Gait analysis in patients with idiopathic scoliosis

Introduction The goal of this study was to observe scoliotic subjects during level walking to identify asymmetries—which may be related to a neurological dysfunction or the spinal deformity itself—and to correlate these to the severity of the scoliotic curve.Methods We assessed the gait pattern of ten females (median age 14.4) with idiopathic scoliosis characterised by a left-lumbar and a right-thoracic curve component. Gait analysis consisted of 3D kinematic (VICON) and kinetic (Kistler force plates) measurements. The 3D-segment positions of the head, trunk and pelvis, as well as the individual joint angles of the upper and lower extremities, were computed during walking and static standing. Calculation of pertinent kinetic and kinematic parameters allowed statistical comparison.Results All subjects walked at a normal velocity (median: 1.22 m/s; range:1.08–1.30 m/s; height-adjusted velocity: 0.75 m/s; range: 0.62–0.88 m/s). The timing of the individual gait phases was normal and symmetrical for the whole group. Sagittal plane hip, knee and ankle motion followed a physiological pattern. Significant asymmetry was observed in the trunks rotational behaviour in the transverse plane. During gait, the pelvis and the head rotated symmetrically to the line of progression, whereas trunk rotation was asymmetric, with increased relative forward rotation of the right upper body in relation to the pelvis. This produced a torsional offset to the line of progression. Minimal torsion (at right heel strike) measured: median 1.0° (range: 5.1°–8.3°), and maximal torsion (at left heel strike) measured 11.4° (range 6.9°–17.9°). The magnitude of the torsional offset during gait correlated to the severity of the thoracic deformity and to the standing posture, whereas the range of the rotational movement was not affected by the severity of the deformity. The ground reaction forces revealed a significant asymmetry of [Msz], the free rotational moment around the vertical axis going through the point of equivalent force application. On the right side, the initial endo-rotational moment was lower, followed by a higher exo-rotational moment than on the left. All the other force parameters (vertical, medio–lateral, anterior–posterior), did not show a significant side difference for the whole group. The use of a brace stiffened torsional motion. However the torsional offset and the asymmetry of the free rotational moment remained unchanged.Conclusion The most significant and marked asymmetry was seen in the transverse plane, denoted as a torsional offset of the upper trunk in relation to the symmetrically rotating pelvis. This motion pattern was reflected by a ground-reaction-force asymmetry of the free rotational moment. Further studies are needed to investigate whether this behaviour is solely an expression of the structural deformity or whether it could enhance the progression of the torsional deformity.No financial assistance was provided for this work     

Noninvasive visualization of coronary arteries using contrast-enhanced multidetector CT: influence of heart rate on image quality and stenosis detection

OBJECTIVE: Although multidetector CT (MDCT) with retrospectively ECG-gated image reconstruction has been shown to permit noninvasive visualization of the coronary arteries, the 125-250 msec required for image acquisition frequently causes motion artifacts. We investigated the influence of a patient's heart rate on the presence of motion artifacts and on accuracy of stenosis detection on contrast-enhanced MDCT. MATERIALS AND METHODS: In 100 patients, MDCT was performed, and ECG-gated cross-sectional images were retrospectively reconstructed. From the 10 data sets obtained for each patient (reconstructed at 0-90% of the cardiac cycle in increments of 10%), we chose the best data set for every coronary artery. The images of the arteries were evaluated for occurrence of artifacts and the presence of high-grade stenosis (diameter reduction exceeding 70%) or occlusions. MDCT results were compared with coronary angiographic findings. RESULTS: Of the 400 coronary arteries, 115 (29%) could not be evaluated because of motion artifacts (n = 84) or other reasons (n = 31). Overall, 51 (49%) of 104 stenoses were revealed on MDCT. For detecting stenosis in those arteries that we could evaluate, MDCT had a sensitivity of 91% (51 of 56 stenoses detected) and a specificity of 89%. As the heart rate increased, the number of arteries that could be evaluated decreased, and overall sensitivity for stenosis detection decreased from 62% (heart rate < or = 70 beats per minute) to 33% (heart rate > 70 beats per minute). CONCLUSION: MDCT can reveal coronary stenoses, but the usefulness of MDCT as an aid in accurately evaluating stenoses decreases as a patient's heart rate increases.     

Short- and long-term results of liver transplantation in infants aged less than 6 months

BACKGROUND: Despite major surgical and medical advances, it is still a challenge to perform transplantation in small infants. This study, focusing on short- and long-term outcomes, summarizes our 10-year experience with liver transplantation (LTx) in infants aged less than 6 months. PATIENTS AND METHODS: We analyzed 43 patients aged 6 months or less (range: 12-184 days, median: 136 days) whose median weight at the time of LTx was 5.8 kg (range: 2.8-8.0 kg). The reasons for LTx were biliary atresia (n=27; 62.8%), neonatal hepatitis (n=6; 14%), neonatal cholestasis (n=4; 9.3%), and miscellaneous (n=6; 14%). The patients were followed up for a median time of 3 years and evaluated with respect to graft function, physical, and neurodevelopmental outcome. RESULTS: The patient survival was 90.7% after 1 year and 87.2% after 2 years. The graft survival was 86% after 1 year and 82.1% after 2 years. Twelve patients (27.9%) experienced 15 surgical complications requiring intervention, two of whom demonstrated vascular thrombosis (4.7%). Acute early rejection occurred in 15 patients (34.9%), and chronic rejection occurred in 3 patients (7%); 83.3% of the patients had normal liver function test results at the time of evaluation. Complications such as posttransplant lymphoproliferative disease (4.7%) and persistent arterial hypertension (4.7%) were rarely seen. The physical and neurodevelopmental outcomes were good. CONCLUSIONS: LTx in infants aged less than 6 months provides excellent short- and long-term results. Low weight or young age of infants awaiting LTx should not be exclusion criteria for LTx.     

Gender-specific differences of the foot during the first year of walking

BACKGROUND: It is is well established that gender-specific differences in foot shape exist in adults. However, no information is available whether these differences are present already in children's feet and at what stage in the development these changes become evident. METHODS: Plantar pressure patterns and footprints of 42 healthy infants (20 male, 22 female) were evaluated over the course of one year and compared regarding gender-specific differences. The age at initial evaluation of the children was 16.1 months, and they were evaluated every 3 months. Anthropometric data, foot shape, and foot loading parameters for the whole foot, as well as for selected regions of interest, were evaluated. RESULTS: Significant differences in the foot shape and dynamic foot loading parameters were noted between boys and girls already at this young age. Boys demonstrated a broader midfoot, indicating a lower arch. Girls showed a more pronounced dynamic loading, especially in the heel and forefoot regions. CONCLUSIONS: The differences seen in this study should be taken into account by the shoe industry responsible for the design of children's shoes to support healthy development of the growing foot. Foot disorders are not only caused by hereditary factors but may be due to disturbances during foot growth and development. Since today's society is dependent on wearing shoes for foot protection, shoes should be designed not only according to the fashion demands of the customers but also to the biomechanical needs. Therefore, it is important to ensure that shoes fit the shape of the feet, which is different for boys and girls already when walking begins.     

Drug treatment strategies for epilepsy revisited: starting early or late? One drug or several drugs?

There are two popular strategies for current drug treatment of epilepsy; starting early may be better and polytherapy conveys advantages over monotherapy. This review briefly examines if the historical record is much of a guide to determine the clinical value of these two strategies. Great clinical scientists of the 19^th and early 20^th century, such as Sir William Gowers, and William Aldren Turner, offered vivid single case studies and showed early results of seizure remission in groups of subjects. The historical record offered, however, no evidence of clear clinical benefits for early treatment and polytherapy. Combination treatment was thought to be useful in only some cases. In agreement, current evidence shows no clear clinical benefit of starting treatment early, except perhaps in severe epilepsy. Polytherapy is clinically useful in a subgroup of subjects, but despite being a standard treatment strategy for over one hundred years, it has been poorly studied. In fact, there is no compelling experimental or clinical evidence for a difference in seizure outcome between monotherapy and polytherapy. This surprising finding should prompt a re‐appraisal regarding the need to test both strategies separately for the licensing of new antiepileptic drugs.     

A new off-pump hybrid open and endovascular repair to treat ductus Botalli and ascendens aneurysms

To report a combined ascending aorta and aortic arch hybrid repair, we performed off-pump with no aortic graft replacement. A 65-year-old man, developing progressive recurrent laryngeal nerve paralysis, underwent a computed tomography (CT) angiography detecting nonpatent residual ductus Botalli aneurysm and ascending aorta aneurysm. Due to severe multimorbidities, a less-invasive alternative was elaborated. In a first step, appropriate proximal landing zone for aortic stent grafting was achieved by ascending aorta diameter reduction, with epiaortic wrapping, and debranching the supra-aortic trunks. In the second step, endovascular stent grafts were deployed from proximal ascending aorta to descending aorta, excluding the ductus Botalli aneurysm. Six-month follow-up CT shows ductus Botalli aneurysm exclusion, stable stent graft position, and ascending diameter and patent and stenosis-free supra-aortic grafts. This case supports this alternative treatment to open aortic repair under circulatory arrest and deep hypothermia, especially in those patients considered unfit for such invasive treatment.     

Composite aortic root replacement in acute type A dissection: time to rethink the indications?

OBJECTIVE: The indications for aortic root replacement in acute type A dissection are unclear. We reviewed the immediate and long-term outcome of consecutive patients in a series in which a low-threshold policy of composite aortic root replacement had evolved. METHODS: From a prospectively compiled aortic surgery database, we identified 162 patients who had either supracoronary interposition grafting, Group A (n=89), or composite root replacement, Group B (n=73) for acute type A dissection. Patients receiving total arch replacements were excluded. Operative and clinical details were analyzed and patient survival was compared to an age and gender matched census cohort. Need for reoperation on the proximal or distal aorta was also noted. Follow-up totaled 795.5 patient-years. RESULTS: Hospital mortality rates were identical in both groups (12.3%: 11 deaths in group A; 9 in group B). Chronic pulmonary disease, diabetes, malperfusion, hemodynamic compromise and aortic root dilatation were independent risk factors for hospital death. Actuarial survival estimates at 1, 5 and 10 years were 79% (71-88%), 64% (53-75%), and 55% (41-68%) for group A, and 79% (70-86%), 73% (62-83%), and 65% (52-78%) for group B (P=0.48). Age and operative patency of the ascending false lumen were independent risk factors for death after hospital discharge. Proximal aortic reoperation was required for four patients in group A and none in group B (P=0.085). CONCLUSION: A strategy of replacement rather than repair of the dissected aortic root for specific indications in type A dissection yielded high survival and low proximal reoperation rates. These results support an aggressive policy of composite root replacement in acute type A dissection.     

On-line hemodiafiltration does not induce inflammatory response in end-stage renal disease patients: results from a multicenter cross-over study

BACKGROUND: On-line hemodiafiltration (HDF) represents the supreme blood purification modality for end-stage renal disease (ESRD) patients. Large-volume infusion of on-line prepared substitution fluid may, however, expose patients to inflammatory contaminants. As a result, on-line HDF might aggravate chronic inflammation, which correlates with malnutrition, cardiovascular disease, and mortality among ESRD patients. METHODS: In a multicenter cross-over study, 27 ESRD patients were randomly assigned to treatment with on-line HDF and low-flux hemodialysis (HD). After 6 months, patients were crossed to the other treatment modality, and treatment continued for another 6 months. Both on-line HDF and low-flux HD were conducted with polysulfone membranes and ultrapure dialysis fluid. Samples were drawn at the end of each treatment period. RESULTS: Inflammatory parameters were elevated in the study population when compared to healthy controls. Induction of interleukin-1 receptor antagonist (IL-1Ra) and tumor necrosis factor alpha (TNF-alpha) was comparable for on-line HDF and low-flux HD, and there was no intradialytic increase in cytokine production. As a result, interleukin-6 (IL-6) plasma levels did not differ significantly between the two treatment modalities. Similarly, no difference between on-line HDF and low-flux HD was observed for C-reactive protein (CRP) and albumin. Markers of endothelial cell activation (soluble intercellular and vascular cell adhesion molecules sICAM-1 and sVCAM-1) as well as the cardiovascular risk marker cardiac troponin T (cTnT) remained elevated compared to healthy subjects, but showed no difference between the two treatment modalities. CONCLUSIONS: On-line HDF, as the most effective renal replacement therapy, does not provoke inflammatory response and is both safe and highly biocompatible.