Modeling foot rockers via functional calibration for use in clinical gait analysis.

BACKGROUND: Goal of this work is a quantitative description of Jacquelin Perry's rocker concept by locating the position of the heel rocker and the forefoot rocker within segments of the foot via functional calibration. METHODS: Two functional calibration tasks with the foot in ground contact were performed by ten typical developed adults and foot marker motion was captured. After applying a least-square method for constructing foot segments, their motion relative to the floor was analyzed via a functional algorithm. Resulting reference positions - namely the heel rotation center and the metatarsal rotation axis - were calculated. Further, the repeatability of the method and variability of outcome within the cohort was tested. RESULTS: The heel rotation center is located substantially posterior (25 mm) and slightly more inferior (5 mm). to the midpoint of the two markers placed medially and laterally on the calcaneus. Repeated measures reveal a variation of this location around 5 mm. The forefoot center is slightly more medial to the "toe marker" (DMT2) and substantially more inferior (19 mm). The metatarsal rotation axis is slightly tilted in the frontal and transverse plane against the metatarsal line given between markers on MT1 and MT5 with small variation in repeated measures (1-2°). SIGNIFICANCE: The determination of heel rotation center and the metatarsal rotation axis relative to foot segments can be determined with good repeatability and their location meet the intuitive expectation. Since they have a direct biomechanical meaning in the foot roll-over process in gait, they may be used for a more functionally oriented definition of foot segments potentially improving the calculation of foot kinematics and kinetics in future work.

Identification and interpretation of gait analysis features and foot conditions by explainable AI.

Clinical gait analysis is a crucial step for identifying foot disorders and planning surgery. Automating this process is essential for efficiently assessing the substantial amount of gait data. In this study, we explored the potential of state-of-the-art machine learning (ML) and explainable artificial intelligence (XAI) algorithms to automate all various steps involved in gait analysis for six specific foot conditions. To address the complexity of gait data, we manually created new features, followed by recursive feature elimination using Support Vector Machines (SVM) and Random Forests (RF) to eliminate low-variance features. SVM, RF, K-nearest Neighbor (KNN), and Logistic Regression (LREGR) were compared for classification, with a Majority Voting (MV) model combining trained models. KNN and MV achieved mean balanced accuracy, recall, precision, and F1 score of 0.87. All models were interpreted using Local Interpretable Model-agnostic Explanation (LIME) method and the five most relevant features were identified for each foot condition. High success scores indicate a strong relationship between selected features and foot conditions, potentially indicating clinical relevance. The proposed ML pipeline, adaptable for other foot conditions, showcases its potential in aiding experts in foot condition identification and planning surgeries.

Dunbar syndrome - case report.

Dunbar syndrome is diagnosed by excluding other possible causes of abdominal pains. Surgical treatment comprises complete dissection of the ligament and the surrounding nerve ganglion. This report describes the case of a previously healthy 45-year-old male patient who presented with epigastric abdominal pain irradiating to the back and weakness. Initially, abdominal computed tomography was ordered, showing arteriopathy of the celiac trunk and mesenteric artery with stenosis. The patient underwent surgical treatment because of the refractory pain, but findings were nonspecific. It was necessary to continue workup with serial angiotomography to follow the case. After around 6 months, thickening of the arcuate ligament was found, with compression of the proximal third of the celiac trunk and 80% stenosis. The patient therefore underwent laparoscopy to relieve celiac trunk compression, with satisfactory postoperative recovery.

A new alignment device for standardization of marker placement on the hindfoot.

BACKGROUND: For multi-segment foot models, next to a (dorsal) heel marker, further markers are typically placed medially (MCL) and laterally (LCL) on the calcaneus. However, there is a lack of easily identifiable landmarks on the hindfoot limiting the repeatability of measurements. For a more consistent placement of these markers, an improved Hindfoot Alignment Device (HiAD) was developed. METHODS: With the HiAD, the position of the MCL and LCL can be individually scaled. Flexible bars allow the adaptation to foot deformities. Three rater placed markers with the HiAD four times on ten typical developed subjects (20 feet). Rigid segment residuals of the hindfoot were calculated and compared with the residuals when using the device of Simon et al. (2006) [12]. The variability of the placement of MCL, LCL and the clinical parameter medial arch were determined. For assessing the inter- and intra-rater reliability, intraclass correlation coefficient (ICC) and the standard error of measurement (SEM) were calculated. RESULTS: Rigid segment residuals of the hindfoot could be reduced by 70 % by using the HiAD. Largest inter-rater variability in the MCL and LCL placement was found in z-direction with less than 3.2 ± 2.7 mm and 3.8 ± 2.8 mm, respectively. Correspondingly, largest intra-rater variability was 3.4 ± 2.3 mm for LCL and 2.4 ± 1.9 mm for MCL, respectively. Regarding reliability ICC showed good to excellent results for the medial arch (interrater ICC 0.471-0.811). SIGNIFICANCE: The application of HiAD to place MCL and LCL appear to be a reliable method with robust marker positions and could be implemented in any multi segment foot model. However, further investigation would be helpful to determine the sensitivity of the marker positions in detecting hindfoot deformities.

Stick a Needle in My Eye: A Case Report of Penetrating Needlefish Injury Causing Cavernous Sinus Thrombosis and Carotid Cavernous Fistula.

While swimming in the ocean on vacation in Cuba, a previously healthy 17-year-old female was unexpectedly stabbed through her orbit and into her brain by a needlefish. This is a unique case of a penetrating injury causing orbital cellulitis, retro-orbital abscess, cerebral venous sinus thrombosis and carotid cavernous fistula. After initial management at a local emergency department, she was transferred to a tertiary care trauma centre where she was treated by a team of emergency, neurosurgery, stroke neurology, ophthalmology, neuroradiology and infectious disease physicians. The patient faced a significant risk of a thrombotic event. There was careful consideration from the multidisciplinary team about the utility of thrombolysis or an interventional neuroradiology procedure. Ultimately, the patient was treated conservatively with intravenous antibiotics, low molecular weight heparin and observation. The patient continued to show clinical improvement several months later, which supported the challenging decision to opt for conservative management. There are very few cases to guide the treatment of this type of contaminated penetrating orbital and brain injury.

Síndrome de Dunbar - relato de caso / Dunbar syndrome - case report

Resumo A síndrome de Dunbar constitui um diagnóstico de exclusão dentro dos quadros de dor abdominal. O tratamento cirúrgico consiste na dissecção completa do ligamento e do gânglio nervoso circundante. Dessa forma, o presente caso refere-se a um paciente do sexo masculino, 45 anos, previamente hígido, com queixa de dor abdominal epigástrica com irradiação para o dorso e fraqueza. Inicialmente, foi realizada tomografia computadorizada de abdome para complementação do quadro, que evidenciou arteriopatia do tronco celíaco e da artéria mesentérica em associação com estenose. Optou-se por tratamento cirúrgico devido à refratariedade da dor, mas os achados foram inespecíficos. Houve necessidade de complementação da propedêutica com angiotomografia seriada para acompanhamento do caso. Após cerca de 6 meses, notou-se espessamento do ligamento arqueado, com compressão do terço proximal do tronco celíaco e estenose de 80%. Em meio a esse cenário, o paciente foi submetido a laparoscopia para descompressão do tronco celíaco, evoluindo satisfatoriamente no pós-operatório.

Abstract Dunbar syndrome is diagnosed by excluding other possible causes of abdominal pains. Surgical treatment comprises complete dissection of the ligament and the surrounding nerve ganglion. This report describes the case of a previously healthy 45-year-old male patient who presented with epigastric abdominal pain irradiating to the back and weakness. Initially, abdominal computed tomography was ordered, showing arteriopathy of the celiac trunk and mesenteric artery with stenosis. The patient underwent surgical treatment because of the refractory pain, but findings were nonspecific. It was necessary to continue workup with serial angiotomography to follow the case. After around 6 months, thickening of the arcuate ligament was found, with compression of the proximal third of the celiac trunk and 80% stenosis. The patient therefore underwent laparoscopy to relieve celiac trunk compression, with satisfactory postoperative recovery.

Transversal Malalignment and Proximal Involvement Play a Relevant Role in Unilateral Cerebral Palsy Regardless the Subtype.

Classification of gait disorders in cerebral palsy (CP) remains challenging. The Winters, Gage, and Hicks (WGH) is a commonly used classification system for unilateral CP regarding the gait patterns (lower limb kinematics) solely in the sagittal plane. Due to the high number of unclassified patients, this classification system might fail to depict all gait disorders accurately. As the information on trunk/pelvic movements, frontal and transverse planes, and kinetics are disregarded in WGH, 3D instrumented gait analysis (IGA) for further characterization is necessary. The objective of this study was a detailed analysis of patients with unilateral CP using IGA taking all planes/degrees of freedom into account including pelvic and trunk movements. A total of 89 individuals with unilateral CP matched the inclusion criteria and were classified by WGH. Subtype-specific differences were analyzed. The most remarkable findings, in addition to the established WGH subtype-specific deviations, were pelvic obliquity and pelvic retraction in all WGH types. Furthermore, the unclassified individuals showed altered hip rotation moments and pelvic retraction almost throughout the whole gait cycle. Transversal malalignment and proximal involvement are relevant in all individuals with unilateral CP. Further studies should focus on WGH type-specific rotational malalignment assessment (static vs. dynamic, femoral vs. tibial) including therapeutic effects and potential subtype-specific compensation mechanisms and/or tertiary deviations of the sound limb.

Estimation of a midfoot joint center in typically developed adults using functional calibration methods.

BACKGROUND: There are detailed findings on hip and knee joint parameters determined via functional calibration methods for use in instrumented 3D-gait analysis but these methods have not yet been addressed to the foot. RESEARCH QUESTION: Are functional calibration methods feasible for determining foot joint parameters and may they help for clinical interpretation of foot deformities? METHODS: Rigid segments were formed by markers on forefoot and hindfoot via a least square method. The position of the midfoot joint articulating both foot segments was then determined via a functional calibration motion. This two-stage procedure was applied on a cohort of 17 typically developed adults and one subject with severe planovalgus foot deformity for determining the location of the midfoot joint and kinematics of hindfoot and forefoot. RESULTS: The position of the midfoot joint center could be estimated in the typically developed cohort and also in the demonstration case with planovalgus foot deformity. Depending on the choice of marker set for hindfoot and forefoot, the position of the joint center varied in the anatomic midfoot region with most robust results when addressing the marker on the navicular to the hindfoot. CONCLUSION: The presented method for joint center determination within the foot and the characteristic results of the foot joint angles appear promising for typically developed feet. However, further validation of the method is needed for application in clinical context.

Providing optimal care for active youth in Canada.

Sports are important activities for youth, with millions of children and adolescents participating in organized sports and recreational activities every year. Sports participation has many benefits but can also cause injuries, accounting for two-thirds of all injuries in Canadian adolescents and resulting in hundreds of thousands of medical visits annually. Despite the frequency of sport-related injuries in youth, many practising pediatricians are not comfortable managing these issues, citing lack of teaching and clinical exposure during training. Many studies have found deficits in musculoskeletal (MSK) and sport and exercise medicine (SEM) training in residency programs in North America, including Canadian pediatric residency programs. To address this learning gap, Canadian pediatric residency programs should incorporate more MSK/SEM training and clinical exposure to these issues. A standardized national curriculum in MSK/SEM will help ensure that community pediatricians practicing in Canada are adequately prepared to care for active youth.

Le sport est une activité importante pour les jeunes. Chaque année, des millions d'enfants et d'adolescents participent à des activités sportives et récréatives organisées. La pratique d'un sport présente de nombreux avantages, mais peut aussi provoquer des blessures. Celles-ci représentent les deux tiers de toutes les blessures chez les adolescents canadiens et entraînent des centaines de milliers de visites médicales chaque année. Malgré la fréquence des blessures liées au sport chez les jeunes, bien des pédiatres en exercice ne se sentent pas à l'aise de gérer ces problèmes, invoquant le manque d'enseignement et d'exposition clinique pendant leur formation. De nombreuses études ont révélé des lacunes dans la formation en médecine musculo-squelettique (MMS) et en médecine du sport et de l'exercice (MSE) dans les programmes de résidence en Amérique du Nord, y compris dans les programmes de résidence en pédiatrie au Canada. Pour combler ce déficit d'apprentissage, les programmes canadiens de résidence en pédiatrie devraient étoffer la formation en MMS/MSE et l'exposition clinique aux troubles de ce type. Un programme national standardisé en MMS/MSE contribuerait à préparer adéquatement les pédiatres communautaires au Canada à soigner les jeunes actifs.

Short-term results of gait analysis with the Heidelberg foot measurement method and functional outcome after operative treatment of ankle fractures.

BACKGROUND: Ankle fractures are common fractures in trauma surgery. Several studies have compared gait patterns between affected patients and control groups. However, no one used the Heidelberg Foot Measurement Method in combination with statistical parametric mapping of the entire gait cycle in this patient cohort. We sought to identify possible mobility deficits in the tibio-talar joint and medial arch in patients after ankle fractures as a sign of stiffness and pain that could result in a pathological gait pattern. We focused on the tibio-talar flexion as it is the main movement in the tibio-talar joint. Moreover, we examined the healing progress over time. METHODS: Fourteen patients with isolated ankle fractures were included prospectively. A gait analysis using the Heidelberg Foot Measurement Method was performed 9 and 26 weeks after surgery to analyse the tibio-talar dorsal flexion, the foot tibia dorsal flexion, the subtalar inversion and the medial arch as well as the cadence, the walking speed and the ground reaction force. The American Orthopedic Foot & Ankle Society ankle hindfoot score was used to obtain clinical data. Results were compared to those from 20 healthy participants. Furthermore, correlations between the American Orthopedic Foot & Ankle Society hindfoot score and the results of the gait analysis were evaluated. RESULTS: Statistical parametric mapping showed significant differences for the Foot Tibia Dorsal Flexion for patients after 9 weeks (53-75%: p = 0.001) and patients after 26 weeks (58-70%: p = 0.011) compared to healthy participants, respectively. Furthermore, significant differences regarding the tibio-talar dorsal flexion for patients 9 weeks after surgery (15-40%: p < 0.001; 56,5-70%: p = 0.007; 82-88%: p = 0.033; 97-98,5%: p = 0.048) as well as patients after 26 weeks (62,5-65%: p = 0.049) compared to healthy participants, respectively. There were no significant differences looking at the medial arch and the subtalar inversion. Moreover, significant differences regarding the ground reaction force were found for patients after 9 weeks (0-17%: p < 0.001; 21-37%: p < 0.001; 41-54%: p < 0.001; 60-64%: p = 0.013) as well as patients after 26 weeks (0-1,5%: p = 0.046; 5-15%: p < 0.001; 27-33%: p = 0.001; 45-49%: p = 0.005; 57-59%: p = 0.049) compared to healthy participants, respectively. In total, the range of motion in the tibio-talar joint and the medial arch was reduced in affected patients compared to healthy participants. Patients showed significant increase of the range of motion between 9 and 26 weeks. CONCLUSIONS: This study shows, that patients affected by ankle fractures show limited mobility in the tibio-talar joint and the medial arch when compared to healthy participants. Even though the limitation of motion remains at least over a period of 26 weeks, a significant increase can be recognized over time. Furthermore, if we look at the absolute values, the patients' values tend to get closer to those of the control group. TRIAL REGISTRATION: This study is registered at the German Clinical Trials Register ( DRKS00023379 ).

Can SARS-CoV-2 induce hematologic malignancies in predisposed individuals? A case series and review of the literature.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) may present with extrapulmonary manifestations, including hematologic changes. Previous studies suggest that severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) can interact with the renin-angiotensin system, ultimately causing increased production of angiotensin II. By reporting the cases of previously healthy young adults diagnosed with a hematologic malignancy after experiencing COVID-19, we raise the hypothesis that the SARS-Cov-2 infection could act as a trigger for leukemogenesis in predisposed individuals. METHODS: This was a case series performed through extraction of relevant clinical information from the medical records of three patients admitted to our Hematology unit between August 2020 and September 2020. MAIN RESULTS: Considering the relatively rapid development of cytopenias following recovery from COVID-19, it cannot be ruled out that SARS-Cov-2 played a role in leukemogenesis in those patients. Based on previous in vitro studies, the renin-angiotensin system imbalance induced by SARS-CoV-2 could potentially promote in vivo leukemogenesis through several mechanisms. CONCLUSION: Despite the advances in pathophysiological and clinical characterization of COVID-19, the consequences of the pandemic to the incidence of hematologic diseases are still to be elucidated. In this context, future dissection of the status of the local bone marrow renin-angiotensin system in leukemogenesis is a clinically relevant basic research area.

Can SARS-CoV-2 induce hematologic malignancies in predisposed individuals? A case series and review of the literature

Abstract Introduction Coronavirus disease 2019 (COVID-19) may present with extrapulmonary manifestations, including hematologic changes. Previous studies suggest that severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) can interact with the renin-angiotensin system, ultimately causing increased production of angiotensin II. By reporting the cases of previously healthy young adults diagnosed with a hematologic malignancy after experiencing COVID-19, we raise the hypothesis that the SARS-Cov-2 infection could act as a trigger for leukemogenesis in predisposed individuals. Methods This was a case series performed through extraction of relevant clinical information from the medical records of three patients admitted to our Hematology unit between August 2020 and September 2020. Main Results Considering the relatively rapid development of cytopenias following recovery from COVID-19, it cannot be ruled out that SARS-Cov-2 played a role in leukemogenesis in those patients. Based on previous in vitro studies, the renin-angiotensin system imbalance induced by SARS-CoV-2 could potentially promote in vivo leukemogenesis through several mechanisms. Conclusion Despite the advances in pathophysiological and clinical characterization of COVID-19, the consequences of the pandemic to the incidence of hematologic diseases are still to be elucidated. In this context, future dissection of the status of the local bone marrow renin-angiotensin system in leukemogenesis is a clinically relevant basic research area.

Prepubescent Female Genital Examination Images: Evidence-Informed Learning Opportunities.

OBJECTIVES: To determine diagnoses and image features that are associated with difficult prepubescent female genital image interpretations. DESIGN AND SETTING: This was a mixed-methods study conducted at a tertiary care pediatric center using images from a previously developed education platform. PARTICIPANTS: Participants comprised 107 medical students, residents, fellows, and attendings who interpreted 158 cases to derive case difficulty estimates. INTERVENTIONS: This was a planned secondary analysis of participant performance data obtained from a prospective multi-center cross-sectional study. An expert panel also performed a descriptive review of images with the highest frequency of diagnostic error. MAIN OUTCOME MEASURES: We derived the proportion of participants who interpreted an image correctly, and features that were common in images with the most frequent diagnostic errors. RESULTS: We obtained 16,906 image interpretations. The mean proportion correct scores for each diagnosis were as follows: normal/normal variants 0.84 (95% confidence interval [CI] 0.82, 0.87); infectious/dermatology pathology 0.59 (95% CI 0.45, 0.73); anatomic pathology 0.61 (95% CI 0.41, 0.81); and, traumatic pathology 0.64 (95% CI 0.49, 0.79). The mean proportion correct scores varied by diagnosis (P < .001). The descriptive review demonstrated that poor image quality, infant genitalia, normal variant anatomy, external material (eg, diaper cream) in the genital area, and nonspecific erythema were common features in images with lower accuracy scores. CONCLUSIONS: A quantitative and qualitative examination of prepubescent female genital examination image interpretations provided insight into diagnostic challenges for this complex examination. These data can be used to inform the design of teaching interventions to improve skill in this area.

Queimaduras por tentativa de suicídio e homicídio e a sua associação com o prognóstico / Burns caused by attempted suicide and homicide and its association with prognosis / Quemaduras por intento de suicidio y homicidio y su asociación con el pronóstico

Objetivo: Descrever as características clínicas e epidemiológicas de pacientes vítimas de queimaduras infligidas intencionalmente internados em uma unidade de terapia intensiva de um centro de tratamento especializado em queimaduras de um hospital universitário. Método: Foi realizado um estudo longitudinal retrospectivo na unidade de Terapia Intensiva de um Centro de Tratamento de Queimados. A amostragem foi de conveniência de todos os pacientes adultos queimados internados consecutivamente no período de maio de 2011 a novembro de 2013. Foram coletados dados clínicos e do diagnóstico da queimadura, além de escores prognósticos. Resultados: Dos 178 pacientes incluídos no estudo, 19,7% tiveram lesões intencionais, sendo 10,7% ocasionadas por tentativa de suicídio e 9,0% por tentativa de homicídio. As lesões autoinfligidas e por agressão foram mais graves quando comparadas a lesões acidentais. A média da superfície corpórea queimada total foi maior nas lesões intencionais (39,2%; DP=21,6%) comparada às acidentais (25,3%, DP=15,6%; p<0,001) e a lesão inalatória foi mais frequente nas intencionais (71,43%) do que nas acidentais (38,4%; p<0,001). A taxa de mortalidade foi maior nas queimaduras intencionais (65,7%) comparada aos acidentes (30,7%; p<0,001). As mulheres foram o principal grupo de risco associado às queimaduras intencionais (p<0,001). As variáveis clínicas e prognósticos apresentaram resultados semelhantes entre os pacientes com queimaduras por tentativa de suicídio e homicídio. Conclusões: Identificou-se que as lesões intencionais são um fator de risco para o pior prognóstico e mortalidade de pacientes queimados.

Objective: To describe the clinical and epidemiological features of burn victims inflicted intentionally admitted to an intensive care unit of a specialized burn center at a university hospital. Method: Retrospective longitudinal study conducted in the intensive care unit of a Burn Treatment Center. Convenience sampling of all burned adult patients consecutively admitted from May 2011 to November 2013. Clinical data and burn diagnosis as well as prognostic scores were collected. Results: Of the 178 patients included in the study 19.7% had intentional injuries, 10.7% caused by attempted suicide and 9.0% attempted homicide. Self-inflicted injury and assault resulted in more serious injury compared to accidental injuries. The average of the total burned body area was higher in intentional injuries (39.2% and standard deviation ­ SD=21.6%) compared with accidental (25.3%, SD=15.6%, p<0.001) and inhalation injury was more frequent in intentional (71.43%) than in accidental (38.4%; p<0.001). The mortality rate was higher in intentional burns (65.7%) compared to accidents (30.7%; p<0.001). Women had higher risk associated intentional burns (p<0.001). Clinical and prognostic variables showed similar results among patients with burns of attempted suicide and homicide. Conclusions: It was found that intentional injuries are a risk factor for poor prognosis and mortality in burned patients.

Objetivo: Describir las características clínicas y epidemiológicas de pacientes víctimas de quemaduras infligidas intencionalmente internados en una unidad de cuidados intensivos de un centro de tratamiento especializado para quemaduras de un hospital universitario. Método: Estudio retrospectivo longitudinal en la unidad de cuidados intensivos de un centro de tratamiento especializado para quemaduras. El muestreo fue de conveniencia, de todos los pacientes adultos quemados internados consecutivamente a partir de mayo de 2011 hasta noviembre de 2013. Se recogieron datos clínicos y del diagnóstico de quemaduras, así como las puntuaciones de pronóstico. Resultados: De los 178 pacientes incluidos en el estudio, 19,7% tenían lesiones intencionales, siendo 10,7% por tentativa de suicidio y 9,0% por tentativa de homicidio. Las lesiones autoinfligidas y por agresión resultaron en lesiones más graves cuando comparadas a lesiones accidentales. El promedio de la superficie total del cuerpo quemado fue mayor en las lesiones intencionales (39,2%; DE=21,6%) en comparación a las accidentales (25,3%; DE=15,6%, p<0,001) y la lesión por inhalación fue más frecuente en las intencionales (71,43%) que en las accidentales (38,4%; p<0,001). La tasa de mortalidad fue mayor en las quemaduras intencionales (65,7%) en comparación a los accidentes (30,7%; p<0,001). Las mujeres fueron el principal grupo de riesgo asociado a quemaduras intencionales (p<0,001). Las variables clínicas y pronóstico presentaron resultados similares entre los pacientes con quemaduras de intento de suicidio y homicidio. Conclusiones: Se identificó que las lesiones intencionales son un factor de riesgo para peor pronóstico y mortalidad en pacientes quemados.

Nutrition labels on pre-packaged foods: a systematic review.

OBJECTIVE: To review research on consumer use and understanding of nutrition labels, as well as the impact of labelling on dietary habits. DESIGN: A systematic review was conducted by searching electronic databases. Relevant articles were screened by two reviewers and included if they met inclusion criteria, including eight methodological criteria. A total of 120 articles were included in the review, including cross-sectional surveys (n 96), experimental designs (n 17), 'natural experiments' (n 7) and longitudinal population-based surveys (n 2). SETTING: Articles covered seven jurisdictions: USA (n 88), Europe (n 12), Canada (n 9), Australia and New Zealand (n 4), Norway (n 2), Thailand (n 1) and Trinidad (n 1). SUBJECTS: Participants were from a wide range of age groups, socio-economic strata and geographical regions. RESULTS: Nutrition labels on pre-packaged foods are among the most prominent sources of nutrition information. Nutrition labels are perceived as a highly credible source of information and many consumers use nutrition labels to guide their selection of food products. Evidence also shows a consistent link between the use of nutrition labels and healthier diets. However, the use of labels varies considerably across subgroups, with lower use among children, adolescents and older adults who are obese. Research also highlights challenges in terms of consumer understanding and appropriate use of labelling information. CONCLUSIONS: Nutrition labels on pre-packaged foods are a cost-effective population-level intervention with unparalleled reach. However, to capitalize on their potential, governments will need to explore new formats and different types of information content to ensure that nutrition information is accessible and understandable.

Correlation of computed tomography imaging features with pain response in patients with spine metastases after radiation therapy.

PURPOSE: To correlate computed tomography (CT) imaging features of spinal metastases with pain relief after radiotherapy (RT). METHODS AND MATERIALS: Thirty-three patients receiving computed tomography (CT)-simulated RT for spinal metastases in an outpatient palliative RT clinic from January 2007 to October 2008 were retrospectively reviewed. Forty spinal metastases were evaluated. Pain response was rated using the International Bone Metastases Consensus Working Party endpoints. Three musculoskeletal radiologists and two orthopaedic surgeons evaluated CT features, including osseous and soft tissue tumor extent, presence of a pathologic fracture, severity of vertebral height loss, and presence of kyphosis. RESULTS: The mean patient age was 69 years; 24 were men and 9 were women. The mean worst pain score was 7/10, and the mean total daily oral morphine equivalent was 77.3 mg. Treatment doses included 8 Gy in one fraction (22/33), 20 Gy in five fractions (10/33), and 20 Gy in eight fractions (1/33). The CT imaging appearance of spinal metastases included vertebral body involvement (40/40), pedicle involvement (23/40), and lamina involvement (18/40). Soft tissue component (10/40) and nerve root compression (9/40) were less common. Pathologic fractures existed in 11/40 lesions, with resultant vertebral body height loss in 10/40 and kyphosis in 2/40 lesions. At months 1, 2, and 3 after RT, 18%, 69%, and 70% of patients experienced pain relief. Pain response was observed with various CT imaging features. CONCLUSIONS: Pain response after RT did not differ in patients with and without pathologic fracture, kyphosis, or any other CT features related to extent of tumor involvement. All patients with painful spinal metastases may benefit from palliative RT.

Elderly patients with painful bone metastases should be offered palliative radiotherapy.

PURPOSE: To investigate the efficacy of palliative radiotherapy (RT) in relieving metastatic bone pain in elderly patients. METHODS AND MATERIALS: The response to RT for palliation of metastatic bone pain was evaluated from a prospective database of 558 patients between 1999 and 2008. The pain scores and analgesic intake were used to calculate the response according to the International Bone Metastases Consensus Working Party palliative RT endpoints. Subgroup analyses for age and other demographic information were performed. RESULTS: No significant difference was found in the response rate in patients aged >or=65, >or=70, and >or=75 years compared with younger patients at 1, 2, or 3 months after RT. The response was found to be significantly related to the performance status. CONCLUSION: Age alone did not affect the response to palliative RT for bone metastases. Elderly patients should be referred for palliative RT for their painful bone metastases, regardless of age, because they receive equal benefit from the treatment.

Would larger radiation fields lead to a faster onset of pain relief in the palliation of bone metastases?

PURPOSE: Hemibody irradiation has been shown to relieve bony metastatic pain within 24-48 hours of treatment, whereas for local external beam radiation, onset of pain relief is 1-4 weeks after radiation. The primary objective of this study is to examine whether there is a relationship between the areas of radiation treatment and onset of pain relief. METHODS AND MATERIALS: From Jan 1999 to Jan 2002, a total of 653 patients with symptomatic bone metastases were treated with external beam radiation. Pain scores and analgesic consumption were recorded at baseline and Weeks 1, 2, 4, 8, and 12. The areas of radiation treatment for all patients were calculated, then correlated with the response and analyzed in various ways. We first compared pain score alone with mean radiation field size. Second, we combined pain score and analgesic consumption. Last, we implemented the International Consensus end points for pain score and analgesic intake. RESULTS: Assessment of 653 patients showed no significant correlation comparing pain scores alone with radiation field area, with the exception of Week 4 for partial responders. Again, no significant correlation was found when combining both analgesic intake and pain score against radiation field size. Even when implementing the International Consensus end point definitions for radiation response, the only significant correlation between radiation field size and response was observed in Week 2 for partial response. CONCLUSION: There was no statistical significance between mean areas of radiation treatment with the onset of pain relief.

The palliative performance scale: examining its inter-rater reliability in an outpatient palliative radiation oncology clinic.

INTRODUCTION: The Palliative Performance Scale (PPS) was developed by the Victoria Hospice Society in 1996 to modernize the Karnofsky Performance Scale. Currently, it is being used to measure palliative patient performance status in a variety of settings. Despite its widespread use, only one study has examined the inter-rater reliability of the PPS. PURPOSE: To examine the inter-rater reliability of the PPS in measuring performance status in patients seen in an outpatient palliative radiation oncology clinic METHODS: Performance status for 102 consecutive patients was assessed by an oncologist (MD), a radiation therapist (RT), and a research assistant (RA) in the Rapid Response Radiotherapy Program at the Odette Cancer Centre in Toronto, Ontario, Canada. Raters' scores were analyzed for correlation and compared to evaluate the inter-rater reliability of the PPS tool. RESULTS: Excellent correlation was found between the scores rated by the MD and RA (r = 0.86); good correlation was observed between scores rated by the MD and RT (r = 0.69) and the RT and RA (r = 0.77). Scores between all three raters, as well as between rater pairs, were also found to have good reliability as measured by the Chronbach's alpha coefficient. Significant results were obtained for the range of PPS scores in which the majority of our patients fell: 40-80%. CONCLUSION: PPS was shown to have good overall inter-rater reliability in an outpatient palliative setting, but more research is needed to establish the validity and reliability of the tool in a variety of different palliative settings.

Rare bone metastases of the olecranon.

Abstract Bone metastases are prevalent in patients with cancer, especially with primary lung, breast, renal cell, thyroid, and prostate carcinomas. When looking specifically at primary renal cell carcinoma, approximately 40% of patients will develop bone metastases during the course of their disease. However, distal bony involvement to the appendicular skeleton occurs less frequently, developing below the elbow and knee in approximately 7% of metastatic renal cell carcinoma patients. The incidence of olecranon metastasis is extremely rare in all cancers and so far only two cases have been reported in literature. We report the third case of an olecranon metastasis in a patient with renal cell carcinoma.