Research Spotlight

Al-Moraissi, E. A. and L. M. Wolford (2016). “Is counterclockwise rotation of the maxillomandibular complex stable compared with clockwise rotation in the correction of dentofacial deformities? A systematic review and meta-analysis.” J Oral Maxillofac Surg. 2016 Jun 2011 [Epub ahead of print].

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PURPOSE: To compare postsurgical skeletal stability between counterclockwise rotation (CCWR) of the maxillomandibular complex (MMC) and clockwise rotation (CWR) of the MMC for the correction of dentofacial deformities. MATERIALS AND METHODS: To address the study purpose, we designed and implemented a systematic review with meta-analysis based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search strategy was developed, and a search of major databases-PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL)-was conducted to find all pertinent articles published from inception through March 2016. The inclusion criteria were randomized controlled trials, controlled clinical trials, retrospective studies, and case series with the aim of comparing postsurgical stability of CCWR and CWR of the MMC. The analysis was performed using lateral cephalometric analysis of postsurgical mean values and correlation between the surgical and postsurgical changes of the occlusal plane angle and linear changes at A point and B point. A weighted mean difference analysis using a random-effects model with 95% confidence intervals was performed. RESULTS: A total of 133 patients were enrolled from 3 studies (CCWR, n = 83; CWR, n = 50). All included studies were at moderate risk of bias. There was a statistically significant difference between CCWR and CWR of the MMC in the postsurgical changes of the occlusal plane angle (P = .034), but no statistically significant difference was found in the correlation between the surgical and postsurgical changes of the occlusal plane angle in the 2 groups. There was no statistically significant difference between CCWR and CWR of the MMC for stability between assessments immediately after surgery and at longest follow-up relative to the vertical and horizontal positions at A point and B point (P > .05). CONCLUSIONS: CCWR compared with CWR for the correction of dentofacial deformities in the absence of pre-existing temporomandibular joint pathology is skeletally stable relative to the postsurgical changes of the occlusal plane, as well as the vertical and horizontal changes of the maxilla and mandible.

Walsh, M. V., T. W. Armstrong, J. Poritz, T. R. Elliott, W. T. Jackson and T. Ryan (2016). “Resilience, Pain Interference, and Upper Limb Loss: Testing the Mediating Effects of Positive Emotion and Activity Restriction on Distress.” Arch Phys Med Rehabil 97(5): 781-787.

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OBJECTIVE: To test mediating effects of positive emotion and activity restriction on the associations of resilience and pain interference with distress reported by individuals with traumatic upper limb loss evaluated for prosthetics. DESIGN: Cross-sectional correlational study of several demographic and self-report measures of resilience, pain interference, activity restriction, positive emotions, and symptoms of depression and posttraumatic stress. SETTING: Six regional centers throughout the United States. PARTICIPANTS: A total of 263 prospective participants consented to be evaluated for eligibility and need for upper extremity prosthetics; participants (N=202; 57 women [28.2%] and 145 men [71.8%]; mean age, 41.81+/-14.83y; range, 18.01-72.95y) who sustained traumatic injuries were retained in this study. Most of them were identified as white (70.8%; n=143), followed by black (10.4%; n=21), Hispanic (9.9%; n=20), Asian (3.0%; n=6), other (1.5%; n=3), and missing (4.5%; n=9). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Primary Care Posttraumatic Stress Disorder Screen and depression screen. RESULTS: Resilience and pain interference were significantly correlated in predicted directions with positive emotions, activity restriction, and the 2 distress variables. A path model revealed that the associations of resilience and pain interference with both distress variables were completely mediated by positive emotions and activity restriction. There were no significant direct effects of resilience or pain interference on either distress variable. CONCLUSIONS: Resilience may facilitate adjustment via beneficial and predicted associations with positive emotions and active engagement with the environment. These relations are independent of the significant and inverse associations of pain interference with these same variables. Longitudinal research is needed to understand interactions between positive emotions and activity over time in promoting adjustment after traumatic limb loss. Individuals reporting depression and/or posttraumatic stress disorder symptoms may require interventions that reduce avoidance and promote activities that may increase the likelihood of experiencing positive emotions.

Pedowitz, D. I., J. M. Kane, G. M. Smith, H. L. Saffel, C. Comer and S. M. Raikin (2016). “Total ankle arthroplasty versus ankle arthrodesis: a comparative analysis of arc of movement and functional outcomes.” Bone Joint J 98-b(5): 634-640.

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AIMS: Few reports compare the contribution of the talonavicular articulation to overall range of movement in the sagittal plane after total ankle arthroplasty (TAA) and tibiotalar arthrodesis. The purpose of this study was to assess changes in ROM and functional outcomes following tibiotalar arthrodesis and TAA. PATIENTS AND METHODS: Patients who underwent isolated tibiotalar arthrodesis or TAA with greater than two-year follow-up were enrolled in the study. Overall arc of movement and talonavicular movement in the sagittal plane were assessed with weight-bearing lateral maximum dorsiflexion and plantarflexion radiographs. All patients completed Short Form-12 version 2.0 questionnaires, visual analogue scale for pain (VAS) scores, and the Foot and Ankle Ability Measure (FAAM). RESULTS: In all, 41 patients who underwent TAA and 27 patients who underwent tibiotalar arthrodesis were enrolled in the study. The mean total arc of movement was 34.2 degrees (17.0 degrees to 59.1 degrees ) with an average contribution from the talonavicular joint of 10.5 degrees (1.2 degrees to 28.8 degrees ) in the TAA cohort. The average total arc of movement was 24.3 degrees (6.9 degrees to 44.3 degrees ) with a mean contribution from the talonavicular joint of 22.8 degrees (5.6 degrees to 41.4 degrees ) in the arthrodesis cohort. A statistically significant difference was detected for both total sagittal plane movement (p = 0.00025), and for talonavicular motion (p < 0.0001). A statistically significant lower VAS score (p = 0.0096) and higher FAAM (p = 0.01, p = 0.019, respectively) was also detected in the TAA group. CONCLUSION: TAA preserves more anatomical movement, has better pain relief and better patient-perceived post-operative function compared with patients undergoing fusion. The relative increase of talonavicular movement in fusion patients may play a role in the outcomes compared with TAA and may predispose these patients to degenerative changes over time. TAKE HOME MESSAGE: TAA preserves more anatomic sagittal plane motion and provides greater pain relief and better patient-perceived outcomes compared with ankle arthrodesis.

Kristensen, S. L., F. Martinez, P. S. Jhund, J. L. Arango, J. Belohlavek, S. Boytsov, W. Cabrera, E. Gomez, A. A. Hagege, J. Huang, S. Kiatchoosakun, K. S. Kim, I. Mendoza, M. Senni, I. B. Squire, D. Vinereanu, R. C. Wong, J. Gong, M. P. Lefkowitz, A. R. Rizkala, J. L. Rouleau, V. C. Shi, S. D. Solomon, K. Swedberg, M. R. Zile, M. Packer and J. J. McMurray (2016). “Geographic variations in the paradigm-hf heart failure trial.” Eur Heart J: 2016 June [Epub ahead of print].

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AIMS: The globalization of clinical trials has highlighted geographic variations in patient characteristics, event rates, and treatment effects. We investigated these further in PARADIGM-HF, the largest and most globally representative trial in heart failure (HF) to date. METHODS AND RESULTS: We looked at five regions: North America (NA) 622 (8%), Western Europe (WE) 1680 (20%), Central/Eastern Europe/Russia (CEER) 2762 (33%), Latin America (LA) 1413 (17%), and Asia-Pacific (AP) 1487 (18%). Notable differences included: WE patients (mean age 68 years) and NA (65 years) were older than AP (58 years) and LA (63 years) and had more coronary disease; NA and CEER patients had the worst signs, symptoms, and functional status. North American patients were the most likely to have a defibrillating-device (53 vs. 2% AP) and least likely prescribed a mineralocorticoid receptor antagonist (36 vs. 61% LA). Other evidence-based therapies were used most frequently in NA and WE. Rates of the primary composite outcome of cardiovascular (CV) death or HF hospitalization (per 100 patient-years) varied among regions: NA 13.5 (95% CI 11.7-15.6), WE 9.6 (8.6-10.6), CEER 12.3 (11.4-13.2), LA 11.2 (10.0-12.5), and AP 12.5 (11.3-13.8). After adjustment for prognostic variables, relative to NA, the risk of CV death was higher in LA and AP and the risk of HF hospitalization lower in WE. The benefit of sacubitril/valsartan was consistent across regions. CONCLUSION: There were many regional differences in PARADIGM-HF, including in age, symptoms, comorbidity, background therapy, and event-rates, although these did not modify the benefit of sacubitril/valsartan.

Okumura, N., P. S. Jhund, J. Gong, M. P. Lefkowitz, A. R. Rizkala, J. L. Rouleau, V. C. Shi, K. Swedberg, M. R. Zile, S. D. Solomon, M. Packer and J. J. McMurray (2016). “Importance of clinical worsening of heart failure treated in the outpatient setting: Evidence from the prospective comparison of arni with acei to determine impact on global mortality and morbidity in heart failure trial (paradigm-hf).” Circulation 133(23): 2254-2262.

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BACKGROUND: Many episodes of worsening of heart failure (HF) are treated by increasing oral therapy or temporary intravenous treatment in the community or emergency department (ED), without hospital admission. We studied the frequency and prognostic importance of these episodes of worsening in the Prospective Comparison of ARNI (angiotensin-receptor-neprilysin inhibitor) with ACEI (angiotensin-converting enzyme inhibitor) to Determine Impact on Global Mortality and Morbidity in Heart Failure Trial (PARADIGM-HF). METHODS AND RESULTS: Outpatient intensification of HF therapy was added to an expanded composite outcome with ED visits, HF hospitalizations, and cardiovascular deaths. In an examination of first nonfatal events, 361 of 8399 patients (4.3%) had outpatient intensification of HF therapy without a subsequent event (ie, ED visit/HF hospitalizations) within 30 days; 78 of 8399 (1.0%) had an ED visit without previous outpatient intensification of HF therapy or a subsequent event within 30 days; and 1107 of 8399 (13.2%) had HF hospitalizations without a preceding event. The risk of death (in comparison with no-event patients) was similar after each manifestation of worsening: outpatient intensification of HF therapy (hazard ratio, 4.8; 95% confidence interval, 3.9-5.9); ED visit (hazard ratio, 4.5; 95% confidence interval, 3.0-6.7); HF hospitalizations (hazard ratio, 5.9; 95% confidence interval, 5.2-6.6). The expanded composite added 14% more events and shortened time to accrual of a fixed number of events. The benefit of sacubitril/valsartan over enalapril was similar to the primary outcome for the expanded composite (hazard ratio, 0.79; 95% confidence interval, 0.73-0.86) and was consistent across the components of the latter. CONCLUSIONS: Focusing only on HF hospitalizations underestimates the frequency of worsening and the serious implications of all manifestations of worsening. For clinical trials conducted in an era of heightened efforts to avoid HF hospitalizations, inclusion of episodes of outpatient treatment intensification (and ED visits) in a composite outcome adds an important number of events and shortens the time taken to accrue a target number of end points in an event-driven trial.