Effect of stiffness-optimized ankle foot orthoses on joint work in adults with neuromuscular diseases is related to severity of push-off deficits.

BACKGROUND: People with plantar flexor weakness generate less ankle push-off work during walking, resulting in inefficient proximal joint compensations. To increase push-off work, spring-like ankle foot orthoses (AFOs) can be provided. However, whether and in which patients AFOs increase push-off work and reduce compensatory hip and knee work is unknown. METHODS: In 18 people with bilateral plantar flexor weakness, we performed a 3D gait analysis at comfortable walking speed with shoes-only and with AFOs of which the stiffness was optimized. To account for walking speed differences between conditions, we compared relative joint work of the hip, knee and ankle joint. The relationships between relative work generated with shoes-only and changes in joint work with AFO were tested with Pearson correlations. RESULTS: No differences in relative ankle, knee and hip work over the gait cycle were found between shoes-only and AFO (p>0.499). Percentage of total ankle work generated during pre-swing increased with the AFO (AFO: 85.3±9.1% vs Shoes: 72.4±27.1%, p=0.026). At the hip, the AFO reduced relative work in pre-swing (AFO: 31.9±7.4% vs Shoes: 34.1±10.4%, p=0.038) and increased in loading response (AFO: 18.0±11.0% vs Shoes: 11.9±9.8%, p=0.022). Ankle work with shoes-only was inversely correlated with an increase in ankle work with AFO (r=-0.839, p<0.001) and this increase correlated with reduction in hip work with AFO (r=-0.650, p=0.004). DISCUSSION: Although stiffness-optimized AFOs did not alter the work distribution across the ankle, knee and hip joint compared to shoes-only walking, relative more ankle work was generated during push-off, causing a shift in hip work from pre-swing to loading response. Furthermore, larger ankle push-off deficits when walking with shoes-only were related with an increase in ankle work with AFO and reduction in compensatory hip work, indicating that more severely affected individuals benefit more from the energy storing-and-releasing capacity of AFOs.

The interaction between muscle pathophysiology, body mass, walking speed and ankle foot orthosis stiffness on walking energy cost: a predictive simulation study.

BACKGROUND: The stiffness of a dorsal leaf AFO that minimizes walking energy cost in people with plantarflexor weakness varies between individuals. Using predictive simulations, we studied the effects of plantarflexor weakness, passive plantarflexor stiffness, body mass, and walking speed on the optimal AFO stiffness for energy cost reduction. METHODS: We employed a planar, nine degrees-of-freedom musculoskeletal model, in which for validation maximal strength of the plantar flexors was reduced by 80%. Walking simulations, driven by minimizing a comprehensive cost function of which energy cost was the main contributor, were generated using a reflex-based controller. Simulations of walking without and with an AFO with stiffnesses between 0.9 and 8.7 Nm/degree were generated. After validation against experimental data of 11 people with plantarflexor weakness using the Root-mean-square error (RMSE), we systematically changed plantarflexor weakness (range 40-90% weakness), passive plantarflexor stiffness (range: 20-200% of normal), body mass (+ 30%) and walking speed (range: 0.8-1.2 m/s) in our baseline model to evaluate their effect on the optimal AFO stiffness for energy cost minimization. RESULTS: Our simulations had a RMSE < 2 for all lower limb joint kinetics and kinematics except the knee and hip power for walking without AFO. When systematically varying model parameters, more severe plantarflexor weakness, lower passive plantarflexor stiffness, higher body mass and walking speed increased the optimal AFO stiffness for energy cost minimization, with the largest effects for severity of plantarflexor weakness. CONCLUSIONS: Our forward simulations demonstrate that in individuals with bilateral plantarflexor the necessary AFO stiffness for walking energy cost minimization is largely affected by severity of plantarflexor weakness, while variation in walking speed, passive muscle stiffness and body mass influence the optimal stiffness to a lesser extent. That gait deviations without AFO are overestimated may have exaggerated the required support of the AFO to minimize walking energy cost. Future research should focus on improving predictive simulations in order to implement personalized predictions in usual care. Trial Registration Nederlands Trial Register 5170. Registration date: May 7th 2015.  http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5170.

Interacting effects of AFO stiffness, neutral angle and footplate stiffness on gait in case of plantarflexor weakness: A predictive simulation study.

To maximize effects of dorsal leaf ankle foot orthoses (AFOs) on gait in people with bilateral plantarflexor weakness, the AFO properties should be matched to the individual. However, how AFO properties interact regarding their effect on gait function is unknown. We studied the interaction of AFO bending stiffness with neutral angle and footplate stiffness on the effect of bending stiffness on walking energy cost, gait kinematics and kinetics in people with plantarflexor weakness by employing predictive simulations. Our simulation framework consisted of a planar 11 degrees of freedom model, containing 11 muscles activated by a reflex-based neuromuscular controller. The controller was optimized by a comprehensive cost function, predominantly minimizing walking energy cost. The AFO bending and footplate stiffness were modelled as torsional springs around the ankle and metatarsal joint. The neutral angle of the AFO was defined as the angle in the sagittal plane at which the moment of the ankle torsional spring was zero. Simulations without AFO and with AFO for 9 bending stiffnesses (0-14 Nm/degree), 3 neutral angles (0-3-6 degrees dorsiflexion) and 3 footplate stiffnesses (0-0.5-2.0 Nm/degree) were performed. When changing neutral angle towards dorsiflexion, a higher AFO bending stiffness minimized energy cost of walking and normalized joint kinematics and kinetics. Footplate stiffness mainly affected MTP joint kinematics and kinetics, while no systematic and only marginal effects on energy cost were found. In conclusion, the interaction of the AFO bending stiffness and neutral angle in bilateral plantarflexor weakness, suggests that these should both be considered together when matching AFO properties to the individual patient.

Diagnostic utility of the lymphoid screening tube supplemented with TRBC1 for the assessment of T-cell clonality.

INTRODUCTION: Flow cytometric panels for the investigation of lymphoproliferative disorders, such as the EuroFlow Lymphoid Screening Tube (LST), often fail to demonstrate T-cell clonality, as a suitable clonality marker was unavailable until recently. Aim of this study was to evaluate the added value of supplementing TRBC1, a flow cytometric T-cell clonality marker, to the LST. METHODS: Flow cytometric analysis was performed on 830 routine samples referred to our lab for suspicion of hematological malignancy. T-cells with monotypic TRBC1-expression were additionally characterized with a 12-color T-cell tube and molecular T-cell receptor gamma gene rearrangement (TRG). RESULTS: LST analysis revealed 97 (11.7%) samples with the presence of a monotypic T-cell population according to TRBC1, including 21 (2.5%) "high-count" (≥500 cells/µL blood or ≥15% of lymphocytes) and 76 (9.2%) "low-count" (<500 cells/µL blood or <15% of lymphocytes) populations. Clinical symptoms indicative for T-CLPD could be correlated to 11/21 "high-count" and 17/76 "low-count" monotypic T-cell populations. Molecular TRG analysis demonstrated a monoclonal result in 76% (16/21) of "high-count" samples and in 64% (42/66; 10 samples not tested) of "low-count" samples, but also in 9/20 samples with polytypic TRBC1 results. CONCLUSION: Analysis of an LST tube supplemented with TRBC1 led to the detection of a high number of monotypic T-cell populations. The detection of numerous small monotypic T-cell populations raises the question of their clinical significance. A possible flowchart for assessment of these populations, based on the available literature, is proposed. Molecular TRG analysis is complementary and cannot be omitted from T-cell clonality assessment.

The relationship between quantitative magnetic resonance imaging of the ankle plantar flexors, muscle function during walking and maximal strength in people with neuromuscular diseases.

BACKGROUND: Progression of plantar flexor weakness in neuromuscular diseases is usually monitored by muscle strength measurements, although they poorly relate to muscle function during walking. Pathophysiological changes such as intramuscular adipose tissue affect dynamic muscle function independent from isometric strength. Diffusion tensor imaging and T2 imaging are quantitative MRI measures reflecting muscular pathophysiological changes, and are therefore potential biomarkers to monitor plantar flexor functioning during walking in people with neuromuscular diseases. METHODS: In fourteen individuals with plantar flexor weakness diffusion tensor imaging and T2 scans of the plantar flexors were obtained, and the diffusion indices fractional anisotropy and mean diffusivity calculated. With a dynamometer, maximal isometric plantar flexor strength was measured. 3D gait analysis was used to assess maximal ankle moment and power during walking. FINDINGS: Fractional anisotropy, mean diffusivity and T2 relaxation time all moderately correlated with maximal plantar flexor strength (r > 0.512). Fractional anisotropy and mean diffusivity were not related with ankle moment or power (r < 0.288). T2 relaxation time was strongly related to ankle moment (r = -0.789) and ankle power (r = -0.798), and moderately related to maximal plantar flexor strength (r < 0.600). INTERPRETATION: In conclusion, T2 relaxation time, indicative of multiple pathophysiological changes, was strongly related to plantar flexor function during walking, while fractional anisotropy and mean diffusivity, indicative of fiber size, only related to maximal plantar flexor strength. This indicates that these measures may be suitable to monitor muscle function and gain insights into the pathophysiological changes underlying a poor plantar flexor functioning during gait in people with neuromuscular diseases.

Energy cost optimized dorsal leaf ankle-foot-orthoses reduce impact forces on the contralateral leg in people with unilateral plantar flexor weakness.

BACKGROUND: In individuals with unilateral plantar flexor weakness, the second peak of the vertical ground reaction force (GRF) is decreased. This leads to a higher ground reaction force, e.g. impact, of the contralateral leg, potentially explaining quadriceps muscle and/or knee joint pain. Energy cost optimized dorsal leaf ankle-foot-orthoses (AFOs) may increase the push-off ground reaction force, which in turn could lead to lower impact forces on the contralateral leg. RESEARCH QUESTIONS: 1) Are impact forces increased in the contralateral leg of people with unilateral plantar flexor weakness compared to healthy subjects? 2) Do energy cost optimized AFOs reduce impact forces and improve leg impact symmetry compared to walking without AFO in people with unilateral plantar flexor weakness? METHODS: Nine subjects with unilateral plantar flexor weakness were provided a dorsal leaf AFO with a stiffness primarily optimized for energy cost. Using 3D gait analyses peak vertical GRF during loading response with and without AFO, and the symmetry between the legs in peak GRF were calculated. Peak GRF and symmetry were compared with reference data of 23 healthy subjects. RESULTS: The contralateral leg showed a significant higher peak vertical GRF (12.0 ± 0.9 vs 11.2 ± 0.6 N/kg, p = 0.005) compared to healthy reference data. When walking with AFO, the peak vertical GRF of the contralateral leg significantly reduced (from 12.0 ± 0.9 to 11.4 ± 0.7 N/kg, p = 0.017) and symmetry improved compared to no AFO (from 0.93 ± 0.06 to 1.01 ± 0.05, p < 0.001). CONCLUSION: In subjects with unilateral plantar flexor weakness, impact force on the contralateral leg was increased when compared to healthy subjects and dorsal leaf AFOs optimized for energy cost substantially reduced this force and improved impact symmetry when compared to walking without AFO. This indicates that dorsal leaf AFOs may reduce pain resulting from increased impact forces during gait in the contralateral leg in people with unilateral plantar flexor weakness.

Effectiveness of 3D-printed orthoses for traumatic and chronic hand conditions: A scoping review.

BACKGROUND: In the field of orthotics, the use of three-dimensional (3D) technology as an alternative to the conventional production process of orthoses is growing. PURPOSE: This scoping review aimed to systematically map and summarize studies assessing the effectiveness of 3D-printed orthoses for traumatic and chronic hand conditions, and to identify knowledge gaps. METHODS: The Cochrane Library, PubMed, EMBASE, CINAHL, Web of Science, IEEE, and PEDro were searched for studies of any type of 3D-printed orthoses for traumatic and chronic hand conditions. Any outcome related to the effectiveness of 3D-printed orthoses was considered. Two reviewers selected eligible studies, charted data on study characteristics by impairment type, and critically appraised the studies, except for case reports/series. RESULTS: Seventeen studies were included: four randomized controlled trials, four uncontrolled trials, four case series and five case reports. Only three studies had a sample size >20. Impairments described were forearm fractures (n = 5), spasticity (n = 5), muscle weakness (n = 4), joint contractures (n = 2) and pain (n = 1). Four poor to fair quality studies on forearm fractures supported the effectiveness of 3D-printed orthoses on hand function, functionality, and satisfaction. One good quality study on spasticity demonstrated the effectiveness of 3D-printed orthoses on hand function. One poor quality pain study reported limited positive effects on satisfaction. Studies on muscle weakness and joint contractures showed no benefits. CONCLUSION: Current literature addressing the effectiveness of 3D-printed orthoses for traumatic and chronic hand conditions consists primarily of small and poor methodological quality studies. There is a need for well-designed controlled trials including patient-related outcomes, production time and cost analyses.

Validation of forward simulations to predict the effects of bilateral plantarflexor weakness on gait.

BACKGROUND: Bilateral plantarflexor muscle weakness is a common impairment in many neuromuscular diseases. However, the way in which severity of plantarflexor weakness affects gait in terms of walking energy cost and speed is not fully understood. Predictive simulations are an attractive alternative to human experiments as simulations allow systematic alterations in muscle weakness. However, simulations of pathological gait have not yet been validated against experimental data, limiting their applicability. RESEARCH QUESTION: Our first aim was to validate a predictive simulation framework for walking with bilateral plantarflexor weakness by comparing predicted gait against experimental gait data of patients with bilateral plantarflexor weakness. Secondly, we aimed to evaluate how incremental levels of bilateral plantarflexor weakness affect gait. METHODS: We used a planar musculoskeletal model with 9 degrees of freedom and 9 Hill-type muscle-tendon units per leg. A state-dependent reflex-based controller optimized for a function combining energy cost, muscle activation squared and head acceleration was used to simulate gait. For validation, strength of the plantarflexors was reduced by 80 % and simulated gait compared with experimental data of 16 subjects with bilateral plantarflexor weakness. Subsequently, strength of the plantarflexors was reduced stepwise to evaluate its effect on gait kinematics and kinetics, walking energy cost and speed. RESULTS: Simulations with 80 % weakness matched well with experimental hip and ankle kinematics and kinetics (R > 0.64), but less for knee kinetics (R < 0.55). With incremental strength reduction, especially beyond a reduction of 60 %, the maximal ankle moment and power decreased. Walking energy cost and speed showed a strong quadratic relation (R2>0.82) with plantarflexor strength. SIGNIFICANCE: Our simulation framework predicted most gait changes due to bilateral plantarflexor weakness, and indicates that pathological gait features emerge especially when bilateral plantarflexor weakness exceeds 60 %. Our framework may support future research into the effect of pathologies or assistive devices on gait.

Which cancer survivors are at risk for a physically inactive and sedentary lifestyle? Results from pooled accelerometer data of 1447 cancer survivors.

BACKGROUND: Physical activity has beneficial effects on the health of cancer survivors. We aimed to investigate accelerometer-assessed physical activity and sedentary time in cancer survivors, and describe activity profiles. Additionally, we identify demographic and clinical correlates of physical activity, sedentary time and activity profiles. METHODS: Accelerometer, questionnaire and clinical data from eight studies conducted in four countries (n = 1447) were pooled. We calculated sedentary time and time spent in physical activity at various intensities using Freedson cut-points. We used latent profile analysis to identify activity profiles, and multilevel linear regression analyses to identify demographic and clinical variables associated with accelerometer-assessed moderate to vigorous physical activity (MVPA), sedentary time, the highly active and highly sedentary profile, adjusting for confounders identified using a directed acyclic graph. RESULTS: Participants spent on average 26 min (3%) in MVPA and 568 min (66%) sedentary per day. We identified six activity profiles. Older participants, smokers and participants with obesity had significantly lower MVPA and higher sedentary time. Furthermore, men had significantly higher MVPA and sedentary time than women and participants who reported less fatigue had higher MVPA time. The highly active profile included survivors with high education level and normal body mass index. Haematological cancer survivors were less likely to have a highly active profile compared to breast cancer survivors. The highly sedentary profile included older participants, males, participants who were not married, obese, smokers, and those < 12 months after diagnosis. CONCLUSIONS: Cancer survivors engage in few minutes of MVPA and spend a large proportion of their day sedentary. Correlates of MVPA, sedentary time and activity profiles can be used to identify cancer survivors at risk for a sedentary and inactive lifestyle.

Effects and moderators of exercise on sleep in adults with cancer: Individual patient data and aggregated meta-analyses.

OBJECTIVES: To evaluate the effects of exercise interventions on sleep disturbances and sleep quality in patients with mixed cancer diagnoses, and identify demographic, clinical, and intervention-related moderators of these effects. METHODS: Individual patient data (IPD) and aggregated meta-analyses of randomized controlled trials (RCTs). Using data from the Predicting OptimaL cAncer RehabIlitation and Supportive care project, IPD of 2173 adults (mean age = 54.8) with cancer from 17 RCTs were analyzed. A complementary systematic search was conducted (until November 2018) to study the overall effects and test the representativeness of analyzed IPD. Effect sizes of exercise effects on self-reported sleep outcomes were calculated for all included RCTs. Linear mixed-effect models were used to evaluate the effects of exercise on post-intervention outcome values, adjusting for baseline values. Moderator effects were studied by testing interactions for demographic, clinical and intervention-related characteristics. RESULTS: For all 27 eligible RCTs from the updated search, exercise interventions significantly decreased sleep disturbances in adults with cancer (g = -0.09, 95% CI [-0.16; -0.02]). No significant effect was obtained for sleep quality. RCTs included in IPD analyses constituted a representative sample of the published literature. The intervention effects on sleep disturbances were not significantly moderated by any demographic, clinical, or intervention-related factor, nor by sleep disturbances. CONCLUSIONS: This meta-analysis provides some evidence that, compared to control conditions, exercise interventions may improve sleep disturbances, but not sleep quality, in cancer patients, although this effect is of a small magnitude. Among the investigated variables, none was found to significantly moderate the effect of exercise interventions on sleep disturbances.

Return to work experiences of patients treated with stem cell transplantation for a hematologic malignancy.

PURPOSE: This qualitative study aimed to identify hematopoietic stem cell transplantation (HSCT) survivors' (1) work perceptions; (2) barriers to and facilitators of return to work (RTW); and (3) possible solutions to improve RTW. METHOD: Fifteen patients treated with HSCT 1-5 years ago participated in face-to-face semi-structured interviews. Interviews were analyzed following the steps of thematic content analyses. RESULTS: RTW was often characterized as a complex and prolonged trajectory, and it was frequently incomplete in working hours, tasks, and/or responsibilities. Work perceptions varied between patients; most valued work as positive, but some also reported a decline in work capacity and/or in importance. Perceived barriers included the duration and side effects of cancer treatment, the presence of comorbidity and poor health before diagnosis, having difficulties commuting and doing household tasks. Perceived facilitators were financial incentives, keeping in touch with the workplace, support of other patients and family, and looking after one's health. Proposed solutions to improve RTW included discussing RTW at the hospital, enhanced employer support, improved accessibility of rehabilitation programs, and more information about the consequences of being sick-listed. CONCLUSIONS: Many HSCT survivors value work as important and they are motivated to RTW. Insight in work perceptions, RTW barriers, and solutions might help researchers, healthcare professionals, and employers to develop and/or tailor individualized multidisciplinary care to facilitate RTW.

Lessons learnt from a process evaluation of an exercise intervention in patients treated with autologous stem cell transplantation.

This paper describes the process evaluation of an 18-week supervised exercise programme in 50 patients treated with high-dose chemotherapy followed by autologous stem cell transplantation. The intervention included 30 exercise sessions with six resistance exercises and interval training. We evaluated the context, dose delivered and received, and patients' and physiotherapists' satisfaction with the intervention. Ninety-two per cent of the patients trained within 15 km of their home address, with an average session attendance of 86%. Most patients trained at the prescribed intensity for four of the six resistance exercises, but the dose delivered and received of the two remaining resistance exercises and interval training could not be determined. Both patients and physiotherapists highly appreciated the programme (score of 8.3 and 7.9 out of 10 respectively). This process evaluation provided valuable lessons for future trials: (1) It is possible to deliver supervised exercise training to this patient group in local physiotherapy practices; (2) to determine dose received all intervention components should be standardised; and (3) to optimise data collection, all study materials should be tested more extensively prior to the start of the intervention.

Surviving critical illness: what is next? An expert consensus statement on physical rehabilitation after hospital discharge.

BACKGROUND: The study objective was to obtain consensus on physical therapy (PT) in the rehabilitation of critical illness survivors after hospital discharge. Research questions were: what are PT goals, what are recommended measurement tools, and what constitutes an optimal PT intervention for survivors of critical illness? METHODS: A Delphi consensus study was conducted. Panelists were included based on relevant fields of expertise, years of clinical experience, and publication record. A literature review determined five themes, forming the basis for Delphi round one, which was aimed at generating ideas. Statements were drafted and ranked on a 5-point Likert scale in two additional rounds with the objective to reach consensus. Results were expressed as median and semi-interquartile range, with the consensus threshold set at ≤0.5. RESULTS: Ten internationally established researchers and clinicians participated in this Delphi panel, with a response rate of 80 %, 100 %, and 100 % across three rounds. Consensus was reached on 88.5 % of the statements, resulting in a framework for PT after hospital discharge. Essential handover information should include information on 15 parameters. A core set of outcomes should test exercise capacity, skeletal muscle strength, function in activities of daily living, mobility, quality of life, and pain. PT interventions should include functional exercises, circuit and endurance training, strengthening exercises for limb and respiratory muscles, education on recovery, and a nutritional component. Screening tools to identify impairments in other health domains and referral to specialists are proposed. CONCLUSIONS: A consensus-based framework for optimal PT after hospital discharge is proposed. Future research should focus on feasibility testing of this framework, developing risk stratification tools and validating core outcome measures for ICU survivors.

A novel approach for BCR-ABL1 standardization to improve International Scale estimation.

INTRODUCTION: Standardization of BCR-ABL1 messenger RNA quantification by real-time PCR on the International Scale (IS) is critical for monitoring therapy response in chronic myelogenous leukaemia. Since 2006, BCR-ABL1 IS standardization is propagated along reference laboratories by calculating a laboratory-specific conversion factor (CF), co-ordinated in Europe through the European Treatment and Outcome Study project. Although this process has proven successful to some extent, it has not been achievable for all laboratories due to the complexity of the process and the stringent requirements in terms of numbers of samples to be exchanged. In addition, several BCR-ABL1 IS quantification methods and secondary reference materials became commercially available. However, it was observed that different IS methods generate consistently different results. METHODS: To overcome these difficulties, we have developed an alternative and simple approach of CF calculation, based on the retrospective analysis of existing external quality assessment (EQA) data. Our approach does not depend on the exchange of samples and is solely based on the mathematical CF calculation using EQA results. RESULTS AND CONCLUSION: We have demonstrated by thorough statistical validation that this approach performs well in converting BCR-ABL1 measurements to improve IS estimation. In expectation of a true golden standard method for BCR-ABL1 IS quantification, the proposed method is a valuable alternative.

Early intervention leads to long-term developmental improvements in very preterm infants, especially infants with bronchopulmonary dysplasia.

AIM: Various early intervention programmes have been developed in response to the high rate of neurodevelopmental problems in very preterm infants. We investigated longitudinal effects of the Infant Behavioral Assessment and Intervention Program on cognitive and motor development of very preterm infants at the corrected ages of six months to five and a half years. METHODS: This randomised controlled trial divided 176 infants with a gestational age <32 weeks or birthweight <1500 g into intervention (n = 86) and control (n = 90) groups. Cognitive development and motor development were assessed with the Bayley Scales of Infant Development at the CAs of six, 12 and 24 months and at five and a half years with the Wechsler Preschool and Primary Scale of Intelligence and the Movement Assessment Battery for Children. RESULTS: We found significant longitudinal intervention effects (0.4 SD, p = 0.006) on motor development, but no significant impact on cognitive development (p = 0.063). Infants with bronchopulmonary dysplasia showed significant longitudinal intervention effects for cognitive (0.7 SD; p = 0.019) and motor (0.9 SD; p = 0.026) outcomes. Maternal education had little effect on intervention effects over time. CONCLUSION: The Infant Behavioral Assessment and Intervention Program led to long-term developmental improvements in the intervention group, especially in infants with BPD.

Elevated plasma inflammatory mediators in post-polio syndrome: No association with long-term functional decline.

A key feature of post-polio syndrome (PPS) is progressive loss of muscle strength. In other chronic diseases systemic inflammation has been linked to muscle wasting. In this study plasma TNF-α, IL-6, IL-8, and leptin levels were significantly increased in PPS-patients compared to healthy controls. There was however no association between these raised systemic levels of inflammatory mediators and long-term decline in quadriceps strength or other clinical parameters. In conclusion, there is evidence for systemic inflammation in PPS, yet the relationship with clinical deterioration remains tenuous.

Bing-Neel syndrome: Two unexpected cases and a review of the literature.

Waldenström macroglobulinemia (WM) is a lymphoplasmacytic lymphoma characterized by the proliferation of small B-lymphocytes in the bone marrow that produce monoclonal immunoglobulin M (IgM). We describe two patients with WM who presented with neurological symptoms due to infiltration of lymphoplasmacytoid tumor cells in the central nervous system, a condition known as Bing-Neel syndrome. A literature review revealed that this syndrome is rare and commonly missed in clinical practice due to its variable presentation and a lack of awareness or knowledge. Brain and spinal magnetic resonance imaging may show a focal mass or diffuse infiltration. The diagnosis of Bing-Neel syndrome requires proof of IgM or lymphoplasmacytoid cells in cerebrospinal fluid or in a brain biopsy. Treatment with intravenous and/or intrathecal chemotherapy and cranial radiotherapy is described in literature with generally poor outcome, although a combination of these therapies seems to improve outcome. Nevertheless, insufficient data are currently available to make general treatment recommendations.

Data-driven directions for effective footwear provision for the high-risk diabetic foot.

AIMS: Custom-made footwear is used to offload the diabetic foot to prevent plantar foot ulcers. This prospective study evaluates the offloading effects of modifying custom-made footwear and aims to provide data-driven directions for the provision of effectively offloading footwear in clinical practice. METHODS: Eighty-five people with diabetic neuropathy and a recently healed plantar foot ulcer, who participated in a clinical trial on footwear effectiveness, had their custom-made footwear evaluated with in-shoe plantar pressure measurements at three-monthly intervals. Footwear was modified when peak pressure was ≥ 200 kPa. The effect of single and combined footwear modifications on in-shoe peak pressure at these high-pressure target locations was assessed. RESULTS: All footwear modifications significantly reduced peak pressure at the target locations compared with pre-modification levels (range -6.7% to -24.0%, P < 0.001). The metatarsal heads were most frequently targeted. Repositioning an existing (trans-)metatarsal pad in the shoe insole (-15.9% peak pressure relief), applying local cushioning to the insole (-15.0%) and replacing the insole top cover with Plastazote (-14.2%) were the most effective single modifications. Combining a new Plastazote top cover with a trans-metatarsal bar (-24.0% peak pressure relief) or with local cushioning (-22.0%) were the most effective combined modifications. CONCLUSIONS: In people with diabetic neuropathy and a recently healed plantar foot ulcer, significant offloading can be achieved at high-risk foot regions by modifying custom-made footwear. These results provide data-driven directions for the design and evaluation of custom-made footwear for high-risk people with diabetes, and essentially mean that each shoe prescribed should incorporate those design features that effectively offload the foot.

Change in physical mobility over 10 years in post-polio syndrome.

Post-polio syndrome is characterised by progressive muscle weakness and other symptoms which can limit physical mobility. We assessed the rate of decline in mobility over 10 years in relation to strength decline; and investigated potential predictors for the rate of decline of walking capacity, a measure of mobility, in 48 patients with post-polio syndrome and proven quadriceps dysfunction at baseline. Average walking capacity and self-reported physical mobility declined over 10 years, by 6 and 14%, respectively. Concomitantly people lost an average of 15% of isometric quadriceps strength. Significantly more people used walking aids offering greater support at follow-up. Notably, there was much individual variation, with 18% of participants losing a substantial amount of walking capacity (27% decline) and concomitant self-reported physical mobility (38% decline). Loss of quadriceps strength only explained a small proportion of the variance of the decline in walking capacity (R = 11%) and the rate of decline could not be predicted from baseline values for strength, walking capacity, self-reported physical mobility or basic demographics. The individual variability, yet lack of predictive factors, underscores the need for personally tailored care based on actual functional decline in patients with post-polio syndrome.

Feasibility of Post-Intensive Care Unit Clinics: an observational cohort study of two different approaches.

BACKGROUND: Post-ICU clinics have been advocated to reduce long-term physical and psychological impairments among ICU survivors. A format for optimal structure, timing, and care content has not yet been established. We developed and implemented two post-ICU clinics in different hospital settings and evaluated the feasibility. METHODS: In this prospective cohort study ICU-survivors of a university hospital (AMC) and a general hospital (TG), who were mechanically ventilated ≥ 2 days and discharged to their homes, were invited to the post-ICU clinic one month after hospital discharge (AMC) or three months after ICU discharge (TG). Feasibility was evaluated as 1) the number of eligible ICU-survivors and the proportion that attended; 2) the prevalence of ICU-related abnormalities, that required referral for further treatment; and 3) patient satisfaction. RESULTS: Forty-five of 629 AMC-patients and 70 of 142 TG-patients were eligible for the post-ICU clinic. Of these, 49% and 67% respectively, visited the outpatient clinic (P=0.026). The majority of all screened patients had functional restrictions, and 68% required referral for further diagnosis and treatment. Patient satisfaction was high. CONCLUSION: This study provides valuable information to support the implementation of post-ICU clinics. The use of validated screening instruments facilitates the identification of patients with need for further treatment. Early in-hospital screening and recruiting patients at highest risk for adverse outcome could be a more targeted approach to achieve greater benefit.