Traumatic limb amputations and subsequent mortality from cardiovascular disease and other causes

Long-Term Health Outcomes of Limb Salvage Compared with Amputation for Combat-Related Trauma

BACKGROUND

There are little long-term health data, particularly in terms of body composition and development of metabolic syndromes, to help surgeons to guide the decision between limb salvage and amputation in patients with limb-threatening trauma. The purpose of this study was to compare long-term health outcomes after high-energy lower-extremity trauma between patients who underwent attempted flap-based limb salvage or amputation.

METHODS

We performed a retrospective review of servicemembers with a minimum 10-year follow-up who underwent flap-based limb salvage followed by unilateral amputation or continued limb salvage after combat-related, lower-extremity trauma between 2005 and 2011. Patient demographic characteristics, injury characteristics, and health outcomes including body mass index (BMI) and development of metabolic disease (e.g., hyperlipidemia, hypertension, heart disease, and diabetes) were compared between treatment cohorts. Adjusted BMIs were calculated for the amputation cohort to account for lost surface area. We performed multivariable and propensity score analysis to determine the likelihood of developing obesity or metabolic disease.

RESULTS

In this study, 110 patients had available long-term follow-up (mean, 12.2 years) from the time of the injury. Fifty-six patients underwent limb salvage and 54 patients underwent unilateral amputation. There was no difference in preinjury BMI (p = 0.30). After adjusting for limb loss, the amputation cohort had a trend toward higher BMIs at ≥1 years after the injury, a higher rate of obesity, and a greater increase in BMI from baseline after the injury. The development of metabolic comorbidities was common after both amputation (23 [43%] of 54) and limb salvage (27 [48%] of 56). With the numbers available, we were unable to demonstrate a difference in risk for the development of hypertension, hyperlipidemia, diabetes, heart disease, or any comorbidity other than obesity (p > 0.05).

CONCLUSIONS

Amputations may be medically necessary and may decrease pain, improve mobility, and/or expedite return to activity compared with limb salvage after similar injuries. However, limb loss may negatively impact metabolic regulation and may contribute to a higher risk of obesity despite beneficial effects on mobility.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

All-cause and cause-specific mortality rates after severe extremity injuries among previously deployed active duty service members

BACKGROUND

Previous research has shown that active duty military personnel who sustain extremity injuries while in service are at elevated risk for serious physical and psychological health issues that could affect their long-term functioning and quality of life yet longer-term mortality has not been studied in this population.

OBJECTIVE

To determine whether rates of all-cause and cause-specific mortality are elevated for active duty U.S. service members who sustained traumatic limb injuries in service, compared to the broader population of deploying service members. To assess differences in mortality rates between service members with traumatic limb injuries that did versus did not result in amputation.

DESIGN

Retrospective cohort study; archival Department of Defense deployment, personnel, medical, and death records were combined and analyzed. Standardized mortality ratios (SMR) adjusted for age, sex, and ethnoracial group, along with associated 95% confidence intervals (CIs), were calculated to directly compare all-cause and cause-specific mortality rates in each of the two injury groups to rates in the total study population.

SETTING

Not applicable.

PARTICIPANTS

Service members who deployed in support of the global war on terror between 2001 and 2016 were eligible for inclusion; the final sample included 1,875,206 individuals surveilled through 2019.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

All-cause and cause-specific mortality rates.

RESULTS

Overall, the number of deaths was over three times higher than expected among service members with amputations (SMR = 3.01; CI: 2.36-3.65), and nearly two times higher among those with serious limb injuries not resulting in amputation (SMR = 1.72; CI: 1.54-1.90) when compared to the larger study population. Rates for both internal and external causes of death were significantly elevated among those with limb injuries.

CONCLUSIONS

Long-term mortality rates are elevated among service members with traumatic limb injuries, though mortality patterns may differ based on whether the injury results in amputation. Although further research into causal mechanisms is needed, these results may inform the development of interventions to improve long-term health outcomes among injured military personnel.

Influence of traumatic lower-limb amputation on physical activity, body composition, and cardiometabolic risks: A descriptive preliminary study

BACKGROUND

Following traumatic lower-limb amputation (LLA), humans are predisposed to numerous unfavorable changes in health, including the development of secondary chronic health conditions such as metabolic disorders and cardiovascular disease.

OBJECTIVE

To determine within and between group differences in cardiometabolic component risks, body composition, and physical activity (PA) in individuals with traumatic unilateral and bilateral LLA, compared to noninjured controls.

DESIGN

Prospective observational cohort study.

SETTING

A military complex trauma rehabilitation center.

PARTICIPANTS

Sixteen males with traumatic LLA (8 unilateral, mean age 30 ± 5 years and 8 bilateral, mean age 29 ± 3 years). Thirteen active age-matched males with no LLA (28 ± 5 years) acted as controls and performed habitual activities of daily living.

INTERVENTION

Participants with LLA attended two 4-week periods of inpatient rehabilitation, separated by two 6-week periods of home-based recovery.

MAIN OUTCOME MEASURES

Venous blood samples were taken prior to and following a 75 g oral glucose load, for determination of biomarkers, including insulin and glucose, at baseline and 20 weeks. Body composition (dual X-ray absorptiometry) was measured at baseline, 10 weeks, and 20 weeks. Daily PA was recorded using a triaxial accelerometer for 7 days during inpatient rehabilitation and while at home. Energy expenditure was estimated using population-specific equations.

RESULTS

Individuals with bilateral LLA demonstrated more unfavorable mean body composition values, lower PA, and increased cardiometabolic health risk compared to controls. Cardiometabolic syndrome was identified in 63% of individuals with bilateral LLA. No statistically significant differences in cardiometabolic component risk factors, body composition, and estimated daily PA were reported between unilateral LLA and control groups (p > .05). While at home, mean PA counts.day^-1 reduced by 17% (p = .018) and 42% (p = .001) in the unilateral and bilateral LLA groups, respectively.

CONCLUSIONS

Despite extensive inpatient rehabilitation, cardiometabolic component risks are elevated in individuals with bilateral LLA but are comparable between unilateral LLA and active noninjured control groups. Innovative strategies that improve/support the long-term PA and cardiometabolic health of severely injured individuals with bilateral LLA are warranted.

Males With Traumatic Lower Limb Loss Differ in Body Fat Distribution Compared to Those Without Limb Loss

OBJECTIVES

The primary objective was to examine body fat composition in males with traumatic lower limb loss and a comparison group without limb loss. A secondary objective was to determine if there are differences in body fat composition by traumatic limb loss level.

RESEARCH METHODS AND PROCEDURES

Cross-sectional analyses of baseline in-person intake data was completed at a large military medical center. Data were collected from 2011 to 2020, and analysis was conducted in 2020. Participants (n = 89) included males who sustained traumatic lower limb loss (n = 50) and an age-matched comparison group without limb loss (n = 39). Mean age of participants was 36.0 ± 13.2 years. Main outcomes measured included age, height, body mass index, weight, body fat mass and percent, android fat mass and percent, gynoid fat mass and percent, and android/gynoid percent fat ratio. Differences between groups were assessed using t-tests or Mann-Whitney U tests. Differences between limb loss levels were assessed using one-way ANOVA or Wilcoxon signed-rank test.

RESULTS

Body fat percent (P = .001), gynoid fat percent (P = .010), android fat mass (P = .01), and percent (P = .02) were higher in the group with limb loss. There were no differences in body fat composition between limb loss levels (P > .05).

CONCLUSION

Males with traumatic lower limb loss had a higher body fat percent compared to those without limb loss. Given higher body fat composition in individuals with limb loss and the relationship between body fat composition and cardiovascular disease risk, including body composition analysis with clinical screening could identify changes and allow for early intervention.

Effect of lower extremity amputation on cardiovascular hemodynamic environment: An in vitro study

Lower extremity amputation (LEA) was associated with a greater risk of cardiovascular disease, but its hemodynamic mechanisms have not been fully studied. Therefore, to clarify the interrelationship between them, and figure out the potential pathogenesis, the exploration of the hemodynamic environment change of patients after LEA was premeditatedly executed. A near-physiological mock circulatory system (MCS) was employed in the present work to replicate the cardiovascular circulation after LEA in a short time and the unsteady-state numerical simulation was utilized as an auxiliary method to observe the changes of the hemodynamic environment inside the blood vessel. Higher severity of LEA leads to higher peripheral vascular impedance, higher blood pressure, and more obvious redistribution of blood perfusion volume. In addition, higher severity of LEA leads to lower wall shear stress (WSS), higher oscillatory shear index (OSI), and higher relative residence time (RRT) appeared in the infrarenal abdominal aorta and the iliac artery, while these changes are closely related to the higher probability of cardiovascular diseases. Results showed that different degrees of LEA (varying heights, unilateral/bilateral) have diverse effects on the patient's hemodynamic environment. This study explained the potential pathogenesis of cardiovascular diseases after LEA from a hemodynamic perspective and provided a certain reference value for the improvement of the cardiovascular hemodynamic environment and the prevention of cardiovascular diseases in lower extremity amputees.

Association between combat-related traumatic injury and cardiovascular risk

Objective

The association between combat-related traumatic injury (CRTI) and cardiovascular risk is uncertain. This study aimed to investigate the association between CRTI and both metabolic syndrome (MetS) and arterial stiffness.

Methods

This was a prospective observational cohort study consisting of 579 male adult UK combat veterans (UK-Afghanistan War 2003–2014) with CRTI who were frequency-matched to 565 uninjured men by age, service, rank, regiment, deployment period and role-in-theatre. Measures included quantification of injury severity (New Injury Severity Score (NISS)), visceral fat area (dual-energy X-ray absorptiometry), arterial stiffness (heart rate-adjusted central augmentation index (cAIx) and pulse wave velocity (PWV)), fasting venous blood glucose, lipids and high-sensitivity C reactive protein (hs-CRP).

Results

Overall the participants were 34.1±5.4 years, with a mean (±SD) time from injury/deployment of 8.3±2.1 years. The prevalence of MetS (18.0% vs 11.8%; adjusted risk ratio 1.46, 95% CI 1.10 to 1.94, p<0.0001) and the mean cAIx (17.61%±8.79% vs 15.23%±8.19%, p<0.0001) were higher among the CRTI versus the uninjured group, respectively. Abdominal waist circumference, visceral fat area, triglycerides, estimated insulin resistance and hs-CRP levels were greater and physical activity and high-density lipoprotein-cholesterol lower with CRTI. There were no significant between-group differences in blood glucose, blood pressure or PWV. CRTI, injury severity (↑NISS), age, socioeconomic status (SEC) and physical activity were independently associated with both MetS and cAIx.

Conclusions

CRTI is associated with an increased prevalence of MetS and arterial stiffness, which are also influenced by age, injury severity, physical activity and SEC. The longitudinal impact of CRTI on clinical cardiovascular events needs further examination.

Trends in cardiovascular disease in Scottish military veterans: a retrospective cohort study

OBJECTIVES

To examine the risk of cardiovascular disease (CVD) in Scottish military veterans in comparison with people who had never served in long-term follow-up to 2017, and to compare the findings with our earlier study to 2012 to assess trends.

DESIGN

Retrospective cohort study with up to 37 years follow-up.

SETTING

Pseudo-anonymised extract of computerised Scottish National Health Service records and national vital records.

PARTICIPANTS

78 000 veterans and 253 000 people with no record of service matched for age, sex and area of residence.

OUTCOME MEASURES

Risk of first occurrence of acute myocardial infarction, peripheral arterial disease and stroke in veterans compared with non-veterans, overall and by sex and birth cohort.

RESULTS

A first episode of CVD was recorded in 5.7% of veterans and 4.8% of non-veterans overall, Cox proportional HR 1.16, 95% CIs 1.12 to 1.20, p=0.001. The difference was only significant for men, and for veterans born before 1960, and was highest in veterans with the shortest service. In all categories, the difference in risk was less than at the end of 2012.

CONCLUSIONS

The excess burden of CVD in veterans which was evident at the end of 2012 has reduced in the following 5 years from 23% to 16% overall. The increased risk continues to affect only those veterans born prior to 1960, suggesting that improvements in military health promotion since 1978, when veterans born from 1960 joined the armed forces, have had an important and ongoing beneficial effect on the long-term health of veterans.

Time to weigh in on obesity and associated comorbidities in combat-wounded amputees

BACKGROUND

The Joint Trauma System database estimates that about 1,200 individuals have sustained a combat-related amputation during the Global War on Terror. Previous retrospective studies have demonstrated that combat-related amputees develop obesity and cardiovascular disease, but the incidence of obesity and associated comorbidities in this population is unknown. The objectives of this study are to determine the prevalence of obesity in the military amputee population and to compare this with the general population.

METHODS

This is a retrospective review of 978 patients who sustained a combat-related amputation from 2003 to 2014. Prevalence of obesity and comorbid conditions were determined. A multivariate logistic regression model was performed to identify risk factors for postamputation obesity. Kaplan-Meier curves were constructed using obesity as the event of interest.

RESULTS

A total of 1,233 charts were reviewed with 978 patients included for analysis. The median age of injury was 24 years. Median follow-up time was 8.7 years, ranging from 0.5 years to 16.9 years. The average Injury Severity Score was 23.3. The average body mass index preinjury was 25.6 kg/m2, and the average most recent corrected body mass index was found to be 31.4 kg/m2. Prevalence of comorbidities was higher in the amputee population. Fifty percent of patients who progressed to obesity did so within 1.3 years.

CONCLUSION

There is a notable prevalence of obesity that develops in the amputee population that is much higher than the general population. We determined that the amputee population is at risk, and these patients should be closely monitored for 1 to 2.5 years following injury. This study provides a targeted period for which monitoring and intervention can be implemented.

LEVEL OF EVIDENCE

Retrospective, basic science, outcomes analysis, level III/IV.

Study protocol for a prospective, longitudinal cohort study investigating the medical and psychosocial outcomes of UK combat casualties from the Afghanistan war: the ADVANCE Study

INTRODUCTION

The Afghanistan war (2003-2014) was a unique period in military medicine. Many service personnel survived injuries of a severity that would have been fatal at any other time in history; the long-term health outcomes of such injuries are unknown. The ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) study aims to determine the long-term effects on both medical and psychosocial health of servicemen surviving this severe combat related trauma.

METHODS AND ANALYSIS

ADVANCE is a prospective cohort study. 1200 Afghanistan-deployed male UK military personnel and veterans will be recruited and will be studied at 0, 3, 6, 10, 15 and 20 years. Half are personnel who sustained combat trauma; a comparison group of the same size has been frequency matched based on deployment to Afghanistan, age, sex, service, rank and role. Participants undergo a series of physical health tests and questionnaires through which information is collected on cardiovascular disease (CVD), CVD risk factors, musculoskeletal disease, mental health, functional and social outcomes, quality of life, employment and mortality.

ETHICS AND DISSEMINATION

The ADVANCE Study has approval from the Ministry of Defence Research Ethics Committee (protocol no:357/PPE/12) agreed 15 January 2013. Its results will be disseminated through manuscripts in clinical/academic journals and presentations at professional conferences, and through participant and stakeholder communications.

TRIAL REGISTRATION NUMBER

The ADVANCE Study is registered at ISRCTN ID: ISRCTN57285353.

Cardiometabolic risk parameters of individuals with lower extremity amputation: What is the effect of adherence to DASH diet and Mediterranean diet?

Objectives

The aim of our study was to investigate the relationship between nutrition (adherence to Mediterranean Diet [MD] and Dietary Approaches to Stop Hypertension [DASH] diets) and cardiovascular disease risk factors in patients with traumatic lower limb amputation (LLA).

Patients and methods

A total of 35 male patients (mean age 36.9±9.3 years; range, 21 to 54 years) with unilateral traumatic LLA between April 2019 and November 2019 were included. Data including age, education status, clinical data, level of amputation, time of amputation, comorbidities, physical activities, medications including nutritional supplements were collected. Blood pressure and anthropometric measurements including weight, height, waist, hip, and upper median arm circumferences were measured. Three-day food records were evaluated to determine daily nutrient intake of each patient. The patients were divided into groups according to their diet scores.

Results

The DASH scores showed a moderate, negative correlation with the body mass index (BMI), hip circumference, waist circumference, waist-to-hip ratio, waist-to-height ratio, serum total cholesterol (TC), triglyceride (TG), and low-density lipoprotein cholesterol (LDL-C). The MD scores showed a moderate, negative correlation with the BMI, waist circumference, hip circumference, waist-to-height ratio, serum TC, TG, and LDL-C.

Conclusion

Patients with traumatic LLA should be monitored closely for accompanying conditions such as cardiovascular diseases, and it is necessary to encourage them for healthy nutrition habits.

The Relationship between Military Combat and Cardiovascular Risk: A Systematic Review and Meta-Analysis

Background and Objectives

Cardiovascular disease (CVD) is a leading cause of death among military veterans with several reports suggesting a link between combat and related traumatic injury (TI) to an increased CVD risk. The aim of this paper is to conduct a widespread systematic review and meta-analysis of the relationship between military combat ± TI to CVD and its associated risk factors.

Methods

PubMed, EmbaseProQuest, Cinahl databases and Cochrane Reviews were examined for all published observational studies (any language) reporting on CVD risk and outcomes, following military combat exposure ± TI versus a comparative nonexposed control population. Two investigators independently extracted data. Data quality was rated and rated using the 20-item AXIS Critical Appraisal Tool. The risk of bias (ROB using the ROBANS 6 item tool) and strength of evidence (SOE) were also critically appraised.

Results

From 4499 citations, 26 studies (14 cross sectional and 12 cohort; 78–100% male) met the inclusion criteria. The follow up period ranged from 1 to 43.6 years with a sample size ranging from 19 to 621901 participants in the combat group. Combat-related TI was associated with a significantly increased risk for CVD (RR 1.80: 95% CI 1.24–2.62; I² = 59%, p = 0.002) and coronary heart disease (CHD)-related death (risk ratio 1.57: 95% CI 1.35–1.83; I² = 0%, p = 0.77: p < 0.0001), although the SOE was low. Military combat (without TI) was linked to a marginal, yet significantly lower pooled risk (low SOE) of cardiovascular death in the active combat versus control population (RR 0.90: CI 0.83–0.98; I² = 47%, p = 0.02). There was insufficient evidence linking combat ± TI to any other cardiovascular outcomes or risk factors.

Conclusion

There is low SOE to support a link between combat-related TI and both cardiovascular and CHD-related mortality. There is insufficient evidence to support a positive association between military combat ± any other adverse cardiovascular outcomes or risk factors. Data from well conducted prospective cohort studies following combat are needed.

Retrospective study of cardiovascular disease risk factors among a cohort of combat veterans with lower limb amputation

Introduction

Previous studies have shown that veterans with lower limb amputation have a higher risk for cardiovascular disease (CVD) compared with population-based controls. American veterans who have served in Iraq and Afghanistan with lower limb amputation may be at a similarly higher risk.

Patients and methods

The Navel Health Research Center (NHRC) maintains the Expeditionary Medical Encounter Database (EMED) of military personnel who have sustained combat limb amputation or serious limb injury during the conflicts in Iraq and Afghanistan. Department of Veterans Affairs data from 2003 to April 2015 was used to analyze CVD risk factors in this cohort. Veterans with either unilateral (n=442) or bilateral (n=146) lower limb amputation were compared to those with serious lower limb trauma without amputation (n=184). Multivariate regression was used to measure associations between lower limb amputation and CVD risk factors over an average of 8 years of follow-up. Outcomes included mean arterial pressure (MAP), low-density lipoprotein, high-density lipoprotein (HDL), and serum triglycerides (TG).

Results

Compared with the limb injury group, those with unilateral lower limb amputation had significantly lower HDL (p<0.05) and higher TG (p<0.05). Those with bilateral lower limb amputation had significantly higher MAP (p<0.05), lower HDL (p<0.01), and higher TG (p<0.001). The prevalence of metabolic syndrome, defined as type 2 diabetes or a constellation of blood pressure and lipid changes consistent with metabolic syndrome, was 8.7%, 14.9%, and 21.9% for limb injury, unilateral amputation, and bilateral amputation groups, respectively. Veterans with bilateral lower limb amputation had a 2.25-increased odds ratio (95% confidence interval 1.19–5.05) of type 2 diabetes or blood pressure and lipid changes consistent with metabolic syndrome compared to those with limb injury.

Conclusions

Results suggest that veterans with lower limb amputation have a higher risk for metabolic syndrome. Primary care interventions to manage weight, blood pressure, and lipid levels are fundamental in order to reduce cardiac risk in this relatively young cohort.

Dietary intakes and prevalence of overweight/obesity in male non-dysvascular lower limb amputees

BACKGROUND

Lower limb amputees are at higher risk of cardiovascular disease compared to non-amputees. Dietary intake, a major determinant of cardiovascular disease risk, has not previously been studied in this group.

OBJECTIVE

The aim of this study was to investigate dietary intakes and prevalence of overweight/obesity in adult lower limb amputees.

STUDY DESIGN

A cross-sectional survey was used to investigate the dietary intake and prevalence of overweight/obesity in adults with lower limb amputations living in the United Kingdom.

METHOD

Dietary intakes of male adult lower limb amputees ( n = 46, non-dysvascular) were assessed using food frequency questionnaires and results were compared to dietary reference values in the United Kingdom. Prevalence of overweight/obesity was assessed through body mass index and waist-to-hip ratio and compared to the general population according to the Health Survey for England 2011.

RESULTS

Dietary intake risk factors for cardiovascular disease such as sugars (22.01%), total fat (34.87%), saturated fat (12.72%) and sodium (2660.10 mg/day) were significantly higher ( p < 0.001, p < 0.001, p = 0.043, p < 0.001; p < 0.001; respectively) than the dietary reference values. A high prevalence (82.8%) of overweight/obesity was found with a significantly higher body mass index and waist-to-hip ratio ( p = 0.027; p = 0.001; respectively) compared to the Health Survey for England 2011.

CONCLUSION

High intakes of sugars, dietary fats, sugars and salts, combined with high prevalence of overweight/obesity observed in lower limb amputees are concerning. These findings suggest that greater emphasis on dietary intakes should be considered for rehabilitation programmes.

CLINICAL RELEVANCE

Findings highlight poor dietary habits in lower limb amputees with respect to fat, sugar and salt intake, also high levels of overweight/obesity. Considering greater emphasis on dietary intake and including lifestyle changing interventions in rehabilitation programmes for lower limb amputees may lower the risk of obesity and CVD.

Anesthetic management in a spinal cord-injured parturient woman with a left hip resection and secondary scoliosis: A case report

RATIONALE

Pregnancy after spinal cord injury, hip resection, leg amputation, and scoliosis is an uncommon event. Given the specific pathophysiological changes in this patient, an aesthetic management presented a particular challenge. The effects on the physiological changes associated with pregnancy, aesthetic methods, blood loss, autotransfusion from uterine contractions and thrombotic risk had to be considered.

PATIENT CONCERNS

A 25-year-old female earthquake survivor was admitted at 36.4 weeks of pregnancy for preterm labor. She had suffered from a spinal cord injury and complex trauma and had subsequently undergone left hip resection, bilateral amputations, and multiple surgical procedures during the previous 6 years. Additionally, she had developed severe scoliosis due to her weight-bearing posture.

DIAGNOSES

High amputation after earthquake injury; Scoliosis; Vulvar reconstruction; Intrauterine pregnancy (35.6 weeks) with a single live fetus with possible premature delivery.

INTERVENTIONS

We administered general anesthesia during a cesarean section for the parturient woman. Both the central venous pressure and pleth variability index were used to continuously evaluate intraoperative fluid management and blood loss.

OUTCOMES

Delivery and patient recovery were uneventful.

LESSONS

Anesthetic management of a pregnant woman with a spinal injury, scoliosis, left total leg and right below-knee amputations, and left hip resection requires considerable attention. Advances in medical technology have provided clinicians with insights into managing patients with this condition.

The risk of major cardiovascular events for adults with transfemoral amputation

BACKGROUND

It is well-known that the risk of cardiac disease is increased for those with lower-limb amputations, likely as a result of the etiology of the amputation. Using a longitudinal population-based dataset, we examined the association between transfemoral amputation (TFA) status and the risk of experiencing a major cardiac event for those undergoing either dysvascular or traumatic amputations. The association of receiving a prosthesis with the risk of experiencing a major cardiac event was also examined.

METHODS

Study Population: All individuals with TFA (N 162), i.e. knee disarticulation and transfemoral amputation, residing in Olmsted County, MN, between 1987 and 2014. Each was matched (1:10 ratio) with non-TFA adults on age, sex, and duration of residency.

DATA ANALYSIS

A competing risk Cox proportional hazard model was used to estimate the relative likelihood of an individual with a TFA experiencing a major cardiac event in a given time period as compared to the matched controls. The cohort was divided by amputation etiology: dysvascular vs trauma/cancer. Additional analysis was performed by combining all individuals with a TFA to look at the relationship between prosthesis receipt and major cardiac events.

RESULTS

Individuals with a dysvascular TFA had an approximately four-fold increased risk of a cardiac event after undergoing an amputation (HR 3.78, 95%CI: 3.07-4.49). These individuals also had an increased risk for non-cardiac mortality (HR 6.27, 95%CI: 6.11-6.58). The risk of a cardiac event was no higher for those with a trauma/cancer TFA relative to the able-bodied controls (HR 1.30, 95%CI: 0.30-5.85). Finally, there was no difference in risk of experiencing a cardiac event for those with or without prosthesis (HR 1.20, 95%CI: 0.55-2.62).

CONCLUSION

The high risk of initial mortality stemming from an amputation event may preclude many amputees from cardiovascular disease progression. Amputation etiology is also an important factor: cardiac events appear to be more likely among patients with a dysvascular TFA. Providing a prosthesis does not appear to be associated with a reduced risk of a major cardiac event following amputation.

Immediate and 24-h blood pressure-lowering effects of arm crank exercise in patients with traumatic lower-limb amputation: a randomized cross-over study

AIM

This study aimed to investigate the clinic and 24-h postexercise hypotension (PEH) after a moderate-intensity arm crank exercise session in individuals with traumatic lower-limb amputation.

PARTICIPANTS AND METHODS

Nine men (46±17 years) with unilateral traumatic lower-limb amputation participated in two experimental sessions conducted randomly: an aerobic exercise (EXE: arm crank ergometer, 30 min) or a control session (CON: participants remained seated on the cycle ergometer, 30 min). Clinic and 24-h systolic, diastolic, and mean blood pressure (BP) response were measured after both sessions. The clinical measurements of blood flow and forearm vascular resistance (FVR) were also performed.

RESULTS

Compared with the preintervention period, the BP levels did not change in the CON session. However, EXE resulted in a significant hypotensive effect in systolic (-10±0.9 mmHg, P≤0.05), diastolic (-11±1.5 mmHg, P≤0.05), and mean BP (-11±1.2 mmHg, P≤0.05) during the entire postexercise period. The PEH was accompanied by a decreased FVR over the entire postintervention period (P≤0.05). Significant reductions were found for 24-h average systolic, diastolic, and mean BP levels (P=0.03, 0.01, and 0.02, respectively) following EXE compared with the CON session.

CONCLUSION

These results showed, for the first time, that individuals with traumatic lower-limb amputation presented immediate and 24-h PEH after a single bout of arm crank exercise testing. The PEH at the clinic condition was justified, at least in part, by the reduction in peripheral FVR.

Impact of Traumatic Lower Extremity Injuries Beyond Acute Care: Movement-Based Considerations for Resultant Longer Term Secondary Health Conditions

Significance: Advances in field-based trauma care, surgical techniques, and protective equipment have collectively facilitated the survival of a historically large number of service members (SMs) following combat trauma, although many sustained significant composite tissue injuries to the extremities, including limb loss (LL) and limb salvage (LS). Beyond the acute surgical and rehabilitative efforts that focus primarily on wound care and restoring mobility, traumatic LL and LS are associated with several debilitating longer term secondary health conditions (e.g., low back pain [LBP], osteoarthritis [OA], and cardiovascular disease [CVD]) that can adversely impact physical function and quality of life. Recent Advances: Despite recent advancements in prosthetic and orthotic devices, altered movement and mechanical loading patterns have been identified among persons with LL and salvage, which are purported risk factors for the development of longer term secondary musculoskeletal conditions and may limit functional outcomes and/or concomitantly impact cardiovascular health. Critical Issues: The increased prevalence of and risk for LBP, OA, and CVD among the relatively young cohort of SMs with LL and LS significantly impact physiological and psychological well-being, particularly over the next several decades of their lives. Future Directions: Longitudinal studies are needed to characterize the onset, progression, and recurrence of health conditions secondary to LL and salvage. While not a focus of the current review, detailed characterization of physiological biomarkers throughout the rehabilitation process may provide additional insight into the current understanding of disease processes of the musculoskeletal and cardiovascular systems.

Lower-limb amputation and body weight changes in men

Little is known about the relationship between lower-limb amputation (LLA) and subsequent changes in body weight. We conducted a retrospective cohort study using clinical and administrative databases to identify and follow weight changes in 759 males with amputation (partial foot amputation [PFA], n = 396; transtibial amputation [TTA], n = 267; and transfemoral amputation [TFA], n = 96) and 3,790 nondisabled persons frequency-matched (5:1) on age, body mass index, diabetes, and calendar year from eight Department of Veterans Affairs medical care facilities in the Pacific Northwest. We estimated and compared longitudinal percent weight change from baseline during up to 39 mo of follow-up in participants with and without amputation. Weight gain in the 2 yr after amputation was significantly more in men with an amputation than without, and in men with a TTA or TFA (8%-9% increase) than in men with a PFA (3%-6% increase). Generally, percent weight gain peaked at 2 yr and was followed by some weight loss in the third year. These findings indicate that LLA is often followed by clinically important weight gain. Future studies are needed to better understand the reasons for weight gain and to identify intervention strategies to prevent excess weight gain and the deleterious consequences that may ensue.

Physical and social factors determining quality of life for veterans with lower-limb amputation(s): a systematic review

PURPOSE

Most veterans live for many years after their war-related traumatic lower-limb amputation, which is why understanding which factors influence health-related quality of life (HRQoL) remains important to their long-term management. The objective of this study was to perform a review of the literature to summarize any evidence on the physical and social determinants for HRQoL in veterans with uni- or bilateral lower-limb amputation(s).

METHOD

MEDLINE, EMBASE, PEDro, CINAHL, Scopus and Cochrane databases were searched systematically for eligible studies. Inclusion criteria were: traumatic lower-limb amputation(s), HRQoL outcome and veterans. Physical and social factors that influence HRQoL were extracted.

RESULTS

The literature search identified 2073 citations, leading to the inclusion of 10 studies in the systematic review. Physical activity level, sport participation, level of amputation, back pain, years of education, as well as duration and severity of phantom pain were found to be determining factors for HRQoL among veterans with lower-limb amputation.

CONCLUSIONS

The identified physical and social determinants were similar to those found in civilian traumatic amputees. More high quality research designs, interventions and complex statistical analyses are warranted to identify the physical and social factors that influence the HRQoL of veteran amputees. Implications for Rehabilitation Rehabilitation staff should promote physical activity and participation in sport among veterans with lower-limb amputation(s). Level of amputation, back pain severity, years of education, duration of phantom pain and severity of phantom pain have been found to be determining factors for HRQoL and should be taken into consideration when planning rehabilitation programs for veterans with lower-limb amputations.

Effects of Traumatic Amputation on β-Trace Protein and β2-Microglobulin Concentrations in Male Soldiers

BACKGROUND

Serum creatinine (SCr) levels are decreased following traumatic amputation, leading to the overestimation of glomerular filtration rate (GFR). β-Trace protein (BTP) and β2-microglobulin (B2M) strongly correlate with measured GFR and have not been studied following amputation. We hypothesized that BTP and B2M would be unaffected by traumatic amputation.

METHODS

We used the Department of Defense Serum Repository to compare pre- and post-traumatic amputation serum BTP and B2M levels in 33 male soldiers, via the N Latex BTP and B2M nephelometric assays (Siemens Diagnostics, Tarrytown, N.Y., USA). Osterkamp estimation using DEXA scan measurements was used to establish percent estimated body weight loss (%EBWL). Results were analyzed for small (3-5.9% EBWL), medium (6-13.5%), and large (>13.5%) amputation subgroups; and for a control group matched 1:1 to the 12 large amputation subjects. Paired Student's t test was used for comparisons.

RESULTS

Mean serum BTP levels were unchanged in controls, all amputees, and the small and medium amputation subgroups. BTP appeared to decrease following large %EBWL amputation (p = 0.05). Mean serum B2M levels were unchanged in controls, all amputees, and the small and medium amputation subgroups. B2M appeared to increase following large %EBWL amputation (p = 0.05).

CONCLUSIONS

BTP and B2M levels are less affected than SCr by amputation, and should be considered for future study of GFR estimation. BTP and B2M changes following large %EBWL amputation require validation and may offer insight into non-GFR BTP and B2M determinants as well as increased cardiovascular disease and mortality following amputation.

Factors affecting outcome after traumatic limb amputation

BACKGROUND

Traumatic leg amputation commonly affects young, active people and leads to poor long-term outcomes. The aim of this review was to describe common causes of disability and highlight therapeutic interventions that may optimize outcome after traumatic leg amputation.

METHODS

A comprehensive search of MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature databases was performed, using the terms 'leg injury', 'amputation' and 'outcome'. Articles reporting outcomes following traumatic leg amputation were included.

RESULTS

Studies demonstrated that pain, psychological illness, decreased physical and vocational function, and increased cardiovascular morbidity and mortality were common causes of disability after traumatic leg amputation. The evidence highlights that appropriate preoperative management and operative techniques, in conjunction with suitable rehabilitation and postoperative follow-up, can lead to improved treatment outcome and patient satisfaction.

CONCLUSION

Patients who undergo leg amputation after trauma are at risk of poor long-term physical and mental health. Clinicians involved in their care have many opportunities to improve their outcome using a variety of therapeutic variables. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Arterial stiffness in lower limb amputees

BACKGROUND

A high carotid-femoral pulse wave velocity (PWV) has been related to increased cardiovascular morbidity and mortality, but has not been previously evaluated in amputees. The aim of this study was to compare PWV between amputees and nonamputees.

METHODS

In this cross-sectional study, data were collected from 60 male lower limb amputees and 86 male age-matched nonamputees. PWV was measured noninvasively using a Complior(®) device. All participants underwent laboratory investigations and anthropometry. The difference in PWV between amputee and nonamputees was estimated. Multivariate regression was used to adjust for differences between the groups as a result of potential confounders.

RESULTS

PWV was higher in amputees than in nonamputees (10.8 ± 1.9 m/sec versus 9.9 ± 1.8 m/sec, P = 0.008, respectively). This difference remained even after adjusting for confounding factors.

CONCLUSION

A higher PWV was demonstrated in lower limb amputees. Routine assessment of PWV may contribute to cardiovascular risk stratification in amputees.

Increased mortality risk for workers with a compensated, permanent occupational disability of the upper or lower extremities: a 21-year follow-up study

This 1986-2006 study sought to determine whether specific causes led to increased mortality risks for Taiwanese workers with an approved compensation claim for permanent occupational disability (ACCPOD) of the upper or lower extremities. All cases of ACCPOD between 1986 and 2006 were collected from the database of compensation claims at the Bureau of Labor Insurance. Standardized mortality ratios and 95% confidence intervals were calculated for different causes of death among workers with an ACCPOD of the upper or lower extremities. A total of 800,047 person-years were accrued for 71,001 workers with a single type of disability. Standardized mortality ratios were significantly increased for all causes, including liver cirrhosis, injuries, and intentional self-harm. Standardized mortality ratios for workers with amputations of the lower extremities increased to 7.66 (95% confidence interval (CI): 5.36, 10.61), 2.40 (95% CI: 1.44, 3.75), 2.07 (95% CI: 1.03, 3.70), and 5.09 (95% CI: 2.20, 10.03) for those with diabetes mellitus, cerebrovascular disease, liver cirrhosis, and chronic renal failure, respectively. The authors concluded that workers with occupational disabilities involving an upper or lower extremity should be assisted to prevent further injuries or intentional self-harm, whereas those with lower limb amputations should be provided care related to proactive control of diabetes mellitus and associated complications during rehabilitation.

Coronary Artery Disease and Risk Factors in People With Posttraumatic Vision Loss

OBJECTIVE

To examine the prevalence of coronary artery disease (CAD) and its risk factors in people with posttraumatic vision loss (PTVL).

DESIGN

Cross-sectional, controlled study.

SETTING

The general community.

PARTICIPANTS

Study groups included 82 subjects with PTVL, 49 siblings, 58 blind subjects with retinitis pigmentosa (RP), and the general population in Israel.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Sociodemographic and biomedical data collected by using a structured questionnaire and medical records.

RESULTS

The prevalence of CAD among subjects with PTVL (24%) was 2 to 3 times higher than the control groups ( P <.001). However, the prevalence of the CAD risk factors in these subjects was similar to or lower than those in the control groups. For example, significantly fewer subjects with PTVL were physically inactive (16%) than patients with RP (55%, P <.01). The only variable that was significantly associated with CAD prevalence was the cause of blindness-that is, trauma versus disease; the odds of having CAD after traumatic vision loss was 3.75 times higher than after RP.

CONCLUSIONS

People with PTVL exhibit elevated rates of risk for CAD similar to those of other groups with physical disability. The traumatic injury that caused vision loss might be an important factor underlying that risk.

Increased cardiovascular disease mortality rates in traumatic lower limb amputees

We evaluated the 24-year mortality rates of male traumatic lower limb amputees (n = 201) of the Israeli army, wounded between 1948 and 1974 compared with a cohort sample representing the general population (n = 1,832). Mortality rates were significantly higher (21.9% vs 12.1%, p <0.001) in amputees than in controls. Cardiovascular disease (CVD) mortality was the main cause for this difference. The prevalence of selected risk factors for CVD was determined in 101 surviving amputees (aged 50 to 65 years) and a sample of the controls (n = 96) matched by age and ethnic origin. Amputees had higher plasma insulin levels (during fasting and in response to oral glucose loading) and increased blood coagulation activity. No differences were found in rates of current symptoms of ischemic heart disease or of cerebrovascular disease, obesity, hypertension, altered plasma lipoprotein profile, impaired physical activity, smoking, or nutritional habits. Traumatic lower limb amputees had increased mortality rates due to CVD. Surviving amputees had hyperinsulinemia, increased coagulability, and increased sympathetic and parasympathetic responses (described previously). These established CVD risk factors may explain the excess mortality due to CVD in traumatic amputees.

Cardiovascular disease in patients with dysvascular amputation

Cardiovascular diseases are the most common causes of morbidity and mortality in individuals with peripheral vascular disease (PVD). Among patients who have undergone lower extremity amputation as a result of PVD, the prevalence of concomitant cardiovascular disease may be as high as 75%. Comorbid heart disease may complicate the postamputation course of recovery, delay initiation of rehabilitation training, and inhibit the achievement of maximal functional independence. A variety of methods have been used to assess cardiac status and risk in amputation patients undergoing physical training; these have included clinical evaluation, resting electrocardiography, and continuous dynamic electrocardiography during either standard physical therapy exercise or adapted ergometry. Several conditioning training programs have been developed to improve the cardiovascular fitness of patients with dysvascular amputation, the results of which have been favorable. These assessment and intervention strategies have extensive applicability in the clinical management of patients with dysvascular amputation.

Management of severe proximal vascular and neural injury of the upper extremity

PURPOSE

Early amputation has been suggested to be the optimal treatment for severe combined vascular and neural injuries of the proximal upper extremity. This retrospective study was done to evaluate the long-term clinical outcome of our policy of limb salvage by revascularization and delayed treatment of neural injuries.

METHODS

Forty-six patients with neural and vascular trauma to the upper extremity were treated at our institution. All of these patients had aggressive treatment directed at limb salvage with restoration of vascular supply and nerve function. Long-term vascular and neurologic outcomes were recorded. Neurologic deficits were validated by the American Medical Association's standardized disability impairment scale (0% to 100%).

RESULTS

The rate of preoperative disability was 83%, which improved to 52% (p < 0.01) after treatment (mean follow-up, 43 months). Overall, 87% showed improvement.

CONCLUSION

These results suggest that early amputation should not be performed unless there is massive tissue loss or an attempt at limb salvage might endanger life. Final outcomes cannot be predicted on the basis of initial clinical presentation. As a group, the majority of these patients improved with aggressive intervention.

Insulin resistance and autonomic function in traumatic lower limb amputees

This study examined plasma insulin response to oral glucose load and autonomic nervous system activity in male lower limb amputees (n = 52) aged 50-65 years, compared to matched controls (n = 53). The groups had similar body mass index, blood pressure and plasma lipid levels. The amputees had higher mean fasting plasma insulin levels (18.4 +/- 9.7 (SD) versus 13.7 +/- 5.1 mU/l, p = 0.005) and during an oral glucose tolerance test (OGTT) (1 h levels 88.1 +/- 45.3 versus 62.1 +/- 42.7, p = 0.016) with similar plasma glucose levels, indicating insulin resistance. At baseline with the subjects supine, there were no group differences in low- or high-frequency power of heart rate variability or in plasma levels of norepinephrine (NE) or epinephrine (EPI). In response to orthostasis, the groups had similarly increased plasma NE levels. During the OGTT, amputees had significantly larger increments in low-frequency power than did controls (2.2 +/- 1.3 versus 1.6 +/- 0.9 (beats/min)2 respectively, p < 0.01) and plasma NE levels increased significantly in amputees (1595 +/- 849 versus 1941 +/- 986 pM, p = 0.0008) but not in controls. At 1 h after glucose administration, plasma EPI levels were decreased significantly from baseline in both groups; at both 1 and 2 h after glucose administration, plasma EPI levels were higher in the amputees than controls. Amputees appear to have a combination of enhanced sympathoneural responsiveness and attenuated suppression of adrenomedullary secretion during glucose challenge. As catecholamines antagonize insulin effects, one possible explanation for insulin resistance in amputees is hyperglycaemia-induced sympathoneural activation and a failure of hyperglycaemia to decrease adrenomedullary secretion.

Predicting oxygen uptake during counterclockwise arm crank ergometry in men with lower limb disabilities

OBJECTIVE

This study was conducted to develop a new equation for predicting oxygen uptake (VO2) during counterclockwise arm crank ergometry (ACE) in men with lower limb disabilities, cross-validate the new equation in a similar group of men, and compare the predictive accuracy of the new equation to previously published equations for clockwise ACE.

PATIENTS

The metabolic responses of 55 men, 17 to 69 years of age, with spinal cord injuries (n = 50) or lower limb fractures (n = 5) were recorded during maximal ACE-graded exercise tests. Participants were volunteers from area hospital rehabilitation centers, and wheelchair sport teams.

DESIGN

Subjects were partitioned by level of injury and randomly assigned to a prediction (PRE) or validation (VAL) group.

RESULTS

No differences were found between the PRE and VAL groups for age, anthropometric or peak exercise variables. Using stepwise regression, a prediction equation (EXP) was derived from the PRE group data. The resulting model: VO2 (mL/min) = 127.06 + 7.201 (Watts) + 4.502 (weight in kg) + 0.033 (Watts2) explained 89.8% of the variance in the PRE group VO2, standard error of estimate (SEE) = 151.9 mL/min. The equation performed similarly in the VAL group (SEE = 144.0mL/min).

CONCLUSIONS

In this sample, the EXP equation had less prediction error than equations derived for clockwise ACE. Accuracy was not substantially influenced by level of injury. Comparison of the data to that published previously for clockwise ACE by men with paraplegia suggests greater metabolic economy for counterclockwise as compared with clockwise ACE.

Associations between serum lipids and indicators of adiposity in men with spinal cord injury

Several reports indicate that dyslipidemia, primarily depressed high density lipoprotein cholesterol, is common in persons with spinal cord injury. The purpose of this study was to assess the relationships between anthropometric and near infrared interactance measurements to the serum lipoprotein profiles of 46 men with spinal cord injury of > 6 months duration. Mean age (+/- SD) was 49.5 +/- 15.0 y and duration of injury was 17.5 +/- 13.0 y. Forty-one percent of the subjects had low high density lipoprotein cholesterol (< 35 mg dl-1) and 57% had elevated total cholesterol to high density lipoprotein cholesterol ratios (> 4.5). Abdominal circumference was most closely associated with the overall lipid profile and abdominal circumference/height ratio was the second strongest correlate. Body mass index, conicity index, and percent body fat estimated by near infrared interactance were significantly related to some lipid parameters; however, the relationships were weaker than for abdominal circumference or abdominal circumference/height. Significant correlations were found between abdominal circumference and serum high density lipoprotein cholesterol (r = -0.421, P < 0.01) and log10 triglyceride (r = 0.587, P < 0.001) concentrations as well as the total cholesterol:high density lipoprotein cholesterol (r = 0.482, P < 0.01) and low density lipoprotein cholesterol-to-high density lipoprotein cholesterol (r = 0.387, P < 0.05) ratios. Based on these findings, the sample was partitioned by abdominal circumference into low (< 95 cm), moderate, and high (> or = 102 cm) risk subgroups.(ABSTRACT TRUNCATED AT 250 WORDS)

Exercise capacity of untrained spinal cord injured individuals and the relationship of peak oxygen uptake to level of injury

Twenty spinal cord injured individuals were tested for maximal oxygen uptake (VO2 peak using a hysteresis brake wheelchair ergometer. The subjects were divided into 4 groups as follows: (a) quadriplegics (4 subjects); (b) untrained female paraplegics (5 subjects); (c) untrained male paraplegics (7 subjects); and (d) trained male paraplegics (4 subjects). The VO2 peak were analysed by a one way ANOVA and Fisher's LSD multiple comparisons. The F-ratio (50.93) was significant (p = less than 0.0001). Fisher's LSD post hoc multiple comparisons found the following differences: (a) quadriplegics were significantly lower than the untrained paraplegic females, untrained paraplegic males and trained paraplegic males; (b) untrained females were significantly lower than the untrained male paraplegics, and trained paraplegic males; (c) untrained paraplegic males were significantly lower than the trained male paraplegics. A Spearman Rho correlation was calculated using injury level and VO2 max for all the untrained SCI individuals. The correlation was 0.68 and had a significance level of 0.0019. The present study combined with the known research literature gives strong evidence that VO2 peak in the untrained SCI is highly related to level of injury.

The prevalence of hypertension, ischaemic heart disease and diabetes in traumatic spinal cord injured patients and amputees

The clinical impression that spinal cord injured and traumatic lower limb amputees are more prone to develop degenerative diseases was investigated by comparing the prevalence of hypertension, ischaemic heart disease, and diabetes mellitus in these two patient groups with the prevalence of these diseases among a group of healthy age-matched controls. Seventy seven spinal cord injured patients and 53 amputees fulfilled the criteria for inclusion in this study. Our results show a significant increased incidence of hypertension and ischaemic heart disease among those with spinal cord injuries compared with their controls; and among the amputees, a significant increased incidence of ischaemic heart disease and of diabetes mellitus.

Hyperinsulinemia

Patients with mild or early non-insulin-dependent diabetes mellitus often display a delay in insulin response followed by late hyperinsulinemia during oral glucose tolerance testing. Those patients with long-standing disease or elevations of fasting plasma glucose in excess of 140 mg/dl are generally hypoinsulinemic in response to an oral glucose tolerance test. Diabetic patients who do not have an acute response to intravenous glucose may have normal responses to intravenous tolbutamide or intravenous arginine, suggesting that delayed responsiveness to glucose is not due to decreased pancreatic insulin content. An association between hyperinsulinemia and hypertension has been suggested by recent studies from several laboratories. In a homogeneous population of men who suffered traumatic bilateral above-the-knee amputation in the Vietnam War with subsequent development of obesity, it was shown that there was strong correlation between hypertension and hyperinsulinemia during oral glucose tolerance testing despite only mild glucose intolerance. In addition, a subset of hypertensive women who were in their third trimester of pregnancy were markedly hyperinsulinemic during oral glucose tolerance testing in the absence of any abnormalities of glucose tolerance. Thus, the relationship between hyperinsulinemia and hypertension, and the possible reasons for this relationship, are fields of active investigation at present.

Insulin as a potential factor influencing blood pressure in amputees

War-injured, bilateral above-knee amputees are known to be at increased risk for cardiovascular mortality. To evaluate possible risk factors, we compared blood pressures and plasma glucose and insulin responses to orally administered glucose in 19 above-knee amputees from the Vietnam War (mean age, 36 +/- 1 years) with those of 12 age-matched unilateral below-elbow amputees. Body composition by densitometry and maximal oxygen consumption during arm or leg exercise were also determined. Nine of 19 leg amputees were hypertensive compared with one of 12 arm amputees. Their 3-hour average insulin responses were markedly increased (260 +/- 60 microU/ml) compared with those of normotensive leg (125 +/- 24 microU/ml) and arm amputees (101 +/- 20 microU/ml), and their mean body fat content (37.2%) also was elevated compared with that in both of these groups (23.2 and 22.6%, respectively). A unique finding was that both insulin response and body fat content were strongly and independently correlated with diastolic blood pressure (r = 0.55, p less than 0.01, and r = 0.62, p less than 0.01, respectively). We conclude that insulin may be a major factor in blood pressure regulation in the maturity-onset obesity that develops following traumatic leg amputation in young, healthy men.

Amputation after extremity injury

Extremity injury is a significant cause of morbidity and mortality in the trauma patient. The decision to amputate is a difficult one to make in a patient population still in the productive years of life. At the University of Louisville Hospital from 1976 to 1984, 37 patients with traumatic extremity injury required amputation. Ninety percent of these injuries were to the lower extremities. A decision for amputation was based on the absence of neurovascular function, the presence of fracture of the involved extremity, the presence of a large soft tissue defect, and the presence of severe contamination. Prompt amputation of such severely damaged limbs may be preferable to attempts at salvage. Early amputation offers the opportunity for prosthetic replacement and good long-term functional recovery.

Physical impairment, stress, and cardiovascular disorders

Physical impairments bring about social and psychological consequences leading to stress. Here Dutch epidemiological data were used to test whether the physically disabled have an increased risk of CD. Results indicated this was partly so. Possible confounding variables, however, severely limit a firm statement concerning the relationship between disabling impairments and cardiovascular disorders.