Mechanical load applied by Intraosseous Transcutaneous Amputation Prosthesis (ITAP) during walking on level and sloped treadmill: A case study

This proof of concept study presents a method to collect and analyse kinetic data from one participant with a transfemoral amputation fitted with a percutaneous osseointegrated implant walking on a level and sloped treadmill. We describe the construction of and results from a bespoke wireless six axis load cell built into one participant's prosthetic assembly. The load cell does not clinically compromise the participant in any way and is an initial milestone in the development of a light-weight wireless load cell for use with percutaneous osseointegrated implants. In this case, it is the first time that kinetic data from a participant fitted with an Intraosseous Transcutaneous Amputation Prosthesis has been published. We propose that the data can be used to model the load transfer to the host bone, with several clinically significant applications. The raw dynamic data are made available and quasi-static load cases for each functional phase of gait are presented. Peak forces obtained in the medio-lateral (X), cranio-caudal (Y) and antero-posterior (Z) axes over level ground respectively were -243.8 N (0.24 BW), 1321.5 N (1.31 BW) and -421.8 N (0.42 BW); uphill were -141.0 N (0.14 BW), 1604.2 N (1.59 BW), -498.1 N (0.49 BW); downhill were -206.0 N (0.20 BW), 1103.9 N (1.09 BW), -547.2 N (0.54 BW). The kinetics broadly followed able bodied gait patterns with some gait strategies consistent in participants with other implant designs or prosthetic socket connections, for example offloading the artificial limb downhill.

Pre-hospital ECPR in an Australian metropolitan setting: a single-arm feasibility assessment-The CPR, pre-hospital ECPR and early reperfusion (CHEER3) study

INTRODUCTION

Survival from refractory out of hospital cardiac arrest (OHCA) without timely return of spontaneous circulation (ROSC) utilising conventional advanced cardiac life support (ACLS) therapies is dismal. CHEER3 was a safety and feasibility study of pre-hospital deployed extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) for refractory OHCA in metropolitan Australia.

METHODS

This was a single jurisdiction, single-arm feasibility study. Physicians, with pre-existing ECMO expertise, responded to witnessed OHCA, age < 65 yrs, within 30 min driving-time, using an ECMO equipped rapid response vehicle. If pre-hospital ECPR was undertaken, patients were transported to hospital for investigations and therapies including emergent coronary catheterisation, and standard intensive care (ICU) therapy until either cardiac and neurological recovery or palliation occurred. Analyses were descriptive.

RESULTS

From February 2020 to May 2023, over 117 days, the team responded to 709 "potential cardiac arrest" emergency calls. 358 were confirmed OHCA. Time from emergency call to scene arrival was 27 min (15-37 min). 10 patients fulfilled the pre-defined inclusion criteria and all were successfully cannulated on scene. Time from emergency call to ECMO initiation was 50 min (35-62 min). Time from decision to ECMO support was 16 min (11-26 min). CPR duration was 46 min (32-62 min). All 10 patients were transferred to hospital for investigations and therapy. 4 patients (40%) survived to hospital discharge neurologically intact (CPC 1/2).

CONCLUSION

Pre-hospital ECPR was feasible, using an experienced ECMO team from a single-centre. Overall survival was promising in this highly selected group. Further prospective studies are now warranted.

Evaluating the Use of CT-Derived Lung Volumes in Donor-Recipient Lung Size Matching for Lung Transplantation in Patients With Interstitial Lung Disease and/or Idiopathic Pulmonary Fibrosis

PURPOSE

This study aims to assess the efficacy of current measurement strategies for lung sizing and the feasibility of future use of computed tomography (CT)-derived lung volumes to predict a donor-recipient lung size match during bilateral lung transplants.

METHODS

We reviewed the data of 62 patients who underwent bilateral lung transplantation for interstitial lung disease and/or idiopathic pulmonary fibrosis from 2018 to 2019. Data for recipients was retrieved from the department's transplant database and medical records, and the donor's data was retrieved from the DonorNet. The data included demographic data, lung heights, measured total lung capacity (TLC) from plethysmography for recipients and estimated TLC for donors, clinical data, and CT-derived lung volumes in both pre- and post-transplant recipients. The post-transplant CT-derived lung volume in recipients was used as a surrogate for donor lung CT volumes due to inadequate or poor donor CT data. Computed tomography-derived lung volumes were calculated using thresholding, region growing, and cutting techniques on Computer-Aided Design and Mimics (Materialise NV, Leuven, Belgium) programs. Preoperative CT-derived lung volumes in recipients were compared with the plethysmography TLC, Frustum Model, and donor-predicted TLC. The ratio of the recipient's pre-and postoperative CT-derived volumes, the ratio of preoperative CT-derived lung volume, and donor-estimated TLC were studied to detect a correlation with 1-year outcomes.

RESULTS

The recipient preoperative CT-derived volume correlated with the recipient preoperative plethysmography TLC (Pearson correlation coefficient [PCC] of 0.688) and with the recipient Frustum model volume (PCC of 0.593). The recipient postoperative CT-derived volume correlated with the recipient's postoperative plethysmography TLC (PCC of 0.651). There was no statistically significant correlation between recipients' CT-derived pre- or postoperative volume with donor-estimated TLC. The ratio of preoperative CT-derived volume to donor-estimated TLC correlated inversely with the length of ventilation (P value = .0031). The ratio of postoperative CT-derived volume to preoperative CT-derived volume correlated inversely with delayed sternal closure (P = .0039). No statistically significant correlations were found in evaluating outcomes related to lung oversizing in the recipient (defined as a postoperative to preoperative CT-derived lung volume ratio of >1.2).

CONCLUSIONS

Generating CT-derived lung volumes is a valid and convenient method for evaluating lung volumes for transplantation in patients with ILD and/or IPF. Donor-estimated TLC should be interpreted carefully. Further studies should derive donor lung volumes from CT scans for a more accurate evaluation of lung size matching.

Ear-EEG sensitivity modeling for neural sources and ocular artifacts

The ear-EEG has emerged as a promising candidate for real-world wearable brain monitoring. While experimental studies have validated several applications of ear-EEG, the source-sensor relationship for neural sources from across the brain surface has not yet been established. In addition, modeling of the ear-EEG sensitivity to sources of artifacts is still missing. Through volume conductor modeling, the sensitivity of various configurations of ear-EEG is established for a range of neural sources, in addition to ocular artifact sources for the blink, vertical saccade, and horizontal saccade eye movements. Results conclusively support the introduction of ear-EEG into conventional EEG paradigms for monitoring neural activity that originates from within the temporal lobes, while also revealing the extent to which ear-EEG can be used for sources further away from these regions. The use of ear-EEG in scenarios prone to ocular artifacts is also supported, through the demonstration of proportional scaling of artifacts and neural signals in various configurations of ear-EEG. The results from this study can be used to support both existing and prospective experimental ear-EEG studies and applications in the context of sensitivity to both neural sources and ocular artifacts.

Robust decoding of the speech envelope from EEG recordings through deep neural networks

OBJECTIVE

Smart hearing aids which can decode the focus of a user's attention could considerably improve comprehension levels in noisy environments. Methods for decoding auditory attention from electroencephalography (EEG) have attracted considerable interest for this reason. Recent studies suggest that the integration of deep neural networks (DNNs) into existing auditory attention decoding algorithms is highly beneficial, although it remains unclear whether these enhanced algorithms can perform robustly in different real-world scenarios. To this end, we sought to characterise the performance of DNNs at reconstructing the envelope of an attended speech stream from EEG recordings in different listening conditions. In addition, given the relatively sparse availability of EEG data, we investigate possibility of applying subject-independent algorithms to EEG recorded from unseen individuals.

APPROACH

Both linear models and nonlinear DNNs were employed to decode the envelope of clean speech from EEG recordings, with and without subject-specific information. The mean behaviour, as well as the variability of the reconstruction, was characterised for each model. We then trained subject-specific linear models and DNNs to reconstruct the envelope of speech in clean and noisy conditions, and investigated how well they performed in different listening scenarios. We also established that these models can be used to decode auditory attention in competing-speaker scenarios.

MAIN RESULTS

The DNNs offered a considerable advantage over their linear counterpart at reconstructing the envelope of clean speech. This advantage persisted even when subject-specific information was unavailable at the time of training. The same DNN architectures generalised to a distinct dataset, which contained EEG recorded under a variety of listening conditions. In competing-speakers and speech-in-noise conditions, the DNNs significantly outperformed the linear models. Finally, the DNNs offered a considerable improvement over the linear approach at decoding auditory attention in competing-speakers scenarios.

SIGNIFICANCE

We present the first detailed study into the extent to which DNNs can be employed for reconstructing the envelope of an attended speech stream. We conclusively demonstrate that DNNs have the ability to improve the reconstruction of the attended speech envelope. The variance of the reconstruction error is shown to be similar for both DNNs and the linear model. Overall, DNNs are demonstrated to show promise for real-world auditory attention decoding, since they perform well in multiple listening conditions and generalise to data recorded from unseen participants.

Complications and functional outcomes after ileo-anal pouch excision-a systematic review of 14 retrospective observational studies

PURPOSE

The ileo-anal pouch (IAP) has been the gold standard procedure for maintenance of bowel continuity after panproctocolectomy for ulcerative colitis, familial adenomatous polyposis or hereditary non-polyposis colorectal cancer. However, the IAP has an estimated failure rate of 13% at 10 years post-procedure (Tulchinsky et al., Ann Surg 238(2):229-34, 2003), which can result in pouch excision (P.E.). This systematic review aims to synthesise all the available studies reporting post-operative outcomes of P.E. and its impact on patient quality of life (QoL), when available, which have not previously been summarised.

METHODS

PubMed, Embase, Medline and the Cochrane library databases were searched with terms 'Pouch AND excision' OR 'Pouch AND removal' OR 'Pouch AND remove' OR 'IAP AND excision'. All studies reporting post-operative morbidity, mortality or functional outcomes in patients who had P.E. were included. Studies with < 5 patients, non-English studies and conference abstracts were excluded.

RESULTS

14 studies comprising 1601 patients were included. Overall complications varied from 18 to 63% with the most common being persistent perineal sinus (9-40%) or surgical site infection (wound-2 to 30%; intra-abdominal collection-3 to 24%). The mortality rate was between 0.58 and 1.4%. QoL is generally lower in P.E. patients compared to the normal population across various QoL measures and P.E. patients often had urinary and sexual dysfunction post-operatively.

CONCLUSIONS

There is a substantial incidence of complications after P.E.; however, there is no evidence describing QoL pre- and post-P.E. Further longitudinal research comparing QoL in patients undergoing P.E. and other treatment options such as indefinite diversion is required to definitively assess QoL post-procedure.

Hartmann's procedure versus intersphincteric abdominoperineal excision (HiP Study): a multicentre prospective cohort study

AIM

In patients with low rectal cancer it is occasionally necessary to avoid a low coloanal anastomosis due to patient frailty or poor function. In such situations there are two alternative approaches: Hartmann's procedure (HP) or intersphincteric abdominoperineal excision (IAPE). There are few data to guide surgeons as to which of these two procedures is the safest. The aim of this study was to determine the surgical complication rates associated with each procedure.

METHOD

This was a multicentre, nonrandomized prospective cohort study of patients undergoing either HP or IAPE. The primary objective was to determine surgical complication rates. Secondary objectives included length of stay, time to adjuvant therapy and quality of life at 90 days.

RESULTS

One hundred and seventy nine patients were recruited between April 2016 and June 2019; approximately two thirds of patients underwent HP and one third IAPE. The overall complication rate was high in both groups (54% for the HP group and 52% for the IAPE group). Surgery-specific complication rates were also high, but not significantly different: 43% for HP and 48% for IAPE. The pelvic abscess rate in HP was 11% and was significantly higher in patients with a palpable staple line (15% vs 2%). There was a higher incidence of serious medical complications following IAPE (16% vs 5%), along with a reduction in 90-day quality of life scores.

CONCLUSION

This is the largest prospective study to compare HP and IAPE in patients undergoing rectal cancer surgery where primary anastomosis is not deemed appropriate. With similar complication rates, these data support the ongoing use of either HP or IAPE in this patient group.

First report of Fusarium proliferatum causing necrotic leaf lesions and bulb rot on storage onion (Allium cepa) in southwestern Idaho

In September 2014, a high rate of bulb rot (5-15% depending on producer) was reported across all cultivars developing early in the storage season in the onion producing region of southwestern Idaho. Spanish yellow onion bulbs cv. Vaquero displaying tan to light brown necrotic rot were obtained. The bulb rot originated in the neck and spread to successive scales (Figure 1). In August 2015, onion cv. Redwing and Vaquero were observed to have wet necrotic lesions developing on leaves in the field (Figure 2). Margins of necrotic tissue, 1-2 cm3, were excised, surface sterilized, plated on water agar medium and incubated at 24°C. Hyphal growth was sub-cultured from eight strains (A- D in 2014; E-H in 2015) to fresh potato dextrose agar to obtain pure cultures. Cultures were characteristic of Fusarium species as described by Nelson et al. (1983) with the presence of microconidia formed on polyphialides with macroconidia present. Primers ITS4-A1 and ITS5 primers (White et al. 1990); EF-1 and EF-2 (O'Donnell et al. 1998); and fRPB2-5F and fRPB2-7cR (Liu et al. 1999) were used to amplify regions of the ITS, elongation factor 1-α and the second largest subunit of DNA-directed RNA polymerase II. Amplicons were sequenced and analyzed using BLAST (https://www.ncbi.nlm.nih.gov/) and in combination using Pairwise DNA Alignment and Polyphasic Identification (http://www.westerdijkinstitute.nl/Fusarium/DefaultInfo.aspx?Page=Home) as described by O'Donnell et al. 2015. Analysis indicated that these strains are Fusarium proliferatum, which is part of the F. fujikuroi species complex (O'Donnell et al. 1998). Similarity (99.5%) was observed in pairwise analyses and the polyphasic identification clustering to representative F. proliferatum strain NRRL 22944 and others. Sequences were submitted to Genbank and registered accession numbers are found in Table 1. To complete Koch's postulates, cv. Vaquero onion bulbs were surface sterilized and injected with 3 × 105 microconidia into the shoulder of each bulb. Five bulbs were inoculated for each isolate, placed in a mesh bag, and incubated at 30°C in the dark. Five bulbs injected with sterile water and five non-inoculated bulbs served as controls. After 14 days, each bulb was sliced vertically down the center and inspected for rot. All eight strains induced tan to light brown necrotic rot symptoms in each inoculated bulb. No symptoms were observed for the water inoculated and the non-inoculated onion bulbs. A fungus was isolated from the necrotic tissue and confirmed to be F. proliferatum as described above. Ten µl aliquots containing 1 × 105 microconidia of F. proliferatum strains (C, E-H) were applied to leaves in triplicate of 12-week-old onion plants (cv. Vaquero) wounded with a 21-gauge needle. Water controls were included. Within three days lesions, with light chlorosis, began to form and quickly spread on the leaves. A fungus was isolated and confirmed to be F. proliferatum as described above. This is the first extensive description and identification of F. proliferatum causing bulb rot in storage in Idaho (Mohan et al. 1997). In addition, this is the first report of the fungus causing leaf infection in the field. These findings confirm F. proliferatum as the causal agent of the high incidence of bulb rot observed in 2014 and 2015. This bulb rot continues to occur in southwestern Idaho and since the pathogen can cause leaf infections growers are encouraged to be vigilant for both leaf lesions during the growing season and bulb rot in storage.

Transvaginal repair of recurrent pouch-vaginal fistula

AIM

Pouch-vaginal fistula is an uncommon but unpleasant complication. The chance of successful repair with various surgical procedures is around 50% and the early promise of collagen button plugs was not followed by good long-term results. We report a series of patients who underwent transvaginal repair of pouch-vaginal fistula after failed collagen plugs accompanied by a video to show the operative technique.

METHOD

Patients were identified from a prospectively maintained database. Patient demographics, operation notes, complications and ultimate outcome were recorded.

RESULTS

Eleven patients, each of whom had previously undergone an attempt to close the fistula with a collagen button plug, underwent transvaginal repair. Nine (81%) were successful at a median follow-up of 14 (6-56) months. The remaining two patients reported symptomatic improvement.

CONCLUSION

Pouch-vaginal fistula can be successfully closed by the transvaginal technique after a failed button plug procedure.

Eosinophil peroxidase induces the expression and function of acid-sensing ion channel-3 in allergic rhinitis: in vitro evidence in cultured epithelial cells

BACKGROUND

Acid-sensing ion channels (ASIC) are a family of acid-activated ligand-gated cation channels. As tissue acidosis is a feature of inflammatory conditions, such as allergic rhinitis (AR), we investigated the expression and function of these channels in AR.

OBJECTIVES

The aim of the study was to assess expression and function of ASIC channels in the nasal mucosa of control and AR subjects.

METHODS

Immunohistochemical localization of ASIC receptors and functional responses to lactic acid application were investigated. In vitro studies on cultured epithelial cells were performed to assess underlying mechanisms of ASIC function.

RESULTS

Lactic acid at pH 7.03 induced a significant rise in nasal fluid secretion that was inhibited by pre-treatment with the ASIC inhibitor amiloride in AR subjects (n = 19). Quantitative PCR on cDNA isolated from nasal biopsies from control and AR subjects demonstrated that ASIC-1 was equally expressed in both populations, but ASIC-3 was significantly more highly expressed in AR (P < 0.02). Immunohistochemistry confirmed significantly higher ASIC-3 protein expression on nasal epithelial cells in AR patients than controls (P < 0.01). Immunoreactivity for EPO+ eosinophils in both nasal epithelium and submucosa was more prominent in AR compared with controls. A mechanism of induction of ASIC-3 expression relevant to AR was suggested by the finding that eosinophil peroxidase (EPO), acting via ERK1/2, induced the expression of ASIC-3 in epithelial cells. Furthermore, using a quantitative functional measure of epithelial cell secretory function in vitro, EPO increased the air-surface liquid depth via an ASIC-dependent chloride secretory pathway.

CONCLUSIONS

This data suggests a possible mechanism for the observed association of eosinophils and rhinorrhoea in AR and is manifested through enhanced ASIC-3 expression.

Hard choices: a qualitative study of influences on the treatment decisions made by advanced lung cancer patients

OBJECTIVE

Most patients with non-small cell lung cancer (NSCLC) present with an incurable, advanced disease, and treatment decisions may be hard. This study explored the factors that influence patients' choice of treatment during the oncologist-patient consultation.

DESIGN

Semi-structured interviews conducted within 1 month of a consultation with an oncologist.

PARTICIPANTS

Five patients newly diagnosed with incurable NSCLC and facing a treatment decision following a consultation with an oncologist.

SETTING

A regional oncology unit in the UK.

RESULTS

Some of the participants who opted for chemotherapy had made a decision before seeing the oncologist, presented with fewer symptoms, had been more active in seeking information before the consultation, and were willing to accept the risk of side effects. Participants opting for radiotherapy were not willing to accept the risk of side effects for the possibility of a small survival gain and instead focused on symptom relief.

CONCLUSION

Some participants sought information before the consultation from various formal and informal sources. This may undermine the oncologist-patient consultation as the information may be incomplete or inaccurate. Patients vary in their willingness to accept risks for small potential gains. More research is required into methods to communicate the extent of the risks of treatment. The Clinical Nurse Specialist performed a valuable role for the patients and was seen as a trusted source of information.

Effective awake thoracic epidural anesthetic for major abdominal surgery in two high-risk patients with severe pulmonary disease--a case report

Awake thoracic epidural anaesthesia as the sole anaesthetic technique was successfully employed for two high risk surgical patients with chronic obstructive pulmonary disease undergoing abdominal surgery. The procedure was tolerated well and the anaesthetic technique which has been shown to reduce intra-operative and post-operative cardiac, respiratory and gastrointestinal complications, may have significantly contributed to the prompt, complication free recovery experienced by both patients. We report two cases of awake major abdominal surgery in two high-risk surgical patients with severe pulmonary disease, performed effectively under thoracic epidural anaesthesia as a sole technique. The first case was an elective open sigmoid colectomy in a sixty one year old cancerous patient with chronic obstructive pulmonary disease [COPD] and recent thoracotomy for a wedge resection of a bronchial adenocarcinoma [pT1NoMx]. The second case was an emergency open cholecystectomy in an adult patient with end-stage COPD. Reviewing the literature, no similar cases were reported recently.

Beyond the dots in the box: Microseismicity-constrained fracture models for reservoir simulation

Monitoring induced microseismic events usually results in locations for these events and a geometrical interpretation of these “dots in the box.” In this study, we show how additional information obtained from observed microseismic events, namely the source mechanisms, were used to generate a discrete fracture network. Using the wide aperture of a surface star-like array allows inversion for both shear- and nonshear-source mechanisms. Both volumetric and shear-only source mechanism inversion was done on microseismic events from the treatment of a shale gas reservoir in the continental United States. During the same hydraulic fracture stimulation treatment, both dip-slip and reverse faulting sources were active in this reservoir. The source mechanisms revealed fracture orientations more accurately than could be inferred from microseismic event locations alone. The activity of different mechanisms is interpreted as indicating reactivation of existing fractures in the rock, as well as suggesting generation of new fractures.

A low oxygen consumption pneumatic ventilator for emergency construction during a respiratory failure pandemic

The UK influenza pandemic plan predicts up to 750 000 additional deaths with hospitals prioritising patients against inadequate resources. We investigated three prototype low‐cost, gas‐efficient, pneumatic ventilators in a test lung model at different compliance and rate settings. Mean (SD) oxygen consumption was 0.913 (0.198) and 1.119 (0.267) l.min⁻¹ at tidal volumes of 500 ml and 700 ml respectively. Values of F_Io₂ increased marginally as lung compliance reduced, reflecting the increased ventilator workload and consequent increased enrichment of breathing gas by waste oxygen from the pneumatic mechanism. We also demonstrated that a stable nitric oxide concentration could be delivered by this design following volumetric principles. It is possible to make a gas‐efficient ventilator costing less than £200 from industrial components for use where oxygen is available at 2‐4 bar, with no pressurised air or electrical requirements. Such a device could be mass‐produced for crises characterised by an overwhelming demand for mechanical ventilation and a limited oxygen supply.

Benefits of activity and virtual reality based balance exercise programmes for adults with traumatic brain injury: Perceptions of participants and their caregivers

OBJECTIVE

To explore multi-dimensional benefits of exercise participation perceived by adults with traumatic brain injury (TBI) and their caregivers.

METHODS

Adults (n=27, aged 18-66) with moderate or severe TBI 6 months or more earlier participated in focus groups following 6 weeks of an activity-based (ABE) or a virtual reality (VR) delivered balance exercise programme. Family members and care providers participated in separate focus groups. Perceptions related to programme participation as well as balance confidence and lower extremity function were extracted from focus group verbatim and quantitative scales, respectively.

OUTCOMES

Benefits in three domains, psychosocial, physical and programme, were identified from transcription and analyses of focus group verbatim. Improvements were noted in balance confidence and function in both groups. Substantially greater enthusiasm and knowledge was expressed by participants in the VR group and their caregivers.

CONCLUSIONS

Both exercise programmes offered benefits in addition to improved balance. The VR participants had greater improvements on quantitative measures and provided more comments expressing enjoyment and improved confidence. Applications in terms of community reintegration and quality of life are discussed.

Genome-wide pharmacogenetic investigation of a hepatic adverse event without clinical signs of immunopathology suggests an underlying immune pathogenesis

One of the major goals of pharmacogenetics is to elucidate mechanisms and identify patients at increased risk of adverse events (AEs). To date, however, there have been only a few successful examples of this type of approach. In this paper, we describe a retrospective case-control pharmacogenetic study of an AE of unknown mechanism, characterized by elevated levels of serum alanine aminotransferase (ALAT) during long-term treatment with the oral direct thrombin inhibitor ximelagatran. The study was based on 74 cases and 130 treated controls and included both a genome-wide tag single nucleotide polymorphism and large-scale candidate gene analysis. A strong genetic association between elevated ALAT and the MHC alleles DRB1(*)07 and DQA1(*)02 was discovered and replicated, suggesting a possible immune pathogenesis. Consistent with this hypothesis, immunological studies suggest that ximelagatran may have the ability to act as a contact sensitizer, and hence be able to stimulate an adaptive immune response.

Non-conventional uses of the Aintree Intubating Catheter in management of the difficult airway

We present 14 cases, of which three have been previously reported, in which non-conventional use was made of the Aintree Intubating Catheter (AIC). In seven cases the AIC was used via a ProSeal Laryngeal mask airway (PLMA). Two patients had anticipated difficult intubation, two unexpected difficult intubation and two required rescue of an obstructed airway prior to AIC-assisted intubation. In two cases of tracheal stenosis the AIC was used as a 'long narrow tracheal tube' during fibre-optic intubation: the AIC facilitated passage through the narrowed trachea and smooth railroading of a tracheal tube. In two cases the AIC was used in an awake patient. In three cases the AIC was used successfully despite gross laryngeal oedema. In three cases attempted AIC deployment failed: two patients had undergone radiotherapy to the mouth and PLMA placement failed; in the third, supraglottic oedema prevented visualisation of the larynx. The AIC via an LMA Classic was successful in one of these cases. In all cases where the larynx was visualised the AIC was rapidly successful without complications. In eight cases the anaesthetist had no experience of the technique outside workshops. These cases demonstrate general utility of the technique and successful use of the AIC via the PLMA, in awake patients, as an adjunct to fibre-optic intubation and in patients with an oedematous larynx. Finally, cases where the combination of the PLMA and AIC was unsuccessful demonstrate the technique, like many, is not always successful.

Outcomes of intervention programs using flatscreen virtual reality

Virtual reality (VR) has the potential to offer experiences which are engaging and rewarding. In VR, the focus is shifted from the person's efforts in producing a movement or completing a task to that of interaction with the virtual environment. We have found that participants place value and meaning on and enjoy the activities programmed. Virtual reality interventions have been shown to improve cognitive function and concentration through an individual's interaction with a pleasant activity. Importantly, the enjoyment experienced while working with VR may increase the level of participation. In addition to generating realistic situations for testing, intervention and collection of data, the provision of immediate and positive feedback through VR has been shown to increase self esteem and empowerment. We will report outcomes from several intervention and feasibility trials using a flat screen virtual reality system with survivors of traumatic brain injury, community living older adults and children with spastic cerebral palsy. Gross motor movements were elicited through various game-like VR applications without the need for head-mounted displays or other peripherals. The impact of VR exercise participation ranged from improvements in clinical measures of functional balance and mobility, time on task, as well as participant and care provider perceptions of enjoyment, independence and confidence. Although still preliminary, our data suggest that simple applications of virtual reality have significant impacts on physical and psychosocial variables. Possibilities for and benefits of home and community-based access to virtual reality based programs will be explored.

ICP34.5 deleted herpes simplex virus with enhanced oncolytic, immune stimulating, and anti-tumour properties

Herpes simplex virus type-1 (HSV1) in which the neurovirulence factor ICP34.5 is inactivated has been shown to direct tumour-specific cell lysis in several tumour models. Such viruses have also been shown to be safe in Phase I clinical trials by intra-tumoral injection in glioma and melanoma patients. Previous work has used serially passaged laboratory isolates of HSV1 which we hypothesized may be attenuated in their lytic capability in human tumour cells as compared to more recent clinical isolates. To produce ICP34.5 deleted HSV with enhanced oncolytic potential, we tested two clinical isolates. Both showed improved cell killing in all human tumour cell lines tested compared to a laboratory strain (strain 17+). ICP34.5 was then deleted from one of the clinical isolate strains (strain JS1). Enhanced tumour cell killing with ICP34.5 deleted HSV has also been reported by the deletion of ICP47 by the up-regulation of US11 which occurs following this mutation. Thus to further improve oncolytic properties, ICP47 was removed from JS1/ICP34.5-. As ICP47 also functions to block antigen processing in HSV infected cells, this mutation was also anticipated to improve the immune stimulating properties of the virus. Finally, to provide viruses with maximum oncolytic and immune stimulating properties, the gene for human or mouse GM-CSF was inserted into the JS1/34.5-/47- vector backbone. GM-CSF is a potent immune stimulator promoting the differentiation of progenitor cells into dendritic cells and has shown promise in clinical trials when delivered by a number of means. Combination of GM-CSF with oncolytic therapy may be particularly effective as the necrotic cell death accompanying virus replication should serve to effectively release tumour antigens to then induce a GM-CSF-enhanced immune response. This would, in effect, provide an in situ, patient-specific, anti-tumour vaccine. The viruses constructed were tested in vitro in human tumour cell lines and in vivo in mice demonstrating significant anti-tumour effects. These were greatly improved compared to viruses not containing each of the modifications described. In vivo, both injected and non-injected tumours showed significant shrinkage or clearance and mice were protected against re-challenge with tumour cells. The data presented indicate that JS1/ICP34.5-/ICP47-/GM-CSF acts as a powerful oncolytic agent which may be appropriate for the treatment of a number of solid tumour types in man.

A randomised comparison of a foot pump and low-molecular-weight heparin in the prevention of deep-vein thrombosis after total knee replacement

Patients who undergo total knee replacement (TKR)are at high risk of venous thromboembolism. Low-molecular-weight heparins (LMWH) are the most suitable chemical prophylactic agents but there are some uncertainties about their safety and effectiveness. The foot pump offers an alternative.

We randomised 229 patients undergoing primary, unilateral TKR to receive either the A-V Impulse foot pump or enoxaparin, a LMWH. Ascending venography was undertaken between the sixth and eighth postoperative day in 188 patients without knowledge of the randomisation category. The prevalence of venographic deep-vein thrombosis was 58% (57/99) in the foot-pump group and 54% (48/89) in the LMWH group which was not statistically significant. There were four cases of proximal thrombi and two of fatal pulmonary emboli in the foot-pump group and none in the LMWH group. There were fewer haemorrhagic complications and soft-tissue effects in the foot-pump group.

We conclude that the neither method provides superior prophylaxis.

A randomised comparison of a foot pump and low-molecular-weight heparin in the prevention of deep-vein thrombosis after total knee replacement

Patients who undergo total knee replacement (TKR) are at high risk of venous thromboembolism. Low-molecular-weight heparins (LMWH) are the most suitable chemical prophylactic agents but there are some uncertainties about their safety and effectiveness. The foot pump offers an alternative. We randomised 229 patients undergoing primary, unilateral TKR to receive either the A-V Impulse foot pump or enoxaparin, a LMWH. Ascending venography was undertaken between the sixth and eighth postoperative day in 188 patients without knowledge of the randomisation category. The prevalence of venographic deep-vein thrombosis was 58% (57/99) in the foot-pump group and 54% (48/89) in the LMWH group which was not statistically significant. There were four cases of proximal thrombi and two of fatal pulmonary emboli in the foot-pump group and none in the LMWH group. There were fewer haemorrhagic complications and soft-tissue effects in the foot-pump group. We conclude that the neither method provides superior prophylaxis.

Therapeutic embolization of the genicular arteries for recurrent hemarthrosis after total knee arthroplasty

The case of a recurrent hemarthrosis initially presenting 30 months after a total knee arthroplasty in a patient on lifelong warfarin is described. Angiography was used to aid in the diagnosis, and therapeutic selective embolization of the superior genicular arteries was performed with satisfactory clinical results.

Type I laryngeal cleft: late presentation

Laryngeal cleft anomalies are rare congenital defects of the posterior laryngotracheal wall that usually present with a history of recurrent respiratory tract infections during the early neonatal period. Presentation of type I clefts can be subtle and subsequently can result in late diagnosis or indeed failure to present. We report on the case of a type I laryngeal cleft presenting with a history of recurrent lower respiratory tract infections and severe gastro-oesophageal reflux disease, at 19 years of age. This is the oldest documented initial presentation of a congenital laryngeal cleft, and emphasizes the importance of maintaining a suspicion of the diagnosis into early adulthood. We further highlight the role of gastro-oesophageal reflux disease in the presentation of laryngeal clefts.

P1 and NR1 plasmid replication during the cell cycle of Escherichia coli

Replication patterns of the miniP1 plasmid pZC176, the miniNR1 plasmid pRR933, and the high-copy miniNR1 derivative pRR942 were examined during the Escherichia coli cell division cycle and compared to the cycle-specific replication pattern of a minichromosome and the cycle nonspecific pattern of pBR322. In E. coli cells growing with doubling times of 40 and 60 min, the miniP1 plasmid was found to replicate with a slight periodicity during the division cycle. The periodicity was not nearly as pronounced as that of the minichromosome, was not affected by the presence of a minichromosome, and was not evident in cells growing more rapidly with a doubling time of 25 min. Both miniNR1 plasmids, pRR933 and pRR942, replicated with patterns indistinguishable from that of pBR322 and clearly different from that of the minichromosome. It is concluded that both P1 and NR1 plasmids can replicate at all stages of the cell cycle but that P1 displays a slight periodicity in replication probability in the cycle of slower growing cells. This periodicity does not appear to be coupled to a specific age in the cycle, but could be associated with the achievement of a specific cell mass per plasmid. During temperature shifts of a dnaC(Ts) mutant, the miniP1 plasmid and pBR322 replicated with similar patterns that differed from that of the minichromosome, but were consistent with a brief eclipse between rounds of replication.

Creation of genome-wide protein expression libraries using random activation of gene expression

Here we report the use of random activation of gene expression (RAGE) to create genome-wide protein expression libraries. RAGE libraries containing only 5 x 10(6) individual clones were found to express every gene tested, including genes that are normally silent in the parent cell line. Furthermore, endogenous genes were activated at similar frequencies and expressed at similar levels within RAGE libraries created from multiple human cell lines, demonstrating that RAGE libraries are inherently normalized. Pools of RAGE clones were used to isolate 19,547 human gene clusters, approximately 53% of which were novel when tested against public databases of expressed sequence tag (EST) and complementary DNA (cDNA). Isolation of individual clones confirmed that the activated endogenous genes can be expressed at high levels to produce biologically active proteins. The properties of RAGE libraries and RAGE expression clones are well suited for a number of biotechnological applications including gene discovery, protein characterization, drug development, and protein manufacturing.

Cell-cycle research with synchronous cultures: an evaluation

The baby-machine system, which produces new-born Escherichia coli cells from cultures immobilized on a membrane, was developed many years ago in an attempt to attain optimal synchrony with minimal disturbance of steady-state growth. In the present article, we put forward a model to describe the behaviour of cells produced by this method, and provide quantitative evaluation of the parameters involved, at each of four different growth rates. Considering the high level of selection achievable with this technique and the natural dispersion in interdivision times, we believe that the output of the baby machine is probably close to optimal in terms of both quality and persistence of synchrony. We show that considerable information on events in the cell cycle can be obtained from populations with age distributions very much broader than those achieved with the baby machine and differing only modestly from steady state. The data presented here, together with the long and fruitful history of findings employing the baby-machine technique, suggest that minimisation of stress on cells is the single most important factor for successful cell-cycle analysis.

The radiographic quantitation of aortic valve calcification: implications for assessing bioprosthetic valve calcification in vitro

Calcification of natural aortic and bioprosthetic heart valves is a poorly understood phenomenon that results in valvular obstruction and tissue failure. We describe a non-destructive quantitative computed microtomographic (QCT) technique for determining both calcium content and local calcium distribution within explanted valves. As a reference standard, a dual-energy x-ray absorptiometry (DEXA) system with an accuracy demonstrated to be within 1% of the true calcium mass of test material was used to obtain the total calcium content of 24 human aortic valve cusps recovered at autopsy from patients aged 51-80 years. These cusps were then scanned using our unique volume QCT scanner, with multiple x-ray projections acquired by rotating the explanted tissue through a single axis of rotation. A three-dimensional cross-sectional map was reconstructed for each cusp. Voxel size was 0.003 mm3 and a calibration phantom was used to calculate calcium content. The minimum detection limit for calcium mass was 1 mg within the whole cusp. The DEXA and QCT scans were compared with respect to total calcium content, which ranged from 0 to 15 mg. An excellent correlation between the two independent techniques was demonstrated with an r2 value of 0.94 (p < 0.001). Non-destructive microtomographic CT scanning provided excellent volumetric density measurements, with quantitative 3D images permitting an assessment of any individual area of the cusp for calcium content and spatial distribution. This new approach to valve tissue analysis allows for subsequent histologic assessment.

Surface geometric analysis of anatomic structures using biquintic finite element interpolation

The surface geometry of anatomic structures can have a direct impact upon their mechanical behavior in health and disease. Thus, mechanical analysis requires the accurate quantification of three-dimensional in vivo surface geometry. We present a fully generalized surface fitting method for surface geometric analysis that uses finite element based hermite biquintic polynomial interpolation functions. The method generates a contiguous surface of C2 continuity, allowing computation of the finite strain and curvature tensors over the entire surface with respect to a single in-surface coordinate system. The Sobolev norm, which restricts element length and curvature, was utilized to stabilize the interpolating polynomial at boundaries and in regions of sparse data. A major advantage of the current method is its ability to fully quantify surface deformation from an unstructured grid of data points using a single interpolation scheme. The method was validated by computing both the principal curvature distributions for phantoms of known curvatures and the principal stretch and principal change of curvature distributions for a synthetic spherical patch warping into an ellipsoidal shape. To demonstrate the applicability to biomedical problems, the method was applied to quantify surface curvatures of an abdominal aortic aneurysm and the principal strains and change of curvatures of a deforming bioprosthetic heart valve leaflet. The method proved accurate for the computation of surface curvatures, as well as for strains and curvature change for a surface undergoing large deformations.

Effect of oxiplex* films (PEO/CMC) on adhesion formation and reformation in rabbit models and on peritoneal infection in a rat model

OBJECTIVE

To assess the efficacy of Oxiplex (FzioMed, Inc., San Luis Obispo, CA) barriers.

DESIGN

Film of polyethylene oxide and carboxymethylcellulose (Oxiplex) were tested for strength and tissue adherence. Films were selected for evaluation in models for biocompatability and adherence. Three films were selected for evaluation in efficacy studies, and one was evaluated for effects on bacterial peritonitis. Handling characteristics of Oxiplex film were evaluated via laparoscopy.

SETTING

University laboratory.

PATIENT(S)

Rabbits, rats, pigs.

INTERVENTION(S)

Placement of Oxiplex prototypes at the site of injury.

MAIN OUTCOME MEASURE(S)

Mechanical properties, biocompatibility, tissue adherence, adhesion development, infection potentiation, and device handling.

RESULT(S)

Mechanical tests indicated that tensile strength and elongation were inversely correlated. All films tested had excellent tissue adherence properties. Selected films, based on residence time and biocompatibility, prevented adhesion formation in all animals and were highly efficacious in preventing adhesion reformation. The optimal Oxiplex prototype prevented adhesion reformation in 91% of the animals. This Oxiplex film, dyed to allow visualization, prevented adhesion reformation and did not affect bacterial peritonitis. In a laparoscopic model, the Oxiplex film, delivered in FilmSert forceps, via a 5.0-mm trocar, rapidly unfurled and could be easily applied to tissue with strong adherence.

CONCLUSION(S)

These data show development of an adhesion prevention material that is tissue adherent, can be placed via laparoscopy, and does not affect host resistance.

Anti-Kaposi's sarcoma and antiangiogenic activities of sulfated dextrins

Delivery of the sulfated polysaccharide dextrin 2-sulfate by the intraperitoneal route to the lymphatic circulation resulted in a clinically significant improvement in Kaposi's sarcoma in three patients. Our in vitro studies show that although sulfated dextrins do not interfere with the growth of isolated human umbilical vein endothelial cells, they do inhibit the morphological differentiation of endothelial cells into tubes as well as reduce new vessel formation in a placental angiogenesis assay. The antiangiogenic effect of dextrin 6-sulfate is greater than that of dextrin 2-sulfate and is independent of their anti-human immunodeficiency virus type 1 activities.

Assessment of maintenance therapy with reduced doses of PTH(1-34) in combination with a raloxifene analogue (LY117018) following anabolic therapy in the ovariectomized rat

This experiment was designed to evaluate the ability of a raloxifene analogue (RA), LY117018, with or without reduced dosing of human parathyroid hormone (hPTH)(1-34) to maintain gains in bone mass after a fully anabolic treatment regimen given to aging osteopenic rats. Six-month-old rats were ovariectomized (ovx) or sham-operated (sham). After 1 month, ovx rats were treated with an anabolic regimen consisting of subcutaneous hPTH(1-34) 80 microg/kg/day and oral raloxifene 3 mg/kg/day, each given 5 days/week for 3 months. Thereafter, the treated ovx rats went on to an 8 week maintenance phase of treatment with either RA alone at the same dose, hPTH(1-34) at a reduced dosing interval (twice a week), or a combination of the two. Bone mineral density (BMD) was measured ex vivo at four skeletal sites, lumbar spine (L2-4), proximal hemipelvis, whole femur, and tibia, by dual-energy X-ray densitometry. All four sites showed a similar pattern of response. After the 3 month anabolic phase, the sham group had significantly higher BMD values than ovx rats at all skeletal sites (p < or = 0.002). The ovx rats treated with PTH + RA during the anabolic phase of the protocol had significantly higher BMD than the sham group in the femur, tibia, and spine (p < or = 0.02) and higher but not significantly different values in the pelvis. Following the 2 month maintenance phase, comparisons were made with the PTH-RA group at the end of the anabolic phase. Decrements in BMD were seen in all three maintenance therapy groups, but they were not statistically significant in the RA plus reduced PTH dose group. However, reduced hPTH(1-34) dosing and RA alone resulted in significant reductions of bone mass measurements at several skeletal sites during the maintenance phase. We conclude that the raloxifene analogue LY117018 may be useful in maintaining bone mass in aging ovx rats following anabolic therapy with hPTH(1-34) and raloxifene analogue, but that this strategy only allows for dose reduction of hPTH(1-34) rather than its discontinuation.

The addition of a raloxifene analog (LY117018) allows for reduced PTH(1-34) dosing during reversal of osteopenia in ovariectomized rats

To test the hypothesis that an antiresorptive agent might reduce the dosing requirement for an anabolic drug during reversal of osteopenia due to estrogen deficiency, the following experiment was conducted in 6-month-old female rats. Ovariectomy or sham surgery was performed and the following six experimental groups were studied. Untreated (SHAM) or ovariectomized (OVX) animals served as control groups. Four weeks post-OVX, osteopenic rats (now 7 months old), were treated in one of four experimental protocols: human parathyroid hormone (hPTH(1-34)), 80 microg/kg/day, given by subcutaneous injection 5 days/week; a selective estrogen receptor modulator (SERM), raloxifene analog LY117018 (RA), 3 mg/kg/day, given by gavage 5 days/week; and two combinations of LY117018 at the same dose and frequency with hPTH(1-34) (same dose, 5 times/week) and a reduced dosing interval of hPTH(1-34) (same dose, 2 times/week). After 12 weeks of treatment, the four experimental groups were sacrificed at age 10 months. SHAM and OVX controls were also studied at 7 and 10 months of age. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at four skeletal sites: two mixed cortical/trabecular sites (femur and tibia) and two predominantly trabecular sites (lumbar spine and pelvis). The differences in BMD were consistent at all four sites. RA alone maintained BMD at all skeletal sites, but the results were not significantly improved over OVX controls, at age 10 months. hPTH(1-34) injections given 5 days/week resulted in BMD increments significantly higher than in either OVX or SHAM controls (p < 0.001). While the RA did not enhance the anabolic effects of full doses of hPTH(1-34), the addition of RA treatment to twice-weekly hPTH(1-34) dosing resulted in BMD increments at all four skeletal sites that were similar to the more intensive anabolic regimen of hPTH(1-34) therapy given 5 times/week. Therefore, an antiresorptive agent such as SERMs may potentially reduce the pharmacologic doses of PTH needed to reverse estrogen deficiency-induced osteopenia.

Nasotemporal directional bias of V1 neurons in young infant monkeys

PURPOSE

Optokinetic nystagmus (OKN) in young infants typically shows a temporal-to-nasal asymmetry under monocular viewing conditions. The neural basis for this asymmetry has been a matter of debate. One idea is that the OKN asymmetry reflects a similar asymmetry in the directional sensitivity of primary visual cortical (V1) neurons. An alternative hypothesis is that the OKN asymmetry is due to an immaturity in the ability of cortical neurons to influence the activity of subcortical structures that directly control OKN. We addressed this issue by studying the directional sensitivity of V1 neurons in young infant monkeys.

METHODS

The neuronal activity of V1 units was recorded from anesthetized and paralyzed rhesus monkeys ranging in age from 6 days to 8 weeks using standard extracellular single-unit recording methods. For comparison, V1 units from normal adult monkeys were also studied. Using drifting sinusoidal gratings of the optimal spatial frequency and a moderate contrast, we measured the responsiveness of individual units to 24 directions of stimulus movement. The preferred stimulus direction and the magnitude of the directional response bias were determined by a vector summation method.

RESULTS

No clear signs of nasotemporal asymmetries in direction tuning were found in our cell population from infant monkeys. However, the overall directional sensitivity and the peak monocular response amplitudes of these units were significantly lower, and binocular suppression was greater during the first 4 weeks of life than in adults.

CONCLUSIONS

The OKN asymmetry in young infants may be more closely associated with the lower overall directional sensitivity and the subnormal responsiveness of V1 neurons rather than with an obvious asymmetry in the directional properties of V1 neurons.