Detection of myocardial damage in patients with sarcoidosis.

BACKGROUND: In patients with sarcoidosis, sudden death is a leading cause of mortality, which may represent unrecognized cardiac involvement. Delayed-enhancement cardiovascular magnetic resonance (DE-CMR) can detect minute amounts of myocardial damage. We sought to compare DE-CMR with standard clinical evaluation for the identification of cardiac involvement. METHODS AND RESULTS: Eighty-one consecutive patients with biopsy-proven extracardiac sarcoidosis were prospectively recruited for a parallel and masked comparison of cardiac involvement between (1) DE-CMR and (2) standard clinical evaluation with the use of consensus criteria (modified Japanese Ministry of Health [JMH] guidelines). Standard evaluation included 12-lead ECG and at least 1 dedicated non-CMR cardiac study (echocardiography, radionuclide scintigraphy, or cardiac catheterization). Patients were followed for 21+/-8 months for major adverse events (death, defibrillator shock, or pacemaker requirement). Patients were predominantly middle-aged (46+/-11 years), female (62%), and black (73%) and had chronic sarcoidosis (median, 7 years) and preserved left ventricular ejection fraction (median, 56%). DE-CMR identified cardiac involvement in 21 patients (26%) and JMH criteria in 10 (12%, 8 overlapping), a >2-fold higher rate for DE-CMR (P=0.005). All patients with myocardial damage on DE-CMR had coronary disease excluded by x-ray angiography. Pathology evaluation in 15 patients (19%) identified 4 with cardiac sarcoidosis; all 4 were positive by DE-CMR, whereas 2 were JMH positive. On follow-up, 8 had adverse events, including 5 cardiac deaths. Patients with myocardial damage on DE-CMR had a 9-fold higher rate of adverse events and an 11.5-fold higher rate of cardiac death than patients without damage. CONCLUSIONS: In patients with sarcoidosis, DE-CMR is more than twice as sensitive for cardiac involvement as current consensus criteria. Myocardial damage detected by DE-CMR appears to be associated with future adverse events including cardiac death, but events were few, and this needs confirmation in a larger cohort.

Isolated eyelid closure myotonia in two families with sodium channel myotonia.

Sodium channelopathies (NaCh), as part of the non-dystrophic myotonic syndromes (NDMs), reflect a heterogeneous group of clinical phenotypes accompanied by a generalized myotonia. Because of recent availability of diagnostic genetic testing in NDM, there is a need for identification of clear clinical genotype-phenotype correlations. This will enable clinicians to distinguish NDMs from myotonic dystrophy, thus allowing them to inform patients promptly about the disease, perform genetic counseling, and orient therapy (Vicart et al. Neurol Sci 26:194-202, 2005). We describe the first distinctive clinical genotype-phenotype correlation within NaCh: a strictly isolated eyelid closure myotonia associated with the L250P mutation in SCN4A. Using clinical assessment and needle EMG, we identified this genotype-phenotype correlation in six L250P patients from one NaCh family and confirmed this finding in another, unrelated NaCh family with three L250P patients.

Redefining the clinical phenotypes of non-dystrophic myotonic syndromes.

OBJECTIVE: To redefine phenotypical characteristics for both chloride (ClCh) and sodium channelopathies (NaCh) in non-dystrophic myotonic syndromes (NDM). METHODS: In a cross-sectional, nationwide study, standardised interviews and clinical bedside tests were performed in 62 genetically confirmed NDM patients, 32 ClCh and 30 NaCh. RESULTS: Standardised interviews revealed that ClCh reported a higher frequency of muscle weakness (75 vs 36.7%; p<0.01), the warm-up phenomenon (100 vs 46.7%; p<0.001), and difficulties in standing up quickly (90.6 vs 50.0%; p<0.001), running (90.6% vs 66.7; p<0.05) and climbing stairs (90.6 vs 63.3%; p = 0.01). Patients with NaCh reported an earlier onset (4.4 vs 9.6 years; p<0.001), and higher frequencies of paradoxical (50.0 vs 0%; p<0.001) and painful myotonia (56.7 vs 28.1%; p<0.05). Standardised clinical bedside tests showed a higher incidence and longer relaxation times of myotonia in the leg muscles for ClCh (100 vs 60%; mean duration of chair tests 12.5 vs 6.3 s; p<0.001), and in eyelid muscles for NaCh (96.7 vs 46.9%; mean relaxation time of 19.2 vs 4.3 s; p<0.001). Transient paresis was only observed in ClCh (62.5%) and paradoxical myotonia only in NaCh (30.0%). Multivariate logistic regression analyses allowed clinical guidelines to be proposed for genetic testing. CONCLUSION: This study redefined the phenotypical characteristics of NDM in both ClCh and NaCh. The clinical guidelines proposed may help clinicians working in outpatient clinics to perform a focused genetic analysis of either CLCN1 or SCN4A.

Trunk sway analysis to quantify the warm-up phenomenon in myotonia congenita patients.

OBJECTIVE: Patients with autosomal recessive myotonia congenita display myotonia and transient paresis that diminish with repetitive muscle contractions (warm-up phenomenon). A new approach is presented to quantify this warm-up phenomenon under clinically relevant gait and balance tasks. METHODS: Ten patients with DNA proven autosomal recessive myotonia congenita and 14 age-matched controls participated. Subjects performed six everyday gait and balance tasks. Balance control during these tasks was monitored using two angular velocity transducers that measured trunk movements in anterior-posterior (pitch) and medio-lateral (roll) directions at the level of the lumbar vertebral column. Tasks were performed under two conditions in randomised order: after a 10-minute seated rest period ("rested") and after having consecutively repeated the task five times ("warm-up"). Controls were also tested twice. RESULTS: "Rested" patients showed the greatest abnormalities (increased sway in pitch and roll) for tandem walking and walking stairs. Balance impairment was also evident for all other tasks. After "warm-up," balance was markedly improved in patients, as reflected by decreased trunk sway (especially during tandem walking) and reduced task duration for all tasks. These results were not only evident at the group level but also clearly present in individual patients. CONCLUSION: The results show that trunk sway analysis detects postural instability in myotonia congenita patients during everyday gait and balance tasks. Moreover, this technique provides a useful tool to quantify the warm-up phenomenon, suggesting a potential use as clinical endpoint in future clinical trials.

Cardiac tamponade in the fibrinolytic era: analysis of >100,000 patients with ST-segment elevation myocardial infarction.

BACKGROUND: Cardiac tamponade is a life-threatening complication of acute myocardial infarction (MI). Data on the incidence, risk factors, and outcome of tamponade in patients with acute MI in the fibrinolytic era are limited. METHODS: Data from a combined clinical trials database of ST-segment elevation MI were used to evaluate the incidence of cardiac tamponade, baseline characteristics, and outcomes in patients with and without tamponade. Univariable and multivariable analyses assessed the relationship between patient characteristics and tamponade development, and the influence of tamponade on mortality. RESULTS: Of 102,060 patients, 865 (0.85%) developed isolated cardiac tamponade during initial hospitalization. Patients with tamponade were older (median 71.9 vs 61.6 years, P < .001), were more likely to be female (54.0% vs 25.1%, P < .001), were more likely to have an anterior MI (61.9% vs 41.5%, P < .001), and had a longer time from symptom onset to reperfusion (median 3.5 vs 2.8 hours, P < .001) than those without tamponade. Multivariable analyses identified increasing age, anterior MI location, female sex, and increased time from symptom onset to treatment as significant independent predictors of tamponade. Patients with tamponade had an increased death rate at 30 days (hazard ratio 7.9, 95% CI 4.7-13.5). CONCLUSION: Cardiac tamponade occurs in < 1% of patients with fibrinolytic-treated acute MI and is associated with increased 30-day mortality. Time from symptom onset to treatment strongly predicted the development of tamponade, underscoring the need for continued efforts to increase speed to treatment in acute MI.

Relation of ventricular premature complexes during recovery from a myocardial perfusion exercise stress test to myocardial ischemia.

Ventricular premature complexes (VPCs) during exercise have long been believed to be harbingers of increased mortality. A recent study has shown that VPCs during the recovery phase of a treadmill exercise test are more predictive of mortality than VPCs that develop during exercise. However, no study to date has examined the relation of VPCs in recovery to the presence of ischemia on myocardial perfusion imaging. We examined the database of perfusion imaging at the Duke University Medical Center from September 1993 to July 2003. We examined the incidence of VPCs during exercise, during the recovery phase, and during the 2 phases. Logistic regression modeling was used to evaluate the significance of VPCs during stress and during recovery in predicting ischemia. VPCs developed during recovery in 561 of 2,828 patients (19.8%). Compared with patients without VPCs during recovery, those with VPCs during recovery were more likely to have a history of hypertension (64.0% vs 56.9%, p = 0.002) and previous coronary artery bypass grafting (25.3% vs 17.1%, p = 0.001). They were also more likely to be older, men, and Caucasian, and to have 3-vessel coronary artery disease (31.9% vs 21.0%, p = 0.001). After adjusting for differences in patient characteristics, VPCs during recovery were significantly associated with ischemia (odds ratio 1.27, 95% confidence interval 1.04 to 1.56, p = 0.017), whereas VPCs during stress were not (p = 0.128). In conclusion, VPCs during the recovery phase of an exercise study are predictive of ischemia on myocardial perfusion imaging.

Drug treatment for myotonia.

BACKGROUND: Abnormal delayed relaxation of skeletal muscles, known as myotonia, can cause disability in myotonic disorders. Sodium channel blockers, tricyclic antidepressive drugs, benzodiazepines, calcium-antagonists, taurine and prednisone may be of use in reducing myotonia. OBJECTIVES: To consider the evidence from randomised controlled trials on the efficacy and tolerability of drug treatment in patients with clinical myotonia due to a myotonic disorder. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group trials register (April 2004), MEDLINE (January 1966 to December 2003) and EMBASE (January 1980 to December 2003). Grey literature was handsearched and reference lists of identified studies and reviews were examined. Authors, disease experts and manufacturers of anti-myotonic drugs were contacted. SELECTION CRITERIA: We considered all (quasi) randomised trials of participants with myotonia treated with any drug treatment versus no therapy, placebo or any other active drug treatment. The primary outcome measure was:reduced clinical myotonia using two categories: (1) no residual myotonia or improvement of myotonia or (2) No change or worsening of myotonia. Secondary outcome measures were:(1) clinical relaxation time; (2) electromyographic relaxation time; (3) stair test; (4) presence of percussion myotonia; and (5) proportion of adverse events. DATA COLLECTION AND ANALYSIS: Two authors extracted the data independently onto standardised extraction forms and disagreements were resolved by discussion. MAIN RESULTS: Nine randomised controlled trials were found comparing active drug treatment versus placebo or another active drug treatment in patients with myotonia due to a myotonic disorder. Included trials were double-blind or single-blind crossover studies involving a total of 137 patients of which 109 had myotonic dystrophy type 1 and 28 had myotonia congenita. The studies were of poor quality. Therefore, we were not able to analyse the results of all identified studies. Two small crossover studies without a washout period demonstrated a significant effect of imipramine and taurine in myotonic dystrophy. One small crossover study with a washout period demonstrated a significant effect of clomipramine in myotonic dystrophy. Meta-analysis was not possible. AUTHORS' CONCLUSIONS: Due to insufficient good quality data and lack of randomised studies, it is impossible to determine whether drug treatment is safe and effective in the treatment of myotonia. Small single studies give an indication that clomipramine and imipramine have a short-term beneficial effect and that taurine has a long-term beneficial effect on myotonia. Larger, well-designed randomised controlled trials are needed to assess the efficacy and tolerability of drug treatment for myotonia.

Evidence-based therapies and mortality in patients hospitalized in December with acute myocardial infarction.

BACKGROUND: Previous studies suggest that patients hospitalized with acute myocardial infarction (MI) in December have poor outcomes, and some studies have hypothesized that the cause may be the infrequent use of evidence-based therapies during the December holiday season. OBJECTIVE: To compare the care and outcomes of patients with acute MI hospitalized in December and patients hospitalized during other months. DESIGN: Retrospective analysis of data from the Cooperative Cardiovascular Project. SETTING: Nonfederal, acute care hospitals in the United States. PATIENTS: 127 959 Medicare beneficiaries hospitalized between January 1994 and February 1996 with confirmed acute MI. MEASUREMENTS: Use of aspirin, beta-blockers, and reperfusion therapy (thrombolytic therapy or percutaneous coronary intervention), and 30-day mortality. RESULTS: When the authors controlled for patient, hospital, and physician characteristics, the use of evidence-based therapies was not significantly lower but 30-day mortality was higher (21.7% vs. 20.1%; adjusted odds ratio, 1.07 [95% CI, 1.02 to 1.12]) among patients hospitalized in December. LIMITATIONS: This was a nonrandomized, observational study. Unmeasured characteristics may have contributed to outcome differences. CONCLUSIONS: Thirty-day mortality rates were higher for Medicare patients hospitalized with acute MI in December than in other months, although the use of evidence-based therapies was not significantly lower.

State-mandated continuing medical education and the use of proven therapies in patients with an acute myocardial infarction.

OBJECTIVES: The purpose of this study was to determine whether state-mandated continuing medical education (CME) requirements affect the use of evidence-based therapies and outcomes in patients with acute myocardial infarction (AMI). BACKGROUND: The Institute of Medicine recommends that educational programs demonstrate their effect through process and outcome measures. METHODS: We analyzed 134,609 patients according to whether or not CME was mandated in the state of physician practice. A hierarchical multivariable model was developed that controlled for state, hospital, physician, and patient level characteristics to determine the association between state CME requirements and the use of evidence-based therapies. Primary outcome measures were admission aspirin use and reperfusion therapy, and discharge aspirin and beta-blocker prescription. Thirty-day and one-year mortality were secondary outcome measures. RESULTS: States with and without CME requirements had similar rates of aspirin use at admission and discharge (79.9% vs. 79.4% and 72.5% vs. 72.5%, respectively) and beta-blocker prescription at discharge (53.6% vs. 55.3%). The rate of reperfusion therapy at admission was significantly higher in states requiring CME (53.1%) compared with states without CME (47.9%) (p < 0.0001). After adjustment, patients admitted in CME-requiring states were significantly more likely to receive reperfusion therapy, mainly owing to "patented" thrombolytic therapy (odds ratio 1.15; p = 0.016). There was no association between CME requirements and one-year mortality. CONCLUSIONS: State-mandated CME had little association with AMI care or outcome, other than an increased use of patented thrombolytic therapy. Further research is needed to maximize the measurable effect of CME on the use of proven therapies irrespective of whether patented or generic medications are involved.

Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative.

BACKGROUND: Although intravenous morphine is commonly used for the treatment of chest pain in patients presenting with non-ST-segment elevation acute coronary syndromes (NSTE ACS), its safety has not been evaluated. The CRUSADE Initiative is a nonrandomized, retrospective, observational registry enrolling patients with NSTE ACS to evaluate acute medications and interventions, inhospital outcomes, and discharge treatments. METHODS: The study population comprised patients presenting with NSTE ACS at 443 hospitals across the United States from January 2001 through June 2003 (n = 57,039). Outcomes were evaluated in patients receiving morphine versus not and between patients treated with morphine versus intravenous nitroglycerin. RESULTS: A total of 17,003 patients (29.8%) received morphine within 24 hours of presentation. Patients treated with any morphine had a higher adjusted risk of death (odds ratio [OR] 1.48, 95% CI 1.33-1.64) than patients not treated with morphine. Relative to those receiving nitroglycerin, patients treated with morphine also had a higher adjusted likelihood of death (OR 1.50, 95% CI 1.26-1.78). Utilizing a propensity score matching method, the use of morphine was associated with increased inhospital mortality (OR 1.41, 95% CI 1.26-1.57). The increased risk of death in patients receiving morphine persisted across all measured subgroups. CONCLUSIONS: Use of morphine either alone or in combination with nitroglycerin for patients presenting with NSTE ACS was associated with higher mortality even after risk adjustment and matching on propensity score for treatment. This analysis raises concerns regarding the safety of using morphine in patients with NSTE ACS and emphasizes the need for a randomized trial.

Incidence, predictors, and outcomes of high-degree atrioventricular block complicating acute myocardial infarction treated with thrombolytic therapy.

BACKGROUND: In the fibrinolytic era, several studies have suggested that the rate of atrioventricular block (AVB) in the setting of acute myocardial infarction (MI) is high and is associated with increased short-term mortality. We sought to delineate predictors of AVB and determine long-term mortality of patients developing AVB in the setting of ST-segment elevation MI (STEMI) treated with thrombolytic therapy. METHODS: We combined data on patients from 4 similar studies of STEMI. We identified independent predictors of AVB and compared the 6-month and 1-year mortality rates of patients with AVB (5251) to the rates of patients without AVB (70 742). RESULTS: The incidence of AVB was 6.9%. Significant independent predictors of AVB included inferior MI, older age, worse Killip class at presentation, female sex, enrollment in the United States, current smoking, hypertension, and diabetes. Adjusted mortality was significantly higher in patients with AVB than in patients without AVB within 30 days (OR 3.2, 95% CI 2.7-3.7), 6 months (OR 1.6, 95% CI 1.5-1.8), and 1 year (OR 1.5, 95% CI 1.3-1.6). For patients with AVB and inferior MI, mortality odds ratios (ORs) were 2.2 (95% CI 1.7-2.7), 2.6 (95% CI 2.4-2.9), and 2.4 (95% CI 2.2-2.6) within 30 days, 6 months, and 1 year, respectively. For patients with AVB and anterior MI, mortality ORs were 3.0 (95% CI 2.2-4.1), 3.5 (95% CI 3.1-3.8), and 3.3 (95% CI 3.0-3.7) within 30 days, 6 months, and 1 year, respectively. CONCLUSIONS: In the thrombolytic era, AVB in the setting of STEMI is common and associated with higher mortality. Future studies should focus on determining therapies that are effective at reducing mortality rates in such patients.

Safety and effectiveness of transdermal nicotine patch in smokers admitted with acute coronary syndromes.

An analysis of smokers admitted with acute coronary syndrome who received transdermal nicotine therapy and those who did not was performed. Propensity analysis was used to match patients. Transdermal nicotine therapy appears safe and does not have an effect on the mortality of patients with acute coronary syndromes.

A history of orthotopic heart transplantation.

Orthotopic human heart transplantation today is performed at more than 150 U.S. centers, and the average survival is more than 10 years. Its prevalence and success, however, belies the fact that just 40 years ago, no one had ever attempted the procedure in humans and that the procedure seemed destined for failure just a year after the first transplant. This article reviews the history of orthotopic heart transplantation, beginning with ancient Greek legends and culminating in modern successes.

Cardiac imaging impaired by a silicone breast implant.

The authors report a case of a left-sided silicone breast implant interfering with nuclear imaging of the myocardium. Cardiac SPECT imaging of a woman documented widespread infarct in the anterolateral, inferior, and posterolateral walls, as well as mixed ischemia/infarct in the anterior wall. Subsequent cardiac MRI revealed just anterolateral and inferolateral infarct. The anterior wall was completely viable. Also apparent on the MR images was a left breast implant overlying the anterior myocardial wall. This case of a left-sided silicone breast implant interfering with nuclear imaging of the myocardium highlights the importance of understanding the potential interference from silicone breast implants.

[The spectrum of hereditary skeletal-muscle channelopathies]. / Het spectrum van de erfelijke skeletspierkanalopathieën.

Channelopathies are a heterogeneous group of genetic diseases in which a defective ion channel is responsible for the symptoms. They manifest as diseases of the heart, brain or skeletal muscle. Hereditary skeletal-muscle channelopathies are characterised by myotonia, periodic paralysis or a combination of both and can be categorised as chloride, sodium and calcium channelopathies. When there is myotonia, the skeletal-muscle membrane is overexcited. In cases of periodic paralysis, the skeletal-muscle membrane is inactive. It is difficult to classify hereditary muscle channelopathies on the basis of clinical criteria only. A more reliable diagnosis is made using DNA analysis. Scientific research should focus on genotype-phenotype relationships.

Should we cross the valve: the risk of retrograde catheterization of the left ventricle in patients with aortic stenosis.

CLINICAL SCENARIO: A 67-year-old man is referred to your cardiology clinic complaining of worsening angina and dyspnea on exertion. Physical examination reveals a harsh grade IV/VI late-peaking crescendo-decresendo systolic murmur, loudest at the upper sternal border. The aortic closure sound is diminished. Echocardiography demonstrates left ventricular hypertrophy, an ejection fraction of 50%, no evidence of mitral regurgitation, and severe aortic stenosis (AS) with a peak aortic gradient of 4.8 m/s (92 mm Hg) and a mean aortic gradient of 55 mm Hg. You schedule him for coronary angiography but wonder whether you should reevaluate his aortic valve gradient invasively. LITERATURE SEARCH: Combining the keywords "aortic valve stenosis" and "heart catheterization/adverse effects," you find 72 articles. From these you choose the following: Omran H, Schmidt H, Hackenbroch M, et al. Silent and apparent cerebral embolism after retrograde catheterization of the aortic valve in valvular stenosis: a prospective randomized study. Lancet 2003;361:1241-6. QUESTION: What is the stroke risk of retrograde catheterization of the aortic valve in patients with AS? DESIGN: The study was prospective and randomized; unblinded treatment but with blinded assessment of outcomes. SETTING: The study was conducted at a single center in Bonn, Germany. PATIENTS: A total of 152 patients with known or suspected AS undergoing cardiac catheterization were randomized to catheterization with or without retrograde passage of the aortic valve in a 2:1 randomization format. Patients underwent brain magnetic resonance imaging (MRI) the day before and within 48 hours after cardiac catheterization. Patients with unclear echo findings or contraindications to MRI or transesophageal echocardiography were excluded. There were no significant baseline differences between the 2 groups: mean age 70.5 years, left ventricular ejection fraction 62%, and mean aortic valve gradient 51 mm Hg. All patients were evaluated in the groups to which they had been randomized and, other than the experimental intervention, the 2 groups were treated similarly (with the exception of the administration of 5000 units of intravenous heparin to the group receiving retrograde aortic catheterization). A control group of 32 patients without aortic valvular stenosis was evaluated as well. INTERVENTION: The intervention consisted of retrograde passage of the aortic valve for the purpose of obtaining an invasive aortic valve pressure gradient. MAIN OUTCOME MEASURES: The main outcome measures were acute cerebral embolic events, defined by MRI findings within 48 hours after catheterization (as compared to precatheterization MRI) and by clinical examination. MAIN RESULTS: Twenty-two of 101 patients (22%) assigned to retrograde catheterization developed new focal MRI abnormalities consistent with acute cerebral embolic events. Three of these patients (3%) demonstrated clinically apparent neurologic deficits. None of the patients who did not undergo retrograde catheterization--and none of the control patients--had MRI or clinical evidence of cerebral embolism.

The additive value of combined assessment of myocardial perfusion and ventricular function studies.

In addition to providing quantitative ventricular function information, gated SPECT and radionuclide angiocardiographic studies can evaluate regional wall motion and ventricular volumes. This review focuses on the combined assessment of myocardial perfusion and left ventricular function. Two clear roles for nuclear imaging in clinical practice include the diagnosis of coronary artery disease and assessment of prognosis in patients with known coronary artery disease. Ventricular function information can help differentiate an attenuation artifact from an infarct and is helpful in diagnosing 3-vessel coronary disease. Additionally, several studies have highlighted the prognostic benefit to combined assessment of myocardial perfusion and ventricular function. Several new modalities have recently been reported that promise to continue to solidify the place of nuclear imaging in the diagnosis and prognosis of coronary artery disease.

An intracardiac mass in a young man with congenitally acquired HIV.

A case of a 19-year-old man with congenitally acquired HIV infection who was found to have a large intracardiac mass is presented. Presurgical imaging studies and subsequent pathologic findings and histology are discussed.

Quality of life in patients with diabetic foot ulcers.

PURPOSE: To compare Quality of Life (QoL) between diabetic patients with (former or present) and without foot ulcers. METHODS: Two patient groups of comparable age, sex distribution, type distribution and duration of diabetes were studied. Fourteen patients with former or present, but clinically stable diabetic foot ulcers (DFUs) were studied. The control group was 24 unknown patients with DFUs. None of the participants had other diabetic complications or conditions that would potentially affect QoL. A diabetic foot risk score and QoL were assessed. QoL was scored with the RAND-36, the Barthel Score (ADL) and the Walking and Walking Stairs Questionnaire (WSQ). RESULTS: Marked and significant differences were found in physical functioning (p < 0.001), social functioning (p < 0.05), physical role (p < 0.001) and health experience (p < 0.05) between the two groups with the RAND-36 and the four subscales of the WSQ (all p < 0.001). On all these scales, QoL was significantly poorer in the study group. A correlation was found between the risk scores and QoL (physical functioning and physical role Spearman's r: -0.66, -0.56 and WSQ -0.63, -0.64, -0.67 and 0.71, respectively). CONCLUSION: Presence or history of DFUs has a large impact on physical role, physical functioning and mobility. Physical impairments especially influenced QoL. Probably, QoL can be increased by providing attention that will enhance mobility and by giving advice about adaptations and special equipment.

[Postsurgical pain and weakness in the shoulder-arm region: iatrogenic or not?]. / Postoperative pijn en krachtsverlies in de schouder-armregio; iatrogeen of niet?

Four patients, one man aged 66 years and three women aged 69, 33 and 55 years, respectively, had postsurgical pain and weakness in the shoulder-arm region. Initially, a peripheral nerve lesion on a mechanical basis was suspected in all patients. However, because of the sharp pain starting after a postsurgical pain-free interval ranging from a few hours to two days, followed after some time by local muscular weakness, the diagnosis 'neuralgic amyotrophy' was made later. The electromyographic findings were in agreement with this diagnosis. The chronological sequence of the symptoms only became clear after targeted questioning. After 6-24 months, the strength was more or less restored. Usually, the prognosis of neuralgic amyotrophy is favourable, although full functional recovery may take two to three years and in a minority of cases recovery remains incomplete. Early diagnosis is important because of the prognostic aspects and to prevent unnecessary investigations or even surgical explorations, as well as legal claims. Therefore, not only neurologists but particularly surgeons and anaesthesiologists should be aware of this postsurgical condition.