Is the irritable bladder associated with anterior compartment relaxation? A critical look at the 'integral theory of pelvic floor dysfunction'

The 'integral theory of pelvic floor dysfunction', first proposed by Petros and Ulmsten in 1990, claims that anterior vaginal wall relaxation is associated with symptoms of urgency, frequency, nocturia and urge incontinence. A retrospective study was designed to test this hypothesis. Imaging data and urodynamic reports from 272 women suffering from symptoms of lower urinary tract dysfunction were evaluated. Opening of the retrovesical angle, bladder neck descent, urethral rotation and descent of a cystocele during Valsalva were used to quantify anterior vaginal wall laxity None of the tested parameters were associated with symptoms and signs of detrusor overactivity. On the contrary, patients with higher grades of urethral and bladder descent were less likely to suffer from nocturia and urge incontinence and were less likely to leave sensory urgency and detrusor instability diagnosed on urodynamic testing. The findings of this study therefore do not support this hypothesis of the 'integral theory'.

Stress radiography and posterior pathological laxity of knee: comparison between two different techniques.

Stress radiographs have been recommended in order to obtain a better objective quantification of abnormal compartment knee motion. This tool has showed to be superior in quantifying a posterior cruciate ligament (PCL) lesion compared to clinical or arthrometer evaluation. Different radiographic techniques have been described in literature to quantify posterior pathological laxity. In this study we evaluated the total amount of posterior displacement (PTD) and side to side difference (SSD), before and after surgical reconstruction of PCL or PCL and posterolateral complex (PLC), using two different stress radiography techniques (Telos stress and kneeling view). Twenty patients were included in this study. We found a statistical significant difference about both total PTD and SSD among the two techniques preoperatively and at follow-up, with greatest values occurring using the kneeling view. Although stress radiographies has been introduced to allow an objective quantification of laxity in ligamentous injured knee, we believe that further studies on a large numbers of subjects are required to define the relationship between PTD values, measured with stress knee radiography, particularly using kneeling view, and ligamentous knee injury, in order to obtain a real useful tool in the decision making process, as well as to evaluate the outcome after ligamentous surgery.

Laxity dynamics and LLF schedulability analysis on multiprocessor platforms

LLF (Least Laxity First) scheduling, which assigns a higher priority to a task with a smaller laxity, has been known as an optimal preemptive scheduling algorithm on a single processor platform. However, little work has been made to illuminate its characteristics upon multiprocessor platforms. In this paper, we identify the dynamics of laxity from the system’s viewpoint and translate the dynamics into LLF multiprocessor schedulability analysis. More specifically, we first characterize laxity properties under LLF scheduling, focusing on laxity dynamics associated with a deadline miss. These laxity dynamics describe a lower bound, which leads to the deadline miss, on the number of tasks of certain laxity values at certain time instants. This lower bound is significant because it represents invariants for highly dynamic system parameters (laxity values). Since the laxity of a task is dependent of the amount of interference of higher-priority tasks, we can then derive a set of conditions to check whether a given task system can go into the laxity dynamics towards a deadline miss. This way, to the author’s best knowledge, we propose the first LLF multiprocessor schedulability test based on its own laxity properties. We also develop an improved schedulability test that exploits slack values. We mathematically prove that the proposed LLF tests dominate the state-of-the-art EDZL tests. We also present simulation results to evaluate schedulability performance of both the original and improved LLF tests in a quantitative manner.

Recurrent dominant mutations affecting two adjacent residues in the motor domain of the monomeric kinesin KIF22 result in skeletal dysplasia and joint laxity.

Spondyloepimetaphyseal dysplasia with joint laxity, leptodactylic type (lepto-SEMDJL, aka SEMDJL, Hall type), is an autosomal dominant skeletal disorder that, in spite of being relatively common among skeletal dysplasias, has eluded molecular elucidation so far. We used whole-exome sequencing of five unrelated individuals with lepto-SEMDJL to identify mutations in KIF22 as the cause of this skeletal condition. Missense mutations affecting one of two adjacent amino acids in the motor domain of KIF22 were present in 20 familial cases from eight families and in 12 other sporadic cases. The skeletal and connective tissue phenotype produced by these specific mutations point to functions of KIF22 beyond those previously ascribed functions involving chromosome segregation. Although we have found Kif22 to be strongly upregulated at the growth plate, the precise pathogenetic mechanisms remain to be elucidated.

Ligamentous and tendinous anatomy of the intermetacarpal and common carpometacarpal joints: evaluation with MR imaging and MR arthrography.

PURPOSE: The purpose of this work was to demonstrate the normal ligamentous and tendinous anatomy of the intermetacarpal (IMC) and common carpometacarpal (CCMC) joints with MRI and MR arthrography. METHOD: MR images of 22 wrists derived from fresh human cadavers were obtained before and after arthrography. The MR imaging features of the ligaments and tendons about the CCMC and IMC joints and the joints themselves were analyzed in a randomized fashion and correlated with those seen on anatomic sections. RESULTS: Six CCMC ligaments were visualized. The dorsal and palmar CCMC ligaments and the pisometacarpal ligament were best visualized in the sagittal plane. The radial and ulnar CCMC collateral ligaments and the capito-third metacarpal ligament were best visualized in the coronal plane. Three main IMC ligaments were observed: a dorsal and a palmar ligament and an interosseous ligament complex. All three ligaments were best visualized in the axial plane. Four tendinous insertions to the metacarpal bases were evident. CONCLUSION: The anatomy of the ligaments and tendinous insertions about the second to fifth IMC and the CCMC joints is well demonstrated by MR imaging and MR arthrography. MR arthrography does not significantly improve the visualization of these complex structures.

Analysis of joint laxity after total ankle arthroplasty: cadaver study.

BACKGROUND: Clinical results of total ankle arthroplasty with early designs were disappointing. Recently-developed ankle prostheses have good mid-term results; however, limited information is available regarding effects of total ankle arthroplasty on ankle laxity. METHODS: Eight cadaveric lower extremities were tested with a custom device which enabled measurement of multi-axial forces, moments, and displacement during applied axial, shear, and rotational loading. Tests consisted of anterior-posterior and medial-lateral translation and internal-external rotation of the talus relative to the tibia during axial loads on the tibia simulating body weight (700 N) and an unloaded condition (5 N). Tests were performed in neutral, dorsiflexion, and plantarflexion. Laxity was determined for the intact ankle, and following insertion of an unconstrained total ankle implant, comparing load-displacement curve. FINDINGS: Laxity after total ankle arthroplasty did not approximate the normal ankle in most conditions tested. Displacement was significantly greater for total ankle arthroplasty in both posterior and lateral translation, and internal rotation, with 5 N axial loading, and anterior-posterior, medial-lateral translation, and internal-external rotation for 700 N axial loading. For the 700 N axial load condition, in the neutral ankle position, total anterior-posterior translation averaged 0.4 mm (SD 0.2 mm), but 6.0 mm (SD 1.5 mm) after total ankle arthroplasty (P<0.01). This study demonstrated more laxity in the replaced ankle than normal ankle for both unloaded and 700 N axially loaded conditions. INTERPRETATION: These data indicate the increased responsibility of the ligaments for ankle laxity after total ankle arthroplasty and suggest the importance of meticulous ligament reconstruction with total ankle arthroplasty operations.

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In the past 2 decades, there has been an increase in both basic science research detailing the anatomy and biomechanics of the native posterior cruciate ligament (PCL) and outcome studies evaluating manage- ment of the ruptured PCL. While the methodology of the latter continues to improve, results based on the current level of evidence must be interpreted cautiously (18). The focus of many recent studies has been double-bundle versus single-bundle reconstruction techniques. The theoretical advantage goes to double-bundle techniques, but a clinical difference in outcome has not been consistently demonstrated (8,17). Some biomechanical studies have reported improved control of posterior laxity with double-bundle reconstruc- tion; however, results appear to be more dependent on tunnel position and graft tensioning (13). In acute isolated symptomatic PCL injuries in which the posteromedial bundle and the meniscofemoral ligament remain intact, a single-bundle augmentation procedure may be the preferred surgical technique. In more complex PCL ruptures with associated injuries involving the posterolateral structures (PLS) or medial collateral ligament, more benefit may be derived from double-bundle reconstruction. Again, cadaveric testing of double-bundle PCL reconstruction has not consistently outperformed single-bundle techniques in combined PCL/PLS injury (3). Multi-ligamentous injuries are commonly associated with PCL rupture (15), and their management should be considered carefully in the decision to reconstruct one or both of the functionally dis- tinct PCL bundles. However, the technical complexity of double-bundle reconstruction, the longer surgical time required, as well as the inconclusive clinical outcome are all factors that must be weighed carefully.

Apoptosis of ligamentous cells of the cranial cruciate ligament from stable stifle joints of dogs with partial cranial cruciate ligament rupture

OBJECTIVE To describe the presence and amount of apoptotic ligamentous cells in different areas of partially ruptured canine cranial cruciate ligaments (prCCLs) and to compare these findings with apoptosis of ligamentous cells in totally ruptured cranial cruciate ligaments (trCCLs). ANIMALS 20 dogs with prCCLs and 14 dogs with trCCLs. PROCEDURES Dogs with prCCLs or trCCLs were admitted to the veterinary hospital for stifle joint treatment. Biopsy specimens of the intact area of prCCLs (group A) and the ruptured area of prCCLs (group B) as well as specimens from trCCLs (group C) were harvested during arthroscopy. Caspase-3 and poly (ADP-ribose) polymerase (PARP) detection were used to detect apoptotic ligamentous cells by immunohistochemistry. RESULTS No difference was found in the degree of synovitis or osteophytosis between prCCLs and trCCLs. No difference was found in degenerative changes in ligaments between groups A and B. A substantial amount of apoptotic cells could be found in > 90% of all stained slides. A correlation (r(s) = 0.71) was found between the number of caspase-3-and PARP-positive cells. No significant difference was found in the amount of apoptotic cells among the 3 groups. No significant correlation could be detected between the degree of synovitis and apoptotic cells or osteophyte production and apoptotic cells. CONCLUSIONS AND CLINICAL RELEVANCE The lack of difference between the 3 groups indicates that apoptosis could be a factor in the internal disease process leading to CCL rupture and is not primarily a consequence of the acute rupture of the ligament.

Temporary Internal Fixation for Ligamentous and Osseous Lisfranc Injuries: Outcome and Technical Tip

BACKGROUND Open rather than closed reduction and internal fixation as well as primary definitive arthrodesis are well accepted for ligamentous and osseous Lisfranc injuries. For ligamentous injuries, a better outcome after primary definitive partial arthrodesis has been published. METHODS Of 135 Lisfranc injuries that were treated from 1998 to 2012 with open reduction, temporary internal fixation by screws and plates, and restricted weight bearing in a lower leg cast for 3 months followed by an arch support for another 4 to 6 weeks, 29 ligamentous Lisfranc injuries were available for follow-up. They were compared with 29 osseous Lisfranc injuries matched in age and gender. RESULTS Between the groups, there were no significant differences in average age (39.9 vs 38 years) or in average follow-up time (8.3 vs 9.1 years). Also, no significant differences were seen in the AOFAS midfoot score (84 vs 85.3 points), the FFI pain scale (9.9 vs 14.9 points), SF 36 physical component (56.2 vs 53.9 points), SF 36 mental component (57 vs 56.4 points), or VAS for pain (1.6 vs 1.5 points). The FFI function scale was significantly lower in the ligamentous group (11.6 vs 19.5 points). Radiographically, loss of reduction was recorded 3 times in the ligamentous injuries and 4 times in the osseous injuries. Arthritis was mild/moderate/severe in 5/3/0 ligamentous injuries and in 7/2/1 osseous injuries, requiring 1 definitive secondary Lisfranc arthrodesis in each group. CONCLUSION With longer and conservative postoperative management, open reduction and temporary internal fixation in ligamentous and osseous Lisfranc injuries led to equal medium-term outcome. Inferior outcome in ligamentous injuries was not found. LEVEL OF EVIDENCE Level III, retrospective comparative cohort study.

Medial upper eyelid shortening to correct medial eyelid laxity in floppy eyelid syndrome: A new surgical approach

Purpose: To describe and present the results of a new surgical technique for patients with floppy eyelid syndrome, based on the medial upper eyelid stretching encountered in this condition. Methods: A case series of 24 patients with floppy eyelid syndrome who where found to have symptomatic predominately medial upper eyelid laxity was analyzed. The history, clinical features, histopathology, and outcome were reviewed after patients underwent medial upper eyelid shortening with or without upper eyelid skin reduction as the first surgical procedure. Results: Of the 24 patients, 18 were men (75%) with a mean age at referral of 56 years, having ocular discomfort and conjunctival irritation/papillary conjunctivitis as the main complaints at presentation. Obesity was present in 96% of cases, with lower eyelid laxityl/ectropion (50%) and upper eyelid eyelash ptosis (29%) in conjunction with the upper eyelid laxity. The affected side was related to sleeping habits or recurrent mechanical eyelid trauma. Histologic studies showed a nonspecific inflammatory cell infiltrate and loss of elastin with loose dermal connective tissue. After surgery, complete relief of ocular symptoms and good functional and cosmetic results were present in all cases after 18 months of follow-up. Conclusions: This new surgical approach is based on the presence of predominately medial upper laxity in patients with floppy eyelid syndrome. The excision of this stretched area stabilized the upper eyelid in an anatomic fashion, providing a good and stable long-term result. The possible mechanisms involved in the medial upper eyelid stretching are discussed.

Market reform and fiscal laxity in Communist and post-Communist Hungary: A path-dependent approach

Purpose – The purpose of this paper is to present a conceptual framework in order to analyse and understand the twin developments of successful microeconomic reform on the one hand and failed macroeconomic stabilisation attempts on the other hand in Hungary. The case study also attempts to explore the reasons why Hungarian policymakers were willing to initiate reforms in the micro sphere, but were reluctant to initiate major changes in public finances both before and after the regime change of 1989/1990. Design/methodology/approach – The paper applies a path-dependent approach by carefully analysing Hungary's Communist and post-Communist economic development. The study restricts itself to a positive analysis but normative statements can also be drawn accordingly. Findings – The study demonstrates that the recent deteriorating economic performance of Hungary is not a recent phenomenon. By providing a path-dependent explanation, it argues that both Communist and post-Communist governments used the general budget as a buffer to compensate the losers of economic reforms, especially microeconomic restructuring. The gradualist success of the country – which dates back to at least 1968 – in the field of liberalisation, marketisation and privatisation was accompanied by a constant overspending in the general government. Practical implications – Hungary has been one of the worst-hit countries of the 2008/2009 financial crisis, not just in Central and Eastern Europe but in the whole world. The capacity and opportunity for strengthening international investors' confidence is, however, not without doubts. The current deterioration is deeply rooted in failed past macroeconomic management. The dissolution of fiscal laxity and state paternalism in a broader context requires, therefore, an all-encompassing reform of the general government, which may trigger serious challenges to the political regime as well. Originality/value – The study aims to show that a relatively high ratio of redistribution, a high and persistent public deficit and an accelerated indebtedness are not recent phenomena in Hungary. In fact, these trends characterised the country well before the transformation of 1989/1990, and have continued in the post-socialist years, too. To explain such a phenomenon, the study argues that in the last couple of decades the hardening of the budget constraint of firms have come at the cost of maintaining the soft budget constraint of the state.

Spontaneous tendon rupture in systemic lupus erythematosus: association with Jaccoud`s arthropathy

Tendon rupture has rarely been described in patients with systemic lupus erythematosus. From observation of three cases of Jaccoud`s arthropathy with tendon rupture, and considering that this arthropathy is more related to an inflammatory process of the tendon sheath than to synovitis per se, the intention of this study was to review the cases of tendon rupture in patients with systemic lupus erythematosus, in the hope of determining the frequency of Jaccoud`s arthropathy associated with this complication. Systematic review using MEDLINE, Scielo and LILACS databases (1966 to 2009) and the following keywords: systemic lupus erythematosus, tendon rupture, Jaccoud`s arthropathy. Secondary references were additionally obtained. Additionally, three Brazilian systemic lupus erythematosus patients who developed tendon rupture are described. Only 40 articles obtained fulfilled the previously established criteria. They were all case reports; the number of cases reported was 52 which, together with the three cases presented herein add up to 55 cases. Forty-six patients were women aged between 19 and 71 years, with a mean age of 40.1 +/- 12.4 years, and the average duration of the disease was 10 years. The most frequently observed rupture sites were the patellar and Achilles` tendons. While almost all patients described were on various doses of corticosteroids, 16 patients concomitantly had Jaccoud`s arthropathy (29%). In conclusion, the association between Jaccoud`s arthropathy and tendon rupture in systemic lupus erythematosus has been underestimated. As almost one-third of the systemic lupus erythematosus patients with tendon rupture also have Jaccoud`s arthropathy, this arthropathy may be recognized as risk marker for tendon rupture. Lupus (2010) 19, 247-254.

Echocardiographic identification of the oblique vein of the left atrium: its relationship to the persistent left superior caval vein

Thus far, little has been written concerning echocarchographic identification of the oblique of the left atrium, or Marshall`s vein. There is much discussion, nonetheless, on the potential significance of the vein, or its ligamentous remnant, as an arrhythmic substrate. We describe here four patients in whom transthoracic echocardiography revealed a venous structure protruding within the cavity of the left atrium. We discuss the possibility that these structures represent Marshall`s vein, albeit probably as part of a persistent left superior caval vein.

The relation between the transversus abdominis muscles, sacroilac joint mechanics, and low back pain

Study Design. Two abdominal muscle patterns were tested in the same group of individuals, and their effects were compared in relation to sacroiliac joint laxity. One pattern was contraction of the transversus abdominis, Independently of the other abdominals; the other was a bracing action that used all the lateral abdominal muscles. Objectives. To demonstrate the biomechanical effect of the exercise for the transversus abdominis known to be effective in low back pain. Summary of Background Data. Drawing in the abdominal wall is a specific exercise for the transversus abdominis muscle (in cocontraction with the multifidus), which is used in the treatment of back pain. Clinical effectiveness has been demonstrated to be a reduction of 3-year recurrence from 75% to 35%. To the authors' best knowledge, there is not yet in vivo proof of the biomechanical effect of this specific exercise. This study of a biomechanical model on the mechanics of the sacroiliac joint, however, predicted a significant effect of transversus abdominis muscle force. Methods. Thirteen healthy individuals who could perform the test patterns were included. Sacroiliac joint laxity values were recorded with study participants in the prone position during the two abdominal muscle patterns. The values were recorded by means of Doppler Imaging of vibrations. Simultaneous electromyographic recordings and ultrasound imaging were used to verify the two muscle patterns. Results. The range of sacroiliac joint laxity values observed in this study was comparable with levels found in earlier studies of healthy individuals. These values decreased significantly in all individuals during both muscle patterns (P < 0.001). The independent transversus abdominis contraction decreased sacroiliac joint laxity (or rather increased sacroiliac joint stiffness) to a significantly greater degree than the general abdominal exercise pat-tern (P < 0.0260). Conclusions. Contraction of the transversus abdominis significantly decreases the laxity of the sacroiliac joint. This decrease in laxity is larger than that caused by a bracing action using all the lateral abdominal muscles. These findings are in line with the authors' biomechanical model predictions and support the use of independent transversus abdominis contractions for the treatment of low back pain.

LLF schedulability analysis on multiprocessor platforms

LLF (Least Laxity First) scheduling, which assigns a higher priority to a task with smaller laxity, has been known as an optimal preemptive scheduling algorithm on a single processor platform. However, its characteristics upon multiprocessor platforms have been little studied until now. Orthogonally, it has remained open how to efficiently schedule general task systems, including constrained deadline task systems, upon multiprocessors. Recent studies have introduced zero laxity (ZL) policy, which assigns a higher priority to a task with zero laxity, as a promising scheduling approach for such systems (e.g., EDZL). Towards understanding the importance of laxity in multiprocessor scheduling, this paper investigates the characteristics of ZL policy and presents the first ZL schedulability test for any work-conserving scheduling algorithm that employs this policy. It then investigates the characteristics of LLF scheduling, which also employs the ZL policy, and derives the first LLF-specific schedulability test on multiprocessors. It is shown that the proposed LLF test dominates the ZL test as well as the state-of-art EDZL test.