Congenital duodenal obstruction repair with and without transanastomotic tube feeding: a systematic review and meta-analysis

OBJECTIVE

To determine the impact of transanastomotic tube (TAT) feeding in congenital duodenal obstruction (CDO).

DESIGN

Systematic review with meta-analysis.

PATIENTS

Infants with CDO requiring surgical repair.

INTERVENTIONS

TAT feeding following CDO repair versus no TAT feeding.

MAIN OUTCOME MEASURES

The main outcome was time to full enteral feeds. Additional outcomes included use of parenteral nutrition (PN), cost and complications from either TAT or central venous catheter. Meta-analyses were undertaken using random-effects models (mean difference (MD) and risk difference (RD)), and risk of bias was assessed using the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool.

RESULTS

Twelve out of 373 articles screened met the inclusion criteria. All studies were observational and two were prospective. Nine studies, containing 469 infants, were available for meta-analysis; however, four were excluded due to serious or critical risk of bias. TAT feeding was associated with reduced time to full enteral feeds (-3.34; 95% CI -4.48 to -2.20 days), reduced duration of PN (-6.32; 95% CI -7.93 to -4.71 days) and reduction in nutrition cost of £867.36 (95% CI £304.72 to £1430.00). Other outcomes were similar between those with and without a TAT including inpatient length of stay (MD -0.97 (-5.03 to 3.09) days), mortality (RD -0.01 (-0.04 to 0.01)) and requirement for repeat surgery (RD 0.01 (-0.03 to 0.05)).

CONCLUSION

TAT feeding following CDO repair appears beneficial, without increased risk of adverse events; however, certainty of available evidence is low. Earlier enteral feeding and reduced PN use are known to decrease central venous catheter-associated risks while significantly reducing cost of care.

PROSPERO REGISTRATION NUMBER

CRD42022328381.

Towards optimal use of antithrombotic therapy of people with cancer at the end of life: A research protocol for the development and implementation of the SERENITY shared decision support tool

BACKGROUND

Even though antithrombotic therapy has probably little or even negative effects on the well-being of people with cancer during their last year of life, deprescribing antithrombotic therapy at the end of life is rare in practice. It is often continued until death, possibly resulting in excess bleeding, an increased disease burden and higher healthcare costs.

METHODS

The SERENITY consortium comprises researchers and clinicians from eight European countries with specialties in different clinical fields, epidemiology and psychology. SERENITY will use a comprehensive approach combining a realist review, flash mob research, epidemiological studies, and qualitative interviews. The results of these studies will be used in a Delphi process to reach a consensus on the optimal design of the shared decision support tool. Next, the shared decision support tool will be tested in a randomised controlled trial. A targeted implementation and dissemination plan will be developed to enable the use of the SERENITY tool across Europe, as well as its incorporation in clinical guidelines and policies. The entire project is funded by Horizon Europe.

RESULTS

SERENITY will develop an information-driven shared decision support tool that will facilitate treatment decisions regarding the appropriate use of antithrombotic therapy in people with cancer at the end of life.

CONCLUSIONS

We aim to develop an intervention that guides the appropriate use of antithrombotic therapy, prevents bleeding complications, and saves healthcare costs. Hopefully, usage of the tool leads to enhanced empowerment and improved quality of life and treatment satisfaction of people with advanced cancer and their care givers.

Mapping internal temperatures during high-rate battery applications

Electric vehicles demand high charge and discharge rates creating potentially dangerous temperature rises. Lithium-ion cells are sealed during their manufacture, making internal temperatures challenging to probe1. Tracking current collector expansion using X-ray diffraction (XRD) permits non-destructive internal temperature measurements2; however, cylindrical cells are known to experience complex internal strain3,4. Here, we characterize the state of charge, mechanical strain and temperature within lithium-ion 18650 cells operated at high rates (above 3C) by means of two advanced synchrotron XRD methods: first, as entire cross-sectional temperature maps during open-circuit cooling and second, single-point temperatures during charge-discharge cycling. We observed that a 20-minute discharge on an energy-optimized cell (3.5 Ah) resulted in internal temperatures above 70 °C, whereas a faster 12-minute discharge on a power-optimized cell (1.5 Ah) resulted in substantially lower temperatures (below 50 °C). However, when comparing the two cells under the same electrical current, the peak temperatures were similar, for example, a 6 A discharge resulted in 40 °C peak temperatures for both cell types. We observe that the operando temperature rise is due to heat accumulation, strongly influenced by the charging protocol, for example, constant current and/or constant voltage; mechanisms that worsen with cycling because degradation increases the cell resistance. Design mitigations for temperature-related battery issues should now be explored using this new methodology to provide opportunities for improved thermal management during high-rate electric vehicle applications.

1195 EFFECTIVENESS OF A NEW PROACTIVE MULTIDISCIPLINARY CARE SERVICE FOR OLDER PEOPLE WITH FRAILTY: A NON-RANDOMISED CONTROLLED TRIAL

Introduction

Integrated care potentially improves health outcomes for older people with frailty. We aimed to assess the effectiveness of a new, proactive, multidisciplinary care service in improving the wellbeing and quality-of-life of older people with frailty.

Methods

A community-based non-randomised controlled trial. Participants (≥65 years, electronic Frailty Index ≥0.36) received either this new integrated care service plus usual care, or usual care alone. Data collection was at 3 time points: baseline, 2-4 weeks, and 10-14 weeks; the primary outcome was patient well-being at 2-4 weeks, measured using the Integrated Patient Outcome scale, IPOS. The secondary outcome was quality-of-life, measured using EQ-5D. Wellbeing and quality-of-life at 10-14 weeks were measured to test safety and duration of effect. Data was analysed with STATA v17.

Results

199 intervention and 54 control participants were recruited. At baseline, participants were similar in age/gender/body mass index/ethnicity/living status. At 2-4 weeks, the intervention group had improved well-being (median IPOS reduction 5, versus control group increase 2, p<0.001) and improved quality of life (median EQ-5D index values increase 0.12, versus control 0.00, p<0.001); these were clinically significant. After adjusting for age, gender and living status, intervention group had an average total IPOS score reduction of 6.34 (95% CI: -9.01: -4.26, p<0.05). Propensity score matching analysis based on functional status/deprivation score showed similar results (reduction in IPOS score in intervention group 7.88 (95% CI: -12.80: -2.96, p<0.001). At 10-14 weeks, the intervention group sustained well-being improvement (median IPOS score reduction 4, versus control increase 2, p<0.001) and improved quality of life (median EQ-5D index values increase 0.06, versus control -0.01, p<0.001).

Conclusion

This new integrated care service improves the overall wellbeing and quality of life of older people with frailty at 2-4 weeks; improvement was sustained at 3 months.

Ethics Approval: IRAS-250981 and NHS Research Ethics Committee 18/YH/0470.

Implementing two-stage consent pathway in neonatal trials

Perinatal trials sometimes require rapid recruitment processes to facilitate inclusion of participants when interventions are time-critical. A two-stage consent pathway has been used in some trials and is supported by national guidance. This pathway includes seeking oral assent for participation during the time-critical period followed by informed written consent later. This approach is being used in the fluids exclusively enteral from day one (FEED1) trial where participants need to be randomised within 3 hours of birth. There is some apprehension about approaching parents for participation via the oral assent pathway. The main reasons for this are consistent with previous research: lack of a written record, lack of standardised information and unfamiliarity with the process. Here, we describe how the pathway has been implemented in the FEED1 trial and the steps the trial team have taken to support sites. We provide recommendations for future trials to consider if they are considering implementing a similar pathway. Trial registration number: ISRCTN89654042.

Optimising growth in very preterm infants: reviewing the evidence

Infants born before 32 weeks' postmenstrual age are at a high risk of growth failure. International guidelines have long recommended that they match the growth of an equivalent fetus, despite the challenges posed by ex utero life and comorbidities of prematurity. Several groups have recently questioned the necessity or desirability of this target, shifting attention to aiming for growth which optimises important long-term outcomes. Specifically, recent research has identified the neurodevelopmental benefits of enhanced growth during the neonatal period, but work in term infant suggests that rapid growth may promote the metabolic syndrome in later life. In this context, defining a pattern of growth which optimises outcomes is complex, controversial and contested. Even if an optimal pattern of growth can be defined, determining the nutritional requirements to achieve such growth is not straightforward, and investigations into the nutritional needs of the very preterm infant continue. Furthermore, each infant has individual nutritional needs and may encounter a number of barriers to achieving good nutrition. This article offers a narrative review of recent evidence for the competing definitions of optimal growth in this cohort. It examines recent advances in the determination of macronutrient and micronutrient intake targets along with common barriers to achieving good nutrition and growth. Finally, key implications for clinical practice are set out and a recommendation for structured multidisciplinary management of nutrition and growth is illustrated.

Characteristics and outcome of infants with bronchopulmonary dysplasia established on long-term ventilation from neonatal intensive care

INTRODUCTION

Ex-preterm infants with severe bronchopulmonary dysplasia (BPD) sometimes require long-term ventilation (LTV) to facilitate weaning from respiratory support. There are however limited data characterizing this cohort. We aim to describe the background characteristics, neonatal comorbidities, characteristics at the initiation of ventilation, and outcomes of neonatal unit graduates with BPD established on LTV.

METHODS

A retrospective cohort study of infants born <32 weeks gestation with BPD referred to a regional LTV service between January 2015 and December 2020.

RESULTS

Twenty-five infants were referred during the study period. Median birth gestation was 26 + 1 weeks (24 + 0-30 + 4) and birth weight 645 g (430-1485). At 36 weeks postmenstrual age (PMA), median FiO₂ was 0.45 (0.24-0.80) and one-quarter of infants remained on invasive ventilation. Twenty (80%) infants were established on noninvasive ventilation (NIV), with the smallest weighing 2085 g, and five (20%) required tracheostomy invasive ventilation (TIV). At initiation of NIV/TIV, median PMA was 41 + 1 weeks and median FiO₂ 0.40 (0.29-0.80). Infants established on TIV spent almost five times longer in hospital before discharge compared to those on NIV (p = 0.003). By March 2022, 18 (72%) infants had discontinued ventilation, spending a median total time of 113 days (18-1792) on ventilation.

CONCLUSION

Due to advances in interfaces, headgear, and ventilator technology, NIV is an attractive and practically achievable option for infants with severe BPD as small as 2 kg. Initiation and weaning should take place in a facility with the required multidisciplinary expertize.

Changes in the growth of very preterm infants in England 2006-2018

OBJECTIVE

To compare weight gain from birth to term equivalent age in very preterm infants in England born during two eras (2006-2011 and 2014-2018); to assess demographic and care factors influencing weight gain.

METHODS

Data for infants born before 32 weeks of gestation during 2014-2018 in England were obtained (29 687 infants). Weight gain modelled using SuperImposition by Translation And Rotation (SITAR), with infants grouped by gestational week. A cohort from 2006 to 2011 was used for comparison (3288 infants). Multiple linear regression was used to assess factors influencing change in weight SD score from birth to 36 weeks postmenstrual age.

RESULTS

Weight gain velocity (termed 'intensity' in SITAR models) was greater in the more recent cohort for all gestation groups born before 30 weeks of gestation. After adjustment for gestation, birth weight and other perinatal factors, care elements associated with faster weight gain included delivery in a level 3 unit (0.09 SD less weight gain deficit, 95% CI: 0.07 to 0.10) and parenteral nutrition initiation during the first day of life (0.08 SD, 95% CI: 0.06 to 0.10). Factors associated with slower weight gain included early ventilation (-0.07 SD, 95% CI: -0.08 to -0.05) and less deprived neighbourhood (-0.012 SD per Index of Multiple Deprivation decile, 95% CI: -0.015 to -0.009).

CONCLUSIONS

Weight gain for extremely preterm infants was faster during 2014-2018 than during 2006-2011. Early initiation of parenteral nutrition and birth in a level 3 unit may contribute to faster weight gain.

Total body water in full-term and preterm newborns: systematic review and meta-analysis

BACKGROUND

Total body water (TBW) is one component of fat-free mass and changes in TBW are influenced by fluid shifts (especially during transition to postnatal life), electrolyte balance and nutritional status. Normal values for term-born neonates and preterm infants at birth have not been defined in large cohorts, limiting investigation into its monitoring and use in clinical practice.

OBJECTIVE

To systematically review the evidence base for percentage of TBW in term-born infants, quantify the effect of prematurity on TBW at birth, and describe normal progression of TBW over time in preterm infants.

METHODS

Systematic review of Medline, Web of Science Core Collection and EBSCO-CINAHL (January 1946 to January 2020). Included articles used dilutional methods to assess TBW.

RESULTS

Searches identified 2349 articles of which 22 included data suitable for analysis. Mean TBW in term-born newborns was 73.8% (95% CI 72.47% to 75.06%, 15 studies, 433 infants). Meta-regression showed that TBW was higher in preterm infants (up to 90% at 26 weeks gestation, dropping to 75% at 36 weeks corrected gestation) and was negatively correlated with gestation at birth, falling 1.44% per week (95% CI 0.63% to 2.24%, 9 studies, 179 infants). Analysis of TBW over time during the ex utero growth of preterm infants was not possible due to paucity of data.

CONCLUSION

This review defines the normal TBW percentage in term-born infants and confirms and quantifies previous findings that preterm infants have a higher TBW percentage.

Generating longitudinal growth charts from preterm infants fed to current recommendations

OBJECTIVE

To use repeated measurements of weight, length and head circumference to generate growth centile charts reflecting real-world growth of a population of very preterm infants with a well-described nutritional intake close to current recommendations.

DESIGN

Infants born before 30 weeks gestational age (GA) were recruited. Infants received nutrition according to an integrated care pathway, with nutrient intake recorded daily, weight recorded twice-weekly and length and head circumference weekly. The LMS method was used to construct growth centile charts between 24 and 36 weeks corrected GA for each parameter.

SETTING

A single tertiary neonatal unit in England.

PATIENTS

212 infants (124 male) (median GA at birth: 27.3 weeks, median birth weight: 900 g).

RESULTS

Median daily energy, protein, carbohydrate and fat intake were within 3% of published recommendations. The total number of measurements recorded was 5944 (3431 for weight, 1227 for length and 1286 for head circumference). Centile charts were formed for each parameter. Data for male and female infants demonstrated similar patterns of growth and were pooled for LMS analysis. A web application was created and published (bit.ly/sotongrowth) to allow infants to be plotted on these charts with changes in SD score of measurements reported and graphically illustrated.

CONCLUSIONS

These charts reflect growth in a real-world cohort of preterm infants whose nutrient intakes are close to current recommendations. This work demonstrates the feasibility of forming growth charts from serial measurements of growing preterm infants fed according to current recommendations which will aid clinicians in setting a benchmark for achievable early growth.

Home use of breast milk fortifier to promote postdischarge growth and breast feeding in preterm infants: a quality improvement project

To improve the postdischarge growth of exclusively breastfed preterm infants, born weighing ≤1.8 kg, by using breast milk fortifier (BMF) supplements postdischarge until 48 weeks' gestational age. A quality improvement (QI) project involving plan-do-study-act (PDSA) cycles. A tertiary surgical neonatal unit. Preterm infants weighing ≤1.8 kg at birth. We completed four PDSA cycles to develop and improve an electronic patient information sheet to promote the use BMF beyond discharge. Safety, feasibility and attitudes of parents to home BMF were assessed using questionnaires. A retrospective audit (July 2015-September 2017) was completed investigating the effects of home BMF on growth up to 1 year of age. Change in SD scores for weight for age, length for age and head circumference of age at various time points compared with those at birth were calculated. Compared with baseline measurements (infants born October 2012-November 2013), the QI project resulted in improved growth (measured as the change in SD score from birth, cSDS) at discharge for weight (cSDS -0.7), head circumference (cSDS 0.4) and length (cSDS-0.8), and at 1 year for weight (cSDS 0.9) and length (cSDS 0.8). Home BMF appeared to be safe, and parents found its use acceptable. QI methods facilitated the successful integration of BMF into routine clinical care after discharge, improving the growth trajectory of exclusively breastfed preterm infants discharged home, as well as supporting breast feeding in this vulnerable population group.

Early postnatal growth failure in preterm infants is not inevitable

BACKGROUND

Previously published data have demonstrated that preterm infants experience a fall across marked centile lines for weight in early life with early poor head growth also reported. This study describes a single neonatal unit's experience of longitudinal change in weight, head circumference (HC) and length in a cohort of preterm infants born <32 weeks' gestation.

METHODS

Data were collected from a single neonatal unit between July 2012 and June 2017. This period followed the introduction of improved nutritional guidelines. Patients were grouped according to their gestational age at birth. Growth lines were constructed for weight, HC and length in each gestational age group from the median measures and compared with reference centile lines.

RESULTS

Data were analysed from 396 patients consisting of 2808, 1991 and 2004 measures for weight, HC and length, respectively. Longitudinal growth plots did not show an initial absolute weight loss in any of the subgroups. Across all groups, the mean change in SD score between birth and 36 weeks was -0.27 (95% CI -0.39 to -0.15).

CONCLUSIONS

This description of longitudinal growth in a cohort of preterm infants demonstrates that early postnatal growth failure is not inevitable, with most infants growing along a trajectory close to their birth centile. There is no evidence of a 2 marked centile line weight decrease or weight loss. These data provide evidence to suggest that extrauterine weight gain tracking centile lines can be achieved.

Development of a core outcome set for trials on induction of labour: an international multistakeholder Delphi study

OBJECTIVE

To develop a set of core outcomes to be minimally reported in trials on induction of labour.

DESIGN

Two-round Delphi survey and consensus meeting.

POPULATION

Four stakeholder groups: midwives, obstetricians, neonatologists, and women's representatives.

METHODS

Protocol registered with COMET (Registration Number: 695). Stakeholders rated reported outcomes for importance (1-limited to 9-critical). The median rating of each outcome was calculated. The consensus criteria to include outcomes were as follows: ≥70% participants rated outcomes as critical and <15% rated outcomes as limited importance. Outcomes that did not achieve consensus were taken to round two and, if there was still no consensus, to the final consensus meeting.

MAIN OUTCOME MEASURES

Outcomes in trials of induction of labour.

RESULTS

Of the 159 invited participants, 54% (86/159) completed the first round, and 83% completed the second round (71/86). The core outcome set included 28 core outcomes in four domains: Short-term maternal outcomes (n = 18)-cardiorespiratory arrest, damage to internal organs, death, haemorrhage, hysterectomy, infection, intensive care admission, length of hospital stay, mode of delivery, need for more than one induction agent, oxytocin augmentation, postnatal depression, pulmonary embolus, satisfaction with care, stroke, time from induction to delivery, uterine hyperstimulation, uterine scar dehiscence/rupture; short-term offspring outcomes (n = 8)-admission to the neonatal unit, birth trauma, death, hypoxic ischaemic encephalopathy/need for therapeutic hypothermia, meconium aspiration syndrome, need for respiratory support, infection, and seizures; long-term maternal outcomes (n = 1)-operative pelvic floor repair; long-term offspring outcomes (n = 1)-disability including neurodevelopmental delay.

CONCLUSION

Trials on induction of labour should include this core outcome set to standardise reporting.

TWEETABLE ABSTRACT

International multistakeholder Delphi study identifies a core outcome set for trials on induction of labour.

Epidemiology, management and outcome of ultrashort bowel syndrome in infancy

Ultrashort bowel syndrome (USBS) is a group of heterogeneous disorders where the length of small bowel is less than 10 cm or 10% of expected for the age. It is caused by massive loss of the gut which in the neonatal period can be a result of vanishing gastroschisis or surgical resection following mid-gut volvulus, jejunoileal atresia and/or extensive necrotising enterocolitis. The exact prevalence of USBS is not known although there is a clear trend towards increasing numbers because of increased incidence and improved survival. Long-term parenteral nutrition (PN) is the mainstay of treatment and is best delivered by a multidisciplinary intestinal rehabilitation team. Promoting adaptation is vital to improving long-term survival and can be achieved by optimising feeds, reducing intestinal failure liver disease and catheter-related bloodstream infections. Surgical techniques that can promote enteral tolerance and hence improve outcome include establishing intestinal continuity and bowel lengthening procedures. The outcome for USBS is similar to patients with intestinal failure due to other causes and only a small proportion of children who develop irreversible complications of PN and will need intestinal transplantation. In this review, we will summarise the available evidence focusing particularly on the epidemiology, management strategies and outcome.

Chronic breathlessness associated with poorer physical and mental health-related quality of life (SF-12) across all adult age groups

Little is known about the impact of chronic breathlessness (modified Medical Research Council (mMRC) score ≥2 for most days, at least three of the last six months) on health-related quality of life (Short Form-12 (SF-12)). 3005 adults from randomly selected households were interviewed face-to-face in South Australia. mMRC ≥2 community prevalence was 2.9%. Adjusted analyses showed clinically meaningful and statistically significant decrements of physical and mental components of SF-12 (mean SF-12 summary scores in physical (-13.0 (-16.0 to -10.2)) and mental (-10.7 (-13.7 to -7.8)) components compared with people with mMRC=0) as chronic breathlessness severity increased, across five age groupings.

Implementation of the Needs Assessment Tool for patients with interstitial lung disease (NAT:ILD): facilitators and barriers

A Needs Assessment Tool (NAT) was developed previously to help clinicians identify the supportive/palliative needs of people with interstitial lung disease (ILD) (NAT:ILD). This letter presents barriers and facilitators to clinical implementation. Data from (1) a focus group of respiratory clinicians and (2) an expert consensus group (respiratory and palliative clinicians, academics, patients, carers) were analysed using Framework Analysis. Barriers related to resources and service reconfiguration, and facilitators to clinical need, structure, objectiveness, flexibility and benefits of an ‘aide-memoire’. Identified training needs included communication skills and local service knowledge. The NAT:ILD was seen as useful, necessary and practical in everyday practice.

Preferred and actual place of death in haematological malignancy

Objectives

Home is considered the preferred place of death for many, but patients with haematological malignancies (leukaemias, lymphomas and myeloma) die in hospital more often than those with other cancers and the reasons for this are not wholly understood. We examined preferred and actual place of death among people with these diseases.

Methods

The study is embedded within an established population-based cohort of patients with haematological malignancies. All patients diagnosed at two of the largest hospitals in the study area between May 2005 and April 2008 with acute myeloid leukaemia, diffuse large B-cell lymphoma or myeloma, who died before May 2010 were included. Data were obtained from medical records and routine linkage to national death records.

Results

323 deceased patients were included. A total of 142 (44%) had discussed their preferred place of death; 45.8% wanted to die at home, 28.2% in hospital, 16.9% in a hospice, 5.6% in a nursing home and 3.5% were undecided; 63.4% of these died in their preferred place. Compared to patients with evidence of a discussion, those without were twice as likely to have died within a month of diagnosis (14.8% vs 29.8%). Overall, 240 patients died in hospital; those without a discussion were significantly more likely to die in hospital than those who had (p≤0.0001). Of those dying in hospital, 90% and 75.8% received haematology clinical input in the 30 and 7 days before death, respectively, and 40.8% died in haematology areas.

Conclusions

Many patients discussed their preferred place of death, but a substantial proportion did not and hospital deaths were common in this latter group. There is scope to improve practice, particularly among those dying soon after diagnosis. We found evidence that some people opted to die in hospital; the extent to which this compares with other cancers is of interest.

Variations in specialist palliative care referrals: findings from a population-based patient cohort of acute myeloid leukaemia, diffuse large B-cell lymphoma and myeloma

Objective

To develop and implement a methodology for capturing complete haematological malignancy pathway data and use it to identify variations in specialist palliative care (SPC) referrals.

Methods

In our established UK population-based patient cohort, 323 patients were diagnosed with acute myeloid leukaemia, diffuse large B-cell lymphoma or myeloma between May 2005 and April 2008, and died before April 2010. A day-by-day calendar approach was devised to collect pathway data, including SPC referrals, to supplement routinely collected information on clinical presentation, diagnosis, treatment, response, and date and place of death.

Results

155 (47.9%) of the 323 patients had at least one SPC referral. The likelihood of referral increased with survival (OR 6.58, 95% CIs 3.32 to 13.03 for patients surviving ≥1 year compared to ≤1 month from diagnosis), and varied with diagnosis (OR 1.96, CIs 1.15 to 3.35 for myeloma compared to acute myeloid leukaemia). Compared to patients dying in hospital, those who died at home or in a hospice were also more likely to have had an SPC referral (OR 3.07, CIs 1.59 to 5.93 and 4.74, CIs 1.51 to 14.81, respectively). No associations were found for age and sex.

Conclusions

Our novel approach efficiently captured pathway data and SPC referrals, revealing evidence of greater integration between haematology and SPC services than previously reported. The likelihood of referral was much higher among those dying outside hospital, and variations in practice were observed by diagnosis, emphasising the importance of examining diseases individually.

Restoring ADL function after wrist surgery in children with cerebral palsy: a novel Bilateral robot system design

Cerebral palsy is a leading cause of disability in children and reducing its effects on arm function will improve quality of life. Our goal is to train children with CP after wrist tendon transfer surgery using a robotic therapy system consisting of two robot arms and wrist robots. The therapeutic goal is to determine if the robot training combined with surgery intervention improved functional outcomes significantly more than surgery alone. To accomplish this long-term goal we have developed a Bilateral ADL Exercise Robot, BiADLER aimed at training children with CP in reach to grasp coordination on ADLs. Specifically, the robot will provide active training using an assist-as-needed. This paper presents the design concepts.

Experimental evaluation of liquid film resistance in oxygen transport to microbial cells

A membrane probe was used to monitor the dissolved oxygen concentrations in continuous cultures of Candida utilis and Micrococcus roseus growing at low dissolved oxygen concentrations and various agitation levels. For the yeast fermentations, increasing the agitation level within the range of 0.1 to 0.3 w per liter lowered steady-state dissolved oxygen concentrations in the fermentor. The steady-state dissolved oxygen concentration in the fermentor was not influenced by the agitation level within the range of 0.3 to 1.8 w per liter. With M. roseus, no effect of agitation on steady-state dissolved oxygen concentrations in the fermentor was observed within the range of 0.1 to 1.8 w per liter. It was concluded that, under the conditions used, a measurable transfer barrier from the liquid to the yeast cells existed at agitation levels below 0.3 w per liter and that this barrier did not exist at agitation levels above 0.3 w per liter. The transfer barrier from the liquid to the yeast surface could be represented by a stagnant film of liquid 0.6 x 10 cm thick surrounding the cell at an agitation level of 0.10 w per liter. This film represented an oxygen concentration drop of 1.3 x 10 M from the bulk of the medium to the cells under the experimental conditions.

Cell yields of bacteria grown on methane

Several mixed cultures of methane-oxidizing bacteria have been isolated. Among them, culture HR (consisting of two gram-negative rods, one 0.5 x 1.0 mu, the other 0.8 x 2 to 3 mu) was found to be the fastest-growing and to give the highest yields. Optimal conditions for rapid growth and high cell yields from methane were found to be: 30 C, NH(4) as nitrogen source, and pH 6.5. Requirements for CO(2) and Cu were observed. Under these conditions, generation times of approximately 3 hr and cell yields from methane between 65 and 70% could be attained. Culture HR can utilize methane, methanol, ethyl alcohol, 1-propanol, n-butyl alcohol, and glucose, but not propane, for growth. Yeast and beef extracts are inhibitory. Carbon balances demonstrate that few if any products other than cells and CO(2) are produced from methane under the growth conditions used. Cell analyses for carbon, hydrogen, nitrogen, and amino acid content of culture HR were also made.

'They've got to learn'--a qualitative study exploring the views of patients and staff regarding medical student teaching in a hospice

UK medical school curricula incorporate training in end-of-life care as recommended by Tomorrow's Doctors. Previous research suggests that hospice staff have concerns about the burden on patients when participating in medical student teaching and may gatekeep access to patients. This qualitative study uses semistructured interviews to explore and compare the views of hospice patients and health care staff about patient involvement in medical student teaching. Fifteen patients and 14 staff members were recruited from a single UK hospice involved in teaching third year medical students. Hospice patients, who have been involved in teaching, are strongly positive about meeting medical students and staff carefully select patients based on a number of issues.

Assessing impaired arm use and learned bias after stroke using unimanual and bimanual steering tasks

Learned nonuse is often seen in stroke survivors with hemiparesis. In these cases, stroke survivors exhibit a bias for using the less impaired arm on daily living tasks despite latent functionality as measured by clinical motor function. We used the TheraDrive system, a low-cost, stroke rehabilitation system using commercial force-feedback steering wheels along with unimanual and bimanual steering tasks, to quantify the motor impairment, arm use bias and the effect of functioning levels on tracking performance. We present the methodology and tracking results that support the use of steering tasks to detect the presence of motor impairment in the contralateral side of the brain injury, the presence of learned nonuse, the relationship between level of functionality (low-to-medium versus high stroke) and these measures and the effect of handedness and side of injury after stroke.

Meningitis in diabetic patients

Community acquired bacterial (CBM) meningitis in diabetic patients was analyzed for risk factors and outcome in a cohort of 201 cases of meningitis within last 17 years: 15 patients with diabetes mellitus and meningitis were identified and compared for etiology and mortality as well as for neurologic sequellae with all CBM cases.

Meningococcal meningitis is still the commonest neuroinfection in the community in tropics: overview of 62 cases

Within last 17 years we went through all charts of bacterial meningitis within our nationwide survey and among 372 cases we found 62 cases of MM, in 12 cases with meningococcal disease (with shock, petechial effusions or disseminated intravascular coagulation or digital gangrenes). MM was usually observed in young adults without any of investigated risk factors like neoplasia, ENT (ear, nose, throat) focuses, elderly age, sepsis, diabetes, alcoholism, trauma, neonatal VLBW etc. Trauma, diabetes mellitus, alcohol abuse and chronic sinusitis/otitis were significantly less frequently found as a risk factor for MM. Mortality was very low, only 4.8% and was lower than overall mortality in CBM (12.4%, NS). Also the proportion of neurologic sequellae (9.7%) and initial treatment failure (8.1%) were comparable or even lower. This positive outcome results are probably because all N. meningitis strains were susceptible to penicillin, chloramphenicol, cefotaxim, cotrimoxazol or ciprofloxacin. Other reason for low mortality was that most cases received oral antibiotic immediately, even before admission (50 of 62). 95.2% of cases survived, 90.3% without any transient neurological residual symptoms.

Comparison of postsurgical and community acquired bacterial meningitis--analysis of 372 cases within a nationwide survey

The aim of this study was to assess if differences in etiology and risk factors among 372 cases of bacterial meningitis acquired after surgery (PM) or in community (CBM) have impact on outcome of infected patients. Among 372 cases of bacterial meningitis within last 17 years from 10 major Slovak hospitals, 171 were PM and 201 CBM. Etiology, risk factors such as underlying disease, cancer, diabetes alcoholism, surgery, VLBW, ENT infections, trauma, sepsis were recorded and mortality, survival with sequellae, therapy failure were compared in both groups. Significant differences in etiology and risk factors between both groups were reported. Those after neurosurgery had more frequently Coagulase negative staphylococci (p<0.001), Enterobacteriaceae (p=0.01) and Acinetobacter baumannii (p=0.0008) isolated from CSF and vice versa Streptococcus pneumoniae (p<0.001), Neisseria meningitis (p<0.001) and Haemophillus influenza (p=0.0009) were more commonly isolated from CSF in CBM. Neurosurgery (p<0.001), sepsis (p=0.006), VLBW neonates (p=0.00002) and cancer (p=0.0007) were more common in PM and alcohol abuse (p<0.001) as well as otitis/sinusitis (p<0.001) and Roma ethnic group (p=0.001) in CAM. Initial treatment success was significantly more frequently observed among CAM (p<0.001) but cure after modification was more common in PM (p=0.002). Therefore outcome in both groups was similar (14.6% vs. 12.4%, p=NS).

Bacterial meningitis after craniocerebral trauma in the community

Craniocerebral trauma is one of major risk factors for development of meningitis. We reviewed 30 cases of bacterial meningitis occurring in community after craniocerebral trauma. Alcohol abuse was significant risk factor occurring in trauma patients with meningitis present in 50% in our cohort (p=0.0001). The most common pathogen in posttraumatic meningitis was Str. pneumoniae (90% vs. 33.8%, p=0.0001). However mortality was very low, only 5% probably because of early diagnosis and treatment of patients at risk for bacterial meningitis but neurologic sequellea were significantly more common (p=0.00001) in patients after craniocerebral trauma.

TheraDrive: a new stroke therapy concept for home-based, computer-assisted motivating rehabilitation

Stroke results in functional arm impairments that persist even after rehabilitation training. The increasing numbers of persons at-risk in the population for stroke creates an increased need for therapy programs that can be effectively administered in both home and outpatient clinics. The aim of this work is to create a low-cost, commercially-viable, home-based rehabilitation system that can capitalize on computer-assisted motivating rehabilitation concepts of game therapy and skill training with functional training related to real activities to induce user-dependent CNS plasticity. The TheraDrive concept combines the motivational elements of relearning steering tasks with playing driving video games using commercial force-feedback steering wheels to create an upper arm stroke therapy environment that is usable at home or in the clinic. This paper presents the concept and reports on investigations to evaluate the main commercial building blocks for the prototype: the steering wheel and driving software. Evaluation results of three force-feedback steering wheels and the driving gaming software called SmartDriver are presented. Future evaluation trials with stroke subjects will be completed.

Genetic diagnosis of haemophilia and other inherited bleeding disorders

Inherited deficiencies of plasma proteins involved in blood coagulation generally lead to lifelong bleeding disorders, whose severity is inversely proportional to the degree of factor deficiency. Haemophilia A and B, inherited as X-linked recessive traits, are the most common hereditary hemorrhagic disorders caused by a deficiency or dysfunction of blood coagulation factor VIII (FVIII) and factor IX (FIX). Together with von Willebrand's disease, a defect of primary haemostasis, these X-linked disorders include 95% to 97% of all the inherited deficiencies of coagulation factors. The remaining defects, generally transmitted as autosomal recessive traits, are rare with prevalence of the presumably homozygous forms in the general population of 1:500,000 for FVII deficiency and 1 in 2 million for prothrombin (FII) and factor XIII (FXIII) deficiency. Molecular characterization, carrier detection and prenatal diagnosis remain the key steps for the prevention of the birth of children affected by coagulation disorders in developing countries, where patients with these deficiencies rarely live beyond childhood and where management is still largely inadequate. These characterizations are possible by direct or indirect genetic analysis of genes involved in these diseases, and the choice of the strategy depends on the effective available budget and facilities to achieve a large benefit. In countries with more advanced molecular facilities and higher budget resources, the most appropriate choice in general is a direct strategy for mutation detection. However, in countries with limited facilities and low budget resources, carrier detection and prenatal diagnosis are usually performed by linkage analysis with genetic markers. This article reviews the genetic diagnosis of haemophilia, genetics and inhibitor development, genetics of von Willebrand's disease and of rare bleeding disorders.

Palliative care for patients with heart failure: description of a service

Over the past 10 years, there has been an increasing demand for heart failure patients to have access to palliative care services. The concerns of this group have been highlighted and there is growing recognition in national palliative care and cardiology bodies that these concerns should be addressed. In spite of this, there is little improvement. There are concerns about the acceptability of hospice services to heart failure patients, worries about service overload, lack of appropriate knowledge and skills and difficulty in knowing when to refer a heart failure patient for palliative care. In Scarborough, a joint approach by a cardiologist and palliative care physician was set up in September 2000. This paper describes the service so far in an attempt to address some of the above reservations and to provide a catalyst and encouragement to others beginning a similar venture.

Combined sagittal and coronal plane postural stability model

We present a preliminary study of combined anterior posterior (AP) and medial lateral (ML) sway assuming a classic inverted pendulum with included subtalar movement. Based on a feedback control posture model in the sagittal plane as presented by Maurer and Peterka, we have investigated parameters needed to model ML sway components. Center of pressure (COP) data was collected from a population of 8 normal adults (age 18 to 30 years) using a dual AMTI force plate system. Fourteen different sway metrics were calculated. The collected data was successfully compared to numerous simulations of the model where model parameters were varied and the goal was to reproduce both AP and ML components.

Pancam multispectral imaging results from the Opportunity Rover at Meridiani Planum

Panoramic Camera (Pancam) images from Meridiani Planum reveal a low-albedo, generally flat, and relatively rock-free surface. Within and around impact craters and fractures, laminated outcrop rocks with higher albedo are observed. Fine-grained materials include dark sand, bright ferric iron-rich dust, angular rock clasts, and millimeter-size spheroidal granules that are eroding out of the laminated rocks. Spectra of sand, clasts, and one dark plains rock are consistent with mafic silicates such as pyroxene and olivine. Spectra of both the spherules and the laminated outcrop materials indicate the presence of crystalline ferric oxides or oxyhydroxides. Atmospheric observations show a steady decline in dust opacity during the mission. Astronomical observations captured solar transits by Phobos and Deimos and time-lapse observations of sunsets.

Pancam multispectral imaging results from the Spirit Rover at Gusev Crater

Panoramic Camera images at Gusev crater reveal a rock-strewn surface interspersed with high- to moderate-albedo fine-grained deposits occurring in part as drifts or in small circular swales or hollows. Optically thick coatings of fine-grained ferric iron-rich dust dominate most bright soil and rock surfaces. Spectra of some darker rock surfaces and rock regions exposed by brushing or grinding show near-infrared spectral signatures consistent with the presence of mafic silicates such as pyroxene or olivine. Atmospheric observations show a steady decline in dust opacity during the mission, and astronomical observations captured solar transits by the martian moons, Phobos and Deimos, as well as a view of Earth from the martian surface.

Pancam multispectral imaging results from the Spirit Rover at Gusev Crater

Panoramic Camera images at Gusev crater reveal a rock-strewn surface interspersed with high- to moderate-albedo fine-grained deposits occurring in part as drifts or in small circular swales or hollows. Optically thick coatings of fine-grained ferric iron-rich dust dominate most bright soil and rock surfaces. Spectra of some darker rock surfaces and rock regions exposed by brushing or grinding show near-infrared spectral signatures consistent with the presence of mafic silicates such as pyroxene or olivine. Atmospheric observations show a steady decline in dust opacity during the mission, and astronomical observations captured solar transits by the martian moons, Phobos and Deimos, as well as a view of Earth from the martian surface.

The relationship between insulin and insulin-like growth factor binding protein-1 is modified by pre-eclampsia

Insulin is the main negative regulator of insulin-like growth factor binding protein-1 (IGFBP-1) in the non-pregnant state. Although changes in insulin resistance and circulating level of IGFBP-1 occur in pre-eclampsia, little is known about the relationship between insulin and IGFBP-1 in pregnancies complicated by the disease. In this study, we have investigated whether the relationship between insulin and IGFBP-1 is modified by pre-eclampsia. Maternal levels of insulin and IGFBP-1 were measured, at 4-weekly intervals between 16 and 36 weeks' gestation, in plasma samples obtained from ten normal pregnant controls and ten women who developed pre-eclampsia. The controls were chosen to be similar in maternal age and booking body mass index to the pre-eclampsia group. Insulin levels increased in both the normal controls and the women who developed pre-eclampsia. The levels in pre-eclampsia were significantly greater than those in normal pregnancy at 32 and 36 weeks' gestation (p = 0.02 and 0.005, respectively). IGFBP-1 levels were unchanged in normal pregnancy and rose in pre-eclampsia. In normal pregnancy, insulin levels were inversely related to IGFBP-1 levels throughout. In women developing pre-eclampsia, the relationship between insulin and IGFBP-1 was negative at 16 weeks and positive from 24 weeks. These data suggest that whereas the inverse relationship between insulin and IGFBP-1 is maintained during normal pregnancy, this relationship is reversed in women who develop pre-eclampsia.