Tunable Light-Responsive Polyurethane-urea Elastomer Driven by Photochemical and Photothermal Coupling Mechanism

Light-driven soft actuators based on photoresponsive materials can be used to mimic biological motion, such as hand movements, without involving rigid or bulky electromechanical actuations. However, to our knowledge, no robust photoresponsive material with desireable mechanical and biological properties and relatively simple manufacture exists for robotics and biomedical applications. Herein, we report a new visible-light-responsive thermoplastic elastomer synthesized by introducing photoswitchable moieties (i.e., azobenzene derivatives) into the main chain of poly(ε-caprolactone) based polyurethane urea (PAzo). A PAzo elastomer exhibits controllable light-driven stiffness softening due to its unique nanophase structure in response to light, while possessing excellent hyperelasticity (stretchability of 575.2%, elastic modulus of 17.6 MPa, and strength of 44.0 MPa). A bilayer actuator consisting of PAzo and polyimide films is developed, demonstrating tunable bending modes by varying incident light intensities. Actuation mechanism via photothermal and photochemical coupling effects of a soft-hard nanophase is demonstrated through both experimental and theoretical analyses. We demonstrate an exemplar application of visible-light-controlled soft "fingers" playing a piano on a smartphone. The robustness of the PAzo elastomer and its scalability, in addition to its excellent biocompatibility, opens the door to the development of reproducible light-driven wearable/implantable actuators and lightweight soft robots for clinical applications.

An Assistive Coughing Device for Post-Laryngectomy Patients

People who have undergone total laryngectomy typically have difficulties speaking and coughing. Coughing, the protective reflex action where air is rapidly expelled from the lungs to clear the airway, is crucial in everyday life. Insufficiency in coughing can lead to serious chest infections. In this research we present a bionic assistive coughing device (RoboCough) to improve coughing efficacy among laryngectomy patients by increasing pressure and flow rate. RoboCough was designed to mimic the function of the glottis and trachea in the upper respiratory system. Experimental results show a significant increase (t(64) = 4.9, p < 0.0001) in peak cough flow rate and peak cough pressure (t(64) = 12.6, p < 0.0001) among 33 control participants using RoboCough. A pilot study with a smaller cohort of laryngectomy patients shows improvement in peak cough pressure (p = 0.0159) using RoboCough. Preliminary results also show that post-laryngectomy coughs achieved similar peak cough flow (Z = -0.9933, p = 0.32) to the control group’s natural cough. Coughing capabilities could be improved through using RoboCough. Applications of RoboCough include simulation of vocal folds and respiratory conditions, rehabilitation of ineffective coughs from laryngeal and respiratory diseases and as a test-bed for the development of medical devices for respiratory support.

Retrospective analysis of real-world treatment patterns and clinical outcomes in patients with advanced non-small cell lung cancer starting first-line systemic therapy in the United Kingdom

BACKGROUND

The treatment landscape for advanced non-small cell lung cancer (aNSCLC) has evolved rapidly since immuno-oncology (IO) therapies were introduced. This study used recent data to assess real-world treatment patterns and clinical outcomes in aNSCLC in the United Kingdom.

METHODS

Electronic prescribing records of treatment-naive patients starting first-line (1 L) treatment for aNSCLC between June 2016 and March 2018 (follow-up until December 2018) in the United Kingdom were assessed retrospectively. Patient characteristics and treatment patterns were analyzed descriptively. Outcomes assessed included overall survival (OS), time to treatment discontinuation, time to next treatment, and real-world tumor response.

RESULTS

In all, 1003 patients were evaluated (median age, 68 years [range, 28-93 years]; 53.9% male). Use of 1 L IO monotherapy (0-25.9%) and targeted therapy (11.8-15.9%) increased during the study period, but chemotherapy remained the most common 1 L treatment at all time points (88.2-58.2%). Median OS was 9.5 months (95% CI, 8.8-10.7 months) for all patients, 8.1 months (95% CI, 7.4-8.9 months) with chemotherapy, 14.0 months (95% CI, 10.7-20.6 months) with IO monotherapy, and 20.2 months (95% CI, 16.0-30.5 months) with targeted therapy. In the 28.6% of patients who received second-line treatment, IO monotherapy was the most common drug class (used in 51.6%).

CONCLUSIONS

Although use of 1 L IO monotherapy for aNSCLC increased in the United Kingdom during the study period, most patients received 1 L chemotherapy. An OS benefit for first-line IO monotherapy vs chemotherapy was observed but was numerically smaller than that reported in clinical trials. Targeted therapy was associated with the longest OS, highlighting the need for improved treatment options for tumors lacking targetable mutations.

Development of a more clinically relevant bladder and urethral model for catheter testing

This paper sets out the rationale and design for a more physiologically representative bladder/urethral model than the current rigid funnel industry standard. We suggest this flexible model can better serve as a basis for evaluating new catheters. We investigated the parameters and the validation tests required to construct and test with more flexible materials. The protocol includes static and impact force tests, while measuring internal retention balloon pressure. We have designed a flexible elastomer bladder floor and urethral model and tested it with a Foley balloon catheter. The tests showed that the model could hold the catheter with static loads up to 0.7 kg, but that the catheter was pulled out by impact forces from dropped weights. The Foley catheter design and its associated standards make no provision to mitigate urethral injury in the surprisingly common event of removal with a filled balloon. Our design is a more realistic model for testing retention and extraction characteristics of a urethral catheter. Validation tests have confirmed the feasibility of measuring urethral dilation and balloon pressure, both under traction and during progressive deflation. We suggest this model improves upon the current standard tests and will enable the design of safer catheters.

All-Soft Skin-Like Structures for Robotic Locomotion and Transportation

Human skins are active, smart, and stretchable. Artificial skins that can replicate these properties are promising materials and technologies that will enable lightweight, cost-effective, portable, and deployable soft devices and robots. We show an active, stretchable, and portable artificial skin (ElectroSkin) that combines dielectric elastomer actuators (DEAs) and soft electroadhesives (EAs) in a fully compliant multilayer composite skin-like structure. By taking advantage of the common characteristics of DEA and EA, we define regions of the composite artificial skin as either active or passive. Active areas can be exploited as electromechanical actuators or as electrostatic gripper elements, or both simultaneously. This embedded multimodality delivers a new technology of deformable active skins that can grip and move objects and self-locomote. ElectroSkins can be fabricated using all-soft elastomers and readily available conductive materials. We demonstrate their capabilities in the first soft self-actuating conveyor belt, with a conveyoring speed of 0.28 mm/s, and a pocketable fully soft crawler robot. This new, self-actuating, self-gripping, and self-locomoting soft artificial skin has the potential to significantly impact on functional soft-smart composites, deployable robots, soft-smart conveyoring, and compliant gripping and manipulation applications.

Swimming like algae: biomimetic soft artificial cilia

Cilia are used effectively in a wide variety of biological systems from fluid transport to thrust generation. Here, we present the design and implementation of artificial cilia, based on a biomimetic planar actuator using soft-smart materials. This actuator is modelled on the cilia movement of the alga Volvox, and represents the cilium as a piecewise constant-curvature robotic actuator that enables the subsequent direct translation of natural articulation into a multi-segment ionic polymer metal composite actuator. It is demonstrated how the combination of optimal segmentation pattern and biologically derived per-segment driving signals reproduce natural ciliary motion. The amenability of the artificial cilia to scaling is also demonstrated through the comparison of the Reynolds number achieved with that of natural cilia.

Biomimetic chromatophores for camouflage and soft active surfaces

Chromatophores are the pigment-containing cells in the skins of animals such as fish and cephalopods which have chromomorphic (colour-changing) and controllable goniochromic (iridescent-changing) properties. These animals control the optical properties of their skins for camouflage and, it is speculated, for communication. The ability to replicate these properties in soft artificial skin structures opens up new possibilities for active camouflage, thermal regulation and active photovoltaics. This paper presents the design and implementation of soft and compliant artificial chromatophores based on the cutaneous chromatophores in fish and cephalopods. We demonstrate artificial chromatophores that are actuated by electroactive polymer artificial muscles, mimicking the radially orientated muscles found in natural chromatophores. It is shown how bio-inspired chromomorphism may be achieved using both areal expansion of dielectric elastomer structures and by the hydrostatic translocation of pigmented fluid into an artificial dermal melanophore.

Identification of an HLA-A*0201 cytotoxic T lymphocyte epitope specific to the endothelial antigen Tie-2

Tie-2 stabilises pericyte-endothelial interactions during angiogenesis and is highly expressed on endothelium during several diseases, including arthritis, age-related macular degeneration and cancer. A vaccine that targets endothelium overexpressing Tie-2 may result in vessel damage and stimulate an inflammatory cascade resulting in disease regression. We have identified a region unique to Tie-2 (amino acids 1-196) that is homologous in humans and mice. Using computer algorithms, several HLA-A*0201 epitopes that are identical in mice and humans were predicted within this region; however, binding assays showed that the majority of these epitopes were of low affinity. Modification of the anchor residues of 4 epitopes enhanced HLA binding. These epitopes were incorporated by site-directed mutagenesis into a Tie-2 DNA construct. Immunisation of HLA*0201 transgenic mice with one of the modified Tie-2 constructs stimulated CTLs that recognised both wild-type and modified peptide-pulsed target cells. In contrast, no CTLs were generated in mice immunised with wild-type Tie-2 construct, demonstrating that the modified epitope was necessary in the generation of CTLs. Moreover, CTLs from mice immunised with the modified construct killed HLA-A*0201 endothelial cells overexpressing Tie-2. Our study demonstrates that it is possible to break tolerance to the endothelial antigen Tie-2, suggesting that it may be feasible to design a vaccine to activate CTLs to kill endothelial cells overexpressing Tie-2.

Benchmarking and quality improvement: the Harvard Emergency Department Quality Study

PURPOSE

To determine whether feedback of comparative information was associated with improvement in medical record and patient-based measures of quality in emergency departments.

SUBJECTS AND METHODS

During 1-month study periods in 1993 and 1995, all medical records for patients who presented to five Harvard teaching hospital emergency departments with one of six selected chief complaints (abdominal pain, shortness of breath, chest pain, hand laceration, head trauma, or vaginal bleeding) were reviewed for the percent compliance with process-of-care guidelines. Patient-reported problems and patient ratings of satisfaction with emergency department care were collected from eligible patients using patient questionnaires. After reviewing benchmark information, emergency department directors designed quality improvement interventions to improve compliance with the process-of-care guidelines and improve patient-reported quality measures.

RESULTS

In the preintervention period, 4,876 medical records were reviewed (99% of those eligible), 2,327 patients completed on-site questionnaires (84% of those eligible), and 1,386 patients completed 10-day follow-up questionnaires (80% of a random sample of eligible participants). In the postintervention period, 6,005 medical records were reviewed (99% of those eligible), 2,899 patients completed on-site questionnaires (84% of those eligible), and 2,326 patients completed 10-day follow-up questionnaires (80% of all baseline participants). In multivariate analyses, adjusting for age, urgency, chief complaint, and site, compliance with process-of-care guidelines increased from 55.9% (preintervention) to 60.4% (postintervention, P = 0.0001). We also found a 4% decrease (from 24% to 20%) in the rate of patient-reported problems with emergency department care (P = 0.0001). There were no significant improvements in patient ratings of satisfaction.

CONCLUSION

Feedback of benchmark information and subsequent quality improvement efforts led to small, although significant, improvement in compliance with process-of-care guidelines and patient-reported measures of quality. The measures that relied on patient reports of problems with care, rather than patient ratings of satisfaction with care, seemed to be more responsive to change. These results support the value of benchmarking and collaboration.

Demonstration of high-fidelity simulation team training for emergency medicine

Emergency medicine (EM) presents many cognitive, social, and systems challenges to practitioners. Coordination and communication under stress between and among individuals and teams representing a number of disciplines are critical for optimal care of the patient. The specialty is characterized by uncertainty, complexity, rapidly shifting priorities, a dependence on teamwork, and elements common to other risky domains such as perioperative medicine and aviation. High-fidelity simulators have had a long tradition in aviation, and in the past few years have begun to have a significant impact in anesthesiology. A national, multicenter research program to document the costs of teamwork failures in EM and provide a remedy in the form of an Emergency Team Coordination Course has developed to the point that high-fidelity medical simulators will be added to the hands-on training portion of the course. This paper describes an evolving collaborative effort by members of the Center for Medical Simulation, the Harvard Emergency Medicine Division, and the MedTeams program to design, demonstrate, and refine a high-fidelity EM simulation course to improve EM clinician performance, increase patient safety, and decrease liability. The main objectives of the paper are: 1) to present detailed specifications of tools and techniques for high-fidelity medical simulation; 2) to share the results of a proof-of-concept EM simulation workshop introducing multiple mannequin/ three-patient scenarios; and 3) to focus on teamwork applications. The authors hope to engage the EM community in a wide-ranging discussion and handson exploration of these methods.

The effect of supervision of residents on quality of care in five university-affiliated emergency departments

PURPOSE

To assess the impact of direct supervision of resident physicians by attending physicians on quality of care in emergency departments.

METHOD

In 1993, compliance with process-of-care guidelines was measured for 3,667 patients cared for by residents in five emergency departments in Boston and Cambridge, Massachusetts. Those patients presented with abdominal pain, asthma/COPD, chest pain, hand laceration, head trauma, or vaginal bleeding. A follow-up survey to assess patient satisfaction and reported problems with care was completed by 1,094 randomly sampled patients.

RESULTS

In multivariate analysis, residents directly supervised by attending physicians had significantly (p < .0001) higher adjusted mean percentage compliance with guidelines (64%) than did residents alone (55%). Better compliance was also associated with higher level of training of the resident and greater patient urgency. There was no significant difference between supervised and unsupervised residents in either adjusted patient satisfaction or reported problems with care.

CONCLUSIONS

Direct supervision of residents in emergency departments is significantly associated with better compliance with guidelines, regardless of level of training. However, direct supervision was not shown to influence patients' experience with care.

Two regions of simian virus 40 large T-antigen independently extend the life span of primary C57BL/6 mouse embryo fibroblasts and cooperate in immortalization

Expression of the SV40 large T-antigen allows primary cells to escape senescence and thereby become immortalized. Immortalization occurs in two steps, extension of life span and acquisition of unlimited cell division potential. By following the increase in expression of a senescence-associated marker with increased cell passage, we show that C57Bl/6 mouse embryo fibroblast (B6MEF) cultures senesce by passage 4. Thus, the development of colonies from cultures transfected with T-antigen expressing constructs indicates extension of life span. Two T-antigen regions independently extended the life span of B6MEF. Expression of either a T-antigen consisting of amino acids 1-147 (T1-147) or a T-antigen consisting of amino acids 251-708 (T251-708) resulted in colony development. However, the colonies expressing these truncated T-antigens could not be expanded into cell lines efficiently. In contrast, coexpression of T1-147 and T251-708 produced colonies that could be expanded into cell lines as efficiently as could colonies expressing full-length T-antigen. Thus, the two regions of T-antigen contain analogous activities that are sufficient to extend cell life span; they cooperate to immortalize primary B6MEF; and they act in trans, indicating that the functions involved are independent.

Effect of oral digoxin, topical ouabain and salbutamol on transepithelial nasal potential difference in patients with cystic fibrosis

1. Airway epithelium in cystic fibrosis is characterized by a defect in chloride secretion across the apical membrane and an increase in sodium absorption. The increased rate of sodium absorption can be inhibited in vitro by ouabain, a Na(+)-K(+)-ATPase inhibitor, and in cystic fibrosis patients the number and activity of nasal epithelial Na(+)-K(+)-ATPase pumps is increased. 2. We have performed a series of studies to determine whether drugs which modify airway epithelial Na(+)-K(+)-ATPase activity in vitro can modify nasal potential in cystic fibrosis patients in vivo. As transepithelial nasal potential difference measurements were used to study the effect of drug modulation of airway epithelial ion transport in vivo, the repeatability of the technique was first evaluated. In order to assess the effectiveness of the technique used for measuring nasal potential difference, a pilot study was carried out using topical amiloride, a drug which has previously been shown to inhibit airway epithelium sodium transport in vivo. We then studied the effects of ouabain and digoxin, two inhibitors of Na(+)-K(+)-ATPase, on nasal potential difference. 3. In study 1, nasal potential difference measurements were repeated on non-consecutive days in 20 patients with cystic fibrosis and 20 healthy individuals. Healthy subjects had a mean (SEM) potential difference value of -19.5 (0.9) mV with a 95% range for a single estimate of 75-133%. In patients with cystic fibrosis, the mean (SEM) potential difference was -40.4, (2.1) mV, with a 95% range for a single estimate of 74-136%.(ABSTRACT TRUNCATED AT 250 WORDS)

Simian virus 40 large T antigen contains two independent activities that cooperate with a ras oncogene to transform rat embryo fibroblasts

The simian virus 40 large T antigen immortalizes growing primary cells in culture. In addition, this viral oncoprotein cooperates with an activated ras protein to produce dense foci on monolayers of rat embryo fibroblasts (REF). The relationship between independent immortalization and cooperative transformation with ras has not been defined. Previously, two regions of T antigen were shown to contain immortalization activities. An N-terminal fragment consisting of amino acids 1 to 147 immortalizes rodent cells (L. Sompayrac and K. J. Danna, Virology 181:412-415, 1991). Loss-of-function analysis indicated that immortalization depended on integrity of the T-antigen segments containing amino acids 351 to 450 and 533 to 626 (T. D. Kierstead and M. J. Tevethia, J. Virol. 67:1817-1829, 1993). The experiments described here were directed toward determining whether these same T-antigen regions were sufficient for cooperation with ras. Initially, constructs that produce T antigens containing amino acids 176 to 708 (T176-708) or 1 to 147 were tested in a ras cooperation assay. Both polypeptides cooperated with ras to produce dense foci on monolayers of primary REF. These results showed that T antigen contains two separate ras cooperation activities. In order to determine the N-terminal limit of the ras cooperation activity contained within the T176-708 polypeptide, a series of constructs designed to produce fusion proteins containing T-antigen segments beginning at residues 251, 301, 337, 351, 371, 401, 451, 501, 551, 601, and 651 was generated. Each of these constructs was tested for the capacity to cooperate with ras to produce dense foci on REF monolayers. The results indicated that a polypeptide containing T-antigen amino acids 251 to 708 (T251-708) was sufficient to cooperate with ras, whereas the more extensively truncated products were not. The abilities of the N-terminally truncated T antigens to bind p53 were examined in p53-deficient cells infected with a recombinant vaccinia virus expressing a phenotypically wild-type mouse p53. The results showed that polypeptides containing T-antigen amino acids 251 to 708, 301 to 708, 337 to 708, or 351 to 708 retained p53-binding capacity. The introduction into the T251-708 polypeptide of deletions that either prevented p53 binding (dl434-444) or did not prevent p53 binding (dl400) abrogated ras cooperation. These results indicated that although p53 binding may be necessary for ras cooperation, an additional, as-yet-undefined activity contained within the T251-708 polypeptide is needed.

Hypomagnesemia is a frequent finding in the emergency department in patients with chest pain

STUDY OBJECTIVE

To evaluate the frequency of low blood levels of total and ultrafilterable magnesium (total and ultrafilterable hypomagnesemia) in patients with chest pain in the emergency department, and to determine if hypomagnesemia is associated with other clinically important diagnostic and outcome variables in cardiac care.

SETTING

An emergency department of a university teaching hospital.

DESIGN

Prospective study of extracellular magnesium homeostasis in patients with chest pain in the emergency department and a cohort of patients without chest pain with a clinical indication for blood sampling.

PATIENTS

During a 4-month period, 147 patients presenting to the emergency department were studied: 67 patients (mean +/- SD age, 61.4 +/- 13 years) with a chief complaint of chest pain (study group) and 80 patients (55.6 +/- 19 years) with other diagnoses (control group).

RESULTS

Total and ultrafilterable hypomagnesemia occurred more frequently in patients with chest pain (20/67 [30%] and 9/67 [13%]) than in the control group (12/80 [15%] and 3/80 [4%]). Patients with a chief complaint of chest pain who were receiving diuretic medications were hypomagnesemic more frequently (9/16 [56%]) than patients not receiving diuretics (12/51 [23%]). In patients with chest pain admitted to the hospital with a diagnosis of "rule out" myocardial infarction, the frequency of hypokalemia was greater among hypomagnesemic patients (6/14 [43%]) than normomagnesemic patients (3/31 [10%]). A similar frequency of hypomagnesemia was noted in patients with a final diagnosis of myocardial infarction (4/15 [27%]) when compared with other patients admitted with chest pain (10/31 [32%]) in whom myocardial infarction was excluded. No association was noted among hypomagnesemia and length of hospital stay or the occurrence of hypotension or dysrhythmias.

CONCLUSIONS

Total and ultrafilterable hypomagnesemia are frequent occurrences in patients with and without chest pain in the emergency department. Diuretic use is associated with hypomagnesemia in patients presenting with chest pain in the emergency department. These results support the concept that hypomagnesemia is common in patients with chest pain in the emergency department and is associated with hypokalemia but is not predictive of whether the patient with chest pain has had an acute myocardial infarction.

Urinary cyclic AMP and post-traumatic acute renal failure

Consecutive daily urinary excretion of cyclic AMP has been investigated in 16 patients with severe trauma or illness, five of whom developed acute renal failure (ARF). Fluctuations in the nucleotide excretion exceeded the range found in 20 healthy volunteers (1.26-14.74, mean 7.13+/-1.18 vs. 2.04-10.10, mean 5.07+/-2.21 micronmol/24 h). This resulted in a 41% increase of cAMP excretion in the group with normal renal function (P less than 0.003) with the highest individual increase of 87%. The excretion usually reached its peak by 24 h after trauma and its lowest value by the third day, (first day vs. third day; 7.82+/-4.23 vs. 3.96+/-2.58 micronmol/24 h, P less than 0.05 for a group of 11 patients), while creatinine clearance remained normal. In four patients with severe ARF, the mean urine volume was above control value but the cAMP excretion was reduced to 3.9 to 14.4% and in one patient with a mild ARF to 60.6%. Creatinine excretion of the group was less reduced than that of cAMP (41.2% vs. 19.6%, resp.). cAMP excretion declined proportionally with diminishing creatinine clearance. In the category of 33-65 ml/min it decreased by 33.4% to 3.39 micronmol+/-1.16 micronmol/24 h. cAMP/creatinine ratio proved to be a less sensitive indicator than cAMP/24 h. Daily output of cAMP and creatinine correlated highly with diuresis in ARF patients, controls (always P less than 0.001) and less in patients with normal renal function (P less than 0.02). Urinary cAMP appears to be a very sensitive and early indicator of the onset of ARF and subsequent recovery. This warrants its further study.

The effect of severe trauma on urinary cyclic AMP in children of different ages

Under routine clinical conditions the urinary excretion of cyclic AMP was studied in 97 healthy children (3 months to 16 years old) and 65 child victims of various forms of trauma and proved to be age-dependent. The mean admission cAMP urinry levels for children of all ages were increased by 44.8% and were time dependent. In 26 injured children (3 months to 9.5 years old) the excretion increased to 12.10 +/-1.29 mumol cAMP/g creatinine as compared to 8.06 +/- 2.25 mumol cAMP/g crEAtinine (50.0%; P less than 0.01) and in 38 children (9.5-16 years) it rose to 6.43 +/- 4.12 from 4.72 mumol +/- 1.10 (36.2%; P less than 0.001). In 23 victims admitted within the first two hours after trauma the cAMP levels were elevated by 31.25% in contrast to 49.2% elevation in those admitted from 2 to 24 h after trauma. In a five-day follow-up of a group of 15 surviving patients the highest excretion of cAMP was found on the first day. It was followed by a steep decline until the values plateaued on the third day at values slightly elevated above control. Compared with the fifth day, the first day excretion expressed as mumol cAMP/24 h was enhanced by 92.3% (P less than 0.01) and as a ratio to creatinine (muol/g creatine) by 52.24% (P less than 0.05. In comparison with injured adults studied previously under analogical conditions, the cAMP excretory response to trauma in children differs in higher intensity (P less than 0.01) and in the nature of the daily pattern starting with the third day. It is pointed out that the intensity of the cAMP response to pathological stimuli may be age-dependent also in other clinical conditions.