Lower extremity amputation in people with diabetes: Trends and determinants

Introduction: The prevalence of diabetes is rising rapidly. Assessing quality of diabetes care is difficult. Lower Extremity Amputation (LEA) is recognised as a marker of the quality of diabetes care. The focus of this thesis was first to describe the trends in LEA rates in people with and without diabetes in the Republic of Ireland (RoI) in recent years and then, to explore the determinants of LEA in people with diabetes. While clinical and socio-demographic determinants have been well-established, the role of service-related factors has been less well-explored. Methods: Using hospital discharge data, trends in LEA rates in people with and without diabetes were described and compared to other countries. Background work included concordance studies exploring the reliability of hospital discharge data for recording LEA and diabetes and estimation of diabetes prevalence rates in the RoI from a nationally representative study (SLAN 2007). To explore determinants, a systematic review and meta-analysis assessed the effect of contact with a podiatrist on the outcome of LEA in people with diabetes. Finally, a case-control study using hospital discharge data explored determinants of LEA in people with diabetes with a particular focus on the timing of access to secondary healthcare services as a risk factor. Results: There are high levels of agreement between hospital discharge data and medical records for LEA and diabetes. Thus, hospital discharge data was deemed sufficiently reliable for use in this PhD thesis. A decrease in major diabetes-related LEA rates in people with diabetes was observed in the RoI from 2005-2012. In 2012, the relative risk of a person with diabetes undergoing a major LEA was 6.2 times (95% CI 4.8-8.1) that of a person without diabetes. Based on the systematic review and meta-analysis, contact with a podiatrist did not significantly affect the relative risk (RR) of LEA in people with diabetes. Results from the case-control study identified being single, documented CKD and documented hypertension as significant risk factors for LEA in people with diabetes whilst documented retinopathy was protective. Within the seven year time window included in the study, no association was detected between LEA in patients with diabetes and timing of patient access to secondary healthcare for diabetes management. Discussion: Many countries have reported reduced major LEA rates in people with diabetes coinciding with improved organisation of healthcare systems. Reassuringly, these first national estimates in people with diabetes in the RoI from 2005 to 2012 demonstrated reducing trends in major LEA rates. This may be attributable to changes in diabetes care and also, secular trends in smoking, dyslipidaemia and hypertension. Consistent with international practice, LEA trends data in Ireland can be used to monitor quality of care. Quantifying this improvement precisely, though, is problematic without robust denominator data on the prevalence of diabetes. However, a reduction in major diabetes-related LEA rates suggests improved quality of diabetes care. Much controversy exists around the reliability of hospital discharge data in the RoI. This thesis includes the first multi-site study to explore this issue and found hospital discharge data reliable for the reporting of the procedure of LEA and diagnosis of diabetes. This project did not detect protective effects of access to services including podiatry and secondary healthcare for LEA in people with diabetes. A major limitation of the systematic review and meta-analysis was the design and quality of the included studies. The data available in the area of effect of contact with a podiatrist on LEA risk are too sparse to say anything definitive about the efficacy of podiatry on LEA. Limitations of the case-control study include lack of a diabetes register in Ireland, restricted information from secondary healthcare and lack of data available from primary healthcare. Due to these issues, duration of disease could not be accounted for in the study which limits the conclusions that can be drawn from the results. The model of diabetes care in the RoI is currently undergoing a re-configuration with plans to introduce integrated care. In the future, trends in LEA rates should be continuously monitored to evaluate the effectiveness of changes to the healthcare system. Efforts are already underway to improve the availability of routine data from primary healthcare with the recent development of the iPCRN (Irish Primary Care Research Network). Linkage of primary and secondary healthcare records with a unique patient identifier should be the goal for the future.

The incidence of unacceptable movement with motor evoked potentials during craniotomy for aneurysm clipping.

OBJECTIVE: To review the experience at a single institution with motor evoked potential (MEP) monitoring during intracranial aneurysm surgery to determine the incidence of unacceptable movement. METHODS: Neurophysiology event logs and anesthetic records from 220 craniotomies for aneurysm clipping were reviewed for unacceptable patient movement or reason for cessation of MEPs. Muscle relaxants were not given after intubation. Transcranial MEPs were recorded from bilateral abductor hallucis and abductor pollicis muscles. MEP stimulus intensity was increased up to 500 V until evoked potential responses were detectable. RESULTS: Out of 220 patients, 7 (3.2%) exhibited unacceptable movement with MEP stimulation-2 had nociception-induced movement and 5 had excessive field movement. In all but one case, MEP monitoring could be resumed, yielding a 99.5% monitoring rate. CONCLUSIONS: With the anesthetic and monitoring regimen, the authors were able to record MEPs of the upper and lower extremities in all patients and found only 3.2% demonstrated unacceptable movement. With a suitable anesthetic technique, MEP monitoring in the upper and lower extremities appears to be feasible in most patients and should not be withheld because of concern for movement during neurovascular surgery.

Alternate lower extremity resistance training to increase stability in young and elderly adults

Gemstone Team BALANCE

Unipedal balance is affected by lower extremity joint arthroplasty procedure 1 year following surgery.

Lower Extremity Joint Arthroplasty (LEJA) surgery is an effective way to alleviate painful osteoarthritis. Unfortunately, these surgeries do not normalize the loading asymmetry during the single leg stance phase of gait. Therefore, we examined single leg balance in 234 TJA patients (75 hips, 65 knees, 94 ankles) approximately 12 months following surgery. Patients passed if they maintained single leg balance for 10s with their eyes open. Patients one year following total hip arthroplasty (THA-63%) and total knee arthroplasty (TKA-69%) had similar pass rates compared to a total ankle arthroplasty (TAA-9%). Patients following THA and TKA exhibit better unilateral balance in comparison with TAA patients. It may be beneficial to include a rigorous proprioception and balance training program in TAA patients to optimize functional outcomes.

Fractures in myelomeningocele.

BACKGROUND: In patients with myelomeningocele (MMC), a high number of fractures occur in the paralyzed extremities, affecting mobility and independence. The aims of this retrospective cross-sectional study are to determine the frequency of fractures in our patient cohort and to identify trends and risk factors relevant for such fractures. MATERIALS AND METHODS: Between March 1988 and June 2005, 862 patients with MMC were treated at our hospital. The medical records, surgery reports, and X-rays from these patients were evaluated. RESULTS: During the study period, 11% of the patients (n = 92) suffered one or more fractures. Risk analysis showed that patients with MMC and thoracic-level paralysis had a sixfold higher risk of fracture compared with those with sacral-level paralysis. Femoral-neck z-scores measured by dual-energy X-ray absorptiometry (DEXA) differed significantly according to the level of neurological impairment, with lower z-scores in children with a higher level of lesion. Furthermore, the rate of epiphyseal separation increased noticeably after cast immobilization. Mainly patients who could walk relatively well were affected. CONCLUSIONS: Patients with thoracic-level paralysis represent a group with high fracture risk. According to these results, fracture and epiphyseal injury in patients with MMC should be treated by plaster immobilization. The duration of immobilization should be kept to a minimum (<4 weeks) because of increased risk of secondary fractures. Alternatively, patients with refractures can be treated by surgery, when nonoperative treatment has failed.

Dietary inference from upper and lower molar morphology in platyrrhine primates.

The correlation between diet and dental topography is of importance to paleontologists seeking to diagnose ecological adaptations in extinct taxa. Although the subject is well represented in the literature, few studies directly compare methods or evaluate dietary signals conveyed by both upper and lower molars. Here, we address this gap in our knowledge by comparing the efficacy of three measures of functional morphology for classifying an ecologically diverse sample of thirteen medium- to large-bodied platyrrhines by diet category (e.g., folivore, frugivore, hard object feeder). We used Shearing Quotient (SQ), an index derived from linear measurements of molar cutting edges and two indices of crown surface topography, Occlusal Relief (OR) and Relief Index (RFI). Using SQ, OR, and RFI, individuals were then classified by dietary category using Discriminate Function Analysis. Both upper and lower molar variables produce high classification rates in assigning individuals to diet categories, but lower molars are consistently more successful. SQs yield the highest classification rates. RFI and OR generally perform above chance. Upper molar RFI has a success rate below the level of chance. Adding molar length enhances the discriminatory power for all variables. We conclude that upper molar SQs are useful for dietary reconstruction, especially when combined with body size information. Additionally, we find that among our sample of platyrrhines, SQ remains the strongest predictor of diet, while RFI is less useful at signaling dietary differences in absence of body size information. The study demonstrates new ways for inferring the diets of extinct platyrrhine primates when both upper and lower molars are available, or, for taxa known only from upper molars. The techniques are useful in reconstructing diet in stem representatives of anthropoid clade, who share key aspects of molar morphology with extant platyrrhines.

Adjunctive β2-agonist treatment reduces glycogen independently of receptor-mediated acid α-glucosidase uptake in the limb muscles of mice with Pompe disease.

Enzyme or gene replacement therapy with acid α-glucosidase (GAA) has achieved only partial efficacy in Pompe disease. We evaluated the effect of adjunctive clenbuterol treatment on cation-independent mannose-6-phosphate receptor (CI-MPR)-mediated uptake and intracellular trafficking of GAA during muscle-specific GAA expression with an adeno-associated virus (AAV) vector in GAA-knockout (KO) mice. Clenbuterol, which increases expression of CI-MPR in muscle, was administered with the AAV vector. This combination therapy increased latency during rotarod and wirehang testing at 12 wk, in comparison with vector alone. The mean urinary glucose tetrasaccharide (Glc4), a urinary biomarker, was lower in GAA-KO mice following combination therapy, compared with vector alone. Similarly, glycogen content was lower in cardiac and skeletal muscle following 12 wk of combination therapy in heart, quadriceps, diaphragm, and soleus, compared with vector alone. These data suggested that clenbuterol treatment enhanced trafficking of GAA to lysosomes, given that GAA was expressed within myofibers. The integral role of CI-MPR was demonstrated by the lack of effectiveness from clenbuterol in GAA-KO mice that lacked CI-MPR in muscle, where it failed to reverse the high glycogen content of the heart and diaphragm or impaired wirehang performance. However, the glycogen content of skeletal muscle was reduced by the addition of clenbuterol in the absence of CI-MPR, as was lysosomal vacuolation, which correlated with increased AKT signaling. In summary, β2-agonist treatment enhanced CI-MPR-mediated uptake and trafficking of GAA in mice with Pompe disease, and a similarly enhanced benefit might be expected in other lysosomal storage disorders.

Kinematics and EMG analysis of expert pole vaulter's lower limb during take off phase (P218)

Introduction: The critical phase, in jumping events in track and field, appears to be between touchdown and take-off. Since obvious similarities exist between the take off phase in both long jump and pole vault, numerous 3D kinematics and electromyographic studies have only looked at long jump. Currently there are few detailed kinematics electromyographic data on the pole vault take-off phase. The aim of this study was therefore to characterise kinematics and electromyographic variables during the take-off phase to provide a better understanding of this phase in pole vaulting and its role in performance outcome. Material and methods: Six pole-vaulters took part in the study. Kinematics data were captured with retro reflective markers fixed on the body. Hip, knee and ankle angle were calculated. Differential bipolar surface electrodes were placed on the following muscles of the take-off leg: tibialis anterior, lateral gastrocnemius, vastus lateralis, rectus femoris, bicep femoris and gluteus maximus. EMG activity was synchronously acquired with the kinematic data. EMG data were rectified and smoothed using a second order low pass Butterworth Bidirectional filter (resulting in a 4th order filter) with a cut-off frequency of 14 Hz. Results: Evolution of hip, knee and ankle angle show no significant differences during the last step before touchdown, the take-off phase and the beginning of fly phase. Meanwhile, strong differences in EMG signal are noted inter and intra pole vaulter. However for a same subject the EMG activities seem to converge to some phase locked point. Discussion: All pole vaulters have approximately the same visible coordination This coordination reflects a different muscular control among pole vaulters but also for a considered pole vaulter. These phase locked point could be considered as invariant of motor control i.e. a prerequisite for a normal sequence of the movement and performance realization.

The meso-scale response of subarctic North Pacific seabird community structure to lower trophic level abundance and diversity

Understanding the mechanisms that structure communities and influence biodiversity are fundamental goals of ecology. To test the hypothesis that the abundance and diversity of upper-trophic level predators (seabirds) is related to the underlying abundance and diversity of their prey (zooplankton) and ecosystem-wide energy availability (primary production), we initiated a monitoring program in 2002 that jointly and repeatedly surveys seabird and zooplankton populations across a 7,500 km British Columbia-Bering Sea-Japan transect. Seabird distributions were recorded by a single observer (MH) using a strip-width technique, mesozooplankton samples were collected with a Continuous Plankton Recorder, and primary production levels were derived using the appropriate satellite parameters and the Vertically Generalized Production Model (Behrenfeld and Falkowski 1997). Each trophic level showed clear spatio-temporal patterns over the course of the study. The strongest relationship between seabird abundance and diversity and the lower trophic levels was observed in March/April ('spring') and significant relationships were also found through June/July ('summer'). No discernable relationships were observed during the September/October ('fall') months. Overall, mesozooplankton abundance and biomass explained the dominant portion of seabird abundance and diversity indices (richness, Simpson's Index, and evenness), while primary production was only related to seabird richness. These findings underscore the notion that perturbations of ocean productivity and lower trophic level ecosystem constituents influenced by climate change, such as shifts in timing (phenology) and synchronicity (match-mismatch), could impart far-reaching consequences throughout the marine food web.

La Mancha Triassic and Lower Lias Stratigraphy, a well log interpretation

La estratigrafía del intervalo sedimentario correspondiente al Keuper, Triásico, y al Lías basal ha atraído históricamente mucho menos interés que los sedimentos adyacentes del Muschelkalk y Buntsandstein, y del Lías Inferior y Medio. Se ha confeccionado una correlación de 12 sondeos profundos del área de La Mancha para mostrar la distribución de facies de estas formaciones, así como su ordenación en secuencias sedimentarias. Los datos de pozo muestran la existencia de secuencias evaporíticas complejas y multiepisódicas en la unidad inferior K1, de carácter más salino, y en la unidad superior K4-K5, relativamente más anhidrítica. El episodio clástico correspondiente a las unidades K2-K3 está extendido en toda la zona, con varias áreas preferenciales de acumulación de arenas. La unidad K6, la más alta del Keuper, constituye un excelente nivel guía. La sedimentación continúa en el Lías basal con otra potente unidad evaporítica, la Zona de Anhidrita, que muestra un episodio salino muy signifi cativo en la parte central de la correlación. Es de resaltar la buena correlación que existe entre los afl oramientos y las sondeos para estas formaciones.