Large-scale smart bioreactor with fully integrated wireless multivariate sensors and electronics for long-term in situ monitoring of stem cell culture

Achieving large-scale, cost-effective, and reproducible manufacturing of stem cells with the existing devices is challenging. Traditional single-use cell-bag bioreactors, limited by their rigid and single-point sensors, struggle with accuracy and scalability for high-quality cell manufacturing. Here, we introduce a smart bioreactor system that enables multi-spatial sensing for real-time, wireless culture monitoring. This scalable system includes a low-profile, label-free thin-film sensor array and electronics integrated with a flexible cell bag, allowing for simultaneous assessment of culture properties such as pH, dissolved oxygen, glucose, and temperature, to receive real-time feedback for up to 30 days. The experimental results show the accurate monitoring of time-dynamic and spatial variations of stem cells and myoblast cells with adjustable carriers from a plastic dish to a 2-liter cell bag. These advances open up the broad applicability of the smart sensing system for large-scale, lower-cost, reproducible, and high-quality engineered cell manufacturing for broad clinical use.

Soft implantable printed bioelectronic system for wireless continuous monitoring of restenosis

Atherosclerosis is a prominent cause of coronary artery disease and broader cardiovascular diseases, the leading cause of death worldwide. Angioplasty and stenting is a common treatment, but in-stent restenosis, where the artery re-narrows, is a frequent complication. Restenosis is detected through invasive procedures and is not currently monitored frequently for patients. Here, we report an implantable vascular bioelectronic device using a newly developed miniaturized strain sensor via microneedle printing methods. A capillary-based printing system achieves high-resolution patterning of a soft, capacitive strain sensor. Ink and printing parameters are evaluated to create a fully printed sensor, while sensor design and sensing mechanism are studied to enhance sensitivity and minimize sensor size. The sensor is integrated with a wireless vascular stent, offering a biocompatible, battery-free, wireless monitoring system compatible with conventional catheterization procedures. The vascular sensing system is demonstrated in an artery model for monitoring restenosis progression. Collectively, the artery implantable bioelectronic system shows the potential for wireless, real-time monitoring of various cardiovascular diseases and stent-integrated sensing/treatments.

Fully implantable batteryless soft platforms with printed nanomaterial-based arterial stiffness sensors for wireless continuous monitoring of restenosis in real time

Atherosclerosis is a common cause of coronary artery disease and a significant factor in broader cardiovascular diseases, the leading cause of death. While implantation of a stent is a prevalent treatment of coronary artery disease, a frequent complication is restenosis, where the stented artery narrows and stiffens. Although early detection of restenosis can be achieved by continuous monitoring, no available device offers such capability without surgeries. Here, we report a fully implantable soft electronic system without batteries and circuits, which still enables continuous wireless monitoring of restenosis in real-time with a set of nanomembrane strain sensors in an electronic stent. The low-profile system requires minimal invasive implantation to deploy the sensors into a blood vessel through catheterization. The entirely printed, nanomaterial-based set of soft membrane strain sensors utilizes a sliding mechanism to offer enhanced sensitivity and detection of low strain while unobtrusively integrating with an inductive stent for passive wireless sensing. The performance of the soft sensor platform is demonstrated by wireless monitoring of restenosis in an artery model and an ex-vivo study in a coronary artery of ovine hearts. The capacitive sensor-based artery implantation system offers unique advantages in wireless, real-time monitoring of stent treatments and arterial health for cardiovascular disease.

Fully implantable wireless batteryless vascular electronics with printed soft sensors for multiplex sensing of hemodynamics

The continuous monitoring of hemodynamics attainable with wireless implantable devices would improve the treatment of vascular diseases. However, demanding requirements of size, wireless operation, and compatibility with endovascular procedures have limited the development of vascular electronics. Here, we report an implantable, wireless vascular electronic system, consisting of a multimaterial inductive stent and printed soft sensors capable of real-time monitoring of arterial pressure, pulse rate, and flow without batteries or circuits. Developments in stent design achieve an enhanced wireless platform while matching conventional stent mechanics. The fully printed pressure sensors demonstrate fast response times, high durability, and sensing at small bending radii. The device is monitored via inductive coupling at communication distances notably larger than prior vascular sensors. The wireless electronic system is validated in artery models, while minimally invasive catheter implantation is demonstrated in an in vivo rabbit study. Overall, the vascular system offers an adaptable framework for comprehensive monitoring of hemodynamics.

At-home wireless monitoring of acute hemodynamic disturbances to detect sleep apnea and sleep stages via a soft sternal patch

Obstructive sleep apnea (OSA) affects more than 900 million adults globally and can create serious health complications when untreated; however, 80% of cases remain undiagnosed. Critically, current diagnostic techniques are fundamentally limited by low throughputs and high failure rates. Here, we report a wireless, fully integrated, soft patch with skin-like mechanics optimized through analytical and computational studies to capture seismocardiograms, electrocardiograms, and photoplethysmograms from the sternum, allowing clinicians to investigate the cardiovascular response to OSA during home sleep tests. In preliminary trials with symptomatic and control subjects, the soft device demonstrated excellent ability to detect blood-oxygen saturation, respiratory effort, respiration rate, heart rate, cardiac pre-ejection period and ejection timing, aortic opening mechanics, heart rate variability, and sleep staging. Last, machine learning is used to autodetect apneas and hypopneas with 100% sensitivity and 95% precision in preliminary at-home trials with symptomatic patients, compared to data scored by professionally certified sleep clinicians.

Recent Advances in Printing Technologies of Nanomaterials for Implantable Wireless Systems in Health Monitoring and Diagnosis

The development of wireless implantable sensors and integrated systems, enabled by advances in flexible and stretchable electronics technologies, is emerging to advance human health monitoring, diagnosis, and treatment. Progress in material and fabrication strategies allows for implantable electronics for unobtrusive monitoring via seamlessly interfacing with tissues and wirelessly communicating. Combining new nanomaterials and customizable printing processes offers unique possibilities for high-performance implantable electronics. Here, this report summarizes the recent progress and advances in nanomaterials and printing technologies to develop wireless implantable sensors and electronics. Advances in materials and printing processes are reviewed with a focus on challenges in implantable applications. Demonstrations of wireless implantable electronics and advantages based on these technologies are discussed. Lastly, existing challenges and future directions of nanomaterials and printing are described.

All-printed nanomembrane wireless bioelectronics using a biocompatible solderable graphene for multimodal human-machine interfaces

Recent advances in nanomaterials and nano-microfabrication have enabled the development of flexible wearable electronics. However, existing manufacturing methods still rely on a multi-step, error-prone complex process that requires a costly cleanroom facility. Here, we report a new class of additive nanomanufacturing of functional materials that enables a wireless, multilayered, seamlessly interconnected, and flexible hybrid electronic system. All-printed electronics, incorporating machine learning, offers multi-class and versatile human-machine interfaces. One of the key technological advancements is the use of a functionalized conductive graphene with enhanced biocompatibility, anti-oxidation, and solderability, which allows a wireless flexible circuit. The high-aspect ratio graphene offers gel-free, high-fidelity recording of muscle activities. The performance of the printed electronics is demonstrated by using real-time control of external systems via electromyograms. Anatomical study with deep learning-embedded electrophysiology mapping allows for an optimal selection of three channels to capture all finger motions with an accuracy of about 99% for seven classes.

Though wearable electronics remain an attractive technology for bioelectronics, fabrication methods that precisely print biocompatible materials for electronics are needed. Here, the authors report an additive manufacturing process that yields all-printed nanomaterial-based wireless electronics.

Printed, Soft, Nanostructured Strain Sensors for Monitoring of Structural Health and Human Physiology

Soft strain sensors that are mechanically flexible or stretchable are of significant interest in the fields of structural health monitoring, human physiology, and human-machine interfaces. However, existing deformable strain sensors still suffer from complex fabrication processes, poor reusability, limited adhesion strength, or structural rigidity. In this work, we introduce a versatile, high-throughput fabrication method of nanostructured, soft material-enabled, miniaturized strain sensors for both structural health monitoring and human physiology detection. Aerosol jet printing of polyimide and silver nanowires enables multifunctional strain sensors with tunable resistance and gauge factor. Experimental study of soft material compositions and multilayered structures of the strain sensor demonstrates the capabilities of strong adhesion and conformal lamination on different surfaces without the use of conventional fixtures and/or tapes. A two-axis, printed strain gauge enables the detection of force-induced strain changes on a curved stem valve for structural health management while offering reusability over 10 times without losing the sensing performance. Direct comparison with a commercial film sensor captures the advantages of the printed soft sensor in enhanced gauge factor and sensitivity. Another type of a stretchable strain sensor in skin-wearable applications demonstrates a highly sensitive monitoring of a subject's motion, pulse, and breathing, validated by comparing it with a clinical-grade system. Overall, the presented comprehensive study of materials, mechanics, printing-based fabrication, and interfacial adhesion shows a great potential of the printed soft strain sensor for applications in continuous structural health monitoring, human health detection, machine-interfacing systems, and environmental condition monitoring.

Soft, wireless periocular wearable electronics for real-time detection of eye vergence in a virtual reality toward mobile eye therapies

Recent advancements in electronic packaging and image processing techniques have opened the possibility for optics-based portable eye tracking approaches, but technical and safety hurdles limit safe implementation toward wearable applications. Here, we introduce a fully wearable, wireless soft electronic system that offers a portable, highly sensitive tracking of eye movements (vergence) via the combination of skin-conformal sensors and a virtual reality system. Advancement of material processing and printing technologies based on aerosol jet printing enables reliable manufacturing of skin-like sensors, while the flexible hybrid circuit based on elastomer and chip integration allows comfortable integration with a user's head. Analytical and computational study of a data classification algorithm provides a highly accurate tool for real-time detection and classification of ocular motions. In vivo demonstration with 14 human subjects captures the potential of the wearable electronics as a portable therapy system, whose minimized form factor facilitates seamless interplay with traditional wearable hardware.

Soft Material-Enabled Electronics for Medicine, Healthcare, and Human-Machine Interfaces

Soft material-enabled electronics offer distinct advantages over conventional rigid and bulky devices for numerous wearable and implantable applications. Soft materials allow for seamless integration with skin and tissues due to the enhanced mechanical flexibility and stretchability. Wearable devices with multiple sensors offer continuous, real-time monitoring of biosignals and movements, which can be applied for rehabilitation and diagnostics, among other applications. Soft implantable electronics offer similar functionalities, but with improved compatibility with human tissues. Biodegradable soft implantable electronics are also being developed for transient monitoring, such as in the weeks following surgeries. New composite materials, integration strategies, and fabrication techniques are being developed to further advance soft electronics. This paper reviews recent progresses in these areas towards the development of soft material-enabled electronics for medicine, healthcare, and human-machine interfaces.

Soft Materials, Stretchable Mechanics, and Optimized Designs for Body-Wearable Compliant Antennas

Among the various methods to develop flexible wearable antennas, a serpentine, mesh structure has been a great interest because of its mechanical reliability upon applied strain. However, there is still a significant lack of design guidelines for the open-mesh concept that account for both material and electromagnetic (EM) properties of antennas. In this work, we introduce a comprehensive study of materials, mechanics, fabrication, and system integration for the development of stretchable dipole and patch antennas that have networks of two-dimensional serpentine patterns. A set of computational modeling and experimental validation of open-mesh structures provides the key design guidelines to offer the maximum mechanical stretchability and minimum effective moduli of wearable antennas. Integration of the thin-film antenna traces with various substrates captures the versatility of the deterministic fabrication and material transfer printing methods. The influence of antenna stretching on the EM properties, including return loss, electric and magnetic fields, and far-field radiation patterns, is investigated. EM characterization with mechanical stretching results in different properties of fabricated antennas. The simulation study of specific absorption rates shows a potential for safe applications of dipole and patch stretchable antennas on the human skin.

Fully Printed, Wireless, Stretchable Implantable Biosystem toward Batteryless, Real-Time Monitoring of Cerebral Aneurysm Hemodynamics

This study introduces a high-throughput, large-scale manufacturing method that uses aerosol jet 3D printing for a fully printed stretchable, wireless electronics. A comprehensive study of nanoink preparation and parameter optimization enables a low-profile, multilayer printing of a high-performance, capacitance flow sensor. The core printing process involves direct, microstructured patterning of biocompatible silver nanoparticles and polyimide. The optimized fabrication approach allows for transfer of highly conductive, patterned silver nanoparticle films to a soft elastomeric substrate. Stretchable mechanics modeling and seamless integration with an implantable stent display a highly stretchable and flexible sensor, deployable by a catheter for extremely low-profile, conformal insertion in a blood vessel. Optimization of a transient, wireless inductive coupling method allows for wireless detection of biomimetic cerebral aneurysm hemodynamics with the maximum readout distance of 6 cm through meat. In vitro demonstrations include wireless monitoring of flow rates (0.05-1 m s-1) in highly contoured and narrow human neurovascular models. Collectively, this work shows the potential of the printed biosystem to offer a high throughput, additive manufacturing of stretchable electronics with advances toward batteryless, real-time wireless monitoring of cerebral aneurysm hemodynamics.

All-in-One, Wireless, Stretchable Hybrid Electronics for Smart, Connected, and Ambulatory Physiological Monitoring

Commercially available health monitors rely on rigid electronic housing coupled with aggressive adhesives and conductive gels, causing discomfort and inducing skin damage. Also, research-level skin-wearable devices, while excelling in some aspects, fall short as concept-only presentations due to the fundamental challenges of active wireless communication and integration as a single device platform. Here, an all-in-one, wireless, stretchable hybrid electronics with key capabilities for real-time physiological monitoring, automatic detection of signal abnormality via deep-learning, and a long-range wireless connectivity (up to 15 m) is introduced. The strategic integration of thin-film electronic layers with hyperelastic elastomers allows the overall device to adhere and deform naturally with the human body while maintaining the functionalities of the on-board electronics. The stretchable electrodes with optimized structures for intimate skin contact are capable of generating clinical-grade electrocardiograms and accurate analysis of heart and respiratory rates while the motion sensor assesses physical activities. Implementation of convolutional neural networks for real-time physiological classifications demonstrates the feasibility of multifaceted analysis with a high clinical relevance. Finally, in vivo demonstrations with animals and human subjects in various scenarios reveal the versatility of the device as both a health monitor and a viable research tool.

Two-year analysis of Clostridium difficile ribotypes associated with increased severity

Background

Certain Clostridium difficile ribotypes have been associated with complex disease phenotypes including recurrence and increased severity, especially the well-described hypervirulent RT027. This study aimed to determine the pattern of ribotypes causing infection and the association, if any, with severity.

Methods

All faecal samples submitted to a large diagnostic laboratory for C. difficile testing between 2011 and 2013 were subject to routine testing and culture. All C. difficile isolates were ribotyped, and associated clinical and demographic patient data were retrieved and linked to ribotyping data.

Results

In total, 86 distinct ribotypes were identified from 705 isolates of C. difficile. RT002 and RT015 were the most prevalent (22.5%, N=159). Only five isolates (0.7%) were hypervirulent RT027. Ninety of 450 (20%) patients with clinical information available died within 30 days of C. difficile isolation. RT220, one of the 10 most common ribotypes, was associated with elevated median C-reactive protein and significantly increased 30-day all-cause mortality compared with RT002 and RT015, and with all other ribotypes found in the study.

Conclusions

A wide range of C. difficile ribotypes were responsible for C. difficile infection presentations. Although C. difficile-associated mortality has reduced in recent years, expansion of lineages associated with increased severity could herald increases in future mortality. Enhanced surveillance for emerging lineages such as RT220 that are associated with more severe disease is required, with genomic approaches to dissect pathogenicity.

Soft Material-Enabled, Flexible Hybrid Electronics for Medicine, Healthcare, and Human-Machine Interfaces

Flexible hybrid electronics (FHE), designed in wearable and implantable configurations, have enormous applications in advanced healthcare, rapid disease diagnostics, and persistent human-machine interfaces. Soft, contoured geometries and time-dynamic deformation of the targeted tissues require high flexibility and stretchability of the integrated bioelectronics. Recent progress in developing and engineering soft materials has provided a unique opportunity to design various types of mechanically compliant and deformable systems. Here, we summarize the required properties of soft materials and their characteristics for configuring sensing and substrate components in wearable and implantable devices and systems. Details of functionality and sensitivity of the recently developed FHE are discussed with the application areas in medicine, healthcare, and machine interactions. This review concludes with a discussion on limitations of current materials, key requirements for next generation materials, and new application areas.

International Harmonization of Nomenclature and Diagnostic Criteria (INHAND): Progress to Date and Future Plans

The International Harmonization of Nomenclature and Diagnostic Criteria for Lesions in Rats and Mice proposal (INHAND) has been operational since 2005. A Global Editorial Steering Committee manages the overall objectives of the project, and the development of harmonized terminology for each organ system is the responsibility of the Organ Working Groups, drawing upon experts from North America, Europe, and Japan. Great progress has been made with 9 systems published to date--respiratory, hepatobiliary, urinary, central/peripheral nervous systems, male reproductive and mammary, zymbals, clitoral, and preputial glands in Toxicologic Pathology and the integument and soft tissue and female reproductive in the Journal of Toxicologic Pathology as supplements and on a Web site--www.goReni.org. INHAND nomenclature guides offer diagnostic criteria and guidelines for recording lesions observed in rodent toxicity and carcinogenicity studies. The guides provide representative photomicrographs of morphologic changes, information regarding pathogenesis, and key references. The purpose of this brief communication is to provide an update on the progress of INHAND.

Does surgery followed by physiotherapy improve short and long term outcome for patients with atraumatic shoulder instability compared with physiotherapy alone? - protocol for a randomized controlled clinical trial

Background

Shoulder instability is a common problem affecting young adults. Stabilization surgery followed by physiotherapy rehabilitation has been shown to reduce the chance of further episodes of shoulder dislocation and to improve quality of life in patients who sustain a shoulder dislocation as a result of a high collision trauma, but it is unclear if surgical intervention is beneficial for patients with atraumatic shoulder instability who have structural damage at the shoulder. The aim of this randomized controlled clinical trial is to determine if the addition of surgical intervention to physiotherapy rehabilitation improves outcomes for patients with atraumatic shoulder instability who have sustained soft tissue damage at their joint.

Methods/Design

140 participants will be recruited. Patients with feelings of insecurity (apprehension) at their shoulder joint, which is not the result of a collision injury, with physical signs of shoulder joint instability will be invited to participate. Consenting participants will undergo arthroscopic investigation of the shoulder joint. Patients with capsulolabral damage will be randomly allocated using a concealed allocation procedure to either stabilization surgery immediately following the arthroscopic examination or no additional surgical procedure. All participants will then receive the same postoperative physiotherapy protocol for up to 6 months. Outcomes (pain, functional impairment and number of shoulder dislocations sustained) will be evaluated prior to surgery and, together with participant-reported improvement, again at 6, 12 and 24 months after randomization. The primary endpoint will be pain and functional impairment at 2 years. Participants, clinical staff (but not surgeons) and assessors will be blind to whether stabilization surgery was performed. Data analysis will be conducted on an intention-to-treat basis with the focus on estimation of the effect.

Discussion

This trial will have a direct and immediate impact on clinical decision making by establishing if patients presenting with soft tissue shoulder damage associated with atraumatic shoulder instability should be referred for stabilization surgery before commencing physiotherapy rehabilitation in order to ensure optimal outcome. This in turn will ensure effective, efficient use of scarce health resources to manage this common often disabling musculoskeletal condition.

Trial registration

Study was registered with National Institutes of Health Clinical Trials Protocol Registration System in December 2012.

ClinicalTrials.gov Identifier: NCT01751490.

Development and testing of a field diagnostic assay for peste des petits ruminants virus

We have developed an immunochromatographic test for the diagnosis of peste des petits ruminants (PPR) under field conditions. The diagnostic assay has been tested in the laboratory and also under field conditions in Ivory Coast, Pakistan, Ethiopia and Uganda. The test is carried out on a superficial swab sample (ocular or nasal) and showed a sensitivity of 84% relative to PCR. The specificity was 95% over all nasal and ocular samples. The test detected as little as 10³ TCID₅₀ (50% tissue culture infectious doses) of cell culture-grown virus, and detected virus isolates representing all four known genetic lineages of peste des petits ruminants virus. Virus could be detected in swabs from animals as early as 4 days post-infection, at a time when clinical signs were minimal. Feedback from field trials was uniformly positive, suggesting that this diagnostic tool may be useful for current efforts to control the spread of PPR.

The passive mechanical properties of muscle and their adaptations to altered patterns of use

The length and stiffness of a relaxed muscle are determined by the mechanical properties of its intramuscular connective tissue and/or intracellular structures. Viscous deformation of these components of muscle is responsible for the increase in muscle length seen immediately after stretching, but this increase is transient. Lasting changes in muscle length can only be brought about by adaptations of the structure of muscle. An understanding of the nature of the stimulus for muscle to adapt can provide therapists with a theoretical basis for therapeutic intervention aimed at producing changes in muscle length.

Dimensional structure and course of post-traumatic stress symptomatology in World Trade Center responders

BACKGROUND

Post-traumatic stress disorder (PTSD) in response to the World Trade Center (WTC) disaster of 11 September 2001 (9/11) is one of the most prevalent and persistent health conditions among both professional (e.g. police) and non-traditional (e.g. construction worker) WTC responders, even several years after 9/11. However, little is known about the dimensionality and natural course of WTC-related PTSD symptomatology in these populations.

METHOD

Data were analysed from 10 835 WTC responders, including 4035 police and 6800 non-traditional responders who were evaluated as part of the WTC Health Program, a clinic network in the New York area established by the National Institute for Occupational Safety and Health. Confirmatory factor analyses (CFAs) were used to evaluate structural models of PTSD symptom dimensionality; and autoregressive cross-lagged (ARCL) panel regressions were used to examine the prospective interrelationships among PTSD symptom clusters at 3, 6 and 8 years after 9/11.

RESULTS

CFAs suggested that five stable symptom clusters best represent PTSD symptom dimensionality in both police and non-traditional WTC responders. This five-factor model was also invariant over time with respect to factor loadings and structural parameters, thereby demonstrating its longitudinal stability. ARCL panel regression analyses revealed that hyperarousal symptoms had a prominent role in predicting other symptom clusters of PTSD, with anxious arousal symptoms primarily driving re-experiencing symptoms, and dysphoric arousal symptoms primarily driving emotional numbing symptoms over time.

CONCLUSIONS

Results of this study suggest that disaster-related PTSD symptomatology in WTC responders is best represented by five symptom dimensions. Anxious arousal symptoms, which are characterized by hypervigilance and exaggerated startle, may primarily drive re-experiencing symptoms, while dysphoric arousal symptoms, which are characterized by sleep disturbance, irritability/anger and concentration difficulties, may primarily drive emotional numbing symptoms over time. These results underscore the importance of assessment, monitoring and early intervention of hyperarousal symptoms in WTC and other disaster responders.

Trajectories of PTSD risk and resilience in World Trade Center responders: an 8-year prospective cohort study

BACKGROUND

Longitudinal symptoms of post-traumatic stress disorder (PTSD) are often characterized by heterogeneous trajectories, which may have unique pre-, peri- and post-trauma risk and protective factors. To date, however, no study has evaluated the nature and determinants of predominant trajectories of PTSD symptoms in World Trade Center (WTC) responders.

METHOD

A total of 10835 WTC responders, including 4035 professional police responders and 6800 non-traditional responders (e.g. construction workers) who participated in the WTC Health Program (WTC-HP), were evaluated an average of 3, 6 and 8 years after the WTC attacks.

RESULTS

Among police responders, longitudinal PTSD symptoms were best characterized by four classes, with the majority (77.8%) in a resistant/resilient trajectory and the remainder exhibiting chronic (5.3%), recovering (8.4%) or delayed-onset (8.5%) symptom trajectories. Among non-traditional responders, a six-class solution was optimal, with fewer responders in a resistant/resilient trajectory (58.0%) and the remainder exhibiting recovering (12.3%), severe chronic (9.5%), subsyndromal increasing (7.3%), delayed-onset (6.7%) and moderate chronic (6.2%) trajectories. Prior psychiatric history, Hispanic ethnicity, severity of WTC exposure and WTC-related medical conditions were most strongly associated with symptomatic trajectories of PTSD symptoms in both groups of responders, whereas greater education and family and work support while working at the WTC site were protective against several of these trajectories.

CONCLUSIONS

Trajectories of PTSD symptoms in WTC responders are heterogeneous and associated uniquely with pre-, peri- and post-trauma risk and protective factors. Police responders were more likely than non-traditional responders to exhibit a resistant/resilient trajectory. These results underscore the importance of prevention, screening and treatment efforts that target high-risk disaster responders, particularly those with prior psychiatric history, high levels of trauma exposure and work-related medical morbidities.

Prognosis and prognostic factors for patients with persistent wrist pain who proceed to wrist arthroscopy

Wrist pain is common. People with persistent pain commonly undergo arthroscopic investigation. Little is known about the prognosis or prognostic factors for these patients. The purpose of the study was to evaluate prognosis and prognostic factors for pain and functional disability in patients with persistent wrist pain who proceed to arthroscopic investigation. The study design used was a prospective cohort study. One hundred and five consecutive participants who underwent arthroscopic investigation for undiagnosed wrist pain for at least four-week duration were recruited. Patient-rated wrist and hand evaluation (PRWHE) scores were determined at baseline (before arthroscopy) and one year after arthroscopy. One-year follow-up data were obtained for 97 (92%) of 105 participants. Mean PRWHE total score declined from 49 of 100 (standard deviation [SD] 18.5) at baseline to 26 of 100 (SD 20.4) at one year. Two prognostic factors were identified: baseline PRWHE and duration of symptoms. These factors explained 19% and 5% of the variability in the final PRWHE score, respectively. Results of provocative wrist tests and arthroscopic findings did not significantly contribute to prognosis in this cohort. This study provides the first robust evidence of the prognosis of persistent wrist pain. Participants who underwent arthroscopic investigation for persistent wrist pain improved on average by approximately 50% at one year; however, most continued to have some pain and disability. Duration of pain and PRWHE at baseline explained 24% of the one-year PRWHE score.

LEVEL OF EVIDENCE

Level 2.

Internet-based randomized controlled trials: a systematic review

BACKGROUND

The internet is increasingly being used to conduct randomized controlled trials (RCTs). Knowledge of the types of interventions evaluated and the methodological quality of these trials could inform decisions about whether to conduct future trials using conventional methods, fully online or a mixture of the two.

OBJECTIVE

To identify and describe the scope of internet-based RCTs for human health condition interventions and evaluate their methodological quality.

METHODS

A systematic review of RCTs of any health intervention conducted fully or primarily on the internet was carried out.

RESULTS

23 fully and 27 primarily internet-based RCTs were identified. The first was conducted in 2000. The majority of trials evaluated interventions that involved providing health information to participants, but a few evaluated self-administered interventions (eg, valerian, stretching). Methodological quality was variable and the methods were generally poorly reported. The risk of bias was low in only a small number of trials; most had substantial methodological shortcomings. Only one trial was identified as meeting all criteria for adequate methodological quality. A particular problem was high rates of loss to follow-up (fully online: mean 47%; primarily online: mean 36%).

CONCLUSIONS

It is theoretically possible but perhaps difficult to test the effectiveness of health interventions rigorously with RCTs conducted fully or primarily over the internet. The use of the internet to conduct trials is more suited to pragmatic rather than explanatory trials. The main limitation of these trials is that they typically experience high rates of loss to follow-up. Methodological standards now accepted for traditional RCTs needs to be evident for online RCTs as well, especially in reporting of their methods.

Nurse-delivered universal point-of-care testing for HIV in an open-access returning traveller clinic

BACKGROUND

Early diagnosis of HIV infection reduces morbidity and mortality associated with late presentation. Despite UK guidelines, the HIV testing rate has not increased. We have introduced universal HIV screening in an open-access returning traveller clinic.

METHODS

Data were prospectively recorded for all patients attending the open-access returning traveller clinic between August 2008 and December 2010. HIV testing was offered to all patients from May 2009; initially testing with laboratory samples (phase 1) and subsequently a point-of-care test (POCT) (phase 2).

RESULTS

A total of 4965 patients attended the clinic; 1342 in phase 0, 792 in phase 1 and 2831 in phase 2. Testing rates for HIV increased significantly from 2% (38 of 1342) in phase 0 to 23.1% (183 of 792) in phase 1 and further increased to 44.5% (1261 of 2831) during phase 2 (P < 0.0001). Two new diagnoses of HIV-1 were identified in phase 1 (1.1% of tested); seven patients had a reactive POCT test in phase 2, of whom five (0.4% of those tested) were confirmed in a 4th generation assay. The patients with false reactive tests had a concurrent Plasmodium falciparum infection. Patients travelling to the Middle East and Europe were less likely to accept an HIV test with POCT.

CONCLUSIONS

A nurse-delivered universal point-of-care HIV testing service has been successfully introduced and sustained in an acute medical clinic in a low-prevalence country. Caution is required in communicating reactive results in low-prevalence settings where there may be alternative diagnoses or a low population prevalence of HIV infection.

The Extent and Quality of Evidence in Neurological Physiotherapy: An Analysis of the Physiotherapy Evidence Database (PEDro)

Evidence-based practice involves the use of evidence from systematic reviews and randomised controlled trials. The extent of this evidence in neurological physiotherapy has not previously been surveyed. The aim of this study was to describe the quantity and quality of randomised controlled trials, and the quantity and scope of systematic reviews relevant to neurological physiotherapy. PEDro (the Physiotherapy Evidence Database) was searched for trials and reviews relevant to neurological physiotherapy (adult and paediatric). The quality and quantity of trials were analysed, and the topics and conclusions of reviews were synthesised. The search revealed a total of 265 records, consisting of 238 randomised controlled trials and 27 systematic reviews. Since the first trial was published in 1958, the number of trials has expanded exponentially. Fifty-four percent of trials were categorised as being of moderate to high quality, rating five or more out of ten. The first review was published in 1991. Many of the reviews have been unable to reach firm conclusions due to the paucity of available trials. The results show that there is a substantial body of evidence relevant to neurological physiotherapy. However, there remains scope for improvements in the quality of the conduct and reporting of clinical trials. There is an urgent need for more randomised controlled trials and systematic reviews.

Comorbid diabetes and end-of-life expenditures among Medicare beneficiaries with heart failure

BACKGROUND

Diabetes is associated with increased risk of mortality in heart failure. We examined the association of diabetes with expenditures, hospitalizations, and procedures among Medicare beneficiaries with heart failure during the last 6 months of life.

METHODS AND RESULTS

In a 5% national Medicare sample, the prevalence of diabetes was 41.7% among 16,613 beneficiaries who died in 2007 with a diagnosis of heart failure. Diabetes was associated with higher expenditures during the last 6 months of life (mean $39,042 vs $29,003; P < .001), even after adjusting for covariates, including age, sex, race, geographic location, comorbidities, and preceding hospitalizations (cost ratio 1.08, 95% CI 1.05-1.12). For both diabetic and nondiabetic adults, more than one-half of Medicare expenditures were related to hospitalization costs (mean $22,516 vs $15,721; P < .001). Compared with their counterparts without diabetes, beneficiaries with diabetes had higher rates of hospitalization (adjusted incidence rate ratio 1.09, 95% CI 1.05-1.12) and days spent in the intensive care unit.

CONCLUSIONS

Comorbid diabetes was common in heart failure and associated with higher expenditures, much of which was driven by increased rates of hospitalizations. Programs that focus on prevention of hospitalizations may reduce the substantial costs associated with heart failure near the end of life.

Improving regional variation using quality of care measures

There is significant regional variability in the quality of care provided in the United States. This article compares regional performance for three measures that focus on transitions in care, and the care of patients with multiple conditions. Admissions for people with ambulatory care-sensitive conditions, hospital readmissions within 30 days of discharge, and compliance with practice guidelines for people with three chronic conditions (congestive heart failure, chronic obstructive pulmonary disease, and diabetes) were analyzed using data drawn from the Centers for Medicare & Medicaid Services’ Standard Analytic Files for 5% of a 2004 national sample of Medicare beneficiaries which was divided by hospital referral regions and regional performance. There were significant regional differences in performance which we hypothesize could be improved through better care coordination and system management.

Trastuzumab use and CNS metastasis in Medicare patients diagnosed with metastatic breast cancer (MBC)

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Background: While trastuzumab was approved in 1998 for treating patients with HER-2-positive MBC, there is little information on its use in the Medicare setting. Methods: We used SEER-Medicare data to examine patterns of trastuzumab use in women diagnosed with MBC . An index date was defined as either the date of diagnosis (stage IV) or of first distant recurrence (stage 0-III). Included patients were diagnosed in 2000–2002, and had their first claim for trastuzumab between their index date and December 31, 2005, the end of the observation period. Patients were divided into those who received trastuzumab as part of their first treatment following their index date (Group A), and those who began trastuzumab after at least one course of chemotherapy (Group B). Chemotherapy agents were grouped into antimicrotubule (vinorelbine, docetaxel, paclitaxel, vincristine), anthracycline (doxorubicin, epirubicin), cyclophosphamide, other, and unknown. Results: 281 patients met the inclusion criteria. Overall, the median (mean) time from the index date to initial chemotherapy and/or trastuzumab treatment was 35 (94) days (range 1–1,587 days). The average duration of trastuzumab use (first to last administration) was 371 days (median 239), during which patients averaged 2.3 trastuzumab claims per month. There were 192 (68%) patients in Group A. The median (mean) time from diagnosis to initial treatment in Group A was 34 (94) days. 64 (33%) received trastuzumab alone, and 121 (63%) received trastuzumab with an antimicrotubule. In Group B (89 patients), the median (mean) time to initial chemotherapy was 41 (92) days. 36 (40%) received anthracycline and/or cyclophosphamide based therapy, 22 (25%) received an antimicrotubule without either an anthracycline or cyclophosphamide. The median (mean) time from initial chemotherapy to initial trastuzumab therapy was 233 (368) days. At that time, 29 (33%) received trastuzumab alone, and 54 (61%) received trastuzumab plus an antimicrotubule. Conclusions: To our knowledge, this is the first study to describe patterns of trastuzumab use in Medicare. When used for metastatic breast cancer, trastuzumab was most often provided soon after diagnosis as part of initial treatment, and usually with an antimicrotubule agent.

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Idiopathic chondrolysis condition in two young, wild-caught Cynomolgus monkeys (Macaca fascicularis) reared in captivity

Idiopathic chondrolysis is a human clinical entity typically reported in adolescent individuals. In this brief communication, we report 2 cases of presumptive idiopathic chondrolysis of the femoral head in Cynomolgus macaques and discuss the clinical symptomatology and pathology of the disease. In detail, we describe the histomorphologic changes of idiopathic chondrolysis and compare these findings with those typically observed in the primary differential diagnoses of Legg-Calve-Perthes disease and nonspecific osteoarthritis. Consideration of this entity among differential diagnoses in young Cynomolgus macaques with unilateral osteoarthritis could be important both for laboratory animal veterinarians and pathologists.

Correlation of postoperative epidural analgesia with morbidity and mortality following total knee replacement in Medicare patients

It is unclear whether perioperative epidural analgesia is associated with a decrease in mortality in patients who undergo orthopedic procedures. We examined 35,878 patients' data obtained from a random sample of Medicare beneficiaries who underwent elective total knee replacement. Division of patients into 2 groups was based on presence or absence of billing for postoperative epidural analgesia. Outcomes assessed were death and major morbidity 30 days after surgery. Multivariate regression analysis revealed no between-groups difference in mortality 30 days after surgery. Postoperative epidural analgesia was not associated with lower incidence of mortality or major morbidity in Medicare patients who underwent elective total knee replacement.

Using Propensity Scores Subclassification to Estimate Effects of Longitudinal Treatments

BACKGROUND

When using observational data to compare the effectiveness of medications, it is essential to account parsimoniously for patients' longitudinal characteristics that lead to changes in treatments over time.

OBJECTIVES

We developed a method of estimating effects of longitudinal treatments that uses subclassification on a longitudinal propensity score to compare outcomes between a new drug (exenatide) and established drugs (insulin and oral medications) assuming knowledge of the variables influencing the treatment assignment. RESEARCH DESIGN/SUBJECTS: We assembled a retrospective cohort of patients with diabetes mellitus from among a population of employed persons and their dependents.

METHODS

The data, from i3Innovus, includes claims for utilization of medications and inpatient and outpatient services. We estimated a model for the longitudinal propensity score process of receiving a medication of interest. We used our methods to estimate the effect of the new versus established drugs on total health care charges and hospitalization.

RESULTS

We had data from 131,714 patients with diabetes filling prescriptions from June through December 2005. Within propensity score quintiles, the explanatory covariates were well-balanced. We estimated that the total health care charges per month that would have occurred if all patients had been continually on exenatide compared with if the same patients had been on insulin were minimally higher, with a mean monthly difference of $397 [95% confidence interval (CI), $218-$1054]. The odds of hospitalization were also comparable (relative odds, 1.02; 95% CI, 0.33-1.98).

CONCLUSIONS

We used subclassification of a longitudinal propensity score for reducing the multidimensionality of observational data, including treatments changing over time. In our example, evaluating a new diabetes drug, there were no demonstrable differences in outcomes relative to existing therapies.

Correlation of postoperative epidural analgesia on morbidity and mortality after colectomy in Medicare patients

STUDY OBJECTIVE

To examine, with a large database, the effect of postoperative epidural analgesia (vs systemic analgesia) on mortality after colectomy is unclear.

DESIGN

Retrospective cohort (database) design.

SETTING

Medicare beneficiaries undergoing elective colectomy.

PATIENTS

We examined a cohort of 12817 patients obtained from a 5% nationally random sample of Medicare beneficiaries from 1997 to 2001 who underwent elective partial excision of the large intestine.

INTERVENTIONS

Patients were divided into two groups depending on the presence or absence of billing for postoperative epidural analgesia (Current Procedural Terminology code 01996).

MEASUREMENTS

The primary outcomes assessed were death at 7 and 30 days after the procedure. The rates of major morbidity were also compared. Multivariate regression analysis incorporating race, gender, age, comorbidities, hospital size, hospital teaching status, and hospital technology status was performed to determine whether the presence of postoperative epidural analgesia had an independent effect on mortality or major morbidity.

MAIN RESULTS

Multivariate regression analysis revealed that there was no difference between the groups with regard to overall major morbidity; however, the presence of epidural analgesia was associated with a significantly lower odds of death at 7 days (odds ratio, 0.35; 95% confidence interval, 0.21-0.59; P < 0.0001) and 30 days (odds ratio, 0.54; 95% confidence interval, 0.42-0.70; P < 0.0001) after surgery.

CONCLUSIONS

The presence of postoperative epidural analgesia may decrease the odds of death after elective colectomy; however, the mechanism of such a benefit is not clear from our analysis.