Reconstruction of occluded pelvis markers during marker-based motion capture with industrial exoskeletons

Industrial back support exoskeletons are a promising solution to alleviate lumbar musculoskeletal strain. Due to the complexity of spinal loading, evaluation of EMG data alone has been considered insufficient to assess their support effects, and complementary kinematic and dynamic data are required. However, the acquisition of marker-based kinematics is challenging with exoskeletons, as anatomical reference points, particularly on the pelvis, are occluded by exoskeleton structures. The aim of this study was therefore to develop and validate a method to reliably reconstruct the occluded pelvic markers. The movement data of six subjects, for whom pelvic markers could be placed while wearing an exoskeleton, were used to test the reconstructions and compare them to anatomical landmarks during lifting, holding and walking. Two separate approaches were used for the reconstruction. One used a reference coordinate system based on only exoskeleton markers (EXO), as has been suggested in the literature, while our proposed method adds a technical marker in the lumbar region (LUMB) to compensate for any shifting between exoskeleton and pelvis. Reconstruction with EXO yielded on average an absolute linear deviation of 54 mm ± 16 mm (mean ± 1SD) compared to anatomical markers. The additional marker in LUMB reduced mean deviations to 14 mm ± 7 mm (mean ± 1SD). Both methods were compared to reference values from the literature for expected variances due to marker placement and soft tissue artifacts. For LUMB 99% of reconstructions were within the defined threshold of 24 mm ±9 mm while for EXO 91% were outside.

Awareness of Pregnant Patients about Congenital Cytomegalovirus Infection-A Semi-Systematic Review

Background: Cytomegalovirus (CMV) infection represents a major issue worldwide, since it constitutes the most common viral congenital infection, with a prevalence of 0.58% and 1-5% in developed and developing countries, respectively. According to recent studies, prenatal treatment significantly decreases the risk of vertical CMV transmission, and early intervention may even prevent the termination of pregnancy. This study aimed to investigate the level of awareness of CMV among pregnant patients through a semi-systematic review. Methods: We included all of the original articles investigating knowledge and awareness about CMV infection among pregnant women. Our research included the PubMed database. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement, the Covidence system automatically guided us to screen the titles and/or abstracts, and then full-texts, followed by data extraction from the eligible studies. Results: We screened 764 studies altogether, with 13 studies included in this analysis. Knowledge about the existence of CMV infection risk varied between the articles, ranging from 11.4% in a study performed in Ireland to 60% reported in a study on the French population. Studies analyzing the impact of educational interventions on patients' knowledge about preventive measures reported significant improvement compared to their level of awareness before the intervention. Conclusions: Patients' awareness and knowledge about CMV seemed to be generally low or very low during the last decade before the development of effective secondary prevention methods. Educational interventions seem to be effective, and therefore their wide use could be of potential benefit. In the era of available secondary prevention of vertical transmission, it is crucial to concentrate the efforts of different stakeholders to increase the awareness of cCMV among pregnant women.

Effect of robotic tilt table verticalization on recovery in patients with disorders of consciousness: a randomized controlled trial

Verticalization is a common therapeutic intervention during rehabilitation of patients with disorders of consciousness (DoC). The Erigo®Pro is a robotic tilt-table (RTT) with built-in stepping unit for the lower extremities to prevent orthostatic hypotension during verticalization. In addition, the system also provides functional electrical stimulation (FES) of muscles of the lower extremities. In this randomized controlled clinical trial (RCT), 47 patients with subacute DoC received a 4-week verticalization regime (16 verticalization sessions) and were allocated to one of three experimental groups: (1) verticalization by means of RTT with FES, (2) by means of RTT without FES, or (3) by conventional physiotherapy (CPT). Level of consciousness (LoC), spasticity, functional independence in daily activities, and functional brain connectivity measured by means of high-density quantitative EEG were assessed at baseline, directly after the verticalization program and after 6 months. There was a similar clinical improvement in all three experimental groups. RTT was not associated with an effect on any of the clinical outcomes. Verticalization or mobilization time during the study period was significantly positively correlated with recovery of consciousness (rho = 0.494, p < 0.001) in the short term and showed a statistical trend at the 6 months follow-up (rho = 0.244, p = 0.078). In conclusion, RTT treatment is not more effective in promoting recovery of consciousness than CPT in subacute DoC patients. Yet, our data suggest, that verticalization may be an important and feasible rehabilitation intervention in this group of patients. ClinicalTrials.gov NCT Number NCT02639481, registered on December 24, 2015.

PerBrain: a multimodal approach to personalized tracking of evolving state-of-consciousness in brain-injured patients: protocol of an international, multicentric, observational study

BACKGROUND

Disorders of consciousness (DoC) are severe neurological conditions in which consciousness is impaired to various degrees. They are caused by injury or malfunction of neural systems regulating arousal and awareness. Over the last decades, major efforts in improving and individualizing diagnostic and prognostic accuracy for patients affected by DoC have been made, mainly focusing on introducing multimodal assessments to complement behavioral examination. The present EU-funded multicentric research project "PerBrain" is aimed at developing an individualized diagnostic hierarchical pathway guided by both behavior and multimodal neurodiagnostics for DoC patients.

METHODS

In this project, each enrolled patient undergoes repetitive behavioral, clinical, and neurodiagnostic assessments according to a patient-tailored multi-layer workflow. Multimodal diagnostic acquisitions using state-of-the-art techniques at different stages of the patients' clinical evolution are performed. The techniques applied comprise well-established behavioral scales, innovative neurophysiological techniques (such as quantitative electroencephalography and transcranial magnetic stimulation combined with electroencephalography), structural and resting-state functional magnetic resonance imaging, and measurements of physiological activity (i.e. nasal airflow respiration). In addition, the well-being and treatment decision attitudes of patients' informal caregivers (primarily family members) are investigated. Patient and caregiver assessments are performed at multiple time points within one year after acquired brain injury, starting at the acute disease phase.

DISCUSSION

Accurate classification and outcome prediction of DoC are of crucial importance for affected patients as well as their caregivers, as individual rehabilitation strategies and treatment decisions are critically dependent on the latter. The PerBrain project aims at optimizing individual DoC diagnosis and accuracy of outcome prediction by integrating data from the suggested multimodal examination methods into a personalized hierarchical diagnosis and prognosis procedure. Using the parallel tracking of both patients' neurological status and their caregivers' mental situation, well-being, and treatment decision attitudes from the acute to the chronic phase of the disease and across different countries, this project aims at significantly contributing to the current clinical routine of DoC patients and their family members.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04798456 . Registered 15 March 2021 - Retrospectively registered.

AB0444 ENPATORAN: PRECLINICAL EVIDENCE SUPPORTING GLUCOCORTICOID DOSE REDUCTION AND PHASE II STUDY DESIGN IN PATIENTS WITH SLE AND/OR CLE (WILLOW)

Background

Enpatoran is a potent selective dual inhibitor of toll-like receptor (TLR) 7 and TLR8, aberrant activation of which may be involved in systemic lupus erythematosus (SLE) pathogenesis and glucocorticoid resistance.1,2,3 Enpatoran suppressed disease development in lupus mouse models, improving survival and reducing proteinuria, autoantibodies, and the interferon (IFN) gene signature.1 In healthy participants and patients hospitalized with COVID-19 pneumonia, enpatoran was well tolerated and demonstrated effective TLR7/8 engagement.4 Enpatoran is potentially glucocorticoid sparing and may help avoid the detrimental effects of long-term corticosteroid use in SLE management.5,6

Objectives

To evaluate the glucocorticoid-sparing effect of enpatoran and design a basket trial to assess its efficacy and safety in patients with SLE and/or cutaneous lupus erythematosus (CLE).

Methods

Cytokine concentrations and gene expression changes were measured in stimulated human peripheral blood mononuclear cells (PBMCs) from healthy donors after treatment with dexamethasone, TLR7/8 inhibitor, or both. A Phase II, basket design proof-of-concept, dose-finding study in patients with SLE and/or CLE (WILLOW) was designed.

Results

In healthy donor PBMCs, synergy was observed between TLR7/8 inhibitor and dexamethasone. Combination treatment inhibited cytokine release (IL-6) with greater potency than either treatment alone and reduced the expression of nuclear factor-kappa B and IFN-regulated genes. WILLOW is a Phase II, basket proof-of-concept, dose-finding, randomized, double-blind, placebo (PBO)-controlled 24-week study with two cohorts (NCT05162586, Figure 1). The primary objectives of WILLOW are to evaluate the dose–response relationship of enpatoran in reducing disease activity based on Cutaneous Lupus Erythematosus Disease Area and Severity Index-A (CLASI-A) or BILAG-Based Composite Lupus Assessment (BICLA) response rate. The secondary objectives are to investigate effects on both BICLA response and clinically meaningful corticosteroid reduction and evaluate disease control (including clinically meaningful corticosteroid reduction) in patients with predominantly active CLE or SLE. Cohort A will enroll patients with CLE (active subacute CLE and/or discoid LE) or SLE with predominantly active lupus rash. Cohort B, in two parts, will enroll SLE patients with moderate to severe systemic disease activity. Part 1 will assess clinical signal and Part 2 may be adapted to improve dose finding. Glucocorticoid-sparing will be evaluated by mandatory tapering to a prednisone-equivalent dose of ≤5 mg/day.

Figure 1.

WILLOW study design.

Cohort A and Cohort B Part 1 will start in parallel.

*Part 2 will be initiated after a pre-specified number of patients are enrolled in Part 1; enpatoran doses in Part 2 may be adapted to improve dose finding (dashed boxes).

BILAG, British Isles Lupus Assessment Group; CLASI-A, Cutaneous Lupus Erythematosus Disease Area and Severity Index-A; CLE, cutaneous lupus erythematosus; CS, corticosteroid; DBPC, double-blind placebo-controlled; DLE, discoid lupus erythematosus; PBO, placebo; SCLE, Subacute cutaneous lupus erythematosus; SLE, systemic lupus erythematosus; SLEDAI, Systemic Lupus Erythematosus Disease Activity Index.

Conclusion

Enpatoran is a novel TLR7/8 inhibitor and may enable glucocorticoid dose reduction in patients with SLE and CLE. The WILLOW study incorporates multiple novel elements including a basket design and evaluation of glucocorticoid-sparing.

References

[1]Vlach, et al. J Pharmacol Exp Ther. 2021;376:397–409;

[2]Northcott, et al. Lancet Rheumatol. 2021;5:e357–e370;

[3]Guiducci, et al. Nature. 2010;465:937–941;

[4]Port, et al. Pharmacol Res Perspect. 2021;9:e00842;

[5]Thamer, et al. J Rheumatol. 2009;36:560–564;

[6]Ruiz-Irastorza, et al. Rheumatology. 2012;51:1145–1153.

Acknowledgements

This study was sponsored by the healthcare business of Merck KGaA, Darmstadt, Germany (CrossRef Funder ID: 10.13039/100009945), who funded medical writing support by Bioscript Stirling Ltd.

Disclosure of Interests

Eric F. Morand: None declared, Andrew Bender Shareholder of: Shares in Merck KGaA, Employee of: EMD Serono Research & Development institute (an affiliate of Merck KGaA), Aditee Deshpande Employee of: EMD Serono Research & Development institute (an affiliate of Merck KGaA), Bharat Vaidyanathan Employee of: EMD Serono Research & Development institute (an affiliate of Merck KGaA), cristina vazquez mateo Employee of: EMD Serono Research & Development institute (an affiliate of Merck KGaA), Melinda Przetak Employee of: EMD Serono Research & Development institute (an affiliate of Merck KGaA), Flavie Moreau Employee of: EMD Serono Research & Development institute (an affiliate of Merck KGaA), Mukhy Khursheed Employee of: Merck Serono Ltd (an affiliate of Merck KGaA), Sanjeev Roy Employee of: Ares Trading SA (an affiliate of Merck KGaA), David Pearson Consultant of: Biogen Inc.

Dataset for multidimensional assessment to incentivise decentralised energy investments in Sub-Saharan Africa

In this data article, we present datasets from the construction of a composite indicator, the Photovoltaic Decentralised Energy Investment (PV-DEI) index, presented in detail in [1]. This article consists of a comprehensive energy-related data collected in practice from several sources, and from the outputs of the methodology described in [1]. The PV-DEI was designed and developed to measure the multidimensional factors that currently direct decentralised renewable energy investments. The PV-DEI index includes 52 indicators and was constructed because factors stimulating investment cannot be captured by a single indicator, e.g. competitiveness, affordability, or governance [1]. The PV-DEI index was built in alignment with a theoretical framework guided by an extensive review of the literature surrounding investment in decentralised Photovoltaic (PV), which led to the selection of its indicators. The structure of the PV-DEI was evaluated for its soundness using correlational assessments and principal component analyses (PCA). The raw data provided in this article can enable stakeholders to focus on specific country indicators, and how scores on these indicators contributed to a countries overall rank within the PV-DEI index. The data can be used to weight indicators depending on the specifications of several different stakeholders (such as NGOs, private sector or international institutions).

Occupational inequality in disability pension among persons with diabetes and comorbidity

Background

Persons with type 2 diabetes (DM2) have higher probability of an early exit from the labour market and to receive permanent disability pension compared with persons without DM2.

Objectives

To assess the association between occupational class and disability pension among persons without disease, with DM2 only and DM2 with six comorbid conditions (CVD, musculoskeletal disorders, mental disease, cancer, cerebrovascular disease and ≥2 comorbid diseases).

Methods

All employed persons aged 40-64 living in Denmark in the period 2011-2017(n, year 2011=1,454,649) were stratified according to DM2 and six major concomitant diseases. We estimated the relative risk of disability pension dependent on DM2 comorbidity status and occupational class by means of a log-binomial regression. Reference group was upper non manual employees with no disease.

Results

The highest risks of disability pension were seen for DM2 + mental disease, age 40-59 (RR = 2.45 [2.3-2.5]), DM2 + cerebrovascular disease (RR = 2.45 CI 95% [2.1-2.8]) and DM2 + ≥2 diseases (RR = 2.98 [2.9-3.1]). Unskilled and manual workers were more likely to receive disability pension. The occupational inequality was highest among younger persons and groups of persons with DM2 only and DM2 + CVD and lowest for persons with more than one concomitant disease.

Conclusions

The results suggest that among people with DM2, labour market exit depend on both comorbid conditions and occupational class. Overall, our results show that the relative effects of occupational class on disability pension decrease in cases with severe comorbid conditions. In younger persons the mechanisms may be more nuanced, suggesting that persons with DM2 + comorbid conditions in particular have difficulties fulfilling the working requirements of lower occupational jobs. Practitioners may use the results in targeting prevention interventions to persons in high risk of early labour market exit.

Key messages

Low occupational class and comorbidity increase the risks of disability pension among persons with DM2. Constrained work-flexibility of low occupational jobs may influence diabetes self-care and explain high inequality in disability pension.

A health inequality impact assessment of leveling down overweight and obesity

Background

Social differences in the proportion of overweight and obesity have increased in recent decades. Health impact assessments provide population-level valuations of changes in disease prevalence related to scenarios with different risk factors levels. These scenarios can be focused on reducing overweight and obesity among people with low socioeconomic position.

Methods

This study included the projected population of Copenhagen, Denmark in year 2040 (n = 742,130). Using the DYNAMO-HIA tool we conducted a health inequality impact assessment. Future prevented disease prevalence (IHD, diabetes, stroke, and multi-morbidity) and change in life expectancy related to an equalized scenario were estimated in a scenario where the prevalence of overweight/obesity (OWOB) in the group of people with short and medium educational attainment was reduced to the levels of people with long education.

Results

A higher proportion of people with short and medium education were OWOB than among people with long education and they had higher prevalence of cardiometabolic diseases. The diabetes prevalence among people with short education was reduced by 8-10% for men and 12-13% for women and life expectancy with diabetes decreased by one year in the group of women with short education. No notable effect of the equalized OWOB was seen regarding life expectancy with and prevalence of stroke and IHD.

Conclusions

Reaching the low prevalence of OWOB observed among people with high educational level, will reduce future cardiometabolic disease, increase life expectancy and meanwhile reduce the social inequality in health. These findings can serve as relevant references points for public health planners.

Key messages

This study is the first to combine advanced mathematical modelling and population data to assess changes in health from reducing socioeconomic inequality in obesity and overweight. These results propose valuable reference values for outcome assessments of interventions on inequalities in health.

QSAR-derived affinity fingerprints (part 1): fingerprint construction and modeling performance for similarity searching, bioactivity classification and scaffold hopping

An affinity fingerprint is the vector consisting of compound’s affinity or potency against the reference panel of protein targets. Here, we present the QAFFP fingerprint, 440 elements long in silico QSAR-based affinity fingerprint, components of which are predicted by Random Forest regression models trained on bioactivity data from the ChEMBL database. Both real-valued (rv-QAFFP) and binary (b-QAFFP) versions of the QAFFP fingerprint were implemented and their performance in similarity searching, biological activity classification and scaffold hopping was assessed and compared to that of the 1024 bits long Morgan2 fingerprint (the RDKit implementation of the ECFP4 fingerprint). In both similarity searching and biological activity classification, the QAFFP fingerprint yields retrieval rates, measured by AUC (~ 0.65 and ~ 0.70 for similarity searching depending on data sets, and ~ 0.85 for classification) and EF5 (~ 4.67 and ~ 5.82 for similarity searching depending on data sets, and ~ 2.10 for classification), comparable to that of the Morgan2 fingerprint (similarity searching AUC of ~ 0.57 and ~ 0.66, and EF5 of ~ 4.09 and ~ 6.41, depending on data sets, classification AUC of ~ 0.87, and EF5 of ~ 2.16). However, the QAFFP fingerprint outperforms the Morgan2 fingerprint in scaffold hopping as it is able to retrieve 1146 out of existing 1749 scaffolds, while the Morgan2 fingerprint reveals only 864 scaffolds.

European Academy of Neurology guideline on the diagnosis of coma and other disorders of consciousness

BACKGROUND AND PURPOSE

Patients with acquired brain injury and acute or prolonged disorders of consciousness (DoC) are challenging. Evidence to support diagnostic decisions on coma and other DoC is limited but accumulating. This guideline provides the state-of-the-art evidence regarding the diagnosis of DoC, summarizing data from bedside examination techniques, functional neuroimaging and electroencephalography (EEG).

METHODS

Sixteen members of the European Academy of Neurology (EAN) Scientific Panel on Coma and Chronic Disorders of Consciousness, representing 10 European countries, reviewed the scientific evidence for the evaluation of coma and other DoC using standard bibliographic measures. Recommendations followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The guideline was endorsed by the EAN.

RESULTS

Besides a comprehensive neurological examination, the following suggestions are made: probe for voluntary eye movements using a mirror; repeat clinical assessments in the subacute and chronic setting, using the Coma Recovery Scale - Revised; use the Full Outline of Unresponsiveness score instead of the Glasgow Coma Scale in the acute setting; obtain clinical standard EEG; search for sleep patterns on EEG, particularly rapid eye movement sleep and slow-wave sleep; and, whenever feasible, consider positron emission tomography, resting state functional magnetic resonance imaging (fMRI), active fMRI or EEG paradigms and quantitative analysis of high-density EEG to complement behavioral assessment in patients without command following at the bedside.

CONCLUSIONS

Standardized clinical evaluation, EEG-based techniques and functional neuroimaging should be integrated for multimodal evaluation of patients with DoC. The state of consciousness should be classified according to the highest level revealed by any of these three approaches.

P5645Lifetime sex-specific sudden cardiac death prediction using ECG global electrical heterogeneity: the atherosclerosis risk in communities (ARIC) study

Background

Sex-based differences in sudden cardiac death (SCD) exist and screening methods for SCD are inadequate.

Purpose

To develop sex-specific lifetime risk prediction models using electrocardiographic (ECG) global electrical heterogeneity (GEH) and clinical characteristics.

Methods

Participants from the Atherosclerosis Risk in Communities study with analyzable ECGs (n=14,725; age, 54.2±5.8 yrs; 55% female, 74% white) were followed up for 24.4 years (median). Traditional ECG and GEH variables were measured on 12-lead ECGs. A Cox regression model was used to develop a prediction model. In women, the final model included race, age, coronary heart disease (CHD), stroke, hypertension, diabetes, smoking, high-density lipoprotein, albumin, uric acid, education level, heart rate, QTc, sum absolute QRST integral, spatial peak QRS-T angle. In men, the final prediction model included age, race, CHD, stroke, hypertension, diabetes, total cholesterol, physical activity, smoking, serum phosphorus, albumin, chronic kidney disease, spatial area QRS-T angle, area spatial ventricular gradient (SVG) elevation and magnitude, and peak SVG magnitude.

Results

There were a total of 530 SCDs. Our prediction models showed robust prediction of SCD in both sexes [(Harrell's C-statistic women 0.863 (95% CI 0.845–0.882), men 0.786 (95% CI 0.786–0.803)]. In women when ECG and GEH variables were added to clinical variables, the net reclassification improved by 9% (P=0.001) (Table). In men there was no significant reclassification improvement.

Net reclassification Lifetime SCD Risk: Clinical + ECG + GEH Variables Women Men <5% 5–15% >15% Total <5% 5–15% >15% Total SCD Cases <5% 82 14 0 96 103 16 0 119 5–15% 7 59 10 76 12 116 12 140 >15% 0 0 20 20 0 5 74 79 Lifetime SCD Risk: Total 89 73 30 192 115 137 86 338 Clinical Variables Only Non-Cases <5% 6,956 131 2 7,089 4,411 264 0 4,675 5–15% 180 509 42 731 210 1,059 48 1,317 >15% 0 28 84 112 0 56 214 270 Total 7,136 668 128 7,932 4,621 1,379 262 6,262

Conclusions

We were the first to develop sex-specific lifetime SCD prediction models. The addition of ECG GEH to clinical variables improved SCD risk reclassification in women, but not in men. Prediction of SCD was more accurate in women as compared to men.

Physico-chemical aspects of grape juices produced in the region of Campanha Gaucha, RS, Brazil (Southern Brazil)

The Campanha Gaucha region, southern Brazil, has received significant investments in Viticulture during the last decades, especially for the production of quality wines. However, implementing the production of American and hybrid grapes in this region constitutes and opportunity to supply the increasing demand of the grape juice market in Brazil. Juices of two varieties, “Bordô” and “Concord”, from two locations, Dom Pedrito and Santana do Livramento, were analysed in terms of the following physico-chemical aspects: total city, volatile acidity, density, pH, soluble solids content, color intensity, and hue. “Bordô” juices presented higher total acidity and did not differ in relation to location. Higher volatile acidity was found in “Concord” juice from Santana do Livramento. Higher pH was found in the variety “Concord” and in the location Dom Pedrito. For this same location, the “Concord” grape juices showed higher soluble solids values. Color intensity was higher in Santana do Livramento. Color hue was higher in Dom Pedrito. Both variety and location impacted significantly on physico-chemical aspects of grape juices, although all the grapes were produced within the Campanha Gaucha region.

Mediolateral force distribution at the knee joint shifts across activities and is driven by tibiofemoral alignment

AIMS

Tibiofemoral alignment is important to determine the rate of progression of osteoarthritis and implant survival after total knee arthroplasty (TKA). Normally, surgeons aim for neutral tibiofemoral alignment following TKA, but this has been questioned in recent years. The aim of this study was to evaluate whether varus or valgus alignment indeed leads to increased medial or lateral tibiofemoral forces during static and dynamic weight-bearing activities.

PATIENTS AND METHODS

Tibiofemoral contact forces and moments were measured in nine patients with instrumented knee implants. Medial force ratios were analysed during nine daily activities, including activities with single-limb support (e.g. walking) and double-limb support (e.g. knee bend). Hip-knee-ankle angles in the frontal plane were analysed using full-leg coronal radiographs.

RESULTS

The medial force ratio strongly correlated with the tibiofemoral alignment in the static condition of one-legged stance (R² = 0.88) and dynamic single-limb loading (R² = 0.59) with varus malalignment leading to increased medial force ratios of up to 88%. In contrast, the correlation between leg alignment and magnitude of medial compartment force was much less pronounced. A lateral shift of force occurred during activities with double-limb support and higher knee flexion angles.

CONCLUSION

The medial force ratio depends on both the tibiofemoral alignment and the nature of the activity involved. It cannot be generalised to a single value. Higher medial ratios during single-limb loading are associated with varus malalignment in TKA. The current trend towards a 'constitutional varus' after joint replacement, in terms of overall tibiofemoral alignment, should be considered carefully with respect to the increased medial force ratio. Cite this article: Bone Joint J 2017;99-B:779-87.

In vivo hip joint loads and pedal forces during ergometer cycling

The rising prevalence of osteoarthritis and an increase in total hip replacements calls for attention to potential therapeutic activities. Cycling is considered as a low impact exercise for the hip joint and hence recommended. However, there are limited data about hip joint loading to support this claim. The aim of this study was to measure synchronously the in vivo hip joint loads and pedal forces during cycling. The in vivo hip joint loads were measured in 5 patients with instrumented hip implants. Data were collected at several combinations of power and cadence, at two saddle heights. Joint loads and pedal forces showed strong linear correlation with power. So the relationship between the external pedal forces and internal joint forces was shown. While cycling at different cadences the minimum joint loads were acquired at 60RPM. The lower saddle height configuration results in an approximately 15% increase compared to normal saddle height. The results offered new insights into the actual effects of cycling on the hip joint and can serve as useful tools while developing an optimum cycling regimen for individuals with coxarthrosis or following total hip arthroplasty. Due to the relatively low contact forces, cycling at a moderate power level of 90W at a normal saddle height is suitable for patients.

Synthesis and in vitro Antiviral Properties of Amphiphilic Dinucleoside Phosphate Derivatives of 2′,3-dideoxycytidine (ddC)

N4-hexadecyl-5′-0-(4-monomethoxytrityl)-2′-deoxycytidine-3′-hydrogenphosphonate and 5′-0-(4-monomethoxytrityl)-2′-deoxythymidine-3′-0-hydrogenphosphonate were condensed with 2′,3′-dideoxycytidine (ddC) according to the hydrogenphosphonate method to yield N4-hexadecyl-2′-deoxycytidylyl-(3′-5′)-2′,3′-dideoxycytidine (N4-hexadecyldC-ddC) and 2′-deoxythymidylyl-(3′-5′)-N4-palmitoyl-2′,3′-dideoxycytidine (dT-N4-palmddC). N4-palmitoyl-2′,3′-dideoxycytidine (N4-palmddC) was synthesized by reacting palmitic anhydride with ddC. Both dinucleoside phosphates have amphiphilic properties and represent a new class of ddC derivatives in which in the case of the dinucleosides, the ddC-5′-monophosphate is masked with lipophilic residues of variable stability. The ddC derivatives can be solubilized in water by micelle formation and, because they have lipophilic residues, they can be incorporated into the lipid membranes of liposomes. The ddC derivatives were shown to have antiviral activities comparable to those of AZT and ddC when tested in vitro against HIV-1-infected HeLa and H9 cells as well as infected human monocytes/macrophages.

Systematic selection of small molecules to promote differentiation of embryonic stem cells and experimental validation for generating cardiomyocytes

Small molecules are being increasingly used for inducing the targeted differentiation of stem cells to different cell types. However, until now no systematic method for selecting suitable small molecules for this purpose has been presented. In this work, we propose an integrated and general bioinformatics- and cheminformatics-based approach for selecting small molecules which direct cellular differentiation in the desired way. The approach was successfully experimentally validated for differentiating stem cells into cardiomyocytes. All predicted compounds enhanced expression of cardiac progenitor (Gata4, Nkx2-5 and Mef2c) and mature cardiac markers (Actc1, myh6) significantly during and post-cardiac progenitor formation. The best-performing compound, Famotidine, increased the percentage of Myh6-positive cells from 33 to 56%, and enhanced the expression of Nkx2.5 and Tnnt2 cardiac progenitor and cardiac markers in protein level. The approach employed in the study is applicable to all other stem cell differentiation settings where gene expression data are available.

Prevalence and severity of foot pad alterations in German turkey poults during the early rearing phase

In the previously performed field study from 2007 to 2009, it became evident that foot pad alterations were already commonly found in turkeys at the age of 6 wk. At this early age, 45% of the clinically examined birds were diagnosed with epithelial necrosis. Therefore, it became important to specifically analyze the situation during the early rearing phase. The present study reflects the prevalence and severity of foot pad alterations of turkey poults up to the age of 35 d (5 wk), starting as early as the age of 3 d. From 24 turkey farms throughout Germany, in general 5,531 turkeys [3,131 male and 2,400 female] of the British United Turkeys 6 strain from 46 flocks, were examined to that effect. Prevalence and severity increased within the duration of stay in the stable, and the prevalence was higher (P < 0.001) during the second visit between d 22 to 35 (factor: 0.94). Therefore, 27.3% (d 3 to 5; male/female: 39.1/25.0%) and 63.3% (d 22 to 35: 61.3/65.7%) of the examined poults had alterations of the foot pads, such as hyperkeratosis (d 3 to 5: 20.4/14.2%; d 22 to 35: 17.6/17.1%), high-grade hyperkeratosis with adhesive dirt (d 3 to 5: 8.7/10.7%; d 22 to 35: 29.2/39.3%), and epithelial necrosis (d 3 to 5: 0.1/0.1%; d 22 to 35: 14.6/9.3%). Female poults showed a higher risk (P < 0.001) of developing food pad alterations (factor: 0.76) than male poults. Male poults developed a higher percentage of epithelial necrosis than hens shortly before relocation. A higher stocking density during the very early rearing phase (d 3 to 5) led to a worse foot pad health status (P < 0.001). Because even mild alterations in the foot pad condition can be indicators for suboptimal design of the rearing environment and are to be seen as a pre-state for severe cases of foot pad dermatitis, it is important to set the main focus on the early rearing phase.

Clinicopathological differences between breast cancer in patients with primary metastatic disease and those without: a multicentre study

OBJECTIVE

Approximately 6% of breast cancer (BC) patients present with primary metastatic disease (pmBC) at first diagnosis. The clinicopathological differences between tumours from patients who have metastatic disease and those who do not are unclear.

METHODS

This study was an exploratory analysis of patients with pmBC treated in 8 German breast cancer centres between 1998 and 2010. Phenotypes were defined using the following immunohistochemical markers: oestrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (Her2). The control arm included the group of patients who had neither local recurrence nor distant metastases at a follow-up of at least 30 months after initial diagnosis.

RESULTS

A total of 2214 patients were included. Of these, 1642 had non metastatic BC, and 572 had pmBC. Eighty-five patients (15%) with pmBC were diagnosed at stage T1. On multivariate analysis, factors associated with pmBC were as follows: positive lymph node status, grade 3, lobular histology and Luminal B phenotype (Her 2 positive). Of the sample, 197 patients (34%) with pmBC were diagnosed as stage T2, 90 patients (16%) were diagnosed as stage T3, and 200 patients (35%) were diagnosed as stage T4. Only positive lymph node status and grade 3 were reported as risk factors for distant metastases in patients with stage T3 and T4 cancer.

CONCLUSION

There are differences in the clinicopathological features among breast cancer patients with primary metastases and those without. Receptor expression and histological type play a minor role in the risk for metastasis in patients with stage T3 and T4 disease when compared to patients with T1 pmBC tumours. On initial diagnosis, lobular histology and Luminal B positivity (Her 2 positive) in T1 pmBC were determined to be risk factors for primary metastatic disease.

In vivo measurement of shoulder joint loads during walking with crutches

BACKGROUND

Following surgery or injury of the lower limbs, the use of walking aids like crutches can cause high loads on the shoulder joint. These loads have been calculated so far with computer models but with strongly varying results.

METHODS

Shoulder joint forces and moments were measured during crutch-assisted walking with complete and partial unloading of the lower limbs. Using telemeterized implants in 6 subjects axillary crutches and forearm crutches were compared. A force direction was more in the direction of the long humeral axis, and slightly lower forces were assumed using axillary crutches. Similar force magnitudes as those experienced during previously measured wheelchair weight relief tasks were expected for complete unloading. The friction-induced moment was hypothesized to act mainly around the medio-lateral axis during the swing phase of the body.

FINDINGS

Maximum loads of up 170% of the bodyweight and 0.8% of the bodyweight times meter were measured with large variations among the patients. Higher forces were found in most of the patients using forearm crutches. The hypothesized predominant moment around the medio-lateral axis was only found in some patients. More often, the other two moments had larger magnitudes with the highest values in female patients. The assumed different load direction could only be found during partial unloading.

INTERPRETATION

In general the force magnitudes were in the range of activities of daily living. However, the number of repetitions during long-lasting crutch use could lead to shoulder problems as a long-term consequence. The slightly lower forces with axillary crutches could be caused by loads acting directly from the crutch on the scapula, thus bypassing the glenohumeral joint. The higher bending moments in the female patients could be a sign of lacking muscle strength for centring the humeral head on the glenoid.

Spinal and cortical activity-dependent plasticity following learning of complex arm movements in humans

Activity-dependent plasticity is a fundamental requirement for human motor learning, which takes place at several stages of the motor system and involves various mechanisms in neuronal circuitry. Here, we investigate parameters of cortical and spinal excitability before and immediately after a single session of locomotion-like arm training (LMT) or sequential visuo-motor learning (VMT). Both training paradigms focused especially on mainly activating the flexor carpi radialis muscle (FCR). The activity-dependent change in the excitability of FCR-associated neurons was investigated using standard transcranial magnetic stimulation, including analysis of motor-evoked potentials (MEP) amplitude, short-interval intracortical inhibition and intracortical facilitation (ICF). Furthermore, spinal plasticity was also assessed by means of homosynaptic FCR H-reflex depression (HD). LMT decreased HD and ICF. In contrast, VMT had no significant effect on cortical and spinal parameters. There was a nonsignificant tendency of an increase in MEP amplitudes after both interventions. This implies that human locomotor-related learning involves spinal mechanisms. Despite the decreasing importance of quadrupedal coordination in the course of evolution, these changes in transsynaptic plasticity may reflect a persisting locomotor memory-encoding function in the spinal circuitry of the human upper extremities. Evaluating FCR HD might be helpful for the evaluation and development of locomotor rehabilitation strategies.

Protein analysis through Western blot of cells excised individually from human brain and muscle tissue

Comparing protein levels from single cells in tissue has not been achieved through Western blot. Laser capture microdissection allows for the ability to excise single cells from sectioned tissue and compile an aggregate of cells in lysis buffer. In this study we analyzed proteins from cells excised individually from brain and muscle tissue through Western blot. After we excised individual neurons from the substantia nigra of the brain, the accumulated surface area of the individual cells was 120,000, 24,000, 360,000, 480,000, 600,000 μm2. We used an optimized Western blot protocol to probe for tyrosine hydroxylase in this cell pool. We also took 360,000 μm2 of astrocytes (1700 cells) and analyzed the specificity of the method. In muscle we were able to analyze the proteins of the five complexes of the electron transport chain through Western blot from 200 human cells. With this method, we demonstrate the ability to compare cell-specific protein levels in the brain and muscle and describe for the first time how to visualize proteins through Western blot from cells captured individually.

P4-10-07: Clinico-Pathologic Features of Breast Cancer Patients with Primary Metastatic Disease Versus Localized Disease: A Multicenter Study

Objective: Approximately 6% of breast cancer patients present with primary metastatic disease (pmBC) at first diagnosis. Clinicopathological differences to non-metastatic patients are undetermined.

Methods: Exploratory analysis of patients with pmBC treated in 8 breast cancer units between 1998 and 2010. Tumor characteristics of these patients were compared with non-metastatic breast cancer patients (BC) of one breast cancer center who had neither local-recurrence nor distant metastases during 30 months of follow-up after first diagnosis. Standard staging in patients with first diagnosis of BC included chest X-ray, abdominal ultrasonography and bone scan. Molecular subtypes were analyzed and defined by immunohistochemical markers (ER, PR, Her2-receptor).

Results: 2.214 patients were included, 1.642 with BC and 572 with pmBC, respectively. Patients with pmBC were 7 years older (BC 58 years of age vs. pmBC 65 years; p=0.000) and were more likely to be postmenopausal (74% vs. 83%; p=0.000). Most common localizations of distant first metastases were bone (61,5%), liver (24%), lung (21%) and non-axillary lymph nodes (12%).

85 (15%) patients with pmBC were diagnosed in stage T1. Factors associated with pmBC in multivariate analysis for this group were positive lymph node status (OR 3.4; 95%CI 2.3−6.0; p=0.000), grading 3 (OR 2.3; 95%CI 1.3−4.0; p=0.003), lobular histology (OR 2.3; 95%CI 1.2−4.5; p=0,010) and phenotype Luminal B (OR 2.4; 95%CI 1.25−5.0; p=0.014). 197 (34%) patients with pmBC were diagnosed in stage T2; positive lymph node status (OR 4.8; 95%CI 1.1−3.0; p=0.017) and grading 3 (OR 1.6; 95% CI 1.6−2.3; p=0.019) were reported as risk factors for this group. 90 (16%) and 200 (35%) patients were diagnosed with stages T3 and T4, respectively. In T3/4 tumors a positive lymph node status (OR 5.2; 95% CI 2.9−9.3; p=0.000) and grading 3 (OR 2.2; 95%CI 1.2−3.9; p=0.009) could be defined as significant risk factors for distant metastases. Postmenopausal status was associated with primary metastases in stage T2 (OR 1.8; 95%CI 1.2−2.9; p=0.008) and T3/4 (OR 2.4; 95%CI 1.2−4.7; p=0.011) but not in T1 tumors (OR 1.3; 95%CI 0.7−2.1; p=0.420). There was no association with hormone or Her2 receptor status nor with a specific phenotype for T2-4 tumors.

Conclusion: The clinico-pathological features of breast cancer patients with or without primary metastases differ. In all stages positive lymph node status and higher grading were associated with pmBC significantly. Lobular histology was reported as a risk factor for T1-2 compared to patients without metastases. This feature was not found for T3/4 pmBC. T1 pmBC were likely to be associated with luminal B phenotype. T3-4 pmBC have not been associated with any phenotype or hormone receptor constellation as risk factor for metastases. Tumor biology seems to play a minor role for risk of metastases in T3-4 stages compared to patients with T1-tumors. Findings from this analysis should be considered in the choice of staging methods, especially in stage T1.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-10-07.

The crossed leg sign indicates a favorable outcome after severe stroke

OBJECTIVE

We investigated whether crossed legs are a prognostic marker in patients with severe stroke.

METHODS

In this controlled prospective observational study, we observed patients with severe stroke who crossed their legs during their hospital stay and matched them with randomly selected severe stroke patients who did not cross their legs. The patients were evaluated upon admission, on the day of leg crossing, upon discharge, and at 1 year after discharge. The Glasgow Coma Scale, the NIH Stroke Scale (NIHSS), the modified Rankin Scale (mRS), and the Barthel Index (BI) were obtained.

RESULTS

Patients who crossed their legs (n = 34) and matched controls (n = 34) did not differ in any scale upon admission. At the time of discharge, the GCS did not differ, but the NIHSS was better in crossed legs patients (6.5 vs 10.6; p = 0.0026), as was the mRS (3.4 vs 5.1, p < 0.001), and the BI (34.0 vs 21.1; p = 0.0073). At 1-year follow-up, mRS (2.9 vs 5.1, p < 0.001) and the BI (71.3 vs 49.2; p = 0.045) were also better in the crossed leg group. The mortality between the groups differed grossly; only 1 patient died in the crossing group compared to 18 in the noncrossing group (p < 0.001).

CONCLUSION

Leg crossing is an easily obtained clinical sign and is independent of additional technical examinations. Leg crossing within the first 15 days after severe stroke indicates a favorable outcome which includes less neurologic deficits, better independence in daily life, and lower rates of death.

Determination of typical patterns from strongly varying signals

Forces measured in human joints vary considerably when an activity such as walking is carried out by different subjects or when it is repeated. 'Typical' standardised force-time patterns are needed to test and improve joint implants. Mechanically most important for their endurance are the magnitudes and times of force maxima and minima. They should equal the arithmetic means from the single measurements. Similar problems exist when evaluating other strongly varying signals, as in gait analysis. The new method to calculate typical signals (TSs) enhances existing dynamic time warping (DTW) procedures. It allows us to combine any number of signals. The sequence of input signals--used for calculating the TS--has only a minor influence. The accuracy of the method was tested numerically on signals for which the typical patterns could be defined exactly, and also on real joint forces that varied to different extents.

Creatine in mouse models of neurodegeneration and aging

The supplementation of creatine has shown a marked neuroprotective effect in mouse models of neurodegenerative diseases (Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis). This has been assigned to the known bioenergetic, anti-apoptotic, anti-excitotoxic and anti-oxidant properties of creatine. As aging and neurodegeneration share pathophysiological pathways, we investigated the effect of oral creatine supplementation on aging in 162 aged wild-type C57Bl/6J mice. The median healthy life span of creatine-fed mice was 9% higher than in their control littermates, and they performed significantly better in neurobehavioral tests. In brains of creatine-treated mice, there was a trend toward a reduction of reactive oxygen species and significantly lower accumulation of the "aging pigment" lipofuscin. Expression profiling showed an upregulation of genes implicated in neuronal growth, neuroprotection, and learning. These data showed that creatine improves health and longevity in mice. Creatine may, therefore, be a promising food supplement to promote healthy human aging. However, the strong neuroprotective effects in animal studies of creatine have not been reproduced in human clinical trials (that have been conducted in Parkinson's disease, Huntington's disease, and amyotrophic lateral sclerosis). The reasons for this translational gap are discussed. One obvious cause seems to be that all previous human studies may have been underpowered. Large phase III trials over long time periods are currently being conducted for Parkinson's disease and Huntington's disease, and will possibly solve this issue.