Early postoperative C-terminal agrin fragment (CAF) serum levels predict graft loss and proteinuria in renal transplant recipients.

BACKGROUND: C-terminal agrin fragment (CAF), cleavage product of agrin, was previously correlated with kidney function in renal transplant patients. This article studies the predictive value of CAF for long-term outcomes in renal transplant recipients. METHODS: In this observational cohort study, serum CAF, creatinine and blood-urea-nitrogen (BUN) concentrations and eGFR (CKD-EPI) were assessed 1-3 months after transplantation in 105 patients undergoing kidney transplantation. Cox regression models were used to analyse the predictive value of all parameters concerning all-cause mortality (ACM), graft loss (GL), doubling of creatinine/proteinuria at the end of follow-up. RESULTS: Median follow-up time was 3.1 years. The mean concentrations were 191.9±152.4 pM for CAF, 176±96.8 µmol/L for creatinine, 12.6±6.2 mmol/L for BUN and 44.9±21.2 mL/min for CKD-EPI formula, respectively. In univariate analysis CAF and BUN concentrations predicted ACM (CAF: HR=1.003, 1.1-fold risk, p=0.043; BUN: HR=1.037, 1.3-fold risk, p=0.006). Concerning GL, CAF (HR=1.006, 3.1-fold risk, p<0.001), creatinine (HR=2.396, 2.6-fold risk, p<0.001), BUN (HR=1.048, 1.7-fold risk, p=0.001) and eGFR (CKD-EPI) (HR=0.941, 0.45-fold risk reduction, p=0.006) showed a statistically significant association. CAF was the only parameter significantly associated with doubling of proteinuria (HR=1.005, 1.7-fold risk, p<0.001). In multiple regression analysis (CAF only) the association remained significant for GL and doubling of proteinuria but not ACM. CONCLUSIONS: Early postoperative serum CAF appears to be a useful tool for the assessment of long-term outcomes in renal transplant recipients. Most importantly it represents a promising predictor for the development of proteinuria.

Is a Profiled Annuloplasty Ring Suitable for Repair of Degenerative Mitral Regurgitation? A Single-Center Experience Comprising 200 Patients.

Background Various devices have been proposed for ring annuloplasty in patients with degenerative mitral valve disease. This study reports for the first time midterm results with the rigid three-dimensional Medtronic Profile 3D (Medtronic, Minneapolis, Minnesota, United States) annuloplasty ring. Methods Between June 2009 and June 2011, 200 patients (mean age 61 ± 13 years, 70% male) with severe degenerative mitral regurgitation underwent mitral valve repair using the Medtronic Profile 3D annuloplasty ring. A total of 106 patients (53.0%) underwent isolated mitral valve repair and 94 patients (47.0%) underwent a concomitant procedure such as coronary artery bypass grafting (n = 21), tricuspid valve surgery (n = 49), AF ablation (n = 17), and aortic valve surgery (n = 13). The follow-up is 94.5% complete (mean 2.5 ± 0.5 years). Results Thirty-day mortality was 1.5%. Survival at 3 years was 97.1 ± 1.6% for isolated procedures and 92.4 ± 2.8% for combined procedures (p = 0.137). Freedom from mitral valve-related reoperation at 3 years was 97.1 ± 1.7% for isolated procedures and 95.5 ± 2.2% for combined procedures (p = 0.561). Seven patients (3.5%) required a mitral valve-related reoperation. Two of these reoperations were required for endocarditis, two for ring dehiscence, one for progression of the native disease (flail leaflet), one for leaflet suture dehiscence, and one for persistent systolic anterior motion. Conclusion The three-dimensional Medtronic Profile 3D annuloplasty ring is suitable for mitral valve repair for degenerative diseases. This saddle-shaped annuloplasty device provides excellent early results with a very good functional outcome at midterm either in isolated or combined procedures.

Impact of active thermoregulation on the microcirculation of free flaps.

BACKGROUND: While it is a known fact that warming increases blood flow in healthy tissue, little is known about the impact of active thermoregulation on the altered microcirculation of free flaps. The objective of the study was to identify the impact of postoperative active thermoregulation on free flap microcirculation. METHODS: Tissue temperature was assessed in 25 free perforator flaps using an implanted probe. Active thermoregulation was achieved using a water circulation based system. Changes in microcirculation were evaluated at the day of surgery and throughout the first three postoperative days after passive cooling (room temperature), passive warming (wound dressing), active warming (38 °C) and active cooling (15 °C) using laser Doppler flowmetry and remission spectroscopy. RESULTS: Active warming increased flap temperature by 7.7% to 36.4 °C ± 0.5 °C in comparison to the initial values of flaps without dressing (P < 0.001). As a result, the blood flow increased by 77.7% of the base value (P < 0.001). A significant correlation between all microcirculation parameters and tissue temperature was observed with a 5.52 AU blood flow increase per degree temperature increase (r = 0.7; P < 0.001). All microcirculation parameters showed a statistically significant increase after both passive and active warming, whereby active warming showed significantly higher values than passive warming. CONCLUSIONS: Active thermoregulation using water-based circulation is an effective and safe procedure to improve microcirculation in free flaps and is superior to conventional passive warming strategies.

Simultaneous integrated vs. sequential boost in VMAT radiotherapy of high-grade gliomas.

BACKGROUND: In 20 patients with high-grade gliomas, we compared two methods of planning for volumetric-modulated arc therapy (VMAT): simultaneous integrated boost (SIB) vs. sequential boost (SEB). The investigation focused on the analysis of dose distributions in the target volumes and the organs at risk (OARs). METHOD: After contouring the target volumes [planning target volumes (PTVs) and boost volumes (BVs)] and OARs, SIB planning and SEB planning were performed. The SEB method consisted of two plans: in the first plan the PTV received 50 Gy in 25 fractions with a 2-Gy dose per fraction. In the second plan the BV received 10 Gy in 5 fractions with a dose per fraction of 2 Gy. The doses of both plans were summed up to show the total doses delivered. In the SIB method the PTV received 54 Gy in 30 fractions with a dose per fraction of 1.8 Gy, while the BV received 60 Gy in the same fraction number but with a dose per fraction of 2 Gy. RESULTS: All of the OARs showed higher doses (Dmax and Dmean) in the SEB method when compared with the SIB technique. The differences between the two methods were statistically significant in almost all of the OARs. Analysing the total doses of the target volumes we found dose distributions with similar homogeneities and comparable total doses. CONCLUSION: Our analysis shows that the SIB method offers advantages over the SEB method in terms of sparing OARs.

In vitro assessment of knee MRI in the presence of metal implants comparing MAVRIC-SL and conventional fast spin echo sequences at 1.5 and 3 T field strength.

PURPOSE: To assess lesion detection and artifact size reduction of a multiacquisition variable-resonance image combination, slice encoding for metal artifact correction (MAVRIC-SEMAC) hybrid sequence (MAVRIC-SL) compared to standard sequences at 1.5T and 3T in porcine knee specimens with metal hardware. MATERIALS AND METHODS: Artificial cartilage and bone lesions of defined size were created in the proximity of titanium and steel screws with 2.5 mm diameter in 12 porcine knee specimens and were imaged at 1.5T and 3T magnetic resonance imaging (MRI) with MAVRIC-SL PD and short T1 inversion recovery (STIR), standard fast spin echo (FSE) T2 PD, and STIR and fat-saturated T2 FSE sequences. Three radiologists blinded to the lesion locations assessed lesion detection rates on randomized images for each sequence using receiver operating characteristic (ROC). Artifact length and width were measured. RESULTS: Metal artifact sizes were largest in the presence of steel screws at 3T (FSE T2 FS: 28.7 cm(2) ) and 1.5T (16.03 cm(2) ). MAVRIC-SL PD and STIR reduced artifact sizes at both 3T (1.43 cm(2) ; 2.46 cm(2) ) and 1.5T (1.16 cm(2) ; 1.59 cm(2) ) compared to FS T2 FSE sequences (27.57 cm(2) ; 13.20 cm(2) ). At 3T, ROC-derived AUC values using MAVRIC-SL sequences were significantly higher compared to standard sequences (MAVRIC-PD: 0.87, versus FSE-T2 -FS: 0.73 [P = 0.025]; MAVRIC-STIR: 0.9 vs. T2 -STIR: 0.78 [P = 0.001] and vs. FSE-T2 -FS: 0.73 [P = 0.026]). Similar values were observed at 1.5T. Comparison of 3T and 1.5T showed no significant differences (MAVRIC-SL PD: P = 0.382; MAVRIC-SL STIR: P = 0.071). CONCLUSION: MAVRIC-SL sequences provided superior lesion detection and reduced metal artifact size at both 1.5T and 3T compared to conventionally used FSE sequences. No significant disadvantage was found comparing MAVRIC-SL at 3T and 1.5T, although metal artifacts at 3T were larger. J. Magn. Reson. Imaging 2015;41:1291-1299. © 2014 Wiley Periodicals, Inc.

Single-day sodium picosulfate and magnesium citrate versus split-dose polyethylene glycol for bowel cleansing prior to colonoscopy: A prospective randomized endoscopist-blinded trial.

BACKGROUND AND AIM: The intake of polyethylene glycol (PEG) prior colonoscopy is frequently associated with nausea and abdominal discomfort. The aim of this study was to investigate whether sodium picosulfate and magnesium citrate (PMC) is superior to a polyethylene glycol (PEG) preparation in regard to patient acceptance. Furthermore, it investigates possible differences in efficiency and patient safety. METHODS: In a randomised, prospective, and endoscopist-blinded study patients were 1:1 randomized to either use PMC or 4-L PEG in order to prepare for colonoscopy. Cleansing regimes consisted of a split-dose administration in the PEG arm and standard administration in the PMC arm. Primary end point was proportion of patients evaluating the bowel preparation procedure as "very distressing," defined as ≥ 8 points on a 10-point numeric rating scale (NRS). Secondary end points were quality of bowel preparation and electrolyte parameters. RESULTS: PMC bowel-cleansing procedure was better tolerated compared with PEG (PMC(NRS<8) = 89.9% vs PEG(NRS<8) = 79.2%, P = 0.037). Mean declines in serum sodium (ΔSodium(PEG) = -0.76 ± 3.07 vs ΔSodium(PMC) = -3.38 ± 3.56 mmol/L; P < 0.001), chloride (ΔChloride(PEG) = -1.00 ± 3.22 vs ΔChloride(PMC) = -3.49 ± 3.51 mmol/L; P < 0.001), and osmolality (ΔOsmolality(PEG) = -4.23 ± 6.82 vs ΔOsmolality(PMC) = -8.83 ± 7.43 mosmol/kg; P < 0.001) were higher in the PMC arm than in the PEG arm. Hyponatremia after bowel preparation occurred more often in PMC (21.2%) than in PEG (4.0%) (P < 0.001). Successful preparation was achieved more frequently in the PEG arm (42.9% vs 82.2%; P < 0.001). CONCLUSION: Standard picosulfate/magnesium citrate is better accepted than a split-dose PEG regimen. From the perspective of successful preparation and patients' safety, PEG is superior to PMC.

Matched Comparison of Two Different Biological Prostheses for Complete Supra-annular Aortic Valve Replacement.

Objective The aim of this retrospective study was to evaluate the hemodynamic performance of the St. Jude Medical Trifecta (SJM Trifecta; St. Jude Medical, St Paul, Minnesota, United States) and the Carpentier-Edwards Perimount Magna Ease (CEPM Ease; Edwards Lifesciences, Irvine, California, United States) bioprostheses early postoperative and at 1 year. Methods From October 2007 to October 2008, a total of 61 consecutive patients underwent aortic valve replacement (AVR) with the CEPM Ease prosthesis. From a prospective cohort of 201 patients (March 2011 to January 2012) who received AVR with the SJM Trifecta valve, a matched group of 51 patients was selected. Matching was conducted 1:1 by ejection fraction, gender, age, and body surface area. A Hegar dilator was used to define the aortic tissue annulus diameter. Data were grouped on the basis of the patient's tissue annulus diameter (≤22 mm; 23-24 mm; ≥25 mm). Results Early postoperative and at 1 year mean pressure gradients (MPGs) in the various groups ranged from 7.2 ± 4.6 to 7.1 ± 2.4 mm Hg and from 10.0 ± 4.3 to 8.0 ± 2.8 mm Hg in the SJM Trifecta group and from 18.0 ± 5.0 to 12.1 ± 3.6 mm Hg and from 17.7 ± 4.5 to 11.8 ± 3.2 mm Hg in the CEPM Ease group, respectively. Likewise, effective orifice areas (EOAs) ranged from 1.7 ± 0.5 to 2.0 ± 0.5 cm(2) and from 1.5 ± 0.3 to 1.7 ± 0.4 cm(2) in the SJM Trifecta group and from 1.3 ± 0.5 to 1.9 ± 0.5 cm(2) and from 1.2 ± 0.3 to 1.8 ± 0.3 cm(2) in the CEPM Ease group, respectively. A marked left ventricular mass (LVM) regression across all annulus sizes was noted in both groups. Severe patient-prosthesis mismatch (PPM) was infrequent overall. Conclusion The SJM Trifecta valve showed lower MPGs early postoperative and at 1 year as well as higher EOA and effective orifice area index early postoperative. No significant differences were detected with regard to LVM regression and PPM.

Prevalence and topography of lymph node metastases in early esophageal and gastric cancer.

OBJECTIVE: To determine the prevalence and localization of lymph node metastases in patients with pT1 carcinoma of the esophagus, esophagogastric junction, and stomach. BACKGROUND: Retrospective analysis and topographic description. METHODS: We included 793 consecutive patients with pT1 carcinomas who underwent primary surgery for squamous cell carcinoma (SCC) of the esophagus, adenocarcinomas of the esophagogastric junction (AEG), or gastric cancer (GC). Clinical records and pathology reports were reviewed, and the prevalence and topography of lymph node metastases were identified. RESULTS: The prevalence of lymph node metastases in SCC, AEG, and GC was 7%, 0%, and 5% for pT1a tumors and 24%, 18%, and 14% for pT1b tumors, respectively. Positive lymph node status was associated with worse overall survival (P<0.001). Not only infiltration of the submucosa (P=0.002) but also lymphatic vessel invasion (P<0.001), multifocal tumor growth (P=0.001), lower patient age (P=0.001), and poor tumor differentiation (P=0.05) were associated with nodal disease. These 5 parameters allowed the compilation of a nomogram to estimate the individual risk of lymph node metastases. In SCC, lymph node metastases were found from the neck to the celiac axis. In AEG, nodal disease was limited to the lower mediastinum and the D1 compartment. In GC, lymphatic spread exceeded the D1 compartment in 7% of node positive patients. CONCLUSIONS: Risk estimation for lymph node metastases should not be based on depth of tumor infiltration alone but additional clinicopathological parameters should also be considered. The extent of lymphadenectomy in surgical procedures should respect the presented topography of lymph node metastases.

Prospective comparison of computed tomography, diffusion-weighted magnetic resonance imaging and [11C]choline positron emission tomography/computed tomography for preoperative lymph node staging in prostate cancer patients.

PURPOSE: The aim of this study was to prospectively compare diffusion-weighted magnetic resonance imaging (DWI) and [(11)C]choline positron emission tomography/computed tomography (PET/CT) with computed tomography (CT) for preoperative lymph node (LN) staging in prostate cancer (PCa) patients. METHODS: Between June 2010 and May 2012, CT, DWI and [(11)C]choline PET/CT were performed preoperatively in 33 intermediate- and high-risk PCa patients undergoing radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND) including obturator fossa and internal, external and common iliac fields. Patient- and field-based performance characteristics for all three imaging techniques based on histopathological results are reported. Imaging techniques were compared by means of the area under the curve (AUC). RESULTS: LN metastases were detected in 92 of 1,012 (9%) LNs from 14 of 33 (42%) patients. On patient-based analysis, sensitivity, specificity and accuracy for CT were 57, 68 and 64%, respectively, for DWI were 57, 79 and 70%, respectively, and for [(11)C]choline PET/CT were 57, 90 and 76%, respectively. On field-based analysis, these numbers for CT were 47, 94 and 88%, respectively, for DWI were 56, 97 and 92%, respectively, and for [(11)C]choline PET/CT were 62, 96 and 92%, respectively. Neither DWI nor [(11)C]choline PET/CT performed significantly better than CT on pairwise comparison of patient- and field-based results. CONCLUSION: All three imaging techniques exhibit a rather low sensitivity with less than two thirds of LN metastases being detected on patient- and field-based analysis. Overall diagnostic efficacy did not differ significantly between imaging techniques, whereas distinct performance characteristics, esp. patient-based specificity, were best for [(11)C]choline PET/CT followed by DWI and CT.

Radiographic signs for detection of femoroacetabular impingement and hip dysplasia should be carefully used in patients with osteoarthritis of the hip.

BACKGROUND: During the last years, terms like acetabular retroversion, excessive overcoverage, and abnormal head-neck-junction with the so called "pistol-grip-deformity" has been added to the classical description of hip dysplasia. These anatomical changes could lead to a femoroacetabular impingement (FAI). Both kinds of FAI has been indentified as a main reason for hip pain and progressive degenerative changes leading to early osteoarthritis of the hip. A lot of radiographic criteria on pelvic views have been established to detect classical dysplasia and FAI. The present study was initiated to assess the hypothesis that age and severity of osteoarthritis affect measurements of different radiographic parameters. METHODS: The pelvic radiographs of 1614 patients were measured for head-ratio, CE-angle, roof obliquity, extrusion-index, depth-to-width ratio, CCD-angle, sharp's angle. To evaluate the severity of osteoarthritis of the hip the classification by Kellgren and Lawrence was used. Associations between age and radiographic parameters or severity of osteoarthritis were assessed by Spearman's (ρ) or Kendall's (r) rank correlation coefficient, respectively. RESULTS: 366 (22.7%) patients presented no sign of osteoarthritis, 367 (22.7%) patients presented I° osteoarthritis, 460 (28.5%) patients presented II° osteoarthritis, 307 (19%) III° osteoarthritis and 114 (7.1%) IV° osteoarthritis of the hip. The mean head-ratio of all patients was 1.13 ± 0.26 (0.76 - 2.40), the mean CE-angle 40.05° ± 10.13° (0° - 70°), the mean roof obliquity was 35.27° ± 4.96° (10° - 55°), the mean extrusion-index was 12.99 ± 9.21 (6.20 - 95.2), the mean depth-to-width ratio was 59.30 ± 8.90 (6.30 - 100), the mean CCD-angle was 127.68° ± 7.22° (123° - 162°) and the mean sharp's angle was 9.75° ± 5.40° (1° - 34°) There was a weak association between age and the severity of osteoarthritis of the hips (left: r= 0.291; right: r=0.275; both P<0.001) with higher osteoarthritis levels observable for elderly patients). CONCLUSION: Severity of osteoarthritis has a negative impact on measurements of different radiographic parameters. Therefore - in our opinion - epidemiological studies on prearthrotic deformities should only be performed in healthy adults with no signs of osteoarthritic changes.

Correction to: Electromagnetic interference in implantable cardioverter defibrillators: present but rare.

The original version of this article unfortunately contained a mistake.

Influence of spine surgery on the ability to perform an emergency stop while driving a car.

BACKGROUND: Spinal surgeries have strongly increased in number over the past decade. The question of when it is safe to resume driving is thereby one the most frequently asked questions that patients ask of their treating physician. OBJECTIVE: The aim of this study was to assess braking performance before and after spine surgery. METHODS: Reaction time, foot transfer time (together brake response time [BRT]), and brake force (BF) were evaluated in a drive simulator. A longitudinal patient cohort (n= 27) was tested preoperatively and at the first follow-up. A cross-sectional cohort (n= 27) was tested at > 1 year postoperatively. The values from these groups were compared with a healthy age-matched control group of 24 volunteers. RESULTS: No significant improvement in BRT was seen in lumbar fusion three months postoperatively (p= 0.597); BF was even weaker than it was preoperatively (p= 0.044). In comparison to the control group (median BRT 479 ms), preoperative BRT was already impaired in lumbar fusion patients (median 560 ms), representing an increased braking distance of 2.25 m at 100 km/h. CONCLUSION: Although most patients performed adequately, about one third presented critical braking performance. Risk factors for impaired braking may include scheduled multisegmental fusion surgery, female sex, and pain.

INFLUENCE OF AGE ON PARAMETERS FOR FEMOROACETABULAR IMPINGEMENT AND HIP DYSPLASIA IN X-RAYS.

OBJECTIVE: While several radiographic parameters have been established to describe the geometry and pathology of the hip, their reference values and clinical significance remain a matter of dispute. The present study tests the hypothesis that age has a relevant impact on radiographic hip parameters. METHOD: Pelvic antero-posterior views were measured for CE angle, Sharp's angle, acetabular depth-to-width ratio, femoral head extrusion index, roof obliquity, caput-collum-diaphyseal (CCD) angle, and Murray's femoral head ratio, and the values obtained were correlated with age. RESULTS: Significant weak and moderate linear correlations (all Ps<0.001) were observed between age and CE angle (ρ=0.31), Sharp's angle (ρ=-0.38), extrusion index (ρ=-0.22), CCD angle (ρ=-0.15), depth-to-width ratio (ρ=-0.38), and roof obliquity (ρ=-0.19), while Murray's femoral head ratio (ρ=0.05; P=0.274) was not associated with age. Interestingly, the parameters describing the acetabulum all showed a relevant increase in coverage with age, leading to CE-angles well beyond 40° and a Sharp's angle below 35° in a large portion of asymptomatic older adults. CONCLUSION: While a decrease in CCD angle with age is described in most orthopedic textbooks, the changes observed with age in acetabular geometry far exceed those measured at the femoral head-neck junction. We recommend considering these alterations that may be attributable to age when formulating a radiographic diagnosis. Level of Evidence III, Diagnostic Studies - Investigating a Diagnostic Test.

OBJETIVO: Embora tenham sido estabelecidos vários parâmetros radiográficos para descrever a geometria e a patologia do quadril, seus valores de referência e significância clínica continuam sendo uma questão controversa. O presente estudo testa a hipótese de que a idade tem impacto relevante sobre os parâmetros radiográficos do quadril. MÉTODO: As vistas pélvicas anteroposteriores foram medidas quanto ao ângulo CE, ângulo de Sharp, proporção entre profundidade e largura acetabular, índice de extrusão da cabeça do fêmur, obliquidade do lábio do acetábulo (teto), ângulo cabeça-colo-diafisário (CCD) e razão da cabeça do fêmur de Murray e os valores obtidos foram correlacionados com a idade. RESULTADOS: Foram observadas correlações lineares significantes, fracas e moderadas (todos os P < 0,001) entre idade e ângulo CE (ρ = 0,31), ângulo de Sharp (ρ = -0,38), índice de extrusão da cabeça do fêmur (ρ = -0,22), ângulo CCD (ρ = -0,15), proporção entre profundidade e largura acetabular (ρ = -0,38) e obliquidade do lábio do acetábulo (ρ = -0,19), enquanto a razão da cabeça do fêmur de Murray (ρ = 0,05; P = 0,274) não foi associada à idade. Curiosamente, todos os parâmetros que descrevem o acetábulo mostraram um aumento relevante de cobertura com idade, levando a ângulos CE bem além de 40° e ângulos de Sharp abaixo de 35° em uma grande parcela de idosos assintomáticos. CONCLUSÃO: Embora a diminuição do ângulo CCD com a idade seja descrita na maioria dos livros didáticos de ortopedia, as alterações na geometria acetabular observadas com a idade ultrapassam, de longe, as medidas na junção entre cabeça e colo do fêmur. Recomendamos considerar essas alterações que podem ser atribuídas à idade ao formular um diagnóstico radiográfico. Nível de Evidência III, Estudos Diagnósticos - Investigação de um Exame para Diagnóstico.

The Effects of Hip and Spine Orthoses on Braking Parameters: A Simulated Study With Healthy Subjects.

BACKGROUND: Although a person's fitness to drive has gained more attention over the past few years, investigations have focused mainly on postsurgical (eg, hip arthroplasty) driving performance. Few data are available on how orthoses affect the ability to perform an emergency stop. OBJECTIVE: To determine whether common lumbar and hip orthoses impair driving performance by increasing brake response time and weakening brake force (BF). DESIGN: Crossover repeated measures design. SETTING: University hospital. PARTICIPANTS: A crossover, repeated-measures design was used to test 30 healthy volunteers with and without each of the orthoses in random order. METHODS: A custom-made simulator was created from a car cabin fitted with measurement equipment to record braking parameters under realistic spatial constraints. MAIN OUTCOME MEASUREMENTS: Reaction time (RT), foot transfer time (FTT) (these 2 together: brake response time), and maximum BF. RESULTS: Although spine orthoses lead to statistically significant increases in RT (Vertebradyn-Strong, P = .002; Horizon 637 LSO, P = .32; and SofTec Dorso, P = .013), this effect was not observed in hip orthoses, where instead FTT was prolonged (DynaCox and Hohmann-like orthosis, P < .001). BF was not significantly altered in any of the orthoses. CONCLUSIONS: This study demonstrates that hip and spine orthoses lead to impaired driving performance. Depending on the type of immobilization, this effect mostly increases RT or FTT, lengthening total stopping distances by up to half a meter at 100 km/h. However, in the absence of an underlying pathological condition in individuals with orthoses, their braking performance should be sufficient to continue driving.

Activated Protein C Resistance Does Not Increase Risk for Recurrent Stroke or Death in Stroke Patients.

BACKGROUND: Activated protein C (APC) resistance is the most common inherited prothrombotic disorder. The role of APC resistance in ischemic stroke is controversially discussed. OBJECTIVES: The aim of this single center follow up study was to investigate the effect of APC resistance on stroke recurrence and survival in stroke patients. PATIENTS/METHODS: We retrospectively identified 966 patients who had had an ischemic stroke or transitory ischemic attack (TIA) and in whom laboratory tests for APC resistance had been conducted. These patients were contacted to determine the primary outcomes of recurrent ischemic stroke or death. RESULTS: A total of 858 patients with an average follow up time of 8.48 years were included. APC resistance did not influence cumulative incidence functions for stroke free and total survival. In multivariate analyses, crude and adjusted hazard ratios for recurrent stroke as well as for death where not significantly increased in patients with APC resistance. This also applies to the subgroups of young patients, patients with cryptogenic stroke and patients with atrial fibrillation. CONCLUSION: APC-resistance is not a risk factor for subsequent stroke or death in patients with a first ischemic stroke or TIA. Testing for APC-resistance in stroke patients therefore cannot be routinely recommended.

Non-volumetric echocardiographic indices and qualitative assessment of right ventricular systolic function in Ebstein's anomaly: comparison with CMR-derived ejection fraction in 49 patients.

AIMS: Ebstein's anomaly (EA) is often associated with right ventricular (RV) dysfunction. Data on echocardiographic quantification of RV function are, however, rare. The aim of this study was to determine how non-volumetric echocardiographic indices and qualitative assessment of global systolic RV function correlate with cardiovascular magnetic resonance (CMR)-derived RV ejection fraction (EF). METHODS AND RESULTS: We compared six echocardiographic indices and qualitative assessment of RV function with the gold standard CMR. A total of 49 unoperated patients with EA and a mean age of 32 ± 18 years were examined. Tricuspid annular plane systolic excursion, tissue Doppler myocardial velocities (peak S and IVA) and 2D strain and strain rate measures for the RV were compared with CMR-derived EF. Only 2D global longitudinal strain (2D-GLS), out of the six parameters investigated, showed a weak, although statistically significant correlation with CMR-derived RVEF (R = -0.4, P = 0.01). Using a cut-off value of -20.15, 2D-GLS sensitivity (77%) and specificity (46%) in detecting patients with a CMR-derived EF of <50% were comparable with qualitative assessment (sensitivity 77%, specificity 45%). CONCLUSION: Overall echocardiographic parameters of RV function correlate poorly with CMR-derived EF in patients with EA. Only 2D global longitudinal RV strain correlated weakly with CMR-derived RVEF. However, the sensitivity and specificity for detecting RV dysfunction using 2D strain imaging were comparable with qualitative RV functional assessment.

Electromagnetic interference in implantable cardioverter defibrillators: present but rare.

PURPOSE: Electromagnetic interference (EMI) with implantable cardioverter defibrillators (ICDs) can cause oversensing and subsequently inappropriate ICD therapies. We retrospectively investigated the current incidence and clinical relevance of oversensing related EMI in a large cohort of ICD patients. METHODS: From January 2005 to April 2013, all ICD interrogations performed at our institution were analyzed for the occurrence of oversensing related EMI. EMI episodes were classified as clinically significant, potentially significant or of minor significance. To identify risk factors for EMI, we also analyzed different lead models in our cohort (integrated vs true bipolar leads). RESULTS: Data of 2940 ICD patients (mean age 63 ± 16 years, 2322 male patients, 7772 patient-years) were retrospectively analyzed for the occurrence of EMI. During the observation period, a total of 145 (hospital environment n = 97, non-hospital environment n = 48) episodes occurred and resulted in an overall EMI incidence, i.e. event rate, of 1.87 % per patient per year. Focusing on clinically significant or potentially significant episodes, the EMI incidence was 0.27 % per patient per year. Cox proportional hazards regression analysis did not reveal a statistically significant higher hazard of oversensing for patients with integrated bipolar leads compared to patients with true bipolar leads (HR = 2.21; 95 % CI 0.90-5.39; p = 0.083). CONCLUSIONS: Our data demonstrate that EMI continues to occur in everyday life. Patients should be well informed about the potential sources and risks of EMI but they need not be overly concerned since the risk of EMI-especially in a non-hospital environment-is low.

How do ankle braces affect braking performance? An experimental driving simulation study with healthy volunteers.

BACKGROUND: Fitness to drive a car has been investigated increasingly over recent years. However, most research has focussed on perioperative driving performance, and few data are available on how orthoses influence the ability to perform an emergency stop. This study investigated the effect of 4 common ankle braces (Kallassy, CaligaLoc, Air-Stirrup, ASO) on reaction time, foot transfer time (together: brake response time) and brake force. The hypothesis was that wearing these braces on the right ankle impairs braking performance, specifically by increasing foot transfer time, but also by altering brake force. METHODS: A car cabin was set up with measurement equipment to register reaction time, foot transfer time, brake response time and brake force under realistic spatial constraints. A crossover repeated measures design was used to test 30 healthy volunteers with and without each of the braces. RESULTS: All 4 braces resulted in statistically significantly increased foot transfer time (p < 0.001), compared with measurements without a brace. Reaction time with a brace was significantly prolonged, with the exception of the Kallasy. Brake force was not statistically significantly impaired. CONCLUSION: This study demonstrates that ankle braces lead to impaired braking performance. Depending on the type of brace, a stopping distance increase of more than 1 m at 100 km/h can be expected.

Pronator quadratus repair after volar plating of distal radius fractures or not? Results of a prospective randomized trial.

BACKGROUND: The purpose of the present study was to investigate the influence of the pronator quadratus (PQ) muscle repair following volar plate fixation of distal radius fractures with special regards to the forearm pronation strength. During the early recovery period of 3 months, an improvement of pronation strength and functional scorings was hypothesized for the PQ repair when compared to no repair. METHODS: The inclusion criteria were (1) men or women between 18 and 80 years, (2) isolated, closed fractures of the distal radius, (3) A2 to B2 types of fracture according to the AO fracture classification system, (4) primary volar locking plate osteosynthesis. Patients were randomized to group A = PQ repair and group B = no repair. Follow-up examinations after 6 and 12 weeks included bilateral isometric pronation strength measurement, range of motion, the QuickDASH and the Mayo-Wrist-Score, and a visual analog scale (VAS). RESULTS: 60 patients (n = 31 in group A and n = 29 in group B) with an average age of 54 years (range 22-77 years) returned for both follow-up visits. The pronation strength measurements showed no significant differences between groups (PQ repair vs. no repair) neither at 6 weeks nor at 12 weeks. Additionally, no statistical significant differences were noted for ROM, QuickDASH-Score or Mayo-Wrist-Score. The VAS scoring revealed a significant decreased pain level after PQ repair at 6 weeks postoperatively (p = 0.017). CONCLUSION: An improved pronation strength after PQ repair in the early rehabilitation period could not be confirmed. However, the PQ repair might reduce pain in the early postoperative period. TRIAL REGISTRATION NUMBER: NCT02595229 (ClinicalTrials.gov, registered 02 November 2015).