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Aksu F, Akkoc RF. Prevalence of Frank's sign in healthy young individuals, morphological characteristics, and its association with family history of chronic disease. Forensic Sci Med Pathol 2024:10.1007/s12024-024-00868-7. [PMID: 39093375 DOI: 10.1007/s12024-024-00868-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2024] [Indexed: 08/04/2024]
Abstract
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.
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Affiliation(s)
- Feyza Aksu
- Department of Anatomy, Faculty of Medicine, Firat University, Elazig, Turkey
| | - Ramazan Fazil Akkoc
- Department of Anatomy, Faculty of Medicine, Firat University, Elazig, Turkey.
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Rivas-Mundiña B, Fernández-Ascariz L, García-Mato E, Diniz-Freitas M, Gude-Sampedro F, Abeleira-Pazos M. Detection of Frank's sign in the dental setting: A population-based cohort study. SPECIAL CARE IN DENTISTRY 2024; 44:1211-1218. [PMID: 38415987 DOI: 10.1111/scd.12975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/20/2024] [Accepted: 01/27/2024] [Indexed: 02/29/2024]
Abstract
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.
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Affiliation(s)
- Berta Rivas-Mundiña
- Medical-Surgical Dentistry Research Group (OMEQUI), Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - Lucía Fernández-Ascariz
- Medical-Surgical Dentistry Research Group (OMEQUI), Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - Eliane García-Mato
- Medical-Surgical Dentistry Research Group (OMEQUI), Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - Marcio Diniz-Freitas
- Medical-Surgical Dentistry Research Group (OMEQUI), Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - Francisco Gude-Sampedro
- Epidemiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Maite Abeleira-Pazos
- Medical-Surgical Dentistry Research Group (OMEQUI), Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela (USC), Santiago de Compostela, Spain
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Molina-Gallardo R, Aurelien-Cabezas NS, Tiburcio-Jimenez D, Plata-Florenzano JE, Guzman-Esquivel J, Rodriguez-Sanchez IP, Martinez-Fierro ML, Molina-Osorio R, De-la-Madrid-Cernas AA, Barriguete-Melendez JA, Delgado-Enciso I. 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. Int J Hypertens 2024; 2024:5598134. [PMID: 38948003 PMCID: PMC11213639 DOI: 10.1155/2024/5598134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/29/2024] [Accepted: 06/10/2024] [Indexed: 07/02/2024] Open
Abstract
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.
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Affiliation(s)
- Rogelio Molina-Gallardo
- Facultad de Medicina, Universidad de Colima, Colima, 28040, Mexico
- Instituto Mexicano del Seguro Social, Delegación Colima, Villa de Álvarez, Colima, 28983, Mexico
| | | | | | | | - Jose Guzman-Esquivel
- Instituto Mexicano del Seguro Social, Delegación Colima, Villa de Álvarez, Colima, 28983, Mexico
| | - Iram P. Rodriguez-Sanchez
- Laboratorio de Fisiología Molecular y Estructural, Facultad de Ciencias Biológicas, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, 66455, Nuevo León, Mexico
| | | | - Roque Molina-Osorio
- Instituto Mexicano del Seguro Social, Delegación Colima, Villa de Álvarez, Colima, 28983, Mexico
| | | | | | - Ivan Delgado-Enciso
- Facultad de Medicina, Universidad de Colima, Colima, 28040, Mexico
- Instituto Estatal de Cancerología, IMSS-Bienestar Colima, Colima, 28085, Mexico
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Lovato A, Biral M, Postiglione M, Gagliardi G, Gagliardi V, Ceccherelli F. A Possible Correlation Between Auricular Angiomas and Breast Cancer Through Auricular Acupuncture Diagnosis: An Observational Case-Control Study. Cureus 2024; 16:e60834. [PMID: 38910685 PMCID: PMC11190853 DOI: 10.7759/cureus.60834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2024] [Indexed: 06/25/2024] Open
Abstract
Introduction Auricular acupuncture (AA) can be used for both diagnosis and therapy. Diagnosis done with AA has become more prominent, with inspection by evaluating skin alterations considered the most important step. Literature on AA diagnosis in cancer patients is scarce. Globally, breast cancer (BC) is the most commonly diagnosed cancer in women. Materials and methods Subjects accessing the outpatient Breast Unit Clinic of Padua for BC were evaluated for auricle angiomas, with collected data including a number of angiomas, Romoli's Sectogram sector of identified angiomas, laterality of the auricle with the angioma, age, and laterality of BC. Results Of the 438 subjects evaluated, 129 had BC, and 64 had an identifiable auricle angioma. The odds of an auricular angioma were higher in subjects with BC diagnosis, mainly localized in tumor area II and predominantly ipsilateral to the side affected by BC. Conclusions AA auricle inspection is a simple, quick, and easy diagnostic tool. Screening for the presence and location of auricular angiomas may help health practitioners refer women for BC screening for early diagnosis.
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Affiliation(s)
- Antonello Lovato
- Integrative Medicine, Pain Therapy Clinic, Vicenza, ITA
- Complementary Medicine, A.I.R.A.S. (Italian Association for the Research and the Scientific Update), Padua, ITA
| | - Mario Biral
- Complementary Medicine, A.I.R.A.S. (Italian Association for the Research and the Scientific Update), Padua, ITA
| | - Marco Postiglione
- Epidemiology and Public Health, A.I.R.A.S. (Italian Association for the Research and the Scientific Update), Padua, ITA
| | - Giuseppe Gagliardi
- Anesthesiology, AULSS 5 Polesana, Rovigo, ITA
- Pain Therapy, A.I.R.A.S. (Italian Association for the Research and the Scientific Update), Padua, ITA
| | | | - Francesco Ceccherelli
- Anesthesiology and Pain Therapy, A.I.R.A.S. (Italian Association for the Research and the Scientific Update), Padua, ITA
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Lee DH, Lee HS, Kim BH, Lee SW. Is the Surface Anatomy of the Popliteal Crease Related to Lower Extremity Alignment or Knee Osseous Morphology? A Radiographic Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1849. [PMID: 37893567 PMCID: PMC10608488 DOI: 10.3390/medicina59101849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/12/2023] [Accepted: 10/15/2023] [Indexed: 10/29/2023]
Abstract
Background and objectives: The popliteal crease varies among individuals, and there has been no prior study on this aspect. We assumed that it may be associated with lower extremity alignment and osseous morphology. To demonstrate this, we conducted a radiographic analysis. Materials and Methods: The study was conducted on 121 knees of 63 patients, whose popliteal creases were well distinguished on clinical photographs. PCOA was defined as the angle between the longitudinal axis of the lower leg and the popliteal crease. Through the radiologic examinations performed, the HKA, MPTA, mLDFA, JLCA, MFCA/TEA, and PCA/TEA were measured. Pearson correlation analysis and multiple linear regression analysis were performed on the PCOA and the six radiologic measurements to analyze the relationship. Results: Pearson correlation analysis found HKA had the highest coefficient at 0.568. In multiple linear regression, only HKA was associated, excluding all other measurements. Conclusions: Popliteal crease obliquity is significantly associated with coronal plane lower extremity alignment and exhibits a stronger correlation than with underlying knee osseous morphology. If future research is conducted based on this, popliteal crease could serve as a valuable clue for predicting lower extremity alignment and the risk of osteoarthritis development.
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Affiliation(s)
| | | | | | - Se-Won Lee
- Department of Orthopedic Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 10, 63-Ro, Seoul 07345, Republic of Korea; (D.H.L.); (B.-H.K.)
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Xu J, Wang L, Zhang C, Wang J, Zheng D, Huang Y, Zhang X, You S, Cao Y, Liu CF. The prognostic value of deep earlobe creases in patients with acute ischemic stroke. Front Cardiovasc Med 2023; 10:1096044. [PMID: 37324621 PMCID: PMC10266351 DOI: 10.3389/fcvm.2023.1096044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 05/09/2023] [Indexed: 06/17/2023] Open
Abstract
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.
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Affiliation(s)
- Jiaping Xu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Lixuan Wang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
- Department of Neurology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, China
| | - Chunqing Zhang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiayun Wang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
- Department of Neurology, Qinghai University Affiliated Hospital, Xining, China
| | - Danni Zheng
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Yaqian Huang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xia Zhang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Shoujiang You
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yongjun Cao
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
- Institutes of Neuroscience, Soochow University, Suzhou, China
| | - Chun-Feng Liu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
- Institutes of Neuroscience, Soochow University, Suzhou, China
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Laksono S, Ramadhan M, Salsabila S. Earlobe crusade as useful screening for coronary artery disease in low- and middle-income countries of Asian; Bring the ear–Heart axis to the spotlight in cardiology: Systematic review and implications for clinical practice. APOLLO MEDICINE 2023. [DOI: 10.4103/am.am_116_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
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Wang J, Zhu ZF, Liu FQ, Liu C, Ou-Yang AM, Chen WW, Wang EG, Wang XM. Patients with Earlobe Crease May Associate with Lower Concentration of the Age-Suppressing Hormone Klotho. Int J Gen Med 2021; 14:8797-8803. [PMID: 34858047 PMCID: PMC8629917 DOI: 10.2147/ijgm.s300309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/02/2021] [Indexed: 11/24/2022] Open
Abstract
Objective Earlobe crease (ELC) has been considered as a skin sign of atherosclerosis, and its pathophysiological mechanism is still unclear. Our study aims to test the hypothesis that ELC patients with lower serum levels of the age-suppressing hormone Klotho, which is not only associated with premature aging but also with endothelial dysfunction, may be associated with atherosclerosis. Methods A total of 135 patients aged 40–68 years underwent coronary angiography. According to the presence or absence of coronary heart disease (CAD) and ELC, they were divided into three groups: CAD group and ELC group (ELC group, n = 45); no ELC group (non-ELC group, n = 45). There was no ELC or CAD in the control group (control group, n = 45). Serum Klotho concentration was obtained by enzyme-linked immunosorbent assay (ELISA). Results The Klotho level in the ELC group was 365.6 ± 38.1 pg/mL, while the Klotho level in the non-ELC group was 568.8 ± 44.9 pg/mL. It is worth noting that the Klotho level of the ELC group was significantly lower than that of the non-ELC group (P < 0.001). The serum Klotho level of the control group was higher than that of the non-ELC group (593.3±45.3 vs 568.8±44.9 pg/mL, P = 0.702), but the difference was not statistically significant. Multiple logistic regression analysis showed that the Klotho level is a parameter that affects the appearance of ELC. Conclusion Serum Klotho levels were considerably lower in patients with ELC. We concluded that the perturbations of Klotho in patients might be associated with ELC and with CAD.
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Affiliation(s)
- Jian Wang
- Department of Radiology, Jinan Central Hospital Affiliated to Shandong University, Jinan, Shandong, 250013, People's Republic of China
| | - Zhan-Fang Zhu
- Department of Internal Medicine, The Hospital of Xi'an Jiaotong University, Xi'an, 710049, People's Republic of China
| | - Fu-Qiang Liu
- Department of Cardiovascular, Shaanxi Provincial People's Hospital, Xi'an, 710068, People's Republic of China
| | - Cun Liu
- Department of Ultrasound, Jinan Central Hospital Affiliated to Shandong University, Jinan, Shandong, 250013, People's Republic of China
| | - Ai-Mei Ou-Yang
- Department of Radiology, Jinan Central Hospital Affiliated to Shandong University, Jinan, Shandong, 250013, People's Republic of China
| | - Wei-Wei Chen
- Department of Radiology, Jinan Central Hospital Affiliated to Shandong University, Jinan, Shandong, 250013, People's Republic of China
| | - En-Guo Wang
- Department of Radiology, Jinan Central Hospital Affiliated to Shandong University, Jinan, Shandong, 250013, People's Republic of China
| | - Xi-Ming Wang
- Department of Radiology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250021, People's Republic of China.,Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, People's Republic of China
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Frank's sign and paired ear creases of the helix : Current concepts of significance for morbidity. Wien Klin Wochenschr 2021; 134:237-242. [PMID: 34817665 DOI: 10.1007/s00508-021-01969-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/14/2021] [Indexed: 10/19/2022]
Abstract
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.
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Wei N, Zhang R, Zhu Z, Li R, Yu Q, Wang Q, Xu C, Ma M, Mu S, Liu F, Wang J. Adropin and Irisin Deficiencies Are Associated With Presence of Diagonal Earlobe Crease in CAD Patients. Front Cardiovasc Med 2021; 8:719763. [PMID: 34712706 PMCID: PMC8545887 DOI: 10.3389/fcvm.2021.719763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: Diagonal earlobe crease (ELC) has been considered a potential cutaneous marker of atherosclerosis. However, the potential mechanism by which ELC and atherosclerosis are linked has not been adequately defined. Roles of adropin and irisin, novel biomarkers of endothelial function, in ELC have not been well-studied. This study aimed to test whether individuals with ELC are deficient in adropin and irisin, a characteristic that would likely promote endothelial dysfunction and provide a plausible common pathological basis for atherosclerosis and ELC. Methods: Patients diagnosed with coronary artery disease (CAD) with (n = 45) and without (n = 45) ELC were consecutively enrolled in the study. The ages of the patients enrolled ranged from 40–70 years. Other patients (n = 45) without ELC or CAD were recruited as the control group. All patients underwent coronary angiography. Serum adropin and irisin concentrations were assessed via enzyme-linked immunosorbent assay. Results: Circulating levels of irisin in the ELC group were significantly lower than those in the non-ELC group, and were highest in the control group. Serum adropin levels of the ELC group were significantly lower than those of the non-ELC group (P < 0.001). Interestingly, although the serum adropin level of the control group was greater than that of the non-ELC group, the difference failed to achieve statistical significance. In subgroup analysis of CAD and ELC, both serum adropin and irisin levels of the CAD and ELC groups were lower than those of the control group (P < 0.001). Receiver-operating characteristic curve analysis revealed that adropin and irisin have similar prognostic power for CAD and ELC. Conclusions: Low adropin and irisin were significantly associated with CAD and ELC. The deficiencies in adropin and irisin may be a common cause of both atherosclerosis and ELC, which explains why patients with ELC are prone to CAD.
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Affiliation(s)
- Na Wei
- Department of Cardiovascular, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Ronghuai Zhang
- Department of Cardiovascular, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Zhanfang Zhu
- Xi'an Jiaotong University Hospital, Xi'an, China
| | - Rui Li
- Shaanxi Provincial Clinical Research Center for Geriatric Medicine, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Qi Yu
- Shaanxi Key Laboratory of Ischemic Cardiovascular Diseases, Institute of Basic and Translational Medicine, Xi'an Medical University, Xi'an, China
| | - Qingyu Wang
- Department of Cardiovascular, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Cuixiang Xu
- Shaanxi Provincial Key Laboratory of Infection and Immune Diseases, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Meijuan Ma
- Department of Cardiovascular, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Shengzhi Mu
- Department of Burn and Plastic Surgery, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Fuqiang Liu
- Department of Cardiovascular, Shaanxi Provincial People's Hospital, Xi'an, China.,Shaanxi Provincial Clinical Research Center for Geriatric Medicine, Shaanxi Provincial People's Hospital, Xi'an, China.,Shaanxi Key Laboratory of Ischemic Cardiovascular Diseases, Institute of Basic and Translational Medicine, Xi'an Medical University, Xi'an, China
| | - Junkui Wang
- Department of Cardiovascular, Shaanxi Provincial People's Hospital, Xi'an, China.,Shaanxi Provincial Clinical Research Center for Geriatric Medicine, Shaanxi Provincial People's Hospital, Xi'an, China
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Tsampasian V, Vassiliou VS, Corballis N. What do Steven Spielberg, Mel Gibson and Emperor Hadrian have in common? Frank's sign and the link with coronary artery disease. Oxf Med Case Reports 2021; 2021:omab097. [PMID: 34729196 PMCID: PMC8557473 DOI: 10.1093/omcr/omab097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/04/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Vasiliki Tsampasian
- Department of Cardiology, Norwich Medical School, University of East Anglia, Norwich, UK
- Norfolk and Norwich University Hospital, Norwich, UK
| | - Vassilios S Vassiliou
- Department of Cardiology, Norwich Medical School, University of East Anglia, Norwich, UK
- Norfolk and Norwich University Hospital, Norwich, UK
| | - Natasha Corballis
- Department of Cardiology, Norwich Medical School, University of East Anglia, Norwich, UK
- Norfolk and Norwich University Hospital, Norwich, UK
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Baudouin R, Simon F. Authors’ response to the letter concerning “The Medici earlobe crease”. Eur Ann Otorhinolaryngol Head Neck Dis 2021; 138:319. [DOI: 10.1016/j.anorl.2021.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Reply to Baudouin and Simon: “The Medici earlobe crease”. Eur Ann Otorhinolaryngol Head Neck Dis 2021; 138:317. [DOI: 10.1016/j.anorl.2021.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 12/24/2020] [Accepted: 01/26/2021] [Indexed: 11/19/2022]
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Gasga A, Phan BAP. Familial Frank's Sign: Diagonal Earlobe Creases and Premature Coronary Artery Disease. J Gen Intern Med 2021; 36:1106-1107. [PMID: 33483813 PMCID: PMC8042075 DOI: 10.1007/s11606-020-06393-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 12/03/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Arturo Gasga
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Binh An P Phan
- Division of Cardiology at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
- University of California, San Francisco, San Francisco, CA, USA
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15
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Alimohammadi H, Shojaee M, Sohrabi MR, Salahi S. HEART Score in Predicting One-Month Major Adverse Cardiac Events in Patients with Acute Chest Pain; a Diagnostic Accuracy Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2021; 9:e31. [PMID: 34027426 PMCID: PMC8126359 DOI: 10.22037/aaem.v9i1.1052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction Screening of high-risk patients and accelerating their therapeutic procedures can reduce the burden of acute coronary syndrome (ACS). This study aimed to evaluate the accuracy of HEART score in predicting the risk of one-month major adverse cardiac events (MACE) in these patients. Methods In this prospective cross-sectional study, the accuracy of HEART score in patients over 18 years old who presented to emergency department following acute chest pain, was evaluated during a 21-month period. Each patient was followed up regarding the incidence of MACE for one month via phone call and the hospital's integrated health information system. Results 240 cases with the mean age of 60.50 ± 16.07 years were studied (56.3% male). MACE was observed in 77 (32.1%) cases. The most common MACE was percutaneous coronary artery revascularization (PCAR) (12.9%). The mean HEART score of studied cases was 4.74 ± 2.12. The mean score of cases with MACE was significantly higher than others (6.25 ± 1.97 versus 4.03 ± 1.79; p < 0.0001). Based on this score, the risk of MACE was high in 34 (14.2%), moderate in 118 (49.2%), and low in 88 (36.7%) cases. The incidence of one-month MACE was 85.3% in high-risk cases, 35.6% in moderate one, and 6.8% in low-risk cases based on HEART score. The area under the ROC curve of HEART score in predicting the risk of MACE was 0.796 (95% CI: 0.736 - 0.856). The best cut off point of HEART score in this regard was calculated as 4.5. The sensitivity and specificity of this score in 4.5 cut off were 83.11% (95% CI: 72.49 - 90.35) and 66.25% (95% CI: 58.38 - 73.35), respectively. Conclusion Based on the findings of the present study the mean HEART score of ACS patients with one-month MACE was significantly higher than others and the incidence of MACE in high-risk patients was significantly higher. But the overall accuracy of score in predicting one-month MACE in ACS patients was in moderate range.
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Affiliation(s)
- Hossein Alimohammadi
- Emergency Department, Imam Hossein Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Shojaee
- Emergency Department, Imam Hossein Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Sohrabi
- Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Email
| | - Saman Salahi
- Emergency Department, Imam Hossein Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Stoyanov GS, Dzhenkov D, Petkova L, Sapundzhiev N, Georgiev S. The Histological Basis of Frank's Sign. Head Neck Pathol 2020; 15:402-407. [PMID: 32712879 PMCID: PMC8134579 DOI: 10.1007/s12105-020-01205-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 06/26/2020] [Accepted: 07/17/2020] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- George S Stoyanov
- Department of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Marin Drinov 55 str., 9002, Varna, Bulgaria.
| | - Deyan Dzhenkov
- Department of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Marin Drinov 55 str., 9002, Varna, Bulgaria
| | - Lilyana Petkova
- Department of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Marin Drinov 55 str., 9002, Varna, Bulgaria
| | - Nikolay Sapundzhiev
- Division of ENT Diseases Faculty of Medicine, Department of Neurosurgery and ENT Diseases, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Marin Drinov 55 str., Varna, Bulgaria
| | - Svetoslav Georgiev
- Division of Cardiology, First Department of Internal Diseases, Faculty of Medicine, Medical University - Varna "Prof. Dr. Paraskev Stoyanov", Marin Drinov 55 str., Varna, Bulgaria
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Sekiguchi A, Inoue Y, Yamazaki S, Uchiyama A, Ishikawa O, Kuribayashi S, Uraoka T, Hara K, Yamaguchi K, Maeno T, Uchida M, Koyama H, Motegi SI. Prevalence and clinical characteristics of earlobe crease in systemic sclerosis: Possible association with vascular dysfunction. J Dermatol 2020; 47:870-875. [PMID: 32424835 DOI: 10.1111/1346-8138.15400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 04/20/2020] [Indexed: 11/30/2022]
Abstract
Patients with systemic sclerosis (SSc) develop various vasculopathy-induced vascular disorders such as Raynaud's phenomenon, abnormal nail-fold capillaries, persistent digital ischemia, digital ulcers (DU), and sometimes develop renal crisis and pulmonary artery hypertension (PAH), affecting prognosis. Earlobe crease (ELC), also known as Frank's sign, is a wrinkle extending from the tragus to the outer border of the earlobe and is generally recognized as the sign of cardiovascular events. However, no previous study analyzed the association between ELC and SSc. In this study, we examined the prevalence and clinical characteristics of ELC in SSc patients. We analyzed 145 Japanese SSc patients and found that the prevalence of ELC in SSc patients was 23.4% (43/145), similar to that previously reported in the general population without SSc. Using univariate analysis, we found that SSc patients with ELC were characterized by old age, high incidence of DU, ILD and PAH, and high complication of coronary artery diseases (CAD) compared with SSc patients without ELC. In multivariate analysis, ELC was significantly associated with old age and incidence of DU. PAH tended to correlate with ELC without statistical significance. These results suggest that ELC may be associated with vascular disorders in SSc patients. This is the first report concerning the prevalence and clinical characteristics of ELC in patients with SSc. ELC is very easy to detect in clinical practice and helps physicians to identify SSc patients at risk of developing vascular disorders such as DU and PAH.
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Affiliation(s)
- Akiko Sekiguchi
- Departments of, Department of, Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yuta Inoue
- Departments of, Department of, Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Sahori Yamazaki
- Departments of, Department of, Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Akihiko Uchiyama
- Departments of, Department of, Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Osamu Ishikawa
- Departments of, Department of, Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Shiko Kuribayashi
- Department of, Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Toshio Uraoka
- Department of, Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Kenichiro Hara
- Department of, Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Kouichi Yamaguchi
- Department of, Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Toshitaka Maeno
- Department of, Respiratory Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Mitsuo Uchida
- Department of, Public Health, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hiroshi Koyama
- Department of, Public Health, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Sei-Ichiro Motegi
- Departments of, Department of, Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
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Wakasugi M, Nagai M, Yokota S, Omori K, Fujikawa H, Aoike I, Omori T, Kazama JJ, Narita I. The Association between Earlobe Creases and Cardiovascular Events in Japanese Hemodialysis Patients: A Prospective Cohort Study. Intern Med 2020; 59:927-932. [PMID: 31839659 PMCID: PMC7184083 DOI: 10.2169/internalmedicine.3943-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Minako Wakasugi
- Division of Comprehensive Geriatrics in Community, Niigata University Graduate School of Medical and Dental Sciences, Japan
| | - Masaaki Nagai
- Department of Internal Medicine, Sakura Clinic, Japan
| | - Saori Yokota
- Department of Internal Medicine, Medical Corporation Group Omori Medical Clinic, Japan
| | - Kentaro Omori
- Department of Internal Medicine, Medical Corporation Group Omori Medical Clinic, Japan
| | | | - Ikuo Aoike
- Department of Internal Medicine, Koyo Medical Clinic, Japan
| | - Tsukasa Omori
- Department of Internal Medicine, Medical Corporation Group Omori Medical Clinic, Japan
| | | | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Japan
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Pacei F, Bersano A, Brigo F, Reggiani S, Nardone R. Diagonal earlobe crease (Frank's sign) and increased risk of cerebrovascular diseases: review of the literature and implications for clinical practice. Neurol Sci 2019; 41:257-262. [PMID: 31641899 DOI: 10.1007/s10072-019-04080-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Federico Pacei
- Department of Neurology, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, Milan, Italy
| | - Anna Bersano
- Division Cerebrovascular Disease Unit, IRCCS Foundation "C. Besta", Neurological Institute, Milan, Italy
| | - Francesco Brigo
- Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy.,Division of Neurology, Franz Tappeiner Hospital, Via Rossini, 5, 39012, Merano, BZ, Italy
| | - Stefano Reggiani
- Department of Neurology, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, Milan, Italy
| | - Raffaele Nardone
- Division of Neurology, Franz Tappeiner Hospital, Via Rossini, 5, 39012, Merano, BZ, Italy. .,Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.
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20
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Del Brutto OH, Mera RM, Costa AF, Castillo PR, Matcha G. On the association between earlobe crease and the carotid intima-media thickness: A population-based study. Heliyon 2019; 5:e01556. [PMID: 31049449 PMCID: PMC6482315 DOI: 10.1016/j.heliyon.2019.e01556] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/19/2019] [Accepted: 04/18/2019] [Indexed: 01/21/2023] Open
Abstract
The earlobe crease (ELC) has been linked to coronary artery disease, but there is limited information on the association between ELC and extracranial atherosclerosis. Using the Atahualpa Project cohort, we aimed to assess the association between ELC and increased carotid intima-media thickness (cIMT). Atahualpa residents aged ≥40 years underwent visual inspection of both earlobes to evaluate ELC presence, and ultrasound examinations of carotid arteries to calculate the cIMT. The association between both variables was assessed by logistic regression and predictive models, after adjusting for relevant confounders. Mean age of 570 enrolled individuals was 61.5 ± 12.4 years (58% women). ELC was present in 221 (39%) participants. The mean cIMT was 0.85 ± 0.19 mm, with 81 individuals (14%) having an increased cIMT (>1 mm). Univariate logistic regression showed a significant association between ELC presence and increased cIMT (OR: 1.67; 95% C.I.: 1.04-2.69), which disappeared when age (OR: 1.09; 95% C.I.: 0.65-1.85) and other covariables (OR: 1.06; 95% C.I.: 0.62-1.84) were added to the model. Predictive cIMT margins did not differ according to ELC presence or absence, with participants stratified in quartiles of age. This study shows that the effect of the increase in cIMT in subjects with ELC is related to aging.
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Affiliation(s)
- Oscar H. Del Brutto
- School of Medicine, Universidad Espíritu Santo – Ecuador, Guayaquil, Ecuador
- Corresponding author. Air Center 3542, PO Box 522970, Miami, Fl, 33152-2970, USA.
| | - Robertino M. Mera
- Department of Epidemiology, Gilead Sciences, Inc., Foster City, CA, USA
| | - Aldo F. Costa
- School of Medicine, Universidad Espíritu Santo – Ecuador, Guayaquil, Ecuador
| | - Pablo R. Castillo
- Sleep Disorders Center, Mayo Clinic School of Medicine, Jacksonville, Fl, USA
| | - Gautam Matcha
- Internal Medicine Department, Mayo Clinic School of Medicine, Jacksonville, Fl, USA
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The Association between Earlobe Crease (Frank's Sign) and Abnormal Ankle-Brachial Index Determination Is Related to Age: A Population-Based Study. Int J Vasc Med 2018; 2018:4735731. [PMID: 30245883 PMCID: PMC6139202 DOI: 10.1155/2018/4735731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/31/2018] [Accepted: 08/09/2018] [Indexed: 11/17/2022] Open
Abstract
Background Information on the association between earlobe crease (ELC) and peripheral artery disease is limited. We assessed this association in community-dwelling older adults. Study Design A total of 294 Atahualpa residents aged ≥60 years were enrolled. ELC were visually identified by two raters. The ankle-brachial index (ABI), used as a surrogate of peripheral artery disease, was categorized using American Heart Association criteria. Using logistic regression and probability models, adjusted for demographics and cardiovascular risk factors, we assessed the relationship between ELC and abnormal ABI determinations, as well as the influence of age on this association. Results ELC was identified in 141 (48%) individuals, and abnormal ABI determination was carried out in 56 (19%). The association between ELC and abnormal ABI was nonsignificant in logistic regression and probability models with individuals stratified according to their median age. Conclusions The association between ELC and abnormal ABI determinations is probably attenuated by the high prevalence of both conditions in older persons. ELC might not be useful for identifying candidates for ABI determination.
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Abstract
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.
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Affiliation(s)
- Saleh Nazzal
- From the Department of Medicine, Baruch Padeh Poria Medical Center, Azrieli Faculty of Medicine, Bar Ilan University, Israel
| | - Arnon Blum
- From the Department of Medicine, Baruch Padeh Poria Medical Center, Azrieli Faculty of Medicine, Bar Ilan University, Israel
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Abstract
Despite advancements in diagnostic tools, physical signs such as xanthelasmata, arcus corneae, facial wrinkles, and gray hair are useful indicators of underlying diseases. The presence of bilateral diagonal earlobe creases (DELCs), also known as Frank's sign, correlates with a myriad of cardiovascular diseases such as coronary artery disease, cerebrovascular disease, and peripheral vascular disease. The use of Frank's sign as a bedside predictor of underlying coronary artery disease is controversial among clinicians. We report a case of a patient with bilateral DELCs found to have significant coronary artery disease during diagnostic coronary angiography for recurrent chest pain.
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Affiliation(s)
| | | | - Htoo Kyaw
- Cardiology Department, Cardiology Fellow, Brooklyn Hospital Center
| | - Joseph Abboud
- Cardiology Department, Cardiology Attending, Brooklyn Hospital Center
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Bawaskar HS, Bawaskar PH, Bawaskar PH. Diagonal ear lobe crease: A premonitory diagnostic sign of impeding ischemic heart disease. J Family Med Prim Care 2018; 7:1361-1367. [PMID: 30613525 PMCID: PMC6293914 DOI: 10.4103/jfmpc.jfmpc_181_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
| | - Parag Himmatrao Bawaskar
- Department of Cardiology, Topiwala National Medical College and BYL Nair Hospital, Mumbai, Maharashtra, India
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Nazzal S, Hijazi B, Khalila L, Blum A. Diagonal Earlobe Crease (Frank's Sign): A Predictor of Cerebral Vascular Events. Am J Med 2017; 130:1324.e1-1324.e5. [PMID: 28460854 DOI: 10.1016/j.amjmed.2017.03.059] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 03/31/2017] [Accepted: 03/31/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Frank's sign was first described in 1973 by an American physician (Sonders T. Frank). It is a diagonal crease in the earlobe that starts from the tragus to the edge of the auricle in an angle of 45° in varying depths. Frank's sign was described as a predictor of future coronary heart disease and peripheral vascular diseases. The aim of the study was to examine the association between Frank's sign and the development of ischemic stroke. METHODS This was a prospective study that enrolled consecutive patients admitted with an acute ischemic stroke. Frank's sign was tested in both ears. Clinical data included age, gender, type 2 diabetes mellitus, and hypertension. The study was approved by the institutional review board (the institutional ethics committee). RESULTS A total of 241 consecutive patients who were hospitalized with an acute stroke and were eligible to take part in the study were recruited. Frank's sign was present in 190 patients (78.8%). Patients were divided according to clinical findings and the findings from brain computed tomography. There were 153 patients with transient ischemic attacks (63.6% of the patients) and 88 with cerebrovascular accidents (36.4% of the patients). A total of 112 patients with transient ischemic attacks had Frank's sign (73.2%), and 78 patients with cerebrovascular accidents had Frank's sign (88.6%), with a statistically significant difference (P <.01). DISCUSSION Frank's sign could predict ischemic cerebrovascular events. Patients with classical cardiovascular risk factors had Frank's sign at a higher frequency.
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Affiliation(s)
- Saleh Nazzal
- Department of Medicine, Baruch Padeh Poria Medical Center, Faculty of Medicine in the Galilee, Bar-Ilan University, Tiberias, Lower Galilee, Israel
| | - Basem Hijazi
- Department of Medicine, Baruch Padeh Poria Medical Center, Faculty of Medicine in the Galilee, Bar-Ilan University, Tiberias, Lower Galilee, Israel
| | - Luai Khalila
- Department of Medicine, Baruch Padeh Poria Medical Center, Faculty of Medicine in the Galilee, Bar-Ilan University, Tiberias, Lower Galilee, Israel
| | - Arnon Blum
- Department of Medicine, Baruch Padeh Poria Medical Center, Faculty of Medicine in the Galilee, Bar-Ilan University, Tiberias, Lower Galilee, Israel.
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Diagonal Earlobe Crease is a Visible Sign for Cerebral Small Vessel Disease and Amyloid-β. Sci Rep 2017; 7:13397. [PMID: 29042572 PMCID: PMC5645376 DOI: 10.1038/s41598-017-13370-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/21/2017] [Indexed: 11/16/2022] Open
Abstract
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.
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Reinhart RA. Robert E. Lee's Right Ear and the Relation of Earlobe Crease to Coronary Artery Disease. Am J Cardiol 2017. [DOI: 10.1016/j.amjcard.2017.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Oda N, Maruhashi T, Kishimoto S, Kajikawa M, Iwamoto Y, Iwamoto A, Matsui S, Hidaka T, Kihara Y, Chayama K, Goto C, Aibara Y, Nakashima A, Noma K, Hirano H, Higashi Y. Relation of the Bilateral Earlobe Crease to Endothelial Dysfunction. Am J Cardiol 2017; 119:1983-1988. [PMID: 28438303 DOI: 10.1016/j.amjcard.2017.03.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/15/2017] [Accepted: 03/15/2017] [Indexed: 11/15/2022]
Abstract
The presence of an earlobe crease (ELC) may be a simple sign to predict atherosclerosis. We evaluated the relation between ELC and vascular function. We measured flow-mediated vasodilation (FMD) and nitroglycerine-induced vasodilation (NID) and observed bilateral earlobes in 400 consecutive subjects. At first, the subjects were divided into 3 groups: non-ELC group, unilateral ELC group, and bilateral ELC group. FMD and NID were significantly lower in the unilateral and bilateral ELC groups than those in the non-ELC group. After adjustment of cardiovascular risk factors, bilateral ELC, but not unilateral ELC, was associated with lower FMD and lower NID. We also investigated whether an increase in the number of ELCs worsens endothelial function, whether the difference in ELC structure (cross stripes and/or ramification) affects endothelial function, and whether endothelial function is impaired in subjects with superficial wrinkles depending on age. The number of ELCs, shape of the ELC, and superficial wrinkles were not associated with endothelial dysfunction. In conclusion, these findings suggest that the presence of bilateral ELCs is associated with vascular dysfunction.
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Affiliation(s)
- Nozomu Oda
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tatsuya Maruhashi
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinji Kishimoto
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masato Kajikawa
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yumiko Iwamoto
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akimichi Iwamoto
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shogo Matsui
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takayuki Hidaka
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Institute of Biomedical and Health Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Chikara Goto
- Hiroshima International University, Hiroshima, Japan
| | - Yoshiki Aibara
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Ayumu Nakashima
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan; Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Kensuke Noma
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan; Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Harutoyo Hirano
- College of Engineering, Academic Institute, Shizuoka University, Shizuoka, Japan
| | - Yukihito Higashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan; Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan.
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Honma M, Shibuya T, Iwasaki T, Iinuma S, Takahashi N, Kishibe M, Minami-Hori M, Ishida-Yamamoto A. Prevalence of coronary artery calcification in Japanese patients with psoriasis: A close correlation with bilateral diagonal earlobe creases. J Dermatol 2017; 44:1122-1128. [PMID: 28464401 DOI: 10.1111/1346-8138.13895] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 03/23/2017] [Indexed: 11/28/2022]
Abstract
Psoriasis is a multifactorial inflammatory disorder, in which the inflammation affects not only the skin but also the other internal organs, and can induce cardiovascular and cerebrovascular involvements. However, few predictive factors of cardiovascular diseases have been clarified in patients with psoriasis. This study was performed to verify whether diagonal earlobe creases (ELC) can reflect the hidden comorbidities in Japanese psoriatic patients. Prevalence and subtypes of ELC were analyzed in patients with psoriatic and with non-psoriatic skin diseases, and the correlation with coronary artery calcification (CAC) or fatty liver (FL) detected by computed tomography. Prevalence of CAC was approximately twice higher than data of a Japanese resident-based study previously reported. Generally, prevalence of ELC in a psoriatic group and mean age of psoriatic groups accompanied by ELC were higher and younger than those of a non-psoriatic skin disease group, respectively. Statistically significant differences were detected in the mean age of total or male subjects accompanied by bilateral ELC with complete and incomplete length. Bilateralism of ELC was closely correlated with prevalence of CAC and CAC on multiple branches in psoriatic patients (P = 6.6e-6 and odds ratio [OR] = 14.1, P = 0.00884 and OR = 10.7, respectively), but not with that of FL. On the contrary, body mass index of more than 25 was closely correlated with prevalence of FL, but not that of CAC. Comorbidities of psoriatic patients are frequently unnoticed. ELC, an apparatus-related feature, can be a useful predictive factor for hidden coronary artery involvements in psoriatic patients.
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Affiliation(s)
- Masaru Honma
- Department of Dermatology, Asahikawa Medical University, Asahikawa, Japan
| | - Takashi Shibuya
- Department of Dermatology, Asahikawa Medical University, Asahikawa, Japan
| | - Takeshi Iwasaki
- Department of Dermatology, Asahikawa Medical University, Asahikawa, Japan
| | - Shin Iinuma
- Department of Dermatology, Asahikawa Medical University, Asahikawa, Japan
| | | | - Mari Kishibe
- Department of Dermatology, Asahikawa Medical University, Asahikawa, Japan
| | - Masako Minami-Hori
- Department of Dermatology, Asahikawa Medical University, Asahikawa, Japan
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Rubio O, Galera V, Alonso MC. Morphological variability of the earlobe in a Spanish population sample. HOMO-JOURNAL OF COMPARATIVE HUMAN BIOLOGY 2017; 68:222-235. [PMID: 28416164 DOI: 10.1016/j.jchb.2017.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 01/03/2017] [Indexed: 11/16/2022]
Abstract
This article shows the morphological variability of the earlobe in a Spanish population of European origin. The frequencies of four lobe characteristics (attachment, contour, modeling, and size) and their degree of expression were studied. The relationship among the characteristics and the differences involving sex and laterality were also considered. The least frequent morphology, and of main use in solving forensic cases, was the very small size with triangle-pulled contour into the skin and crossed-discontinuous modeling. The most frequent morphology, and most clinically useful, was the medium-sized lobe with free-arched contour and eminent or cross-continuous modeling. The characteristics were all symmetric. Size and modeling showed sexual dimorphism. Some characteristics were associated with each other: attachment with contour and modeling and the contour with modeling and size. The least frequent peculiarities were sharp lobe and virgule. The literature is scarce on this matter, practically non-existent for some characteristics, especially modeling and peculiarities. For the first time, the associations of the ear characteristics were analyzed, and this information could be applied to forensic identification.
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Affiliation(s)
- O Rubio
- University Institute of Research in Police Sciences (IUICP), Faculty of Law, Alcalá University, Libreros, 27, Ground Floor, 28802 Alcalá de Henares, Madrid, Spain; Department of Life Science, Alcalá University, 28871 Alcalá de Henares, Madrid, Spain.
| | - V Galera
- University Institute of Research in Police Sciences (IUICP), Faculty of Law, Alcalá University, Libreros, 27, Ground Floor, 28802 Alcalá de Henares, Madrid, Spain; Department of Life Science, Alcalá University, 28871 Alcalá de Henares, Madrid, Spain
| | - M C Alonso
- University Institute of Research in Police Sciences (IUICP), Faculty of Law, Alcalá University, Libreros, 27, Ground Floor, 28802 Alcalá de Henares, Madrid, Spain; Department of Physics and Mathematics, Alcalá University, 28871 Alcalá de Henares, Madrid, Spain
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Wang Y, Mao LH, Jia EZ, Li ZY, Ding XQ, Ge PC, Liu Z, Zhu TB, Wang LS, Li CJ, Ma WZ, Yang ZJ. Relationship between diagonal earlobe creases and coronary artery disease as determined via angiography. BMJ Open 2016; 6:e008558. [PMID: 26868940 PMCID: PMC4762085 DOI: 10.1136/bmjopen-2015-008558] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE This study was designed to examine the prevalence of unilateral and bilateral diagonal earlobe creases (DELCs) with respect to the diagnosis of coronary heart disease (CHD). METHODS A total of 558 consecutive participants (402 males and 156 females) aged 36-91 years who underwent coronary angiography were enrolled in this study. The participants were classified as being without a DELC, having a unilateral DELC and having bilateral DELCs; participants with either a unilateral DELC or bilateral DELCs were defined as participants with DELCs. Significant CHD was defined as at least one major vessel with >50% stenosis, and coronary atherosclerosis severity was defined using the Gensini scoring system. RESULTS In the present study, bilateral DELCs were more frequently among male (p=0.001), CHD (p=0.000), older people (p=0.000) and those with more severe coronary artery atherosclerosis (p=0.000). The results of the multiple regression analyses indicated that DELCs (OR, 4.861; 95% CI 3.093 to 7.642, p=0.000) remained independently associated with a risk of CHD. It was assumed that participants without a DELC have a certain background risk for CHD (OR is assumed to be 1); the results of the multivariate logistic regression indicated that the relative risk of CHD among participants with bilateral DELCs was 5.690 among all participants (OR, 5.690; 95% CI 3.450 to 9.384, p=0.000), 5.436 among male participants (OR, 5.436; 95% CI 2.808 to 10.523, p=0.000) and 7.148 among female participants (OR, 7.148; 95% CI 3.184 to 16.049, p=0.000). Moreover, a positive association between DELC and age (SI=1.21, SIM=1.65, AP =0.132), gender (SI=2.09, SIM=0.81, AP=0.49) and smoking status (SI=1.49, SIM=0.73, AP=0.29) was found, respectively. CONCLUSIONS The results of the present study indicated that DELCs are a simple and a feasible means of identifying CHD. However, the exact mechanism underlying the relationship between DELCs and CHD warrants further study.
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Affiliation(s)
- Yong Wang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
- Department of Cardiovascular Medicine, The People's Hospital of Gaochun, Nanjing, Jiangsu Province, China
| | - Li-Hua Mao
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
- Department of Cardiovascular Medicine, The Jurong City Hospital of Traditional Chinese Medicine, Zhenjiang, Jiangsu Province, China
| | - En-Zhi Jia
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Zhao-Yang Li
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Xiao-Qing Ding
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Peng-Cheng Ge
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Zhe Liu
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Tie-Bing Zhu
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Lian-Sheng Wang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Chun-Jian Li
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Wen-Zhu Ma
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Zhi-Jian Yang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
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