Measurement of upper limb function in ALS: a structure review of current methods and future directions

Measurement of upper limb function is critical for tracking clinical severity in amyotrophic lateral sclerosis (ALS). The Amyotrophic Lateral Sclerosis Rating Scale-revised (ALSFRS-r) is the primary outcome measure utilised in clinical trials and research in ALS. This scale is limited by floor and ceiling effects within subscales, such that clinically meaningful changes for subjects are often missed, impacting upon the evaluation of new drugs and treatments. Technology has the potential to provide sensitive, objective outcome measurement. This paper is a structured review of current methods and future trends in the measurement of upper limb function with a particular focus on ALS. Technologies that have the potential to radically change the upper limb measurement field and explore the limitations of current technological sensors and solutions in terms of costs and user suitability are discussed. The field is expanding but there remains an unmet need for simple, sensitive and clinically meaningful tests of upper limb function in ALS along with identifying consensus on the direction technology must take to meet this need.

Predation by introduced cats Felis catus on Australian frogs: compilation of species records and estimation of numbers killed

Abstract ContextWe recently estimated the numbers of reptiles, birds and mammals killed by cats (Felis catus) in Australia, with these assessments providing further evidence that cats have significant impacts on Australian wildlife. No previous studies have estimated the numbers of frogs killed by cats in Australia and there is limited comparable information from elsewhere in the world. AimsWe sought to (1) estimate the numbers of frogs killed by cats in Australia and (2) compile a list of Australian frog species known to be killed by cats. MethodsFor feral cats, we estimated the number of frogs killed from information on their frequency of occurrence in 53 cat dietary studies (that examined stomach contents), the mean number of frogs in dietary samples that contained frogs, and the numbers of cats in Australia. We collated comparable information for take of frogs by pet cats, but the information base was far sparser. Key resultsFrogs were far more likely to be reported in studies that sampled cat stomachs than cat scats. The mean frequency of occurrence of frogs in cat stomachs was 1.5%. The estimated annual per capita consumption by feral cats in Australia’s natural environments is 44 frogs, and, hence, the annual total take is estimated at 92 million frogs. The estimated annual per capita consumption by pet cats is 0.26 frogs, for a total annual kill of one million frogs by pet cats. Thirty native frog species (13% of the Australian frog fauna) are known to be killed by cats: this tally does not include any of the 51 threatened frog species, but this may simply be because no cat dietary studies have occurred within the small ranges typical of threatened frog species. ConclusionsThe present study indicated that cats in Australia kill nearly 100 million frogs annually, but further research is required to understand the conservation significance of such predation rates. ImplicationsThe present study completed a set of reviews of the impacts of cats on Australian terrestrial vertebrates. Cat predation on Australian frogs is substantial, but is likely to be markedly less than that on Australian reptiles, birds and mammals.

High-flow Nasal Cannulae, Bronchopulmonary Dysplasia and Retinopathy of Prematurity

Aims To determine if HFNC use was associated with changes in incidence of BPD and ROP. Methods This retrospective study examined premature infants (<30 weeks GA or <1500g) in a tertiary neonatal unit from 2010- 2016. Patients were compared before and after introduction of HFNC. Further analysis of high-risk infants (<28 weeks GA or <750g or ventilated) compared those who received HFNC to those who did not across the whole period. Primary outcomes were incidence of BPD and ROP requiring surgery. Results Incidence of BPD rose following the introduction of HFNC (82/232 (35.3%) after vs 33/251 (13.1%) before, p<0.001). On multivariate analysis, the chance of developing BPD after HFNC introduction remained higher (OR 4.353, 95% CI 2.546-7.443). More infants received surgery for ROP following HFNC introduction (0/214 vs 11/205 (5.4%), p=<0.001). In the second analysis, the rate of BPD was higher in those who received HFNC (90/132 (68.1%) vs 33/153 (21.6%), p<0.001). Receiving HFNC demonstrated higher chance of BPD in multivariate analysis (OR 7.802, 95% CI 4.223-14.423). Rate of ROP surgery was higher in those who received HFNC (0/153 vs 13/134 (9.7%), p<0.001). Conclusions In this study, use of HFNC was associated with significantly increased risk of adverse outcomes.

How many reptiles are killed by cats in Australia?

Context Feral cats (Felis catus) are a threat to biodiversity globally, but their impacts upon continental reptile faunas have been poorly resolved. Aims To estimate the number of reptiles killed annually in Australia by cats and to list Australian reptile species known to be killed by cats. Methods We used (1) data from >80 Australian studies of cat diet (collectively >10 000 samples), and (2) estimates of the feral cat population size, to model and map the number of reptiles killed by feral cats. Key results Feral cats in Australia’s natural environments kill 466 million reptiles yr–1 (95% CI; 271–1006 million). The tally varies substantially among years, depending on changes in the cat population driven by rainfall in inland Australia. The number of reptiles killed by cats is highest in arid regions. On average, feral cats kill 61 reptiles km–2 year–1, and an individual feral cat kills 225 reptiles year–1. The take of reptiles per cat is higher than reported for other continents. Reptiles occur at a higher incidence in cat diet than in the diet of Australia’s other main introduced predator, the European red fox (Vulpes vulpes). Based on a smaller sample size, we estimate 130 million reptiles year–1 are killed by feral cats in highly modified landscapes, and 53 million reptiles year–1 by pet cats, summing to 649 million reptiles year–1 killed by all cats. Predation by cats is reported for 258 Australian reptile species (about one-quarter of described species), including 11 threatened species. Conclusions Cat predation exerts a considerable ongoing toll on Australian reptiles. However, it remains challenging to interpret the impact of this predation in terms of population viability or conservation concern for Australian reptiles, because population size is unknown for most Australian reptile species, mortality rates due to cats will vary across reptile species and because there is likely to be marked variation among reptile species in their capability to sustain any particular predation rate. Implications This study provides a well grounded estimate of the numbers of reptiles killed by cats, but intensive studies of individual reptile species are required to contextualise the conservation consequences of such predation.

Coping strategies in carers of young people with a first episode of psychosis

BACKGROUND

Carers of young people with first episode psychosis (FEP) often face burden. Understanding ways in which carers cope is not only important for providing support to them but might maximise patient outcomes. The aim of this study was to examine strategies carers use to cope with the burden of caring for a young person with FEP.

METHODS

The study was part of a randomized controlled trial focusing on the effectiveness of a problem-solving bibliotherapy intervention for carers of FEP patients, in terms of promoting coping and reducing psychological distress. Baseline data on the Ways of Coping (WOC) scale was available for 124 carers aged between 18 and 66 years. Principal component analysis with PROMAX rotation was used to determine the number of factors that could be used to characterise coping behaviour. Regression analyses were used to determine how the factors were related to carers' demographics, burden, psychological well-being and expressed emotion.

RESULTS

Approximately half of the carers reported that they frequently use positive coping techniques such as self-talk, active problem solving, and positive reframing. The factor analysis yielded five factors: (i) cognitive-escape coping; (ii) optimistic coping; (iii) seeking connections; (iv) tension reduction; and (v) distancing. The relationships between these factors and demographic characteristics, carers' perception of burden, expressed emotion, and psychological distress are reported.

CONCLUSIONS

Avoidance coping strategies are related to psychological distress, emotional over-involvement, and increased carer burden. Interventions facilitating the use of adaptive problem solving and positive re-appraisal will promote carer coping and reduce psychological distress.

Investigating the feasibility of using a grit blasting process to coat nitinol stents with hydroxyapatite

This study investigates the feasibility of utilising a grit blasting process to coat three nitinol substrates (a planer 2D surface, a circular wire and a cardiovascular stent geometry) with a hydroxyapatite coating. Surface characteristics of the coating on the three substrates were determined and additionally the durability of the coating post fatigue testing was analysed. The coating process resulted in a consistent covering of the substrate that resulted in an extremely hydrophilic stent surface. The surface roughness was dependant on grit blasting particle size. A general trend of smaller particle size resulted in a lower surface roughness, while particle size did not have an effect on the hydroxyapatite coating thickness. Fatigue integrity tests that simulated 16 months implantation demonstrated minimal damage to the coating. In conclusion we demonstrated the initial feasibility of using a grit blasting method to produce a consistent, hydrophilic, and durable HAp stent coating that has the capability of incorporating a drug eluting function.

Mechanical characterization of a customized decellularized scaffold for vascular tissue engineering

Several challenges persist when attempting to utilize decellularized tissue as a scaffold for vascular tissue engineering. Namely: poor cell infiltration/migration, excessive culture times associated with repopulating the scaffolds, and the achievement of a quiescent medial layer. In an attempt to create an optimum vascular scaffold, we customized the properties of decellularized porcine carotid arteries by: (i) creating cavities within the medial layer to allow direct injection of cells, and (ii) controlling the amount of collagen digestion to increase the porosity. Histological examination of our customized scaffold revealed a highly porous tissue structure containing consistent medial cavities running longitudinally through the porous scaffold wall. Mechanical testing of the customized scaffold showed that our minimal localized disruption to the ECM does not have a detrimental effect on the bulk mechanical response of the tissue. The results demonstrate that an increased stiffness and reduced distensibility occurs after decellularization when compared to the native tissue, however post scaffold customization we can revert the scaffold tensile properties back to that of the native tissue. This most noteworthy result occurs in the elastin dominant phase of the tensile response of the scaffold, indicating that no disruption has occurred to the elastin network by our decellularization and customization techniques. Additionally, the bulk seeding potential of the customized scaffold was demonstrated by direct injection of human smooth muscle cells through the medial cavities. The optimum cell dispersion was observed in the highest porosity scaffold, with large cell numbers retained within the medial layer after 24 h static culture. In summary, this study presents a novel customized decellularized vascular scaffold that has the capability of bulk seeding the media, and in tandem to this method, the porosity of the scaffold has been increased without compromising the mechanical integrity.

Introducing random safety audits (RSA) in a neonatal intensive care unit (NICU)

Random safety audits (RSA) have been shown to be effective in improving standards of clinical practice. 19 data collection audits were performed relating to hygiene, safe prescribing, oxygen pulse oximetry monitoring and documentation in keeping with the requirements of the new Medical Practitioners Act (MPA) 2007. Hygiene audits (range from 20/25 to 21/21 80%-100%) and safe prescribing audits (range from 23/25 to 25/25 86%-100%) achieved n=25 100% compliance with unit guidelines over a 3 month period. Compliance with oxygen pulse oximetry monitoring guideline limits improved from 4/27 (15%) to 9/16 (56%). Compliance with requirement and use of Physician IMC registration number in documentation was only 10/18 (56%). RSA's led to improvements in hygiene and prescribing. Compliance with oxygen monitoring guideline limits highlighted the need for greater education. Awareness of legal requirements relating to documentation improved but this has not translated into a change in practice. RSA's can facilitate real time quality improvement in daily clinical practice.

Palivizumab use in preterm neonates

Respiratory syncytial virus (RSV) is the leading cause of bronchiolitis in infants. Palivizumab is an immunoprophylactic agent for RSV prevention in preterm infants and those with neonatal chronic lung disease. This study examines its use across neonatal units in Ireland. A questionnaire was administered to one Consultant Neonatologist or Paediatrician in each of the 20 maternity centres in Ireland about their guidelines for Palivizumab administration. There is variation in administration of Palivizumab with little consistency found between protocols reported in terms of age and presence of chronic lung disease. Ten centres have in house protocols, 3 centres use the American Academy of Paediatrics (AAP) guidelines, 2 centres prefer the UK Joint Committee on Vaccination and Immunisation (JCVI) guidelines and 3 centres do not have a set protocol. Four participants felt its use has impacted on hospital admissions and 61% believe its use is cost effective. The budgetary implication for immunoprophylaxis with Palivizumab in Ireland is estimated at 1.5 to 2 million euros annually. Given current pharmacoeconomic constraints there is a need to implement a national protocol on RSV immunoprophylaxis.

Benchmarking care for very low birthweight infants in Ireland and Northern Ireland

BACKGROUND

Benchmarking is that process through which best practice is identified and continuous quality improvement pursued through comparison and sharing. The Vermont Oxford Neonatal Network (VON) is the largest international external reference centre for very low birth weight (VLBW) infants. This report from 2004-7 compares survival and morbidity throughout Ireland and benchmarks these results against VON.

METHODS

A standardised VON database for VLBW infants was created in 14 participating centres across Ireland and Northern Ireland.

RESULTS

Data on 716 babies were submitted in 2004, increasing to 796 babies in 2007, with centres caring for from 10 to 120 VLBW infants per year. In 2007, mortality rates in VLBW infants varied from 4% to 19%. Standardised mortality ratios indicate that the number of deaths observed was not significantly different from the number expected, based on the characteristics of infants treated. There was no difference in the incidence of severe intraventricular haemorrhage between all-Ireland and VON groups (5% vs 6%, respectively). All-Ireland rates for chronic lung disease (CLD; 15-21%) remained lower than rates seen in the VON group (24-28%). The rates of late onset nosocomial infection in the all-Ireland group (25-26%) remained double those in the VON group (12-13%).

DISCUSSION

This is the first all-Ireland international benchmarking report in any medical specialty. Survival, severe intraventricular haemorrhage and CLD compare favourably with international standards, but rates of nosocomial infection in neonatal units are concerning. Benchmarking clinical outcomes is critical for quality improvement and informing decisions concerning neonatal intensive care service provision.

Fatal acute fulminant hepatic failure caused by parenteral amiodarone: A case report and review of the literature

Parenteral amiodarone is used frequently in acutely ill patients, but it can be associated with hepatotoxicity. We present a case of fatal fulminant hepatic failure attributable to intravenous amiodarone. We review the literature and explore possible reasons for the severe reaction seen in our patient.

Persistent lactic acidosis in neonatal hypoxic-ischaemic encephalopathy correlates with EEG grade and electrographic seizure burden

BACKGROUND

Predicting at birth which infants with perinatal hypoxic-ischaemic injury will progress to significant encephalopathy remains a challenge.

OBJECTIVE

To determine whether lactic acidosis at birth in asphyxiated neonates could predict the grade of EEG encephalopathy by examining the relationship between time taken for the normalisation of lactate, severity of encephalopathy and seizure burden.

METHODS

Continuous early video-EEG monitoring was performed in babies at risk for hypoxic-ischaemic encephalopathy. Encephalopathy was graded from the EEG data. Total seizure burden (seconds) was calculated for each baby. Initial blood gas measurements of pH, base deficit and lactate were taken within 30 minutes of delivery. Time to normal serum lactate was determined in hours from birth for each infant.

RESULTS

All 50 term infants had raised initial serum lactate (median (lower, upper quartiles) 11.7 (10.2, 14.9)). There were no significant differences between the initial serum lactate, pH and base deficit in infants with normal/mildly abnormal (n = 24), moderately abnormal (n = 14), severely abnormal (n = 5) and inactive EEGs (n = 7). Time to normal lactate varied significantly with EEG grade (median (lower, upper quartile) 6.0 (4.1, 9.5) for mild/normal EEG, 13.5 (6.8, 23.5) moderate EEG, 41.5 (30.0, 55.5) severe group, 12.0 (8.1, 21.5) inactive group; p<0.001). Time to normal lactate correlated significantly with EEG seizure burden (seconds; R = 0.446, p = 0.002). Mean (SD) time to normal lactate was 10.0 (7.2) hours in infants who did not have seizures and 27.3 (19.0) hours in the 13 infants with electrographic seizures (p = 0.002).

CONCLUSIONS

Serum lactate levels in the first 30 minutes of life do not predict the severity of the ensuing encephalopathy. In contrast, sustained lactic acidosis is associated with severe encephalopathy on EEG and correlates with seizure burden.

Defining the gap between electrographic seizure burden, clinical expression and staff recognition of neonatal seizures

BACKGROUND

Neonatal seizures are often subclinical, making accurate diagnosis difficult.

OBJECTIVE

To describe the clinical manifestations of electrographic seizures recorded on continuous video-EEG, and to compare this description with the recognition of clinical seizures by experienced neonatal staff.

METHODS

Term infants, at risk of seizures, were monitored by continuous 12-channel video-EEG from <6 hours of birth for up to 72 hours. All clinical seizures were recorded by experienced neonatal staff on individual seizure charts. Video-EEG recordings were subsequently analysed. The number, duration and clinical expression of electrographic seizures were calculated (in seconds), and compared with the seizures clinically suspected by the neonatal staff.

RESULTS

Of 51 infants enrolled, nine had electrographic seizures. A further three had clinically suspected seizures, without associated electrographic abnormality. Of the total 526 electrographic seizures, 179 (34%) had clinical manifestations evident on the simultaneous video recording. The clinical seizure activity corresponded to 18.8% of the total electrographic seizure burden. Overdiagnosis also occurred frequently. Of the 177 clinically suspected seizure episodes documented by staff, 48 (27%) had corresponding electrographic evidence of seizure activity Thus, only 9% (48/526) of electrographic seizures were accompanied by clinical manifestations, which were identified and documented by neonatal staff.

CONCLUSION

Only one-third of neonatal EEG seizures displays clinical signs on simultaneous video recordings. Moreover, two-thirds of these clinical manifestations are unrecognised, or misinterpreted by experienced neonatal staff. In the recognition and management of neonatal seizures clinical diagnosis alone is not enough.

Have we stopped looking for a red reflex in newborn screening?

Best medical evidence indicates that surgical treatment of significant congenital cataracts is required within the first 3 months of life for optimal visual outcome. The aim of the present study was to review when the diagnosis of congenital cataracts was made in our region, by whom it was made, and the visual outcome at 2 years of age or more. This was a retrospective study in a region with a population of 546,000 and approximately 8500 births per annum, served by a single Regional Ophthalmology centre. All children under 15 years, diagnosed with Congenital Cataract over a 10-year period (1991-2002), were identified using the Hospital In-Patient Enquiry [HIPE] database. Children with cataract(s) from infancy from a congenital cause and those first presenting outside infancy but with salient clinical features indicating early cataract were included in the study. 27 cases of congenital and infantile cataract 15 (56%) males, 12 (44%) females were retrieved. 17 infants (63%) were diagnosed with bilateral disease, while the remainder were unilateral 10 (37%). Most of the cases 17 (63%) were diagnosed following presentation with parental/carer concerns about visual function (usually a squint). However only 2 of these 17 cases presented before 3 months of age. The remaining cases of congenital cataracts were diagnosed by general practitioners 8 (24%), paediatricians 4 (12%), ophthalmologists 3 (9%) or School Medical Officer (1, 3%). No case of congenital cataract was diagnosed by newborn screening examination. Six of 8 infants diagnosed with congenital cataracts before three months of age had a good visual outcome, (visual acuity < 6/24 at 2 years or more). In contrast only 3 of 19 cases who were diagnosed after 3 months of age had good visual outcomes. Despite their relative rarity, it is imperative that congenital cataracts are diagnosed and treated within 3 months of birth. The onus of diagnosis rests with newborn screening examiners at birth and with general practitioners at the 6-8 week checks. Parental concerns about a possible squint should be addressed by performing a red light reflex examination and urgent specialist ophthalmological referral if a flaw is detected.

The influence of grain size on the ductility of micro-scale stainless steel stent struts

Vascular stents are used to restore blood flow in stenotic arteries, and at present the implantation of a stent is the preferred revascularisation method for treating coronary artery disease, as the introduction of drug eluting stents (DESs) has lead to a significant improvement in the clinical outcome of coronary stenting. However the mechanical limits of stents are being tested when they are deployed in severe cases. In this study we aimed to show (by a combination of experimental tests and crystal plasticity finite element models) that the ductility of stainless steel stent struts can be increased by optimising the grain structure within micro-scale stainless steel stent struts. The results of the study show that within the specimen size range 55 to 190 microm ductility was not dependent on the size of the stent strut when the grain size maximised. For values of the ratio of cross sectional area to characteristic grain length less than 1,000, ductility was at a minimum irrespective of specimen size. However, when the ratio of cross sectional area to characteristic grain length becomes greater than 1,000 an improvement in ductility occurs, reaching a plateau when the ratio approaches a value characteristic of bulk material properties. In conclusion the ductility of micro-scale stainless steel stent struts is sensitive to microstructure and can be improved by reducing the grain size.

Genomic comparisons of Salmonella enterica serovar Dublin, Agona, and Typhimurium strains recently isolated from milk filters and bovine samples from Ireland, using a Salmonella microarray

Salmonella-induced enterocolitis is the leading food-borne illness with a lethal outcome and causes millions of cases of gastroenteritis each year. We examined genomic variation among 12 environmental, veterinary, and clinical Salmonella enterica serovar Dublin, Agona, and Typhimurium strains isolated in Ireland between 2000 and 2003, as well as two clinical isolates from Canada and four archival isolates, which belonged to serovars Dublin and Agona. Using DNA-DNA hybridization to a microarray consisting of most of the predicted protein-encoding sequences of the S. enterica serovar Typhimurium LT2 genome, we identified a number of genomic regions that were absent in one or more serovars. The 34 genomic regions encoded proteins involved in sugar metabolism, transport, fimbrial and phage biogenesis, and transcriptional regulation, as well as inner and outer membrane-associated proteins. Two of the four prophages identified in strain LT2, prophages Gifsy-1 and Gifsy-2, were present in all six serovar Typhimurium strains examined. Prophage Fels-1 was absent from all 18 isolates examined, and Fels-2 was completely absent from the serovar Typhimurium isolates and the Salmonella Reference Collection B serovar Dublin strain Du2. All five Salmonella pathogenicity islands were present in all isolates. Plasmid pSLT was absent from all serovar Agona isolates, and only homologues of the spv genes were present in eight of the nine serovar Dublin strains. Only limited intraserovar diversity was found among the nine serovar Dublin, three serovar Agona, and six serovar Typhimurium isolates examined even though these isolates had extensive geographic, temporal, and source differences.

Comparison of three manual ventilation devices using an intubated mannequin

OBJECTIVE

To compare three devices for manual neonatal ventilation.

DESIGN

Participants performed a two minute period of ventilation using a self inflating device, an anaesthesia bag with attached manometer, and a Neopuff device. An intubated neonatal mannequin, approximating a 1 kg infant with functional lungs, was used for the study. Target ventilation variables included a rate of 40 breaths per minute, peak inspiratory pressure (PIP) of 20 cm H2O, and positive end expiratory pressure (PEEP) of 4 cm H2O. The circuit was attached to a laptop computer for data recording.

RESULTS

Thirty five participants were enrolled, including consultant neonatologists, paediatricians, and anaesthetists, paediatric and anaesthetic registrars, and neonatal nurses. The maximum PIP recorded using the self inflating bag, anaesthetic bag, and Neopuff device were 75.9, 35.5, and 22.4 cm H2O respectively. There were significant differences between the devices for mean PIP (30.7, 18.1, and 20.1 cm H2O), mean PEEP (0.2, 2.8, and 4.4 cm H2O), mean airway pressure (7.6, 8.5, and 10.9 cm H2O), % total breaths < or = 21 cm H2O PIP (39%, 92%, and 98%), and % total breaths > or = 30 cm H2O PIP (45%, 0, and 0). There was no difference between doctors and allied health professionals for the variables examined.

CONCLUSION

The anaesthetic bag with manometer and Neopuff device both facilitate accurate and reproducible manual ventilation. Self inflating devices without modifications are not as consistent by comparison and should incorporate a manometer and a PEEP device, particularly when used for resuscitation of very low birthweight infants.

Mining the microbiota of the neonatal gastrointestinal tract for conjugated linoleic acid-producing bifidobacteria

This study was designed to isolate different strains of the genus Bifidobacterium from the fecal material of neonates and to assess their ability to produce the cis-9, trans-11 conjugated linoleic acid (CLA) isomer from free linoleic acid. Fecal material was collected from 24 neonates aged between 3 days and 2 months in a neonatal unit (Erinville Hospital, Cork, Ireland). A total of 46 isolates from six neonates were confirmed to be Bifidobacterium species based on a combination of the fructose-6-phosphate phosphoketolase assay, RAPD [random(ly) amplified polymorphic DNA] PCR, pulsed-field gel electrophoresis (PFGE), and partial 16S ribosomal DNA sequencing. Interestingly, only 1 of the 11 neonates that had received antibiotic treatment produced bifidobacteria. PFGE after genomic digestion with the restriction enzyme XbaI demonstrated that the bifidobacteria population displayed considerable genomic diversity among the neonates, with each containing between one and five dominant strains, whereas 11 different macro restriction patterns were obtained. In only one case did a single strain appear in two neonates. All genetically distinct strains were then screened for CLA production after 72 h of incubation with 0.5 mg of free linoleic acid ml(-1) by using gas-liquid chromatography. The most efficient producers belonged to the species Bifidobacterium breve, of which two different strains converted 29 and 27% of the free linoleic acid to the cis-9, trans-11 isomer per microgram of dry cells, respectively. In addition, a strain of Bifidobacterium bifidum showed a conversion rate of 18%/microg dry cells. The ability of some Bifidobacterium strains to produce CLA could be another human health-promoting property linked to members of the genus, given that this metabolite has demonstrated anticarcinogenic activity in vitro and in vivo.

Coronary Stent Strut Size Dependent Stress–Strain Response Investigated Using Micromechanical Finite Element Models

Cardiovascular stents are metal scaffolds that are used in the treatment of atherosclerosis. These devices are typically composed of very thin struts (< or = 100 microm thickness, for coronary applications). At this size-scale the question arises as to the suitability of using bulk material properties in stent design. This paper investigates the use of finite element analysis to predict the mechanical failure of stent struts, typical of the strut size used in coronary stents. 316 L stainless steel in uniaxial loading was considered. To accurately represent the constitutive behavior of the material at this size-scale, a computational micromechanics approach was taken involving an explicit representation of the grain structure in the steel struts, and the use of crystal plasticity theory to represent the constitutive behavior of the individual grains. The development of the finite element models is discussed and results are presented for the predictions of tensile mechanical behavior as a function of strut thickness. The results showed that using this modelling approach, a size effect, already seen experimentally, is produced. This has significant implications for stent design, especially in the context of the desire to produce smaller stents for small bore neurovascular and peripheral artery applications.

Multi-axial fatigue failure of orthopedic bone cement - experiments with tubular specimens

Bone cement is subjected to multi-axial cyclic loading when used to fixate orthopedic prostheses for joint arthroplasty. In this study, tubular specimens of poly(methylmethacrylate) (PMMA) bone cement are subjected to internal pressure and cyclic axial loading to ascertain the influence of multi-axial loading on fatigue life. As expected, it was found that the probability of survival of specimens under multi-axial loading was very much reduced relative to specimens loaded uniaxially. Furthermore, the variability of the fatigue life was increased by multi-axial loading. In conclusion, the results point to the importance of characterizing the behavior of bone cements under the multi-axial fatigue experienced in vivo, and of the importance of accounting for the multi-axial stress state when predicting implant longevity.

The stress-strain behavior of coronary stent struts is size dependent

Coronary stents are used to re-establish the vascular lumen and flow conditions within the coronary arteries; the typical thickness of a stent strut is 100 microm, and average grain sizes of approximately 25 microm exist in stainless steel stents. The purpose of this study is to investigate the effect of strut size on the stress strain behavior of 316 L stainless steel. Other materials have shown a size dependence at the micron size scale; however, at present there are no studies that show a material property size dependence in coronary stents. Electropolished stainless steel stent struts within the size range of 60-500 microm were tensile tested. The results showed that within the size range of coronary stent struts a size dependent stress-strain relationship is required to describe the material. Finite element models of the final phase of fracture, i.e., void growth models, explained partially the reason for this size effect. This study demonstrated that a size based stress-strain relationship must be used to describe the tensile behavior material of 316 L stainless steel at the size scale of coronary stent struts.

Posthaemorrhagic ventricular dilatation in the premature infant: natural history and predictors of outcome

OBJECTIVE

To investigate the natural history and predictors of outcome of posthaemorrhagic ventriculomegaly in the very low birthweight (VLBW) infant.

METHODS

All VLBW infants admitted between September 1994 and September 1997 to the neonatal intensive care units of Brigham and Women's Hospital (Boston), Children's Hospital (Boston), and Christchurch Women's Hospital (New Zealand) with germinal matrix intraventricular haemorrhage (IVH) were identified. All charts and ultrasound scans were reviewed to define the natural history and perinatal and/or postnatal factors of value in prediction of the course of posthaemorrhagic ventriculomegaly. Progressive ventricular dilatation (PVD) was defined from the results of serial cranial ultrasound scans.

RESULTS

A total of 248 VLBW infants had evidence of IVH (22% of all VLBW infants, mean (SD) gestational age 26.8 (2.6) weeks). A quarter of the infants exhibited PVD. Spontaneous arrest of PVD occurred without treatment in 38% of infants with PVD. Of the remaining 62% with persistent PVD, 48% received non-surgical treatment only (pharmacological and/or drainage of cerebrospinal fluid by serial lumbar punctures), 34% received surgical treatment with insertion of a ventriculoperitoneal reservoir and/or shunt, and 18% died. The development of PVD after IVH and adverse short term outcome, such as the requirement for surgery, were predicted most strongly by the severity of IVH.

CONCLUSIONS

These data reflect the natural history of PVD in the 1990s and show that, despite a slight reduction in its overall incidence, there appears to be a more aggressive course, with appreciable mortality and morbidity in the extremely premature infant. The major predictor of adverse short term outcome, defined as death or need for surgical intervention, was the severity of IVH. These findings may be valuable for the management of very small premature infants.

The relationship between stress, porosity, and nonlinear damage accumulation in acrylic bone cement

The long-term survival of cemented hip replacements depends on the ability of the cemented fixation to resist fatigue damage. Damage has been assumed to accumulate linearly (Miner's law) even though it is unlikely to be the case in such a porous brittle material. This study addresses the nonlinear stress-dependent nature of fatigue damage accumulation in acrylic bone cement. Specimens were subjected to a zero-to-tension fatigue load in water at 37 degrees C. A total of 15 specimens were tested, i.e., five specimens at each of three stress levels. The specimens were cyclically loaded to a certain fraction of their fatigue lives and the amount of microcracking present at that time was quantified by counting each crack and measuring its length. This procedure was repeated until the specimen failed. A total of 801 cracks formed in the 15 specimens. All cracks were found to initiate at pores. Crack propagation directions were distributed normally about the direction perpendicular to the applied load at the lower stress levels, but at higher stress, the distribution tended to be broader. At higher stresses, more cracks were produced per pore. The damage accumulation process in acrylic bone cement was found to be nonlinear with the degree of nonlinearity increasing with stress. Furthermore, great variability was found which was attributed to the differences in porosity between specimens. A power law equation is given which describes the predicted relationship between damage accumulation and number of loading cycles as a function of the stress level.

Line scan diffusion tensor MRI of the cervical spinal cord in preterm infants

Line scan diffusion tensor magenetic resonance imaging (DT-MRI) of the cervical spinal cord was demonstrated in vivo for unsedated preterm (gestational age 24-30 weeks at birth), very low birthweight (birthweight 620-1300 g) infants at postmenstrual ages from 29-40 weeks. Scalar invariant measures of diffusion [apparent diffusion coefficient (ADC) and relative anisotropy (RA)] determined from a cervical cord region of interest in each case are reported, characterizing the maturational status of the normal third trimester and newborn spinal cord. Mean ADC of 11 infants was 1.2 +/- 0.1 microm(2)/msec and the mean RA was 24.3 +/- 4.9%. Normal infant cord neural fiber tract morphology was visualized using a mapping of the predominant diffusion tensor eigenvector. Potential clinical applications of line scan DT-MRI of the spinal cord of preterm and term newborns for assessment of spinal cord injury are discussed. J. Magn. Reson. Imaging 2001;13:949-953.

Impaired cerebral cortical gray matter growth after treatment with dexamethasone for neonatal chronic lung disease

OBJECTIVE

The specific aim of this study was to quantify at term the influence of postnatal systemic dexamethasone treatment for neonatal chronic lung disease on subsequent brain growth and development in premature infants without evidence of severe intraventricular hemorrhage or white matter injury.

METHODS

Eighteen premature (23 to 31 weeks) infants, 7 treated with dexamethasone and 11 not treated, were studied at term, ie, 38 to 41 postconceptional weeks, by an advanced quantitative volumetric 3-dimensional magnetic resonance imaging (MRI) technique to quantify cerebral tissue volumes. Fourteen healthy term infants also were studied for comparison. A sequence of image processing algorithms was used to segment each of the MRI slices into the following separate tissue classes: cerebral cortical gray matter, basal ganglia/thalami, unmyelinated white matter, myelinated white matter, and cerebrospinal fluid, all classified based on magnetic resonance signal intensity and anatomic location. A final summing of voxels for each tissue class was performed to compute absolute volumes in milliliters.

RESULTS

Cerebral cortical gray matter volume in premature infants treated with dexamethasone was reduced 35% when compared with gray matter volume in premature infants not treated with dexamethasone (mean +/- standard deviation, 130.3 +/- 54.0 vs 200.6 +/- 35.1 mL, respectively). Subcortical gray matter volumes (basal ganglia and thalami) and myelinated and unmyelinated white matter volumes were not significantly different among the treated and untreated groups. However, premature infants treated with dexamethasone exhibited a reduction (30%) in total cerebral tissue volume compared with total cerebral tissue volume in both the premature infants not treated with dexamethasone and the control term infants (312.7 +/- 43.7 vs 448.2 +/- 50.2 and 471.6 +/- 36.4 mL respectively). This latter finding relates primarily to the decrease in cerebral cortical gray matter volume.

CONCLUSIONS

The data suggest an impairment in brain growth, principally affecting cerebral cortical gray matter, secondary to systemic dexamethasone therapy. Although the premature infants who received dexamethasone were smaller with more severe respiratory disease, these findings are consistent with growing evidence of a potential deleterious effect of dexamethasone on neonatal brain and subsequent neurodevelopmental outcome. This apparent deleterious effect should be taken into consideration by clinicians when weighing the potential risks and benefits of this therapy for low birth weight infants with neonatal chronic lung disease.

Mortality among the residents of the Three Mile Island accident area: 1979-1992

The largest U.S. population exposed to low-level radioactivity released by an accident at a nuclear power plant is composed of residents near the Three Mile Island (TMI) Plant on 28 March 1979. This paper (a collaboration of The University of Pittsburgh and the Pennsylvania Department of Health) reports on the mortality experience of the 32,135 members in this cohort for 1979-1992. We analyzed standardized mortality ratios (SMRs) using a local comparison population and performed relative risk regression modeling to assess overall mortality and specific cancer risks by confounding factors and radiation-related exposure variables. Total mortality was significantly elevated for both men and women (SMRs = 109 and 118, respectively). All heart disease accounted for 43.3% of total deaths and demonstrated elevated SMRs for heart disease of 113 and 130 for men and women, respectively; however, when controlling for confounders and natural background radiation, these elevations in heart disease were no longer evident. Overall cancer mortality was similar in this cohort as compared to the local population (male SMR = 100; female SMR = 101). In the relative risk modeling, there was a significant effect for all lymphatic and hematopoietic tissue in males in relation to natural background exposure (p = 0.04). However, no trend was noted. We found a significant linear trend for female breast cancer risk in relation to increasing levels of TMI-related likely [gamma]-exposure (p = 0.02). Although such a relationship has been noted in other investigations, emissions from the TMI incident were significantly lower than in other documented studies. Therefore, it is unlikely that this observed increase is related to radiation exposure on the day of the accident. The mortality surveillance of this cohort does not provide consistent evidence that radioactivity released during the TMI accident has a significant impact on the mortality experience of this cohort to date. However, continued follow-up of these individuals will provide a more comprehensive description of the morbidity and mortality experience of the cohort.

Measurement of non-linear microcrack accumulation rates in polymethylmethacrylate bone cement under cyclic loading

Damage accumulation in the cement mantle used to fixate bone prosthesis is one failure scenario for joint reconstruction. It can be described as the phenomenon of numerous microcracks initiating and propagating within the material. Microcracks grow in the cement mantle causing it to gradually lose its mechanical integrity, leading to loosening of the prosthesis. In this study microcracking within acrylic bone cement was quantified over the course of a fatigue test. Identification of new cracks and the growth of pre-existing cracks was monitored at intervals during fatigue testing of five specimens at a mean cyclic stress of 7.5 MPa. Given these measurements, an average damage evolution curve was derived for acrylic bone cement. It was observed that the initiation sites for microcracks were the pore perimeters; therefore, the number of microcracks present in a sample is dependent on porosity. Variability was found within the results and the majority of the variability was accounted for by the difference in the porosity of each sample. Results have identified non-linear damage evolution. On a simplified level a power law equation can be used to describe the damage evolution process.

Electrophysiological measurements of spectral mechanisms in the retinas of two cervids: white-tailed deer (Odocoileus virginianus) and fallow deer (Dama dama)

Electroretinogram (ERG) flicker photometry was used to study the spectral mechanisms in the retinas of white-tailed deer (Odocoileus virginianus) and fallow deer (Dama dama). In addition to having a rod pigment with maximum sensitivity (lambda max) of about 497 nm, both species appear to have two classes of photopic receptors. They share in common a short-wavelength-sensitive cone mechanism having lambda max in the region of 450-460 nm. Each also has a cone having peak sensitivity in the middle wavelengths, but these differ slightly for the two species. In white-tailed deer the lambda max of this cone is about 537 nm; for the fallow deer the average lambda max value for this mechanism was 542 nm. Deer resemble other ungulates and many other types of mammal in having two classes of cone pigment and, thus, the requisite retinal basis for dichromatic color vision.

N-(phenylacetyl)glycyl-D-aziridine-2-carboxylate, an acyclic amide substrate of beta-lactamases: importance of the shape of the substrate in beta-lactamase evolution

Certain acyclic depsipeptides, but not peptides, are substrates of typical beta-lactamases [Pratt, R.F., & Govardhan, C.P. (1984) Proc. Natl. Acad. Sci. U.S.A. 81, 1302]. This may reflect either the greater chemical reactivity of depsipeptides (and of beta-lactams, the natural substrates) than peptides or the greater ease of distortion of the depsipeptide (ester) than the peptide (amide) group into a penicillin-like conformation. The latter explanation has been shown to be more likely by employment of a novel beta-lactamase substrate. N-(phenylacetyl)glycyl-D-aziridine-2-carboxylate, which combines a high chemical reactivity with a close to tetrahedral amide nitrogen atom. Although this substrate was better (higher kcat/KM) than a comparable depsipeptide for beta-lactamases, it was poorer than the depsipeptide for the Streptomyces R61 D-alanyl-D-alanine peptidase (which catalyzes specific peptide hydrolysis). It therefore seems likely that one vital feature of the putative evolution of a DD-peptidase into a beta-lactamase would have been modification of the active site to, on one hand, accommodate bicyclic beta-lactams and, on the other, exclude productive binding of planar acyclic amides. Certain serine beta-lactamases and the R61 DD-peptidase also catalyze methanolysis and aminolysis by D-phenylalanine of the N-acylaziridine. The latter reaction, the first amide aminolysis shown to be catalyzed by a beta-lactamase, is a very close analogue of the transpeptidase reaction of DD-peptidases. The methanolysis reaction appeared to proceed by way of the same acyl-enzyme intermediate as formed from depsipeptides possessing the same acyl moiety as the aziridine. The kinetics of methanolysis were employed to determine whether acylation or deacylation was rate limiting to the hydrolysis reaction under saturating substrate concentrations. The kinetics of the aminolysis reaction, catalyzed by the Enterobacter cloacae P99 beta-lactamase, showed the characteristics of, and were interpreted in terms of, a sequential mechanism previously deduced for depsipeptides and this enzyme [Pazhanisamy, S., & Pratt, R. F. (1989) Biochemistry 28, 6875-6882]. This mechanism features two separate binding sites, only one of which is productive. Strikingly, the binding of the N-acylaziridine to the nonproductive site was very tight, such that essentially all hydrolysis at substrate concentrations above 0.1Km proceeded via the ternary complex; this could also be true of penicillins.

A thiono-beta-lactam substrate for the beta-lactamase II of Bacillus cereus. Evidence for direct interaction between the essential metal ion and substrate

An 8-thionocephalosporin was shown to be a substrate of the beta-lactamase II of Bacillus cereus, a zinc metalloenzyme. Although it is a poorer substrate, as judged by the Kcat./Km parameter, than the corresponding 8-oxocephalosporin, the discrimination against sulphur decreased when the bivalent metal ion in the enzyme active site was varied in the order Mn2+ (the manganese enzyme catalysed the hydrolysis of the oxo compound but not that of the thiono compound), Zn2+, Co2+ and Cd2+. This result is taken as evidence for kinetically significant direct contact between the active-site metal ion of beta-lactamase II and the beta-lactam carbonyl heteroatom. No evidence was obtained, however, for accumulation of an intermediate with such co-ordination present.

Evidence for an oxyanion hole in serine beta-lactamases and DD-peptidases

A thionocephalosporin is shown to be a much poorer substrate of representative serine beta-lactamases of class A (RTEM-2) and class C (Enterobacter cloacae P99) and a much poorer inhibitor of the Streptomyces R61 DD-peptidase than is the analogous oxo beta-lactam. These results provide kinetic evidence for the existence of a catalytic oxyanion hole in these enzymes.

Cerebral air embolism resulting from invasive medical procedures. Treatment with hyperbaric oxygen

The introduction of air into the venous or arterial circulation can cause cerebral air embolism, leading to severe neurological deficit or death. Air injected into the arterial circulation may have direct access to the cerebral circulation. A patent foramen ovale provides a right-to-left shunt for venous air to embolize to the cerebral arteries. The ability of the pulmonary vasculature to filter air may be exceeded by bolus injections of large amounts of air. Sixteen patients underwent hyperbaric oxygen therapy for cerebral air embolism. Neurological symptoms included focal motor deficit, changes in sensorium, and visual and sensory deficits. Eight patients (50%) had complete relief of symptoms as a result of hyperbaric treatment, five (31%) had partial relief, and three patients (19%) had no benefit, two of whom died. The treatment of cerebral air embolism with hyperbaric oxygen is based upon mechanical compression of air bubbles to a much smaller size and the delivery of high doses of oxygen to ischemic brain tissue.

Ability of the inflatable penile prosthesis to withstand rapid changes in altitude

Small air bubbles unavoidably included in the fluid of the inflatable penile prosthesis will expand upon exposure to increased altitude. Three prostheses with predetermined amounts of air underwent decompressions in an altitude chamber. The device was able to contain the expanded air bubbles with no extravasation of fluid or air or damage to the system.

Factitious decompression sickness

The diagnosis of decompression sickness is made largely by history; there are few physical findings and no radiographic or laboratory tests to support the diagnosis. We present three cases of factitious decompression sickness in which patients fabricated an appropriate history and underwent compression therapy. Due to the potential severity of decompression sickness and the relative safety of compression therapy, the initiation of therapy must not be delayed in a case of decompression sickness. Once therapy is begun, investigation into the particulars of a suspicious case can be made.

Alcohol consumption and cigarette smoking in Busselton, 1966-1978

In Busselton, mass health examination (MHE) questionnaires about alcohol consumption indicate that more people are drinking wine and fewer people are drinking beer. The evidence suggests an increase in the number of women consuming alcohol. The proportion of drinkers was higher among patients attending doctors with interests in wineries and/or vineyards compared with those patients attending doctors without such interests. More patients of doctors who smoked were smokers compared with those patient of doctors who were non-smokers. Smoking in Busselton appears to be declining at the rate of 0.5% to 1% of the population per annum; this decline is more marked in people who had attended one or more MHEs than in newcomers to MHEs. These trends have encouraged a more active approach to the prevention of smoking in school children.

Drug usage in a western Australian rural community

Drug usage in two agricultural shires, Kondinin and Kulin, was surveyed by questionnaire. Both prescription and over the counter (OTC) drugs were recorded together with age, sex, forced expiratory volume in one second (FEV1), systolic blood pressure (SBP) and body weight, and 1284 people, or 55.8% of the eligible population over six years of age, participated. Approximately 35%, 53% and 12% of people said they were taking no drugs, one to two drugs and three or more drugs respectively, a result very similar to that found in an earlier urban study (Traralgon). The interaction of all five factors on drug consumption was studied jointly by multivariate analysis; FEV1, SBP and weight were normalised using standard tables. Prescription drug usage was directly related to obesity, respiratory impairment and sex (P less than 0.01) but not to age or SBP. People taking either OTC drugs or none at all differed only in sex, with females taking more than males (P less than 0.01). There were no differences in the factors studied between prescription only and prescription plus OTC drug users.