Lee, Jong-Hyuk; Lee, Young-Don; Kim, Soon Yul; Chang, Sei-Jin
Background During shoulder surgery, blood pressure is frequently measured at the ankle. Anesthetic complications may result when ankle blood pressure is higher than brachial blood pressure and anesthesiologists misinterpret ankle blood pressure as brachial blood pressure. Therefore, we investigated whether ankle blood pressure is significantly higher than brachial blood pressure before anesthesia induction, during induction, after tracheal intubation, before beach chair position, and in the beach chair position. Methods Thirty patients requiring general anesthesia for shoulder surgery were included in this study. Ankle and brachial blood pressure were simultaneously measured before induction, during induction, after intubation, before beach chair position, and in the beach chair position. Results Ankle blood pressure was higher than brachial blood pressure before induction, during induction, after intubation, before beach chair position, and in the beach chair position. Ankle-brachial blood pressure differences in the beach chair condition were much higher than in four other conditions. The correlation coefficient between mean ankle-brachial blood pressure differences before the beach chair position and mean ankle-brachial blood pressure differences in the beach chair position was 0.616. Brachial systolic blood pressure could be predicted by regression equations (R2 = 0.306-0.771). Conclusions These results suggest that anesthesiologists should consider these ankle-brachial blood pressure differences when monitoring anesthesia in the beach chair position. PMID:23277812
Choi, Jae Chan; Lee, Jong-Hyuk; Lee, Young-Don; Kim, Soon Yul; Chang, Sei-Jin
During shoulder surgery, blood pressure is frequently measured at the ankle. Anesthetic complications may result when ankle blood pressure is higher than brachial blood pressure and anesthesiologists misinterpret ankle blood pressure as brachial blood pressure. Therefore, we investigated whether ankle blood pressure is significantly higher than brachial blood pressure before anesthesia induction, during induction, after tracheal intubation, before beach chair position, and in the beach chair position. Thirty patients requiring general anesthesia for shoulder surgery were included in this study. Ankle and brachial blood pressure were simultaneously measured before induction, during induction, after intubation, before beach chair position, and in the beach chair position. Ankle blood pressure was higher than brachial blood pressure before induction, during induction, after intubation, before beach chair position, and in the beach chair position. Ankle-brachial blood pressure differences in the beach chair condition were much higher than in four other conditions. The correlation coefficient between mean ankle-brachial blood pressure differences before the beach chair position and mean ankle-brachial blood pressure differences in the beach chair position was 0.616. Brachial systolic blood pressure could be predicted by regression equations (R(2) = 0.306-0.771). These results suggest that anesthesiologists should consider these ankle-brachial blood pressure differences when monitoring anesthesia in the beach chair position.
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Su, Ho-Ming; Lee, Kun-Tai; Chu, Chih-Sheng; Lee, Ming-Yi; Lin, Tsung-Hsien; Voon, Wen-Chol; Sheu, Sheng-Hsiung; Lai, Wen-Ter
This study evaluated the effects of heart rate (HR) on brachial-ankle pulse wave velocity (baPWV) and ankle-brachial pressure index (ABI). Thirty-two patients without significant organic heart disease underwent elective cardiac catheterization or electrophysiologic study, and were then enrolled in right atrial pacing (RAP; 11 men, 9 women; aged 48 -/+ 15 years) or right ventricular pacing (RVP; 6 men, 6 women, aged 45 -/+ 13 years) studies. Three different HR levels (90, 100, and 110 beats per minute) were paced in random order. By stepwise, multiple linear regression analysis, age, systolic blood pressure (SBP), and pulse pressure (PP) correlated positively with baseline baPWV. In the RAP group, as HR increased, baPWV and left brachial diastolic blood pressure increased significantly (p < or = 0.015), while ABI, left ankle SBP, left brachial PP, and left ankle PP decreased significantly (p < or = 0.013). In the RVP group, as HR increased, baPWV also increased significantly (p = 0.001), while ABI, left ankle SBP, and PP decreased significantly (p < or = 0.034). Values of baPWV and ABI may be influenced by HR in young and middle-aged patients without significant organic heart disease. When these values are used to evaluate and follow up cardiovascular risk in patients, HR changes should be considered.
Espeland, Mark A; Lewis, Cora E; Bahnson, Judy; Knowler, William C; Regensteiner, Judith G; Gaussoin, Sarah A; Beavers, Daniel; Johnson, Karen C
To assess whether weight loss improves markers of peripheral artery disease and vascular stenosis. The Action for Health in Diabetes randomized clinical trial compared intensive lifestyle intervention (ILI) for weight loss to a control condition of diabetes support and education (DSE) in overweight or obese adults with type 2 diabetes. Annual ankle and brachial blood pressures over four years were used to compute ankle-brachial indices (ABIs) and to assess interartery blood pressure differences in 5018 participants. ILI, compared to DSE, produced 7.8% (Year 1) to 3.6% (Year 4) greater weight losses. These did not affect prevalence of low (<0.90) ABI (3.60% in DSE versus 3.14% in ILI; P = 0.20) or elevated (>1.40) ABI (7.52% in DSE versus 7.59% in ILI: P = 0.90), but produced smaller mean (SE) maximum interartery systolic blood pressure differences among ankle sites [19.7 (0.2) mmHg for ILI versus 20.6 (0.2) mmHg for DSE (P < 0.001)] and between arms [5.8 (0.1) mmHg for ILI versus 6.1 (0.1) mmHg for DSE (P = 0.01)]. Four years of intensive behavioral weight loss intervention did not significantly alter prevalence of abnormal ABI, however, it did reduce differences in systolic blood pressures among arterial sites. Copyright © 2013 The Obesity Society.
Rucigaj, Tanja Planinsek
Ultrasound examinations are noninvasive diagnostic methods which, along with appropriate history and clinical examination, provide basic information on the etiology and spread of the disease, as well as on treatment options required in patients with chronic venous insufficiency and arterial flow impairment. Doppler flow meter offers useful data on venous blood return, primarily in great veins, while both deep and superficial veins as well as arteries can be visualized and data on venous and arterial hemodynamics obtained by duplex ultrasonography. In addition, Doppler flow meter provides data on the peripheral arterial system action through ankle brachial index measurement, which will guide the choice of compression therapy when deciding on the treatment of peripheral arterial disease and mixed arteriovenous leg ulcers. However, diagnosis of arterial insufficiency requires additional examinations.
Ena, Javier; Lozano, Teresa; Verdú, Gema; Argente, Carlos R; González, Victor L
Upper arm automated blood pressure devices are widely available and could be used to estimate the ankle-brachial index. We conducted a trial to determine the equivalence of ankle-brachial index estimated by an upper arm blood pressure measuring device as index method compared to the handheld Doppler method as the reference standard. A total of 110 patients with diabetes mellitus were sequentially examined by two methods. The prevalence of peripheral arterial disease was 32%. The index method obtained valid measurements in 104 (95%) patients. Ankle-brachial index was lower with the index method compared to the reference standard (mean difference: -0.05; 95% confidence interval [CI]: -0.50 to 0.39). This confidence interval was above the boundaries clinically established as equivalence margins in our study. The kappa agreement between two methods was 0.45. The performance of the index method was: sensitivity: 67%; specificity: 87%; positive likelihood ratio: 5.25; negative likelihood ratio: 0.18; positive predictive value: 71%; negative predictive value: 85%; and the area under the receiving operating characteristic curve: 0.87 (95% CI: 0.78-0.93). Upper arm automated blood pressure measuring devices cannot replace the handheld Doppler method to estimate the ankle-brachial index in patients with diabetes mellitus. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
Shirasu, Takuro; Hoshina, Katsuyuki; Akagi, Daisuke; Miyahara, Takuya; Yamamoto, Kota; Watanabe, Toshiaki
Ankle brachial index can be falsely elevated in cases of medial arterial calcification, and its clinical use should be limited, especially in patients with diabetes. The aim of this study was to evaluate the potential role of pulse volume recording in detecting falsely elevated ankle brachial index. Two parameters of the pulse waveform were automatically calculated: upstroke time and percentage mean artery pressure. Pulse volume recordings were retrospectively evaluated in 171 consecutive patients (342 limbs); 73 (43%) had a diagnosis of diabetes. On multivariate analysis, diabetes (hazard ratio = 1.7), ankle brachial index ≤ 0.90 (hazard ratio = 4.4), upstroke time ≥ 180 ms (hazard ratio = 2.1), and percentage mean artery pressure ≥ 45% (hazard ratio = 2.8) were significantly related to toe brachial index < 0.60. Further analysis for falsely elevated ankle brachial index was performed in 196 limbs (146 patients) with ankle brachial index > 0.90. The difference between ankle brachial index and toe brachial index differentiated the limbs of diabetic patients, with percentage mean artery pressure ≥ 45%, from controls (0.45 ± 0.17 vs. 0.35 ± 0.16, p = 0.03); upstroke time was not found to be a discriminating factor. Although measurement of ankle brachial index remains the gold standard for diagnosing peripheral arterial disease, percentage mean artery pressure, automatically obtained in ankle brachial index measurement, may be useful to detect falsely elevated ankle brachial index, especially in patients with diabetes. © The Author(s) 2016.
Chesbro, Steven B; Asongwed, Elmira T; Brown, Jamesha; John, Emmanuel B
The purposes of this study were to: (1) identify the interrater and intrarater reliability of systolic blood pressures using a stethoscope and Doppler to determine an ankle-brachial index (ABI), and (2) to determine the correlation between the 2 methods. Peripheral arterial disease (PAD) affects approximately 8 to 12 million people in the United States, and nearly half of those with this disease are asymptomatic. Early detection and prompt treatment of PAD will improve health outcomes. It is important that clinicians perform tests that determine the presence of PAD. Two individual raters trained in ABI procedure measured the systolic blood pressures of 20 individuals' upper and lower extremities. Standard ABI measurement protocols were observed. Raters individually recorded the systolic blood pressures of each extremity using a stethoscope and a Doppler, for a total of 640 independent measures. Interrater reliability of Doppler measurements to determine SBP at the ankle was very strong (intraclass correlation coefficient [ICC], 0.93-0.99) compared to moderate to strong reliability using a stethoscope (ICC, 0.64-0.87). Agreement between the 2 devices to determine SBP was moderate to very weak (ICC, 0.13-0.61). Comparisons of the use of Doppler and stethoscope to determine ABI showed weak to very weak intrarater correlation (ICC, 0.17-0.35). Linear regression analysis of the 2 methods to determine ABI showed positive but weak to very weak correlations (r2 = .013, P = .184). A Doppler ultrasound is recommended over a stethoscope for accuracy in systolic pressure readings for ABI measurements.
Wang, Anxin; Tao, Jie; Guo, Xiuhua; Liu, Xuemei; Luo, Yanxia; Liu, Xiurong; Huang, Zhe; Chen, Shuohua; Zhao, Xingquan; Jonas, Jost B; Wu, Shouling
To investigate potential associations between resting heart rate, blood pressure and the product of both, and the brachial-ankle pulse wave velocity (baPWV) as a maker of arterial stiffness. The community-based "Asymptomatic Polyvascular Abnormalities in Community (APAC) Study" examined asymptomatic polyvascular abnormalities in a general Chinese population and included participants with an age of 40+ years without history of stroke and coronary heart disease. Arterial stiffness was defined as baPWV≥1400 cm/s. We measured and calculated the product of resting heart rate and systolic blood pressure (RHR-SBP) and the product of resting heart rate and mean arterial pressure (RHR-MAP). The study included 5153 participants with a mean age of 55.1 ± 11.8 years. Mean baPWV was 1586 ± 400 cm/s. Significant (P<0.0001) linear relationships were found between higher baPWV and higher resting heart rate or higher arterial blood pressure, with the highest baPWV observed in individuals from the highest quartiles of resting heart rate and blood pressure. After adjusting for confounding parameters such as age, sex, educational level, body mass index, fasting blood concentrations of glucose, blood lipids and high-sensitive C-reactive protein, smoking status and alcohol consumption, prevalence of arterial stiffness increased significantly (P<0.0001) with increasing RHR-SBP quartile (Odds Ratio (OR): 2.72;95%Confidence interval (CI):1.46,5.08) and increasing RHR-MAP (OR:2.10;95%CI:1.18,3.72). Similar results were obtained in multivariate linear regression analyses with baPWV as continuous variable. Higher baPWV as a marker of arterial stiffness was associated with a higher product of RHR-SBP and RHR-MAP in multivariate analysis. In addition to other vascular risk factors, higher resting heart rate in combination with higher blood pressure are risk factors for arterial stiffness.
Lilly, Scott M; Jacobs, David R; Kronmal, Richard; Bluemke, David A; Criqui, Michael; Lima, Joao; Allison, Matthew; Duprez, Daniel; Segers, Patrick; Chirinos, Julio A
A low ankle-brachial index is associated with cardiovascular disease and reduced arterial compliance. A high ankle-brachial index is also associated with an increased risk of cardiovascular events. We tested the hypothesis that subjects with a high ankle-brachial index demonstrate a lower arterial compliance. In addition, we assessed whether pulse pressure amplification is increased among subjects with a high ankle-brachial index. We studied 6814 adults enrolled in the Multiethnic Study of Atherosclerosis who were, by definition, free of clinical cardiovascular disease at baseline. Differences in total arterial compliance (ratio of stroke volume to pulse pressure), aortic and carotid distensibility (measured with magnetic resonance imaging and duplex ultrasound, respectively) were compared across ankle-brachial index subclasses (≤0.90, 0.91-1.29; ≥1.30) with analyses adjusted for cardiovascular risk factors and subclinical atherosclerosis. Peripheral arterial disease was detected in 230 (3.4%) and high ABI in 648 (9.6%) of subjects. Those with high ankle-brachial index demonstrated greater aortic/radial pulse pressure amplification than those with a normal ankle-brachial index. In adjusted models aortic and carotid distensibility as well as total arterial compliance, were lowest among those with ankle-brachial index≤0.9 (p<0.01 vs. all), but were not reduced in subjects with an ankle-brachial index≥1.3. Lower aortic, carotid and total arterial compliance is not present in subjects free of overt cardiovascular disease and with a high ankle-brachial index. However, increased pulse pressure amplification contributes to a greater ankle-brachial index in the general population and may allow better characterization of individuals with this phenotype. Published by Elsevier Ireland Ltd.
Yiming, Gulinuer; Zhou, Xianhui; Lv, Wenkui; Peng, Yi; Zhang, Wenhui; Cheng, Xinchun; Li, Yaodong; Xing, Qiang; Zhang, Jianghua; Zhou, Qina; Zhang, Ling; Lu, Yanmei; Wang, Hongli; Tang, Baopeng
Brachial-ankle pulse wave velocity (baPWV), a direct measure of aortic stiffness, has increasingly become an important assessment for cardiovascular risk. The present study established the reference and normal values of baPWV in a Central Asia population in Xinjiang, China. We recruited participants from a central Asia population in Xinjiang, China. We performed multiple regression analysis to investigate the determinants of baPWV. The median and 10th-90th percentiles were calculated to establish the reference and normal values based on these categories. In total, 5,757 Han participants aged 15-88 years were included in the present study. Spearman correlation analysis showed that age (r = 0.587, p < 0.001) and mean blood pressure (MBP, r = 0.599, p <0.001) were the major factors influencing the values of baPWV in the reference population. Furthermore, in the multiple linear regression analysis, the standardized regression coefficients of age (0.445) and MBP (0.460) were much higher than those of body mass index, triglyceride, and glycemia (-0.054, 0.035, and 0.033, respectively). In the covariance analysis, after adjustment for age and MBP, only diabetes was the significant independent determinant of baPWV (p = 0.009). Thus, participants with diabetes were excluded from the reference value population. The reference values ranged from 14.3 to 25.2 m/s, and the normal values ranged from 13.9 to 21.2 m/s. This is the first study that has established the reference and normal values for baPWV according to age and blood pressure in a Central Asia population.
Espeland, Mark A.; Lewis, Cora E.; Bahnson, Judy; Knowler, William C.; Regensteiner, Judith G.; Gaussoin, Sarah A.; Beavers, Daniel; Johnson, Karen C.
Objective To assess whether weight loss improves markers of peripheral artery disease and vascular stenosis. Design and Methods The Action for Health in Diabetes randomized clinical trial compared intensive lifestyle intervention (ILI) for weight loss to a control condition of diabetes support and education (DSE) in overweight or obese adults with type 2 diabetes. Annual ankle and brachial blood pressures over four years were used compute ankle-brachial indices (ABIs) and to assess inter-artery blood pressure differences in 5018 participants. Results ILI, compared to DSE, produced 7.8% (Year 1) to 3.6% (Year 4) greater weight losses. These did not affect prevalence of low (<0.90) ABI (3.60% in DSE versus 3.14% in ILI; p=0.20) or elevated (>1.40) ABI (7.52% in DSE versus 7.59% in ILI: p=0.90), but produced smaller mean (SE) maximum inter-artery systolic blood pressure differences among ankle sites [19.7 (0.2) mmHg for ILI versus 20.6 (0.2) mmHg for DSE (p<0.001)] and between arms [5.8 (0.1) mmHg for ILI versus 6.1 (0.1) mmHg for DSE (p=0.01)]. Conclusions Four years of intensive behavioral weight loss intervention did not significantly alter prevalence of abnormal ABI, however it did reduce differences in systolic blood pressures among arterial sites. PMID:24174392
Kendrick, Jessica; Ix, Joachim H.; Targher, Giovanni; Smits, Gerard; Chonchol, Michel
Higher levels of serum phosphorus that remain within the reference range are associated with increased risk of cardiovascular disease (CVD). However, the mechanisms by which higher serum phosphorus concentrations may contribute to the development of CVD remain unclear. Cross-sectional association between serum phosphorus levels and arterial stiffness as estimated by an ankle brachial pressure index (ABPI) >1.3, was examined in 581 participants in the Third National Health and Nutrition Examination Survey. Logistic regression analysis was performed to evaluate whether higher serum phosphorus levels were associated with high ABPI, independently of several potential confounders. Among the 581 participants, 38% and 10% had a serum phosphorus levels >3.5 and >4.0 mg/dL, respectively. An ABPI >1.3 was present in 7.3% of participants. Higher quartiles of serum phosphorus levels were associated with a greater prevalence of high ABPI: 5.4%, 3.7%, 7.8%, and 12.9% for quartiles 1 (<3.1 mg/dL), 2 (3.1 to 3.4 mg/dL), 3 (3.4 to 3.7 mg/dL) and 4 (3.7 to 5.0 mg/dL), respectively. There was a strong, positive association between the highest quartile of serum phosphorus (3.7 to 5.0 mg/dL) and high ABPI when compared to the reference group (3.1 to 3.4 mg/dL) after adjustment for demographics, traditional CVD risk factors, kidney function, C-reactive protein, serum calcium, and 25-hydroxyvitamin D levels (adjusted odds ratio 4.78, 95% CI 1.73 to 13.2; p=0.003). In conclusion, serum phosphorus levels, even within the reference range, are independently associated with high ABPI, a marker of arterial stiffness, in the US adult population. PMID:20691317
Congnard, Florian; Bruneau, Antoine; Abraham, Pierre; Colas-Ribas, Christophe; Picquet, Jean; Noury-Desvaux, Benedicte
Ankle to brachial index after heavy load exercise is the most accurate way of diagnosing minor arterial lesions in athletes, such as endofibrosis. The reliability and practical aspects of ankle to brachial index measurements after heavy-load exercise have not been studied. The purpose of this study was to analyze the interest of oscillometric automatic vs. manual Doppler measurements, for the calculation of ankle to brachial index, after heavy-load exercise in athletes. Prospective single-center study. Fifteen healthy trained athletes performed an incremental test twice. Ankle to brachial index measurements were performed at Rest, as soon as possible after exercise (Rec-0), and then started at the 3rd minute of recovery (Rec-3), by two operators using each one of the two ankle to brachial index measurement methods. Mean times for automatic vs. manual ankle to brachial availability were 99 ± 18 s vs. 113 ± 25 s (p = 0.005) and 44 ± 25 s vs. 53 ± 12 s (p = 0.001) respectively at Rec-0 and Rec-3. Ankle to brachial index values from the two methods were highly correlated (r = 0.89). Mean absolute differences of automatic vs. manual ankle to brachial values from test-retest were 0.04 ± 0.05 vs. 0.08 ± 0.08 (p > 0.05) and 0.07 ± 0.05 vs. 0.09 ± 0.10 (p > 0.05) at Rest and Rec-0. Automatic method allows obtaining faster and simultaneously post-exercise ankle to brachial index measurement compare to the manual Doppler. This time issue does not result in a significant change in absolute ankle to brachial index values, nor in the absolute differences of these in test-retest. Nevertheless, the test-retest variability of post-exercise ankle to brachial index results seems smaller with the automatic than the manual method. Copyright © 2014 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
Mlačak, Blaž; Blinc, Aleš; Pohar, Maja; Stare, Janez
Aim To test how the presence of peripheral arterial disease predicted mortality of middle-aged and elderly residents of Metlika county, a rural area in southeastern Slovenia. Methods In 1987, we interviewed and examined a representative cohort of 646 subjects aged 45-80 years at inclusion without overt coronary or cerebrovascular disease, for cardiovascular risk factors and measured the ankle-brachial pressure index (ABPI). Peripheral arterial disease was defined as ABPI<0.90. The subjects were followed up 15 years or until death. All-cause mortality and cardiovascular mortality were assessed and compared between subjects with and without peripheral arterial disease in a multivariate model. Results There were 580 subjects with normal ABPI and 66 subjects with peripheral arterial disease, among which 49 were asymptomatic and 17 had intermittent claudication. Because subjects with peripheral arterial disease were on average 10 years older than those without peripheral arterial disease, the mere presence of peripheral arterial disease was not an independent predictor of mortality. However, there was a significant interaction of peripheral arterial disease with age, with a more pronounced adverse prognostic effect of peripheral arterial disease in younger than in older age groups. For a 55-year-old subject with peripheral arterial disease, the hazard ratio of dying from any cause in the follow-up period was 2.44 (95% confidence interval [CI], 1.15-4.96) in comparison to an age-matched subject without peripheral arterial disease, but at 75 years of age, the hazard ratio decreased to only 0.71 (95% CI, 0.46-1.09). For cardiovascular mortality, the hazard ratio in the presence of peripheral arterial disease was 6.05 (95% CI, 1.87-16.27) at 55 years and 0.92 (95% CI, 0.54-1.52) at 75 years. Among patients with peripheral arterial disease, each decrement of ABPI at inclusion by 0.10 significantly increased the cardiovascular mortality after 15 years by 30% (P = 0
Nault, Patrice; Halman, Samantha; Paradis, Josée
This study investigated the effects of a high-sympathetic stimulus environment (high-altitude hypoxia) on limb-specific systolic blood pressure (sBP) and ankle-brachial index (ABI) in normal volunteers. We hypothesized that currently accepted normal values for ABI may in fact not reflect an actual normal vascular state in all patients. Twenty climbers (17 males, 3 females) from Gatineau-Hull (Québec, Canada) participated in this study and ascended Mount Kilimanjaro, Africa. Ankle-brachial index measurements were performed at sea level and on Mount Kilimanjaro at approximately 4100 m. The data were analyzed using predictive analytics software SPSS 14.0. Data obtained at sea level were compared to those obtained at approximately 4100 m, with participants serving as their own controls. Ankle-brachial indices measured at approximately 4100 m (mean = 1.20) were greater than those measured at sea level (mean = 0.97) (n = -6.23; 95% CI: -.32 to -.17; P < .001). There were no significant differences between the systolic brachial pressures at approximately 4100 m when compared to those at sea level (P = .814). Contrarily, systolic ankle pressures at sea level (mean = 132) were significantly greater than those measured at approximately 4100 m (mean = 152) (t = -3.5, 95% CI: -29 to -7.4; P = .002). This study is the first to physiologically demonstrate that in response to a high adrenergic stimulus in healthy volunteers there is a greater increase in sBP in the legs vs the arms.
Castro-Sánchez, Adelaida María; Moreno-Lorenzo, Carmen; Matarán-Peñarrocha, Guillermo A; Feriche-Fernández-Castanys, Belén; Sánchez Labraca, Nuria; Sánchez Joya, María del Mar
Type 2 diabetes mellitus is a highly prevalent disease that can favour the development of peripheral arterial disease. The objective of this study was to analyse the efficacy of a massage and exercise programme on the ankle-brachial index and arterial pressure of patients with diabetes mellitus type 2 and peripheral arterial disease. An experimental study with placebo control group was performed. Sixty-six type 2 diabetes patients with Leriche-Fontaine stage II peripheral arterial disease were randomly assigned to an intervention (exercise and massage) or placebo control (simulated magnetotherapy) group. Study variables were arterial pressure and ankle-brachial index. After 10 weeks of treatment, significant (P<0.05) differences between the intervention and placebo groups were found in right and left ankle-brachial index values and in systolic and diastolic pressures in right and left lower extremities. A combined programme of exercise and massage improves arterial blood pressure and ankle brachial index values in type 2 diabetics with peripheral arterial disease. Copyright 2009 Elsevier España, S.L. All rights reserved.
Giri, Subhash; Rathi, Vinita; Ranga, Gajender Singh
Introduction Due to increase in Coronary Artery Disease (CAD) at a younger age, we should try to diagnose atherosclerotic process and population at risk, at the earliest. Flow Mediated Dilatation (FMD), Carotid Intima-Media Thickness (CIMT) and Ankle-Brachial Pressure Index (ABI) are probable markers for early atherosclerosis and may be useful in coronary risk stratification. Aim To compare and correlate the FMD, CIMT, ABI and Pulse Pressure (PP) in young male patients of Myocardial Infarction (MI) with age and sex matched healthy controls. Materials and Methods Eighty male patients of MI aged ≤45 years, who presented to the Cardiac Care Unit and Department of Medicine of Guru Teg Bahadur Hospital, Delhi, India, from November 2010 to April 2012 were recruited consecutively for this case control study and same number of age and sex matched healthy controls were also analyzed. Six weeks after MI, FMD of the brachial artery, intima media thickness of carotid artery, ABPI and PP were measured in the cases and compared with healthy controls. Results The FMD was lower among young patients of MI than controls (p<0.001). CIMT was higher among cases than controls (p=0.001). ABI was lower among cases than controls (p<0.001). Compared to controls, PP was higher among cases (p=0.001). In all subjects, a negative correlation between FMD and CIMT (r=–0.220, p=0.005) and a positive correlation between FMD and ABPI (r=0.304, p<0.001) was found. A statistically significant negative correlation was found between endothelial dependent FMD and PP among cases and control groups (r=–0.209, p=0.007). Conclusion Biophysical parameters were deranged in young post MI patients. Majority of our young male patients fell in low risk Framingham risk score but still they manifested with CAD. Despite six weeks of treatment among young male patients of MI, various biophysical parameters were still deranged. PMID:27891375
Asbeutah, Akram M; AlMajran, Abdullah A; Asfar, Sami K
Ankle-brachial pressure index-systolic (ABI-s) can be falsely elevated in the presence of calcified lower limb arteries in some diabetic patients and therefore loses its value in this cohort of patients. We aim at investigating the feasibility of using the diastolic (ABI-d) instead of ABI-s to calculate the ABI in diabetic patients with calcified limb arteries. A total of 51 patients were chosen from the diabetic foot clinic. Twenty six of these patients had calcified leg arteries by Duplex scan (Group A) and 25 patients did not have calcifications in their leg arteries (Group B). Twenty five healthy volunteers were enrolled in the study for group C and they were matched with other participants from group B and A in age and sex. ABI measurement was performed using "boso ABI-system 100 machine". Systolic ABI (ABI-s) and diastolic ABI (ABI-d) were calculated based on bilateral brachial and ankle oscillometric pressures. ABI is considered normal when it is ≥0.9. Repeated measures ANOVA test was used to test for comparing mean scores for ABI-s and ABI-d across the three groups. Statistical significance is considered when P < .05. The mean age of all participants (±SD) was 64.30 ± 7.1 years (range, 50-82 years). ABI-s mean ± SD was 1.3 ± 0.10 (range, 1.18-1.58) in group A patients, 1.07 ± 0.05 (range, 1-1.16) in group B patients, and 1.06 ± 0.05 (range, 1-1.16) in group C volunteers. While ABI-d mean ± SD was 1.07 ± 0.05 (range, 1.1-1.17) in group A patients, 1.06 ± 0.05 (1-1.14) in group B patients, and 1.05 ± 0.04 (range, 1.01-1.14) in group C volunteers. In group A, repeated measures ANOVA test showed statistical significant difference between ABI-s and ABI-d (P < 0.001) whereas in group B & C was not (P > 0.05). ABI-d may be helpful and can be used as a complementary measure instead of ABI-s in falsely elevated ABI caused by partial incompressible vessel.
Sprynger, M; Fassotte, C; Verhaeghe, R
This observational study (Survey of Peripheral Arterial Disease Epidemiology, SPADE) evaluated the prevalence of asymptomatic peripheral arterial disease (PAD) in general practice. PAD was determined as an ankle-brachial pressure index (ABI) <0.9 measured with Doppler ultrasound. Included patients had a history of ischemic events and/or risk factors for PAD, but no spontaneous complaints of intermittent claudication. Patients with an ABI <0.9 filled in a standardized questionnaire and their drug use was registered. A total of 4 536 patients was included. The prevalence of PAD was 18.7% for the total population, 26.5% for those with a history of ischemic events and 15.2% for those without such history. The prevalence increased with age, but was independent of gender. A standard questionnaire revealed leg pain when walking uphill or when hurrying in 2/3 of patients with an ABI <0.9 and in 45% criteria for claudication were met. ABI detects PAD in a considerable number of asymptomatic patients at increased risk and followed in general practice. When properly questioned almost half of these patients appear to have intermittent claudication.
Foo, Jong Yong Abdiel
Ankle brachial index is useful in monitoring the pathogenesis of peripheral arterial occlusive diseases. Sphygmomanometer is the standard instrument widely used but frequent prolonged monitoring can be less comfortable for patients. Pulse transit time is known to be inversely correlated with blood pressure and a ratio-based pulse transit time measurement has been proposed as a surrogate ankle brachial index marker. In this study, 17 normotensive adults (9 men; aged 25.4 +/- 3.9 years) were recruited. Two postural change test activities were performed to induce changes in the stiffness of the arterial wall of the moved periphery. Results showed that only readings from the limbs that adopted a new posture registered significant blood pressure and pulse transit time changes (P < .05). Furthermore, there was significant correlation between the ankle brachial index and pulse transit time ratio measure for both test activities (R(2) > or = 0.704). The findings herein suggest that pulse transit time ratio is a surrogate and accommodating ankle brachial index marker.
Narula, Amar; Benenstein, Ricardo J; Duan, Daisy; Zagha, David; Li, Lilun; Choy-Shan, Alana; Konigsberg, Matthew W; Lau, Ginger; Phillips, Lawrence M; Saric, Muhamed; Vreeland, Lisa; Reynolds, Harmony R
Individuals referred for stress testing to identify coronary artery disease may have nonobstructive atherosclerosis, which is not detected by stress tests. Identification of increased risk despite a negative stress test could inform prevention efforts. Abnormal ankle-brachial index (ABI) is associated with increased cardiovascular risk. Routine ABI testing in the stress laboratory will identify unrecognized peripheral arterial disease in some patients. Participants referred for stress testing without known history of atherosclerotic disease underwent ABI testing (n = 451). Ankle-brachial index was assessed via simultaneous arm and leg pressure using standard measurement, automated blood-pressure cuffs at rest. Ankle-brachial index was measured after exercise in 296 patients and 30 healthy controls. Abnormal postexercise ABI was defined as a >20% drop in ABI or fall in ankle pressure by >30 mm Hg. Overall, 2.0% of participants had resting ABI ≤0.90, 3.1% had ABI ≥1.40, and 5.5% had borderline ABI. No patient with abnormal or borderline ABI had an abnormal stress test. Participants who met peripheral arterial disease screening criteria (age ≥65 or 50-64 with diabetes or smoking) tended toward greater frequency of low ABI (2.9% vs 1.0%; P = 0.06) and were more likely to have borderline ABI (0.91 to 0.99; 7.8% vs 2.9%; P = 0.006). Postexercise ABI was abnormal in 29.4% of patients and 30.0% of controls (P not significant). Ankle-brachial index screening at rest just before stress testing detected low ABI in 2.0% of participants, all of whom had negative stress tests. © 2015 Wiley Periodicals, Inc.
Cheng, Yi-Bang; Li, Yan; Sheng, Chang-Sheng; Huang, Qi-Fang; Wang, Ji-Guang
Brachial-ankle pulse wave velocity (PWV) is increasingly used for the measurement of arterial stiffness. In the present study, we quantified the interrelationship between brachial-ankle and carotid-femoral PWV in a workplace population, and investigated the associations with cardiovascular risk factors and carotid intima-media thickness (IMT). Brachial-ankle and carotid-femoral PWV were measured using the Omron-Colin VP1000 and SphygmoCor devices, respectively. We investigated the interrelationship by the Pearson's correlation analysis and Bland-Altman plot, and performed sensitivity and specificity analyses. The 954 participants (mean ± standard deviation age 42.6 ± 14.2 years) included 630 (66.0%) men and 203 (21.3%) hypertensive patients. Brachial-ankle (13.4 ± 2.7 m/s) and carotid-femoral PWV (7.3 ± 1.6 m/s) were significantly correlated in all subjects (r = 0.75) as well as in men (r = 0.72) and women (r = 0.80) separately. For arterial stiffness defined as a carotid-femoral PWV of 10 m/s or higher, the sensitivity and specificity of brachial-ankle PWV of 16.7 m/s or higher were 72 and 94%, respectively. The area under the receiver operating characteristic curve was 0.953. In multiple stepwise regression, brachial-ankle and carotid-femoral PWV were significantly (p < 0.001) associated with age (partial r = 0.33 and 0.34, respectively) and systolic blood pressure (partial r = 0.71 and 0.66, respectively). In addition, brachial-ankle and carotid-femoral PWV were significantly (p < 0.001) associated with carotid IMT (r = 0.57 and 0.55, respectively) in unadjusted analysis, but not in analysis adjusted for cardiovascular risk factors (p ≥ 0.08). Brachial-ankle and carotid-femoral PWV were closely correlated, and had similar determinants. Brachial-ankle PWV can behave as an ease-of-use alternative measure of arterial stiffness for assessing cardiovascular risk.
Cheng, Yi-Bang; Li, Yan; Sheng, Chang-Sheng; Huang, Qi-Fang; Wang, Ji-Guang
Background Brachial-ankle pulse wave velocity (PWV) is increasingly used for the measurement of arterial stiffness. In the present study, we quantified the interrelationship between brachial-ankle and carotid-femoral PWV in a workplace population, and investigated the associations with cardiovascular risk factors and carotid intima-media thickness (IMT). Methods Brachial-ankle and carotid-femoral PWV were measured using the Omron-Colin VP1000 and SphygmoCor devices, respectively. We investigated the interrelationship by the Pearson's correlation analysis and Bland-Altman plot, and performed sensitivity and specificity analyses. Results The 954 participants (mean ± standard deviation age 42.6 ± 14.2 years) included 630 (66.0%) men and 203 (21.3%) hypertensive patients. Brachial-ankle (13.4 ± 2.7 m/s) and carotid-femoral PWV (7.3 ± 1.6 m/s) were significantly correlated in all subjects (r = 0.75) as well as in men (r = 0.72) and women (r = 0.80) separately. For arterial stiffness defined as a carotid-femoral PWV of 10 m/s or higher, the sensitivity and specificity of brachial-ankle PWV of 16.7 m/s or higher were 72 and 94%, respectively. The area under the receiver operating characteristic curve was 0.953. In multiple stepwise regression, brachial-ankle and carotid-femoral PWV were significantly (p < 0.001) associated with age (partial r = 0.33 and 0.34, respectively) and systolic blood pressure (partial r = 0.71 and 0.66, respectively). In addition, brachial-ankle and carotid-femoral PWV were significantly (p < 0.001) associated with carotid IMT (r = 0.57 and 0.55, respectively) in unadjusted analysis, but not in analysis adjusted for cardiovascular risk factors (p ≥ 0.08). Conclusions Brachial-ankle and carotid-femoral PWV were closely correlated, and had similar determinants. Brachial-ankle PWV can behave as an ease-of-use alternative measure of arterial stiffness for assessing cardiovascular risk. PMID:27195246
Hamasaki, Hidetaka; Hamasaki, Yasuteru
Currently, no international diagnostic criteria for diabetic neuropathy (DN) have been established. Recently, a novel point-of-care sural nerve conduction device has been developed. We aimed to investigate associations between DN and clinical parameters related to the development and progression of DN by using this novel device. We conducted a retrospective observational study in patients with diabetes whose sural nerve functions were measured using DPN Check between January 2015 and October 2016. Multiple and logistic regression analyses were conducted to assess the associations of sural nerve conduction velocity (SNCV) and amplitude (SNAP) with clinical parameters related to DN. A total of 740 patients were enrolled in this study. At baseline, 211 patients were diagnosed with DN by using DPN Check. The sensitivity, specificity, and positive likelihood ratio of DPN Check compared with ankle reflex as reference were 81%, 46%, and 1.5, respectively. Of these, 182 patients were followed up for approximately 1 year to measure changes in SNCV and SNAP. Both SNCV and SNAP were inversely associated with duration of diabetes, plasma glucose levels, and hemoglobin A1c levels at baseline, whereas these were positively associated with ankle-brachial index. Logistic regression analysis revealed that poor glycemic control was associated with increased risk of reduction in both SNCV [odds ratio = 1.570; 95% confidence interval (CI) = 1.298-1.898; p < 0.001] and SNAP (odds ratio = 1.408; 95% CI = 1.143-1.735; p = 0.001), and longer duration of diabetes was also significantly associated with an increased risk of reduction in both SNCV (odds ratio = 1.058; 95% CI = 1.032-1.084; p < 0.001) and SNAP (odds ratio = 1.049; 95% CI = 1.019-1.079; p = 0.001). Sural nerve functions were significantly associated with glycemic control and arteriosclerosis in patients with diabetes. DPN Check may be useful as a screening tool to identify DN in
Song, Yun; Xu, Benjamin; Xu, Richard; Tung, Renee; Frank, Eric; Tromble, Wayne; Fu, Tong; Zhang, Weiyi; Yu, Tao; Zhang, Chunyan; Fan, Fangfang; Zhang, Yan; Li, Jianping; Bao, Huihui; Cheng, Xiaoshu; Qin, Xianhui; Tang, Genfu; Chen, Yundai; Yang, Tianlun; Sun, Ningling; Li, Xiaoying; Zhao, Lianyou; Hou, Fan Fan; Ge, Junbo; Dong, Qiang; Wang, Binyan; Xu, Xiping; Huo, Yong
Pulse wave velocity (PWV) has been shown to influence the effects of antihypertensive drugs in the prevention of cardiovascular diseases. Data are limited on whether PWV is an independent predictor of stroke above and beyond hypertension control. This longitudinal analysis examined the independent and joint effect of brachial-ankle PWV (baPWV) with hypertension control on the risk of first stroke. This report included 3310 hypertensive adults, a subset of the China Stroke Primary Prevention Trial (CSPPT) with baseline measurements for baPWV. During a median follow-up of 4.5 years, 111 participants developed first stroke. The risk of stroke was higher among participants with baPWV in the highest quartile than among those in the lower quartiles (6.3% versus 2.4%; hazard ratio, 1.66; 95% confidence interval, 1.06-2.60). Similarly, the participants with inadequate hypertension control had a higher risk of stroke than those with adequate control (5.1% versus 1.8%; hazard ratio, 2.32; 95% confidence interval, 1.49-3.61). When baPWV and hypertension control were examined jointly, participants in the highest baPWV quartile and with inadequate hypertension control had the highest risk of stroke compared with their counterparts (7.5% versus 1.3%; hazard ratio, 3.57; 95% confidence interval, 1.88-6.77). There was a significant and independent effect of high baPWV on stroke as shown among participants with adequate hypertension control (4.2% versus 1.3%; hazard ratio, 2.29, 95% confidence interval, 1.09-4.81). In summary, among hypertensive patients, baPWV and hypertension control were found to independently and jointly affect the risk of first stroke. Participants with high baPWV and inadequate hypertension control had the highest risk of stroke compared with other groups.
Wang, Y.; Mu, J.J.; Geng, L.K.; Wang, D.; Ren, K.Y.; Guo, T.S.; Chu, C.; Xie, B.Q.; Liu, F.Q.; Yuan, Z.Y.
Accumulating evidence has suggested that high salt and potassium might be associated with vascular function. The aim of this study was to investigate the effect of salt intake and potassium supplementation on brachial-ankle pulse wave velocity (PWV) in Chinese subjects. Forty-nine subjects (28-65 years of age) were selected from a rural community of northern China. All subjects were sequentially maintained on a low-salt diet for 7 days (3.0 g/day NaCl), a high-salt diet for an additional 7 days (18.0 g/day NaCl), and a high-salt diet with potassium supplementation for a final 7 days (18.0 g/day NaCl+4.5 g/day KCl). Brachial-ankle PWV was measured at baseline and on the last day of each intervention. Blood pressure levels were significantly increased from the low-salt to high-salt diet, and decreased from the high-salt diet to high-salt plus potassium supplementation. Baseline brachial-ankle PWV in salt-sensitive subjects was significantly higher than in salt-resistant subjects. There was no significant change in brachial-ankle PWV among the 3 intervention periods in salt-sensitive, salt-resistant, or total subjects. No significant correlations were found between brachial-ankle PWV and 24-h sodium and potassium excretions. Our study indicates that dietary salt intake and potassium supplementation, at least in the short term, had no significant effect on brachial-ankle PWV in Chinese subjects. PMID:25493387
Wang, Yan; Zhang, Jin; Qain, Yuesheng; Tang, Xiaofeng; Ling, Huawei; Chen, Kemin; Li, Yan; Gao, Pingjin; Zhu, Dingliang
Intracranial arterial stenosis is a common cause of ischemic stroke in Asians. We therefore sought to explore the relationship of brachial-ankle pulse wave velocity and intracranial arterial stenosis in 834 stroke-free hypertensive patients. Intracranial arterial stenosis was evaluated through computerized tomographic angiography. Brachial-ankle pulse wave velocity was measured by an automated cuff device. The top decile of brachial-ankle pulse wave velocity was significantly associated with intracranial arterial stenosis (P = .027, odds ratio = 1.82; 95% confidence interval: 1.07-3.10). The patients with the top decile of brachial-ankle pulse wave velocity showed 56% higher risk for the presence of intracranial arterial stenosis to the whole population, which was more significant in patients younger than 65 years old. We also found that brachial-ankle pulse wave velocity related to both intracranial arterial stenosis and homocysteine. Our study showed the association of brachial-ankle pulse wave velocity with asymptomatic intracranial arterial stenosis in hypertension patients, especially in relative younger subjects. Brachial-ankle pulse wave velocity might be a relatively simple and repeatable measurement to detect hypertension patients in high risk of intracranial arterial stenosis. Copyright © 2016. Published by Elsevier Inc.
Korhonen, Päivi; Syvänen, Kari; Aarnio, Pertti
Peripheral artery tonometry (PAT) is a novel method for assessing arterial stiffness of small digital arteries. Pulse pressure can be regarded as a surrogate of large artery stiffness. When ankle-brachial index (ABI) is calculated using the higher of the two ankle systolic pressures as denominator (ABI-higher), leg perfusion can be reliably estimated. However, using the lower of the ankle pressures to calculate ABI (ABI-lower) identifies more patients with isolated peripheral arterial disease (PAD) in ankle arteries. We aimed to compare the ability of PAT, pulse pressure, and different calculations of ABI to detect atherosclerotic disease in lower extremities. We examined PAT, pulse pressure, and ABI in 66 cardiovascular risk subjects in whom borderline PAD (ABI 0.91 to 1.00) was diagnosed 4 years earlier. Using ABI-lower to diagnose PAD yielded 2-fold higher prevalence of PAD than using ABI-higher. Endothelial dysfunction was diagnosed in 15/66 subjects (23%). In a bivariate correlation analysis, pulse pressure was negatively correlated with ABI-higher (r = −0.347, p = 0.004) and with ABI-lower (r = −0.424, p < 0.001). PAT hyperemic response was not significantly correlated with either ABI-higher (r = −0.148, p = 0.24) or with ABI-lower (r = −0.208, p = 0.095). Measurement of ABI using the lower of the two ankle pressures is an efficient method to identify patients with clinical or subclinical atherosclerosis and worth performing on subjects with pulse pressure above 65 mm Hg. The usefulness of PAT measurement in detecting PAD is vague. PMID:22942632
Pieniak, Marcin; Cieślicki, Krzysztof; Żyliński, Marek; Górski, Piotr; Murgrabia, Agnieszka; Cybulski, Gerard
According to international guidelines, patients with Peripheral Artery Disease (PAD) are burdened with high cardiovascular risk. One of the simplest, non-invasive methods for PAD detection is the ankle-brachial index (ABI) measurement. The ABI is calculated as the ratio of systolic blood pressure at the ankle (pressure in the posterior tibial artery or the dorsal artery) to the systolic pressure in the arm (in the brachial artery) when the body is in a horizontal position. The physiological value of the ABI is assumed to be between 1 and 1.3; however, these limits vary from study to study. A value less than 0.9 indicates PAD. Some authors propose also measuring the ABI on both sides of the body to highlight possible differences in blood pressure between the opposite arterial segments. The aim of this study was to perform a meta-analysis of the ABI diagnostic criteria used in different publications. Additionally, ABI measurements were performed on 19 healthy patients in age ranged from 20 to 63 years. The results showed a slight dependence between age and the differences between the values obtained from left and right sides of the body.
Nead, Kevin T.; Cooke, John P.; Olin, Jeffrey W.; Leeper, Nicholas J.
Objectives To determine whether utilization of an alternative ankle-brachial index (ABI) calculation method improves mortality risk prediction compared to traditional methods. Background The ABI is used to diagnose peripheral arterial disease (PAD), and to identify those at risk for cardiovascular events. Traditionally, the ABI is calculated using the higher of the dorsalis pedis and posterior tibial ankle arteries. Studies directly comparing calculation methods are limited. Methods The ABI was calculated at baseline in 1,413 study participants undergoing non-emergent coronary angiography subsequently followed for all-cause and cardiovascular mortality. There were 224 individuals assigned to the traditional-PAD group (ABI < 0.90) using the traditional ABI method. Of those remaining, an alternative ABI method utilizing the lower of the two ankle pressures assigned 282 patients to the alternative-PAD group. The 862 individuals not assigned to PAD by either method were the no-PAD group. Results There were 163 mortalities during a median follow-up of 5.0 years. Adjusted Cox regression models showed that the alternative-PAD group had an increased risk for all-cause (HR=1.49; 95% CI, 1.01-2.19) and cardiovascular mortality (HR=3.21; 95% CI, 1.53-6.37) versus the no-PAD group. Additionally, in the no-PAD group, there was an 11% (HR=1.11; 95% CI, 1.05-1.17) increased risk of all-cause mortality per 1mm Hg increased difference between the left and right brachial systolic pressures. Conclusion The implementation of an alternative ABI method and use of the brachial difference identifies individuals at an increased risk for mortality who are currently missed using traditional ABI methods. Current ABI protocols may need to be evaluated. PMID:23707317
Herráiz-Adillo, Ángel; Cavero-Redondo, Iván; Álvarez-Bueno, Celia; Martínez-Vizcaíno, Vicente; Pozuelo-Carrascosa, Diana P; Notario-Pacheco, Blanca
The use of oscillometric ankle brachial index (ABI) to diagnose peripheral arterial disease (PAD) has raised concern, especially due to a lack of agreement and sensitivity. This study aimed to evaluate those factors affecting the validity of oscillometric ABI in comparison to Doppler ABI to detect PAD. Through univariate and multivariate linear regression, we studied those factors affecting the differences between oscillometric and Doppler ABI; through univariate and multivariate logistic regression we analyzed the false negative rate of oscillometric ABI to detect PAD. We analyzed 197 consecutive subjects (394 legs) from two settings: Primary Care and Vascular Service. The means of oscillometric ABI and Doppler ABI were 1.094 (95%CI: 0.843-1.345) and 1.073 (95%CI: 0.769-1.374) (p<0.001), respectively. In men, covariates explaining the differences between oscillometric and Doppler ABI were Doppler ankle blood pressure (β=‒0.610, p<0.001), ankle circumference (β=0.176, p=0.004) and oscillometric brachial blood pressure (β=0.136, p=0.037); in women, those were weight (β=0.351, p<0.001) and Doppler ankle blood pressure (β=‒0.318, p<0.001). Sensitivity and specificity of oscillometric ABI to detect PAD were 80.6% and 97.4%, respectively, and covariates explaining the rate of false negatives in PAD population were setting (Exp(β)=17.21, p=0.009) and tobacco (packs/year) (Exp(β)=1.049, p=0.002). Although some factors influencing the lack of agreement between oscillometric and Doppler ABI were identified, the correction of oscillometric ABI seems impractical, since Doppler is needed, the bias is not always uniformly distributed and its clinical relevance is small. According to sensitivity, borderline oscillometric ABI in Primary Care settings and smokers suggest PAD.
Understanding Task Force Recommendations Screening for Peripheral Artery Disease and Cardiovascular Disease Risk Assessment with Ankle Brachial Index in Adults The U.S. Preventive Services Task Force (Task Force) has issued a ...
Chenglong, Zhang; Jing, Lei; Xia, Ke; Yang, Tianlun
Previous studies have demonstrated that both low and high hemoglobin concentrations are predictive of adverse cardiovascular outcomes in various populations. However, an association of hemoglobin with the ankle-brachial index, which is widely used as a screening test for peripheral arterial disease, has not yet been identified. We examined 786 subjects (236 women and 550 men) who received routine physical check-ups. The ankle-brachial index and several hematological parameters, including the hemoglobin level, hematocrit and red blood cell count and other demographic and biochemical characteristics were collected. Univariate and multivariate linear regression analyses were performed to assess the relationships between the ankle-brachial index and the independent determinants. Receiver operating characteristic curve analysis was conducted to calculate the cut-off level of hemoglobin for detecting a relatively low ankle-brachial index (less than 20% of all subjects, which was 1.02). The hemoglobin level, hematocrit and red blood cell count were correlated with the ankle-brachial index in the males (r=-0.274, r=-0.224 and r=-0.273, respectively, p<0.001 for all), but these associations were not significant in the females. Multivariate linear regression analysis revealed that the independent determinants of the ankle-brachial index included age, total cholesterol, high-density lipoprotein cholesterol and the white blood cell count for the females and age, hypertension, total cholesterol and hemoglobin (β=-0.001, p<0.001) for the males after adjusting for confounding factors. Receiver operating characteristic curve analysis revealed that the cut-off level of hemoglobin for predicting a low ankle-brachial index was 156.5 g/L in the males. A high hemoglobin concentration was independently correlated with a low ankle-brachial index in the healthy males, indicating that an elevation in this level may be associated with an increased atherosclerosis risk.
The run-off resistance (ROR) assessed on MR angiograms may serve as a valid scoring system in patients with symptomatic peripheral arterial disease (PAD) and correlates with the ankle-brachial pressure index (ABI).
Gorny, O; Santner, W; Fraedrich, G; Jaschke, W; Greiner, A; Schocke, M F
To investigate the correlation between the hemodynamic parameter ankle-brachial pressure index (ABI) and the run-off resistance (ROR) assessed on MR angiograms (MRA) in patients with peripheral arterial disease (PAD) Fontaine Stage I and II and its potential as reliable reporting system in clinical routine. Contrast-enhanced MRA was performed in 321 PAD patients using a 1.5T MR scanner with moving bed technique. The ROR and resting ABI were determined in each patient's leg and correlation analysis was performed using the Pearson test. A significant negative correlation (r = -.513; p<.001) between ROR (mean 11.03±5.42) and resting ABI (mean .81±.26) was identified. An even more pronounced correlation was found in patients younger than median age who had higher ABI values (r = -.608; p<.001). The ROR scoring system evaluated in this series correlates better with the ABI than previously published scoring systems and could be suggested as reporting system for routine MRA evaluation. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
van der Slegt, Jasper; Verbogt, Nathalie Pa; Mulder, Paul Gh; Steunenberg, Stijn L; Steunenberg, Bastiaan E; van der Laan, Lijckle
An automated ankle-brachial index device could lead to potential time savings and more accuracy in ankle-brachial index-determination after vascular surgery. This prospective cross-sectional study compared postprocedural ankle-brachial indices measured by a manual method with ankle-brachial indices of an automated plethysmographic method. Forty-two patients were included. No significant difference in time performing a measurement was observed (1.1 min, 95% CI: -0.2 to +2.4; P = 0.095). Mean ankle-brachial index with the automated method was 0.105 higher (95% CI: 0.017 to 0.193; P = 0.020) than with the manual method, with limits of agreement of -0.376 and +0.587. Total variance amounted to 0.0759 and the correlation between both methods was 0.60. Reliability expressed as maximum absolute difference (95% level) between duplicate ankle-brachial index-measurements under identical conditions was 0.350 (manual) and 0.152 (automated), although not significant (p = 0.053). Finally, the automated method had 34% points higher failure rate than the manual method. In conclusion based on this study, the automated ankle-brachial index-method seems not to be clinically applicable for measuring ankle-brachial index postoperatively in patients with vascular disease. © The Author(s) 2016.
Amer, Moatasem S; Tawfik, Heba M; Abd Elmotteleb, Ayman M; Maamoun, Manar M A
There is a high prevalence of combined peripheral and coronary artery disease, with increasing morbidity and decline in cardiac function. The aim of the present study was to find an association between ankle brachial index, a non-invasive measure of peripheral artery disease, and ejection fraction in elderly patients with severe coronary artery disease. A case-control study recruiting 200 elderly male and female ischemic patients in Ain Shams University hospitals was carried out. All participants had significant coronary artery disease lesions in coronary angiography carried out before the study. Cases and controls were divided according to ankle brachial index, with further subdivision of each group according to age. Measurements include: ankle brachial index using Bistos handheld vascular Doppler (BT 200V,8 MHz), electrocardiography and echocardiography showing left ventricular ejection fraction. Coronary artery disease severity was estimated using the number of diseased vessels. The mean age of our study group was 67 years. Although our participants had mild to moderate peripheral artery disease, ejection fraction statistically decreased with decreasing ankle brachial index, being the lowest in participants aged > 70 years (46.84 ± 9.82 years) and the highest in controls aged >70 years (53.02 ± 5.53 years; P = 0.009). Ejection fraction was positively correlated with ankle brachial index (P = 0.011, 0.006) for cases and controls, respectively. Ankle brachial index can correlate with ejection fraction in elderly ischemic Egyptians with more severe coronary artery disease. © 2014 Japan Geriatrics Society.
Assessing Ankle-Brachial Index is an essential procedure in clinical settings, but since its measurement by the gold standard Doppler Ultrasonic (DU) technique is impaired by technical difficulties, it is underperformed. The aim of this study was to assess the efficacy of an automated oscillometric device (AOD) by performing Ankle-Brachial Index (ABI) assessments and to suggest delta brachial-brachial (delta-BB) and delta-ABI as markers of cardiovascular risk. In this observational and descriptive study, 247 patients (56.2% females, mean age 62.0 years) had their arterial blood pressure (ABP) measured for ABI calculation. Two AOD (OMRON-HEM705CP) devices were used for simultaneous measurements of the ABP, first of the two arms and then of the arm with higher systolic ABP and a leg, first the left and then the right one. When leg ABP measurements were not possible, ABI determination was performed by using the standard Doppler Ultrasonic (DU) technique. Patients were designated to Group N (normal ABI: 0.91 to 1.30) or Group A (abnormal ABI: < or =0.90 or >1.30). Other indexes were also calculated: delta-BB (absolute difference in mmHg of systolic ABP between arms) and delta-ABI (absolute difference of ABI between legs) and the results were compared. In most patients (90.7%), it was possible to determine the ABI. Group N data allowed calculation of the 95th percentile reference values (RV) of delta-BB (0 to 8 mmHg) and delta-ABI (0 to 0.13). When compared to Group N, Group A had a significantly higher prevalence of high values greater than the RVs of delta-ABI (30 of 52 and 10 of 195, respectively; Odds Ratio = 25.23; p<0.0001) and delta-BB (13 of 52 and 7 of 195, respectively; Odds Ratio = 8.95; p<0.0001). In most patients, the ABI could be measured by AOD. Both indexes, delta-BB and delta-ABI greater than the RVs, were significantly more prevalent in patients with abnormal ABI values, and their usefulness as new markers of cardiovascular disease should be further
Del Brutto, Oscar H; Sedler, Mark J; Mera, Robertino M; Lama, Julio; Gruen, Jadry A; Phelan, Kelsie J; Cusick, Elizabeth H; Zambrano, Mauricio; Brown, David L
An abnormal ankle-brachial index has been associated with overt stroke and coronary heart disease, but little is known about its relationship with silent cerebral small vessel disease. To assess the value of ankle-brachial index as a predictor of silent small vessel disease in an Ecuadorian geriatric population. Stroke-free Atahualpa residents aged ≥60 years were identified during a door-to-door survey. Ankle-brachial index determinations and brain magnetic resonance imaging were performed in consented persons. Ankle-brachial index ≤0.9 and ≥1.4 were proxies of peripheral artery disease and noncompressible arteries, respectively. Using logistic regression models adjusted for age, gender, and cardiovascular health status, we evaluated the association between abnormal ankle-brachial index with silent lacunar infarcts, white matter hyperintensities, and cerebral microbleeds. Mean age of the 224 participants was 70 ± 8 years, 60% were women, and 80% had poor cardiovascular health status. Ankle-brachial index was ≤0.90 in 37 persons and ≥1.4 in 17. Magnetic resonance imaging showed lacunar infarcts in 27 cases, moderate-to-severe white matter hyperintensities in 47, and cerebral microbleeds in 26. Adjusted models showed association of lacunar infarcts with ankle-brachial index ≤ 0.90 (OR: 3.72, 95% CI: 1.35-10.27, P = 0.01) and with ankle-brachial index ≥ 1.4 (OR: 3·85, 95% CI: 1.06-14.03, P = 0.04). White matter hyperintensities were associated with ankle-brachial index ≤ 0.90 (P = 0.03) and ankle-brachial index ≥ 1.4 (P = 0.02) in univariate analyses. There was no association between ankle-brachial index groups and cerebral microbleeds. In this population-based study conducted in rural Ecuador, apparently healthy individuals aged ≥60 years with ankle-brachial index values ≤0.90 and ≥1.4 are almost four times more likely to have a silent lacunar infarct. Ankle-brachial index screening might allow recognition
Background We examined the relationship between central blood pressure (BP), brachial BP with carotid atherosclerosis and microvascular complications in type 2 diabetes mellitus (T2DM). Methods We recruited 201 patients who were evaluated for central BP, brachial BP, carotid ultrasonography, brachial-ankle pulse wave velocity (baPWV), ankle-brachial index (ABI) and microvascular complications. Central BP were calculated using a radial automated tonometric system. Results Agreement between central BP and brachial BP was very strong (concordance correlation coefficient between central and brachial SBP = 0.889, between central and brachial PP = 0.816). Central pulse pressure (PP) was correlated with mean carotid intima-media thickness (CIMT), baPWV and ABI, whereas brachial PP was borderline significantly correlated with CIMT. The prevalence of nephropathy(DN) and retinopathy(DR) according to the brachial PP tertiles increased, the prevalences of microvascular complications were not different across central PP tertiles. In multivariate analysis, the relative risks (RRs) for the presence of DR were 1.2 and 4.6 for the brachial PP tertiles 2 and 3 when compared with the first tertile. Also, the RRs for the presence of DN were 1.02 and 3 for the brachial PP tertiles 2 and 3 when compared with the first tertile. Conclusions Agreement of central BP and brachial BP was very strong. Nonetheless, this study showed that higher brachial PP levels are associated with increased probability for the presence of microvascular complications such as DR/DN. However, there are no associations with central SBP and central PP with microvascular complications. Central BP levels than brachial BP are correlated with surrogate marker of macrovascular complications. PMID:24555866
Ito, Norihisa; Ohishi, Mitsuru; Takagi, Takashi; Terai, Minako; Shiota, Atsushi; Hayashi, Norihiro; Rakugi, Hiromi; Ogihara, Toshio
The goal of this study was to clarify the clinical usefulness and limitations of brachial-ankle pulse wave velocity (PWV) to evaluate hypertensive complications, in comparison with carotid-femoral PWV. Patients with essential hypertension (n=296, male/female=161/135; age=61.1+/-0.7 years) were enrolled. We measured brachial-ankle PWV, femoral-ankle PWV and carotid-femoral PWV simultaneously, and evaluated target organ damage and associated clinical conditions (cerebrovascular and cardiovascular disease) using the World Health Organization classification modified in 1999. Carotid-femoral PWV (p<0.0001; r=0.521) and brachial-ankle PWV (p<0.0001; r=0.478) but not femoral-ankle PWV were significantly correlated with age. Carotid-femoral PWV was significantly higher in patients with associated clinical conditions compared with that in patients with target organ damage (p<0.05) and those with no complications (p<0.0001). Brachial-ankle PWV was significantly higher in patients with associated clinical conditions (p<0.05) and target organ damage (p<0.05) compared to those with no complications, but there was no significant difference in brachial-ankle PWV between these two groups. Moreover, femoral-ankle PWV was significantly lower in patients with associated clinical conditions compared with that in patients with target organ damage (p<0.05). These data suggest that brachial-ankle PWV could underestimate arterial stiffness in hypertensive patients with a history of cardiovascular events.
Mitu, F; Mitu, O; Leon, Maria-Magdalena; Jitaru, Alexandra
On a global scale, the cardiovascular diseases constitute the prime factor of death and invalidity. The premature mortality percentage caused by these varies from 4% in high developed countries to 40% in underdeveloped countries. Atherosclerosis is the most important etiological factor. The presence of various degrees of atherosclerosis in a certain vascular area (in our case, the lower limb arteries), increases the probability of affecting other areas as well (coronary, cerebral, renal, mesenteric arteries). The evaluation and description of the correlations between the ankle-brachial index levels and the cardiovascular risk factors, taken individually or as part of the metabolic syndrome. The values of the ankle-brachial index were divided in normal and abnormal. The evaluated cardiovascular risk factors were: age, sex, arterial hypertension, obesity, smoking, high levels of cholesterol and basal glucose, low levels of HDL-cholesterol. There were significant statistical differences between the normal ankle-brachial index lot and the one with abnormal values, specifically in patients with diabetes mellitus and metabolic syndrome. More so, the study demonstrates that the ankle-brachial index is considerably smaller in patients with metabolic syndrome. The simple measurement of the afore mentioned index, as a atherosclerosis marker for the lower limb arteries, represents an independent prediction over the metabolic syndrome and the conventional risk factors, in the development of the cardiovascular diseases. The routine measurement of this parameter in medical practice might imply the early diagnosis of high risk manifested cardiovascular disease patients.
Barone Gibbs, Bethany; Dobrosielski, Devon A.; Althouse, Andrew D.; Stewart, Kerry J.
Introduction Though being physically active has associated with a healthier ankle-brachial index (ABI) in observational studies, ABI usually does not change with exercise training in patients with peripheral artery disease (PAD). Less is known about the effect of exercise training on ABI in patients without PAD but at high risk due to the presence of type 2 diabetes (T2DM). Methods Participants (n=140) with uncomplicated T2DM, and without known cardiovascular disease or PAD, aged 40–65 years, were randomized to supervised aerobic and resistance training 3 times per week for 6 months or to a usual care control group. ABI was measured before and after the intervention. Results Baseline ABI was 1.02±0.02 in exercisers and 1.03±0.01 in controls (p=0.57). At 6 months, exercisers vs. controls improved ABI by 0.04±0.02 vs. −0.03±0.02 (p=0.001). This change was driven by an increase in ankle pressures (p<0.01) with no change in brachial pressures (p=0.747). In subgroup analysis, ABI increased in exercisers vs. controls among those with baseline ABI<1.0 (0.14±0.03 vs. 0.02±0.02, p=0.004), but not in those with a baseline ABI≥1.0 (p=0.085). The prevalence of ABI between 1.0–1.3 increased from 63% to 78% in exercisers and decreased from 62% to 53% in controls. Increased ABI correlated with decreased HbA1c, systolic and diastolic blood pressure, but the effect of exercise on ABI change remained significant after adjustment for these changes (β=0.061, p=0.004). Conclusion These data suggest a possible role for exercise training in the prevention or delay of PAD in T2DM, particularly among those starting with an ABI <1.0. PMID:23958264
Sona, Alessandro; Comba, Monica; Brescianini, Alessia; Corsinovi, Laura; Zanocchi, Mauro; Fonte, Gianfranco; Bo, Mario
Low (< or = 90) Ankle Brachial Index (ABI) values identify patients at high risk for cardiovascular (CV) disease and mortality. Implications for CV risk classification from routinely measuring ABI in the context of a Lipid Clinic have not been fully investigated. We aimed to evaluate whether and to what extent routine ABI determination on top of conventional risk prediction models may modify CV risk classification. Consecutive asymptomatic non-diabetic individuals free from previous CV events attending for a first visit at a Lipid Clinic underwent routine ABI determination and conventional CV risk classification according either to national CUORE model (including age, gender, smoking, total and high density lipoprotein cholesterol, systolic blood pressure and current use of blood pressure lowering drugs) and SCORE model for low risk countries. In the overall sample (320 subjects, mean age 64.8 years) 77 subjects (24.1%) were found to have low ABI value. Forty-two of 250 subjects (16.8%) and 47 of 215 individuals (21.3%) at low or moderate risk according to the CUORE and SCORE models, respectively, were found to have low ABI values, and should be reclassified at high risk. In a series of consecutive asymptomatic individuals in a Lipid Clinic, we observed a high prevalence of low ABI values among subjects deemed at low or moderate risk on conventional prediction models, leading to CV high-risk reclassification of roughly one fifth of patients. These findings reinforce recommendations for routine determination of ABI at least within referral primary prevention settings.
Syvänen, Kari; Aarnio, Pertti; Jaatinen, Pekka; Korhonen, Päivi
BACKGROUND Smoking is a well-known risk factor for peripheral arterial disease (PAD). Data regarding differences in the prevalence of PAD between sexes are somewhat controversial. In addition, most studies indicate that the prevalence of PAD increases with age in both sexes. In the present study, the effects of sex, age and smoking on the ankle-brachial index (ABI) in a Finnish cardiovascular risk population were investigated. OBJECTIVES To investigate the relationship between the ankle-brachial index, and age, sex and smoking in a Finnish population at risk for cardiovascular disease. METHODS All men and women between 45 and 70 years of age living in a rural town (Harjavalta, Finland; total population 7700) were invited to participate in a population survey (Harmonica study). Patients with previously diagnosed diabetes or vascular disease were excluded. In total, 2856 patients were invited to participate in the study. From these subjects, a cardiovascular risk population was screened. Complete data were available from 1028 persons. ABI (the ratio between the posterior tibial or dorsalis pedis artery and brachial artery pressures) was measured, and questionnaires were used to detect smoking status and relevant medical history. Only current smoking status was taken into account. RESULTS The mean ABI for the entire study population was 1.10 (range 0.56 to 1.64). Current smokers had a lower mean ABI (1.06; P<0.001). There was no statistically significant difference in ABI values among age groups, although the majority of patients with ABI values below 0.9 were older than 60 years of age. There was no statistically significant difference in ABI between sexes. CONCLUSION As previously reported, the present study shows the significant effect of smoking in the development of PAD. No statistically significant difference was found among age groups, but the tendency was toward lower ABIs in the oldest age groups. Sex had a minimal effect on the ABI. PMID:22477327
Syvänen, Kari; Aarnio, Pertti; Jaatinen, Pekka; Korhonen, Päivi
Smoking is a well-known risk factor for peripheral arterial disease (PAD). Data regarding differences in the prevalence of PAD between sexes are somewhat controversial. In addition, most studies indicate that the prevalence of PAD increases with age in both sexes. In the present study, the effects of sex, age and smoking on the ankle-brachial index (ABI) in a Finnish cardiovascular risk population were investigated. To investigate the relationship between the ankle-brachial index, and age, sex and smoking in a Finnish population at risk for cardiovascular disease. All men and women between 45 and 70 years of age living in a rural town (Harjavalta, Finland; total population 7700) were invited to participate in a population survey (Harmonica study). Patients with previously diagnosed diabetes or vascular disease were excluded. In total, 2856 patients were invited to participate in the study. From these subjects, a cardiovascular risk population was screened. Complete data were available from 1028 persons. ABI (the ratio between the posterior tibial or dorsalis pedis artery and brachial artery pressures) was measured, and questionnaires were used to detect smoking status and relevant medical history. Only current smoking status was taken into account. The mean ABI for the entire study population was 1.10 (range 0.56 to 1.64). Current smokers had a lower mean ABI (1.06; P<0.001). There was no statistically significant difference in ABI values among age groups, although the majority of patients with ABI values below 0.9 were older than 60 years of age. There was no statistically significant difference in ABI between sexes. As previously reported, the present study shows the significant effect of smoking in the development of PAD. No statistically significant difference was found among age groups, but the tendency was toward lower ABIs in the oldest age groups. Sex had a minimal effect on the ABI.
Rada, C; Oummou, S; Merzouk, F; Amarir, B; Boussabnia, G; Bougrini, H; Benzaroual, D; Elkarimi, S; Elhattaoui, M
Peripheral arterial disease is a marker of systemic atherosclerosis; it is associated with a high risk of cardiovascular disease. The aim of our study was to assess the prevalence of peripheral arterial disease by measuring the ankle-brachial pressure index in patients at high cardiovascular risk and to study the risk factors associated with this disease. This was a descriptive and analytic cross-sectional study which focused on 370 patients seen at the medical consultation for atherosclerosis prevention. The ankle-brachial index was measured with a portable Doppler (BIDOP 3) using 4 and 8Hz dual frequency probes. The standards were: normal ankle-brachial index 0.9 to 1.3; peripheral artery obstructive disease ankle-brachial index less than 0.9; poorly compressible artery (medial arterial calcification) ankle-brachial index greater than 1.3. Cardiovascular risk factors were also studied. Three hundred and seventy subjects (mean age 65.5±8.7years) were screened Cardiovascular risk factors were: sedentary lifestyle (91.5 %), hypertension (68.1 %), elevated LDL-cholesterolemia (36.3 %), diabetes (48.3 %) and tobacco smoking (33.8 %). The prevalence of peripheral artery disease was 32.4 % of which 77.5 % were asymptomatic. We found a significant correlation with smoking, diabetes, dyslipidemia and the presence of coronary artery disease or vascular cerebral disease. Screening for peripheral arterial disease (PAD) with the ankle-brachial index has increased the percentage of polyvascular patients from 6.2 to 29 %. Factors independently associated with PAD were advanced age, presence of cardiovascular disease, smoking and glycated hemoglobin. PAD is a common condition in people at high cardiovascular risk, the frequency of asymptomatic forms justifies the screening with pocket Doppler which is a simple, inexpensive and effective test to assess the overall cardiovascular risk. Copyright Â© 2016 Elsevier Masson SAS. All rights reserved.
Gronewold, Janine; Hermann, Dirk M; Lehmann, Nils; Kröger, Knut; Lauterbach, Karl; Berger, Klaus; Weimar, Christian; Kälsch, Hagen I M; Moebus, Susanne; Jöckel, Karl-Heinz; Bauer, Marcus; Erbel, Raimund
Predictors of future stroke events gain importance in vascular medicine. Herein, we investigated the value of the ankle-brachial index (ABI), a simple non-invasive marker of atherosclerosis, as stroke predictor in addition to established risk factors that are part of the Framingham risk score (FRS). 4299 subjects from the population-based Heinz Nixdorf Recall study (45-75 years; 47.3% men) without previous stroke, coronary heart disease or myocardial infarcts were followed up for ischemic and hemorrhagic stroke events over 109.0±23.3 months. Cox proportional hazard regressions were used to evaluate ABI as stroke predictor in addition to established vascular risk factors (age, sex, systolic blood pressure, LDL, HDL, diabetes, smoking). 104 incident strokes (93 ischemic) occurred (incidence rate: 2.69/1000 person-years). Subjects suffering stroke had significantly lower ABI values at baseline than the remaining subjects (1.03±0.22 vs. 1.13±0.14, p<0.001). In a multivariable Cox regression, ABI predicted stroke in addition to classical risk factors (hazard ratio=0.77 per 0.1, 95% confidence interval=0.69-0.86). ABI predicted stroke events in subjects above and below 65 years, both in men and women. ABI specifically influenced stroke risk in subjects belonging to the highest (>13%) and intermediate (8-13%) FRS tercile. In these subjects, stroke incidence was 28.13 and 8.13/1000 person-years, respectively, for ABI<0.9, compared with 3.97 and 2.07/1000 person-years for 0.9≤ABI≤1.3. ABI predicts stroke in the general population, specifically in subjects with classical risk factors, where ABI identifies subjects at particularly high stroke risk. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Busch, Markus A; Lutz, Katrin; Röhl, Jens-Eric; Neuner, Bruno; Masuhr, Florian
A low ankle-brachial blood pressure index (ABI) is an established risk marker for cardiovascular disease and mortality in the general population, but little is known about its prognostic value in individuals with acute ischemic stroke or transient ischemic attack (TIA). An inception cohort of 204 patients with acute ischemic stroke or TIA was followed up for a mean of 2.3 years. At baseline, patients underwent ABI measurement and were assessed for risk factors, cardiovascular comorbidities, and cervical or intracranial artery stenosis. The association between low ABI (=0.9) and the risk of the composite outcome of stroke, myocardial infarction, or death was examined by Kaplan-Meier and Cox regression analyses. A low ABI was found in 63 patients (31%) and was associated with older age, current smoking, hypertension, peripheral arterial disease, and cervical or intracranial stenosis. During a total of 453.0 person-years of follow-up, 37 patients experienced outcome events (8.2% per person-year), with a higher outcome rate per person-year in patients with low ABI (12.8% vs 6.3%, P=0.03). In survival analysis adjusted for age and stroke etiology, patients with a low ABI had a 2 times higher risk of stroke, myocardial infarction, or death than those with a normal ABI (hazard ratio=2.2; 95% CI, 1.1 to 4.5). Additional adjustment for risk factors and cardiovascular comorbidities did not attenuate the association. A low ABI independently predicted subsequent cardiovascular risk and mortality in patients with acute stroke or TIA. ABI measurement may help to identify high-risk patients for targeted secondary stroke prevention.
RAC-ALBU, Marius; ILIUTA, Luminita; GUBERNA, Suzana Maria; SINESCU, Crina
The presence of peripheral arterial disease (PAD) is associated with higher cardiovascular morbidity and mortality, regardless of gender or its clinical form of presentation (symptomatic or asymptomatic). PAD is considered an independent predictor for cardiovascular mortality, more important for survival than clinical history of coronary artery disease. The ankle brachial index (ABI) is a sensitive and cost-effective screening tool for PAD. ABI is valuable for screening of peripheral artery disease in patients at risk and for diagnosing the disease in patients who present with lower-extremity symptoms. Compared to other diagnostic methods, ABI is superior because it is s a simple, noninvasive test, which could be routinely determined in all patients. Normal cut-off values for ABI are between 0.9 and 1.4. An abnormal ankle-brachial index- below 0.9-is a powerful independent marker of cardiovascular risk. There is an inverse correlation between ABI values, non-fatal cardiac events (myocardial infarction, stroke and heart failure exacerbation) and mortality (cardiovascular and global), the relation being nonlinear, patients with very low ABI (<0.3) having a significantly higher additional risk. Also, ABI values over 1.3-1.4 correlate with major adverse cardiovascular events. Therefore, ABI can be considered a generalized atherosclerotic predictor, identifying patients at high risk for developing cardio- or cerebrovascular events and should be incorporated into routine clinical practice. PMID:25705296
Figueroa, Arturo; Kalfon, Roy; Wong, Alexei
High ankle systolic blood pressure (SBP; ≥175 mm Hg) is associated with arterial stiffness (pulse wave velocity [PWV]) and cardiac events. This study aims to investigate the effects of whole-body vibration (WBV) training on ankle SBP and its associations with changes in PWV and aortic SBP in postmenopausal women. Thirty-six postmenopausal women were randomized to a control group (n = 12) or a WBV training group (3 d/wk) that was stratified by ankle SBP into WBV-high (n = 12) and WBV-normal (n = 12). Ankle SBP, brachial SBP, aortic SBP, femoral-ankle PWV (legPWV), carotid-femoral PWV, and brachial-ankle PWV (baPWV) were examined before and after 12 weeks. Baseline ankle SBP was higher (P < 0.05) in the WBV-high group compared with the WBV-normal group. WBV-high reduced mean (SEM) ankle SBP (-24  mm Hg, P < 0.05) compared with WBV-normal and control. Both WBV groups decreased (P < 0.05) mean (SEM) brachial SBP (-11  mm Hg), aortic SBP (-11  mm Hg), legPWV (-0.80 [0.17] m/s), and baPWV (-1.18 [0.27] m/s) compared with the control group. Reductions in legPWV were correlated (P < 0.05) with decreases in ankle SBP (r = 0.43), brachial SBP (r = 0.42), aortic SBP (r = 0.42), and baPWV (r = 0.75). WBV training decreases ankle SBP in postmenopausal women with high ankle SBP. WBV training reduces aortic SBP, legPWV, and baPWV, but not carotid-femoral PWV, in postmenopausal women independently of ankle SBP. Therefore, reductions in peripheral and central SBP induced by WBV training are explained by a reduction in peripheral PWV.
Shin, Ming-Chen Paul; Lee, Mei-Yueh; Huang, Jiun-Chi; Tsai, Yi-Chun; Chen, Jui-Hsin; Chen, Szu-Chia; Chang, Jer-Ming; Chen, Hung-Chun
Abstract Aortic arch calcification (AoAC) is associated with cardiovascular and all-cause mortality in end-stage renal disease population. AoAC can be simply estimated with an AoAC score using plain chest radiography. The objective of this study is to evaluate the association of AoAC with brachial-ankle pulse wave velocity (baPWV) and cardiomegaly in patients who have undergoing hemodialysis (HD). We retrospectively determined AoAC and cardiothoracic ratio (CTR) by chest x-ray in 220 HD patients who underwent the measurement of baPWV. The values of baPWV were measured by an ankle-brachial index-form device. Multiple stepwise logistic regression analysis was used to identify the factors associated with AoAC score >4. Compared patients with AoAC score ≦4, patients with AoAC score >4 had older age, higher prevalence of diabetes and cerebrovascular disease, lower diastolic blood pressure, higher baPWV, higher CTR, higher prevalence of CTR ≧50%, lower total cholesterol, and lower creatinine level. After the multivariate stepwise logistic analysis, old age, cerebrovascular disease, high baPWV (per 100 cm/s, odds ratio [OR] 1.065, 95% confidence interval [CI] 1.003–1.129, P = 0.038), CTR (per 1%, OR 1.116, 95% CI 1.046–1.191, P = 0.001), and low total cholesterol level were independently associated with AoAC score >4. Our study demonstrated AoAC severity was associated with high baPWV and high CTR in patients with HD. Therefore, we suggest that evaluating AoAC on plain chest radiography may be a simple and inexpensive method for detecting arterial stiffness in HD patients. PMID:27175684
Liu, Miao; He, Yao; Jiang, Bin; Wu, Lei; Wang, Jian-hua; Yang, Shan-shan; Wang, Yi-yan; Li, Xiao-ying
To evaluate the association between brachial-ankle pulse wave velocity (ba-PWV) and metabolic syndrome (MetS) among the Chinese elderly and the gender difference. We conducted a population-based cross-sectional study in a representative urban area of Beijing, China. A sample of 2 102 community elderly (848 males, and 1 254 females) aged 60 to 95 years were included in the study. MetS was defined according to the 2009 harmonizing definition. The prevalence of MetS was 59.1% (50.1% in males and 65.2% in females, P<0.001). The baPWV value was between 8.2 to 45.6 (20.0 ± 4.4) m/s, and showed an increasing trend with age (P<0.001). The partial correlation showed baPWV was positively associated with BMI (r=0.076, P=0.037), systolic blood pressure (r=0.380, P<0.001), diastolic blood pressure (r=0.276, P<0.001), triglyceride (r=0.040, P=0.046), fasting blood glucose (r=0.140, P<0.001), 2-hour post-meal blood glucose (r=0.121, P<0.001), and negatively associated with HDL-C (r=-0.128, P=0.048). There was a strong association between baPWV and prevalence of MetS and its component number in females but not in males. Compared with the lowest quartile of baPWV, the adjusted ORs were 1.22 (95%CI 0.83-1.79), 1.32 (95%CI 0.90-1.93), 1.46(95%CI 1.00-2.14) in males and 1.28 (95%CI 0.93-1.77), 1.55 (95%CI 1.12-2.16), 1.86(95%CI 1.32-2.61) in females for the second, third and top quartiles. The prevalence of MetS increases substantially with increasing levels of baPWV among the Chinese elderly, especially in females.
Kim, Ju-Hyun; Kim, Mee-Young; Lee, Jeong-Uk; Lee, Lim-Kyu; Yang, Seung-Min; Jeon, Hye-Joo; Lee, Won-Deok; Noh, Ji-Woong; Kwak, Taek-Yong; Lee, Tae-Hyun; Kim, Jin-Hwan; Huh, Yong; Kim, Junghwan
[Purpose] Brachial-ankle pulse wave velocity (BaPWV), which has been reported as an index of arterial stiffness, is very closely related to cardiovascular risk factors. A high BaPWV indicates high cardiovascular risk. However, BaPWV and pressure waveforms after stroke are not fully understood. [Methods] BaPWV was measured in thirty-two subjects (twenty-two healthy volunteers and ten stroke patients) while they were in the supine position. It was measured in their bilateral upper and lower extremities. [Results] BaPWV was significantly increased in the stroke group compared with the healthy volunteers. It was also significantly increased on both the affected and non-affected sides of stroke patients in the stroke group. Furthermore, analysis of the pressure waveforms showed that the peak pressure was significantly increased in the stroke group compared with the control group. The peak pressure on both the affected and non-affected sides was also significantly greater than in the control group. However, the rise and decay times were significantly decreased in the stroke group compared with the control group. The rise and decay time on both the affected and non-affected sides were also significantly more decreased than in the control group. [Conclusion] The results demonstrated that increased BaPWV and changed pulse waves are closely associated with the pathologic states of hemiplegic stroke patients.
Amer, Moatasem S; Tawfik, Heba Mohamed; Elmoteleb, Ayman M Abd; Maamoun, Manar M A
We investigated the association between ankle brachial index (ABI) and coronary heart disease (CHD) severity in elderly Egyptians using different measures. We conducted a case-control study from November 2010 to June 2012 including 200 male and female patients with ischemia≥60 years who were divided into 100 cases and 100 controls according to ABI and redivided according to age. They underwent coronary angiography followed by ABI measurement using a hand-held Doppler. The CHD severity was estimated using the SYNTAX and Jeopardy scores and number of diseased vessels, which increased significantly in patients with peripheral artery disease (P<.001) for all. All 3 measures had strong negative correlation with ABI (P≤.001 for Jeopardy, <.001 for SYNTAX scores, and .004 for number of diseased vessels) and were correlated with each other. We concluded that ABI can reflect CHD severity in elderly Egyptians.
Singh, Asha; Bahadorani, Bobby; Wakefield, Brett J; Makarova, Natalya; Kumar, Priya A; Tong, Michael Zhen-Yu; Sessler, Daniel I; Duncan, Andra E
Brachial arterial catheters better estimate aortic pressure than radial arterial catheters but are used infrequently because complications in a major artery without collateral flow are potentially serious. However, the extent to which brachial artery cannulation promotes complications remains unknown. The authors thus evaluated a large cohort of cardiac surgical patients to estimate the incidence of related serious complications. The institutional Society of Thoracic Surgeons Adult Cardiac Surgery Database and Perioperative Health Documentation System Registry of the Cleveland Clinic were used to identify patients who had brachial artery cannulation between 2007 and 2015. Complications within 6 months after surgery were identified by International Classification of Diseases, Ninth Revision diagnostic and procedural codes, Current Procedural Terminology procedure codes, and Society of Thoracic Surgeons variables. The authors reviewed electronic medical records to confirm that putative complications were related plausibly to brachial arterial catheterization. Complications were categorized as (1) vascular, (2) peripheral nerve injury, or (3) infection. The authors evaluated associations between brachial arterial complications and patient comorbidities and between complications and in-hospital mortality and duration of hospitalization. Among 21,597 qualifying patients, 777 had vascular or nerve injuries or local infections, but only 41 (incidence 0.19% [95% CI, 0.14 to 0.26%]) were potentially consequent to brachial arterial cannulation. Vascular complications occurred in 33 patients (0.15% [0.10 to 0.23%]). Definitely or possibly related infection occurred in 8 (0.04% [0.02 to 0.08%]) patients. There were no plausibly related neurologic complications. Peripheral arterial disease was associated with increased risk of complications. Brachial catheter complications were associated with prolonged hospitalization and in-hospital mortality. Brachial artery cannulation for
Borderline ankle-brachial index is associated with increased prevalence of micro- and macrovascular complications in type 2 diabetes: A cross-sectional analysis of 12,772 patients from the Joint Asia Diabetes Evaluation Program.
Yan, Bryan P; Zhang, Yuying; Kong, Alice P S; Luk, Andrea O Y; Ozaki, Risa; Yeung, Roseanne; Tong, Peter C Y; Chan, Wing Ban; Tsang, Chiu-Chi; Lau, Kam-Piu; Cheung, Yu; Wolthers, Troels; Lyubomirsky, Greg; So, Wing-Yee; Ma, Ronald C W; Chow, Francis C C; Chan, Juliana C N
Borderline ankle-brachial index is increasingly recognised as a marker of cardiovascular risk. We evaluated the impact of borderline ankle-brachial index in 12,772 Chinese type 2 diabetes patients from the Joint Asia Diabetes Evaluation Program between 2007 and 2012. Cardiovascular risk factors, complications and health-related quality of life were compared between patients with normal ankle-brachial index (1.0-1.4), borderline ankle-brachial index (0.90-0.99) and peripheral arterial disease (ankle-brachial index < 0.9). The prevalence of peripheral arterial disease and borderline ankle-brachial index was 4.6% and 9.6%, respectively. Borderline ankle-brachial index patients were older, more likely to be smokers and hypertensive, had longer duration of diabetes, poorer kidney function and poorer health-related quality of life than patients with normal ankle-brachial index. After adjustment for traditional cardiovascular risk factors, borderline ankle-brachial index was an independent predictor of diabetes-related micro- and macrovascular complications including retinopathy (odd ratios: 1.19 (95% confidence interval: 1.04-1.37)), macroalbuminuria (1.31 (1.10-1.56)), chronic kidney disease (1.22 (1.00-1.50)) and stroke (1.31 (1.05-1.64)). These findings suggest that patients with diabetes and borderline ankle-brachial index are at increased cardiovascular risk and may benefit from more intensive management. © The Author(s) 2015.
Lewis, Jane Ea; Williams, Paul; Davies, Jane H
This cross-sectional study aimed to individually and cumulatively compare sensitivity and specificity of the (1) ankle brachial index and (2) pulse volume waveform analysis recorded by the same automated device, with the presence or absence of peripheral arterial disease being verified by ultrasound duplex scan. Patients (n=205) referred for lower limb arterial assessment underwent ankle brachial index measurement and pulse volume waveform recording using volume plethysmography, followed by ultrasound duplex scan. The presence of peripheral arterial disease was recorded if ankle brachial index <0.9; pulse volume waveform was graded as 2, 3 or 4; or if haemodynamically significant stenosis >50% was evident with ultrasound duplex scan. Outcome measure was agreement between the measured ankle brachial index and interpretation of pulse volume waveform for peripheral arterial disease diagnosis, using ultrasound duplex scan as the reference standard. Sensitivity of ankle brachial index was 79%, specificity 91% and overall accuracy 88%. Pulse volume waveform sensitivity was 97%, specificity 81% and overall accuracy 85%. The combined sensitivity of ankle brachial index and pulse volume waveform was 100%, specificity 76% and overall accuracy 85%. Combining these two diagnostic modalities within one device provided a highly accurate method of ruling out peripheral arterial disease, which could be utilised in primary care to safely reduce unnecessary secondary care referrals.
Yao, W-M; Zhang, H-F; Zhu, Z-Y; Zhou, Y-L; Liang, N-X; Xu, D-J; Zhou, F; Sheng, Y-H; Yang, R; Gong, L; Yin, Z-J; Chen, F-K; Cao, K-J; Li, X-L
Elevated levels of circulating triglycerides and increased arterial stiffness are associated with cardiovascular disease. Numerous studies have reported an association between levels of circulating triglycerides and arterial stiffness. We used Mendelian randomization to test whether this association is causal. We investigated the association between circulating triglyceride levels, the apolipoprotein A-V (ApoA5) -1131T>C single nucleotide polymorphism and brachial-ankle pulse wave velocity (baPWV) by examining data from 4421 subjects aged 18-74 years who were recruited from the Chinese population. baPWV was significantly associated with the levels of circulating triglycerides after adjusting for age, sex, body mass index (BMI), systolic blood pressure, heart rate, waist-to-hip ratio, antihypertensive treatment and diabetes mellitus status. The -1131C allele was associated with a 5% (95% confidence interval 3-8%) increase in circulating triglycerides (adjusted for age, sex, BMI, waist-to-hip ratio, diabetes mellitus and antihypertensive treatment). Instrumental variable analysis showed that genetically elevated levels of circulating triglycerides were not associated with increased baPWV. These results do not support the hypothesis that levels of circulating triglycerides have a causal role in the development of arterial stiffness.
The ankle-brachial index (ABI) can be measured to diagnose peripheral artery disease (PAD) and used as an independent marker of cardiovascular risk. What are the teaching methods for ABI in French medical schools? What are the data in the literature showing the link between and educational interventions and ABI competency? A questionnaire to assess how ABI is taught in the second and third cycles of French medical schools was sent to vascular medicine chairs of each faculty. A systematic review of the literature in PubMed was performed including articles that studied the effect of an educational intervention on this competency. Sixty-five percent of vascular medicine chairs (teachers) responded. ABI was taught in the second cycle in all medical schools. In 75% of schools, ABI was taught as part of lectures on PAD. Practical training was implemented in the second cycle in 20% of medical schools and in the third cycle in 60%. Teachers are statistically less satisfied with their way of teaching in the second cycle compared with the third cycle. Four articles have studied the effect of an educational intervention. Practical training improves student performance. Most of vascular medicine teachers used lectures to teach ABI. This type of teaching does not favor the development of this medical competency. The best way of teaching this competency should be addressed. Homogenization in the way ABI is taught would be necessary at national and international levels. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
Beckman, Joshua A; Higgins, Caitlin O; Gerhard-Herman, Marie
Peripheral arterial disease (PAD) remains underdiagnosed by primary care and cardiovascular physicians. The office-based assessment of PAD is limited by the need for specialized equipment and the time required for performance of the ankle-brachial index (ABI). We explored whether the accuracy of automated ABI measurement by oscillometry compared favorably with the gold-standard method using continuous-wave Doppler ultrasound. Consecutive patients referred to our university hospital noninvasive vascular laboratory for ABI measurement were invited for participation. Of 205 patients, 201 participated, including 55 with PAD. The ABI was measured by automated oscillometry and Doppler ultrasound. The test of trends revealed a correlation coefficient of 0.78 in the left leg and 0.78 in the right leg (P<0.01 for both). The mean ABI difference between methods was 0.04+/-0.01 and 0.06+/-0.01, respectively, in the left and right legs. The differences between the methods followed a normal distribution. Oscillometric determination of the ABI provides an accurate determination of the ABI in an outpatient population. Our findings show automated oscillometry to be a reliable and easier method of ABI measurement, lowering the barrier to incorporation of this diagnostic test into clinical practice.
Chaudru, S; de Müllenheim, P-Y; Le Faucheur, A; Kaladji, A; Jaquinandi, V; Mahé, G
To conduct a systematic review focusing on the impact of training programs on ankle-brachial index (ABI) performance by medical students, doctors and primary care providers. Lower extremity peripheral artery disease (PAD) is a highly prevalent disease affecting ∼202 million people worldwide. ABI is an essential component of medical education because of its ability to diagnose PAD, and as it is a powerful prognostic marker for overall and cardiovascular related mortality. A systematic search was conducted (up to May 2015) using Medline, Embase, and Web of Science databases. Five studies have addressed the impact of a training program on ABI performance by either medical students, doctors or primary care providers. All were assigned a low GRADE system quality. The components of the training vary greatly either in substance (what was taught) or in form (duration of the training, and type of support which was used). No consistency was found in the outcome measures. According to this systematic review, only few studies, with a low quality rating, have addressed which training program should be performed to provide the best way of teaching how to perform ABI. Future high quality researches are required to define objectively the best training program to facilitate ABI teaching and learning. Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Chevtchouk, Liliana; Silva, Marcio Heitor Stelmo da; Nascimento, Osvaldo José Moreira do
To evaluate neuropathic pain and peripheral vascular disease in diabetics and compare this with the length of time since diagnosis in type 1, and type 2 diabetes. A cross-sectional study with 225 diabetics chosen from their responses on the DN4 questionnaire, who were then evaluated with the ankle-brachial index (ABI), separating type 1 diabetes from type 2 diabetes. A higher incidence of neuropathic pain in those over 60 years of age showed an ABI > 1.3. Neuropathic pain was related to an abnormal ABI in 144 patients (64.2%). A statistically significant value was obtained in type 2 diabetes patients with more than 10 years from disease onset, 69 with altered ABI and 25 with normal ABI. There was an altered ABI (< 0.9) observed in 33% of type 1 diabetes patients and in 67% of type 2 diabetes patients. The ABI test in type 1 diabetes and type 2 diabetes patients is important even in those who are asymptomatic. A diagnosis of more than 10 years prior, regardless of the presence of neuropathic pain or ischemic signs, altered the ABI.
Randhawa, Mandeep Singh; Reed, Grant W; Grafmiller, Kevin; Gornik, Heather L; Shishehbor, Mehdi H
Approximately 20% of patients undergoing ankle brachial index testing for critical limb ischemia have noncompressible vessels because of tibial artery calcification. This represents a clinical challenge in determining tibial artery patency. We sought to identify the prevalence of tibial artery and pedal arch patency by angiography in these patients. One hundred twenty-five limbs (of 89 patients) with critical limb ischemia and ankle brachial index ≥1.4 who underwent lower extremity angiograms within 1 year were included. Reviewers of angiography were blinded to results of physiological testing. Tibial artery vessels were classified as completely occluded, significantly stenosed (≥50%), or patent (<50% stenosis). The sensitivity of toe brachial index and pulse volume recording to predict tibial artery disease was also determined. Of 125 limbs with noncompressible ankle brachial index, 72 (57.6%) anterior tibial and 80 (64%) posterior tibial arteries were occluded. Another 23 (18.4%) anterior tibial and 13 (10.4%) posterior tibial arteries had ≥50% stenosis. Pulse volume recording was moderate to severely dampened in 54 of 119 (45.4%) limbs. Toe brachial index <0.7 was found in 75 of 83 (90.4%) limbs. Moderate to severe pulse volume recording dampening was 43.6% sensitive, whereas toe brachial index <0.7 was 89.7% sensitive in diagnosing occluded or significantly stenotic tibial artery disease. The pedal arch was absent or incomplete in 86 of 103 (83.5%) limbs. Among patients with critical limb ischemia and noncompressible ankle brachial index results, the prevalence of occlusive tibial and pedal arch disease is very high. Toe brachial index <0.7 is more sensitive in diagnosing occluded and significantly stenotic tibial artery disease in these patients compared with ankle pulse volume recording. © 2017 American Heart Association, Inc.
Shahvazian, Najmeh; Rafiee, Mansour; Rahmanian, Masoud; Razavi-ratki, Seyed Kazem; Farahzadi, Mohammad Hadi
Background: Remote ischemic preconditioning (RIPC) is a phenomenon where a short period of ischemia in one organ protects against further ischemia in the other organs. We hypothesized that RIPC occurring in diabetic patients with ankle brachial index (ABI) between 0.70 and 0.90 were included with peripheral arterial disease, would make the better coronary flow resulted in the increasing ABI. Materials and Methods: This randomized clinical trial study was done in the Afshar Cardiovascular Hospital in Yazd between 2013 and 2014. Sixty participants were randomly divided into two groups (intervention and control groups). The intervention group was undergoing RIPC, and the control group was tested without RIPC. RIPC was stimulated by giving three cycles of 5 min of ischemia followed by 5 min of reperfusion of both upper arms using a blood pressure cuff inflated to 200 mm Hg (n = 30). This was compared with no RIPC group which consisted of placing a deflated blood pressure cuff on the upper limbs (n = 30). Results: The mean of ABI level before intervention in the RIPC and control group group was 0.82 ± 0.055 and 0.83 ± 0.0603 (P = 0.347) respectively, with no significant difference. It was 0.86 ± 0.066 in the RIPC group compared the control 0.83 ± 0.0603 (P = 0.046). So levels of ABI were greater after intervention in the RIPC group. The mean of ABI level increase from 0.82 ± 0.05 to 0.86 ± 0.06 in RIPC group (P = 0.008). So the intervention group showed a significant increase in ABI. Conclusions: RIPC through using a simple, noninvasive technique, composing three cycles of 5 min-ischemia of both upper arms, showing a significant increase in ABI level in diabetic patients. PMID:28401075
Shahvazian, Najmeh; Rafiee, Mansour; Rahmanian, Masoud; Razavi-Ratki, Seyed Kazem; Farahzadi, Mohammad Hadi
Remote ischemic preconditioning (RIPC) is a phenomenon where a short period of ischemia in one organ protects against further ischemia in the other organs. We hypothesized that RIPC occurring in diabetic patients with ankle brachial index (ABI) between 0.70 and 0.90 were included with peripheral arterial disease, would make the better coronary flow resulted in the increasing ABI. This randomized clinical trial study was done in the Afshar Cardiovascular Hospital in Yazd between 2013 and 2014. Sixty participants were randomly divided into two groups (intervention and control groups). The intervention group was undergoing RIPC, and the control group was tested without RIPC. RIPC was stimulated by giving three cycles of 5 min of ischemia followed by 5 min of reperfusion of both upper arms using a blood pressure cuff inflated to 200 mm Hg (n = 30). This was compared with no RIPC group which consisted of placing a deflated blood pressure cuff on the upper limbs (n = 30). The mean of ABI level before intervention in the RIPC and control group group was 0.82 ± 0.055 and 0.83 ± 0.0603 (P = 0.347) respectively, with no significant difference. It was 0.86 ± 0.066 in the RIPC group compared the control 0.83 ± 0.0603 (P = 0.046). So levels of ABI were greater after intervention in the RIPC group. The mean of ABI level increase from 0.82 ± 0.05 to 0.86 ± 0.06 in RIPC group (P = 0.008). So the intervention group showed a significant increase in ABI. RIPC through using a simple, noninvasive technique, composing three cycles of 5 min-ischemia of both upper arms, showing a significant increase in ABI level in diabetic patients.
Mauer, Karin; Exaire, J. Emilio; Stoner, Julie A.; Guthery, Leslie D.; Montgomery, Polly S.; Gardner, Andrew W.
Background Lipid abnormalities are associated with lower extremity peripheral arterial disease (PAD), and contribute to vascular damage and functional impairment. Women with PAD have more limited walking and physical function than men, but the mechanisms for their lower exercise performance are not clear. We determined if alterations in individual lipid components, such as decreased high-density lipoprotein cholesterol (HDL-C), are associated with worsening lower extremity claudication in postmenopausal women with PAD. Methods This cross-sectional cohort study included 69 postmenopausal women with intermittent claudication (Fontaine stage II PAD). Lower extremity walking performance was assessed using a validated treadmill test to measure initial claudication distance (ICD), absolute claudication distance (ACD), peak oxygen uptake, and ankle systolic blood pressure. The lipid profile was determined from a standard lipid panel drawn in a fasted state to obtain cholesterol, triglyceride, HDL-C, and low-density lipoprotein cholesterol (LDL-C). Results HDL-C was positively correlated with ankle brachial index (r = 0.29, p = 0.019). No other individual components of the lipid profile were associated with exercise performance and hemodynamic measures. Among women with impaired HDL-C (below 50 mg/dL, n=43), the median peak oxygen uptake level was significantly lower (p=0.021) relative to women with normal HDL-C (above 50 mg/dL, n=26). Conclusion Lower HDL-C levels are associated with worse ankle brachial index and decreased peak oxygen uptake in post-menopausal women with PAD. PMID:20529977
Martínez-Vizcaíno, Vicente; Cavero-Redondo, Iván; Álvarez-Bueno, Celia; Garrido-Miguel, Miriam; Notario-Pacheco, Blanca
Background Peripheral arterial disease (PAD) is an indicator of widespread atherosclerosis. However, most individuals with PAD, in spite of being at high cardiovascular risk, are asymptomatic. This fact, together with the limitations of the Doppler ankle-brachial index (ABI), contributes to PAD underdiagnose. The aim of this study was to compare oscillometric ABI and Doppler ABI to diagnose peripheral arterial disease, and also to examine the influence of oscillometric errors and calcified legs on the PAD diagnoses. Methods and Findings We measured the ankle-brachial indexes of 90 volunteers (n = 180 legs, age 70 ± 14 years, 43% diabetics) using both oscillometer OMRON-M3 and Doppler. For concordance analyses we used the Bland and Altman method, and also estimated the intraclass correlation coefficient. Receiver Operating Characteristic Curves were used to examine the diagnostic performance of both methods. The ABI means were 1.06 ± 0.14 and 1.04 ± 0.16 (p = 0.034) measured by oscillometer and Doppler ABIs respectively, with limits of agreement of ± 0.20 and intraclass correlation coefficient = 0.769. Oscillometer yielded 23 “error” measurements, and also overestimated the measurements in low ankle pressures. Using Doppler as gold standard, oscillometer performance for diagnosis of PAD showed an Area Under Curve = 0.944 (sensitivity: 66.7%, specificity: 96.8%). Moreover, when considered calcified legs and oscillometric “error” readings as arteriopathy equivalents, sensitivity rose to 78.2%, maintaining specificity in 96%. The best oscillometer cut-off point was 0.96 (sensitivity: 87%, specificity: 91%, positive likelihood ratio: 9.66 and negative likelihood ratio: 0.14). Conclusion Despite its limitations, oscillometric ABI could be a useful tool for the diagnosis of PAD, particularly when considering calcified legs and oscillometric “errors” readings as peripheral arterial disease equivalents. PMID:27898734
Ribera, Aida; Ferreira-González, Ignacio; Marsal, Josep Ramón; Cascant, Purificación; Permanyer-Miralda, Gaietà; Abdul-Jawad, Omar; Iñigo-Garcia, Luis Antonio; Guarinos-Oltra, Jordi; Cequier, Angel; Goicolea-Güemez, Leire; García-Del-Blanco, Bruno; Martí, Gerard; García-Dorado, David
Advanced atherosclerotic disease increases the risk of stent thrombosis after drug-eluting stent (DES) implantation. We aimed to determine if an abnormal ankle-brachial index (ABI) value as a surrogate of atherosclerotic disease and vascular inflammation provides information on 1-year risk of cardiovascular events after DES implantation. A prospective cohort of 1,437 consecutive patients undergoing DES implantation from January through April 2008 in 26 Spanish hospitals was examined. ABI was calculated by Doppler in a standardized manner. Patients were followed to 12 months after the percutaneous coronary intervention to determine total and cardiovascular mortality, stroke, nonfatal acute coronary syndrome (ACS), and new revascularizations. Association of an abnormal ABI value (i.e., ≤ 0.9 or ≥ 1.4) with outcomes was assessed by conventional logistic regression and by propensity-score analysis. Patients with abnormal ABI values (n = 582, 40.5%) in general had higher global cardiovascular risk, the reason for DES implantation was more often ACS, and had a higher rate of complications during admission (heart failure or stroke or major hemorrhage 11.3% vs 5.3%, p <0.001). An abnormal ABI value was independently associated with 1-year total mortality (odds ratio 2.23, 95% confidence interval 1.13 to 4.4) and cardiovascular mortality (odds ratio 2.06, 95% confidence interval 1.04 to 4.22). No independent association was found between an abnormal ABI value and 1-year nonfatal ACS, stroke, and new revascularizations. In conclusion, although an abnormal ABI value was associated with fatal outcomes in patients receiving DESs, no association was found with nonfatal ACS and new revascularizations. A clear relation between abnormal ABI and surrogates of DES thrombosis could not be established.
Meng, Jerry; Wassel, Christina L.; Kestenbaum, Bryan R.; Collins, Tracie C.; Criqui, Michael H.; Lewis, Cora E.; Cummings, Steve R.; Ix, Joachim H.
A higher serum phosphorus level is associated with cardiovascular disease (CVD) events among community-living populations. Mechanisms are unknown. The ankle-brachial index (ABI) provides information on both atherosclerosis and arterial stiffness. In this cross-sectional study (2000–2002), the authors evaluated the association of serum phosphorus levels with low (<0.90) and high (≥1.40 or incompressible) ABI as compared with intermediate ABI in 5,330 older US men, among whom the mean serum phosphorus level was 3.2 mg/dL (standard deviation, 0.4), 6% had a low ABI, and 5% had a high ABI. Each 1-mg/dL increase in serum phosphorus level was associated with a 1.6-fold greater prevalence of low ABI (95% confidence interval (CI): 1.2, 2.1; P < 0.001) and a 1.4-fold greater prevalence of high ABI (95% CI: 1.0, 1.9; P = 0.03) in models adjusted for demographic factors, traditional CVD risk factors, and kidney function. However, the association of phosphorus with high ABI differed by chronic kidney disease (CKD) status (in persons with CKD, prevalence ratio = 2.96, 95% CI: 1.61, 5.45; in persons without CKD, prevalence ratio = 1.14, 95% CI: 0.81, 1.61; interaction P = 0.04). In conclusion, among community-living older men, higher phosphorus levels are associated with low ABI and are also associated with high ABI in persons with CKD. These associations may explain the link between serum phosphorus levels and CVD events. PMID:20237150
Lahoz, C; Barrionuevo, M; García-Fernández, T; Vicente, I; García-Iglesias, M F; Mostaza, J M
Abnormal ankle-brachial index (ABI) is associated with a high risk of cardiovascular disease. This study has aimed to investigate the association between low ABI and risk of cardiovascular death in a general population attended in a primary care center. A total of 1,361 volunteers aged between 60 and 79 years without any evidence of peripheral artery disease who attended a primary care center participated in the study. They underwent a complete physical examination, together with standard blood tests and ABI was determined. The participants were contacted by telephone 4 years later and asked about any cardiovascular problems for that period. Causes of death and hospitalization were confirmed in the medical records in the primary care center and/or hospital. Information was obtained about the clinical evolution of 1,300 participants (mean age 69.9 years, 38.2% men). Mean follow-up was 49.8 months. There were 13 cardiovascular death and 49 major cardiovascular events. Low ABI (<0.9) was associated with a significant higher risk of cardiovascular death (adjusted relative risk 6.83; 95% confidence interval 1.36-34.30, P=.020), and with a higher risk of major cardiovascular events (adjusted relative risk 2.42; 95% confidence interval 0.99-5.91, P=.051). High or uncompressible ABI was not associated with higher cardiovascular risk. A low ABI was associated with higher risk of cardiovascular death in the general population followed-up in a primary care center. Copyright © 2013 Elsevier España, S.L. All rights reserved.
Hammad, Tarek A; Hiatt, William R; Gornik, Heather L; Shishehbor, Mehdi H
Prior studies have assessed the prognostic value of a decrease, not an increase, of the post-exercise ankle-brachial index (ABI) among patients with normal resting results. Thus, we sought to evaluate the prognostic significance of an increase in post-exercise ABI among these patients. From a single center vascular laboratory database between September 2005 and January 2010, we retrospectively identified 1437 consecutive patients with a normal resting ABI (1.00-1.40) and available post-exercise results. We classified them into group 1 (normal subjects; post-exercise ABI drop ⩽ 20%, 58%) and group 2 (post-exercise ABI increase, 42%) after excluding those with an ABI drop > 20% (peripheral artery disease) as they had known disease ( n=192). The primary outcome was to assess the risk of ischemic events, defined as a composite of unadjudicated death, stroke, or myocardial infraction (MACE). Associations between groups and outcomes were examined using multivariable Cox proportional hazard and propensity analyses. Both groups had similar prevalence of cardiovascular comorbidities. In unadjusted analysis, group 2 was more likely to have MACE ( p = 0.001). After adjusting for all baseline characteristics, an increase in post-exercise ABI compared to normal subjects was associated with a higher MACE (adjusted HR: 1.70, 95% CI: 1.14-2.53; p=0.009). This association stayed statistically significant after propensity matching (adjusted HR: 1.80, 95% CI: 1.17-2.76; p=0.007). This hypothesis-generating analysis showed that an increase in post-exercise ABI appears to identify a population with a higher risk for MACE. A prospective study of this association and mechanisms of risk should be conducted.
Hua, Simin; Loehr, Laura R; Tanaka, Hirofumi; Heiss, Gerardo; Coresh, Josef; Selvin, Elizabeth; Matsushita, Kunihiro
Individuals with peripheral artery disease (PAD) often have reduced physical activity, which may increase the future risk of diabetes mellitus. Although diabetes is a risk factor for PAD, whether low ankle-brachial index (ABI) predates diabetes has not been studied. We examined the association of ABI with incident diabetes using Cox proportional hazards models in the ARIC Study. ABI was measured in 12,247 black and white participants without prevalent diabetes at baseline (1987-1989). Incident diabetes cases were identified by blood glucose levels at three subsequent visits (1990-92, 1993-95, and 1996-98) or self-reported physician diagnosis or medication use at those visits or during annual phone interview afterward through 2011. A total of 3305 participants developed diabetes during a median of 21 years of follow-up. Participants with low (≤0.90) and borderline low (0.91-1.00) ABI had 30-40% higher risk of future diabetes as compared to those with ABI of 1.10-1.20 in the demographically adjusted model. The associations were attenuated after further adjustment for other potential confounders but remained significant for ABI 0.91-1.00 (HR = 1.17, 95% CI 1.04-1.31) and marginally significant for ABI ≤ 0.90 (HR = 1.19, 0.99-1.43). Although the association was largely consistent across subgroups, a stronger association was seen in participants without hypertension, those with normal fasting glucose, and those with a history of stroke compared to their counterparts. Low ABI was modestly but independently associated with increased risk of incident diabetes in the general population. Clinical attention should be paid to the glucose trajectory among people with low ABI but without diabetes.
Chen, Liying; Zhu, Wenhua; Mai, Linhe; Fang, Lizheng; Ying, Kejing
Brachial-ankle pulse wave velocity (baPWV) can reflect both central and peripheral arterial stiffness. Metabolic syndrome (MS) and its components may increase arterial stiffness and the risks of cardiovascular diseases. However, the correlation of MS and its components with arterial stiffness has not been not well studied. The aim of this study was to investigate the correlation between MS/its components and arterial stiffness by the measurement of baPWV in south China population. A total of 8599 subjects were selected from those who underwent health examination in our hospital. MS was defined by Joint Scientific Statement. BaPWV, waist circumference, blood pressure (BP), fasting plasma glucose (FPG), lipid profile and serum uric acid (UA) were measured. The relationship between baPWV and MS/its components was analyzed. BaPWV was significantly higher in the subjects with MS than in those without MS (P < 0.001 for both genders). By multivariate regression analysis, all the metabolic components were correlated to baPWV in the male and female subjects except low HDL-C and high UA in the male group. BP and FPG had the strongest correlation factors. The values of baPWV were positively correlated with the advanced age (P < 0.001) and the values of the MS components, and this correlation was stronger in the females than in the males (P < 0.001). Metabolic syndrome and its individual components were positively correlated with baPWV. Monitoring baPWV is helpful to identify early stage of arterial stiffness in those people with MS. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Ramos, Rafel; Baena-Díez, Jose Miguel; Quesada, Miquel; Solanas, Pascual; Subirana, Isaac; Sala, Joan; Alzamora, Maite; Forès, Rosa; Masiá, Rafel; Elosua, Roberto; Grau, María; Cordón, Ferran; Pera, Guillem; Rigo, Fernando; Martí, Ruth; Ponjoan, Anna; Cerezo, Carlos; Brugada, Ramon; Marrugat, Jaume
The recommendation of screening with ankle brachial index (ABI) in asymptomatic individuals is controversial. The aims of the present study were to develop and validate a pre-screening test to select candidates for ABI measurement in the Spanish population 50-79 years old, and to compare its predictive capacity to current Inter-Society Consensus (ISC) screening criteria. Two population-based cross-sectional studies were used to develop (n = 4046) and validate (n = 3285) a regression model to predict ABI < 0.9. The validation dataset was also used to compare the model's predictive capacity to that of ISC screening criteria. The best model to predict ABI < 0.9 included age, sex, smoking, pulse pressure and diabetes. Assessment of discrimination and calibration in the validation dataset demonstrated a good fit (AUC: 0.76 [95% CI 0.73-0.79] and Hosmer-Lemeshow test: χ(2): 10.73 (df = 6), p-value = 0.097). Predictions (probability cut-off value of 4.1) presented better specificity and positive likelihood ratio than the ABI screening criteria of the ISC guidelines, and similar sensitivity. This resulted in fewer patients screened per diagnosis of ABI < 0.9 (10.6 vs. 8.75) and a lower proportion of the population aged 50-79 years candidate to ABI screening (63.3% vs. 55.0%). This model provides accurate ABI < 0.9 risk estimates for ages 50-79, with a better predictive capacity than that of ISC criteria. Its use could reduce possible harms and unnecessary work-ups of ABI screening as a risk stratification strategy in primary prevention of peripheral vascular disease. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.
Tsivgoulis, Georgios; Bogiatzi, Chrysi; Heliopoulos, Ioannis; Vadikolias, Konstantinos; Boutati, Eleni; Tsakaldimi, Soultana; Al-Attas, Omar S; Charalampidis, Paris; Piperidou, Charitomeni; Maltezos, Efstratios; Papanas, Nikolaos
Low ankle-brachial blood pressure index (ABI) identifies patients with symptomatic and asymptomatic peripheral arterial disease (PAD). We sought to investigate the association of low ABI with early risk of stroke recurrence in patients with acute cerebral ischemia (ACI) and without history of symptomatic PAD. Consecutive patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) and no previous history of PAD were prospectively evaluated with ABI measurements. Demographic characteristics, vascular risk factors and secondary prevention therapies were documented. An ABI ≤0.90 in either leg was considered as evidence of asymptomatic PAD, and an ABI >0.90 was considered as normal. Patients with elevated ABI (>1.30) were excluded. The outcome of interest was recurrent stroke during 30-day follow-up. A total of 176 patients with acute cerebral ischemia (mean age 64±14 years, 59.1% men, 76.7% AIS) were evaluated. Asymptomatic PAD was detected in 14.8% (95%CI: 10.2-20.8%) of the studied population. The following factors were independently associated with low ABI on multivariate logistic regression models, after adjustment for potential confounders: coronary artery disease (p=0.008), diabetes mellitus (p=0.017) and increasing age (p=0.042). The cumulative 30-day recurrence rate was higher in patients with low ABI (19.2%; 95%CI: 4.1-34.3) compared to the rest (3.3%; 95%CI: 0.4-6.2%; p=0.001). Atherothrombotic stroke (ASCO grade I; p<0.001), increasing age (p=0.002) and low ABI (p=0.004) were independent predictors of stroke recurrence on multivariate Cox regression models adjusting for confounders. Low ABI appears to be associated with a higher risk of early recurrent stroke in patients with ACI and no history of symptomatic PAD. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
Gupta, Deepak K.; Skali, Hicham; Claggett, Brian; Kasabov, Rumen; Cheng, Susan; Shah, Amil M.; Loehr, Laura R.; Heiss, Gerardo; Nambi, Vijay; Aguilar, David; Wruck, Lisa Miller; Matsushita, Kunihiro; Folsom, Aaron R.; Rosamond, Wayne D.; Solomon, Scott D.
Objectives To describe the relationship between ankle brachial index (ABI) and the risk for heart failure (HF). Background The ABI is a simple, non-invasive measure associated with atherosclerotic cardiovascular disease and death; however, the relationship between ABI and risk of HF is less well characterized. Methods Between 1987–1989 in the Atherosclerosis Risk in Communities study an oscillometric device was used to measure blood pressure in a single upper and randomly chosen lower extremity to determine the ABI. Incident HF events were defined by the first hospitalization with an ICD-9 code 428.x through 2008. The risk of HF was assessed across the ABI range using restricted cubic splines and Cox proportional hazards models. Results ABI was available in 13,150 participants free from prevalent HF. Over a mean 17.7 years of follow up, 1809 incident HF events occurred. After adjustment for traditional HF risk factors, prevalent CHD, subclinical carotid atherosclerosis, and interim MI, as compared to an ABI of 1.01–1.40, participants with an ABI ≤0.90 were at increased risk for HF (HR 1.40, 95% CI 1.12–1.74), as were participants with an ABI of 0.91–1.00 (HR 1.36, 95%CI 1.17–1.59). Conclusions In a middle aged community cohort, an ABI ≤ 1.00 was significantly associated with an increased risk of HF independent of traditional HF risk factors, prevalent CHD, carotid atherosclerosis, and interim MI. Low ABI may not only reflect overt atherosclerosis, but also pathologic processes in the development of HF beyond epicardial atherosclerotic disease and MI alone. A low ABI, as a simple non-invasive measure, may be a risk marker for HF. PMID:25194293
Fowkes, FGR; Murray, GD; Butcher, I; Folsom, AR; Hirsch, AT; Couper, DJ; DeBacker, G; Kornitzer, M; Newman, AB; Sutton-Tyrrell, KC; Cushman, M; Lee, AJ; Price, JF; D’Agostino, RB; Murabito, JM; Norman, PE; Masaki, KH; Bouter, LM; Heine, RJ; Stehouwer, CDA; McDermott, MM; Stoffers, HEJH; Knottnerus, JA; Ogren, M; Hedblad, B; Koenig, W; Meisinger, C; Cauley, JA; Franco, OH; Hunink, MGM; Hofman, A; Witteman, JC; Criqui, MH; Langer, RD; Hiatt, WR; Hamman, RF
Background The ankle brachial index (ABI) is related to risk of cardiovascular events independent of the Framingham risk score (FRS). The aim of this study was to develop and evaluate a risk model for cardiovascular events incorporating the ABI and FRS. Design An analysis of participant data from 18 cohorts in which 24,375 men and 20,377 women free of coronary heart disease had ABI measured and were followed up for events. Methods Subjects were divided into a development and internal validation dataset and an external validation dataset. Two models, comprising FRS and FRS + ABI, were fitted for the primary outcome of major coronary events. Results In predicting events in the external validation dataset, C-index for the FRS was 0.672 (95% CI 0.599 to 0.737) in men and 0.578 (95% CI 0.492 to 0.661) in women. The FRS + ABI led to a small increase in C-index in men to 0.685 (95% CI 0.612 to 0.749) and large increase in women to 0.690 (95% CI 0.605 to 0.764) with net reclassification improvement (NRI) of 4.3% (95% CI 0.0 to 7.6%, p = 0.050) and 9.6% (95% CI 6.1 to 16.4%, p < 0.001), respectively. Restricting the FRS + ABI model to those with FRS intermediate 10-year risk of 10 to 19% resulted in higher NRI of 15.9% (95% CI 6.1 to 20.6%, p < 0.001) in men and 23.3% (95% CI 13.8 to 62.5%, p = 0.002) in women. However, incorporating ABI in an improved newly fitted risk factor model had a nonsignificant effect: NRI 2.0% (95% CI 2.3 to 4.2%, p = 0.567) in men and 1.1% (95% CI 1.9 to 4.0%, p = 0.483) in women. Conclusions An ABI risk model may improve prediction especially in individuals at intermediate risk and when performance of the base risk factor model is modest. PMID:24367001
Tziomalos, Konstantinos; Giampatzis, Vasilios; Bouziana, Stella; Pavlidis, Athinodoros; Spanou, Marianna; Papadopoulou, Maria; Kagelidis, Giannis; Boutari, Chrysoula; Savopoulos, Christos; Hatzitolios, Apostolos
Peripheral arterial disease (PAD) is frequently present in patients with acute ischemic stroke. However, there are limited data regarding the association between ankle brachial index (ABI) ≤ 0.90 (which is diagnostic of PAD) or > 1.40 (suggesting calcified arteries) and the severity of stroke and in-hospital outcome in this population. We aimed to evaluate these associations in patients with acute ischemic stroke. We prospectively studied 342 consecutive patients admitted for acute ischemic stroke (37.4 % males, mean age 78.8 ± 6.4 years). The severity of stroke was assessed with the National Institutes of Health Stroke Scale (NIHSS)and the modified Rankin scale (mRS) at admission. The outcome was assessed with the mRS and dependency (mRS 2 - 5) at discharge and in-hospital mortality. An ABI ≤ 0.90 was present in 24.6 % of the patients whereas 68.1 % had ABI 0.91 - 1.40 and 7.3 % had ABI > 1.40. At admission, the NIHSS score did not differ between the 3 groups (10.4 ± 10.6, 8.3 ± 9.3 and 9.3 ± 9.4, respectively). The mRS score was also comparable in the 3 groups (3.6 ± 1.7, 3.1 ± 1.8 and 3.5 ± 2.3, respectively). At discharge, the mRS score did not differ between the 3 groups (2.9 ± 2.2, 2.3 ± 2.1 and 2.7 ± 2.5, respectively) and dependency rates were also comparable (59.5, 47.6 and 53.3 %, respectively). In-hospital mortality was almost two-times higher in patients with ABI ≤ 0.90 than in patients with ABI 0.91 - 1.40 or > 1.40 but this difference was not significant (10.9, 6.6 and 6.3 %, respectively). An ABI ≤ 0.90 or > 1.40 does not appear to be associated with more severe stroke or worse in-hospital outcome in patients with acute ischemic stroke.
The prevalence and significance of low normal and abnormal ankle brachial index (ABI) values in a community dwelling population of sedentary, older individuals is unknown. We describe the prevalence of categories of definite peripheral artery disease (PAD), borderline ABI, low-normal ABI and no PAD...
Velescu, A; Clara, A; Martí, R; Ramos, R; Perez-Fernandez, S; Marcos, L; Grau, M; Degano, I R; Marrugat, J; Elosua, R
The clinical significance of a high ankle brachial index (ABI) and its relationship to cardiovascular disease (CVD) and mortality is controversial. The aim of this study was to estimate the association between abnormally high ABI ≥ 1.4 and coronary heart disease (CHD), cerebrovascular disease, and all-cause mortality in a Mediterranean population without CVD. A prospective population based cohort study of 6352 subjects was followed up for a median 6.2 years. Subjects under 35 years, with a history of CVD or an ABI < 0.9 were excluded. All CHD events (angina, myocardial infarction, coronary revascularisation), cerebrovascular events (stroke, transient ischaemic attack), and all-cause mortality were recorded. A total of 5679 subjects fulfilled the inclusion criteria, of which 5517 (97.1%) had a normal ABI whereas 162 (2.9%) had an ABI ≥ 1.4. The profile of individuals with abnormally high ABI revealed as independent related factors age (OR = 1.0; p = .045), female sex (OR = 0.4; p < .01), diabetes (OR = 1.9; p = .02), and lower diastolic blood pressure (OR = 0.9; p < .001). During follow-up 309 (5.4%) participants presented with a CV event and 286 (5.0%) died. An ABI ≥ 1.4 was associated with a higher incidence of CV events in the univariate (HR = 1.7) but not in the multivariate survival Cox regression analysis. An ABI ≥ 1.4 was independently associated with all-cause mortality (HR = 2.0; IC 95% 1.32-2.92) and cardiovascular mortality (HR = 3.1; IC 95% 1.52-6.48). In subjects without CVD, those with abnormally high ABI do not have a greater CV event rate than those with a normal ABI. However, there seems to be a trend towards higher mortality risk, supporting the guidelines that consider this subgroup to be a high risk population. Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Sumin, A N; Krasilova, T A; Masin, A N
The aim was to study the dynamics of ankle-brachial index (ABI) after treadmill test, after six-minute walk test (SWT) and after electric muscle stimulation (EMS) in aged patients. We conducted a survey of 80 aged patients (73,0 +/- 16,0 years). ABI was determined at rest and immediately after the following tests: 1) treadmill-test for five minutes, 2) SWT, and 3) EMS for five minutes. Atherosclerotic lesions of lower limb arteries was absent only in 21,3% of patients according to color duplex scanning. ABI significantly decreased on both limbs after treadmill-test ant after SWT. During EMS, in contrast, ABI was increased. Thus, you can use SWT in the diagnosis of subclinical atherosclerosis in a general clinical practice as an alternative to treadmill-tests. Good tolerability of EMS patients and ABI increase show the availability of EMS in physical rehabilitation of aged patients with peripheral atherosclerosis.
Kinjo, Yoshino; Ishida, Akio; Kinjo, Kozen; Ohya, Yusuke
Arterial stiffness is associated with the pathogenesis of cerebral microbleeds (CMBs). The ankle-brachial index (ABI) is used to predict arterial stiffness. We hypothesized that the increase in ABI with age occurs as a result of increasing arterial stiffness and wave reflection, and is thus associated with target organ damage. The aim of this study was to investigate the relationship between ABI, brachial-ankle pulse wave velocity (baPWV), and CMBs. We recruited 990 cardiovascular disease-free and stroke-free participants [median age 53 (24-86) years, 531 were woman] who underwent brain MRI, ABI, and baPWV at a health checkup. The prevalence of CMBs was 4%. Both ABI (1.14 vs. 1.10) and baPWV (17.29 vs. 14.68 m/s) were higher in participants with CMBs than those without. Cutoff values of ABI and baPWV for the presence of CMBs were 1.12 and 16.07 m/s, respectively. Multivariate logistic regression analysis showed that ABI at least 1.12 [odds ratio (OR) 2.57, 95% confidence interval (CI) 1.30-5.37, P < 0.05] and baPWV at least 16.07 m/s (OR 2.08, 95% CI 1.02-4.38, P < 0.05) were independently associated with CMBs. Moreover, the combination of ABI at least 1.12 and baPWV at least 16.07 m/s was strongly associated with CMBs (OR 5.26, 95% CI 1.93-16.92, P < 0.05). A high normal ABI, combined with a high baPWV, was strongly associated with CMBs in a screened Japanese cohort, suggesting a novel use for ABI as a predictor for target organ damage.
[Risk of cardiovascular diseases in lead-exposed workers of crystal glassworks. Part II. Lead impact on the cardiovascular system based on ultrasound assessment of carotid arteries, electrocardiograms and ankle-brachial index].
Doroszko, Adrian; Skoczyńska, Anna; Drozdz, Katarzyna; Kreczyńska, Bogusława
Cardiovascular diseases are one of the most common causes of the prevalence and mortality in the general population. Progressing pollution of the environment, as well as occupational exposure to heavy metals, including lead, may potentially accelerate the development of these disorders. Lead is a well known risk factor of arterial hypertension, and may be involved in atherogenesis. The aim of this study was to assess the influence of occupational lead exposure on the activity of cardiovascular system (CVS). The study group comprised 153 potentially healthy volunteers, working in a crystal glass foundry. They were examined using ultrasound assessment of carotid arteries, electrocardiograms and ankle-brachial index (ABI). The toxicological assessment of the study group for occupational lead poisoning was performed. Correlations between the degree of intoxication and functional changes in CVS were analyzed. A negative linear correlation between blood lead level or fluorethylenepropylene (FEP) concentration and ABI values was shown, but only in a subgroup with normal lipid pattern. In the persons with higher blood lead levels, the higher values of arterial blood pressure and longer QT-space in electrocardiogram were evidenced. In addition, the right bundle branch block was more frequently observed (in 23% of workers). Lead may be an independent risk factor of cardiovascular diseases, especially in workers with normal lipid parameters. An increased arterial blood pressure and a decreased ankle-brachial index in the persons with normal cholesterol level can be regarded as a marker of this risk.
Kröger, K; Bock, E; Hohenberger, T; Moysidis, Th; Santosa, F; Pfeifer, M
Different modes of ankle-brachial -index (ABI) calculation lead to different information. We looked for the peripheral arterial disease (PAD) prevalence estimated from ABI-high and ABI-low and analysed the effect of age and classical risk factors. Based on the Arteriomobil Project data, ABI was calculated considering the lowest of the four ankle artery pressures (ABI-low) or the higher ankle artery pressure of each leg (ABI-high), respectively. ABI <0.9 were defined to prove PAD. Prevalence of PAD estimated using ABI-low was much higher than those using ABI- high (15.7% vs. 8.0%). Thus 8% of men and 7.5% of women suspected for PAD were not detected if prevalence rates are based on ABI-high alone. Estimating PAD prevalence only by measuring posterior tibial artery (ATP) pressure, prevalence rates were lowest with 2.4% for the left and 2.7% for the right ATP. Estimating PAD prevalence only by measuring anterior tibial artery pressure, prevalence rates were slightly higher, but still low. ABI-high systematically shows lower prevalence rates compared to ABI-low without divergence of the prevalence rates with increasing age. This parallelism of the curves remained unchanged when prevalence rates were separated for self-reported risk-factors; smoking, hypertension, hypercholesterolemia and diabetes. The presented analysis of the Arteriomobil Project data support the hypothesis that the differences in prevalence rates estimated from ABI-high and ABI-low are mainly determined by anatomic variations of the plantar arch. Additional angiographic controlled studies are necessary to prove this hypothesis.
Suckel, Andreas; Muller, Otto; Wachter, Nikolaus; Kluba, Torsten
Ankle joint affections and injuries are common problems in sports traumatology and in the daily routine of arthroscopic surgeons. However, there is little knowledge regarding intraarticular loads. Pressures on the ankle were determined in a dynamic model on 8 cadaver specimens, applying forces to tendons of the foot over the stance phase under vertical loading. A characteristic course of loading in the tibiotalar joint with a rapid increase upon heel contact was observed. It increased gradually to reach a maximum after 70% of the stance phase, during the push-off phase. The major torque in the ankle joint is located anterolaterally. A dynamic loading curve of the ankle joint can be demonstrated. These observations explain phenomena such as the appearance of osteophytes on the anterior tibia in the case of ankle osteoarthritis and the relatively low incidence of posterior tibial edge fragments in the case of trimalleolar ankle fracture. Furthermore, the medial side of the talus is less loaded compared to the lateral side, which appears relevant to the treatment of osteochondrosis dissecans.
Chen, Szu-Chia; Lee, Mei-Yueh; Huang, Jiun-Chi; Shih, Ming-Chen Paul; Chang, Jer-Ming; Chen, Hung-Chun
Peripheral artery occlusive disease and vascular calcification are highly prevalent in hemodialysis (HD) patients, however the association of the combination of ankle-brachial index (ABI) and aortic arch calcification (AoAC) with clinical outcomes in patients undergoing HD is unknown. In this study, we investigated whether the combination of ABI and AoAC is independently associated with overall and cardiovascular mortality in HD patients. The median follow-up period was 5.7 years. Calcification of the aortic arch was assessed by chest X-ray. Forty-seven patients died including 24 due to cardiovascular causes during the follow-up period. The study patients were stratified into four groups according to an ABI < 0.95 or ≥0.95 and an AoAC score of >4 or ≤4 according to receiver operating characteristic curve. Those with an ABI < 0.95 and AoAC > 4 (vs. ABI ≥ 0.95 and AoAC score ≤ 4) were associated with overall (hazard ratio [HR], 4.913; 95% confidence interval [CI], 1.932 to 12.497; p = 0.001) and cardiovascular (HR, 3.531; 95% CI, 1.070 to 11.652; p = 0.038) mortality in multivariable analysis. The combination of a low ABI and increased AoAC was associated with increased overall and cardiovascular mortality in patients undergoing HD. PMID:27608939
Espeland, Mark A.; Newman, Anne B.; Sink, Kaycee; Gill, Thomas M.; King, Abby C.; Miller, Michael E.; Guralnik, Jack; Katula, Jeff; Church, Timothy; Manini, Todd; Reid, Kieran F.; McDermott, Mary M.
OBJECTIVE To evaluate cross-sectional and longitudinal associations between ankle-brachial index (ABI) and indicators of cognitive function DESIGN Randomized clinical trial (Lifestyle Interventions and Independence for Elders Trial) SETTING Eight US academic centers PARTICIPANTS 1,601 adults (ages 70–89 years, sedentary, non-demented, and with functional limitations MEASUREMENTS Baseline ABI and interviewer- and computer-administered cognitive function assessments were obtained from which compared a physical activity intervention with a health education control. Cognitive function was re-assessed 24 months later (interviewer-administered) and 18 or 30 months later (computer-administered) and central adjudication was used to classify individuals as having mild cognitive impairment, probable dementia, or neither. RESULTS Lower ABI had a modest independent association poorer cognitive functioning at baseline (partial r=0.09; p<0.001). While, lower baseline ABI was not associated with overall changes in cognitive function test scores, it was associated with higher odds for two-year progression to a composite of either mild cognitive impairment or probable dementia (OR=2.60 per unit lower ABI; 95% confidence interval [1.06,6.37]). Across two years, changes in ABI were not associated with changes in cognitive function. CONCLUSION In an older cohort of non-demented sedentary individuals with functional limitations, lower baseline ABI was independently correlated with cognitive function and associated with greater 2-year risk for progression to mild cognitive impairment or probable dementia. PMID:25869993
Je, Hyung Gon; Kim, Bo Hyun; Cho, Kyoung Im; Jang, Jae Sik; Park, Yong Hyun; Spertus, John
Improvement in quality of life (QoL) is a primary treatment goal for patients with peripheral arterial disease (PAD). The current study aimed to quantify improvement in the health status of PAD patients following peripheral revascularization using the peripheral artery questionnaire (PAQ) and ankle-brachial index (ABI), and to evaluate possible correlation between the two methods. The PAQ and ABI were assessed in 149 symptomatic PAD patients before, and three months after peripheral revascularization. Mean PAQ summary scores improved significantly three months after revascularization (+49.3 ± 15 points, p < 0.001). PAQ scores relating to patient symptoms showed the largest improvement following revascularization. The smallest increases were seen in reported treatment satisfaction (all p’s < 0.001). As expected the ABI of treated limbs showed significant improvement post-revascularization (p < 0.001). ABI after revascularization correlated with patient-reported changes in the physical function and QoL domains of the PAQ. Twenty-two percent of PAD patients were identified as having a poor response to revascularization (increase in ABI < 0.15). Interestingly, poor responders reported improvement in symptoms on the PAQ, although this was less marked than in patients with an increase in ABI > 0.15 following revascularization. In conclusion, data from the current study suggest a significant correlation between improvement in patient-reported outcomes assessed by PAQ and ABI in symptomatic PAD patients undergoing peripheral revascularization. PMID:25993299
Garcia, Ana Beatriz Andrêo; Dardin, Luciana Paula; Minali, Paulo Alexandre; Czapkowsky, Adriano; Ajzen, Sergio Aron; Trevisani, Virginia Fernandes Moça
Primary Sjögren syndrome is a chronic inflammatory autoimmune disease. The delay in diagnosis allows the establishment of a chronic inflammatory state, which makes primary Sjögren syndrome an interesting model for the study of atherosclerosis. The aim of this study was to evaluate subclinical atherosclerosis in 49 patients with Sjögren syndrome using noninvasive methods. We assessed traditional risk factors such as hypertension, diabetes, dyslipidemia, smoking, and family history of atherosclerosis. Patients with prior cardiovascular events and a history of atherosclerosis were excluded. Clinical and laboratory features were recorded, as well as the European League Against Rheumatism Sjögren's Syndrome Activity Index calculation. The atherosclerosis evaluation was done by carotid intima-media thickness, measured by ultrasonography, and ankle-brachial index (ABI). Fifteen patients (31%) had at least 1 traditional risk factor, and 65.3% had a European League Against Rheumatism Sjögren's Syndrome Activity Index score from mild to moderate. Only 2 patients had increased carotid intima-media thickness. However, 59% presented ABI alterations. Multiple correspondence analysis showed a clear correlation between low ABI and the positivity of autoantibodies (antinuclear antibodies, anti-SSA, rheumatoid factor). The subgroup of patients with positive autoantibodies showed low ABI, which may represent a higher risk of early atherosclerosis and indicate the need for more careful monitoring in this group.
Je, Hyung Gon; Kim, Bo Hyun; Cho, Kyoung Im; Jang, Jae Sik; Park, Yong Hyun; Spertus, John
Improvement in quality of life (QoL) is a primary treatment goal for patients with peripheral arterial disease (PAD). The current study aimed to quantify improvement in the health status of PAD patients following peripheral revascularization using the peripheral artery questionnaire (PAQ) and ankle-brachial index (ABI), and to evaluate possible correlation between the two methods. The PAQ and ABI were assessed in 149 symptomatic PAD patients before, and three months after peripheral revascularization. Mean PAQ summary scores improved significantly three months after revascularization (+49.3 ± 15 points, p < 0.001). PAQ scores relating to patient symptoms showed the largest improvement following revascularization. The smallest increases were seen in reported treatment satisfaction (all p's < 0.001). As expected the ABI of treated limbs showed significant improvement post-revascularization (p < 0.001). ABI after revascularization correlated with patient-reported changes in the physical function and QoL domains of the PAQ. Twenty-two percent of PAD patients were identified as having a poor response to revascularization (increase in ABI < 0.15). Interestingly, poor responders reported improvement in symptoms on the PAQ, although this was less marked than in patients with an increase in ABI > 0.15 following revascularization. In conclusion, data from the current study suggest a significant correlation between improvement in patient-reported outcomes assessed by PAQ and ABI in symptomatic PAD patients undergoing peripheral revascularization.
Lefebvre, Kristin M.; Cody, Crystal; Jayne, Erika; Mason, Jennifer; Monaghan, Rebecca; Palombaro, Kerstin
Introduction The ankle brachial index (ABI) is a valid and reliable measurement of lower extremity circulation and can be used as a screening tool for peripheral arterial disease (PAD), but the usage pattern in physical therapy practice is virtually unknown. Purpose This study was performed to describe the phenomenon of using the ABI in outpatient physical therapy practice. Methods Nine participants from 3 different outpatient physical therapy clinics were provided with a hand held Doppler and education on how to accurately perform an ABI. Over a 3-month period, participants performed the ABI on any patient presenting with age > 50 with at least two risk factors for PAD. Immediately following the 3-month data collection period, two focus group interviews were performed to examine the therapist's experience using the ABI. Transcripts were analyzed to identify facilitators and barriers to implementation. Results Facilitators identified include familiarity, ease of use, accuracy, and confidence with results. Barriers included flow and routine disruption, patient did not want/refused, and issues related to direct access. Conclusion Although some barriers to use of the ABI in an outpatient clinical setting need to be considered, most participants found the experience of using the ABI positive and feasible. PMID:23754934
Petramala, Luigi; Lorenzo, D'Elia; Iannucci, Gino; Concistré, Antonio; Zinnamosca, Laura; Marinelli, Cristiano; De Vincentis, Giuseppe; Ciardi, Antonio; De Toma, Giorgio
Background Cushing syndrome (CS) has been described as a killing disease due its cardiovascular complications. In fact, chronic cortisol excess leads to a constellation of complications, including hypertension, hyperglycemia, adiposity, and thromboembolism. The main vascular alteration associated with CS is atherosclerosis. Methods Aim of this study was to analyze carotid intima-media thickness (cIMT) and ankle-brachial index (ABI), two surrogate markers of subclinical atherosclerosis in a consecutive series of CS patients, compared to patients with essential hypertension (EH) and health subjects (HS). Results Patients with CS showed a significant increase (P<0.05) of cIMT (0.89±0.17 mm) compared to EH (0.81±0.16 mm) and HS (0.75±0.4 mm), with a high prevalence of plaque (23%; P<0.03). Moreover, CS patients showed a mean ABI values (1.07±0.02) significantly lower respect to HS (1.12±0.11; P<0.05), and a higher percentage (20%) of pathological values of ABI (≤0.9; P<0.03). Conclusion In conclusion, we confirmed and extended the data of cIMT in CS, and showed that the ABI represent another surrogate marker of subclinical atherosclerosis in this disease. PMID:26354490
Miname, M; Bensenor, I M; Lotufo, P A
The ankle-brachial index (ABI) is a marker of subclinical atherosclerosis related to health-adverse outcomes. ABI is inexpensive compared to other indexes, such as coronary calcium score and determination of carotid artery intima-media thickness (IMT). Our objective was to identify how the ABI can be applied to primary care. Three different methods of calculating the ABI were compared among 13,921 men and women aged 35 to 74 years who were free of cardiovascular diseases and enrolled in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). The ABI ratio had the same denominator for the three categories created (the highest value for arm systolic blood pressure), and the numerator was based on the four readings for leg systolic blood pressure: the highest (ABI-HIGH), the mean (ABI-MEAN), and the lowest (ABI-LOW). The cut-off for analysis was ABI<1.0. All determinations of blood pressure were done with an oscillometric device. The prevalence of ABI<1% was 0.5, 0.9, and 2.7 for the categories HIGH, MEAN and LOW, respectively. All methods were associated with a high burden of cardiovascular risk factors. The association with IMT was stronger for ABI-HIGH than for the other categories. The proportion of participants with a 10-year Framingham Risk Score of coronary heart disease >20% without the inclusion of ABI<1.0 was 4.9%. For ABI-HIGH, ABI-MEAN and ABI-LOW, the increase in percentage points was 0.3, 0.7, and 2.3%, respectively, and the relative increment was 6.1, 14.3, and 46.9%. In conclusion, all methods were acceptable, but ABI-LOW was more suitable for prevention purposes.
Miname, M.; Bensenor, I.M.; Lotufo, P.A.
The ankle-brachial index (ABI) is a marker of subclinical atherosclerosis related to health-adverse outcomes. ABI is inexpensive compared to other indexes, such as coronary calcium score and determination of carotid artery intima-media thickness (IMT). Our objective was to identify how the ABI can be applied to primary care. Three different methods of calculating the ABI were compared among 13,921 men and women aged 35 to 74 years who were free of cardiovascular diseases and enrolled in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). The ABI ratio had the same denominator for the three categories created (the highest value for arm systolic blood pressure), and the numerator was based on the four readings for leg systolic blood pressure: the highest (ABI-HIGH), the mean (ABI-MEAN), and the lowest (ABI-LOW). The cut-off for analysis was ABI<1.0. All determinations of blood pressure were done with an oscillometric device. The prevalence of ABI<1% was 0.5, 0.9, and 2.7 for the categories HIGH, MEAN and LOW, respectively. All methods were associated with a high burden of cardiovascular risk factors. The association with IMT was stronger for ABI-HIGH than for the other categories. The proportion of participants with a 10-year Framingham Risk Score of coronary heart disease >20% without the inclusion of ABI<1.0 was 4.9%. For ABI-HIGH, ABI-MEAN and ABI-LOW, the increase in percentage points was 0.3, 0.7, and 2.3%, respectively, and the relative increment was 6.1, 14.3, and 46.9%. In conclusion, all methods were acceptable, but ABI-LOW was more suitable for prevention purposes. PMID:27901176
Chen, Szu-Chia; Lee, Mei-Yueh; Huang, Jiun-Chi; Mai, Hsiu-Chin; Kuo, Po-Lin; Chang, Jer-Ming; Chen, Hung-Chun; Yang, Yi-Hsin
Peripheral artery occlusive disease is common among diabetes mellitus (DM) and end-stage renal disease patients, and tends to progress faster and lead to worse outcomes. This study compared the association of DM with the decline in ankle-brachial index (ABI) among patients on hemodialysis (HD). This was a longitudinal analysis of ABI in HD patients from 2009 to 2015. Medical records and yearly ABI values were obtained. A longitudinal mixed-model analysis was used to evaluate ABI changing trends while accounting for within-patients correlation. There were 296 patients on HD in the period of 2009–2015. In a 6-year follow-up, those with DM had a more rapid ABI decline compared to non-DM patients (slopes: -0.014 vs. 0.010 per year, interaction p < 0.001). In DM patients, female sex, high pulse pressure, high triglyceride, low creatinine, and high uric acid were associated with a decrease in ABI. In non-DM patients, old age, high pulse pressure, high low-density lipoprotein cholesterol, and high uric acid were associated with a decreased in ABI. There were 49.6% of patients with a normal ABI experienced a decrease at least 0.1 of ABI from baseline, and 35.3% had a final ABI < 0.9 in patients with a baseline ABI ≥ 0.9 (n = 232). In this study, DM patients on HD tend to develop a more rapid decline in ABI than non-DM patients on HD. Age, sex, pulse pressure, lipid profile, creatinine, and uric acid are associated with a decreased in ABI. PMID:28406941
Hodson, Bryan; Norton, Gavin R; Booysen, Hendrik L; Sibiya, Moekanyi J; Raymond, Andrew; Maseko, Muzi J; Majane, Olebogeng H I; Libhaber, Elena; Sareli, Pinhas; Woodiwiss, Angela J
Although several characteristics of aortic function, which are largely determined by age, predict outcomes beyond brachial blood pressure (BP), the extent to which brachial BP control accounts for age-related variations in aortic function is uncertain. We aimed to determine the extent to which brachial BP control in the general population (systolic/diastolic BP < 140/90 mm Hg) accounts for age-related aortic hemodynamic changes across the adult lifespan. Central aortic pulse pressure (PPc), backward wave pressure (Pb), pulse wave velocity (PWV), and PP amplification (PPamp) (applanation tonometry and SphygmoCor software) were determined in 1,185 participants from a community sample (age >16 years; 36.4% uncontrolled BP). With adjustments for distending pressure (mean arterial pressure, MAP), no increases in PPc, Pb, or PWV and decreases in PPamp were noted in those with an uncontrolled brachial BP younger than 50 years. In those older than 50 years with an uncontrolled brachial BP, MAP-adjusted aortic hemodynamic variables were only modestly different to those with a controlled brachial BP (PPc, 46±14 vs. 42±15 mm Hg, P < 0.02, Pb, 23±8 vs. 21±8 mm Hg, PWV, 8.42±3.21 vs. 8.19±3.37 m/second, PPamp, 1.21±0.17 vs. 1.21±0.14). Nonetheless, with adjustments for MAP, marked age-related increases in PPc, Pb, and PWV and decreases in PPamp were noted in those with uncontrolled and controlled brachial BP across the adult lifespan (P < 0.0001). Brachial BP control in the general population fails to account for most distending pressure-independent, age-related changes in aortic hemodynamics across the adult lifespan. © American Journal of Hypertension, Ltd 2015. All rights reserved. For Permissions, please email: firstname.lastname@example.org.
Wedderburn, Sarah; Pateria, Puraskar; Panegyres, Peter K.
It is generally regarded that patients with hereditary neuropathy to pressure palsies, due to a deletion in the PMP22 gene, show recurrent pressure palsy and generalised peripheral neuropathy (pes cavus and hammer toes sometimes develop). Brachial plexopathy is rarely identified as a first presentation of hereditary neuropathy to pressure palsies. We describe a young man who developed a painless flail upper limb with a clinical diagnosis of a brachial plexopathy after his partner slept on his arm – a PMP22 deletion was found. His father, who had a symmetrical polyneuropathy without recurrent mononeuropathies, shared the PMP22 deletion. PMID:25685136
Liu, Hao; Shi, Hong; Yu, Jinming; Chen, Fang; Jiang, Qingwu; Hu, Dayi
Chronic kidney disease (CKD) is an important risk factor for cardiovascular disease (CVD) events. A high ankle brachial index (ABI), a marker of lower arterial stiffness, is associated with CVD events. It remains unknown whether high ABI is associated with CKD. The objectives of this study were to determine the association of CKD with high ABI in adults at high CVD risk. The study enrolled hospital-based patients at high CVD risk and measured kidney function and ABI. The glomerular filtration rate (GFR) was estimated using the Modification of Dietin Renal Desease (MDRD) equation and ABI was categorized as low (< 0.90), low-normal (0.90 to 1.09), normal (1.10 to 1.40), and high (≥ 1.40 or incompressible). Logistic regression was used to evaluate the associations of CKD with ABI categories. Among 6412 participants, 25% had CKD, 25% had an ABI measurement < 0.90, and 1% had an ABI > 1.40. In models adjusted for age, sex, hypertension, diabetes, body mass index, low-density and high-density lipoprotein cholesterol, and smoking, only low ABI was associated with an increased risk of CKD; however, both low ABI (OR: 2.1, 1.6-2.8) and high ABI (OR: 2.4, 1.0-6.4) were associated with an increased risk of CKD in diabetic individuals. Additionally, only low ABI was associated with advanced eGFR levels. High ABI values are associated with an increased risk of CKD in diabetic individuals at high cardiovascular risk. Future studies are required to speculate whether high ABI might lead to diminished kidney function through nonatherosclerotic pathways and to understand the mechanisms linking them to CVD events and diabetes.
Yu, W-C; Chuang, S-Y; Lin, Y-P; Chen, C-H
Carotid-femoral pulse wave velocity (cf-PWV) is a validated marker of arterial stiffening over the central arteries. Brachial-ankle pulse wave velocity (ba-PWV) integrates the mechanical properties from both the central and peripheral arteries and may be more representative than cf-PWV as arterial load for left ventricle (LV). We compared ba-PWV with cf-PWV for the association of cardiovascular structure and function in 320 subjects with various degrees of abnormality in cardiac structure and function. ba-PWV (by oscillometric technique) and cf-PWV (by tonometric technique) were measured simultaneously, and were highly correlated (r=0.79, P<0.001). Both ba-PWV and cf-PWV were significantly correlated with LV mass, but the correlation was better with ba-PWV (r=0.29 vs r=0.22, P=0.0219). While ba-PWV and cf-PWV were similarly significantly correlated with LV end-systolic elastance and mitral E/A ratio, ba-PWV had better correlation with isovolumic relaxation constant (r=0.34 vs r=0.27, P=0.0202) than cf-PWV. In addition, the correlation was also significantly stronger with ba-PWV than with cf-PWV for other indices of arterial stiffness, including carotid incremental modulus (r=0.59 vs 0.50, P=0.0013), effective arterial elastance (r=0.41 vs r=0.33, P=0.0081) and carotid augmentation index (r=0.38 vs r=0.32, P=0.0368). In conclusion, ba-PWV correlates better with LV mass and diastolic function and other indices of arterial function than cf-PWV, probably because ba-PWV encompasses a greater territory of arterial tree than cf-PWV.
Toma, Yuichiro; Ishida, Akio; Kinjo, Kozen; Ohya, Yusuke
The temporal change in ankle-brachial index (ABI) in the general population, especially in those aged <40 years, remains unclear. ABIs of 23,673 individuals were measured in 1-day health checkups between 2003 and 2010. Among them, 1,117 participants aged 28-76 years (mean 53±9 years) whose ABI was measured at least twice within an interval of ≥4 years (mean: 4.9 years) were selected for this study. Baseline ABI was the lowest at age <40 years and increased with age. ABI significantly increased in participants aged <40 and 40-49 years, but not in participants aged 50-59 and ≥60 years. ABI increased in participants with borderline-low baseline ABI (0.9
Yamashita, Masaomi; Murata, Yasuaki; Eguchi, Yawara; Aoki, Yasuchika; Ataka, Hiromi; Hirayama, Jiro; Ozawa, Tomoyuki; Morinaga, Tatsuo; Arai, Hajime; Mimura, Masaya; Kamoda, Hiroto; Orita, Sumihisa; Miyagi, Masayuki; Miyashita, Tomohiro; Okamoto, Yuzuru; Ishikawa, Tetsuhiro; Sameda, Hiroaki; Kinoshita, Tomoaki; Hanaoka, Eiji; Suzuki, Miyako; Suzuki, Munetaka; Aihara, Takato; Ito, Toshinori; Inoue, Gen; Yamagata, Masatsune; Toyone, Tomoaki; Kubota, Gou; Sakuma, Yoshihiro; Oikawa, Yasuhiro; Inage, Kazuhide; Sainoh, Takeshi; Yamauchi, Kazuyo; Takahashi, Kazuhisa
Purpose The pathological mechanism of lumbar spinal stenosis is reduced blood flow in nerve roots and degeneration of nerve roots. Exercise and prostaglandin E1 is used for patients with peripheral arterial disease to increase capillary flow around the main artery and improve symptoms; however, the ankle-brachial index (ABI), an estimation of blood flow in the main artery in the leg, does not change after treatment. Lumbar spinal nerve roots contain somatosensory, somatomotor, and unmyelinated autonomic nerves. Improved blood flow by medication with prostaglandin E1 and decompression surgery in these spinal nerve roots may improve the function of nerve fibers innervating muscle, capillary, and main vessels in the lower leg, resulting in an increased ABI. The purpose of the study was to examine whether these treatments can improve ABI. Materials and Methods One hundred and seven patients who received conservative treatment such as exercise and medication (n=56) or surgical treatment (n=51) were included. Low back pain and leg pain scores, walking distance, and ABI were measured before treatment and after 3 months of conservative treatment alone or surgical treatment followed by conservative treatment. Results Low back pain, leg pain, and walking distance significantly improved after both treatments (p<0.05). ABI significantly increased in each group (p<0.05). Conclusion This is the first investigation of changes in ABI after treatment in patients with lumbar spinal stenosis. Improvement of the spinal nerve roots by medication and decompression surgery may improve the supply of blood flow to the lower leg in patients with lumbar spinal stenosis. PMID:23709437
Núñez, Daniel; Morillas, Pedro; Quiles, Juan; Cordero, Alberto; Guindo, Josep; Soria, Federico; Mazón, Pilar; Lekuona, Iñaki; Rodríguez-Padial, Luis; Llácer, Angel; González-Juanatey, José Ramón; Bertomeu, Vicente
The presence of peripheral arterial disease in patients with coronary artery disease is associated with a poor cardiovascular outcome. However, the majority of affected patients are asymptomatic and the condition is underdiagnosed. The ankle-brachial index (ABI) provides a simple method of diagnosis. The aim of this study was to assess the usefulness of an abnormal ABI for identifying multivessel coronary artery disease in patients with acute coronary syndrome (ACS). We analyzed data on all ACS patients included in the PAMISCA multicenter study (with 94 participating hospitals) who underwent catheterization during admission. Patients were diagnosed with multivessel coronary disease if two or more major epicardial vessels or the left main coronary artery, or both, were affected. An ABI
Ohkuma, Toshiaki; Ninomiya, Toshiharu; Tomiyama, Hirofumi; Kario, Kazuomi; Hoshide, Satoshi; Kita, Yoshikuni; Inoguchi, Toyoshi; Maeda, Yasutaka; Kohara, Katsuhiko; Tabara, Yasuharu; Nakamura, Motoyuki; Ohkubo, Takayoshi; Watada, Hirotaka; Munakata, Masanori; Ohishi, Mitsuru; Ito, Norihisa; Nakamura, Michinari; Shoji, Tetsuo; Vlachopoulos, Charalambos; Yamashina, Akira
An individual participant data meta-analysis was conducted in the data of 14 673 Japanese participants without a history of cardiovascular disease (CVD) to examine the association of the brachial-ankle pulse wave velocity (baPWV) with the risk of development of CVD. During the average 6.4-year follow-up period, 687 participants died and 735 developed cardiovascular events. A higher baPWV was significantly associated with a higher risk of CVD, even after adjustments for conventional risk factors (P for trend <0.001). When the baPWV values were classified into quintiles, the multivariable-adjusted hazard ratio for CVD increased significantly as the baPWV quintile increased. The hazard ratio in the subjects with baPWV values in quintile 5 versus that in those with the values in quintile 1 was 3.50 (2.14-5.74; P<0.001). Every 1 SD increase of the baPWV was associated with a 1.19-fold (1.10-1.29; P<0.001) increase in the risk of CVD. Moreover, addition of baPWV to a model incorporating the Framingham risk score significantly increased the C statistics from 0.8026 to 0.8131 (P<0.001) and also improved the category-free net reclassification (0.247; P<0.001). The present meta-analysis clearly established baPWV as an independent predictor of the risk of development of CVD in Japanese subjects without preexisting CVD. Thus, measurement of the baPWV could enhance the efficacy of prediction of the risk of development of CVD over that of the Framingham risk score, which is based on the traditional cardiovascular risk factors. © 2017 American Heart Association, Inc.
Holland-Letz, Tim; Endres, Heinz G; Biedermann, Stefanie; Mahn, Matthias; Kunert, Joachim; Groh, Sabine; Pittrow, David; von Bilderling, Peter; Sternitzky, Reinhardt; Diehm, Curt
The reliability of ankle-brachial index (ABI) measurements performed by different observer groups in primary care has not yet been determined. The aims of the study were to provide precise estimates for all effects influencing the variability of the ABI (patients' individual variability, intra- and inter-observer variability), with particular focus on the performance of different observer groups. Using a partially balanced incomplete block design, 144 unselected individuals aged > or = 65 years underwent double ABI measurements by one vascular surgeon or vascular physician, one family physician and one nurse with training in Doppler sonography. Three groups comprising a total of 108 individuals were analyzed (only two with ABI < 0.90). Errors for two repeated measurements for all three observer groups did not differ (experts 8.5%, family physicians 7.7%, and nurses 7.5%, p = 0.39). There was no relevant bias among observer groups. Intra-observer variability expressed as standard deviation divided by the mean was 8%, and inter-observer variability was 9%. In conclusion, reproducibility of the ABI measurement was good in this cohort of elderly patients who almost all had values in the normal range. The mean error of 8-9% within or between observers is smaller than with established screening measures. Since there were no differences among observers with different training backgrounds, our study confirms the appropriateness of ABI assessment for screening peripheral arterial disease (PAD) and generalized atherosclerosis in the primary case setting. Given the importance of the early detection and management of PAD, this diagnostic tool should be used routinely as a standard for PAD screening. Additional studies will be required to confirm our observations in patients with PAD of various severities.
Higuchi, Terumi; Abe, Masanori; Yamazaki, Toshio; Mizuno, Mari; Okawa, Erina; Ando, Hideyuki; Oikawa, Osamu; Okada, Kazuyoshi; Kikuchi, Fumito; Soma, Masayoshi
Background and Aims: Atherosclerotic cardiovascular disease is the most common cause of mortality in patients with end-stage kidney disease. Chronic kidney disease patients often exhibit a deficiency in l-carnitine due to loss during hemodialysis (HD). We studied the effects of l-carnitine supplementation on brachial-ankle pulse wave velocity (baPWV), a marker of atherosclerosis, in HD patients. Methods: This was a prospective, open-label, randomized, parallel controlled, multi-center trial testing the anti-atherosclerotic efficacy of oral l-carnitine administration (20 mg/kg/day). HD patients (n = 176, mean age, 67.2 ± 10.3 years old; mean duration of HD, 54 ± 51 months) with plasma free l-carnitine deficiency (<40 μmol/L) were randomly assigned to the oral l-carnitine group (n = 88) or control group (n = 88) and monitored during 12 months of treatment. Results: There were no significant differences in baseline clinical variables between the l-carnitine and control groups. l-carnitine supplementation for 12 months significantly increased total, free, and acyl carnitine levels, and reduced the acyl/free carnitine ratio. The baPWV value decreased from 2085 ± 478 cm/s at baseline to 1972 ± 440 cm/s after six months (p < 0.05) to 1933 ± 363 cm/s after 12 months (p < 0.001) of l-carnitine administration, while no significant changes in baPWV were observed in the control group. Baseline baPWV was the only factor significantly correlated with the decrease in baPWV. Conclusions: l-carnitine supplementation significantly reduced baPWV in HD patients. l-carnitine may be a novel therapeutic strategy for preventing the progression of atherosclerotic cardiovascular disease. PMID:25533009
Tanaka, Shingo; Kaneko, Hidehiro; Kano, Hiroto; Matsuno, Shunsuke; Suzuki, Shinya; Takai, Hideaki; Otsuka, Takayuki; Uejima, Tokuhisa; Oikawa, Yuji; Nagashima, Kazuyuki; Kirigaya, Hajime; Sagara, Koichi; Yajima, Junji; Sawada, Hitoshi; Aizawa, Tadanori; Yamashita, Takeshi
Low ankle-brachial index (ABI) is associated with increased mortality and an increased incidence of cardiovascular events. The purpose of this study was to investigate the value of borderline ABI in predicting clinical outcomes. The data were derived from the Shinken Database 2004-2012, from a single hospital-based cohort study (N = 19,994). ABI was measured in 5205 subjects; 4756 subjects whose ABI was 0.91-1.39 and having no history of peripheral artery disease were enrolled. The subjects were classified into two groups as follows: borderline ABI (0.91-1.00; n = 324) and normal ABI (1.01-1.39; n = 4432). Subjects in the borderline ABI group had more comorbidities, including diabetes mellitus, aortic disease, and stroke. Moreover, the borderline ABI group was associated with higher levels of hemoglobin A1c and brain natriuretic peptide, larger diameters of left atrium and left ventricle, and lower levels of estimated glomerular filtration rate and left ventricular ejection fraction. All-cause death and cardiovascular death occurred in 9.3% and 4.6% of subjects in the borderline ABI group, and in 2.0% and 0.8% of subjects in the normal ABI group, respectively. An adjusted Cox regression model showed that borderline ABI was associated with a higher incidence of all-cause death (hazard ratio [HR] 2.27, p = 0.005) and cardiovascular death (HR 3.47, p = 0.003). A borderline ABI was independently associated with worse clinical outcomes in relatively high risk population. Our data should be confirmed in larger populations including those with low risk profiles. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
Abbott, J. Dawn; Lombardero, Manuel S.; Barsness, Gregory W.; Pena-Sing, Ivan; Buitrón, L. Virginia; Singh, Premranjan; Woodhead, Gail; Tardif, Jean-Claude; Kelsey, Sheryl F.
Background Peripheral arterial disease (PAD) increases cardiovascular risk in many patient populations. The risks associated with an abnormal ankle-brachial index (ABI) in patients with type 2 diabetes (T2D) and stable coronary artery disease (CAD) have not been well described with respect to thresholds and types of cardiovascular events. Methods We examined 2368 patients in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial that underwent ABIassessment at baseline. Death and major cardiovascular events (death, myocardial infarction (MI) and stroke) during follow-up (average 4.3 years) were assessed across the ABI spectrum and by categorizedABI: low (≤0.90), normal (0.91–1.3), high (>1.3), or non-compressible. Results A total of 12,568 person-years were available for mortality analysis. During follow-up, 316 patients died and 549 suffered major cardiovascular events. After adjustment for potential confounders, with normal ABI as the referent group, a low ABI conferred an increased risk of death (relative risk (RR) 1.6; C.I. 1.2, 2.2; p=.0005) and major cardiovascular events (RR 1.4; C.I. 1.1, 1.7; p=.004). Patients with a high ABI had similar outcomes as patients with a normal ABI, but risk again increased in patients with a non-compressible ABI with a risk of death (RR1.9; C.I. 1.3, 2.8; p=.001) and major cardiovascular event (RR 1.5, C.I. 1.1, 2.1; p=.01). Conclusions In patients with CAD and T2D ABI screening and identification of ABI abnormalities including a low ABI (<1.0) or non-compressible artery provide incremental prognostic information. PMID:23067918
Manzano, Jennifer Justice F; De Silva, Deidre A; Pascual, Jose Leonard R; Chang, Hui-Meng; Wong, Meng-Cheong; Chen, Christopher P L H
Low ankle-brachial index (ABI), indicative of peripheral arterial disease (PAD), is a risk factor for stroke. ABI has been shown to be associated with cerebral arterial disease and prognosis following stroke. We studied the associations of the degree of ABI lowering with extracranial carotid disease (ECD), intracranial large artery disease (ICLAD), and subsequent vascular events in a prospective cohort of acute ischemic stroke patients. ABI, extracranial and intracranial cerebral arteries were assessed in a blinded manner. ABI was categorized into 0.9-1.3 (normal), 0.8-0.89 (mildly lowered) and <0.8 (severely lowered). Follow-up data at 1 year were obtained from standardized telephone interviews and verified with medical records. Among the 1311 patients, 73% had normal ABI, 13% had ABI 0.8-0.89 and 13% had ABI <0.8. Compared to patients with normal ABI, those with ABI<0.8 had higher prevalence of severe ECD (15% vs. 5%, p = 0.006) and ICLAD (72% vs. 48%, p = 0.003), even after adjustment for age, gender, hypertension, diabetes, hyperlipidemia, smoking, ischemic heart disease and atrial fibrillation (severe ECD p < 0.001, ICLAD p < 0.001). At 1 year, patients with ABI <0.8 had a higher incidence of composite vascular events (19% vs. 11%, p = 0.02), stroke (15% vs. 10%, p = 0.06) and myocardial infarction (4% vs. 2%, p = 0.07) than patients with normal ABI. Among ischemic stroke patients, large cerebral arterial disease and incidence of subsequent vascular events at 1 year were associated with severe ABI lowering <0.8, but not with mild ABI lowering (0.8-0.89). Copyright © 2012 Elsevier Ltd. All rights reserved.
Davies, Jane H; Kenkre, Joyce; Williams, E Mark
Peripheral arterial disease (PAD) is a marker of systemic atherosclerosis and associated with a three to six fold increased risk of death from cardiovascular causes. Furthermore, it is typically asymptomatic and under-diagnosed; this has resulted in escalating calls for the instigation of Primary Care PAD screening via Ankle Brachial Index (ABI) measurement. However, there is limited evidence regarding the feasibility of this and if the requisite core skills and knowledge for such a task already exist within primary care. This study aimed to determine the current utility of ABI measurement in general practices across Wales, with consideration of the implications for its use as a cardiovascular risk screening tool. A self-reporting questionnaire was distributed to all 478 General Practices within Wales, sent via their responsible Health Boards. The survey response rate was 20%. ABI measurement is primarily performed by nurses (93%) for the purpose of wound management (90%). It is infrequently (73% < 4 times per month) and often incorrectly used (42% out of compliance with current ABI guidance). Only 52% of general practitioners and 16% of nurses reported that patients with an ABI of ≤ 0.9 require aggressive cardiovascular disease risk factor modification (as recommended by current national and international guidelines). ABI measurement is an under-utilised and often incorrectly performed procedure in the surveyed general practices. Prior to its potential adoption as a formalised screening tool for cardiovascular disease, there is a need for a robust training programme with standardised methodology in order to optimise accuracy and consistency of results. The significance of a diagnosis of PAD, in terms of associated increased cardiovascular risk and the necessary risk factor modification, needs to be highlighted.
Sadeghi, Masoumeh; Heidari, Ramin; Mostanfar, Baharak; Tavassoli, Aliakbar; Roghani, Farshad; Yazdekhasti, Safoura
The current study aims to determine the relation between ankle-brachial index (ABI) and angiographic findings and major cardiovascular risk factors in patients with suspected coronary artery diseases (CAD) in Isfahan. In this cross-sectional descriptive-analytic research, patients with suspected CAD were studied. Characteristics of studied subjects including demographics, familial history, past medical history and atherosclerotic risk factors such as diabetes mellitus, hypertension, hyperlipidemia and smoking were obtained using a standard questionnaire. ABI was measured in all studied patients. ABI≤0.9 (ABI(+)) was considered as peripheral vessel disease and ABI>0.9 (ABI(-)) was considered as normal. Then, all studied patients underwent coronary artery angiography. The results of the questionnaire and angiographic findings were compared in ABI(+) and ABI(-) groups. Data were analyzed by SPSS 15 using ANOVA, t-test, Spearman's rank correlation coefficient, and discriminant analysis. In this study, 125 patients were investigated. ABI≤0.9 was seen in 25 patients (20%). The prevalence of ABI(+) among men and women was 25.9% and 7.5%, respectively (P=0.01). The prevalence of atherosclerotic risk factors was significantly higher in ABI(+) patients than in ABI(-) ones (P<0.05). ABI(+) patients had more significant stenosis than ABI(-) ones. The mean of occlusion was significantly higher in ABI(+) patients with left main artery (LMA), right coronary artery (RCA), left anterior descending artery (LAD), diagonal artery 1 (D1) and left circumflex artery (LCX) involvements (P<0.05). The findings of this research indicated that ABI could be a useful method in assessing both the atherosclerotic risk factors and the degree of coronary involvements in suspected patients. However, in order to make more accurate decisions for using this method in diagnosing and preventing CAD, we should plan further studies in large sample sizes of general population.
Nishimura, Hitoshi; Miura, Takashi; Minamisawa, Masatoshi; Ueki, Yasushi; Abe, Naoyuki; Hashizume, Naoto; Mochidome, Tomoaki; Harada, Mikiko; Shimizu, Kunihiko; Shoin, Wataru; Yoshie, Koji; Oguchi, Yasutaka; Ebisawa, Soichiro; Motoki, Hirohiko; Izawa, Atsushi; Koyama, Jun; Ikeda, Uichi; Kuwahara, Koichiro
Reduced ankle-brachial index (ABI) is a predictor of cardiovascular events. However, the significance of high ABI remains poorly understood. This study aimed to assess the characteristics and outcomes of patients with high ABI. The IMPACT-ABI study was a retrospective cohort study that enrolled and examined ABI in 3,131 patients hospitalized for cardiovascular disease between January 2005 and December 2012. From this cohort, 2,419 patients were identified and stratified into two groups: high ABI (> 1.4; 2.6%) and normal ABI (1.0-1.4; 97.3%). The primary endpoint was the cumulative incidence of major adverse cardiovascular events (MACE), including cardiovascular-associated death, myocardial infarction, and stroke. Compared with the normal ABI group, patients in the high ABI group showed significantly lower body mass index (BMI) and hemoglobin level, but had higher incidence of chronic kidney disease and hemodialysis. Multivariate logistic regression analysis revealed that hemodialysis was the strongest predictor of high ABI (odds ratio, 6.18; 95% confidence interval (CI), 3.05-12.52; P < 0.001). During the follow-up (median, 4.7 years), 172 cases of MACE occurred. Cumulative MACE incidence in patients with high ABI was significantly increased compared to that in those with normal ABI (32.5% vs. 14.5%; P = 0.005). In traditional cardiovascular risk factors-adjusted multivariate Cox proportional hazard analysis, high ABI was an independent predictor of MACE (hazard ratio, 2.07; 95% CI, 1.02-4.20; P = 0.044). Lower BMI, chronic kidney disease, and hemodialysis are more frequent in patients with high ABI. Hemodialysis is the strongest predictor of high ABI. High ABI is a parameter that independently predicts MACE.
Ratanakorn, Disya; Keandoungchun, Jesada; Tegeler, Charles H
Abnormal ankle brachial index (ABI) identifies a stroke subgroup with high risk of subsequent stroke and other vascular events. There are few data regarding the prevalence of abnormal ABI in ischemic stroke in Asian countries. We evaluated the prevalence of abnormal ABI in 747 Thai patients with ischemic stroke or transient ischemic attack and assessed the correlation of abnormal ABI with stroke risk factors and stroke subtypes. The prevalence of abnormal ABI (≤0.9) in ischemic stroke patients was 18.1%. Abnormal ABI in ischemic stroke patients was significantly correlated with female gender (odds ratio [OR], 1.61; confidence interval [CI], 1.09-2.40; P = .017), age ≥ 60 years (OR, 3.54; CI, 2.14-5.85; P < .001), and previous ischemic events, including coronary artery disease (OR, 2.55; CI, 1.47-4.43; P = .001), cerebrovascular disease (OR, 2.15; CI, 1.37-3.55; P = .002), and atrial fibrillation (OR, 1.71; CI, 1.03-2.82; P = .036). There was a significant difference in the prevalence of abnormal ABI among stroke subtypes (P < .001), which tended to be more frequent in those with large artery disease (20.4%), cardioembolic stroke (29.2%), and undetermined etiology (20.6%). An ABI examination should be considered in patients with ischemic stroke to facilitate the early detection and treatment of asymptomatic peripheral arterial disease and identification of excess risk for subsequent stroke or other vascular events. Copyright © 2012 National Stroke Association. Published by Elsevier Inc. All rights reserved.
Hashimoto, Tomoko; Ichihashi, Shigeo; Iwakoshi, Shinichi; Kichikawa, Kimihiko
The ankle-brachial index (ABI) measurement is widely used as a screening tool to detect peripheral arterial disease (PAD). With the advent of the oscillometric ABI device incorporating a system for the measurement of pulse volume recording (PVR), not only ABI but also other parameters, such as the percentage of mean arterial pressure (%MAP) and the upstroke time (UT), can be obtained automatically. The purpose of the present study was to compare the diagnostic accuracy for PAD with ABI alone with that of a combination of ABI, %MAP and UT. This study included 108 consecutive patients on whom 216 limb measurements were performed. The sensitivity, specificity and positive and negative predictive values of ABI, %MAP, UT and their combination were evaluated and compared with CT angiography that was used as a gold standard for the detection of PAD. The diagnostic accuracy as well as the optimal cutoff values of %MAP and UT were evaluated using receiver operating characteristic (ROC) curve analysis. The combination of ABI, %MAP and UT achieved higher sensitivity, negative predictive value and accuracy than ABI alone, particularly for mild stenosis. The areas under the ROC curve for the detection of 50% stenosis with UT and %MAP were 0.798 and 0.916, respectively. The optimal UT and %MAP values to detect ≧50% stenosis artery were 183 ms and 45%, respectively. The combination of ABI, %MAP and UT contributed to the improvement of the diagnostic accuracy for PAD. Consideration of the values of %MAP and UT in addition to ABI may have a significant impact on the detection of early PAD lesions.
Takashima, N; Turin, T C; Matsui, K; Rumana, N; Nakamura, Y; Kadota, A; Saito, Y; Sugihara, H; Morita, Y; Ichikawa, M; Hirose, K; Kawakani, K; Hamajima, N; Miura, K; Ueshima, H; Kita, Y
Brachial-ankle pulse wave velocity (baPWV) is a non-invasive measure of arterial stiffness obtained using an automated system. Although baPWVs have been widely used as a non-invasive marker for evaluation of arterial stiffness, evidence for the prognostic value of baPWV in the general population is scarce. In this study, we assessed the association between baPWV and future cardiovascular disease (CVD) incidence in a Japanese population. From 2002 to 2009, baPWV was measured in a total of 4164 men and women without a history of CVD, and they were followed up until the end of 2009 with a median follow-up period of 6.5 years. Hazard ratios (HRs) for CVD incidence according to baPWV levels were calculated using a Cox proportional hazards model adjusted for potential confounding factors, including seated or supine blood pressure (BP). During the follow-up period, we observed 40 incident cases of CVD. In multivariable-adjusted model, baPWV as a continuous variable was not significantly associated with future CVD risk after adjustment for supine BP. However, compared with lower baPWV category (<18 m s(-1)), higher baPWV (< or = 18.0 m s(-1)) was significantly associated with an increased CVD risk (HR: 2.70, 95% confidence interval: 1.18-6.19). Higher baPWV (< or = 18.0 m s(-1)) would be an independent predictor of future CVD event in the general Japanese population.
Izzo, Joseph L
This critique is intended to provide background for the reader to evaluate the relative clinical utilities of brachial cuff systolic blood pressure (SBP) and its derivatives, including pulse pressure, central systolic pressure, central augmentation index (AI), and pulse pressure amplification (PPA). The critical question is whether the newer indicators add sufficient information to justify replacing or augmenting brachial cuff blood pressure (BP) data in research and patient care. Historical context, pathophysiology of variations in pulse wave transmission and reflection, issues related to measurement and model errors, statistical limitations, and clinical correlations are presented, along with new comparative data. Based on this overview, there is no compelling scientific or practical reason to replace cuff SBP with any of the newer indicators in the vast majority of clinical situations. Supplemental value for central SBP may exist in defining patients with exaggerated PPA ("spurious systolic hypertension"), managing cardiac and aortic diseases, and in studies of cardiovascular drugs, but there are no current standards for these possibilities.
AlGhatrif, Majd; Zane, Ariel; Oberdier, Matt; Canepa, Marco; Studenski, Stephanie; Simonsick, Eleanor; Spencer, Richard G; Fishbein, Kenneth; Reiter, David; Lakatta, Edward G; McDermott, Mary M; Ferrucci, Luigi
Lower muscle mitochondrial energy production may contribute to impaired walking endurance in patients with peripheral arterial disease. A borderline ankle-brachial index (ABI) of 0.91 to 1.10 is associated with poorer walking endurance compared with higher ABI. We hypothesized that in the absence of peripheral arterial disease, lower ABI is associated with lower mitochondrial energy production. We examined 363 men and women participating in the Baltimore Longitudinal Study of Aging with an ABI between 0.90 and 1.40. Muscle mitochondrial energy production was assessed by post-exercise phosphocreatine recovery rate constant (kPCr) measured by phosphorus magnetic resonance spectroscopy of the left thigh. A lower post-exercise phosphocreatine recovery rate constant reflects decreased mitochondria energy production.The mean age of the participants was 71±12 years. A total of 18.4% had diabetes mellitus and 4% were current and 40% were former smokers. Compared with participants with an ABI of 1.11 to 1.40, those with an ABI of 0.90 to 1.10 had significantly lower post-exercise phosphocreatine recovery rate constant (19.3 versus 20.8 ms(-1), P=0.015). This difference remained significant after adjusting for age, sex, race, smoking status, diabetes mellitus, body mass index, and cholesterol levels (P=0.028). Similarly, post-exercise phosphocreatine recovery rate constant was linearly associated with ABI as a continuous variable, both in the ABI ranges of 0.90 to 1.40 (standardized coefficient=0.15, P=0.003) and 1.1 to 1.4 (standardized coefficient=0.12, P=0.0405). An ABI of 0.90 to 1.10 is associated with lower mitochondrial energy production compared with an ABI of 1.11 to 1.40. These data demonstrate adverse associations of lower ABI values with impaired mitochondrial activity even within the range of a clinically accepted definition of a normal ABI. Further study is needed to determine whether interventions in persons with ABIs of 0.90 to 1.10 can prevent subsequent
Fortier, Catherine; Sidibé, Aboubacar; Desjardins, Marie-Pier; Marquis, Karine; De Serres, Sacha A; Mac-Way, Fabrice; Agharazii, Mohsen
Aortic stiffness, a cardiovascular risk factor, depends on the operating mean arterial pressure (MAP). The impact of aortic stiffness on cardiovascular outcomes is proposed to be mediated by the attenuation or the reversal of the arterial stiffness gradient. We hypothesized that arterial stiffness gradient is less influenced by changes in MAP. We aimed to study the relationship between MAP and aortic stiffness, brachial stiffness, and arterial stiffness gradient. In a cross-sectional study of a dialysis cohort (group A, n=304) and a cohort of hypertensive or kidney transplant recipient with an estimated glomerular filtration rate of >45 mL/min/1.73 m(2) (group B, n=114), we assessed aortic and brachial stiffness by measuring carotid-femoral and carotid-radial pulse wave velocities (PWV). We used aortic-brachial PWV ratio as a measure of arterial stiffness gradient. Although there was a positive relationship between MAP and carotid-femoral PWV (R(2)=0.10 and 0.08; P<0.001 and P=0.003) and MAP and carotid-radial PWV (R(2)=0.22 and 0.12; P<0.001 and P<0.001), there was no statistically or clinically significant relationship between MAP and aortic-brachial PWV ratio (R(2)=0.0002 and 0.0001; P=0.8 and P=0.9) in group A and B, respectively. Dialysis status and increasing age increased the slope of the relationship between MAP and cf-PWV. However, we found no modifying factor (age, sex, dialysis status, diabetes mellitus, cardiovascular disease, and class of antihypertensive drugs) that could affect the lack of relationship between MAP and aortic-brachial PWV ratio. In conclusion, these results suggest that aortic-brachial PWV ratio could be considered as a blood pressure-independent measure of vascular aging. © 2016 American Heart Association, Inc.
Climie, R E D; Picone, D S; Keske, M A; Sharman, J E
Brachial-to-radial-systolic blood pressure amplification (Bra-Rad-SBPAmp) can affect central SBP estimated by radial tonometry. Patients with type 2 diabetes mellitus (T2DM) have vascular irregularities that may alter Bra-Rad-SBPAmp. By comparing T2DM with non-diabetic controls, we aimed to determine the (1) magnitude of Bra-Rad-SBPAmp; (2) haemodynamic factors related to Bra-Rad-SBPAmp; and (3) effect of Bra-Rad-SBPAmp on estimated central SBP. Twenty T2DM (64±8 years) and 20 non-diabetic controls (60±8 years; 50% male both) underwent simultaneous cuff deflation and two-dimensional ultrasound imaging of the brachial and radial arteries. The first Korotkoff sound (denoting SBP) was identified from the first inflection point of Doppler flow during cuff deflation. Bra-Rad-SBPAmp was calculated by radial minus brachial SBP. Upper limb and systemic haemodynamics were recorded by tonometry and ultrasound. Radial SBP was higher than brachial SBP for T2DM (136±19 vs 127±17 mm Hg; P<0.001) and non-diabetic controls (135±12 vs 121±11 mm Hg; P<0.001), but Bra-Rad-SBPAmp was significantly lower in T2DM (9±8 vs 14±7 mm Hg; P=0.042). The product of brachial mean flow velocity × brachial diameter was inversely and independently correlated with Bra-Rad-SBPAmp in T2DM (β=-0.033 95% confidence interval -0.063 to -0.004, P=0.030). When radial waveforms were calibrated using radial, compared with brachial SBP, central SBP was significantly higher in both groups (T2DM, 116±13 vs 125±15 mm Hg; and controls, 112±10 vs 124±11 mm Hg; P<0.001 both) and there was a significant increase in the number of participants classified with 'central hypertension' (SBP⩾130 mm Hg; P=0.004). Compared with non-diabetic controls, Bra-Rad-SBPAmp is significantly lower in T2DM. Regardless of disease status, radial SBP is higher than brachial SBP and this results in underestimation of central SBP using brachial-BP-calibrated radial tonometry.
Vu, Thanh-Huyen T.; Stamler, Jeremiah; Liu, Kiang; McDermott, Mary M.; Lloyd-Jones, Donald M.; Pirzada, Amber; Garside, Daniel B.; Daviglus, Martha L.
Background Data are sparse regarding the long-term association of favorable levels of all major cardiovascular disease risk factors (RFs) (ie, low risk [LR]) with ankle-brachial index (ABI). Methods and Results In 2007–2010, the Chicago Healthy Aging Study reexamined a subset of participants aged 65 to 84 years from the Chicago Heart Association Detection Project in Industry cohort (baseline examination, 1967–1973). RF groups were defined as LR (untreated blood pressure ≤120/≤80 mm Hg, untreated serum cholesterol <200 mg/dL, body mass index <25 kg/m2, not smoking, no diabetes) or as 0 RFs, 1 RF, or 2+ RFs based on the presence of blood pressure ≥140/≥90 mm Hg or receiving treatment, serum cholesterol ≥240 mg/dL or receiving treatment, body mass index ≥30 kg/m2, smoking, or diabetes. ABI at follow-up was categorized as indicating PAD present (≤0.90), as borderline PAD (0.91 to 0.99), or as normal (1.00 to 1.40). We included 1346 participants with ABI ≤1.40. After multivariable adjustment, the presence of fewer baseline RFs was associated with a lower likelihood of PAD at 39-year follow-up (P for trend is <0.001). Odds ratios (95% CIs) for PAD in persons with LR, 0 RFs, or 1 RF compared with those with 2+ RFs were 0.14 (0.05 to 0.44), 0.28 (0.13 to 0.59), and 0.33 (0.16 to 0.65), respectively; findings were similar for borderline PAD (P for trend is 0.005). The association was mainly due to baseline smoking status, cholesterol, and diabetes. Remaining free of adverse RFs or improving RF status over time was also associated with PAD. Conclusions LR profile in younger adulthood (ages 25 to 45) is associated with the lowest prevalence of PAD and borderline PAD 39 years later. PMID:23316312
Non-invasive vascular assessment in the foot with diabetes: sensitivity and specificity of the ankle brachial index, toe brachial index and continuous wave Doppler for detecting peripheral arterial disease.
Tehan, Peta Ellen; Bray, Alan; Chuter, Vivienne Helaine
Non-invasive lower limb vascular assessment in people at risk of peripheral arterial disease (PAD) including those with diabetes is crucial. There is evidence that standard assessment techniques such as the ankle-brachial index (ABI) may be less effective in people with diabetes. However there is limited evidence for other frequently used tests including continuous wave Doppler (CWD), and the toe-brachial index (TBI). The aim of this study was to determine the sensitivity and specificity of, ABI, CWD and TBI in a population with, and without diabetes. Participants with and without diabetes who met current guidelines for vascular screening were recruited, and CWD waveforms, an ABI and a TBI were obtained from the right lower limb. Diagnostic accuracy was determined using colour duplex ultrasound (CFDU). Receiver operating characteristic curves were calculated. 117 participants were recruited, seventy-two with diabetes and forty-five without diabetes. CWD had the highest sensitivity in people with diabetes (74%) and without (84%). CWD also had the highest specificity in people with diabetes (74%) and without (84%) compared to both TBI and ABI. In participants with diabetes, the ABI was a poor test, area under the curve: 0.58 (p=0.27). CWD waveform is more likely to detect significant PAD compared to ABI and TBI in people with and without diabetes. Copyright © 2016 Elsevier Inc. All rights reserved.
Bursztyn, Michael; Norton, Gavin R; Ben-Dov, Iddo Z; Booysen, Hendrik L; Sibiya, Moekanyi J; Sareli, Pinhas; Woodiwiss, Angela J
Although aortic-to-brachial pulse pressure amplification (PPamp) may offer prognostic information beyond brachial blood pressure (BP), this approach is limited in resource-limited settings. We aimed to derive an equation to impute central aortic PP (PPc) from simple clinical measures and assess whether imputed PPamp adds to the ability of brachial BP to predict mortality. An imputation equation for PPc, incorporating brachial PP, age, mean arterial pressure, and pulse rate, was identified from multivariate modeling of the factors associated with radial applanation tonometry-derived (measured) PPc in 1,179 community participants and validated in a clinical sample of 351 patients. We applied the equation to ambulatory awake BP and pulse rate values in a separate group of 4,796 patients referred for ambulatory monitoring and evaluated the impact on all-cause mortality. Imputed PPc values closely approximated measured PPc (r (2) = 0.96, mean difference ± (2 × SD) = 1.4±6.2mm Hg). In adjusted Cox proportional models including adjustments for awake brachial PP during 47,111 person-years of follow-up, where 648 patients died, hazards ratio for all-cause mortality per SD of awake PPamp was 0.79 (95% confidence interval (CI): 0.68-0.93, P < 0.005). The hazards ratio for brachial PP with (1.49, CI = 1.36-1.64, P < 0.0001) or without (1.46, CI = 1.35-1.59, P < 0.0001) PPamp in the model was similar. Awake PPamp also predicted survival independent of awake brachial systolic BP (P < 0.0001). PPc imputed from simple clinical assessments closely approximates measured PPc. PPamp derived from imputed PPc adds to the ability of brachial BP to predict survival. In resource-limited settings, an imputation equation may be employed to approximate aortic BP and enhance risk prediction. © American Journal of Hypertension, Ltd 2015. All rights reserved. For Permissions, please email: email@example.com.
Wassel, Christina L; Allison, Matthew A; Ix, Joachim H; Rifkin, Dena E; Forbang, Nketi I; Denenberg, Julie O; Criqui, Michael H
Peripheral artery disease (PAD) affects millions of people, both in the U.S. and worldwide. Even when asymptomatic, PAD and the ankle-brachial index (ABI), the major clinical diagnostic criterion for PAD, are associated with decreased functional status and quality of life, as well as mobility impairment. Whether the ABI or change in the ABI predicts decline in functional status over time has not been previously assessed in a population-based setting. Participants were 812 non-Hispanic white, African American, Hispanic, and Asian men and women from the San Diego Population Study (SDPS) who attended a baseline examination (1994-1998), and follow-up clinic examination approximately 11 years later. The Medical Outcomes Study 36-Item Short Form (SF-36) was obtained at both the baseline and follow-up examinations, and the summary performance score (SPS) at the follow-up examination. Associations of the baseline ABI and clinically relevant change in the ABI (<-0.15 vs ≥-0.15) with change in SF-36 scores over time were assessed using growth curve models, a type of mixed model that accounts for within participant correlation of measurements over time, and using linear regression for SPS. Models were adjusted for baseline age, sex, race/ethnicity, body mass index, ever smoking, physical activity, hypertension, diabetes, and dyslipidemia. Mean ± standard deviation (SD) for the baseline ABI was 1.11 ± 0.10, and 50.8 ± 9.0 for the baseline Physical Component Score (PCS), 50.1 ± 9.5 for the baseline Mental Component Score (MCS), and 11.2 ± 1.9 for the SPS at the follow-up examination. In fully adjusted models, each SD lower of the baseline ABI was significantly associated with an average decrease over time of 0.6 (95% confidence interval [CI], -1.1 to -0.1; P = .02) units on SF-36 PCS. Each SD lower of the baseline ABI was also significantly associated with an average decrease over time of 1.2 units (95% CI, -2.3 to -0.2; P = .02) on the SF-36 physical
Wassel, Christina L.; Allison, Matthew A.; Ix, Joachim H.; Rifkin, Dena E.; Forbang, Nketi I.; Denenberg, Julie O.; Criqui, Michael H.
Background Peripheral artery disease (PAD) affects millions of people, both in the US and world-wide. Even when asymptomatic, PAD and the ankle brachial index (ABI), the major clinical diagnostic criterion for PAD, are associated with decreased functional status and quality of life, as well as mobility impairment. Whether the ABI or change in the ABI predicts decline in functional status over time has not been previously assessed in a population-based setting. Methods Participants were 812 non-Hispanic white, African-American, Hispanic and Asian men and women from the San Diego Population Study (SDPS) who attended a baseline exam (1994–98), and follow up clinic exam approximately 11 years later. The Medical Outcomes Study 36-item short form (SF-36) was obtained at both the baseline and follow-up exams, and the summary performance score (SPS) at the follow up exam. Associations of the baseline ABI and clinically relevant change in the ABI (<−0.15 vs ≥−0.15) with change in SF-36 scores over time were assessed using growth curve models, a type of mixed model which accounts for within participant correlation of measurements over time, and using linear regression for SPS. Models were adjusted for baseline age, sex, race/ethnicity, body mass index, ever smoking, physical activity, hypertension, diabetes, and dyslipidemia. Results Mean±SD for the baseline ABI was 1.11±0.10, and 50.8±9.0 for the baseline PCS, 50.1±9.5 for the baseline MCS, and 11.2±1.9 for the SPS at the follow-up exam. In fully adjusted models, each SD lower of the baseline ABI was significantly associated with an average decrease over time of 0.6 (95% CI (−1.1, −0.1), p=0.02) units on SF-36 PCS. Each SD lower of the baseline ABI was also significantly associated with an average decrease over time of 1.2 units ((−2.3, −0.2), p=0.02) on the SF-36 physical functioning subscale, and a decrease of 1.3 units ((−2.3, −0.3), p=0.01) on the SF-36 energy/vitality subscale in fully adjusted
Norton, Gavin R; Majane, Olebogeng H I; Maseko, Muzi J; Libhaber, Carlos; Redelinghuys, Michelle; Kruger, Deirdre; Veller, Martin; Sareli, Pinhas; Woodiwiss, Angela J
Central aortic blood pressure (BP; BPc) predicts outcomes beyond brachial BP. In this regard, the application of a generalized transfer function (GTF) to radial pulse waves for the derivation of BPc is an easy and reproducible measurement technique. However, the use of the GTF may not be appropriate in all circumstances. Although the peak of the second shoulder of the radial waveform (P2) is closely associated with BPc, and, hence, BPc may be assessed without the need for a GTF, whether P2-derived BPc is associated with adverse cardiovascular changes independent of brachial BP is uncertain. Thus, P2- and GTF-derived aortic BPs were assessed using applanation tonometry and SphygmoCor software. Left ventricular mass was indexed for height(1.7) (n=678) and carotid intima-media thickness (IMT; n=462) was determined using echocardiography and vascular ultrasound. With adjustments for nurse-derived brachial pulse pressure (PP), P2-derived central PP was independently associated with left ventricular mass indexed for height(1.7) (partial r=0.18; P<0.0001) and IMT (partial r=0.40; P<0.0001). These relations were similar to nurse-derived brachial PP-independent relations between GTF-derived central PP and target organ changes (left ventricular mass indexed for height(1.7): partial r=0.17, P<0.0001; IMT: partial r=0.37, P<0.0001). In contrast, with adjustments for central PP, nurse-derived brachial PP-target organ relations were eliminated (partial r=-0.21 to 0.05). Twenty-four-hour, day, and night PP-target organ relations did not survive adjustments for nurse-derived brachial BP. In conclusion, central PP derived from P2, which does not require a GTF, is associated with cardiovascular target organ changes independent of brachial BP. Thus, when assessing adverse cardiovascular effects of aortic BP independent of brachial BP, P2-derived measures may complement GTF-derived measures of aortic BP.
A brachial plexus lesion is not common in hereditary neuropathy with liability to pressure palsy (HNPP). We report the clinical and electrodiagnostic features of young soldiers with HNPP presenting with brachial plexopathy. By reviewing 2year medical records from Korean military hospitals, we identified soldiers with brachial plexus lesions. Among them, patients diagnosed with HNPP were determined and clinical and electrophysiological findings were compared between HNPP and non-HNPP patients with a brachial plexus lesion. Thirteen patients (6.8%) were diagnosed with HNPP among 189 patients with a brachial plexus lesion. Push-ups, as either a punishment or an exercise, was the most frequent preceding event in HNPP patients (76.9%), whereas it was rare in non-HNPP patients. The distal motor latency of the median nerve showed the highest sensitivity (90.9%) and specificity (100%) for HNPP in patients with a brachial plexus lesion. In conclusion, HNPP should be suspected in patients with brachial plexopathy if brachial plexopathy develops after push-ups or if the distal motor latency of median nerves is prolonged.
London, Gérald M
Epidemiological studies have emphasized the relationship between blood pressure (BP) and the incidence of cardiovascular diseases. Severity of hypertension was in the past judged on the basis of diastolic BP. More recent epidemiological studies have directed attention to systolic pressure as a better guide to cardiovascular and all-cause mortality. Traditionally, hypertension was appreciated by measures of BP recorded in peripheral arteries, usually brachial artery which was assumed to reflect pressures in all parts of arterial system. All these studies neglected that peripheral systolic BP differs from pressure recorded in the aorta and central arteries. While mean and diastolic pressures are almost constant along the arterial tree, due to the stiffness and geometric heterogeneity of large arteries and the timing and magnitude of wave reflections systolic BP and pulse pressure are amplified from the aorta to peripheral arteries, and brachial systolic BP only indirectly reflects the systolic BP in the aorta and central arteries. Several recent studies have shown that the effects of antihypertensive drugs are not the same in peripheral and central arteries, fact which could account for different effects of various drugs on end-organ damage, such as regression of left ventricular hypertrophy. Moreover, it has been shown that aortic and central artery pressure (or their determinants) are stronger predictors of end-organ damage and cardiovascular outcome than conventionally measured brachial pressure. These studies have focused the attention on the physical properties of large arteries and on the way they influence the level of systolic and pulse pressures along the arterial tree.
El-Menyar, Ayman; Amin, Haitham; Rashdan, Ibrahim; Souliman, Kadhim; Deleu, Dirk; Saadat, Kamran; Al Mahmeed, Wael; Bakir, Sharif; Wasif, Adel; Ben Brek, Azan; Bazargani, Nooshin; Ahmed Abdel Aziz; Singh, Rajvir; Hatou, Iman; Mahmoud, Hisham; Al Suwaidi, Jassim
To assess the extent of atherothrombosis and the use of the ankle-brachial index (ABI) in populations from the Middle East, we conducted a multicenter study similar to AGATHA (a Global Atherothrombosis Assessment), AGATHA-ME, which included 1341 patients from 18 centers from 5 countries (United Arab Emirates, Kuwait, Qatar, Bahrain, and Oman). Patients were assigned to 2 groups: the with-disease and at-risk groups. Abnormal ABI (< or =0.9) was seen in 31.5% of at-risk patients and 28.2% of with-disease patients. Patients with peripheral arterial disease had the highest frequency of abnormal ABI (77.6%), with 97.8 negative predictive value. The AGATHA-ME study confirms that atherothrombosis disease often occurs at more than 1 site. The ABI is related to the risk factor profile and to the site and extent of atherothrombosis. Gender and diabetes mellitus are associated with the worst parameters.
Breznik, Silva; Ekart, Robert; Hren, Martin; Rupreht, Mitja; Balon, Breda Pečovnik
Vascular calcification is a frequent complication of chronic kidney disease and end stage renal disease. In both the general population and patients with end stage renal disease, vascular calcification is related to arterial stiffness and is a predictor of cardiovascular morbidity and mortality. Various diagnostic methods are currently used to assess vascular calcification. There is a preference for simple, reliable methods that can be used in daily practice. Therefore, several imaging and laboratory methods are investigated. Twenty-eight patients with mean age of 62 years on chronic hemodialysis were enrolled in the study. The mean duration of hemodialysis treatment was 70 months (range 3 to 350 months). Vascular calcification was assessed with coronary computed tomography and lateral lumbar, pelvic and hand radiographs. Vascular stiffness was evaluated using aortic pulse wave velocity and ankle-brachial index measurements, and finally serum levels of fibroblast growth factor-23 were followed. A statistically significant correlation was demonstrated between all the following parameters: coronary artery calcification score, aortic pulse wave velocity, abdominal aortic calcification score, simple vascular calcification scores in pelvis and hand. A statistically significant correlation of ankle-brachial index >1.3 to coronary artery calcification score was found. There was no correlation between the previous parameters and fibroblast growth factor-23. The results of our study indicate that simple imaging methods could provide confident vascular damage assessment and therefore potentially guide therapy adjustments. An association between fibroblast growth factor-23 and the other diagnostic modalities in our study was not found. © 2013 The Authors. Therapeutic Apheresis and Dialysis © 2013 International Society for Apheresis.
Kwiatkowska, Wiesława; Knysz, Brygida; Arczyńska, Katarzyna; Drelichowska, Justyna; Czarnecki, Marcin; Gąsiorowski, Jacek; Karczewski, Maciej; Witkiewicz, Wojciech
Background Peripheral arterial disease (PAD) is a clinical manifestation of atherosclerosis and mainly refers to elderly patients, having a negative impact on their functionality and quality of life. The findings of previous studies in HIV-infected patients have shown that cardiovascular risk is higher and PAD occurs more frequently than in the general population. There are also contradictory observations. Much less is known about the ankle-brachial index (ABI) value in asymptomatic HIV-infected patients. The aim of this study was to evaluate the prevalence of PAD and ankle-brachial index abnormalities as well as to determine risk factors related to the disease in a group of Polish HIV–positive patients. Methods and Findings One hundred and eleven young to middle aged HIV–positive subjects and 40 noninfected subjects were enrolled into the study. Resting ABI measurements were performed and cardiovascular risk was analysed as well. Subgroups were created according to the ABI values: low (PAD), borderline, normal, high and altered ABI. Symptomatic PAD was observed in 2 HIV–positive patients, asymptomatic PAD was not diagnosed. The ABI value is lower and more varied, in 22.5% of the study group altered ABI values were found. Six subjects demonstrated borderline ABI, and 15 high ABI, including >1.4. In the control group no low or very high values were reported. A relation between low ABI and cardiovascular family history and between altered ABI and high–density–lipoprotein cholesterol (HDL–C) level was demonstrated. Conclusions In young and middle–aged HIV–positive patients, symptomatic PAD prevalence is comparable to that observed in the overall population. Among asymptomatic patients PAD is not reported. The ABI value in HIV–positive patients is more varied compared to the HIV–negative subjects; the altered ABI shows a strong relation with low HDL–C levels and metabolic syndrome. PMID:25503743
Maeda, Yasutaka; Inoguchi, Toyoshi; Etoh, Erina; Kodama, Yoshimi; Sasaki, Shuji; Sonoda, Noriyuki; Nawata, Hajime; Shimabukuro, Michio; Takayanagi, Ryoichi
Whether brachial-ankle pulse wave velocity (baPWV), a noninvasive marker for arterial stiffness, is a useful predictive maker for cardiovascular events in subjects with diabetes is not established. In the present cohort study, we evaluated the benefit of baPWV for the prediction of cardiovascular morbidity and mortality in subjects with diabetes. A total of 4,272 outpatients with diabetes were enrolled in the Kyushu Prevention Study of Atherosclerosis. Of these, 3,628 subjects, excluding those with an ankle-brachial index of <0.9, were prospectively followed for 3.2 ± 2.2 years. The baPWV at baseline was classified by recursive partitioning (RP) for each end point. We plotted the Kaplan-Meier curves for high- and low-baPWV groups, which were designated based on the cutoff points, and calculated Cox proportional hazards models. The elevation of baPWV quartiles was significantly correlated to the incidence of coronary artery events, cerebrovascular events, and all-cause mortality. RP revealed baPWVs of 14 and 24 m/s as statistically adequate cutoff points for cardiovascular events and mortality, respectively. High-baPWV classes showed significantly low event-free ratios in Kaplan-Meier curves for all end points and remained independent risks for all-cause mortality and cerebrovascular events, but not for coronary artery events after adjustments for age, sex, BMI, hypertension, hyperlipidemia, smoking, and hemoglobin A1c by Cox proportional hazards models. This large-scale cohort study provided evidence that high baPWV is a useful independent predictor of mortality and cardiovascular morbidity in subjects with diabetes. © 2014 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.
Butlin, Mark; Qasem, Ahmad; Avolio, Alberto P
There is increasing interest in non-invasive estimation of central aortic waveform parameters in the clinical setting. However, controversy has arisen around radial tonometric based systems due to the requirement of a trained operator or lack of ease of use, especially in the clinical environment. A recently developed device utilizes a novel algorithm for brachial cuff based assessment of aortic pressure values and waveform (SphygmoCor XCEL, AtCor Medical). The cuff was inflated to 10 mmHg below an individual's diastolic blood pressure and the brachial volume displacement waveform recorded. The aortic waveform was derived using proprietary digital signal processing and transfer function applied to the recorded waveform. The aortic waveform was also estimated using a validated technique (radial tonometry based assessment, SphygmoCor, AtCor Medical). Measurements were taken in triplicate with each device in 30 people (17 female) aged 22 to 79 years of age. An average for each device for each individual was calculated, and the results from the two devices were compared using regression and Bland-Altman analysis. A high correlation was found between the devices for measures of aortic systolic (R(2)=0.99) and diastolic (R(2)=0.98) pressure. Augmentation index and subendocardial viability ratio both had a between device R(2) value of 0.82. The difference between devices for measured aortic systolic pressure was 0.5±1.8 mmHg, and for augmentation index, 1.8±7.0%. The brachial cuff based approach, with an individualized sub-diastolic cuff pressure, provides an operator independent method of assessing not only systolic pressure, but also aortic waveform features, comparable to existing validated tonometric-based methods.
Solá, J; Proença, M; Chételat, O
The clinical demand for technologies to monitor Blood Pressure (BP) in ambulatory scenarios with minimal use of inflation cuffs is strong: new generation of BP monitors are expected to be not only accurate, but also non-occlusive. In this paper we review recent advances on the use of the so-called Pulse Wave Velocity (PWV) technologies to estimate BP in a beat-by-beat basis. After introducing the working principle and underlying methodological limitations, two implementation examples are provided. Pilot studies have demonstrated that novel PWV-based BP monitors depict accuracy scores falling within the limits of the British Hypertensive Society (BHS) Grade A standard. The reported techniques pave the way towards ambulatory-compliant, continuous and non-occlusive BP monitoring devices, where the use of inflation cuffs is drastically reduced.
Sugawara, Rie; Horinaka, Shigeo; Yagi, Hiroshi; Ishimura, Kimihiko; Honda, Takeharu
Recently, a method of estimating the central systolic blood pressure (C-SBP) using an N-point moving average method in the radial or brachial artery waveform has been reported. Then, we investigated the relationship between the C-SBP estimated from the brachial artery pressure waveform using the N-point moving average method and the C-SBP measured invasively using a catheter. C-SBP using a N/6 moving average method from the scaled right brachial artery pressure waveforms using VaSera VS-1500 was calculated. This estimated C-SBP was compared with the invasively measured C-SBP within a few minutes. In 41 patients who underwent cardiac catheterization (mean age: 65 years), invasively measured C-SBP was significantly lower than right cuff-based brachial BP (138.2 ± 26.3 vs 141.0 ± 24.9 mm Hg, difference -2.78 ± 1.36 mm Hg, P = 0.048). The cuff-based SBP was significantly higher than invasive measured C-SBP in subjects with younger than 60 years old. However, the estimated C-SBP using a N/6 moving average method from the scaled right brachial artery pressure waveforms and the invasively measured C-SBP did not significantly differ (137.8 ± 24.2 vs 138.2 ± 26.3 mm Hg, difference -0.49 ± 1.39, P = 0.73). N/6-point moving average method using the non-invasively acquired brachial artery waveform calibrated by the cuff-based brachial SBP was an accurate, convenient and useful method for estimating C-SBP. Thus, C-SBP can be estimated simply by applying a regular arm cuff, which is greatly feasible in the practical medicine.
Nath, Rahul Kumar; Bowen, Margaret Elaine; Eichhorn, Mitchell George
Brachial plexus upper trunk injury is associated with winged scapula owing to the close anatomical course of the long thoracic nerve and upper trunk. Needle electromyography is a common diagnostic test for this injury; however, it does not detect injury in most patients with upper trunk damage. The pressure-specified sensory device may be an alternative to needle electromyography. Thirty patients with winged scapula and upper trunk injury were evaluated with needle electromyography (EMG) and pressure-specified sensory device (PSSD) tests. EMG testing of the biceps muscle was compared with PSSD testing of the dorsal hand skin (C6 damage), and EMG testing of the deltoid and spinati muscles was compared with PSSD testing of the deltoid skin (C5 damage). PSSD pressure values were significantly higher on the affected arm. On the basis of published and calculated threshold values the PSSD was found to be significantly more sensitive than EMG. The PSSD tests consistently identified injuries that were not detected by needle EMG tests. These findings provide strong evidence that the PSSD is more effective than needle EMG in the detection of brachial plexus upper trunk injury.
Nakagomi, Atsushi; Okada, Sho; Shoji, Toshihiro; Kobayashi, Yoshio
Our aim was to assess the discrepancy in the blood pressure amplification (BPA) value defined as the aortic-to-brachial increase in systolic BP (SBP) between invasive and noninvasive brachial cuff-based methods. In 45 patients undergoing cardiac catheterization, BP in the brachial artery and ascending aorta were measured with an invasive catheter and a brachial cuff-based oscillometric device. To calculate aortic SBP, brachial waveforms were calibrated by the brachial systolic and diastolic BP (DBP) (C1 calibration) or by the brachial mean BP and DBP (C2 calibration). C1 calibration underestimated aortic SBP (-17.7 mm Hg (95% confidence interval: -21.9 to -13.5)), whereas C2 calibration generated an approximately accurate aortic SBP (1.8 mm Hg (-2.4 to 5.9)). Regarding brachial SBP, noninvasively measured values were markedly underestimated (22.2 mm Hg (-26.4 to -18.0)), resulting in a slightly low BPA value in C1 calibration (11.9±6.3 mm Hg) and a paradoxical negative BPA value in C2 calibration (-7.6±6.7 mm Hg). Multiple linear regression analysis showed that the cuff-catheter difference of BPA was positively correlated with the cuff-catheter difference of brachial SBP in both calibrations (C1 calibration: β=0.51; C2 calibration: β=0.50; both P<0.01). Although noninvasively measured BPA was associated with invasively measured BPA only in C1 calibration (r=0.33, P=0.03), when using invasively measured brachial SBP instead of a cuff-based measurement, the BPA was well associated with invasively measured BPA in both calibrations (C1 calibration: r=0.57; C2 calibration: r=0.52; both P<0.001). In conclusion, there was a trade-off in accuracy between brachial cuff-based noninvasive aortic SBP and BPA because of the inherent inaccuracies in the cuff-based method. This finding should be fully considered in establishing standardized reference values for aortic BP.
Liu, Qing; Dang, Ai-Min; Chen, Bing-Wei; Lv, Na-Qiang; Wang, Xu; Zheng, De-Yu
Takayasu arteritis (TA) is associated with increased cardiovascular morbidity and mortality, and the degree of arterial stiffness is an independent predictor of cardiovascular mortality in a variety of diseases. In addition, the levels of N-terminal pro-brain natriuretic peptide (NT-proBNP), a marker of ventricular dysfunction, have been found to be higher in patients with TA than in healthy controls. In this study, we aimed to investigate the relationship between the plasma NT-proBNP levels and arterial stiffness in patients with TA. Seventy-two patients with TA were recruited in this study. The participants were analyzed with respect to the NT-proBNP levels, cardiovascular risk factors, TA-related variables and arterial stiffness assessed according to the brachial-ankle pulse wave velocity (baPWV). The patients were divided into two groups based on the mean baPWV, and the association between the NT-proBNP and baPWV values was tested using uni- and multivariate analyses. Twenty-four patients (33.3%) were classified into the high-baPWV group. The body mass index (p=0.035), systolic blood pressure (p＜0.001), diastolic blood pressure (p=0.001), mean blood pressure (p＜0.001), plasma NT-proBNP levels (p=0.036) and total cholesterol levels (p=0.030) were significantly higher in the high-baPWV group than in the low-baPWV group. A stepwise multiple linear regression analysis revealed the mean blood pressure (p＜0.001), age (p=0.002), and NT-proBNP level (p=0.002) to be independent determinants of the ba-PWV after adjusting for other confounding factors. The plasma NT-proBNP levels are independently associated with the degree of arterial stiffness measured according to the baPWV in patients with TA.
Central aortic pressures are better predictors of cardiovascular events than peripheral pressures. However, central aortic blood pressures cannot be measured noninvasively; for this reason, estimating aortic pressures from noninvasive measurements of peripheral pressures has been the subject of numerous studies. In the present study, a novel method was proposed to noninvasively estimate aortic pressures from the oscillometric wave of a suprasystolic brachial cuff. The errors of estimation were evaluated in relation to various cardiovascular properties using an integrated cardiovascular-cuff model. Obtained results demonstrated that the estimation errors are affected mainly by aortic stiffness. The estimation errors for aortic systolic pressure, diastolic pressure, pulse pressure and wave shape under the assumed cardiovascular conditions were 5.84 ± 1.58 mmHg, -0.28 ± 0.41 mmHg, 6.12 ± 1.42 mmHg and 1.72 ± 0.57 mmHg, respectively, all of which fell within the error ranges established by existing devices. Since the method is easy to be automated and bases the estimation fully on patient-specific information, its clinical application is promising, although further clinical studies are awaited to validate the method in vivo.
Ruiz Comellas, Anna; Pera, Guillem; Baena Díez, José Miguel; Heras, Antonio; Alzamora Sas, Maria Teresa; Forés Raurell, Rosa; Torán Monserrat, Pere; Mundet Tudurí, Xavier
High levels of daily physical activity have been shown to be linked to decreased functional impairment in peripheral artery disease (PAD) patients and positively related to the ankle brachial index (ABI) in subjects without PAD. The aim of this study was to examine the relationship between leisure time physical activity (LTPA) and the ABI in a general population. Baseline data from the ARTPER study cohort corresponding to 2,840 subjects>49 years from Barcelona were analyzed. The LTPA variable was obtained through the validated Spanish short version of the Minnesota Leisure Time Physical Activity Questionnaire. ABI<0.9 was taken to indicate PAD. Multivariate logistic regression analysis was performed to evaluate the independent association between LTPA and PAD. Subjects with more LTPA were younger, female, less smokers, and suffered fewer PAD. Total activity, measured in metabolic energy turnover (MET) and the LTPA hours, was significantly higher in subjects without PAD (P<.001). There was an inverse relationship between LTPA and the risk of suffering PAD (odds ratio 0.56, 95% confidence interval 0.38-0.81 for those who expended 2,700 METs or more in 14 days) adjusting for confounding factors. In our study, LTPA was positively related to the ABI, with those with PAD being the ones with less LTPA. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.
Moyer, Virginia A
Update of the 2005 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for peripheral artery disease (PAD). The USPSTF reviewed the evidence on the use of resting ankle-brachial index (ABI) as a screening test for PAD or as a risk predictor for cardiovascular disease (CVD). The review focused on resting ABI as the sole screening method; the diagnostic performance of ABI testing in primary care populations, unselected populations, and asymptomatic populations; the predictive value of ABI testing for major CVD outcomes in primary care or unselected populations; and the effect of treatment on general CVD and PAD-specific morbidity in patients with asymptomatic or minimally symptomatic PAD. This recommendation applies to asymptomatic adults who do not have a known diagnosis of PAD, CVD, severe chronic kidney disease, or diabetes. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for PAD and CVD risk assessment with the ABI in adults. (I statement).
Woźnicka-Leśkiewicz, L; Posadzy-Małaczyńska, A; Juszkat, R
The aim of the study was to evaluate the usefulness of ankle brachial index (ABI) and pulse wave velocity (PWV) in patients with or without coronary artery disease (CAD) and hypertension (HT) in cardiovascular risk prediction. We studied 200 patients randomized to one of four groups: CAD+HT+; CAD+HT-; CAD-HT+; CAD-HT- (Department of Hypertensiology, Angiology and Internal Diseases, Poznan, Poland: 2009-2012). We evaluated: patient age, lipids profile, ABI and PWV. The cardiovascular risks according to SCORE and Framingham scales were assessed. Statistical calculations were performed in StatSoft Statistica 10. The most interesting aspects of this study were: logistic regression model evaluated the simultaneously influence of ABI and PWV on cardiovascular risk by the SCORE scale and logistic regression model evaluated the influence of ABI and PWV on cardiovascular risk according to the Framingham scale. They showed the possibility (SCORE) of more accurate estimation of cardiovascular risk in an individual patient and graduation of this risk in the exemplary patients. Analysis of the assessment of both: ABI and PWV in predicting of cardiovascular risk according to SCORE and Framingham scales using a logistic regression model indicates that the Framingham scale is less precise than the SCORE scale because it underestimates the real high cardiovascular risk.
Singh, Premranjan P; Abbott, J Dawn; Lombardero, Manuel S; Sutton-Tyrrell, Kim; Woodhead, Gail; Venkitachalam, Lakshmi; Tsapatsaris, Nicholas P; Piemonte, Thomas C; Lago, Rodrigo M; Rutter, Martin K; Nesto, Richard W
To examine ankle-brachial index (ABI) abnormalities in patients with type 2 diabetes and coronary artery disease (CAD). An ABI was obtained in 2,240 patients in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Trial. ABIs were classified as: normal, 0.91-1.3; low, ≤ 0.9; high, >1.3; or noncompressible artery (NC). Baseline characteristics were examined according to ABI and by multivariate analysis. RESULTS ABI was normal in 66%, low in 19%, and high in 8% of patients, and 6% of patients had NC. Of the low ABI patients, 68% were asymptomatic. Using normal ABI as referent, low ABI was independently associated with smoking, female sex, black race, hypertension, age, C-reactive protein, diabetes duration, and lower BMI. High ABI was associated with male sex, nonblack race, and higher BMI; and NC artery was associated with diabetes duration, higher BMI, and hypertension. ABI abnormalities are common and often asymptomatic in patients with type 2 diabetes and CAD.
Joo, Hyung Joon; Cho, Sang-A; Cho, Jae-Young; Lee, Seunghun; Park, Jae Hyoung; Hwang, Sung Ho; Hong, Soon Jun; Yu, Cheol Woong
Aim: Although arterial stiffness has been associated with the development of atherosclerosis, the role of brachial-ankle pulse wave velocity (baPWV) for diagnosing composite coronary and carotid atherosclerosis has not been completely elucidated. Method: We enrolled 773 asymptomatic individuals who were referred from 25 public health centers in Seoul and who underwent carotid ultrasonography and coronary computed tomography. Noninvasive hemodynamic parameters, including baPWV, were also measured. Composite coronary and carotid atherosclerosis was defined as follows: 1) coronary artery calcium (CAC) score ≥ 100, 2) coronary artery stenosis (CAS) ≥ 50% of diameter stenosis, 3) carotid intima medial thickness (CIMT) ≥ 0.9 mm, or 4) presence of carotid artery plaque (CAP). Results: The incidence of composite coronary and carotid atherosclerosis was 28.2%. Coronary atherosclerosis (CAC and CAS) was significantly associated with carotid atherosclerosis (CIMT and CAP). Subjects with higher baPWV (highest quartile) had a higher prevalence of composite coronary and carotid atherosclerosis (p < .001). Although multivariate analysis failed to show baPWV as an independent predictor for composite atherosclerosis, baPWV had moderate diagnostic power to detect a subject with more than two positive subclinical atherosclerosis exams [area under the curve (AUC), 0.692]. Conclusion: baPWV was associated with the composite coronary and carotid atherosclerotic burden in a community-based asymptomatic population. PMID:27251176
Rodriguez-Roca, Gustavo C; Villarín-Castro, Alejandro; Carrasco-Flores, Javier; Artigao-Rodenas, Luis M; Carbayo-Herencia, Julio A; Escobar-Cervantes, Carlos; Alonso-Moreno, Francisco J; Segura-Fragoso, Antonio; Gómez-Serranillos, Manuel; Hernández-Moreno, Julio
To evaluate the concordance between automated oscillometric measurement (WatchBP® Office ABI) of the ankle- brachial index (ABI) and the traditional measurement by eco-Doppler in a Spanish population without peripheral artery disease attended in primary care. The ABI was determined by both methods in a general population aged ≥ 18 years, from the RICARTO study. The intraclass correlation coefficient was calculated to assess the concordance between both techniques and the Bland-Altman plot was determined to analyze the agreement between them. A total of 322 subjects (mean age 47.7 ± 16.0 years; 54.3% women) were included in the study. With regard to cardiovascular risk factors, 70.5% of subjects had dyslipidemia, 26.7% hypertension, 24.8% obesity, 8.4% diabetes and 25.5% were smokers. Mean ABI measured by eco-Doppler and the automated method were 1.17 ± 0.1 and 1.2 ± 0.1, respectively (mean differences - 0.03 ± 0.09; p < 0.001). The Pearson correlation coefficient and the intraclass correlation coefficient were in both cases 0.70. The automated oscillometric measurement of ABI is a reliable and useful alternative to conventional eco-Doppler determination in the general population without peripheral artery disease attended in primary care.
Trasande, Leonardo; Urbina, Elaine M.; Khoder, Mamdouh; Alghamdi, Mansour; Shabaj, Ibrahim; Alam, Mohammed S.; Harrison, Roy M.; Shamy, Magdy
Background Polycyclic aromatic hydrocarbons (PAH) are produced by the burning and processing of fuel oils, and have been associated with oxidant stress, insulin resistance and hypertension in adults. Few studies have examined whether adolescents are susceptible to cardiovascular effects of PAHs. Objective To study associations of PAH exposure with blood pressure (BP) and brachial artery distensibility (BAD), an early marker of arterial wall stiffness, in young boys attending three schools in Jeddah, Saudi Arabia in varying proximity to an oil refinery. Methods Air samples collected from the three schools were analyzed for PAHs. PAH metabolites (total hydroxyphenanthrenes and 1-hydroxypyrene) were measured in urine samples from 184 adolescent males, in whom anthropometrics, heart rate, pulse pressure, brachial artery distensibility and blood pressure were measured. Descriptive, bivariate and multivariable analyses were performed to assess relationships of school location and urinary PAH metabolites with cardiovascular measures. Results Total suspended matter was significantly higher (444 ± 143 µg/m3) at the school near the refinery compared to a school located near a ring road (395 ± 65 µg/m3) and a school located away from vehicle traffic (232 ± 137 µg/m3), as were PAHs. Systolic (0.47 SD units, p = 0.006) and diastolic (0.53 SD units, p < 0.001) BP Z-scores were highest at the school near the refinery, with a 4.36-fold increase in prehypertension (p = 0.001), controlling for confounders. No differences in pulse pressure, BAD and heart rate were noted in relationship to school location. Urinary total hydroxyphenanthrenes and 1-hydroxypyrene were not associated with cardiovascular outcomes. Conclusions Proximity to an oil refinery in Saudi Arabia is associated with prehypertension and increases in PAH and particulate matter exposures. Further study including insulin resistance measurements, better control for confounding, and longitudinal measurement is
Sibiya, Moekanyi J; Woodiwiss, Angela J; Booysen, Hendrik L; Raymond, Andrew; Millen, Aletta M E; Maseko, Muzi J; Majane, Olebogeng H I; Sareli, Pinhas; Libhaber, Elena; Norton, Gavin R
To determine whether brachial blood pressure (BP)-independent relations between aortic pressure and cardiovascular damage are better explained by reflected (backward) (Pb) or forward (Pf) wave pressure effects. In 1174 participants from a community of African ancestry, we assessed central aortic pulse pressure (PPc), Pb, and Pf (radial applanation tonometry, SphygmoCor) as well as left ventricular mass index (LVMI) (n = 786), aortic pulse wave velocity (PWV) (n = 1019), carotid intima-media thickness (IMT) (n = 578), transmitral early-to-late left ventricular diastolic velocity (E/A) (n = 779) and estimated glomerular filtration rate (eGFR) (n = 1174). Independent of mean arterial pressure and confounders, PPc, and both Pb and Pf were associated with end-organ measures or damage (P < 0.05 to P < 0.0001). With adjustments for brachial PP and confounders, Pb remained directly associated with LVMI (partial r = 0.09, P < 0.01), PWV (partial r = 0.28, P < 0.0001), and IMT (partial r = 0.28, P < 0.0001), and inversely associated with E/A (partial r = -0.31, P < 0.0001) and eGFR (partial r = -0.14, P < 0.0001). Similar relations were noted with the presence of end-organ damage (P < 0.05 to P < 0.0001). In contrast, with adjustments for brachial PP and confounders, Pf no longer retained direct relations with LVMI, PWV, and IMT or inverse relations with E/A and eGFR. Adjustments for Pb, but not Pf, diminished brachial PP-independent relationships between PPc and end-organ measures. Independent relations between Pb, but not Pf and end-organ measures, were largely attributed to Pb accounting for most of the variation in brachial-to-aortic PP amplification. In communities of African ancestry, brachial BP-independent relations between aortic pressure and end-organ changes are largely attributed to an impact of reflected rather than forward wave pressures.
Vucković, Ilvana; Hadzić, Admir; Dilberović, Faruk; Kulenović, Amela; Mornjaković, Zakira; Zulić, Irfan; Divanović, Kucuk-Alija; Kapur, Eldan; Cosović, Esad; Voljevica, Alma
In the last few decades there has been a great development of regional anesthesia; all the postulates are defined and all the techniques of usage are perfected. However, like any other medical procedure, the block of brachial plexus carries a risk of certain unwanted complications, like possible intraneural and intravascular injections. The reason for great discrepancy between the injury of brachial plexus and other periphery nerves while performing the nerve blockade is the frequent usage of this block, but also the specific proximity of neurovascular structures in axilla. The purpose of this work is to determine the values of pressures which appear in para-neural, intraneural and intravascular injection applications of local anesthetic, and to compare those values in order to avoid cases of intraneural and intravascular injections in clinical practice with consequential complications. In experimental study there have been used 12 Wistar rats of both genders. After anesthesia with ether and mid-humoral access to the neurovascular structures in axilla, the injection of 2% lidocaine with epinephrine was performed with the help of automatic syringe charge. The needle was at first placed para-neural, and then also intraneural and intravascular. During every application the pressure values were monitored using the manometer, and then they were analyzed by special software program. All para-neural injections resulted with the pressure between 13,96-27,92 kPa. The majority of intraneural injections were combined with the injection pressure greater than 69,8 kPa, while the intravascular injections were combined with injection pressure less than 6,98 kPa. Based on the available data it can be noticed that so far none of the methods of prevention from unwanted complications of regional anesthesia can insure the avoidance of intraneural and intravascular injection of local anesthetic. Based on our research it is obvious that the measuring of pressure during the nerve
Shih, Yuan-Ta; Cheng, Hao-Min; Sung, Shih-Hsien; Hu, Wei-Chih; Chen, Chen-Huan
The N-point moving average (NPMA) is a mathematical low-pass filter that can smooth peaked noninvasively acquired radial pressure waveforms to estimate central aortic systolic pressure using a common denominator of N/4 (where N=the acquisition sampling frequency). The present study investigated whether the NPMA method can be applied to brachial pressure waveforms. In the derivation group, simultaneously recorded invasive high-fidelity brachial and central aortic pressure waveforms from 40 subjects were analyzed to identify the best common denominator. In the validation group, the NPMA method with the obtained common denominator was applied on noninvasive brachial pressure waveforms of 100 subjects. Validity was tested by comparing the noninvasive with the simultaneously recorded invasive central aortic systolic pressure. Noninvasive brachial pressure waveforms were calibrated to the cuff systolic and diastolic blood pressures. In the derivation study, an optimal denominator of N/6 was identified for NPMA to derive central aortic systolic pressure. The mean difference between the invasively/noninvasively estimated (N/6) and invasively measured central aortic systolic pressure was 0.1±3.5 and -0.6±7.6 mm Hg in the derivation and validation study, respectively. It satisfied the Association for the Advancement of Medical Instrumentation standard of 5±8 mm Hg. In conclusion, this method for estimating central aortic systolic pressure using either invasive or noninvasive brachial pressure waves requires a common denominator of N/6. By integrating the NPMA method into the ordinary oscillometric blood pressure determining process, convenient noninvasive central aortic systolic pressure values could be obtained with acceptable accuracy.
Kodaira, Minori; Kodama, Satoshi; Kamijo, Yui; Kaneko, Tomoki; Sekijima, Yoshiki
There have been few studies regarding physical training-induced peripheral nerve dysfunction in patients with hereditary neuropathy with liability to pressure palsies (HNPP), with the exception of soldiers that trained intensively. Here, we report a 15-year-old boy without family history of HNPP who developed bilateral painless brachial plexopathy following short-term barbell and plank training during a school baseball club activity. Muscle training-induced painless brachial plexopathy could be an initial symptom and may be underdiagnosed in adolescents with sporadic HNPP.
Cary, Theodore W.; Sultan, Laith R.; Sehgal, Chandra M.; Reamer, Courtney B.; Mohler, Emile R.
Purpose: To use feed-forward active contours (snakes) to track and measure brachial artery vasomotion on ultrasound images recorded in both transverse and longitudinal views; and to compare the algorithm's performance in each view. Methods: Longitudinal and transverse view ultrasound image sequences of 45 brachial arteries were segmented by feed-forward active contour (FFAC). The segmented regions were used to measure vasomotion artery diameter, cross-sectional area, and distention both as peak-to-peak diameter and as area. ECG waveforms were also simultaneously extracted frame-by-frame by thresholding a running finite-difference image between consecutive images. The arterial and ECG waveforms were compared as they traced each phase of the cardiac cycle. Results: FFAC successfully segmented arteries in longitudinal and transverse views in all 45 cases. The automated analysis took significantly less time than manual tracing, but produced superior, well-behaved arterial waveforms. Automated arterial measurements also had lower interobserver variability as measured by correlation, difference in mean values, and coefficient of variation. Although FFAC successfully segmented both the longitudinal and transverse images, transverse measurements were less variable. The cross-sectional area computed from the longitudinal images was 27% lower than the area measured from transverse images, possibly due to the compression of the artery along the image depth by transducer pressure. Conclusions: FFAC is a robust and sensitive vasomotion segmentation algorithm in both transverse and longitudinal views. Transverse imaging may offer advantages over longitudinal imaging: transverse measurements are more consistent, possibly because the method is less sensitive to variations in transducer pressure during imaging.
Nishimura, Hitoshi; Miura, Takashi; Minamisawa, Masatoshi; Ueki, Yasushi; Abe, Naoyuki; Hashizume, Naoto; Mochidome, Tomoaki; Harada, Mikiko; Shimizu, Kunihiko; Shoin, Wataru; Yoshie, Koji; Oguchi, Yasutaka; Ebisawa, Soichiro; Motoki, Hirohiko; Izawa, Atsushi; Koyama, Jun; Ikeda, Uichi; Kuwahara, Koichiro
Background Reduced ankle–brachial index (ABI) is a predictor of cardiovascular events. However, the significance of high ABI remains poorly understood. This study aimed to assess the characteristics and outcomes of patients with high ABI. Methods The IMPACT-ABI study was a retrospective cohort study that enrolled and examined ABI in 3,131 patients hospitalized for cardiovascular disease between January 2005 and December 2012. From this cohort, 2,419 patients were identified and stratified into two groups: high ABI (> 1.4; 2.6%) and normal ABI (1.0–1.4; 97.3%). The primary endpoint was the cumulative incidence of major adverse cardiovascular events (MACE), including cardiovascular-associated death, myocardial infarction, and stroke. Results Compared with the normal ABI group, patients in the high ABI group showed significantly lower body mass index (BMI) and hemoglobin level, but had higher incidence of chronic kidney disease and hemodialysis. Multivariate logistic regression analysis revealed that hemodialysis was the strongest predictor of high ABI (odds ratio, 6.18; 95% confidence interval (CI), 3.05–12.52; P < 0.001). During the follow-up (median, 4.7 years), 172 cases of MACE occurred. Cumulative MACE incidence in patients with high ABI was significantly increased compared to that in those with normal ABI (32.5% vs. 14.5%; P = 0.005). In traditional cardiovascular risk factors-adjusted multivariate Cox proportional hazard analysis, high ABI was an independent predictor of MACE (hazard ratio, 2.07; 95% CI, 1.02–4.20; P = 0.044). Conclusion Lower BMI, chronic kidney disease, and hemodialysis are more frequent in patients with high ABI. Hemodialysis is the strongest predictor of high ABI. High ABI is a parameter that independently predicts MACE. PMID:27880852
Background Shoulder surgery is often performed in the beach-chair position, a position associated with arterial hypotension and subsequent risk of cerebral ischaemia. It can be performed under general anaesthesia or with an interscalene brachial plexus block, each of which has specific advantages but also specific negative effects on blood pressure control. It would be worthwhile to combine the advantages of the two, but the effects of the combination on the circulation are not well investigated. We studied blood pressure, heart rate, and incidence of adverse circulatory events in patients undergoing shoulder surgery in general anaesthesia with or without an interscalene block. Methods Prospective, randomised, blinded study in outpatients (age 18 to 80 years) undergoing shoulder arthroscopy. General anaesthesia was with propofol/opioid, interscalene block with 40 ml 1% mepivacaine. Hypotension requiring treatment was defined as a mean arterial pressure <60 mmHg or a systolic pressure <80% of baseline; relevant bradycardia was a heart rate <50 bpm with a decrease in blood pressure. Results Forty-two patients had general anaesthesia alone, 41 had general anaesthesia plus interscalene block. The average systolic blood pressure under anaesthesia in the beach-chair position was 114 ± 7.3 vs. 116 ± 8.3 mmHg (p = 0.09; all comparisons General vs. General-Regional). The incidence of a mean arterial pressure under 60 mmHg or a decrease in systolic pressure of more than 20% from baseline was 64% vs. 76% (p = 0.45). The number of patients with a heart rate lower than 50 and a concomitant blood pressure decrease was 8 vs. 5 (p = 0.30). Conclusion One can safely combine interscalene block with general anaesthesia for surgery in the beach-chair position in ASA I and II patients. Clinical trial number DRKS00005295. PMID:25002832
Cainzos-Achirica, Miguel; Rampal, Sanjay; Chang, Yoosoo; Ryu, Seungho; Zhang, Yiyi; Zhao, Di; Cho, Juhee; Choi, Yuni; Pastor-Barriuso, Roberto; Lim, So Yeon; Bruguera, Jordi; Elosua, Roberto; Lima, Joao A C; Shin, Hocheol; Guallar, Eliseo
To evaluate the association between brachial-ankle pulse wave velocity (baPWV), a convenient, non-radiating, readily available measurement of arterial stiffness, and coronary artery calcium (CAC), a reliable marker of coronary atherosclerosis, in a large sample of young and middle-aged asymptomatic adults; and to assess the incremental value of baPWV for detecting prevalent CAC beyond traditional risk factors. Cross-sectional study of 15,185 asymptomatic Korean adults who voluntarily underwent a comprehensive health screening program including measurement of baPWV and CAC. BaPWV was measured using an oscillometric method with cuffs placed on both arms and ankles. CAC burden was assessed using a multi-detector CT scan and scored following Agatston's method. The prevalence of CAC > 0 and CAC > 100 increased across baPWV quintiles. The multivariable-adjusted odds ratios (95% CI) for CAC > 0 comparing baPWV quintiles 2-5 versus quintile 1 were 1.06 (0.87-1.30), 1.24 (1.02-1.50), 1.39 (1.15-1.69) and 1.60 (1.31-1.96), respectively (P trend < 0.001). Similarly, the relative prevalence ratios for CAC > 100 were 1.30 (0.74-2.26), 1.59 (0.93-2.71), 1.74 (1.03-2.94) and 2.59 (1.54-4.36), respectively (P trend < 0.001). For CAC > 100, the area under the ROC curve for baPWV alone was 0.71 (0.68-0.74), and the addition of baPWV to traditional risk factors significantly improved the discrimination and calibration of models for detecting prevalent CAC > 0 and CAC > 100. BaPWV was independently associated with the presence and severity of CAC in a large sample of young and middle-aged asymptomatic adults. BaPWV may be a valuable tool for identifying apparently low-risk individuals with increased burden of coronary atherosclerosis. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Early intervention of long-acting nifedipine GITS reduces brachial-ankle pulse wave velocity and improves arterial stiffness in Chinese patients with mild hypertension: a 24-week, single-arm, open-label, prospective study.
Zhang, Jidong; Wang, Yan; Hu, Haijuan; Yang, Xiaohong; Tian, Zejun; Liu, Demin; Gu, Guoqiang; Zheng, Hongmei; Xie, Ruiqin; Cui, Wei
Nifedipine gastrointestinal therapeutic system (GITS) is used to treat angina and hypertension. The authors aimed to study the early intervention impact on arterial stiffness and pulse wave velocity (PWV) independent of its blood-pressure-(BP) lowering effect in mild hypertensive patients. This single-center, single-arm, open-label, prospective, Phase IV study recruited patients with mild hypertension and increased PWV from December 2013 to December 2014 (N=138; age, 18-75 years; systolic blood pressure, 140-160 mmHg; diastolic BP, 90-100 mmHg; increased brachial-ankle pulse wave velocity [baPWV, ≥12 m/s]). Nifedipine GITS (30 mg/d) was administered for 24 weeks to achieve target BP of <140/90 mmHg. The dose was uptitrated at 60 mg/d in case of unsatisfactory BP reduction after 4 weeks. Primary study end point was the change in baPWV after nifedipine GITS treatment. Hemodynamic parameters (office BP, 24-hour ambulatory BP monitoring, and heart rate and adverse events) were evaluated at baseline and followed-up at 2, 4, 8, 12, 18, and 24 weeks. Majority of patients (n=117; 84.8%) completed the study. baPWV decreased significantly at 4 weeks compared with baseline (1,598.87±239.82 vs 1,500.89±241.15 cm/s, P<0.001), was stable at 12 weeks (1,482.24±215.14 cm/s, P<0.001), and remained steady through 24 weeks (1,472.58±205.01 cm/s, P<0.001). Office BP reduced from baseline to week 4 (154/95 vs 136/85 mmHg) and remained steady until 24 weeks. Nifedipine GITS significantly decreased 24-hour ambulatory BP monitoring (P<0.001) after 24 weeks from baseline. Mean arterial pressure and pulse pressure were lowered significantly after 4, 12, and 24 weeks of treatment (P<0.001). These changes in baPWV were significantly correlated with changes in systolic blood pressure, diastolic BP, and mean arterial pressure (P<0.05), but not with changes in pulse pressure (P>0.05). There were no other drug-related serious adverse events. Nifedipine GITS was considerably effective in
Sluyter, John D; Hughes, Alun D; Lowe, Andrew; Parker, Kim H; Camargo, Carlos A; Hametner, Bernhard; Wassertheurer, Siegfried; Scragg, Robert K R
Comparing the relationships of antihypertensive medications with brachial blood pressure (BP) and aortic waveform parameters may help clinicians to predict the effect on the latter in brachial BP-based antihypertensive therapy. We aimed to make such comparisons with new waveform measures and a wider range of antihypertensive regimens than examined previously. Cross-sectional analysis of 2933 adults (61% male; aged 50-84years): 1637 on antihypertensive treatment and 1296 untreated hypertensives. Sixteen medicine regimens of up to 4 combinations of drugs from 6 antihypertensive classes were analysed. Aortic systolic BP, augmentation index (AIx), excess pressure integral (EPI), backward pressure amplitude (Pb), reflection index (RI) and pulse wave velocity (PWV) were calculated from aortic pressure waveforms derived from suprasystolic brachial measurement. Forest plots of single-drug class comparisons across regimens with the same number of drugs (for between 1- and 3-drug regimens) revealed that AIx, Pb, RI and/or loge(EPI) were higher (maximum difference=5.6%, 2.2mmHg, 0.0192 and 0.13 loge(mmHg⋅s), respectively) with the use of a beta-blocker compared with vasodilators and diuretics, despite no brachial systolic and diastolic BP differences. These differences were reduced (by 34-57%) or eliminated after adjustment for heart rate, and similar effects occurred when controlling for systolic ejection period or diastolic duration. Beta-blocker effects on brachial BP may overestimate effects on aortic waveform parameters. Compared to other antihypertensives, beta-blockers have weaker associations with wave reflection measures and EPI; this is predominantly due to influences on heart rate. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
Ki, Young-Jae; Choi, Dong-Hyun; Lee, Young-Min; Lim, Leejin; Song, Heesang; Koh, Young-Youp
The aim of this study was to determine the associations of brachial-ankle pulse wave velocity (baPWV), high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-B type natriuretic peptide (NT-proBNP) with the development of adverse outcomes after percutaneous coronary intervention (PCI). The baPWV, hs-cTnT and NT-proBNP were analyzed in 372 patients who underwent PCI. The primary endpoint was cardiac death. There were 21 events of cardiac death during a mean of 25.8 months of follow-up. When the baPWV cut-off level was set to 1672 cm/s using the receiver operating characteristic curve, the sensitivity was 85.7% and the specificity was 60.1% for differentiating between the group with cardiac death and the group without cardiac death. Kaplan-Meier analysis revealed that the higher baPWV group (≥1672 cm/s) had a significantly higher cardiac death rate than the lower baPWV group (<1672 cm/s) (11.4% vs. 1.4%, log-rank: P<0.0001). This value was more useful in patients with myocardial injury (hs-cTnT≥0.1 ng/mL) or heart failure (NT-proBNP≥450 pg/mL). The results of this study show that high baPWV is a predictive marker for cardiac death after PCI. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Ishii, Hideki; Takahashi, Hiroshi; Ito, Yasuhiko; Aoyama, Toru; Kamoi, Daisuke; Sakakibara, Takashi; Umemoto, Norio; Kumada, Yoshitaka; Suzuki, Susumu; Murohara, Toyoaki
Protein-energy wasting (PEW) is highly prevalent in hemodialysis (HD) patients. We investigated the association of abnormal ankle brachial index (ABI), PEW, and chronic inflammation status with clinical prognosis in HD patients. A total of 973 HD patients were enrolled and were followed-up for 8 years. As a marker of the PEW, geriatric nutritional risk index (GNRI) was used. Cut-off levels were 91.2 for GNRI defined from previous studies and 1.9 mg/L for C-reactive protein (CRP) as median value, respectively. Abnormal ABI was seen in 332 (34.1%) patients. Declined GNRI and elevated CRP levels were independently associated with abnormal ABI (odds ratio (OR) 0.97, 95% confidence interval (CI) 0.96-0.99, p = 0.0009 and OR 1.40, 95% CI 1.07-1.83, p = 0.013, respectively). GNRI levels were also independently correlated with CRP levels (β = -0.126, p < 0.0001). During follow-up period, 283 (29.1%) patients died, including 123 (12.6%) due to cardiovascular disease (CVD). Abnormal ABI (adjusted hazard ratio (HR) 1.62, 95% CI 1.13-2.32, p = 0.0096), GNRI < 91.2 (adjusted HR 1.57, 95% CI 1.06-2.33, p = 0.023) and CRP > 1.9 mg/L (adjusted HR 1.89, 95% CI 1.31-2.77, p = 0.0007) independently predicted mortality due to CVD, respectively. In conclusion, abnormal ABI, GNRI, and CRP levels were closely associated with each other, and the combination of these variables increase their predictive values for the risk of mortality due to CVD and all-cause mortality in HD patients.
Herráiz-Adillo, Ángel; Cavero-Redondo, Iván; Álvarez-Bueno, Celia; Martínez-Vizcaíno, Vicente; Pozuelo-Carrascosa, Diana P; Notario-Pacheco, Blanca
Peripheral arterial disease (PAD) remains underdiagnosed and undertreated, partly because of limitations in the Doppler ankle-brachial index (ABI), the non-invasive gold standard. This systematic review and meta-analysis aims to compare the diagnostic accuracy of the oscillometric ABI and the Doppler ABI, and to examine the influence of two approaches to analysis: legs vs subjects and inclusion of oscillometric errors as PAD equivalents vs exclusion. Systematic searches in EMBASE, MEDLINE, Web of Science and the Cochrane Library databases were performed, from inception to February 2017. Random-effects models were computed with the Moses-Littenberg constant. Hierarchical summary receiver operating characteristic curves (HSROC) were used to summarise the overall test performance. Twenty studies (1263 subjects and 3695 legs) were included in the meta-analysis. The pooled diagnostic odds ratio (dOR) for the oscillometric ABI was 32.49 (95% CI: 19.6-53.8), with 65% sensitivity (95% CI: 57-74) and 96% specificity (95%CI: 93-99). In the subgroup analysis, the "per subjects" group showed a better performance than the "per legs" group (dOR 36.44 vs 29.03). Similarly, an analysis considering oscillometric errors as PAD equivalents improved diagnostic performance (dOR 31.48 vs 28.29). The time needed for the oscillometric ABI was significantly shorter than that required for the Doppler ABI (5.90 vs 10.06 minutes, respectively). The oscillometric ABI showed an acceptable diagnostic accuracy and feasibility, potentially making it a useful tool for PAD diagnosis. We recommend considering oscillometric errors as PAD equivalents, and a "per subject" instead of a "per leg" approach, in order to improve sensitivity. Borderline oscillometric ABI values in diabetic population should raise concern of PAD. © 2017 John Wiley & Sons Ltd.
Chen, Szu-Chia; Lee, Mei-Yueh; Huang, Jiun-Chi; Kuo, I-Ching; Mai, Hsiu-Chin; Kuo, Po-Lin; Chang, Jer-Ming; Hwang, Shang-Jyh; Chen, Hung-Chun
Background and Aim: The ankle-brachial index (ABI) is recognized to be a good marker for atherosclerosis, and is useful in the diagnosis of peripheral artery occlusive disease (PAOD) which is prevalent among patients on hemodialysis (HD). Methods: This randomized trial aimed to evaluate the effect of far-infrared radiation (FIR) therapy on ABI in HD patients with PAOD. PAOD was defined as patients with ABI < 0.95. One hundred and eight HD patients were enrolled, including 50 in the control group and 58 in the FIR group. A WS TY101 FIR emitter was applied for 40 minutes during each HD session, three times per week for six months. The ABI was measured before and after the FIR therapy. Results: Regardless of FIR therapy, the bilateral ABI decreased (in the FIR group, left: 0.88±0.22 to 0.85±0.24, p = 0.188; right: 0.92±0.20 to 0.90±0.23, p = 0.372; in control group, left: 0.91±0.23 to 0.88±0.21, p = 0144; right: 0.93±0.17 to 0.89±0.21, p = 0.082). Multivariate logistic analysis of the FIR group revealed that high uric acid (odds ratio [OR]: 2.335; 95% confidence interval [CI]: 1.117-4.882; p=0.024) and aspirin use (OR: 16.463; 95% CI: 1.787-151.638; p=0.013) were independently associated with increased bilateral ABI after FIR therapy. Conclusions: This study demonstrates that ABI is not increased after FIR therapy in HD patients with PAOD. However, in the FIR group, patients with higher uric acid level or those who used aspirin have increased bilateral ABI after FIR therapy. PMID:27994503
Chen, Szu-Chia; Lee, Mei-Yueh; Huang, Jiun-Chi; Kuo, I-Ching; Mai, Hsiu-Chin; Kuo, Po-Lin; Chang, Jer-Ming; Hwang, Shang-Jyh; Chen, Hung-Chun
Background and Aim: The ankle-brachial index (ABI) is recognized to be a good marker for atherosclerosis, and is useful in the diagnosis of peripheral artery occlusive disease (PAOD) which is prevalent among patients on hemodialysis (HD). Methods: This randomized trial aimed to evaluate the effect of far-infrared radiation (FIR) therapy on ABI in HD patients with PAOD. PAOD was defined as patients with ABI < 0.95. One hundred and eight HD patients were enrolled, including 50 in the control group and 58 in the FIR group. A WS TY101 FIR emitter was applied for 40 minutes during each HD session, three times per week for six months. The ABI was measured before and after the FIR therapy. Results: Regardless of FIR therapy, the bilateral ABI decreased (in the FIR group, left: 0.88±0.22 to 0.85±0.24, p = 0.188; right: 0.92±0.20 to 0.90±0.23, p = 0.372; in control group, left: 0.91±0.23 to 0.88±0.21, p = 0144; right: 0.93±0.17 to 0.89±0.21, p = 0.082). Multivariate logistic analysis of the FIR group revealed that high uric acid (odds ratio [OR]: 2.335; 95% confidence interval [CI]: 1.117-4.882; p=0.024) and aspirin use (OR: 16.463; 95% CI: 1.787-151.638; p=0.013) were independently associated with increased bilateral ABI after FIR therapy. Conclusions: This study demonstrates that ABI is not increased after FIR therapy in HD patients with PAOD. However, in the FIR group, patients with higher uric acid level or those who used aspirin have increased bilateral ABI after FIR therapy.
Bąk, Ewelina; Marcisz, Czesław; Kadłubowska, Monika; Michalik, Anna; Krawczyk, Bożena; Dobrzyń-Matusiak, Dorota; Krzemińska, Sylwia; Fiałkowski, Tomasz; Glądys, Elżbieta; Drosdzol-Cop, Agnieszka
Peripheral arterial disease (PAD) belongs to the commonly-occurring pathologies associated with elderly age. A simple tool for defining the severity of PAD is the ankle-brachial index (ABI). The purpose of this research was to determine independent factors of changes of ABI in elderly patients with occlusive PAD disease (PAOD) with and without diabetes. The research was carried out on 49 elderly patients with PAOD, including 29 patients with type 2 diabetes, and 20 patients without diabetes. The concentration of interleukin-6 (IL-6), E-selectin, fibrinogen, and C-reactive protein (CRP) in the blood serum was marked. In all patients, the independent factors of changes of ABI were determined with the use of the multiple logistic regression analysis. Our results show that in the group of patients with PAOD suffering from diabetes, it was demonstrated that the ABI was related to age, the duration of the symptoms of PAD, body mass index (BMI), low-density lipoprotein cholesterol, fibrinogen, and sex (determination coefficient R2 = 0.699). In patients with PAOD without diabetes, the ABI was related to age, the duration of the symptoms of PAD, the levels of CRP, E-selectin, high-density lipoprotein cholesterol, and the glomerular filtration rate(determination coefficient R2 = 0.844). We conclude that in elderly patients with PAOD with and without diabetes, the participation of independent factors related to the ABI is diversified; in patients with diabetes, the concentration of IL-6 and fibrinogen is lower, and the concentration of E-selectin is higher than in patients without diabetes. PMID:27834825
Guéant-Rodriguez, Rosa Maria; Spada, Rosario; Moreno-Garcia, Maira; Anello, Guido; Bosco, Paolo; Lagrost, Laurent; Romano, Antonino; Elia, Maurizio; Guéant, Jean-Louis
The ankle brachial index (ABI) is an indicator of lower extremity peripheral arterial disease (PAD) and a predictor of atherothrombosis. ApoA-I and HDL are associated with PAD, in humans. Homocysteine influences the liver expression of ApoA-I and decreases its blood level and HDL in genetic mice models. We aimed therefore to evaluate whether homocysteine and its nutritional determinants, folate and vitamin B12 are associated with ABI by influencing HDL metabolism, in an ambulatory elderly population. 667 elderly volunteers from rural Sicily were assessed for ABI, homocysteine and its determinants, lipid markers and other predictors of PAD. HDL size was assessed in 15 sera in upper and lower quartiles of Hcy distribution. In multivariate analysis, ApoA-I and homocysteine were two predictors of ABI (β-coefficient = 2.86, P<0.004 and β-coefficient = -3.41, P<0.001, respectively). Homocysteine correlated negatively with ApoA-I (R = -0.147, P<0.001) and with HDL-Cholesterol (R = -0.113, P = 0.003). The associations of homocysteine, vitamin B12 and methylmalonic acid with ApoA-I and HDL2a particles and that of homocysteine with increased small size HDL3c suggested mechanisms related with impaired synthesis of ApoA-I and HDL and abnormal maturation of HDL particles. The influence of homocysteine on ApoA-I and HDL metabolism provides new insights on its role on vascular diseases, at a cross-point between atherosclerosis and atherothrombosis. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.
Ali, Zeenat; Ellington, Allison A; Mosley, Thomas H; Kullo, Iftikhar J
Osteoprotegerin (OPG), a member of tumor necrosis factor receptor superfamily, has been implicated in vascular disease. We investigated the association of serum OPG with the ankle-brachial index (ABI) and urine albumin:creatinine ratio (UACR), in a bi-ethnic cohort of 1324 African-Americans (mean age 64 years, 71% women) and 1237 non-Hispanic whites (mean age 59 years, 57% women) belonging to hypertensive sibships. Serum levels of OPG were measured by solid phase sandwich immunoassay. ABI was measured using a standard protocol and peripheral arterial disease (PAD) defined as ABI<0.90. UACR was expressed as mg albumin/gm creatinine. Multivariable regression analysis using generalized estimating equations (GEE) were performed to assess whether serum OPG levels were associated with ABI and UACR. After adjustment for conventional risk factors (age, sex, diabetes, waist circumference, history of smoking, total and HDL cholesterol, hypertension), prior history of myocardial infarction or stroke, and medication (renin-angiotensin-aldosterone system inhibitors, statins, aspirin, estrogen) use, higher OPG levels were significantly associated with lower ABI and higher UACR in African-Americans (P=0.001 and P<0.0001, respectively) and non-Hispanic whites (P=0.017 and P=0.002, respectively); the association remained significant after further adjustment for plasma C-reactive protein (CRP) in both ethnic groups. In multivariable logistic regression analysis, higher OPG levels were associated with PAD in African-Americans, independent of the covariates listed above (P=0.026); the association remained significant after additional adjustment for plasma CRP (P=0.047). In non-Hispanic whites, the association of higher OPG levels with PAD was of borderline significance after adjustment for the relevant covariates (P=0.106). We conclude that higher OPG levels are associated with lower ABI and higher UACR, independent of conventional risk factors and plasma CRP.
Meng, Jerry; Wassel, Christina L; Kestenbaum, Bryan R; Collins, Tracie C; Criqui, Michael H; Lewis, Cora E; Cummings, Steve R; Ix, Joachim H
A higher serum phosphorus level is associated with cardiovascular disease (CVD) events among community-living populations. Mechanisms are unknown. The ankle-brachial index (ABI) provides information on both atherosclerosis and arterial stiffness. In this cross-sectional study (2000-2002), the authors evaluated the association of serum phosphorus levels with low (<0.90) and high (> or =1.40 or incompressible) ABI as compared with intermediate ABI in 5,330 older US men, among whom the mean serum phosphorus level was 3.2 mg/dL (standard deviation, 0.4), 6% had a low ABI, and 5% had a high ABI. Each 1-mg/dL increase in serum phosphorus level was associated with a 1.6-fold greater prevalence of low ABI (95% confidence interval (CI): 1.2, 2.1; P < 0.001) and a 1.4-fold greater prevalence of high ABI (95% CI: 1.0, 1.9; P = 0.03) in models adjusted for demographic factors, traditional CVD risk factors, and kidney function. However, the association of phosphorus with high ABI differed by chronic kidney disease (CKD) status (in persons with CKD, prevalence ratio = 2.96, 95% CI: 1.61, 5.45; in persons without CKD, prevalence ratio = 1.14, 95% CI: 0.81, 1.61; interaction P = 0.04). In conclusion, among community-living older men, higher phosphorus levels are associated with low ABI and are also associated with high ABI in persons with CKD. These associations may explain the link between serum phosphorus levels and CVD events.
Jang, Kyeongmin; Kim, Hack-Lyoung; Park, Miri; Oh, Sohee; Oh, So Won; Lim, Woo-Hyun; Seo, Jae-Bin; Kim, Sang-Hyun; Zo, Joo-Hee; Kim, Myung-A
The aim of this study was to investigate whether information on arterial stiffness can improve the value of single-photon emission computed tomography (SPECT) in the detection of obstructive coronary artery disease (CAD). A total of 233 patients (age: 62.2±10.8 years, 60.3% males) with detected ischemia on SPECT undergoing invasive coronary angiography (ICA) and brachial-ankle pulse wave velocity (baPWV) measurement within a month was retrospectively reviewed. Of the 233 patients, 190 (81.5%) had obstructive CAD (≥50% luminal stenosis). The difference in baPWV according to the presence of obstructive CAD was significant in patients in the mild ischemia group [summed stress score (SSS): 4-8] (1,770±364 cm versus 1,490±328 cm, p＜0.001) but not in the moderate (SSS: 9-13) or severe (SSS: ≥14) ischemia groups (p＞0.05 for each). Receiver operating characteristic curve analyses showed that the diagnostic value of baPWV for obstructive CAD was significant only in patients in the mild ischemia group (area under curve: 0.714; p=0.001) but not in the moderate or severe ischemia groups (p＞0.05 for each). Adding information on baPWV to SPECT results and clinical parameters significantly increased diagnostic accuracy in the detection of obstructive CAD in patients with mild ischemia (integrated discrimination improvement p=0.006) but not in those with moderate or severe ischemia on SPECT (p＞0.05 for each). The results of this study suggest that baPWV may have additional value to SPECT for the detection of obstructive CAD, especially in patients with mild ischemia on SPECT.
Han, Eun Young; Im, Sang Hee; Kim, Bo Ryun; Seo, Min Ji; Kim, Myeong Ok
Brachial-ankle pulse wave velocity (baPWV) evaluates arterial stiffness and also predicts early outcome in stroke patients. The objectives of this study were to investigate arterial stiffness of subacute nonfunctional ambulatory stroke patients and to compare the effects of robot-assisted gait therapy (RAGT) combined with rehabilitation therapy (RT) on arterial stiffness and functional recovery with those of RT alone. The RAGT group (N = 30) received 30 minutes of robot-assisted gait therapy and 30 minutes of conventional RT, and the control group (N = 26) received 60 minutes of RT, 5 times a week for 4 weeks. baPWV was measured and calculated using an automated device. The patients also performed a symptom-limited graded exercise stress test using a bicycle ergometer, and parameters of cardiopulmonary fitness were recorded. Clinical outcome measures were categorized into 4 categories: activities of daily living, balance, ambulatory function, and paretic leg motor function and were evaluated before and after the 4-week intervention. Both groups exhibited significant functional recovery in all clinical outcome measures after the 4-week intervention. However, peak aerobic capacity, peak heart rate, exercise tolerance test duration, and baPWV improved only in the RAGT group, and the improvements in baPWV and peak aerobic capacity were more noticeable in the RAGT group than in the control group. Robot-assisted gait therapy combined with conventional rehabilitation therapy represents an effective method for reversing arterial stiffness and improving peak aerobic capacity in subacute stroke patients with totally dependent ambulation. However, further large-scale studies with longer term follow-up periods are warranted to measure the effects of RAGT on secondary prevention after stroke.
Chotik-anuchit, Songkram; Nilanont, Yongchai; Poungvarin, Niphon
Relationship between high sensitivity C-reactive protein (hs-CRP), Ankle Brachial index (ABI), severity of atherosclerosis and risk of ischemic stroke has been well documented. Studies concerning the association of ABI, hs-CRP and initial disability level in acute ischemic stroke are scarce. This study aimed to investigate the relationship between hs-CRP, ABI and level of initial disability in acute stroke setting. We conducted a prospective observational study in patients with acute ischemic stroke within 48 hours of onset. Initial ABI, hs-CRP were measured. Disability level was assessed at admission and 3 months using the modified Rankin scale (mRS) and the National Institue of Health Stroke scale (NIHSS). Statistical analysis was performed using Pearson's correlation coefficient. This study included 36 patients with a mean +/-SD age of 67.8 +/- 9.3 years. Sixteen (44.4%) were male. Median NIHSS and mRS were 10 and 4 respectively. Correlation between initial ABI and hs-CRP was poor (r(s) = -0.11, p = 0.57). There was a significant negative relationship between ABI and mRS at 0 and 3 months with a correlation coefficient of -0.45 (p = 0.006) and -0.41 (p = 0.02), respectively. There was a significant inverse relationship between ABI and initial stroke disability. However, correlation coefficient indicated only fair agreement beyond chance. This findings suggest that ABI may be used as a clinical predictor of initial disability level in acute stroke.
McDermott, Mary M.; Applegate, William B.; Bonds, Denise E.; Buford, Thomas W.; Church, Timothy; Espeland, Mark A.; Gill, Thomas M.; Guralnik, Jack M.; Haskell, William; Lovato, Laura C.; Pahor, Marco; Pepine, Carl J.; Reid, Kieran F.; Newman, Anne
Background The prevalence and significance of low normal and abnormal ankle brachial index (ABI) values in a community‐dwelling population of sedentary, older individuals is unknown. We describe the prevalence of categories of definite peripheral artery disease (PAD), borderline ABI, low normal ABI, and no PAD and their association with lower‐extremity functional performance in the LIFE Study population. Methods and Results Participants age 70 to 89 in the LIFE Study underwent baseline measurement of the ABI, 400‐m walk, and 4‐m walking velocity. Participants were classified as follows: definite PAD (ABI <0.90), borderline PAD (ABI 0.90 to 0.99), low normal ABI (ABI 1.00 to 1.09), and no PAD (ABI 1.10 to 1.40). Of 1566 participants, 220 (14%) had definite PAD, 250 (16%) had borderline PAD, 509 (33%) had low normal ABI, and 587 (37%) had no PAD. Among those with definite PAD, 65% were asymptomatic. Adjusting for age, sex, race, body mass index, smoking, and comorbidities, lower ABI was associated with longer mean 400‐m walk time: (definite PAD=533 seconds; borderline PAD=514 seconds; low normal ABI=503 seconds; and no PAD=498 seconds [P<0.001]). Among asymptomatic participants with and without PAD, lower ABI values were also associated with longer 400‐m walk time (P<0.001) and slower walking velocity (P=0.042). Conclusion Among older community‐dwelling men and women, 14% had PAD and 49% had borderline or low normal ABI values. Lower ABI values were associated with greater functional impairment, suggesting that lower extremity atherosclerosis may be a common preventable cause of functional limitations in older people. Clinical Trial Registration URL: http://clinicaltrials.gov/ Unique identifier: NCT01072500. PMID:24222666
K O, Thejaswini; M S, Roopakala; G, Dayananda; S P, Chandrakala; Kumar K M, Prasanna
The Ankle-Brachial Index (ABI) objectively assesses the lower extremity arterial perfusion. A low ABI suggests atherosclerosis and Peripheral Arterial Disease (PAD). PAD is more common in individuals with type2 Diabetes mellitus (Type2 DM). Inflammatory markers are found to be associated with Type2 DM. But the association of the inflammatory markers with the atherosclerotic burden remains poorly defined. To compare the ABI and the hsCRP in the Type 2 DM patients with those in the normal subjects and to study the association of serum hsCRP with ABI in the Type 2 DM patients and in normal subjects. The subjects were 40 Type2 DM and 40 age, sex and BMI matched normal subjects who were aged between 45-60 yrs. The subjects were assigned to two different groups, Group1- the Type2 DM patients and Group2- the healthy controls. The serum hsCRP levels were determined by the turbidimetry method (BIOSYSTEMS) and the ABI values were determined by using the traditional continuous wave (CW) Doppler of NICOLET VERSALAB. The data was analyzed by using the Student's t test (two tailed; independent) to find the significance of the study parameters between the two groups. Pearson's Correlation was used to find the correlation of serum hsCRP with the ABI in the two groups. The ABI showed a significantly low value (P=0.035*) and the serum hsCRP showed a trend towards a significant increase (p = 0.069+) in the type2diabetics as compared to those in the normals. There was a significant negative correlation between ABI and hsCRP in the Type 2 DM patients (r=-0.560, p<0.001**). However, such correlation was not observed in the normal subjects. As serum hsCRP is associated with ABI in the type2 DM patients, inflammation may play a role in the pathogenesis of atherosclerosis.
Wilkins, John T.; McDermott, Mary M.; Liu, Kiang; Chan, Cheeling; Criqui, Michael H.; Lloyd-Jones, Donald M.
Background The association between measures of arterial compliance and peripheral arterial disease (PAD) is unclear. Early changes in arterial wall compliance could be a useful marker of patients at high risk for developing lower extremity atherosclerosis. Methods We used linear and logistic regression models on baseline data from 2803 female and 2558 male participants in the Multi-Ethnic Study of Atherosclerosis (MESA) to study associations between tonometry-derived baseline measures of arterial compliance (large artery compliance [C1] and small artery compliance [C2]) and the baseline ankle-brachial index (ABI), as well as change in the ABI over approximately 3 years of follow up. Results In cross-sectional analyses, lower C1 and C2 values, indicating poorer arterial compliance, were associated with lower ABI. There were significant linear trends across strata of ABI, especially in C2 which ranged from 3.7ml/mmHg × 100 (95% confidence interval (CI) 3.3 to 4.2) in women with an ABI < 0.90 to 4.2ml/mmHg × 100 (95% CI 4.1 to 4.3 p<0.001) in women with ABI 1.10 - <1.40. Similar significant trends (p<0.001) were seen in men. In prospective analyses, those with the lowest tertile of C2 values at baseline had a greater multivariable-adjusted odds for decline in ABI of ≥ 0.15 over 3 years compared to those with the highest C2 values at baseline (OR 1.80 95% CI 1.23–2.64). Conclusions We observed that less compliant arteries were significantly associated with low ABI in cross-sectional analysis and with greater decline in ABI over time. PMID:22357412
Epstein, Benjamin J; Anderson, Shawn
The role of beta-blockers in uncomplicated hypertension has been challenged recently. Compared with other antihypertensives, beta-blockers are less effective for preventing cardiovascular events in patients with uncomplicated hypertension. Moreover, a recent meta-analysis of placebo-controlled clinical trials concluded that atenolol is not more efficacious than placebo for preventing cardiovascular events in patients with hypertension. Although these agents lower blood pressure measured conventionally over the brachial artery with a blood pressure cuff, they do not exert a commensurate effect on blood pressure in the central aorta. Central aortic blood pressure and aortic augmentation index are strong predictors of left ventricular hypertrophy, an independent risk factor for cardiovascular events. Emerging data are illuminating the antihypertensive paradox whereby antihypertensive agents may elicit discordant effects on central and peripheral blood pressure and hemodynamics. Vasodilatory antihypertensives, such as renin-angiotensin-aldosterone system inhibitors and calcium channel blockers, elicit reductions in central aortic blood pressure equal to or greater than that in the brachial artery. Conversely, beta-blockers lower central aortic blood pressure to a lesser degree even when blood pressure measured by sphygmomanometry is reduced substantially. Given the strong relationship between central aortic blood pressure and target organ damage, the effectiveness of beta-blockers may be overestimated in practice on the basis of conventional blood pressure measurements alone. Differences in central and peripheral blood pressure may account for the lack of cardiovascular protection afforded by beta-blockers in clinical trials and could account for a portion of the apparent "benefit beyond blood pressure" reduction with other classes of antihypertensive agents. Future studies should aim to better clarify the role of central aortic blood pressure in the treatment of
Lakhal, K; Ehrmann, S; Martin, M; Faiz, S; Réminiac, F; Cinotti, R; Capdevila, X; Asehnoune, K; Blanloeil, Y; Rozec, B; Boulain, T
Since arrhythmia induces irregular pulse waves, it is widely considered to cause flawed oscillometric brachial cuff measurements of blood pressure (BP). However, strong data are lacking. We assessed whether the agreement of oscillometric measurements with intra-arterial measurements is worse during arrhythmia than during regular rhythm. Among patients of three intensive care units (ICUs), a prospective comparison of three pairs of intra-arterial and oscillometric BP readings was performed among patients with arrhythmia and an arterial line already present. After each inclusion in the arrhythmia group, one patient with regular rhythm was included as a control. International Organization for Standardization (ISO) standard validation required a mean bias <5 (sd 8) mm Hg. In 135 patients with arrhythmia, the agreement between oscillometric and intra-arterial measurements of systolic, diastolic and mean BP was similar to that observed in 136 patients with regular rhythm: for mean BP, similar mean bias [-0.1 (sd 5.2) and 1.9 (sd 5.9) mm Hg]. In both groups, the ISO standard was satisfied for mean and diastolic BP, but not for systolic BP (sd >10 mm Hg) in our ICU population. The ability of oscillometry to detect hypotension (systolic BP <90 mm Hg or mean BP <65 mm Hg), response to therapy (>10% increase in mean BP after cardiovascular intervention) and hypertension (systolic BP >140 mm Hg) was good and similar during arrhythmia and regular rhythm (respective areas under the receiver operating characteristic curves ranging from 0.89 to 0.96, arrhythmia vs regular rhythm between-group comparisons all associated with P>0.3). Contrary to widespread belief, arrhythmia did not cause flawed automated brachial cuff measurements. © The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: firstname.lastname@example.org.
Objective: To assess whether weight loss improves markers of peripheral artery disease and vascular stenosis. Methods: The Action for Health in Diabetes randomized clinical trial compared intensive lifestyle intervention (ILI) for weight loss to a control condition of diabetes support and education...
Murabito, Joanne M.; White, Charles C.; Kavousi, Maryam; Sun, Yan V.; Feitosa, Mary F.; Nambi, Vijay; Lamina, Claudia; Schillert, Arne; Coassin, Stefan; Bis, Joshua C.; Broer, Linda; Crawford, Dana C.; Franceschini, Nora; Frikke-Schmidt, Ruth; Haun, Margot; Holewijn, Suzanne; Huffman, Jennifer E.; Hwang, Shih-Jen; Kiechl, Stefan; Kollerits, Barbara; Montasser, May E.; Nolte, Ilja M.; Rudock, Megan E.; Senft, Andrea; Teumer, Alexander; van der Harst, Pim; Vitart, Veronique; Waite, Lindsay L.; Wood, Andrew R.; Wassel, Christina L.; Absher, Devin M.; Allison, Matthew A.; Amin, Najaf; Arnold, Alice; Asselbergs, Folkert W.; Aulchenko, Yurii; Bandinelli, Stefania; Barbalic, Maja; Boban, Mladen; Brown-Gentry, Kristin; Couper, David J.; Criqui, Michael H.; Dehghan, Abbas; Heijer, Martin den; Dieplinger, Benjamin; Ding, Jingzhong; Dörr, Marcus; Espinola-Klein, Christine; Felix, Stephan B.; Ferrucci, Luigi; Folsom, Aaron R.; Fraedrich, Gustav; Gibson, Quince; Goodloe, Robert; Gunjaca, Grgo; Haltmayer, Meinhard; Heiss, Gerardo; Hofman, Albert; Kieback, Arne; Kiemeney, Lambertus A.; Kolcic, Ivana; Kullo, Iftikhar J.; Kritchevsky, Stephen B.; Lackner, Karl J.; Li, Xiaohui; Lieb, Wolfgang; Lohman, Kurt; Meisinger, Christa; Melzer, David; Mohler, Emile R; Mudnic, Ivana; Mueller, Thomas; Navis, Gerjan; Oberhollenzer, Friedrich; Olin, Jeffrey W.; O’Connell, Jeff; O’Donnell, Christopher J.; Palmas, Walter; Penninx, Brenda W.; Petersmann, Astrid; Polasek, Ozren; Psaty, Bruce M.; Rantner, Barbara; Rice, Ken; Rivadeneira, Fernando; Rotter, Jerome I.; Seldenrijk, Adrie; Stadler, Marietta; Summerer, Monika; Tanaka, Toshiko; Tybjaerg-Hansen, Anne; Uitterlinden, Andre G.; van Gilst, Wiek H.; Vermeulen, Sita H.; Wild, Sarah H.; Wild, Philipp S.; Willeit, Johann; Zeller, Tanja; Zemunik, Tatijana; Zgaga, Lina; Assimes, Themistocles L.; Blankenberg, Stefan; Boerwinkle, Eric; Campbell, Harry; Cooke, John P.; de Graaf, Jacqueline; Herrington, David; Kardia, Sharon L. R.; Mitchell, Braxton D.; Murray, Anna; Münzel, Thomas; Newman, Anne; Oostra, Ben A.; Rudan, Igor; Shuldiner, Alan R.; Snieder, Harold; van Duijn, Cornelia M.; Völker, Uwe; Wright, Alan F.; Wichmann, H.-Erich; Wilson, James F.; Witteman, Jacqueline C.M.; Liu, Yongmei; Hayward, Caroline; Borecki, Ingrid B.; Ziegler, Andreas; North, Kari E.; Cupples, L. Adrienne; Kronenberg, Florian
Background Genetic determinants of peripheral arterial disease (PAD) remain largely unknown. To identify genetic variants associated with the ankle-brachial index (ABI), a noninvasive measure of PAD, we conducted a meta-analysis of genome-wide association study data from 21 population-based cohorts. Methods and Results Continuous ABI and PAD (ABI≤0.9) phenotypes adjusted for age and sex were examined. Each study conducted genotyping and imputed data to the ~2.5 million SNPs in HapMap. Linear and logistic regression models were used to test each SNP for association with ABI and PAD using additive genetic models. Study-specific data were combined using fixed-effects inverse variance weighted meta-analyses. There were a total of 41,692 participants of European ancestry (~60% women, mean ABI 1.02 to 1.19), including 3,409 participants with PAD and with GWAS data available. In the discovery meta-analysis, rs10757269 on chromosome 9 near CDKN2B had the strongest association with ABI (β= −0.006, p=2.46x10−8). We sought replication of the 6 strongest SNP associations in 5 population-based studies and 3 clinical samples (n=16,717). The association for rs10757269 strengthened in the combined discovery and replication analysis (p=2.65x10−9). No other SNP associations for ABI or PAD achieved genome-wide significance. However, two previously reported candidate genes for PAD and one SNP associated with coronary artery disease (CAD) were associated with ABI : DAB21P (rs13290547, p=3.6x10−5); CYBA (rs3794624, p=6.3x10−5); and rs1122608 (LDLR, p=0.0026). Conclusions GWAS in more than 40,000 individuals identified one genome-wide significant association on chromosome 9p21 with ABI. Two candidate genes for PAD and 1 SNP for CAD are associated with ABI. PMID:22199011
Garimella, Pranav S; Ix, Joachim H; Katz, Ronit; Shlipak, Michael G; Criqui, Michael H; Siscovick, David S; Kramer, Holly; Sibley, Christopher T; Sarnak, Mark J
Low ankle-brachial index (ABI) is a reflection of atherosclerotic disease, and high ABI is an indicator of calcified vessels. The associations of albuminuria and cystatin C level with incidence of either low or high ABI are unknown. Prospective longitudinal cohort study. MESA (Multi-Ethnic Study of Atherosclerosis) enrolled community-dwelling adults (N=6,814) aged 45-84 years who were free of clinical cardiovascular disease at baseline. Baseline albumin-creatinine ratio (ACR) and serum cystatin C level. Development of low (<0.90), and high (>1.40) ABI using multinomial regression among persons with ABI of 0.90-1.40 at baseline. During 9.8 years of follow-up, 221 and 89 participants progressed to low and high ABIs, respectively. Baseline ACR and cystatin C level were higher among progressors compared with nonprogressors. In multivariable analyses, doubling of ACR was associated with increased risk of progression to low (OR, 1.08; 95% CI, 0.99-1.20) and high (OR, 1.16; 95% CI, 1.01-1.32) ABIs. Compared to the lowest quintile, the highest quintile of ACR had a significantly increased risk of progression to low (OR, 1.79; 95% CI, 1.03-3.12) and high (OR, 2.76; 95% CI, 1.32-5.77) ABIs. Higher cystatin C levels were associated with progression to low (OR per 1-SD greater, 1.12; 95% CI, 1.00-1.26) but not high (OR per 1-SD greater, 1.01; 95% CI, 0.81-1.25) ABI, but the highest quintile of cystatin C was not associated independently with either outcome. Single measure of albuminuria and low number of progressors to high ABI. In adults free of clinical cardiovascular disease, albuminuria was a strong independent risk factor for the development of both high and low ABIs, important and different measures of peripheral artery disease. Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
Wassel, Christina L; Ellis, Alicia M; Suder, Natalie C; Barinas-Mitchell, Emma; Rifkin, Dena E; Forbang, Nketi I; Denenberg, Julie O; Marasco, Antoinette M; McQuaide, Belinda J; Jenny, Nancy S; Allison, Matthew A; Ix, Joachim H; Criqui, Michael H
The ankle-brachial index (ABI) is inadequate to detect early-stage atherosclerotic disease, when interventions to prevent functional decline may be the most effective. We determined associations of femoral artery atherosclerosis with physical functioning, across the spectrum of the ABI, and within the normal ABI range. In 2007-2011, 1103 multiethnic men and women participated in the San Diego Population Study, and completed all components of the summary performance score. Using Doppler ultrasound, superficial and common femoral intima media thickness and plaques were ascertained. Logistic regression was used to assess associations of femoral atherosclerosis with the summary performance score and its individual components. Models were adjusted for demographics, lifestyle factors, comorbidities, lipids, and kidney function. In adjusted models, among participants with a normal-range ABI (1.00-1.30), the highest tertile of superficial intima media thickness was associated with lower odds of a perfect summary performance score of 12 (odds ratio=0.56 [0.36, 0.87], P=0.009), and lower odds of a 4-m walk score of 4 (0.34 [0.16, 0.73], P=0.006) and chair rise score of 4 (0.56 [0.34, 0.94], P=0.03). Plaque presence (0.53 [0.29, 0.99], P=0.04) and greater total plaque burden (0.61 [0.43, 0.87], P=0.006) were associated with worse 4-m walk performance in the normal-range ABI group. Higher superficial intima media thickness was associated with lower summary performance score in all individuals (P=0.02). Findings suggest that use of femoral artery atherosclerosis measures may be effective in individuals with a normal-range ABI, especially, for example, those with diabetes mellitus or a family history of peripheral artery disease, when detection can lead to earlier intervention to prevent functional declines and improve quality of life. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.
Delaney, Joseph A C; Jensky, Nicole E.; Criqui, Michael H.; Whitt-Glover, Melicia C.; Lima, João A. C.; Allison, Matthew A.
Objective Both coronary artery calcification (CAC) and the ankle brachial index (ABI) are measures of subclinical atherosclerotic disease. The influence of physical activity on the longitudinal change in these measures remains unclear. To assess this we examined the association between these measures and self-reported physical activity in the Multi-Ethnic Study of Atherosclerosis (MESA). Methods At baseline, the MESA participants were free of clinically evident cardiovascular disease. We included all participants with an ABI between 0.90 and 1.40 (n=5656). Predictor variables were based on self-reported measures with physical activity being assessed using the Typical Week Physical Activity Survey from which metabolic equivalent-minutes/week of activity were calculated. We focused on physical activity intensity, intentional exercise, sedentary behavior, and conditioning. Incident peripheral artery disease (PAD) was defined as the progression of ABI to values below 0.90 (given the baseline range of 0.90 to 1.40). Incident CAC was defined as a CAC score >0 Agatston units upon follow up with a baseline score of 0 Agatston units. Results Mean age was 61 years, 53% were female, and mean body mass index was 28 kg/m2. After adjusting for traditional cardiovascular risk factors and socioeconomic factors, intentional exercise was protective for incident peripheral artery disease (Relative Risk (RR)= 0.85, 95% Confidence Interval (CI): 0.74 to 0.98). After adjusting for traditional cardiovascular risk factors and socioeconomic factors, there was a significant association between vigorous PA and incident CAC (RR=0.97, 95% CI: 0.94 to 1.00). There was also a significant association between sedentary behavior and increased amount of CAC among participants with CAC at baseline (Δlog(Agatston Units +25)=0.027, 95% CI 0.002, 0.052). Conclusions These data suggest that there is an association between physical activity/sedentary behavior and the progression of two different measures
Ueki, Yasushi; Miura, Takashi; Miyashita, Yusuke; Motoki, Hirohiko; Shimada, Kentaro; Kobayashi, Masanori; Nakajima, Hiroyuki; Kimura, Hikaru; Akanuma, Hiroshi; Mawatari, Eiichiro; Sato, Toshio; Hotta, Shoji; Kamiyoshi, Yuichi; Maruyama, Takuya; Watanabe, Noboru; Eisawa, Takayuki; Aso, Shinichi; Uchikawa, Shinichiro; Hashizume, Naoto; Sekimura, Noriyuki; Morita, Takehiro; Ebisawa, Soichiro; Izawa, Atsushi; Koyama, Jun; Ikeda, Uichi
The Synergy Between PCI With TAXUS and Cardiac Surgery (SYNTAX) score is effective in predicting clinical outcome after percutaneous coronary intervention (PCI). However, its prediction ability is low because it reflects only the coronary characterization. We assessed the predictive value of combining the ankle-brachial index (ABI) and SYNTAX score to predict clinical outcomes after PCI. The ABI-SYNTAX score was calculated for 1,197 patients recruited from the Shinshu Prospective Multi-center Analysis for Elderly Patients with Coronary Artery Disease Undergoing Percutaneous Coronary Intervention (SHINANO) registry, a prospective, observational, multicenter cohort study in Japan. The primary end points were major adverse cardiovascular and cerebrovascular events (MACE; all-cause death, myocardial infarction, and stroke) in the first year after PCI. The ABI-SYNTAX score was calculated by categorizing and summing up the ABI and SYNTAX scores. ABI ≤ 0.49 was defined as 4, 0.5 to 0.69 as 3, 0.7 to 0.89 as 2, 0.9 to 1.09 as 1, and 1.1 to 1.5 as 0; an SYNTAX score ≤ 22 was defined as 0, 23 to 32 as 1, and ≥ 33 as 2. Patients were divided into low (0), moderate (1 to 2), and high (3 to 6) groups. The MACE rate was significantly higher in the high ABI-SYNTAX score group than in the lower 2 groups (low: 4.6% vs moderate: 7.0% vs high: 13.9%, p = 0.002). Multivariate regression analysis found that ABI-SYNTAX score independently predicted MACE (hazards ratio 1.25, 95% confidence interval 1.02 to 1.52, p = 0.029). The respective C-statistic for the ABI-SYNTAX and SYNTAX score for 1-year MACE was 0.60 and 0.55, respectively. In conclusion, combining the ABI and SYNTAX scores improved the prediction of 1-year adverse ischemic events compared with the SYNTAX score alone.
Miura, Takashi; Minamisawa, Masatoshi; Ueki, Yasushi; Abe, Naoyuki; Nishimura, Hitoshi; Hashizume, Naoto; Mochidome, Tomoaki; Harada, Mikiko; Oguchi, Yasutaka; Yoshie, Koji; Shoin, Wataru; Saigusa, Tatsuya; Ebisawa, Soichiro; Motoki, Hirohiko; Koyama, Jun; Ikeda, Uichi; Kuwahara, Koichiro
The ankle-brachial index (ABI) is a marker of generalized atherosclerosis and is predictive of future cardiovascular events. However, few studies have assessed its relation to long-term future cardiovascular events, especially in patients with borderline ABI. We therefore evaluated the relationship between long-term future cardiovascular events and ABI. In the IMPACT-ABI study, a single-center, retrospective cohort study, we enrolled 3131 consecutive patients (67 ± 13 years; 82% male) hospitalized for cardiovascular disease and measured ABI between January 2005 and December 2012. After excluding patients with an ABI > 1.4, the remaining 3056 patients were categorized as having low ABI (≤ 0.9), borderline ABI (0.91-0.99), or normal ABI (1.00-1.40). The primary endpoint was MACE (cardiovascular death, myocardial infarction [MI] and stroke). The secondary endpoints were cardiovascular death, MI, stroke, admission due to heart failure, and major bleeding. During a 4.8-year mean follow-up period, the incidences of MACE (low vs. borderline vs. normal: 32.9% vs. 25.0% vs. 14.6%, P<0.0001) and cardiovascular death (26.2% vs. 18.7% vs. 8.9%, P<0.0001) differed significantly across ABIs. The incidences of stroke (9.1% vs. 8.6% vs. 4.8%, P<0.0001) and heart failure (25.7% vs. 20.8% vs. 8.9%, P<0.0001) were significantly higher in the low and borderline ABI groups than in the normal ABI group. But the incidences of MI and major bleeding were similar in the borderline and normal ABI groups. The hazard ratios for MACE adjusted for traditional atherosclerosis risk factors were significantly higher in patients with low and borderline ABI than those with normal ABI (HR, 1.93; 95%CI: 1.44-2.59, P < 0.0001, HR, 1.54; 95% CI: 1.03-2.29, P = 0.035). The incidence of long-term adverse events was markedly higher among patients with low or borderline ABI than among those with normal ABI. This suggests that more attention should be paid to patients with borderline ABIs, especially with
Wassel, Christina L.; Berardi, Cecilia; Pankow, James S.; Larson, Nicholas B.; Decker, Paul A.; Hanson, Naomi Q.; Tsai, Michael Y.; Criqui, Michael H.; Allison, Matthew A.; Bielinski, Suzette J.
Objective To determine the association of circulating P-selectin with prevalent and incident peripheral artery disease (PAD), the ankle brachial index (ABI), and change in the ABI. Methods The Multi-Ethnic Study of Atherosclerosis (MESA) is a prospective population-based cohort study including 6814 European descent, African American, Hispanic and Chinese men and women aged 45–84 at baseline. Four clinical exams took place after the baseline exam. After excluding those with ABI>1.4, prevalent and incident PAD were defined as an ABI≤0.90. ABI progression was defined as progression from a normal ABI (0.91–1.4) to abnormal (≤0.90 or >1.4) at a later exam. Results In adjusted models, each SD (13 ng/mL) higher P-selectin was significantly associated with 0.007 lower ABI (95% CI ((−0.011, −0.004)), p<0.001), and an average change in the ABI of − 0.006 ((−0.010, −0.003, p<0.001). P-selectin was significantly associated with a 1.17-fold greater odds of prevalent PAD ((1.02, 1.33), p=0.03), and a 30% greater risk of incident PAD ((1.11, 1.53), p=0.001), as well as progression from a normal ABI to an ABI≤ 0.90 (p=0.003), but not to an ABI>1.4 (p=0.96). Addition of P-selectin to models containing traditional PAD risk factors and markers of inflammation/coagulation significantly improved the net reclassification for ABI progression (p=0.03), but was only marginally significant for incident PAD (p=0.06). Conclusions P-selectin is significantly associated with the development of PAD. However, further research is needed in population-based studies to confirm prospective associations of P-selectin with incident PAD and change in the ABI, as well as its potential predictive ability. PMID:25682040
K.O., Thejaswini; M.S, Roopakala; G., Dayananda; S.P, Chandrakala; Kumar K.M., Prasanna
Background: The Ankle-Brachial Index (ABI) objectively assesses the lower extremity arterial perfusion. A low ABI suggests atherosclerosis and Peripheral Arterial Disease (PAD). PAD is more common in individuals with type2 Diabetes mellitus (Type2 DM). Inflammatory markers are found to be associated with Type2 DM. But the association of the inflammatory markers with the atherosclerotic burden remains poorly defined. Aims: To compare the ABI and the hsCRP in the Type 2 DM patients with those in the normal subjects and to study the association of serum hsCRP with ABI in the Type 2 DM patients and in normal subjects. Methods: The subjects were 40 Type2 DM and 40 age, sex and BMI matched normal subjects who were aged between 45-60 yrs. The subjects were assigned to two different groups, Group1- the Type2 DM patients and Group2- the healthy controls. The serum hsCRP levels were determined by the turbidimetry method (BIOSYSTEMS) and the ABI values were determined by using the traditional continuous wave (CW) Doppler of NICOLET VERSALAB. Statistical Analysis: The data was analyzed by using the Student’s t test (two tailed; independent) to find the significance of the study parameters between the two groups. Pearson’s Correlation was used to find the correlation of serum hsCRP with the ABI in the two groups. Results: The ABI showed a significantly low value (P=0.035*) and the serum hsCRP showed a trend towards a significant increase (p = 0.069+) in the type2diabetics as compared to those in the normals. There was a significant negative correlation between ABI and hsCRP in the Type 2 DM patients (r=-0.560, p<0.001**). However, such correlation was not observed in the normal subjects. Conclusion: As serum hsCRP is associated with ABI in the type2 DM patients, inflammation may play a role in the pathogenesis of atherosclerosis. PMID:23450165
Garimella, Pranav S.; Ix, Joachim H.; Katz, Ronit; Shlipak, Michael G.; Criqui, Michael H.; Siscovick, David S.; Kramer, Holly; Sibley, Christopher T.; Sarnak, Mark J.
Background Low ankle-brachial index (ABI) is a reflection of atherosclerotic disease, and high ABI is an indicator of calcified vessels. The associations of albuminuria and cystatin C with incidence of either low or high ABI are unknown. Study Design Prospective longitudinal cohort study. Setting & Participants The Multi-Ethnic Study of Atherosclerosis (MESA) enrolled community-dwelling adults (N=6,814) aged 45–84 years who were free of clinical cardiovascular disease (CVD) at baseline. Predictors Baseline albumin-creatinine ratio (ACR) and serum cystatin C levels. Outcomes Development of low (< 0.90), and high (> 1.40) ABI using multinomial regression among persons with ABI 0.90–1.40 at baseline. Results During 9.8 years of follow up, 221 and 89 participants progressed to low and high ABI, respectively. Baseline ACR and cystatin C were higher among progressors compared to non-progressors. In multivariable analyses, doubling of ACR was associated with increased risk of progression to low (OR, 1.08; 95% CI, 0.99–1.20) and high (OR, 1.16; 95% CI, 1.01–1.32) ABI. Compared to the lowest quintile, the highest quintile of ACR had a significantly increased risk of progression to low (OR, 1.79; 95% CI, 1.03–3.12) and high (OR, 2.76; 95% CI, 1.32–5.77) ABI. Higher cystatin C levels were associated with progression to low (OR per 1-SD greater, 1.12; 95% CI, 1.00–1.26) but not high (OR per 1-SD greater, 1.01; 95% CI, 0.81–1.25) ABI, but the highest quintile of cystatin C was not independently associated with either outcome. Limitations Single measure of albuminuria and low number of progressors to high ABI. Conclusions In adults free of clinical CVD, albuminuria was a strong, independent risk factor for the development of both high and low ABI, important and different measures of peripheral artery disease. PMID:24998036
Alimerzaloo, Farnaz; Kashani, Reza V; Saeedi, Hassan; Farzi, Marjan; Fallahian, Nader
Heel clearance and ankle status (free or locked) are of major determinants affecting peak plantar pressures and contact area in patellar tendon bearing brace and have been separately studied by many researchers. This study investigated the combined effect of ankle status and heel clearance on contact area and peak plantar pressure in different areas of foot (hindfoot, midfoot, and forefoot). Before-after repeated measurement trial. Nine healthy male volunteers walked 8 m with normal shoe and four conditions of patellar tendon bearing brace wear. Repeated-measure analysis of variance test was used to compare contact area and plantar pressure changes in three areas of the foot. Application of patellar tendon bearing brace significantly reduced overall plantar pressure and contact area (p < 0.01). Although both contact area and plantar pressure significantly decreased in hindfoot and midfoot, plantar pressure increased in forefoot area (p < 0.05). Application of the patellar tendon bearing brace can reduce the overall peak plantar pressure in the foot but increases focal plantar pressure in forefoot. Excessive lifting of the heel seems to minimize the contact area, thus increase focal pressure in forefoot. Overall, plantar pressure seems to be more effectively off-loaded by combining maximum heel clearance and restriction of the ankle joint. Although effective parameters of patellar tendon bearing brace have been separately addressed in previous studies, no study was found that investigated the combined effect of ankle status and heel clearance. This study investigates the combined effect of these parameters and provides detailed information on clinical application of the patellar tendon bearing brace.
Tullos, Bobby W; Sung, Jung Hye; Lee, Jae Eun; Criqui, Michael H; Mitchell, Marc E; Taylor, Herman A
To examine the associations of peripheral atherosclerosis, assessed by the ABI at baseline with the extent of AAC and with CAC measured by MDCT at follow-up examination in the Jackson Heart Study cohort. Four categories of ABI: <0.90, 0.90-0.99, 1.00-1.39; >1.40. Presence of CAC/AAC was defined as scoring above the 75th percentile among participants with non-zero CT calcium scores. We conducted multivariable log-binomial models for this analysis examining the relationship between ABI and the presence of CAC or AAC using normal ABI (1.0 ≤ ABI ≤ 1.39) as the reference group. We estimated prevalence ratios adjusted for age, smoking, HTN, DM, BMI, LDL, HDL, CRP, systolic and diastolic blood pressure, and use of lipid-lowering medication. There were 2,398 patients in this analysis (women: 65 %, average age 55 years). AAC scores were not significantly different between sex. CAC scores were significantly higher in males than females regardless of ABI groups. The prevalence of significant AAC was 1.7 times higher for ABI < 0.90 (PR = 1.70; 95 % CI = 1.26-2.28; p = 0.0004) and 1.57 times higher for ABI 0.90-0.99 (PR = 1.57; 95 % CI = 1.20-2.03; p = 0.0008) than the normal ABI; AAC prevalence did not differ between subjects with ABI > 1.40 compared to those with normal ABI. The prevalence of the significant CAC was higher for ABI < 0.90 (PR = 1.55; 95 % CI = 1.12-2.14; p value = 0.0081) and ABI 0.90-0.99 (PR = 1.60; 95 % CI = 1.05-2.46; p = 0.0402) compared to normal ABI; CAC prevalence did not differ between subjects with ABI > 1.40 compared to those with normal ABI. Lower ABI was significantly associated with the extent of AAC and CAC in this cohort. ABI can provide clinicians with an inexpensive additional tool to assess vascular health and cardiovascular risk without exposing the patient to ionizing radiation.
Tullos, Bobby W.; Sung, Jung Hye; Lee, Jae Eun; Criqui, Michael H.; Mitchell, Marc E.; Taylor, Herman A.
Introduction To examine the associations of peripheral atherosclerosis, assessed by the ABI at baseline with the extent of AAC and with CAC measured by MDCT at follow-up examination in the Jackson Heart Study cohort. Methods Four categories of ABI: <0.90, 0.90–0.99, 1.00–1.39; >1.40. Presence of CAC/AAC was defined as scoring above the 75th percentile among participants with non-zero CT calcium scores. We conducted multivariable log-binomial models for this analysis examining the relationship between ABI and the presence of CAC or AAC using normal ABI (1.0 ≤ ABI ≤ 1.39) as the reference group. We estimated prevalence ratios adjusted for age, smoking, HTN, DM, BMI, LDL, HDL, CRP, systolic and diastolic blood pressure, and use of lipid-lowering medication. Results There were 2,398 patients in this analysis (women: 65%, average age 55 years). AAC scores were not significantly different between sex. CAC scores were significantly higher in males than females regardless of ABI groups. The prevalence of significant AAC was 1.7 times higher for ABI < 0.90 (PR=1.70; 95% CI=1.26–2.28; p=0.0004) and 1.57 times higher for ABI 0.90–0.99 (PR=1.57; 95% CI=1.20–2.03; p=0.0008) than the normal ABI; AAC prevalence did not differ between subjects with ABI > 1.40 compared to those with normal ABI. The prevalence of the significant CAC was higher for ABI <0.90 (PR=1.55; 95% CI=1.12–2.14; p-value=0.0081) and ABI 0.90–0.99 (PR=1.60; 95% CI=1.05–2.46; p=0.0402) compared to normal ABI; CAC prevalence did not differ between subjects with ABI > 1.40 compared to those with normal ABI Conclusion Lower ABI was significantly associated with the extent of AAC and CAC in this cohort. ABI can provide clinicians with an inexpensive additional tool to assess vascular health and cardiovascular risk without exposing the patient to ionizing radiation. PMID:23111408
Prognostic value of ankle brachial index for future incident heart failure in patients without previous heart failure: data from the impressive predictive value of ankle brachial index for clinical long term outcome in patients with cardiovascular disease examined by ABI study.
Nishimura, Hitoshi; Miura, Takashi; Minamisawa, Masatoshi; Ueki, Yasushi; Abe, Naoyuki; Hashizume, Naoto; Mochidome, Tomoaki; Harada, Mikiko; Shimizu, Kunihiko; Shoin, Wataru; Yoshie, Koji; Oguchi, Yasutaka; Ebisawa, Soichiro; Motoki, Hirohiko; Izawa, Atsushi; Koyama, Jun; Ikeda, Uichi
The ankle brachial index (ABI) is regarded as a predictor of future cardiovascular events. However, the relationship between ABI and incident heart failure (HF) in patients without previous HF is poorly understood. This study aimed to assess the prognostic value of ABI for incident HF in patients without previous HF. The IMPACT-ABI study was a retrospective, single-center, cohort study that enrolled and measured ABI in 3131 patients hospitalized for cardiovascular disease between January 2005 and December 2012. From this cohort, 307 patients were excluded because of previous HF and high (>1.4) ABI. The remaining 2824 patients were stratified into three groups: low ABI (≤0.9), borderline ABI (0.91-0.99), and normal ABI (1.0-1.4). The primary endpoint was hospitalization for HF. Over a mean 4.8-year follow-up, 105 cases of HF occurred. The cumulative incidence of HF was significantly higher in patients with low and borderline ABIs than in those with normal ABI (19.3 vs. 21.0 vs. 10.4 %, log rank P <0.001). In multivariate Cox proportional hazard analysis, low ABI and borderline ABI were independent predictors of incident HF [hazard ratio (HR) 3.00; 95 % confidence interval (CI) 1.70-5.28; P < 0.001 and HR 2.68; 95 % CI 1.35-5.34; P = 0.005, respectively]. In conclusion, low and borderline ABI were strong predictors for future incident HF in patients without previous HF.
Chi, C; Yu, S-K; Auckle, R; Argyris, A A; Nasothimiou, E; Tountas, C; Aissopou, E; Blacher, J; Safar, M E; Sfikakis, P P; Zhang, Y; Protogerou, A D
Both brachial blood pressure (BP) level and its variability (BPV) significantly associate with left ventricular (LV) structure and function. Recent studies indicate that aortic BP is superior to brachial BP in the association with LV abnormalities. However, it remains unknown whether aortic BPV better associate with LV structural and functional abnormalities. We therefore aimed to investigate and compare aortic versus brachial BPV, in terms of the identification of LV abnormalities. Two hundred and three participants who underwent echocardiography were included in this study. Twenty-four-hour aortic and brachial ambulatory BP was measured simultaneously by a validated BP monitor (Mobil-O-Graph, Stolberg, Germany) and BPV was calculated with validated formulae. LV mass and LV diastolic dysfunction (LVDD) were evaluated by echocardiography. The prevalence of LV hypertrophy (LVH) and LVDD increased significantly with BPV indices (P⩽0.04) in trend tests. After adjustment to potential confounders, only aortic average real variability (ARV), but not brachial ARV or weighted s.d. (wSD, neither aortic nor brachial) significantly associated with LV mass index (P=0.02). Similar results were observed in logistic regression. After adjustment, only aortic ARV significantly associated with LVH (odds ratio (OR) and 95% confidence interval (CI): 2.28 (1.08, 4.82)). As for LVDD, neither the brachial nor the aortic 24-hour wSD, but the aortic and brachial ARV, associated with LVDD significantly, with OR=2.28 (95% CI: (1.03, 5.02)) and OR=2.36 (95% CI: (1.10, 5.05)), respectively. In summary, aortic BPV, especially aortic ARV, seems to be superior to brachial BPV in the association of LV structural and functional abnormalities.
Resting and Post-Exercise Ankle-Brachial Index Measurements to Diagnose Asymptomatic Peripheral Arterial Disease in Middle Aged and Elderly Chronic Obstructive Pulmonary Disease Patients: A Pilot Study
Alagiakrishnan, Kannayiram; Brokop, Michael; Cave, Andrew; Rowe, Brian H.; Wong, Eric; Senthilselvan, Ambikaipakan
Background Chronic obstructive pulmonary disease (COPD) patients are at risk for asymptomatic peripheral arterial disease (PAD) because smoking is a risk factor for COPD and PAD. The objectives of this study were to determine the proportion of COPD patients with asymptomatic PAD and to investigate whether the estimated risk of asymptomatic PAD in subjects with COPD differs using resting and exercise ankle-brachial index (ABI) in smokers. Methods Using a cross-sectional study design, consecutive smokers > 50 years old were recruited over 2 months from the inpatient units and the outpatient clinics. Subjects previously diagnosed with PAD, unstable angina, recent (< 3 months) myocardial infarction or abdominal, intracranial, eye or lung surgery, and palliative care patients were excluded. Vascular risk factors, ABI (supine and post-3-minute walk supine), self-reported PAD symptoms, and spirometry were obtained. Two measurements of systolic blood pressure on all limbs were obtained using a sphygmomanometer and a Doppler ultrasound, and the ABI was calculated. Data were expressed as means ± standard deviation (SD). Dichotomous outcomes were assessed using Chi-square statistics; P-values of < 0.05 were considered significant. Results Thirty patients with no previous diagnosis of PAD were recruited. Mean age was 67.7 years (SD: 10.5). Overall, 21 subjects (70%) had spirometry-proven COPD. Significant ABI for PAD (< 0.9) was seen in 7/21 COPD (33.5%) and 0/9 non-COPD subjects in the supine resting position (P = 0.07), and in 9/21 COPD (42.9%) vs. 0/9 non-COPD subjects after exercise (P = 0.03). Conclusions A significant proportion of patients with spirometry-proven COPD screened positive for asymptomatic PAD after exercise. Resting ABI may not be very sensitive to diagnose asymptomatic PAD in COPD subjects. ABI may be a reliable, sensitive and practical screening tool to assess cardiovascular risk in COPD patients. Future large-scale studies are required to confirm this
Nguyen, M T; Pham, I; Chemla, D; Valensi, P; Cosson, E
To document the stroke volume to pulse pressure ratio (SV/PP, an index of total arterial compliance) and its correlates in patients with type 2 diabetes (T2DM) aged over 50 years whose peripheral neuropathy and silent myocardial ischemic (SMI) status were known. A total of 360 patients with T2DM aged ≥ 50 years, without cardiac history or symptom, left ventricular systolic dysfunction, dilatation and hypokinesia, were retrospectively enrolled. The SV/PP was calculated from echocardiographic left ventricular measurements and brachial blood pressure at rest. Peripheral neuropathy was defined as the presence of any two or more of the following: neuropathic symptoms, decreased distal sensation, or decreased or absent ankle reflexes. SMI was defined as an abnormal stress myocardial scintigraphy and/or stress echocardiography. A low SV/PP ratio (<0.53 ml/m²/mmHg, first tertile) was associated with age, creatinine clearance, 24 h urinary albumin excretion rate, peripheral neuropathy, hypertension, serum total cholesterol and triglycerides levels (p < 0.05-0.0001). In multivariate analysis, age (OR 1.1 [1.0-1.2], p < 0.01), triglycerides (OR 1.5 [1.2-2.0], p = 0.01) and peripheral neuropathy (OR 2.2 [1.2-3.9], p = 0.009) were independently associated with a low SV/PP. The patients with peripheral neuropathy had lower SV (p < 0.01) and higher PP (p < 0.05) than those without, and only lower SV after adjustment for age and nephropathy. Similar results were obtained in the patients with and without SMI. Peripheral neuropathy was independently associated with decreased SV/PP, mainly through decreased SV, in patients with T2DM over 50 years. Copyright © 2013 Elsevier B.V. All rights reserved.
Espinosa, N; Walti, M; Favre, P; Snedeker, J G
A major cause of the limited longevity of total ankle replacements is premature polyethylene component wear, which can be induced by high joint contact pressures. We implemented a computational model to parametrically explore the hypothesis that intercomponent positioning deviating from the manufacturer's recommendations can result in pressure distributions that may predispose to wear of the polyethylene insert. We also investigated the hypothesis that a modern mobile-bearing design may be able to better compensate for imposed misalignments compared with an early two-component design. Two finite element models of total ankle replacement prostheses were built to quantify peak and average contact pressures on the polyethylene insert surfaces. Models were validated by biomechanical testing of the two implant designs with use of pressure-sensitive film. The validated models were configured to replicate three potential misalignments with the most version of the tibial component, version of the talar component, and relative component rotation of the two-component design. The misalignments were simulated with use of the computer model with physiologically relevant boundary loads. With use of the manufacturer's guidelines for positioning of the two-component design, the predicted average joint contact pressures exceeded the yield stress of polyethylene (18 to 20 MPa). Pressure magnitudes increased as implant alignment was systematically deviated from this reference position. The three-component design showed lower-magnitude contact pressures in the standard position (<10 MPa) and was generally less sensitive to misalignment. Both implant systems were sensitive to version misalignment. In the tested implants, a highly congruent mobile-bearing total ankle replacement design yields more evenly distributed and lower-magnitude joint contact pressures than a less congruent design. Although the mobile-bearing implant reduced susceptibility to aberrant joint contact
Schultz, Martin G; Hughes, Alun D; Davies, Justin E; Sharman, James E
Central augmentation pressure (AP) and index (AIx) predict cardiovascular events and mortality, but underlying physiological mechanisms remain disputed. While traditionally believed to relate to wave reflections arising from proximal arterial impedance (and stiffness) mismatching, recent evidence suggests aortic reservoir function may be a more dominant contributor to AP and AIx. Our aim was therefore to determine relationships among aortic-brachial stiffness mismatching, AP, AIx, aortic reservoir function, and end-organ disease. Aortic (aPWV) and brachial (bPWV) pulse wave velocity were measured in 359 individuals (aged 61 ± 9, 49% male). Central AP, AIx, and aortic reservoir indexes were derived from radial tonometry. Participants were stratified by positive (bPWV > aPWV), negligible (bPWV ≈ aPWV), or negative stiffness mismatch (bPWV < aPWV). Left-ventricular mass index (LVMI) was measured by two-dimensional-echocardiography. Central AP and AIx were higher with negative stiffness mismatch vs. negligible or positive stiffness mismatch (11 ± 6 vs. 10 ± 6 vs. 8 ± 6 mmHg, P < 0.001 and 24 ± 10 vs. 24 ± 11 vs. 21 ± 13%, P = 0.042). Stiffness mismatch (bPWV-aPWV) was negatively associated with AP (r = -0.18, P = 0.001) but not AIx (r = -0.06, P = 0.27). Aortic reservoir pressure strongly correlated to AP (r = 0.81, P < 0.001) and AIx (r = 0.62, P < 0.001) independent of age, sex, heart rate, mean arterial pressure, and height (standardized β = 0.61 and 0.12, P ≤ 0.001). Aortic reservoir pressure independently predicted abnormal LVMI (β = 0.13, P = 0.024). Positive aortic-brachial stiffness mismatch does not result in higher AP or AIx. Aortic reservoir function, rather than discrete wave reflection from proximal arterial stiffness mismatching, provides a better model description of AP and AIx and also has clinical relevance as evidenced by an independent association of aortic reservoir pressure with LVMI.
Becker, HP; Rosenbaum, D; Claes, L; Gerngro, H
INTRODUCTION:: Chronic functional instability of the lateral ankle may be difficult to distinguish from mechanical instability when radiological stress tests reveal only small ligamentous defects. For decision making whether to surgically reconstruct the ligaments or not, it can be helpful to use additional information on joint and foot function. Therefore, the aim of a prospective study of patients with longstanding chronic ankle instability was to demonstrate that the dynamic measurement of plantar pressure distribution can identify patients with functional ankle instability. [Table: see text] MATERIALS AND METHODS:: Sixty five patients (mean age 24 (4.6 years)) were included. After clinical examination and radiological stress views, plantar pressure patterns were measured during gait using a capacitive platform, the EMED-SF 2-system. Five trials of each foot were documented and the maximum impulses in eight points of the foot (central heel, lateral and medial heel, midfoot, 1st, 2nd, 5th metatarsal head and hallux) were calculated intraindividually and compared with a group of 100 healthy subjects. The medio-lateral loading factor (MLF) as the quotient of the medial and lateral relative impulses indicated the tendency to walk on the lateral edge of the foot. RESULTS:: Based on clinical criteria alone, two comparable groups of patients were separated, 35 with functional instability and 30 with mechanical instability. After collective analyses of the results, the patients with functional instability showed a significantly increased lateral loading of the unstable foot (p=0 0 1), whereas the mechanically unstable group tended to walk more on the medial side of the unstable foot (Table 1). DISCUSSION:: Dynamic measurement of plantar pressure can identify a group of patients walking on the lateral side of the unstable foot when compared with the stable foot. This finding is explained by a deficit of peroneal strength during stance phase based on a proprioceptive
Bulusu, Srinivas; McMillan, Hugh J
Patients with hereditary neuropathy with liability to pressure palsy (HNPP) typically present with a mononeuropathy (particularly peroneal or ulnar palsy) or a brachial plexopathy. Careful electrodiagnostic testing has an important role in establishing the diagnosis of HNPP differentiating this condition from other inherited or acquired neuropathies as well as obviating the need for unnecessary surgeries. We present a case of a patient who presented with a painless brachial plexopathy who was found to have multiple sites of segmental demyelination on nerve conduction studies, consistent with HNPP. We review the clinical and electrodiagnostic features of HNPP including the key electrodiagnostic findings to screen for this disorder.
The brachial plexus is a group of nerves that run from the lower neck through the upper shoulder area. ... Damage to the brachial plexus nerves can cause muscle and sensation problems that are often associated with pain in the same area. Symptoms ...
Khadilkar, Satish V.; Khade, Snehaldatta S.
Brachial plexus injury can occur as a result of trauma, inflammation or malignancies, and associated complications. The current topic is concerned with various forms of brachial plexopathy, its clinical features, pathophysiology, imaging findings, and management. Idiopathic brachial neuritis (IBN), often preceded with antecedent events such as infection, commonly present with abruptonset painful asymmetric upper limb weakness with associated wasting around the shoulder girdle and arm muscles. Idiopathic hypertrophic brachial neuritis, a rare condition, is usually painless to begin with, unlike IBN. Hereditary neuralgic amyotrophy is an autosomal-dominant disorder characterized by repeated episodes of paralysis and sensory disturbances in an affected limb, which is preceded by severe pain. While the frequency of the episodes tends to decrease with age, affected individuals suffer from residual deficits. Neurogenic thoracic outlet syndrome affects the lower trunk of the brachial plexus. It is diagnosed on the basis of electrophysiology and is amenable to surgical intervention. Cancer-related brachial plexopathy may occur secondary to metastatic infiltration or radiation therapy. Traumatic brachial plexus injury is commonly encountered in neurology, orthopedic, and plastic surgery set-ups. Trauma may be a direct blow or traction or stretch injury. The prognosis depends on the extent and site of injury as well as the surgical expertise. PMID:23661957
Triplet, Jacob J; Lonetta, Christopher M; Everding, Nathan G; Moor, Molly A; Levy, Jonathan C
Estimation of cerebral perfusion pressure during elective shoulder surgery in the beach chair position is regularly performed by noninvasive brachial blood pressure (NIBP) measurements. The relationship between brachial mean arterial pressure and estimated temporal mean arterial pressure (eTMAP) is not well established and may vary with patient positioning. Establishing a ratio between eTMAP and NIBP at varying positions may provide a more accurate estimation of cerebral perfusion using noninvasive measurements. This prospective study included 57 patients undergoing elective shoulder surgery in the beach chair position. All patients received an interscalene block and general anesthesia. After the induction of general anesthesia, values for eTMAP and NIBP were recorded at 0°, 30°, and 70° of incline. A statistically significant, strong, and direct correlation between NIBP and eTMAP was found at 0° (r = 0.909, P ≤ .001), 30° (r = 0.874, P < .001), and 70° (r = 0.819, P < .001) of incline. The mean ratios of eTMAP to NIBP at 0°, 30°, and 70° of incline were 0.939 (95% confidence interval [CI], 0.915-0.964), 0.738 (95% CI, 0.704-0.771), and 0.629 (95% CI, 0.584-0.673), respectively. There was a statistically significant decrease in the eTMAP/NIBP ratio as patient incline increased from 0° to 30° (P < .001) and from 30° to 70° (P < .001). The eTMAP-to-NIBP ratio decreases as an anesthetized patient is placed into the beach chair position. Awareness of this phenomenon is important to ensure adequate cerebral perfusion and prevent hypoxic-related injuries. Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.
Redelinghuys, Michelle; Norton, Gavin R; Maseko, Muzi J; Majane, Olebogeng H I; Woodiwiss, Angela J
To compare the intra-familial aggregation and heritability of central (aortic) (PPc) versus peripheral (brachial) (PPp) pulse pressure after imputing pretreatment blood pressures (BPs) in treated participants in a community of black African ancestry. Central PPc [generalized transfer function (GTF) and radial P2-derived] was determined with applanation tonometry at the radial artery (SphygmoCor software) in 946 participants from 258 families with 23 families including three generations from an urban developing community of black Africans. In the 24.1% of participants receiving antihypertensive treatment, pretreatment brachial BP was imputed from published overall averaged effects of therapy grouped by class and dose, specific for groups of black African descent. From these data PPc was estimated from proportionate differences in central aortic and brachial PP. Heritability estimates were determined from SAGE software. Echocardiography was evaluated in 507 participants in order to determine stroke volume. With adjustments for confounders, parent-child (P < 0.05) and sibling-sibling (P < 0.0005) correlations were noted for log PPc, whilst for log PPp only sibling-sibling correlations were noted. No mother-father correlations were noted for either PPc or PPp. Independent of confounders the heritability for log GTF-derived (h = 0.33 ± 0.07, P < 0.0001) and P2-derived (h = 0.30 ± 0.07, P < 0.0001) PPc was greater than the heritability for log PPp (h = 0.11 ± 0.06, P < 0.05) (P < 0.05 for comparison of heritability estimates). After imputing pretreatment BP values, central aortic PP is significantly more inherited than brachial PP. These data suggest that in groups of African descent the genetic determinants of PP may be underestimated when employing brachial rather than central aortic PP measurements.
Gadsden, Jeff C; Choi, Jason J; Lin, Emily; Robinson, Allegra
Needle trauma may cause neuropathy after nerve blockade. Even without injection, nerve injury can result from forceful needle-nerve contact (NNC). High opening injection pressures (OIPs) have been associated with intrafascicular needle tip placement and nerve damage; however, the relationship between OIP and NNC is unclear. The authors conducted a prospective, observational study to define this relationship. Sixteen patients scheduled for shoulder surgery under interscalene block were enrolled if they had clear ultrasound images of the brachial plexus roots. A 22-gauge stimulating needle was inserted within 1 mm of the root, and 1-ml D5W injected at 10 ml/min by using an automated pump. OIP was monitored using an in-line pressure manometer and injections aborted if 15 psi or greater. The needle was advanced to displace the nerve slightly (NNC), and the procedure repeated. Occurrence of evoked motor response and paresthesia were recorded. Fifteen patients had at least one clearly visible root. OIP at 1 mm distance from the nerve was less than 15 psi (mean peak pressure 8.2 ± 2.4 psi) and the 1-ml injection could be completed in all but two cases (3%). In contrast, OIP during NNC was 15 psi or greater (mean peak pressure 20.9 ± 3.7 psi) in 35 of 36 injections. Aborting the injection when OIP reached 15 psi prevented commencement of injection in all cases of NNC except one. High OIP (≥15 psi) consistently detected NNC, suggesting that injection pressure monitoring may be useful in preventing injection against nerve roots during interscalene block.
Engvall, J.; Sonnhag, C.; Nylander, E.; Stenport, G.; Karlsson, E.; Wranne, B.
OBJECTIVE--To evaluate the difference in systolic blood pressure at the arm and ankle at rest and after various exercise tests for the assessment of aortic coarctation. METHODS--22 patients (mean age 33 years, range 17-66) were investigated on the suspicion of having haemodynamically significant aortic coarctation. Eight had undergone previous coarctation surgery, of whom five had received vascular grafts and three end to end anastomoses. The patients exercised submaximally while supine, seated on a bicycle, and walking on a treadmill, as well as exercising maximally on a treadmill. Arm and ankle blood pressure were measured with a cuff at rest and 1-10 minutes after exercise. Invasive pressures and cardiac output by thermodilution were recorded during catheterisation while patients were at rest and during and after supine bicycle exercise. The degree of constriction was assessed by angiography. Twelve healthy volunteers (mean age 32 years, range 17-56) provided reference values for cuff pressures after exercise. RESULTS--All patients with a difference in cuff pressure at rest of 35 mm Hg or more had a difference in invasive pressure of 35 mm Hg or more. Increasing severity of constriction on angiography correlated with larger pressure gradients at rest and during exercise (P < 0.0001). When cuff measurements after exercise were considered singly or combined to form a predictor they did not improve the prediction of the invasive pressure gradients at rest or after maximal exercise. A pressure gradient between arm and ankle also developed in normal subjects after maximal but not after submaximal exercise. CONCLUSION--In most patients with suspected haemodynamically significant coarctation the difference in cuff pressure between arm and ankle at rest is sufficient to select patients in need of further evaluation. If exercise is performed submaximal exercise is preferable. PMID:7727189
... your primary doctor. Treatments of the Ankle Achilles Tendinosis Surgery Achilles Tendon Rupture Surgery Ankle Arthrodesis Ankle ... for Osteochondral Lesions of the Talus Insertional Achilles Tendinosis Surgery Lateral Ankle Ligament Reconstruction Lateral Ankle Stabilization ...
Mettler, Abby; Chinn, Lisa; Saliba, Susan A; McKeon, Patrick O; Hertel, Jay
Chronic ankle instability (CAI) occurs in some people after a lateral ankle sprain and often results in residual feelings of instability and episodes of the ankle's giving way. Compared with healthy people, patients with CAI demonstrated poor postural control and used a more anteriorly and laterally positioned center of pressure (COP) during a single-limb static-balance task on a force plate. Balance training is an effective means of altering traditional COP measures; however, whether the overall location of the COP distribution under the foot also changes is unknown. To determine if the spatial locations of COP data points in participants with CAI change after a 4-week balance-training program. Randomized controlled trial. Laboratory. Thirty-one persons with self-reported CAI. Participants were randomly assigned to a 4-week balance-training program or no balance training. We collected a total of 500 COP data points while participants balanced using a single limb on a force plate during a 10-second trial. The location of each COP data point relative to the geometric center of the foot was determined, and the frequency count in 4 sections (anteromedial, anterolateral, posteromedial, posterolateral) was analyzed for differences between groups. Overall, COP position in the balance-training group shifted from being more anterior to less anterior in both eyes-open trials (before trial = 319.1 ± 165.4, after trial = 160.5 ± 149.5; P = .006) and eyes-closed trials (before trial = 387.9 ± 123.8, after trial = 189.4 ± 102.9; P < .001). The COP for the group that did not perform balance training remained the same in the eyes-open trials (before trial = 214.1 ± 193.3, after trial = 230.0 ± 176.3; P = .54) and eyes-closed trials (before trial = 326.9 ± 134.3, after trial = 338.2 ± 126.1; P = .69). In participants with CAI, the balance-training program shifted the COP location from anterolateral to posterolateral. The program may have repaired some of the damaged
Yiou, Eric; Hussein, Tarek; LaRue, Jacques
We investigated whether ankle loading modifies the relationship between temporal pressure and motor coordination during a whole-body paired task. Eight young healthy adults standing in an erect posture performed multiple series of simultaneous rapid leg flexions paired with ipsilateral index finger extensions. They repeated the task ten times in three load conditions: unloaded, loaded (where additional 5-kg inertia was attached to the ankles), and post-loaded (immediately following the loaded condition). These conditions were conducted in two blocks of temporal pressure: self-initiated (SI) versus reaction time (RT). When participants were unloaded, the results showed that index finger extension preceded swing heel-off in RT, and conversely in SI. By contrast, when the participants were loaded, swing heel-off preceded index finger extension in both SI and RT, showing that loading modified the relationship between temporal pressure and movement synchronization in RT only. However, loading did not induce any increase in the error of synchronization. Furthermore, in both the unloaded and loaded conditions, the duration of "anticipatory postural adjustments" (APA) was shorter when the temporal pressure was increased. Interestingly, the shorter APA duration was compensated by an increase in APA amplitude. Thus, loading did not modify the relationship between temporal pressure and anticipatory postural dynamics. Post-loaded and unloaded conditions produced the same results. These results show that the central nervous system optimally adapts the relationship between temporal pressure and motor coordination to transitory changes in the mechanical properties of the lower limbs, here due to ankle loading.
Manisty, Charlotte H; Hughes, Alun D
AIMS Brachial systolic blood pressure (bSBP) exceeds aortic pressure by a variable amount, and estimated central systolic blood pressure (cSBP) may be a better indicator of cardiovascular risk than bSBP. We undertook a systematic review and meta-analysis to compare the effect of single and multiple antihypertensive agents on bSBP, cSBP and augmentation index (AIx). Methods A random effects meta-analysis was performed on 24 randomized controlled trials of antihypertensives with measurements of bSBP, cSBP and/or AIx. Separate analyses were performed for drug comparisons with or without placebo, and drug combinations. Results In the placebo vs. drug meta-analysis, antihypertensive therapy reduced bSBP more than cSBP and there was no statistically significant evidence of heterogeneity by drug class, although the number of individual studies was small. In placebo-adjusted drug vs. drug comparison, treatment with β-blockers, omapatrilat and thiazide diuretics lowered cSBP significantly less than bSBP (i.e. central to brachial amplification decreased), whereas other monotherapies lowered cSBP and bSBP to similar extents. Sample sizes were too small and effect estimates insufficiently precise to allow firm conclusions to be made regarding comparisons between individual drug classes. Antihypertensive combinations that included β-blockers decreased central to brachial amplification. β-Blockers increased AIx, whereas all other antihypertensive agents reduced AIx to similar extents. CONCLUSIONS A reduction in central to brachial amplification by some classes of antihypertensive drug will result in lesser reductions in cSBP despite achievement of target bSBP. This effect could contribute to differences in outcomes in randomized clinical trials when β-blocker- and/or diuretic-based antihypertensive therapy are compared with other regimens. PMID:22625662
Manisty, Charlotte H; Hughes, Alun D
Brachial systolic blood pressure (bSBP) exceeds aortic pressure by a variable amount, and estimated central systolic blood pressure (cSBP) may be a better indicator of cardiovascular risk than bSBP. We undertook a systematic review and meta-analysis to compare the effect of single and multiple antihypertensive agents on bSBP, cSBP and augmentation index (AIx). A random effects meta-analysis was performed on 24 randomized controlled trials of antihypertensives with measurements of bSBP, cSBP and/or AIx. Separate analyses were performed for drug comparisons with or without placebo, and drug combinations. In the placebo vs. drug meta-analysis, antihypertensive therapy reduced bSBP more than cSBP and there was no statistically significant evidence of heterogeneity by drug class, although the number of individual studies was small. In placebo-adjusted drug vs. drug comparison, treatment with β-blockers, omapatrilat and thiazide diuretics lowered cSBP significantly less than bSBP (i.e. central to brachial amplification decreased), whereas other monotherapies lowered cSBP and bSBP to similar extents. Sample sizes were too small and effect estimates insufficiently precise to allow firm conclusions to be made regarding comparisons between individual drug classes. Antihypertensive combinations that included β-blockers decreased central to brachial amplification. β-Blockers increased AIx, whereas all other antihypertensive agents reduced AIx to similar extents. A reduction in central to brachial amplification by some classes of antihypertensive drug will result in lesser reductions in cSBP despite achievement of target bSBP. This effect could contribute to differences in outcomes in randomized clinical trials when β-blocker- and/or diuretic-based antihypertensive therapy are compared with other regimens. © 2012 The Authors. British Journal of Clinical Pharmacology © 2012 The British Pharmacological Society.
Minamisawa, Masatoshi; Ueki, Yasushi; Abe, Naoyuki; Nishimura, Hitoshi; Hashizume, Naoto; Mochidome, Tomoaki; Harada, Mikiko; Oguchi, Yasutaka; Yoshie, Koji; Shoin, Wataru; Saigusa, Tatsuya; Ebisawa, Soichiro; Motoki, Hirohiko; Koyama, Jun; Ikeda, Uichi; Kuwahara, Koichiro
Background The ankle—brachial index (ABI) is a marker of generalized atherosclerosis and is predictive of future cardiovascular events. However, few studies have assessed its relation to long-term future cardiovascular events, especially in patients with borderline ABI. We therefore evaluated the relationship between long-term future cardiovascular events and ABI. Methods In the IMPACT-ABI study, a single-center, retrospective cohort study, we enrolled 3131 consecutive patients (67 ± 13 years; 82% male) hospitalized for cardiovascular disease and measured ABI between January 2005 and December 2012. After excluding patients with an ABI > 1.4, the remaining 3056 patients were categorized as having low ABI (≤ 0.9), borderline ABI (0.91–0.99), or normal ABI (1.00–1.40). The primary endpoint was MACE (cardiovascular death, myocardial infarction [MI] and stroke). The secondary endpoints were cardiovascular death, MI, stroke, admission due to heart failure, and major bleeding. Results During a 4.8-year mean follow-up period, the incidences of MACE (low vs. borderline vs. normal: 32.9% vs. 25.0% vs. 14.6%, P<0.0001) and cardiovascular death (26.2% vs. 18.7% vs. 8.9%, P<0.0001) differed significantly across ABIs. The incidences of stroke (9.1% vs. 8.6% vs. 4.8%, P<0.0001) and heart failure (25.7% vs. 20.8% vs. 8.9%, P<0.0001) were significantly higher in the low and borderline ABI groups than in the normal ABI group. But the incidences of MI and major bleeding were similar in the borderline and normal ABI groups. The hazard ratios for MACE adjusted for traditional atherosclerosis risk factors were significantly higher in patients with low and borderline ABI than those with normal ABI (HR, 1.93; 95%CI: 1.44–2.59, P < 0.0001, HR, 1.54; 95% CI: 1.03–2.29, P = 0.035). Conclusions The incidence of long-term adverse events was markedly higher among patients with low or borderline ABI than among those with normal ABI. This suggests that more attention should be paid
Matthews, Evan L; Brian, Michael S; Ramick, Meghan G; Lennon-Edwards, Shannon; Edwards, David G; Farquhar, William B
Recent studies demonstrate that high dietary sodium (HS) impairs endothelial function in those with salt-resistant (SR) blood pressure (BP). The effect of HS on endothelial function in those with salt-sensitive (SS) BP is not currently known. We hypothesized that HS would impair brachial artery flow-mediated dilation (FMD) to a greater extent in SS compared with SR adults. Ten SR (age 42 ± 5 yr, 5 men, 5 women) and 10 SS (age 39 ± 5 yr, 5 men, 5 women) healthy, normotensive participants were enrolled in a controlled feeding study consisting of a run-in diet followed by a 7-day low dietary sodium (LS) (20 mmol/day) and a 7-day HS (300 mmol/day) diet in random order. Brachial artery FMD and 24-h BP were assessed on the last day of each diet. SS BP was individually assessed and defined as a change in 24-h mean arterial pressure (MAP) of >5 mmHg between the LS and HS diets (ΔMAP: SR -0.6 ± 1.2, SS 7.7 ± 0.4 mmHg). Brachial artery FMD was lower in both SS and SR individuals during the HS diet (P < 0.001), and did not differ between groups (P > 0.05) (FMD: SR LS 10.6 ± 1.3%, SR HS 7.2 ± 1.5%, SS LS 12.5 ± 1.7%, SS HS 7.8 ± 1.4%). These data indicate that an HS diet impairs brachial artery FMD to a similar extent in adults with SS BP and SR BP.
Matthews, Evan L.; Brian, Michael S.; Ramick, Meghan G.; Lennon-Edwards, Shannon; Edwards, David G.
Recent studies demonstrate that high dietary sodium (HS) impairs endothelial function in those with salt-resistant (SR) blood pressure (BP). The effect of HS on endothelial function in those with salt-sensitive (SS) BP is not currently known. We hypothesized that HS would impair brachial artery flow-mediated dilation (FMD) to a greater extent in SS compared with SR adults. Ten SR (age 42 ± 5 yr, 5 men, 5 women) and 10 SS (age 39 ± 5 yr, 5 men, 5 women) healthy, normotensive participants were enrolled in a controlled feeding study consisting of a run-in diet followed by a 7-day low dietary sodium (LS) (20 mmol/day) and a 7-day HS (300 mmol/day) diet in random order. Brachial artery FMD and 24-h BP were assessed on the last day of each diet. SS BP was individually assessed and defined as a change in 24-h mean arterial pressure (MAP) of >5 mmHg between the LS and HS diets (ΔMAP: SR −0.6 ± 1.2, SS 7.7 ± 0.4 mmHg). Brachial artery FMD was lower in both SS and SR individuals during the HS diet (P < 0.001), and did not differ between groups (P > 0.05) (FMD: SR LS 10.6 ± 1.3%, SR HS 7.2 ± 1.5%, SS LS 12.5 ± 1.7%, SS HS 7.8 ± 1.4%). These data indicate that an HS diet impairs brachial artery FMD to a similar extent in adults with SS BP and SR BP. PMID:26078434
... ankle - arthroscopy; Surgery - ankle - arthroscopic References Cerrato R, Campbell J, Triche R. Ankle arthroscopy. In: Miller MD, ... and ankle. In: Canale ST, Beaty JH, eds. Campbell's Operative Orthopaedics . 12th ed. Philadelphia, PA: Elsevier Mosby; ...
Tanno, Jun; Gatate, Yodo; Kasai, Takatoshi; Nakano, Shintaro; Senbonmatsu, Takaaki; Sato, Osamu; Ichioka, Shigeru; Kuro-O, Makoto; Nishimura, Shigeyuki
In peripheral arterial disease (PAD) of the lower extremities, the presence of flow-limiting stenoses can be objectively detected by the ankle-brachial index (ABI). However, the severity of ischemic symptoms is not necessarily associated with the ABI value. Atherosclerotic plaque in lower extremity PAD induces ankle arterial stiffness and reduces ankle vascular resistance, which may decrease ankle blood flow and cause ischemic symptoms. We hypothesized that the ankle hemodynamic index (AHI), defined as the ratio of ankle arterial stiffness to ankle vascular resistance, could be used to assess the blood supply deficiency in a diseased lower limb in patients with PAD. The 85 consecutive patients with PAD who were retrospectively analyzed in this study had Rutherford grade 1 to grade 6 ischemia diagnosed as PAD and significant stenotic lesions (>50% diameter stenosis) of the lower extremity on contrast angiography. The AHI was calculated as the product of the ankle pulse pressure and the ratio of heart rate to ankle mean arterial pressure (ankle pulse pressure × heart rate/ankle mean arterial pressure). The Rutherford grade was significantly correlated with the AHI (r = 0.50, P < 0.001), but not with the ABI (r = 0.07, P = 0.52). Multiple ordinal regression analysis showed that anemia (odds ratio 0.66, P = 0.002) and AHI (odds ratio 1.04, P = 0.02) were independently associated with Rutherford grade. Our study shows that AHI, a novel parameter based on the ABI measurement, is well correlated with ischemic symptoms, and may be a useful means to assess the arterial blood supply of the lower extremities of patients with PAD.
Maltz, Jonathan S; Tison, Geoffrey H; Alley, Hugh F; Budinger, Thomas F; Owens, Christopher D; Olgin, Jeffrey
The integrity of endothelial function in major arteries (EFMA) is a powerful independent predictor of heart attack and stroke. Existing ultrasound-based non-invasive assessment methods are technically challenging and suitable only for laboratory settings. EFMA, like blood pressure (BP), is both acutely and chronically affected by factors such as lifestyle and medication. Consequently, lab-based measurements cannot fully gauge the effects of medical interventions on EFMA. EFMA and BP have, arguably, comparable (but complementary) value in the assessment of cardiovascular health. Widespread deployment of EFMA assessment is thus a desirable clinical goal. To this end, we propose a device based on modifying the measurement protocol of a standard electronic sphygmomanometer. Methods The protocol involves inflating the cuff to sub-diastolic levels to enable recording of the pulse waveform before and after vasodilatory stimulus. The mechanical unloading of the arterial wall provided by the cuff amplifies the distension that occurs with each pulse, which is measured as a pressure variation in the cuff. We show that the height of the rising edge of each pulse is proportional to the change in lumen area between diastole and systole. This allows the effect of vasodilatory stimuli on the artery to be measured with high sensitivity. We compare the proposed cuff flow-mediated dilation (cFMD) method to ultrasound FMD (uFMD). Results We find significant correlation (r=0.55, p = 0.003, N=27) between cFMD- and uFMD-based metrics obtained when the release of a 5-minute cuff occlusion is employed to induce endothelial stimulus via reactive hyperemia. cFMD is approximately proportional to the square of uFMD, representing a typical increase in sensitivity to vasodilation of 300–600%. Conclusion This study illustrates the potential for an individual to conveniently measure his/her EFMA by using a low-cost reprogrammed home sphygmomanometer. PMID:26393958
Wassel, Christina L.; Lamina, Claudia; Nambi, Vijay; Coassin, Stefan; Mukamal, Kenneth J.; Ganesh, Santhi K.; Jacobs, David R.; Franceschini, Nora; Papanicolaou, George J.; Gibson, Quince; Yanek, Lisa R.; van der Harst, Pim; Ferguson, Jane F.; Crawford, Dana C.; Waite, Lindsay L.; Allison, Matthew A.; Criqui, Michael H.; McDermott, Mary M.; Mehra, Reena; Cupples, L. Adrienne; Hwang, Shih-Jen; Redline, Susan; Kaplan, Robert C.; Heiss, Gerardo; Rotter, Jerome I.; Boerwinkle, Eric; Taylor, Herman A.; Eraso, Luis H.; Haun, Margot; Li, Mingyao; Meisinger, Christa; O’Connell, Jeffrey R.; Shuldiner, Alan R.; Tybjærg-Hansen, Anne; Frikke-Schmidt, Ruth; Kollerits, Barbara; Rantner, Barbara; Dieplinger, Benjamin; Stadler, Marietta; Mueller, Thomas; Haltmayer, Meinhard; Klein-Weigel, Peter; Summerer, Monika; Wichmann, H.-Erich; Asselbergs, Folkert W.; Navis, Gerjan; Leach, Irene Mateo; Brown-Gentry, Kristin; Goodloe, Robert; Assimes, Themistocles L.; Becker, Diane M.; Cooke, John P.; Absher, Devin M.; Olin, Jeffrey W.; Mitchell, Braxton D.; Reilly, Muredach P.; Mohler, Emile R.; North, Kari E.; Reiner, Alexander P.; Kronenberg, Florian; Murabito, Joanne M.
Background Candidate gene association studies for peripheral artery disease (PAD), including subclinical disease assessed with the ankle-brachial index (ABI), have been limited by the modest number of genes examined. We conducted a two stage meta-analysis of ~50,000 SNPs across ~2100 candidate genes to identify genetic variants for ABI. Methods and results We studied subjects of European ancestry from 8 studies (n = 21,547, 55% women, mean age 44–73 years) and African American ancestry from 5 studies (n = 7267, 60% women, mean age 41–73 years) involved in the candidate gene association resource (CARe) consortium. In each ethnic group, additive genetic models were used (with each additional copy of the minor allele corresponding to the given beta) to test each SNP for association with continuous ABI (excluding ABI > 1.40) and PAD (defined as ABI < 0.90) using linear or logistic regression with adjustment for known PAD risk factors and population stratification. We then conducted a fixed-effects inverse-variance weighted meta-analyses considering a p < 2 × 10−6 to denote statistical significance. Results In the European ancestry discovery meta-analyses, rs2171209 in SYTL3 (β = −0.007, p = 6.02 × 10−7) and rs290481 in TCF7L2 (β = −0.008, p = 7.01 × 10−7) were significantly associated with ABI. None of the SNP associations for PAD were significant, though a SNP in CYP2B6 (p = 4.99 × 10−5) was among the strongest associations. These 3 genes are linked to key PAD risk factors (lipoprotein(a), type 2 diabetes, and smoking behavior, respectively). We sought replication in 6 population-based and 3 clinical samples (n = 15,440) for rs290481 and rs2171209. However, in the replication stage (rs2171209, p = 0.75; rs290481, p = 0.19) and in the combined discovery and replication analysis the SNP–ABI associations were no longer significant (rs2171209, p = 1.14 × 10−3; rs290481, p = 8.88 × 10−5). In African Americans, none of the SNP associations for
Broholm, Rikke; Wiinberg, Niels; Simonsen, Lene
Measurement of the ankle and toe pressures are often performed using a plethysmograph, compression cuffs and a strain gauge. Usually, the strain gauge contains mercury but other alternatives exist. From 2014, the mercury-containing strain gauge will no longer be available in the European Union. The aim of this study was to compare an indium-gallium strain gauge to the established mercury-containing strain gauge. Consecutive patients referred to the Department of Clinical Physiology and Nuclear Medicine at Bispebjerg and Frederiksberg Hospitals for measurements of systolic ankle and toe pressures volunteered for the study. Ankle and toe pressures were measured twice with the mercury and the indium-gallium strain gauge in random order. Comparison of the correlation between the mean pressure using the mercury and the indium-gallium device and the difference between the two devices was performed for both toe and ankle level. A total of 53 patients were included (36 male). Mean age was 69 (range, 45-92 years). Mean pressures at toe and ankle level with the mercury and the indium-gallium strain gauges were 77 (range, 0-180) mm Hg and 113 (range, 15-190) mm Hg, respectively. Comparison between the mercury and the indium-gallium strain gauge showed a difference in toe blood pressure values of - 0.7 mm Hg (SD: 7.0). At the ankle level, a difference of 2.0 mm Hg (SD: 8.6) was found. The two different devices agree sufficiently in the measurements of systolic ankle and toe pressure for the indium-gallium strain gauge to replace the mercury strain gauge.
Dillin, L; Hoaglund, F T; Scheck, M
Brachial neuritis is an unusual syndrome of unknown etiology that can be confused with other causes of pain or weakness, or both, of the shoulder and arm. It is important to distinguish this disorder because of its dramatic symptoms and relatively good prognosis. Sharp pain, usually in the elbow or shoulder, marks the onset of brachial neuritis, but is relatively short-lived. Weakness generally occurs as the pain is subsiding and most frequently involves the deltoid, spinati, serratus anterior, biceps, and triceps. Paresthesias, atrophy, and sensory loss are inconstant features. Electromyographic findings of fibrillation potentials and positive waves characteristically are found in a pattern indicating combined nerve-root and peripheral nerve involvement. Electromyography more frequently than clinical examination shows that the lesion is bilateral, and also is of both diagnostic and prognostic value. Other laboratory studies serve only to exclude other causes of shoulder pain. The clinical course is variable, but in 90 per cent of patients complete recovery occurs within three years. Recurrences are uncommon.
Haarala, A; Kähönen, M; Lehtimäki, T; Aittoniemi, J; Jylhävä, J; Hutri-Kähönen, N; Taittonen, L; Laitinen, T; Juonala, M; Viikari, J; Raitakari, O T; Hurme, M
Human cytomegalovirus (CMV) infection is associated with a higher risk of cardiovascular disease in immunocompromised organ transplant patients. It has been linked with the pathogenesis of elevated arterial blood pressure. However, controversy exists as to whether CMV infection is associated with endothelial function, and little is known about its role as a potential risk factor for early atherosclerosis development at a young age. We aimed to discover if CMV antibody titres are associated with early vascular changes (carotid intima-media thickness, carotid artery distensibility and brachial artery flow-mediated dilation), blood pressure elevation or other traditional cardiovascular risk factors. CMV antibody titres were measured in 1074 women and 857 men (aged 24-39 years) taking part in the Cardiovascular Risk in Young Finns study. CMV antibody titres were significantly higher in women compared to men. In men, high CMV antibody titres were associated directly with age (P < 0·001) and systolic (P = 0·053) and diastolic (P = 0·002) blood pressure elevation, and associated inversely with flow-mediated dilation (P = 0·014). In women, CMV antibody titres did not associate with any of the analysed parameters. In a multivariate regression model, which included traditional atherosclerotic risk factors, CMV antibody titres were independent determinants for systolic (P = 0·029) and diastolic (P = 0·004) blood pressure elevation and flow-mediated dilation (P = 0·014) in men. High CMV antibody titres are associated independently with blood pressure and brachial artery flow-mediated dilation in young men. This association supports the hypothesis that common CMV infection and/or an immune response to CMV may lead to impaired vascular function at a young age. © 2012 The Authors. Clinical and Experimental Immunology © 2012 British Society for Immunology.
Papadopoulos, Emmanuel S; Nikolopoulos, Christos; Badekas, Athanasios; Vagenas, George; Papadakis, Stamatios A; Athanasopoulos, Spyros
Background Several studies have been carried out in order to investigate the effect of ankle bracing on ankle joint function and performance. However, no study so far has examined the role of skin-brace interface pressure in neuromuscular control. The aim of this study was to investigate the effect of different skin-ankle brace interface pressures on quiet single limb balance and the electromyographic (EMG) activation sequence of four lower limb muscles. Methods Thirty three male physical education students who volunteered to take part in the study were measured under three ankle brace conditions: i) without brace, ii) with brace and 30 kPa application pressure and iii) with brace and 60 kPa application pressure. Single limb balance (anteroposterior and mediolateral parameter) was assessed on the dominant lower limb, with open and closed eyes, on a force platform, simultaneously with the EMG recording of four lower lower limb muscles' (gastrocnemius, peroneus longus, rectus femoris and biceps femoris) activation onset. Results The results showed that overall balance (total stability parameter) was not significantly affected in any of the three ankle brace conditions. However, the anteroposterior centre of pressure excursion and centre of pressure excursion velocity were significantly increased with the application of ankle brace, both with 30 and 60 kPa application pressures. Furthermore, it was found that single limb balance was significantly worse with closed eyes compared to open eyes. EMG measurements showed that the sequence of lower limb activation onset was not affected in any of the three ankle brace application conditions. The results of this study showed that the application of an ankle brace with two different skin-brace interface pressures had no effect on overall single limb balance and the sequence of lower limb muscle activation. Conclusion These findings suggest that peripheral joint receptors are either not adequately stimulated by the brace
deSouza, Ian S; Benabbas, Roshanak; McKee, Sean; Zangbar, Bardiya; Jain, Ashika; Paladino, Lorenzo; Boudourakis, Leon; Sinert, Richard
Penetrating Extremity Trauma (PET) may result in arterial injury, a rare but limb- and life-threatening surgical emergency. Timely, accurate diagnosis is essential for potential intervention in order to prevent significant morbidity. Using a systematic review/meta-analytic approach, we determined the utility of physical examination, Ankle-Brachial Index (ABI), and Ultrasonography (US) in the diagnosis of arterial injury in emergency department (ED) patients who have sustained PET. We applied a test-treatment threshold model to determine which evaluations may obviate CT Angiography (CTA). We searched PubMed, Embase, and Scopus from inception to November 2016 for studies of ED patients with PET. We included studies on adult and pediatric subjects. We defined the reference standard to include CTA, catheter angiography, or surgical exploration. When low-risk patients did not undergo the reference standard, trials must have specified that patients were observed for at least 24 hours. We used the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) to evaluate bias and applicability of the included studies. We calculated positive and negative likelihood ratios (LR+ and LR-) of physical examination ("hard signs" of vascular injury), US, and ABI. Using established CTA test characteristics (sensitivity = 96.2%, specificity = 99.2%) and applying the Pauker-Kassirer method, we developed a test-treatment threshold model (testing threshold = 0.14%, treatment threshold = 72.9%). We included eight studies (n = 2,161, arterial injury prevalence = 15.5%). Studies had variable quality with most at high risk for partial and double verification bias. Some studies investigated multiple index tests: physical examination (hard signs) in three studies (n = 1,170), ABI in five studies (n = 1,040), and US in four studies (n = 173). Due to high heterogeneity (I(2) > 75%) of the results, we could not calculate LR+ or LR- for hard signs or LR+ for ABI. The
Kobayashi, Masatake; Oshima, Kazutaka; Iwasaki, Yoichi; Kumai, Yuto; Avolio, Alberto; Yamashina, Akira; Takazawa, Kenji
Brachial systolic pressure (BSP) is often monitored during exercise by the stress test; however, central systolic pressure (CSP) is thought to be a more direct measure of cardiovascular events. Although some studies reported that exercise and aging may play roles in changes of both BSP and CSP, the relationship between BSP and CSP with age following the exercise stress test remains unclear. The aim of this study was to evaluate the effect of age on the relationship between BSP and CSP measured after exercise. Ninety-six subjects underwent the diagnostic treadmill exercise stress test, and we retrospectively divided them into the following 3 groups by age: the younger age group (43 ± 4 years), middle age group (58 ± 4 years), and older age group (70 ± 4 years). Subjects exercised according to the Bruce protocol, to achieve 85 % of their age-predicted maximum heart rate or until the appearance of exercise-associated symptoms. BSP, CSP, and pulse rate (PR) were measured using a HEM-9000AI (Omron Healthcare, Japan) at rest and after exercise. BSP, CSP, and PR at rest were not significantly different among the 3 groups (p = 0.92, 0.21, and 0.99, respectively). BSP and PR immediately after exercise were not significantly different among the groups (p = 0.70 and 0.38, respectively). However, CSP immediately after exercise was 144 ± 18 mmHg (younger age), 149 ± 17 mmHg (middle age), and 158 ± 19 mmHg (older age). CSP in the older age group was significantly higher than that in the younger age group (p < 0.01). Despite similar BSPs in all age groups after exercise, CSP was higher in the older age group. Therefore, older subjects have a higher CSP after exercise, which is not readily assessed by conventional measurements of BSP.
Sarafidis, P A; Lazaridis, A A; Imprialos, K P; Georgianos, P I; Avranas, K A; Protogerou, A D; Doumas, M N; Athyros, V G; Karagiannis, A I
Ambulatory blood pressure monitoring is an important tool in hypertension diagnosis and management. Although several ambulatory devices exist, comparative studies are scarce. This study aimed to compare for the first time brachial blood pressure levels of Spacelabs 90217A and Mobil-O-Graph NG, under static and ambulatory conditions. We examined 40 healthy individuals under static (study A) and ambulatory (study B) conditions. In study A, participants were randomized into two groups that included blood pressure measurements with mercury sphygmomanometer, Spacelabs and Mobil-O-Graph devices with reverse order of recordings. In study B, simultaneous 6-h recordings with both devices were performed with participants randomized in two sequences of device positioning with arm reversal at 3 h. Finally, all the participants filled in a questionnaire rating their overall preference for a device. In study A, brachial systolic blood pressure (117.2±10.3 vs 117.1±9.8 mm Hg, P=0.943) and diastolic blood pressure (73.3±9.4 mm Hg vs 74.1±9.4 mm Hg, P=0.611) did not differ between Spacelabs and Mobil-O-Graph or vs sphygmomanometer (117.8±11.1 mm Hg, P=0.791 vs Spacelabs, P=0.753 vs Mobil-O-Graph). Similarly, no differences were found in ambulatory systolic blood pressure (117.9±11.4 vs 118.3±11.0 mm Hg, P=0.864), diastolic blood pressure (73.7±7.4 vs 74.7±8.0 mm Hg, P=0.571), mean blood pressure and heart rate between Spacelabs and Mobil-O-Graph. Correlation analyses and Bland-Altman plots showed agreement between the monitors. Overall, the participants showed a preference for the Mobil-O-Graph. Spacelabs 90217A and Mobil-O-Graph NG provide practically identical measurements during the static and ambulatory conditions in healthy individuals and can be rather used interchangeably in clinical practice.
... to the shoulder, arm, and hand. Brachial plexus injuries are caused by damage to those nerves. Symptoms ... sensation in the arm or hand Brachial plexus injuries can occur as a result of shoulder trauma, ...
The brachial plexus is a group of nerves that originate from the neck region and branch off to give ... movement in the upper limb. Injuries to the brachial plexus are common and can be debilitating. If ...
Shirai, Kohji; Utino, Junji; Saiki, Atsuhito; Endo, Kei; Ohira, Masahiro; Nagayama, Daiji; Tatsuno, Ichiro; Shimizu, Kazuhiro; Takahashi, Mao; Takahara, Akira
Arterial stiffness has been known to be a surrogate marker of arteriosclerosis, and also of vascular function. Pulse wave velocity (PWV) had been the most popular index and was known to be a predictor of cardiovascular events. But, it depends on blood pressure at measuring time. To overcome this problem, cardio-ankle vascular index (CAVI) is developed. CAVI is derived from stiffness parameter β by Hayashi, and the equation of Bramwell-Hill, and is independent from blood pressure at a measuring time. Then, CAVI might reflect the proper change of arterial wall by antihypertensive agents. CAVI shows high value with aging and in many arteriosclerotic diseases and is also high in persons with main coronary risk factors. Furthermore, CAVI is decreased by an administration of α1 blocker, doxazosin for 2-4 hours, Those results suggested that CAVI reflected the arterial stiffness composed of organic components and of smooth muscle cell contracture. Angiotensin II receptor blocker, olmesartan decreased CAVI much more than that of calcium channel antagonist, amlodipine, even though the rates of decreased blood pressure were almost same. CAVI might differentiate the blood pressure-lowering agents from the point of the effects on proper arterial stiffness. This paper reviewed the principle and rationale of CAVI, and the possibilities of clinical applications, especially in the studies of hypertension. PMID:23807874
... or outside of your ankle or along the Achilles tendon, which connects the muscles in your lower ... home. Accessed Dec. 15, 2015. Draper TR. Non-Achilles ankle tendinopathy. http://www.uptodate.com/home. Accessed ...
Sands, Andrew; White, Charles; Blankstein, Michael; Zderic, Ivan; Wahl, Dieter; Ernst, Manuela; Windolf, Markus; Hagen, Jennifer E; Richards, R Geoff; Stoffel, Karl; Gueorguiev, Boyko
Lateral talar process fragment excision may be followed by hindfoot instability and altered biomechanics. There is controversy regarding the ideal fragment size for internal fixation versus excision and a concern that excision of a large fragment may lead to significant instability. The aim of this study was to assess the effect of a simulated large lateral talar process excision on ankle and subtalar joint stability.A custom-made seesaw rig was designed to apply inversion/eversion stress loading on 7 fresh-frozen human cadaveric lower legs and investigate them in pre-excision, 5 cm and 10 cm lateral talar process fragment excision states. Anteroposterior radiographs were taken to assess ankle and subtalar joint tilt and calculate angular change from neutral hindfoot alignment to 10-kg forced inversion/eversion. Ankle joint pressures and contact areas were measured under 30-kg axial load in neutral hindfoot alignment.In comparison to the pre-excision state, no significantly different mediolateral angular change was observed in the subtalar joint after 5 and 10 cm lateral talar process fragment excision in inversion and eversion. With respect to the ankle joint, 10-cm fragment excision produced significantly bigger inversion tibiotalar tilt compared with the pre-excision state, P = .04. No significant change of the ankle joint pressure and contact area was detected after 5 and 10-cm excision in comparison with the pre-excison state.An excision of up to 10 cm of the lateral talar process does not cause a significant instability at the level of the subtalar joint but might be a destabilizing factor at the ankle joint under inversion stress. The latter could be related to extensive soft tissue dissection required for resection.
Fourcade, G; Taieb, G; Renard, D; Labauge, P; Pradal-Prat, D
Brachial plexus is rarely involved in "Saturday night palsy". A young man was admitted for numbness and weakness of his right upper limb after awaking from sleep. Neurophysiological studies, consistent with brachial plexopathy, revealed presence of proximal conduction blocks. Patient presented spontaneous clinical and neurophysiological improvement. Diagnosis of compressive brachial plexopathy needs to eliminate other causes of neuropathy with conduction block. Copyright © 2010 Elsevier Masson SAS. All rights reserved.
Bokuda, Kanako; Ichihara, Atsuhiro; Sakoda, Mariyo; Mito, Asako; Kinouchi, Kenichiro; Itoh, Hiroshi
Angiotensin receptor blockers (ARBs) are known to reduce the cardiovascular risk in hypertensive patients. This study was designed to examine the effect of an ARB candesartan on subclinical atherosclerosis assessed by cardio-ankle vascular index (CAVI) in comparison with calcium channel blockers (CCBs) alone in hypertensive patients with metabolic syndrome (MetS). A total of 53 consecutive hypertensive patients with MetS were randomly assigned to the candesartan group, in which candesartan was added on, or the CCBs group, in which CCBs were added on. Clinical and biological parameters were obtained before and after the 12-month treatment period. The primary measure of efficacy was the %change in CAVI. When treated with candesartan, but not CCBs, CAVI significantly decreased from 8.7 to 7.7 by 11%. Blood pressure (BP) significantly decreased with both treatments, but the differences between groups were not significant. The changes in other parameters remained unchanged in both the groups. Analysis of covariance found that both the BP reduction and the therapy difference contributed to the decrease in CAVI, but the BP reduction was not involved in the decrease in CAVI caused by the difference in the therapy. Candesartan may be a better antihypertensive drug than CCBs to improve subclinical atherosclerosis of patients with MetS. PMID:20730073
Butlin, M; Alqahtani, A; Qasem, A; Turner, M; Avolio, A P
For ease of measurement, and the utility of ambulatory central aortic blood pressure measurement, there has been a move toward brachial cuff-based devices for non-invasive computation of central aortic blood pressure quantities based on waveform features. However, waveforms detected by volumetric cuff displacement techniques are inherently more damped than signals obtained by applanation tonometry, potentially impacting on parameters reliant on higher frequency components of the pulse waveform. In 45 subjects (age 46 ± 17 years, 30 male), in-clinic, seated measurements taken in triplicate using three brachial cuff-based devices (BPLab, [Petr Telgin]; Oscar2, [SunTech/AtCor Medical]; SphygmoCor XCEL, [AtCor Medical]) were compared using repeated measures ANOVA and Bland-Altman statistics against radial tonometric assessment of central aortic pressure (SphygmoCor CvMS, [AtCor Medical]). Results are expressed as means ± standard error. There was good agreement between devices for aortic systolic pressure (aSP) and aortic diastolic pressure (aDP). There was great variability in aortic augmentation index (aAIx), ejection duration (ED) and subendocardial viability ratio (SEVR, Table). Cuff-based device regression slopes against the tonometer-based method varied markedly for aSP (BPLab, 0.76; Oscar2, 0.92; XCEL, 0.77), aAIx (BPLab, 0.32; Oscar2, 0.74; XCEL, 0.88), ED (BPLab, 1.07; Oscar2 does not report; XCEL, 0.83), and SEVR (BPLab, 0.16; Oscar2 does not report; XCEL, 0.81).(Figure is included in full-text article.) : Parameters relying on the low frequency components of the peripheral waveform have better agreement between cuff-based devices than parameters that rely on higher frequency waveform components. Further research is required for quantitative assessment of filtering methods utilised in cuff-based devices, as well as the cuff-based approach itself for use in measuring AIx, ED and SEVR.
Peluso, Gonzalo; García-Espinosa, Victoria; Curcio, Santiago; Marota, Marco; Castro, Juan; Chiesa, Pedro; Giachetto, Gustavo; Bia, Daniel; Zócalo, Yanina
In adults, central blood pressure (cBP) is reported to associate target organ damages (TODs) rather than peripheral blood pressure (pBP). However, data regarding the association of pre-clinical TODs with cBP and pBP in pediatric populations are scarce. To evaluate in children and adolescents the importance of cBP and pBP levels, in terms of their association with hemodynamic and vascular changes. 315 subjects [age (mean/range) 12/8-18 years] were included. pBP (oscillometry, Omron-HEM433INT and Mobil-O-Graph), cBP levels and waveforms (oscillometry, Mobil-O-Graph; applanation tonometry, SphygmoCor), aortic wave reflection-related parameters, carotid intima-media thickness (CIMT) and carotid (elastic modulus, stiffness-index) and aortic stiffness (carotid-femoral pulse wave velocity, PWV). Four groups were defined considering pBP and cBP percentiles (th): cBP ≥90th, cBP <90th, pBP ≥90th, pBP <90th. In each group, haemodynamic and vascular parameters were compared for subgroups defined considering the level of the remaining blood pressure (cBP or pBP). Subgroups were matched for anthropometric and cardiovascular risk factors (propensity matching-score). Subjects with high cBP showed a worse cardiovascular risk profile in addition to worse peripheral hemodynamic conditions. The CIMT, carotid and aortic stiffness levels were also higher in those subjects. CIMT and carotid stiffness remained statistically higher when subjects were matched for pBP and other cardiovascular risk factors. There were no differences in arterial properties when subjects were analyzed (compared) considering similar pBP levels, during normal and high cBP conditions. Compared with pBP, the cBP levels show a greater association with vascular alterations (high CIMT and arterial stiffness), in children and adolescents.
Chakraborty, Partha Pratim; Ray, Sayantan; Biswas, Dibakar; Baidya, Arjun; Bhattacharjee, Rana; Mukhopadhyay, Pradip; Ghosh, Sujoy; Mukhopadhyay, Satinath; Chowdhury, Subhankar
Background: Off-loading of the ulcer area is extremely important for the healing of plantar ulcers. Off-loading with total contact cast (TCC) may be superior to other off-loading strategies studied so far, but practical limitations can dissuade clinicians from using this modality. This study was conducted to evaluate the efficacy of TCC compared with that of a pressure-relieving ankle foot orthosis (PRAFO) in healing of diabetic neuropathic foot ulcers and their effect on gait parameters. Methods: Thirty adult diabetic patients attending the foot clinic with neuropathic plantar ulcers irrespective of sex, age, duration and type of diabetes were randomly assigned to 1 of 2 off-loading modalities (TCC and PRAFO). Main outcome measures were ulcer healing after 4 weeks of randomization and effect of each of the modalities on various gait parameters. Results: The percentage reduction of the ulcer surface area at 4 weeks from baseline was 75.75 ± 9.25 with TCC and 34.72 ± 13.07 with PRAFO, which was significantly different (P < .001). The results of this study however, showed that most of the gait parameters were better with PRAFO than with TCC. Conclusions: This study comprehensively evaluated the well known advantages and disadvantages of a removable (PRAFO) and a nonremovable device (TCC) in the treatment of diabetic neuropathic foot ulcer. Further studies are needed involving larger subjects and using 3D gait analysis to collect more accurate data on gait parameters and wound healing with different off-loading devices. PMID:25452635
Bradley, W G; Madrid, R; Thrush, D C; Campbell, M J
The clinical, electrophysiological and pathological changes in 3 patients with recurrent attacks of non-traumatic brachial plexus neuropathy have been described. Two had recurrent attacks and a dominant family history of similar attacks, together with evidence of lesser degrees of nerve involvement outside the brachial plexus. In one patient the attacks were moderately painful, while in the other there was little or no pain. Only one showed undue slowing of motor nerve conduction during ischaemia, but in both cases the sural nerves had the changes of tomaculous neuropathy, with many sausage-shaped swellings of the myelin sheaths, and extensive segmental demyelination and remyelination. The third patient had two attacks of acute brachial plexus neuropathy which were both extremely painful. The clinical features were compatible with a diagnosis of neuralgic amuotrophy. In the second attack, there was vagus nerve involvement and the sural nerve showed evidence of healed extensive segmental demyelination. The various syndromes presenting with acute non-traumatic brachial plexus neuropathy are reviewed, and a tentative nonsological classification advanced. Most patients fall into the category of acute, painful paralysis with amyotrophy, with no family history and no evidence of lesions outside the brachial plexus. It is suggested that the term "neuralgic amyotrophy" be restricted to this group. Patients with features outside this clinical picture probably suffer from other disease entities presenting with brachial plexus neuropathy. The familial cases constitute one or more aetioliogical subgroups, differing from neuralgic amyotrophy in the frequency of recurrences, the relative freedom from pain in the attacks, the frequency of nerve lesions outside the brachial plexus, and of hypotelorism. Individual attacks of acute brachial plexus neuropathy, however, may be identical in patients with the different diseases, and further pathological and biochemical studies are
... the sole of the foot is facing inwards, stretching and possibly damaging the ligaments on the outer ... sprains: Always warm up and use the recommended stretching techniques for your ankles before playing sports, exercising, ...
... is surgery to replace the damaged bone and cartilage in the ankle joint. Artificial joint parts (prosthetics) ... Your surgeon will remove the damaged bone and cartilage. Your surgeon will replace the damaged part of: ...
You, Young Youl; Chung, Sin Ho; Lee, Hyung Jin
[Purpose] This study was to examine the changes in the gait lines and plantar pressures in static and dynamic circumstances, according to the differences in the strengths of the plantar flexors in the ankle joints on the affected sides of hemiplegic patients, and to determine their impacts on walking symmetry. [Subjects and Methods] A total of thirty hospitalized stroke patients suffering from hemiplegia were selected in this study. The subjects had ankylosing patterns in the ankle joints of the affected sides. Fifteen of the patients had plantar flexor manual muscle testing scores between poor and fair, while fifteen of the patients had zero and trace. [Results] The contact pattern of the plantar surface with the ground is a reliable method for walking analysis, which is an important index for understanding the ankle mechanism and the relationship between the plantar surface and the ground. [Conclusion] The functional improvement of patients with stroke could be supported through a verification of the analysis methods of the therapy strategy and walking pattern. PMID:27942112
You, Young Youl; Chung, Sin Ho; Lee, Hyung Jin
[Purpose] This study was to examine the changes in the gait lines and plantar pressures in static and dynamic circumstances, according to the differences in the strengths of the plantar flexors in the ankle joints on the affected sides of hemiplegic patients, and to determine their impacts on walking symmetry. [Subjects and Methods] A total of thirty hospitalized stroke patients suffering from hemiplegia were selected in this study. The subjects had ankylosing patterns in the ankle joints of the affected sides. Fifteen of the patients had plantar flexor manual muscle testing scores between poor and fair, while fifteen of the patients had zero and trace. [Results] The contact pattern of the plantar surface with the ground is a reliable method for walking analysis, which is an important index for understanding the ankle mechanism and the relationship between the plantar surface and the ground. [Conclusion] The functional improvement of patients with stroke could be supported through a verification of the analysis methods of the therapy strategy and walking pattern.
Miyoshi, Toru; Ito, Hiroshi
Background Arterial stiffness is an independent predictor of outcomes for patients with cardiovascular disease. Although measurement of pulse wave velocity is a widely accepted, noninvasive approach for the assessment of arterial stiffness, its accuracy is affected by changes in blood pressure. Summary The cardio-ankle vascular index (CAVI) is an index of the overall stiffness of the artery from the origin of the aorta to the ankle and is theoretically independent of blood pressure at the time of measurement. CAVI increases linearly with age and is elevated even in mild arteriosclerotic disease. It can identify differences in the degree of arteriosclerosis among patients with severe arteriosclerotic disease and better reflects the severity of disease of the coronary artery than does brachial-ankle pulse wave velocity. Patients with higher CAVI values show a poor prognosis compared with those with lower CAVI values. Furthermore, CAVI can be lowered by controlling diabetes mellitus and hypertension. Key Messages The primary aims of assessing arterial stiffness using CAVI are to assist in the early detection of arteriosclerosis, allowing timely treatment and lifestyle modification, and to quantitatively evaluate the progression of disease and the effectiveness of treatment. Whether CAVI-guided therapy can improve prognosis in high-risk patients needs to be further examined to confirm the clinical usefulness of this measure. PMID:27493899
Children and Adolescent Obesity Associates with Pressure-Dependent and Age-Related Increase in Carotid and Femoral Arteries' Stiffness and Not in Brachial Artery, Indicative of Nonintrinsic Arterial Wall Alteration
García-Espinosa, Victoria; Curcio, Santiago; Castro, Juan Manuel; Arana, Maite; Giachetto, Gustavo; Chiesa, Pedro; Zócalo, Yanina
Aim. To analyze if childhood obesity associates with changes in elastic, transitional, and/or muscular arteries' stiffness. Methods. 221 subjects (4–15 years, 92 females) were assigned to normal weight (NW, n = 137) or obesity (OB, n = 84) groups, considering their body mass index z-score. Age groups were defined: 4–8; 8–12; 12–15 years old. Carotid, femoral, and brachial artery local stiffness was determined through systodiastolic pressure-diameter and stress-strain relationships. To this end, arterial diameter and peripheral and aortic blood pressure (BP) levels and waveforms were recorded. Carotid-femoral, femoropedal, and carotid-radial pulse wave velocities were determined to evaluate aortic, lower-limb, and upper-limb regional arterial stiffness, respectively. Correlation analysis between stiffness parameters and BP was done. Results. Compared to NW, OB subjects showed higher peripheral and central BP and carotid and femoral stiffness, reaching statistical significance in subjects aged 12 and older. Arterial stiffness differences disappeared when levels were normalized for BP. There were no differences in intrinsic arterial wall stiffness (elastic modulus), BP stiffness relationships, and regional stiffness parameters. Conclusion. OB associates with BP-dependent and age-related increase in carotid and femoral (but not brachial) stiffness. Stiffness changes would not be explained by intrinsic arterial wall alterations but could be associated with the higher BP levels observed in obese children. PMID:27066273
Fourchet, François; Kuitunen, Sami; Girard, Olivier; Beard, Adam J.; Millet, Grégoire P.
Several studies have already reported that specific foot/ankle muscle reinforcement strategies induced strength and joint position sense performance enhancement. Nevertheless the effects of such protocols on sprint performance and plantar loading distribution have not been addressed yet. The objective of the study is to investigate the influence of a 5-wk foot/ankle strength training program on plantar loading characteristics during sprinting in adolescent males. Sixteen adolescent male athletes of a national training academy were randomly assigned to either a combined foot/ankle electromyostimulation and resistance training (FAST) or a control (C) group. FAST consisted of foot medial arch and extrinsic ankle muscles reinforcement exercises, whereas C maintained their usual training routine. Before and after training, in-shoe loading patterns were measured during 30-m running sprints using pressure sensitive insoles (right foot) and divided into nine regions for analysis. Although sprint times remained unchanged in both groups from pre- to post- training (3.90 ± 0.32 vs. 3.98 ± 0.46 s in FAST and 3.83 ± 0.42 vs. 3.81 ± 0.44 s in C), changes in force and pressure appeared from heel to forefoot between FAST and C. In FAST, mean pressure and force increased in the lateral heel area from pre- to post- training (67.1 ± 44.1 vs. 82.9 ± 28.6 kPa [p = 0.06]; 25.5 ± 17.8 vs. 34.1 ± 14.3 N [p = 0.05]) and did not change in the medial forefoot (151.0 ± 23.2 vs. 146.1 ± 30.0 kPa; 142.1 ± 29.4 vs. 136.0 ± 33.8; NS). Mean area increased in FAST under the lateral heel from pre- to post- (4.5 ± 1.3 vs. 5.7 ± 1.6 cm2 [p < 0.05]) and remained unchanged in C (5.5 ± 2.8 vs. 5.0 ± 3.0 cm2). FAST program induced significant promising lateral and unwanted posterior transfer of the plantar loads without affecting significantly sprinting performance. Key points We have evaluated the effects of a foot/ankle strength training program on sprint performance and on related
Hopkins, J Ty; Coglianese, Mark; Glasgow, Philip; Reese, Shane; Seeley, Matthew K
Participants with ankle instability demonstrate more foot inversion during the stance phase of gait than able-bodied subjects. Invertor excitation, coupled with evertor inhibition may contribute to this potentially injurious position. The purpose of this experiment was to examine evertor/invertor muscle activation and foot COP trajectory during walking in participants with functional ankle instability (FI). Twelve subjects were identified with FI and matched to healthy controls. Tibialis anterior (TA) and peroneus longus (PL) electromyography (EMG), as well as COP, were recorded during walking. Functional analyses were used to detect differences between FI and control subjects with respect to normalized EMG and COP trajectory during walking. Relative to matched controls, COP trajectory was more laterally deviated in the FI group from 20% to 90% of the stance phase. TA activation was greater in the FI group from 15% to 30% and 45% to 70% of stance. PL activation was greater in the FI group at initial heel contact and toe off and trended lower from 20% to 40% of stance in the FI group. Altered motor strategies appear to contribute to COP deviations in FI participants and may increase the susceptibility to repeated ankle inversion injury.
... 18-21yrs. Healthy Living Healthy Living Healthy Living Nutrition Fitness Sports Oral Health Emotional Wellness Growing Healthy Sleep Safety & ... Head Neck & Nervous System Heart Infections Learning Disabilities Obesity Orthopedic Prevention ... Children > Health Issues > Conditions > Orthopedic > Sprained Ankles Health Issues ...
Romaña, M C; Rogier, A
Obstetrical brachial plexus palsy is considered to be the result of a trauma during the delivery, even if there remains some controversy surrounding the causes. Although most babies recover spontaneously in the first 3 months of life, a small number remains with poor recovery which requires surgical brachial plexus exploration. Surgical indications depend on the type of lesion (producing total or partial palsy) and particularly the nonrecovery of biceps function by the age of 3 months. In a global palsy, microsurgery will be mandatory and the strategy for restoration will focus first on hand reinnervation and secondarily on providing elbow flexion and shoulder stability. Further procedures may be necessary during growth in order to avoid fixed contractured deformities or to give or increase strength of important muscle functions like elbow flexion or wrist extension. The author reviews the history of obstetrical brachial plexus injury, epidemiology, and the specifics of descriptive and functional anatomy in babies and children. Clinical manifestations at birth are directly correlated with the anatomical lesion. Finally, operative procedures are considered, including strategies of reconstruction with nerve grafting in infants and secondary surgery to increase functional capacity at later ages. However, normal function is usually not recovered, particularly in total brachial plexus palsy.
Andersen, John; Watt, Joe; Olson, Jaret; Van Aerde, John
BACKGROUND Perinatal brachial plexus palsy (PBPP) is a flaccid paralysis of the arm at birth that affects different nerves of the brachial plexus supplied by C5 to T1 in 0.42 to 5.1 infants per 1000 live births. OBJECTIVES To identify antenatal factors associated with PBPP and possible preventive measures, and to review the natural history as compared with the outcome after primary or secondary surgical interventions. METHODS A literature search on randomized controlled trials, systematic reviews and meta-analyses on the prevention and treatment of PBPP was performed. EMBASE, Medline, CINAHL and the Cochrane Library were searched until June 2005. Key words for searches included ‘brachial plexus’, ‘brachial plexus neuropathy’, ‘brachial plexus injury’, ‘birth injury’ and ‘paralysis, obstetric’. RESULTS There were no prospective studies on the cause or prevention of PBPP. Whereas birth trauma is said to be the most common cause, there is some evidence that PBPP may occur before delivery. Shoulder dystocia and PBPP are largely unpredictable, although associations of PBPP with shoulder dystocia, infants who are large for gestational age, maternal diabetes and instrumental delivery have been reported. The various forms of PBPP, clinical findings and diagnostic measures are described. Recent evidence suggests that the natural history of PBPP is not all favourable, and residual deficits are estimated at 20% to 30%, in contrast with the previous optimistic view of full recovery in greater than 90% of affected children. There were no randomized controlled trials on nonoperative management. There was no conclusive evidence that primary surgical exploration of the brachial plexus supercedes conservative management for improved outcome. However, results from nonrandomized studies indicated that children with severe injuries do better with surgical repair. Secondary surgical reconstructions were inferior to primary intervention, but could still improve arm
... ankle replacement. Your surgeon removed and reshaped damaged bones, and put in an artificial ankle joint. You received pain medicine and were shown how to treat swelling around your new ankle joint.
Ergunes, Kazim; Yilik, Levent; Ozsoyler, Ibrahim; Kestelli, Mert; Ozbek, Cengiz; Gurbuz, Ali
We performed this retrospective study to analyze our strategies for managing and surgically treating brachial artery injuries. Fifty-seven patients with a total of 58 traumatic brachial artery injuries underwent surgery at our institution, from August 1996 through November 2004. Fifty-four patients were male and 3 were female (age range, 7 to 75 years; mean, 29.4 years). Forty-four of the patients had penetrating injuries (18 had stab wounds; 16, window glass injuries; and 10, industrial accidents), 10 had blunt trauma injuries (traffic accidents), and 3 had gunshot injuries. Fourteen patients (24.6%) had peripheral nerve injury. All patients underwent Doppler ultrasonographic examination. The repair of the 58 arterial injuries involved end-to-end anastomosis for 32 injuries (55.2%), reverse saphenous vein graft interpositional grafts for 18 (31%), and primary repair for 8 (13.8%). Venous continuity was achieved in 11 (84.6%) of 13 patients who had major venous injuries. Nine of the 57 patients (15.8%) required primary fasciotomy. Follow-up showed that 5 of the 14 patients with peripheral nerve injury had apparent disabilities due to nerve injury. One patient underwent amputation. There were no deaths. We believe that good results can be achieved in patients with brachial artery injuries by use of careful physical examination, Doppler ultrasonography, and restoration of viability with vascular repair and dbridement of nonviable tissues. Traumatic neurologic injury frequently leads to disability of the extremities. PMID:16572866
Bae, Ji Yong; Park, Kyung Soon; Seon, Jong Keun; Jeon, Insu
To show the causal relationship between normal walking after various lateral ankle ligament (LAL) injuries caused by acute inversion ankle sprains and alterations in ankle joint contact characteristics, finite element simulations of normal walking were carried out using an intact ankle joint model and LAL injury models. A walking experiment using a volunteer with a normal ankle joint was performed to obtain the boundary conditions for the simulations and to support the appropriateness of the simulation results. Contact pressure and strain on the talus articular cartilage and anteroposterior and mediolateral translations of the talus were calculated. Ankles with ruptured anterior talofibular ligaments (ATFLs) had a higher likelihood of experiencing increased ankle joint contact pressures, strains and translations than ATFL-deficient ankles. In particular, ankles with ruptured ATFL + calcaneofibular ligaments and all ruptured ankles had a similar likelihood as the ATFL-ruptured ankles. The push off stance phase was the most likely situation for increased ankle joint contact pressures, strains and translations in LAL-injured ankles.
Doherty, Cailbhe; Bleakley, Chris; Hertel, Jay; Caulfield, Brian; Ryan, John; Delahunt, Eamonn
Instrumented postural control analysis plays an important role in evaluating the effects of injury on dynamic stability during balance tasks, and is often conveyed with measures based on the displacement of the center-of-pressure (COP) assessed with a force platform. However, the desired outcome of the task is frequently characterized by a loss of dynamic stability, secondary to injury. Typically, these failed trials are discarded during research investigations, with the potential loss of informative data pertaining to task success. The novelty of the present study is that COP characteristics of failed trials in injured participants are compared to successful trial data in another injured group, and a control group of participants, using the fractal dimension (FD) method. Three groups of participants attempted a task of eyes closed single limb stance (SLS): twenty-nine participants with acute ankle sprain successfully completed the task on their non-injured limb (successful injury group); twenty eight participants with acute ankle sprain failed their attempt on their injured limb (failed injury group); sixteen participants with no current injury successfully completed the task on their non-dominant limb (successful non-injured group). Between trial analyses of these groups revealed significant differences in COP trajectory FD (successful injury group: 1.58±0.06; failed injury group: 1.54±0.07; successful non-injured group: 1.64±0.06) with a large effect size (0.27). These findings demonstrate that successful eyes-closed SLS is characterized by a larger FD of the COP path when compared to failed trials, and that injury causes a decrease in COP path FD.
Spronck, Bart; Mestanik, Michal; Tonhajzerova, Ingrid; Jurko, Alexander; Jurko, Tomas; Avolio, Alberto P; Butlin, Mark
Cardio-ankle vascular index (CAVI) as measured using the VaSera device (CAVIVS, Fukuda Denshi), has been proposed as a stiffness index that does not depend on blood pressure. We have recently shown theoretically that CAVIVS still exhibits blood pressure dependence, and proposed the corrected index CAVI0. The present study aims to establish a method of calculating [Formula: see text] either (i) from VaSera-reported values of cardiac-brachial and brachial-ankle pulse transit times (tb and tba, respectively) and blood pressure, or (ii) directly from CAVIVS. To derive this method, the relationship among CAVIVS and its scale constants a and b, tb, tba, and blood pressure has to be established. From data of 497 subjects, eight candidate CAVI parameters were defined and calculated, containing all combinations of left or right tb/tba/blood pressure. Candidates were evaluated through correlation with measured left and right CAVIVS. Correlations were compared statistically. Once the correct candidates were determined, two constants (a and b) required for converting CAVIVS to CAVI0 were estimated through linear regression. Left and right CAVIVS are calculated using left and right tba; however, both left and right CAVIVS are calculated using right brachial blood pressures and right tb. Constants a and b for conversion of CAVIVS to CAVI0 were estimated to be 0.842 [0.836 0.848] and 0.753 [0.721 0.786] (mean [95%CI]), respectively. Equations to estimate CAVI0 from CAVIVS, and to directly calculate CAVI0 from the VaSera output are provided in this paper, as well as in a directly usable spreadsheet supplement. Our results permit straightforward calculation of [Formula: see text] during a study, as well as retrospective estimation of [Formula: see text] from CAVIVS in already published studies or where the original transit time values are not available, paving the way for thorough comparison of CAVI0 to CAVIVS in clinical and research settings. Novelty and significance Cardio-ankle
Upper limbs palsy as a result of affliction of plexus brachialis nervous bunch is disorder, whose frequency moves among 0.42-5.1 / 1000 liveborn children. Delivery mechanism itself certain weighty, no however only cause rising paralysis. Some way paralysis rise already intrauterinne, some way then at surgical childbirth per sectionem caeseream. Brachial plexus palsy isn't benign disorder. If isn't this disorder in time diagnosed and accordingly treated, child threatens late aftermath, especially significant limitation of limbs movement with functional consequencies.
Pondaag, Willem; van Dijk, J Gert; Nelissen, Rob G H H; Malessy, Martijn J A
Obstetric palsy is a birth injury that occurs when the brachial plexus is damaged by traction. In the majority of patients spontaneous recovery will occur; however, in case of incomplete spontaneous recovery early neurosurgical intervention may be indicated. We present 3 case reports in this article, as well as describing the strategy favoured in our clinic. We recommend referring patients who have incomplete spontaneous recovery at the age of 1 month. At that age a good prediction of prognosis can be made by combining neurological examination with needle electromyography (EMG) of the biceps muscle.
Ankle arthritis results in a stiff and painful ankle and can be a major cause of disability. For people with end-stage ankle arthritis, arthrodesis (ankle fusion) is effective at reducing pain in the shorter term, but results in a fixed joint, and over time the loss of mobility places stress on other joints in the foot that may lead to arthritis, pain and dysfunction. Another option is to perform a total ankle joint replacement, with the aim of giving the patient a mobile and pain-free ankle. In this article we review the efficacy of this procedure, including how it compares to ankle arthrodesis, and consider the indications and complications.
Alfonso, Daniel T
The causes of brachial plexus palsy in neonates should be classified according to their most salient associated feature. The causes of brachial plexus palsy are obstetrical brachial plexus palsy, familial congenital brachial plexus palsy, maternal uterine malformation, congenital varicella syndrome, osteomyelitis involving the proximal head of the humerus or cervical vertebral bodies, exostosis of the first rib, tumors and hemangioma in the region of the brachial plexus, and intrauterine maladaptation. Kaiser Wilhelm syndrome, neonatal brachial plexus palsy due to placental insufficiency, is probably not a cause of brachial plexus palsy. Obstetrical brachial plexus palsy, the most common alleged cause of neonatal brachial plexus palsy, occurs when the forces generated during labor stretch the brachial plexus beyond its resistance. The probability of obstetrical brachial plexus palsy is directly proportional to the magnitude, acceleration, and cosine of the angle formed by the direction of the vector of the stretching force and the axis of the most vulnerable brachial plexus bundle, and inversely proportional to the resistance of the must vulnerable brachial plexus bundle and of the shoulder girdle muscles, joints, and bones. Since in most nonsurgical cases neither the contribution of each of these factors to the production of the obstetrical brachial plexus palsy nor the proportion of traction and propulsion contributing to the stretch force is known, we concur with prior reports that the term of obstetrical brachial plexus palsy should be substituted by the more inclusive term of birth-related brachial plexus palsy.
Oliveras, Víctor; Martín-Baranera, Montserrat; Gracia, Maya; Del Val, José Luís; Plans, Miquel; Pujol-Moix, Núria
The ankle-brachial index allows for the detection of subclinical cardiovascular disease and risk, by diagnosing peripheral arterial disease and arterial calcification. Asymptomatic hypertensive men, between 45-55 years and with the suspicion of low risk, could be an important population group to benefit from this technique. The aim of the study was to compare the frequency of abnormal ankle-brachial index (subclinical peripheral arterial disease and arterial calcification) between asymptomatic hypertensive and non-hypertensive men, of the same age and suspicion of low risk. Two hundred and forty-four asymptomatic men (122 hypertensive and 122 non-hypertensive), between 45 and 55 years and an REGICOR index<10, were voluntarily recruited using consecutive sampling. Complete anamnesis, physical examination, laboratory tests and ankle-brachial index determination were carried out on all patients. We detected abnormal ankle-brachial index values in 9.8% (12 cases) of the hypertensive subjects and in 1.6% (2 cases) of non-hypertensive subjects (P=.006). In the multivariate analysis, hypertension was significantly associated with an abnormal ankle-brachial index (P<.026) (odds ratio [OR] 5.9, 95% confidence interval [95% CI] 1.2-28.3), smoking (P=.018) (OR 2.7; 95% CI 1.2-6.2) and abdominal obesity (P=.005) (OR 2.8; 95% CI 1.3-5.9). The population group analyzed in this study might be considered as an overriding segment for detecting subclinical cardiovascular disease and risk with the ankle-brachial index. Further studies are needed to establish the prevalence of abnormal ankle-brachial index in this population in order to assess its efficiency. Copyright © 2013 Elsevier España, S.L.U. All rights reserved.
... the brachial plexus can be affected during a difficult delivery. Injury may be caused by: The infant's head and neck pulling toward the side as the shoulders pass through the birth canal Stretching of the infant's shoulders during a ...
Mestanik, Michal; Jurko, Alexander; Mestanikova, Andrea; Jurko, Tomas; Tonhajzerova, Ingrid
Elevated blood pressure (BP) is a major risk factor for atherosclerosis. As the studies concerning vascular alterations in pediatric patients are rare, we aimed to study the relationship between hypertension and arterial stiffness in adolescence by novel method independent from BP during examination. Twenty nonobese adolescent boys (16.5 ± 0.4 years) with newly diagnosed essential hypertension, 20 adolescent boys (16.7 ± 0.4 years) with newly diagnosed white-coat hypertension, and 20 healthy controls matched to age and body mass index were examined. Cardio-ankle vascular index (CAVI), brachial-ankle pulse wave velocity (baPWV), pre-ejection period (PEP), and ejection time (ET) were evaluated. CAVI was significantly increased in essential hypertension patients compared with controls (p < 0.05) with no significant difference in white-coat hypertension patients. Significantly higher baPWV was found in essential and white-coat hypertension patients compared with controls (both p < 0.001). White-coat hypertension patients showed significantly shortened PEP and ET compared with controls (p < 0.01 and p < 0.001, respectively) and essential hypertension patients (both p < 0.05). For the first time, the arterial stiffness in adolescents with newly diagnosed essential and white-coat hypertension was studied using BP-independent index CAVI combined with conventional baPWV. Our study revealed significantly increased CAVI in adolescents with newly diagnosed essential hypertension compared with controls. Our findings could help to understand hypertension-atherosclerosis interaction.
... Risk for Newly Active Baby Boomers The American College of Foot and Ankle Surgeons has a valuable lesson for Baby Boomers now getting back into fitness and sports: Get your ankles checked for chronic instability caused ...
Mai, Nicholas; Cooper, Leslie
School nurses are faced with the challenge of identifying and treating ankle injuries in the school setting. There is little information guiding the assessment and treatment of these children when an injury occurs. It is essential for school nurses to understand ankle anatomy, pathophysiology of the acute ankle injury, general and orthopedic…
Mai, Nicholas; Cooper, Leslie
School nurses are faced with the challenge of identifying and treating ankle injuries in the school setting. There is little information guiding the assessment and treatment of these children when an injury occurs. It is essential for school nurses to understand ankle anatomy, pathophysiology of the acute ankle injury, general and orthopedic…
Iwamoto, Yumiko; Maruhashi, Tatsuya; Fujii, Yuichi; Idei, Naomi; Fujimura, Noritaka; Mikami, Shinsuke; Kajikawa, Masato; Matsumoto, Takeshi; Kihara, Yasuki; Chayama, Kazuaki; Noma, Kensuke; Nakashima, Ayumu; Higashi, Yukihito
Cardiovascular diseases are associated with impaired flow-mediated vasodilation (FMD) and increase in carotid intima-media thickness (IMT). Both FMD and IMT are independent predictors for cardiovascular outcomes. When measuring FMD and nitroglycerine-induced vasodilation in the brachial artery, IMT can also be simultaneously assessed in the same brachial artery. The purpose of this study was to determine the relationships between IMT of the brachial artery, vascular function, and cardiovascular risk factors. We measured brachial IMT, FMD, and nitroglycerine-induced vasodilation by ultrasound in 388 subjects who underwent health examination (mean age, 45±22 years; age range, 19-86), including patients with cardiovascular diseases. Univariate regression analysis revealed that brachial IMT significantly correlated with age (r=0.71; P<0.001), body mass index (r=0.27; P<0.001), systolic blood pressure (r=0.40; P<0.001), diastolic blood pressure (r=0.31; P<0.001), heart rate (r=0.15; P=0.002), glucose level (r=0.18; P=0.01), and smoking pack-years (r=0.42; P<0.001), as well as Framingham risk score, a cumulative cardiovascular risk index for heart attack (r=0.49; P<0.001). FMD and nitroglycerine-induced vasodilation were inversely associated with brachial IMT (r=-0.39, P<0.001; r=-0.32, P<0.001, respectively). In addition, there was a significant relationship between brachial IMT and carotid IMT (r=0.58; P<0.001). Multivariate analysis revealed that age, sex, hypertension, and brachial artery diameter were independent predictors of brachial IMT. These findings suggest that brachial IMT may be a marker of the grade of atherosclerosis and may be used as a marker of vascular function, providing additive information for stratifying subjects with cardiovascular risk factors.
Ohno, Yoichi; Miyazaki, Takashi; Sato, Makiko; Araki, Ryuichiro; Takahashi, Sachiko; Takenaka, Tsuneo; Suzuki, Hiromichi; Shibazaki, Satomi
This study was attempted to investigate whether lifestyle modifications supported by regional health nurses should improve cardio-metabolic factors--including adipocytokines, oxidative stress, and arterial stiffness--in subjects with metabolic syndrome. Thirty-six subjects with metabolic syndrome were enrolled, 28 of whom completed the 6-month lifestyle modifications (male:female=19:9). Blood and urine test results were examined in relation to metabolic factors before and after 6-month nutritional and physical activity modifications. In addition, oral glucose tolerance tests were performed and arterial stiffness was measured by brachial-ankle pulse wave velocity and radial augmentation index before and after them. Six-month lifestyle modifications significantly reduced body weight, homeostasis model assessment index, and low-density lipoprotein cholesterol (LDL-C). They significantly attenuated oxidative stress measured by the urinary 8-hydroxy-2-deoxyguanosine/creatinine ratio. They also lowered brachial and central systolic blood pressure. They tended to decrease waist circumferences and the levels of C-reactive protein. However they did not significantly change the levels of adipocytokines, including tumour necrosis factor, soluble tumour necrosis factor receptors, and interleukin 6, or arterial stiffness measured by brachial-ankle pulse wave velocity and radial augmentation index. Six-month lifestyle modifications supported by regional health nurses lowered body weight, insulin resistance, LDL-C, oxidative stress, and peripheral and central blood pressure in subjects with metabolic syndrome. Copyright © 2015 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
Vriz, Olga; Aboyans, Victor; Minisini, Rosalba; Magne, Julien; Bertin, Nicole; Pirisi, Mario; Bossone, Eduardo
Arterial stiffness can predict cardiovascular events, and the aim of this study was to produce age- and sex-specific reference values for echo-tracking carotid stiffness in healthy subjects. A total of 900 subjects (500 males, mean age 45.8±19 years) were enrolled. Common carotid artery stiffness and compliance, using a high-definition echo-tracking ultrasound system, were evaluated. To compare stiffness parameters across the different age groups, individual scores were transformed into T-scores, indicating how many standard deviation (s.d.) units an individual's score was above or below the mean that was observed in the group including same-sex individuals aged 36 to 44 years. Carotid stiffness was similar among genders, except compliance, which was lower in women (P<0.0001). These characteristics were also maintained when the studied population was divided into seven age groups. Stiffness parameters increased significantly with age, but the opposite occurred for compliance. The T-score was found to increase significantly across all age groups, with a steeper increase in stiffness around the age of 60 years in women. For each T-score s.d., the corresponding carotid absolute values for arterial stiffness and compliance were obtained. In a multivariate model, carotid stiffness parameters were constantly and independently associated with age, mean arterial pressure, pulse pressure, heart rate and body mass index. Our study provides a normogram of carotid arterial stiffness and compliance indices obtained with the echo-tracking method in a large population of healthy subjects stratified by gender and age that can be used in clinical practice.Hypertension Research advance online publication, 2 March 2017; doi:10.1038/hr.2017.24.
Arthroscopic ankle arthrodesis is a cost-effective option for many patients with posttraumatic arthritis of the ankle joint. Rehabilitation is generally quicker than conventional open techniques, and rates of fusion are comparable or better than traditional open techniques. Unless the arthroscopic surgeon has considerable experience, the best results are seen in patients with very little deformity in the ankle joint. Copyright © 2016 Elsevier Inc. All rights reserved.
Wolfe, M W; Uhl, T L; Mattacola, C G; McCluskey, L C
Without adequate care, acute ankle trauma can result in chronic joint instability. Use of a standardized protocol enhances the management of ankle sprains. In patients with grades I or II sprains, emphasis should be placed on accurate diagnosis, early use of RICE (rest, ice, compression and elevation), maintenance of range of motion and use of an ankle support. Sprains with complete ligament [corrected] tears (grade III) may require surgical intervention. Although early motion and mobility are recommended, ligamentous strength does not return until months after an ankle sprain.
Giannini, Sandro; Buda, Roberto; Mosca, Massimiliano; Parma, Alessandro; Di Caprio, Francesco
Posterior ankle impingement is a common cause of chronic ankle pain and results from compression of bony or soft tissue structures during ankle plantar flexion. Bony impingement is most commonly related to an os trigonum or prominent trigonal process. Posteromedial soft tissue impingement generally arises from an inversion injury, with compression of the posterior tibiotalar ligament between the medial malleolus and talus. Posterolateral soft tissue impingement is caused by an accessory ligament, the posterior intermalleolar ligament, which spans the posterior ankle between the posterior tibiofibular and posterior talofibular ligaments. Finally, anomalous muscles have also been described as a cause of posterior impingement.
Martínez, Fernando; Pinazzo, Samantha; Moragues, Rodrigo; Suarez, Elizabeth
Although traumatic brachial plexus injuries are relatively rare in trauma patients, their effects on the functionality of the upper limb can be very disabling. The authors' objective was to assess the complications in a series of patients operated for brachial plexus injuries. This was a retrospective evaluation of patients operated on by the authors between August 2009 and March 2013. We performed 36 surgeries on 33 patients. The incidence of complications was 27.7%. Of these, only 1 (2.7%) was considered serious and associated with the procedure (iatrogenic injury of brachial artery). There was another serious complication (hypoxia in patients with airway injury) but it was not directly related to the surgical procedure. All other complications were considered minor (wound dehiscence, hematoma, infection). There was no mortality in our series. The complications in our series are similar to those reported in the literature. Serious complications (vascular, neural) are rare and represent less than 5% in all the different series. Given the rate of surgical complications and the poor functional perspective for a brachial plexus injury without surgery, we believe that surgery should be the treatment of choice. Copyright © 2013 Sociedad Española de Neurocirugía. Published by Elsevier España. All rights reserved.
Steinberg, H S
The brachial plexus and its associated structures demonstrate a propensity for certain disease processes not common to other areas of the nervous system. Brachial plexus disease produces a gait disturbance that may mimic musculoskeletal disease. When evaluating a case with possible traumatic brachial plexus disease, one relies heavily on historical, physical, and neurologic information when differentiating musculoskeletal disorders, although both may sometimes be present simultaneously in the same limb. With inflammatory disease, electromyography is extremely helpful, although an empiric dietary change may help confirm a suspicion. Brachial plexus surgery requires careful planning and meticulous technique. Attempts to remove malignant schwannomas have not been as successful as one would hope (Table 2). To a large extent, these dogs are treated late in the course of their disease because they are often treated for extended periods of time for musculoskeletal disease first. Early diagnosis and prompt surgical intervention would help many of these dogs. New histopathologic techniques, electrodiagnostic equipment, and radiographic techniques are helping to define peripheral nerve disease in the companion animal. These techniques will help us categorize and treat these diseases with greater success in the future.
... foot and ankle surgeons. All Fellows of the College are board certified by the American Board of Foot and Ankle Surgery. Copyright © 2017 American College of Foot and Ankle Surgeons (ACFAS), All Rights ...
Physician and Sportsmedicine, 1986
Types of ankle sprains, surgical versus nonsurgical treatment, tape versus brace for support, rehabilitation, exercise, and prevention of ankle sprains are discussed by a panel of experts. An acute ankle taping technique is illustrated. (MT)
Posterior ankle impingement syndrome is a clinical disorder characterized by posterior ankle pain that occurs in forced plantar flexion. The pain may be acute as a result of trauma or chronic from repetitive stress. Pathology of the os trigonum-talar process is the most common cause of this syndrome, but it also may result from flexor hallucis longus tenosynovitis, ankle osteochondritis, subtalar joint disease, and fracture. Patients usually report chronic or recurrent posterior ankle pain caused or exacerbated by forced plantar flexion or push-off maneuvers, such as may occur during dancing, kicking, or downhill running. Diagnosis of posterior ankle impingement syndrome is based primarily on clinical history and physical examination. Radiography, scintigraphy, computed tomography, and magnetic resonance imaging depict associated bone and soft-tissue abnormalities. Symptoms typically improve with nonsurgical management, but surgery may be required in refractory cases.
Doherty, Cailbhe; Bleakley, Chris; Hertel, Jay; Caulfield, Brian; Ryan, John; Delahunt, Eamonn
To quantify the dynamic balance deficits that characterise a group with chronic ankle instability compared to lateral ankle sprain copers and non-injured controls using kinematic and kinetic outcomes. Forty-two participants with chronic ankle instability and twenty-eight lateral ankle sprain copers were initially recruited within 2 weeks of sustaining a first-time, acute lateral ankle sprain and required to attend our laboratory 1 year later to complete the current study protocol. An additional group of non-injured individuals were also recruited to act as a control group. All participants completed the anterior, posterior-lateral and posterior-medial reach directions of the star excursion balance test. Sagittal plane kinematics of the lower extremity and associated fractal dimension of the centre of pressure path were also acquired. Participants with chronic ankle instability displayed poorer performance in the anterior, posterior-medial and posterior-lateral reach directions compared with controls bilaterally, and in the posterior-lateral direction compared with lateral ankle sprain copers on their 'involved' limb only. These performance deficits in the posterior-lateral and posterior-medial directions were associated with reduced flexion and dorsiflexion displacements at the hip, knee and ankle at the point of maximum reach, and coincided with reduced complexity of the centre of pressure path. In comparison with lateral ankle sprain copers and controls, participants with chronic ankle instability were characterised by dynamic balance deficits as measured using the SEBT. This was attested to reduced sagittal plane motions at the hip, knee and ankle joints, and reduced capacity of the stance limb to avail of its supporting base. III.
Al-Mohrej, Omar A.; Al-Kenani, Nader S.
Ankle sprain is reported to be among the most common recurrent injuries. About 20% of acute ankle sprain patients develop chronic ankle instability. The failure of functional rehabilitation after acute ankle sprain leads to the development of chronic ankle instability. Differentiation between functional and anatomical ankle instability is very essential to guide the proper treatment. Stability testing by varus stress test and anterior drawer test should be carried out. Subtalar instability is an important pathology that is commonly by passed during the assessment of chronic ankle instability. Unlike acute ankle sprain, chronic ankle instability might require surgical intervention. The surgical and conservative management options can be very much developed by in-depth knowledge of the ankle anatomy, biomechanics, and pathology. Anatomical repair, augmentation by tendon, or both are the basic methods of surgical intervention. Arthroscopy is becoming more popular in the management of chronic ankle instability. PMID:27843798
Reilingh, Mikel L.; Zengerink, Maartje; van Bergen, Christiaan J. A.
Osteochondral defects of the ankle can either heal and remain asymptomatic or progress to deep ankle pain on weight bearing and formation of subchondral bone cysts. The development of a symptomatic OD depends on various factors, including the damage and insufficient repair of the subchondral bone plate. The ankle joint has a high congruency. During loading, compressed cartilage forces its water into the microfractured subchondral bone, leading to a localized high increased flow and pressure of fluid in the subchondral bone. This will result in local osteolysis and can explain the slow development of a subchondral cyst. The pain does not arise from the cartilage lesion, but is most probably caused by repetitive high fluid pressure during walking, which results in stimulation of the highly innervated subchondral bone underneath the cartilage defect. Understanding the natural history of osteochondral defects could lead to the development of strategies for preventing progressive joint damage. PMID:20151110
van Dijk, C Niek; Reilingh, Mikel L; Zengerink, Maartje; van Bergen, Christiaan J A
Osteochondral defects of the ankle can either heal and remain asymptomatic or progress to deep ankle pain on weight bearing and formation of subchondral bone cysts. The development of a symptomatic OD depends on various factors, including the damage and insufficient repair of the subchondral bone plate. The ankle joint has a high congruency. During loading, compressed cartilage forces its water into the microfractured subchondral bone, leading to a localized high increased flow and pressure of fluid in the subchondral bone. This will result in local osteolysis and can explain the slow development of a subchondral cyst. The pain does not arise from the cartilage lesion, but is most probably caused by repetitive high fluid pressure during walking, which results in stimulation of the highly innervated subchondral bone underneath the cartilage defect. Understanding the natural history of osteochondral defects could lead to the development of strategies for preventing progressive joint damage.
Konishi, Takanori; Ohki, Shin-ichi; Saito, Tsutomu; Misawa, Yoshio
A 57-year-old man, who was a chronic axillary crutch user as a result of childhood poliomyelitis, was referred to our hospital because of a sudden onset of right forearm ischemia. The right forearm had no pulse, and three-dimensional computed tomography (3DCT) showed an aneurysm of the right brachial artery associated with arterial occlusion. The thrombosed aneurysm of the brachial artery was resected and the brachial artery was successfully revascularized by interposing a saphenous vein graft. Postoperative 3DCT revealed an asymptomatic left brachial artery aneurysm. His postoperative course was uneventful under warfarin anticoagulation therapy.
Espeland, Mark A; Regensteiner, Judith G; Jaramillo, Sarah A; Gregg, Edward; Knowler, William C; Wagenknecht, Lynne E; Bahnson, Judy; Haffner, Steven; Hill, James; Hiatt, William R
Many protocols have been used in clinical and research settings for collecting systolic blood pressure (SBP) measurements to calculate the ankle–brachial index (ABI); however, it is not known how useful it is to replicate measurements and which measures best reflect cardiovascular risk. Standardized measurements of ankle and arm SBP from 5140 overweight or obese individuals with type 2 diabetes were used to estimate sources of variation. Measurement characteristics of leg-specific ABI, as calculated using a standard algorithm based on the highest SBP of the dorsalis pedis or posterior tibial arteries, were projected using simulations. Coefficients of variability ranged from 2% to 3% when single SBP measurements were used and ABI was overestimated by 2–3%. Taking two SBP measurements at each site reduced standard errors and bias each by 30–40%. The sensitivity of detecting low ABI ranges exceeded 90% for ABI within 0.05 of the 0.90 clinical cut-point. The average and the minimum of the two (i.e. right and left) leg-specific ABI values had similar U-shaped relationships with Framingham risk scores; however, the average leg ABI had slightly greater precision. Replicating SBP measurements reduces the error and bias of ABI. Averaging leg-specific values may increase power for characterizing cardiovascular disease risk. PMID:18687759
Zhang, Yihong; Li, Ning; Sun, Junzhi; Su, Quansheng
This study examined the effects of combined traditional Chinese physical and mental exercises on the blood pressure of adult female hypertensive patients. Twenty female hypertensive patients aged between 50 and 60 years voluntarily participated in the study. The participants performed the combined exercises for 24 weeks, twice a week, and 60 min each time in low-to-moderate intensity. After the 24-week training, the participants showed significant decreases in systolic blood pressure (p = 0.000), diastolic blood pressure (p = 0.006), pulse pressure (p = 0.001), and right ankle brachial pressure index (p = 0.041). The combined Chinese traditional physical and mental exercises were found to have beneficial effects on adult female hypertensive patients.
Roukis, Thomas S
Lateral ankle instability is frequently encountered when performing total ankle replacement and remains a challenge. In the present techniques report, I have described a modification of the Evans peroneus brevis tendon lateral ankle stabilization harvested through limited incisions using simple topographic anatomic landmarks. The harvested peroneus brevis is then transferred either to the anterior distal tibia concomitantly with total ankle replacement or through the tibia when performed after total ankle replacement and secured with plate and screw fixation. This modified Evans peroneus brevis tendon is useful in providing lateral ankle stability during or after primary and revision total ankle replacement.
Malleolar fracture; Tri-malleolar; Bi-malleolar; Distal tibia fracture; Distal fibula fracture; Malleolus fracture ... Some ankle fractures may require surgery when: The ends of the bone are out of line with each other (displaced). The ...
... help to ease pain and swelling. You can buy these medicines without a prescription. DO NOT use ... easily. Your ankle is increasingly discolored (red or black and blue), or it becomes numb or tingly. ...
Jeng, Clifford L; Lin, Jason S; Amoyal, Karen; Campbell, John; Myerson, Mark S
The purpose of this study was to compare the brake reaction time of patients with successful right ankle fusion to normal volunteers without an ankle fusion. Ten patients who underwent successful right ankle arthrodesis were evaluated using a driving simulator as well as an in-shoe pedobarographic measuring system. Brake reaction time, braking force, peak pressure, contact area, and the center of force between the foot and the brake pedal were recorded. SF-12 scores were obtained from all study patients. A control group of ten age-matched individuals without ankle fusion was included for comparison. Mean brake reaction time for the ankle fusion group (0.42+/-0.14 seconds) was significantly slower than for the control group (0.33+/-0.06 seconds) (p=0.03). The center of force was consistently isolated to the forefoot in the ankle fusion group compared to controls who distributed the center of force over both the forefoot and midfoot. There was no significant difference between the ankle fusion and control groups with respect to braking force, peak pressure, or contact area. The mean brake reaction time following successful right ankle arthrodesis was significantly slower than that of normal controls. However, the fusion group time was still below the threshold for what is defined as a safe brake reaction time by the United States Federal Highway Administration.
McEniery, Carmel M.; Cockcroft, John R.; Roman, Mary J.; Franklin, Stanley S.; Wilkinson, Ian B.
Pressure measured with a cuff and sphygmomanometer in the brachial artery is accepted as an important predictor of future cardiovascular risk. However, systolic pressure varies throughout the arterial tree, such that aortic (central) systolic pressure is actually lower than corresponding brachial values, although this difference is highly variable between individuals. Emerging evidence now suggests that central pressure is better related to future cardiovascular events than is brachial pressure. Moreover, anti-hypertensive drugs can exert differential effects on brachial and central pressure. Therefore, basing treatment decisions on central, rather than brachial pressure, is likely to have important implications for the future diagnosis and management of hypertension. Such a paradigm shift will, however, require further, direct evidence that selectively targeting central pressure, brings added benefit, over and above that already provided by brachial artery pressure. PMID:24459197
Collado-Vazquez, S; Jimenez-Antona, C; Carrillo, J M
Lesions of the peripheral nerves have been known since ancient times, but there are few references to the treatments that were used in the past. AIM. To analyse obstetric brachial palsy and its treatments throughout history. There are a number of different references to the peripheral nerves and their lesions, although little is known about the treatments that were applied in the past. William Smellie first reported obstetric brachial palsy in 1764 and the term was coined by Duchenne de Boulogne in 1872. In 1877, Erb analysed four cases of obstetric brachial palsy and conducted studies on the excitation of the brachial plexus with electric currents. In 1885, Klumpke described palsy of the lower roots of the brachial plexus. In the late 19th century pathophysiology studies were carried out and at the beginning of the 20th century the first surgical interventions were performed. Today, microsurgery techniques, protocols on how to proceed, and rehabilitation treatment of this lesion are all available and offer good outcomes. Since the first clinical description of obstetric brachial palsy by Smellie and the reports of the different types of brachial palsy by Duchenne, Erb and Klumpke, many pathophysiological studies have been conducted. Notable developments have been made in conservative and surgical treatments, with very favourable recoveries being observed in children with obstetric brachial palsy.
Lin, Che-Yu; Kang, Jiunn-Horng; Wang, Chung-Li; Shau, Yio-Wha
Measurement of viscosity of the ankle joint complex is a novel method to assess mechanical ankle instability. In order to further investigate the clinical significance of the method, this study intended to investigate the relationship between ankle viscosity and severity of functional ankle instability. Cross-sectional study. 15 participants with unilateral inversion ankle sprain and 15 controls were recruited. Their ankles were further classified into stable and unstable ankles. Ankle viscosity was measured by an instrumental anterior drawer test. Severity of functional ankle instability was measured by the Cumberland Ankle Instability Tool. Unstable ankles were compared with stable ankles. Injured ankles were compared with uninjured ankles of both groups. The spearman's rank correlation coefficient was applied to determine the relationship between ankle viscosity and severity of functional ankle instability in unstable ankles. There was a moderate relationship between ankle viscosity and severity of functional ankle instability (r=-0.64, p<0.0001). Unstable ankles exhibited significantly lower viscosity (p<0.005) and more severe functional ankle instability (p<0.0001) than stable ankles. Injured ankles exhibited significantly lower viscosity and more severe functional ankle instability than uninjured ankles (p<0.0001). There was a moderate relationship between ankle viscosity and severity of functional ankle instability. This finding suggested that, severity of functional ankle instability may be partially attributed to mechanical insufficiencies such as the degenerative changes in ankle viscosity following the inversion ankle sprain. In clinical application, measurement of ankle viscosity could be a useful tool to evaluate severity of chronic ankle instability. Copyright © 2014 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
Kakkar, Rahul; Siddique, M S
The ankle is a highly congruent joint with a surface area of 11-13 cm(2). Total ankle replacements have been attempted since the early 1970s and design has continually evolved as the early designs were a failure. This was because the stresses involved and the mutiaxial motion of the ankle has not been understood until recently. It has been shown that the talus slides as well as rolls during the ankle arc of motion from plantarflexion to dorsiflexion. Furthermore, the articular surfaces and the calcaneofibular and tibiocalcaneal ligaments have been shown to form a four bar linkage dictating ankle motion. A new design ankle replacement has been suggested recently which allows multiaxial motion at the ankle while maintaining congruency throughout the arc of motion. The early results of this ankle replacement have been encouraging without any reported failures due to mechanical loosening.
Singh, Sukhchain; Sethi, Ankur; Singh, Mukesh; Khosla, Kavia; Grewal, Navsheen; Khosla, Sandeep
Association of inter-arm systolic blood pressure difference (IASBPD) with cardiovascular (CV) morbidity and mortality remains controversial. We aimed to thoroughly examine all available evidence on inter-limb blood pressure (BP) difference and its association with CV risk and outcomes. We searched PubMed, EMBASE, CINAHL, Cochrane library, and Ovid for studies reporting bilateral simultaneous BP measurements in arms or legs and risk of peripheral arterial disease (PAD), coronary artery disease, cerebrovascular disease, subclavian stenosis, or mortality. Random-effect meta-analysis was performed to compare effect estimates. Twenty-seven studies met inclusion criteria, but only 17 studies (18 cohorts) were suitable for analysis. IASBPD of 10 mmHg or more was associated with PAD (risk ratios, 2.22; 1.41-3.5; P = .0006; sensitivity 16.6%; 6.7-35.4; specificity 91.9%; 83.1-96.3; 8 cohorts; 4774 subjects), left ventricular mass index (standardized mean difference 0.21; 0.03-0.39; P = .02; 2 cohort; 1604 subjects), and brachial-ankle pulse wave velocity (PWV) (one cohort). Association of PAD remained significant at cutoff of 15 mmHg (risk ratios, 1.91; 1.28-2.84; P = .001; 5 cohorts; 1914 subjects). We could not find statistically significant direct association of coronary artery disease, cerebrovascular disease, CV, and all-cause mortality in subjects with IASBPD of 10 mmHg or more, 15 mmHg or more, and inter-leg systolic BP difference of 15 mmHg or more. Inter-leg BP difference of 15 mmHg or more was strong predictor of PAD (P = .0001) and brachial-ankle PWV (P = .0001). Two invasive studies showed association of IASBPD and subclavian stenosis (estimates could not be combined). In conclusion, inter-arm and leg BP differences are strong predictors of PAD. IASBPD may be associated with subclavian stenosis, high left ventricular mass effect, and higher brachial-ankle PWVs. Inter-leg BP difference may also be associated with high left ventricular mass effect and higher
Than, Khoi D; Mummaneni, Praveen V; Smith, Zachary A; Hsu, Wellington K; Arnold, Paul M; Fehlings, Michael G; Mroz, Thomas E; Riew, K Daniel
Retrospective, multicenter case-series study and literature review. To determine the prevalence of brachial plexopathy after cervical spine surgery and to review the literature to better understand the etiology and risk factors of brachial plexopathy after cervical spine surgery. A retrospective case-series study of 12 903 patients at 21 different sites was performed to analyze the prevalence of several different complications, including brachial plexopathy. A literature review of the US National Library of Medicine and the National Institutes of Health (PubMed) database was conducted to identify articles pertaining to brachial plexopathy following cervical spine surgery. In our total population of 12 903 patients, only 1 suffered from postoperative brachial plexopathy. The overall prevalence rate was thus 0.01%, but the prevalence rate at the site where this complication occurred was 0.07%. Previously reported risk factors for postoperative brachial plexopathy include age, anterior surgical procedures, and a diagnosis of ossification of the posterior longitudinal ligament. The condition can also be due to patient positioning during surgery, which can generally be detected via the use of intraoperative neuromonitoring. Brachial plexopathy following cervical spine surgery is rare and merits further study.
Daly, Charles A; Payne, S Houston; Seiler, John G
This article reports a series of severe permanent brachial plexus injuries in American football players. The authors describe the mechanisms of injury and outcomes from a more contemporary treatment approach in the form of nerve transfer tailored to the specific injuries sustained. Three cases of nerve transfer for brachial plexus injury in American football players are discussed in detail. Two of these patients regained functional use of the extremity, but 1 patient with a particularly severe injury did not regain significant function. Brachial plexus injuries are found along a spectrum of brachial plexus stretch or contusion that includes the injuries known as "stingers." Early identification of these severe brachial plexus injuries allows for optimal outcomes with timely treatment. Diagnosis of the place of a given injury along this spectrum is difficult and requires a combination of imaging studies, nerve conduction studies, and close monitoring of physical examination findings over time. Although certain patients may be at higher risk for stingers, there is no evidence to suggest that this correlates with a higher risk of severe brachial plexus injury. Unfortunately, no equipment or strengthening program has been shown to provide a protective effect against these severe injuries. Patients with more severe injuries likely have less likelihood of functional recovery. In these patients, nerve transfer for brachial plexus injury offers the best possibility of meaningful recovery without significant morbidity. [ Orthopedics. 2016; 39(6):e1188-e1192.].
Tse, Raymond; Pondaag, Willem; Malessy, Martijn
Surgical exploration and reconstruction of the brachial plexus requires adequate exposure beyond the zone of injury. In the case of extensive lesions, some authors advocate clavicle osteotomy for an extensile approach. Such an osteotomy introduces further morbidity and may impact upon the delicate nerve reconstruction. A new simple but effective method of clavicle elevation is described that provides access to the retroclavicular brachial plexus during exploration for birth brachial plexus palsy.
... Habits for TV, Video Games, and the Internet X-Ray Exam: Ankle KidsHealth > For Parents > X-Ray Exam: Ankle Print A A A What's in ... You Have Questions What It Is An ankle X-ray is a safe and painless test that uses ...
... Old Feeding Your 1- to 2-Year-Old X-Ray Exam: Ankle KidsHealth > For Parents > X-Ray Exam: Ankle A A A What's in this ... español Radiografía: tobillo What It Is An ankle X-ray is a safe and painless test that uses ...
Takao, Masato; Glazebrook, Mark; Stone, James; Guillo, Stéphane
Ankle instability is a condition that often requires surgery to stabilize the ankle joint that will improve pain and function if nonoperative treatments fail. Ankle stabilization surgery may be performed as a repair in which the native existing anterior talofibular ligament or calcaneofibular ligament (or both) is imbricated or reattached. Alternatively, when native ankle ligaments are insufficient for repair, a reconstruction of the ligaments may be performed in which an autologous or allograft tendon is used to reconstruct the anterior talofibular ligament or calcaneofibular ligament (or both). Currently, ankle stabilization surgery is most commonly performed through an open incision, but arthroscopic ankle stabilization using repair techniques has been described and is being used more often. We present our technique for anatomic ankle arthroscopic reconstruction of the lateral ligaments (anti-ROLL) performed in an all–inside-out manner that is likely safe for patients and minimally invasive. PMID:26900560
Takao, Masato; Glazebrook, Mark; Stone, James; Guillo, Stéphane
Ankle instability is a condition that often requires surgery to stabilize the ankle joint that will improve pain and function if nonoperative treatments fail. Ankle stabilization surgery may be performed as a repair in which the native existing anterior talofibular ligament or calcaneofibular ligament (or both) is imbricated or reattached. Alternatively, when native ankle ligaments are insufficient for repair, a reconstruction of the ligaments may be performed in which an autologous or allograft tendon is used to reconstruct the anterior talofibular ligament or calcaneofibular ligament (or both). Currently, ankle stabilization surgery is most commonly performed through an open incision, but arthroscopic ankle stabilization using repair techniques has been described and is being used more often. We present our technique for anatomic ankle arthroscopic reconstruction of the lateral ligaments (anti-ROLL) performed in an all-inside-out manner that is likely safe for patients and minimally invasive.
Ritterman, Scott A; Fellars, Todd A; Digiovanni, Christopher W
The ankle is the most commonly injured joint in athletic and work activities. In contrast, osteoarthritis of the ankle joint is relatively rare and is typically post-traumatic or inflammatory in nature. Common symptoms that prompt an orthopaedic consultation include pain, disability and altered gait mechanics. Non-operative management has been the mainstay for previously undiagnosed patients. For those with advanced disease, ankle fusion or total ankle replacement may be the only surgical options. Though some recent studies have shown patients' preference for a well functioning ankle replacement, significant long- term follow-up data is lacking.
Forte, A; Gallinaro, L S; Bertagni, A; Montesano, G; Prece, V; Illuminati, G
Neurinomas, also referred to as neurilemmomas and schwannomas, are rare benign tumours of the peripheral nerves, a low proportion of which arise from the brachial plexus. Authors report a case of an ancient schwannoma arising from the brachial plexus. The tumour, usually asymptomatic, may cause sensory radicular symptoms, or rarely motor deficits in the involved arm. Enucleation of the tumour from the nerve without damage to any of the fascicles is the correct treatment.
Franson, Justin; Baravarian, Bob
Many articles have been published that discuss various lateral ankle injuries and specific lateral ankle pathology. The purpose of this article is to explore and present a specific combination of findings that the author's multiphysician practice has noticed on a frequently recurring basis. The triple injury of ankle synovitis, ankle instability, and peroneal tendon tear can be termed the Lateral Ankle Triad. While it is common to find each of these specific injuries individually, they are often found in combination. Copyright © 2011. Published by Elsevier Inc.
Ye, Yicong; Ding, Faming; Li, Mentao; Yang, Xinglin; Pang, Haiyu; Wang, Qian; Xu, Dong; Kang, Lin; Zeng, Xiaofeng; Zhang, Shuyang
This study was performed to determine the relationship between systemic lupus erythematosus (SLE) and the interarm blood pressure difference (IAD) and to elucidate the role of the IAD as a surrogate marker for early detection of peripheral artery disease (PAD) in patients with SLE. In total, 135 patients with SLE and 135 age- and gender-matched subjects were enrolled. The IAD and risk of an abnormal IAD were compared between the SLE and control groups, and logistic regression analysis was performed to determine the relationship between SLE and an abnormal IAD. The specificity and sensitivity of an IAD of 10 mm Hg or greater for diagnosis of PAD (ankle brachial index of <0.90) were calculated. Both the systolic and diastolic IADs were significantly higher in the SLE group than in the control group (P < 0.001). After adjustment for confounding factors, SLE remained significantly associated with an abnormal IAD (P = 0.039). Both the systolic and diastolic IADs were negatively associated with the ankle brachial index. Using a systolic IAD of 10 mm Hg or greater as the cutoff point, the specificity and sensitivity for PAD were 90% and 41%, respectively. A diastolic IAD of 10 mm Hg or greater exhibited higher specificity (92%), but lower sensitivity (30%). Systemic lupus erythematosus is independently associated with an abnormal IAD, and an IAD of 10 mm Hg or greater predicts PAD with high specificity but low sensitivity. Blood pressure should be measured at least once in both arms in patients with SLE for early detection of asymptomatic PAD.
Suzuki, Keiko; Juo, Suh-Hang Hank; Rundek, Tanja; Boden-Albala, Bernadette; Disla, Norbelina; Liu, Rui; Park, Naeun; Di Tullio, Marco R.; Sacco, Ralph L.; Homma, Shunichi
Background Brachial artery flow-mediated dilation (FMD) is a non-invasive measure of endothelial function. Endothelial dysfunction has been associated with traditional vascular risk factors and increased risk of cardiovascular disease. The importance of genetic contribution to FMD and baseline brachial artery diameter has not been shown in Hispanic populations. The purpose of this study was to estimate the heritability of FMD. Methods Flow mediated dilation and brachial artery diameter were measured in a subset of Caribbean Hispanic families from the ongoing Northern Manhattan Family Study (NOMAFS), which studies the contribution of genetics to stroke and cardiovascular risk factors. The age- and sex-adjusted heritability of FMD was estimated using variance component methods. Results The current data include 620 subjects (97 probands and 523 relatives) from 97 families. The age and sex-adjusted heritability of brachial artery diameter was 0.57 (p < 0.01). The age- and sex-adjusted heritability of FMD was 0.20 (p = 0.01). After additional adjustment for systolic and diastolic blood pressure, body mass index, smoking, lipid, diabetes mellitus, medication, and baseline brachial artery diameter, the heritability of FMD was 0.17 (p = 0.01). Conclusions We found modest heritability of FMD. FMD might be a reasonable phenotype for further investigation of genetic contribution to atherosclerosis. PMID:17462653
Lui, Tun Hing
Posterior ankle endoscopy is a safe and effective approach for treatment of posterior ankle impingement. This is usually performed with the patient in prone position. The purpose of this technical note is to describe an arthroscopic approach of decompression of posterior ankle impingement with the patient in supine position. This is indicated if there is posterior ankle impingement together with other ankle pathology requiring anterior ankle arthroscopy. This approach allows treatment of both anterior ankle and posterior ankle pathology with the patient in the supine position. Concomitant anterior ankle arthroscopy can be performed with the usual orientation without the need of change of patient's position.
Kachramanoglou, Carolina; Carlstedt, Thomas; Koltzenburg, Martin; Choi, David
Complete brachial plexus avulsion injury is a severe disabling injury due to traction to the brachial plexus. Brachial plexus reimplantation is an emerging surgical technique for the management of complete brachial plexus avulsion injury. We assessed the functional recovery in 15 patients who underwent brachial plexus reimplantation surgery after complete brachial plexus avulsion injury with clinical examination and electrophysiological testing. We included all patients who underwent brachial plexus reimplantation in our institution between 1997 and 2010. Patients were assessed with detailed motor and sensory clinical examination and motor and sensory electrophysiological tests. We found that patients who had reimplantation surgery demonstrated an improvement in Medical Research Council power in the deltoid, pectoralis, and infraspinatous muscles and global Medical Research Council score. Eight patients achieved at least grade 3 MRC power in at least one muscle group of the arm. Improved reinnervation by electromyelography criteria was found in infraspinatous, biceps, and triceps muscles. There was evidence of ongoing innervation in 3 patients. Sensory testing in affected dermatomes also showed better recovery at C5, C6, and T1 dermatomes. The best recovery was seen in the C5 dermatome. Our results demonstrate a definite but limited improvement in motor and sensory recovery after reimplantation surgery in patients with complete brachial plexus injury. We hypothesize that further improvement may be achieved by using regenerative cell technologies at the time of repair. Copyright © 2017 The Author(s). Published by Elsevier Inc. All rights reserved.
Nguyen, Hoang C; Fath, Erwin; Wirtz, Sebastian; Bey, Tareg
Depending on the approach to the upper brachial plexus, severe complications have been reported. We describe a novel posterolateral approach for brachial plexus block which, from an anatomical and theoretical point of view, seems to offer advantages. Twenty-seven patients were scheduled to undergo elective major surgery of the upper arm or shoulder using this new transscalene brachial plexus block. The success rate was 85.2% for surgery. Two patients required additional analgesia with IV sufentanil. In two others, regional anesthesia was inadequate. The side effects of this technique included reversible recurrent laryngeal nerve blockade in two patients and a reversible Horner syndrome in one patient. Further studies are needed to compare the transscalene brachial plexus block with other approaches to the brachial plexus.
Lui, Tun Hing
Adhesive capsulitis of the ankle is also known as frozen ankle and results in marked fibrosis and contracture of the ankle capsule. Arthroscopic capsular release is indicated for symptomatic frozen ankle that is resistant to conservative treatment. It is contraindicated for ankle stiffness due to degenerative joint disease, intra-articular malunion, or adhesion of the extensors of the ankle. The procedure consists of endoscopic posterior ankle capsulectomy and arthroscopic anterior ankle capsulotomy. It has the advantages of being minimally invasive surgery and allowing early postoperative vigorous mobilization of the ankle joint.
Bishop, David; Moore, Allan; Chandrashekar, Naveen
Traumatic knee injuries in automobile accidents and sports often lead to damage of the peroneal nerve. A lack of control of muscles innervated by the peroneal nerve due to this damage, results in the inability to dorsiflex and evert the foot and to extend the toes. This condition is commonly known as foot drop. Foot drop reduces the stability in the body while walking and running and may also cause injury due to lack of foot clearance during the swing phase of the gait. Traditionally, an ankle foot orthosis (AFO), comprised of a moulded sheet of plastic that conforms around the posterior calf and distally contains all or part of the calcaneous as well as the plantar foot, is used to treat foot drop. The intent of this orthosis is to dorsiflex the foot to provide clearance during the swing phase of walking and running. Traditional AFO results in increased pressures due to a decrease in dorsiflexion range of motion at the ankle and make the orthosis increasingly uncomfortable to wear. Several other existing designs of foot drop AFO suffer from similar inadequacies. To address these issues, a new AFO was developed. The device was successfully used by one person with foot drop without issues for more than one year. This new design conforms to the lower anterior shin and dorsum of the foot using dorsiassist Tamarack ankle joints to allow for greater plantar and dorsiflexion range of motion. While still limiting ankle inversion it does allow for more ankle eversion. This orthosis can be discretely worn inside shoes due to its smaller size, and can be worn for a longer period of time without discomfort.
Wang, Yan; Li, Zengyong; Wong, Duo Wai-Chi; Zhang, Ming
Background/Methodology Ankle arthrodesis is one popular surgical treatment for ankle arthritis, chronic instability, and degenerative deformity. However, complications such as foot pain, joint arthritis, and bone fracture may cause patients to suffer other problems. Understanding the internal biomechanics of the foot is critical for assessing the effectiveness of ankle arthrodesis and provides a baseline for the surgical plan. This study aimed to understand the biomechanical effects of ankle arthrodesis on the entire foot and ankle using finite element analyses. A three-dimensional finite element model of the foot and ankle, involving 28 bones, 103 ligaments, the plantar fascia, major muscle groups, and encapsulated soft tissue, was developed and validated. The biomechanical performances of a normal foot and a foot with ankle arthrodesis were compared at three gait instants, first-peak, mid-stance, and second-peak. Principal Findings/Conclusions Changes in plantar pressure distribution, joint contact pressure and forces, von Mises stress on bone and foot deformation were predicted. Compared with those in the normal foot, the peak plantar pressure was increased and the center of pressure moved anteriorly in the foot with ankle arthrodesis. The talonavicular joint and joints of the first to third rays in the hind- and mid-foot bore the majority of the loading and sustained substantially increased loading after ankle arthrodesis. An average contact pressure of 2.14 MPa was predicted at the talonavicular joint after surgery and the maximum variation was shown to be 80% in joints of the first ray. The contact force and pressure of the subtalar joint decreased after surgery, indicating that arthritis at this joint was not necessarily a consequence of ankle arthrodesis but rather a progression of pre-existing degenerative changes. Von Mises stress in the second and third metatarsal bones at the second-peak instant increased to 52 MPa and 34 MPa, respectively, after
Polovina, Svetislav; Cvjeticanin, Miljenko; Milicić, Jasna; Proloscić, Tajana Polovina
Perinatal brachial plexus palsy (PBPP) is a handicap quite commonly encountered in daily routine. Although birth trauma is considered to be the major cause of the defect, it has been observed that PBPP occurs only in some infants born under identical or nearly identical conditions. The aim of this study was to test the hypothesis of genetic predisposition for PBPP. It is well known that digito-palmar dermatoglyphs can be used to determine hereditary roots of some diseases. Thus, we found it meaningful to do a study analysis of digito-palmar dermatoglyphs in this disease as well, conducting it on 140 subjects (70 males and 70 females) diagnosed with PBPP. The control group was composed of fingerprints obtained from 400 adult and phenotypically healthy subjects (200 males and 200 females) from the Zagreb area. The results of multivariate and univariate analysis of variance have shown statistically significant differences between the groups observed. In spite of lower percentage of accurately classified female subjects by discriminant analysis, the results of quantitative analysis of digito-palmar dermatoglyphs appeared to suggest a genetic predisposition for the occurrence of PBPP.
Russell, Jeffrey A
Ankle sprain is a common injury in dancers. Because of the relative frequency of this injury and its wide acceptance as a likely part of an active lifestyle, in many individuals it may not receive the careful attention it deserves. An extreme ankle range of motion and excellent ankle stability are fundamental to success in dance. Hence, following a proper treatment protocol is crucial for allowing a dancer who suffers an ankle sprain to return to dance as soon as possible without impaired function. This article reviews the basic principles of the etiology and management of ankle sprain in dancers. Key concepts are on-site examination and treatment, early restoration, dance-specific rehabilitation, and a carefully administered safe return to dance. Additionally, injuries that may occur in conjunction with ankle sprain are highlighted, and practical, clinically relevant summary concepts for dance healthcare professionals, dance scientists, dance teachers, and dancers are provided.
Franko, O I; Khalpey, Z; Gates, J
Phrenic nerve palsy has previously been associated with brachial plexus root avulsion; severe unilateral phrenic nerve injury is not uncommonly associated with brachial plexus injury. Brachial plexus injuries can be traumatic (gunshot wounds, lacerations, stretch/contusion and avulsion injuries) or non-traumatic in aetiology (supraclavicular brachial plexus nerve block, subclavian vein catheterisation, cardiac surgeries, or obstetric complications such as birth palsy). Despite the known association, the incidence and morbidity of a phrenic nerve injury and hemidiaphragmatic paralysis associated with traumatic brachial plexus stretch injuries remains ill-defined. The incidence of an associated phrenic nerve injury with brachial plexus trauma ranges from 10% to 20%; however, because unilateral diaphragmatic paralysis often presents without symptoms at rest, a high number of phrenic nerve injuries are likely to be overlooked in the setting of brachial plexus injury. A case report is presented of a unilateral phrenic nerve injury associated with brachial plexus stretch injury presenting with a recalcitrant left lower lobe pneumonia.
14 Selected outcomes stratified by PAB protocol .............. ... ... . .......... . .... 15 Ankle Injury Model...use of medical services: Rates/1 ,000 male trainees during 2 week risk period, by year of training and PAS protocol , n=68,418 ROC Curve for ankle ...knee injury during 2 week risk period LIST OF TABLES Parachute ankle brace protocol periods, 1998 - 2006 Descriptive characteristics of U.S. Army
The ANKLE TRIAL (ANKLE treatment after injuries of the ankle ligaments): what is the benefit of external support devices in the functional treatment of acute ankle sprain? : a randomised controlled trial
Background Acute lateral ankle ligament injuries are very common problems in present health care. Still there is no hard evidence about which treatment strategy is superior. Current evidence supports the view that a functional treatment strategy is preferable, but insufficient data are present to prove the benefit of external support devices in these types of treatment. The hypothesis of our study is that external ankle support devices will not result in better outcome in the treatment of acute ankle sprains, compared to a purely functional treatment strategy. Overall objective is to compare the results of three different strategies of functional treatment for acute ankle sprain, especially to determine the advantages of external support devices in addition to functional treatment strategy, based on balance and coordination exercises. Methods/design This study is designed as a randomised controlled multi-centre trial with one-year follow-up. Adult and healthy patients (N = 180) with acute, single sided and first inversion trauma of the lateral ankle ligaments will be included. They will all follow the same schedule of balancing exercises and will be divided into 3 treatment groups, 1. pressure bandage and tape, 2. pressure bandage and brace and 3. no external support. Primary outcome measure is the Karlsson scoring scale; secondary outcomes are FAOS (subscales), number of recurrent ankle injuries, Visual Analogue Scales of pain and satisfaction and adverse events. They will be measured after one week, 6 weeks, 6 months and 1 year. Discussion The ANKLE TRIAL is a randomized controlled trial in which a purely functional treated control group, without any external support is investigated. Results of this study could lead to other opinions about usefulness of external support devices in the treatment of acute ankle sprain. Trial registration Netherlands Trial Register (NTR): NTR2151 PMID:22340371
Acute ankle injury, a common musculoskeletal injury, can cause ankle sprains. Some evidence suggests that previous injuries or limited joint flexibility may contribute to ankle sprains. The initial assessment of an acute ankle injury should include questions about the timing and mechanism of the injury. The Ottawa Ankle and Foot Rules provide clinical guidelines for excluding a fracture in adults and children and determining if radiography is indicated at the time of injury. Reexamination three to five days after injury, when pain and swelling have improved, may help with the diagnosis. Therapy for ankle sprains focuses on controlling pain and swelling. PRICE (Protection, Rest, Ice, Compression, and Elevation) is a well-established protocol for the treatment of ankle injury. There is some evidence that applying ice and using nonsteroidal antiinflammatory drugs improves healing and speeds recovery. Functional rehabilitation (e.g., motion restoration and strengthening exercises) is preferred over immobilization. Superiority of surgical repair versus functional rehabilitation for severe lateral ligament rupture is controversial. Treatment using semirigid supports is superior to using elastic bandages. Support devices provide some protection against future ankle sprains, particularly in persons with a history of recurrent sprains. Ankle disk or proprioceptive neuromuscular facilitation exercise regimens also may be helpful, although the literature supporting this is limited.
Pesquer, Lionel; Guillo, Stephane; Meyer, Philippe; Hauger, Olivier
Ankle impingement is a common condition occurring secondary to sprain or repeated microtrauma. Clinical symptoms are chronic pain located in the affected region and limited range of ankle motion. There are three types of ankle impingement syndrome: anterior impingement, which can be subdivided into anterolateral, anteromedial and purely anterior impingement; posterior impingement, which can be subdivided into posterior and posteromedial impingement; and calcaneal peroneal impingement which is secondary to planovalgus foot deformity. This paper evaluates physiological and clinical elements of these three types of ankle impingement syndrome as well as the role of ultrasound (US) imaging and US-guided treatment.
... needed to repair the damage, especially in competitive athletes. For severe ankle sprains, your doctor may also ... includes resting, protecting and reducing swelling of your injured ankle. Phase II includes restoring your ankle's flexibility, ...
... foot and ankle surgeons. All Fellows of the College are board certified by the American Board of Foot and Ankle Surgery. Copyright © 2017 American College of Foot and Ankle Surgeons (ACFAS), All Rights ...
Brachial plexus injuries offer a unique challenge to the athletic trainer because of their relatively high frequency rate in contact sports and because of the complexity of the neuroanatomy in the cervical area. During a game, athletic trainers must make a fast, accurate decision regarding a player's return to competition. It is imperative that the athletic trainer be able to quickly differentiate between minor injuries and more serious injuries warranting removal from the game and/or physician referral. A systematic approach to the evaluation of a brachial plexus injury is essential to ensure proper treatment. This paper will present a structured approach to an on-the-field assessment of brachial plexus injuries.
Kim, Jeong-Gil; Chung, Sun G
Herpes zoster, commonly known as shingles, is an infectious viral disease characterized by painful, unilateral skin blisters occurring in specific sensory dermatomes. Motor paresis is reported in 0.5% to 5% of patients. Although the mechanism of zoster paresis is still unclear, the virus can spread from the dorsal root ganglia to the anterior horn cell or anterior spinal nerve roots. It rarely involves the brachial plexus. We report a case of brachial plexitis following herpes zoster infection in which pathological lesions were diagnosed using brachial plexus magnetic resonance imaging and treated with ultrasound-guided perineural corticosteroid injection.
Pai, Rohini V Bhat; Hegde, Harihar V; Santhosh, MCB; Roopa, S; Deshpande, Shrinivas S; Rao, P Raghavendra
Hypertrophic obstructive cardiomyopathy (HOCM) is a challenge to anesthesiologists due to the complex pathophysiology involved and various perioperative complications associated with it. We present a 50-year-old man, a known case of HOCM, who successfully underwent emergency haemostasis, and debridement of the traumatically amputated right upper limb and the contused lacerated wound on the left forearm under bilateral brachial plexus blocks. His co-morbidities included hypertension (in hypertensive crisis) and diabetes mellitus. He was full stomach and also had an anticipated difficult airway. The management included invasive pressure monitoring and labetalol infusion for emergent control of blood pressure. The regional anaesthesia technique required careful consideration to the dosage of local anaesthetics and staggered performance of brachial plexus blocks on each of the upper limbs to avoid local anaesthetic toxicity. Even though bilateral brachial plexus blocks are rarely indicated, it seemed to be the most appropriate anaesthetic technique in our patient. With careful consideration of the local anaesthetic toxicity and meticulous technique, bilateral brachial plexus blocks can be successfully performed in those patients where general anaesthesia is deemed to be associated with higher risk. PMID:23716772
Upadhyaya, Vaishali; Upadhyaya, Divya Narain; Kumar, Adarsh; Pandey, Ashok Kumar; Gujral, Ratni; Singh, Arun Kumar
Magnetic Resonance Imaging (MRI) is being increasingly recognised all over the world as the imaging modality of choice for brachial plexus and peripheral nerve lesions. Recent refinements in MRI protocols have helped in imaging nerve tissue with greater clarity thereby helping in the identification, localisation and classification of nerve lesions with greater confidence than was possible till now. This article on Magnetic Resonance Neurography (MRN) is based on the authors’ experience of imaging the brachial plexus and peripheral nerves using these protocols over the last several years. PMID:26424974
Mooney, Luke M; Lai, Cara H; Rouse, Elliott J
By design, commonly worn energy storage and release (ESR) prosthetic feet cannot provide biologically realistic ankle joint torque and angle profiles during walking. Additionally, their anthropomorphic, cantilever architecture causes their mechanical stiffness to decrease throughout the stance phase of walking, opposing the known trend of the biological ankle. In this study, the design of a quasi-passive pneumatic ankle-foot prosthesis is detailed that is able to replicate the biological ankle's torque and angle profiles during walking. The prosthetic ankle is comprised of a pneumatic piston, bending spring and solenoid valve. The mechanical properties of the pneumatic ankle prosthesis are characterized using a materials testing machine and the properties are compared to those from a common, passive ESR prosthetic foot. The characterization spanned a range of ankle equilibrium pressures and testing locations beneath the foot, analogous to the location of center of pressure within the stance phase of walking. The pneumatic ankle prosthesis was shown to provide biologically appropriate trends and magnitudes of torque, angle and stiffness behavior, when compared to the passive ESR prosthetic foot. Future work will focus on the development of a control system for the quasi-passive device and clinical testing of the pneumatic ankle to demonstrate efficacy.
de Rezende, Marcelo Rosa; Silva, Gustavo Bersani; de Paula, Emygdio José Leomil; Junior, Rames Mattar; de Camargo, Olavo Pires
Brachial plexus injuries, in all their severity and complexity, have been extensively studied. Although brachial plexus injuries are associated with serious and often definitive sequelae, many concepts have changed since the 1950s, when this pathological condition began to be treated more aggressively. Looking back over the last 20 years, it can be seen that the entire approach, from diagnosis to treatment, has changed significantly. Some concepts have become better established, while others have been introduced; thus, it can be said that currently, something can always be offered in terms of functional recovery, regardless of the degree of injury. Advances in microsurgical techniques have enabled improved results after neurolysis and have made it possible to perform neurotization, which has undoubtedly become the greatest differential in treating brachial plexus injuries. Improvements in imaging devices and electrical studies have allowed quick decisions that are reflected in better surgical outcomes. In this review, we intend to show the many developments in brachial plexus surgery that have significantly changed the results and have provided hope to the victims of this serious injury. PMID:23644864
Rihane, B; Le Borgne, J M; Bélair, C
We report a case of idiopathic brachial nevralgia of the right shoulder in a 30-year-old female, after caesarean section, under spinal anaesthesia. Two days after surgery, intense cervical pain appeared on the second day, associated with rapid collapse of muscular shoulder belt. Full recovery occurred in four months.
Roukis, Thomas S; Prissel, Mark A
Medial ankle instability secondary to deltoid ligament insufficiency is frequently encountered when performing total ankle replacement and remains a challenge. In the present techniques report, we describe a "reverse" Evans peroneus brevis tendon nonanatomic deltoid ligament reconstruction for medial ankle stabilization harvested through limited incisions using simple topographic anatomic landmarks. The harvested peroneus brevis tendon is brought through a drill hole in the talus from laterally to medially, aiming for the junction of the talar neck and body plantar to the midline. The tendon is the brought superiorly and obliquely to the anterior medial aspect of the distal tibia where it is secured under a plate and screw construct. This modified Evans peroneus brevis tendon nonanatomic deltoid ligament reconstruction is useful in providing medial ankle stability during or after primary and revision total ankle replacement.
Weinstein, M L
Returning to full activity is of primary concern for the injured patient with a second-degree ankle sprain. This is especially true of a member of the United States Marine Corps. Unfortunately, many patients are not referred to physical therapy for comprehensive management of acute ankle sprains. An ankle protocol based on previous clinical experience was developed which included an acute and rehabilitative phase. An air stirrup orthosis was used as an adjunct to therapy to resume activities safely. This combination allowed Marines to return to full duty in less than 2 weeks.
Upadhyaya, Vaishali; Upadhyaya, Divya N; Kumar, Adarsh; Gujral, Ratni B
Imaging of the brachial plexus has come a long way and has progressed from plain radiography to CT and CT myelography to MRI. Evolution of MR imaging sequences has enabled good visualization of the small components of the plexus. The purpose of our study was to correlate the results of MR neurography (MRN) in patients with traumatic brachial plexopathy with their operative findings. We wanted to determine the usefulness of MRN and how it influenced surgical planning and outcome. Twenty patients with features of traumatic brachial plexopathy who were referred to the MRI section of the Department of Radiology between September 2012 and January 2014 and subsequently underwent exploration were included in the study. MR neurography and operative findings were recorded at three levels of the brachial plexus-roots, trunks and cords. Findings at the level of roots and trunks were noted in 14 patients each and at the level of the cords in 16 patients. 10 patients had involvement at all levels. Axillary nerve involvement as a solitary finding was noted in two patients. These patients were subsequently operated and their studies were assigned a score based on the feedback from the operating surgeons. The MRN study was scored as three (good), two (average) or one (poor) depending on whether the MR findings correlated with operative findings at all three levels, any two levels or at any one level, respectively. MR neurography is an extremely useful modality to image the traumatized brachial plexus. It influences both surgical planning and outcome/prognosis. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Denegar, Craig R.; Miller, Sayers J., III
Investigates whether chronic ankle instability can be prevented, discussing: the relationship between mechanical and functional instability; normal ankle mechanics, sequelae to lateral ankle sprains, and abnormal ankle mechanics; and tissue healing, joint dysfunction, and acute lateral ankle sprain management. The paper describes a treatment model…
Denegar, Craig R.; Miller, Sayers J., III
Investigates whether chronic ankle instability can be prevented, discussing: the relationship between mechanical and functional instability; normal ankle mechanics, sequelae to lateral ankle sprains, and abnormal ankle mechanics; and tissue healing, joint dysfunction, and acute lateral ankle sprain management. The paper describes a treatment model…
Lötscher, P; Lang, T H; Zwicky, L; Hintermann, B; Knupp, M
Injuries of the ankle joint have a high incidence in daily life and sports, thus, playing an important socioeconomic role. Therefore, proper diagnosis and adequate treatment are mandatory. While most of the ligament injuries around the ankle joint are treated conservatively, great controversy exists on how to treat deltoid ligament injuries in ankle fractures. Missed injuries and inadequate treatment of the medial ankle lead to inferior outcome with instability, progressive deformity, and ankle joint osteoarthritis.
Ozen, Mustafa; Sayman, Onur; Havitcioglu, Hasan
Total ankle replacement (TAR) is a relatively new concept and is becoming more popular for treatment of ankle arthritis and fractures. Because of the high costs and difficulties of experimental studies, the developments of TAR prostheses are progressing very slowly. For this reason, the medical imaging techniques such as CT, and MR have become more and more useful. The finite element method (FEM) is a widely used technique to estimate the mechanical behaviors of materials and structures in engineering applications. FEM has also been increasingly applied to biomechanical analyses of human bones, tissues and organs, thanks to the development of both the computing capabilities and the medical imaging techniques. 3-D finite element models of the human foot and ankle from reconstruction of MR and CT images have been investigated by some authors. In this study, data of geometries (used in modeling) of a normal and a prosthetic foot and ankle were obtained from a 3D reconstruction of CT images. The segmentation software, MIMICS was used to generate the 3D images of the bony structures, soft tissues and components of prosthesis of normal and prosthetic ankle-foot complex. Except the spaces between the adjacent surface of the phalanges fused, metatarsals, cuneiforms, cuboid, navicular, talus and calcaneus bones, soft tissues and components of prosthesis were independently developed to form foot and ankle complex. SOLIDWORKS program was used to form the boundary surfaces of all model components and then the solid models were obtained from these boundary surfaces. Finite element analyses software, ABAQUS was used to perform the numerical stress analyses of these models for balanced standing position. Plantar pressure and von Mises stress distributions of the normal and prosthetic ankles were compared with each other. There was a peak pressure increase at the 4th metatarsal, first metatarsal and talus bones and a decrease at the intermediate cuneiform and calcaneus bones, in
Chopra, Swati; Rouhani, Hossein; Assal, Mathieu; Aminian, Kamiar; Crevoisier, Xavier
Previous studies assessed the outcome of ankle arthrodesis (AA) and total ankle replacement (TAR) surgeries; however, the extent of postoperative recovery towards bilateral gait mechanics (BGM) is unknown. We evaluated the outcome of the two surgeries at least 2 years post rehabilitation, focusing on BGM. 36 participants, including 12 AA patients, 12 TAR patients, and 12 controls were included. Gait assessment over 50 m distance was performed utilizing pressure insoles and 3D inertial sensors, following which an intraindividual comparison was performed. Most spatiotemporal and kinematic parameters in the TAR group were indicative of good gait symmetry, while the AA group presented significant differences. Plantar pressure symmetry among the AA group was also significantly distorted. Abnormality in biomechanical behavior of the AA unoperated, contralateral foot was observed. In summary, our results indicate an altered BGM in AA patients, whereas a relatively fully recovered BGM is observed in TAR patients, despite the quantitative differences in several parameters when compared to a healthy population. Our study supports a biomechanical assessment and rehabilitation of both operated and unoperated sides after major surgeries for ankle osteoarthrosis.
Tehan, Peta; Bray, Alan; Keech, Ruth; Rounsley, Richard; Carruthers, Angela; Chuter, Vivienne Helaine
The toe-brachial index (TBI) is an alternative to the ankle-brachial index (ABI) in screening for peripheral arterial disease (PAD); however, there is limited evidence comparing their diagnostic accuracy. This study compared the diagnostic accuracy of the ABI and TBI in a population at risk of PAD. The sensitivity and specificity of the ABI and TBI were determined by color duplex sonography. Receiver operating characteristic (ROC) analysis was performed. A total of 119 participants were recruited (75 male and 44 female). The sensitivity for PAD was highest for the TBI (71%; ABI, 45%), and the specificity was highest for the ABI (93%; TBI, 78%). Receiver operating characteristic analysis indicated that the TBI (ROC area, 0.77; P = .0001) had greater clinical efficacy for diagnosis of PAD than the ABI (ROC area, 0.65; P = .005). In specific populations, the TBI may have greater clinical efficacy than the ABI for diagnosis of PAD. © 2015 by the American Institute of Ultrasound in Medicine.
Graf, S.; Valero, M. J.; Craiem, D.; Torrado, J.; Farro, I.; Zócalo, Y.; Valls, G.; Bía, D.; Armentano, R. L.
Endothelial function can be assessed non-invasively with ultrasound, analyzing the change of brachial diameter in response to transient forearm ischemia. We propose a new technique based in the same principle, but analyzing a continuous recording of carotid-radial pulse wave velocity (PWV) instead of diameter. PWV was measured on 10 healthy subjects of 22±2 years before and after 5 minutes forearm occlusion. After 59 ± 31 seconds of cuff release PWV decreased 21 ± 9% compared to baseline, reestablishing the same after 533 ± 65 seconds. There were no significant changes observed in blood pressure. When repeating the study one hour later in 5 subjects, we obtained a coefficient of repeatability of 4.8%. In conclusion, through analysis of beat to beat carotid-radial PWV it was possible to characterize the temporal profiles and analyze the acute changes in response to a reactive hyperemia. The results show that the technique has a high sensitivity and repeatability.
... feet - legs; Ankle swelling; Foot swelling; Leg swelling; Edema - peripheral; Peripheral edema ... 51. Trayes KP, Studdiford JS, Pickle S, Tully AS. Edema: Diagnosis and management. Am Fam Phys . 2013;88( ...
... by a condition such as osteoporosis or a stress fracture. You may be at higher risk of a broken foot or ankle if you: Participate in high-impact sports. The stresses, direct blows and twisting injuries ...
Abdulmassih, Sami; Phisitkul, Phinit; Femino, John E; Amendola, Annunziato
Restricted ankle dorsiflexion secondary to contracture of the gastrocnemius-soleus complex is frequently encountered in patients with foot and ankle pain and is well documented in the literature. During gait, decreased dorsiflexion shifts weight-bearing pressures from the heel to the forefoot, which may result in or exacerbate one of several pathologic conditions. Modest success has been achieved with nonsurgical management of triceps surae contracture, including splinting and stretching exercises. Surgical lengthening of the gastrocnemius-soleus complex at multiple levels has been described, and early clinical results have been promising. Additional research is required to further elucidate the long-term outcomes of various lengthening techniques.
Mouser, J Grant; Ade, Carl J; Black, Christopher D; Bemben, Debra A; Bemben, Michael G
Blood flow restriction (BFR), the application of external pressure to occlude venous return and restrict arterial inflow, has been shown to increase muscular size and strength when combined with low-load resistance exercise. BFR in the research setting uses a wide range of pressures, applying a pressure based upon an individual's systolic pressure or a percentage of occlusion pressure; not a directly determined reduction in blood flow. The relationship between relative pressure and blood flow has not been established. To measure blood flow in the arm under relative levels of BFR. Forty-five people (18-40 years old) participated. Arterial occlusion pressure in the right arm was measured using a 5-cm pneumatic cuff. Blood flow in the brachial artery was measured at rest and at pressures between 10% and 90% of occlusion using ultrasound. Blood flow decreased in a nonlinear, stepped fashion. Blood flow decreased at 10% of occlusion and remained constant until decreasing again at 40%, where it remained until 90% of occlusion. The decrease in brachial blood flow is not proportional to the applied relative pressure. The prescription of blood flow restriction should take into account the stimulus provided at each relative level of blood flow. © 2017 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd.
Sclar, Gary; Maniker, Allen; Danto, Joseph
Myokymic discharges are spontaneous bursts of semirhythmic potentials that are sometimes correlated with rippling movements of skin and muscle. They have been reported in limb muscles in patients with Guillain-Barré syndrome, spinal stenosis, nerve root and nerve compression, and envenomations. They commonly occur with radiation induced plexopathies (approximately 60% of patients), but have not been reported in obstetrically related brachial plexopathies. We report 2 instances of myokymia in children with obstetric brachial plexus palsies. Each child was studied twice, and it was only at the later study, when the child was 10 or 11 months of age, that these potentials were noted. This could represent ongoing recovery from lesions incurred at birth or developmental changes. The final common pathway of all causes of myokymia could be to generate axonal membrane hyperexcitability.
Chen, Liang; Gu, Yu-Dong; Wang, Huan
The incidence of obstetric brachial plexus palsy is not declining. Heavy birth weight of the infant and breech delivery are considered two important risk factors and Caesarean section delivery seems to be a protective factor. There are two clinical appearances, that is, paralysis of the upper roots and that of total roots, and Klumpke's palsy involving the C8 and T1 roots is rarely seen. Computed tomography myelography (CTM) is still the best way of visualizing nerve roots. Surgical intervention is needed for 20-25% of all patients and clinical information is decisive for the indication of surgery. Most often, a conducting neuroma of the upper trunk is encountered, and it is believed that neuroma resection followed by microsurgical reconstruction of the brachial plexus gives the best results. Copyright 2008 Wiley-Liss, Inc. Microsurgery, 2008.
Trachet, B; Reymond, P; Kips, J; Swillens, A; De Buyzere, M; Suys, B; Stergiopulos, N; Segers, P
Recently a new method has been proposed as a tool to measure arterial pulse wave velocity (PWV), a measure of the stiffness of the large arteries and an emerging parameter used as indicator of clinical cardiovascular risk. The method is based on measurement of brachial blood pressure during supra-systolic pressure inflation of a simple brachial cuff [the device is known as the Arteriograph (Tensiomed, Budapest, Hungary)]. This occlusion yields pronounced first and secondary peaks in the pressure waveform, the latter ascribed to a reflection from the aortic bifurcation, and PWV is calculated as the ratio of twice the jugulum-symphysis distance and the time difference between the two peaks. To test the validity of this working principle, we used a numerical model of the arterial tree to simulate pressures and flows in the normal configuration, and in a configuration with an occluded brachial artery. A pronounced secondary peak was indeed found in the brachial pressure signal of the occluded model, but its timing was only related to brachial stiffness and not to aortic stiffness. We also compared PWV's calculated with three different methods: PWVATG (approximately Arteriograph principle), PWVcar-fem (approximately carotid-femoral PWV, the current clinical gold standard method), and PWVtheor (approximately Bramwell-Hill equation). Both PWVATG (R2=0.94) and PWVcar-fem (R2=0.95) correlated well with PWVtheor, but their numerical values were lower (by 2.17+/-0.42 and 1.08+/-0.70 m/s for PWVATG and PWVcar-fem, respectively). In conclusion, our simulations question the working principle of the Arteriograph. Our data indicate that the method picks up wave reflection phenomena confined to the brachial artery, and derived values of PWV rather reflect the stiffness of the brachial arteries.
Kim, Byeong-Jo; Lee, Jung-Hoon; Kim, Chang-Tae; Lee, Sun-Min
[Purpose] To report the effects of ankle balance taping for a patient with chronic ankle instability (CAI). [Subject] A 33-year-old man with a 10 year history of chronic ankle stability. [Methods] ABT with kinesiology tape was performed for 2 months (average, 16 h/day) around the right ankle. [Results] At the end of two months, no ankle instability was noted when ascending and descending the stairs, jumping, turning, operating the pedals while driving, and lifting heavy objects. [Conclusion] The repeated use of kinesiology tape in ankle balance taping may be an effective treatment for recovering the ankle stability of patients with chronic ankle instability. PMID:26311206
Kim, Byeong-Jo; Lee, Jung-Hoon; Kim, Chang-Tae; Lee, Sun-Min
[Purpose] To report the effects of ankle balance taping for a patient with chronic ankle instability (CAI). [Subject] A 33-year-old man with a 10 year history of chronic ankle stability. [Methods] ABT with kinesiology tape was performed for 2 months (average, 16 h/day) around the right ankle. [Results] At the end of two months, no ankle instability was noted when ascending and descending the stairs, jumping, turning, operating the pedals while driving, and lifting heavy objects. [Conclusion] The repeated use of kinesiology tape in ankle balance taping may be an effective treatment for recovering the ankle stability of patients with chronic ankle instability.
Sakellariou, Vasileios I.; Badilas, Nikolaos K.; Stavropoulos, Nikolaos A.; Mazis, George; Kotoulas, Helias K.; Kyriakopoulos, Stamatios; Tagkalegkas, Ioannis; Sofianos, Ioannis P.
The incidence of brachial plexus injuries is rapidly growing due to the increasing number of high-speed motor-vehicle accidents. These are devastating injuries leading to significant functional impairment of the patients. The purpose of this review paper is to present the available options for conservative and operative treatment and discuss the correct timing of intervention. Reported outcomes of current management and future prospects are also analysed. PMID:24967125
Polovina, Svetislav; Milicić, Jasna; Cvjeticanin, Miljenko; Proloscić, Tajana Polovina
It has been considered for many years that the cause of perinatal brachial plexus palsy (PBPP) is excessive lateral traction applied to the fetal head at delivery, in association with anterior shoulder dystocia, but this do not explain all cases of brachial plexus palsy. The incidence found in several family members could be suggestive for inheritance with variable expression. The aim of this study was to prove early found confirmations of genetic predisposition for PBPP In the previous studies, the quantitative dermatoglyphic analysis showed some differences in digito-palmar dermatoglyphs between patients with PBPP and healthy controls. Now this qualitative analysis will try to determine hereditary of those diseases. We analyzed digito-palmar dermatoglyphics from 140 subjects (70 males and 70 females) diagnosed with PBPP and 400 phenotypically healthy adults (200 males and 200 females) from Zagreb area as control group. The results of Chi-square test showed statistically significant differences for frequencies of patterns on fingers in females between the groups observed. Statistically significant differences were found on palms in III and IV interdigital areas in both males and females and in thenar and I interdigital area only in females. As it was found in previous researches on quantitative dermatoglyphic traits, more differences are found between females with PBPP and control group, than between males. The fact, that the main presumed cause of PBPP is obstetrical trauma, it could be associated with congenital variability in formation of brachial plexus.
van den Heuvel, Alexander; Van Bouwel, Saskia; Dereymaeker, Greta
The ankle joint has unique anatomical, biomechanical and cartilaginous structural characteristics that allow the joint to withstand the very high mechanical stresses and strains over years. Any minor changes to any of these features predispose the joint to osteoarthritis. Total ankle replacement (TAR) is evolving as an alternative to ankle arthrodesis for the treatment of end-stage ankle osteoarthritis. Initial implant designs from the early 1970s had unacceptably high failure and complication rates. As a result many orthopaedic surgeons have restricted the use of TAR in favour of ankle arthrodesis. Long term follow-up studies following ankle arthrodesis show risks of developing adjacent joint osteoarthritis. Therefore research towards a successful ankle replacement continues. Newer designs and longer-term outcome studies have renewed the interest in ankle joint replacement. We present an overview of the evolution, results and current concepts of total ankle replacement.
Alfonso, Israel; Papazian, Oscar; Shuhaiber, Hans; Yaylali, Ilker; Grossman, John A I
Obstetrical brachial plexus injury occurs when the forces preventing the stretch of the brachial plexus are overcome by the forces stretching it. This report describes an 8-day-old male delivered by uncomplicated cesarean section with right obstetrical brachial plexus palsy and congenital arm atrophy. The patient had a history of decreased right arm movement detected by fetal ultrasound at 18 to 20 weeks of gestation. The purpose of this article is to report that stretching of brachial plexus at birth sufficient to produce a plexus injury may occur in a patient with a vulnerable plexus even in the absence of traction during delivery.
Gerstner Garces, Juan Bernardo
Chronic instability of the ankle and anterolateral impingement syndrome are abnormalities that present as a result of inversion and forced plantar-flexion traumas of the foot, despite strict conservative management in the ER and in rehabilitation. A conservative approach is always the first choice of treatment, including anti-inflammatory medications, rehabilitation and proprioception, infiltration with steroids in impingement cases, and use of orthotics, whose true effectiveness is the subject of multiple studies and much debate. Good to excellent results can be obtained surgically with a minimally invasive approach, such as the arthroscopic technique presented herein. Such an approach is useful in managing a combination of conditions such as anterolateral impingement, synovitis, and osteochondral lesions of the talus. The method is easily reproducible, its learning curve is rapid, and it has the advantage of not preventing the use other arthroscopic methods, or open anatomic or nonanatomic methods (tendon transfers), in the case of failure. No nerve lesion was recorded, probably owing to the use of the security zone, and neither was there any arthrofibrosis, possibly related to the use of nonsteroidal anti-inflammatory medications in the immediate postsurgical period coupled with aggressive rehabilitation from the fourth week. The success of the technique is due to multidisciplinary team work leading to the ultimate achievement of patient satisfaction. This technique is not indicated for patients with a high sports demand or for sport professionals, until further biomechanical studies on its use and success are completed. Copyright © 2012 Elsevier Inc. All rights reserved.
Yamaguchi, Satoshi; Tanaka, Yasuhito; Banks, Scott; Kosugi, Shinichi; Sasho, Takahisa; Takahashi, Kazuhisa; Takakura, Yoshinori
Relatively high rates of loosening and implant failure have been reported after total ankle arthroplasty. Abnormal kinematics and incongruency of the articular surface may cause increased contact pressure and rotational torque applied to the implant, leading to loosening and implant failure. We measured in vivo kinematics of two-component total ankle arthroplasty (TNK ankle), and assessed congruency of the articular surface during the stance phase of gait. Eighteen ankles of 15 patients with a mean age of 75±6 years (mean±standard deviation) and follow-up of 44±38 months were enrolled. Lateral fluoroscopic images were taken during the stance phase of gait. 3D-2D model-image registration was performed using the fluoroscopic image and the implant models, and three-dimensional kinematics of the implant and incongruency of the articular surface were determined. The mean ranges of motion were 11.1±4.6°, 0.8±0.4°, and 2.6±1.5° for dorsi-/plantarflexion, inversion/eversion, and internal/external rotation, respectively. At least one type of incongruency of the articular surface occurred in eight of 18 ankles, including anterior hinging in one ankle, medial or lateral lift off in four ankles, and excessive axial rotation in five ankles. Among the four ankles in which lift off occurred during gait, only one ankle showed lift off in the static weightbearing radiograph. Our observations will provide useful data against which kinematics of other implant designs, such as three-component total ankle arthroplasty, can be compared. Our results also showed that evaluation of lift off in the standard weightbearing radiograph may not predict its occurrence during gait.
Wilkin, Emily Jane; Hunt, Adrienne; Nightingale, Elizabeth Jean; Munn, Joanne; Kilbreath, Sharon Lynne; Refshauge, Kathryn Margaret
To assess inter-rater reliability of ankle manual tests. We also correlated the manual tests with the Cumberland Ankle Instability Tool (CAIT). One ankle from each of 60 participants was assessed using four different manual tests (anterior drawer in supine and crook lying, talar tilt, inversion tilt). Three different raters, varying in experience, tested each participant. The CAIT questionnaire was also administered. The study received ethics approval from the University of Sydney Human Research Ethics Committee. Intraclass correlation coefficients (ICC), standard error of the mean (SEM) and percent close agreement (PCA) were used to determine reliability of the four tests. Pearson's correlation coefficients were used to determine relationships between the manual tests and CAIT scores. Inter-rater reliability for the four manual tests was poor regardless of therapist's experience (ICC([1,1]) -0.12 to 0.33; SEM 0.93-1.69). Correlations between the CAIT and manual tests were also low varying between r = -0.12 and -0.42. Inter-rater reliability was poor for manual tests of ankle stability. Reliability may be improved by using a grading scale with fewer intervals. The CAIT scores and manual tests correlated poorly, potentially reflecting the variety of conditions leading to ankle instability. Crown Copyright © 2012. Published by Elsevier Ltd. All rights reserved.
Héritier, Odile; Vasseur Maurer, Sabine; Reinberg, Olivier; Cotting, Jacques; Perez, Marie-Hélène
This paper describes a one-month-old girl presenting with respiratory and growth failure due to diaphragmatic paralysis associated with left brachial plexus palsy after forceps delivery. Despite continuous positive pressure ventilation and nasogastric feeding, the situation did not improve and a laparoscopic diaphragmatic plication had to be performed. When dealing with a child born with brachial plexus palsy, one must think of this possible association and if necessary proceed to the complementary radiological examinations. The treatment must avoid complications like feeding difficulties and failure to thrive, respiratory infections or atelectasis. It includes intensive support and a good evaluation of the prognosis of the lesion to decide the best moment for a surgical therapy.
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Hui, S H; Lui, T H
Introduction: Periosteal reaction has a long list of differential diagnoses ranging from trauma, infection, metabolic disease to malignancy. The morphology of periosteal reaction shown in imaging studies helps to narrow down the list of differential diagnoses. Case report: A 25 year old gentleman had an inversion injury to his left ankle. He complained of lateral ankle and posterior heel pain and swelling after the injury. Radiograph of his left ankle revealed solid, smooth periosteal reaction at posterior aspect of left distal tibia. MRI showed periosteal reaction at the corresponding site, which was better demonstrated in CT scan. Follow up MRI and CT showed maturation of the new bone formation at the site of periosteal reaction. Findings were compatible with subperiosteal hematoma formation from injury, which ossified with time. Conclusion: Smooth, thick periosteal reaction favours benign process, while interrupted pattern is an alarming feature for more aggressive causes. PMID:27299131
Gosk, Jerzy; Rutowski, Roman
Risk factors of obstetrical brachial plexus palsy include: (1) large birth weight, (2) shoulder dystocia and prolonged second stage of labour, (3) instrumental vaginal delivery (forceps delivery, vacuum extraction), (4) diabetes mellitus and mother's obesity, (5) breech presentation, (6) delivery and infant with obstetrical brachial plexus palsy in antecedent delivery. The purpose was analysis of the classical risk factors for brachial plexus palsy based on our own clinical material. Clinical material consists of 83 children with obstetrical brachial plexus palsy treated at the Department of Trauma and Hand Surgery (surgically--54, conservatively--29). Control group consists of 56 healthy newborns. Data recorded included: birth weight, body length, head and chest circumference, Apgar test at 1 min., type of brachial palsy and side affected, type of birth, presentation, duration of delivery (II stage), age of mother, mother's diseases, parity. The infants treated surgically have had a significantly higher birth weight, body height, head and chest circumference, in compression with control group and group treated conservatively. The differences were statistically important. Shoulder dystocia occurred in 32.9% of all vaginal delivery. Instrumental vaginal delivery was observed in 11.3% and breech presentation in 4.9% cases. There were no incidences of obstetrical brachial plexus palsy recurrence. Diabetes mellitus and mother's obesity was found in 3 cases. (1) Fetal macrosomia is the important risk factor of the obstetrical brachial plexus palsy. (2) Obstetrical brachial plexus palsy may occur also in the absence of the classical risk factors.
Zungsontiporn, Nath; Ndhlovu, Lishomwa C; Mitchell, Brooks I; Stein, James H; Kallianpur, Kalpana J; Nakamoto, Beau; Keating, Sheila M; Norris, Philip J; Souza, Scott A; Shikuma, Cecilia M; Chow, Dominic C
This study aimed to evaluate the relationship between inflammatory biomarkers and endothelial dysfunction (ED), as measured by brachial artery flow-mediated dilation (FMD). We conducted a cross-sectional analysis utilizing baseline data of 135 participants with HIV infection on stable antiretroviral therapy (ART) in the Hawaii Aging with HIV-Cardiovascular (HAHC-CVD) study who had available baseline inflammatory biomarkers and brachial artery FMD measurements. We observed significant associations between brachial artery FMD and baseline brachial artery diameter, age, male gender, traditional cardiovascular disease (CVD) risk factors such as BMI, waist to hip ratio, hypertension, systolic blood pressure (BP), diastolic BP, and LDL cholesterol, and 10-year coronary heart disease (CHD) risk estimated by Framingham risk score (FRS). Of all biomarkers tested, higher level of C-reactive protein (CRP) (beta = - 0.695, P = 0.030) and serum amyloid P (SAP) (beta = - 1.318, P = 0.021) were significantly associated with lower brachial artery FMD in univariable regression analysis. After adjusting for baseline brachial artery diameter, age, and selected traditional CVD risk factors in multivariable model, SAP remained significantly associated with brachial artery FMD (beta = - 1.094, P = 0.030), while CRP was not (beta = - 0.391, P = 0.181). Serum amyloid P was independently associated with impaired brachial artery FMD and may potentially relate to ED and increased CVD risk in HIV-infected patients on stable ART.
Bony fusion of the ankle in a functionally favorable position for restitution of a painless weight bearing while avoiding a leg length discrepancy. Disabling, painful osteoarthritis of the ankle with extensive bone defect secondary to trauma, infection, or serious deformities such as congenital malformations or diabetic osteoarthropathies. Acute joint infection. Severe arterial occlusive disease of the involved limb. Lateral approach to the distal fibula. Fibular osteotomy 7 cm proximal to the tip of the lateral malleolus and posterior flipping of the distal fibula. Exposure of the ankle. Removal of all articular cartilage and debridement of the bone defect. Determination of the size of the defect and harvesting of a corresponding tricortical bone graft from the iliac crest. Also harvesting of autogenous cancellous bone either from the iliac crest or from the lateral part of the proximal tibia. Insertion of the tricortical bone graft and filling of the remaining defect with cancellous bone. Fixation with three 6.5-mm titanium lag screws. Depending on the extent of the defect additional stabilization of the bone graft with a titanium plate. Fixation of the lateral fibula on talus and tibia with two 3.5-mm titanium screws for additional support. Wound closure in layers. Split below-knee cast with the ankle in neutral position. Between January 2002 and January 2004 this technique was used in five patients with extensive bone defects (four women, one man, average age 57 years [42-77 years]). No intra- or early postoperative complications. The AOFAS (American Orthopedic Foot and Ankle Society) Score was improved from 23 points preoperatively to 76 points postoperatively (average follow-up time of 25 months). Two patients developed a nonunion and underwent a revision with an ankle arthrodesis nail. A valgus malposition after arthrodesis in one patient was corrected with a supramalleolar osteotomy.
Lee, Sun-Min; Lee, Jung-Hoon
[Purpose] The aim of this study was to report the effects of ankle eversion taping using kinesiology tape on ankle inversion sprain. [Subject] The subject was a 21-year-old woman with Grade 2 ankle inversion sprain. [Methods] Ankle eversion taping was applied to the sprained left ankle using kinesiology tape for 4 weeks (average, 15 h/day). [Results] Ankle instability and pain were reduced, and functional dynamic balance was improved after ankle eversion taping for 4 weeks. The Cumberland Ankle Instability Tool score and reach distances in the Y-Balance and lunge tests were increased. [Conclusion] Repeated ankle eversion taping may be an effective treatment intervention for ankle inversion sprain. PMID:27064668
Lee, Sun-Min; Lee, Jung-Hoon
[Purpose] The aim of this study was to report the effects of ankle eversion taping using kinesiology tape on ankle inversion sprain. [Subject] The subject was a 21-year-old woman with Grade 2 ankle inversion sprain. [Methods] Ankle eversion taping was applied to the sprained left ankle using kinesiology tape for 4 weeks (average, 15 h/day). [Results] Ankle instability and pain were reduced, and functional dynamic balance was improved after ankle eversion taping for 4 weeks. The Cumberland Ankle Instability Tool score and reach distances in the Y-Balance and lunge tests were increased. [Conclusion] Repeated ankle eversion taping may be an effective treatment intervention for ankle inversion sprain.
Guillén-Rogel, Paloma; San Emeterio, Cristina; Marín, Pedro J
[Purpose] This study assessed the relationships between the ankle dorsiflexion range of motion and foot and ankle strength. [Subjects and Methods] Twenty-nine healthy (young adults) volunteers participated in this study. Each participant completed tests for ankle dorsiflexion range of motion, hallux flexor strength, and ankle plantar and dorsiflexor strength. [Results] The results showed (1) a moderate correlation between ankle dorsiflexor strength and dorsiflexion range of motion and (2) a moderate correlation between ankle dorsiflexor strength and first toe flexor muscle strength. Ankle dorsiflexor strength is the main contributor ankle dorsiflexion range of motion to and first toe flexor muscle strength. [Conclusion] Ankle dorsiflexion range of motion can play an important role in determining ankle dorsiflexor strength in young adults.
Muthukumar, Natarajan; Santhanakrishnan, Alwar Govindan; Sivakumar, Krishnaswamy
Obstetric brachial plexus palsy is not uncommon. However, lesions masquerading as obstetric brachial plexus palsy are rare. A child with a cervicothoracic arachnoid cyst masquerading as obstetric brachial plexus palsy is presented, and the relevant literature is reviewed. A girl born by vaginal delivery at full term without any antecedent risk factors for obstetric brachial plexus palsy was noted to have decreased movements of the right upper extremity. After 7 months, there was no improvement. An MRI scan was obtained, which revealed a cervicothoracic spinal extradural arachnoid cyst. During surgery, the cyst was found to communicate with the dura at the axilla of the C-7 nerve root. The cyst was excised in toto. Six months later, there was improvement in the infant's neurological status. This case illustrates that spinal arachnoid cysts should be entertained in the differential diagnosis when a child presents with obstetric brachial plexus palsy without known antecedent risk factors for obstetric palsy.
Weber, Jason M; Maleski, Richard M
Lateral ankle sprains are among the most common sports injuries. Although ankle sprains are treated conservatively at the present time, for years the treatment was based on acute repair of the ruptured ligaments. Several differing opinions currently exist as to the treatment of lateral ankle sprains. A review of the literature and explanation of the benefits and risks of each treatment protocol is undertaken.
Ekstrand, Jan; And Others
Investigates relationship between ankle sprains and participation time in competitive orienteering. Examined 15,474 competitors in races in the Swedish O-ringen 5-day event in 1987. Injuries requiring medical attention were analyzed, showing 137 (23.9 percent) ankle sprains. Injury incidence was 8.4/10,000 hours. Incidence of ankle sprains was…
Johnson, Sarah A; Figueroa, Arturo; Navaei, Negin; Wong, Alexei; Kalfon, Roy; Ormsbee, Lauren T; Feresin, Rafaela G; Elam, Marcus L; Hooshmand, Shirin; Payton, Mark E; Arjmandi, Bahram H
Postmenopausal women have a high prevalence of hypertension and often develop arterial stiffness thereby increasing cardiovascular disease risk. Although antihypertensive drug therapies exist, increasing numbers of people prefer natural therapies. In vivo studies and a limited number of clinical studies have demonstrated the antihypertensive and vascular-protective effects of blueberries. To examine the effects of daily blueberry consumption for 8 weeks on blood pressure and arterial stiffness in postmenopausal women with pre- and stage 1-hypertension. This was an 8-week, randomized, double-blind, placebo-controlled clinical trial. Forty-eight postmenopausal women with pre- and stage 1-hypertension recruited from the greater Tallahassee, FL, area participated. Participants were randomly assigned to receive either 22 g freeze-dried blueberry powder or 22 g control powder. Resting brachial systolic and diastolic blood pressures were evaluated and arterial stiffness was assessed using carotid-femoral pulse wave velocity and brachial-ankle pulse wave velocity. C-reactive protein, nitric oxide, and superoxide dismutase were measured at baseline, 4 weeks, and 8 weeks. Statistical analysis was performed using a split plot model of repeated measures analysis of variance. After 8 weeks, systolic blood pressure and diastolic blood pressure (131±17 mm Hg [P<0.05] and 75±9 mm Hg [P<0.01], respectively) and brachial-ankle pulse wave velocity (1,401±122 cm/second; P<0.01) were significantly lower than baseline levels (138±14 mm Hg, 80±7 mm Hg, and 1,498±179 cm/second, respectively), with significant (P<0.05) group×time interactions in the blueberry powder group, whereas there were no changes in the group receiving the control powder. Nitric oxide levels were greater (15.35±11.16 μmol/L; P<0.01) in the blueberry powder group at 8 weeks compared with baseline values (9.11±7.95 μmol/L), whereas there were no changes in the control group. Daily blueberry consumption may
Bhargava, Amita N.; Kasundra, Gaurav M.; Khichar, Subhakaran; Bhushan, Bharat S. K.
We describe a patient who presented with a history of lightning strike injury. Following the injury, he sustained acute right upper limb weakness with pain. Clinically, the lesion was located to the upper and middle trunk of the right brachial plexus, and the same confirmed with electrophysiological studies. Nerve damage due to lightning injuries is considered very rare, and a plexus damage has been described infrequently, if ever. Thus, the proposed hypothesis that lightning rarely causes neuropathy, as against high-voltage electric current, due to its shorter duration of exposure not causing severe burns which lead to nerve damage, needs to be reconsidered. PMID:25288846
Bhargava, Amita N; Kasundra, Gaurav M; Khichar, Subhakaran; Bhushan, Bharat S K
We describe a patient who presented with a history of lightning strike injury. Following the injury, he sustained acute right upper limb weakness with pain. Clinically, the lesion was located to the upper and middle trunk of the right brachial plexus, and the same confirmed with electrophysiological studies. Nerve damage due to lightning injuries is considered very rare, and a plexus damage has been described infrequently, if ever. Thus, the proposed hypothesis that lightning rarely causes neuropathy, as against high-voltage electric current, due to its shorter duration of exposure not causing severe burns which lead to nerve damage, needs to be reconsidered.
Lederman, R.J.; Wilbourn, A.J.
We reviewed clinical and electrodiagnostic features of 16 patients with neoplastic brachial plexopathy (NBP) and 17 patients with radiation-induced plexopathy (RBP). The groups were similar in symptom-free interval after cancer diagnosis and location of the plexus lesions. NBP patients had pain and Horner's syndrome; RBP patients had paresthesias, but rarely Horner's. NBP patients presented earlier after symptom onset and had a shorter course. RBP patients more frequently had abnormal sensory and normal motor nerve conduction studies and characteristically had fasciculations or myokymia on EMG.
Hay, S M; Hay, F A; Austwick, D H
A case of brachial plexus block is presented, following a bee sting in the posterior triangle of the neck. The onset of neurological symptoms was rapid as was their subsequent resolution. Delayed peripheral neurological symptoms believed to have an immunological basis have been reported in response to stings from bees and other Hymenoptera both in the central and peripheral nervous systems (Goldstein et al., 1960; Means et al., 1973; Bachman et al., 1982; Weatherall et al., 1987; Van Antwerpen et al., 1988), but to the authors' knowledge no similar case of immediate peripheral block has been reported. PMID:1492899
Chan, Kwok Bill; Lui, Tun Hing
To report the operative findings of ankle arthroscopy during open reduction and internal fixation of acute ankle fractures. This was a retrospective review of 254 consecutive patients with acute ankle fractures who were treated with open reduction and internal fixation of the fractures, and ankle arthroscopy was performed at the same time. The accuracy of fracture reduction, the presence of syndesmosis disruption and its reduction, and the presence of ligamentous injuries and osteochondral lesions were documented. Second-look ankle arthroscopy was performed during syndesmosis screw removal 6 weeks after the key operation. There were 6 patients with Weber A, 177 patients with Weber B, 51 patients with Weber C, and 20 patients with isolated medial malleolar fractures. Syndesmosis disruption was present in 0% of patients with Weber A fracture, 52% of patients with Weber B fracture, 92% of patients with Weber C fracture, and 20% of the patients with isolated medial malleolar fracture. Three patients with Weber B and one patient with Weber C fracture have occult syndesmosis instability after screw removal. Osteochondral lesion was present in no patient with Weber A fracture, 26% of the Weber B cases, 24% of the Weber C cases, and 20% of isolated medial malleolar fracture cases. The association between the presence of deep deltoid ligament tear and syndesmosis disruption (warranting syndesmosis screw fixation) in Weber B cases was statistically significant but not in Weber C cases. There was no statistically significant association between the presence of posterior malleolar fracture and syndesmosis instability that warrant screw fixation. Ankle arthroscopy is a useful adjuvant tool to understand the severity and complexity of acute ankle fracture. Direct arthroscopic visualization ensures detection and evaluation of intra-articular fractures, syndesmosis disruption, and associated osteochondral lesions and ligamentous injuries. Level IV, case series
Kim, Kyung-Min; Hart, Joseph M; Saliba, Susan A; Hertel, Jay
Application of cryotherapy over an injured joint has been shown to improve muscle function, yet it is unknown how ankle cryotherapy affects postural control. Our purpose was to determine the effects of a 20-min focal ankle joint cooling on unipedal static stance in individuals with and without chronic ankle instability (CAI). Fifteen young subjects with CAI (9 males, 6 females) and 15 healthy gender-matched controls participated. All subjects underwent two intervention sessions on different days in which they had a 1.5L plastic bag filled with either crushed ice (active treatment) or candy corn (sham) applied to the ankle. Unipedal stance with eyes closed for 10s were assessed with a forceplate before and after each intervention. Center of pressure (COP) data were used to compute 10 specific dependent measures including velocity, area, standard deviation (SD), and percent range of COP excursions, and mean and SD of time-to-boundary (TTB) minima in the anterior-posterior (AP) and mediolateral directions. For each measure a three-way (Group-Intervention-Time) repeated ANOVAs found no significant interactions and main effects involving intervention (all Ps > 0.05). There were group main effects found for mean velocity (F(1,28) = 6.46, P = .017), area (F(1,28) = 12.83, P = .001), and mean of TTB minima in the AP direction (F(1,28) = 5.19, P = .031) indicating that the CAI group demonstrated greater postural instability compared to the healthy group. Postural control of unipedal stance was not significantly altered following focal ankle joint cooling in groups both with and without CAI. Ankle joint cryotherapy was neither beneficial nor harmful to single leg balance.
Bonnin, Michel P; Laurent, Jean-Raphael; Casillas, Mark
The return to sporting activities after ankle arthroplasty has rarely been evaluated. The purpose of the present study was to evaluate function and return to sports after total ankle arthroplasty. One hundred seventy-nine Salto Total Ankle Arthroplasties (TAA) were implanted between 1997 and 2005. A self-administered questionnaire including the Foot Function Index (FFI) and Foot and Ankle Ability Measurement (FAAM) was sent to all patients. At last followup, six were deceased, 22 were not available for evaluation, and six questionnaires were incomplete. One hundred forty-five questionnaires were available. The mean age was 60.9 years and the mean followup was 53.8 months. The main indications for TAA were osteoarthritis (OA) in 100 cases and Rheumatoid arthritis (RA) in 40 cases. 15.2% of the patients said that their operated ankle was "normal'' 60.7%" nearly normal''; 20% "abnormal'' and 4.1% "highly abnormal.'' The FFI scores were 13.7 +/- 17 for "activity limitations'', 31.7 +/- 23 for "disability'' and 16.9 +/- 19 for "pain''. The FAAM scores were 74.9 +/- 18 for activities of daily living and 48.9 +/- 28 for sports activities. On a Visual Analog Scales (0 to 100 were 100 is the "pre-pathology level'') the mean rating was 70.2 +/- 19.6 for Activities of Daily Living and 53.7 +/- 28 for sport activities. In the OA patients, 38 regularly road bicycle, 21 perform recreational gymnastics, 58 swimming, 50 home gardening, 27 dancing, and 43 hiking. Seven patients regularly practice tennis, nine cross-country skiing, 17 downhill skiing, and six regularly run more than 500 m. This study showed that TAA improved the quality of life and that return to recreational activities was generally possible but the return to impact sport was rarely possible.
Clark, Christopher E; Campbell, John L; Powell, Roy J; Thompson, John F
A blood pressure (BP) difference between the upper limbs is often encountered in primary care. Knowledge of its prevalence and importance in the accurate measurement of BP is poor, representing a source of error. Current hypertension guidelines do not emphasize this. To establish the prevalence of an inter-arm blood pressure difference (IAD) and explore its association with other indicators of peripheral vascular disease (PVD) in a hypertensive primary care population. This was a cross-sectional study. Primary care, one rural general practice, was the setting of the study. The methods were controlled simultaneous measurement of brachial BPs, ankle-brachial pressure index (ABPI) and tiptoe stress testing in 94 subjects. In all, 18 of 94 [19%, 95% confidence interval (CI) 11-27%] subjects had mean systolic inter-arm difference (sIAD) > or =10 mmHg and seven of 94 (7%, 95% CI 2-12%) had mean diastolic inter-arm difference (dIAD) > or =10 mmHg. Nineteen of 91 (20%, 95% CI 12-28%) had a reduced ABPI <0.9. There was negative correlation between systolic (Pearson's correlation coefficient - 0.378; P = 0.01) and diastolic (Pearson's correlation coefficient - 0.225; P = 0.05) magnitudes of IAD with ABPI. On tiptoe testing, 9/90 subjects (10%, 95% CI 4-16%) had a pressure drop > or =20%. An IAD and asymptomatic PVD are common in a primary care hypertensive population. Magnitude of the IAD is inversely correlated with ABPI, supporting the hypotheses that IADs are causally linked to PVD, and that IAD is a useful marker for the presence of PVD. Consequently, detection of an IAD should prompt the clinician to screen subjects for other signs of vascular disease and target them for aggressive cardiovascular risk factor modification.
Collins, Natalie; Teys, Pamela; Vicenzino, Bill
Physiotherapists frequently use manipulative therapy techniques to treat dysfunction and pain resulting from ankle sprain. This study investigated whether a Mulligan's mobilization with movement (MWM) technique improves talocrural dorsiflexion, a major impairment following ankle sprain, and relieves pain in subacute populations. Fourteen subjects with subacute grade II lateral ankle sprains served as their own control in a repeated measures, double-blind randomized controlled trial that measured the initial effects of the MWM treatment on weight bearing dorsiflexion and pressure and thermal pain threshold. The subacute ankle sprain group studied displayed deficits in dorsiflexion and local pressure pain threshold in the symptomatic ankle. Significant improvements in dorsiflexion occurred initially post-MWM ( F(2,26) = 7.82, P = 0.002 ), but no significant changes in pressure or thermal pain threshold were observed after the treatment condition. Results indicate that the MWM treatment for ankle dorsiflexion has a mechanical rather than hypoalgesic effect in subacute ankle sprains. The mechanism by which this occurs requires investigation if we are to better understand the role of manipulative therapy in ankle sprain management.
Williams, Glenn N; Jones, Morgan H; Amendola, Annunziato
Ankle sprains are among the most common athletic injuries and represent a significant source of persistent pain and disability. Despite the high incidence of ankle sprains in athletes, syndesmosis injuries have historically been underdiagnosed, and assessment in terms of severity and optimal treatment has not been determined. More recently, a heightened awareness in sports medicine has resulted in more frequent diagnoses of syndesmosis injuries. However, there is a low level of evidence and a paucity of literature on this topic compared with lateral ankle sprains. As a result, no clear guidelines are available to help the clinician assess the severity of injury, choose an imaging modality to visualize the injury, make a decision in terms of operative versus nonoperative treatment, or decide when the athlete may return to play. Increased knowledge and understanding of these injuries by clinicians and researchers are essential to improve the prevention, diagnosis, and treatment of this significant condition. This review will discuss the anatomy, mechanism of injury, diagnosis, and treatment of syndesmosis sprains of the ankle while identifying controversies in management and topics for future research.
Cavallo, M; Natali, S; Ruffilli, A; Buda, R; Vannini, F; Castagnini, F; Ferranti, E; Giannini, S
The ankle joint can be affected by several diseases, with clinical presentation varying from mild pain or swelling to inability, becoming in some cases a serious problem in daily life activities. Arthroscopy is a widely performed procedure in orthopedic surgery, due to the low invasivity compared to the more traditional open field surgery. The ankle joint presents anatomical specificities, like small space and tangential view that make arthroscopy more difficult. From 2000 more than 600 ankle arthroscopies were performed at our institution. The treated pathologies were mostly impingement syndrome and osteochondral lesions, and in lower percentage instabilities and ankle fractures. In the impingement, the AOFAS scores at FU showed an increase compared to scores collected preoperatively, with improvement of symptoms in most of the cases, good or excellent results in 80 % of cases. In ligament injuries, AOFAS score significatively improved at the maximum follow-up. In fractures all patients had an excellent AOFAS score at maximum follow-up, with complete return to their pre-injury activities. In osteochondral injuries, the clinical results showed a progressive improvement over time with the different performed procedures. Control MRI and bioptic samples showed a good regeneration of the cartilage and bone tissue in the lesion site. The encouraging obtained clinical results, in line with the literature, show how the arthroscopic technique, after an adequate learning curve, may represent a precious aid for the orthopedic surgeon and for the patient's outcome. Case series, Level IV.
The dancer's foot and ankle are subjected to high forces and unusual stresses in training and performance. Injuries are common in dancers, and the foot and ankle are particularly vulnerable. Ankle sprains, ankle impingement syndromes, flexor hallucis longus tendonitis, cuboid subluxation, stress fractures, midfoot injuries, heel pain, and first metatarsophalangeal joint problems including hallux valgus, hallux rigidus, and sesamoid injuries will be reviewed. This article will discuss these common foot and ankle problems in dancers and give typical clinical presentation and diagnostic and treatment recommendations.
Sahu, DK; Sahu, Anjana
A lateral approach described by Volker Hempel and Dr. Dilip Kotharihas been further studied, evaluated and described in detail in the present study. The aim of this study was to evaluate lateral approach of supraclavicular brachial plexus block, mainly in terms of successes rate and complication rate. The study was conducted in secondary level hospital and tertiary level hospital from 2004 to 2008. It was a prospective nonrandomized open-level study. Eighty-two patients of both sexes, aged between 18 and 65 years with ASA Grade I and II scheduled to undergo elective major surgery of the upper limb below the midarm, were selected for this new lateral approach of brachial plexus block. The onset and duration of sensory and motor block, any complications and need for supplement anaesthesia were observed. Success and complication rate were calculated in percentage. Average onset and duration of sensory and motor block was calculated as mean ± SD and percentage. Out of 82 patients, 75 (92%) have got successful block with no significant complication in any case. PMID:20885867
Kishan, Amar U; Syed, Sana; Fiorito-Torres, Franchesca; Thakore-James, Manisha
Pancoast syndrome, classically considered as a constellation of (1) pain along the C8–T2 dermatomes, (2) weakness and atrophy of the hand and (3) Horner's syndrome, often presents a diagnostic challenge. In fact, it may manifest as a singular orthopaedic complaint, prompting a futile barrage of tests and referrals. The authors present the case of an elderly man who initially presented with severe shoulder pain. Due to progressive pain and weakness, he was referred to rheumatology and was treated with corticosteroid injections for a presumed musculoskeletal lesion. Ultimately, he manifested gross muscular atrophy and worsening pain, prompting a referral to neurology. An electromyogram (EMG) suggested a lower brachial plexopathy, and a follow-up brachial plexus MRI identified a large Pancoast tumour. Unfortunately, his disease was rapidly progressive, and he passed away within 2 months. While the MRI remains the gold standard for diagnosing Pancoast syndrome, an EMG can facilitate diagnosis in difficult cases such as this one. PMID:22744250
Dimou, Stefan; Biggs, Michael; Tonkin, Michael; Hickie, Ian B.; Lagopoulos, Jim
In the past decade, research has demonstrated that cortical plasticity, once thought only to exist in the early stages of life, does indeed continue on into adulthood. Brain plasticity is now acknowledged as a core principle of brain function and describes the ability of the central nervous system to adapt and modify its structural organization and function as an adaptive response to functional demand. In this clinical case study we describe how we used neuroimaging techniques to observe the functional topographical expansion of a patch of cortex along the sensorimotor cortex of a 27-year-old woman following brachial plexus transfer surgery to re-innervate her left arm. We found bilateral activations present in the thalamus, caudate, insula as well as across the sensorimotor cortex during an elbow flex motor task. In contrast we found less activity in the sensorimotor cortex for a finger tap motor task in addition to activations lateralized to the left inferior frontal gyrus and thalamus and bilaterally for the insula. From a pain perspective the patient who had experienced extensive phantom limb pain (PLP) before surgery found these sensations were markedly reduced following transfer of the right brachial plexus to the intact left arm. Within the context of this clinical case the results suggest that functional improvements in limb mobility are associated with increased activation in the sensorimotor cortex as well as reduced PLP. PMID:23966938
Keuter, X H A; Kessels, A G H; de Haan, M H; van der Sande, F M; Tordoir, J H M
Ischemia is a devastating complication after arteriovenous fistula (AVF) creation. When not timely corrected, it may lead to amputation. Symptomatic ischemia occurs in 3.7-5% of the hemodialysis population. Upper arm AVFs have a higher incidence of ischemia compared to forearm AVFs. As more patients may need upper arm AVFs in the growing and older hemodialysis population, occurrence of symptomatic ischemia may increase. The purpose of this study is to identify predictors for occurrence of ischemia. A prospective evaluation of ischemia was performed in patients randomised for either a brachial-basilic (BB-) AVF or a prosthetic forearm loop AVF. Clinical parameters, preoperative vessel diameters, access flows, digital blood pressures, digit-to-brachial indices (DBI) and interventions for ischemia were recorded. Sixty-one patients (BB-AVF 28) were studied. Seventeen patients (BB-AVF 8) developed ischemic symptoms. Six patients (BB-AVF 3) needed interventions for severe symptoms. Age, history of peripheral arterial reconstruction and radial artery volume flow were significant predictors for the occurrence of ischemia. Symptomatic ischemia occurred in 28% of patients with brachial-basilic and prosthetic forearm AVFs. Age, history of peripheral arterial reconstruction and radial artery volume flow might be important for prediction of ischemia.
Zheng, Meili; Xu, Xiping; Wang, Xiaobin; Huo, Yong; Xu, Xin; Qin, Xianhui; Tang, Genfu; Xing, Houxun; Fan, Fangfang; Cui, Wei; Yang, Xinchun
Blood pressure (BP) changes with age. We conducted a cross-sectional study in rural Chinese adults to investigate: (1) what is the relationship between age, arterial stiffness, and BP in Chinese men and women; and (2) to what degree can the age-BP relationship be explained by arterial stiffness, controlling for other covariables. These analyses included a total of 1688 subjects (males/females: 623/1065), aged 40 to 88 years. Among them, 353 (20.9%) had hypertension (defined as systolic blood pressure (SBP) ≥ 140 mm Hg or diastolic blood pressure (DBP) ≥ 90 mm Hg). Arterial stiffness was measured by brachial-ankle pulse wave velocity (baPWV). baPWV appeared to be more strongly correlated with BP (including SBP, DBP, mean arterial pressure [MAP], pulse pressure [PP]) than age (P < 0.001 for comparisons between Spearman correlation coefficients). Furthermore, baPWV was associated with BP (including SBP, DBP, MAP, and PP) and risk of hypertension in a dose-response fashion, independent of age; in contrast, the age-BP associations were either attenuated or became negative after adjusting for baPWV. Arterial stiffness appears to be an independent contributor to hypertension, even after adjusting for age and other covariables. In contrast, age-BP associations became attenuated or negative after adjusting for baPWV. The utility of baPWV as a diagnostic, prognostic, and therapeutic indicator for hypertension warrants further investigation.
van Dijk, C Niek; Reilingh, Mikel L; Zengerink, Maartje; van Bergen, Christiaan J A
Most osteochondral lesions (defects) of the talar dome are caused by trauma, which may be a single event or repeated, less intense events (microtrauma). A lesion may heal, remain asymptomatic, or progress to deep ankle pain on weight bearing, prolonged joint swelling, and the formation of subchondral bone cysts. During loading, compression of the cartilage forces water into the microfractured subchondral bone. The increased flow and pressure of fluid in the subchondral bone can cause osteolysis and the slow development of a subchondral cyst. The pain does not arise from the cartilage lesion but most likely is caused by repetitive high fluid pressure during walking and a concomitant decrease in pH produced by osteoclasts, which sensitize the highly innervated subchondral bone. Prevention of further degeneration depends on several factors, including the repair of the subchondral bone plate and the correct alignment of the ankle joint.
Lee, M S; Hofbauer, M H
The diagnosis and management of lateral ankle injuries require the physician to obtain an accurate history, complete a thorough physical examination, and institute appropriate treatment protocol. Labeling all acute lateral ankle injuries as ankle sprains can lead to long-term mechanical and functional instability and chronic pain around the ankle. Appropriate and aggressive functional rehabilitation of the acute ankle limits the postinjury convalescence and need for surgical reconstruction. If surgical repair of the chronic or acute ankle is warranted, the Brostrom-Gould procedure serves as a highly successful anatomic repair. Lateral ankle tenodesing procedures also are effective; however, in most cases, the loss of rearfoot motion limits this procedure to a secondary reconstructive procedure.
Al-Mohrej, Omar A.; Al-Kenani, Nader S.
Ankle sprains fall into two main categories: acute ankle sprains and chronic ankle instability, which are among the most common recurrent injuries during occupational activities, athletic events, training and army service. Acute ankle sprain is usually managed conservatively and functional rehabilitation failure by conservative treatment leads to development of chronic ankle instability, which most often requires surgical intervention. Enhancing the in-depth knowledge of the ankle anatomy, biomechanics and pathology helps greatly in deciding the management options. Cite this article: Al-Mohrej OA, Al-Kenani NS. Acute ankle sprain: conservative or surgical approach? EFORT Open Rev 2016;1:34-44. DOI: 10.1302/2058-5241.1.000010. PMID:28461926
Cugat, Ramon; Ares, Oscar; Cuscó, Xavier; Garcia, Montserrat; Samitier, Gonzalo; Seijas, Roberto
Ankle arthroscopy provides a minimally invasive approach to the diagnosis and treatment of certain ankle disorders. Neurological complications resulting from ankle arthroscopy have been well documented in orthopaedic and podiatric literature. Owing to the superficial location of the ankle joint and the abundance of overlying periarticular neurovascular structures, complications reported in ankle arthroscopy are greater than those reported for other joints. In particular, all reported neurovascular injuries following ankle arthroscopy have been the direct result of distractor pin or portal placement. The standard posteromedial portal has recognized risks because of the proximity of the posterior neurovascular structures. There can be considerable variability in the course of these portals and their proximity to the neurovascular structures. We found one report of intra-articular damage to the posterior tibial nerve as a result of ankle arthroscopy in the English-language literature and we report this paper as a second case described in the literature.
Cheng, Hao-Min; Wang, Kang-Ling; Chen, Ying-Hwa; Lin, Shing-Jong; Chen, Lung-Ching; Sung, Shih-Hsien; Ding, Philip Yu-An; Yu, Wen-Chung; Chen, Jaw-Wen; Chen, Chen-Huan
Current noninvasive techniques for assessing central aortic pressure require the recording of an arterial pressure wave using a high-fidelity applanation tonometer. We therefore developed and validated a novel method to estimate the central aortic systolic pressure using an oscillometric blood pressure monitor alone. Invasive high-fidelity right brachial and central aortic pressure waves, and left-brachial pulse volume plethysmography from an oscillometric blood pressure monitor, were obtained at baseline and 3 min after administration of sublingual nitroglycerin in 100 patients during cardiac catheterization. In the initial 50 patients (Generation Group), Central systolic blood pressure was predicted by a multi-variate prediction model generated from the comprehensive analysis of the invasive brachial pressure wave, including brachial late-systolic shoulder pressure value and parameters related to wave reflection and arterial compliance. Another prediction model was similarly constructed from the noninvasively calibrated pulse volume plethysmography. Both models were validated in the subsequent 50 patients (Validation Group) with results: r=0.98 (P<0.001) and mean difference=0.5+/-4.5 (95% confidence interval -8.3 to 9.3) mm Hg for the invasive model, and r=0.93 (P<0.001) and mean difference=-0.1+/-7.6 (95% confidence interval -15.0 to 14.8) mm Hg for the noninvasive model. Thus, our results indicate that central aortic systolic blood pressure could be estimated by analysis of the noninvasive brachial pressure wave alone from an oscillometric blood pressure monitor.
Falyar, Christian R; Shaffer, Katherine M; Perera, Robert A
Interscalene brachial plexus blocks are performed for perioperative management of surgeries involving the shoulder. Historically, these procedures employed anatomic landmarks (AL) to determine the location of the brachial plexus as it passes between the anterior and middle scalene muscles in the neck. In this study, we compared the actual location of the brachial plexus as found with sonography (US) to the anticipated location using AL. The location of the brachial plexus was evaluated using US and AL in 96 subjects. The distance between the two locations was measured. A multivariate analysis of variance was used to determine the significance of the difference and a 2 × 2 analysis of variance was used to compare differences in gender, height, and body mass index. The brachial plexus was located on average 1.8 cm inferior (p = 0.0001) and 0.2 cm lateral (p = 0.09) to the location determined with AL. A significant difference was also associated with gender (p = 0.03), but not with height or body mass index. US is a reliable method that accurately pinpoints the roots of the brachial plexus. The brachial plexus is often located inferior to the location anticipated using AL. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:411-415, 2016. © 2016 Wiley Periodicals, Inc.
Lee, Sun-Min; Lee, Jung-Hoon
[Purpose] The purpose of this study was to report the effects of ankle inversion taping using kinesiology tape in a patient with a medial ankle sprain. [Subject] A 28-year-old amateur soccer player suffered a Grade 2 medial ankle sprain during a match. [Methods] Ankle inversion taping was applied to the sprained ankle every day for 2 months. [Results] His symptoms were reduced after ankle inversion taping application for 2 months. The self-reported function score, the reach distances in the Star Excursion Balance Test, and the weight-bearing ankle dorsiflexion were increased. [Conclusion] This study showed that ankle inversion taping using kinesiology tape may be an effective therapy for a patient with a medial ankle sprain. PMID:26311991
Lee, Sun-Min; Lee, Jung-Hoon
[Purpose] The purpose of this study was to report the effects of ankle inversion taping using kinesiology tape in a patient with a medial ankle sprain. [Subject] A 28-year-old amateur soccer player suffered a Grade 2 medial ankle sprain during a match. [Methods] Ankle inversion taping was applied to the sprained ankle every day for 2 months. [Results] His symptoms were reduced after ankle inversion taping application for 2 months. The self-reported function score, the reach distances in the Star Excursion Balance Test, and the weight-bearing ankle dorsiflexion were increased. [Conclusion] This study showed that ankle inversion taping using kinesiology tape may be an effective therapy for a patient with a medial ankle sprain.
Sharpe, S R; Knapik, J; Jones, B
The purpose of this study was to examine the effectiveness of ankle bracing and taping in preventing recurrencess of ankle sprains, specifically in female athletes. Varsity soccer players' medical records over a five-year period were retrospectively reviewed at a Division III women's college. Data were extracted regarding any history of ankle sprain(s), type of intervention used as prophylaxis after the ankle sprain, number of exposures, and any incidence of recurrence. All collegiate varsity soccer players who had suffered a previous sprain to either one or both ankles (38 players) were identified as subjects. Each previously injured ankle (n = 56) was considered as a case for the analysis. Ankles that had a previous sprain received one of four interventions: 1) a canvas, laced ankle brace (n = 19), 2) taping (n = 12), 3) a combination of taping and ankle bracing (n = 8), or 4) no treatment (n = 17). The four intervention groups had a total of 1717 practice exposures and 650 competitive game exposures; exposures did not differ among the 4 groups. Ankle sprain recurrence frequency was 0%, 25%, 25%, and 35% for the braced, taped, combination, and untreated groups, respectively. The recurrence incidence for the braced group was significantly lower than that of the other three groups. The ankle sprain recurrence frequency did not differ among the taped, combination, and no treatment groups. We suggest that prophylactic ankle bracing is effective in reducing the incidence of ankle sprains in female soccer players with a previous history of ankle sprains.
Buckley, W. E.; Denegar, Craig R.
Objective: To identify subjects' changes in postural control during single-leg stance in the 4 weeks after acute lateral ankle sprain. Design and Setting: We used a 2 × 2 × 3 (side-by-plane-by-session) within-subjects design with repeated measures on all 3 factors. All tests were performed in a university laboratory. Subjects: Seventeen young adults (9 men, 8 women; age, 21.8 ± 5.9 years; mass, 74.9 ± 10.5 kg; height, 176.9 ± 7.1 cm) who had sustained unilateral acute mild or moderate lateral ankle sprains. Measurements: Measures of center-of-pressure excursion length, root mean square velocity of center-of-pressure excursions (VEL), and range of center-of-pressure excursions (RANGE) were calculated separately in the frontal and sagittal planes during 5-second trials of static single-leg stance. Results: We noted significant side-by-plane-by-session interactions for magnitude of center-of-pressure excursions in a given trial (PSL) (P = .004), VEL (P = .011), and RANGE (P = .009). Both PSL and VEL in the frontal plane were greater in the injured limbs compared with the uninjured limbs on day 1 and during week 2 but not during week 4, whereas sagittal-plane differences existed during all 3 testing sessions. Injured-limb, frontal-plane RANGE scores were greater than uninjured values at day 1 but not during weeks 2 or 4. No significant differences in sagittal-plane RANGE scores were seen. Conclusions: Postural control was significantly impaired in the injured limbs at day 1 and during week 2 after lateral ankle sprain but not during week 4. Consistent improvement in postural control measures on both injured and uninjured limbs was seen throughout the 4 weeks after ankle sprain. PMID:12937477
Zhong, Li-Yuan; Wang, Ai-Ping; Hong, Li; Chen, Sheng-Hua; Wang, Xian-Qin; Lv, Yun-Cheng; Peng, Tian-Hong
To provide the anatomical basis of brachial plexus roots for the diagnosis and treatment of brachial plexus root avulsion injury. The morphological features of brachial plexus roots were observed and measured on 15 cervicothoracic spine of adult cadavers. The relationship of brachial plexus nerve roots and the surrounding tissues also were observed, as well as the blood supply of anterior and posterior roots of the brachial plexus. Origination of the nerve roots in the dorsal-ventral direction from the midline was fine-tuned at each level along the spinal cord. The minimum distance of the origin of the nerve root to midline was 2.2 mm at C 5, while the maximum was 3.1 mm at T 1. Inversely, the distance between the origin of the posterior root and the midline of the spinal cord gradually decreased, the maximum being 4.2 mm at C 5 and minimum 2.7 mm at T 1. Meanwhile, there was complicated fibrous connection among posterior roots of the brachial plexus. The C 5-6 nerve roots interlaced with tendons of the scalenus anterior and scalenus medius and fused with the transverse-radicular ligaments in the intervertebral foramina. However, these ligaments were not seen in C 7-8, and T 1. The blood supply of the anterior and posterior roots of the brachial plexus was from the segmental branches of the vertebral artery, deep cervical artery and ascending cervical artery, with a mean outer diameter of 0.61 mm. The systematic and comprehensive anatomic data of the brachial plexus roots provides the anatomical basis to diagnose and treat the brachial plexus root avulsion injury.
Sale, D G; Moroz, D E; McKelvie, R S; MacDougall, J D; McCartney, N
Brachial arterial pressure, oesophageal pressure, and knee joint angle were monitored in eight untrained young men as they performed bilateral leg-press actions (simultaneous hip and knee extension and ankle plantarflexion) against resistance. Single maximal leg-press actions on an isokinetic device evoked mean peak arterial (systolic/diastolic) pressures of 35.4/26.2 and 34.0/23.4 kPa at lever arm velocities of 0.262 and 1.31 rad.s-1, respectively. The corresponding oesophageal pressures were 13.2 and 10.4 kPa, respectively. Although the peak force was 30% greater, and duration of the action 3-4 times longer at 0.262 than 1.31 rad.s-1, the arterial and oesophageal pressure responses did not differ. On a weight-lifting machine, a set of repetitions [mean (SEM): 11 (3)] to failure at 80-90% one repetition maximum evoked peak arterial pressures of 45.5/32.8 kPa; the corresponding oesophageal pressure was 15.7 kPa. The peak systolic and diastolic pressures observed during weight-lifting were significantly (P < 0.05) higher than during isokinetic actions at both velocities, whereas oesophageal pressure was more elevated only in relation to isokinetic actions at the higher velocity. These data indicate that resisted leg-press actions cause extreme elevations in arterial blood pressure. The degree of voluntary effort is the major determinant of the blood pressure response, rather than the resistance mode or the type (concentric, eccentric, isometric) of muscle action. Repetitive resistance exercise (e.g. a set of repetitions to failure in weight-lifting) tends to produce greater pressure elevations than isolated, single maximal effort actions.
Karabiber, Hamza; Ozkan, K Ugur; Garipardic, Mesut; Parmaksiz, Gonul
Diaphragmatic paralysis in newborns is related to brachial plexus palsy. It can be overlooked if thorough examination isn't done. We present a two-weeks-old baby with a birth weight of 3800 grams who had a left-sided brachial plexus palsy and torticollis with an undiagnosed left diaphragmatic paralysis even though he was examined by different physicians several times. The role of physical examination, the chest x-rays of patients with brachial paralysis and the treatment modalities of diaphragmatic paralysis due to obstetrical factors are discussed.
Boffeli, Troy J; Collier, Rachel C
Lower extremity contracture associated with stroke commonly results in a nonreducible, spastic equinovarus deformity of the foot and ankle. Rigid contracture deformity leads to gait instability, pain, bracing difficulties, and ulcerations. The classic surgical approach for stroke-related contracture of the foot and ankle has been combinations of tendon lengthening, tendon transfer, osteotomy, and joint fusion procedures. Recovery after traditional foot and ankle reconstructive surgery requires a period of non-weightbearing that is not typically practical for these patients. Little focus has been given in published studies on minimally invasive soft tissue release of contracture. We present the case of a 61-year-old female with an equinovarus foot contracture deformity secondary to stroke. The patient underwent Achilles tendon lengthening, posterior tibial tendon Z lengthening, and digital flexor tenotomy of each toe with immediate weightbearing in a walking boot, followed by transition to an ankle-foot orthosis. The surgical principles and technique tips are presented to demonstrate our minimally invasive approach to release of foot and ankle contracture secondary to stroke. The main goal of this approach is to improve foot and ankle alignment for ease of bracing, which, in turn, will improve gait, reduce the risk of falls, decrease pain, and avoid the development of pressure sores. Copyright © 2014 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Background The design of foot and ankle orthoses is currently limited by the methods used to fabricate the devices, particularly in terms of geometric freedom and potential to include innovative new features. Additive manufacturing (AM) technologies, where objects are constructed via a series of sub-millimetre layers of a substrate material, may present the opportunity to overcome these limitations and allow novel devices to be produced that are highly personalised for the individual, both in terms of fit and functionality. Two novel devices, a foot orthosis (FO) designed to include adjustable elements to relieve pressure at the metatarsal heads, and an ankle foot orthosis (AFO) designed to have adjustable stiffness levels in the sagittal plane, were developed and fabricated using AM. The devices were then tested on a healthy participant to determine if the intended biomechanical modes of action were achieved. Results The adjustable, pressure relieving FO was found to be able to significantly reduce pressure under the targeted metatarsal heads. The AFO was shown to have distinct effects on ankle kinematics which could be varied by adjusting the stiffness level of the device. Conclusions The results presented here demonstrate the potential design freedom made available by AM, and suggest that it may allow novel personalised orthotic devices to be produced which are beyond the current state of the art. PMID:22642941
Robati, Shibby; Salih, Alan; Ghosh, Koushik; Vinayakam, Parthiban
The complex anatomy of the articular bone surfaces, ligaments, tendon attachments and muscles makes the ankle joint difficult to replicate in prosthetic replacements. Ever since the early 1970s, which saw the dawn of the first total ankle replacements, there have been numerous other attempts at replicating the joint, often with poor clinical outcomes. The anatomy of the ankle is discussed, followed by evidence of the normal ankle biomechanics and the ideal requirements of an ankle replacement. We focus on the Scandinavian Total Ankle Replacement and evaluate whether these requirements have been met.
Robati, Shibby; Salih, Alan; Ghosh, Koushik; Vinayakam, Parthiban
The complex anatomy of the articular bone surfaces, ligaments, tendon attachments and muscles makes the ankle joint difficult to replicate in prosthetic replacements. Ever since the early 1970s, which saw the dawn of the first total ankle replacements, there have been numerous other attempts at replicating the joint, often with poor clinical outcomes. The anatomy of the ankle is discussed, followed by evidence of the normal ankle biomechanics and the ideal requirements of an ankle replacement. We focus on the Scandinavian Total Ankle Replacement and evaluate whether these requirements have been met. PMID:26955224
Sato, Yuichi; Miyamoto, Masahito; Yazawa, Masahiko; Nakazawa, Ryuto; Sasaki, Hideo; Miyano, Satetsu; Tsutsumi, Hisashi; Kimura, Kenjiro; Chikaraishi, Tatsuya
As the number of patients on hemodialysis increases, there will also be an increase in the number of patients with inadequate superficial veins for the creation of an autogenous arteriovenous fistula (AVF). In those patients, medical devices such as vascular prostheses or tunneled-cuffed catheters are necessary to maintain dialysis access. However, these devices are frequently associated with bacterial infection. We recently encountered a dialysis patient who underwent tunneled-cuffed catheter insertion because of the lack of usable superficial veins for autogenous access, and this patient subsequently developed catheter-related Staphylococcus aureus bacteremia with multiple metastatic infections. Despite immediate removal of the catheter, the infection persisted over an extended period, which was a condition precluding the further use of catheters or other prosthetic materials. To handle this situation, we utilized the deep brachial vein to construct an autogenous AVF. After ligating numerous branches, the vein was anastomosed to the brachial artery and then transposed to the subcutaneous space. The newly constructed autogenous AVF, which successfully kept the patient free from foreign materials, greatly contributed to the relief of persistent infection. Although the brachial vein is rarely used for AVF creation, we suggest that it can serve as an option to create an alternative AVF in a patient with inadequate superficial veins.
Hadadi, Mohammad; Ebrahimi, Ismaeil; Mousavi, Mohammad Ebrahim; Aminian, Gholamreza; Esteki, Ali; Rahgozar, Mehdi
Chronic ankle instability is associated with neuromechanical changes and poor postural stability. Despite variety of mechanisms of foot and ankle orthoses, almost none apply comprehensive mechanisms to improve postural control in all subgroups of chronic ankle instability patients. The purpose of this study was to investigate the effect of an ankle support implementing combined mechanisms to improve postural control in chronic ankle instability patients. Cross-sectional study. An ankle support with combined mechanism was designed based on most effective action mechanisms of foot and ankle orthoses. The effect of this orthosis on postural control was evaluated in 20 participants with chronic ankle instability and 20 matched healthy participants. The single-limb stance balance test was measured in both groups with and without the new orthosis using a force platform. The results showed that application of combined mechanism ankle support significantly improved all postural sway parameters in chronic ankle instability patients. There were no differences in means of investigated parameters with and without the orthosis in the healthy group. No statistically significant differences were found in postural sway between chronic ankle instability patients and healthy participants after applying the combined mechanism ankle support. The combined mechanism ankle support is effective in improving static postural control of chronic ankle instability patients to close to the postural sway of healthy individual. the orthosis had no adverse effects on balance performance of healthy individuals. Clinical relevance Application of the combined mechanism ankle support for patients with chronic ankle instability is effective in improving static balance. This may be helpful in reduction of recurrence of ankle sprain although further research about dynamic conditions is needed.
Fong, Daniel Tik-Pui; Hong, Youlian; Chan, Lap-Ki; Yung, Patrick Shu-Hang; Chan, Kai-Ming
This article systematically reviews epidemiological studies on sports injury from 1977 to 2005 in which ankle injury was included. A total of 227 studies reporting injury pattern in 70 sports from 38 countries were included. A total of 201,600 patients were included, with 32,509 ankle injuries. Ankle injury information was available from 14,098 patients, with 11 847 ankle sprains. Results show that the ankle was the most common injured body site in 24 of 70 included sports, especially in aeroball, wall climbing, indoor volleyball, mountaineering, netball and field events in track and field. Ankle sprain was the major ankle injury in 33 of 43 sports, especially in Australian football, field hockey, handball, orienteering, scooter and squash. In sports injuries throughout the countries studied, the ankle was the second most common injured body site after the knee, and ankle sprain was the most common type of ankle injury. The incidence of ankle injury and ankle sprain was high in court games and team sports, such as rugby, soccer, volleyball, handball and basketball. This systematic review provides a summary of the epidemiology of ankle injury in sports.
Gatev, Plamen; Thomas, Sherry; Kepple, Thomas; Hallett, Mark
We studied quiet stance investigating strategies for maintaining balance. Normal subjects stood with natural stance and with feet together, with eyes open or closed. Kinematic, kinetic and EMG data were evaluated and cross-correlated.Cross-correlation analysis revealed a high, positive, zero-phased correlation between anteroposterior motions of the centre of gravity (COG) and centre of pressure (COP), head and COG, and between linear motions of the shoulder and knee in both sagittal and frontal planes. There was a moderate, negative, zero-phased correlation between the anteroposterior motion of COP and ankle angular motion.Narrow stance width increased ankle angular motion, hip angular motion, mediolateral sway of the COG, and the correlation between linear motions of the shoulder and knee in the frontal plane. Correlations between COG and COP and linear motions of the shoulder and knee in the sagittal plane were decreased. The correlation between the hip angular sway in the sagittal and frontal planes was dependent on interaction between support and vision.Low, significant positive correlations with time lags of the maximum of cross-correlation of 250-300 ms were found between the EMG activity of the lateral gastrocnemius muscle and anteroposterior motions of the COG and COP during normal stance. Narrow stance width decreased both correlations whereas absence of vision increased the correlation with COP.Ankle mechanisms dominate during normal stance especially in the sagittal plane. Narrow stance width decreased the role of the ankle and increased the role of hip mechanisms in the sagittal plane, while in the frontal plane both increased.The modulation pattern of the lateral gastrocnemius muscle suggests a central program of control of the ankle joint stiffness working to predict the loading pattern. PMID:9882761
Su, Ta-Chen; Torng, Pao-Ling; Jeng, Jiann-Shing; Chen, Ming-Fong; Liau, Chiau-Suong
Background: Vegetarianism is associated with a lower risk of cardiovascular disease. However, studies of arterial function in vegetarians are limited. Methods: This study investigated arterial function in vegetarianism by comparing 49 healthy postmenopausal vegetarians with 41 age-matched omnivores. The arterial function of the common carotid artery was assessed by carotid duplex, while the pulse dynamics method was used to measure brachial artery distensibility (BAD), compliance (BAC), and resistance (BAR). Fasting blood levels of glucose, lipids, lipoprotein (a), high-sensitivity C-reactive protein, homocysteine, and vitamin B12 were also measured. Results: Vegetarians had significantly lower serum cholesterol, high-density and low-density lipoprotein, and glucose compared with omnivores. They also had lower vitamin B12 but higher homocysteine levels. Serum levels of lipoprotein (a) and high-sensitivity C-reactive protein were no different between the two groups. There were no significant differences in carotid beta stiffness index, BAC, and BAD between the two groups even after adjustment for associated covariates. However, BAR was significantly lower in vegetarians than in omnivores. Multiple linear regression analysis revealed that age and pulse pressure were two important determinants of carotid beta stiffness index and BAD. Vegetarianism is not associated with better arterial elasticity. Conclusion: Apparently healthy postmenopausal vegetarians are not significantly better in terms of carotid beta stiffness index, BAC, and BAD, but have significantly decreased BAR than omnivores. Prevention of vitamin B12 deficiency might be beneficial for cardiovascular health in vegetarians. PMID:21915169
Su, Ta-Chen; Torng, Pao-Ling; Jeng, Jiann-Shing; Chen, Ming-Fong; Liau, Chiau-Suong
Vegetarianism is associated with a lower risk of cardiovascular disease. However, studies of arterial function in vegetarians are limited. This study investigated arterial function in vegetarianism by comparing 49 healthy postmenopausal vegetarians with 41 age-matched omnivores. The arterial function of the common carotid artery was assessed by carotid duplex, while the pulse dynamics method was used to measure brachial artery distensibility (BAD), compliance (BAC), and resistance (BAR). Fasting blood levels of glucose, lipids, lipoprotein (a), high-sensitivity C-reactive protein, homocysteine, and vitamin B12 were also measured. Vegetarians had significantly lower serum cholesterol, high-density and low-density lipoprotein, and glucose compared with omnivores. They also had lower vitamin B12 but higher homocysteine levels. Serum levels of lipoprotein (a) and high-sensitivity C-reactive protein were no different between the two groups. There were no significant differences in carotid beta stiffness index, BAC, and BAD between the two groups even after adjustment for associated covariates. However, BAR was significantly lower in vegetarians than in omnivores. Multiple linear regression analysis revealed that age and pulse pressure were two important determinants of carotid beta stiffness index and BAD. Vegetarianism is not associated with better arterial elasticity. Apparently healthy postmenopausal vegetarians are not significantly better in terms of carotid beta stiffness index, BAC, and BAD, but have significantly decreased BAR than omnivores. Prevention of vitamin B12 deficiency might be beneficial for cardiovascular health in vegetarians.
Dragu, A; Horch, R E; Wirth, S; Ingianni, G
Whereas cases of unilateral obstetric brachial plexus paralysis have been sufficiently described and discussed in the literature cases of bilateral obstetric brachial plexus paralysis are extremely rare and so far have not been mentioned and discussed satisfactorily. We present a case of bilateral obstetric brachial plexus paralysis in an 8-months-old white boy. We performed a neurotisation of the Nervus suprascapularis with the Nervus accessorius and an Oberlin procedure on both sides in two operative steps. In an early follow-up 6 months after the second operation and intensive physiotherapy the little patient was able to crawl with the active help of both arms. Bilateral obstetric brachial plexus paralysis is a very rare incidence in infants. An interdisciplinary approach including paediatrics, plastic surgeons, neurosurgeons, neurologists, radiologists and physiotherapists is essential for the success of treatment strategies in such cases.
Patra, Sambeet; Narayana Kurup, Jayakrishnan K; Acharya, Ashwath M; Bhat, Anil K
A 5-year-old child presented to us with weakness of the left upper limb since birth. With the given history of obstetric trauma and limb examination, a diagnosis of birth brachial plexus palsy was made. Brachial plexus exploration along with microsurgery was performed at the same time which included extrinsic neurolysis of the roots and trunks and nerve transfer for better shoulder external rotation and elbow flexion. Both the movements were severely restricted previously due to co-contractures with the shoulder internal rotators and triceps. The problem of birth brachial plexus palsy is proving to be a global health burden both in developed countries and in developing countries such as India. The lack of awareness among the general public and primary healthcare providers and inadequate orthopaedic and neurosurgeons trained to treat the condition have worsened the prognosis. This case lays stress on the delayed complications in birth brachial palsy and its effective management. 2016 BMJ Publishing Group Ltd.
Tao, Xu; Tang, Kanglai; Zhou, Jianbo
To analyse the clinical outcomes of the Z-osteotomy of the distal fibula to correct widened mortice of the ankle after fracture. Between September 2009 and February 2011, 5 patients (5 feet) with widened ankle mortice after fracture underwent Z-osteotomy. There were 4 males and 1 female, aged from 23 to 58 years (mean, 38 years). At 3 months after operation of internal fixation when function exercises were done, patients got pains. The interval between trauma and operation ranged from 5 to 36 months (mean, 13.2 months). Lateral pressure test showed positive in 2 cases and negative in 3 cases. American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 50.2 +/- 17.3. Primary healing of incision was achieved in all cases. Five patients were followed up 9 to 24 months (mean, 15.6 months). Mild to moderate swelling of the affected limb and anterolateral skin numbness of the ipsilateral dorsal foot occurred, and gradually improved. The clinical exam and radiology showed bone union at 12-15 weeks (mean, 13.5 weeks). Postoperative range of motion of ankle had no significant improvement. AOFAS ankle-hindfoot scores were 76.8 +/- 11.2 at 6 months after operation, and 85.4 +/- 3.2 at last follow-up, showing significant differences when compared with preoperative score (P < 0.05). Shortened fibula is the main cause of widened ankle mortice after fracture; Z-osteotomy can effectively reduce the width of the ankle mortice, increase the stability of ankle joint, and decrease the complication rate.
LaClair, Susan Mosier
Cavovarus foot and ankle reconstruction is done to preserve motion whenever possible, and to maintain or impart stability, realigning foot and ankle joints into as anatomic a position as possible to restore a more normal mechanical axis to the extremity, and redistribute joint pressure or load more evenly. In patients who have a flexible deformity based on the Coleman block test, this is accomplished through calcaneal and metatarsal osteotomies to preserve joint motion, even in the presence of osteoarthritis. In cases of rigid and nonreducible deformity, the rigid cavovarus foot and ankle are addressed using a modified triple arthrodesis, an ankle arthrodesis, a tibiotalocalcaneal arthrodesis, or pantalar arthrodesis. In most patients, bony procedures are combined with soft-tissue realignment procedures.
Rubin, Devon I; Vavra, Michael
We report a patient who experienced a rare manifestation of an acute, severe brachial plexopathy as the initial complication of scorpion (presumed Hemiscorpius lepturus species) envenomation. Features suggesting conduction block, due to either proximal demyelination or ion channel dysfunction, along with axonal loss were seen on serial electrophysiological studies. Possible mechanisms of the brachial plexopathy include direct compression from tissue edema or a toxic effect on the membrane channels along the nerve.
Karahanoglu, Ertugrul; Kasapoglu, Taner; Ozdemirci, Safak; Fadıloglu, Erdem; Akyol, Aysegul; Demirdag, Erhan; Yalvac, E Serdar; Kandemir, N Omer
The aim of this study was to evaluate the risk factors for clavicle fracture concurrent with brachial plexus injuries. A retrospective study was conducted at a tertiary centre. The hospital records of 62,288 vaginal deliveries were evaluated retrospectively. There were 35 cases of brachial plexus injury. Of these patients, nine had brachial plexus injuries with clavicle fracture and 26 without clavicle fracture. The analysed risk factors for clavicle fracture concurrent with brachial plexus injury were gestational diabetes, labour induction and augmentation, prolonged second stage of labour, estimated foetal weight above 4000 g, birth weight above 4000 g, risky working hours, and the requirement of manoeuvres to free the impacted shoulder from behind the symphysis pubis. Labour augmentation with oxytocin increased the risk of clavicle fracture in cases of brachial plexus injury (OR 6.67; 95% CI 1.26-35.03). A birth weight higher than 4000 g also increased the risk of clavicle fracture. Risky working hours, gestational diabetes, estimated foetal weight higher than 4000 g, and requirement of shoulder dystocia manoeuvres did not increase the risk of clavicle fracture. Labour augmentation and actual birth weight higher than 4000 g were identified as risk factors for clavicle fracture in cases of brachial plexus injury.
Yang, Lynda J-S; Anand, Praveen; Birch, Rolfe
Brachial plexus palsy affects children differently than adults. In children with obstetric brachial plexus palsy, motor development must depend on nervous system adaptation. Previous studies report sensory plasticity in these children. This noninvasive study provides support for neural plasticity (the general ability of the brain to reorganize neural pathways based on new experiences) in children with obstetric brachial plexus palsy by considering upper limb preference. As in the general population, we expect that 90% of children would prefer their right upper limb. However, only 17% of children affected by right obstetric brachial plexus palsy prefer the right upper limb for overall movement; children with left obstetric brachial plexus palsy did not significantly differ from the general population in upper limb preference. This study also provides the first evidence of a significant correlation between actual task performance and select obstetric brachial plexus palsy outcome measurement systems, thereby justifying the routine use of these outcome measurement systems as a reflection of the practical utility of the affected limb to the patient.
There is a wealth of literature on the management of ankle sprains, but the quality of evidence is variable and conclusions diverge. Practice in emergency departments (EDs) also varies and in some cases does not reflect the evidence base. This article reviews some of the most recent research on the subject and suggests air-stirrup ankle braces can be used in EDs for management of moderate and severe ankle sprains.
Moser, Brad R
Dancers spend a lot of time in the relevé position in demi-pointe and en pointe in their training and their careers. Pain from both osseous and soft tissue causes may start to occur in the posterior aspect of their ankle. This article reviews the potential causes of posterior ankle impingement in dancers. It will discuss the clinical evaluation of a dancer and the appropriate workup and radiographic studies needed to further evaluate a dancer with suspected posterior ankle impingement.
Objective: To describe the functional anatomy of the ankle complex as it relates to lateral ankle instability and to describe the pathomechanics and pathophysiology of acute lateral ankle sprains and chronic ankle instability. Data Sources: I searched MEDLINE (1985–2001) and CINAHL (1982–2001) using the key words ankle sprain and ankle instability. Data Synthesis: Lateral ankle sprains are among the most common injuries incurred during sports participation. The ankle functions as a complex with contributions from the talocrural, subtalar, and inferior tibiofibular joints. Each of these joints must be considered in the pathomechanics and pathophysiology of lateral ankle sprains and chronic ankle instability. Lateral ankle sprains typically occur when the rearfoot undergoes excessive supination on an externally rotated lower leg. Recurrent ankle sprain is extremely common; in fact, the most common predisposition to suffering a sprain is the history of having suffered a previous ankle sprain. Chronic ankle instability may be due to mechanical instability, functional instability, or most likely, a combination of these 2 phenomena. Mechanical instability may be due to specific insufficiencies such as pathologic laxity, arthrokinematic changes, synovial irritation, or degenerative changes. Functional instability is caused by insufficiencies in proprioception and neuromuscular control. Conclusions/Recommendations: Lateral ankle sprains are often inadequately treated, resulting in frequent recurrence of ankle sprains. Appreciation of the complex anatomy and mechanics of the ankle joint and the pathomechanics and pathophysiology related to acute and chronic ankle instability is integral to the process of effectively evaluating and treating ankle injuries. PMID:12937557
Rzonca, E C; Lue, B Y
As has been previously discussed, the incidence and resultant associated disabilities of ankle sprains have been well documented in the literature. The staggering statistics on long-term disability show that there is no such thing as a simple ankle sprain. The degree of disability is related to the extent of the initial injury as well as the follow-up medical care provided. It is this fact that requires a complete understanding of the injury as well as a proper treatment and rehabilitation program. One of the reasons cited for the long-term disability or lack of consistently good results in treating ankle sprains is the lack of uniformity in treatment. One possible reason is the lack of agreement in diagnostic techniques as well as the end diagnosis of a particular grade of ankle sprain. If a sprain is managed correctly, resultant disability will be kept to a minimum. A proper rehabilitation program may be the most important factor in preventing chronic instability. The acronym RICE falls short of complete ankle management. RICE primarily addresses the ankle edema. Thus, the patient's ankle is only partially rehabilitated. A rational approach to the management of ankle sprains is given. Upon reviewing a complete protocol for ankle sprain rehabilitation, the acronym TEMPER can be used judiciously to remember the key steps in the treatment plan. Through the use of this acronym, one can institute a complete rehabilitation program.
Acevedo, Jorge I; Mangone, Peter
Over the last 50 years, the surgical management of chronic lateral ankle ligament insufficiency has focused on 2 main categories: local soft-tissue reconstruction and tendon grafts/transfer procedures. There is an increasing interest in the arthroscopic solutions for chronic instability of the ankle. Recent biomechanical studies suggest the at least one of the arthroscopic techniques can provide equivalent results to current open local soft-tissue reconstruction (such as the modified Brostrom technique). Arthroscopic lateral ankle ligament reconstruction is becoming an increasingly acceptable method for the surgical management of chronic lateral ankle instability. Copyright © 2015 Elsevier Inc. All rights reserved.
Wünschel, Markus; Leichtle, Ulf G; Leichtle, Carmen I; Walter, Christian; Mittag, Falk; Arlt, Eva; Suckel, Andreas
Although mid- to long-term results after total ankle replacement have improved because of available second- and third-generation devices, failure of total ankle replacement is still more common compared with total hip replacement and total knee replacement. The portfolio of available total ankle replacement revision component options is small. Furthermore, the bone stock of the tibiotalar region is scarce making it difficult and in some situations impossible to perform revision total ankle replacement. In these cases tibiotalar and tibiotalocalcaneal fusions are valuable options. This article describes which surgical procedures should be performed depending on the initial situation and gives detailed advice on surgical technique, postoperative care, and clinical results.
Denning, Jaime R
Ankle fractures account for 5% and foot fractures account for approximately 8% of fractures in children. Some complications are evident early in the treatment or natural history of foot and ankle fractures. Other complications do not become apparent until weeks, months, or years after the original fracture. The incidence of long-term sequelae like posttraumatic arthritis from childhood foot and ankle fractures is poorly studied because decades or lifelong follow-up has frequently not been accomplished. This article discusses a variety of complications associated with foot and ankle fractures in children or the treatment of these injuries.
Kim, Da-Rae; Potter, Hollis G.; Li, Angela E.; Chun, Ka-Young; Jung, Yoon Young; Kim, Jin-Su; Young, Ki-Won
With advances in implant technology, total ankle arthroplasty (TAA) has become an increasingly popular alternative to arthrodesis for the management of end-stage ankle arthritis. However, reports in the literature do not focus on the imaging features of TAA. Through a literature review, we demonstrate basic design features of the current ankle arthroplasty system, and the normal and abnormal postoperative imaging features associated with such devices. Pre- and postoperative evaluations of ankle arthroplasty mainly include radiography; in addition, computed tomography and magnetic resonance imaging provide further characterization of imaging abnormalities. Familiarization with multimodal imaging features of frequent procedural complications at various postoperative intervals is important in radiological practice. PMID:27134529
... foot and ankle surgeons. All Fellows of the College are board certified by the American Board of Foot and Ankle Surgery. Copyright © 2017 American College of Foot and Ankle Surgeons (ACFAS), All Rights ...
Ritter, Stephanie; Moore, Marjorie
The lateral ligament complex of the ankle is the most frequently injured structure in the body. Although most simple ankle sprains do not result in long-term disability, a significant number do not completely resolve, leading to residual symptoms that may persist for years. The most commonly reported symptoms, particularly among athletes, include instability, re-injury, and tendinitis. Ballet dancers are a combination of artist and high-performance athlete; consequently, they are subjected to the same types of injuries as other athletes, including lateral ankle sprains and their sequelae. Furthermore, ballet dancers perform in unusual positions such as en pointe, which places the ankle in extreme plantar flexion, requiring stabilization by surrounding muscles. Dancers' extraordinary performance demands place them at risk for other ankle injuries as well, including inflammation ofseveral tendons, especially the peroneals. This report reviews the relevant literature to characterize the scope of lateral ankle sprains and sequelae, discuss the importance of the peroneal muscles in ankle stability, and explore a relationship between lateral ankle sprain and ankle tendinitis in ballet dancers. Informal interviews were conducted with physical therapists who specialize in treating ballet dancers, providing a clinical context for this report. An extensive review of the literature was conducted, including electronic databases, reference lists from papers, and relevant reference texts. Numerous studies have investigated ankle sprains and residual complaints; nearly all report that lateral ankle sprains commonly lead to chronic ankle instability. Studies exploring ankle stability have demonstrated that the peroneal muscles play a crucial role in ankle stabilization; EMG studies confirm they are the first to contract during ankle inversion stress. The dancer's need for exceptional ankle stabilization may lead to peroneal overuse and tendinitis. Studies have linked peroneal
Kostapanos, Michael; McEniery, Carmel M; Wilkinson, Ian B
Vital organs are exposed to the central rather than the brachial blood pressure. To date, central blood pressure can be assessed noninvasively through the use of several devices. In this review, we critically discuss the clinical relevance of central blood pressure assessment. Considerable evidence suggests that central blood pressure is a better predictor of end-organ damage than brachial blood pressure. However, there is still uncertainty concerning the value of central pressure for predicting cardiovascular outcomes, as the existing studies are underpowered to address this issue. A full synthesis of the available data is needed in this regard. Among the different antihypertensive drug classes, beta-blockers appear to lower central blood pressure less than brachial blood pressure. This difference may, at least in part, explain the reduced efficacy of beta-blockers in the prevention of cardiovascular outcomes compared with the other antihypertensive drug classes, which may lower central and brachial blood pressure to a similar extent. Nevertheless, this differential effect might not be relevant to the newer beta-blockers with vasodilating properties, including nebivolol, celliprolol and carvedilol. However, whether a preferential reduction of central blood pressure results in better outcomes should be further assessed by appropriately powered clinical trials. Other emerging challenges include the assessment of the potential predictive value of central blood pressure variability and the development of new antihypertensive medications based on central blood pressure rather than brachial blood pressure.
Figueroa, Arturo; Wong, Alexei; Kinsey, Amber; Kalfon, Roy; Eddy, Wyatt; Ormsbee, Michael J
Obesity and reduced muscle strength are associated with increased blood pressure (BP). We examined the impact of milk proteins and combined exercise training (CET) on BP, arterial function, and muscle strength (one-repetition maximum (1-RM)). Thirty-three obese sedentary women (age = 30 ± 1 years; body mass index = 35.2 ± 0.9 kg/m(2); systolic BP (SBP) = 129 ± 2 mm Hg) were randomized to control carbohydrate (n = 11), whey (n = 11), and casein (n = 11) supplementation for 4 weeks. All participants performed moderate-intensity CET 3 days/week. Brachial and aortic SBP, augmentation index adjusted for 75 beats/minute (AIx@75), arterial stiffness (brachial-ankle pulse wave velocity (baPWV)), and 1-RM were measured before and after the interventions. There were significant (P < 0.05) time-by-group interactions for brachial SBP (bSBP), aortic SBP (aSBP), AIx@75, and baPWV. Whey and casein supplementation significantly (P < 0.05) decreased bSBP (approximately 5mm Hg for both), aSBP (approximately 7 mm Hg and approximately 6mm Hg, respectively), AIx@75 (approximately 9.2% and approximately 8.1%, respectively) and baPWV (approximately 57 cm/s and approximately 53 cm/s, respectively) compared with no changes in the control group. Upper- (approximately 22.2%) and lower-body 1-RM (approximately 44.0%) increased similarly in all groups. Changes in arterial function and 1-RM were not correlated. Milk protein supplementation with CET reduced SBP, wave reflection, and arterial stiffness in young obese women with prehypertension and hypertension. Because CET did not affect arterial function, milk proteins may have an antihypertensive effect by improving arterial function, as shown by reduced AIx@75 and baPWV. Muscle strength improvements after CET did not affect BP and arterial function. ClinicalTrial.gov Registration NCT01830946.
Hamburg, Naomi M.; Palmisano, Joseph; Larson, Martin G.; Sullivan, Lisa M.; Lehman, Birgitta T.; Vasan, Ramachandran S.; Levy, Daniel; Mitchell, Gary F.; Vita, Joseph A.; Benjamin, Emelia J.
Impaired vascular function contributes to the development of clinical cardiovascular disease. The relation between vasodilator function assessed non-invasively in the brachial and digital arteries remains incompletely defined. In the Framingham Offspring, Third Generation and Omni cohorts, we measured flow-mediated dilation (FMD) (n=7031, age 48±13 years, 19-88 years, 54% women) and peripheral arterial tonometry (PAT) ratio (n=4352, 55±16 years, 19-90 years, 51% women). Abnormal vascular function for each measure was defined by the sex-specific 5th percentile in a reference group free of conventional cardiovascular risk factors. The prevalence of abnormal FMD but not abnormal PAT ratio was higher with advancing age. In multivariable models, higher body mass index (BMI) was associated with a higher prevalence of both abnormal FMD and PAT ratio. Additional correlates of abnormal FMD included increasing age and higher systolic blood pressure. In contrast, correlates of abnormal PAT ratio included lower systolic blood pressure, increasing total/HDL cholesterol ratio, diabetes, smoking, and lipid-lowering medication. Whereas women had higher FMD and PAT ratio compared with men, using sex-specific reference values women had a higher prevalence of abnormal brachial and digital vascular function. In participants who had concurrent testing (n=1843), PAT ratio was not significantly associated with FMD in multivariable models. In this large, community-based cohort, brachial and digital measures of vascular function had differing relations with cardiovascular risk factors and were nearly uncorrelated with each other. These results suggest that FMD and PAT provide distinct information regarding vascular function in conduit versus smaller digital vessels. PMID:21263120
Murphy, Glenn S; Szokol, Joseph W; Marymont, Jesse H; Avram, Michael J; Vender, Jeffery S; Kubasiak, John
Flushing of radial arterial catheters may be associated with retrograde embolization of air or thrombus into the cerebral circulation. For embolization into the central circulation to occur, sufficient pressure must be generated during the flushing process to reverse antegrade blood flow in the arterial blood vessels of the upper extremity. This ultrasound study was designed to examine whether routine radial catheter flushing practices produce retrograde blood flow patterns in the brachial and proximal axillary arteries. Duplex ultrasound examinations of the brachial and axillary arteries were conducted in 100 surgical patients to quantify direction and velocity of blood flow during catheter flushing. After obtaining Doppler spectral images of brachial and axillary arterial flow patterns, manual flushing was performed by injecting 10 ml flush solution using a syringe at a rate reflecting standard clinical practices. The flow-regulating device on the pressurized (300 mmHg) arterial flushing-sampling system was then opened for 10 s to deliver a rapid bolus of fluid (flush valve opening). The rate of manual flush solution injection through the radial arterial catheter was related to the probability of retrograde flow in the axillary artery (P < 0.001). Reversed arterial flow was noted in the majority of subjects (33 of 51) at a manual flush rate of less than 9 s and in no subjects (0 of 48) at a rate 9 s or greater. Retrograde flow was observed less frequently during flush valve opening (2 of 99 patients; P < 0.001 vs. manual flushing). Rapid manual flushing of radial arterial catheters at rates faster than 1 ml/s produces retrograde flow in the proximal axillary artery.
Figueroa, Arturo; Alvarez-Alvarado, Stacey; Jaime, Salvador J; Kalfon, Roy
Combined isometric exercise or metaboreflex activation (post-exercise muscle ischaemia (PEMI)) and cold pressor test (CPT) increase cardiac afterload, which may lead to adverse cardiovascular events. l-Citrulline supplementation (l-CIT) reduces systemic arterial stiffness (brachial-ankle pulse wave velocity (baPWV)) at rest and aortic haemodynamic responses to CPT. The aim of this study was to determine the effect of l-CIT on aortic haemodynamic and baPWV responses to PEMI+CPT. In all, sixteen healthy, overweight/obese males (age 24 (sem 6) years; BMI 29·3 (sem 4·0) kg/m2) were randomly assigned to placebo or l-CIT (6 g/d) for 14 d in a cross-over design. Brachial and aortic systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP), aortic augmented pressure (AP), augmentation index (AIx), baPWV, reflection timing (Tr) and heart rate (HR) were evaluated at rest and during isometric handgrip exercise (IHG), PEMI and PEMI+CPT at baseline and after 14 d. No significant effects were evident after l-CIT at rest. l-CIT attenuated the increases in aortic SBP and wave reflection (AP and AIx) during IHG, aortic DBP, MAP and AIx during PEMI, and aortic SBP, DBP, MAP, AP, AIx and baPWV during PEMI+CPT compared with placebo. HR and Tr were unaffected by l-CIT in all conditions. Our findings demonstrate that l-CIT attenuates aortic blood pressure and wave reflection responses to exercise-related metabolites. Moreover, l-CIT attenuates the exaggerated arterial stiffness response to combined metaboreflex activation and cold exposure, suggesting a protective effect against increased cardiac afterload during physical stress.
Payne, Kristen A.; Berg, Kris; Latin, Richard W.
Objective: To determine if ankle muscular strength, flexibility and proprioception can predict ankle injury in college basketball players and to compare ankle injury rates in female and male players. Design and Setting: In this prospective, correlational study, subjects were tested at the start of the competitive season for ankle joint muscle strength, flexibility, and proprioception. The first ankle injury for each subject was recorded on an injury report form, and the data were analyzed to determine if any of these preseason measurements predicted future injury. The setting was a competitive 9-week season for four women's and four men's college basketball teams. Subjects: A convenience sample of 31 female and 11 male college basketball players. Measurements: Subjects were tested for ankle dorsiflexion range of motion, various measures of ankle proprioception, and isokinetic peak torque of ankle dorsiflexion-plantar flexion and eversion-inversion at 30°/sec and 180°/sec before the start of the conference basketball seasons. Data were analyzed using a series of multiple regression equations to determine the variance in ankle injury attributed to each variable. Results: Various measures of proprioception predicted left ankle injury in all subjects (p < .05), while ankle strength and flexibility measures failed to account for additional variance. There was no statistically significant difference in ankle injury rate between women and men. Conclusions: Ankle joint proprioceptive deficits can be used to predict ankle injury, but further research is needed to identify other sources of variance. In our study, ankle injury rate was similar in female and male college basketball players. PMID:16558453
Kim, Hak Jun; Yeo, Eui Dong; Rhyu, Im Joo; Lee, Soon-Hyuck; Lee, Yeon Soo; Lee, Young Koo
Malalignment of the ankle joint has been found after trauma, by neurological disorders, genetic predisposition and other unidentified factors, and results in asymmetrical joint loading. For a medial open wedge supramalleolar osteotomy(SMO), there are some debates as to whether concurrent fibular osteotomy should be performed. We assessed the changes in motion of ankle joint and plantar pressure after supramalleolar osteotomy without fibular osteotomy. Ten lower leg specimens below the knee were prepared from fresh-frozen human cadavers. They were harvested from five males (10 ankles)whose average age was 70 years. We assessed the motion of ankle joint as well as plantar pressure for SS(supra-syndesmotic) SMO and IS(intra-syndesmotic) SMO. After the osteotomy, each specimen was subjected to axial compression from 20 N preload to 350 N representing half-body weight. For the measurement of the motion of ankle joint, the changes in gap and point, angles in ankle joint were measured. The plantar pressure were also recorded using TekScan sensors. The changes in the various gap, point, and angles movements on SS-SMO and IS-SMO showed no statistically significant differences between the two groups. Regarding the shift of plantar center of force (COF) were noted in the anterolateral direction, but not statistically significant. SS-SMO and IS-SMO with intact fibula showed similar biomechanical effect on the ankle joint. We propose that IS-SMO should be considered carefully for the treatment of osteoarthrosis when fibular osteotomy is not performed because lateral cortex fracture was less likely using the intrasyndesmosis plane because of soft tissue support.
Ueda, Takashi; Miura, Shin-ichiro; Suematsu, Yasunori; Shiga, Yuhei; Kuwano, Takashi; Sugihara, Makoto; Ike, Amane; Iwata, Atsushi; Nishikawa, Hiroaki; Fujimi, Kanta; Saku, Keijiro
Background A blood pressure (BP) monitoring system (PASESA®) can be used to easily analyze the characteristics of central and peripheral arteries during the measurement of brachial BP. Methods We enrolled 108 consecutive patients (M/F = 86/22, age 70 ± 10 years) who underwent coronary angiography (CAG) due to suspected coronary artery disease (CAD) in whom we could measure various parameters using PASESA® in addition to brachial-ankle pulse wave velocity (baPWV). The patients were divided into two groups: patients who did not have significantly stenosed coronary vessel disease (n = 33, non-SVD group) and those who had at least one significantly stenosed coronary vessel (n = 75, SVD group). The characteristics of central and peripheral arteries (arterial velocity pulse index (AVI) and arterial pressure volume index (API), respectively) and baPWV were measured. Estimated central BP (eCBP) was calculated from the data obtained from PASESA®, and CBP was also measured simultaneously by invasive catheterization. Results API, but not AVI and baPWV, in the SVD group was significantly higher than that in the non-SVD group. Although eCBP was significantly associated with CBP, there was no difference in eCBP between the groups. There were significant associations among API, AVI and baPWV, albeit these associations were relatively weak. A multivariate logistic regression revealed that API and β-blocker were significant independent variables that were associated with the presence of significant coronary stenosis. The cut-off level of API that gave the greatest sensitivity and specificity for the presence of SVD was 24 units (sensitivity 0.636 and specificity 0.667). Conclusion In conclusion, API, but not AVI or baPWV, is associated with the presence of significant coronary stenosis. PMID:27429681
Barg, A; Elsner, A; Hefti, D; Hintermann, B
The standard treatment for end-stage osteoarthritis of the ankle joint in haemophilic patients has been fusion of the ankle joint. Total ankle replacement is still controversial as a treatment option. The objective of this prospective study was to evaluate the mid-term outcome in patients treated with total ankle replacement using an unconstrained three-component ankle implant. Ten haemophilic ankles in eight patients (mean age: 43.2 years, range 26.7-57.5) treated with total ankle replacement were followed up for a minimum of 2.7 years (mean: 5.6, range 2.7-7.6). The outcome was measured with clinical and radiological evaluations. There were no intra- or peri-operative complications. The AOFAS-hindfoot-score increased from 38 (range 8-57) preoperatively to 81 (range 69-95) postoperatively. All patients were satisfied with the results. Four patients became pain free; in the whole patient cohort pain level decreased from 7.1 (range 4-9) preoperatively to 0.8 (range 0-3) postoperatively. All categories of SF-36 score showed significant improvements in quality of life. In one patient, open ankle arthrolysis was performed because of painful arthrofibrosis. For patients with haemophilic osteoarthritis of the ankle joint, total ankle replacement is a valuable alternative treatment to ankle fusion.
Twilley, Heidi; Jones, Sarahjane
To investigate the relationship between pressure ulcers of the heel and peripheral arterial disease (PAD) and determine the feasibility of conducting a statistically powered matched case control study. Evidence indicates a relationship between chronic leg ulcers and vascular disease. The relationship between pressure ulcers of the heel and vascular disease is less well established. A matched case control study. Data were collected between March 2014 and January 2015. 15 patients identified as having a grade 2, 3 or 4 pressure ulcer of the heel were compared with 15 matched controls without pressure ulcers of the heel. The primary clinical outcome measure was the ankle brachial pressure index (ABPI), where an ABPI <0.9 or >1.3 was considered clinically indicative of PAD. The primary feasibility outcome measure was the rate of recruitment. Eighty seven patients were reported as having foot and heel ulcers; 36 of whom were identified as having pressure ulcers of the heel, 15 (42%) of whom were recruited to the study. Patients presenting with pressure ulcers of the heel were significantly more likely to simultaneously have previously undiagnosed PAD compared with age, gender and ethnicity matched controls without pressure ulcers of the heel (odds ratio: 11, 95% confidence interval 1.99-60.57). The formation of pressure ulcers of the heel could, in some patients, be related to the presence of PAD rather than a consequence of poor quality care. Healthcare professionals should assess the patient to exclude or confirm PAD. Copyright © 2016 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.
Liang, Weidong; Browning, Roger L.; Lauer, Ronald M.; Sonka, Milan
Atherosclerosis begins in childhood with the accumulation of lipid in the intima of arteries to form fatty streaks, advances through adult life when occlusive vascular disease may result in coronary heart disease, stroke and peripheral vascular disease. Non-invasive B-mode ultrasound has been found useful in studying risk factors in the symptom-free population. Large amount of data is acquired from continuous imaging of the vessels in a large study population. A high quality brachial vessel diameter measurement method is necessary such that accurate diameters can be measured consistently in all frames in a sequence, across different observers. Though human expert has the advantage over automated computer methods in recognizing noise during diameter measurement, manual measurement suffers from inter- and intra-observer variability. It is also time-consuming. An automated measurement method is presented in this paper which utilizes quality assurance approaches to adapt to specific image features, to recognize and minimize the noise effect. Experimental results showed the method's potential for clinical usage in the epidemiological studies.
Wukich, Dane K; Tuason, Dominick A
The differential diagnosis for chronic ankle pain is quite broad. Ankle pain can be caused by intra-articular or extra-articular pathology and may be a result of a traumatic or nontraumatic event. A detailed patient history and physical examination, coupled with judicious selection of the appropriate imaging modalities, are vital in making an accurate diagnosis and providing effective treatment. Chronic ankle pain can affect all age groups, ranging from young athletes to elderly patients with degenerative joint and soft-tissue disorders. It has been estimated that 23,000 ankle sprains occur each day in the United States, representing approximately 1 sprain per 10,000 people per day. Because nearly one in five ankle injuries result in chronic symptoms, orthopaedic surgeons are likely to see patients with chronic ankle pain. Many patients with chronic ankle pain do not recall any history of trauma. Reviewing the management of the various disorders that can cause chronic ankle pain will help orthopaedic surgeons provide the best treatment for their patients.
Acute ankle and foot trauma is a regular emergency presentation and prompt strategic assessment skills are required to enable nurses to categorise and prioritise these injuries appropriately. This article provides background information on the anatomy and physiology of the lower limb to help nurses to identify various grades of ankle sprain as well as injuries that are limb threatening
Isakov, E; Mizrahi, J
OBJECTIVE: To evaluate uninjured and recurrent sprained ankles during single leg standing, both with and without visual input, and the contribution of related proprioceptive feedback in this event. METHODS: A force measuring system was used for monitoring reaction forces in the anteroposterior and mediolateral directions during single leg standing. Differences between selected variables obtained in the uninjured and sprained ankles were analysed using two way analysis of variance. RESULTS: Foot-ground reaction forces in both anteroposterior and mediolateral directions were the same in normal and sprained ankles of each subject while standing with either open or closed eyes. However, standing with closed eyes, irrespective of the ankle status, always produced significantly higher reaction forces than those obtained with open eyes (P < 0.05). CONCLUSIONS: The amount of postural sway during single leg standing is similar in the chronically sprained and the uninjured ankle joint. Images p66-a PMID:9132216
Harrasser, N; Eichelberg, K; Pohlig, F; Waizy, H; Toepfer, A; von Eisenhart-Rothe, R
Because of their frequency, ankle sprains are of major clinical and economic importance. The simple sprain with uneventful healing has to be distinguished from the potentially complicated sprain which is at risk of transition to chronic ankle instability. Conservative treatment is indicated for the acute, simple ankle sprain without accompanying injuries and also in cases of chronic instability. If conservative treatment fails, good results can be achieved by anatomic ligament reconstruction of the lateral ankle ligaments. Arthroscopic techniques offer the advantage of joint inspection and addressing intra-articular pathologies in combination with ligament repair. Accompanying pathologies must be adequately addressed during ligament repair to avoid persistent ankle discomfort. If syndesmotic insufficiency and tibiofibular instability are suspected, the objective should be early diagnosis with MRI and surgical repair.
Khan, Zeeshan; Hussain, Shakir; Carter, Simon R
Sarcomas are rare tumours and particularly rarer in the foot and ankle region. The complex anatomy of the foot and ankle makes it unique and hence poses a challenge to the surgeon for limb salvage surgery. Other lesions found in the foot and ankle region are benign bone and soft tissue tumours, metastasis and infection. The purpose of this article is to discuss the relevance of the complex anatomy of the foot and ankle in relation to tumours, clinical features, their general management principles and further discussion about some of the more common bone and soft tissue lesions. Discussion of every single bone and soft tissue lesion in the foot and ankle region is beyond the scope of this article.
Prusinowska, Agnieszka; Krogulec, Zbigniew; Turski, Piotr; Przepiórski, Emil; Małdyk, Paweł; Księżopolska-Orłowska, Krystyna
Functions of the ankle joint are closely connected with the gait and ability to maintain an upright position. Degenerative lesions of the joint directly contribute to postural disorders and greatly restrict propulsion of the foot, thus leading to abnormal gait. Development of total ankle replacement is connected with the use of the method as an efficient treatment of joint injuries and continuation of achievements in hip and knee surgery. The total ankle replacement technique was introduced as an alternative to arthrodesis, i.e. surgical fixation, which made it possible to preserve joint mobility and to improve gait. Total ankle replacement is indicated in post-traumatic degenerative joint disease and joint destruction secondary to rheumatoid arthritis. In this paper, total ankle replacement and various types of currently used endoprostheses are discussed. The authors also describe principles of early postoperative rehabilitation as well as rehabilitation in the outpatient setting.
Credeur, Daniel P.; Dobrosielski, Devon A.; Arce-Esquivel, Arturo A.; Welsch, Michael A.
The purpose of this study was to examine the flow velocity pattern of the brachial artery and to determine its relationship to measures of physical function. Subjects from the Louisiana Healthy Aging Study (n = 95; age = 84 ± 10 years) were evaluated. Brachial artery flow velocities and dimensions were measured using high-resolution ultrasonography. The continuous scale of physical function and performance test (CS-PFP10) was used to assess physical function. This test is based on the performance of 11 activities of daily living. Total CS-PFP10 score was 39.51 ± 21.21 U. Mean antegrade and retrograde velocities at rest were 14.2 ± 4.7 and 3.6 ± 2.2 cm/s, respectively. Ante-/retrograde ratio was 5.5 ± 4.6. Brachial artery diameter was 4.3 ± 0.7 mm. Pulse pressure and vascular conductance were 66 ± 18 mmHg, and 0.9 ± 0.5 ml/min/mmHg, respectively. Vascular conductance (r = −0.34), ante-/retrograde ratio (r = −0.42) and CS-PFP10 (r = −0.65) were inversely and retrograde velocity (r = 0.40) and pulse pressure (r = 0.36), were directly associated with age. Retrograde velocity was inversely related to vascular conductance (r = −0.27) and CS-PFP10 total score (r = −0.45). A MANOVA revealed that those with the higher CS-PFP10 scores had a lower retrograde velocity (P = 0.0001), but this association was, in part, age-dependent. Among nonagenarians (n = 52), those in the lower tertiles of the CS-PFP10 scores had significantly higher retrograde velocities compared to those in the higher tertiles (P = 0.035). These data indicate an increase in brachial retrograde velocity with age. These hemodynamic changes are related to a decline in physical function. PMID:19565260
Kikuchi, Y; Oishi, M; Shimizu, D
A left brachial plexus and axillary artery of bonobo (Pan paniscus) were examined, and the interrelation between the brachial plexus and the axillary artery was discussed. This is the first report of the brachial plexus and the axillary artery of bonobo. The bonobo brachial plexus formed very similar pattern to that of other ape species and human. On the other hand, the branches of the bonobo axillary artery had uncommon architecture in comparison with human case. The axillary artery did not penetrate the brachial plexus and passes through all way along anterior to the brachial plexus. Only 4.9% of human forelimbs have this pattern. Moreover, the brachial artery runs through superficially anterior to branches of the brachial plexus.
Ferrero-Manzanal, Francisco; Lax-Pérez, Raquel; López-Bernabé, Roberto; Betancourt-Bastidas, José Ramiro; Iñiguez de Onzoño-Pérez, Alvaro
Shoulder surgery is often performed with the patient in the so called "beach-chair position" with elevation of the upper part of the body. The anesthetic procedure can be general anesthesia and/or regional block, usually interscalenic brachial plexus block. We present a case of brachial plexus palsy with a possible mechanism of traction based on the electromyographic and clinical findings, although a possible contribution of nerve block cannot be excluded. We present a case of a 62 year-old female, that suffered from shoulder fracture-dislocation. Open reduction and internal fixation were performed in the so-called "beach-chair" position, under combined general-regional anesthesia. In the postoperative period complete motor brachial plexus palsy appeared, with neuropathic pain. Conservative treatment included analgesic drugs, neuromodulators, B-vitamin complex and physiotherapy. Spontaneous recovery appeared at 11 months. DISCUSION: in shoulder surgery, there may be complications related to both anesthetic technique and patient positioning/surgical maneuvers. Regional block often acts as a confusing factor when neurologic damage appears after surgery. Intraoperative maneuvers may cause eventual traction of the brachial plexus, and may be favored by the fixed position of the head using the accessory of the operating table in the beach-chair position. When postoperative brachial plexus palsy appears, nerve block is a confusing factor that tends to be attributed as the cause of palsy by the orthopedic surgeon. The beach chair position may predispose brachial plexus traction injury. The head and neck position should be regularly checked during long procedures, as intraoperative maneuvers may cause eventual traction of the brachial plexus. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.
Degliūte, Ramune; Pranckevicius, Sigitas; Cekanauskas, Emilis; Buinauskiene, Jūrate; Kalesinskas, Romas Jonas
The aim of this study was to review and to analyze treatment patterns of early and late obstetric brachial plexus palsy. Eighty-one children with early and late obstetric brachial plexus palsy were treated in the Department of Pediatric Orthopedics and in the Postintensive Care Unit within the period 1988-2002. Children were classified into 2 groups according to age: Ist group (67 newborns) was treated conservatively, and IInd group (14 children with late obstetric brachial plexus palsy with deformity) underwent operative treatment. Active hand movements and innervation were evaluated before and after treatment. Thirty newborns had full recovery, 32 newborns had incomplete recovery, and in 5 cases no improvement was seen. Fourteen children with late obstetric brachial plexus palsy underwent the following operations: rotation osteotomy of the humerus was performed in 10 cases, lengthening of biceps and brachialis muscle tendons--in 6 cases, transposition of triceps muscle tendon--in 1 case, transposition of pectoralis major tendon--in 3 cases and flexor carpi transposition--in 1 case. There was an improvement in active hand movements after operative treatment and rehabilitation. According to our experience, in most cases newborns recover spontaneously or after conservative treatment. Secondary reconstructive surgery of late brachial plexus palsy can improve the condition of these patients.
Lorkowski, Jacek; Grzegorowska, Oliwia; Kotela, Ireneusz
A non-invasive method, that can be used to describe the underfoot pressure distribution during stance and gait, is pedobarography. This examination helps to describe biomechanics of foot and ankle. It has been used to diagnose foot disorders, assess the disease progression, monitor the progress of rehabilitation and also evaluate the effectivness of undergone surgical treatment. In this article we describe chosen issues of pedobarographic examination in diagnostics and treatment of foot and ankle in adults. We base on our own experience (about 10 thousand examinations) and review of literature. In our opinion, pedobarography should be used in diagnostics and treatment of foot and ankle more often and widely than now.
Mitchell, Lyneil C.J.; Ford, Kevin R.; Minning, Stephen; Myer, Gregory D.; Mangine, Robert E.
Background The incidence of anterior cruciate ligament (ACL) injuries among females continues at disproportionate rates compared to males, with research indicating inconclusive multifactorial causality. Data from previous retrospective studies suggest an effect of abnormal foot and ankle bio-mechanics on pathology at the knee, including the ACL. Objective To determine if a relationship exists between plantar foot loading patterns during normal gait and high risk biomechanics purported to increase risk of ACL injury. Methods Dynamic barefoot plantar pressure distribution was measured on 33 female collegiate soccer players. Groups were divided according to their predominant gait loading pattern (medial or lateral). Three dimensional (3-D) motion analysis was conducted during drop vertical jumps to assess vertical ground reaction force and discrete angle and joint moment variables of the lower extremities. Results No significant differences occured in sagittal or coronal plane knee joint kinematics and kinetics between the medial and lateral loading groups. Discussion Dynamic foot and ankle biomechanics during gait do not appear to be related to lower extremity kinematics or kinetics during landing in collegiate female soccer players. Conclusion The exact cause of the abnormal differences in female landing biomechanics has not been irrefutably defined. This study suggests no effect of foot and ankle biomechanics exists on the landing mechanics of female soccer players. PMID:20379384
Denegar, Craig R.; Miller, Sayers J.
Objective: To pose the question, “Can chronic ankle instability be prevented?” The evaluation and treatment of chronic ankle instability is a significant challenge in athletic health care. The condition affects large numbers of athletes and is associated with reinjury and impaired performance. The management of acute injuries varies widely but in athletic training has traditionally focused on initial symptom management and rapid return to activity. A review of practice strategies and philosophies suggests that a more detailed evaluation of all joints affected by the injury, correction of hypomobility, and protection of healing structures may lead to a more optimal long-term outcome. Background: Sprains to the lateral ankle are common in athletes, and the reinjury rate is high. These injuries are often perceived as being isolated to the anterior talofibular and calcaneofibular ligaments. It is, however, becoming apparent that a lateral ankle sprain can injure other tissues and result in joint dysfunction throughout the ankle complex. Description: We begin by addressing the relationship between mechanical and functional instability. We then discuss normal ankle mechanics, sequelae to lateral ankle sprains, and abnormal ankle mechanics. Finally, tissue healing, joint dysfunction, and the management of acute lateral ankle sprain are reviewed, with an emphasis on restoring normal mechanics of the ankle-joint complex. A treatment model based on assessment of joint function, treatment of hypomobile segments, and protection of healing tissues at hypermobile segments is described. PMID:12937564
Simondson, David; Brock, Kim; Cotton, Susan
This study aimed to determine the reliability and the smallest real difference of the Ankle Lunge test in an ankle fracture patient population. In the post immobilisation stage of ankle fracture, ankle dorsiflexion is an important measure of progress and outcome. The Ankle Lunge test measures weight bearing dorsiflexion, resulting in negative scores (knee to wall distance) and positive scores (toe to wall distance), for which the latter has proven reliability in normal subjects only. A consecutive sample of ankle fracture patients with permission to commence weight bearing, were recruited to the study. Three measurements of the Ankle Lunge Test were performed each by two raters, one senior and one junior physiotherapist. These occurred prior to therapy sessions in the second week after plaster removal. A standardised testing station was utilised and allowed for both knee to wall distance and toe to wall distance measurement. Data was collected from 10 individuals with ankle fracture, with an average age of 36 years (SD 14.8). Seventy seven percent of observations were negative. Intra and inter-rater reliability yielded intra class correlations at or above 0.97, p < .001. There was a significant systematic bias towards improved scores during repeated measurement for one rater (p = .01). The smallest real difference was calculated as 13.8mm. The Ankle Lunge test is a practical and reliable tool for measuring weightbearing dorsiflexion post ankle fracture. Copyright © 2011 Elsevier Ltd. All rights reserved.
Li, Hong-Yun; Zheng, Jie-Jiao; Zhang, Jian; Cai, Ye-Hua; Hua, Ying-Hui; Chen, Shi-Yi
Lateral ankle sprain is the most common injury. A previous study demonstrated that patients with mechanical ankle instability suffered deficits in postural control, indicating that structural damage of the lateral ankle ligaments may produce a balance deficit. The purpose of this study was to confirm that lateral ligaments reconstruction could improve postural control in patients with mechanical ankle instability. A total of 15 patients were included in the study. Each patient had a history of an ankle sprain with persistent symptoms of ankle instability and a positive anterior drawer test and had been treated nonoperatively for at least 3 months. All patients were diagnosed with lateral ankle ligaments tear by ultrasonography and magnetic resonance imaging. They underwent arthroscopic debridement and open lateral ankle ligaments reconstruction with a modified Broström procedure. One day before and 6 months after the operation, all of the participants underwent single-limb postural sway tests. The anterior drawer test and the American Orthopedic Foot and Ankle Society scale score were used to evaluate the clinical results in these patients. At 6 months after the operation, with the patients' eyes closed, there was significantly decreased postural sway in the anteroposterior direction, the circumferential area, and the total path length on the operated ankles compared with those measurements before the operation. With eyes open, however, no difference was found in postural sway before and after the operation. Postural control was improved by reconstructing the lateral ligaments. IV.
Jeon, In-cheol; Kwon, Oh-yun; Yi, Chung-Hwi; Cynn, Heon-Seock; Hwang, Ui-jae
A variety of ankle self-stretching exercises have been recommended to improve ankle-dorsiflexion range of motion (DFROM) in individuals with limited ankle dorsiflexion. A strap can be applied to stabilize the talus and facilitate anterior glide of the distal tibia at the talocrural joint during ankle self-stretching exercises. Novel ankle self-stretching using a strap (SSS) may be a useful method of improving ankle DFROM. To compare the effects of 2 ankle-stretching techniques (static stretching versus SSS) on ankle DFROM. Randomized controlled clinical trial. University research laboratory. Thirty-two participants with limited active dorsiflexion (<20°) while sitting (14 women and 18 men) were recruited. The participants performed 2 ankle self-stretching techniques (static stretching and SSS) for 3 weeks. Active DFROM (ADFROM), passive DFROM (PDFROM), and the lunge angle were measured. An independent t test was used to compare the improvements in these values before and after the 2 stretching interventions. The level of statistical significance was set at α = .05. Active DFROM and PDFROM were greater in both stretching groups after the 3-week interventions. However, ADFROM, PDFROM, and the lunge angle were greater in the SSS group than in the static-stretching group (P < .05). Ankle SSS is recommended to improve ADFROM, PDFROM, and the lunge angle in individuals with limited DFROM.
Chin, Robin; Hsiao-Wecksler, Elizabeth T; Loth, Eric; Kogler, Géza; Manwaring, Scott D; Tyson, Serena N; Shorter, K Alex; Gilmer, Joel N
Background A self-contained, self-controlled, pneumatic power harvesting ankle-foot orthosis (PhAFO) to manage foot-drop was developed and tested. Foot-drop is due to a disruption of the motor control pathway and may occur in numerous pathologies such as stroke, spinal cord injury, multiple sclerosis, and cerebral palsy. The objectives for the prototype PhAFO are to provide toe clearance during swing, permit free ankle motion during stance, and harvest the needed power with an underfoot bellow pump pressurized during the stance phase of walking. Methods The PhAFO was constructed from a two-part (tibia and foot) carbon composite structure with an articulating ankle joint. Ankle motion control was accomplished through a cam-follower locking mechanism actuated via a pneumatic circuit connected to the bellow pump and embedded in the foam sole. Biomechanical performance of the prototype orthosis was assessed during multiple trials of treadmill walking of an able-bodied control subject (n = 1). Motion capture and pressure measurements were used to investigate the effect of the PhAFO on lower limb joint behavior and the capacity of the bellow pump to repeatedly generate the required pneumatic pressure for toe clearance. Results Toe clearance during swing was successfully achieved during all trials; average clearance 44 ± 5 mm. Free ankle motion was observed during stance and plantarflexion was blocked during swing. In addition, the bellow component repeatedly generated an average of 169 kPa per step of pressure during ten minutes of walking. Conclusion This study demonstrated that fluid power could be harvested with a pneumatic circuit built into an AFO, and used to operate an actuated cam-lock mechanism that controls ankle-foot motion at specific periods of the gait cycle. PMID:19527526
Accurate quantitative measurements of brachial artery cross-sectional vascular area and vascular volume elastic modulus using automated oscillometric measurements: comparison with brachial artery ultrasound
Tomiyama, Yuuki; Yoshinaga, Keiichiro; Fujii, Satoshi; Ochi, Noriki; Inoue, Mamiko; Nishida, Mutumi; Aziki, Kumi; Horie, Tatsunori; Katoh, Chietsugu; Tamaki, Nagara
Increasing vascular diameter and attenuated vascular elasticity may be reliable markers for atherosclerotic risk assessment. However, previous measurements have been complex, operator-dependent or invasive. Recently, we developed a new automated oscillometric method to measure a brachial artery's estimated area (eA) and volume elastic modulus (VE). The aim of this study was to investigate the reliability of new automated oscillometric measurement of eA and VE. Rest eA and VE were measured using the recently developed automated detector with the oscillometric method. eA was estimated using pressure/volume curves and VE was defined as follows (VE=Δ pressure/ (100 × Δ area/area) mm Hg/%). Sixteen volunteers (age 35.2±13.1 years) underwent the oscillometric measurements and brachial ultrasound at rest and under nitroglycerin (NTG) administration. Oscillometric measurement was performed twice on different days. The rest eA correlated with ultrasound-measured brachial artery area (r=0.77, P<0.001). Rest eA and VE measurement showed good reproducibility (eA: intraclass correlation coefficient (ICC)=0.88, VE: ICC=0.78). Under NTG stress, eA was significantly increased (12.3±3.0 vs. 17.1±4.6 mm2, P<0.001), and this was similar to the case with ultrasound evaluation (4.46±0.72 vs. 4.73±0.75 mm, P<0.001). VE was also decreased (0.81±0.16 vs. 0.65±0.11 mm Hg/%, P<0.001) after NTG. Cross-sectional vascular area calculated using this automated oscillometric measurement correlated with ultrasound measurement and showed good reproducibility. Therefore, this is a reliable approach and this modality may have practical application to automatically assess muscular artery diameter and elasticity in clinical or epidemiological settings. PMID:25693851
Fullam, Karl; Caulfield, Brian; Coughlan, Garrett F; McGroarty, Mark; Delahunt, Eamonn
Decreased postural stability is a primary risk factor for lower limb musculoskeletal injuries. During athletic competitions, cryotherapy may be applied during short breaks in play or during half-time; however, its effects on postural stability remain unclear. To investigate the acute effects of a 15-minute ankle-joint cryotherapy application on dynamic postural stability. Controlled laboratory study. University biomechanics laboratory. A total of 29 elite-level collegiate male field-sport athletes (age = 20.8 ± 1.12 years, height = 1.80 ± 0.06 m, mass = 81.89 ± 8.59 kg) participated. Participants were tested on the anterior (ANT), posterolateral (PL), and posteromedial (PM) reach directions of the Star Excursion Balance Test before and after a 15-minute ankle-joint cryotherapy application. Normalized reach distances; sagittal-plane kinematics of the hip, knee, and ankle joints; and associated mean velocity of the center-of-pressure path during performance of the ANT, PL, and PM reach directions of the Star Excursion Balance Test. We observed a decrease in reach-distance scores for the ANT, PL, and PM reach directions from precryotherapy to postcryotherapy (P < .05). No differences were observed in hip-, knee-, or ankle-joint sagittal-plane kinematics (P > .05). We noted a decrease in mean velocity of the center-of-pressure path from precryotherapy to postcryotherapy (P < .05) in all reach directions. Dynamic postural stability was adversely affected immediately after cryotherapy to the ankle joint.
Chen, Allen M; Yoshizaki, Taeko; Velez, Maria A; Mikaeilian, Argin G; Hsu, Sophia; Cao, Minsong
To study the tolerance of the brachial plexus to high doses of radiation exceeding historically accepted limits by analyzing human subjects treated with reirradiation for recurrent tumors of the head and neck. Data from 43 patients who were confirmed to have received overlapping dose to the brachial plexus after review of radiation treatment plans from the initial and reirradiation courses were used to model the tolerance of this normal tissue structure. A standardized instrument for symptoms of neuropathy believed to be related to brachial plexus injury was utilized to screen for toxicity. Cumulative dose was calculated by fusing the initial dose distributions onto the reirradiation plan, thereby creating a composite plan via deformable image registration. The median elapsed time from the initial course of radiation therapy to reirradiation was 24 months (range, 3-144 months). The dominant complaints among patients with symptoms were ipsilateral pain (54%), numbness/tingling (31%), and motor weakness and/or difficulty with manual dexterity (15%). The cumulative maximum dose (Dmax) received by the brachial plexus ranged from 60.5 Gy to 150.1 Gy (median, 95.0 Gy). The cumulative mean (Dmean) dose ranged from 20.2 Gy to 111.5 Gy (median, 63.8 Gy). The 1-year freedom from brachial plexus-related neuropathy was 67% and 86% for subjects with a cumulative Dmax greater than and less than 95.0 Gy, respectively (P=.05). The 1-year complication-free rate was 66% and 87%, for those reirradiated within and after 2 years from the initial course, respectively (P=.06). The development of brachial plexus-related symptoms was less than expected owing to repair kinetics and to the relatively short survival of the subject population. Time-dose factors were demonstrated to be predictive of complications. Copyright © 2017 Elsevier Inc. All rights reserved.
Jia, Xiaotian; Yang, Jianyun; Chen, Lin; Yu, Cong; Kondo, Tadashi
Primary brachial plexus tumors are extremely rare and the treatment is challengeable. Our aim is to share the experiences in the treatment of primary brachial plexus tumors. A retrospective analysis of 143 patients with primary brachial plexus tumors was made in our department from January 2001 to December 2012. The clinical presentation of the patients, the characteristics and pathological results of the tumors and the prognosis were described. Seventy-eight males and sixty-five female were enrolled. The mean age was 48.17 years old. A palpable mass was the most common clinical presentation occurred in 129 patients. The trunks of the brachial plexus were the locations where the tumors originated with high possibility, with 68 cases. Benign tumors were composed of 119 schwannomas and 12 neurofibromas, while malignant tumors were composed of 8 malignant peripheral nerve sheath tumors, 2 malignant granular cell tumors, 1 synovial sarcoma and 1 peripheral primitive neuroectodermal tumor. Appropriate surgical method, radiotherapy and chemotherapy were used according to the condition during operation, preoperative examinations and pathological result. The survival rate was 50.00% with a 3-year follow-up. Local recurrence happened in 7 patients. Five patients presented Metastasis. Appropriate surgical method is the key for the treatment of different brachial plexus tumors. Surgery has a great effect on the treatment of benign tumors. For malignant tumors, adjuvant radiotherapy or chemotherapy should be used according to the pathological result. The general prognosis for malignant brachial plexus tumors is less than ideal. Copyright © 2016 Elsevier B.V. All rights reserved.
Tong, Zhu; Gu, Yongquan; Guo, Lianrui; Guo, Jianming; Gao, Xixiang; Li, Jianxin; Wang, Zhonggao; Zhang, Jian
To examine the complications of brachial and axillary artery punctures and the precautionary measures taken to lower their incidences. Retrospective analysis of 266 cases of brachial and axillary artery punctures was performed for angiography or angioplasty between January 2009 and December 2013 at the Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University. Complications and their causes were assessed. Among all brachial artery punctures (n = 140), there were complications in 3.6 per cent of cases, including local hematoma in 1.4 per cent, pseudoaneurysm in 0.7 per cent, acute arterial thrombosis in 0.7 per cent, and median nerve injury in 0.7 per cent. Among all axillary artery punctures (n = 126), there were complications in 10.3 per cent of cases, including local hematoma in 4.8 per cent, pseudoaneurysm in 0.8 per cent, acute arterial thrombosis in 0.8 per cent, acute venous thrombosis in 0.8 per cent, and nerve injury in 3.2 per cent. The incidence of complications was significantly lower in brachial axillary artery puncture compared with axillary artery puncture (P < 0.05). The main factors associated with complications might be patient's vascular condition, perioperative medication, anatomical features of the artery, puncture site, successful rate of first-attempt puncture, and bandage strength. Incidence of complications of brachial and axillary artery punctures could be lowered by strengthening the choice of indications, improving the perioperative managements, being fully aware of the anatomical characteristics of the brachial and axillary arteries, and applying the standardized techniques of puncture and compression hemostasis.
Avellanet, Merce; Sala-Blanch, Xavier; Rodrigo, Lidia; Gonzalez-Viejo, Miguel A
Interscalene brachial plexus block (IBPB) has been widely used in shoulder surgical procedures. The incidence of postoperative neural injury has been estimated to be as high as 3 %. We report a long-term neurologic deficit after a nerve stimulator assisted brachial plexus block. A 55 year-old male, with right shoulder impingement syndrome was scheduled for elective surgery. The patient was given an oral dose of 10 mg of diazepam prior to the nerve stimulator assisted brachial plexus block. The patient immediately complained, as soon as the needle was placed in the interscalene area, of a sharp pain in his right arm and he was sedated further. Twenty-four hours later, the patient complained of severe shoulder and arm pain that required an increased dose of analgesics. Severe peri-scapular atrophy developed over the following days. Electromyography studies revealed an upper trunk plexus injury with severe denervation of the supraspinatus, infraspinatus and deltoid muscles together with a moderate denervation of the biceps brachii muscle. Chest X-rays showed a diaphragmatic palsy which was not present post operatively. Pulmonary function tests were also affected. Phrenic nerve paralysis was still present 18 months after the block as was dysfunction of the brachial plexus resulting in an inability to perform flexion, abduction and external rotation of the right shoulder. Severe brachial plexopathy was probably due to a local anesthetic having been administrated through the perineurium and into the nerve fascicles. Severe brachial plexopathy is an uncommon but catastrophic complication of IBPB. We propose a clinical algorithm using ultrasound guidance during nerve blocks as a safer technique of regional anesthesia.
Franz, Randall W; Tanga, Christopher F; Herrmann, Joseph W
This review was conducted to evaluate the types of endovascular procedures that can be performed via brachial artery access, evaluate the access success rate, and determine the incidence of technical complications. A retrospective 10-year record review at a tertiary facility from January 1, 2005, through June 30, 2015, was completed. Patients who underwent attempted brachial artery access were eligible for review. Outcomes intended to be evaluated included ability to access the vessel, reach an identified lesion, and perform an indicated procedure, while describing the incidence and type of complications that occurred to clarify the utility and safety of brachial artery access. The review included 265 access cases in 179 patients. The access success rate was 98.9%. Intervention was performed in 223 cases (84.2%). Angioplasty was the most common intervention (59%, [154 cases]), with stents, atherectomy, coiling, and percutaneous thrombectomy having also been performed. Complications included hematoma (2.3%) and pseudoaneurysm (1.5%). Complications requiring intervention occurred in 1.9% of procedures. Interventions were performed on all major vessels as distal as the dorsalis pedis. Sheath sizes ranged from 4F to 7F. Intervention was performed on bilateral lower extremities in 38 cases (14.5%). A femoral bypass graft was present in 141 patients (53%) as the main indication for brachial artery access. Brachial access is a reliable and effective option for treatment of peripheral vascular disease and should be considered when femoral access is difficult or contraindicated and when a bypass graft is present in the femoral region. In addition, bilateral lesions may be approached easily through one brachial artery access site, making this approach advantageous when bilateral lesions are expected. The complication rate is similar to femoral access and can be minimized with ultrasound-guided access distally over the humerus, micropuncture access, and a dedicated
Nakagomi, A; Okada, S; Shoji, T; Kobayashi, Y
Various indices of central hemodynamics, such as aortic pulsatility, pulse pressure amplification (PPA) and augmentation index, have been proposed as novel predictors for coronary artery disease (CAD). However, it remains unknown which parameter is most appropriate for risk estimation. The aim of this study was to compare the predictive value of these indices using an easy-to-use, brachial cuff-based oscillometric device. Consecutive 139 patients undergoing elective coronary angiography were enrolled in this study. Augmentation index adjusted to 75 beats/min (Aix@75), brachial and aortic BP indices were measured with Mobil-O-Graph®. We defined fractional pulse pressure (FPP) as pulse pressure (PP) per mean BP and PPA as brachial PP minus aortic PP. Significant CAD was defined as having more than 50% stenosis in major coronary arteries, and the severity was evaluated with Gensini score. Compared with no CAD patients, CAD patients showed significantly higher PPs and FPPs (brachial PP 48.4 ± 15.5 vs 55.0 ± 16.2mmHg, aortic PP 51.7 ± 19.4 vs 62.2 ± 19.9mmHg, brachial FPP 0.42 ± 0.09 vs 0.49 ± 0.11, aortic FPP 0.46 ± 0.13 vs 0.57 ± 0.14; all p < 0.05) and lower PPA (-3.3 ± 8.7 vs -7.2 ± 7.8; p < 0.05). Other indices including Aix@75 did not differ significantly. Logistic regression analysis revealed aortic PP, brachial FPP, aortic FPP and PPA each correlated with the presence of CAD after adjustment for potential confounders (odds ratio (OR) [95% confidence interval]: aortic PP per 10 mmHg OR = 1.50 [1.08-2.08], brachial FPP per 0.1 OR = 2.26 [1.30-3.94], aortic FPP per 0.1 OR = 2.15 [1.35-3.42], PPA per 1 mmHg OR = 0.93 [0.87-0.99], respectively). However, when aortic FPP plus either aortic PP, brachial FPP, or PPA were included in the model, only aortic FPP remained significant. These indices were all associated with the severity of CAD expressed as Gensini score (correlation coefficient
Sidani, Charif; Saraf-Lavi, Efrat; Lyapichev, Kirill A; Nadji, Mehrdad; Levi, Allan D
Schwannomas of the brachial plexus are rare and typically present as slowly growing masses. We describe a case of a 37-year-old female who presented with acute onset of severe left upper extremity pain. Magnetic resonance imaging (MRI) showed a 2.3 × 2.1 cm peripherally enhancing centrally cystic lesion in the left axilla, along the cords of the left brachial plexus, with significant surrounding edema and enhancement. The mass was surgically removed. Pathology was consistent with a schwannoma with infarction. The pain completely resolved immediately after surgery.
Lemke, Kip A; Creighton, Catherine M
Local anesthetic techniques have the unique ability to block peripheral nociceptive input associated with surgical trauma and inflammation and to prevent sensitization of central nociceptive pathways and the development of pathologic pain. Complete neural blockade of the canine brachial plexus is difficult to achieve using the traditional axillary technique. This article describes paravertebral blockade of the brachial plexus in dogs and a new modified paravertebral technique. Both techniques are relatively easy to perform and produce complete blockade of the forelimb, including the shoulder. A review of relevant clinical anatomy and guidelines for using electrical nerve locators are also included.
Singh, Shiv Kumar; Katyal, Surabhi; Kumar, Amit; Kumar, Pawan
Plexus block is the preferred anesthesia plan for upper limb surgeries. Among the known complications, hematoma formation following the vascular trauma is often occur but this complication is frequently underreported. We present a case where a massive hemothorax developed post operatively in a patient who underwent resection of giant cell tumor of the right hand radius bone followed by arthroplasty under brachial plexus block using supraclavicular approach. This case report attempts to highlight the essence of remaining vigilant postoperatively for first initial days after brachial plexus block, especially after failed or multiple attempts. Ultrasound guided technique in combination with nerve stimulator has proven to be more reliable and safer than traditional techniques.
Vaseenon, Tanawat; Wattanarojanaporn, Thongaek; Intharasompan, Piyapong; Theeraamphon, Nipon; Auephanviriyakul, Sansanee; Phisitkul, Phinit