Key determinants of adaptive strategies of goats to a 2-day nutritional challenge during early lactation

Little is known about the key determinants of the physiological adaptations to environmental challenges and how these determinants interact. We evaluated how the response/recovery profiles to a short-term nutritional challenge during early lactation are affected by early-life nutritional strategies in dairy goats divergently selected for functional longevity. We used 72 females, split into two cohorts, daughters of Alpine bucks divergently selected for functional longevity. The females from the two lines were fed with two divergent diets, normal vs low-energy, from weaning until the middle of first gestation, and then fed with the same standard diet. Individual BW, body condition score, morphology, and plasma samples were collected from birth to first kidding. The adaptative physiological strategy to a nutritional challenge was assessed via a 2-day feed restriction challenge, during early lactation, which consisted of a five-day control period on a standard lactation diet followed by a 2-day challenge with straw-only feeding and then a 10-day recovery period on a standard lactation diet. During the challenge, DM intake, BW, milk yield (MY), and plasma and milk metabolite composition were recorded daily. Linear mixed-effects models were used to analyze all traits, considering the individual nested in the cohort as a random effect and the 2 × 2 treatments (i.e., line and rearing diet) and litter size as fixed effects. Linear mixed-effects models using a piecewise arrangement were used to analyze the response/recovery profiles to nutritional challenge. Random parameters estimated for each individual, using the mixed-effects models without the fixed effects of rearing diet and genetic line, were used in a stepwise model selection based on R2 to identify key determinants of an individual's physiological adaptations to environmental challenges. Differences in stature and body reserves created by the two rearing diets diminished during late gestation and the 5-day control period. Genetic line did not affect body reserves during the rearing phase. Rearing diet and genetic line slightly affected the recovery profiles of evaluated traits and had no effects on prechallenge and response to challenge profiles. The prekidding energy status measures and MY before challenge were selected as strong predictors of variability in response-recovery profiles of milk metabolites that have strong links with body energy dynamics (i.e., isoCitrate, ß-hydroxybutyrate, choline, cholesterol, and triacylglycerols; R2 = 35%). Our results suggested that prekidding energy status and MY are key determinants of adult resilience and that rearing diet and genetic line may affect adult resilience insofar as they affect the animals' energy status.

Responses of selected plasma metabolites to a two-day nutritional challenge of goats divergently selected for functional longevity

Understanding the extent to which genetics × environment plays a role in shaping individual strategies to environmental challenges is of considerable interest for future selection of more resilient animals. Accordingly, the objective of this study was to evaluate the metabolic responses to a nutritional challenge of goats divergently selected for functional longevity based on plasma metabolites and the repeatability of these responses across 2 experimental farms and years. We carried out 6 different experimental trials from years 2018 to 2022 (4 trials on site Bourges (2018-21) and 2 trials (2021-22) on site Grignon) in which 267 first kidding goats, daughters of Alpine bucks divergently selected for functional longevity, longevity plus (n = 137), and longevity minus (n = 130), were exposed to a 2-d nutritional challenge in early lactation. The experiments consisted of a 5 or 7-d control period (pre-challenge) on a standard lactation diet followed by a 2-d nutritional challenge with straw-only feeding and then a 7 or 10-d recovery period on a standard lactation diet, for site Bourges and Grignon, respectively. During the challenge plasma metabolite composition was recorded daily. Linear mixed-effects models were used to analyze all traits, considering the individual as a random effect and the 2x2 treatments (i.e., genetic line and year nested in site) and litter size as fixed effects. The linear mixed-effects model using a piecewise arrangement was used to analyze the response/recovery profiles to the nutritional challenge. Random parameters estimated for each individual, using the mixed-effects models without the fixed effects of genetic line, were used in a Sparse Partial Least Square Discriminant Analysis (sPLS-DA) to compare the goat metabolism response to the challenge on a multivariate scale. The plasma metabolites, glucose, β-hydroxybutyrate (BHB), and nonesterified fatty acids (NEFA), and urea concentrations responded to the 2-d nutritional challenge. Selection for functional longevity did not affect plasma glucose, NEFA, BHB, and urea response/recoveries to a 2-d nutritional challenge. However, site, trial, and litter size affected these responses. Moreover, the plasma metabolites seem not to fully recover to prechallenge levels after the recovery phase. The sPLS-DA analysis did not discriminate between the 2 longevity lines. We observed meaningful between-individuals' variability in plasma BHB, especially on the prechallenge and rate of response and rate of recovery from the 2-d nutritional challenge (CV = 26.2%, 36.1%, and 41.2%, repeatability = 0.749, 0.322, and 0.741, respectively). Plasma NEFA recovery from challenge also demonstrated high between-individuals' variability (CV = 16.4%, repeatability = 0.323). Selection for functional longevity did not affect plasma metabolites responses to a 2-d nutritional challenge in dairy goats. Plasma NEFA and BHB response/recovery presented high between-individuals' variability, indicating individual adaptative characteristics to nutritional challenges not related to the environmental conditions but to inherent individual characteristics.

Multivariate analysis of milk metabolite measures shows potential for deriving new resilience phenotypes

In a context of growing interest in breeding more resilient animals, a noninvasive indicator of resilience would be very valuable. We hypothesized that the time-course of concentrations of several milk metabolites through a short-term underfeeding challenge could reflect the variation of resilience mechanisms to such a challenge. We submitted 138 one-year-old primiparous goats, selected for extreme functional longevity (i.e., productive longevity corrected for milk yield [60 low longevity line goats and 78 high longevity line goats]), to a 2-d underfeeding challenge during early lactation. We measured the concentration of 13 milk metabolites and the activity of 1 enzyme during prechallenge, challenge, and recovery periods. Functional principal component analysis summarized the trends of milk metabolite concentration over time efficiently without preliminary assumptions concerning the shapes of the curves. We first ran a supervised prediction of the longevity line of the goats based on the milk metabolite curves. The partial least square analysis could not predict the longevity line accurately. We thus decided to explore the large overall variability of milk metabolite curves with an unsupervised clustering. The large year × facility effect on the metabolite concentrations was precorrected for. This resulted in 3 clusters of goats defined by different metabolic responses to underfeeding. The cluster that showed higher β-hydroxybutyrate, cholesterol, and triacylglycerols increase during the underfeeding challenge was associated with poorer survival compared with the other 2 clusters. These results suggest that multivariate analysis of noninvasive milk measures show potential for deriving new resilience phenotypes.

EAONO/JOS classification for acquired cholesteatoma: evaluating the impact of the number of affected sites on treatment and outcomes

PURPOSE

The European and Japanese system for cholesteatoma classification proposed an anatomical differentiation in five sites. In stage I disease, one site would be affected and in stage II, two to five. We tested the significance of this differentiation by analyzing the influence of the number of affected sites on residual disease, hearing ability and surgical complexity.

METHODS

Cases of acquired cholesteatoma treated at a single tertiary referral center between 2010-01-01 and 2019-07-31 were retrospectively analyzed. Residual disease was determined according to the system. The air-bone gap mean of 0.5, 1, 2, 3 kHz (ABG) and its change with surgery served as hearing outcome. The surgical complexity was estimated regarding the Wullstein's tympanoplasty classification and the procedure approach (transcanal, canal up/down).

RESULTS

513 ears (431 patients) were followed-up during 21.6 ± 21.5 months. 107 (20.9%) ears had one site affected, 130 (25.3%) two, 157 (30.6%) three, 72 (14.0%) four and 47 (9.2%) five. An increasing number of affected sites resulted in higher residual rates (9.4-21.3%, p = 0.008) and surgical complexity, as well poorer ABG (preoperative 14.1 to 25.3 dB, postoperative 11.3-16.8 dB, p < 0.001). These differences existed between the means of cases of stage I and II, but also when only considering ears with stage II classification.

CONCLUSION

The data showed statistically significant differences when comparing the averages of ears with two to five affected sites, questioning the pertinence of the differentiation between stages I and II.

Predictive factors for abscessing tonsillitis: a retrospective analysis

OBJECTIVE

In clinical practice, identifying abscesses in tonsillar infections is crucial for early therapeutic management. Diagnosis of a peritonsillar abscess is usually based on clinical symptoms. Complementary examination procedures, such as laboratory parameters and imaging, are available for confirmation.

PATIENTS AND METHODS

A retrospective analysis was carried out of data for 752 patients who presented with acute tonsillar infection and were hospitalized between January 2012 and February 2021. The data analyses involved evaluating the patient's clinical symptoms, inflammatory parameters, and previous medical history in relation to the predictive power of these factors for the presence of an abscess.

RESULTS

Predictor analysis for the presence of an abscess showed significant values for trismus (OR 2.392; 95% CI, 1.305 to 4.383; p=0.005) and palatal arch protrusion (OR 29.679; 95% CI, 17.460 to 50.447; p=0.000). The inflammatory parameter C-reactive protein and the leukocyte count were not statistically significant as predictors.

CONCLUSIONS

The presence of a tonsillar abscess can be diagnosed from the clinical presentation alone if the findings are clear. Further diagnostic procedures are indicated in case of inconclusive findings, and ultrasound should be the primary noninvasive method. Computed tomography is only required in selected cases. Inflammatory parameters can be assessed in order to monitor therapy, but do not predict the presence of an abscess. However, if defined action sequences are being considered, tonsillar abscesses can be differentiated at an early point.

Analysis of reproduction success, growth and milk trajectories and response to nutritional challenge in two Alpine goat lines selected on divergent longevity

This study aims to investigate whether the variation in reproduction success, growth, and milk trajectories is associated with different adaptive strategies in the short term (response to an acute nutritional challenge), using two Alpine goat lines. A total of 382 Alpine goats (179 low longevity (low_LGV) and 203 high longevity (high_LGV)), selected for divergent functional longevity from a commercial population, were monitored for 4 years and recorded for BW, reproduction and milking performance. Every year, an average of fifty primiparous goats were exposed to a 2-d nutritional challenge in early lactation. A polynomial model was used to analyse the lifetime trajectory of lactation and BW. A piecewise model was used to analyse the individual milk yield and responses of milk components to the nutritional challenges. The statistical analysis revealed that the two lines had a similar performance for total milk yield in the first lactation, BW at birth and at first kidding, litter size and weight, kidding interval and interval from the first insemination to conception. BW trajectories revealed that low_LGV goats had a greater BW in pregnancy but then lost more weight in early lactation compared to high_LGV goats, which showed a greater BW after kidding. Milk trajectories showed that the high_LGV goats had a higher initial milk yield, an earlier but less marked lactation peak and more persistency in milk production in late lactation than low_LGV goats. Except for milk protein content, quite similar response and recovery profiles of milk yield and milk fat content were observed during the challenge for both lines. The response to the challenge was positively correlated to the initial level of milk production in early lactation but negatively correlated with milk production decline after the peak. This finding suggests that the low_LGV goats were more adapted to allocate resources to meet an expected physiological change such as gestation and lactation. However, high_LGV goats allocate more than low_LGV goats for structural mass and may better cope with an unexpected environmental change such as nutritional deficit.

Fluorometric determination of isocitrate dehydrogenase (EC 1.1.1.42; 1; NADP+ dependent) in ruminant milk

The enzyme isocitrate dehydrogenase (EC 1.1.1.42; 1; NADP⁺ dependent) located in the mammary cell cytosol mediates the synthesis of the majority of reducing equivalents for the energetically demanding milk fat and cholesterol synthesis in mammary cell cytosol. The present article presents a novel fluorometric method for quantification of the activity of this enzyme (IDH) in ruminant milk without pretreatment of the sample. Further, 493 goat milk samples - harvested before, during and after a nutritional restriction - were analysed for IDH activity i) with addition of extra substrate (isocitrate), and ii) with the intrinsic isocitrate solely. The IDH activity ranged from 0.22 to 15.4 units [nano moles product/(ml * min)] (un-supplemented) and from 0.22 to 45.6 units (isocitrate supplemented). The IDH activity increased considerably in milk during the nutritional restriction period concomitant with the increase in the metabolite isocitrate concentration and somatic cell count and returned to the initial level shortly after restriction period. The present 'high through-put' analytical method may be beneficial in future studies to phenotype modifications in mammary energy metabolism and milk fat synthesis, for which IDH activity may be a biomarker.

Animal Board Invited Review: Meta-analysis of genetic parameters for resilience and efficiency traits in goats and sheep

Genetic selection focused purely on production traits has proven very successful in improving the productive performance of livestock. However, heightened environmental and infectious disease challenges have raised the need to also improve the resilience of animals to such external stressors, as well as their efficiency in utilising available resources. A better understanding of the relationship between efficiency and production and health traits is needed to properly account for it in breeding programmes and to produce animals that can maintain high production performance in a range of environmental conditions with minimal environmental footprint. The aim of this study was to perform a meta-analysis of genetic parameters for production, efficiency and health traits in sheep and goats. The dataset comprised 963 estimates of heritability and 572 genetic correlations collated from 162 published studies. A threelevel meta-analysis model was fitted. Pooled heritability estimates for milk production traits ranged between 0.27 ± 0.03 and 0.48 ± 0.13 in dairy goats and between 0.21 ± 0.06 and 0.33 ± 0.07 in dairy sheep. In meat sheep, the heritability of efficiency traits ranged from 0.09 ± 0.02 (prolificacy) up to 0.32 ± 0.14 (residual feed intake). For health traits, pooled heritability was 0.07 ± 0.01 (faecal egg count) and 0.21 ± 0.01 (somatic cell score) in dairy goats and 0.14 ± 0.04 (faecal egg count) and 0.13 ± 0.02 (somatic cell score) in dairy sheep. In meat sheep, the heritability of disease resistance and survival traits ranged between 0.07 ± 0.02 (mastitis) and 0.50 ± 0.10 (breech strike). Pooled estimates of genetic correlations between resilience and efficiency traits in dairy goats were not significantly different from zero with the exception of somatic cell score and fat content (-0.19 ± 0.01). In dairy sheep, only the unfavourable genetic correlation between somatic cell score and protein content (0.12 ± 0.03) was statistically significant. In meat sheep only, the correlations between growth and faecal egg count (-0.28 ± 0.11) as well as between growth and dagginess (-0.33 ± 0.13) were statistically significant and favourable. Results of this meta-analysis provide evidence of genetic antagonism between production and health in dairy sheep and goats. This was not observed in meat sheep where most of the pooled estimates had high standard errors and were non-significant. Based on the obtained results, it seems feasible to simultaneously improve efficiency and health in addition to production by including the different types of traits in the breeding goal. However, a better understanding of potential trade-offs between these traits would be beneficial. Particularly, more studies focused on reproduction and resilience traits linked to the animal's multi-trait response to challenges are required.

The COVID-19 pandemic and its consequences for the diagnosis and therapy of head and neck malignancies

OBJECTIVE

The COVID-19 pandemic and the measures accompanying it have been accused of having a negative influence on the frequency and methods of treatment of various diseases including head and neck cancer (HNSCC). To go further into this assumption, the diagnoses made, and treatments performed at one of Germany's largest head and neck cancer centres were evaluated.

PATIENTS AND METHODS

This study consisted of one single centre and involved a retrospective review of all patients with newly diagnosed or recurrent HNSCC. The diagnosis and treatment methods used in the pre-COVID-19 time period between March 1st, 2019, and March 1st, 2020, were analysed and compared with the COVID-19 time period from April 1st, 2020, until April 1st, 2021. The primary objective was defined as the number of malignant diagnoses and the secondary objectives as the disease stage and the time to therapy.

RESULTS

A total of 612 patients (160♀; mean 63 yrs.) were included. 319 patients (52%) were treated in the pre-COVID-19 time. The two groups did not differ in terms of age (p=0.304), gender (p=0.941), presence of recurrent disease (p=0.866), tumour subsite (p=0.194) or the duration from presentation to the multidisciplinary tumour board until start of therapy (p=0.202). There were no significant differences in the T stage (p=0.777), N stage (p=0.067) or UICC stage (p=0.922). During the pre-COVID-19 period more patients presented with distant metastases (n= 23 vs. n=8; p=0.011).

CONCLUSIONS

This study shows that there was no significant change in either the number and severity of HNSCC diagnoses or the time until start of therapy at this large head and neck cancer centre as a result of the COVID-19 pandemic.

Divergent selection on milk somatic cell count in goats improves udder health and milk quality with no effect on nematode resistance

Milk somatic cell count (SCC) is commonly higher in goats than in cattle and sheep. Furthermore, the ability of milk SCC to predict mastitis is considered lower in goats than in cattle and sheep, and the relevance of somatic cell score (SCS)-based selection in this species has been questioned. To address this issue, we created 2 divergent lines of Alpine goats using artificially inseminated bucks with extreme estimated breeding values for SCS. A total of 287 goats, 158 in high- and 129 in low-SCS lines, were scrutinized for mastitis infections. We subjected 2,688 milk samples to conventional bacteriological analyses on agarose and bacterial counts were estimated for positive samples. The SCS, milk yield, fat content, and protein content were recorded every 3 wk. Clinical mastitis was systematically noted. A subset of 40 goats (20 from each line) was subsequently challenged with Haemonchus contortus and monitored for anemia (blood packed cell volume) and fecal egg counts to see if SCS-based selection had an indirect effect on resistance to gastrointestinal nematodes. Milk production traits, including milk quantity, fat content, and protein content, were similar in both goat lines. In contrast, the raw milk SCC almost doubled between the lines, with 1,542,000 versus 855,000 cells/mL in the high- and low-SCS lines, respectively. The difference in breeding value for SCS between lines was 1.65 genetic standard deviation equivalents. The Staphylococcus spp. most frequently isolated from milk were S. xylosus, S. caprae, S. epidermidis, and S. aureus. The frequency of positive bacteriology samples was significantly higher in the high-SCS line (49%) than in the low-SCS line (33%). The highest odds ratio was 3.49 (95% confidence interval: 11.95-6.25) for S. aureus. The distribution of bacterial species in positive samples between lines was comparable. The average quantity of bacteria in positive samples was also significantly higher in high-SCS goats (69 ± 80 growing colonies) than in low-SCS goats (38 ± 62 growing colonies). Clinical cases were rare and equally distributed between high- (n = 4; 2.5%) and low-SCS (n = 3; 2.3%) lines. Furthermore, the larger the amounts of bacteria in milk the higher the SCS level. Conversely, goats with repeatedly culture-negative udders exhibited the lowest SCC levels, with an average of below 300,000 cells/mL. We therefore confirmed that SCS is a relevant predictor of intramammary infection and hygienic quality of milk in goats and can be used for prophylactic purposes. After challenge with H. contortus, goats were anemic with high fecal egg counts but we found no difference between the genetic lines. This result provides initial evidence that resistance to mastitis or to gastrointestinal nematodes infections is under independent genetic regulation. Altogether, this monitoring of the goat lines indicated that SCS-based selection helps to improve udder health by decreasing milk cell counts and reducing the incidence of infection and related bacterial shedding in milk. Selection for low SCC should not affect a goat's ability to cope with gastrointestinal nematodes.

A dose ranging study of 2 different formulations of 15-valent pneumococcal conjugate vaccine (PCV15) in healthy infants

BACKGROUND

Two new formulations of an investigational 15-valent pneumococcal conjugate vaccine (PCV15-A and PCV15-B) were developed using 2 different protein-polysaccharide conjugation processes and evaluated in separate phase I/II studies (NCT02037984 [V114-004] and NCT02531373 [V114-005]) to assess optimal concentrations of pneumococcal polysaccharide (PnPs) and Aluminum Phosphate Adjuvant.

METHODS

Various lots of PCV15-A and PCV15-B containing different concentrations of PnPs and/or adjuvant were compared to PCV13 in young adults and infants. Adults received single dose and infants received 4 doses at 2, 4, 6, and 12-15 months of age. Adverse events (AEs) were collected after each dose. Serotype-specific immunoglobulin G (IgG) concentrations and opsonophagocytic activity (OPA) were measured prior and 30 days postvaccination in adults, at 1 month postdose 3 (PD3), pre-dose4, and postdose 4 (PD4) in infants.

RESULTS

Safety profiles were comparable across vaccination groups. At PD3, serotype-specific IgG GMCs were generally lower for either PCV15 formulation than PCV13 for most shared serotypes. PCV15 consistently elicited higher antibody responses to the 2 serotypes unique to the vaccine (22F and 33F) and serotype 3 for which PCV13 was shown to be ineffective. Except for serotypes 6A and 6B, no dose-response effect was observed with increasing concentrations of PnPs and/or adjuvant.

CONCLUSION

PCV15 is safe and induces IgG and OPA responses to all 15 serotypes in the vaccine. No significant differences in antibody responses were observed with increases in PnPs and/or Aluminum Phosphate Adjuvant.

Instrumented gait analysis in patients with medial osteoarthritis of the knee after mobile-bearing unicompartmental knee arthroplasty

BACKGROUND

Unicompartmental knee arthroplasty (UKA) is an effective treatment for patients with medial osteoarthritis of the knee joint. Instrumented gait analysis provides an objective measure to quantify and qualify postoperative changes of gait. The purpose of this study was to evaluate standardized instrumented gait analysis for functional recovery and gait as an outcome of mobile-bearing UKA in patients with medial osteoarthritis of the knee.

METHODS

Twenty-one patients with isolated medial osteoarthritis of the knee joint received mobile-bearing UKA. They were examined by a gait analysis before surgery and after an average follow-up time of seven months. Gait analysis was performed on a treadmill with six infrared-cameras to identify changes of gait characteristics (e.g., velocity, stride time, stride length, knee adduction and hip abduction).

RESULTS

Mean velocity (chosen by individuals) increased from 0.61 to 0.76m/s and further significant advancements, particularly in the knee adduction and the hip abduction were detected. Time and length of strides improved significantly as well as the clinical scores American Knee Society Score (AKSS), Oxford-12, Hannover Functional Ability Questionnaire for Osteoarthritis (FFbH-OA) Score and Devane Score.

CONCLUSION

Mobile-bearing UKA can restore physiological axis of the leg and improve gait and function of the knee joint. The combination of instrumented gait analysis with clinical scores constitutes an eligible measuring instrument to quantify and qualify changes in patients' gait patterns.

Invited review: Low milk somatic cell count and susceptibility to mastitis

An enduring controversy exists about low milk cell counts and susceptibility to mastitis. The concentration of milk leukocytes, or somatic cell count (SCC), is a well-established direct indicator of mammary gland inflammation that is highly correlated with the presence of a mammary infection. The SCC is also used as a trait for the selection of dairy ruminants less prone to mastitis. As selection programs favor animals with less SCC, and as milk cells contribute to the defense of the mammary gland, the idea that susceptibility to mastitis could possibly be increased in the long term has been put forward and is still widely debated. Epidemiological and experimental studies aimed at relating SCC to susceptibility to mastitis have yielded results that seem contradictory at first sight. Nevertheless, by taking into account the immunobiology of milk and mammary tissue cells and their role in the defense against infection, along with recent studies on SCC-based divergent selection of animals, the issue can be settled. Apparent SCC-linked susceptibility to mastitis is a phenotypic trait that may be linked to immunomodulation but not to selection.

Somatic cell count-based selection reduces susceptibility to energy shortage during early lactation in a sheep model

During the transition from late gestation to early lactation ruminants experience a negative energy balance (NEB), which is considered to increase susceptibility to mammary infections. Our previous study in 2 divergent lines of sheep selected for high and low somatic cell score (SCS) suggested an association between the response to NEB and genetic susceptibility to mastitis. Forty-eight early-lactation primiparous dairy ewes from the 2 SCS genetic lines were allocated to 2 homogeneous subgroups-an NEB group, which was energy restricted and received 60% of the energy requirements for 15 d, and a control-fed group-to obtain 4 balanced groups of 12 ewes: high-SCS positive energy balance, low-SCS positive energy balance, high-SCS NEB, and low-SCS NEB. High-SCS ewes showed greater weight loss and increased plasmatic concentrations of β-hydroxybutyrate and nonesterified fatty acids than low-SCS ewes when confronted with an induced NEB. The aim of this study was to further characterize this interaction by combining transcriptomic and phenotypic data with a generalized partial least squares discriminant analysis using mixOmics package framework. A preliminary analysis using 3 blocks of phenotypes (fatty acids, weight and production, blood metabolites) revealed a high correlation between fat-to-protein ratio, β-hydroxybutyrate, and nonesterified fatty acids concentrations with milk long-chain fatty acid yields. These phenotypes allowed good discrimination of the energy-restricted high-SCS ewes and confirmed a high level of adipose tissue mobilization in this group. A second analysis, which included RNA-seq data, revealed high correlations between the long-chain fatty acid yields in milk and PDK4, CPT1A, SLC25A20, KLF10, and KLF11 expression, highlighting the relationship between mobilization of body reserves and enhanced fatty acids utilization for energy production in blood cells. Finally, analysis of milk composition measured in 1,025 ewes from the 2 genetic lines over 10 yr confirmed significant higher fat-to-protein ratio in high-SCS ewes in early lactation. Altogether, our results strongly confirmed a genetic link between susceptibility to mastitis and metabolic adaptation to energy shortage. Improving genetic resistance to mastitis using SCS should be accompanied by a favorable effect on the response to metabolic stress, especially in highly stressful early lactation. Moreover, this study suggests that the fat-to-protein ratio could be used as a low-cost tool for monitoring energy balance and ketosis during this critical phase of lactation.

Validity and reliability of a locomotor stage-based functional rating scale in spinal cord injury

STUDY DESIGN

This is a prospective observational cohort study.

OBJECTIVES

The objectives of this study were to apply and adapt a rating scale based on locomotor stages (LSs) derived from cerebral palsy (CP) to spinal cord injury (SCI) and to quantify its inter-rater reliability and construct validity.

METHODS

The inter-rater reliability of LSs originally developed for children with CP was tested in a chronic SCI cohort. On the basis of the distribution of the LSs for CP, Locomotor Stages in Spinal Cord Injury (LOSSCI) were defined. Their validity was then tested with the Spinal Cord Independence Measure (SCIM) in another acute SCI cohort.

RESULTS

The 10-point LSs for CP were assessed by two raters in 65 chronic patients. Weighted Cohen's kappa (WCk) was 0.985 (P<0.0001). Only four mismatches were found, resulting in an accuracy of 93.4%. On the basis of the distribution of the LSs for CP in SCI, the five-point LOSSCI grading scale was developed. WCk of LOSSCI was 0.976 (P<0.0001). Only three mismatches between raters were found, resulting in an overall accuracy of 95.1%. The validity data sets consisted of 448 SCIM records from 161 patients obtained within the first year after injury. Spearman's correlation coefficients were the highest between LOSSCI and SCIM indoor mobility (room and toilet; R=0.82) and the lowest between LOSSCI and SCIM respiration and sphincter management (R=0.68).

CONCLUSION

LOSSCI provides a reliable and valid clinical tool to assess locomotor function in SCI. LOSSCI not only reflects bipedal walking but also covers a wide range of key motor skills.

Steer by ear: Myoelectric auricular control of powered wheelchairs for individuals with spinal cord injury

PURPOSE

Providing mobility solutions for individuals with tetraplegia remains challenging. Existing control devices have shortcomings such as varying or poor signal quality or interference with communication. To overcome these limitations, we present a novel myoelectric auricular control system (ACS) based on bilateral activation of the posterior auricular muscles (PAMs).

METHODS

Ten able-bodied subjects and two individuals with tetraplegia practiced PAM activation over 4 days using visual feedback and software-based training for 1 h/day. Initially, half of these subjects were not able to voluntarily activate their PAMs. This ability was tested with regard to 8 parameters such as contraction rate, lateralized activation, wheelchair speed and path length in a virtual obstacle course. In session 5, all subjects steered an electric wheelchair with the ACS.

RESULTS

Performance of all subjects in controlling their PAMs improved steadily over the training period. By day 5, all subjects successfully generated basic steering commands using the ACS in a powered wheelchair, and subjects with tetraplegia completed a complex real-world obstacle course. This study demonstrates that the ability to activate PAM on both sides together or unilaterally can be learned and used intuitively to steer a wheelchair.

CONCLUSIONS

With the ACS we can exploit the untapped potential of the PAMs by assigning them a new, complex function. The inherent advantages of the ACS, such as not interfering with oral communication, robustness, stability over time and proportional and continuous signal generation, meet the specific needs of wheelchair users and render it a realistic alternative to currently available assistive technologies.

Change of gait in patients with lateral osteoarthritis of the knee after mobile-bearing unicompartmental knee arthroplasty

PURPOSE

Patients with lateral osteoarthritis of the knee suffer not only from pain but also impaired gait and limited mobility. Common treatment options are total knee replacement and lateral unicompartmental knee arthroplasty (UKA). The domed lateral mobile-bearing Oxford Uni is a new treatment option for patients with isolated osteoarthritis of the lateral compartment of the knee joint. We used instrumented gait analysis and clinical scores to study patients before and after lateral UKA.

METHODS

Nineteen patients suffering from lateral osteoarthritis underwent implantation of a mobile-bearing lateral UKA. They were examined in a gait analysis before the operation and after an average follow-up time of 7 months. Gait analysis was performed on a treadmill with six infrared cameras to identify gait characteristics (e.g. velocity, stride time, stride length, knee abduction or hip adduction).

RESULTS

Mean velocity changed from 0.58 to 0.73 m/s. Significant advancements were also found in knee abduction and hip adduction. Time and length of strides improved significantly as well as the clinical scores American Knee Society Score, Oxford-12, FFb-H-OA and Devane Score.

CONCLUSION

Patients with lateral osteoarthritis of the knee showed an impaired gait with an increased knee abduction and hip adduction angle. Implantation of a lateral mobile UKA can restore normal axis of the leg and improve gait and function of the knee. Instrumented gait analysis is a suitable measuring instrument to quantify and qualify the post-operative change of gait.

LEVEL OF EVIDENCE

II.

[Novel aspects of diagnostics and therapy of spinal cord diseases]

BACKGROUND

Both non-traumatic and traumatic spinal cord injuries have in common that a relatively minor structural lesion can cause profound sensorimotor and autonomous dysfunction. Besides treating the cause of the spinal cord injury the main goal is to restore lost function as far as possible.

AIM

This article provides an overview of current innovative diagnostic (imaging) and therapeutic approaches (neurorehabilitation and neuroregeneration) aiming for recovery of function after non-traumatic and traumatic spinal cord injuries.

MATERIAL AND METHODS

An analysis of the current scientific literature regarding imaging, rehabilitation and rehabilitation strategies in spinal cord disease was carried out.

RESULTS

Novel magnetic resonance imaging (MRI) based techniques (e.g. diffusion-weighted MRI and functional MRI) allow visualization of structural reorganization and specific neural activity in the spinal cord. Robotics-driven rehabilitative measures provide training of sensorimotor function in a targeted fashion, which can even be continued in the homecare setting. From a preclinical point of view, defined stem cell transplantation approaches allow for the first time robust structural repair of the injured spinal cord.

CONCLUSION

Besides well-established neurological and functional scores, MRI techniques offer the unique opportunity to provide robust and reliable "biomarkers" for restorative therapeutic interventions. Function-oriented robotics-based rehabilitative interventions alone or in combination with stem cell based therapies represent promising approaches to achieve substantial functional recovery, which go beyond current rehabilitative treatment efforts.

Genetic parameter estimation for major milk fatty acids in Alpine and Saanen primiparous goats

Genetic parameters for 18 fatty acids or groups of fatty acids (FA), milk production traits, and somatic cell score (SCS) were estimated by restricted maximum likelihood with a repeatability animal model, using 45,259 test-day records from the first lactations of 13,677 Alpine and Saanen goats. Fatty acid data were collected as part of an extensive recording scheme (PhénoFinLait), and sample testing was based on mid-infrared spectra estimates. The total predicted FA content in milk was approximately 3.5% in Alpine and Saanen goats. Goat milk fat showed similar saturated FA to cattle and sheep, but higher contents of capric (C10:0) FA (~ 9.7 g/100g of milk fat). Heritability estimates ranged from 0.18 to 0.49 for FA and estimates were generally higher when FA were expressed in g/100g of milk fat compared with g/100g of milk. In general, the 3 specific short- and medium-chain goat FA, caproic acid (C6:0), caprylic acid (C8:0), and especially capric (C10:0) acid, had among the highest heritability estimates (from 0.21 to 0.37; average of 0.30). Heritability estimates for milk yield, fat and protein contents, and SCS were 0.22, 0.23, 0.39, 0.09, and 0.24, 0.20, 0.40, and 0.15, in Alpine and Saanen goats, respectively. When FA were expressed in g/100g of milk, genetic correlations between fat content and all FA were high and positive. Genetic correlations between the fat content and FA groups expressed in g/100g of fat led to further investigation of the association between fat content and FA profile within milk fat. Accordingly, in both Saanen and Alpine breeds, no significant genetic correlations were found between fat content and C16:0, whereas the correlations between fat content and specific goat FA (C6:0 to C10:0) were positive (0.17 to 0.59). In addition, the genetic correlation between fat content and C14:0 was negative (-0.17 to -0.35). The values of the genetic correlations between protein content and individual FA were similar, although genetic correlations between protein content and FA groups were close to zero. Genetic correlations of milk yield or SCS with the FA profile were weak. Results for genetic parameters for FA, however, should be further validated, because the low predicting ability of certain FA using mid-infrared spectra and the limited calibration data set might have resulted in low accuracy. In conclusion, our results indicated substantial genetic variation in goat milk FA that supported their amenability for genetic selection. In addition, selection on protein and fat contents is not expected to have an undesirable effect on the FA profile in regard to specificity of goat products and human health.

Effect of formal training in scaling, scoring and classification of the International Standards for Neurological Classification of Spinal Cord Injury

STUDY DESIGN

Prospective, longitudinal cohort study.

OBJECTIVES

To quantify the effect of formal training in the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) on the classification accuracy and to identify the most difficult ISNCSCI rules.

SETTINGS

European Multicenter Study on Human Spinal Cord Injury (EMSCI).

METHODS

EMSCI participants rated five challenging cases of full sensory, motor and anorectal examinations before (pre-test) and after (post-test) an ISNCSCI instructional course. Classification variables included sensory and motor levels (ML), completeness, ASIA Impairment Scale (AIS) and the zones of partial preservation.

RESULTS

106 attendees were trained in 10 ISNCSCI workshops since 2006. The number of correct classifications increased significantly (P<0.00001) from 49.6% (2628 of 5300) in pre-testing to 91.5% (4849 of 5300) in post-testing. Every attendee improved, 12 (11.3%) achieved 100% correctness. Sensory levels (96.8%) and completeness (96.2%) are easiest to rate in post-testing, while ML (81.9%) and AIS (88.1%) are more difficult to determine. Most of the errors in ML determination arise from sensory levels in the high cervical region (C2-C4), where by convention the ML is presumed to be the same as the sensory level. The most difficult step in AIS classification is the determination of motor incompleteness.

CONCLUSION

ISNCSCI training significantly improves the classification skills regardless of the experience in spinal cord injury medicine. These findings need to be considered for the appropriate preparation and interpretation of clinical trials in spinal cord injury.

Genetic parameters for milk somatic cell score and relationship with production and udder type traits in dairy Alpine and Saanen primiparous goats

Goat milk somatic cell counts have been collected for several years in France by the national milk recording organization. Information is used for health management, because repeatedly elevated somatic cell counts are a good indirect predictor of intramammary infection. Genetic parameters were estimated for 67,882 and 49,709 primiparous goats of the dairy Alpine and Saanen breeds, respectively, with complete information for milk somatic cell counts and milk production traits. About 40% of the goats had additional information for 11 udder type traits scored by official classifiers of the breeders' association CAPGENES. Estimates were obtained by REML with an animal model. The studied trait was lactation somatic cell score (LSCS), the weighted mean of somatic cell score (log-transformed SCC) adjusted for lactation stage. Heritability of LSCS was 0.20 and 0.24 in the Alpine and Saanen breeds, respectively. Relationships with milk production and udder type traits were additionally estimated by using multitrait analyses. Heritability estimates in first lactation ranged from 0.30 to 0.35 for lactation milk, fat, and protein yields; from 0.60 to 0.67 for fat and protein contents; and from 0.22 to 0.50 for udder type traits. Genetic correlations of somatic cell score with milk production traits were generally low, ranging from -0.13 to 0.12. Slightly more negative correlations were estimated for fat content: -0.18 and -0.20 in Saanen and Alpine breeds, respectively. Lactation somatic cell score was genetically correlated with udder floor position (r(g)=-0.24 and -0.19 in the Alpine and Saanen breeds, respectively), and, in Saanen, teat length, teat width, and teat form (r(g)=0.29, 0.34 and -0.27, respectively). These results suggest that a reduction in somatic cell count can be achieved by selection while still improving milk production and udder type and teat traits.

Silicon Carbide Cvd Approaches Industrial Needs

In this paper an overview is given on the current state of epitaxial growth of SiC with special regard to our work at SIEMENS CRD. Problems concerning impurity incorporation and ways to achieve background doping levels as low as 1014 cm−3 are discussed as well as the influence of high speed wafer rotation on the gas flow in our reactor and related effects on uniformity in thickness and doping. Precise control of the C/Si ratio in the gas phase, which is easily achieved in the described reactor, and the use of reduced pressure lead to a good control of dopant incorporation over more than 3 orders of magnitude while maintaining smooth surface morphology even at growth rates higher than 5 μm/h. Doping variations <±8 % across 30 mm wafers can routinely be obtained. The quality of the egilayers is proven by electrical breakdown fields as high as 2*106 V/cm at NA−ND=5* 10−15 cm−and an electron mobility greater than 700 cm2 /Vs at 300 K (4H-SiC).

Finally it is demonstrated that the gas composition at the end of the epitaxial growth process is an important step in order to get oxygen resistant surface properties for subsequent device processing.

Combining Brain-Computer Interfaces and Assistive Technologies: State-of-the-Art and Challenges

In recent years, new research has brought the field of electroencephalogram (EEG)-based brain–computer interfacing (BCI) out of its infancy and into a phase of relative maturity through many demonstrated prototypes such as brain-controlled wheelchairs, keyboards, and computer games. With this proof-of-concept phase in the past, the time is now ripe to focus on the development of practical BCI technologies that can be brought out of the lab and into real-world applications. In particular, we focus on the prospect of improving the lives of countless disabled individuals through a combination of BCI technology with existing assistive technologies (AT). In pursuit of more practical BCIs for use outside of the lab, in this paper, we identify four application areas where disabled individuals could greatly benefit from advancements in BCI technology, namely, “Communication and Control”, “Motor Substitution”, “Entertainment”, and “Motor Recovery”. We review the current state of the art and possible future developments, while discussing the main research issues in these four areas. In particular, we expect the most progress in the development of technologies such as hybrid BCI architectures, user–machine adaptation algorithms, the exploitation of users’ mental states for BCI reliability and confidence measures, the incorporation of principles in human–computer interaction (HCI) to improve BCI usability, and the development of novel BCI technology including better EEG devices.

Response to somatic cell count-based selection for mastitis resistance in a divergent selection experiment in sheep

A divergent selection experiment in sheep was implemented to study the consequences of log-transformed somatic cell score (SCS)-based selection on resistance to natural intramammary infections. Using dams and progeny-tested rams selected for extreme breeding values for SCS, we created 2 groups of ewes with a strong divergence in SCS of approximately 3 genetic standard deviations. A survey of 84 first-lactation ewes of both the High and Low SCS lines indicated favorable responses to SCS-based selection on resistance to both clinical and subclinical mastitis. All clinical cases (n = 5) occurred in the High SCS line. Additionally, the frequency of chronic clinical mastitis, as detected by the presence of parenchymal abscesses, was much greater in the High SCS line (n = 21) than in the Low SCS line (n = 1). According to monthly milk bacteriological examinations of udder halves, the prevalence of infection was significantly greater (odds ratio = 3.1) in the High SCS line than in the Low SCS line, with predicted probabilities of 37 and 16%, respectively. The most frequently isolated bacteria responsible for mastitis were staphylococci: Staphylococcus auricularis (42.6% of positive samples), Staphylococcus simulans, Staphylococcus haemoliticus, Staphylococcus xylosus, Staphylococcus chromogenes, Staphylococcus lentus, Staphylococcus warneri, and Staphylococcus aureus. The incidence of positive bacteriology was greater in the High SCS line (39%) than in the Low SCS line (12%) at lambing, indicating that High SCS line ewes were especially susceptible to postpartum subclinical mastitis. Negativation of bacteriological results from one sampling time point to the next was markedly different between lines after weaning (e.g., 41 and 84% in the High and Low SCS lines, respectively). This result was consistent with differences in the duration of infection, which was much greater in the High SCS line compared with the Low SCS line. Finally, ewes from the High SCS line consistently had greater SCS in positive milk samples than did ewes from the Low SCS line (+2.04 SCS, on average), with an especially large difference between lines during the suckling period (+3.42 SCS). Altogether, the preliminary results suggest that the better resistance of Low SCS line ewes, compared with High SCS line ewes, was principally characterized by a better ability to limit infections during the peripartum period, to eliminate infections during lactation, and quantitatively to limit the inflammation process and its clinical consequences.

Identification of seven haplotypes of the caprine PrP gene at codons 127, 142, 154, 211, 222 and 240 in French Alpine and Saanen breeds and their association with classical scrapie

In sheep, susceptibility to scrapie is mainly influenced by polymorphisms of the PrP gene. In goats, there are to date few data related to scrapie susceptibility association with PrP gene polymorphisms. In this study, we first investigated PrP gene polymorphisms of the French Alpine and Saanen breeds. Based on PrP gene open reading frame sequencing of artificial insemination bucks (n=404), six encoding mutations were identified at codons 127, 142, 154, 211, 222 and 240. However, only seven haplotypes could be detected: four (GIH154RQS, GIRQ211QS, GIRRK222S and GIRRQP240) derived from the wild-type allele (G127I142R154R211Q222S240) by a single-codon mutation, and two (S127IRRQP240 and GM142RRQP240) by a double-codon mutation. A case–control study was then implemented in a highly affected Alpine and Saanen breed herd (90 cases/164 controls). Mutations at codon 142 (I/M), 154 (R/H), 211 (R/Q) and 222 (Q/K) were found to induce a significant degree of protection towards natural scrapie infection. Compared with the baseline homozygote wild-type genotype I142R154R211Q222/IRRQ goats, the odds of scrapie cases in IRQ211Q/IRRQ and IRRK222/IRRQ heterozygous animals were significantly lower [odds ratio (OR)=0.133, P<0.0001; and OR=0.048, P<0.0001, respectively]. The heterozygote M142RRQ/IRRQ genotype was only protective (OR=0.243, P=0.0186) in goats also PP240 homozygous at codon 240. However, mutated allele frequencies in French Alpine and Saanen breeds were low (0.5–18.5 %), which prevent us from assessing the influence of all the possible genotypes in natural exposure conditions.

MesP1 drives vertebrate cardiovascular differentiation through Dkk-1-mediated blockade of Wnt-signalling

ES-cell-based cardiovascular repair requires an in-depth understanding of the molecular mechanisms underlying the differentiation of cardiovascular ES cells. A candidate cardiovascular-fate inducer is the bHLH transcription factor MesP1. As one of the earliest markers, it is expressed specifically in almost all cardiovascular precursors and is required for cardiac morphogenesis. Here we show that MesP1 is a key factor sufficient to induce the formation of ectopic heart tissue in vertebrates and increase cardiovasculogenesis by ES cells. Electrophysiological analysis showed all subtypes of cardiac ES-cell differentiation. MesP1 overexpression and knockdown experiments revealed a prominent function of MesP1 in a gene regulatory cascade, causing Dkk-1-mediated blockade of canonical Wnt-signalling. Independent evidence from ChIP and in vitro DNA-binding studies, expression analysis in wild-type and MesP knockout mice, and reporter assays confirm that Dkk-1 is a direct target of MesP1. Further analysis of the regulatory networks involving MesP1 will be required to preprogramme ES cells towards a cardiovascular fate for cell therapy and cardiovascular tissue engineering. This may also provide a tool to elicit cardiac transdifferentiation in native human adult stem cells.

[Gait analysis in limb-preserving tumour surgery--kinematic gait patterns after resection of malignant bone tumours near the knee joint]

AIM

Limb-preserving surgery is the most common therapeutic approach in cases of malignant bone tumours near the knee joint. Although good functional results have been reported for tumours located in the distal femur, tumours in the proximal tibia have been investigated less frequently. The objective of the current study was to compare the kinematic gait patterns in patients with tumours in the femur vs. the tibia.

METHOD

11 patients with an arthroplasty after a primary malignant bone tumour were included (5 femur, 6 tibia). Their speed-specific kinematic gait patterns were quantified. 10 healthy volunteers and 6 patients with normal knee arthroplasty served as a reference group.

RESULTS

The tibia patients walked significantly more slowly than the femur patients. They showed a similar overall gait pattern predominantly characterised by a hyperextended knee during stance.

CONCLUSION

The differences in walking speed between the two groups of tumour patients did not transfer to different gait patterns. Limb-preserving surgery is thus a valuable therapeutic option also for patients with primary tumours in the tibia.

Neuroprosthetics of the upper extremity--clinical application in spinal cord injury and challenges for the future

The complete restoration of movements lost due to a spinal cord injury (SCI) is the greatest hope of physicians, therapists and certainly of the patients themselves. Particularly, in patients with lesions of the cervical spinal cord every little improvement of missing or weak grasp function will result in a large gain in quality of life. Despite the fact that novel drugs for axonal regeneration in the spinal cord are in the phase of imminent human application, up to now, the only possibility of restoration of basic movements in SCI persons consists in the use of functional electrical stimulation (FES). While FES systems in the lower extremities for standing or walking have not reached widespread clinical acceptance yet, devices are available for demonstrable improvement of the grasp function. This applies to tetraplegic patients with stable, active shoulder function, but missing control of hand and fingers. Particularly, with the use of implantable systems a long-term stable, user-friendly application is possible. Most recent work aims at the development of minimally invasive, subminiature systems for individual functional support. The possibility of direct brain control of FES systems will extend the application of grasp neuroprostheses to patients with injuries of the highest cervical spinal cord.

Association of Bovine Leukocyte Antigen (BoLA) DRB3.2 with Immune Response, Mastitis, and Production and Type Traits in Canadian Holsteins

Data collected from 328 Canadian Holsteins in a research herd at the University of Guelph were used to study associations among expression of bovine leukocyte antigen (BoLA) DRB3.2 alleles, immune response, mastitis resistance via somatic cell counts (SCC), and clinical mastitis, as well as to extend these results to production and type traits. Accordingly, groups of cows were evaluated in vivo for both the antibody-mediated immune response (AMIR) and the cell-mediated immune response (CMIR), which generally predominate in responses to extracellular and intracellular pathogens, respectively. Of note was that associations between BoLA DRB3.2 alleles and immune responses tended to be in the opposite sign for the 2 AMIR and CMIR traits examined. For example, alleles DRB3.2*3 and *24 were associated with higher AMIR but lower CMIR, whereas allele *22 was associated with lower AMIR but higher CMIR. This finding is in agreement with the hypothesis that both traits are genetically independent and represent opposing type 1 and type 2 immune responses. Additionally, BoLA DRB3.2*3 and *11 were associated with lower SCC, whereas alleles *22 and *23 were associated with higher SCC. Finally, allele DRB3.2*3 was also associated with less clinical mastitis, whereas allele *8 was associated with higher mastitis risk. Allele *3 was of particular relevance because it was associated with increased antibodies, as well as reduced mastitis and SCC. This could be due to an indirect relationship between the ability to produce a high antibody response and enhanced defense against intrammamary infections caused by extracellular pathogens. Consequently, the BoLA DRB3.2*3 allele should be investigated further as a candidate for resistance to some types of intramammary infections, the important caveat being its association with lower CMIR, particularly with one of the test antigens used to evaluate delayed-type hypersensitivity. The results of associations between BoLA DRB3.2 and production traits were, in some cases, antagonistic in that BoLA DRB3.2 alleles *11 and *23, which are associated with increased production traits, were associated with lower and higher SCC, respectively. Collectively, these findings advocate the use of alleles *3, *23, and *22 as reference points for more detailed mechanistic studies. This does not imply that genetic selection for mastitis resistance should be based on BoLA alleles, but that information on a variety of genes may aid in identification and selection for improved health.

[Functional electrical stimulation instead of surgery? Improvement of grasping function with FES in a patient with C5 tetraplegia]

The aim of this study was to restore the grasp function of a tetraplegic patient with a C5 spinal cord injury (SCI) by means of functional electrical stimulation (FES). Using three pairs of surface electrodes and orthotic wrist stabilisation a simple palmar grasp was realised. The FES was controlled with a switch mounted on a wheelchair or-for the first time-with an EEG-based brain-computer interface (BCI). Application of this stimulation system enabled the patient to drink for the first time after the accident from a glass without any additional help.

Funktionelle Rehabilitation von Querschnittgel�hmten durch Neuroprothetik

Recent technological advancements in microelectronics have led to the establishment of systems for restoration of basic functions in spinal cord injured (SCI) persons using functional electrical stimulation (FES). FES systems for the restoration of bladder and diaphragm function are well established in clinical practice. While FES systems in the lower extremities for standing/walking have not yet achieved widespread clinical acceptance, devices which enhance or restore the grasp function in tetraplegic patients with missing control of hand and fingers are demonstrably successful. Especially with the use of implantable systems a reliable, easy to handle application is possible. The most recent developments in micromechanical engineering are aimed at providing minimally invasive, subminiature systems for functional support in incomplete SCI persons. The possibility of direct brain control of FES systems will expand the application of neuroprostheses for patients with injury of the high cervical spinal cord.