Prognostic significance of incorporating exercise tissue doppler mitral annular early diastolic velocity in exercise diastolic dysfunction assessment.

BACKGROUND: The existing algorithm for defining exercise-induced diastolic dysfunction incorporates resting e' velocity as a surrogate of myocardial relaxation. The additive prognostic value of incorporating post-exercise e' velocity in definition of exercise-induced diastolic dysfunction is poorly studied. AIM: To define the additive prognostic value of post-exercise e' septal velocity in the assessment of exercise-induced diastolic dysfunction compared to the traditional approach. METHODS: This retrospective study included 1409 patients undergoing exercise treadmill echocardiography with available full set of diastolic variables. Doppler measures of diastolic function included resting septal e' velocity, post-exercise septal e' velocity, post-exercise E/e' ratio, and post-exercise tricuspid regurgitant jet velocity. Approaches incorporating resting septal e' velocity and post-exercise septal e' velocity were compared in defining exercise-induced diastolic dysfunction, and for association with adverse cardiovascular outcomes. RESULTS: The mean age of study subjects was 56.3 ± 16.5 years and 791 (56%) patients were women. A total of 524 patients had disagreement between resting and post exercise septal e' velocities, and these values showed only weak agreement (kappa statistics: .28, P = .02). All categories of the traditional exercise-induced DD approach incorporating resting septal e' velocity witnessed reclassification when exercise septal e' velocity was used. When both approaches were compared, increased event rates were only evident when both approaches agreed on exercise-induced diastolic dysfunction (HR: 1.92, P < .001, 95% CI: 1.37-2.69). This association persisted after multivariable adjustment and propensity score matching for covariates. CONCLUSION: Incorporation of post-exercise e' velocity into the set of variables defining exercise-induced diastolic dysfunction can improve the prognostic utility of diastolic function assessment.

Esthetic, clinical, and radiographic outcomes of two surgical approaches for single implant in the esthetic area: 1-year results of a randomized controlled trial with parallel design.

AIM: The objectives of this study were to compare (a) esthetic, (b) clinical, (c) radiographic, and (d) patient-centered outcomes following immediate (Type 1) and early implant placement (Type 2). MATERIAL AND METHODS: Forty-six subjects needing a single extraction (premolar to premolar) were randomly allocated to Type 1 or Type 2 implant placement. One year following permanent restoration, evaluation of (a) Esthetics using soft tissue positions, and the pink and white esthetic scores (PES/WES), (b) Clinical performance using probing depth, modified plaque index, and sulcus bleeding index (c) Radiographic bone level, and (d) Patient satisfaction by means of visual analogue scales (VAS) was recorded. RESULTS: Thirty-five patients completed the one-year examination (Type 1, n = 20; Type 2, n = 15). Type 1 implants lost 1.03 ± 0.24 mm (mean ± SE) of mid-facial soft tissue height while Type 2 implants lost 1.37 ± 0.28 mm (p = 0.17). The papillae height on the mesial and distal was reduced about 1 mm following both procedures. Frequency of clinical acceptability as defined by PES ≥ 6 (Type 1: 55% vs. Type 2 40%), WES ≥ 6 (Type 1: 45% vs. Type 2 27%) was not significantly different between groups (p > 0.05). Clinical and radiographic were indicative of peri-implant health. Patient-centered outcomes failed to demonstrate significant differences between the two cohorts. CONCLUSION: One year after final restoration, there were no significant differences in esthetic, clinical, radiographic, and patient-centered outcomes following Type 1 and Type 2 implant placement. At one year, patient satisfaction may be achieved irrespective of the two placement protocols.

Golf Swing Rotational Velocity: The Essential Follow-Through.

OBJECTIVE: To evaluate if shoulder and pelvic angular velocities differ at impact or peak magnitude between professional and amateur golfers. Golf swing rotational biomechanics are a key determinant of power generation, driving distance, and injury prevention. We hypothesize that shoulder and pelvic angular velocities would be highly consistent in professionals. METHODS: Rotational velocities of the upper-torso and pelvis throughout the golf swing and in relation to phases of the golf swing were examined in 11 professionals and compared to 5 amateurs using three-dimensional motion analysis. RESULTS: Peak rotational velocities of professionals were highly consistent, demonstrating low variability (coefficient of variation [COV]), particularly upper-torso rotational velocity (COV=0.086) and pelvic rotational velocity (COV=0.079) during down swing. Peak upper-torso rotational velocity and peak X-prime, the relative rotational velocity of uppertorso versus pelvis, occurred after impact in follow-through, were reduced in amateurs compared to professionals (p=0.005 and p=0.005, respectively) and differentiated professionals from most (4/5) amateurs. In contrast, peak pelvic rotational velocity occurred in down swing. Pelvic velocity at impact was reduced in amateurs compared to professionals (p=0.019) and differentiated professionals from most (4/5) amateurs. CONCLUSION: Golf swing rotational velocity of professionals was consistent in pattern and magnitude, offering benchmarks for amateurs. Understanding golf swing rotational biomechanics can guide swing modifications to help optimize performance and prevent injury.

Dorsal Scaphoid Subluxation on Sagittal Magnetic Resonance Imaging as a Marker for Scapholunate Ligament Tear.

PURPOSE: To evaluate the diagnostic utility of scaphoid dorsal subluxation on magnetic resonance imaging (MRI) as a predictor of scapholunate interosseous ligament (SLIL) tears and compare this with radiographic findings. METHODS: Thirty-six MRIs were retrospectively reviewed: 18 with known operative findings of complete Geissler IV SLIL tears that were surgically repaired, and 18 MRIs performed for ulnar-sided wrist pain but no SLIL tear. Dorsal subluxation of the scaphoid was measured on the sagittal MRI cut, which demonstrated the maximum subluxation. Independent samples t tests were used to compare radiographic measurements of scapholunate (SL) gap, SL angle, and capitolunate/third metacarpal-lunate angles between the SLIL tear and the control groups and to compare radiographic measurements between wrists that had dorsal subluxation of the scaphoid and wrists that did not have dorsal subluxation. Interrater reliability of subluxation measurements on lateral radiographs and on MRI were calculated using kappa coefficients. RESULTS: Thirteen of 18 wrists with complete SLIL tears had greater than 10% dorsal subluxation of the scaphoid relative to the scaphoid facet. Average subluxation in this group was 34%. Four of 18 wrists with known SLIL tears had no subluxation. No wrists without SLIL tears (control group) had dorsal subluxation. The SL angle, capitolunate/third metacarpal-lunate angle and SL gap were greater in wrists that had dorsal subluxation of the scaphoid on MRI. Interrater reliability of measurements of dorsal subluxation of the scaphoid was superior on MRI than on lateral x-ray. CONCLUSIONS: An MRI demonstration of dorsal subluxation of the scaphoid, of as little as 10%, as a predictor of SLIL tear had a sensitivity of 72% and a specificity of 100%. The high positive predictive value indicates that the presence of dorsal subluxation accurately predicts SLIL tear. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Selective Denervation for Persistent Knee Pain After Total Knee Arthroplasty: A Report of 50 Cases.

BACKGROUND: Despite the general success of total knee arthroplasty (TKA), up to 20% of patients report dissatisfaction following surgery. One potential cause of this dissatisfaction is residual pain secondary to neuroma formation in the sensory nerve branches that innervate the knee. We found, after performing a retrospective review, that up to 9.7% of patients following primary TKA and up to 21% of revision cases exhibited persistent knee pain attributable to neuroma formation. Despite the high incidence of this pathology, little is known about the effective diagnosis or treatment of neuroma formation following TKA. METHODS: Between 2011 and 2014, 50 patients with persistent symptomatic neuroma pain following TKA underwent selective denervation. These patients had demonstrated the appropriate selection criteria and had failed conservative management. Patients were evaluated by the visual analog scale pain score and the Knee Society Score to determine the outcome of the described treatment. RESULTS: Thirty-two patients (64%) rated their outcome as excellent, 10 (20%) as good, 3 (6%) as fair, and 2 (4%) reported no change. The mean visual analog scale pain score was improved from 9.4 ± 0.8 to 1.1 ± 1.6 following surgery (P ≤ .001). The mean Knee Society Scores increased from 45.5 ± 14.3 to 94.1 ± 8.6 points (P ≤ .0001). Three patients (6%) required the second neurectomy due to recurrent pain and received excellent pain relief postoperatively. There were 2 complications of superficial skin peri-incisional hyperemia related to dressings. Average follow-up duration was 24 months (range, 16-38 months). CONCLUSION: Our study suggests that selective denervation provides an effective and long-lasting option for the management of this pathology.

MRI bullseye sign: An indicator of peripheral nerve constriction in parsonage-turner syndrome.

INTRODUCTION: The role of MRI in identifying hourglass constrictions (HGCs) of nerves in Parsonage-Turner syndrome (PTS) is largely unknown. METHODS: Six patients with PTS and absent or minimal recovery underwent MRI. Surgical exploration was performed at identified pathologic sites. RESULTS: The time between symptom onset and surgery was 12.4 ± 6.9 months; the time between MRI and surgery was 1.3 ± 0.6 months. Involved nerves included suprascapular, axillary, radial, and median nerve anterior interosseous and pronator teres fascicles. Twenty-three constriction sites in 10 nerves were identified on MRI. A "bullseye sign" of the nerve, identified immediately proximal to 21 of 23 sites, manifested as peripheral signal hyperintensity and central hypointensity orthogonal to the long axis of the nerve. All constrictions were confirmed operatively. CONCLUSIONS: In PTS, a bullseye sign on MRI can accurately localize HGCs, a previously unreported finding. Causes of HGCs and the bullseye sign are unknown. Muscle Nerve 56: 99-106, 2017.

Esthetic, clinical and patient-centered outcomes of immediately placed implants (Type 1) and early placed implants (Type 2): preliminary 3-month results of an ongoing randomized controlled clinical trial.

AIM: The objective of the study was to compare (i) esthetic, (ii) clinical and (iii) patient-centered outcomes following immediate (Type 1) and early implant placement (Type 2). MATERIAL AND METHODS: Thirty-eight subjects needing a single extraction (premolar to premolar) were randomly allocated to Type 1 or Type 2 implant placement. Three months following permanent crown insertion, evaluation of (i) esthetic outcomes using soft tissue positions, and the pink and white esthetic scores (PES/WES), (ii) clinical performance using probing pocket depth (PPD), modified plaque index (mPI) and modified sulcus bleeding index (mSBI) around each implant and (iii) patient satisfaction by means of a questionnaire using a visual analogue scale (VAS) was performed. RESULTS: Thirty-two patients completed the 3-month follow-up examination (Type 1, n = 17; Type 2, n = 15) with a 100% implant survival rate. Type 1 implants lost 0.54 ± 0.18 mm of mid-facial soft tissue height, while Type 2 implants lost 0.47 ± 0.31 mm (P > 0.05). The papillae height on the mesial and distal was reduced about 1 mm following both procedures. The PES/WES following Type 1 implant placement amounted to 13.7 ± 0.6 and 12.5 ± 0.7 in the Type 2 group (P > 0.05). PPD, mPI and mSBI were low in both groups (P > 0.05). Patient-centered outcomes failed to demonstrate any statistical difference between the two cohorts. CONCLUSION: Three months following final crown delivery, there were no significant differences in esthetic, clinical and patient-centered outcomes following Type 1 and Type 2 implant placement. On the short term, one may achieve good optimal esthetic and clinical results irrespective of these two placement protocols. These results need to be confirmed on the long term.

Thrombodynamics of microvascular repairs: effects of antithrombotic therapy on platelets and fibrin.

PURPOSE: To evaluate the hypothesis that platelets and fibrin differentially accrue at microvascular anastomoses in arteries versus veins and under different pharmacologic conditions. METHODS: We evaluated mouse arterial and venous anastomoses with intravital fluorescence imaging, using fluorophore-labeled platelets and anti-fibrin antibodies to measure the extent of thrombus component development in the intraluminal anastomotic site. We evaluated systemic heparin or eptifibatide (platelet aggregation inhibitor) to determine their relative influences on thrombus composition. RESULTS: Platelets accumulated rapidly in both arterial and venous repairs, and then fell in number after 10 to 30 minutes of reflow. Fibrin had a relatively steady development over 60 minutes in veins, with a more variable increase in arteries. Heparin reduced platelet accumulation in arteries and fibrin development in veins. Eptifibatide reduced platelets in both arteries and veins and had an apparent effect on lowering the amount of fibrin in veins. CONCLUSIONS: These findings show that platelets have a rapid, transient response, whereas fibrin has a slower, more sustained accrual in both arterial and venous anastomoses. Furthermore, inhibition of either coagulation or platelet aggregation can influence presumably non-targeted components of thrombosis in vascular repairs of both arteries and veins. CLINICAL RELEVANCE: Preventing replantation failure using antithrombotic therapies requires a better understanding of the effect of each pharmacologic compound on the various aspects of thrombogenesis.

Rotational biomechanics of the elite golf swing: benchmarks for amateurs.

The purpose of this study was to determine biomechanical factors that may influence golf swing power generation. Three-dimensional kinematics and kinetics were examined in 10 professional and 5 amateur male golfers. Upper-torso rotation, pelvic rotation, X-factor (relative hip-shoulder rotation), O-factor (pelvic obliquity), S-factor (shoulder obliquity), and normalized free moment were assessed in relation to clubhead speed at impact (CSI). Among professional golfers, results revealed that peak free moment per kilogram, peak X-factor, and peak S-factor were highly consistent, with coefficients of variation of 6.8%, 7.4%, and 8.4%, respectively. Downswing was initiated by reversal of pelvic rotation, followed by reversal of upper-torso rotation. Peak X-factor preceded peak free moment in all swings for all golfers, and occurred during initial downswing. Peak free moment per kilogram, X-factor at impact, peak X-factor, and peak upper-torso rotation were highly correlated to CSI (median correlation coefficients of 0.943, 0.943, 0.900, and 0.900, respectively). Benchmark curves revealed kinematic and kinetic temporal and spatial differences of amateurs compared with professional golfers. For amateurs, the number of factors that fell outside 1-2 standard deviations of professional means increased with handicap. This study identified biomechanical factors highly correlated to golf swing power generation and may provide a basis for strategic training and injury prevention.

A simple device to monitor flexion and lateral bending of the lumbar spine.

Monitoring compliance with exercise and motivating patients with lower back pain to perform prescribed exercise regimens are considerable tasks. The objective of this study was to develop and test a low-cost device that can be used by a patient at home to both record and provide real-time biofeedback of lumbar position in the midsagittal and frontal planes during exercises. Our device utilizes strain gages on a thin stainless steel beam to measure lumbar flexion-extension and an optical mouse sensor attached to the end of the blade to measure lateral bending. In comparison tests with a standard electrogoniometer, our device was shown to be accurate within 3 degrees in both the sagittal and frontal planes in healthy subjects. Furthermore, users were capable of reapplying the device themselves and obtaining measurements that were repeatable within 4 degrees in both planes. The capability of this simple device to accurately measure lumbar spine position in a nonlaboratory setting makes it well suited as a tool for providing feedback on exercise performance to both patients and clinicians.