Shoe and Field Surface Risk Factors for Acute Lower Extremity Injuries Among Female Youth Soccer Players.

OBJECTIVE: To describe acute lower extremity injuries and evaluate extrinsic risk factors in female youth soccer. DESIGN: Nested case-control study. SETTING: Youth soccer clubs in Seattle, WA. PARTICIPANTS: Female soccer players (n = 351) ages 11 to 15 years randomly selected from 4 soccer clubs from which 83% of their players were enrolled with complete follow-up for 92% of players. INTERVENTIONS: Injured players were interviewed regarding injury, field surface, shoe type, and position. Uninjured controls, matched on game or practice session, were also interviewed. MAIN OUTCOME MEASURES: The association between risk factors and acute lower extremity injury using logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI). RESULTS: One hundred seventy-three acute lower extremity injuries occurred involving primarily the ankle (39.3%), knee (24.9%), and thigh (11.0%). Over half (52.9%) recovered within 1 week, whereas 30.2% lasted beyond 2 weeks. During practices, those injured were approximately 3-fold (OR, 2.83; 95% CI, 1.49-5.31) more likely to play on grass than artificial turf and 2.4-fold (95% CI, 1.03-5.96) more likely to wear cleats on grass than other shoe and surface combinations. During games, injured players were 89% (95% CI, 1.03-4.17) more likely to play defender compared with forward. CONCLUSIONS: Half of the acute lower extremity injuries affected the ankle or knee. Grass surface and wearing cleats on grass increased training injuries. CLINICAL RELEVANCE: The majority, 64%, of female youth soccer players' acute injuries involve the ankle and knee and injury prevention strategies in this age group should target these areas. When considering playing surfaces for training, communities and soccer organizations should consider the third-generation artificial turf a safe alternative to grass.

A randomized, double-blind phase I/IIa study of intranasal glutathione in Parkinson's disease.

BACKGROUND: Depletion of reduced glutathione is associated with PD and glutathione augmentation has been proposed as a disease-modifying strategy. The aim of this study was to determine the safety and tolerability of intranasal reduced glutathione in individuals with PD. METHODS: Thirty individuals with PD were randomized to either placebo (saline), 300 mg/day, or 600 mg/day of intranasal glutathione in three divided daily doses. Follow-up visits included side effect screening of PD symptoms and cognition, blood chemistry, sinus irritation, and hyposmia. Tolerability was measured by frequency and severity of reported adverse events, compliance, and withdrawals from the study. RESULTS: After 3 months, there were no substantial differences between groups in the number of adverse events reported or observed among all safety measures assessed. All groups met tolerability criteria. CONCLUSIONS: These data support the safety and tolerability of intranasal glutathione in this population. Pharmacokinetic and dose-finding studies are warranted.

Agreement between allergen-specific IgE assays and ensuing immunotherapy recommendations from four commercial laboratories in the USA.

BACKGROUND: Canine allergen-specific IgE assays in the USA are not subjected to an independent laboratory reliability monitoring programme. HYPOTHESIS/OBJECTIVES: The aim of this study was to evaluate the agreement of diagnostic results and treatment recommendations of four serum IgE assays commercially available in the USA. METHODS: Replicate serum samples from 10 atopic dogs were submitted to each of four laboratories for allergen-specific IgE assays (ACTT(®) , VARL Liquid Gold, ALLERCEPT(®) and Greer(®) Aller-g-complete(®) ). The interlaboratory agreement of standard, regional panels and ensuing treatment recommendations were analysed with the kappa statistic (κ) to account for agreement that might occur merely by chance. Six comparisons of pairs of laboratories and overall agreement among laboratories were analysed for ungrouped allergens (as tested) and also with allergens grouped according to reported cross-reactivity and taxonomy. RESULTS: The overall chance-corrected agreement of the positive/negative test results for ungrouped and grouped allergens was slight (κ = 0.14 and 0.13, respectively). Subset analysis of the laboratory pair with the highest level of diagnostic agreement (κ = 0.36) found slight agreement (κ = 0.13) for ungrouped plants and fungi, but substantial agreement (κ = 0.71) for ungrouped mites. The overall agreement of the treatment recommendations was slight (κ = 0.11). Altogether, 85.1% of ungrouped allergen treatment recommendations were unique to one laboratory or another. CONCLUSIONS AND CLINICAL IMPORTANCE: Our study indicated that the choice of IgE assay may have a major influence on the positive/negative results and ensuing treatment recommendations.

Reproducibility of a quantitative cutaneous cytological technique.

BACKGROUND: Cutaneous cytology is a valuable tool for diagnosis of canine superficial pyoderma. Current published reproducible techniques are semiquantitative. HYPOTHESIS/OBJECTIVES: The aim of this study was to evaluate the reproducibility of a quantitative method for skin surface cytology in dogs with superficial pyoderma. ANIMALS: Impression smears were collected from five normal dogs and 20 dogs with clinical and cytological evidence of superficial pyoderma. METHODS: Four investigators evaluated 10 oil immersion fields (OIF) on 25 slides, selecting fields with inflammatory cells, nuclear streaming and or keratinocytes under ×10 magnification. Investigators repeated blinded evaluations of all slides at least twice. For each OIF, polymorphonuclear leukocytes (PMNs), intracellular (IC) cocci, extracellular (EC) cocci, IC rods, EC rods and yeast were quantified. Nuclear streaming was scored as present or absent. For each parameter, within-reader and between-reader agreements were expressed by the intraclass correlation (ICC) value (≤0.20 poor, 0.21-0.40 fair, 0.41-0.60 moderate, 0.61-0.80 good and 0.81-1.00 excellent) or kappa statistic (κ). RESULTS: Reproducible parameters included: PMNs (ICC = 0.58), nuclear streaming (ICC = 0.68), EC cocci (ICC = 0.64) and IC cocci (ICC = 0.32). When qualified as present or absent, within-reader κ for IC cocci was 0.71. The method demonstrated 93% sensitivity in identifying dogs with superficial pyoderma and 51% specificity in identifying normal dogs according to established criteria. However, if criteria for normal dogs were limited to the absence of PMNs and IC bacteria, sensitivity of 64% and specificity of 98% were demonstrated. CONCLUSIONS AND CLINICAL IMPORTANCE: For several parameters, including PMNs, nuclear streaming, EC cocci and IC cocci, a reproducible, quantitative cytological technique was identified.

Evaluation of the Zachery Lystedt Law among female youth soccer players.

BACKGROUND: Despite recent increased awareness about sports concussions, few studies have evaluated the effect of concussion laws on concussion outcomes among young athletes. The purpose of our study was to evaluate the effect of the Washington State Zachery Lystedt Concussion Law on playing with concussion symptoms and being evaluated by a health care provider. METHODS: We performed a prospective cohort study of 351 elite female soccer players, aged 12 to 15 years, from 33 randomly selected youth soccer teams in the Puget Sound region of Washington State from 2008 to 2012. The Washington State Zachery Lystedt Concussion Law went into effect on July 1, 2009. Among concussed players (N = 59), we assessed the risk of playing with symptoms, the evaluation by a health care professional, and receiving a concussion diagnosis before and after the law was passed using logistic regression to estimate odds ratios and 95% CIs. RESULTS: The majority of concussed players (59.3%) continued to play with symptoms, and we found no statistically significant difference in the proportion of players who played with symptoms before and after the law was passed. Only 44.1% of concussed players were evaluated by a health care provider, with no difference before and after the law was passed. Among those evaluated by a health care professional, players were 2.1-fold (95% CI, 1.0-10.1) more likely to receive a concussion diagnosis after the law was passed. CONCLUSION: The majority of concussed female youth soccer players report playing with symptoms. Legislation mandating concussion education and evaluation prior to returning to play was not associated with an increase in concussion evaluations by health care providers.

A Machine Learning Approach for Predicting Real-time Risk of Intraoperative Hypotension in Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) is a major cause of death and disability. Episodes of hypotension are associated with worse TBI outcomes. Our aim was to model the real-time risk of intraoperative hypotension in TBI patients, compare machine learning and traditional modeling techniques, and identify key contributory features from the patient monitor and medical record for the prediction of intraoperative hypotension. METHODS: The data included neurosurgical procedures in 1005 TBI patients at an academic level 1 trauma center. The clinical event was intraoperative hypotension, defined as mean arterial pressure <65 mm Hg for 5 or more consecutive minutes. Two types of models were developed: one based on preoperative patient-level predictors and one based on intraoperative predictors measured per minute. For each of these models, we took 2 approaches to predict the occurrence of a hypotensive event: a logistic regression model and a gradient boosting tree model. RESULTS: The area under the receiver operating characteristic curve for the intraoperative logistic regression model was 0.80 (95% confidence interval [CI]: 0.78-0.83), and for the gradient boosting model was 0.83 (95% CI: 0.81-0.85). The area under the precision-recall curve for the intraoperative logistic regression model was 0.16 (95% CI: 0.12-0.20), and for the gradient boosting model was 0.19 (95% CI: 0.14-0.24). Model performance based on preoperative predictors was poor. Features derived from the recent trend of mean arterial pressure emerged as dominantly predictive in both intraoperative models. CONCLUSIONS: This study developed a model for real-time prediction of intraoperative hypotension in TBI patients, which can use computationally efficient machine learning techniques and a streamlined feature-set derived from patient monitor data.

Development and validation of the Canine Atopic Dermatitis Lesion Index, a scale for the rapid scoring of lesion severity in canine atopic dermatitis.

BACKGROUND: The third iteration of the Canine Atopic Dermatitis Extent and Severity Index (CADESI-03) is the only tool rigorously validated for canine atopic dermatitis (CAD) lesion scoring. The CADESI-03 requires 248 evaluations, limiting its widespread use. HYPOTHESIS/OBJECTIVES: The goal of the study was to develop and validate a practical method of grading CAD lesions that requires scoring only the frequently affected body regions. ANIMALS: Fifty-seven privately owned atopic dogs were used in the study. METHODS: The Canine Atopic Dermatitis Lesion Index (CADLI) was evaluated in an open, multicentre reliability study. Validity was assessed with expert opinion (content validity) and comparison of CADLI with existing disease severity measures (construct and criterion validity). Reliability was evaluated by analysing repeated observations of each dog. Convenience was assessed in terms of the time required to complete the scale. RESULTS: The CADLI scores correlated with overall assessment scores (r = 0.60, P < 0.001, linear mixed model) and pruritus severity scores (r = 0.53, P < 0.001, linear mixed model), establishing construct validity. The CADLI was strongly correlated with CADESI-03 (r = 0.84, P < 0.001, linear mixed model), establishing criterion validity. The CADLI values obtained by two observers correlated very strongly (r = 0.91, P < 0.001), as did the repeat values for the same observer (r = 0.98, P < 0.001). The mean time to complete the CADLI was less than that required for CADESI-03 (1.9 and 12.6 min, respectively), a highly significant difference (P < 0.001). CONCLUSION AND CLINICAL IMPORTANCE: The CADLI was found to be an effective measure of CAD lesion severity, strongly correlating with CADESI-03. The convenience of CADLI makes it suitable for use in both clinical research and practice.

Cytotoxic Effects of Common Irrigation Solutions on Chondrosarcoma and Giant Cell Tumors of Bone.

BACKGROUND: Irrigation is commonly used as an adjuvant treatment during the intralesional curettage of bone tumors. The goal of the present study was to analyze the in vitro cytotoxicity of commonly used irrigation solutions on chondrosarcoma and giant cell tumor (GCT) cells as there is no consensus on which solution leads to the greatest amount of cell death. METHODS: An in vitro evaluation was performed by exposing human GCT and human chondrosarcoma cell lines to 0.9% saline solution, sterile water, 70% ethanol, 3% hydrogen peroxide, 0.05% chlorhexidine gluconate (CHG), and 0.3% povidone iodine solutions independently for 2 and 5 minutes. A low-cytotoxicity control (LCC) and a high-cytotoxicity control (HCC) were established to determine the mean cytotoxicity of each solution and each solution's superiority to LCC and non-inferiority to HCC. RESULTS: The present study demonstrated that 0.05% CHG was non-inferior to the HCC when chondrosarcoma was exposed for 5 minutes and when GCT was exposed for 2 and 5 minutes (mean cytotoxicity, 99% to 102%) (p < 0.003 for all). Sterile water was superior to the LCC when chondrosarcoma was exposed for 5 minutes and when GCT was exposed for 2 minutes (mean, 28% to 37%) (p < 0.05). Sterile water (mean, 18% to 38%) (p < 0.012) and 3% hydrogen peroxide (mean, 7% to 16%) (p < 0.001) were both inferior to the HCC. The 3 other solutions were non-superior to the LCC (mean, -24% to -5%) (p < 0.023). CONCLUSIONS: In vitro irrigation in 0.05% CHG provided high cytotoxicity, comparable with the HCC. Therefore, the use of a 0.05% CHG solution clinically could serve as a potential chemical adjuvant during intralesional curettage of chondrosarcoma and GCT. CLINICAL RELEVANCE: In an effort to reduce the burden of residual tumor cells, irrigation solutions are often utilized as adjuvant local therapy. Use of a 0.05% CHG solution clinically could serve as a potential chemical adjuvant to intralesional curettage of chondrosarcoma and GCT. Further in vivo studies may be indicated to assess clinical outcomes and safety associated with the use of 0.05% CHG in the treatment of chondrosarcoma and GCT.

Comparison of anal sac cytological findings and behaviour in clinically normal dogs and those affected with anal sac disease.

No previous study has explored the relationship between cytology and the frequency of behaviours associated with anal sac disease (ASD). The goals of the study were: (i) to compare the cytological findings between anal sac secretions from normal dogs with no history of ASD to those with non-neoplastic ASD; (ii) to determine whether anal sac cytological findings can be used to differentiate between normal dogs and dogs with ASD; (iii) to explore the correlation of anal sac cytology and behaviour between normal dogs and dogs with ASD; and (iv) to describe behaviours typical of ASD as reported by owners. Thirty dogs were selected for this study, based on their behavioural history as detailed in a questionnaire completed by their owners. Of the thirty dogs, ten were considered normal insofar as they had no history of ASD clinical signs. The remaining 20 dogs were characterized as having ASD, with a chronic history of perianal pruritus, but no other pruritus. All dogs had their anal sacs manually expressed, and the discharge was examined microscopically in a blinded manner. A total of 171 oil immersion fields (OIFs) were examined from normal dogs and 333 OIFs from dogs with ASD. The behavioural results for dogs with ASD revealed that scooting recurred with a median frequency of 3 weeks post-anal sac expression. There were no clinically statistically significant cytological differences between normal dogs and those with ASD, thereby leading to the conclusion that cytology is an ineffective tool for diagnosing ASD.

Implementing Primary Palliative Care in Post-acute nursing home care: Protocol for an embedded pilot pragmatic trial.

INTRODUCTION: Older adults with serious illness frequently receive post-acute rehabilitative care in nursing homes (NH) under the Part A Medicare Skilled Nursing Facility (SNF) Benefit. Treatment is commonly focused on disease-modifying therapies with minimal consideration for goals of care, symptom relief, and other elements of palliative care. INTERVENTION: The evidence-based Primary Palliative Care in Post-Acute Care (PPC-PAC) intervention for older adults is delivered by nurse practitioners (NP). PPC-PAC NPs assess and manage symptoms, conduct goals of care discussions and assist with decision making; they communicate findings with NH staff and providers. Implementation of PPC-PAC includes online and face-to-face training of NPs, ongoing facilitation, and a template embedded in the NH electronic health record to document PPC-PAC. OBJECTIVES: The objectives of this pilot pragmatic clinical trial are to assess the feasibility, acceptability, and preliminary effectiveness of the PPC-PAC intervention and its implementation for 80 seriously ill older adults newly admitted to a NH for post-acute care. METHODS: Design is a two-arm nonequivalent group multi-site pilot pragmatic clinical trial. The unit of assignment is at the NP and unit of analysis is NH patients. Recruitment occurs at NHs in Pennsylvania, New Jersey, Delaware, and Maryland. Effectiveness (patient quality of life) data are collected at two times points-baseline and 14-21 days. CONCLUSION: This will be the first study to evaluate the implementation of an evidence-based primary palliative care intervention specifically designed for older adults with serious illness who are receiving post-acute NH care.

Hemorrhage and large lipid-rich necrotic cores are independently associated with thin or ruptured fibrous caps: an in vivo 3T MRI study.

OBJECTIVE: Histological studies suggest associations between hemorrhage and large lipid-rich/necrotic cores with thin or ruptured fibrous caps in advanced atherosclerosis. We investigated these associations in carotid arteries with mild to severe stenosis by in vivo 3T MRI. METHODS AND RESULTS: Seventy-seven patients with >or=50% carotid stenosis in at least one side by duplex ultrasound underwent bilateral multi-contrast carotid MRI scans. Measurements for wall and lipid-rich/necrotic core sizes, presence of hemorrhage, and fibrous cap status (classified as intact thick, intact thin or ruptured) were recorded. Arteries with poor image quality, occlusion, or no detectable lipid-rich/necrotic core were excluded. For the 798 MRI slices included, multivariate ordinal regression analysis demonstrated larger %lipid-rich/necrotic core (odds ratio for 10% increase, 1.49; P=0.02) and presence of hemorrhage (odds ratio, 5.91; P<0.001) were independently associated with a worse (intact thin or ruptured) stage of fibrous cap status. For artery-based multivariate analysis, a larger maximum %lipid-rich/necrotic core and presence of hemorrhage independently associated with worse fibrous cap status (P<0.001, for both). No hemorrhage was detected in arteries with thick fibrous caps. CONCLUSIONS: Hemorrhage and larger %lipid-rich/necrotic core were independently associated with a thin or ruptured fibrous cap status at an early to advanced stage of carotid atherosclerosis.

Spatial distribution of sequential ventilation during mechanical ventilation of the uninjured lung: an argument for cyclical airway collapse and expansion.

BACKGROUND: Ventilator-induced lung injury (VILI) is a recognized complication of mechanical ventilation. Although the specific mechanism by which mechanical ventilation causes lung injury remains an active area of study, the application of positive end expiratory pressure (PEEP) reduces its severity. We have previously reported that VILI is spatially heterogeneous with the most severe injury in the dorsal-caudal lung. This regional injury heterogeneity was abolished by the application of PEEP = 8 cm H2O. We hypothesized that the spatial distribution of lung injury correlates with areas in which cyclical airway collapse and recruitment occurs. METHODS: To test this hypothesis, rabbits were mechanically ventilated in the supine posture, and regional ventilation distribution was measured under four conditions: tidal volumes (VT) of 6 and 12 ml/kg with PEEP levels of 0 and 8 cm H2O. RESULTS: We found that relative ventilation was sequentially redistributed towards dorsal-caudal lung with increasing tidal volume. This sequential ventilation redistribution was abolished with the addition of PEEP. CONCLUSIONS: These results suggest that cyclical airway collapse and recruitment is regionally heterogeneous and spatially correlated with areas most susceptible to VILI.

Evaluation of otoscope cone disinfection techniques and contamination level in small animal private practice.

The objective of this study was to evaluate the level of bacterial contamination of otoscope cones in veterinary private practice, and to determine the most effective method of disinfection. Fifty small animal practices participated in this study, which included a detailed survey regarding otoscope cleaning, storage and usage and quantitative culture of the cleaned and stored otoscope cones. Using sterile technique, two cones from each of the 50 hospitals were swabbed and submitted for quantitative culture. Contamination was present in 29% of the samples and the following organisms were isolated: Flavobacterium brevis (10%), Pseudomonas aeruginosa (6%), Pseudomonas alcaligenes (4%), Staphylococcus intermedius (4%), Corynebacterium spp. (2%), Bacillus spp. (1%), Enterococcus faecalis (1%) Malassezia spp. (1%). There was no statistically significant difference between storage type (dry versus stored in solution) and for the instrumentation used to clean the cones (brush, cotton-tipped applicator, both versus none). There was a statistically significant difference between the different cleaning solutions (P < 0.001) and between the storage solutions (P = 0.003). A single most effective cleaning solution was unable to be determined due to the large number of solutions utilized. Cetylcide G (Cetylite Industries, Inc., Pennsauken, NJ, USA) was the most effective of the three most commonly used storage solutions (Cetylcide G, Benz-all, and 2% Chlorhexidine gluconate) when used as directed (P < 0.001). The level of contamination had a positive association with the frequency of cone use and a negative association with the frequency of storage solution replacement.

Regional lung blood flow and ventilation in upright humans studied with quantitative SPECT.

We used quantitative Single Photon Emission Computed Tomography (SPECT) to study the effect of the upright posture on regional lung blood flow and ventilation. Nine (upright) plus seven (prone and supine) healthy volunteers were studied awake, breathing spontaneously. Regional blood flow and ventilation were marked in sitting upright, supine and prone postures using (113m)In-labeled macroaggregates and inhaled Technegas ((99m)Tc); both remain fixed in the lung after administration. All images were obtained while supine. In comparison with horizontal postures, both blood flow and ventilation were greater in caudal regions when upright. The redistribution was greater for blood flow than for ventilation, resulting in decreasing ventilation-to-perfusion ratios down the lung when upright. We conclude that gravity redistributes regional blood flow and ventilation in the upright posture, while the influence is much less in the supine and prone postures.

Subclassification of desmoplastic melanoma: pure and mixed variants have significantly different capacities for lymph node metastasis.

BACKGROUND: There is disagreement about the behavior and optimal management of desmoplastic melanoma (DM), particularly regarding the incidence of lymph node (LN) involvement. Recently, investigators have noted the frequently heterogeneous histologic composition of DM and have found significant differences between pure desmoplastic melanoma (PDM) (>or=90% comprised of histologically typical DM) and mixed desmoplastic melanoma (MDM) [>or=10% DM and >10% conventional melanoma (CM)]. METHOD: We reviewed 87 cases of DM comparing the histologic and clinical features of PDM (n = 44) to MDM (n = 43). RESULTS: At surgical staging, there were LN metastases in 5 of 23 (22%) MDM patients, whereas all 17 PDM patients had negative LN biopsies (0%) (p = 0.04). PDM was less often clinically pigmented (36% vs. 67%) and had a lower mean mitotic index (1.3 vs. 3.0). CONCLUSIONS: There are differences between PDM and MDM, the most important of which is the incidence of LN involvement. Our findings support the clinical utility of classifying DM into pure and mixed subtypes because the negligible rate of nodal involvement in PDM does not support the routine performance of sentinel LN biopsy in this subgroup of melanoma patients. In contrast, the incidence of LN involvement in MDM is comparable to that of CM.

Changes in arterial oxygenation and self-reported oxygen use after lung volume reduction surgery.

RATIONALE: Lung volume reduction surgery (LVRS) is inconsistently reported to improve arterial oxygenation in patients with chronic obstructive pulmonary disease. OBJECTIVES: We studied the effects of surgery on oxygenation in a large cohort and identified predictors of postoperative oxygenation improvement. METHODS: We evaluated oxygenation in 1,078 subjects with chronic obstructive pulmonary disease enrolled in the National Emphysema Treatment Trial after LVRS compared with medical control subjects, including arterial blood gases, use of supplemental oxygen during treadmill walking, and self-reported use of oxygen during rest, exertion, and sleep. MEASUREMENTS AND MAIN RESULTS: Pa(O(2)) breathing room air was equal in medical and surgical subjects at baseline (64.8 vs. 65.0 mm Hg, P = not significant), but lower in medical subjects at 6 months (63.6 vs. 70.0 mm Hg, P < 0.001), 12 months (63.9 vs. 68.7 mm Hg, P < 0.001), and 24 months (62.4 vs. 68.0 mm Hg, P < 0.001). Fewer medical subjects required oxygen for treadmill walking at baseline compared with surgical subjects (46 vs. 53%, P = 0.02). However, more medical subjects required oxygen for this activity at 6 months (49 vs. 33%, P < 0.001), 12 months (50 vs. 36%, P < 0.001), and 24 months (52 vs. 42%, P = 0.02). Self-reported oxygen use was greater in medical than in surgical subjects at 6, 12, and 24 months. Multivariate modeling of preoperative characteristics showed baseline oxygenation status was the best predictor of postoperative oxygenation. CONCLUSIONS: LVRS increases Pa(O(2)), and decreases treadmill and self-reported use of oxygen for up to 24 months post-procedure. Clinical trial registered with www.clinicaltrials.gov (NCT 00000606).

Quantitative exposure-response relations between physical workload and prevalence of lateral epicondylitis in a working population.

BACKGROUND: Lateral epicondylitis is a common work-related musculoskeletal disorder. The objective of this study was to identify risk factors associated with lateral epicondylitis among active workers. METHODS: Seven-hundred thirty-three workers in 12 Washington worksites participated in structured interviews, physical examinations, and individual exposure assessments of biomechanical and psychosocial factors. Multivariable logistic modeling was used. RESULTS: Thirty-eight subjects (5.2%) had lateral epicondylitis. Age (36-50 years-old), being female, and low social support at work were significant risk factors. Frequency of forceful exertion (> or =5 vs. < 1 times/min (OR 5.17, 95%CI 1.78-15.02), and > or =1 to <5 vs. <1 (OR 4.47, 95%CI 1.57-13.71)) and forearm supination at > or =45 degrees for > or =5% of the time with high lifting force (OR = 2.98, 95% CI 1.18-7.55) were significant physical load factors. CONCLUSIONS: Frequency of forceful exertion or a combination of forearm supination and forceful lifting were significant physical factors and should be considered for prevention strategies.

Carotid plaque morphology and composition: initial comparison between 1.5- and 3.0-T magnetic field strengths.

PURPOSE: To prospectively compare the interpretation and quantification of carotid vessel wall morphology and plaque composition at 1.5-T with those at 3.0-T magnetic resonance (MR) imaging. MATERIALS AND METHODS: Twenty participants (mean age, 69.8 years [standard deviation] +/- 10.5; 75% men) with 16%-79% carotid stenosis at duplex ultrasonography were imaged with 1.5-T and 3.0-T MR imaging units with bilateral four-element phased-array surface coils. This HIPAA-compliant study was approved by the institutional review board, and all participants gave written informed consent. Protocols designed for similar signal-to-noise ratios across platforms were implemented to acquire axial T1-weighted, T2-weighted, intermediate-weighted, time-of-flight, and contrast material-enhanced T1-weighted images. Lumen area, wall area, total vessel area, wall thickness, and presence or absence and area of plaque components were documented. Continuous variables from different field strengths were compared by using the intraclass correlation coefficient (ICC) and repeated measures analysis. The Cohen kappa was used to evaluate agreement between 1.5 T and 3.0 T on compositional dichotomous variables. RESULTS: There was a strong level of agreement between field strengths for all morphologic variables, with ICCs ranging from 0.88 to 0.96. Agreement in the identification of presence or absence of plaque components was very good for calcification (kappa = 0.72), lipid-rich necrotic core (kappa = 0.73), and hemorrhage (kappa = 0.66). However, the visualization of hemorrhage was greater at 1.5 T than at 3.0 T (14.7% vs 7.8%, P < .001). Calcifications measured significantly (P = .03) larger at 3.0 T, while lipid-rich necrotic cores without hemorrhage were similar between field strengths (P = .9). CONCLUSION: At higher field strengths, the increased susceptibility of calcification and paramagnetic ferric iron in hemorrhage may alter quantification and/or detection. Nevertheless, imaging criteria at 1.5 T for carotid vessel wall interpretation are applicable at 3.0 T.

Effect of rosuvastatin therapy on carotid plaque morphology and composition in moderately hypercholesterolemic patients: a high-resolution magnetic resonance imaging trial.

BACKGROUND: Magnetic resonance imaging (MRI) can noninvasively assess changes in atherosclerotic plaque morphology and composition. The ORION trial assessed the effects of rosuvastatin on carotid plaque volume and composition. METHODS: The randomized, double-blind ORION trial used 1.5-T MRI to image carotid atherosclerotic plaques at baseline and after 24 months of treatment. Forty-three patients with fasting low-density lipoprotein cholesterol > or = 100 and < 250 mg/dL and 16% to 79% carotid stenosis by duplex ultrasound were randomized to receive either a low (5 mg) or high (40/80 mg) dose of rosuvastatin. RESULTS: After 24 months, 33 patients had matched serial MRI scans to compare by reviewers blinded to clinical data, dosage, and temporal sequence of scans. Low-density lipoprotein cholesterol was significantly reduced from baseline in both the low- and high-dose groups (38.2% and 59.9%, respectively, both P < .001). At 24 months, there were no significant changes in carotid plaque volume for either dosage group. In all patients with a lipid-rich necrotic core (LRNC) at baseline, the mean proportion of the vessel wall composed of LRNC (%LRNC) decreased by 41.4% (P = .005). CONCLUSIONS: In patients with moderate hypercholesterolemia, both low- and high-dose rosuvastatin were effective in reducing low-density lipoprotein cholesterol. Furthermore, rosuvastatin was associated with a reduction in %LRNC, whereas the overall plaque burden remained unchanged over the course of 2 years of treatment. These findings provide evidence that statin therapy may have a beneficial effect on plaque volume and composition, as assessed by noninvasive MRI.

Testing the hypothesis of atherosclerotic plaque lipid depletion during lipid therapy by magnetic resonance imaging: study design of Carotid Plaque Composition Study.

BACKGROUND: In vivo testing of the lipid depletion hypothesis in human beings during lipid-modifying therapy has not been possible until recent developments in magnetic resonance imaging (MRI). TRIAL DESIGN: The Carotid Plaque Composition Study is a prospective, randomized study designed to test the lipid depletion hypothesis in vivo. One hundred twenty-three subjects with coronary artery disease (CAD) or carotid disease and with levels of apolipoprotein B > or = 120 mg/dL (low-density lipoprotein levels 100-190 mg/dL) were enrolled and randomized to (1) single therapy--atorvastatin alone, placebos for extended release (ER)-niacin and colesevelam; (2) double therapy--atorvastatin plus ER-niacin (2 g/d), and placebo for colesevelam; (3) triple therapy--atorvastatin, ER-niacin, plus colesevelam (3.8 g/d). All subjects will undergo MRI scans of bilateral carotid arteries at baseline and annually for 3 years for a total of 4 examinations while on active therapy. Among these 123 subjects with mean age of 55 years and mean body mass index of 30 kg/m2, 73% are male, 43% have a family history of premature cardiovascular disease, 37% have had a previous myocardial infarction, 80% have clinically established CAD, 52% are hypertensive, 12% have diabetes, 23% are current smokers, and 47% meet the criteria for metabolic syndrome. The baseline carotid disease is evaluated using a MRI-modified American Heart Association lesion type definition. Of the 123 enrolled subjects, 40% have type III lesions with small eccentric plaque, 52% have type IV to V lesions with a necrotic core, and only 4% have calcified plaque based on the most diseased carotid location. CONCLUSIONS: The Carotid Plaque Composition Study uses a state-of-the-art imaging technology and comprehensive lipid management to test the plaque lipid depletion hypothesis in CAD subjects.