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PubMed1999

Survival of patients with melanoma of the lower extremity decreases with distance from the trunk.

BACKGROUND: Early stage melanoma of the lower extremity is generally associated with a favorable prognosis. However, several retrospective studies have suggested that melanoma on the foot portends poor survival. The authors hypothesized that the region of the lower extremity has prognostic importance. METHODS: Between January 1, 1971, and December 31, 1991, 652 patients were seen at the John Wayne Cancer Institute for a primary melanoma on the foot (92 patients), calf (336 patients), or thigh (224 patients). All patients had clinically or histopathologically negative regional lymph nodes. The duration of follow-up after first diagnosis was 9 -302 months, with a minimum of 6 years for survivors. Survival curves were estimated by the Kaplan-Meier method. Pearson chi-square test was used to test differences associated with the regional site of the lower-extremity melanoma. The log rank test was used for univariate analysis, and Cox proportional hazards regression was used for multivariate analysis. RESULTS: Univariate analysis identified regional site, gender, Breslow depth, Clark level, and age at diagnosis as significant for both overall survival (OS) and disease free survival (DFS) (P = 0.0001). Multivariate analysis confirmed regional site as an independent prognostic variable for OS (P = 0.0002) and DFS (P = 0.0005). Ten-year rates of OS and DFS were 71% and 66%, respectively, for patients with foot melanomas, compared with 92% and 87% for those with calf melanomas and 95% and 94% for those with thigh melanomas. CONCLUSIONS: The prognosis for patients with primary melanoma of the lower extremity is affected by the distance of the lesion from the trunk. Thus, distal (foot) lesions carry a higher risk than thigh lesions. This difference should be considered as a covariate when stratifying patients in clinical trials.

Adult↗
PubMed1976

[Dynamics of neurologic disorders following embolism of the bifurcation of the aorta and major arteries of the lower extremities].

The authors conducted a clinico-EMG study of 118 patients with an embolism of the aortal bifurcation and magistral arteries of the lower extremities. Among this contingent 58 were studied in the remote period -- from 2-7 years following a surgical operation. The clinical symptoms of embolism were expressed in severe pain, sensory, motor and vegetative-trophic disturbances in the affected extremities. Three degrees of the nervous system lesions were distinguished in an embolism. It was also demonstrated that there were significant changes in the bioelectrical muscle activity of the extremities. In the remote period following embolectomia, in most of the patients there still were sequalae of acute ischemia of the nervous tissue, the expressiveness of which depended upon the calibre of the occluded vessel, degree of tissue ischemia, the time of treatment and the time following the operation. A retarded restitution may be explained by the degree of the nervous tissue lesion and the persisting insufficiency of circulation in the extremities.

Aortic Diseases↗
PubMedDate not supplied

Scintigraphic imaging of lower-extremity acute venous thrombosis.

The need for a radiopharmaceutical that will yield a definitive diagnosis of acute venous thrombosis in the lower extremities is evident from (1) the current difficulty in making a diagnosis on the basis of clinical signs and symptoms alone; (2) the sometimes inadequate or less sensitive diagnosis made on the basis of contrast venography or ultrasound; and (3) the need to prevent pulmonary embolism, death, and other long-term sequelae that may result from undetected acute venous thrombosis. A new radiopharmaceutical was recently approved for use in the scintigraphic imaging of acute venous thrombosis in the lower extremities of patients who have signs and symptoms of acute venous thrombosis. This radiopharmaceutical (ACUTECT) is a complex of the small synthetic peptide apcitide and the radionuclide technetium (Tc) 99m (99mTc-apcitide). Apcitide binds to glycoprotein IIb/IIIa receptors, which are expressed on the surface of activated platelets, making the radiopharmaceutical specific for acute, not chronic, thrombi. 99mTc-Apcitide allows accurate imaging of the entire lower extremities, including the calf. It has an excellent safety profile, is easy to administer by injection into an antecubital vein, and allows early imaging of acute deep-vein thrombosis (10 to 60 minutes postinjection). 99mTc-Apcitide may be used as an alternative to contrast venography and a complement to ultrasonography in the detection of acute venous thrombosis in the lower extremities.

Acute Disease↗
PubMed1999

Outpatient use of low molecular weight heparin (Dalteparin) for the treatment of deep vein thrombosis of the upper extremity.

Upper extremity deep vein thrombosis (DVT) is now recognized as a major cause of morbidity and mortality. There is little information regarding the most effective treatment of this condition. We report a prospective cohort study of the use of low molecular weight heparin (LMWH) in the outpatient management of upper extremity DVT. Forty-six patients were managed as outpatients for objectively documented upper extremity DVT with dalteparin (200 aXa u/kg), for a minimum of five days. Warfarin was usually initiated on the first day with a target INR of 2.0-3.0. Most patients had an underlying malignancy or a history of a central line. All patients were followed for 12 weeks from diagnosis. Only one patient had a major bleed. No patients developed pulmonary emboli. One patient had a recurrence of DVT during the treatment with LMWH with extension of the existing thrombus. Seven patients died, all due to their underlying disease. This study supports the safety and effectiveness of dalteparin in the treatment of upper extremity DVT. Given that these patients were treated as outpatients, there is a potential for huge cost savings.

Adolescent↗
PubMed1999

Going to extremes: family structure, children's well-being, and social science.

In this article I argue that public discussions of demographic issues are often conducted in a troubling pattern in which one extreme position is debated in relation to the opposite extreme. This pattern impedes our understanding of social problems and is a poor guide to sound public policies. To illustrate this thesis I use the case of social scientific research examining how children are affected by not living with two biological parents while they are growing up. Over the last decade, I maintain, most of the public, and even many social scientists, have been puzzled and poorly informed by this debate. In particular I consider Judith Wallerstein's clinically based claims of the pervasive, profound harm caused by divorce and, at the other extreme, Judith Rich Harris's reading of behavioral genetics and evolutionary psychology, which leads her to dismiss the direct effects of divorce. Neither extreme gives a clear picture of the consequences of growing up in a single-parent family or a stepfamily.

Child↗
PubMed1997

[Experimental study on the effect of extremities ischemia reperfusion inducing anterior tibial compartment pressure].

We observed the changes of compartment pressure after extremities were reperfused at different intervals of ischemia and its relationship with the changes of serum MDA and CPK content. The protective effect of mannite on extremities ischemia reperfusion was also studied. 18 New Zealand rabbits were separated into three groups: group A (ischemia 4 h); group B (ischemia 8 h); group C (ischemia 4 h). The rabbits of group A and B were intravenous injected with normal saline (NS), and group C was injected with 20% mannite. The changes of compartment pressure of serum MDA and CPK content and the histological changes of skeletal muscles in every group were noted at different times: preoperation; the beginning of ischemia; the end of ischemia and reperfusion for 4 h; 24 h; 72 h, respectively. The longer ischmia lasted, the more serious the tissue damage was. Reperfusion made tissue damaged further. After reperfusion for 24 h, the damage was the most serious. Meanwhile, the serum MDA and CPK content also reached the peak value. These changes were in accord with those of compartment pressure. On the other hand, the damage of mannite group was relatively mild. Extremity ischemia reperfusion would led to the increase of compartment pressure, then intensified the damage. The damage was the most serious at 24 h of reperfusion. Using mannite could reduce the tissue damage and compartment pressure. Mannite should be recommended as the first-selected drug for extremity ischemia reperfusion injury.

Animals↗
PubMedDate not supplied

Gait variables of patients after lower extremity burn injuries.

Functional ambulation is an expected outcome of physical therapy after burn injuries on the lower extremities. The purpose of this study was to document temporal and spatial gait parameters of adult patients with the use of the GAITRite system (CIR Systems Inc, Clifton, NJ) after the patients were burned on their lower extremities and to compare these results with previous data reported for normal subjects. Twenty-five adults with lower extremity burns (19 men and 6 women; mean age, 35.6+/-8.3 years) were evaluated within 5 days of discharge from an acute care facility. The GAITRite system, which consists of an electronic walkway that contains 6 sensor pads encapsulated in a rolled-up carpet, was used to collect temporal and spatial variables. The patients walked at their preferred rate of ambulation and completed 2 passes; the 2 passes were then averaged by the software to determine the patients' gait parameters. A 2-tailed t test was used for comparison of the mean values for the patients and the previously published data. The results indicated that for both men and women, cycle time and base of support were significantly higher (P < or = .01) in the patients with burn injuries than in normal subjects. For men, all of the remaining parameters were significantly lower (P < or = .01) in the patients with burns except stride length, which was not significantly different (P > .05). For women, stance time as a percentage of the gait cycle and cadence, velocity, step length, and stride length, were all significantly lower (P < or = .01) in the patients with burn injuries, whereas double support as a percentage of the gait cycle was not significantly different (P > .05) between the 2 groups. These results indicate that immediately after an acute care hospitalization, patients with lower extremity burns have significantly different gait patterns than gender-and age-matched normal subjects. Future studies are necessary to determine whether these impairments in gait limit the functional abilities of a patient.

Adult↗
PubMed2001

Assessment of the clinical significance of asymptomatic lower extremity uptake abnormality in young athletes.

UNLABELLED: This study was undertaken to evaluate our hypothesis that most asymptomatic lower extremity uptake abnormalities are of no clinical consequence and to assess whether these findings should affect patient care. METHODS: One hundred consecutive young athletes referred for bone scintigraphy by a sports medicine clinic because of low back pain were evaluated for the presence of asymptomatic bone scan abnormalities in the lower extremities. The patients were then reexamined by the referring sports medicine physician, who had full knowledge of the bone scan results. Scintigraphic findings were correlated with the clinical evaluation at the time of scintigraphy and on follow-up evaluations ranging from 8 to 14 mo later. RESULTS: Asymptomatic lower extremity abnormalities were present in 34% of patients. There were abnormalities of the feet in 30 patients (focal uptake in 26 patients, diffuse uptake in 10 patients), the tibia in 13 patients (2 focal uptake, 11 diffuse uptake), and the femur in 2 patients (both with diffuse uptake). None of the regions of abnormal lower extremity uptake was symptomatic at the time of initial evaluation. There was no change in the clinical management of any patient because of the scan findings. None of the patients was advised to restrict the activity level because of the asymptomatic scan findings. None of the regions of scan abnormality became symptomatic on follow-up evaluation. CONCLUSION: This study shows that asymptomatic bone scintigraphic abnormalities of the feet, as well as diffuse abnormalities of the tibia, are common in young athletes. These findings are most likely of no clinical consequence and do not require a change in the activity level. Focal abnormalities of the femur or tibia are not commonly seen in asymptomatic young athletes.

Adolescent↗
PubMed2000

Occlusive arterial diseases of the upper and lower extremities found in workers occupationally exposed to vibrating tools.

Hand-arm vibration syndrome (HAVS) is primarily a disorder of the fingers and hands. However, in some cases, vibration-exposed workers are observed to have also episodic blanching of the hands and feet. In latter cases, arteriographies of both the upper and lower extremities are necessary to diagnose the background arterial disorders. In this study, eight HAVS subjects with such disorders were examined by arteriography for differential diagnosis in cases of workers' accident compensation. In three HAVS cases with thromboangiitis obliterans, the arteriographic examination revealed obstructive changes in the palm and forearm as well as three below-knee lesions in the lower extremities. In five HAVS cases with arteriosclerosis obliterans, obstruction kinking or coiling, stenosis and/or tapering-off of the proper digital arteries were observed together with two below-knee lesions and three high lesions in the lower extremities. From the viewpoint of occupational health, palpation of superficial arteries of both the upper and lower extremities should be routinely performed during both pre-placement and periodic medical examinations for workers exposed to vibrating tools for early detection and/or prevention of any worsening of the background disorders.

Adult↗
PubMed2001

Personality factors, stoicism and motivation in subjects under hypoxic stress in extreme environments.

Previous studies on the physiological and psychological adaptation of subjects to survival conditions involving high-altitude hypoxia (>6,500 m) have shown that personality factors are important in this adaptation. We, therefore, proposed personality traits assessments in two groups of subjects engaged in sporting activities under extreme hypoxic environmental conditions: a group of mountaineers at high altitudes (>5,500 m) and a group of free-lung divers at great depths (<30-60 m). These subjects were compared with two control groups: a group of subjects practicing no sport and another one practicing various competitive athletic activities involving speed constraints. The personality traits assessed concerned mainly the subjects' attitudes and their propensities to act out their feelings and fantasies; they were assessed using projective procedures, the Hand Test and Clark's Situational Pain Questionnaire based on the Sensory Decision Theory. Subjects trained in mountaineering and free-lung diving under extreme environmental conditions displayed a high degree of stoicism. These individuals shared some personality traits with other sportsmen, particularly aggressive tendencies and introversion although not to an extent which interfered with normal interpersonal relationships. However, at least when practicing these extreme sports, the subjects did retreat from society. One of our questions concerns the grounds for this social withdrawal, that is, whether it derives from a inner compulsion founded on personality factors or if it is merely an artifact of our perceptions of the subjects, created by the confluence of the individualistic nature of these sports and the extreme environments in which they are performed.

Acclimatization↗
PubMed2001

Post-traumatic stress disorder in extremely poor women: implications for health care clinicians.

OBJECTIVES: To identify childhood antecedents for lifetime post-traumatic stress disorder (PTSD) and to determine how this diagnosis relates to health and service use among extremely poor women. METHODS: We conducted a secondary data analysis of 425 women in the Worcester Family Research Project, a case-control longitudinal study of 220 sheltered homeless and 216 extremely poor housed (never homeless) women in Worcester, Massachusetts. RESULTS: We found that extremely poor women with lifetime PTSD were more likely to have grown up in family environments of violence, threat, and anger than those without PTSD. The strongest risk factor for PTSD was childhood sexual abuse with threat. Low-income women with lifetime PTSD had more bodily pain, even when controlling for other health and demographic factors. Women with PTSD experienced more chronic health conditions and had more problematic relationships with their health care providers and perceived more barriers to care. CONCLUSION: Many low-income women have difficulty using medical care appropriately because of childhood histories of physical and sexual abuse, the subsequent development of post-trauma responses, and structural barriers to care. Given these factors, it is critical that health care clinicians routinely screen for histories of violence and PTSD and develop treatment plans that ensure safety, link current symptoms with prior experiences, and provide support as necessary. A team approach coordinated by a case manager may be the best strategy. Without routine screening for PTSD and sensitive treatment, many extremely poor women will receive compromised health care and may even be retraumatized.

Adult↗
PubMedDate not supplied

Assessment of the temperature distribution during hyperthermia treatment by isolated extremity perfusion.

A finite-element model of the human leg is developed for the assessment of temperature distribution during hyperthermia treatment by isolated extremity perfusion with a heart-lung-machine. The simulation comprises the true geometry, adequate perfusion models for the different parts of the extremity circulation in normal and tumour tissue, and the numerical procedure for the solution of the partial differential heat balance equation used. The simulation is validated using both experimental physiological and clinical data, and predicts temperature distributions and courses for various modifications of the hyperthermia procedure. It is concluded that the homogeneous temperature required in combination with chemotherapy can be achieved by isolated extremity perfusion, if a good thermal insulation is applied. If temperatures >42 degrees C are required, an additional external heat source (microwaves or ultrasound) is necessary. Although these sources may produce high absorption rates, combination with extremity perfusion is useful in reducing higher temperature gradients and the danger of locally lower temperatures.

Chemotherapy, Cancer, Regional Perfusion↗
PubMedDate not supplied

Distal extremity swelling with pitting edema in psoriatic arthritis: a case-control study.

OBJECTIVE: To evaluate the frequency and the clinical characteristics of distal extremity swelling with pitting edema in patients with psoriatic arthritis (PsA). METHODS: This was a case-control study of consecutive outpatients with PsA (old and new diagnosis) observed over a 3-month period in three secondary referral centers in Italy. As controls we used the two consecutive rheumatic outpatients, excluding those with spondylarthropathies, observed after a PsA patient. The demographic and clinical features were assessed by clinical examination and review of the medical records. RESULTS: A total of 183 patients with PsA and 366 controls were evaluated. Distal extremity swelling with pitting edema was recorded in 39/183 (21%) PsA patients and in 18/366 (4.9%) controls (p < 0.0001). In 8/39 (20%) patients this feature presented as a first, isolated manifestation of PsA, and in 8 others it was associated with other features of PsA at diagnosis. The upper and lower extremities were affected, predominantly asymmetrically, in 40% and 60% of the cases respectively. In patients with pitting edema compared to those without this feature, the frequency of Achilles enthesitis and plantar fasciitis, calculated together, was higher (p < 0.05) and the duration of arthritis was significantly lower (p = 0.02). In 7 patients the clinical evidence of a predominant involvement of tenosynovial structures was confirmed by MRI. CONCLUSION: Upper or lower distal extremity swelling with pitting edema due to tenosynovitis, usually unilateral, is a common feature in PsA patients and may represent the first, isolated manifestation of the disease.

Adult↗
PubMed2001

Upper extremity venous gangrene following coronary artery bypass. A case report and review of the literature.

Acute symptomatic upper extremity deep vein thrombosis (DVT) are estimated to account for only 2-4% of all deep vein thrombosis. Upper extremity DVT leading to phlegmasia cerulea dolens (PCD) occurs in an estimated 2-5% of these cases. Progression of PCD to venous gangrene is extremely rare with only 16 previously reported cases in the literature. Only 7 of the cited cases document significant tissue loss. This report describes a 61-year-old male who developed upper extremity DVT complicated by PCD which led to venous gangrene and limb loss.

Amputation, Surgical↗
PubMed2000

Survival pattern among extreme preterm infants.

OBJECTIVE: To look at the survival pattern of extreme preterm Omani infants (23-26 weeks gestation) and compare it with the western countries. METHODS: All extreme preterm Omani infants (gestational age of 23 to 26 weeks) admitted from November 1991 to February 1998 at the Neonatal Intensive Care Unit of Sultan Qaboos University Hospital were reviewed. The detailed records of the infants, including name of mother, age, gravidity, parity, route of delivery, Apgar score, time of birth, inborn or outborn, birth weight, gestational age, sex, need for resuscitation, course in the Neonatal Intensive Care Unit, admission and discharge diagnosis, and outcome were collected from the register. The infants were stratified according to the gestational age and then analyzed for the survival rate among the different gestational ages. RESULTS: A total of 32 extreme preterm infants were admitted to the Neonatal Intensive Care Unit of Sultan Qaboos University Hospital from November 1991 to February 1998. The mean birth weight of the cohort was noted to be 798+123 gram (Range 480-1015 grams). The mean gestational age was noted to be 25.5+0.95 weeks (Range 23-26 weeks). An equal number of males and females were noted in the cohort, with male to female ratio of 1:1. A total of 13 infants survived out of 32 infants. The overall survival rate for the cohort was noted to be 41%. For the present study, the western statistics are averaged and than compared with the Omani statistics. The survival rate for western 26 week preterm infants was (on average) 61% as compared to 44% among Omani preterm infants. The same trend of low survival was noted for 23 and 24 week Omani infants, except for only one 25 week infant. CONCLUSION: The significant lower survival rate suggests the need for more attention and improvement in the management and care provided to the extreme preterm Omani infants.

Birth Weight↗
PubMed2000

Metazoans in extreme environments: adaptations of hydrothermal vent and hydrocarbon seep fauna.

Some of the most extreme environments where animals survive are associated with active vents and seeps in the deep sea. In addition to the extreme pressure, low temperatures, and lack of light that characterize the deep sea in general, a variety of other factors that are hostile to most animals prevail in these environments. Hydrothermal vent regions show extremes in temperature, areas of very low oxygen, and the presence of toxic hydrogen sulfide and heavy metals. Hydrocarbon seeps, though much cooler than vents, also have regions of very low oxygen and high hydrogen sulfide, as well as other potentially harmful substances such as crude oil and supersaturated brine. Specially adapted animals not only tolerate these conditions, they often thrive under them. In most cases this tolerance is due to a combination of physiological and behavioral adaptations that allow animals to avoid the extremes of their habitats and yet benefit from the chemoautotrophic production characteristic of these environments.

Adaptation, Physiological↗
PubMed2001

Forward surgical stabilization of penetrating lower extremity fractures: circular casting versus external fixation.

OBJECTIVE: There are two choices for the stabilization of penetrating lower extremity fractures in the forward surgical environment: bivalved circular casting and external fixation. The material and equipment requirements of these methods are of paramount importance in the austere forward surgical environment. METHODS: Casualties from the Battle of the Black Sea in Somalia 1993 were examined. Penetrating lower extremity fractures requiring immobilization were identified. The relative packing volume and weight for each method of immobilization were analyzed. Finally, the current literature concerning the treatment of penetrating lower extremity fractures sustained in combat was reviewed. RESULTS: The consumable material requirements of cast immobilization are 22.9 times greater by weight and 3.16 times greater by packing volume. Cast immobilization also has a greater durable equipment requirement. External fixation has multiple clinical advantages but is considerably more expensive. CONCLUSION: Based on these variables, the authors determined that external fixation is the treatment of choice for penetrating lower extremity fractures in the forward surgical environment.

Casts, Surgical↗
PubMed1975

Bilateral lower extremity dressing frame.

Completely independent application of lower extremity prostheses and clothing is essential but often difficult to accomplish in optimal rehabilitation of the bilateral above-knee amputee. This paper suggests an occupational therapy treatment plan for above-knee amputations, discusses reasons for dependency and decreased use of lower extremity prostheses and clothing, and describes a bilateral lower extremity dressing frame designed for independent application of prostheses and lower extremity clothing. The cost of rehabilitation can be justified once independence in application of prostheses and clothing is accomplished and functional ambulation is achieved.

Amputees↗