Achilles and patellar tendinopathy display opposite changes in elastic properties: A shear wave elastography study.

To compare tendon elastic and structural properties of healthy individuals with those with Achilles or patellar tendinopathy. Sixty-seven participants (22 Achilles tendinopathy, 17 patellar tendinopathy, and 28 healthy controls) were recruited between March 2015 and March 2016. Shear wave velocity (SWV), an index of tissue elastic modulus, and tendon thickness were measured bilaterally at mid-tendon and insertional regions of Achilles and patellar tendons by an examiner blinded to group. Analysis of covariance, adjusted for age, body mass index, and sex was used to compare differences in tendon thickness and SWV between the two tendinopathy groups (relative to controls) and regions. Tendon thickness was included as a covariate for analysis of SWV. Compared to controls, participants with Achilles tendinopathy had lower SWV at the distal insertion (Mean difference MD; 95% CI: -1.56; -2.49 to -0.62 m/s; P < .001) and greater thickness at the mid-tendon (MD 0.19; 0.05-0.33 cm; P = .007). Compared to controls, participants with patellar tendinopathy had higher SWV at both regions (MD 1.25; 0.40-2.10 m/s; P = .005) and greater thickness proximally (MD 0.17; 0.06-0.29 cm; P = .003). Compared to controls, participants with Achilles and patellar tendinopathy displayed lower Achilles tendon elastic modulus and higher patellar tendon elastic modulus, respectively. More research is needed to explore whether maturation, aging, or chronic load underlie these findings and whether current management programs for Achilles and patellar tendinopathy need to be tailored to the tendon.

Cryotherapy induces an increase in muscle stiffness.

Although cold application (ie, cryotherapy) may be useful to treat sports injuries and to prevent muscle damage, it is unclear whether it has adverse effects on muscle mechanical properties. This study aimed to determine the effect of air-pulsed cryotherapy on muscle stiffness estimated using ultrasound shear wave elastography. Myoelectrical activity, ankle passive torque, shear modulus (an index of stiffness), and muscle temperature of the gastrocnemius medialis were measured before, during an air-pulsed cryotherapy (-30°C) treatment of four sets of 4 minutes with 1-minute recovery in between and during a 40 minutes postcryotherapy period. Muscle temperature significantly decreased after the second set of treatment (10 minutes: 32.3±2.5°C; P<.001), peaked at 29 minutes (27.9±2.2°C; P<.001) and remained below baseline values at 60 minutes (29.5±2.0°C; P<.001). Shear modulus increased by +11.5±11.8% after the second set (10 minutes; P=.011), peaked at 30 minutes (+34.7±42.6%; P<.001), and remained elevated until the end of the post-treatment period (+25.4±17.1%; P<.001). These findings provide evidence that cryotherapy induces an increase in muscle stiffness. This acute change in muscle mechanical properties may lower the amount of stretch that the muscle tissue is able to sustain without subsequent injury. This should be considered when using cryotherapy in athletic practice.

Hip abductor muscle activity during walking in individuals with gluteal tendinopathy.

The external hip adduction moment during walking is greater in individuals with gluteal tendinopathy (GT) than pain-free controls. Although this likely represents a greater demand on the hip abductor muscles implicated in GT, no study has investigated activation of these muscles in GT. For this purpose, fine wire electrodes were inserted into the segments of the gluteus minimus and medius muscles, and surface electrodes placed on the tensor fascia lata, upper gluteus maximus, and vastus lateralis muscles of eight individuals with, and eight without, GT. Participants underwent six walking trials. Individual muscle patterns were compared between groups using a wavelet-based linear effects model and muscle synergy analysis performed using non-negative matrix factorization to evaluate muscle activation patterns, within- and between-participant variability. Compared to controls, individuals with GT exhibited a more sustained initial burst of the posterior gluteus minimus and middle gluteus medius muscle segments. Two muscle synergies were identified; Synergy-1 activated in early-mid stance and Synergy-2 in early stance. In GT participants, posterior gluteus minimus and posterior gluteus medius and tensor fascia lata contributed more to Synergy-1 active during the period of single leg support. Participants with GT exhibited reduced within-participant variability of posterior gluteus medius and reduced between-participant variability of anterior gluteus minimus and medius and upper gluteus maximus. In conclusion, individuals with GT exhibit modified muscle activation patterns of the hip abductor muscles during walking, with potential relevance for gluteal tendon loading.

Genetic testing facilitates prepubertal diagnosis of congenital hypogonadotropic hypogonadism.

Neonatal micropenis and cryptorchidism raise the suspicion of congenital hypogonadotropic hypogonadism (CHH), a rare genetic disorder caused by gonadotropin-releasing hormone deficiency. Low plasma testosterone levels and low gonadotropins during minipuberty provide a clinical diagnostic clue, yet these tests are seldomly performed in general practice. We report a male neonate with no family history of reproductive disorders who was born with micropenis and cryptorchidism. Hormonal testing at age 2.5 months showed low testosterone (0.3 nmol/L) and undetectable gonadotropins (luteinizing hormone and follicle-stimulating hormone both <0.5 U/L), suggestive of CHH. Genetic testing identified a de novo, heterozygous mutation in fibroblast growth factor receptor 1 (FGFR1 p.L630P). L630 resides on the ATP binding cleft of the FGFR1 tyrosine kinase domain, and L630P is predicted to cause a complete loss of receptor function. Cell-based assays confirmed that L630P abolishes FGF8 signaling activity. Identification of a loss-of-function de novo FGFR1 mutation in this patient confirms the diagnosis of CHH, allowing for a timely hormonal treatment to induce pubertal development. Therefore, genetic testing can complement clinical and hormonal assessment for a timely diagnosis of CHH in childhood.

Motor adaptations to unilateral quadriceps fatigue during a bilateral pedaling task.

This study was designed to investigate how motor coordination adapts to unilateral fatigue of the quadriceps during a constant-load bilateral pedaling task. We first hypothesized that this local fatigue would not be compensated within the fatigued muscles leading to a decreased knee extension power. Then, we aimed to determine whether this decrease would be compensated by between-joints compensations within the ipsilateral leg and/or an increased contribution of the contralateral leg. Fifteen healthy volunteers were tested during pedaling at 350 W before and after a fatigue protocol consisting of 15 minutes of electromyostimulation on the quadriceps muscle. Motor coordination was assessed from myoelectrical activity (22 muscles) and joint powers calculated through inverse dynamics. Maximal knee extension torque decreased by 28.3%±6.8% (P<.0005) immediately after electromyostimulation. A decreased knee extension power produced by the ipsilateral leg was observed during pedaling (-22.8±12.3 W, -17.0%±9.4%; P<.0005). To maintain the task goal, participants primarily increased the power produced by the non-fatigued contralateral leg during the flexion phase. This was achieved by an increase in hip flexion power confirmed by a higher activation of the tensor fascia latae. These results suggest no adjustment of neural drive to the fatigued muscles and demonstrate no concurrent ipsilateral compensation by the non-fatigued muscles involved in the extension pedaling phase. Although interindividual variability was observed, findings provide evidence that participants predominantly adapted by compensating with the contralateral leg during its flexion phase. Both neural (between legs) and mechanical (between pedals) couplings and the minimization of cost functions might explain these results.

In vivo quantification of the shear modulus of the human Achilles tendon during passive loading using shear wave dispersion analysis.

The shear wave velocity dispersion was analyzed in the Achilles tendon (AT) during passive dorsiflexion using a phase velocity method in order to obtain the tendon shear modulus (C 55). Based on this analysis, the aims of the present study were (i) to assess the reproducibility of the shear modulus for different ankle angles, (ii) to assess the effect of the probe locations, and (iii) to compare results with elasticity values obtained with the supersonic shear imaging (SSI) technique. The AT shear modulus (C 55) consistently increased with the ankle dorsiflexion (N = 10, p < 0.05). Furthermore, the technique showed a very good reproducibility (all standard error of the mean values <10.7 kPa and all coefficient of variation (CV) values ⩽ 0.05%). In addition, independently from the ankle dorsiflexion, the shear modulus was significantly higher in the proximal location compared to the more distal one. The shear modulus provided by SSI was always lower than C55 and the difference increased with the ankle dorsiflexion. However, shear modulus values provided by both methods were highly correlated (R = 0.84), indicating that the conventional shear wave elastography technique (SSI technique) can be used to compare tendon mechanical properties across populations. Future studies should determine the clinical relevance of the shear wave dispersion analysis, for instance in the case of tendinopathy or tendon tear.

Massage induces an immediate, albeit short-term, reduction in muscle stiffness.

Using ultrasound shear wave elastography, the aims of this study were: (a) to evaluate the effect of massage on stiffness of the medial gastrocnemius (MG) muscle and (b) to determine whether this effect (if any) persists over a short period of rest. A 7-min massage protocol was performed unilaterally on MG in 18 healthy volunteers. Measurements of muscle shear elastic modulus (stiffness) were performed bilaterally (control and massaged leg) in a moderately stretched position at three time points: before massage (baseline), directly after massage (follow-up 1), and following 3 min of rest (follow-up 2). Directly after massage, participants rated pain experienced during the massage. MG shear elastic modulus of the massaged leg decreased significantly at follow-up 1 (-5.2 ± 8.8%, P = 0.019, d = -0.66). There was no difference between follow-up 2 and baseline for the massaged leg (P = 0.83) indicating that muscle stiffness returned to baseline values. Shear elastic modulus was not different between time points in the control leg. There was no association between perceived pain during the massage and stiffness reduction (r = 0.035; P = 0.89). This is the first study to provide evidence that massage reduces muscle stiffness. However, this effect is short lived and returns to baseline values quickly after cessation of the massage.

Time-course effect of exercise-induced muscle damage on localized muscle mechanical properties assessed using elastography.

AIM: Changes in muscle stiffness after exercise-induced muscle damage have been classically inferred from passive torque-angle curves. Elastographic techniques can be used to estimate the shear modulus of a localized muscular area. This study aimed to quantify the changes in shear elastic modulus in different regions of the elbow flexors after eccentric exercise and their relation to muscle length. METHODS: Shear elastic modulus and transverse relaxation time (T2 ) were measured in the biceps brachii and brachialis muscles of sixteen participants, before, 1 h, 48 h and 21 days after three sets of ten maximal isokinetic eccentric contractions performed at 120° s(-1) . RESULTS: The shear elastic modulus of the elbow flexors significantly increased 1 h (+46%; P = 0.005), with no significant change at 48 h and 21D, post-exercise. In contrast, T2 was not modified at 1 h but significantly increased at 48 h (+15%; P < 0.05). The increase in shear elastic modulus was more pronounced at long muscle lengths and reached a similar extent in the different regions of the elbow flexors. The normalized hysteresis area of shear elastic modulus-length relationship for the biceps brachii increased 1 h post-exercise (31%) in comparison with the pre-exercise value (18%), but was not significantly altered after five stretching cycles (P = 0.63). CONCLUSION: Our results show homogeneous changes in muscle shear elastic modulus within and between elbow flexors. The greater increase in shear elastic modulus observed at long muscle lengths suggests the putative involvement of both cross-bridges number and titin in the modifications of muscle shear elastic modulus after damaging exercise.

[Follow-up and management of children born small for gestational age a endocrine and metabolic aspects]. / Suivi et prise en charge des enfants nés petits pour l'âge gestationnel: aspects endo- crinologiques et métaboliques.

Children born premature and/or small for gestational age (SGA) are at risk of growth and metabolic abnormalities. Catch-up growth occurs usually before the age of 2. In the absence of sufficient catch up growth, growth hormone (GH) treatment should be evaluated under certain conditions. Children who were born premature and/or SGA are at higher risk of insulin resistance and metabolic abnormalities, especially in case of excessive weight gain during the first months of life. Puberty in these children occurs normally or slightly advanced, with no effect on gonadic function or fertility. Each step of the development of premature and/or SGA children present specific risks, which the pediatrician has to follow. If necessary, the pediatric endocrinologist will initiate a specific management.

[Caring for patients with pediatric endocrinopathies and diabetes into adulthood: challenges of an often difficult transition]. / Prise en charge des jeunes patients avec endocrinopathies pediatriques chroniques: les défis d'une transition souvent difficile.

The success of therapies for a number of pediatric disorders has posed new challenges for the long-term follow-up of adolescents with chronic endocrinopathies. Unfortunately, too many patients are lost during the transfer from pediatric to adult clinics. The transition process should be well-organized and include the young person and family. Recognizing the special needs of these adolescents is an important step in developing patient-centered approaches to care that enable patients to develop autonomy and self care skills. Key elements in this process include structured policies and guidelines, communication and close collaboration between pediatric and adult clinics, and integrating nurse clinicians in the transition process to help close the gaps in care.

Time of day effects on repeated sprint ability.

The present study aimed at investigating the effects of time-of-day on muscle power and associated electromyographic (EMG) activity level of 4 thigh muscles during a repeated pedalling sprint exercise. After a familiarization session, 12 male subjects were asked to perform the repeated sprint ability test during 2 experimental sessions (randomized order), which were set up either at 06:00 or 18:00 h. For each sprint, peak power output, percentage of peak power decrement and total work were calculated. EMG activity of vastus lateralis, rectus femoris, vastus medialis and biceps femoris muscles was recorded throughout the test and analyzed for each sprint. Total work and percentage of peak power decrement were higher in the evening than in the morning (p<0.01 and p<0.05, respectively). Likewise, peak power was significantly higher at 18:00 than 06:00 h during the first 3 sprints (p<0.01 for sprint 1 and p<0.05 for sprint 2 and 3). There was no time-of-day effect for EMG activity level. The neuromuscular efficiency decreased significantly over the repeated sprint ability test at the 2 times of testing (p<0.01). Despite diurnal fluctuation in muscular power and neuromuscular fatigue during the repeated sprint ability test, EMG activity of major thigh muscles was not time-of-day dependent.

Genetic testing in patients with obesity.

The obesity epidemic is associated with the recent availability of highly palatable and inexpensive caloric food as well as important changes in lifestyle. Genetic factors, however, play a key role in regulating energy balance and numerous twin studies have estimated the BMI heritability between 40 and 70%. While common variants, identified through genome-wide association studies (GWAS) point toward new pathways, their effect size are too low to be of any use in the clinic. This review therefore concentrates on genes and genomic regions associated with very high risks of human obesity. Although there are no consensus guidelines, we review how the knowledge on these "causal factors" can be translated into the clinic for diagnostic purposes. We propose genetic workups guided by clinical manifestations in patients with severe early-onset obesity. While etiological diagnoses are unequivocal in a minority of patients, new genomic tools such as Comparative Genomic Hybridization (CGH) array, have allowed the identification of novel "causal" loci and next-generation sequencing brings the promise of accelerated pace for discoveries relevant to clinical practice.

Phenotypic homogeneity and genotypic variability in a large series of congenital isolated ACTH-deficiency patients with TPIT gene mutations.

CONTEXT: Congenital isolated ACTH deficiency (IAD) is a rare disease characterized by low plasma ACTH and cortisol levels and preservation of all other pituitary hormones. This condition was poorly defined before we identified TPIT, a T-box transcription factor with a specific role in differentiation of the corticotroph lineage in mice and humans, as its principal molecular cause. OBJECTIVE: We have enlarged our series of IAD patients to better characterize the phenotype and the genotype of this rare disease. DESIGN: Each exon of the TPIT gene was amplified and sequenced in IAD patients without any identified cause. A functional analysis of each new TPIT mutation was performed. RESULTS: We described the largest series of 91 IAD patients and identified three distinct groups: neonatal onset complete or partial IAD or late onset IAD. We did not identify any TPIT mutation in patients with partial or late-onset IAD. However, we found a TPIT mutation in 65% of patients with neonatal-onset complete IAD. These patients are homozygous or compound heterozygous for TPIT mutations, and their parents are healthy heterozygous carriers. We identified nine new mutations: four missense, one one-nucleotide deletion, three splice-site mutations, and one large deletion. TPIT mutations lead to loss of function by different mechanisms, such as non-sense-mediated mRNA decay, abnormal mRNA splicing, loss of TPIT DNA binding or protein-protein interaction defects. CONCLUSION: TPIT mutations are responsible for two thirds of neonatal-onset complete IAD but can not be detected in partial or late-onset IAD.

Thigh muscle activities in elite rowers during on-water rowing.

This study analysed the muscle activity levels and patterns of the major thigh muscle activation during training sections at different intensities of on-water rowing. 9 experienced rowers performed 2 imposed-pace sections (B1 and B2) and 2 maximal-speed sections (start, 500 m) of on-water rowing. The knee angle, power output, mean torque and stroke rate were measured using specific instrumentation and were synchronised with surface electromyography signals of 5 superficial quadriceps and hamstring muscles. B1 and B2 sections were not significantly different regarding mechanical parameters and EMG activities, while the start phase induced large differences. The EMG patterns for B1, B2 were similar (cross-correlation coefficients (CC) ranged between 0.972-0.984) and the moderate CC found between both B1 and start (0.605-0.720) and B2 and start (0.629-0.720). Our results suggest that the hamstring muscles have a motor action and contribute to the power production during the leg drive. During an all-out 500 m section, a decrease in power and stroke rate was found (up to 20%). However, EMG patterns were not time shifted for all muscles. During the leg drive, the muscle activity levels of the quadriceps muscles were unchanged, while the activity of the hamstring muscles decreased.

Influence of different racing positions on mechanical and electromyographic patterns during pedalling.

The aim of this study was to test the hypothesis that, in comparison with standard postures, aero posture (AP) would modify the coordination of lower limb muscles during pedalling and consequently would influence the pedal force production. Twelve triathletes were asked to pedal at an intensity near the ventilatory threshold (VT+Delta20%) and at an intenisty corresponding to the respiratory compensation point (RCP). For each intensity, subjects were tested under three positions: (1) upright posture (UP), (2) dropped posture (DP), and (3) AP. Gas exchanges, surface electromyography and pedal effective force were continuously recorded. No significant difference was found for the gas-exchange variables among the three positions. Data illustrate a significant increase [gluteus maximus (GMax), vastus medialis (VM)] and decrease [rectus femoris (RF)] in electromyography (EMG) activity level in AP compared with UP at RCP. A significant shift forward of the EMG patterns (i.e. later onset of activation) was observed for RF (at VT+Delta20% and RCP), GMax, VL, and VM (at RCP) in AP compared with UP. These EMG changes are closely related to alteration of force profile in AP (higher downstroke positive peak force, lower upstroke negative peak force, and later occurrence of these peaks along the crank cycle).

Reliability of new pulse CO-oximeter in victims of carbon monoxide poisoning.

STUDY OBJECTIVE: The purpose of this study was to evaluate the reliability of noninvasive real-time measurement of carboxyhemoglobin (COHb) using a pulse CO-oximeter in victims of carbon monoxide poisoning (COP). METHODS: During the 7-month study period, pulse CO-oximetry was measured on patients admitted to the emergency department (ED) for suspected COP. Each patient included in the study underwent concomitant assessment of COHb by blood sampling and noninvasive pulse CO-oximetry (SpCO). RESULTS: Twelve non-smoker patients were included. Mean age was 40 +/- 17 years. No difference was found between the two COHb assessment techniques (p>0.05). Analysis using the Bland and Altman procedure suggested good alignment of the two techniques with a slight bias (i.e. -1.5%) indicating slight overestimation by the pulse CO-oximeter. Analysis using the Passing and Bablok statistical protocol further documented the reliability of the two methods. CONCLUSION: This study documents the precision of the correlation between readings obtained with the noninvasive pulse CO-oximeter and COHb measurements from blood samples. This preliminary result demonstrates that this simple rapid noninvasive technology could be useful before and after arrival at the ED.

EMG threshold determination in eight lower limb muscles during cycling exercise: a pilot study.

The first aim of this study was to verify the occurrence of the EMG threshold (EMG (Th)) in each of eight lower limb muscles (vastus lateralis [VL], vatus medialis [VM], rectus femoris [RF], semimembranosus [SM], biceps femoris [BF], gastrocnemius lateralis [GL] and medialis [GM], and tibialis anterior [TA]) during incremental cycling exercise. The second aim was to investigate the test-retest reproducibility of the EMG (Th) occurrence. Six sedentary male subjects (27 +/- 1 years) performed the same incremental cycling test until exhausted, (workload increments of 25 W/min starting at 100 W) twice. During the tests, the EMG Root Mean Square (RMS) response was studied in the aforementioned muscles. The EMG (Th) was detected mathematically from the RMS vs. workload relationship. All the subjects showed an EMG (Th) in the VL muscle, and the response was reliable in both tests (246 +/- 33 W and 254 +/- 33 W for the first and second test, respectively; coefficient of variation: 9.6 %, standard error of measurement: 28.9). However, few of them showed an EMG (Th) in the other muscles, especially in RF, SM or GM. When present, the EMG (Th) occurred at 75 - 80 % of the peak power output obtained during the tests. Our results suggest that EMG (Th) determination can be used as a reliable method for studying neuromuscular adjustments in the VL of untrained individuals, but not in other lower limb muscles.

Cellular inflammatory response to persistent localized Staphylococcus aureus infection: phenotypical and functional characterization of polymorphonuclear neutrophils (PMN).

Persistent, localized Staphylococcus aureus infections, refractory to antibiotic treatment, can result in massive tissue destruction and surgical intervention is often the only therapeutic option. In that context, we investigated patients with S. aureus-induced infection at various sites, apparent as either olecranon bursitis, empyema of the knee joint or soft tissue abscess formation. As expected, a prominent leucocyte infiltrate was found, consisting predominantly of polymorphonuclear neutrophils (PMN) (up to 75%) and to a lesser extent of T lymphocytes and natural killer (NK) cells. In line with their bactericidal capacity, PMN expressed the high-affinity receptor for IgG, CD64 and the lipopolysaccharide (LPS) receptor CD14; moreover, the oxygen radical production in response to the bacterial peptide f-MLP was enhanced, while chemotactic activity was greatly reduced. The more intriguing finding, however, was that a portion of PMN had acquired major histocompatibility complex (MHC) class II antigens and CD83, indicative of a transdifferentiation of PMN to cells with dendritic-like characteristics. Of note is that a similar transdifferentiation can be induced in PMN in vitro, e.g. by gamma interferon or by tumour necrosis factor alpha. Co-cultivation of transdifferentiated PMN with autologous T lymphocytes resulted in prominent T cell proliferation, provided that S. aureus enterotoxin A was added. Taken together, persistent S. aureus infection induces PMN to acquire characteristics of dendritic cells, which in turn might promote the local immune response.