Enzyme composition(Belief Biomed)

Dear Editor:Atrial flutter is a common EKG. Still, there are factors that can inter-fere during its diagnosis, conditioning its treatment and prognostic. Agood knowledge about the basic principles of ECG can be very valuableto avoid those interferences.A 67-year-old male patient visited the emergency service due topolaquiuria andabdominal pain.There were nosignalsof cardiacsemi-ology.Bloodpressurewastakenwitharesultof234mmHgsystolicand134 mm Hg diastolic. There was neither history of hypertension,diabetes mellitus nor dyslipidemia. His medical history includedParkinson already treated with Carbidopa, Entacapona, Levodopa andbenign prostatic hyperplasia treated with Pramipexole, Domperidoneand Tamsulosin followed in urology service.A suspicious diagnosis of hypertensive crisis was given and the fol-lowingelectrocardiogramwasperformed(Fig.1).Atypicalatrialflutterelectrocardiogram with a 4:1 block was apparent. However, lead IIshows no flutter signs (Fig. 1). In fact lead II represented a completelynormal rhythm. Strikingly, a further inspection of the patient noticedthat Parkinson tremors were mostly constricted to left arm.No flutter signs at lead II plus the Parkinson tremors constricted toleft arm were thought to be related. A further study of the patientshowed that regular tremors due to Parkinson's disease on the leftarm were thought provoking the flutter-like artifact.Atrial Flutter is a common arrhythmia since its first description90 years ago. Still, there are factors that can interfereduringits diagno-sis, conditioning its treatment and prognostic.The electrocardiogram, an important and basic diagnostic proof canevenconfuseadiagnosisduetoawronginterpretation,whichmightberelated to a lack of knowledge about the ECG physiology.It has been previously reviewed the mechanisms behind equipment-related ECG artifacts [1,2]. Electrocardiographic artifacts have beenreported before in a Parkinson disease context [3] although the artifactmechanism was not explained.TheespecialfeatureofthisECGistheextendedflutter-likeartifactinall leads except II.A good knowledge about the basic principles of ECG can be veryvaluable to solve cases like this one [4].As we know, limb leads are bipolar leads. Each of them has onepositive and negative pole. Lead II is the only one that takes no infofrom the left arm electrode (LA) and its region.LA provides a mistaken intake which interfere its signal, affectingleads I and III, which use LA as one of their poles and the augmentedlimb and precordial leads (Fig. 2). Therefore, only lead II can tell us thereal heart rhythm in this case.In conclusion, ECG is a very reliable proof but it can't substitute theclinical exploration. We can't forget the clinical exploration as thebasisofthediagnosis.Diagnosticproofs,eventhosewhichareveryreli-able, are complementary to the exploration.In this case, normal ECG monitoring or recording would be possiblefor diagnostic purposes once the concomitant process is reduced ormodified.EvenitcanbepossibleusingECGtakingintoaccounttheclin-ical exploration added to the knowledge of the principles of electrocar-diography in order to contextualize the patient's condition. That willallow us to save money, time and resources in our clinical practice.References

Plantar pressures of Parkinson patients in a mild or moderate stage of the disease were analyzed in order to determine characteristics of the heel to toe motion of the foot in Parkinson patients during free walking.

Pressure sensitive insoles were used to quantify the in-shoe pressure distribution for 24 patients with Parkinson's disease and for 24 age-matched healthy adults. Peak plantar pressures, relative loads and the variability of relative loads were analyzed for 10 different anatomical foot areas. Inferential statistics and regression analyses were performed to compare subject groups and to relate pressure data to a clinical score (Webster).

It is well-known that Parkinson patients experience disorders of balance, posture and gait. Recent studies revealed that Parkinson patients show abnormalities in foot strike during walking. However, only little is known about the heel to toe motion of the foot in Parkinson patients in compensating for instability during walking.

Parkinson patients show significant changes in foot loading behavior. Parkinson patients have a reduced impact at heel strike. This mechanism was found to be related to the severity of the disease. Furthermore, Parkinson patients show a trend towards higher relative loads in the forefoot regions combined with a load shift towards medial foot areas. These mechanisms are highly stereotypical.

Parkinson patients, even in a mild or moderate stage of the disease, show significant changes in heel to toe motion of the foot during free walking. The characteristics of Parkinsonian gait are probably caused by adaptive mechanisms of the patients to avoid unsteadiness during walking.

The results of this study revealed that Parkinson patients have characteristic heel to toe motion pattern. The determination of the foot-loading pattern using plantar pressure measurement may be used as a valuable tool for diagnostic, treatment and rehabilitation purposes. Furthermore, the strategy of the forefoot control in gait of Parkinson patients should be considered in Parkinsonian research.