A clinical set-up tool (CST) for rapid stimulator programming

This paper presents an intuitive approach to the programming of Functional Electrical Stimulation (FES) hardware. A stimulation sequence is defined as a Finite State Machine (FSM) that is created and modified via an easy-to-use interface. Using a USB-equipped stimulator, data from an internal accelerometer are streamed to a PC whilst the subject undergoes the motion of interest. Simultaneously, the clinician labels the collected data via a number of key presses in order to train a sequence of simple classifiers. The 'optimal' (in a quantitative sense) parameters are then uploaded directly back to the stimulator for immediate stand-alone operation.

Foot kinematics during walking measured using bone and surface mounted markers

The aim was to compare kinematic data from an experimental foot model comprising four segments ((i) heel, (ii) navicular/cuboid (iii) medial forefoot, (iv) lateral forefoot), to the kinematics of the individual bones comprising each segment. The foot model was represented using two different marker attachment protocols: (a) markers attached directly to the skin; (b) markers attached to rigid plates mounted on the skin. Bone data were collected for the tibia, talus, calcaneus, navicular, cuboid, medial cuneiform and first and fifth metatarsals (n=6). Based on the mean differences between the three data sets during stance, the differences between any two of the three kinematic protocols (i.e. bone vs skin, bone vs plate, skin vs plate) were >3 degrees in only 35% of the data and >5 degrees in only 3.5% of the data. However, the maximum difference between any two of the three protocols during stance was >3 degrees in 100% of the data, >5 degrees in 73% of the data and >8 degrees in 23% of the data. Differences were greatest for motion of the combined navicular/cuboid relative to the calcaneus and the medial forefoot segment relative to the navicular/cuboid. The differences between the data from the skin and plate protocols were consistently smaller than differences between either protocol and the kinematic data for each bone comprising the segment. The pattern of differences between skin and plate protocols and the actual bone motion showed no systematic pattern. It is unlikely that one rigid body foot model and marker attachment approach is always preferable over another.

In vitro study of foot kinematics using a dynamic walking cadaver model

There is a dearth of information on navicular, cuboid, cuneiform and metatarsal kinematics during walking and our objective was to study the kinematic contributions these bones might make to foot function. A dynamic cadaver model of walking was used to apply forces to cadaver feet and mobilise them in a manner similar to in vivo. Kinematic data were recorded from 13 cadaver feet. Given limitations to the simulation, the data describe what the cadaver feet were capable of in response to the forces applied, rather than exactly how they performed in vivo. The talonavicular joint was more mobile than the calcaneocuboid joint. The range of motion between cuneiforms and navicular was similar to that between talus and navicular. Metatarsals four and five were more mobile relative to the cuboid than metatarsals one, two and three relative to the cuneiforms. This work has confirmed the complexity of rear, mid and forefoot kinematics. The data demonstrate the potential for often-ignored foot joints to contribute significantly to the overall kinematic function of the foot. Previous emphasis on the ankle and sub talar joints as the principal articulating components of the foot has neglected more distal articulations. The results also demonstrate the extent to which the rigid segment assumptions of previous foot kinematics research have over simplified the foot.

Whitehead's varnish nasal pack

Whitehead's varnish is a little known but excellent nasal packing agent. We review available literature on the historical aspects and clinical use of Whitehead's varnish. Our personal experience with Whitehead's varnish is described, and we strongly recommend its use.

Comparison of linear accelerations from three measurement systems during "reach & grasp"

Given the increased use of accelerometers in movement analysis, validation of such inertial sensors against conventional 3D camera systems and performance comparisons of different sensors have become important topics in biomechanics. This paper evaluates and compares linear acceleration trajectories obtained from two different 3D accelerometers and derived from Vicon position data for an upper limb "reach & grasp" task. Overall, good correspondence between the three measurement systems was obtained. Sources of error are discussed.

Is undergraduate otorhinolaryngology teaching relevant to junior doctors working in accident and emergency departments?

Undergraduate ENT teaching provides junior doctors with skills and knowledge useful for the practice of medicine. However, ENT has been removed from the curriculum of nine of the 29 medical schools in the United Kingdom, as it was not deemed relevant to general medical practice. A telephone survey was performed of 20 senior house officers working in accident and emergency (A&E) departments across the United Kingdom. The results showed that 90 per cent felt their undergraduate ENT teaching was directly beneficial to working in A&E, 75 per cent felt they had not received enough undergraduate ENT teaching and 45 per cent currently received no postgraduate teaching whilst working in A&E. These results illustrate the importance of ENT teaching in the undergraduate curriculum and its value to practising doctors. They highlight the fact that prospective studies are required to examine the effect on junior doctors of changing the curriculum.

Outcomes of radical conformal radiotherapy and concomitant cisplatin chemotherapy for olfactory neuroblastoma—Review of a single centre experience

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Background: Olfactory neuroblastoma is rare with 25 new cases annually in the UK. Cranio-facial resection and post operative radiotherapy is standard treatment. The use of concomitant chemotherapy has not been fully evaluated, although chemo-sensitivity has been demonstrated by retrospective series. This study evaluates the use of radical radiotherapy and concomitant chemotherapy. Methods: Since 1978 more than 70 patients have been seen at the Institute of Otology and Laryngology. Eighteen patients treated with radiotherapy between 1999 and 2005 were reviewed. These were all CT planned and treated with conformal radiotherapy ± cisplatin chemotherapy 100 mg/m2 D 1, 22 and 43. The radiotherapy prescribed dose varied from 50Gy to 62 Gy in 1.8 to 2 Gy fractions, 10 (56%) received 60Gy in 30 fractions. Overall survival, disease free survival and treatment related morbidity were assessed. Results: Seventeen patients were post operative and 1 was neo-adjuvant. Mean age was 46 years (range 20–83) and the majority were Kadish stage C. Of the 17 post-operative patients, 13 (76%) had surgery as primary treatment and 4 (24%) for recurrence. Eight patients (44%) received concomitant chemotherapy. At the time of analysis follow up ranged from 4 months to 72 months (median 17.5, mean 28.2), 16 (88.9%) patients were alive and 14 (77.8%) disease free. Four (22.2%) patients developed recurrence and 2 died of disease. Of the 4 patients with recurrence, 3 did not receive concurrent cisplatin chemotherapy and the fourth patient did not undergo radical surgery. No patients reported deterioration in vision or significant morbidity following treatment. Conclusions: Post operative radiotherapy with concurrent cisplatin chemotherapy is effective and well tolerated in the management of olfactory neuroblastoma. Where concurrent chemotherapy was not given, relapse rates were high. Our results, although immature, suggest disease free survival superior to published data. A prospective multi-centre study to evaluate concomitant treatment schedules is required.

No significant financial relationships to disclose.

Group B streptococcal cervical osteomyelitis in a neonate

Neonatal cervical osteomyelitis is extremely rare, with only a few reported cases. In most instances, Staphylococcus aureus is the infecting organism. The authors report a case of group B streptococcal osteomyelitis affecting the cervical spine. This case highlights the diagnostic and therapeutic difficulties that these cases present, and emphasises the role of a multidisciplinary team approach to management.

Families’ Perception of the Value of Timed Daily “Family Rounds” in a Trauma ICU

Daily communications between the ICU trauma patients’ families and the trauma team are often limited due to the unpredictable nature of subsequent patient admissions and operative procedures. In order to improve the lines of family-physician communication and educate residents regarding family communication, our level I trauma center instituted daily “Family Rounds” (FR). FR occur at the same time every day, in the patient's ICU room. The purpose of this study was to determine whether families valued the scheduled daily FR, to establish whether FR improved the family-physician relationship, and to delineate strengths and weaknesses of the present structure of our FR. We mailed surveys to family members of trauma patients hospitalized in the trauma ICU for ≥3 days. A total of 55 (22%) families responded. Combining “excellent” and “good” responses, 86.5 per cent of families looked forward to having a specific time of day to meet with the trauma team, and 90 per cent liked having rounds in the ICU room with the patient. However, 36 per cent did not like having only scheduled time for FR. The majority, 75 per cent, believed that all concerns were addressed during FR, and 84.9 per cent rated their overall experience as either excellent or good. Scheduled FR appear to improve communication between trauma surgeons and patients’ families, enhance the family-physician relationship, and strengthen our surgical residency teaching program.

Families' perception of the value of timed daily "family rounds" in a trauma ICU

Daily communications between the ICU trauma patients' families and the trauma team are often limited due to the unpredictable nature of subsequent patient admissions and operative procedures. In order to improve the lines of family-physician communication and educate residents regarding family communication, our level I trauma center instituted daily "Family Rounds" (FR). FR occur at the same time every day, in the patient's ICU room. The purpose of this study was to determine whether families valued the scheduled daily FR, to establish whether FR improved the family-physician relationship, and to delineate strengths and weaknesses of the present structure of our FR. We mailed surveys to family members of trauma patients hospitalized in the trauma ICU for > or = 3 days. A total of 55 (22%) families responded. Combining "excellent" and "good" responses, 86.5 per cent of families looked forward to having a specific time of day to meet with the trauma team, and 90 per cent liked having rounds in the ICU room with the patient. However, 36 per cent did not like having only scheduled time for FR. The majority, 75 per cent, believed that all concerns were addressed during FR, and 84.9 per cent rated their overall experience as either excellent or good. Scheduled FR appear to improve communication between trauma surgeons and patients' families, enhance the family-physician relationship, and strengthen our surgical residency teaching program.

A comparison of CH3-DTPA-GD (NMS60) and GD-DTPA for evaluation of acute myocardial ischemia

PURPOSE

Our objective was to evaluate the use of a new medium weight MRI contrast agent, NMS60 (a synthetic oligomeric Gd-complex containing three Gd(3+) atoms, molecular weight 2158 Da) compared to gadolinium-diethylene triamine pentaacetic acid (Gd-DTPA) in a pig myocardial ischemia model.

MATERIALS

We used 13 male white hybrid pigs. Animals were scanned in the acute phase 2-3 h after the onset of myocardial ischemia. Scans were acquired on a 1.5T GE Signa with dynamic T1-weighted imaging during a bolus injection of 0.1 mmol(gd)/kg of either NMS60 or Gd-DTPA, 2D CINE at 5 min after injection, and T1-weighted spin-echo imaging up to 60 min.

RESULTS

The postcontrast CINE scans showed improved contrast-to-noise ratio after NMS60 injection, compared to Gd-DTPA. There was significantly greater enhancement with NMS60 in both normal myocardium and in the ischemic lesion on T1-weighted spin-echo scans up to 60 min after injection. The dose ranging study shows a 24% greater enhancement with NMS60 compared to Gd-DTPA.

DISCUSSION

This new medium weighted contrast agent offers improved enhancement for cardiac MRI, compared to Gd-DTPA, with similar washout kinetics and lower toxicity, and may prove useful for better detection of myocardial ischemia as well as delayed or hyperenhancement after reperfusion.

Regression Techniques for the Prediction of Lower Limb Kinematics

This work presents a novel and extensive investigation of mathematical regression techniques, for the prediction of laboratory-type kinematic measurements during human gait, from wearable measurement devices, such as gyroscopes and accelerometers. Specifically, we examine the hypothesis of predicting the segmental angles of the legs (left and right foot, shank and thighs), from rotational foot velocities and translational foot accelerations. This first investigation is based on kinematic data emulated from motion-capture laboratory equipment. We employ eight established regression algorithms with different properties, ranging from linear methods and neural networks with polynomial support and expanded nonlinearities, to radial basis functions, nearest neighbors and kernel density methods. Data from five gait cycles of eight subjects are used to perform both inter-subject and intra-subject assessments of the prediction capabilities of each algorithm, using cross-validation resampling methods. Regarding the algorithmic suitability to gait prediction, results strongly indicate that nonparametric methods, such as nearest neighbors and kernel density based, are particularly advantageous. Numerical results show high average prediction accuracy (ρ=0.98∕0.99,RMS=5.63°∕2.30°,MAD=4.43°∕1.52° for inter∕intra-subject testing). The presented work provides a promising and motivating investigation on the feasibility of cost-effective wearable devices used to acquire large volumes of data that are currently collected only from complex laboratory environments.

A comparative evaluation of CH3-DTPA-Gd (NMS60) for contrast-enhanced magnetic resonance angiography

In a canine model the signal dynamics of a new oligomer-based MR contrast agent (NMS60, 2158 Da) were compared to Gd-DTPA to investigate the agents' potential for magnetic resonance angiography (MRA). Twelve male mongrel dogs were imaged sequentially under anesthesia with two different MRA sequences (Tlw 3DSPGR). Initial enhancement was measured every 9 s for eight points in time. Thereafter, spatial highly resolved MRAs were obtained at 5, 10, 15, 20, 30, 45, and 60 min post-injection of two different dosages. Over the first 20 s following bolus administration the average arterial enhancement of 0.1 mmol(Gd)kg NMS60 was 44% greater than Gd-DTPA. Twenty minutes post-injection the relative signal intensity of NMS60 was as high as the peak signal intensity with Gd-DTPA at the same dosage level (0.1 mmol(Gd)/kg). In the animals that received NMS60 injections the vascular conspicuity was overly superior to those who received Gd-DTPA. No significant toxicity effects were noted for either dosage level. The intermediate weight contrast agent NMS60 offers greater vascular enhancement and retention time than Gd-DTPA. For a given set of optimized imaging parameters this offers improved spatial details, less arterial/venous overlap, and better vascular contrast.

Natural marine sponge fiber skeleton: a biomimetic scaffold for human osteoprogenitor cell attachment, growth, and differentiation

Identification of suitable scaffolds onto which human stem cells can be seeded to generate functional three-dimensional tissues is a major research goal. A natural marine sponge skeleton was selected as a potential scaffold on the basis of the hydration potential of the fiber, the presence of open interconnected channels created by the fiber network, the collagenous composition of the fiber, and the structural diversity of fiber architecture. The skeleton of an undetermined species of Spongia (Class Demospongiae: Order Dictyoceratida: Family Spongiidae), composed of spongin, supported growth of human osteoprogenitor cells. Cell attachment and invasion into the framework were observed within 16 h, followed by development into membranous sheets between the sponge fibers by concentric infilling. Histochemical staining for alkaline phosphatase and type I collagen indicated formation of bone matrix as confirmed by birefringence. At 9 and 14 days alkaline phosphatase-specific activity in sponge fiber-osteoprogenitor cell cultures was significantly greater than in control cultures on cell culture plastic. Adsorption with recombinant human bone morphogenetic protein 2 confirmed the potential of this sponge skeleton as a delivery scaffold for osteogenic factors. The abundance and structural diversity of natural marine sponge skeletons and their potential as multifunctional, cell conductive and inductive frameworks indicate a promising new source of scaffold for tissue regeneration.

The effect of maternal undernutrition on the placental growth trajectory and the uterine insulin-like growth factor axis in the pregnant ewe

The placenta is a highly efficient multifunctional organ, mediating the exchange of nutrients, gases and waste products between the dam and fetus. This study investigated the effects of chronic maternal undernutrition (70% of estimated requirement) on the placental growth trajectory in the ewe on days 45, 90 and 135 of gestation. The insulin-like growth factor (IGF) system was investigated using in situ hybridisation analysis to determine if nutritionally mediated alterations in placental growth were regulated through modifications in placental IGF expression. Placental weight increased between days 45 and 90 (P<0.01), accompanied by a reduction in maternal placentome IGF binding protein (IGFBP)-3, -5 and -6 expression (P<0.05), although IGF-II mRNA levels in maternal villi remained unchanged. Placentome number was unaffected by diet or gestational age. Placental weight remained constant between days 90 and 135 in ewes on 100% maintenance rations but decreased over this period (P<0.05) in ewes on the 70% rations. Gross morphology also altered, so the underfed ewes had more type C and type D placentomes and fewer type B placentomes than their well-fed counterparts on day 135 (P<0.05). These changes were accompanied by higher IGFBP-6 mRNA expression in the maternal placental villi in undernourished ewes (P<0.05). The change in shape from a type A to a type C placentome was accompanied by flattening of the placentome and a reduction in the ratio of the area of unattached fetal allantochorion to interdigitated maternal and fetal villi. Within the intercotyledonary endometrium, expression of IGFBPs-3 and -5 mRNA in the glandular epithelium increased between days 45 and 90, showing an opposite trend with time to that found in the adjacent placentomes. This indicates tissue-specific control of IGFBP expression. In conclusion, this study has shown clear time-related changes in the uterine IGFBP system during pregnancy, which accompany changes in placental growth. Altered IGFBP expression may play a role in determining placental size in relation to nutritional status, but is unlikely to be the only mediator.

Occurrence of amyotrophic lateral sclerosis among Gulf War veterans

BACKGROUND

In response to Gulf War veterans' concerns of high rates of ALS, this investigation sought to determine if Gulf War veterans have an elevated rate of ALS.

METHODS

A nationwide epidemiologic case ascertainment study design was used to ascertain all occurrences of ALS for the 10-year period since August 1990 among active duty military and mobilized Reserves, including National Guard, who served during the Gulf War (August 2, 1990, through July 31, 1991). The diagnosis of ALS was confirmed by medical record review. Risk was assessed by the age-adjusted, average, annual 10-year cumulative incidence rate.

RESULTS

Among approximately 2.5 million eligible military personnel, 107 confirmed cases of ALS were identified for an overall occurrence of 0.43 per 100,000 persons per year. A significant elevated risk of ALS occurred among all deployed personnel (RR = 1.92; 95% CL = 1.29, 2.84), deployed active duty military (RR = 2.15, 95% CL = 1.38, 3.36), deployed Air Force (RR = 2.68, 95% CL = 1.24, 5.78), and deployed Army (RR = 2.04; 95% CL = 1.10, 3.77) personnel. Elevated, but nonsignificant, risks were observed for deployed Reserves and National Guard (RR = 2.50; 95% CL = 0.88, 7.07), deployed Navy (RR = 1.48, 95% CL = 0.62, 3.57), and deployed Marine Corps (RR = 1.13; 95% CL = 0.27, 4.79) personnel. Overall, the attributable risk associated with deployment was 18% (95% CL = 4.9%, 29.4%).

CONCLUSIONS

Military personnel who were deployed to the Gulf Region during the Gulf War period experienced a greater post-war risk of ALS than those who were not deployed to the Gulf.