Diagonal Earlobe Crease (Frank's Sign): A Predictor of Cerebral Vascular Events

Advancements in Frank's sign Identification using deep learning on 3D brain MRI

Frank's sign (FS) is a diagnostic marker associated with aging and various health conditions. Despite its clinical significance, there lacks a standardized method for its identification. This study aimed to develop a deep learning model for automated FS detection in 3D facial images derived from MRI scans. Four deep learning architectures were evaluated for FS segmentation on a dataset of 400 brain MRI scans. The optimal model was subsequently validated on two external datasets, comprising 300 brain MRI scans each with varying FS presence. Dice similarity coefficient (DSC) and receiver operating characteristic (ROC) analysis were employed to assess model performance. The U-net architecture demonstrated superior performance in terms of accuracy and efficiency. On the validation datasets, the model achieved a DSC of 0.734, an intra-class correlation coefficient of 0.865, and an area under the ROC curve greater than 0.9 for FS detection. Additionally, the model identified optimal voxel thresholds for accurate FS classification, resulting in high sensitivity, specificity, and accuracy metrics. This study successfully developed a deep learning model for automated FS segmentation in MRI scans. This tool has the potential to enhance FS identification in clinical practice and contribute to further research on FS and its associated health implications.

Prevalence of Frank's sign in healthy young individuals, morphological characteristics, and its association with family history of chronic disease

Frank's sign (FS, earlobe crease) is known to be associated with many chronic diseases i.e. coronary, cerebrovascular, and peripheral vascular diseases. The objective of this study is to investigate the presence and grade of FS in healthy, young-adult individuals aging between 18 and 25. Furthermore, to evaluate the relationship between FS and the chronic disease history of first-degree family members. 853 healthy people with a mean age of 20.09 years were imvolved in the research on a voluntary basis. Of 853 individuals, 85.3% (n:728) had no FS, whereas 14.7% (n:125) had. Of the 125 people observed FS, 41.6% (n:52) were female and 58.4% (n:73) were male. Of the 125 people diagnosed with FS, 32.8% (n:41) had no family history of any chronic disease, and 67.2% (n:84) had at least 1 family history of chronic disease as well. It was determined that there was a statistically significant (p < 0.05) relationship between FS identified in healthy individuals and familial chronic disease history. In this study, while no FS was observed in 85.3% of the participants, grade 1 was detected in 12.4% (n:105), grade 2a in 1.9% (n:16), grade 2b in 0.2% (n:2), and grade 3 in 0.2% (n:2). To the best of our knowledge, this study investigated the relationship between the presence and grade of FS in the healthy, young, Turkish population and the presence/absence of chronic disease in the first-degree relatives of individuals for the very first time. As a result of larger studies, being aware of the presence of FS, especially in young healthy individuals, may help predict some chronic diseases, and caution may be taken to avoid these diseases at an early age in at-risk individuals.

Association of Diagonal Earlobe Crease with Risk of Atrial Fibrillation in Stable Patients with Coronary Artery Disease

Background: Diagonal earlobe crease (DELC) is a proposed visible predictor of coronary artery disease (CAD). However, studies on the association between atrial fibrillation (AF) and DELC are lacking. This study evaluated the association between DELC and the incidence of AF in patients with CAD. Methods: A total of 669 participants aged <65 years (mean, 53.8 ± 7.5 years) diagnosed with CAD and without AF were evaluated for the presence of DELC. The study outcome was the incidence of AF based on the presence of DELC. The study period was planned for 60 months with a minimum follow-up period of 12 months. Results: Herein, the incidence of DELC was 10.8%. During the follow-up period (44.6 ± 14.9 months), the incidences of AF development were 16.4% and 8.4% in DELC and non-DELC groups, respectively. Kaplan-Meier analysis revealed that the occurrence of AF was significantly higher in the DELC group than in the non-DELC group (log-rank test, p = 0.02). Compared with patients without DELC, patients with DELC had a high risk of AF development (adjusted hazard ratio = 1.88, 95% confidence interval = 1.01-3.53). Conclusions: DELC is associated with an increased risk of AF in patients with CAD. These findings may aid in the detection of AF in patients with CAD.

Associations between Earlobe Creases and Magnetic Resonance Imaging Small Vessel Disease Markers in a Chinese Cohort of Patients with Ischemic Stroke

INTRODUCTION

The association between earlobe crease (ELC) and cerebral small vessel disease, including white matter hyperintensities (WMHs) and brain atrophy, is unclear, especially in the setting of acute ischemic stroke (AIS). Here, we aimed to investigate the association between ELC and WMHs as well as brain atrophy among AIS patients.

METHODS

A total of 730 AIS patients from China were enrolled. Patients were divided into groups without and with ELC, unilateral and bilateral ELC according to pictures of bilateral ears. Logistic regression models were employed to assess the impact of ELC, bilateral ELC on WMHs, periventricular hyperintensities (PVHs), deep white matter hyperintensities (DWMHs), and brain atrophy, as measured by the Fazekas scale and global cortical atrophy scale, in brain magnetic resonance imaging.

RESULTS

There were 520 (71.2%) AIS patients with WMHs, 445 (61.0%) with PVH, 462 (63.3%) with DWMH, and 586 (80.3%) with brain atrophy. Compared to those without ELC, patients with ELC were significantly associated with an increased risk of PVH (odds ratio [OR] 1.79; 95% confidence interval [CI], 1.15-2.77) and brain atrophy (OR: 6.18; 95% CI: 3.60-10.63) but not WMHs and DWMH. The presence of bilateral ELC significantly increased the odds of WMHs (OR: 1.60; 95% CI: 1.00-2.56), PVH (OR: 1.87; 95% CI: 1.18-2.96), and brain atrophy (OR: 8.50; 95% CI: 4.62-15.66) when compared to individuals without ELC. Furthermore, we discovered that the association between bilateral ELC and WMHs, PVH, and DWMH was significant only among individuals aged ≤68 (median age) years (all p trend ≤0.041). However, this association was not observed in patients older than 68 years.

CONCLUSIONS

In Chinese AIS patients, the presence of the visible aging sign, ELC, especially bilateral ELC, showed independent associations with both WMHs and brain atrophy, particularly among those younger than 68 years old.

Detection of Frank's sign in the dental setting: A population-based cohort study

BACKGROUND

In 1973, Saunders T. Frank described the diagonal earlobe crease (DELC) as a potential marker of cardiovascular disease. However, this anatomical finding is not routinely examined. The aim of this study was to assess the presence of this crease in the general population attending a dental setting and describe its anatomical variations to be able to categorize it as a physical sign.

METHODOLOGY

A study group of 1050 white adults were selected, as participants in the framework of the "A Estrada Study of Glycation and Inflammation" (AEGIS), a cross-sectional, population-based descriptive study of a representative sample of the general adult population of the municipality of A Estrada (Pontevedra, Spain). Each participant's age, sex, and preferred head position when sleeping were recorded. Both earlobes were visually inspected and the anatomical variables of the crease were recorded (unilateral or bilateral, length, depth, and presence of secondary creases). The relationship between the study variables was analyzed using the chi-squared test, Student's t-test, the analysis of variance (ANOVA), and the nonparametric tests of Mann-Whitney and Kruskal-Wallis.

RESULTS

The DELC was observed in 65.2% of the participants. In 71.5% of the cases, the sign was complete (occupying the space from the tragus to the posterior edge of the earlobe); in 56.9% of the cases, the sign was bilateral; in 45.1% of the cases it was deep; and in the 43.6% of the cases, accessory creases were identified. Neither sex nor the habitual head position when sleeping were related to the prevalence or characteristics of the DELC. The prevalence, extent and depth of Frank's sign increased significantly with age (p < .001).

CONCLUSION

The prevalence of the DELC increases significantly with age, and its morphological characteristics are accentuated. This finding, therefore, gains special relevance as a marker of potential cardiovascular disease when observed in young adults.

Traditional Cardiovascular Risk Factors Associated with Diagonal Earlobe Crease (Frank Sign) in Mexican Adults: Aging, Obesity, Arterial Hypertension, and Being Male Are the Most Important

Introduction

Cardiovascular risk factors such as obesity, type 2 diabetes, hypertension, smoking, and dyslipidemia enfold heart disease morbimortality. Diagonal earlobe crease has been proposed as a prognostic marker of extension and severity of illness in patients with acute coronary syndrome. But its usefulness remains unclear in patients with or without coronary disease.

Methods

A case-control study was carried out on a total of 805 patients with and without cardiovascular risk factors or acute coronary syndrome. Univariate and multivariate binary logistic regression analyses were used to determine the probability of having diagonal earlobe crease with the presence of cardiovascular risk factors and acute coronary syndrome. Data were summarized as odds ratio with 95% confidence intervals and P values.

Results

An unadjusted (univariate) analysis showed that being male, being older than 55 years, obesity, type 2 diabetes mellitus, arterial hypertension, smoking, and dyslipidemia, as well as having acute coronary syndrome, were associated with the presence of diagonal earlobe crease. The multivariate analysis showed that men (OR 1.6, 95% IC 1.1-2.4, P=0.007), being over 55 years old (OR 4.8, 95% IC 3.2-7.2, P < 0.001), being obese (OR 2.1, 95% IC 1.4-3.1, P < 0.001), having arterial hypertension (1.5, 95% IC 1.1-2.3, P=0.025), or suffering from acute coronary syndrome (OR 5.3, 95% IC 2.5-11.1, P < 0.001), were independent factors associated with diagonal earlobe crease. The rest of cardiovascular risk factors were not relevant in the multivariate model.

Conclusions

In Mexican adults, having an acute coronary syndrome is not the only factor associated with diagonal earlobe crease but also being a man, older than 55 years, having high blood pressure and obesity. Diagonal earlobe crease may simply be caused by changes in the skin and connective tissues of the ears because of the aging process, obesity, and/or being male. These factors, by themselves, enfold cardiovascular risk due to well-known pathophysiological causes.

Association of advanced glycation end products with ear lobe crease: A cross-sectional study

OBJECTIVE

Several studies have demonstrated a significant association between the presence of the ear lobe crease (ELC) and cardiovascular disease. Advanced glycation end-products (AGEs) can affect the structures and functions of proteins and contribute to the development of diabetic complications. However, few studies have reported the relationship between AGEs and ELC. The purpose of this study was to investigate the correlation of skin autofluorescence (SAF)-AGEage (SAF-AGEs × age/100) with ELC.

METHODS

This cross-sectional study enrolled 6500 eligible participants from two communities in Beijing. Skin autofluorescence (SAF) was used to measure skin AGEs (SAF-AGEs). SAF-AGEage was defined as AGEs × age/100. Binary logistic regression analysis and linear regression analysis nested in logistic models were applied to test outcomes.

RESULTS

The overall prevalence of ELC with an average age of 62.7 years participants was 57.1% (n = 3714). Age, fasting blood glucose, systolic blood pressure, and lipoprotein cholesterol were all greater in participants with ELC. ELC-positive participants had higher prevalence of coronary heart disease. Logistic analysis showed a significantly positive relationship between quartiles of SAF-AGEage and ELC (odds ratio [OR] 1.526, 95% CI 1.324-1.759; OR 2.072, CI 1.791-2.396; and OR 2.983, CI 2.551-3.489) for the multivariate-adjusted models, respectively. Stratified research revealed that those with a history of diabetes, hypertension, or coronary heart disease experienced the connection between SAF-AGEage and ELC.

CONCLUSION

ELC is associated with coronary heart disease, and the SAF-AGE has a potential role in ELC development in elder people.

Diagonal Earlobe Crease (Frank's Sign): a New Clinical Sign to Look for in Patients With Ruptured and Unruptured Intracranial Aneurysms? Patient Series

BACKGROUND AND IMPORTANCE

Diagonal earlobe crease (DELC, Frank's sign) and intracranial arterial aneurysms (IAA) have a pronounced association with atherosclerosis. Therefore, detecting DELC in patients with IAA could be potential for clinical and research use.

CLINICAL PRESENTATION

During a 2-month period, we diagnosed 20 patients with intracranial arterial aneurysms. Sixteen (80%) were positive for DELC, 12 were female, and 4 were male (ages ranging from 32 to 68 years and a mean of 52 years). Eleven were unruptured and 5 were ruptured. We highlight cases 1, 7, and 8.

CONCLUSION

The interesting tight association of DELC and IAAs to atherosclerosis and the overwhelming presence of DELC in patients with IAAs could lead to potentially associated DELC with the development, growth, and rupture of IAAs. As a result, important clinical and research information could be found.

Part I: Cutaneous manifestations of cardiovascular disease

In this part 1 of a 2-part continuing medical education series, we review the epidemiology and pathophysiology of cardiovascular disease, its association with cutaneous symptoms, and the diagnosis and evaluation of cutaneous features of cardiovascular syndromes, including infective endocarditis, acute rheumatic fever, Kawasaki disease, cholesterol embolization syndrome, lipid disorders, cardiac amyloidosis, and cardiac myxomas. As the incidence and prevalence of cardiovascular diseases increase, dermatologists play an essential role in recognizing the cutaneous manifestations of cardiovascular diseases in order to appropriately connect patients with follow-up care.

The prognostic value of deep earlobe creases in patients with acute ischemic stroke

Background and purpose

Data on earlobe crease (ELC) among patients with acute ischemic stroke (AIS) are limited. Here, we determined the frequency and characteristics of ELC and the prognostic effect of ELC among AIS patients.

Methods

A total of 936 patients with acute AIS were enrolled during the period between December 2018 and December 2019. The patients were divided into those without and with ELC, unilateral and bilateral ELC, and shallow and deep ELC, according to the photographs taken of the bilateral ears. Logistic regression models were used to estimate the effect of ELC, bilateral ELC, and deep ELC on poor functional outcomes at 90 days (a modified Rankin Scale score ≥2) in AIS patients.

Results

Among the 936 AIS patients, there were 746 (79.7%) patients with ELC. Among patients with ELC, there were 156 (20.9%) patients with unilateral ELC and 590 (79.1%) with bilateral ELC and 476 (63.8%) patients with shallow ELC and 270 (36.2%) with deep ELC. After adjusting for age, sex, baseline NIHSS score, and other potential covariates, patients with deep ELC were associated with a 1.87-fold [odds ratio (OR) 1.87; 95% confidence interval (CI), 1.13-3.09] and 1.63-fold (OR 1.63; 95%CI, 1.14-2.34) increase in the risk of poor functional outcome at 90 days in comparison with those without ELC or shallow ELC.

Conclusion

ELC was a common phenomenon, and eight out of ten AIS patients had ELC. Most patients had bilateral ELC, and more than one-third had deep ELC. Deep ELC was independently associated with an increased risk of poor functional outcome at 90 days.

The importance of inspection in clinical cardiology: Frank's sign

The Frank's sign (FS) is a diagonal earlobe crease running from the tragus to the edge of the auricle. In this case, we describe a 71 years-old male patient with FS who presented to the emergency department complaining of epigastric pain. A non-ST elevation myocardial infarction was diagnosed.

Relationship between Diagonal Earlobes Crease and Ischemic Stroke Risk

BACKGROUND: Diagonal earlobe crease has been shown as the association between atherosclerotic disease. AIM: To examine the relationship between diagonal earlobes crease (DELC) and ischemic stroke. METHODS: This prospective study recruited 175 consecutive acute ischemic stroke patients admitted to the Stroke Unit of Srinagarind Hospital, Faculty of Medicine, Khon Kaen University between May 2021 and August 2021. Clinical data included age, gender, underlying disease, clinical presentation, vital signs, brain computed tomography and DELC assessed for both ears.  The study was approved by the Human Ethics Research Committee of Khon Kaen University, Thailand. RESULTS: patients were assessed on clinical presentation and brain computed tomography (CT) findings. There were 31 patients with transient ischemic attacks (17.7% of the patients) and 144 patients with cerebral infarction (82.3%). In all participants were male 58.9% and 72 were female (41.1%). The top three clinical presentations were hemiparesis (29.6%), dysarthria (27.0%), and facial palsy (17.5%). One hundred and thirty-one patients (74.9%) had underlying diseases; hypertension (24.2%), diabetic mellitus (14.4%), atrial fibrillation (4.9%), chronic kidney disease (2.0%), dyslipidemia (8.0%), valvular heart disease (2.3%), coronary heart disease (2.6%), previous stroke (8.1%), and other diseases (8.4%). Only 44 patients (25.1%) had no underlying disease. Frank’s sign (DELC) was present in only 13 patients (7.4%). There were similar proportions of major underlying conditions, hypertension, and diabetic mellitus for both groups, and no differences apparent for gender or old age. On CT scans both DELC and non-DELC patients showed lacunar infarction as the major source of ischemic stroke.  CONCLUSIONS: Due to our very small sample of DELC patients, we could draw no conclusions about the relationship between DELC and ischemic stroke and its predictive utility as a biomarker for ischemic stroke.  Given the much higher proportions of DELC patients reported in international literature we raise the possibility of physiological, genetic, or ethnic differences in Thai, or Asian samples, for future research.

Prevalence of the Frank's sign by aetiopathogenic stroke subtype: A prospective analysis

BACKGROUND AND PURPOSE

The Frank's sign is a diagonal earlobe crease running from the tragus to the edge of the auricle at an angle of 45°. Many studies have associated this sign with coronary artery disease and some with cerebrovascular disease. The objective of this study was to analyse the prevalence of the Frank's sign in patients suffering from acute stroke with a particular focus on its prevalence in each of the five aetiopathogenic stroke subtypes. Special interest is given to embolic stroke of undetermined source (ESUS), correlating the sign with clinical and radiological markers that support an underlying causal profile in this subgroup.

METHODS

Cross-sectional descriptive study including 124 patients admitted consecutively to a stroke unit after suffering an acute stroke. The Frank's sign was evaluated by the same blinded member of the research team from photographs taken of the patients. The stroke subtype was classified following SSS-TOAST criteria and the aetiological study was performed following the ESO guidelines.

RESULTS

The Frank's sign was present in 75 patients and was more prevalent in patients with an ischaemic stroke in comparison with haemorrhagic stroke (63.9 vs. 37.5, p<0.05). A similar prevalence was found in the different ischaemic stroke subtypes. The Frank's sign was significantly associated with age, particularly in patients older than 70 who had vascular risk factors. Atherosclerotic plaques found in carotid ultrasonography were significantly more frequent in patients with the Frank's sign (63.6%, p<0.05). Analysing the ESUS, we also found an association with age and a higher prevalence of the Frank's sign in patients with vascular risk factors and a tendency to a high prevalence of atherosclerosis markers.

CONCLUSION

The Frank's sign is prevalent in all aetiopathogenic ischaemic stroke subtypes, including ESUS, where it could be helpful in suspecting the underlying cardioembolic or atherothrombotic origin and guiding the investigation of atherosclerosis in patients with ESUS and the Frank's sign.

Frank's sign and paired ear creases of the helix : Current concepts of significance for morbidity

Frank's sign (FS) was described in 1973 as an auricular marker for cardiovascular disease presenting as a crease of the auricular lobule. Since its first clinical description, there have been multiple studies underlining the role of FS in a myriad of conditions, such as atherosclerosis, hypertension, cerebrovascular disease, peripheral artery disease, metabolic diseases as well as studies looking at physiological differences in the auricular shape that may mimic FS; however, a complex study to comprehensively analyze the clinical, gross, and histological findings of patients with FS has not yet been performed. Most studies focused on a specific system, mechanism of disease entry. This short review tries to summarize the current knowledge of FS in relation to diseases as well as its clinical classification, histology, and association with the recently described paired ear creases of the helix, as an attempt to reveal the dubious role of FS as a possible prognostic and predictive marker.

Role of White Matter Hyperintensities and Related Risk Factors in Vascular Cognitive Impairment: A Review

White matter hyperintensities (WMHs) of presumed vascular origin are one of the imaging markers of cerebral small-vessel disease, which is prevalent in older individuals and closely associated with the occurrence and development of cognitive impairment. The heterogeneous nature of the imaging manifestations of WMHs creates difficulties for early detection and diagnosis of vascular cognitive impairment (VCI) associated with WMHs. Because the underlying pathological processes and biomarkers of WMHs and their development in cognitive impairment remain uncertain, progress in prevention and treatment is lagging. For this reason, this paper reviews the status of research on the features of WMHs related to VCI, as well as mediators associated with both WMHs and VCI, and summarizes potential treatment strategies for the prevention and intervention in WMHs associated with VCI.

The Histological Basis of Frank's Sign

Frank's sign is a diagonal crease of the ear lobe, supposedly related to cardiac pathology, and has strongly been associated with coronary artery atherosclerosis. A total of 45 consecutive adult patients referred for autopsy in a one-and-a-half-year period were extensively studied. Samples from both the ear lobes were obtained for histopathology, as well as cardiac samples from all four cardiac compartments. When compared patients with Frank's sign and those without it had no statistical difference in age (p = 0.0575). There was however a statistically significant increased cardiac weight (p = 0.0005), left ventricular wall thickness (p = 0.0002), and right ventricular wall thickness (p = 0.0043). Histopathology obtained from the ear lobes revealed myoelastofibrosis in an arterial vessel, located at the base of the crease, diffuse fibrosis, and Wallerian-like degeneration, with eosinophilic inclusions in the peripheral nerves. These changes suggest a time-related progression of the crease-associated changes. Our data suggest a significant correlation between the morphological changes of the myocardium and the presence of the ear lobe creases, with arterial myoelastofibrosis, Wallerian-like degeneration in peripheral nerves and deep tissue fibrosis found in the base of the crease.

The Association between Earlobe Creases and Cardiovascular Events in Japanese Hemodialysis Patients: A Prospective Cohort Study

Objective The earlobe crease, a wrinkle extending from the tragus to the outer border of the earlobe, is a well-known surrogate marker for a high risk of cardiovascular disease. However, information is lacking about its association with cardiovascular events among hemodialysis patients, who already have an increased risk of cardiovascular disease. We tested the hypothesis that earlobe creases are independently associated with the risk of cardiovascular events among Japanese hemodialysis patients. Methods This prospective cohort study followed 247 adult hemodialysis patients with no history of cardiovascular disease for 4 years. The presence of earlobe creases was defined by two researchers using photos of patients' earlobes on both sides while blinded to one another's assessments and clinical data. The primary outcome was defined as the first fatal or nonfatal cardiovascular event (myocardial infarction, ischemic or hemorrhagic stroke, or peripheral vascular disease requiring aortic or peripheral vascular bypass surgery or below- or above-the-knee amputation). A Fine-Gray competing risks regression model was used to examine the association between earlobe creases and cardiovascular events. Results During the 4-year follow-up period, 43 patients suffered cardiovascular events. After the competing risk of non-cardiovascular death was accounted for, patients with earlobe creases had an increased cumulative incidence of cardiovascular events compared to those without earlobe creases (subhazard ratio =2.04, 95% confidence interval: 1.09 to 3.82). This association was no longer significant after adjusting for age. Conclusion Earlobe creases were not independently associated with cardiovascular events among Japanese hemodialysis patients, suggesting that these marks are simply indicative of advanced age.

Diagonal earlobe crease (Frank's sign) and increased risk of cerebrovascular diseases: review of the literature and implications for clinical practice

Diagonal earlobe crease (DELC) or Frank's sign is a diagonal crease in the earlobe that extends diagonally from the tragus to the edge of the auricle with an angle of approximately 45°. Although its presence increases with advancing age, several studies have shown an independent association between DELC and cardiovascular diseases as well as peripheral vascular diseases. DELC has also been demonstrated to increase the risk of cerebrovascular events (mostly ischaemic stroke), probably through atherosclerotic mechanisms. A systematic literature search was conducted using PubMed and Embase to identify studies investigating the relationship between DELC and the occurrence of cerebrovascular diseases. We identified 5 articles (1469 subjects included). Since the presence of DELC can be easily evaluated, patients with the Frank's sign should undergo a diagnostic workup to detect vascular risk factors and implement preventative therapies.

Reevaluation of the earlobe types in Koreans

The shape of the earlobes has a variety of genetic significance. This study analyzed the frequencies of the earlobe shapes in the Korean population. Data were collected on randomly selected 500 males and 500 females in Daegu Metropolitan City, with all participant ages being in their twenties. Obtuse angled earlobes accounted for 41.2% of the earlobes observed, while acute angled earlobes prevalence was calculated at 38.8% and right angled earlobe was 20.0% of the total (sexes combined). In men, the acute angled earlobe was the most frequent type (43.0%), while the obtuse angled earlobe was the most frequent type in females (45.2%). These differences were statistically significant (p = 0.015). Overall, attached type earlobe (61.2%) was more frequent than free type earlobe. The attached type earlobe was more common in both sex groups (57.0% in male and 65.4% in female), and the proportion was significantly higher for females (p = 0.006). In conclusion, the findings in this study suggest that the attached earlobe type is the most common among Koreans, and the proportion of earlobe types among males and females is significantly different. Further studies are needed to understand the genetic background of earlobe types among Koreans.

The association between earlobe crease (Frank's sign) and cognitive performance is related to age. Results from the Atahualpa Project

BACKGROUND

Earlobe crease (ELC) has been linked to cardiovascular diseases, but information on its association with cognitive decline is limited. We aimed to assess the association between ELC and cognitive performance in community-dwelling adults living in rural Ecuador.

METHODS

Of 863 individuals aged ≥40 years enrolled in the Atahualpa Project, 629 (73%) were included. ELC were visually identified by two independent raters, and cognitive performance was measured by the Montreal Cognitive Assessment (MoCA). Using generalized linear and interaction models, adjusted for demographics, cardiovascular risk factors and edentulism, we assessed the association between ELC and cognitive performance, as well as the influence of age in this association.

RESULTS

ELC was present in 246 (39%) individuals, and the mean MoCA score in the entire population was 21.9 ± 4.7 points. A generalized linear model showed no relationship between ELC presence and the MoCA score (p = 0.449). In this model, covariates remaining significant were age (p < 0.001), physical activity (p = 0.014) and edentulism (p < 0.001). When participants were stratified according of quartiles of age, the MoCA score did not differ according to the presence or absence of ELC. Weighted exposure-effect models - using ELC and the MoCA score as the exposure and outcome (respectively) - revealed no association between both variables.

CONCLUSIONS

The association between ELC and the MoCA score is mainly related to age. These findings might be explained by the high prevalence of ELC and cognitive decline in older adults.

Association Between the Frank Sign and Cardiovascular Events

Clinicians have attempted to find early preclinical physical diagnosis signs to detect vascular diseases at the preclinical stage and to prevent clinical deterioration in time. An interesting example of such signs is the Frank sign, which was first described by Dr Sonders T. Frank in 1973. Our goal was to summarize the clinical trials and observational studies that had examined the association between the Frank sign and cardiovascular diseases. Summarizing the 57 studies we found showed that this association could be used for early diagnosis of coronary and vascular diseases in the preclinical stage and that they were found in different populations around the world. Autopsy studies also found a strong association between the Frank sign and cardiovascular causes of death in both sexes. Cardiovascular causes of death included ischemic and hypertensive heart disease, calcific valvular stenosis, ruptured dissecting aneurysm of the thoracic aorta, and ruptured atheromatous aneurysm of the abdominal aorta. The Frank sign was correlated with increased intima-media thickness and stroke and was found in patients with peripheral vascular disease and with cardiovascular risk factors. The Frank sign could serve as a physical sign to help clinicians diagnose cardiovascular diseases.

Diagonal ear lobe crease: A premonitory diagnostic sign of impeding ischemic heart disease

Introduction:

In India, significant number of individuals suffers from ischemic heart disease (IHD). Majority of chest pain victim initially report to his family physician. At times, sudden death is the first and last manifestation of IHD. Doctors are aware of various risk factors for IHD. The diagonal ear lobe crease (DELC) has been characterized in medical literature as a surrogate marker which can be easily identified as high-risk case for impending IHD. We report here the incidence of IHD accompanied with DELC in rural population.

Patients and Methods:

Eight hindered and eighty eight patients attended to general physician Mahad during January 2012 to December 2015 with complaints of chest pain were investigated for presence of DELC. Presence of DELC was correlated to varies risk factors including hypertension, hyperlipidemia, diabetes mellitus (DM), body mass index (BMI), occipital baldness, and tobacco consumption.

Results:

Out of patients studied, 645 (72.6%) had hypertension, 508 (57.2%) had DELC, of these 486 (95%) suffered from IHD, 246 (48%) had DM, 246 (48%) had occipital baldness, and 325 (64%) had hyperlipidemia. Significant association between BMI > 25+ in male >50 years old with odd ratio 2.08 (95% CI: 1.27–3.39; P = 0.003).

Interpretation:

Presence of DELC with or without risk factors is a simple clinical observation easily noted during examination by family physician to investigate and to rule out IHD.

Diagonal Earlobe Crease is a Visible Sign for Cerebral Small Vessel Disease and Amyloid-β

We investigated the frequency and clinical significance of diagonal earlobe crease (DELC) in cognitively impaired patients using imaging biomarkers, such as white matter hyperintensities (WMH) on MRI and amyloid-β (Aβ) PET. A total of 471 cognitively impaired patients and 243 cognitively normal (CN) individuals were included in this study. Compared with CN individuals, cognitively impaired patients had a greater frequency of DELC (OR 1.6, 95% CI 1.1–2.2, P = 0.007). This relationship was more prominent in patients with dementia (OR 1.8, 95% CI 1.2–2.7, P = 0.002) and subcortical vascular cognitive impairment (OR 2.4, 95% CI 1.6–3.6, P < 0.001). Compared with Aβ-negative cognitively impaired patients with minimal WMH, Aβ-positive patients with moderate to severe WMH were significantly more likely to exhibit DELC (OR 7.3, 95% CI 3.4–16.0, P < 0.001). We suggest that DELC can serve as a useful supportive sign, not only for the presence of cognitive impairment, but also for cerebral small vessel disease (CSVD) and Aβ-positivity. The relationship between DELC and Aβ-positivity might be explained by the causative role of CSVD in Aβ accumulation.