Severity of Peripheral Arterial Disease is Associated With Aortic Pressure Augmentation and Subendocardial Viability Ratio

J Clin Hypertens (Greenwich). 2012; 14:855–860. ©2012 Wiley Periodicals, Inc.Peripheral arterial disease (PAD) is associated with increased cardiovascular mortality that correlates with peripheral perfusion impairment as assessed by the ankle‐brachial arterial pressure index (ABI). Furthermore, PAD is associated with arterial stiffness and elevated aortic augmentation index (AIx). The purpose of this study was to investigate whether ABI impairment correlates with AIx and subendocardial viability ratio (SEVR), a measure of cardiac perfusion during diastole. AIx and SEVR were assessed by radial applanation tonometry in 65 patients with stable PAD (Rutherford stage I–III) at a tertiary referral center. AIx corrected for heart rate and SEVR were tested in a multivariate linear and logistic regression model to determine the association with ABI. Mean ABI was 0.8±0.2, AIx 31%±7%, and SEVR 141%±26%. Multiple linear regression with AIx as a dependent variable revealed that AIx was significantly negatively associated with ABI (β=−11.5; 95% confidence interval [CI], −18.6 to −4.5; P=.002). Other variables that were associated with AIx were diastolic blood pressure (β=0.2; 95% CI, 0.1–0.4; P<.001), height (β=−46.2; 95% CI, −62.9 to −29.4; P<.001), body mass index (β=−0.4; 95% CI, −0.8 to −0.1; P=.023), and smoking (β=3.6; 95% CI, 0.6–6.6; P=.019). Multiple regression with SEVR as a dependent variable showed a significant correlation with ABI (β=33.2; 95% CI, 2.3–64.1; P=.036). Severity of lower limb perfusion impairment is related to central aortic pressure augmentation and to subendocardial viability ratio. This may be a potential pathophysiologic link that impacts cardiac prognosis in patients with PAD.

Peripheral arterial disease (PAD) is a common manifestation of atherosclerosis that affects more than 5% of the aged population. ¹ , ² PAD is associated with impairment in functional activity and with an increased risk of cardiovascular events. ³ , ⁴ For this reason, PAD is considered a marker for systemic atherosclerosis. ⁵ To date, the most powerful prognostic indicator in PAD patients is the ankle‐brachial arterial pressure index (ABI). ⁶ , ⁷ , ⁸ ABI is a measure to define impairment of lower limb perfusion that has been shown to predict survival rate in patients with PAD. ¹ , ⁹ , ¹⁰ The mechanisms through which the presence of PAD increases this risk are not understood in detail. PAD represents a vascular disease with extensive atherosclerotic involvement. Systemic inflammation and increased levels of oxidative stress parallel this. Both are known to destabilize atherosclerotic plaque and thus may be associated with vascular events. ¹¹ In addition, the extensive atherosclerotic alterations along the vascular tree conduit are thought to increase pulse wave velocity, and lower limb arterial obstructions may favor premature pulse wave reflections. ¹² , ¹³ Khaleghi and colleagues ¹² reported significant differences in augmentation index (AIx) between subjects with normal and abnormal ABI. Furthermore, an association between ABI and the degree of subendocardial viability ratio (SEVR) impairment in patients with type 1 diabetes has been reported. ¹⁴ A recent publication by Rabkin and colleagues ¹⁵ describes an association between ABI and AIx in patients without PAD. Given that, we assume that ABI impairment might be associated with AIx and SEVR.We therefore tested whether degree of ABI impairment is related to an increased AIx and decreased SVER as assessed noninvasively by radial pulse wave analysis in patients with stable PAD.     

In vivo analysis of cervical kinematics after implantation of a minimally constrained cervical artificial disc replacement

Introduction

To better understand cervical kinematics following cervical disc replacement (CDR), the in vivo behavior of a minimally constrained CDR was assessed.

Methods

Radiographic analysis of 19 patients undergoing a 1-level CDR from C4–5 to C6–7 (DISCOVER, Depuy-Spine, USA) was performed. Neutral–lateral and flexion–extension radiographs obtained at preop, postop and late follow-up were analyzed for segmental angle and global angle (GA C2–7). Flexion–extension range of motion was analyzed using validated quantitative motion analysis software (QMA®, Medical Metrics, USA). The FSU motion parameters measured at the index and adjacent levels were angular range of motion (ROM), translation and center of rotation (COR). Translation and COR were normalized to the AP dimension of the inferior endplate of the caudal vertebra. All motion parameters, including COR, were compared with normative reference data.

Results

The average patient age was 43.5 ± 7.3 years. The mean follow-up was 15.3 ± 7.2 months. C2–7 ROM was 35.9° ± 15.7° at preop and 45.4° ± 13.6° at follow-up (?p < .01). Based on the QMA at follow-up, angular ROM at the CDR level measured 9.8° ± 5.9° and translation was 10.1 ± 7.8 %. Individuals with higher ROM at the CDR level had increased translation at that level (p < .001, r = 0.97), increased translation and ROM at the supra-adjacent level (p < .001, r = .8; p = .005, r = .6). There was a strong interrelation between angular ROM and translation at the supra-adjacent level (p < .001, r = .9) and caudal-adjacent level (p < .001, r = .9). The location of the COR at the CDR- and supra-adjacent levels was significantly different for the COR-X (p < .001). Notably, the COR-Y at the CDR level was significantly correlated with the extent of CDR-level translation (p = .02, r = .6). Shell angle, which may be influenced by implant size and positioning had no impact on angular ROM but was correlated with COR-X (p = .05, r = ?.6) and COR-Y (p = .04, r = ?.5).

Conclusion

The COR is an important parameter for assessing the ability of non-constrained CDRs to replicate the normal kinematics of a FSU. CDR size and location, both of which can impact shell angle, may influence the amount of translation by affecting the location of the COR. Future research is needed to show how much translation is beneficial concerning clinical outcomes and facet loading.     

Long-Term Outcomes Comparing Surgery to Embolization-Ablation for Treatment of Solitary HCC <7 cm

Background

Resection has been the standard of care for patients with solitary hepatocellular carcinoma (HCC). Transarterial embolization and percutaneous ablation are alternative therapies often reserved for suboptimal surgical candidates. Here we compare long-term outcomes of patients with solitary HCC treated with resection versus combined embo-ablation.

Methods

We previously reported a retrospective comparison of resection and embo-ablation in 73 patients with solitary HCC <7 cm after a median follow-up of 23 months. This study represents long-term updated follow-up over a median of 134 months.

Results

There was no difference in survival among Okuda I patients who underwent resection versus embo-ablation (66 vs 58 months, p = .39). There was no difference between the groups in the rate of distant intrahepatic (p = .35) or metastatic progression (p = .48). Surgical patients experienced more complications (p = .004), longer hospitalizations (p < .001), and were more likely to require hospital readmission within 30 days of discharge (p = .03).

Conclusion

Over a median follow up of more than 10 years, we found no significant difference in overall survival of Okuda 1 patients with solitary HCC <7 cm who underwent surgical resection versus embo-ablation. Our data suggest that there may be a greater role for primary embo-ablation in the treatment of potentially resectable solitary HCC.     

Short‐term Effects of Social Exclusion at Work and Worries on Sleep

The present study investigated short‐term effects of daily social exclusion at work on various indicators of sleep quality and tested the mediating role of work‐related worries using a time‐based diary study with ambulatory assessments of sleep quality. Ninety full‐time employees participated in a 2‐week data collection. Multilevel analyses revealed that daily workplace social exclusion and work‐related worries were positively related to sleep fragmentation in the following night. Daily social exclusion, however, was unrelated to sleep onset latency, sleep efficiency and self‐reported sleep quality. Moreover, worries did not mediate the effect of social exclusion at work on sleep fragmentation. Theoretical and practical implications of the results are discussed. Copyright © 2012 John Wiley & Sons, Ltd.     

Die chronische rekurrierende multifokale Osteomyelitis (CRMO)

Chronic recurrent multifocal osteomyelitis (CRMO) is a skeletal disease which occurs in phases. Pathological inflammatory reactions underlie CRMO and can be explained by a genetic predisposition or mutation. Manifestations of CRMO occur mostly in childhood as painful swellings of some parts of the skeletal system normally without signs of systemic inflammation. The mandible can be involved in individual cases (5?%). Radiologically, osteolytic areas can be diagnostically impressive and osteosclerosis increasingly occurs during the course of the disease. Specific laboratory parameters for diagnostics are missing. An additional whole body evaluation should be performed by bone scintigraphy. Although CRMO sometimes shows spontaneous remission drug therapy is recommended because of the prolonged course of the disease. The strategy includes non-steroidal or steroidal anti-inflammatory drug treatment and a benign clinical outcome can be achieved. In cases of therapy failure bisphosphonates or immunomodulating agents can be used.