Efficacy of beta radiation in prevention of post-angioplasty restenosis

Restenosis remains a major limitation of coronary angioplasty in spite of major advances in techniques and technology. Recent studies have demonstrated that ionizing radiation may limit the degree of this problem. Gamma radiation has been shown to be effective in reducing in stent restenosis in humans, and beta radiation following encouraging results in animals has been shown to be feasible in humans. The objective of this study was to assess the feasibility of a 5 F non-centered catheter to deliver beta radiation emitting seeds to the lesion site post angioplasty and its effect on restenosis. Following successful angioplasty, patients were randomized to treatment with 12, 14 or 16 Gy at the angioplasty site. This was delivered with a 5 F non-centered catheter. Twelve beta radiation emitting seeds (90Sr/Y) were delivered to an area 3 cm in length to cover the angioplasty site. Angiographic follow-up was performed at 6 months. Baseline and follow-up angiograms were performed by blinded investigators at a core laboratory. This interim report comprises the first 35 patients to complete 6-month angiographic follow-up. There were no major radiation incidents. Four patients had evidence of angiographic restenosis. The MLD (mm) and percent stenosis were 0.77 +/- 0.27/72.5 +/- 8.6 pre angioplasty, 2.08 +/- 0.4/25.7 +/- 9.8 post angioplasty and radiation and 2.05 +/- 0.59/25.7 +/- 19.8 at follow-up respectively. CONCLUSION: Beta radiation can be feasibly and safely delivered post coronary angioplasty with a very encouraging reduction of restenosis

Classification of coronary artery bifurcation lesions and treatments: Time for a consensus!

Background: Percutaneous coronary intervention (PCI) of coronary bifurcation lesions remains a subject of debate. Many studies have been published in this setting. They are often small scale and display methodological flaws and other shortcomings such as inaccurate designation of lesions, heterogeneity, and inadequate description of techniques implemented. Methods: The aim is to propose a consensus established by the European Bifurcation Club (EBC), on the definition and classification of bifurcation lesions and treatments implemented with the purpose of allowing comparisons between techniques in various anatomical and clinical settings. Results: A bifurcation lesion is a coronary artery narrowing occurring adjacent to, and/or involving, the origin of a significant side branch. The simple lesion classification proposed by Medina has been adopted. To analyze the outcomes of different techniques by intention to treat, it is necessary to clearly define which vessel is the distal main branch and which is (are) the side branche(s) and give each branch a distinct name. Each segment of the bifurcation has been named following the same pattern as the Medina classification. The classification of the techniques (MADS: Main, Across, Distal, Side) is based on the manner in which the first stent has been implanted. A visual presentation of PCI techniques and devices used should allow the development of a software describing quickly and accurately the procedure performed. Conclusion: The EBC proposes a new classification of bifurcation lesions and their treatments to permit accurate comparisons of well described techniques in homogeneous lesion groups. © 2008 Wiley-Liss, Inc

The additional value of patient-reported health status in predicting 1-year mortality after invasive coronary procedures: A report from the Euro Heart Survey on Coronary Revascularisation

Objective: Self-perceived health status may be helpful in identifying patients at high risk for adverse outcomes. The Euro Heart Survey on Coronary Revascularization (EHS-CR) provided an opportunity to explore whether impaired health status was a predictor of 1-year mortality in patients with coronary artery disease (CAD) undergoing angiographic procedures. Methods: Data from the EHS-CR that included 5619 patients from 31 member countries of the European Society of Cardiology were used. Inclusion criteria for the current study were completion of a self-report measure of health status, the EuroQol Questionnaire (EQ-5D) at discharge and information on 1-year follow-up, resulting in a study population of 3786 patients. Results: The 1-year mortality was 3.2% (n = 120). Survivors reported fewer problems on the five dimensions of the EQ-5D as compared with non-survivors. A broad range of potential confounders were adjusted for, which reached a p<0.10 in the unadjusted analyses. In the adjusted analyses, problems with self-care (OR 3.45; 95% CI 2.14 to 5.59) and a low rating (≤ 60) on health status (OR 2.41; 95% CI 1.47 to 3.94) were the most powerful independent predictors of mortality, among the 22 clinical variables included in the analysis. Furthermore, patients who reported no problems on all five dimensions had significantly lower 1-year mortality rates (OR 0.47; 95% CI 0.28 to 0.81). Conclusions: This analysis shows that impaired health status is associated with a 2-3-fold increased risk of all-cause mortality in patients with CAD, independent of other conventional risk factors. These results highlight the importance of including patients' subjective experience of their own health status in the evaluation strategy to optimise risk stratification and management in clinical practice

The response of trabecular bone to physical activity in young sedentary males

Bone is a dynamic tissue that is continuously undergoing cycles of resorption and formation throughout life. Factors known to effect this remodelling process include an individual\u27s nutritional and hormonal status and physical activity and achievable bone density is dependent on the interaction between an individuals chosen lifestyle and genetic make-up. There is considerable evidence that physical activity may have a positive effect on bone mineral density through the effects of mechanical loading and local and systemic physiological mechanisms. Lack of a change in bone mineral density following exercise has also been found, and this discrepancy in the literature may reflect differences in the nature, intensity and duration of the exercise programs that have been used. The complexity of the interaction between lifestyle and genetic factors, age and site specific responses also makes interpretation of the literature difficult. It has been suggested that attainment of a high peak bone mass earUer in life may compensate for the normal loss of bone which occurs and accelerates with aging. Moderate intensity activity has been shown to have a positive effect in the development of skeletal mass in children. However, there is a paucity of prospective information on the effects of physical activity in early-adulthood. The aim of this study was to investigate whether a protocol of running training designed to increase cardiovascular fitness would effect changes in bone mineral density (BMD), bone mineral content (BMC) and bone metabolism of young sedentary males. This study was also designed to assess possible associations between cardiovascular fitness and anthropometric variables and BMD and BMC

Musculo-skeletal adaptation and altered loading environments: An amputee model

Amputation of the lower limb may result in musculo-skeletal changes similar to those that occur following space flight, immobilisation and prolonged bed rest. The similarities desist when one considers the invasive nature of amputation surgery and the impact that partial loss of a limb has on the loading characteristics of the affected leg. The aim of this study was to determine the musculo-skeletal changes that occur following trans-femoral and trans-tibial amputation, and to compare differences in the musculo-skeletal characteristics of these groups, which may occur as a function of the modified loading environment. Unique to this investigation was the study of a new trans-femoral amputee, which was incorporated to investigate the time course of any changes in muscle and bone atrophy and decreases in muscle strength in the early post-operative period. This study was also designed to provide a comparison with longer-term amputees and examine relationships between muscle morphology and strength and identified changes in gait behaviour by reference to normal gait patterns. Eight unilateral trans-femoral and 8 trans-tibial amputees (mean age 35.2yrs. ± 9.8 and 35.3yrs. ± 8.9 respectively) were subjects in the study. There were 7 males and 1 female in each of the amputee groups. A control group of similar number was used, with subjects matched on age, weight, height and gender. In the first phase of the investigation dual energy x-ray absorptiometry and magnetic resonance imaging was used to measure bone mineral density (B:MD) of the lumbar spine (L2-IA) and femoral neck (FN) and to calculate the volume and cross-sectional area (CSA) of selected muscles. Strength evaluation was assessed by measurement of maximal isometric hip torque using a Kin-Com dynamometer. Gait analyses were undertaken to determine differences in the angular kinematics of the residual and sound limb together with an electromyographic (EMG) assessment of the onset and offset of the activity of 4 hip muscles of the residual and sound thigh, which was synchronised with the kinematic measures. Differences in ground reaction force (GRF) between the residual and sound limb of each group were also examined. A single case study involving a 19-year-old motor accident victim who sustained a traumatic trans-femoral amputation of his right leg was conducted to determine the structural and functional changes over a 9-month period. Structural and functional evaluations were repeated every 3 months, beginning at 4 months post amputation, using similar methodologies and procedures described for the longer-term amputees. In the longer-term amputees the volume and CSA of the residual musculature of the trans-femoral group was significantly lower by comparison with the sound limb and no difference was found between the residual and sound musculature of the trans-tibial group. Mean torque of the residual hip was lower than that of the sound hip of the trans-femoral and trans-tibial group but the difference was not significant. Bone mineral density of the residual FN was significantly lower than that of the sound FN of the trans-femoral group but there was no difference in the trans-tibial group. No differences were found between the two experimental groups and controls at the L2-1A site. Muscle volume was significantly correlated with BMD of the L2- 1A vertebrae in the residual and sound limb of the trans-tibial group. Trans-femoral and trans-tibial amputees had a significantly slower walking velocity than that of the control group. Cadence of the trans-femoral group was significantly lower than both trans-tibial and the control groups. Stride length was not significantly different between the trans-femoral and control group but was significantly lower in the trans-tibial group. Significant differences were found between the trans-femoral and control group in the range of ankle and knee motion of the sound limb and between the sound and residual ankle, knee and hip joints of the trans-femoral and trans-tibial group. Mean GRF was lower in the residual limb compared to the sound limb for both groups, although the differences were not significant. The activity of rectus femoris, biceps femoris and adductor longus in the sound limb of the trans-femoral group were generally active for a longer duration compared to the controls and the duration of activity of these same muscles differed between the residual and sound limb musculature of the trans-tibial group. In the case study subject, BMD in the residual FN was 38.4 per cent lower than the sound FN at 4 months, decreasing to 42.1 per cent at the end of the 9-month evaluation. At this time point bone loss of the case study subject was greater than the average difference between the residual and sound limb of the longer-term amputees suggesting some recovery of bone mass may be possible. Rectus femoris and biceps femoris showed greater atrophy than the intact muscles, psoas major, adductor longus and the gluteals. At 7-months post amputation, hip torque of the residual limb in all planes of movement was lower by comparison with the sound limb. There was considerable intra-group variability in the data, which reflected the heterogeneity of the groups with respect to surgical fixation procedures, types of prosthesis used and their different physical activity levels. It was shown that longerterm trans-femoral amputees experienced considerable muscle and bone atrophy of their residual limb, which was greater than that experienced by the trans-tibial group. Although loading was not measured directly the difference between the two groups of amputees perhaps reflected their altered loading environment. Isometric hip torque was not different between the residual and sound limb of the trans-femoral and trans-tibial group, an unexpected result in the trans-femoral group considering the muscle atrophy present. The morphological changes combined with the prosthetic components were likely responsible for differences in amputee gait function. In the more recent amputee, muscle and bone atrophy was most rapid in the first 4 months but the volume and CSA of rectus femoris and biceps femoris continued to decrease up to 13 months post amputation. Isometric torque of the hip flexors and extensors decreased between 7 and 10 months and stabilised by 13 months post amputation while there was no change in the torque of the hip abductors and adductors from the initial measure. The potential for recovery of BMD, muscle size and muscle strength must be considered and may be applied to the design of more effective prostheses and rehabilitation strategies aimed at improving functional outcomes

Musculoskeletal profile of amateur combat athletes: body composition, muscular strength and striking power

Background: Previous research highlighted positive musculoskeletal adaptations resulting from mechanical forces and loadings distinctive to impacts and movements with sports participation. However, little is known about these adaptations in combat athletes. The aim of this study was to quantify bone mineral density, lean muscle mass and punching and kicking power in amateur male combat athletes. Methods: Thirteen male combat athletes (lightweight and middleweight) volunteered all physiological tests including dual energy X-ray absorptiometry for bone mineral density (BMD) segmental body composition (lean muscle mass, LMM), muscle strength and striking power, sedentary controls (n = 15) were used for selected DXA outcome variables. Results: There were significant differences (p < 0.05) between combat groups for lumbar spine (+5.0%), dominant arm (+4.4%) BMD, and dominant and non-dominant leg LMM (+21.8% and +22.6%). Controls had significantly (p < 0.05) high adiposity (+36.8% relative), visceral adipose tissue (VAT) mass (+69.7%), VAT area (+69.5%), lower total body BMD (−8.4%) and lumbar spine BMD (−13.8%) than controls. No differences in lower limb BMD were seen in combat groups. Arm lean mass differences (dominant versus non-dominant) were significantly different between combat groups (p < 0.05, 4.2% versus 7.3%). There were no differences in punch/kick power (absolute or relative) between combat groups. 5RM strength (bench and squat) correlated significantly with upper limb striking power (r = 0.57), dominant and non-dominant leg BMD (r = 0.67, r = 0.70, respectively) and total body BMD (r = 0.59). Conclusion: BMD and LMM appear to be particularly important to discriminate between dominant and non-dominant upper limbs and less so for lower limb dominance in recreational combat athletes

Osteoporosis and low bone mineral density (osteopenia) in rural and remote Queensland

Objective: To report that prevalence rates of osteoporosis and osteopenia differ according to different levels of remoteness in Queensland, Australia. Design: Retrospective analysis of bone mineral density scans undertaken between April 2015 and April 2016. Setting: Mobile laboratory housing a dual energy X-ray absorptiometry in rural and remote Queensland. Participants: Four-thousand-four-hundred-and-twenty-seven referred individuals 70 years of age or older. Main outcome measures: Bone mineral density (g cm−2) at two sites was used to measure the level of bone health as per the World Health Organization criteria for osteoporosis. Results: A slightly higher percentage of women was screened and the percentage screened in both men and women decreased as levels of remoteness increased. Women in outer regional areas had significantly higher odds of having osteopenia over normal bone mineral density, compared to women in an urban setting. Conclusion: As the level of remoteness increased, there was a decrease in the percentage of men and women being screened to determine their risk of osteoporosis. Furthermore, the current data suggest that women in more remote areas have significantly lower bone density, compared to an urban female population. Finally, men and women have similar levels of osteopenia across Queensland, Australia. © 2018 National Rural Health Alliance Ltd

Clinical and angiographic acute and follow up results of intracoronary β brachytherapy in saphenous vein bypass grafts: a subgroup analysis of the multicentre European registry of intraluminal coronary β brachytherapy (RENO)

Objective: To assess clinically and angiographically the feasibility, safety, and effectiveness of vascular brachytherapy (VBT) in saphenous vein bypass grafts (SVG). Patients and methods: 67 of 1098 (6.1%) consecutive patients of the European registry of intraluminal coronary β brachytherapy underwent treatment for 68 SVG lesions by VBT using a Sr/Y(90) source train (BetaCath). Clinical follow up data were obtained for all of them after a mean (SD) of 6.3 (2.4) months and angiographic follow up was performed in 61 patients (91.0%) after 6.9 (2.0) months. Results: 58 (86.6%) patients were men, their mean (SD) age was 66 (10) years, 28 (41.8%) had unstable angina, and 21 (31.3%) had diabetes. Fifty three (77.9%) lesions were in-stent restenosis, 13 (19.1%) de novo lesions, and 2 (3.0%) non-stented restenotic lesions. Mean (SD) reference diameter before the intervention was 4.19 (0.52) mm, mean (SD) lesion length was 23.56 (20.38) mm, and mean (SD) minimum lumen diameter measured 0.73 (0.62) mm. Mean (SD) acute gain was 3.02 (0.88) mm. The prescribed radiation dose was 20.1 (3.2) Gy. Pullback manoeuvres were performed in 17 (25.0%) of cases. Most patients received combined aspirin and thienopyridin treatment for 6 or 12 months after the procedure. Technical success was obtained in 62 (91.2%) treated lesions and in-hospital major adverse cardiac events occurred in 4.5%. At follow up, mean (SD) reference diameter was 4.20 (0.53) mm, minimum lumen diameter 2.94 (1.50) mm, and late loss 0.86 (1.25) mm. The overall major adverse cardiac events rate was 26.7%. Conclusion: VBT of SVG is feasible and safe. At follow up the reintervention rate and cardiac morbidity and mortality seem to be favourable, considering that interventions in SVG usually are associated with the highest risks