Amputation and cardiac comorbidity: analysis of severity of cardiac risk.

OBJECTIVE: To evaluate population-based cardiovascular risk scores and coronary artery calcification scores (CACS) in amputees. DESIGN: A retrospective cohort study of 1300 veterans in a cardiac computed tomography database. SETTING: 1B Veterans Administration medical center. PARTICIPANTS: A total of 76 amputees and similar number of age-, gender-, and Framingham Risk Scores (FRS)-matched control subjects. METHODS: The amputee population was identified and compared for CACS and traditional cardiac risk factors. Two control groups were used: control group 1, with known risk factors including diabetes mellitus, and control group 2, with all risk factors without diabetes mellitus. MAIN OUTCOME MEASURES: Statistical associations between amputee and control group FRS scores, CACS, and other cardiac risk factors were assessed. RESULTS: The study included 57 nontraumatic and 19 traumatic amputees with an average age of 62.4 years. Sixty-six amputees were in the low-to-intermediate cardiac risk groups according to FRS. Despite this classification, the mean CACS were significantly higher in amputees (1285 ± 18) than in either of the control groups: control group 1 (540 ± 84) and control group 2 (481 ± 11), P < .001. CACS also were significantly higher in the nontraumatic subject group (1595 ± 12) compared with the traumatic group (356 ± 57; P < .001). Upon categorization of CACS based on probability of coronary artery disease (CAD), 76% of amputees had a CACS >100 and 38% of amputees had a CACS >1000. Interestingly, CACS were almost the same in finger/toe amputations compared with an above-knee amputation, indicating an already ongoing CAD process irrespective of level of amputation. The predominant clinical significant cardiac risk factors in amputees are hypertension (89.5%), P < .005; chronic kidney disease (31.6%), P < .001; dyslipidemia (72.4%), P < .04; and insulin resistance. Total cholesterol, low-density lipoprotein, and high-density lipoprotein levels were nonsignificantly low in all amputees. Triglycerides were particularly higher in traumatic patients compared with nontraumatic patients, with the triglycerides/high-density lipoprotein ratio >7. CONCLUSION: This study demonstrates that amputees have a much greater burden of underlying atherosclerotic disease as detected by CACS than do control subjects matched by Framingham risk stratification. Early screening for CAD and aggressive targeted interventions may be an important part of management to reduce early mortality after amputation.

Morgagni Stewart Morel syndrome--additional features.

A case of Morgagni Stewart Morel syndrome with progressive depression in frontal bone, headache, transient monoparesis, obesity; imbalance, neuropsychiatric symptoms and recurrent disc prolapse with absent right radial pulse is discussed. This syndrome was first mentioned 235 years back, but till now exact pathology is not known. Balance assessment using dynamic posturography was done, which revealed abnormal vestibular function. To our knowledge this is the first case examined for Dynamic Posturography.

Role of sensory input and muscle strength in maintenance of balance, gait, and posture in Parkinson's disease: a pilot study.

OBJECTIVE: The purpose of this study was to simultaneously evaluate multiple components of disequilibrium in patients with idiopathic Parkinson's disease (PD) in ON and OFF states and healthy age- and sex-matched controls on tests of balance, gait, and dynamometry. DESIGN: Thirty subjects with Parkinson's disease and 30 controls were matched for age and sex. Isokinetic and balance laboratories of a clinical research center were used for assessment. Performance results for static and dynamic balance by dynamic posturography for sensory organization tests (SOT), limits of stability, clinical gait assessment, and dynamometric assessment for the trunk, hip, and ankle at different speeds for concentric muscle strength were obtained. Tests were done both in ON and OFF state in Parkinson's disease patients and results compared. RESULTS: Between OFF state and controls, a significant difference was observed for SOT-2 (proprioception, P < 0.005), SOT-6 (conflicting vision, P < 0.001), and SOT-4 (eyes open with sway support, P < 0.038), and there was less use of ankle strategy in SOT-3 (sway vision, P < 0.04). No significant difference was observed for vestibular function (SOT-5). Significant difference was also observed (P < 0.001) for all variables in limits of stability except for reaction time and for muscle strength of trunk, hip, and ankle (P < 0.001) between OFF state and controls. After antiparkinsonian medications, significant improvement was observed for gait velocity (P < 0.002), muscle strength (P < 0.001), and strategy score in SOT-3 between OFF and ON states. A positive correlation was observed between muscle strength (ankle, hip, and trunk) and gait velocity (ON state r = 0.37, OFF state r = 0.56) and movement velocity (ON state r = 0.39). A positive correlation was also seen between ankle strength and gait velocity in both ON (r = 0.393) and OFF states (r = 0.397) and between ankle strength and ankle strategy in all SOTs except SOT-3 in the OFF state. CONCLUSIONS: The quantitative reduction of muscle strength in the spine, hip, and ankle, along with impaired proprioception, visual sense, and smaller base of support, were the main causes for postural instability in Parkinson's disease patients. A correlation was seen between muscle strength, static and dynamic balance, and gait in both ON and OFF states. In contrast to the previous studies, the present study showed that medications improved the muscle strength, gait speed, and use of ankle strategy but did not worsen proprioceptive sense.

Balance and gait in total hip replacement: a pilot study.

OBJECTIVE: Evaluation of balance, gait changes, sexual functions, and activities of daily living in patients with total hip replacement in comparison with healthy subjects. DESIGN: A total of 30 patients were included in the study after total hip replacement. Balance was examined using dynamic posturography, and gait evaluation was done clinically. Sexual functions and activities of daily living were also assessed. A total of 30 healthy subjects of comparable age and sex served as a control group. RESULTS: Dynamic balance and gait differed significantly in both the groups. Despite capsulectomy, no significant difference was observed on testing proprioception. In the sensory organization tests with difficult tasks, patients needed more sensory input from vision and vestibular sense, despite normal proprioceptive sense. Significant difference was observed for limits of stability, rhythmic weight shifts, and for gait variables other than walking base. Some of the patients had major difficulties with sexual functions and activities of daily living. CONCLUSIONS: Compared with the healthy age- and sex-matched controls, patients with total hip replacement did not have any proprioceptive deficit. Patients required extrasensory input, and there was a delayed motor response. Gait and dynamic balance results also indicated the motor deficit and required a compensatory strategy. Restoration of the postural control in these patients is thus essential. Necessary training is required for balance, gait, and activities of daily living, and proper sexual counseling is necessary in postoperative care.

An unusual nail presentation in Marfan's syndrome.

Skin and nail lesions are very rare in Marfan's syndrome. We reported a 14-year-old boy who presented with pterygium in the nails of both the upper and lower limbs with chest deformity along with other features of Marfan's syndrome. Histopathological findings revealed hyperkeratosis with a scant perivascular inflammatory infiltrate. It was not clear whether this case is the first presentation of pterigium in Marfan's syndrome or congenital lichen planus. To our knowledge, this kind of feature is the first Marfan's syndrome case of its kind.