A narrative review on spinal deformities in people with cerebral palsy: Measurement, norm values, incidence, risk factors and treatment.

Spinal deformities are common in people with cerebral palsy (CP), and there is a concern of an increase during the adult ageing period. There is especially a worry about the increase of scoliosis, thoracic hyperkyphosis, lumbar hyperlordosis, spondylolysis and spondylolisthesis incidence, though supporting literature is lacking. Therefore, the aim of this narrative review is to provide a scientific overview of how spinal curvatures should be measured, what the norm values are and the incidence in people with CP, as well as a description of the risk factors and the treatment regimens for these spinal abnormalities. This review can be used as a guideline relevant for a range of clinicians, including orthopaedic and neurosurgeons, radiologists, physiotherapists, and biokineticists, as well as academics.

Child and adult spinal tuberculosis at tertiary hospitals in the Western Cape, South Africa: 4-year burden and trend.

The aim of this retrospective review was to assess the overall burden and trend in spinal tuberculosis (TB) at tertiary hospitals in the Western Cape Province of South Africa. All spinal TB cases seen at the province's three tertiary hospitals between 2012 and 2015 were identified and clinical records of each case assessed. Cases were subsequently classified as bacteriologically confirmed or clinically diagnosed and reported with accompanying clinical and demographic information. Odds ratios (OR) for severe spinal disease and corrective surgery in child vs. adult cases were calculated. A total of 393 cases were identified (319 adults, 74 children), of which 283 (72%) were bacteriologically confirmed. Adult cases decreased year-on-year (P = 0.04), however there was no clear trend in child cases. Kyphosis was present in 60/74 (81%) children and 243/315 (77%) adults with available imaging. Corrective spinal surgery was performed in 35/74 (47%) children and 80/319 (25%) adults (OR 2.7, 95% confidence interval 1.6-4.5, P = 0.0003). These findings suggest that Western Cape tertiary hospitals have experienced a substantial burden of spinal TB cases in recent years with a high proportion of severe presentation, particularly among children. Spinal TB remains a public health concern with increased vigilance required for earlier diagnosis, especially of child cases.

Relationship between perceived exertion during exercise and subsequent recovery measurements.

The return towards resting homeostasis in the post-exercise period has the potential to represent the internal training load of the preceding exercise bout. However, the relative potential of metabolic and autonomic recovery measurements in this role has not previously been established. Therefore the aim of this study was to investigate which of 4 recovery measurements was most closely associated with Borg's Rating of Perceived Exertion (RPE), a measurement widely acknowledged as an integrated measurement of the homeostatic stress of an exercise bout. A heterogeneous group of trained and untrained participants (n = 36) completed a bout of exercise on the treadmill (3 km at 70% of maximal oxygen uptake) followed by 1 hour of controlled recovery. Expired respiratory gases and heart rate (HR) were measured throughout the exercise and recovery phases of the trial with recovery measurements used to calculate the magnitude of excess post-exercise oxygen consumption (EPOCMAG), the time constant of the EPOC curve (EPOCτ), 1 min heart rate recovery (HRR60s) and the time constant of the HR recovery curve (HRRτ) for each participant. RPE taken in the last minute of exercise was significantly associated with HRR60s (r=-0.69), EPOCτ (r=0.52) and HRRτ (r=0.43) but not with EPOCMAG. This finding suggests that, of the 4 recovery measurements under investigation, HRR60s shows modest potential to represent inter-individual variation in the homeostatic stress of a standardized exercise bout, in a group with a range of fitness levels.

The heart of epilepsy: Current views and future concepts.

Cardiovascular (CV) comorbidities are common in people with epilepsy. Several mechanisms explain why these conditions tend to co-exist including causal associations, shared risk factors and those resulting from epilepsy or its treatment. Various arrhythmias occurring during and after seizures have been described. Ictal asystole is the most common cause. The converse phenomenon, arrhythmias causing seizures, appears extremely rare and has only been reported in children following cardioinihibitory syncope. Arrhythmias in epilepsy may not only result from seizure activity but also from a shared genetic susceptibility. Various cardiac and epilepsy genes could be implicated but firm evidence is still lacking. Several antiepileptic drugs (AEDs) triggering conduction abnormalities can also explain the co-existence of arrhythmias in epilepsy. Epidemiological studies have consistently shown that people with epilepsy have a higher prevalence of structural cardiac disease and a poorer CV risk profile than those without epilepsy. Shared CV risk factors, genetics and etiological factors can account for a significant part of the relationship between epilepsy and structural cardiac disease. Seizure activity may cause transient myocardial ischaemia and the Takotsubo syndrome. Additionally, certain AEDs may themselves negatively affect CV risk profile in epilepsy. Here we discuss the fascinating borderland of epilepsy and cardiovascular conditions. The review focuses on epidemiology, clinical presentations and possible mechanisms for shared pathophysiology. It concludes with a discussion of future developments and a call for validated screening instruments and guidelines aiding the early identification and treatment of CV comorbidity in epilepsy.

How well can step-off and gap distances be reduced when treating intra-articular distal radius fractures with fragment specific fixation when using fluoroscopy.

INTRODUCTION: Although fragment specific fixation has proved to be an effective treatment regime, it has not been established how successfully this treatment could be performed using fluoroscopy and what the added value of arthroscopy could be. Establish gap and step-off distances after in intra-articular distal radius fractures that have been treated with fragment specific fixation while using fluoroscopy. MATERIAL: Forty-four patients with an intra-articular distal radius fracture were treated with fragment specific fixation while using fluoroscopy. METHODS: After the treatment of the intra-articular distal radius fracture with fragment specific fixation and the use of fluoroscopy, but before the completion of the surgical intervention, all gap, and step-off distances were determined by using arthroscopy. In addition, the joint was checked for any other wrist pathologies. RESULTS: Arthroscopy after the surgical intervention showed that in 37 patients no gap distances could be detected, while in six patients a gap distance of≤2mm was found and in one patient, a gap distance of 3mm. Similarly, arthroscopy revealed no step-off distances in 33 patients, while in 11 patients a step-off distance of≤2mm was found. Although additional wrist pathologies were found in 48% of our population, only one patient needed surgical intervention. Three months after the surgical intervention wrist flexion was 41±10°, wrist extension 51±17°, ulnar deviation 19±10°, radial deviation 32±12° while patients could pronate and supinate their wrist to 85±5° and 74±20°, respectively. CONCLUSION: Intra-articular distal radius fractures can be treated successfully with fragment specific fixation and the use of fluoroscopy. As almost all gap and step-off distances could be reduced to an acceptable level, the scope for arthroscopy to further improve this treatment regime is limited. The functional outcome scores that were found 3 months after the surgical intervention were similar to what has been reported in other studies using different treatment option. These findings suggest that fragment specific fixation is a good alternative for treating intra-articular distal radius fractures. As in most cases, only fluoroscopy is needed for fragment specific fixation, this treatment technique is a good treatment option for resource-limited hospitals, setting who do not have access to arthroscopy. LEVEL OF EVIDENCE: III, case-control study.

Increased prevalence of ECG markers for sudden cardiac arrest in refractory epilepsy.

BACKGROUND AND AIM: People with epilepsy are at increased risk of sudden cardiac arrest (SCA) due to ECG-confirmed ventricular tachycardia/fibrillation, as seen in a community-based study. We aimed to determine whether ECG-risk markers of SCA are more prevalent in people with epilepsy. METHODS: In a cross-sectional, retrospective study, we analysed the ECG recordings of 185 people with refractory epilepsy and 178 controls without epilepsy. Data on epilepsy characteristics, cardiac comorbidity, and drug use were collected, and general ECG variables (heart rate (HR), PQ and QRS intervals) assessed. We analysed ECGs for three markers of SCA risk: severe QTc prolongation (male >450 ms, female >470 ms), Brugada ECG pattern, and early repolarisation pattern (ERP). Multivariate regression models were used to analyse differences between groups, and to identify associated clinical and epilepsy-related characteristics. RESULTS: People with epilepsy had higher HR (71 vs 62 bpm, p<0.001) and a longer PQ interval (162.8 vs 152.6 ms, p=0.001). Severe QTc prolongation and ERP were more prevalent in people with epilepsy (QTc prolongation: 5% vs 0%; p=0.002; ERP: 34% vs 13%, p<0.001), while the Brugada ECG pattern was equally frequent in both groups (2% vs 1%, p>0.999). After adjustment for covariates, epilepsy remained associated with ERP (ORadj 2.4, 95% CI 1.1 to 5.5) and severe QTc prolongation (ORadj 9.9, 95% CI 1.1 to 1317.7). CONCLUSIONS: ERP and severe QTc prolongation appear to be more prevalent in people with refractory epilepsy. Future studies must determine whether this contributes to increased SCA risk in people with epilepsy.

Dual implantation of a radio-telemeter and vascular access port allows repeated hemodynamic and pharmacological measures in conscious lean and obese rats.

Expansion of physiological knowledge increasingly requires examination of processes in the normal, conscious state. The current study describes a novel approach combining surgical implantation of radio-telemeters with vascular access ports (VAPs) to allow repeated hemodynamic and pharmacological measures in conscious rats. Dual implantation was conducted on 16-week-old male lean and obese Zucker rats. Continued viability one month after surgery was observed in 67% of lean and 44% of obese animals, giving an overall 54% completion rate. Over the five-week measurement period, reliable and reproducible basal mean arterial pressure and heart rate measures were observed. VAP patency and receptor-independent vascular reactivity were confirmed by consistent hemodynamic responses to sodium nitroprusside (6.25 µg/kg). Acutely, minimal hemodynamic responses to repeated bolus administration of 0.2 mL saline indicated no significant effect of increased blood volume or administration stress, making repeated acute measures viable. Similarly, repeated administration of the ß-adrenoceptor agonist dobutamine (30 µg/kg) at 10 min intervals resulted in reproducible hemodynamic changes in both lean and obese animals. Therefore, our study demonstrates that this new approach is viable for the acute and chronic assessment of hemodynamic and pharmacological responses in both lean and obese conscious rats. This technique reduces the demand for animal numbers and allows hemodynamic measures with minimal disruption to animals' welfare, while providing reliable and reproducible results over several weeks. In conclusion, dual implantation of a radio-telemeter and VAP introduces a valuable technique for undertaking comprehensive studies involving repeated pharmacological tests in conscious animals to address important physiological questions.

Incidental and ablation-induced findings during upper gastrointestinal endoscopy in patients after ablation of atrial fibrillation: a retrospective study of 425 patients.

BACKGROUND: Although rare, atrioesophageal fistula is a serious and often lethal complication of radiofrequency catheter ablation in patients with atrial fibrillation (AF). Consequently, esophagogastroduodenoscopy after AF catheter ablation has been suggested to detect thermal esophageal lesions. OBJECTIVE: To report the incidence of thermal lesions and other incidental gastrointestinal (GI) abnormalities in patients with AF after radiofrequency catheter ablation. METHODS: Four hundred twenty-five (mean age 59 ± 10 years; 64% men) consecutive patients with symptomatic AF who underwent left atrial radiofrequency catheter ablation were scheduled for upper GI endoscopy 1-3 days after the procedure. Patients were asymptomatic for GI diseases, that is, exhibiting no dysphagia, heart burn, or abdominal pain. RESULTS: Pathological GI findings were observed in 328 (77%) patients and included gastral erosions (22%), esophageal erythema (21%), gastroparesis (17%), hiatal hernia (16%), reflux esophagitis (12%), thermal esophageal lesion (11%), and suspected Barrett's esophagus (5%). Biopsies were performed in 70 (17%) patients, showing gastritis (84%), Helicobacter pylori colonization (17%) and mucosa-associated lymphoid tissue (17%), esophagitis (9%), and Barrett's esophagus (4%). Further diagnostic workup or treatment was initiated in 105 (25%) patients. CONCLUSIONS: Upper GI pathologies are observed frequently in asymptomatic patients. Half of all patients have a requirement for treatment. Among the findings, thermal esophageal lesions and gastroparesis can be attributed to AF catheter ablation. The high incidence of gastroparesis is a novel finding that deserves further investigation.

Allometric scaling and predicting cycling performance in (well-) trained female cyclists.

As female cycling attains greater professionalism, a larger emphasis is placed on the ability to predict and monitor changes in their cycling performance. The main aim of this study was to determine if peak power output (PPO) adjusted for body mass (W · kg-0.32) accurately predicts flat 40-km time trial performance (40 km TT) in female cyclists as found in men. 20 (well-) trained female cyclists completed a PPO test including maximal oxygen consumption (VO2max) and a flat 40 km TT test. Relationships between cycling performance parameters were also compared to the cycling performance of 45 male cyclists. Allometrically scaled PPW (W · kg(-0.32)) most accurately predicted 40 km TT performance in the female cyclists (r = -0.87, p<0.0001) compared to any other method, however different slopes between the parameters were found in the female and male cyclists (p=0.000115). In addition gender differences were also found between the relationship between relative PPO (W · kg-1) and relative VO2max (ml · min-1 · kg(-1))(p<0.0001), while no gender differences were found between actual and predicted cycling performance based on the Lamberts and Lambert Submaximal Cycle Test (LSCT), which was used a standardized warm-up. In conclusion, relationships between relative cycling parameters seem to differ between genders, while relationships between absolute cycling parameters seem to be similar. Therefore gender specific regression equations should be used when predicting relative cycling performance parameters.

Esophageal intramural pseudodiverticulosis: endoscopic diagnosis and therapy.

Esophageal intramural pseudodiverticulosis is a rare disease that may lead to esophageal stenosis and dysphagia. The aim of the study was to evaluate the endoscopic diagnosis, treatment and clinical course of intramural pseudodiverticulosis. We retrospectively studied endoscopic criteria of intramural pseudodiverticulitis, associated diseases, and the clinical course, particularly in patients with dysphagia because of esophageal stenosis in a period from 2002 to 2012. In 23 patients, the diagnosis was made according to endoscopic criteria. As risk factors, alcohol and tobacco consumption were present in all patients. Concomitant candida infection was present in six (26%) patients. In 12 (52%) patients esophageal stenosis was present, which was localized in the upper half of the esophagus. In 11 patients bougienage has been performed with excellent improvement of the dysphagia score from 3.7 to 1.3 (P = 0.002). However, dysphagia was recurrent in four patients with need for repeated bougienage. About half of the patients with intramural pseudodiverticulosis present with stenosis of the esophagus at the time of diagnosis. In patients with proximal esophageal stenosis and a typical risk constellation, intramural pseudodiverticulosis should be suspected. Treatment of stenosis with bougienage is effective to resolve dysphagia, but repeated bougienage may be necessary.

Adapting workload improves the measurement of heart rate recovery.

Heart rate after a standardized test varies with a change in training status, possibly compromising the accuracy of measuring changes in heart rate recovery (HRR). The aim of this study was to determine if a change in the exercise intensity would result in a change in heart rate recovery and/or the accuracy of the heart rate recovery measurement. 31 subjects performed 4 submaximal running tests (HIMS). Based on the heart rate after the first HIMS, subjects either completed 4 identical HIMS (SAME (n=9)), 2 standard and 2 faster HIMS (FASTER (n=10)) or 2 standard and 2 slower HIMS (SLOWER (n=12)). Although no changes in heart rate recovery were found when the HIMS protocol was adapted, lower coefficients of variation (CV) and typical errors of measurement (TEM) were found in the SLOWER (CV: 11 ± 7 to 5 ± 3% ( P=0.025)), TEM: 6 to 3 beats and FASTER group (CV: 11 ± 7 to 4 ± 3% ( P=0.048), TEM: 7 to 3 beats). To ensure the highest level of sensitivity in detecting meaningful changes in HRR over time, submaximal testing protocols should target exercise intensities ranging in-between 86-93% of heart rate maximum.

Postictal sleep: syncope or seizure?

A 6-year-old boy presented with prolonged periods of unconsciousness (>60 min) following nausea and dizziness while standing. The application of EEG electrodes provoked a similar episode. These apparently long periods of unconsciousness could be explained by sleep. In view of the triggers (pain, distress, and prolonged standing), the prodromal features, and the transient sinus bradycardia during the EEG examination a diagnosis of vasovagal syncope was made. Sleep is an alternative explanation for delayed recovery after syncope in young children. Prompt recognition might avoid unnecessary investigations, distress, and an incorrect diagnosis.

A novel submaximal cycle test to monitor fatigue and predict cycling performance.

OBJECTIVE: The purpose of this study was to determine the reliability and predictive value of performance parameters, measured by a new novel submaximal cycle protocol, on peak power and endurance cycling performance in well-trained cyclists. METHODS: Seventeen well-trained competitive male road racing cyclists completed four peak power output (PPO) tests and four 40-km time trials (40-km TT). Before each test, all cyclists performed a novel submaximal cycle test (Lamberts and Lambert Submaximal Cycle Test (LSCT)). Parameters associated with performance such as power, speed, cadence and rating of perceived exertion (RPE) were measured during the three stages of the test when cyclists rode at workloads coinciding with fixed predetermined heart rates. Heart rate recovery (HRR) was measured after the last stage of the test. RESULTS: Parameters measured during the second and third stages of the LSCT were highly reliable (intraclass correlation range: R=0.85-1.00) with low typical error of measurements (range: 1.3-4.4%). Good relationships were found between the LSCT and cycling performance measured by the PPO and 40-km TT tests. Mean power had stronger relationships with measures of cycling performance during the second (r=0.80-0.89) and third stages (r=0.91-0.94) of the LSCT than HRR (r=0.55-0.68). CONCLUSIONS: The LSCT is a reliable novel test which is able to predict peak and endurance cycling performance from submaximal power, RPE and HRR in well-trained cyclists. As these parameters are able to detect meaningful changes more accurately than VO(2max), the LSCT has the potential to monitor cycling performance with more precision than other current existing submaximal cycle protocols.

Heart rate recovery as a guide to monitor fatigue and predict changes in performance parameters.

Determining the optimal balance between training load and recovery contributes to peak performance in well-trained athletes. The measurement of heart rate recovery (HRR) to monitor this balance has become popular. However, it is not known whether the impairment in performance, which is associated with training-induced fatigue, is accompanied by a change in HRR. Therefore, the aim of this study was to retrospectively analyze the relationship between changes in HRR and cycling performance in a group of well-trained cyclists (n=14) who participated in a 4-week high-intensity training (HIT) program. Subjects were assigned to either a group that continuous had a increase in HRR (G(Incr)) or a group that showed a decrease in HRR (G(Decr)) during the HIT period. Both groups, G(Incr) and G(Decr), showed improvements in the relative peak power output (P=0.001 and 0.016, respectively) and endurance performance parameters (P=0.001 and <0.048, respectively). The average power during the 40-km time trial (40-km TT), however, improved more in G(Incr) (P=0.010), resulting in a tendency for a faster 40-km TT time (P=0.059). These findings suggest that HRR has the potential to monitor changes in endurance performance and contribute to a more accurate prescription of training load in well-trained and elite cyclists.

Exercising with reserve: exercise regulation by perceived exertion in relation to duration of exercise and knowledge of endpoint.

OBJECTIVE: The purpose of this study was to examine ratings of perceived exertion (RPE) and performance during repetitive maximal effort 40 km time trials as well as after an intervention that aimed to decrease certainty about the remaining distance of the exercise bout. In addition, we examined the RPE during exercise bouts of markedly different duration. METHODS: Part 1: 12 well-trained, competitive-level cyclists completed five 40 km time trials. During the final time trial all feedback was withheld until the final kilometre. In addition, to cause confusion about the remaining distance, they were asked to report their RPE at random intervals from 18 km to 38 km. Part 2: 6 well-trained, recreation-level cyclists randomly completed a 5 km, 10 km, 40 km and 100 km time trial. RESULTS: Part 1: Mean RPE increased during the first four trials and decreased during the final trial. The rate of RPE progression increased in linearity during the first four trials and became more conservative in the final trial. These changes were directly related to performance. Part 2: Mean RPE for longer duration trials (40 km, 100 km) were lower during the first half of trial duration but matched those of shorter trials in the final 20%. CONCLUSIONS: Increased familiarity of the exercise bout and certainty about its endpoint are associated with a more aggressive RPE strategy that produces a superior exercise performance. Certainty about the endpoint and the duration of exercise affect both the RPE strategy and performance.

Exercising with reserve: evidence that the central nervous system regulates prolonged exercise performance.

OBJECTIVE: The purpose of this study was to measure the effects of an amphetamine (methylphenidate) on exercise performance at a fixed rating of perceived exertion of 16. METHODS: Eight elite cyclists ingested 10 mg methylphenidate in a randomised, placebo-controlled crossover trial. RESULTS: Compared with placebo, subjects receiving methylphenidate cycled for approximately 32% longer before power output fell to 70% of the starting value. At the equivalent time at which the placebo trial terminated, subjects receiving methylphenidate had significantly higher power outputs, oxygen consumptions, heart rates, ventilatory volumes and blood lactate concentrations although electromyographic activity remained unchanged. The ingestion of a centrally acting stimulant thus allowed subjects to exercise for longer at higher cardiorespiratory and metabolic stress indicating the presence of a muscular reserve in the natural state. CONCLUSIONS: This suggests that endurance performance is not only "limited" by mechanical failure of the exercising muscles ("peripheral fatigue"). Rather performance during prolonged endurance exercise under normal conditions is highly regulated by the central nervous system to ensure that whole-body homeostasis is protected and an emergency reserve is always present.

Evaluation of alternative sites for islet transplantation in the minipig: interest and limits of the gastric submucosa.

Since the introduction of glucocorticoid-free immunosuppressive regimens, islet transplantation offers a less invasive alternative to pancreas transplantation. However, complications associated with intraportal islet injection and the progressive functional decline of intrahepatic islets encourage the exploration of alternative sites. Herein we evaluated, in the minipig, the use of the gastric submucosa (GS; group 1, n = 5) for islet transplantation compared with the kidney capsule (KC; group 2, n = 5). Subsequently we attempted to improve the vascularization of the submucosal graft (group 3, n = 5) by the addition of an extracellular matrix rich in growth factors (Matrigel). One month after grafting, we evaluated transplanted islet function in vivo and in vitro. Our study showed better function of islets engrafted in the GS than in the KC (P < .05). Despite the growth factors, Matrigel did not offer a more suitable environment to further improve engraftment (group 3, P < .05). Thus, even if the liver remains the gold standard, the GS represents a potential islet engraftment site, confirming the data obtained in vitro and in the rodent. Offering easy access by endoscopy, this site could constitute an interesting alternative for experimental studies in large mammals and, eventually, for clinical application.

Sevoflurane-induced cardioprotection depends on PKC-alpha activation via production of reactive oxygen species.

BACKGROUND: We previously demonstrated the involvement of the Ca2+-independent protein kinase C-delta (PKC-delta) isoform in sevoflurane-induced cardioprotection against ischaemia and reperfusion (I/R) injury. Since sevoflurane is known to modulate myocardial Ca2+-handling directly, in this study we investigated the role of the Ca2+-dependent PKC-alpha isoform in sevoflurane-induced cardioprotective signalling in relation to reactive oxygen species (ROS), adenosine triphosphate-sensitive mitochondrial K+ (mitoK+(ATP)) channels, and PKC-delta. METHODS: Preconditioned (15 min 3.8 vol% sevoflurane) isolated rat right ventricular trabeculae were subjected to I/R, consisting of 40 min superfusion with hypoxic, glucose-free buffer, followed by normoxic glucose-containing buffer for 60 min. After reperfusion, contractile recovery was expressed as percentage of force development before I/R. The role of PKC-alpha, ROS, mitoK+(ATP) channels, and PKC-delta was established using the following pharmacological inhibitors: Go6976 (GO; 50 nM), n-(2-mercaptopropionyl)-glycine (MPG; 300 microM), 5-hydroxydecanoic acid sodium (5HD; 100 microM), and rottlerin (ROT; 1 microM). RESULTS: Preconditioning of trabeculae with sevoflurane improved contractile recovery after I/R [65 (3)% (I/R + SEVO) vs 47 (3)% (I/R); n = 8; P < 0.05]. This cardioprotective effect was attenuated in trabeculae treated with GO [42 (4)% (I/R + SEVO + GO); P > 0.05 vs (I/R)]. In sevoflurane-treated trabeculae, PKC-alpha translocated towards mitochondria, as shown by immunofluorescent co-localization analysis. GO and MPG, but not 5HD or ROT, abolished this translocation. CONCLUSIONS: Sevoflurane improves post-ischaemic contractile recovery via activation of PKC-alpha. ROS production, but not opening of mitoK+(ATP) channels, precedes PKC-alpha translocation towards mitochondria. This study shows the involvement of Ca2+-dependent PKC-alpha in addition to the well-established role of Ca2+-independent PKC isoforms in sevoflurane-induced cardioprotection.