Response to 'Commentary on the published position statement regarding the pathogenesis of fetal basal ganglia- thalamic hypoxic-ischaemic injury' (Anthony et al.)

-

Clinical practice

Basal ganglia and thalamus (BGT) hypoxic-ischaemic brain injury is currently the most contentious issue in cerebral palsy (CP) litigation in South Africa (SA), and merits a consensus response based on the current available international literature. BGT pattern injury is strongly associated with a preceding perinatal sentinel event (PSE), which has a sudden onset and is typically unforeseen and unpreventable. Antepartum pathologies may result in fetal priming, leading to vulnerability to BGT injury by relatively mild hypoxic insults. BGT injury may uncommonly follow a gradual-onset fetal heart rate deterioration pattern, of duration ≥1 hour. To prevent BGT injury in a clinical setting, the interval from onset of PSE to delivery must be short, as little as 10 - 20 minutes. This is difficult to achieve in any circumstances in SA. Each case needs holistic, multidisciplinary, unbiased review of all available antepartum, intrapartum and postpartum and childhood information, aiming at fair resolution without waste of time and resources.

Comparison of analog and digitally evaluated volume of the female breast in reconstructive breast surgery. Validation of a noninvasive measurement method with 3D camera1

BACKGROUND

Reconstructive surgery is established as a standard treatment option after mastectomy due to cancer. It is crucial to patients to achieve a natural and symmetric looking breast through reconstruction. Anthropometric measurements are used to assess the objective symmetry of the breast, which are prone to errors and difficult to reproduce.

OBJECTIVE

The aim of this work is to validate breast volumetry using three-dimensional surface imaging.

METHODS

We compared preoperatively analog and digitally evaluated volume of the breast with our gold standard, direct water displacement measurement of the mastectomy specimen. We examined 34 breast specimens in total.

RESULTS

Each measurement method (Breast Sculptor, VAM, Breast-V) for breast volume/mass determination demonstrates acceptable agreement ranges when compared with resected volumes and masses. The strongest volumetry instrument is Breast Sculptor (digital), the weakest is Breast-V (analog).

CONCLUSIONS

3D surface imaging is a quick, effective, and convenient method to evaluate breast shape and volume. The accuracy, reproducibility, and reliability of 3D surface imaging were comparable with MRI in our study.This takes us a step closer to the long-term goal of establishing robust instruments to plan breast reconstructive surgery, achieve better surgical results, and contribute to quality assurance in breast surgery.

Technical note on introducing a digital workflow for newborns with craniofacial anomalies based on intraoral scans - part II: 3D printed Tübingen palatal plate prototype for newborns with Robin sequence

Background

Orthodontic treatment of newborns and infants with Robin-Sequence using the Tübingen Palatal Plate (TPP) is a complex procedure that could benefit from simplification through digitalization. The design of the velar extension (spur) and the palatal base determines the success of the treatment. Therefore, a prototype must be produced and inserted under endoscopic supervision in order to determine the appropriate shape, length and position of the spur. This technical note demonstrates a fully digital workflow for the design and manufacturing of a functional TPP prototype, based on an intraoral scan. This prototype can be altered and individualized digitally for each patient. After the shape and position of the spur have been optimized, the prototype is duplicated using a silicone mold. Then the definitive TPP is manufactured and inserted. We aim to present a workflow which facilitates the fitting procedure and does not require a conventional impression or a physical model to create the appliance.

Methods

As described in part I of this series, the intraoral scan is performed using the 3Shape TRIOS3 scanner and its corresponding acquisition software. The virtual model is rendered in the 3Shape ortho appliance designer and the base of the palatal plate is designed in the 3Shape dental designer. The palatal plate and the virtual model are then imported into Autodesk Meshmixer and a standardized spur is positioned and merged with the base. The TPP is exported in Standard Tessellation Language (STL) format and manufactured on a W2P Solflex 170 DLP printer using VOCO VPrint Splint material (MDR Class IIa).

Results

Based on an intraoral scan, the TPP prototype could be successfully manufactured and proved suitable for the patients’ treatment.

Conclusion

The new digital workflow for the design of the TPP can been successfully implemented into daily clinical routine in our facility. Patients could be alleviated from having to undergo conventional impression procedures and fitting of the TPP could be facilitated by producing multiple functional prototypes for endoscopic evaluation. Through rapid prototyping, the expenditure of the fitting process was reduced, which makes the TPP therapy more efficient and accessible to a wider range of clinicians.

Technical note on introducing a digital workflow for newborns with craniofacial anomalies based on intraoral scans - part I: 3D printed and milled palatal stimulation plate for trisomy 21

Background

Advanced digital workflows in orthodontics and dentistry often require a combination of different software solutions to create patient appliances, which may be a complex and time-consuming process. The main objective of this technical note is to discuss treatment of craniofacial anomalies using digital technologies. We present a fully digital, linear workflow for manufacturing palatal plates for infants with craniofacial anomalies based on intraoral scanning. Switching to intraoral scanning in infant care is advantageous as taking conventional impressions carries the risk of impression material aspiration and/or infections caused by material remaining in the oronasal cavity.

Material and methods

The fully digital linear workflow presented in this technical note can be used to design and manufacture palatal plates for cleft palate patients as well as infants with functional disorders. We describe the workflow implemented in an infant with trisomy 21. The maxilla was registered using a digital scanner and a stimulation plate was created using dental CAD software and an individual impression tray module on a virtual model. Plates were manufactured using both additive and subtractive methods. Methacrylate based light curing resin and Poly-Ether-Ether-Ketone were the materials used.

Results

The palatal area was successfully scanned to create a virtual model. The plates fitted well onto the palatal area. Manual post-processing was necessary to optimize a functional ridge along the vestibular fold and remove support structures from the additively manufactured plate as well as the milled plate produced from a blank. The additively manufactured plate fitted better than the milled one.

Conclusion

Implementing a fully digital linear workflow into clinical routine for treatment of neonates and infants with craniofacial disorders is feasible. The software solution presented here is suitable for this purpose and does not require additional software for the design. This is the key advantage of this workflow, which makes digital treatment accessible to all clinicians who want to deal with digital technology. Whether additive or subtractive manufacturing is preferred depends on the appliance material of choice and influences the fit of the appliance.

The STM bias voltage-dependent polymorphism of a binary supramolecular network

We control complex multicomponent switches by tuning the local electric field at the liquid/solid interface.

[Medical termination of pregnancy by mifepristone and misoprostol - evaluation of succes rate, complications and satisfaction of patients]

OBJECTIVE

The purpose of this study was to evaluate the success rate and complications of medical termination of pregnancy up to 49 days of amenorrhea and present the outcome of our phone questionaire of satisfaction of patients.

DESIGN

Retrospective analysis.

SETTING

Department of Obstetrics and Gynecology Masaryk University and University Hospital Brno.

METHODS

The analysis of 111 patients, who underwent medical termination of pregnancy at the Department of Obstetrics and Gynecology Masaryk University and University Hospital Brno from 1. 6. 2014 to 30. 6. 2015 using 600 mg of mifepristone (Mifegyne) and 400 µg of misoprostol (Mispregnol). In our set of patients we monitored subjective perception of medical termination of pregnancy (pain, nausea, vomiting, satisfaction with this method) and objective process (hospitalisation, surgical intervention). The view of patients was found out by the phone questionnaire

RESULTS

Complete abortion without a surgical intervention underwent 103 patients. Nausea, pelvic pain, and intensity of bleeding were evaluated as suitable. Only 1 patient (0.9%) was hospitalised for nausea and 1 patient (0.9%) was hospitalised in case of need for an emergency curretage and transfusions. Some kind of contraception after the medical termination of pregnancy started using 98.0% of women. The satisfaction rate of this method was high - 101 patients declared themselves satisfied - 66.7% very satisfied, 24.3% rather satisfied.

CONCLUSION

Medical termination of pregnancy has good efficiency, we consider it safe with minimum side-effects and is well evaluated by patients.

Adapting livestock management to spatio-temporal heterogeneity in semi-arid rangelands

Management strategies in rotational grazing systems differ in their level of complexity and adaptivity. Different components of such grazing strategies are expected to allow for adaptation to environmental heterogeneities in space and time. However, most models investigating general principles of rangeland management strategies neglect spatio-temporal system properties including seasonality and spatial heterogeneity of environmental variables. We developed an ecological-economic rangeland model that combines a spatially explicit farm structure with intra-annual time steps. This allows investigating different management components in rotational grazing systems (including stocking and rotation rules) and evaluating their effect on the ecological and economic states of semi-arid grazing systems. Our results show that adaptive stocking is less sensitive to overstocking compared to a constant stocking strategy. Furthermore, the rotation rule becomes important only at stocking numbers that maximize expected income. Altogether, the best of the tested strategies is adaptive stocking combined with a rotation that adapts to both spatial forage availability and seasonality. This management strategy maximises mean income and at the same time maintains the rangeland in a viable condition. However, we could also show that inappropriate adaptation that neglects seasonality even leads to deterioration. Rangelands characterised by higher inter-annual climate variability show a higher risk of income losses under a non-adaptive stocking rule, and non-adaptive rotation is least able to buffer increasing climate variability. Overall, all important system properties including seasonality and spatial heterogeneity of available resources need to be considered when designing an appropriate rangeland management system. Resulting adaptive rotational grazing strategies can be valuable for improving management and mitigating income risks.

Fine motor and self-care milestones for individuals with Down syndrome using a Retrospective Chart Review

BACKGROUND

Developmental milestone markers for fine motor and self-care skills among children with Down syndrome (DS) are either minimal, anecdotal or out-of date. Our goal was to produce normative expectations for the development of fine motor and self-care milestones specific to children with DS.

METHOD

A cross-sectional retrospective chart review was completed on 274 children with DS seen at a specialty clinic that ranged in age from 4 months to 18 years. Specific skills were assessed at occupational therapy assessments as either present or absent, including fine motor, handwriting, scissor usage, self-feeding and clothing management.

RESULTS

Fine motor milestones describing when 10-30% ('early achievers') and 75-95% ('representative achievement') of children with DS had mastered each skill were developed based upon descriptive review. As the fine motor and self-care skills advanced in complexity, the range of ages for documented skill acquisition was observed to increase.

CONCLUSIONS

Age ranges for the mastery of fine motor developmental milestones for early and representative achievement were developed based upon descriptive analysis of cross-sectional retrospective clinical chart reviews. That the age range for mastering fine motor and self-care skills broadens as children with DS get older is in agreement with what is identified in the DS behavioural phenotype with regard to variable motor skills overall. These fine motor and self-care developmental milestone markers contribute to the field by informing parents, caregivers and healthcare providers of potential fine motor and self-care outcomes and describing normative development for children with DS.

Effects of Respiratory Therapy (bagging) on Respiratory Function, Swallowing Frequency and Vigilance in Tracheotomized Patients in Early Neurorehabilitation

OBJECTIVE

Tracheotomized patients often suffer from impairments in mucociliary clearance and limited capacities for active expectoration of secretions. We investigated the effects of a specific respiratory intervention method (bagging) for tracheotomized patients on respiratory parameters (pO2, pCO2, SpO2, respiratory rates), swallowing frequency, vigilance and secretion viscosity.

METHODS

The bagging method supports enforced mobilization and expectoration of secretions by application of a series of manual hyperinflations with a resuscitation bag during active inspiration and manual cough support on the chest. 30 tracheotomized neurological patients participated in a multiple-baseline study including a three-weeks intervention period and a follow-up measurement three weeks after termination of the treatment.

RESULTS

Most outcome parameters improved significantly during the intervention period: pO2 (p < .01), SpO2 (p < .01), respiratory rates (p < .01), swallowing rates (p < .01), and vigilance scores (p < .01). The quality of bronchial secretions improved in all participants. All effects were sustained up to the follow-up measurements.

CONCLUSION

This preliminary data indicates positive effects for a respiratory intervention method (bagging) on respiratory function and additional respiration-related functions in tracheotomized neurological patients. This easy-to-learn and inexpensive method might expand the range of treatment options for tracheotomized and non-responsive patients.

The effect of calcium supplementation on blood pressure in non-pregnant women with previous pre-eclampsia: An exploratory, randomized placebo controlled study

BACKGROUND

Epidemiological findings suggest that the link between poverty and pre-eclampsia might be dietary calcium deficiency. Calcium supplementation has been associated with a modest reduction in pre-eclampsia, and also in blood pressure (BP).

METHODS

This exploratory sub-study of the WHO Calcium and Pre-eclampsia (CAP) trial aims to determine the effect of 500mg/day elemental calcium on the blood pressure of non-pregnant women with previous pre-eclampsia. Non-pregnant women with at least one subsequent follow-up trial visit at approximately 12 or 24weeks after randomization were included.

RESULTS

Of 836 women randomized by 9 September 2014, 1st visit data were available in 367 women of whom 217 had previously had severe pre-eclampsia, 2nd visit data were available in 201 women. There was an overall trend to reduced BP in the calcium supplementation group (1-2.5mmHg) although differences were small and not statistically significant. In the subgroup with previous severe pre-eclampsia, the mean diastolic BP change in the calcium group (-2.6mmHg) was statistically larger than in the placebo group (+0.8mmHg), (mean difference -3.4, 95% CI -0.4 to -6.4; p=0.025). The effect of calcium on diastolic BP at 12weeks was greater than in those with non-severe pre-eclampsia (p=0.020, ANOVA analysis).

CONCLUSIONS

There is an overall trend to reduced BP but only statistically significant in the diastolic BP of women with previous severe pre-eclampsia. This is consistent with our hypothesis that this group is more sensitive to calcium supplementation, however results need to be interpreted with caution.

[Differential diagnosis and treatment of hyponatremia]

Hyponatremia is one of the most common metabolic disorders in clinical medicine. The value of Na+ in serum equalling 135 mmol/ l and lower is regarded as hyponatremia. Its clinical manifestations are the following: headaches, nausea, vomiting, seizures, numbness, coma and death. Hyponatremia caused by nonosmotic hypersecretion of vasopressin can be divided into: a) hypovolemic, b) normovolemic and c) hypervolemic. Hyponatremia which is not caused by the hypersecretion of vasopressin is the so  called pseudohyponatremia, water intoxication, cerebral salt loss syndrome. Hypovolemic hyponatremia is caused by the loss of Na+ and fluid loss from the organism. It occurs, for example, after using thiazide diuretics, after recurrent diarrhoea, vomiting, after significant blood loss and other causes. Treatment of this disorder must focus on the producing cause and on the parenteral administration of 0.9% NaCl. Normovolemic hyponatremia can be with or without symptoms. Acute normovolemic hyponatremia is treated by the intravenous administration of 3% NaCl and with the simultaneous use of loop diuretics (20- 40 mg Furosemide/ 24 hrs) and restriction of fluid intake. In the case of chronic normovolemic hyponatremia, refractory to the previous treatment, caused by the inappropriate secretion of arginine  vasopressin, it is recommended to use perorally its V2- receptor blocker, Tolvaptan. Hypervolemic hyponatremia occurs in the case of cardiovascular failure, with hepatic cirrhosis, nephrotic syndrome, renal failure, porphyric disease and other conditions. Symptoms occurring with it are swellings, ascites, distension of jugular veins and the presence of unaccented rales in the lungs, which can be detected during physical examination. For treatment it is recommended to restrict fluid intake and to administer NaCl as well as diuretic therapy. Recently it has been recommended to use Tolvaptan which increases excretion of free water (aquaresis), decreases osmolality in the urine, and leads to the increase in serum Na+. Apart from that, we present our three clinical  laboratory observations in the paper: 1. Contrary to the data in the literature, after the Košice Marathon (42.125 km) the serum concentration of Na+ in the runners increased (from 144.4 ± 2.1 mmol/ l to 147 ± 2.8 mmol/ l, p < 0.01) in spite of a significant reduction in the body weight (from 73.2 ± 5.7 kg to 71.9 ± 5.2 kg, p < 0.05), intensive perspiration and dehydration (blood haemoglobin before the run: 150.4 ± 5.5 g/ l, after the run: 152.1 ± 4.8 g/ l, p < 0.05). Apart from that, we detected a significant decrease in the fractional excretion of sodium (FENa) from 1.16 ± 0.30% to 0.34 ± 0.10%, p < 0.01. 2. One patient with chronic intermittent porphyria displayed the syndrome of inappropriate antidiuretic hormone secretion, which had been positively influenced by the restriction of fluid intake in the long term and by peroral administration of 1- 3 g NaCl/ 24 hrs. 3. In 15 haemodialysed patients with chronic renal failure, who displayed recurrent hypervolemic hyponatremia, we achieved, by means of adequate ultrafiltration and a dialysis solution containing Na+ 145 mmol/ l, the serum concentration of Na+ 142 mmol/ l at the end of haemodialysis.

[Respiratory therapy (bagging, air stacking) for patients in early neurorehabilitation]

In a pilot project we examined whether an improvement of oxygen saturation (SPO (2)) can be established by applying a modified respiratory intervention technique (bagging) for patients in early neurorehabilitation. The "bagging" method involves adding air into the lungs during the inspiration phase by using a resuscitation bag. Subsequently, the patient is requested to cough, and is given manual support on the chest by the therapist. We examined a group of 11 patients who received 1 - 2 bagging interventions per day over a period of 12 days. By applying the bagging method, a continuous and stable improvement of oxygen saturation could be accomplished for all patients. A single case analysis confirmed this effect for each patient. Furthermore, we observed an improvement of the patients' vigilance, improved quality of bronchial secretion and marked improvements in swallowing and phonation. The bagging method is an easy-to-learn and inexpensive method that leads to a stable and sustained increase in oxygen saturation and to improvement of other clinical parameters.

System for time resolved spectral studies of pulsed atmospheric discharges in the visible to vacuum ultraviolet range

Vacuum ultraviolet (VUV) emission is believed to play a major role in the development of plasma streamers in pulsed atmospheric discharges, but detection of VUV light is difficult in pulsed experiments at atmospheric pressures. Since VUV light is absorbed in most standard optical materials as well, careful attention must be given to the selection of the lens and mirror optics used in these studies. Of highest interest is the VUV emission during the initial stage of pulsed atmospheric discharges, which has a typical duration in the nanosecond regime. An experiment was designed to study this fast initial stage of VUV emission coupled with fast optical imaging of streamer propagation, both with temporal resolution on the order of nanoseconds. A repetitive solid-state high voltage pulser was constructed which produces triggered flashover discharges with low jitter and consistent pulse amplitude. VUV emission is captured utilizing both photomultiplier and intensified charge-coupled device detectors during the fast stage of streamer propagation. These results are discussed in context with the streamer formation photographed in the visible wavelength regime with 3 ns exposure time.

[Examples for asbestos-related findings in HRCT - criteria for the assessment of causal relationships in surveillance programmes and medical expert opinion]

The increasing use of high-resolution computed tomography in formerly asbestos-exposed workers requires valid diagnostic criteria for the findings which have to be reported as suspicious for being asbestos-related in surveillance programmes and for the assessment of causal relationships between former asbestos exposure and findings in computed tomography. The present article gives examples for asbestos-related findings in HR-CT and discusses the specificity of parenchymal and pleural changes due to asbestos fibres.