Multimodal Assessment of Smoking cue Reactivity During a Smoking Cue Exposure Task

Background. Cue-reactivity as a characteristic symptom of substance use disorders (SUD) is highly context dependent. Paradigms with high context validity need to be established for the investigation of underlying neurobiological mechanisms. While craving can be assessed by self-report as one aspect of cue-reactivity (CR), the assessment of biological measures such as the autonomous response and EEG promises a holistic perspective including CR at an automatized level. In a multimodal approach, smoking cue exposure (CE) effects on heart rate variability (HRV), EEG frequency power, and craving as well as their interrelation were assessed. This pilot study focused on the validity of CR measurements in a naturalistic CE paradigm. Methods. EEG frequency power, HRV, and craving were assessed during resting state (RS) and smoking CE in smokers (n = 14) and nonsmoking controls (n = 10) to investigate the psychophysiological and subjective reactions to CE. Results. Increased beta power was found only in smokers during CE compared to the control condition. There was an inverse correlation of beta power and maximum craving. Likewise, HRV correlated negatively with maximum smoking urges in smokers immediately after the measurements, without differentiation between CE and control condition. Conclusion. The increased beta power in smokers during CE is discussed as increased inhibitory control related to reduced craving in smokers. Furthermore, increased craving during CE seems to be associated to decreased vagal activity. The multimodal measurements during the CE showed ecological validity to be fundamental for CE assessment in clinical populations to evaluate its predictive value.

The Carroll Center for the Blind Ed–Tech Loon Program

In 1988, the Carroll Center for the Blind, with the generosity of TeleSensory, VTEK, and Computer Aids Corporation, initiated a new service that allows Massachusetts schools to borrow adaptive computer devices for their blind students. The Ed-Tech Loan Program enables them to “try before they buy.” For $50 per month, with a three-month maximum, each school can borrow braille printers, large-print processors, talking software, or speech or braille laptops. After that period, the school may purchase the equipment sometimes at a discount.

Clinic Versus Ambulatory Blood Pressure in Resistant Hypertension: Impact of Antihypertensive Medication Nonadherence

Clinic-ambulatory blood pressure (BP) difference is influenced by patients- and device-related factors and inadequate clinic-BP measurement. We investigated whether nonadherence to antihypertensive medications may also influence this difference in a post hoc analysis of the DENERHTN trial (Renal Denervation for Hypertension). We pooled the data of 77 out of 106 evaluable patients with apparent resistant hypertension who received a standardized antihypertensive treatment and had both ambulatory BP and drug-screening results available at baseline after 1 month of standardized triple therapy and at 6 months on a median of 5 antihypertensive drugs. After drug assay samplings on study visits, patients took their antihypertensive treatment under supervision immediately after the start of the ambulatory BP recording, and supine clinic BP was measured 24 hours post-dosing; both allowed to calculate the clinic minus daytime ambulatory systolic BP (SBP) difference (clinic-SBP–day-SBP). A total of 29 (37.7%) were found nonadherent to medications at baseline and 38 (49.4%) at 6 months. At baseline, the mean clinic-SBP–day-SBP difference in the nonadherent group was 12.7 mm Hg (95% CI, 7.8–17.7 mm Hg, P <0.001). In contrast, clinic SBP was almost identical to day-SBP in the adherent group (clinic-SBP–day-SBP difference, 0.1 mm Hg; 95% CI, −3.3 to 3.5 mm Hg; P =0.947). Similar observations were made at 6 months. Using receiver operating characteristics curves, we found that a 6 mm Hg cutoff of clinic-SBP–day-SBP difference had 67% sensitivity and 69% specificity to predict nonadherence to the triple therapy at baseline. In conclusion, a large clinic-SBP–day-SBP difference may help discriminating between adherence and nonadherence to treatment in patients with resistant hypertension.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov . Unique identifier: NCT01570777.

Psychedelics for psychological and existential distress in palliative and cancer care

In recent years, there has been renewed scientific interest in, and associated media coverage of, psychedelics. [...]

Lipoprotein-associated phospholipase A₂ activity is increased in patients with definite familial hypercholesterolemia compared with other forms of hypercholesterolemia

BACKGROUND AND AIM

Lipoprotein-associated phospholipase A₂ (Lp-PLA₂) plays a key role in atherosclerosis development. It is considered a marker of increased risk of cardiovascular disease (CVD) and plaque vulnerability. Familial hypercholesterolemia (FH) is a genetic disorder characterized by elevated plasma levels of low-density lipoprotein cholesterol and a higher prevalence of early CVD. Our aim was to evaluate the differences in Lp-PLA₂ activity in a population of hypercholesterolemic patients with and without definite FH.

METHODS AND RESULTS

Hypercholesterolemic patients were consecutively recruited. Definite FH was defined according to Dutch Lipid Clinic Network criteria ≥8. All patients underwent routine clinical examination and biological assessments and Lp-PLA₂ activity was measured in blood samples. Among 469 patients, 118 had a definite diagnosis of FH. Lp-PLA₂ activity was significantly higher in definite FH patients compared to non-definite FH patients (206.5 ± 54.5 vs. 180.8 ± 48.4 nmol/min/mL, p < 0.0001). Lp-PLA₂ positively correlated with total cholesterol, LDL-C and apolipoprotein B and negatively with HDL-C and apolipoprotein A-1. In multivariate analysis, definite FH diagnosis, LDL-C, HDL-C and statin treatment remained correlates of Lp-PLA₂ independently of systolic blood pressure.

CONCLUSIONS

Lp-PLA₂ activity was higher in definite FH than in non-definite FH patients independently of LDL-C levels and statin treatment. These results highlight the particular phenotype of FH subjects among hypercholesterolemic patients. As increased Lp-PLA₂ activity suggests, FH patients exhibit higher arterial inflammation that may contribute to their high cardiovascular risk. Our results reinforce the potential beneficial role of statins pleiotropic effects and the need for proper identification and treatment of FH patients.

Effects of carotid baroreceptor stimulation on retinal arteriole remodeling evaluated with adaptive optics camera in resistant hypertensive patients

BACKGROUND AND AIM

Baroreceptor activation therapy (BAT) leads to a decrease in blood pressure (BP) in patients affected by resistant hypertension (RH) by reducing sympathetic outflow. This study aimed at evaluating the effects of BAT on RH patients' retinal arteriolar microvasculature, a territory devoid of adrenergic innervation.

PATIENTS AND METHODS

Five patients defined as affected by RH after excluding secondary causes of hypertension and based on number of antihypertensive treatments, underwent the implantation of Barostim™ neo™. Systolic Blood Pressure (SBP) and Diastolic Blood Pressure (DBP) were assessed by office and 24-hours ambulatory BP monitoring (ABPM). Adaptive Optics Camera RTX1^® (ImagineEye, Orsay, France) was used to measure wall thickness (WT), internal diameter (ID), wall cross-sectional area (WCSA) and wall-to-lumen ratio (WLR). A cohort of 21 not-controlled hypertensive patients matched for age, gender and follow-up time, undergoing standard-antihypertensive therapy changes, was selected as a control group. SBP and DBP were assessed by office and home BP monitoring (HBPM). Evaluations were performed at baseline and after 6 months mean follow-up.

RESULTS

Office SBP decreased by 9.7±12.3% and 29.7±12.4% in standard-therapy and BAT group respectively, while office DBP decreased by 7.6±17.4% and 14.8±15.7%. Concerning ABPM/HBPM, a mean reduction of both SBP and DBP of 7.9±11% was observed for the standard-therapy while a reduction of 15.8±10.5% and 15.8%±5.3% was observed for SBP and DBP respectively in BAT group. While in the standard-therapy group a significant reduction in WLR (-5.9%) due to both ID increase (+2.3%) and WT reduction (-5.7%) was observed, without changes in WCSA (-0.3%), RH patients had a significant reduction in WCSA (-12.1%), due to a trend in both WT and ID reduction (-6.5% and -1.7% respectively), without significant changes in WLR (-2%).

CONCLUSION

While a reverse eutrophic remodeling was observed in patients undergoing a standard-antihypertensive treatment, hypotrophic changes were found in RH patients undergoing BAT. Despite the lack of adrenergic receptors on retinal vessels, chronic baroreflex stimulation may exert an effect on retinal microvasculature in RH patients by more systemic than local mechanisms.

Adherence to Antihypertensive Treatment and the Blood Pressure–Lowering Effects of Renal Denervation in the Renal Denervation for Hypertension (DENERHTN) Trial

Background:

The DENERHTN trial (Renal Denervation for Hypertension) confirmed the blood pressure–lowering efficacy of renal denervation added to a standardized stepped-care antihypertensive treatment for resistant hypertension at 6 months. We report the influence of adherence to antihypertensive treatment on blood pressure control.

Methods:

One hundred six patients with hypertension resistant to 4 weeks of treatment with indapamide 1.5 mg/d, ramipril 10 mg/d (or irbesartan 300 mg/d), and amlodipine 10 mg/d were randomly assigned to renal denervation plus standardized stepped-care antihypertensive treatment, or the same antihypertensive treatment alone. For standardized stepped-care antihypertensive treatment, spironolactone 25 mg/d, bisoprolol 10 mg/d, prazosin 5 mg/d, and rilmenidine 1 mg/d were sequentially added at monthly visits if home blood pressure was ≥135/85 mm Hg after randomization. We assessed adherence to antihypertensive treatment at 6 months by drug screening in urine/plasma samples from 85 patients.

Results:

The numbers of fully adherent (20/40 versus 21/45), partially nonadherent (13/40 versus 20/45), or completely nonadherent patients (7/40 versus 4/45) to antihypertensive treatment were not different in the renal denervation and the control groups, respectively ( P =0.3605). The difference in the change in daytime ambulatory systolic blood pressure from baseline to 6 months between the 2 groups was –6.7 mm Hg ( P =0.0461) in fully adherent and –7.8 mm Hg ( P =0.0996) in nonadherent (partially nonadherent plus completely nonadherent) patients. The between-patient variability of daytime ambulatory systolic blood pressure was greater for nonadherent than for fully adherent patients.

Conclusions:

In the DENERHTN trial, the prevalence of nonadherence to antihypertensive drugs at 6 months was high (≈50%) but not different in the renal denervation and control groups. Regardless of adherence to treatment, renal denervation plus standardized stepped-care antihypertensive treatment resulted in a greater decrease in blood pressure than standardized stepped-care antihypertensive treatment alone.

Clinical Trial Registration:

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01570777.

Retinal arteriolar remodeling evaluated with adaptive optics camera: Relationship with blood pressure levels

AIM

To research a retinal arterioles wall-to-lumen ratio or lumen diameter cut-off that would discriminate hypertensive from normal subjects using adaptive optics camera.

PATIENTS AND METHODS

One thousand and five hundred subjects were consecutively recruited and Adaptive Optics Camera rtx1™ (Imagine-Eyes, Orsay, France) was used to measure wall thickness, internal diameter, to calculate wall-to-lumen ratio (WLR) and wall cross-sectional area of retinal arterioles. Sitting office blood pressure was measured once, just before retinal measurements and office blood pressure was defined as systolic blood pressure>=140mmHg and diastolic blood pressure>=90mmHg. ROC curves were constructed to determine cut-off values for retinal parameters to diagnose office hypertension. In another population of 276 subjects office BP, retinal arterioles evaluation and home blood pressure monitoring were obtained. The applicability of retinal WLR or diameter cut-off values were compared in patients with controlled, masked, white-coat and sustained hypertension.

RESULTS

In 1500 patients, a WLR>0.31 discriminated office hypertensive subjects with a 0.57 sensitivity and 0.71 specificity. Lumen diameter<78.2μm discriminated office hypertension with a 0.73 sensitivity and a 0.52 specificity. In the other 276 patients, WLR was higher in sustained hypertension vs normotensive patients (0.330±0.06 vs 0.292±0.05; P<0.001) and diameter was narrower in masked hypertensive vs normotensive subjects (73.0±11.2 vs 78.5±11.6μm; P<0.005).

CONCLUSION

A WLR higher than 0.31 is in favour of office arterial hypertension; a diameter under<78μm may indicate a masked hypertension. Retinal arterioles analysis through adaptive optics camera may help the diagnosis of arterial hypertension, in particular in case of masked hypertension.

[Development and evaluation of ExSel Test to screen for excess salt intake in hypertensive subjects]

OBJECTIVE

Development of a test to screen excess salt intake (ESI) in hypertensive patients.

METHODS

Hypertensive subjects living in Paris area have been included. A 24-hour urinary sodium collection has been performed the day before the visit for a day hospital. A food diary was completed on the day of the urine collection and validated after an interview with a dietetician. An ESI was defined by a urinary sodium ≥ 200mmol/d. Clinical or food characteristics associated to an ESI were retained for the ExSel Test variables. A ROC curve was performed to determine the optimal score for the ExSel Test in detection of ESI in hypertensive patients.

RESULTS

One hundred and forty-eight hypertensive patients have been included living in the Île-de-France area. ESI was observed in 19% with a higher frequency in men. Seven major determinants of ESI have been identified and are the questions that constitute the ExSel Test. A positive response assigns points: man (1); BMI > 30 (2); bread 4 or 5 pieces per day (1) or more than 6 pieces; cheese at least 1 time per day (2); charcuterie at least 2 times per week (2); use of processed broth or pilaf (1); food rich in hidden salt (pizza, cheeseburger, quiche, shrimp, potato chips, smoked fish, olive) at least 2 times per week (1). The ROC curve analysis shows that a score of 5 or more has the best Youden index with a sensitivity of 0.63, specificity of 0.95, PPV of 0.75, NPV of 0.92.

CONCLUSIONS

In hypertensive subjects, an excessive salt intake can be detected by the realization of the ExSel Test based only on a simple food-questionnaire and some clinical parameters. For a clinical use of the ExSel Test, an electronic version is available on http://www.comitehta.org.

Comparing the outcomes between Chopart, Lisfranc and multiple metatarsal shaft fractures

OBJECTIVES

Complex midfoot injuries could lead to severe functional impairment of mobility and quality of daily living. Aim of this study was to compare the clinical and functional outcomes of Chopart, Lisfranc fractures and multiple metatarsal shaft fractures.

DESIGN

Retrospective case series.

SETTING

Level one trauma center.

INTERVENTION

Open or closed reduction and internal fixation with screws, K-wires, plates, external fixation or combination of different technics.

MAIN OUTCOME MEASUREMENTS

The American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score and the Maryland Foot Score were used to assess pain and functional outcome. 3D gait analysis, pedobarographic analysis and radiologic examinations were performed. The activity level was measured by a step counting accelerometer. All results were compared to an age-matched healthy control group.

RESULTS

24 patients with a median age of 44 years (16-72) were included: 12 patients with multiple metatarsal shaft fractures, 6 patients with Chopart and 6 patients with Lisfranc fractures. The median follow-up was 2.6 years. The pedobarographic analysis reports reduced contact time of the total foot (p = 0.08), the forefoot (p = 0.008) and the hallux (p = 0.015) for the injured foot. A median score of 64 for the SF-36, 64 for the AOFAS Midfoot Score and 73 for the Maryland Foot Score indicated a poor restoration of foot function. Multiple metatarsal shaft fractures presented a significantly lower walking speed (p = 0.03) and cadence (p = 0.04).

CONCLUSION

The worst results were reported for multiple metatarsal shaft fractures on outcome scores, pedobarography, gait analysis and activity. Metatarsal serial fractures should not be underestimated as well as Chopart and Lisfranc fractures.

LEVEL OF EVIDENCE

Level IV.

Effects of an exercise intervention on bone mass in pediatric bone tumor patients

The aim was to evaluate the effects of additional exercises during inpatient stays on bone mass in pediatric bone tumor patients. 21 patients were non-randomly allocated either to the exercise group (n = 10) or the control group (n = 11). DXA of the lumbar spine, the non-affected femur and both calcanei was performed after completion of neoadjuvant chemotherapy (baseline), as well as 6 and 12 months after baseline. Bone mineral content (BMC), bone mineral density (BMD) and height-corrected lumbar spine Z-scores were determined. Group changes after 6 and 12 months were compared by covariance analyses. Additionally, daily physical activities (PA) were assessed by means of accelerometry. After adjusting for initial age, height and weight, mean reductions in lumbar spine and femoral BMC were lower in the exercise group (not significant). Effect sizes during the observational period for lumbar spine and femur BMC were generally small (partial η² = 0.03). The exercise group demonstrated substantially higher PA levels in terms of gait cycles per day, per hour and moderate PA (activities above 40 gait cycles per minute). Additional exercises for bone tumor patients are feasible during hospitalization. Though the intervention did not influence BMC, it appeared beneficial regarding PA promotion with respect to volume and intensity.

Discontinuation of statin therapy due to muscular side effects: a survey in real life

BACKGROUNDS AND AIMS

To assess the burden of statin related muscular symptom in real life.

METHODS AND RESULTS

We conducted a wide survey on 10,409 French subjects. Among these, 2850 (27%) had hypercholesterolemia and 1074 were treated with statins. Muscular symptoms were reported by 104 (10%) statin treated patients and led to discontinuation in 30% of the symptomatic patients. The main prescribed statins were low doses rosuvastatin, atorvastatin and simvastatin. Pains were the most commonly described symptoms (87%) but many patients also reported stiffness (62%), cramps (67%), weakness or a loss of strength during exertion (55%). Pain was localized in 70% but mostly described as affecting several muscular groups. Approximately 38% of patients reported that their symptoms prevented even moderate exertion during everyday activities, while 42% of patients suffered major disruption to their everyday life.

CONCLUSION

Muscular symptoms associated with average dosage statin therapy are more frequent than in clinical trials and have a greater impact on patients' life than usually thought.

[Imaging of retinal arteries with adaptative optics, feasibility and reproducibility]

OBJECTIVE

Adaptative optic is a new non-invasive imaging technique that allows to measure arterioles wall thickness and diameter with a resolution near two microns. Our objectives were to evaluate the feasibility and the reproducibility of this technique in untreated hypertensive patients.

DESIGN AND METHODS

In 23 naive hypertensive patients and in 14 normotensives, the internal diameter (ID) and the wall thickness of the superior temporal artery were automatically measured. Those measurements were made on a temporal artery segment and led to determine a whole vessel cross sectional area (WCSA) and a wall to lumen ratio (WLR). Intra-observer reproducibility was evaluated by realizing three consecutive measurements in 14 subjects. Inter-observer reproducibility was assessed by two independent readers in 17 patients. Variation coefficient was calculated as SD/mean values. A comparison of retinal parameters was made between normal and hypertensive subjects.

RESULTS

Inter-observer reproducibility indicated a variation coefficient of 1.3% for ID, 3.7% for the WCSA and 3.2% for the WLR. Intra-observer reproducibility indicated a variation coefficient of 3.2% for the WLR. Arterial remodeling was present in hypertensive patients at baseline with a significantly increased WLR as compared to normal subjects (0.32 ± 0.04 vs. 0.26 ± 0.04; P<0.05), both population having the same ID.

CONCLUSION

Adaptative optics is feasible and reproducible technique. The possibility of a direct and non-invasive assessment of retinal arterioles must assess the attractions in this technique in hypertensive patients' care.

[Instrumented gait and movement analysis of musculoskeletal diseases]

Instrumented 3-dimensional gait analysis is increasingly being used for the evaluation of movement disorders in orthopedic and neurological musculoskeletal diseases. Due to the high reliability of the measurements the procedures are appropriate for diagnostic purposes as well as for outcome assessment after conservative or surgical interventions. Contrary to conventional clinical assessments gait analysis parameters are able to demonstrate a normal physiological gait pattern that can be achieved with improved kinematic and kinetic parameters. For a suitable application in clinically relevant problems the limitations of the procedures should be taken into account. Due to the high instrumental involvement combined with time and cost expenditure instrumented gait analysis will probably not develop to a clinical routine procedure. Nevertheless, an excellent set of information for answering clinical questions is provided. The present contribution presents selected measurement procedures and technologies and illustrates the wide variety of possibilities with the use of selected clinical examples.

Test-retest reliability of dynamic plantar loading and foot geometry measures in diabetics with peripheral neuropathy

Pedobarography is commonly employed in patients with diabetic peripheral neuropathy (DPN). However there is no evidence regarding test-retest reliability of this technique in this population, and therefore it was the purpose of the current study to address this clear gap. Dynamic plantar loading and foot geometry data were collected during barefoot gait with the EMED platform (Novel GmbH, Germany) from 10 patients with DPN over two sessions, separated by 28 days. Intra-class Correlation Coefficients (ICCs) and Coefficients of Variation (CoVs) were calculated to determine test-retest reliability. For dynamic plantar loading, reliability differed by outcome measure and foot region, with ICCs of >0.8 and CoVs of <15% observed in most cases. For dynamic foot geometry, ICCs of >0.88 and CoVs of <3% were observed for hallux angle, arch index and coefficient of spreading, while sub-arch angle was less reliable (ICC 0.76, CoV 23%). Overall, the current study observed high levels of test-retest reliability which were generally commensurate with that previously reported in healthy populations.

[Influence of hospitalisation on drug prescription in arterial hypertension and chronic conditions]

OBJECTIVES

To evaluate the influence of hospitalization on drug prescription in chronic conditions.

METHODS

Admission and discharge prescriptions from 92 patients consecutively admitted in a specialized department of the Assistance Publique-Hôpitaux de Paris hospital were recorded in a prospective two-month study. A Qualitative Therapeutical Score (QTS) was calculated as an estimation of qualitative modifications in the prescription.

RESULTS

Patients admitted for an hospital stay of over 24h have more lines of prescription than patients admitted for an hospitalization shorter than 24h (5.7±4.2/d vs 2.9±2.5/d, P<0.01). For all the patients enrolled, the hospital stay is not associated with any change in the global number of treatments. However, in patients treated with antihyperstensive drug, the number of drug intakes decreases (2.6±1.5/d vs 1.9±1.4/d, P<0.05) as a consequence of an increase in the prescription of fixed-dose combinations. In patients with cardiovascular diseases, the QTS is higher and qualitative modifications are more often found in patients admitted for an hospital stay of over 24h than for those admitted for a an hospitalization shorter than 24h (0.57 vs 0.11; P<0.01 and 31% vs 11%; P<0.05 respectively). Antihypertensive drugs are the most represented drugs within these qualitative modifications.

CONCLUSION

In patients with drug treatments for arterial hypertension or chronic conditions, hospitalization is not associated with quantitative but with qualitative modifications, especially for an over 24h hospital stay.

[An abdominal CT scan in first-line is an efficient investigation of uncontrolled hypertensives suspected to have an adrenal cause]

The prevalence of hypertension resistant to treatment to indicate for renal denervation.

OBJECTIVE

To evaluate the efficiency for imaging the adrenal glands with an abdominal CT scan in first-line in subjects with resistant hypertension suspected to have an adrenal cause.

METHODS

On 75 hypertensive patients uncontrolled by at least a combination therapy, but suspected to have secondary hypertension due to adrenal cause, an abdominal CT scan was performed in first intention. In all subjects, an exploration of the renin-aldosteron axis in standardized conditions, a 24-hour urinary cortisol and a WHO recommended biological analysis were also performed.

RESULTS

An abnormal morphology of adrenal was found by abdominal CT in 64% of patients. The abnormalities observed were: bilateral hyperplasia (27%), unilateral adenoma (15%), unilateral hyperplasia (15%), bilateral adenoma (7%). Abnormal biological and/or hormonal tests for adrenal disease were found in 29% of patients, with a primary aldosteronism (A/R corrected>23) in 11% or K less than 3.5mmol/L in 20%. According to the assessment conducted in first-line, indication to spironolactone is selected in 48% of patients investigated with CT as first-line and in 17% of patients investigated with biological tests (P<0.01) while the indication to adrenal surgery would be held in 15% and 11% of patients respectively.

CONCLUSION

In a population of subjects with uncontrolled hypertension in which an adrenal cause is suspected, achieving a first-line abdominal CT leads to adrenal abnormality observed in 64% of patients while a specific biological abnormality is noted in 29% of subjects. This study shows that assessment that starts with an abdominal CT scan allows to indicate treatment with spironolactone more frequently than when the first assessment is limited to a biological investigation.

Walking ability of children with a hexapod external ring fixator (TSF®) and foot plate mounting at the lower leg

Wearing an external fixator for several months can be expected to profoundly affect the ability to walk, but, in principle, full weight-bearing is possible during corrective procedures with the Taylor Spatial Frame (TSF). The present prospective cohort study was conducted to assess whether patients are able to walk with or without crutches during treatment with a TSF on the lower leg. Twenty-four patients (10 girls, 14 boys; average age 11 years, range 6-17) scheduled for fixator surgery with osteotomies in the lower leg and foot mounting were included. Dynamic foot loading during free walking was measured with plantar pressure measurements. The contact area, contact time and contact pressure on the foot plate were recorded and normalized to body weight. In the first postoperative week, all patients needed crutches and 67% showed partial weight-bearing. At the second measurement, about 6 weeks after surgery, 21% of the patients could walk without crutches and 58% were partially weight-bearing with crutches. On the day before fixator removal, 50% of the patients were fully weight-bearing without crutches and 38% were partially weight-bearing, but 12% could not bear any weight or were unable to walk. When a ring fixator is used to correct lower leg deformity and prevent equinus, there is minimal risk of complete dependence and abasia. This study shows that up to 88% of the pediatric patients are able to walk while wearing the fixator. Already a few days after surgery, two-thirds of the patients were partially weight-bearing with crutches, and only 12% needed a wheelchair and were not able to walk with the fixator.

[Frequency of hypertension resistant to treatment and indication for renal denervation]

OBJECTIVE

To evaluate in hypertensive patients followed in a specialized hypertension unit, the prevalence of subjects uncontrolled despite triple therapy including a diuretic. The aim is to estimate the percentage of hypertensive patients with an indication to renal denervation.

METHOD

From a database of computerized medical records of a unit specialized in hypertension, it was extracted 144 consecutive cases of subjects treated and followed for at least 1year and having had a home pressure monitoring (HPM) on treatment, and if necessary a work-up for a secondary hypertension. The blood pressure (BP) was evaluated in office by automated method (after 2 and 8minutes) and with HPM (average of three measurements in the morning and evening for three consecutive days).

RESULTS

The population has the following characteristics: age 62 with 26% over 70years, treated dyslipidemia (39%), treated diabetes (11%), adrenal hypertension treated medically (14%), severe renal failure (3%). The means of treatment are: a monotherapy (33%), bitherapy (35%), triple therapy (17%), quadritherapy (7%), pentatherapy or more (1%), spironolactone (45%), thiazide diuretics (49%). The uncontrolled hypertension was observed in 26% if the BP is evaluated with HPM, in 52% if the BP is evaluated at the office after 2minutes of rest and 7% if the BP is evaluated after 8minutes of rest (P<0.01). In patients treated with at least a tritherapy in association with a diuretic, an uncontrolled hypertension was observed in 5% if the BP is evaluated with HPM. Failure to control for the SBP is the cause of 80% of resistant hypertension.

CONCLUSION

The frequency of resistant hypertension is 5% of hypertensive patients followed in a specialized hypertension unit when guidelines are applied in the case of uncontrolled hypertension. These results indicate that the indication for renal denervation affects only a small percentage of patients treated for hypertension.

[Objective measurement tools for the assessment of physical activity]

The aim of the present study was to provide an overview about the various measurement options for the quantitative assessment of physical activity in daily life. After briefly discussing the importance of physical activity in this era of civilization-related health problems characterized by increasing malnutrition problems in combination with increasing lack of movement in daily life, the different types of measurement systems available and their applicability are described. It is hoped that this information will assist the potential user or buyer of a new measurement system to make a well-informed decision about the appropriate tool for a specific research interest.

The Māori foot exhibits differences in plantar loading and midfoot morphology to the Caucasian foot

The question being addressed in the current study was whether the diabetic Māori foot was more or less prone to ulceration than the diabetic New Zealand Caucasian (NZC) foot. Harris mat and pedobarographic analyses were employed to assess static and dynamic foot morphology and plantar loading in 40 Māori and NZC diabetic and non-diabetic participants. Significantly higher peak pressures were exhibited by the diabetic Māori participants compared to their NZC peers at the central forefoot. Significantly higher static and dynamic arch index values and significantly higher sub-arch angle values were exhibited by the non-diabetic Māori participants compared to their NZC peers. The latter findings suggest that healthy Māori may have a predisposition towards having a flatter foot than healthy NZC, which may have footwear design implications.

Vascular imaging with positron emission tomography

Atherosclerosis is an inflammatory disease that causes most myocardial infarctions, strokes and acute coronary syndromes. Despite the identification of multiple risk factors and widespread use of drug therapies, it still remains a global health concern with associated costs. Although angiography is established as the gold standard means of detecting coronary artery stenosis, it does not image the vessel wall itself, reporting only on its consequences such as luminal narrowing and obstruction. MRI and computed tomography provide more information about the plaque structure, but recently positron emission tomography (PET) imaging using [(18) F]-fluorodeoxyglucose (FDG) has been advocated as a means of measuring arterial inflammation. This results from the ability of FDG-PET to highlight areas of high glucose metabolism, a feature of macrophages within atherosclerosis, particularly in high-risk plaques. It is suggested that the degree of FDG accumulation in the vessel wall reflects underlying inflammation levels and that tracking any changes in FDG uptake over time or with drug therapy might be a way of getting an early efficacy readout for novel anti-atherosclerotic drugs. Early reports also demonstrate that FDG uptake is correlated with the number of cardiovascular risk factors and possibly even the risk of future cardiovascular events. This review will outline the evidence base, shortcomings and emerging applications for FDG-PET in vascular imaging. Alternative PET tracers and other candidate imaging modalities for measuring vascular inflammation will also be discussed.

Gait patterns after intraarticular treatment of patients with osteoarthritis of the knee--hyaluronan versus triamcinolone: a prospective, randomized, doubleblind, monocentric study

Objective

Evaluation of gait performance and muscle activity patterns as well as clinical efficacy and safety after single intraarticular injection with hyaluronan compared with triamcinolone in patients with knee osteoarthritis.

Materials and Methods

This trial evaluated the influence of a single injection of hyaluronan or triamcinolone on gait pattern and muscle activity. For clinical evaluation a visual analogue scale for pain, Lequesne index, and Knee Society Score were used. Quality of life was assessed with the SF-36.

Results

The complete analysis was performed in 50 of 60 patients. 26 patients were treated with triamcinolone and 24 with hyaluronan. Hyaluronan treatment led to significant improvement of range of motion at hip and knee. Significant improvement could be either demonstrated for the pain scale, Lequesne and Knee Society score in both groups. Quality of life showed greater improvement in the triamcinolone group.

Conclusion

Single application of high-viscosity hyaluronan shows superior range of motion and pain reduction as well as improvement in clinical results. Even if there was a lack of significant differences compared to triamcinolone, this therapy classified as safe and effective in the short follow up.

Pedography and radiographic imaging for the detection of foot deformities in rheumatoid arthritis

BACKGROUND

Patients with Rheumatoid Arthritis often suffer from pain and deformities in the feet. Previous studies demonstrated that pedography is a useful tool in clinical practice for detecting structural changes. Therefore, the aim of the present study was to compare Rheumatoid Arthritis patients' clinical, radiographic and pedographic status in order to investigate the relationship between mechanical damage and plantar pressure distribution under the forefoot.

METHODS

Sixteen right feet of sixteen patients with Rheumatoid Arthritis and 21 right feet of healthy controls were included. Weight-bearing radiographs of the forefoot were obtained for all rheumatoid feet. The grade of erosion in the forefoot was assessed with the established Larsen score. Foot loading parameters were analyzed with pedography.

FINDINGS

The present study revealed no correlation between walking pain and the level of joint destruction in patients with Rheumatoid Arthritis. However, the study revealed a strong correlation between joint erosion in the lateral metatarsophalangeal joints and local pressure values under the lateral forefoot (r=0.85) and a negative correlation between joint erosion in the proximal interphalangeal joint and local pressure values under the lateral toes (r= -0.64).

INTERPRETATION

In patients with Rheumatoid Arthritis, the intensity of walking pain does not characterize the degree of joint destruction under the forefoot. Pedography appears useful for an early diagnosis of pathologic changes in the forefoot. However, even though pedographic measurements might be able to provide indications for destructive changes, they cannot provide information about the exact grade of joint erosion.

Smoking history and frequency of somatic KRAS mutations in adenocarcinoma of the lung

7573

Background: Somatic mutations in the epidermal growth factor receptor (EGFR) gene are more common in patients with adenocarcinoma, especially those who smoked < 15 pack years (py). KRAS mutations are found in ∼25% of lung adenocarcinomas, most commonly in codons 12 and 13 of exon 2 (∼85%) and have been associated with poor prognosis in resected disease [Winton NEJM 2005] and resistance to EGFR tyrosine kinase inhibitors [Pao PLoS Med 2005]. KRAS mutations are uncommon in non-small cell lung cancer histologies other than adenocarcinoma. We sought to determine the association between quantitative measures of cigarette smoking and presence of KRAS mutations in lung adenocarcinomas. Methods: Standard direct sequencing techniques were used to identify KRAS codon 12 and 13 mutations in lung adenocarcinoma specimens from surgical resections between 2001 and 2006 and tumor specimens sent for KRAS molecular analysis in 2006. Surgical specimens were obtained from an institutional tumor bank. Detailed smoking history (age at first cigarette, packs per day, years smoked, years since quitting smoking) was obtained from the medical record and a patient-completed smoking questionnaire. Results: KRAS mutational analysis was performed on 408 lung adenocarcinomas from 242 women and 166 men. Median age was 68 (range 33–89). KRAS mutations were present in 19% (78/408, 95% CI 15 to 23%). The frequency of KRAS mutation was not associated with age or gender. The presence of KRAS mutations was not related to smoking history with 15% (9/61) of never smokers having KRAS mutations compared with 19% (51/275) of former smokers. When compared with never smokers, there was no significant difference in frequency of KRAS mutations for tumors from patients with 1–5 py (5%, p=0.44), 6- 10 py (12%, p=0.99), 11–15 py (25%, p=0.45), 16–25 py (16%, p=0.99), 26–50 py (25%, p=0.129), 51–75 py (20%, p=0.48), >75 py (20%, p=0.47) history of cigarette smoking. Conclusions: While the incidence of EGFR mutations has a strong inverse relationship with the amount of cigarettes smoked, allowing the selective molecular testing for EGFR mutations, the frequency of KRAS mutations cannot be predicted by age, gender, or smoking history. KRAS mutational analysis of all adenocarcinomas is required to reliably identify patients with KRAS mutations.

No significant financial relationships to disclose.

[Retrospective analysis of march fractures in the german armed forces in the years 1998 to 2000]

AIM

The aim of this study was to determine the incidence/frequency of march fractures in the German Armed Forces in the years from 1998 to 2000. In particular, the age, length of service, distribution of the metatarsals and the occurrence of anthropometric risk factors were considered.

METHODS

At the Medicostatistical Institute of the German Armed Forces the records of soldiers, 191 cases with 204 fractures, with diagnosed "march fractures" were selected and analyzed.

RESULTS

82% of the affected soldiers were between 19 and 22 years old. More than 50% of the fractures occurred within the first eight weeks of service. In about 64% the 3rd metatarsal was affected, in 25% the 2nd metatarsal and in only 11% of all cases the 4th, 5th, and 1st metatarsals. Soldiers were exempted from duty for an average of 26.5 days. No specific anthropometric risk factors were found to be connected with the occurrence of march fractures.

CONCLUSION

March fractures in the German Armed Forces are non-predictable injuries of young and physically fit individuals; youth is not a protective factor. There is an increased risk for march fractures during the first weeks of military service. There appears to be no possibility for a screening.

MR imaging anatomy in neurodegeneration: a robust volumetric parcellation method of the frontal lobe gyri with quantitative validation in patients with dementia

BACKGROUND AND PURPOSE

Brain volumetry is widely used for evaluating tissue degeneration; however, the parcellation methods are rarely validated and use arbitrary planes to mark boundaries of brain regions. The goal of this study was to develop, validate, and apply an MR imaging tracing method for the parcellation of 3 major gyri of the frontal lobe, which uses only local landmarks intrinsic to the structures of interest, without the need for global reorientation or the use of dividing planes or lines.

METHODS

Studies were performed on 25 subjects--healthy controls and subjects diagnosed with Lewy body dementia and Alzheimer disease--with significant variation in the underlying gyral anatomy and state of atrophy. The protocol was evaluated by using multiple observers tracing scans of subjects diagnosed with neurodegenerative disease and those aging normally, and the results were compared by spatial overlap agreement. To confirm the results, observers marked the same locations in different brains. We illustrated the variabilities of the key boundaries that pose the greatest challenge to defining consistent parcellations across subjects.

RESULTS

The resulting gyral volumes were evaluated, and their consistency across raters was used as an additional assessment of the validity of our marking method. The agreement on a scale of 0-1 was found to be 0.83 spatial and 0.90 volumetric for the same rater and 0.85 spatial and 0.90 volumetric for 2 different raters. The results revealed that the protocol remained consistent across different neurodegenerative conditions.

CONCLUSION

Our method provides a simple and reliable way for the volumetric evaluation of frontal lobe neurodegeneration and can be used as a resource for larger comparative studies as well as a validation procedure of automated algorithms.