two entities can be difficult based on histologic analysis alone. However, the cytogenetic profiles of ALT and intramuscular lipomas are distinct. Correct classification is important, because aggressive local disease recurrence occurs more frequently in patients with ALT than in patients with intramuscular lipoma. The authors examined their single institutional experience and correlated their classification with clinical features and outcome. METHODS: In the current study, 106 patients with deep-seated, well differentiated adipose tumors of the chest wall and extremities were classified as having ALT or intramuscular lipoma using a combined approach of histology and cytogenetics, if available. The classification was correlated with clinicopathologic features and follow-up data. RESULTS: Fifty-five patients were classified as having intramuscular lipoma and 51 were classified as having ALT. Classification did not correlate with age and gender (P = 0.28 and P = 0.96, respectively). Intramuscular lipomas were smaller than ALTs (P < 0.0001), but there was significant overlap between the 2 groups. ALT occurred preferentially in the lower extremity (P < 0.0009). Four percent of patients with intramuscular lipomas and 27% of patients with ALTs developed local disease recurrence (P = 0.0006). Disease recurrence did not correlate with patient age at diagnosis, patient gender, tumor size, and tumor location (P = 0.45, P = 0.26, P = 0.49, and P = 0.28, respectively). Within the subset of patients with ALTs, disease recurrence did not correlate with patient age at diagnosis, patient gender, or tumor location (P = 0.38, P = 0.54, and P = 0.86, respectively). CONCLUSIONS: Classification of deep-seated, well differentiated lipomatous tumors of the extremities and chest wall using a combined approach of histology and cytogenetics correlated well with biologic behavior/disease recurrence. This combined approach is advocated to better stratify patients for treatment purposes and follow-up.

Adult↗
PubMed2006

Imaging of upper extremity stress fractures in the athlete.

Although it is much less common than injuries in the lower extremities, an upper extremity stress injury can have a significant impact on an athlete. If an accurate and timely diagnosis is to be made, the clinician must have a high index of suspicion of a stress fracture in any athlete who is involved in a throwing, weightlifting, or upper extremity weight-bearing sport and presents with chronic pain in the upper extremity. Imaging should play an integral role in the work-up of these patients; if initial radiographs are unrevealing, further cross-sectional imaging should be strongly considered. Although a three-phase bone scan is highly sensitive in this regard, MRI has become the study of choice at most centers.

Arm Injuries↗
PubMed2026

Partial enumeration of extreme rays in metabolic networks using bit pattern trees.

Extreme ray analysis of metabolic networks, even though very powerful, is currently limited to smaller metabolic networks. Some approaches to generating partial sets of extreme rays exist, but the computational efficiency of the so-called double-description method is yet to be exploited. Previous work highlighted the possibility of sampling within its iterations, enabling partial enumeration for double-description based methods. However, these approaches severely lack computational efficiency to be a suitable alternative. In this work, the highly efficient bit pattern trees are used within the sampling framework to significantly enhance its output and speed. Combined with the recent revision of the Canonical Basis Approach (CBA), our approach outperforms the other tested methods under the reported benchmark conditions even for a full enumeration study, requiring only half the computation time. In addition, a filter setting allows the memory demand to be scaled down while retaining high efficiency. However, some issues with the combinatorial explosion of candidates still persist and are further investigated. This study therefore puts forward a novel, double description-based alternative to partial enumeration of extreme rays. Further improvements in memory efficiency would allow this promising approach to scale powerful extreme ray-based analyses to genome-scale metabolic networks.

constraint-based modelling↗
PubMed1998

Ki-67 detected by MIB-1 predicts distant metastasis and tumor mortality in primary, high grade extremity soft tissue sarcoma.

BACKGROUND: Preoperative staging of localized extremely soft tissue sarcoma (STS) includes tumor grade, size, and depth. A positive microscopic margin (PMM) adds prognostic information postoperatively, which is not helpful for preoperative stratification into low and high risk groups. This study was undertaken to identify molecular markers associated with poor outcome that could be used to refine the preoperative staging of high grade extremity STS. METHODS: Between January 1, 1983, and December 31, 1989, 1416 patients were entered into the STS prospective data base at the Memorial Sloan-Kettering Cancer Center. Of 232 patients identified with primary, high grade extremity lesions, 121 had tissue available for immunohistochemical (IHC) analysis. The clinicopathologic variables and molecular markers for the original 232 patients were correlated with those for the 121 patients analyzed in the current study. Overexpression of Ki-67, p53, and mdm2 and deletion of Rb were determined via standard IHC techniques on serial paraffin sections. Categoric overexpression was defined as > or = 20% nuclear staining. Continuous determination of the percentage of nuclear staining was also used for correlation with distant metastasis (DM) and tumor mortality (TM). Univariate and multivariate analyses were conducted with log rank and Wilcoxon tests and Cox regression analyses, respectively. RESULTS: The median follow-up was 64 months. Fifty-four of the 121 patients (45%) developed DM. Fifty-one of the 121 patients (42%) died of their disease. Factors found to be significant in univariate and multivariate analyses for both DM and TM were Ki-67 score, size, and PMM (all P values <0.05). Five year freedom from DM with a Ki-67 score of <20 was 70% versus 50% for a score. Overexpression of p53 of mdm2 or deletion of Rb did not correlate with increased risk of DM or TM alone or in combination with a Ki-67 score of > or = 20. CONCLUSIONS: In addition to standard preoperative criteria, Ki-67 score is an independent prognostic molecular marker that predicts DM and TM in high grade extremity STS. Selecting patients with high grade tumors for preoperative investigational treatment may be further refined according to whether the patients have Ki-67 score of > or = 20 and large tumor size.

Adult↗
PubMed1982

Extremity lesions in the Intergroup Rhabdomyosarcoma Study (IRS-I): a preliminary report.

The sites in which rhabdomyosarcoma occurs most frequently in children and young adults are the head and neck, genitourinary tract, and the extremities. Among these three sites, tumors of the extremities have been associated with the highest relapse rate and lowest survival rate in patients treated by protocols of the Intergroup Rhabdomyosarcoma Study (IRS). In five of six patients treated by primary extremity amputation, tumor recurred. Seven of 21 patients in Clinical Group I (completely resected tumors), and 9 of 27 patients in Clinical Group II (patients with gross tumor excision but positive lymph nodes, "microscopic residual" disease, or extension beyond the muscle of origin) had relapse. Thirteen of 18 patients (72%) in Clinical Group III (gross residual disease) responded to a chemotherapy-radiotherapy regimen, but ten have subsequently had relapses; and 13 of 18 are dead. Of 30 patients in Clinical Group IV (disseminated disease on entry), 15 initially responded to chemotherapy, but 25 of 30 are dead. The period of surveillance is 2 1/2 to 7 1/2 years, with a mean of 46.3 months at least examination. Increased rates of relapse were seen in patients with extremity tumors, as opposed to tumors in other sites, irrespective of the specific IRS chemotherapy-radiotherapy regimen employed. In Clinical Group I (nonamputation), relapse rates by histologic subtype of rhabdomyosarcoma were alveolar subtype, 5/8; embryonal, 1/7; and all other subtypes, 1/6. Clinical Group II, relapse rates were alveolar, 6/12; embryonal, 5/11; all other subtypes, 3/10.

Amputation, Surgical↗
PubMed2001

Utility of chest computed tomography for staging in patients with T1 extremity soft tissue sarcomas.

BACKGROUND: National Cancer Center Network (NCCN) and Society of Surgical Oncology (SSO) practice guidelines recommend chest computed tomography (CT) as part of the staging evaluation of patients with extremity soft tissue sarcoma (STS). In the current study, the authors evaluated the use and yield of chest roentgenography (CXR) and selective chest CT to screen for pulmonary metastases in patients with T1 STS. METHODS: The utility of these staging studies was evaluated retrospectively in a cohort of 125 consecutive patients who presented to a tertiary care cancer center with T1 primary (nonrecurrent) extremity STS. Two diagnostic strategies (CXR alone vs. CXR plus chest CT) were evaluated using an incremental cost-effectiveness ratio. RESULTS: The majority of tumors (70%) were high grade. The median sarcoma size was 3.0 cm; 64 of the tumors (51%) were located deep to the investing fascia of the extremity. All patients underwent staging CXR; 1 CXR (< 1%) was suspicious for metastatic disease. Fifty-one patients (41%) also underwent chest CT; 1 chest CT, performed in the patient with a suspicious CXR, revealed metastatic disease. With a median follow-up of 76 months, 19 patients (15%) developed metachronous pulmonary metastases. The relatively low yield resulted in an incremental cost-effectiveness ratio of $59,772 per case of synchronous pulmonary metastasis detected by CXR plus chest CT. CONCLUSIONS: Less than 1% of patients with T1 primary extremity STS were found to have pulmonary metastases that were detectable using a staging algorithm that employs routine CXR with the selective use of chest CT. The findings of the current study do not support current NCCN or SSO practice guidelines for patients with high-grade T1 STS.

Adolescent↗
PubMed2003

Identifying cumulative trauma disorders of the upper extremity in workers' compensation databases.

BACKGROUND: Impeding the use of workers' compensation databases for surveillance of cumulative trauma disorder of the upper extremity (CTDUE) is the lack of valid and reliable extraction strategies. METHODS: Using the Z795-96 Coding of Work Injury or Disease Information standard, an algorithm was developed to classify claims as definite, possible, or non-CTDUE. Reliability was assessed with standardized claim reviews. RESULTS: Moderate to substantial agreement (Kappa = 0.48, 95% CI 0.42-0.54, n = 328; weighted Kappa = 0.75, 95% CI 0.70-0.80, n = 328) was demonstrated. The algorithm produced relatively homogeneous groups of definite and non-CTDUE claims but 29.1% of the possible CTDUE claims were categorized as definite CTDUE by claim review. Part of body agreement was almost perfect (Kappa = 0.81-1.00) when determining whether the upper extremity or specific parts of the upper extremity were involved. CONCLUSIONS: The algorithm can be used to estimate the number of CTDUE and extract homogeneous groups of definite and non-CTDUE claims. Furthermore, certain upper extremity part of body codes can be used to target anatomically defined claims.

Algorithms↗
PubMed2007

Holmes-like tremor of the lower extremity following brainstem hemorrhage.

Holmes tremor is an arrhythmic, 2- to 5-Hz resting, postural, and kinetic upper extremity movement disorder that occurs weeks to months after acute mesencephalic pathology. We present a patient who developed tremor in three body parts postbrainstem hemorrhage with subsequent hypertrophic olivary degeneration and discuss the relevant clinical evolution. Our case is unique because in addition to expected upper extremity and cervical dystonic head tremors, the patient also developed a severe lower extremity movement disorder, which we believe to be a form of Holmes tremor. Tremor involving the lower extremity in this setting has not been previously reported.

Acute Disease↗
PubMed2007

A comparative analysis of functional outcomes in adolescents and young adults with lower-extremity bone sarcoma.

BACKGROUND: Comparison of functional mobility and quality of life is performed in patients with lower-extremity bone sarcoma following either amputation, limb-sparing surgery, or rotationplasty with four different types of outcome measures: (1) an objective functional mobility measure that requires patients to physically perform specific tasks, functional mobility assessment (FMA); (2) a clinician administered tool, Musculoskeletal Tumor Society Scale (MSTS); (3) a patient questionnaire, Toronto Extremity Salvage Scale (TESS); and (4) a health-related quality of life (HRQL) measure, Short Form-36 version 2 (SF-36v.2). PROCEDURE: This is a prospective multi-site study including 91 patients with lower-extremity bone sarcoma following amputation, limb-sparing surgery, or rotationplasty. One of three physical therapists administered the quality of life measure (SF-36v.2) as well as a battery of functional measures (FMA, MSTS, and TESS). RESULTS: Differences between patients who had amputation, limb-sparing surgery, or rotationplasty were consistently demonstrated by the FMA. Patients with limb sparing femur surgery performed better than those patients with an above the knee amputation but similarly to a small number of rotationplasty patients. Several of the more conventional self-report measures were shown to not have the discriminative capabilities of the FMA in these cohorts. CONCLUSION: In adolescents with lower-extremity bone sarcoma, it may be advantageous to consider the use of a combination of outcome measures, including the FMA, for objective functional mobility assessment along with the TESS for a subjective measure of disability and the SF-36v.2 for a quality-of-life measure.

Adolescent↗
PubMed2002

How surgeon age affects surveillance strategies for extremity soft tissue sarcoma patients after potentially curative treatment.

BACKGROUND: The optimal strategy for follow-up of extremity soft tissue sarcoma patients after potentially curative treatment remains unknown. We investigated whether the date of completion of formal surgical training affects choice of surveillance strategy. MATERIALS AND METHODS: The 1,592 members of the Society of Surgical Oncology were asked how often they use 12 separate surveillance modalities during years 1-5 and 10 postsurgery. The motivation underlying follow-up was assessed separately. Repeated-measures analysis of variance was used to compare practice patterns by the year in which the surgeon's formal surgery training was completed, controlling for tumor grade, tumor size, and year postsurgery. RESULTS: Of the 716 respondents, 318 performed surgery and also provided long-term postoperative surveillance for their patients. These respondents were considered evaluable. Erythrocyte sedimentation rate, extremity X ray, and bone scan were the follow-up tests which differed significantly among physician age groups. Surgeons who completed training more than 30 years ago ordered erythrocyte sedimentation rate more frequently (P < 0.001). Surgeons in the 21-30 year category ordered extremity X ray and bone scan more frequently (P < 0.05), but the absolute differences among age groups were quite small. Older surgeons were also significantly more likely to believe that follow-up is clinically worthwhile. CONCLUSIONS: The posttreatment surveillance practice patterns of the members of the Society of Surgical Oncology caring for extremity soft tissue sarcoma patients vary only marginally with the length of time since completion of training. Postgraduate education may be one factor homogenizing surgeon behavior in this important aspect of cancer patient care.

Aging↗
PubMedDate not supplied

Multifocal extremity sarcoma: an uncommon and controversial entity.

BACKGROUND: The primary site of metastasis from extremity sarcomas is the lung. When patients with extremity sarcoma present with the disease in more than one site but not in the lung, the question of whether the disease is multifocal or metastatic is difficult to resolve. METHODS: We reviewed 1423 patients admitted with extremity sarcoma from 1982 through 1996. Patient demographics, primary site, other sites, local recurrence, distant metastasis, and survival were analyzed. Statistics were by Fischer exact test, chi 2, Kaplan-Meier method, and log-rank test where appropriate. RESULTS: Sixteen (1%) patients were identified with multifocal disease out of 1423 patients with extremity sarcoma. There was no difference in sex, age, size, grade, depth, and margins between multifocal and unifocal disease. In a mean follow-up time of 57 months, 50% had local recurrence of primary tumor, 80% had distant metastasis, and only 30% were alive at the time of the analysis. Whereas 21% of all patients with solitary disease develop lung metastasis, 63% of patients with apparent multifocal disease develop lung metastasis. The 5-year disease-specific survival of patients with multifocal disease was not different from that of all patients presenting with metastatic disease to lung. CONCLUSION: Whether multifocal disease exists or is merely a form of metastasis is unproven by this analysis, but the outcome is the same. Management algorithms should suggest treating patients with multifocal disease as if it is metastatic disease.

Disease-Free Survival↗
PubMedDate not supplied

Combined modality treatment of extremity soft tissue sarcomas.

BACKGROUND: Substantial progress has been made in the multimodality treatment of soft tissue sarcoma over the past decade. This review summarizes current state-of-the-art management for patients with extremity soft tissue sarcoma. METHODS: Literature-based review of combined modality treatment of extremity sarcoma. RESULTS: The revised staging system of the International Union Against Cancer/American Joint Committee on Cancer (UICC/AJCC) for this disease is described and a practical approach to diagnosis, evaluation, management, and follow-up of patients is presented. Brief summaries of the roles of surgical therapy, pre- and postoperative radiotherapy, pre- and postoperative chemotherapy, and concurrent chemoradiation in the management of extremity soft tissue sarcoma are provided, with summaries of the available data from randomized prospective trials. The data referenced and discussed herein provide the basis for stage-specific treatment recommendations for the management of patients with localized soft tissue sarcoma of the extremities. CONCLUSIONS: Soft tissue sarcoma remains a challenging disease to treat. The majority of patients require an integrated combined modality approach. Future research should be directed at developing more effective systemic therapies and minimizing the toxicities of local therapies.

Antineoplastic Combined Chemotherapy Protocols↗
PubMedDate not supplied

Core needle biopsy for diagnosis of extremity soft tissue sarcoma.

BACKGROUND: Classic teaching has advocated the use of open biopsy to diagnose and grade extremity soft-tissue sarcoma. Reported advantages of core needle biopsy include the minimal morbidity, cost, and time. The perceived disadvantage has been diagnostic inaccuracy. The objective of this study was to compare the diagnostic accuracy of core needle biopsy to incisional or frozen section biopsy for primary extremity masses suspicious for soft-tissue sarcoma. METHODS: Patients presenting with extremity masses were identified from our prospective soft-tissue sarcoma database (malignant) and from the clinical information center (benign) between January 1, 1990, and December 31, 1995. Biopsy and subsequent resection data were collected from the pathologic records. RESULTS: During this time, 164 primary extremity soft-tissue masses were evaluated before any biopsy. As the initial diagnostic approach, there were 60 core needle, 44 incisional, 36 frozen section, and 26 excisional biopsies. Two patients underwent two biopsy procedures. Ninety-three percent of the specimens obtained at core needle biopsy were adequate to make a diagnosis. Of the adequate core needle biopsy specimens, 95%, 88% and 75% correlated with the final resection diagnosis for malignancy, grade, and histologic subtype, respectively. Of the frozen section biopsy specimens, 94% were adequate, and accurate diagnostic results of malignancy were obtained with 88%. However, only 62% and 47% were correct for grade and histologic subtype, respectively, which was significantly different than the results obtained with incisional biopsy. The false-negative and false-positive rates for core needle biopsy were 5% and 0% for malignancy. Two core needle biopsy specimens graded low were found to be high, and one core needle biopsy specimen graded high was subsequently found to be low on final resection. CONCLUSIONS: When read by an experienced pathologist, the results of core needle biopsy provide accurate diagnostic information for malignancy and grade. Adequate core needle biopsy obviates the need for open biopsy and can be used for rational treatment planning. In the absence of adequate tissue, open biopsy is required.

Biopsy, Needle↗
PubMed2005

Development and validation of a performance-based measure of upper extremity functional limitation.

BACKGROUND AND AIMS: While the standardized lower extremity physical performance battery (LEPPB) is widely used to measure lower body functional limitation, no corresponding measure has been developed for upper body functional limitation. We combined three standard measures (William's Hand Test, Hand Signature, Functional Reach) to develop an upper extremity physical performance battery (UEPPB) analogous to the LEPPB, and examined its validity. METHODS: We used baseline data from a community-dwelling cohort of 749 Mexican American and European American elders and combined times to complete the William's Hand Board, Hand Signature, and distance on Functional Reach into a single composite measure, using scoring methods analogous to those for the LEPPB. We summarize concurrent, discriminant, and construct validity evidence for the UEPPB, based on observed associations with established measures of physical functional limitation, disability, and dependence. RESULTS: All correlations were in the expected direction. Shared variance with self-reported upper and lower extremity functional limitation was 10 and 5%, respectively, and with self-reported ADL disability, ADL dependency, and IADL dependency it was 32, 26, and 31%, respectively. In multivariate models of self-reported and performance-based disability and dependency, the UEPPB and LEPPB made significant, independent contributions and, net of contextual variables (age, sex, ethnic group, education, income) explained 4 to 10% of the variance in disability and dependency. CONCLUSIONS: The UEPPB is a valid performance-based measure of upper extremity functional limitation and makes an independent contribution beyond LEPPB in explaining disability and dependence.

Activities of Daily Living↗
PubMed2006

A novel exercise for improving lower-extremity functional fitness in the elderly.

BACKGROUND AND AIMS: Many falls in the elderly are caused by tripping. After tripping, a certain level of lower-extremity functional fitness is necessary, in order to make protective responses and to avoid falling. The purpose of this study was to test whether our new exercise program (a square-stepping exercise: SSE) would improve lower-extremity functional fitness in the elderly. METHODS: Fifty-two individuals aged 60-80 years were divided into two groups (non-randomized control design); SSE (n=26) and controls (n=26). Lower-extremity functional fitness was defined as standing up from a lying position (agility), chair-stand in ten seconds (leg power), walking round two cones (locomotion speed), sit-and-reach (flexibility) and single-leg balance with eyes closed (balance). The SSE group participated in a six-month regimen of SSE once a week. SSE was performed on a thin mat of 250 cm by 100 cm, partitioned into 40 small squares (25 cm each side). SSE included not only forward steps but also backward, lateral and oblique steps, and step patterns were progressively made more complicated. Controls maintained their usual lifestyles. RESULTS: In the SSE group, significant improvements were observed in agility, leg power, locomotion speed, flexibility and balance. No significant changes were detected in any tests in the control group. CONCLUSIONS: The SSE program improved lower-extremity functional fitness, lack of which constitutes a risk factor for falls in the elderly. This program should be tested further to determine if it can effectively reduce the incidence of falls in the elderly.

Accidental Falls↗
PubMed1998

[Free vascularized bone transplantation in the extremities].

There is a growing trend today which calls for reconstructing the loss of bigger bone parts in the area of extremities in a suitable manner. The microvascular bone transplantation for bridging bone defects is--admist other procedures--a distinct enrichment to preserve the extremities. This method of transplantation has the capability of surviving within a weakened transplant bed. Because of this capability one inevitably wants to know the criteria which determine the biological behaviour of the transplants. Furthermore, it is essential to known how this criteria can be best managed, considering the different indications and locations. The bone healing and bone hypertrophy of 81 patients who received vascularised bone transplantations have been examined with respect to different parameters. As the positive capacities of the vital transplants are almost exclusively dependent on the actual supply with blood, angiography have been undertaken during three months after surgery. 71 patients with a patent anastomosis after surgery have been evaluated. Differences in bone healing of the vascularised transplants have been observed in regard to the following parameter:--The tumor group showed a better rate of bone healing than those patients with trauma and congenital tibiapseudarthrosis.--The bone healing results of the group of younger patients were better than those of the group of older patients. Moreover the transplants without a history of infection were better compared with transplants with a history of infection. Clear differences of the fibula hypertrophy behaviour have been observed with respect to the following parameters: upper extremities < lower extremities, thigh < lower leg, longer transplants < shorter transplants, group of older patients (35-60 years) < group of younger patients (1-18 years), plates < screws.

Blood Circulation↗
PubMed1997

[Plastic surgery concepts for coverage of extremity defects within the scope of general surgery].

Soft tissue defects of the extremities are infrequent within the spectrum of general surgery and are predominantly found with perfusion disorders of macro- and microcirculation in the lower extremities. In the upper extremity, they are more frequently seen after i.v. cytostatic drug administration and tumor resections. This article describes the most frequent causes of complex defects of the extremities. Common flaps for the reconstruction of these defects and the pathway to decision making are elucidated.

Antineoplastic Agents↗