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PubMed1996

Extreme obesity may be linked to markers flanking the human OB gene.

Mice with mutations of the ob gene are extremely obese, and the human homologue (OB) has been cloned and physically mapped. The protein product of the ob gene (leptin) reduces body fat in mice when given exogenously, and leptin has been proposed to provide a lipostatic signal that regulates adiposity. Variation in the OB gene may be one genetically determined cause of obesity in human populations. To test this hypothesis, we genotyped siblings from 78 families at markers flanking the human OB gene. Pairs of siblings with extreme obesity (BMI > or = 40; n = 59) shared haplotypes identical-by-descent for the region containing the OB gene at greater than chance levels (corrected P = 0.04). Furthermore, one haplotype containing the OB gene was transmitted by heterozygous parents to extremely obese (BMI > or = 40) offspring more frequently than expected by chance, indicting significant allelic disequilibrium (corrected P = 0.027). One explanation for these linkage findings is that some individuals with extreme obesity have an allelic variant of the OB gene, although other nearby genes could contribute to obesity in these families.

Adipose Tissue↗
PubMed1988

Lower-extremity amputations in NIDDM. 12-yr follow-up study in Pima Indians.

The incidence of lower-extremity amputations was estimated in the Pima Indians of the Gila River Indian Community in Arizona, a population with a high prevalence of non-insulin-dependent diabetes mellitus (NIDDM). Between 1972 and 1984, from a study population of 4399 subjects, lower-extremity amputations were performed on 84 patients, 80 (95%) of whom had NIDDM. Among diabetic subjects, the incidence rate of first lower-extremity amputations was higher in men than in women. Rates increased significantly with increasing duration of diabetes. Presence of medial arterial calcification, retinopathy, or nephropathy; absence of patellar tendon reflexes; impaired great toe vibration-perception threshold; and degree of fasting and 2-h postload hyperglycemia were significant risk factors for amputations. Serum cholesterol concentration, blood pressure, age, and absence of Achilles tendon reflexes were not predictive of amputations. The death rate was greater in diabetic amputees than in diabetic nonamputees of similar age, sex, and duration of diabetes, and a significant increase in cardiovascular deaths was observed in diabetic subjects with amputations. The incidence rate of lower-extremity amputations in diabetic Pima Indians is higher than that reported in other diabetic populations. This may reflect differences in risk or a more complete case ascertainment than was possible in previous studies. If the latter is true, the rate of amputations in diabetic individuals may be higher than has been previously appreciated.

Adolescent↗
PubMed2001

Increased arterial wall stiffness limits flow volume in the lower extremities in type 2 diabetic patients.

OBJECTIVE: To document an association between arterial wall stiffness and reduced flow volume in the lower-extremity arteries of diabetic patients. RESEARCH DESIGN AND METHODS: We recruited 60 consecutive type 2 diabetic patients who had no history or symptoms of peripheral arterial disease (PAD) in the lower extremities and normal ankle/brachial systolic blood pressure index at the time of the study (non-PAD group) and 20 age-matched nondiabetic subjects (control group). We used an automatic device to measure pulse wave velocity (PWV) in the lower extremities as an index of arterial wall stiffness. At the popliteal artery, we evaluated flow volume and the resistive index as an index of arterial resistance to blood flow using gated two-dimensional cine-mode phase-contrast magnetic resonance imaging. RESULTS: Consistent with previous reports, we confirmed that the non-PAD group had an abnormally higher PWV compared with that of the control group (P < 0.001). To further demonstrate decreased flow volume and abnormal flow pattern at the popliteal artery in patients with a higher degree of arterial wall stiffness, we assigned the 60 non-PAD patients to tertiles based on their levels of PWV. In the highest group, magnetic resonance angiograms of the calf and foot arteries showed decreased intravascular signal intensity, indicating the decreased arterial inflow in those arteries. The highest group was also characterized by the lowest late diastolic and total flow volumes as well as the highest resistive index among the groups. From stepwise multiple regression analysis, PWV and autonomic function were identified as independent determinants for late diastolic flow volume (r(2) = 0.300; P < 0.001). CONCLUSIONS: Arterial wall stiffness was associated with reduced arterial flow volume in the lower extremities of diabetic patients.

Aged↗
PubMed2003

Progression of lower-extremity disability in older women with diabetes: the Women's Health and Aging Study.

OBJECTIVE: Older patients with diabetes are more likely to have a higher prevalence of multiple risk factors for physical disability, as a result of diabetic complications. We evaluated the pace of decline in lower-extremity function and the risk for progression of disability in older women with diabetes. RESEARCH DESIGN AND METHODS: We conducted a 3-year longitudinal cohort study of a random sample of 729 physically impaired older women (age > or =65 years) living in the community (Baltimore, MD). Diabetes was ascertained by standard criteria. Self-reported functional status and objective performance measures were assessed at baseline and over six semiannual follow-up visits. RESULTS: The baseline prevalence of diabetes was 14.4%. After adjustment for age and compared with women without diabetes, those with diabetes had an RR of 1.8 (95% CI 1.3-2.5) for incident mobility disability and 1.6 (1.2-2.1) for incident activity of daily living disability. The increased incidence of new disability associated with diabetes was paralleled by a greater decline in objective measures of lower-extremity function. Adjustment for multiple risk factors for disability did not significantly attenuate the risk for disability associated with diabetes. CONCLUSIONS: In older patients, impaired lower-extremity function is a long-term diabetic complication. Comprehensive assessment of older diabetic patients should include a standardized evaluation of lower-extremity performance.

Activities of Daily Living↗
PubMed2004

The epidemiology of lower-extremity disease in veterans with diabetes.

OBJECTIVE: To describe the epidemiology of lower-extremity complications of diabetes in veterans who are users of the Department of Veterans Affairs (VA). RESEARCH DESIGN AND METHODS: Hospital discharge records for care provided in all VA hospitals in 1998 were obtained. All hospitalizations for lower-extremity ulceration, peripheral vascular procedures, and amputation were analyzed using frequency tables. A diabetes denominator was defined as a veteran with at least three ambulatory care visits with at least one diabetes diagnosis code. Age-specific and total age-adjusted rates of discharge with ulceration, vascular procedures, and amputation were calculated. RESULTS: Veterans with diabetes comprised over half of all hospitalizations for lower-extremity ulceration, one-third of all hospitalizations for peripheral vascular procedures, and two-thirds of all hospitalizations for amputation. The age-specific discharge rate per 1,000 diabetic persons for age 0-64 years, 65-74 years, and 75 years and older for ulceration were 28.4, 31.0, and 37.9; for vascular procedures, the rates were 3.5, 4.4, and 4.4; and for amputation, the rates were 7.3, 9.0, and 10.0, respectively. CONCLUSIONS: Veterans with diabetes comprise a significant proportion of hospitalizations for lower-extremity ulceration, peripheral vascular bypass, and amputation. Age-specific rates of diabetic amputation in veterans are lower than U.S. rates.

Adult↗
PubMed1994

Relationship of fatigued run and rapid stop to ground reaction forces, lower extremity kinematics, and muscle activation.

Fatigue may be related to lower extremity injury. The effect of lower extremity fatigue on ground reaction force production, lower extremity kinematics, and muscle activation during the landing phase of a run and rapid stop was investigated. Subjects were 19 female, Division 1 collegiate basketball and volleyball players (mean age = 20.8 +/- 1.8 years, mean weight = 71.7 +/- 6.9 kg, mean height = 174 +/- 5 cm). Dominant leg ground reaction and muscle activation data were sampled at 2,000 Hz. Lower extremity kinematic data were sampled at 200 Hz, and three-dimensional analysis was performed. Knee extensor/flexor muscle activation tended to be delayed during fatigue (p < or = .08). Maximum knee flexion tended to occur earlier during fatigue (p < or = .09). Step-wise multiple regression suggested that the knee may be the primary site of force attenuation following fatigue. During fatigue, biodynamical compensations in the mechanical properties of the knee extensor musculature, as evidenced by differences in knee kinematics and muscle activation times, may occur to enhance knee stability.

Adult↗
PubMed2005

Cervical radiculopathy or Parsonage-Turner syndrome: differential diagnosis of a patient with neck and upper extremity symptoms.

STUDY DESIGN: Resident's case problem. BACKGROUND: The signs and symptoms of cervical radiculopathy (CR) warrant the consideration of several other conditions in CR's differential diagnosis. One condition that may mimic CR, which is not well known amongst physical therapists, is Parsonage-Turner syndrome (PTS). PTS is characterized by an onset of intense pain that typically subsides within days to weeks. However, as pain subsides, weakness and/or paralysis may develop in upper extremity muscles. The purpose of this resident's case problem is to describe a patient who presented to our clinic with a diagnosis of CR, but had findings consistent with PTS. DIAGNOSIS: The patient was a 43-year-old male referred to physical therapy with a diagnosis of CR. He had a previous episode of CR 1 year ago that was treated successfully. He had positive magnetic resonance imaging findings of structural abnormalities suggestive of causative factors for CR. The patient was treated for CR with thoracic and cervical spine manipulations and intermittent cervical traction. The initial acute severe pain subsided, but weakness in the upper extremity worsened. Diagnosis of PTS was made upon exclusion of other potential confounding diagnoses and the findings of fibrillation potentials and positive waves in electrodiagnostic studies. DISCUSSION: CR and PTS are characterized by pain in the cervical spine, shoulder, and upper extremity. CR generally has an insidious onset, while PTS has a rapid onset of intense pain. Symptoms of CR are exacerbated with neck movements, while symptoms related to PTS should not be exacerbated with neck movements. In patients that do not respond to conventional therapy and have a progression of upper extremity muscle weakness, regardless of decreased pain, the diagnosis of PTS should be considered.

Adult↗
PubMed1996

Morphological analysis of the human lower extremity based on the relative muscle weight.

Morphological study of the muscles of the lower extremity is necessary for the analysis of the muscular function and its relation with locomotion. In this study, the muscle weight of the lower extremities from 11 adult Japanese cadavers (6 males and 5 females, aged from 50 to 91 years old) were measured. The morphological characteristic of the human lower extremity is discussed based on the relative muscular weight. The largest muscles were the gluteus maximus (the extensor at the hip joint), the vasti muscles (the extensor at the knee joint) and the soleus (the plantarflexor at the ankle joint). These results reveal that the muscles acting on one joint are developed in the human lower extremity and that these muscles have important roles in human locomotion.

Aged↗
PubMed1999

Variations of the extreme-lateral craniocervical approach: anatomical study and clinical analysis of 69 patients.

OBJECT: The aim of this study was to describe six variations of the extreme-lateral craniocervical approach, their application, and treatment results. METHODS: During a 4-year period 69 patients underwent surgery in which six variations of the extreme-lateral craniocervical approach were performed. The variations included: the transfacetal approach (TFA), performed to treat four lesions in the upper cervical spine anterior or anterolateral to the spinal cord; the retrocondylar approach, to treat five intradural lesions located anterolateral to the medulla oblongata and six vascular lesions to expose the extradural segment of the vertebral artery (VA); the partial transcondylar approach (PTCA), to treat 18 intradural lesions located anterior to the medulla oblongata; the complete transcondylar approach (CTCA), to treat 13 extradural lesions that involved the lower clivus and anterior upper cervical spine; the extreme-lateral transjugular approach, to treat 14 jugular foramen tumors; and the transtubercular approach with or without division of the sigmoid sinus, to treat complex VA and vertebrobasilar junction aneurysms. An anatomical prosection was performed to study the surgical exposure of each of the six variations of the extreme-lateral craniocervical approach. Total removal was achieved in 35 (69%) of the patients with tumor; subtotal resection was achieved in 16 (31%) of those patients. In the 12 patients with VA aneurysms, seven underwent clipping, three underwent trapping and a vein graft bypass procedure, and two underwent trapping without the use of a bypass procedure. In five other patients, different cystic, inflammatory, and other vascular lesions were successfully treated. Fifty percent of the patients who underwent surgery via the TFA, 83% via the of the CTCA, and 11% via the PTCA required an occipitocervical fusion procedure. The mean Karnofsky Performance Scale score was 74.7 preoperatively and 76.4 postoperatively. Major complications were hydrocephalus (nine patients), cerebrospinal fluid leakage (seven patients), worsened cranial nerve function (seven patients), vertebrobasilar vasospasm (one patient), and sigmoid sinus thrombosis (one patient). CONCLUSIONS: To treat lesions in the region of the foramen magnum and surrounding areas, the approach should be tailored to each specific lesion to provide the needed exposure without unnecessary operative steps.

Adult↗
PubMed2002

Extreme lateral-transatlas approach for resection of the dens of the axis.

OBJECT: Various approaches have been described for resection of the dens of the axis, each of which has potential advantages and disadvantages. Anterior approaches such as the transoral route or its modifications are the most commonly used for resection of this structure. The transcondylar approach, however, which allows the surgeon to view the craniovertebral junction (CVJ) from a lateral perspective, has been introduced by Al-Mefty, et al., as an alternative approach. In this report, the authors describe the surgical technique of the extreme lateral-transatlas approach and their clinical experiences. METHODS: The authors first examined the surgical approach to the dens from a lateral perspective in five cadaveric heads. They found that removal of the lateral mass of the atlas provided adequate exposure for resection of the dens. Following this cadaveric study, the extreme lateral-transatlas approach was successfully performed at the authors' institution over a 1-year period (September 1998-August 1999) in five patients with basilar invagination due to congenital anomaly of the CVJ and rheumatoid arthritis. Furthermore, during the same procedure, unilateral occipitocervical fusion was performed following resection of the dens. In all cases complete resection of the dens was achieved using the extreme-lateral transatlas approach. This procedure provides a sterile operative field and the ability to perform occipitocervical fusion immediately following the resection. No postoperative complications or craniocervical instability were observed. The mean follow-up period was 17.2 months (range 13-24 months). CONCLUSIONS: The extreme lateral-transatlas approach for resection of the dens was found to be safe and effective. Knowledge of the anatomy of this region, especially of the V3 segment of the vertebral artery, is essential for the success of this procedure.

Adult↗
PubMed1994

The effects of casting on upper extremity motor disorders after brain injury.

OBJECTIVES: This study compares casting to traditional techniques, such as passive range of motion, static stretch, and splinting, in the treatment of the hypertonic upper extremity in individuals with severe brain injury. METHOD: Fifteen subjects with brain injury were randomly assigned to one of two groups. One group received a month of casting followed by a month of traditional therapy; the second group received 1 month of traditional therapy followed by casting. The subjects' limbs were evaluated for range of motion, clinical indications of spasticity, and functional use of the extremity at three intervals--before intervention, after the first month of intervention, and after the second month of intervention. Two sample t-tests and paired t-tests were used in data analysis. RESULTS: All but one subject showed a greater improvement in range of motion with casting than with traditional treatment; 11 subjects showed a greater improvement in clinical measures of spasticity with casting. There was no apparent correlation between these measures and functional use of the extremity. CONCLUSION: These findings suggest that casting is more effective than traditional techniques in reducing contracture and in decreasing hypertonicity in some cases. The greater improvements in these motor indicators with casting did not translate into greater gains in functional use of the upper extremities.

Adolescent↗
PubMed1994

Occupational cumulative trauma disorders of the upper extremity.

The umbrella term cumulative trauma disorders (CTDs) (also known as repetitive strain injuries, overuse syndromes, and repetitive motion disorders) covers a number of similar conditions arising from overuse of the joints or soft tissues of the upper extremity. Occupational CTDs have become a common problem in the workplace. These disorders are costly to the employer, the worker, and society in terms of time lost from work and resulting disability. Within the past decade, occupational therapists and physical therapists specializing in rehabilitation of work-related musculoskeletal injuries have seen an increase in the incidence of CTDs of the upper extremity in the workplace. Therapists are called upon not just to treat these injured workers, but also to help them regain a functional level for work reentry and to educate them to prevent reinjury. This article reviews the literature on the epidemiology, etiology, pathophysiology, and management of upper-extremity occupational CTDs. Because the ultimate goal of the workplace is to maintain the health and safety of the employee, an educational approach to hand, wrist, elbow, and shoulder use is essential to prevent, decrease, or eliminate the risk of occupational CTDs of the upper extremity.

Arm Injuries↗
PubMed2006

Games researchers play--extreme-groups analysis and mediation analysis in longitudinal occupational health research.

OBJECTIVES: The study of causal processes using a longitudinal design is often hampered by two methodological problems. First, the lagged effects of a predictor variable on an outcome variable tend to be weak after control for a previous measure of this outcome. One approach that is advocated when effects are weak is to increase the extremeness of the study groups; this step often increases the significance and sizes of effects. Second, causal links are often mediated through third variables, and thus relatively complex mediational analyses are needed to understand the causal processes underlying particular associations. The present paper shows whether and when these two approaches are useful in longitudinal research. METHODS: The two approaches were evaluated using data from a three-wave study among 1251 newcomers from various Western countries (mean age 20.6 years, 59% female). RESULTS: Although the significances and effect sizes indeed increased with increasing extremeness of the study groups, extreme-groups analysis in the context of a longitudinal design may grossly bias findings. Cross-sectional applications of mediation analysis cannot provide evidence for any mediational model. Longitudinal models are better suited for examining mediation. CONCLUSIONS: Rather than using extreme-groups analysis to obtain significant effects across time, researchers should maximize the amount of change in their data by focusing on groups for which change can be expected. Especially multiphase longitudinal data sets offer good opportunities for analyzing mediation models.

Adult↗
PubMed2006

Hypothermia and hyperthermia medicolegal investigation of morbidity and mortality from exposure to environmental temperature extremes.

CONTEXT: The determination of the cause of death from exposure to extreme temperatures is a diagnosis of exclusion. Because both clinical and autopsy findings are nonspecific, a thorough investigation of the background and scene, evaluation of temporally relevant environmental conditions, and assessment of the victim's underlying state of health with appropriate laboratory studies, which frequently include autopsy, are essential to establish the cause of injury and/or death with reasonable medical probability. Individuals may encounter environmental extremes in many settings during any season. Both constitutional and external factors exacerbate the stress brought about by extreme temperature. OBJECTIVE: This article reviews guidelines for forensic investigation into environmental temperature extremes that contribute to an important seasonal grouping of morbidity and mortality in the United States. DATA SOURCES: Articles on clinical and pathologic aspects of hyperthermia and hypothermia were collected and reviewed. CONCLUSIONS: Recognition of multiple risk factors predisposing humans to both cold-related and heat-related morbidity and mortality enhances prevention. Awareness of the susceptibility of these exposed at-risk individuals is crucial to investigations by both clinicians and medicolegal death investigators.

Environment↗
PubMed2000

Lower-extremity edema associated with gene transfer of naked DNA encoding vascular endothelial growth factor.

BACKGROUND: Vascular endothelial growth factor (VEGF) promotes angiogenesis and vascular permeability. The extent to which VEGF may cause tissue edema in humans has not been established. OBJECTIVE: To evaluate patients undergoing VEGF gene transfer for evidence of lower-extremity edema. DESIGN: Prospective consecutive case series. SETTING: Hospital outpatient clinic. PATIENTS: 62 patients with critical limb ischemia and 28 patients with claudication. INTERVENTION: Gene transfer of VEGF DNA. MEASUREMENTS: Semiquantitative analysis of lower-extremity edema. RESULTS: Lower-extremity edema was observed in 31 of 90 (34%) patients. Edema was less common in patients with claudication than in those with pain at rest (P = 0.016) or ischemic ulcers (P < 0.001), and it was less common in patients with pain at rest than in those with ischemic ulcers (P= 0.017). Treatment was typically limited to a brief course of oral diuretics. CONCLUSIONS: Vascular endothelial growth factor may enhance vascular permeability in humans. At the doses of plasmid DNA used in this study, lower-extremity edema responded to oral diuretic therapy and did not seem to be associated with serious sequelae.

Administration, Oral↗
PubMed1999

Effect of podiatric medical care on rates of lower-extremity amputation in a Medicare population.

The purpose of this study was to determine whether Medicare patients at risk for lower-extremity amputation due to complications from diabetes, peripheral vascular disease, and/or gangrene who receive the services classified under Level II code M0101 of the Health Care Financing Administration's Common Procedure Coding System (cutting or removal of corns, calluses, and/or trimming of nails, application of skin creams and other hygienic and preventive maintenance care) have lower rates of lower-extremity amputation than those who do not receive such services. Analysis of the data suggests that those at-risk beneficiaries who received these services were nearly four times less likely to experience lower-extremity amputation than those who did not receive such services. The study has both methodologic limitations (the study considers only one variable, receipt or nonreceipt of certain types of podiatric medical care, while other variables may affect rates of lower-extremity amputation) and technological limitations (attempts to link the 2 years of per case Medicare Part B data were unsuccessful, limiting the length of the study to 1 year). Further research on this topic is encouraged.

Aged↗
PubMed2002

Clinical experience with upper extremity venous sonography in a high-risk cancer population.

OBJECTIVE: To determine the frequency of sonographically evident upper extremity venous thrombosis in symptomatic cancer patients with and without central venous catheters. METHODS: Retrospective review of 573 consecutive upper extremity venous sonographic reports from a 26-month period was performed. Findings including distribution of venous thrombosis, the presence of a central line, cancer type, and miscellaneous findings were recorded. RESULTS: Overall, 514 studies (90%) had satisfactory visualization of all upper extremity vessels; 53 (9%) had limited visualization of 1 or more vessels; and 6 (1%) were inconclusive. Venous thrombosis was present in 227 (40%) of 573 studies. Of the studies with positive findings, there were 186 acute, 13 chronic, 19 fibrin sheath versus nonocclusive, and 9 superficial thromboses. Central venous catheters were present in 325 (57%) of 573 studies. Sonographically evident thrombosis was present in 157 (48%) of 325 studies with central catheters versus 70 (28%) of 248 studies without central venous catheters (P = .001) CONCLUSIONS: Upper extremity venous thrombosis is common (40%) in symptomatic cancer patients and is nearly twice as frequent in cancer patients with indwelling central venous catheters.

Arm↗
PubMed2002

High-resolution sonography of lower extremity peripheral nerves: anatomic correlation and spectrum of disease.

OBJECTIVE: The value of sonography for the diagnosis of diseases of the peripheral nervous system is only little known. This image presentation is intended to raise the awareness of sonographers and clinicians of the potential of sonography by giving an anatomic-sonographic correlation of lower extremity peripheral nerves and an overview of commonly encountered diseases. METHODS: On 2 lower extremity cadaver specimens, peripheral nerves were imaged in typical locations such as the tarsal tunnel. During sonography the nerve was injected with blue dye, and thin-slice anatomic sections were obtained at the scan level with a chain saw. In addition, sonographic images of patients with typical diseases are shown. RESULTS: An excellent anatomic-sonographic correlation was obtained, which underlines the feasibility of sonography for imaging of lower extremity peripheral nerves. Reliable results may be obtained with sonography of typical disease processes of lower extremity peripheral nerves. CONCLUSIONS: Recent developments in sonographic technology such as the introduction of high-frequency linear array transducers, compound imaging, and extended field-of-view imaging strongly improve the applicability of transcutaneous sonography for the examination of peripheral nerve disease.

Cadaver↗