Relation between serum cystatin C level and brachial–ankle pulse wave velocity in Chinese general population

Background: The purpose of the study is to evaluate whether serum cystatin C level is associated with arterial stiffness independent of other risk factors in Chinese general population. Hypothesis: Cystatin C is a predictable marker of arterial stiffness in Chinese general population. Methods: Subjects are 748 persons (mean age, 38.8years) who attended a health checkup in Beijing, China. We measured brachial–ankle PWV (baPWV) by using an automatic oscillometric method, and the concentration of serum cystatin C was quantified. Results: The level of baPWV showed a significantly positive correlation with BMI, SBP, DBP, TG, TC, cystatin C (r = 0.251, p < 0.001), and a negative correlation with HDL-C. And when adjustment for age, BMI, and cigarette smoking, these correlations remain significantly. Conclusion: Arterial stiffness increases with an increase in serum cystatin C level in Chinese general population with normal renal function.     

A positive correlation between homocysteine and brachial–ankle pulse wave velocity in patients with systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is associated with premature atherothrombotic complications. Hyperhomocysteinemia is considered a cardiovascular risk factor. Increased vascular stiffness may increase cardiovascular mortality. Pulse wave velocity (PWV) is a noninvasive method of analyzing vascular stiffness in the assessment of atherosclerosis. The objective of this study was to identify the relationship between plasma homocysteine levels and brachial–ankle pulse wave velocity (baPWV) measurement in SLE. Plasma homocysteine, baPWV, ankle–brachial index, blood pressure, C3, C4, anticardiolipin antibody (aCL), and anti-double-stranded DNA antibodies were determined in a total of 58 female patients with SLE. The control group comprised 32 age-matched healthy females. In addition, all patients were further classified into subgroups according to the presence of aCL (SLE/aCL+, n=27 vs SLE/aCL−, n=31) to determine the effect of aCL on the tested variables. The mean values for plasma homocysteine and baPWV were 13.19 μmol/l and 1,482 cm/s, respectively. Plasma homocysteine levels were significantly elevated in SLE patients when compared with the healthy controls. SLE patients with aCL had a significantly higher plasma homocysteine level than those without aCL. A significant positive correlation between plasma homocysteine and baPWV was found in patients with SLE (r=0.335, P=0.028, n=58). Plasma homocysteine also significantly correlated with right baPWV in all SLE patients (r=0.371, P=0.014, n=58) and in the SLE/aCL+ group (r=0.523, P=0.031, n=27). These findings indicate a possible link between plasma homocysteine and baPWV in SLE. In conclusion, SLE patients had an increased level of plasma homocysteine, and this phenomenon appeared to be related to vascular stiffness.     

Total ankle replacement in patients with haemophilia and virus infections – a safe alternative to ankle arthrodesis?

Despite reliable results of ankle fusion for advanced haemophilic arthropathy, total ankle replacement (TAR) may be functionally advantageous. There is only very limited literature data available on TAR in patients with haemophilia. The objective of this study is to evaluate the short‐ and mid‐term results after TAR in patients with end‐stage haemophilic ankle arthropathy and concomitant virus infections. In a retrospective study, results after eleven TAR in 10 patients with severe (n = 8) and moderate (n = 2) haemophilia (mean age: 49 ± 7 years, range, 37–59) were evaluated at a mean follow‐up of 3.0 years (range, 1.2–5.4). Nine patients were positive for hepatitis C, five were HIV‐positive. Range of motion (ROM), AOFAS‐hindfoot‐score, pain status (visual analogue scale, VAS) as well as patient satisfaction were evaluated. In two cases deep prosthesis infection occurred leading to the removal of the implant. In the remaining eight patients the mean AOFAS score improved significantly from 21.5 to 68.0 points (P < 0.0005), the VAS score decreased significantly from 7.6 to 1.9 points (P < 0.0005). ROM increased from 23.2 to 25.0 degrees (P = 0.51). At final follow‐up all patients without any complications were satisfied with the postoperative results. Radiographic examination did not reveal any signs of prosthetic loosening. TAR is a viable surgical treatment option in patients with end‐stage ankle osteoarthritis due to haemophilia. It provides significant pain relieve and high patient satisfaction. However, due to the increased risk of infection and lack of long‐term results, TAR particularly in patients with severe haemophilia and virus infections should be indicated carefully.     

Predictive value of brachial–ankle pulse wave velocity for long-term clinical outcomes after percutaneous coronary intervention in a Korean cohort

Objective

The aim of this study was to determine the associations of brachial–ankle pulse wave velocity (baPWV), high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-B type natriuretic peptide (NT-proBNP) with the development of adverse outcomes after percutaneous coronary intervention (PCI).

Methods

The baPWV, hs-cTnT and NT-proBNP were analyzed in 372 patients who underwent PCI. The primary endpoint was cardiac death.

Results

There were 21 events of cardiac death during a mean of 25.8 months of follow-up. When the baPWV cut-off level was set to 1672 cm/s using the receiver operating characteristic curve, the sensitivity was 85.7% and the specificity was 60.1% for differentiating between the group with cardiac death and the group without cardiac death. Kaplan–Meier analysis revealed that the higher baPWV group (≥ 1672 cm/s) had a significantly higher cardiac death rate than the lower baPWV group (< 1672 cm/s) (11.4% vs. 1.4%, log-rank: P < 0.0001). This value was more useful in patients with myocardial injury (hs-cTnT ≥ 0.1 ng/mL) or heart failure (NT-proBNP ≥ 450 pg/mL).

Conclusions

The results of this study show that high baPWV is a predictive marker for cardiac death after PCI.     

Does calculation of ankle brachial pressure index need revision?

Peripheral arterial disease (PAD) is a commonly encountered but a commonly under-diagnosed condition in clinical practice. Ankle brachial pressure index (ABI) is a widely used procedure in its detection. It is also a very good prognostic marker not only of PAD but also of mortality. According to the current guidelines ABI of a side i.e. either the left or the right, is the quotient of the higher of the systolic blood pressures (SBP) of the two ankle arteries of that limb (either the anterior tibial artery or the posterior tibial artery) and the higher of the two brachial SBP of upper limbs. With the currently existing method of ABI calculation, considering only the higher of the SBP of the two ankle arteries, a distal stenosis of the ankle arterial system with the lower SBP, may be missed. We suggest a modification to the currently existing of calculating ABI. The method has been termed by us as the low ankle pressure method. In this method the lowest ankle pressure between the two ankle arteries of a particular side is to be the numerator and the denominator could be the same as before. A study or a series of studies comparing our proposed method with the current one are needed to test its clinical utility.     

Does rural residence impact total ankle arthroplasty utilization and outcomes?

The objective of this study was to compare total ankle arthroplasty (TAA) utilization and outcomes by patient residence. We used the Nationwide Inpatient Sample (NIS) from 2003 to 2011 to compare utilization and outcomes (post-arthroplasty discharge disposition, length of hospitalization, and mortality) by rural vs. urban residence. Ten thousand eight hundred thirty-three patients in urban and 3,324 patients in rural area underwent TAA. Compared to rural residents, urban residents had: lower mean age, 62.4 vs. 61.8 years (p?<?0.0001); higher percent of women, 49 vs. 56 % (p?=?0.0008); and lower proportion of Whites, 93 vs. 86 % (p?=?0.0005). There were rural-urban disparities in TAA utilization in 2003 (0.32 vs. 0.39/100,000; p?=?0.021), but not in 2011 (1.19 vs. 1.17/100,00; p?=?0.80). TAA outcomes did not differ by rural vs. urban residence: (1) 11.3 % rural vs. 14.2 % urban residents were discharged to an inpatient facility (p?=?0.098); (2) length of hospital stay above the median stay, was 44.8 vs. 42.2 % (p?=?0.30); and (3) mortality was 0.2 vs. 0.1 %, respectively (p?=?0.81). Multivariable-adjusted logistic regression models did not show any significant differences in discharge to home, length of stay, or mortality, by residence. Our study demonstrated an absence of any evidence of rural-urban differences in TAA outcomes. The rural-urban differences in TAA utilization noted in 2003 were no longer significant in 2011.     

Arterial stiffness expressed as brachial–ankle pulse wave velocity and gait assessment independent of lower extremity strength:a cross-sectional study in the older men population

BACKGROUND Older men are more vulnerable to fatal falls than women, and gait disturbances contribute to the risk of falls.Studies have assessed the association between arterial stiffness and gait dysfunction, but the results have been inconclusive. This study aimed to conduct a cross-sectional analysis to evaluate the association between brachial–ankle pulse wave velocity(ba PWV)and gait assessment in older men.METHODS Data from the 2014–2015 Korea Institute of Sport Science Fitness Standards pr...     

Localized nodular pigmented villonodular synovitis of the upper ankle joint – diagnosis and treatment

This paper introduces a case of local pigmented villonodular synovits (PVNS) of the upper ankle joint in a 37-year old patient. PVNS is a neoplasia of the synovial membrane. Two different entities of PVNS are known: generalized diffuse and local nodular. They differ in their degree of destruction and growth configuration, which is crucial for prognosis and operative treatment. The most common location of the local nodular form is the knee joint, followed by the finger joints. Occurrence in the ankle joint is not common but should be considered if clinical findings are present. MRI is the method of choice for diagnosis and assessment of the bone situation. Treatment consists of radical excision of the neoplasia. Radiosynoviorthesis is recommended as a post-operative treatment to increase the probability of a total removal of persisting PVNS cells. The rate of recurrence seems to be between 8 and 46%.     

Is ankle involvement underestimated in rheumatoid arthritis? Results of a multicenter ultrasound study

The aim of this study is to investigate the prevalence of subclinical ankle involvement by ultrasound in patients with rheumatoid arthritis (RA). The study was conducted on 216 patients with RA and 200 healthy sex- and age-matched controls. Patients with no history or clinical evidence of ankle involvement underwent US examination. For each ankle, tibio-talar (TT) joint, tibialis anterior (TA) tendon, extensor halux (EH) and extensor common (EC) tendons, tibialis posterior (TP) tendon, flexor common (FC) tendon and flexor hallux (FH) tendon, peroneous brevis (PB) and longus (PL) tendons, Achilles tendon (AT) and plantar fascia (PF) were assessed. The following abnormalities were recorded: synovitis, tenosynovitis, bursitis, enthesopathy and rupture. BMI, DAS28, RF ESR and CRP were also obtained. A total of 432 ankles of patients with RA and 400 ankles of healthy controls were assessed. In 188 (87%) patients with RA, US showed ankle abnormalities whereas, in control group, US found abnormalities in 57 (28.5 %) subjects (p?=?0.01). The most frequent US abnormality in RA patients was TP tenosynovits (69/216) (31.9 %), followed by PL tenosynovitis (58/216) (26.9 %), TT synovitis (54/216) (25 %), PB tenosynovitis (51/216) (23.6 %), AT enthesopathy (41/216) (19 %) and AT bursitis (22/216) (10.2 %). In 118 RA patients out of 216 (54.6%), a positive PD was found. No statistically significant correlation was found between the US findings and age, disease duration, BMI, DAS28, RF, ESR and CRP. The present study provides evidence of the higher prevalence of subclinical ankle involvement in RA patients than in age- and gender-matched healthy controls identified by US.     

Relationship between ulcer healing after hyperbaric oxygen therapy and transcutaneous oximetry,toe blood pressure and ankle–brachial index in patients with diabetes and chronic foot ulcers

Aims/hypothesis  

The randomised, double-blind, placebo-controlled Hyperbaric Oxygen Therapy (HBOT) in Diabetic Patients with Chronic Foot Ulcers (HODFU) study showed beneficial effect of HBOT. As this treatment is expensive and time-consuming, being able to select patients for therapy would be very useful. The aim of this study was to evaluate whether circulatory variables could help in predicting outcome of HBOT.     

Hyaluronic acid in ankle osteoarthritis: why evidence of efficacy is still lacking?

Intra-articular injections of hyaluronic acid (HA) are useful in the treatment of osteoarthritis (OA), as shown by studies on knee, hip, and trapezio-metacarpal joints. The positive results can be explained by several factors: the restoration of elastic and viscous properties of intra-articular fluid, the anti-inflammatory and the anti-nociceptive activity, and the normalisation of hyaluronan synthesis and inhibition of hyaluronic acid degradation. However, evidence of efficacy of hyaluronic acid in ankle osteoarthritis is still lacking: several studies have been performed without a control group, or have shown similar results to those obtained with different therapeutic procedures. The aim of this paper is to analyse the reasons which can explain the discrepancy between the sound biological background and the inconclusive clinical results. First, it must be considered that the ankle joint, from a biomechanical point of view, is more complex than other joints, and that greater stress is sustained by the articular surfaces. Second, the limited benefit can be related to the use of hyaluronic acid mostly in cases of post-traumatic osteoarthritis, where the treatment must be addressed to solve the biomechanical problems, and then to restore the rheological properties of the ankle joint. A third important explanation of the failure may be the improper technique of administration, that has been performed in all studies, but one, without imaging guidance. Indeed, it is well known that hyaluronic acid, if not delivered directly into the intra-articular space, is unlikely to be effective.     

What is the clinical course of acute ankle sprains? A systematic literature review

Background

Ankle sprains are one of the most common musculoskeletal injuries. In order to evaluate the effectiveness of therapeutic interventions and to guide management decisions, it is important to have clear insight of the course of recovery after an acute lateral ankle injury and to evaluate potential factors for nonrecovery and re-sprains.

Methods

A database search was conducted in MEDLINE, CINAHL, PEDro, EMBASE, and the Cochrane Controlled trial register. Included were observational studies and controlled trials with adult subjects who suffered from an acute lateral ankle sprain that was conventionally treated. One of the following outcomes had to be described: pain, re-sprains, instability, or recovery. Two reviewers independently assessed the methodological quality of each included study. One reviewer extracted relevant data.

Results

In total, 31 studies were included, from which 24 studies were of high quality. There was a rapid decrease in pain reporting within the first 2 weeks. Five percent to 33% of patients still experienced pain after 1 year, while 36% to 85% reported full recovery within a period of 3 years. The risk of re-sprains ranged from 3% to 34% of the patients, and re-sprain was registered in periods ranging from 2 weeks to 96 months postinjury. There was a wide variation in subjective instability, ranging from 0% to 33% in the high-quality studies and from 7% to 53% in the low-quality studies. One study described prognostic factors and indicated that training more than 3 times a week is a prognostic factor for residual symptoms.

Conclusions

After 1 year of follow-up, a high percentage of patients still experienced pain and subjective instability, while within a period of 3 years, as much as 34% of the patients reported at least 1 re-sprain. From 36% up to 85% of the patients reported full recovery within a period of 3 years.     

Synthesis and antibacterial evaluation of 2–substituted–4,5–diphenyl–N–alkyl imidazole derivatives

ObjectiveTo synthesis 2–substituted–4,5–diphenyl–N–alkyl imidazole derivatives. and evaluate their antibacterial activity.MethodsA mixture of benzil (10 mmol) and ammonium acetate (0.1 mol) (immediately fused) in glacial acetic acid (25 mL) was stirred at 80–100 °C for 1 h under nitrogen atmosphere (to prevent incorporation of any atmospheric impurities and moisture). Substituted aldehydes (10 mmol) in glacial acetic acid (5 mL) was added drop-wise over a period of 15–20 min at the same temperature and stirred for another 4 h, the progress of the reaction was monitored by TLC test using ethyl acetate as eluent. The newly synthesized compounds were characterized by IR, ¹HNMR, ¹³CNMR and by mass spectroscopy.ResultsAll the synthesized compounds were confirmed by spectroscopical techniques and evaluated for antimicrobial activity against Staphylococcus aureus(S. aurius), Bacilus subtilus (B. subtilus), and Escheria coli (E. coli). These compounds showed antibacterial activity (zone of inhibition) against S. aurius ranged from 3 mm to 9 mmin diameter, B. subtilus, 4–8 mm, and E. coli 5–12 mm. Out of 2a-2e, only 2a and 2b showed some sort of activity but none of them had considerable activity compared with that of the standard.ConclusionsAll the synthesized compounds show moderate activity against the tested bacteria S. aurius, B. subtilus, and E. coli. So, further structural modification is necessary to improve the antibacterial action of 2-substituted-4,5-diphenyl-N-alkyl imidazole derivatives.     

Prognostic impact of the ankle–brachial index on the development of micro- and macrovascular complications in individuals with type 2 diabetes: the Rio de Janeiro Type 2 Diabetes Cohort Study

Aims/hypothesis

The prognostic importance of the ankle–brachial index (ABI) in individuals with diabetes is controversial. We aimed to evaluate the relationship between the ABI and the occurrence of micro- and macrovascular complications in individuals with type 2 diabetes.

Methods

The ABI was measured at baseline in 668 individuals with type 2 diabetes, and the individuals were followed-up for a median of 10 years. Multivariate Cox analysis was used to examine associations between the ABI and the occurrence of microvascular (retinopathy, microalbuminuria, renal function deterioration and peripheral neuropathy) and macrovascular (total cardiovascular events, major adverse cardiovascular events [MACE] and cardiovascular mortality) complications, and all-cause mortality. The improvement in risk stratification was assessed using the C statistic and the integrated discrimination improvement (IDI) index.

Results

During follow-up, 168 individuals had a cardiovascular event (140 MACE) and 191 individuals died (92 cardiovascular deaths); 156 individuals newly developed or experienced worsening diabetic retinopathy, 194 achieved the renal composite outcome (122 with newly developed microalbuminuria and 93 with deteriorating renal function) and 95 newly developed or experienced worsening peripheral neuropathy. The ABI, either analysed as a continuous or as a categorical variable, was significantly associated with all macrovascular and mortality outcomes, except for non-cardiovascular mortality. Individuals with a baseline ABI of ≤0.90 had a 2.1-fold increased risk of all-cause mortality (95% CI 1.3, 3.5; p?=?0.004), a 2.7-fold excess risk of cardiovascular mortality (95% CI 1.4, 5.4; p?=?0.004) and a 2.5-fold increased risk of MACE (95% CI 1.5, 4.4; p?=?0.001). The ABI improved risk discrimination over classical risk factors, with relative IDIs ranging from 6.3% (for all-cause mortality) to 31% (for cardiovascular mortality). In addition, an ABI of ≤0.90 was associated with the development or worsening of peripheral neuropathy (2.1-fold increased risk [95% CI 1.1, 4.3]; p?=?0.033), but not with retinopathy or renal outcomes.

Conclusions/interpretation

A low ABI is associated with excess risk of adverse cardiovascular outcomes, mortality and peripheral neuropathy development or worsening, and improves cardiovascular risk stratification. The ABI should therefore be routinely evaluated in individuals with type 2 diabetes.

     

Abnormal viscoelastic behaviour of passive ankle joint movement in diabetic patients: an early or a late complication?

Aims/hypothesis The goal of the present study was to compare the range of motion and both the viscous and elastic components of passive ankle joint movement in short- and long-term diabetic patients with that of a control population.Methods Thirty-four diabetic patients and 16 control subjects entered into the study. Patients with a history of over 15 years of diabetes were considered as a long-term diabetic group. In order to quantify the passive ankle joint movement, a device was designed to measure the dorsi- and plantar-flexion angle and the net moment at the ankle. Elastic behaviour was examined as the separate slope of regression lines (stiffness) of plantar and dorsal components in the loading moment–angle curve. It was also examined as the slope of the regression line in the final 10% of each component. Hysteresis, a characteristic of viscoelastic materials that indicates loss of energy during unloading, was corrected for range of motion and used to examine viscous behaviour of the ankle joint.Results Total and plantar ranges of motion were significantly lower in long-term diabetic patients than in short-term diabetic and control groups (p<0.05). Plantar-flexion stiffness was significantly lower in short-term diabetic patients than in control subjects and long-term diabetic groups (p<0.05). Corrected hysteresis was significantly higher in long-term diabetic than in short-term diabetic and control (p<0.05) groups in the dorsal range of motion.Conclusions/interpretation This study shows that both decreased plantar and total ankle joint ranges of motion, and increased viscous component of passive ankle joint movement are among the late complications of diabetes.     

A resuscitation “dilemma” theory–practice–ethics. Is there a theory–practice–ethics gap?

The theory–practice–ethics gap – a new paradigm to contemplate.Practices based on tradition, rituals and outdated information are placed into a nonscientific paradigm called the theory–practice gap. Within this paradigm there is often a gap between theoretical knowledge and its application in practice.This theory–practice gap has always existed [Allmark, P., 1995. A classical view of the theory–practice gap in nursing. J. Adv. Nurs. 22 (1), 18–23; Hewison, A. et al., 1996. The theory–practice gap in nursing: a new dimension. J. Adv. Nurs. 24 (4), 754–761]. Its creation is often sited as a culmination of theory being idealistic and impractical, even if practical and beneficial, are often ignored. Most of the evidence relating to the non integration of theory and practice makes the assumption that environmental factors are responsible and will affect learning and practice outcomes, hence the “gap”.In fact, it is the author’s belief, that to “bridge the gap” between theory and practice an additional component is required, called ethics. A moral duty and obligation ensuring theory and practice integrate. In order to effectively implement new practices, one must deem these practices are worthy and relevant to their role as healthcare providers. Otherwise, we fall victims to providing nothing more than a lip service.This introduces a new concept which the author refers to as the theory–practice–ethics gap. This theory–practice–ethics gap must be considered when reviewing some of the unacceptable outcomes in health care practice. The author believes that there is a crisis of ethics where theory and practice integrate, and as a consequence, malfeasance. We are failing to fulfill our duty as healthcare providers and as patient advocates.One practice of major concern, which the author will endeavor to unfold relates to adult and pediatric resuscitation.