Design and validation of a virtual reality trainer for ultrasound-guided regional anaesthesia

Virtual reality is a form of high-fidelity simulation that may be used to enhance the quality of medical education. We created a bespoke virtual reality trainer software using high resolution motion capture and ultrasound imagery to teach cognitive-motor needling skills necessary for the performance of ultrasound-guided regional anaesthesia. The primary objective of this study was to determine the construct validity between novice and experienced regional anaesthetists. Secondary objectives were: to create learning curves for needling performance; compare the virtual environment immersion with other high-fidelity virtual reality software; and compare cognitive task loads imposed by the virtual trainer compared with real-life medical procedures. We recruited 21 novice and 15 experienced participants, each of whom performed 40 needling attempts on four different virtual nerve targets. Performance scores for each attempt were calculated based on measured metrics (needle angulation, withdrawals, time taken) and compared between the groups. The degree of virtual reality immersion was measured using the Presence Questionnaire, and cognitive burden was measured using the NASA-Task Load Index. Scores by experienced participants were significantly higher than novices (p = 0.002) and for each nerve target (84% vs. 77%, p = 0.002; 86% vs. 79%, p = 0.003; 87% vs. 81%, p = 0.002; 87% vs. 80%, p = 0.003). Log-log transformed learning curves demonstrated individual variability in performance over time. The virtual reality trainer was rated as being comparably immersive to other high-fidelity virtual reality software in the realism, possibility to act and quality of interface subscales (all p > 0.06) but not in the possibility to examine and self-performance subscales (all p < 0.009). The virtual reality trainer created workloads similar to those reported in real-life procedural medicine (p = 0.53). This study achieved initial validation of our new virtual reality trainer and allows progression to a planned definitive trial that will compare the effectiveness of virtual reality training on real-life regional anaesthesia performance.

Quality of life, respiratory symptoms, and health care utilization 1 year following outpatient management of COVID-19: a prospective cohort study

The long-term impact of COVID-19 among those with mild infections is not well characterized. Among 81 adults who completed online assessments at 3- and 12-months following infection, quality of life scores did not significantly improve over time. Among 62 subjects who also completed telephone interviews, respiratory symptoms or exercise limitation were reported by 42% at a median follow-up of 387 days (IQR 251–402 days). Those with persistent respiratory symptoms scored lower on the EQ-5D visual analog score compared to those without. Persistent respiratory symptoms were associated with a lower likelihood of full-time employment at 1 year (aOR 0.09, 95%CI 0.01–0.91; P = 0.041). In an adjusted linear regression, persistent respiratory symptoms (P = 0.037) and female sex (P = 0.016) were both independent risks for increased visits to a primary care provider. This cohort study demonstrates that respiratory symptoms are frequent at 1 year following COVID-19 and more importantly, are associated with negative impacts on employment, quality of life, and health care utilization. Further research is needed to determine the pathophysiology and risk factors for persistent symptoms as well as optimal management strategies to improve the level of functioning and quality of life.

Canada's Prosthetic Coverage: a Review of Provincial Prosthetic Policy

The Canadian healthcare system serves as an example of equity and federal service to citizens across the world. However, it is not without its challenges. Prosthetic coverage across Canada is highly variable and largely unable to provide equal coverage for Canadian persons living with amputation. Many persons with limb loss are forced to rely upon personal resources, fundraising, or the charity of non-governmental organizations in order to meet this basic healthcare need. This disparity in the Canadian healthcare system is unusual and largely undescribed in the literature. We thus explore the nature of Canadian healthcare prosthetic coverage across Canada, investigating the variability in coverage, presence of prosthetic coverage policies, clarity of policy, eligibility criteria, and interval of prosthetic replacement. Our findings highlight potential areas for improvement within current Canadian healthcare policy.

Vasoactive properties of calcitonin gene-related peptide in human skin

AIM

Calcitonin gene-related peptide (CGRP) is a potential mediator of neurogenic inflammation in eczema, psoriasis and rosacea, and also contributes to vasodilatation and oedema in complex regional pain disorder. We investigated the feasibility of administering CGRP and its antagonist CGRP8-37 by iontophoresis in human skin to characterise their vasoactive profiles.

METHODS

Two doses of each peptide were administered by iontophoresis (5 and 10 min duration at 0.1 mA) to the forearm skin of 6 healthy young men. Skin blood flow responses over 25 min were assessed using laser Doppler imaging.

RESULTS

Iontophoresis of CGRP caused a gradual change in blood flow, with no significant difference in response between each dose. The peak change in flow had a coefficient of variation of 21% to 36%, while the variability of the total cumulative response was much greater. Iontophoresis of CGRP8-37 for 5 min caused only a small, transient increase in skin blood flow, while 10 min iontophoresis resulted in a significant increase in blood flow.

CONCLUSION

CGRP and CGRP8-37 can be administered by iontophoresis to human skin. Further experiments are needed to determine the optimum duration of iontophoresis and period of measurement.

Not all stubbed toes are innocuous--A case report of rare malignant eccrine spiradenoma (spiradenocarcinoma) of the toe

Malignant eccrine spiradenoma (MES) is a rare adnexal tumour derived from cutaneous sweat glands. We describe a case of MES arising on the tip of the right middle toe. The lesion had been managed as a non-specific chronic ulcer for 4 years. The lesion was treated by elective amputation. We wish to emphasise through this case report the importance of keeping this rare but potentially lethal tumour in mind when managing chronic non-healing ulcers in extremities.

Does flexion contracture continue to improve up to five years after total knee arthroplasty?

PURPOSE

To determine whether flexion contracture continues to improve up to 5 years after total knee arthroplasty (TKA).

METHODS

Records of 200 women and 123 men (mean age, 72 years) with osteoarthritis and preoperative flexion contracture were reviewed. 155 (48%) involved the left knee and 168 (52%) the right knee. Patients were assessed clinically before TKA and one and 5 years later, by a single researcher using a goniometer to measure flexion contracture, range of movement, maximum flexion, and the Knee Society Score. In all patients the same prosthesis design was used. The surgical technique was standard and involved a medial parapatellar approach with bone resection.

RESULTS

All variables improved significantly from pre-TKA to one-year post-TKA and from one-year post-TKA to 5-year post-TKA; respectively the mean flexion contracture decreased from 11 to 3 to 2 degrees; the mean knee range of movement increased from 90 to 103 to 107 degrees; the mean maximum flexion increased from 101 to 106 to 109 degrees; and the mean Knee Society Scores increased from 39 to 87 to 90.

CONCLUSION

Functional outcome and flexion contracture may continue to improve up to 5 years after TKA.

The Environmental Stewardship System (ESS): a generic system for assuring rural environmental performance

The Environmental Stewardship System (ESS) is proposed as a generic assurance system for demonstrating environmental performance. It incorporates Environmental Management Systems (EMS) and is matched to natural resources management (NRM) and catchment targets. ESS is a framework for aligning and clarifying environmental objectives and targets across scales. It operates at the catchment and farm levels, interdependently, focusing on the main industries, mainstream farming methods and whole-farm business management. For farmers, it provides a staged pathway of increasing levels of performance and audit process that they can progress along, up to full ISO 14001. It is a modular system that is expandable to suit the particular operational needs of land managers, industries and catchment agencies. ESS is an inclusive framework for integrating various industry farm management improvement schemes and other management requirements. It is an auditable system to provide recognition to land managers who deliver environmental stewardship. The ESS was developed from the findings of the Murray–Darling Basin Commission’s Watermark Environmental Stewardship Project. By addressing the four major deficiencies in current arrangements for NRM delivery (the Stewardship Standard is poorly defined at the Murray–Darling Basin and at the local scales; reporting of outcomes is poorly aligned across scales; and auditing arrangements are not integrated) ESS has the potential to significantly improve the delivery of NRM within Australia, when the drivers for uptake are strong enough. In particular, it would reinforce and elaborate the Australian regional NRM delivery model at the subregional scale. The ESS provides a national framework for assured agricultural production and rural land management. It is in the public domain for others to draw from or adopt.

Albuminuria in a remote South Australian Aboriginal community: results of a community-based screening program for renal disease

INTRODUCTION

The poverty, poor environmental living conditions and poor health standards experienced by Aboriginal Australians in some communities in rural and remote Australia have been described recently as 'fourth world'. For more than a century Aboriginal people have suffered the effects of dispossession of their land; destruction of their traditional culture and values; and exposure to infectious diseases, alcohol and the Western diet that is high in fat and sugar. Collectively these factors have contributed to the prevalence of chronic disease that afflicts Aboriginal people. In particular, renal disease has emerged during the last decade as a major contemporary health problem for Aboriginal Australians. According to the latest age- and sex-adjusted figures, Aboriginal people now have approximately nine-fold the risk of non-Aboriginal Australians of developing end-stage renal disease. In parts of Australia's Northern Territory, where Aboriginal people represent over 20% of the Territory's population, the rates of end-stage renal disease have been described as 'epidemic', reaching 2700 per million in the Tiwi Islands. In response to a request from the Umoona Tjutagku Health Service in mid 1997, the Renal Unit at Flinders Medical Centre, Adelaide, South Australia, formed a partnership with the health service to conduct a renal-disease screening program for adult members of the Umoona Community at Coober Pedy, a town 850 kilometres north of Adelaide. The partnership was later expanded to include screening for children (conducted by the Renal Unit at the Women's and Children's Hospital, Adelaide, South Australia). The community named the program 'The Umoona Kidney Project'. The Umoona community had recently experienced the dislocation of a number of its older people who suffered from advanced renal disease and were undergoing dialysis in a variety of centres in South Australia and the Northern Territory. As a result, the community had suffered social trauma. Consistent with the community's overall holistic approach to healthcare, the community wanted the renal program to provide a focus for community awareness of and knowledge about chronic disease, as well as to complement existing health programs.

OBJECTIVES

The study objectives were to identify the prevalence of risk factors for renal disease, notably albuminuria, in adults from a remote Aboriginal community, and to examine the association of albuminuria with other risk factors; to empower Aboriginal health workers to self-manage a sustainable, community-controlled renal health program; and to assess the reliability and cultural acceptability of point-of-care technology for detecting renal disease.

METHOD

The study was a three-year cross-sectional voluntary adult screening program (The Umoona Kidney Project). The study was performed as a partnership between the Flinders Medical Centre Renal Unit and the Umoona Tjutagku Health Service, and it involved nephrologists, medical scientists, Aboriginal health workers and clinical nurses.

SETTING

Umoona Tjutagku Health Service, 850 km north of Adelaide.

PARTICIPANTS

158 adult members of the Umoona community: 58 males (37%; mean age = 43.8 years, range 23-78) and 100 females (63%; mean age = 39.6 years, range 18-72).

MAIN OUTCOME MEASURES

First morning urine albumin : creatinine ratio measured by the Bayer DCA 2000 point-of-care analyser machine (Bayer Australia, Melbourne, Australia); lying and standing blood pressure; random blood glucose; body mass index; urinalysis.

RESULTS

The study found that of screened adults, 29/149 (19%, 95% C.I. 13%-27%) had persistent microalbuminuria and 13/149 (9%, 95% C.I. 4%-14%) had persistent macroalbuminuria; 62/148 participants (42%, 95% C.I. 34%-50%) had overt hypertension; 35/145 participants (24%, 95% C.I. 17%-32%) had diabetes; 3 participants were newly diagnosed as having non-insulin dependent diabetes; 96/148 participants (65%, 95% C.I. 57%-73%) were either overweight or obese. Strong correlation was observed between the progression of albuminuria and age, all blood pressure categories, blood glucose, body mass index and an increasing number of risk factors.

CONCLUSIONS

The Umoona Kidney Project identified a significant community burden of previously unknown incipient and established renal disease that required addressing via clinical- and community-based interventions. The DCA 2000 was a reliable instrument for detecting albuminuria on-site in the remote clinical location and was well accepted by Aboriginal health workers and community participants.

Four novel mutations in the RPE65 gene in patients with Leber congenital amaurosis

Leber congenital amaurosis (LCArpar; is a heterogeneous disorder representing the congenital forms of retinitis pigmentosa accounting for about 5% of all retinal dystrophies. The RPE65 gene product is required for regeneration of the visual pigment for phototransduction. Defects in the RPE65 gene have so far been shown to account for approximately 10 % of known cases of LCA. Here we describe four additional novel mutations in the RPE65 gene (c.889delA, c.131G>A, c.1249G>C, c.430T>G) and several novel polymorphisms in a large series of LCA patients. Hum Mutat 18:164, 2001.

Canadian beef quality audit 1998-99

The second beef quality audit was conducted in Canada in 1998-99 to determine the prevalence of quality defects in slaughtered cattle and to monitor changes since the first audit in 1995. Approximately 0.6% of the number of cattle processed annually in Canada were evaluated. Brands were observed on 49% and tag was observed on 43% of the hides. Both brands and tag had increased from 1995. Seventy percent of the cattle were polled and 5% had full horns; thus, the number of horned cattle had decreased from 1995. Bruises were found on 54% of the carcasses, which was a decrease from 78% in 1995. Sixty-eight percent of the bruises were minor, 28% major, and 4% critical in severity. The distribution of bruises on the carcass was 17% on the chuck, 36% on the rib, 30% on the loin, and 16% on the round. Grubs were observed on 0.008% of the carcasses, and surface injection site lesions were observed on 0.2% of the whole carcasses, a decrease from the 1.3% seen in 1995. Seventy-two percent of the livers were passed for human food and 14% for pet food; 14% were condemned. Approximately 64% of the liver losses were due to abscesses. Five percent of the heads and tongues and 0.3% of the whole carcasses were condemned. The hot carcass weight was highly variable in all cattle, averaging 353 kg (s = 43). The average ribeye area was 90 cm2 (s = 13). Both hot carcass weight and ribeye area had increased from 1995. The average grade fat was 9 mm (s = 5), ranging from 0 mm to 48 mm. Lean meat yield averaged 58.8% (s = 4.6). One percent of the carcasses were devoid of marbling, 17% were Canada A, 49% were Canada AA, 32% were Canada AAA, and 1% were Canada Prime, which was an increase in marbling from 1995. Dark cutters were found in 1% of all carcasses; 1% of steers, 0.5% of heifers, 3% of cows, and 14% of bulls. Three percent of the carcasses were underfinished and 13% were overfinished. The number of overfinished carcasses had increased from 1995. Stages, steers with bullish traits, were infrequently observed in 0.5% of the steers, and 0.2% of the steers and 0.3% of the heifers had poor conformation. Yellow fat was not observed in any steers or heifers, but it was found on 65% of the cow carcasses. Only 0.6% of the heifers had an aged carcass, based on skeletal maturity. Based on August 1998 to July 1999 prices, it was estimated that the Canadian beef industry lost $82.62 per head processed, or $274 million annually, from quality nonconformities, which was an increase from 1995. Additional improvements in management, feeding, handling, genetics, marketing, and grading are needed in the beef industry to reduce quality defects.

Postoperative pain relief using thoracic epidural analgesia: outstanding success and disappointing failures

Six hundred and forty patients received epidural analgesia for postoperative pain relief following major surgery in the 6-year period 1993-1998. Although satisfactory pain relief was achieved in over two-thirds of patients for a median duration of 44 h after surgery, one-fifth of patients (133 individuals) still experienced poor pain relief. Almost one out of three patients (194 individuals) had a problem with their epidural. Eighty-three patients (13%) suffered a technical failure and 84 (13%) patients had their epidurals removed at night time when pain-free because of pressure on beds. Seven patients had their epidural replaced and subsequently experienced excellent pain relief for a median of 77 h. Lack of resources prevented a further 480 patients from receiving the potential benefits of epidural analgesia. These results would suggest that the practical problems of delivering an epidural service far outweigh any differences in drug regimens or modes of delivery of epidural solutions.

Propofol 2% in critically ill patients: effect on lipids

OBJECTIVE

To investigate the concentrations of triglyceride, cholesterol, and high-density lipoprotein during a 50-hr infusion of 2% propofol, starting within 24 hrs of admission to the intensive care unit (ICU).

DESIGN

Prospective, clinical study.

SETTING

ICU, university hospital.

PATIENTS

Thirty adult patients, who were ventilated and expected to be sedated for >2 days, were studied for 50 hrs, beginning at 1800 hrs on the first day of ICU admission.

MEASUREMENTS AND MAIN RESULTS

Triglyceride, cholesterol, and high-density lipoprotein were measured at 2000, 0400, and 0800 hrs. Tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and C-reactive protein were measured at 2000 hrs. Median cholesterol and high-density lipoprotein concentrations were at the low end of the normal range. In seven patients, peak triglyceride concentrations were >3 mmol/L up to a maximum of 4.83 mmol/L. Although there was no statistical difference in lipid concentrations between days 1 and 2, there was an apparent pattern of increasing triglyceride concentrations. There was a correlation between peak triglyceride concentration and total propofol consumption, but there was no correlation between lipids and age, gender, or Acute Physiology and Chronic Health Evaluation II scores. There was a direct correlation between triglyceride and C-reactive protein concentrations, and an inverse correlation between cholesterol and C-reactive protein. Twenty-two patients had evidence of TNF and 11 patients had an IL-6 of >1000 pg/mL, but there was no relationship between concentrations of cytokines and triglycerides in plasma.

CONCLUSIONS

Infusion of 2% propofol to critically ill patients over a 50-hr period does not result in a significant increase in triglyceride concentrations. Mean cholesterol and high-density lipoprotein concentrations were low throughout the study period. There was a significant direct correlation between triglyceride and C-reactive protein and an inverse correlation between cholesterol and C-reactive protein, suggesting that the changes in lipids in critically ill patients may be partly attributable to the acute-phase response.

Use of 2% propofol to produce diurnal sedation in critically ill patients

OBJECTIVE

The assessment of propofol to produce diurnal sedation in critically ill patients.

DESIGN

Prospective clinical study.

SETTING

Intensive Care Unit, University Hospital.

PATIENTS AND PARTICIPANTS

Thirty consecutive patients admitted to the Intensive Care Unit older than 18 years who were expected to be sedated for more than 50 h.

INTERVENTIONS

The patients were randomised into two groups. All received sedation with a constant background infusion of morphine and a variable infusion rate of propofol, which was altered hourly to maintain the intended sedation score. The first group received constant light sedation (CLS) over 50 h aiming for a Ramsay score of 2-3. The second group received CLS between 0600 h and 2200 h and additional night sedation (ANS) with propofol between 2200 h and 0600 h, aiming for a sedation score of 4-5.

MEASUREMENTS AND RESULTS

Patients were studied for 50 h from 1800 h on the first day of admission. Recordings of heart rate, blood pressure, sedation scores and propofol and morphine infusion rates were made hourly. An APACHE II score was recorded for each patient. Sedation scores were analysed by blind visual assessment and cosinor analysis, which is used in chronobiology to examine the correlation of data with a cosine curve. Patients in the ANS group had significantly better rhythmicity of sedation levels using cosinor analysis (r = 26% v 8%) p < 0.01. There was no difference between the CLS and ANS groups with respect to age, sex or APACHE II scores. Nine out of 15 patients in the ANS group achieved diurnal sedation. Three patients in the CLS group showed diurnal rhythmicity of sedation, which can be attributed to natural sleep, and had a median APACHE II score of 12. Five patients in the CLS group and three in the ANS group showed a deep constant sedation pattern. They had high APACHE II scores (median 21.5) and an obtunded conscious level on admission due to severe sepsis.

CONCLUSION

Propofol can safely provide diurnal sedation in the critically ill when titrated against the Ramsay score. Sedation levels cannot be manipulated in some severely ill patients.

Temporal association of cellular immune responses with the initial control of viremia in primary human immunodeficiency virus type 1 syndrome

Virologic and immunologic studies were performed on five patients presenting with primary human immunodeficiency virus type 1 (HIV-1) infection. CD8+ cytotoxic T lymphocyte (CTL) precursors specific for cells expressing antigens of HIV-1 Gag, Pol, and Env were detected at or within 3 weeks of presentation in four of the five patients and were detected in all five patients by 3 to 6 months after presentation. The one patient with an absent initial CTL response had prolonged symptoms, persistent viremia, and low CD4+ T-cell count. Neutralizing antibody activity was absent at the time of presentation in all five patients. These findings suggest that cellular immunity is involved in the initial control of virus replication in primary HIV-1 infection and indicate a role for CTL in protective immunity to HIV-1 in vivo.

Speed of onset of sensory block for elective extradural caesarean section: choice of agent and temperature of injectate

We have studied the effects of choice of local anaesthetic and temperature of extradural injectate on speed of onset of sensory block for elective extradural Caesarean section in a double-blind trial in 120 women allocated randomly to one of four groups to receive either plain 0.5% bupivacaine or 2% lignocaine with 1:200,000 adrenaline at either room temperature or 38 degrees C. The onset time of lignocaine with adrenaline was shorter than that of bupivacaine regardless of temperature (P < 0.01). Warmed lignocaine produced the most rapid block overall (P < 0.025). The incidence of hypotension, ephedrine requirement, shivering, quality of analgesia and additional analgesic requirements were similar for all groups.

Preservation of canine kidneys by hypothermia and hyperbaric oxygen: long-term survival of autografts following 24-hour storage

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