Further evidence of misclassification of the injury deaths in South Africa: When will the barriers to accurate injury death statistics be removed?

BACKGROUND

Contrary to the World Health Organization's internationally recommended medical certificate of cause of death, the South African (SA) death notification form (DNF) does not allow for the reporting of the manner of death to permit accurate coding of external causes of injury deaths.

OBJECTIVES

To describe the injury cause-of-death profile from forensic pathology records collected for the National Cause-of-Death Validation (NCoDV) Project and compare it with profiles from other sources of injury mortality data. In particular, the recording of firearm use in homicides is compared between sources.

METHODS

The NCoDV Project was a cross-sectional study of deaths that occurred during a fixed period in 2017 and 2018, from a nationally representative sample of 27 health subdistricts in SA. Trained fieldworkers scanned forensic records for all deaths investigated at the forensic mortuaries serving the sampled subdistricts during the study period. Forensic practitioners reviewed the records and completed a medical certificate of cause of death for each decedent. Causes of death were coded to the International Statistical Classification of Diseases, 10th revision (ICD-10), using Iris automated coding software. Cause-specific mortality fractions for injury deaths were compared with Injury Mortality Survey 2017 (IMS 2017) and Statistics South Africa 2017 (Stats SA 2017) datasets. The cause profile for all firearm-related deaths was compared between the three datasets.

RESULTS

A total of 5 315 records were available for analysis. Males accounted for 77.6% of cases, and most decedents were aged between 25 and 44 years. Homicide was the leading cause of death (34.7%), followed by transport injuries (32.6%) and suicide (14.7%). This injury cause profile was similar to IMS 2017 but differed markedly from the official statistics, which showed markedly lower proportions of these three causes (15.0%, 11.6% and 0.7%, respectively), and a much higher proportion of other unintentional causes. Investigation of firearm-related deaths revealed that most were homicides in NCoDV 2017/18 (88.5%) and IMS 2017 (93.1%), while in the Stats SA 2017 data, 98.7% of firearm deaths were classified as accidental. Approximately 7% of firearm-related deaths were suicides in NCoDV 2017/18 and IMS 2017, with only 0.3% in Stats SA 2017.

CONCLUSION

The official cause-of-death data for injuries in SA in 2017 differed substantially from findings from the NCoDV 2017/18 study and IMS 2017. Accurate data sources would ensure that public health interventions are designed to reduce the high injury burden. Inclusion of the manner of death on the DNF, as is recommended internationally, is critically important to enable more accurate, reliable and valid reporting of the injury profile.

Predicting complicated appendicitis based on clinical findings: the role of Alvarado and Appendicitis Inflammatory Response scores

PURPOSE

The pre-interventional differentiation between complicated and uncomplicated appendicitis is decisive for treatment. In the context of conservative therapy, the definitive diagnosis of uncomplicated appendicitis is mandatory. This study investigates the ability of clinical scoring systems and imaging to differentiate between the two entities.

METHODS

This is a retrospective analysis of two cohorts from two tertiary referral centers in Switzerland and Germany. All consecutive patients underwent appendectomy between January 2008 and April 2013 (in the first cohort) or between January 2017 and June 2019 (the second cohort). Exclusion criteria did not apply as all patients found by the database search and received an appendectomy were included. Diagnostic testing and calculation of a receiver operating curve were performed to identify a cutoff for clinical scores that resulted in a minimum sensitivity of 90% to detect complicated appendicitis. The cutoff was combined with additional diagnostic imaging criteria to see if diagnostic properties could be improved.

RESULTS

Nine hundred fifty-six patients were included in the analysis. Two hundred twenty patients (23%) had complicated appendicitis, and 736 patients (77%) had uncomplicated appendicitis or no inflammation. The complicated appendicitis cohort had a mean Alvarado score of 7.03 and a mean AIR of 5.21. This compared to a mean Alvarado of 6.53 and a mean AIR of 4.07 for the uncomplicated appendicitis cohort. The highest Alvarado score with a sensitivity of > 90% to detect complicated appendicitis was ≧ 5 (sensitivity = 95%, specificity 8.99%). The highest AIR score with a sensitivity of > 90% to detect complicated appendicitis was ≧ 3 (sensitivity 91.82%, specificity 18.53). The analysis showed that additional CT information did not improve the sensitivity of the proposed cut-offs.

CONCLUSION

AIR and Alvarado scores showed limited capability to distinguish between complicated and uncomplicated appendicitis even with additional imaging in this retrospective cohort. As conservative management of appendicitis needs to exclude patients with complicated disease reliably, appendectomy seems until now to remain the safest option to prevent undertreatment of this mostly benign disease.

Important marine areas for the conservation of northern rockhopper penguins within the Tristan da Cunha Exclusive Economic Zone

The designation of Marine Protected Areas has become an important approach to conserving marine ecosystems that relies on robust information on the spatial distribution of biodiversity. We used GPS tracking data to identify marine Important Bird and Biodiversity Areas (IBAs) for the Endangered northern rockhopper penguin Eudyptes moseleyi within the Exclusive Economic Zone (EEZ) of Tristan da Cunha in the South Atlantic. Penguins were tracked throughout their breeding season from 3 of the 4 main islands in the Tristan da Cunha group. Foraging trips remained largely within the EEZ, with the exception of those from Gough Island during the incubation stage. We found substantial variability in trip duration and foraging range among breeding stages and islands, consistent use of areas among years and spatial segregation of the areas used by neighbouring islands. For colonies with no or insufficient tracking data, we defined marine IBAs based on the mean maximum foraging range and merged the areas identified to propose IBAs around the Tristan da Cunha archipelago and Gough Island. The 2 proposed marine IBAs encompass 2% of Tristan da Cunha’s EEZ, and are used by all northern rockhopper penguins breeding in the Tristan da Cunha group, representing ~90% of the global population. Currently, one of the main threats to northern rockhopper penguins within the Tristan da Cunha EEZ is marine pollution from shipping, and the risk of this would be reduced by declaring waters within 50 nautical miles of the coast as ‘areas to be avoided’.

Prevalence and management of drug-drug interactions with antiretroviral treatment in 2069 people living with HIV in rural Tanzania: a prospective cohort study

OBJECTIVES

Widespread access to antiretroviral therapy (ART) has substantially increased life expectancy in sub-Saharan African countries. As a result, the rates of comorbidities and use of co-medications among people living with HIV are increasing, necessitating a sound understanding of drug-drug interactions (DDIs). We aimed to assess the prevalence and management of DDIs with ART in a rural Tanzanian setting.

METHODS

We included consenting HIV-positive adults initiating ART in the Kilombero and Ulanga Antiretroviral Cohort (KIULARCO) between January 2013 and December 2016. DDIs were classified using www.hiv-druginteractions.org as red (contra-indicated), amber (potential clinical relevance requiring dosage adjustment/monitoring), yellow (weak clinical significance unlikely to require further management) or green (no interaction). We assessed management of amber DDIs by evaluating monitoring of laboratory or clinical parameters, or changes in drug dosages.

RESULTS

Of 2069 participants, 1945 (94%) were prescribed at least one co-medication during a median follow-up of 1.8 years. Of these, 645 (33%) had at least one potentially clinically relevant DDI, with the highest grade being red in nine (< 1%) and amber in 636 (33%) participants. Of the 23 283 prescriptions, 19 (< 1%) and 1745 (7%) were classified as red and amber DDIs, respectively. Overall, 351 (2%) prescriptions were red DDIs or not appropriately managed amber DDIs.

CONCLUSIONS

Co-medication use was common in this rural sub-Saharan cohort. A third of participants had DDIs requiring further management. Of the 9% of participants with not appropriately managed DDIs, most were with cardiovascular and analgesic drugs. This highlights the importance of physicians' awareness of DDIs for their recognition and management.

Marine plastics threaten giant Atlantic Marine Protected Areas

There has been a recent shift in global perception of plastics in the environment, resulting in a call for greater action. Science and the popular media have highlighted plastic as an increasing stressor [1,2]. Efforts have been made to confer protected status to some remote locations, forming some of the world's largest Marine Protected Areas, including several UK overseas territories. We assessed plastic at these remote Atlantic Marine Protected Areas, surveying the shore, sea surface, water column and seabed, and found drastic changes from 2013-2018. Working from the RRS James Clark Ross at Ascension, St. Helena, Tristan da Cunha, Gough and the Falkland Islands (Figure 1A), we showed that marine debris on beaches has increased more than 10 fold in the past decade. Sea surface plastics have also increased, with in-water plastics occurring at densities of 0.1 items m^-3; plastics on seabeds were observed at ≤ 0.01 items m^-2. For the first time, beach densities of plastics at remote South Atlantic sites approached those at industrialised North Atlantic sites. This increase even occurs hundreds of meters down on seamounts. We also investigated plastic incidence in 2,243 animals (comprising 26 species) across remote South Atlantic oceanic food webs, ranging from plankton to seabirds. We found that plastics had been ingested by primary consumers (zooplankton) to top predators (seabirds) at high rates. These findings suggest that MPA status will not mitigate the threat of plastic proliferation to this rich, unique and threatened biodiversity.

Health care provider communication training in rural Tanzania empowers HIV-infected patients on antiretroviral therapy to discuss adherence problems

Objectives

Self‐reported adherence assessment in HIV‐infected patients on antiretroviral therapy (ART) is challenging and may overestimate adherence. The aim of this study was to improve the ability of health care providers to elicit patients’ reports of nonadherence using a “patient‐centred” approach in a rural sub‐Saharan African setting.

Methods

A prospective interventional cohort study of HIV‐infected patients on ART for ≥ 6 months attending an HIV clinic in rural Tanzania was carried out. The intervention consisted of a 2‐day workshop for health care providers on patient‐centred communication and the provision of an adherence assessment checklist for use in the consultations. Patients’ self‐reports of nonadherence (≥ 1 missed ART dose/4 weeks), subtherapeutic plasma ART concentrations (< 2.5th percentile of published population‐based pharmacokinetic models), and virological and immunological failure according to the World Health Organization definition were assessed before and after (1–3 and 6–9 months after) the intervention.

Results

Before the intervention, only 3.3% of 299 patients included in the study reported nonadherence. Subtherapeutic plasma ART drug concentrations and virological and immunological failure were recorded in 6.5%, 7.7% and 14.5% of the patients, respectively. Two months after the intervention, health care providers detected significantly more patients reporting nonadherence compared with baseline (10.7 vs. 3.3%, respectively; P < 0.001), decreasing to 5.7% after 6–9 months. A time trend towards higher drug concentrations was observed for efavirenz but not for other drugs. The virological failure rate remained unchanged whereas the immunological failure rate decreased from 14.4 to 8.7% at the last visit (P = 0.002).

Conclusions

Patient‐centred communication can successfully be implemented with a simple intervention in rural Africa. It increases the likelihood of HIV‐infected patients reporting problems with adherence to ART; however, sustainability remains a challenge.

Endohedral Metallofullerenes: Isolation and Characterization

Since the initial discovery of fullerenes nearly a decade ago [1], material scientists have focused attention on the possibility of encapsulating one or more metal atoms inside these spheroidal carbon frames. The experimental realization of macroscopic quantities of endohedral metallofullerenes (Am@C2n, n=30-55) in the early 1990's has heightened interest in developing this new class of tunable materials with possible electronic and/or optical applications [2,3]. They have been characterized by a number of spectroscopic techniques, for example, scanning tunneling microscope [4,5], EXAFS [6,7] and x-ray diffraction and electron microscopy [8]. However, low production yields and purification difficulties have hampered the development of this new class of materials. The soluble product distribution usually consists of high levels of the empty-caged fullerenes C60, C70, C84 and decreasing levels of the higher fullerenes, while the endohedral metallofullerene fraction usually constitutes less than 1% of the total soluble yield. Furthermore, the endohedral metallofullerene fraction consists of molecules with different numbers of metal atoms encapsulated (m=1-3), cage sizes (C2n) and isomers of the same mass (e.g., Er2@C82). The purification process is further complicated by the chemical reactivity of several endohedral metallofullerenes [9] in aerobic environments. For several years, we have been involved in a collaborative effort to develop methodology for detection, isolation, and characterization of endohedral metallofullerenes. The focus of the present study is on fullerenes encapsulating metals from Group II1b, (Sc@C2n, Y@C2n, and La@C2n) and the lanthanide series metal (Er@C2n).

[Studies enhance evidence and knowledge]

Die Autorinnen der RICH-Nursing-Studie erläutern, wie sich die Studie heute positioniert und geben einen Ausblick über die zukünftige Weiterentwicklung.

Prevalence of risk factors for cardiovascular disease in HIV-infected patients over time: the Swiss HIV Cohort Study

OBJECTIVE

Metabolic changes caused by antiretroviral therapy (ART) may increase the risk of coronary heart disease (CHD). We evaluated changes in the prevalence of cardiovascular risk factors (CVRFs) and 10-year risk of CHD in a large cohort of HIV-infected individuals.

METHODS

All individuals from the Swiss HIV Cohort Study (SHCS) who completed at least one CVRF questionnaire and for whom laboratory data were available for the period February 2000 to February 2006 were included in the analysis. The presence of a risk factor was determined using cut-offs based on the guidelines of the National Cholesterol Education Program (NCEP ATP III), the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7), the American Diabetes Association, and the Swiss Society for Cardiology.

RESULTS

Overall, 8,033 individuals completed at least one CVRF questionnaire. The most common CVRFs in the first completed questionnaire were smoking (57.0%), low high-density lipoprotein (HDL) cholesterol (37.2%), high triglycerides (35.7%), and high blood pressure (26.1%). In total, 2.7 and 13.8% of patients were categorized as being at high (>20%) and moderate (10-20%) 10-year risk for CHD, respectively. Over 6 years the percentage of smokers decreased from 61.4 to 47.6% and the percentage of individuals with total cholesterol >6.2 mmol/L decreased from 21.1 to 12.3%. The prevalence of CVRFs and CHD risk was higher in patients currently on ART than in either pretreated or ART-naive patients.

CONCLUSION

During the 6-year observation period, the prevalence of CVRFs remains high in the SHCS. Time trends indicate a decrease in the percentage of smokers and individuals with high cholesterol.

Study of the elution mechanism of sodium aryl sulfonates on bare silica and a cyano bonded phase with methanol-modified carbon dioxide containing an ionic additive

The elution mechanism of sodium sulfonates on both Deltabond cyanopropyl and bare silica stationary phases with an isocratic mobile phase composed of methanol-modified CO2 wherein an ammonium salt additive was dissolved in the methanol has been studied. The presence of the additive was crucial concerning elution of the sulfonate salts. Solid state 29silicon nuclear magnetic resonance spectroscopy provided some insight concerning the interaction of the mobile phase additive with the silica-based stationary phase. Computational calculations concerning the charge distribution on various ammonium salts were performed in an effort to explain the elution behavior. Ammonium ions are believed to deactivate available silanol sites on both phases. In addition, ammonium ion is speculated to interact with the cyano groups on the bonded phase. For concentrations of additive greater than 2 mM, stationary phase coverage of ammonium ion is anticipated to exceed one monolayer for both bare and bonded silica. The acetate counter-ion is thought to facilitate elution of the anionic sulfonates from the positively charged stationary phase in a pseudo ion exchange mechanism.

Combination cisplatin, 5-fluorouracil and radiation therapy for locally advanced unresectable or medically unfit bladder cancer cases: a Southwest Oncology Group Study

PURPOSE

Patients with locally advanced bladder cancer or who are not medically fit for surgery are a therapeutic dilemma. Radiotherapy with or without single agent cisplatin has been the major therapeutic modality. A phase II Southwest Oncology Group trial investigated the efficacy and feasibility of 5-fluorouracil, cisplatin and radiation in this patient subset.

MATERIALS AND METHODS

Eligible patients had muscle invasive bladder cancer (clinical stages T2-T4) with nodal involvement at or below the level of bifurcation of the iliac vessels, were medically or surgically inoperable, or refused cystectomy. Patients underwent pretreatment cystoscopy and detailed tumor mapping, and were treated with 75 mg. /m.2 cisplatin on day 1 and 1 gm./m.2 daily, 5-fluorouracil on days 1 to 4 and definitive radiotherapy. Chemotherapy was repeated every 28 days, twice during and twice after radiation.

RESULTS

From October 1993 to April 1998, 60 patients were enrolled in study. Of the 56 eligible patients 34% had unresectable tumors, 21% were not medically fit for surgery and 45% refused cystectomy. Overall, 68% of the patients had clinical T3 tumors or greater and 22% had nodal metastasis. Treatment was completed as planned in 32 of 56 (57%) patients. The most frequent grade 3 or 4 toxicities were neutropenia, stomatitis or mucositis, diarrhea, neuropathy and nausea. There were 53 patients who were evaluable for response, although response was not determined for 18. The overall response rate was 51% (95% confidence interval [CI] 37 to 65) based on intent to treat with a complete response rate of 49% (95% CI 35 to 63). Estimated median survival of the 56 patients was 27 months (95% CI 21 to 40 months) with an overall 5-year survival of 32%. The 5-year survival of the 25 patients who refused surgery was 45%.

CONCLUSIONS

Concurrent 5-fluorouracil, cisplatin and radiation therapy is feasible. Despite a promising complete response rate, the overall 5-year survival suggests the need for more effective systemic therapy. The 5-year survival of patients who refused cystectomy suggests that this combined modality may provide another alternative to cystectomy for these patients.

From social integration to health: Durkheim in the new millennium

It is widely recognized that social relationships and affiliation have powerful effects on physical and mental health. When investigators write about the impact of social relationships on health, many terms are used loosely and interchangeably including social networks, social ties and social integration. The aim of this paper is to clarify these terms using a single framework. We discuss: (1) theoretical orientations from diverse disciplines which we believe are fundamental to advancing research in this area; (2) a set of definitions accompanied by major assessment tools; and (3) an overarching model which integrates multilevel phenomena. Theoretical orientations that we draw upon were developed by Durkheim whose work on social integration and suicide are seminal and John Bowlby, a psychiatrist who developed attachment theory in relation to child development and contemporary social network theorists. We present a conceptual model of how social networks impact health. We envision a cascading causal process beginning with the macro-social to psychobiological processes that are dynamically linked together to form the processes by which social integration effects health. We start by embedding social networks in a larger social and cultural context in which upstream forces are seen to condition network structure. Serious consideration of the larger macro-social context in which networks form and are sustained has been lacking in all but a small number of studies and is almost completely absent in studies of social network influences on health. We then move downstream to understand the influences network structure and function have on social and interpersonal behavior. We argue that networks operate at the behavioral level through four primary pathways: (1) provision of social support; (2) social influence; (3) on social engagement and attachment; and (4) access to resources and material goods.

Extracellular matrix effects on a neuroblastoma cell line

Cells of various lines assume similar shapes when grown attached to substrates like coverslips. In contrast, cells cultured in a collagen and/or laminin matrix often assume a relatively normal morphology in comparison with their in situ counterparts. During investigations of neuroblastoma SH-SY5Y cells, an attempt was made to identify culture conditions which would cause the cells to assume a more regular shape. SH-SY5Y cells cultured on bare coverslips, on coverslips coated with rat-tail collagen, and in approximately 1 mm thick gels containing extracellular matrix components were compared. Striking differences were apparent when comparing the gel-cultured cells with cells cultured on coverslips. Cells grown in the gel formed ganglia-like clusters which generated bundles of neurites which targeted other 'ganglia'. The same cells grown on coverslips, whether or not they were collagen-coated, appeared unaware of the presence of other cells, and did not cluster, nor did they generate neurites.

Detection of 2,4-dichlorophenoxyacetic acid using a fluorescence immunoanalyzer

A flow immunoassay method for the measurement of 2,4-dichlorophenoxyacetic acid (2,4-D) was developed. The competitive fluorescence immunoassay relies on the use of antibody- or antigen-coated poly(methyl methacrylate) particles (98 microns diameter) as a renewable solid phase. The assay exhibits a dynamic range of 0.1-100 micrograms l-1 using a monoclonal antibody or alternatively 10 micrograms l-1 to 10 mg l-1 using commercially available antiserum. The assay is demonstrated in buffered saline solution as well as in aquatic environmental media. The relative errors for the environmental matrices were similar to those for the buffer control. The precision of concentration values calculated at 1 mg l-1 (for the assay using antiserum) were +/- 0.28, +/- 0.27 and +/- 0.43 mg l-1 for the buffer, well water and river water matrices, respectively. The method shows cross-reactivity with compounds of closely related structure but little cross-reactivity with compounds dissimilar in structure to 2,4-D. The proposed automated competitive immunoassay method is rapid (between 7 and 15 min per assay), simple and potentially portable.

A PET study of the neural systems of stuttering

The cause of stuttering is unknown. Failure to develop left-hemispheric dominance for speech is a long-standing theory although others implicated the motor system more broadly, often postulating hyperactivity of the right (language nondominant) cerebral hemisphere. As knowledge of motor circuitry has advanced, theories of stuttering have become more anatomically specific, postulating hyperactivity of premotor cortex, either directly or through connectivity with the thalamus and basal ganglia. Alternative theories target the auditory and speech production systems. By contrasting stuttering with fluent speech using positron emission tomography combined with chorus reading to induce fluency, we found support for each of these hypotheses. Stuttering induced widespread overactivations of the motor system in both cerebrum and cerebellum, with right cerebral dominance. Stuttered reading lacked left-lateralized activations of the auditory system, which are thought to support the self-monitoring of speech, and selectively deactivated a frontal-temporal system implicated in speech production. Induced fluency decreased or eliminated the overactivity in most motor areas, and largely reversed the auditory-system underactivations and the deactivation of the speech production system. Thus stuttering is a disorder affecting the multiple neural systems used for speaking.

Use of implicit motor imagery for visual shape discrimination as revealed by PET

Positron emission tomography (PET) can be used to map brain regions that are active when a visual object (for example, a hand) is discriminated from its mirror form. Chronometric studies suggest that viewers 'solve' this visual shape task by mentally modelling it as a reaching task, implicitly moving their left hand into the orientation of any left-hand stimulus (and conversely for a right-hand stimulus). Here we describe an experiment in which visual and somatic processing are dissociated by presenting right hands to the left visual field and vice versa. Frontal (motor), parietal (somatosensory) and cerebellar (sensorimotor) regions similar to those activated by actual and imagined movement are strongly activated, whereas primary somatosensory and motor cortices are not. We conclude that mental imagery is realized at intermediate-to-high order, modality-specific cortical systems, but does not require primary cortex and is not constrained to the perceptual systems of the presented stimuli.

Use of Tc-99m MAA in determining the etiology of increasing cyanosis following SVC-PA anastomosis for the hypoplastic left heart syndrome

The hypoplastic left heart syndrome, which characteristically presents in the first few hours of life with cardiovascular collapse, is treated by reconstructive surgery (Norwood's procedure) beginning in the neonatal period. If untreated, more than 95% of infants with this malformation die within the first month of life. The case described involves the development of increasing cyanosis 7 weeks following bilateral superior vena caval-pulmonary artery (SVC-PA) anastomosis in an infant born with a hypoplastic left heart (including aortic and mitral valve stenosis) and an anatomic variant of bilateral superior vena cavae. The use of Tc-99m MAA proved efficacious in quantitating the differential perfusion to each lung, establishing the site of a postoperative stenosis in an anastomotic channel, and documenting systemic perfusion, thus confirming the right-to-left shunt from the superior vena cava to the systemic circulation that resulted in increasing cyanosis.

Multiple foci of increased accumulation of Ga-67 citrate in a horseshoe kidney. Differentiation of infection from nephroblastomatosis

In the proper clinical setting, Ga-67 citrate appears to be a highly valuable radionuclide which may be used to differentiate an infectious process in the kidney from nephroblastomatosis. The authors present the case of a 7-year-old boy with multiple well-circumscribed foci of intense Ga-67 citrate accumulation in a horseshoe kidney. After a 2-week course of antibiotic therapy, the kidney showed significant improvement.

A "hole in a rib" as a sign of child abuse

Cyst-like radiolucencies ("holes") in ribs can be a manifestation of many different abnormalities. Two cases of child-abuse are presented in which the initial clue leading to the diagnosis of a battered-child was a cyst-like lytic lesion in the posterior rib cage.

Effect of numerical aperture on signal level in cylindrical waveguide evanescent fluorosensors

The effect of numerical aperture on signal level from fluorescent substances or solutions in the evanescent zone of a cylindrical waveguide is analyzed. The analysis applies to the case in which the fluorescence is excited by the evanescent wave of a fiber and the fluorescence signal is that which tunnels back into the same fiber. The analysis is for two cases: bulk fluorescence and fluorescence of a thin film layer. Experimental results are also presented.

Balloon dilatation of the prostatic urethra. Work in progress

Balloon dilatation of the prostatic urethra was performed in eight dogs and one human with benign prostatic hyperplasia. This was done in vivo in six dogs and in vitro in two dogs and one human. Follow-up study at 1-23 weeks showed persistent dilatation, which was documented both radiographically and pathologically. Technical improvements limited complications to the early phase of the study. While results are encouraging, extrapolation to humans is difficult.