The inferocentral whorl region and its directional patterns in the corneal sub-basal nerve plexus: A review.

There has been a growing application of in vivo confocal microscopy (IVCM) in the examination of corneal microstructure, including different corneal layers and corneal nerve fibers in health and in pathological conditions. Corneal nerves forming the sub-basal nerve plexus (SBNP) beneath the corneal basal epithelial cell layer in particular have been intensively researched in health and disease as a marker for corneal neurophysioanatomical and degenerative changes. One intriguing feature in the SBNP that is found inferior to the corneal apex, is a whorl-like pattern (or vortex) of nerves, which represents an anatomical landmark. Evidence has indicated that the architecture of this 'whorl region' is dynamic, changing with time in healthy individuals but also in disease conditions such as in diabetic neuropathy and keratoconus. This review summarizes the known information regarding the characteristics and significance of the whorl region of nerves in the corneal SBNP, as a potential area of high relevance for future disease monitoring and diagnostics.

Comparison of the skeletal stability after mandibular counter-clockwise rotation in three surgical procedures.

The treatment of mandibular deformities with an anterior open bite is challenging. In this study, skeletal stability after mandibular osteotomies was evaluated to determine the best treatment for mandibular prognathism with an anterior open bite in three procedures: intraoral vertical ramus osteotomy (IVRO), conventional sagittal split ramus osteotomy (conv-SSRO), and SSRO without bone fixation (nonfix-SSRO). Patients who underwent mandibular osteotomy to correct skeletal mandibular protrusion were included. Changes in skeletal and soft tissues were assessed using lateral cephalograms taken before (T1), 3 ± 2 days (T2), and 12 ± 3 months (T3) after surgery. Thirty-nine patients were included: nine in the IVRO group and 11 and 19 in the conv- and nonfix-SSRO groups, respectively. The mandibular plane angles (MPAs) of the T2-T1 were - 2.7 ± 2.0 (p = 0.0040), - 3.7 ± 1.7 (p < 0.0001), and - 2.3 ± 0.7 (p < 0.0001) in the IVRO, conv-SSRO, and nonfix-SSRO groups, respectively. The skeletal relapse of the MPAs was not related to the MPA at T2-T1, and it was approximately 1.3° in the conv-SSRO group. The skeletal relapse of the MAPs was significantly correlated with the MPA of T2-T1 in the IVRO (p = 0.0402) and non-fix-SSRO (p = 0.0173) groups. When the relapse of the MPAs was less than 1.3°, the MPA of T2-T1 was calculated as 2.5° in the nonfix-SSRO group. When the MPA of T2-T1 is less than 2.5°, non-fix SSRO may produce a reliable outcome, and when it is more than 2.5°, conv-SSRO may produce better outcomes.

QRS transitional zone rotations and the risk of atrial fibrillation: the Suita Study.

ECG screening can detect people at risk of developing atrial fibrillation (AF). Recent literature indicated that QRS transitional zone rotations could predict several cardiovascular events. Herein, we investigated the association between QRS transitional zone rotations and the future risk of AF. This prospective cohort study included 6794 participants (3178 men and 3616 women), aged 30-84 years, from the urban Japanese city of Suita. QRS transitional zone rotations were diagnosed by ECG during baseline, while AF was diagnosed by ECG, hospital records, and checkups during follow-up. The Cox regression was used to compute the sex-specified hazard ratios (HRs) and 95% confidence intervals (CIs) of incident AF for participants with counterclockwise and clockwise QRS transitional zone rotations compared to those with normal rotation. Within a median follow-up period of 14.6 years, 311 participants (206 men and 105 women) developed AF. Counterclockwise rotation was associated with the reduced risk of AF among men, but not women, in the age-adjusted model: HR (95% CI) = 0.66 (0.44, 0.98) and the multivariable-adjusted model: HR (95% CI) = 0.65 (0.43, 0.97). Clockwise rotation was not associated with AF risk in either sex. To the best of our knowledge, this is the first study to indicate that counterclockwise rotation could be associated with the reduced risk of AF in men. More studies are needed to confirm our findings and elucidate possible mechanisms.

Association between electrocardiographic QRS transition zone and mortality from all causes and cardiovascular diseases: A systematic review and meta-analysis.

AIMS: To investigate whether clockwise rotation (CWR) and counterclockwise rotation (CCWR) of electrocardiographic QRS transition zone is associated with mortality from all causes and cardiovascular diseases (CVD). METHODS: Studies were identified from searching of PubMed, EMBASE and the reference lists of relevant papers. Summary multivariate-adjusted hazard ratios (HRs) and the corresponding 95% confidence intervals (CIs) and 95% prediction intervals (PIs) were computed through meta-analysis. RESULTS: A total of five observational cohort studies fulfilled the inclusion criteria, which included 47,252 participants from the general population (8.8% CWR; 44.1% CCWR). Pooling data revealed that CWR was significantly associated with the increased risk of all-cause mortality (HR, 1.18; 95% CI: 1.12-1.24; 95% PI: 1.03-1.37) and CVD mortality (HR, 1.18; 95% CI: 1.08-1.29; 95% PI: 0.98-1.42) compared to NR pattern, with low heterogeneity among studies (P = 0.29, I2 = 20%; P = 0.37; I2 = 7%; respectively). However, CCWR was inversely associated with the risk of all-cause mortality (HR, 0.92; 95% CI: 0.89-0.95; 95% PI: 0.80-1.05) with low heterogeneity (P = 0.14; I2 = 43%), while no significant association existed between CCWR and CVD mortality (HR, 0.89; 95% CI: 0.77-1.02; 95% PI: 0.53-1.48) with high heterogeneity (P < 0.01; I2 = 78%). CONCLUSION: Our meta-analysis demonstrated CWR was positively associated with higher risk of mortality from all-cause and CVD, while CCWR was negatively associated with the risk of all-cause mortality and no significant association with CVD mortality. These findings suggested that QRS transition zone carries important prognostic value, more attention should be paid in clinical practice.

Electrocardiographic QRS axis shift, rotation and COVID-19.

Background: In patients with coronavirus disease-2019 (COVID-19), severe dyspnea is the most dramatic complication. Severe respiratory difficulties may include electrocardiographic frontal QRS axis rightward shift (Rws) and clockwise rotation (Cwr). Aim: This study investigated the predictability of advanced lung tomography findings with QRS axis shift and rotation. Patients and Methods: This was a retrospective analysis of 160 patients. Patients were divided into the following two groups: normal (n = 80) and low (n = 80) oxygen saturation. These groups were further divided into four groups according to the rightward and leftward axis shift (Lws) on the electrocardiographic follow-up findings. These groups were compared in terms of electrocardiographic rotation (Cwr, counterclockwise rotation, or normal transition), tomographic stage (CO-RADS5(advanced)/CO-RADS1-4), electrocardiographic intervals, and laboratory findings. Results: In patients with low oxygen saturation, the amount of QRS axis shift, Cwr, and tomographic stage were significantly higher in the Rws group than in the Lws group. There were no differences in the above parameters between the Rws and Lws groups in patients with normal oxygen saturation. Logistic regression analysis revealed that the presence of Cwr and Rws independently increased the risk of CO-RADS5 by 18.9 and 4.6 fold, respectively, in patients with low oxygen saturation. Conclusion: In COVID-19 patients who have dyspnea with low oxygen saturation, electrocardiographically clockwise rotation with a rightward axis shift demonstrated good sensitivity (80% [0.657-0.943]) and specificity (80% [0.552->1]) for predicting advanced lung tomographic findings. ClinicalTrialsgov Identifier: NCT04698083.

Comparison of clockwise and counterclockwise right atrial flutter using high-resolution mapping and automated velocity measurements.

BACKGROUND: Only few studies have been performed that explore the electrophysiological differences between clockwise (CW) and counterclockwise (CCW) right atrial (RA) cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL) using the high-resolution Rhythmia mapping system. OBJECTIVES: We sought to compare CW and CCW CTI-dependent AFL in pure right AFL patients (pts) using the ultra-high-definition (ultra-HD) Rhythmia mapping system and we mathematically developed a cartography model based on automatic velocity RA measurements to identify electrophysiological AFL specificities. METHODS AND RESULTS: Thirty-three pts were recruited. The mean age was 71 ± 13 years old. The sinus venosus (SV) block line was present in 32/33 of cases (97%) and no significant difference was found between CCW and CW CTI AFL (100% vs. 91%; p = .7). No line was localized in the region of the crista terminalis (CT). A superior gap was present in the posterior line in 14/31 (45.2%) but this was similarly present in CCW AFL, when compared to CW AFL (10/22 [45.5%] vs. 4/10 [40%]; p = .9). When present, the extension of the posterior line of block was observed in 18/31 pts (58%) without significant differences between CCW and CW CI AFL (12/22 [54.5%] vs. 6/10 [60%]; p = .9) The Eustachian ridge line of block was similarly present in both groups (82% [18/22] vs. 45.5% [5/11]; p = .2). The absence of the Eustachian ridge line of block led to significantly slowed velocity in this area (28 ± 10 cm/s; n = 8), and the velocities were similarly altered between both groups (26 ± 10 [4/22] vs. 29.8 ± 11 cm/s [4/11]; p = .6). We created mathematical, three-dimensional RA reconstruction-velocity model measurements. In each block localization, when the block line was absent, velocity was significantly slowed (≤20 cm/s). A systematic slowdown in conduction velocity was observed at the entrance and exit of the CTI in 100% of cases. This alteration to the conduction entrance was localized at the lateral side of the CTI for the CCW AFL and at the septal side of the CTI for CW AFL. The exit-conduction alteration was localized at the CTI septal side for the CCW AFL and at the CTI lateral side for the CW AFL. CONCLUSION: The ultra-HD Rhythmia mapping system confirmed the absence of significant electrophysiological differences between CCW and CW AFL. The mechanistic posterior SV and Eustachian ridge block lines were confirmed in each arrhythmia. A systematic slowing down at the entrance and exit of the CTI was demonstrated in both CCW and CW AFL, but in reverse positions.

A combined orthodontic / orthognathic approach in the management of obstructive sleep apnoea: Balancing treatment efficacy and facial aesthetics.

Obstructive sleep apnoea (OSA) is a prevalent condition and has been extensively managed with orthognathic surgery using a variety of surgical techniques. This case report describes the successful management of a 56-year-old Caucasian woman with a bimaxillary retrusive profile and macroglossia complicated by OSA and the combined use of orthodontics and orthognathic surgery to improve Apnoea-Hypopnoea Index while maintaining facial aesthetics. The non-extraction treatment plan included: (1) pre-surgical orthodontic treatment to maximise aesthetics and functional occlusion after surgery; (2) maxillomandibular advancement using down fracture of the maxilla (Le Fort 1 osteotomy) with counter-clockwise rotation as well as bilateral sagittal split osteotomy with septoplasty to aid increase in airway function; and (3) post-surgical orthodontic finishing and alignment with self-ligating fixed appliances. Optimum aesthetic and functional results as well as an increase in the airway volume were achieved, without compromising facial aesthetics, with the cooperation of two specialties and the use of state-of-the-art technology during the surgical planning stages.

Surgical Orthodontic Treatment in Case of Severe High Angle Skeletal Class II Malocclusion and Mandibular Retrusion.

This report describes a patient with severe high angle class II malocclusion and mandibular retrusion in whom surgical orthodontic treatment to prevent an increase in ramus height resulted in a significant improvement in esthetics and long-term stability. The patient was a woman aged 30 years 5 months who presented with the chief complaint of maxillary protrusion. She had a convex facial type, a chin button on lip sealing, and a gummy smile. Cephalometric analysis revealed a normal maxilla anterior-posterior position, but significant mandibular retrusion with pronounced clockwise rotation. The anterior maxillary tooth axis was standard, but labially inclined in the mandible. Based on these findings, the diagnosis was skeletal class II high angle malocclusion and mandibular retrusion. The proposed treatment plan comprised 2-jaw surgery with premolar extraction. Le Fort I osteotomy, in particular, was planned in the maxilla to move the ANS upward by 3.0 mm and the PNS downward by 3.0 mm. Sagittal split ramus osteotomy (SSRO) was planned to adjust the mandible and move the mandible forward by 10.0 mm. To prevent postoperative relapse, the short lingual split method was used in performing the SSRO. The mandible was split to minimize stretching of the median pterygoid muscle. Postoperatively, the ANS, PNS, and pogonion showed movement of 2.0 mm upward, 3.0 mm downward, and 8.0 mm forward, respectively. Additionally, lip closure was now natural, and the gummy smile had markedly improved. At 6 years postoperatively, there has been no change skeletally or dentally. Follow-up is being continued to monitor further progress.

Persistent One-Way Walking in a Circular Arena in Drosophila melanogaster Canton-S Strain.

We describe persistent one-way walking of Drosophila melanogaster in a circular arena. Wild-type Canton-S adult flies walked in one direction, counter-clockwise or clockwise, for minutes, whereas white-eyed mutant [Formula: see text] changed directions frequently. Locomotion in the circular arena could be classified into four components: counter-clockwise walking, clockwise walking, nondirectional walking and pausing. Genetic analysis revealed that while wild-type genetic background was associated with reduced directional change and reduced numbers of one-way (including counter-clockwise and clockwise) and nondirectional walks, the white ([Formula: see text]) locus promoted persistent one-way walking by increasing the maximal duration of one-way episodes. The promoting effect of [Formula: see text] was further supported by the observations that (1) [Formula: see text] duplicated to the Y chromosome, (2) four genomic copies of mini-white inserted on the autosomes, and (3) pan-neuronal overexpression of the White protein increased the maximal duration of one-way episodes, and that RNAi knockdown of [Formula: see text] in the neurons decreased the maximal duration of one-way episodes. These results suggested a pleiotropic function of [Formula: see text] in promoting persistent one-way walking in the circular arena.

Distribution and determinants of QRS rotation of black and white persons in the general population.

BACKGROUND: The prevalence and determinants of QRS transition zones are not well established. METHODS: We examined the distributions of Normal, clockwise (CW) and counterclockwise (CCW)) QRS transition zones and their relations to disease, body size and demographics in 4624 black and white men and women free of cardiovascular disease and major ECG abnormalities enrolled in the NHANES-III survey. RESULTS: CW transition zones were least observed (6.2%) and CCW were most prevalent (60.1%) with Normal in an intermediate position (33.7%). In multivariable logistic regression analysis, the adjusted, significant predictors for CCW compared to Normal were a greater proportion of blacks and women, fewer thin people (BMI<20, thin), a greater ratio of chest depth to chest width, and an LVMass index <80g. By contrast, CW persons were older, had larger QRS/T angles, smaller ratio of chest depth to chest width, had a greater proportion of subjects with low voltage QRS, more pulmonary disease, a greater proportion with high heart rates, shorter QRS duration and were more obese (BMI≥30). CONCLUSIONS: Normal rather than being the most prevalent transition zone was intermediate in frequency between the most frequently encountered CCW and the least frequently encountered transition zone CW. Differences in the predictors of CW and CCW exist. This requires further investigation to examine how far these differences explain the differences in the published prognostic differences between CW and CCW.

Cardiac structural and functional profile of patients with delayed QRS transition zone and sudden cardiac death.

AIMS: Delayed QRS transition zone in the precordial leads of the 12-lead electrocardiogram (ECG) has been recently associated with increased risk of sudden cardiac death (SCD), but the underlying mechanisms are unknown. We correlated echocardiographic findings with ECG and clinical characteristics to investigate how alterations in cardiac structure and function contribute to this risk marker. METHODS AND RESULTS: From the ongoing population-based Oregon Sudden Unexpected Death Study (catchment population ∼1 million), SCD cases with prior ECG available (n = 627) were compared with controls (n = 801). Subjects with delayed transition at V5 or later were identified, and clinical and echocardiographic patterns associated with delayed transition were analysed. Delayed transition was present in 31% of the SCD cases and 17% of the controls. These subjects were older and more likely to have cardiovascular risk factors and history of myocardial infarction. Delayed transition was associated with increased left ventricular (LV) mass (122.7 ± 40.2 vs. 102.9 ± 33.7 g/m2; P < 0.001), larger LV diameter (53.3 ± 10.4 vs. 49.2 ± 8.0 mm; P < 0.001), and lower LV ejection fraction (LVEF) (46.4 ± 15.7 vs. 55.6 ± 12.5%; P < 0.001). In multivariate analysis, delayed transition was independently associated with myocardial infarction, reduced LVEF, and LV hypertrophy. The association between delayed transition and SCD was independent of the LVEF (OR 1.57; 95% CI 1.04-2.38; P = 0.032). CONCLUSION: The underpinnings of delayed QRS transition zone extend beyond previous myocardial infarction and reduced LVEF. Since the association with sudden death is independent of these factors, this novel marker of myocardial electrical remodelling should be explored as a potential risk predictor of SCD.

Pre-maxillary complex morphology in bilateral cleft and hypothesis on laterality of deviated pre-maxilla.

INTRODUCTION: Pre-maxillary complex (pre-maxilla [PMX] + vomer) morphology in bilateral complete cleft of primary and secondary palate (BCLCP) is very complex and less reviewed in literature. MATERIALS AND METHODS: In this retrospective cross-sectional study, 200 consecutive BCLCP patients were selected. Their pre-operative clinical photographs and dental casts were evaluated by a single investigator at two different points of time, to study the morphology of PMX and vomer with special emphasis on deviation of vomer and rotation of PMX. RESULTS: It is found that in above 70% of patients, PMX and vomer both displaced or deviated towards left side in horizontal plane and PMX rotated anticlockwise at PMX vomerine suture (PVS). In 10% of cases, both PMX and vomer are displaced towards the right side, PMX rotated clockwise at PVS. In 11% of cases, vomer is displaced towards the left side, but PMX rotated clockwise at PVS. In 5% of cases, vomer is displaced towards the right side, but PMX rotated anticlockwise at PVS. Both PMX and vomer are in midline in 4% of cases. CONCLUSION: Specific morphological deviation of vomer and PMX has been studied. We put forward the probable hypothesis to explain the deviation and rotation of PMX.

Abnormal electrocardiographic QRS transition zone and risk of mortality in individuals free of cardiovascular disease.

AIMS: We examined the prognostic significance of abnormal electrocardiographic QRS transition zone (clockwise and counterclockwise horizontal rotations) in individuals free of cardiovascular disease (CVD). METHODS AND RESULTS: A total of 5541 adults (age 53 ± 10.4 years, 54% women, 24% non-Hispanic black, 25% Hispanic) without CVD or any major electrocardiogram (ECG) abnormalities from the US Third National Health and Nutrition Examination Survey were included in this analysis. Clockwise and counterclockwise horizontal rotations were defined from standard 12-lead ECG using Minnesota ECG Classification. Mortality and cause of death were assessed through 2006. At baseline, 282 participants had clockwise rotation and 3500 had counterclockwise rotation. During a median follow of 14.6 years, 1229 deaths occurred of which 415 were due to CVD. In multivariable-adjusted Cox proportional hazard analysis and compared with normal rotation, clockwise rotation was significantly associated with increased risk of all-cause mortality {hazard ratio (HR) [95% confidence interval (CI)]: 1.43 (1.15-1.78); P = 0.002} and CVD mortality [HR (95% CI): 1.61 (1.09, 2.37) P = 0.016]. In contrast, counterclockwise rotation was associated with significantly lower risk of all-cause mortality [HR (95% CI): 0.86 (0.76, 0.97); P = 0.017] and non-significant association with CVD mortality [HR (95% CI): 1.07 (0.86, 1.33); P = 0.549]. These results were consistent in subgroup analysis stratified by age, sex, and race. CONCLUSION: In a diverse community-based population free of CVD and compared with normal rotation, clockwise rotation was associated with increased risk of all-cause and CVD mortality while counterclockwise rotation was associated with lower risk of all-cause mortality and non-significant association with CVD mortality. These findings call for attention to these often neglected ECG markers, and probably call for revising the current definition of normal rotation.

Influence of two kinematics on canal transportation and centering ability of WaveOne Gold and One Curve files.

This research examines canal transportation and centering ability of single-file systems when operated in continuous rotation or reciprocation. Sixty J-shaped resin blocks were used. The specimens were divided into two main groups (n = 30). Then, based on the motion used to operate the instruments, each group was subdivided into two subgroups (n = 15). Group A1: One Curve/rotation, Group A2: One Curve/clockwise reciprocation, Group B1: WaveOne Gold/Reciprocation, Group B2: WaveOne Gold/counter-clockwise rotation. Pre- and post-instrumentation images were obtained using digital microscope. Canal transportation was measured at five levels. A non-significant difference (p > 0.05) resulted between two motions at all levels. However, group A1 showed significantly less transportation at levels 3 and 4 (p ≤ 0.05), also more centered preparation at level 4 (p ≤ 0.05) than group B1. Within the limitations of this study, the apical transportation and centering ability of single-file systems are unaffected by different kinematics.

Stability of unilateral posterior crossbite treatment with the Function Generating Bite appliance : Association with reduction of mandibular clockwise rotation and increased maxillary transversal width measurements.

PURPOSE: This observational study aimed to evaluate the stability of unilateral posterior crossbite (UPXB) correction with the functional appliance function generating bite (FGB appliance) during follow-up and its effects on craniofacial growth. MATERIALS AND METHOD: A total of 102 age- and gender-matched patients were included: 51 with UPXB (male [M] = 19; female [F] = 32; mean age ± standard deviation [SD] = 7.6 ± 1.4 [years.months]) and 51 controls (C; M = 19; F = 32; mean age ± SD = 7.9 ± 1.3). UPXB was corrected with the FGB appliance. Study casts were collected before treatment (T0), after correction (T1), after a follow-up of 3.7 ± 1.6 [years.months] (T2) and different transversal measurements were performed with calipers: intermolar (IMD), intermolar gingival (IMGD), intercanine (ICD), and intercanine gingival distances (ICGD). In treated patients, in addition, lateral cephalometric tracings were analyzed at T0 and T2. RESULTS: At T0, all maxillary measurements were significantly smaller in the UPXB group compared to the controls (p < 0.001). Between T0 and T1, all maxillary variables increased significantly in the UPXB group (p < 0.001; IMD +4.3 ± 2.1 mm; ICD +3.1 ± 2 mm). Between T1 and T2, maxillary IMD increased further (p < 0.05; +2.2 ± 2 mm). The mean T0-T2 increases were 6.6 ± 2.6 mm (IMD) and 4.3 ± 2.6 mm (ICD). At T0, the cephalometric analysis showed significantly stronger mandibular clockwise rotation (p < 0.01) in the UPXB group compared to the control group. Between T0 and T2, the UPXB group showed a significant reduction of mandibular (p < 0.001; SpP-CoOr T0 = -3.47°±â€¯4.38, T2 = -1.14°±â€¯4.01) and occlusal plane (p < 0.01; SpP-Oc T0 = 11.37°±â€¯3.91, T2 = 9.86°±â€¯3.83) clockwise rotation, and of intermaxillary divergence (p < 0.01; SpP-GoGn T0 = 27.8°±â€¯5.39, T2 = 26.65°±â€¯5.49). CONCLUSIONS: Treatment of UPXB with the FGB appliance effectively increased maxillary transversal width measurements, especially in the posterior region, even after follow-up, indicating stable results. Concurrently, mandibular clockwise rotation was reduced, indicating control of the vertical dimension.

Case Report: Epi-endocardial bridges in refractory cavotricuspid isthmus-dependent atrial flutter: technical analysis of epi-endocardial breakthrough.

Background: Typical isthmus-dependent atrial flutter (AFL) is traditionally treated through radiofrequency (RF) ablation to create a bidirectional conduction block across the cavo-tricuspid isthmus (CTI) in the right atrium. While this approach is successful in many cases, certain anatomical variations can present challenges, making CTI ablation difficult. Methods: We enrolled four patients with typical counter-clockwise AFL who displayed an epicardial bridge at the CTI. Patients underwent high-resolution mapping of the right atrium and CTI ablation. Results: Post-mapping identified areas of early focal activation outside the lesion line which suggested the presence of an epi-endocardial bridge with an endocardial breakthrough, confirmed by recording a unipolar rS pattern on electrograms at that site. A stable CTI block was achieved in all patients only after ablation at the site of the epi-endocardial breakthrough. Conclusions: The presence of an epicardial bridge at the CTI, allowing conduction to persist despite endocardial ablation, should be considered in challenging cases of CTI-dependent AFL. Understanding this phenomenon and utilizing appropriate mapping and ablation techniques are essential for achieving successful and lasting CTI block.

Temperature Changes (ΔT) in Correlation with Number of Implant Osteotomy Preparations in Human Cadaver Tibiae, Comparing Osseodensification (OD) Burs in Clockwise (CW) versus Counterclockwise (CCW) Mode.

(1) Background: OD burs are used in two different modes: (i) CW and (ii) CCW. The purpose of the study was to evaluate the ΔT during the preparation of implant osteotomies in a four-way interaction. (2) Methods: Three hundred and sixty osteotomies were prepared at 12 mm depth in human cadaver tibiae. The ΔT values were calculated similarly to the method used in two previous studies carried out by our group. Four different variables were evaluated for their effect on ΔT. (3) Results: A four-way interaction was observed in the CCW mode, allowing for 1000 RPM to have the least effect in both modes. However, in the CCW mode the use of 3.0 and 4.0 burs after 23 osteotomies showed a statistically significant increase in ΔT, and significant chatter, compared to the CW mode. In the CCW mode, the ΔT was increased significantly as the diameter of the burs increased in 800 and 1200 RPM. (4) Conclusions: The synergistic effect of drills' diameter, CCW mode, 800 and 1200 RPM, and bur usage (over 23 times) had a significant effect on ΔT, which exceeded 47 °C. One thousand (1000) RPM had the least effect in both modes. The 3.0 and 4.0 burs in the CCW mode drastically increased the temperature and produced significant chatter.

Left Ventricular "Longitudinal Rotation" and Conduction Abnormalities-A New Outlook on Dyssynchrony.

BACKGROUND: The complete left bundle branch block (CLBBB) results in ventricular dyssynchrony and a reduction in systolic and diastolic efficiency. We noticed a distinct clockwise rotation of the left ventricle (LV) in patients with CLBBB ("longitudinal rotation"). AIM: The aim of this study was to quantify the "longitudinal rotation" of the LV in patients with CLBBB in comparison to patients with normal conduction or complete right bundle branch block (CRBBB). METHODS: Sixty consecutive patients with normal QRS, CRBBB, or CLBBB were included. Stored raw data DICOM 2D apical-4 chambers view images cine clips were analyzed using EchoPac plugin version 203 (GE Vingmed Ultrasound AS, Horten, Norway). In EchoPac-Q-Analysis, 2D strain application was selected. Instead of apical view algorithms, the SAX-MV (short axis-mitral valve level) algorithm was selected for analysis. A closed loop endocardial contour was drawn to initiate the analysis. The "posterior" segment (representing the mitral valve) was excluded before finalizing the analysis. Longitudinal rotation direction, peak angle, and time-to-peak rotation were recorded. RESULTS: All patients with CLBBB (n = 21) had clockwise longitudinal rotation with mean four chamber peak rotation angle of -3.9 ± 2.4°. This rotation is significantly larger than in patients with normal QRS (-1.4 ± 3°, p = 0.005) and CRBBB (0.1 ± 2.2°, p = 0.00001). Clockwise rotation was found to be correlated to QRS duration in patients with the non-RBBB pattern. The angle of rotation was not associated with a lower ejection fraction or the presence of regional wall abnormalities. CONCLUSIONS: Significant clockwise longitudinal rotation was found in CLBBB patients compared to normal QRS or CRBBB patients using speckle-tracking echocardiography.

Clockwise torque results in higher reoperation rates in left-sided femur fractures.

PURPOSE: Effects of clockwise torque rotation onto proximal femoral fracture fixation have been subject of ongoing debate: fixated right-sided trochanteric fractures seem more rotationally stable than left-sided fractures in the biomechanical setting, but this theoretical advantage has not been demonstrated in the clinical setting to date. The purpose of this study was to identify a difference in early reoperation rate between patients undergoing surgery for left- versus right-sided proximal femur fractures using cephalomedullary nailing (CMN). MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program was queried from 2016-2019 to identify patients aged 50 years and older undergoing CMN for a proximal femoral fracture. The primary outcome was any unplanned reoperation within 30 days following surgery. The difference was calculated using a Chi-square test, and observed power calculated using post-hoc power analysis. RESULTS: In total, of 20,122 patients undergoing CMN for proximal femoral fracture management, 1.8% (n=371) had to undergo an unplanned reoperation within 30 days after surgery. Overall, 208 (2.0%) were left-sided and 163 (1.7%) right-sided fractures (p=0.052, risk ratio [RR] 1.22, 95% confidence interval [CI] 1.00-1.50), odds ratio [OR] 1.23 (95%CI 1.00-1.51), power 49.2% (α=0.05). CONCLUSION: This study shows a higher risk of reoperation for left-sided compared to right-sided proximal femur fractures after CMN in a large sample size. Although results may be underpowered and statistically insignificant, this finding might substantiate the hypothesis that clockwise rotation during implant insertion and (postoperative) weightbearing may lead to higher reoperation rates. LEVEL OF EVIDENCE: Therapeutic level II.

Precision at the Bedside: Practical Efficacy of Clockwise Catheter Torque for Accurate Tip Positioning of Peripherally Inserted Central Catheters.

Precise placement of peripherally inserted central catheters (PICCs) is essential for avoiding treatment risks and ensuring the success of treatment. This is typically performed under imaging guidance, but imaging modalities may not be accessible under resource-limited settings or alternative settings such as communicable disease isolation rooms. Here, we have proposed a new technique for the precise placement of PICCs through the application of clockwise torque. Application of the PICC with this technique in our patient resulted in the precise insertion of the catheter. As this method eliminates the need for imaging modalities, it has promise for application at the bedside and in resource-limited settings. Importantly, it presents a new aspect of catheterization protocols that could hold immense potential for the future. In the future, its efficiency needs to be verified in a larger number of patients under different settings and from different populations.