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Study Objective: To assess the value of a history and physical examination findings in diagnosing the carpal tunnel syndrome, and to determine whether constellations of clinical findings identify patients at high or low risk for the carpal tunnel syndrome.Design: Comparison of diagnostic tests with neurophysiologic testing.Setting: Patients with upper extremity complaints of diverse causes referred to a neurophysiology laboratory for diagnostic studies.Methods: Before nerve conduction testing, a history, demographic and physical examination data, and a hand pain diagram were obtained from each patient. Diagrams were categorized as indicating the classic carpal tunnel syndrome, or as probable, possible, or unlikely to indicate the carpal tunnel syndrome. Associations between clinical data and nerve conduction results were examined in univariate and multivariate analyses.Results: Of 110 patients in the study, 44 (40%) had the carpal tunnel syndrome. Individually, the best predictors were hand pain diagram rating (positive predictive value, 0.59; 95% CI, 0.48 to 0.68) and Tinel sign (positive predictive value, 0.55, CI, 0.45 to 0.65). The combination of a positive Tinel sign and a probable or classic diagram rating had a positive predictive value of 0.71; CI, 0.53 to 0.85. Other findings from physical examination and the history were less useful. Just 9% of patients under 40 years of age with possible or unlikely diagram ratings had the carpal tunnel syndrome.Conclusions: With the exceptions of age, Tinel sign, and hand pain diagram rating, findings from the physical examination and the history had limited diagnostic utility. Patients under 40 years of age with possible or unlikely diagram ratings were at low risk for the carpal tunnel syndrome. This finding, which should be confirmed in an independent population, suggests that subsets of patients may be managed without nerve conduction studies. [ABSTRACT FROM AUTHOR]

Aims: Transthoracic echocardiography is recommended in all patients with acute coronary syndrome but is time-consuming and lacks an evidence base. We aimed to assess the feasibility, diagnostic accuracy, and time efficiency of hand-held echocardiography in patients with acute coronary syndrome and describe the impact of echocardiography on clinical management in this setting., Methods and Results: Patients with acute coronary syndrome underwent both hand-held and transthoracic echocardiographies with agreement between key imaging parameters assessed using kappa statistics. The immediate clinical impact of hand-held echocardiography in this population was systematically evaluated. Overall, 262 patients (65 ± 12 years, 71% male) participated. Agreement between hand-held and transthoracic echocardiographies was good-to-excellent (kappa 0.60-1.00) with hand-held echocardiography having an overall negative predictive value of 95%. Hand-held echocardiography was performed rapidly (7.7 ± 1.6 min) and completed a median of 5 (interquartile range 3-20) h earlier than transthoracic echocardiography. Systematic hand-held echocardiography in all patients with acute coronary syndrome identified an important cardiac abnormality in 50%, and the clinical management plan was changed by echocardiography in 42%. In 85% of cases, hand-held echocardiography was sufficient for patient decision-making, and transthoracic echocardiography was no longer deemed necessary., Conclusion: In patients with acute coronary syndrome, hand-held echocardiography provides comparable results to transthoracic echocardiography, can be more rapidly applied, and gives sufficient imaging information for decision-making in the vast majority of patients. Systematic echocardiography has clinical impact in half of patients, supporting the clinical utility of echocardiography in this population and providing an evidence base for current guidelines., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Cardiac magnetic resonance (CMR) is at the forefront of noninvasive methods for the assessment of myocardial anatomy, function, and most importantly tissue characterization. The role of CMR is becoming even more significant with an increasing recognition that inflammation plays a major role for various myocardial diseases such as myocardial infarction, myocarditis, and takotsubo cardiomyopathy. Ultrasmall superparamagnetic particles of iron oxide (USPIO) are nanoparticles that are taken up by monocytes and macrophages accumulating at sites of inflammation. In this context, USPIO-enhanced CMR can provide valuable additional information regarding the cellular inflammatory component of myocardial and vascular diseases. Here, we will review the recent diagnostic applications of USPIO in terms of imaging myocardial and vascular inflammation, and highlight some of their future potential., Competing Interests: FUNDING SUPPORT AND AUTHOR DISCLOSURES The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Apelin agonism causes systemic vasodilatation and increased cardiac contractility in humans, and improves pulmonary arterial hypertension (PAH) in animal models. Here, the authors examined the short-term pulmonary hemodynamic effects of systemic apelin infusion in patients with PAH. In a double-blind randomized crossover study, 19 patients with PAH received intravenous (Pyr 1 )apelin-13 and matched saline placebo during invasive right heart catheterization. (Pyr 1 )apelin-13 infusion caused a reduction in pulmonary vascular resistance and increased cardiac output. This effect was accentuated in the subgroup of patients receiving concomitant phosphodiesterase type 5 inhibition. Apelin agonism is a novel potential therapeutic target for PAH. (Effects of Apelin on the Lung Circulation in Pulmonary Hypertension; NCT01457170).

Background: Myocardial inflammation and injury occur during coronary artery bypass graft (CABG) surgery. We aimed to characterise these processes during routine CABG surgery to inform the diagnosis of type 5 myocardial infarction., Methods: We assessed 87 patients with stable coronary artery disease who underwent elective CABG surgery. Myocardial inflammation, injury and infarction were assessed using plasma inflammatory biomarkers, high-sensitivity cardiac troponin I (hs-cTnI) and cardiac magnetic resonance imaging (CMR) using both late gadolinium enhancement (LGE) and ultrasmall superparamagnetic particles of iron oxide (USPIO)., Results: Systemic humoral inflammatory biomarkers (myeloperoxidase, interleukin-6, interleukin-8 and c-reactive protein) increased in the post-operative period with C-reactive protein concentrations plateauing by 48 h (median area under the curve (AUC) 7530 [interquartile range (IQR) 6088 to 9027] mg/L/48 h). USPIO-defined cellular myocardial inflammation ranged from normal to those associated with type 1 myocardial infarction (median 80.2 [IQR 67.4 to 104.8] /s). Plasma hs-cTnI concentrations rose by ≥50-fold from baseline and exceeded 10-fold the upper limit of normal in all patients. Two distinct patterns of peak cTnI release were observed at 6 and 24 h. After CABG surgery, new LGE was seen in 20% (n = 18) of patients although clinical peri-operative type 5 myocardial infarction was diagnosed in only 9% (n = 8). LGE was associated with the delayed 24-h peak in hs-cTnI and its magnitude correlated with AUC plasma hs-cTnI concentrations (r = 0.33, p < 0.01) but not systemic inflammation, myocardial inflammation or bypass time., Conclusion: Patients undergoing CABG surgery invariably have plasma hs-cTnI concentrations >10-fold the 99th centile upper limit of normal that is not attributable to inflammatory or ischemic injury alone. Peri-operative type 5 myocardial infarction is often unrecognised and is associated with a delayed 24-h peak in plasma hs-cTnI concentrations.

Background: Current guidelines only recommend the use of an implantable cardioverter defibrillator in patients with dilated cardiomyopathy for the primary prevention of sudden cardiac death (SCD) in those with a left ventricular ejection fraction (LVEF) <35%. However, registries of out-of-hospital cardiac arrests demonstrate that 70% to 80% of such patients have an LVEF >35%. Patients with an LVEF >35% also have low competing risks of death from nonsudden causes. Therefore, those at high risk of SCD may gain longevity from successful implantable cardioverter defibrillator therapy. We investigated whether late gadolinium enhancement (LGE) cardiovascular magnetic resonance identified patients with dilated cardiomyopathy without severe LV systolic dysfunction at high risk of SCD., Methods: We prospectively investigated the association between midwall LGE and the prespecified primary composite outcome of SCD or aborted SCD among consecutive referrals with dilated cardiomyopathy and an LVEF ≥40% to our center between January 2000 and December 2011 who did not have a preexisting indication for implantable cardioverter defibrillator implantation., Results: Of 399 patients (145 women, median age 50 years, median LVEF 50%, 25.3% with LGE) followed for a median of 4.6 years, 18 of 101 (17.8%) patients with LGE reached the prespecified end point, compared with 7 of 298 (2.3%) without (hazard ratio [HR], 9.2; 95% confidence interval [CI], 3.9-21.8; P <0.0001). Nine patients (8.9%) with LGE compared with 6 (2.0%) without (HR, 4.9; 95% CI, 1.8-13.5; P =0.002) died suddenly, whereas 10 patients (9.9%) with LGE compared with 1 patient (0.3%) without (HR, 34.8; 95% CI, 4.6-266.6; P <0.001) had aborted SCD. After adjustment, LGE predicted the composite end point (HR, 9.3; 95% CI, 3.9-22.3; P <0.0001), SCD (HR, 4.8; 95% CI, 1.7-13.8; P =0.003), and aborted SCD (HR, 35.9; 95% CI, 4.8-271.4; P <0.001). Estimated HRs for the primary end point for patients with an LGE extent of 0% to 2.5%, 2.5% to 5%, and >5% compared with those without LGE were 10.6 (95% CI, 3.9-29.4), 4.9 (95% CI, 1.3-18.9), and 11.8 (95% CI, 4.3-32.3), respectively., Conclusions: Midwall LGE identifies a group of patients with dilated cardiomyopathy and an LVEF ≥40% at increased risk of SCD and low risk of nonsudden death who may benefit from implantable cardioverter defibrillator implantation., Clinical Trial Registration: URL: http://clinicaltrials.gov. Unique identifier: NCT00930735., (© 2017 The Authors.)

Objective: Maladaptive repair contributes towards the development of heart failure following myocardial infarction (MI). The α v β 3 integrin receptor is a key mediator and determinant of cardiac repair. We aimed to establish whether α v β 3 integrin expression determines myocardial recovery following MI., Methods: 18 F-Fluciclatide (a novel α v β 3 -selective radiotracer) positron emission tomography (PET) and CT imaging and gadolinium-enhanced MRI (CMR) were performed in 21 patients 2 weeks after ST-segment elevation MI (anterior, n=16; lateral, n=4; inferior, n=1). CMR was repeated 9 months after MI. 7 stable patients with chronic total occlusion (CTO) of a major coronary vessel and nine healthy volunteers underwent a single PET/CT and CMR., Results: 18 F-Fluciclatide uptake was increased at sites of acute infarction compared with remote myocardium (tissue-to-background ratio (TBR mean ) 1.34±0.22 vs 0.85±0.17; p<0.001) and myocardium of healthy volunteers (TBR mean 1.34±0.22 vs 0.70±0.03; p<0.001). There was no 18 F-fluciclatide uptake at sites of established prior infarction in patients with CTO, with activity similar to the myocardium of healthy volunteers (TBR mean 0.71±0.06 vs 0.70±0.03, p=0.83). 18 F-Fluciclatide uptake occurred at sites of regional wall hypokinesia (wall motion index≥1 vs 0; TBR mean 0.93±0.31 vs 0.80±0.26 respectively, p<0.001) and subendocardial infarction. Importantly, although there was no correlation with infarct size (r=0.03, p=0.90) or inflammation (C reactive protein, r=-0.20, p=0.38), 18 F-fluciclatide uptake was increased in segments displaying functional recovery (TBR mean 0.95±0.33 vs 0.81±0.27, p=0.002) and associated with increase in probability of regional recovery., Conclusion: 18 F-Fluciclatide uptake is increased at sites of recent MI acting as a biomarker of cardiac repair and predicting regions of recovery., Trial Registration Number: NCT01813045; Post-results., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Myocardial fibrosis can arise from a range of pathological processes and its presence correlates with adverse clinical outcomes. Cardiac magnetic resonance (CMR) can provide a non-invasive assessment of cardiac structure, function, and tissue characteristics, which includes late gadolinium enhancement (LGE) techniques to identify focal irreversible replacement fibrosis with a high degree of accuracy and reproducibility. Importantly the presence of LGE is consistently associated with adverse outcomes in a range of common cardiac conditions; however, LGE techniques are qualitative and unable to detect diffuse myocardial fibrosis, which is an earlier form of fibrosis preceding replacement fibrosis that may be reversible. Novel T1 mapping techniques allow quantitative CMR assessment of diffuse myocardial fibrosis with the two most common measures being native T1 and extracellular volume (ECV) fraction. Native T1 differentiates normal from infarcted myocardium, is abnormal in hypertrophic cardiomyopathy, and may be particularly useful in the diagnosis of Anderson-Fabry disease and amyloidosis. ECV is a surrogate measure of the extracellular space and is equivalent to the myocardial volume of distribution of the gadolinium-based contrast medium. It is reproducible and correlates well with fibrosis on histology. ECV is abnormal in patients with cardiac failure and aortic stenosis, and is associated with functional impairment in these groups. T1 mapping techniques promise to allow earlier detection of disease, monitor disease progression, and inform prognosis; however, limitations remain. In particular, reference ranges are lacking for T1 mapping values as these are influenced by specific CMR techniques and magnetic field strength. In addition, there is significant overlap between T1 mapping values in healthy controls and most disease states, particularly using native T1, limiting the clinical application of these techniques at present., (Copyright © 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Cardiovascular Magnetic Resonance (CMR) has become a primary tool for non-invasive assessment of cardiovascular anatomy, pathology and function. Existing contrast agents have been utilised for the identification of infarction, fibrosis, perfusion deficits and for angiography. Novel ultrasmall superparamagnetic particles of iron oxide (USPIO) contrast agents that are taken up by inflammatory cells can detect cellular inflammation non-invasively using CMR, potentially aiding the diagnosis of inflammatory medical conditions, guiding their treatment and giving insight into their pathophysiology. In this review we describe the utilization of USPIO as a novel contrast agent in vascular disease.

Background: The aim of the current study was to assess the utility of transmurality of delayed enhancement on cardiac magnetic resonance imaging (MRI) in predicting functional recovery in patients with first ST-elevation myocardial infarction (MI) who had received thrombolysis., Methods: Nineteen patients underwent cine and contrast-enhanced MRI 3 days and 8 weeks after MI. The transmural extent of infarction (TEI) was determined from the late enhancement component of the first scan. Segmental wall thickening was scored from the cine components of both the initial and follow-up scans., Results: The TEI was inversely related to the likelihood of improvement in wall thickening; chi(2) test for trend = 53.9, p < 0.0001. Delayed enhancement with >50% transmurality predicted a lack of recovery with 82% sensitivity and 54% specificity. The equivalent values for >75% transmurality were 57 and 77%, respectively. The proportion of the left ventricular segments exhibiting functional recovery was related to the percentage of the left ventricle that was severely dysfunctional but had

Treatment of the MP joint in the patient with rheumatoid arthritis can lead to very satisfying results. Decision making is based on the degree of compromise in the hand and the knowledge of anticipated outcomes with surgery. In patients in whom pain is an overriding feature, implant surgery is highly successful. The timing for implant surgery in regard to deformity is less clear. Soft tissue correction procedures without implants appear to have value in the treatment of moderate to late disease and further documentation of the long-term outcomes will prove helpful in determining the roles of such procedures. If silicone rubber MCP arthroplasty is performed, one can anticipate an arc of motion in the 50-degree range, with improvement of extensor lag. There also is improvement of ulnar deviation, although recurrence into the 10 to 15 degree range is not unexpected. Complications such as deep infection, recurrent deformity, and implant breakage all play a role in making the decision to undertake surgery. Younger patients obviously have more risk for future prosthetic problems. The development of silicone implant arthroplasty of the MP joint has given the hand surgeon a valuable way of improving hand function in patients with severe rheumatoid involvement. It is a procedure the outcome of which may be anticipated and patients may be reassured with some degree of confidence that the hand surgeon can provide them with improved hand function.

Noninvasive tests for carpal tunnel syndrome (CTS) are of limited diagnostic value. A self-administered hand symptom diagram has been developed for use in the diagnosis and epidemiologic study of CTS. Diagrams are rated classic CTS, probable, possible or unlikely. Diagram ratings were compared with nerve conduction diagnoses in 110 patients with upper extremity complaints. A hand diagram rating of classic or probable CTS had sensitivity of 0.64, specificity of 0.73 and positive predictive value of 0.58. The negative predictive value of an unlikely diagram was 0.91. We conclude that the diagram is a useful diagnostic tool and may be valuable for occupational and population screening.

A self-administered hand diagram has been developed to assist in the evaluation of upper extremity paresthesias. A rating system was devised to classify diagrams into four categories: classic, probable, possible, or unlikely carpal tunnel syndrome. Diagram ratings of 63 patients (85 hands) evaluated in a hand clinic were compared with diagnoses established independent of diagram results by objective clinical criteria. The sensitivity of diagrams rated classic or probable was 80% and specificity was 90%. We conclude that the hand diagram is valuable in the diagnosis of carpal tunnel syndrome among patients with upper extremity paresthesias.

Based upon experimental animal evaluation and a preliminary clinical experience in 18 patients with 3 recognized failing flaps, the implantable thermocouple probe microvascular method of vessel patency assessment would appear to be a promising new technique worthy of further clinical investigation.

Replantation surgery has progressed in 20 years from a laboratory curiosity to a common and useful clinical procedure. All patients with partial or complete amputations should be considered for replantation of the part. However, only a number of these patients are appropriate for replantation. The indications for replantation should not be based only on the potential viability of the limb, but, more important, should be based on the potential function of the replanted part. The function is related to the level of the amputation, to the mechanism of the amputation, and to the age and motivation of the patient. Replantation surgery requires technical competence and clinical acumen. Surgeons performing replantations should maintain their microvascular technique in laboratory work and elective microsurgical procedures. Because the operations are quite arduous and require teams of surgeons relieving each other and because assessment of the appropriateness of replantation requires considerable clinical experience, replantation operations are best performed by teams in large medical centers.

Postoperative monitoring of replanted and revascularized digits with skin temperature probes was performed on the 20 patients admitted to the Duke University Medical Center Orthopaedic Replantation Service from April to July, 1977. Using multiple probes, temperatures were recorded for the replanted digit, a control digit on the same hand, and the dressing which represented the ambient temperature. In addition, the following simultaneous clinical inspections were performed on the digits: capillary refill, skin color, turgor, audibility of arterial Doppler tones, and amplitude of pulp pressure tracing. Temperatures of the replanted digits were in the range of 26.0 degrees to 35.0 degrees C. Control temperatures remained relatively stable, in the range of 33.0 degrees to 35.0 degrees C. From the authors' experience the patterns of temperature change which signaled changes in perfusion of the replanted digit and possible poor prognosis were (1) the temperature of the replanted digit dropping more than 2.5 degrees C while the control temperature stayed constant; (2) the temperature of the replanted digit dropping below 30.0 degrees C for longer than 1 hour; and (3) the control temperature dropping below 30.0 degrees C with no correctable cause found.

Tenosynovitis in the hand of a patient with rheumatoid arthritis will occur in common sites. If the tenosynovitis cannot be controlled by nonsurgical means, there are surgical approaches to the disease. Tenosynovectomy can give successful, long-term relief from the synovitis, and can also prevent tendon ruptures.

1. The destruction of articular cartilage in human rheumatoid and other arthritides is the result of diverse mechanical, inflammatory and local cellular factors. A tissue-culture model for studying cartilage-synovial interactions that may be involved in the final common pathway of joint destruction is described. 2. Matrix breakdown was studied in vitro by using bovine nasal-cartilage discs cultivated in contact with synovium. Synovia were obtained from human and animal sources. Human tissue came from patients with ;classical' rheumatoid arthritis, and animal tissue from rabbits with antigen-induced arthritis. 3. Cartilage discs increased their proteoglycan content 2-3-fold during 8 days in culture. Proteoglycan was also released into culture medium, approx. 70% arising from cartilage breakdown. 4. Synovial explants from human rheumatoid and rabbit antigen-induced arthritis produced equivalent stimulation of proteoglycan release. After an initial lag phase, the breakdown rate rose abruptly to a maximum, resulting in a 2-fold increase of proteoglycan accumulation in culture medium after 8-10 days. 5. High-molecular-weight products shed into culture media were characterized chromatographically and by differential enzymic digestion. Proteoglycan-chondroitin sulphate accounted for 90% of the released polyanion, and its partial degradation in the presence of synovial explants was consistent with limited proteolytic cleavage. 6. Rheumatoid synovium applied to dead cartilage increased the basal rate of proteoglycan release. Living cartilage was capable of more extensive autolysis, even in the absence of synovium. However, optimal proteoglycan release required the interaction of living synovium with live cartilage. These findings support the view that a significant component of cartilage breakdown may be chondrocyte-mediated.

Although alternatives do exist for the treatment of traumatic arthritis in children, all efforts should be directed to treat the initial condition to avoid its progression to arthritis. Once arthritis is established, then follow the axiom, "treat patients, not x-rays." If despite all attempts at conservative treatment, a surgical option is necessary, then attention must be given to potential future growth, joint stability, and alignment, pain relief, and anticipated postoperative range of motion. All cases must be individualized because, unfortunately, none of the alternatives available is capable of guaranteeing a "normal" end result.