Risk factors and prevalence of ramp lesions in ACL ruptures: An analysis from the registry of the Francophone Arthroscopic Society

PURPOSE

The study aimed to estimate the prevalence of ramp lesions among patients undergoing anterior cruciate ligament (ACL) reconstruction and identify risk factors associated with these lesions.

METHODS

A retrospective, multicentre cohort study was conducted using data from the Francophone Arthroscopic Society's registry, including 5359 patients who underwent ACL reconstruction (ACLR) from June 2020 to June 2023. Potential risk factors for ramp lesion such as patient demographics, revision surgery, pivot shift, side-to-side anteroposterior laxity, medial collateral ligament (MCL) injury, lateral meniscal tear and the volume of ligament remnant were evaluated using multivariate regression analyses. BMI and delay to surgery were also assessed.

RESULTS

Ramp lesions were identified in 822 patients (15.3%). Univariate analysis identified male sex, younger age, revision surgery, lateral meniscal injury, percentage of ACL remnant (all p < 0.0001) and pivot shift (p = 0.0103) as significant risk factors. MCL injury was associated with a lower risk (p < 0.0001). In multivariate analysis, male sex, younger age, revision surgery, lateral meniscal injury and percentage of ACL remnants remained significant risk factors, while MCL injury remained a protective factor. The anteroposterior laxity wasn't a significant predictor in either analysis. In subgroup analysis, there were differences concerning body mass index (n.s) and the delay to surgery (n.s).

CONCLUSION

The study identified male sex, younger age, revision surgery, lateral meniscal injury and pourcentage of ACL remnant as significant risk factors for ramp lesions, with MCL injury acting as a protective factor. This will help regarding the suspicion and identification of ramp lesions.

LEVEL OF EVIDENCE

Level III.

Evaluating the Reliability of YouTube as a Source of Information for Meniscal Ramp Lesions

Background

Videos uploaded to YouTube do not go through a review process, and therefore, videos related to medial meniscal ramp lesions may have little educational value.

Purpose

To assess the educational quality of YouTube videos regarding ramp lesions of the meniscus.

Study Design

Cross-sectional study.

Methods

A standard search was performed on the YouTube website using the following terms: "ramp lesion" and "posterior meniscal detachment" and "ramp" and "meniscocapsular" and "meniscotibial detachment," and the top 100 videos based on the number of views were included for analysis. The video duration, publication data, and number of likes and views were retrieved, and the videos were categorized based on video source (health professionals, orthopaedic company, private user), the type of information (anatomy, biomechanics, clinical examination, overview, radiologic, surgical technique), and video content (education, patient support, patient experience/testimony).The content analysis of the information on the videos was evaluated with the use of the DISCERN instrument (score range, 16-80), the Journal of the American Medical Association (JAMA) benchmark criteria (score range, 0-4), and the Global Quality Score (GQS; score range, 1-5).

Results

A total of 74 videos were included. Of these videos, 70 (94.6%) were published by health professionals, while the remaining 4 (5.4%) were published by orthopaedic companies. Most of the videos were about surgical technique (n = 36; 48.6%) and all had an educational aim (n = 74; 100%). The mean length of the videos was 10.35 ± 17.65 minutes, and the mean online period was 18.64 ± 13.85 months. The mean DISCERN score, JAMA benchmark score, and GQS were 31.84 ± 17.14 (range, 16-72), 1.65 ± 0.87 (range, 1-4), and 2.04 ± 1.21 (range, 1-5), respectively. Videos that reported an overview about ramp lesions were the best in terms of quality for DISCERN and JAMA benchmark score, while biomechanics videos were the best according to GQS. The worst category of videos was about surgical technique, with all having lower scores.

Conclusion

The educational content of YouTube regarding medial meniscal ramp lesions showed low quality and validity based on DISCERN score, JAMA benchmark score, and GQS.

Concomitant Injuries Associated With ACL Rupture in Elite Professional Alpine Ski Racers and Soccer Players: A Comparative Study With Propensity Score Matching Analysis

Background

For elite professional soccer players and alpine skiers, injuries associated with anterior cruciate ligament (ACL) rupture, such as meniscal, cartilage, or collateral ligament lesions, could result in a delayed return to sport compared with isolated ACL injury.

Purpose/Hypothesis

The purpose of the study was to provide a detailed description of associated injuries at the time of primary ACL reconstruction in elite soccer players and alpine skiers. It was hypothesized that soccer players and skiers would present different typical injury patterns due to different injury mechanisms.

Study Design

Cohort study; Level of evidence, 3.

Methods

Surgical reports and arthroscopic images of elite professional soccer players and alpine skiers who underwent primary ACL reconstruction at a single institution between January 2010 and June 2022 were analyzed retrospectively. The presence and location of multiligamentous injury, meniscal tears, and chondral lesions were compared between the athlete groups. A propensity score matching analysis with 1:1 ratio was performed between skiers and soccer players to limit the effect of selection bias.

Results

Included were ACL reconstruction data representative of 37 soccer players and 44 alpine skiers. Meniscal pathology was found in 32 (86%) soccer players and 30 (68%) skiers. Chondral injuries were reported in 11 (30%) soccer players and 15 (34%) skiers. Results of the propensity score matching analysis in 15 pairs of soccer players and skiers indicated that soccer players had a significantly higher rate of medial meniscal injuries (73% vs 27%; P = .03) and lateral posterior root tears (33% vs 0%; P = .04) compared with skiers.

Conclusion

A higher prevalence of combined chondral and meniscal injuries versus isolated ACL injuries was observed in both groups of athletes. Professional soccer players were characterized by higher prevalence of medial meniscal tears and lateral posterior root lesions compared with professional alpine skiers.

Semimembranosus Tendon Findings in Acute Anterior Cruciate Ligament Tears: MRI Evaluation and Associated Lesions

BACKGROUND

The semimembranosus (SM) tendon acts as a secondary dynamic stabilizer of the knee. It restrains external rotation and anterior translation of the medial compartment. Its role in the mechanism of injury during anterior cruciate ligament (ACL) rupture is unknown.

HYPOTHESIS

The bone bruise (BB) often detected at the posteromedial tibia in association with acute ACL tear may be related to the traction force from the SM tendon insertion. Magnetic resonance imaging (MRI) alterations can be detectable at the direct arm of the SM tendon in association with acute ACL injury.

STUDY DESIGN

Cross-sectional study: Level of evidence, 3.

METHODS

In the first study phase, 36 noninjured patients underwent knee MRI. The anatomic appearance of the SM tendon was evaluated. An imaging score for evaluating the SM tendon was developed for the purpose of the study. The intensity (in the axial or sagittal plane), morphology, and thickness of the distal SM tendon was evaluated and scored (4 total points). In the second study phase, 52 patients undergoing acute ACL reconstruction were included. Preoperative MRI was examined and scored, with documentation of BB at the posteromedial tibial plateau. Finally, arthroscopic diagnosis of a ramp lesion was confirmed. Logistic regression analysis was carried out for correlation between an altered MRI scoring system and the presence of BB at the posteromedial tibial plateau, the presence of a ramp lesion, or both.

RESULTS

Interrater agreement of 100% was obtained in the noninjured cohort (ie, no alteration found in any patient). The score validation in the cohort of patients with acute ACL injury showed a Cohen κ of 0.78 (interrater agreement, 82.7%). The direct arm of the SM tendon was altered in 35 of 52 patients (67.3%). A ramp lesion of the medial meniscus was arthroscopically detected in 21 patients (40.4%). The presence of BB at the posteromedial tibial plateau was detected in 33 patients (63.5%) and at the posterior medial femoral condyle in 1 (1.9%). Correlation analysis showed a significant association of a pathologic SM score with the presence of BB at the posteromedial tibial plateau (odds ratio = 2.7; P = .001). Conversely, no correlation was observed between the pathologic score and the presence of a ramp lesion (odds ratio = 0.88; P = .578).

CONCLUSION

The prevalence of pathologic findings in the direct arm of the SM tendon insertion was high in the acutely injured cohort with ACL rupture and is correlated with the presence of BB at the posteromedial tibial plateau. The main hypothesis formulated for the study was confirmed.

Risk Factors for Ramp Lesions of the Medial Meniscus: A Systematic Review and Meta-analysis

BACKGROUND

Failure to appropriately identify and repair medial meniscal ramp lesions at the time of anterior cruciate ligament (ACL) reconstruction (ACLR) may result in increased anterior tibial translation and internal rotation, increasing the risk for graft failure. Knowledge of the risk factors leading to the development of ramp lesions may enhance clinicians' vigilance in specific ACL-deficient populations and subsequently repair of these lesions at the time of ACLR.

PURPOSE

To perform a systematic review and meta-analysis of factors tested for associations with ramp lesions and to determine which were significantly associated with the presence of ramp lesions.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

PubMed, OVID/Medline, and Cochrane databases were queried in April 2020. Data pertaining to study characteristics and reported risk factors for ramp lesions were recorded. DerSimonian-Laird binary random-effects models were constructed to quantitatively evaluate the association between risk factors and ramp lesions by generating effect estimates in the form of odds ratios (ORs) with 95% CIs. Qualitative analysis was performed to describe risk factors that were variably reported.

RESULTS

The review included 12 studies with 8410 patients. The overall pooled prevalence of ramp lesions was 21.9% (range, 9.0%-41.7%). A total of 45 risk factors were identified, of which 8 were explored quantitatively. There was strong evidence to support that posteromedial tibial edema on magnetic resonance imaging (MRI) (OR, 2.12; 95% CI, 1.27-3.56; P = .004), age <30 years (OR, 2.02; 95% CI, 1.23-3.22; P = .002), and complete ACL tears (OR, 3.0; 95% CI, 1.41-6.20; P = .004) were risk factors for ramp lesions. There was moderate evidence to support that male sex (OR, 1.58; 95% CI, 1.36-1.83; P < .001) and concomitant lateral meniscal tears (OR, 1.54; 95% CI, 1.11-2.13; P = .009) were risk factors for ramp lesions. Chronic ACL injury (≥24 months) demonstrated minimal evidence as a risk factor (OR, 1.41; 95% CI, 1.14-1.74; P = .001). No significant associations were determined between contact injury or revision ACLR and the presence of ramp lesions.

CONCLUSION

Significant associations between male sex, age <30 years, posteromedial tibial edema on MRI, concomitant lateral meniscal tears, complete ACL tears, injury chronicity, and the presence of ramp lesions were found. Contact injury and revision ACLR were not significantly associated with the presence of ramp lesions.

Amylin Analog Pramlintide Induces Migraine-like Attacks in Patients

OBJECTIVE

Migraine is a prevalent and disabling neurological disease. Its genesis is poorly understood, and there remains unmet clinical need. We aimed to identify mechanisms and thus novel therapeutic targets for migraine using human models of migraine and translational models in animals, with emphasis on amylin, a close relative of calcitonin gene-related peptide (CGRP).

METHODS

Thirty-six migraine without aura patients were enrolled in a randomized, double-blind, 2-way, crossover, positive-controlled clinical trial study to receive infusion of an amylin analogue pramlintide or human αCGRP on 2 different experimental days. Furthermore, translational studies in cells and mouse models, and rat, mouse and human tissue samples were conducted.

RESULTS

Thirty patients (88%) developed headache after pramlintide infusion, compared to 33 (97%) after CGRP (p = 0.375). Fourteen patients (41%) developed migraine-like attacks after pramlintide infusion, compared to 19 patients (56%) after CGRP (p = 0.180). The pramlintide-induced migraine-like attacks had similar clinical characteristics to those induced by CGRP. There were differences between treatments in vascular parameters. Human receptor pharmacology studies showed that an amylin receptor likely mediates these pramlintide-provoked effects, rather than the canonical CGRP receptor. Supporting this, preclinical experiments investigating symptoms associated with migraine showed that amylin treatment, like CGRP, caused cutaneous hypersensitivity and light aversion in mice.

INTERPRETATION

Our findings propose amylin receptor agonism as a novel contributor to migraine pathogenesis. Greater therapeutic gains could therefore be made for migraine patients through dual amylin and CGRP receptor antagonism, rather than selectively targeting the canonical CGRP receptor. ANN NEUROL 2021;89:1157-1171.

Experimental characterization of the moment-angle curve during level and slope locomotion of transtibial amputee: Which parameters can be extracted to quantify the adaptations of microprocessor prosthetic ankle?

In case of transtibial amputation, the deficit resulting from the loss of the lower limb can be partly compensated with a prosthetic foot and adapted rehabilitation. New prosthetic feet have been developed for transtibial amputees to mimic ankle adaptability to varying terrain. Among them, Microprocessor Prosthetic Ankles (MPA) have a microprocessor to control an electric or a hydraulic actuator to adapt ankle kinematics in stairs and slopes. The objective is to investigate parameters extracted from the moment-angle curve (MAC) and use them to compare 3 MPA during level and slope locomotion against energy storing and return (ESR) foot. Five persons with lower limb transtibial amputation successively fitted with 3 MPA (Propriofoot™, Elan™, Meridium™) compared to their ESR foot. The participants had 2 weeks of adaptation before data acquisition and then a 3 week wash-out period. Range of motion, equilibrium point, hysteresis, late stance energy released, and quasi-stiffness were computed on level ground and 12% slope (upward and downward) thanks to the MAC at the ankle. The study shows the relevance of MAC parameters to evaluate the behavior of MPA. In particular, compared to ESR, all MPA tested in the present study demonstrated a better angle adaptation between walking conditions but a decrease of available energy for the propulsion. Among MPA, main results were: (i) for the Propriofoot™: an adaptation of the ankle angle without modification of the pattern of the MAC (ii) for the Elan™: a limited adaptation of the range of motion but a modification of the energy released (iii) for the Meridium™, the highest adaptation of the range of motion but the lowest available energy of propulsion. One of the main findings of the research is to show and quantify the relationship between range of motion and energy available when using different prosthetic feet in different walking conditions.

A New Non-invasive Technique for Measuring 3D-Oxygen Gradients in Wells During Mammalian Cell Culture

Oxygen tension plays an important role in overall cell function and fate, regulating gene expression, and cell differentiation. Although there is extensive literature available that supports the previous statement, little information is to be found about accurate O2 measurements during culture. In fact, O2 concentration at the cell layer during culture is commonly assumed to be equal to that of the incubator atmosphere. This assumption does not consider oxygen diffusion properties, cell type, cell density, media composition, time in culture nor height of the cell culture medium column. In this study, we developed a non-invasive, optical sensor foil-based technique suitable for measuring the 3D oxygen gradient that is formed during cell culture as a result of normal cell respiration. For this propose, we created a 3D printed ramp to which surface an oxygen optode sensor foil was attached. The ramps were positioned inside the culture wells of 24 well plate prior cell seeding. This set up in conjunction with the VisiSens TD camera system allows to investigate the oxygen gradient formation during culture. Cultivation was performed with three different initial cell densities of the cell line A549 that were seeded on the plate containing the ramps with the oxygen sensors. The O2 gradient obtained after 96 h of culture showed significantly lower O2 concentrations closer to the bottom of the well in high cell density cultures compared to that of lower cell density cultures. Furthermore, it was very interesting to observe that even with low cell density culture, oxygen concentration near the cell layer was lower than that of the incubator atmosphere. The obtained oxygen gradient after 96 h was used to calculate the oxygen consumption rate (OCR) of the A549 cells, and the obtained value of ~100 fmol/h/cell matches the OCR value already reported in the literature for this cell line. Moreover, we found our set up to be unique in its ability to measure oxygen gradient formation in several wells of a cell culture plate simultaneously and in a non-invasive manner.

Ramps remain a barrier to safe wheelchair user transit bus ingress/egress

Background: Wheelchair users (WCUs) often rely on ramps for access to transit buses. Previous studies indicate WCUs have difficulty using ramps for bus ingress/egress and many transportation-related incidents occur on ramps. However, experiences of WCU ramp usage during ingress/egress have not been fully described.Methods: Cross-sectional, internet-based survey of WCUs who ride transit buses was conducted. The participants were queried on frequency of bus usage, difficulty and incidents involving ramps, and factors contributing to difficulty and incidents. Wheelchair characteristics, primary condition, and whether participants received travel training were also captured. Chi-square was used to describe relationships between wheelchair type and frequency of difficulties and incidents, and odd ratios were used to determine likelihood of the incidents.Results: The majority (55.7%) of 384 participants reported using public transportation ≥ 1 per week. Seventy-eight percent of WCUs had ≥ 1 ramp incident over the past 3 years, with an increased likelihood of incidents occurring during ingress (OR = 1.53; CI 1.21-1.86). Of those who had an incident, 22% were injured or had damage to their wheelchair. Over 60% of those who had an incident identified steep ramp slope as being the contributing factor. Steep ramp slope, exterior ramp thresholds and wet surfaces were the most common contributing factors to difficulty using ramps.Conclusion: This is the first large-scale US study enabling WCUs to describe their experiences using transit bus ramps. Despite ADA guidelines, steep ramps remain the primary factor contributing to incidents and difficulty when using ramps to access transit buses.Implications for rehabilitationThe discrepancy between ADA maximum allowable ramp slopes for the built environment and transit buses may require an increased level of effort that is a barrier to transportation accessibility for some wheelchair users.Wheelchair users who access transit buses should be made aware of, and trained, to navigate ramp configurations found in the environment.We suggest rehabilitation therapists provide skills training specific to navigating transit bus ramp slopes that may be steeper and narrower than building ramps.

Hemodynamic Effects of Concomitant Mitral Valve Surgery and Left Ventricular Assist Device Implantation

There are conflicting data regarding whether concomitant mitral valve surgery (MVS) at left ventricular assist device (LVAD) implantation is beneficial. This study aimed to assess the hemodynamic effects of concomitant MVS. Of all 73 enrolled patients, 44 patients had undergone concomitant MVS and 29 patients had not. Before LVAD implantation, MVS group had higher pulmonary capillary wedge pressure (p = 0.04). After LVAD implantation, MVS group had higher mean pulmonary artery pressure and cardiac output (CO). During the hemodynamic ramp study, MVS group had steeper CO slopes (0.18 [0.13 0.28] vs. 0.15 [0.08, 0.20] L/min/step; p = 0.04) at incremental LVAD speed and achieved a higher CO at the optimized set speed (5.5 [4.7, 6.9] vs. 4.9 [4.0, 5.7] L/min; p = 0.03). One-year freedom from death or heart failure readmission was statistically comparable between the two groups (61% vs. 80%, p = 0.20). Thus far, after LVAD implantation and concomitant MVS, patients had increased pulmonary hypertension, despite having higher CO and a better response of CO at incremental LVAD speed. The implication of hemodynamic features after concomitant MVS on clinical outcomes warrants further investigation.

Microprocessor prosthetic ankles: comparative biomechanical evaluation of people with transtibial traumatic amputation during standing on level ground and slope

BACKGROUND

The compensations occurrence due to the alteration of the posture and the gait of persons with lower limb amputation is still an issue in prosthetic fitting. Recently, prosthetic feet designed to reproduce the physiological behaviour of the ankle using a microprocessor control have been commercialized to address this issue.

OBJECTIVES

Investigate the relevance of these microprocessor prosthetic ankles (MPAs) in the ability of standing on both level and inclined surfaces.

METHODS

Six persons with transtibial amputation usually fitted with energy storing and returning (ESR) foot tested three MPAs: Elan^® Endolite (MPA1), Meridium^® Ottobock (MPA2), ProprioFoot^® Ossur (MPA3). Each MPA data acquisition was preceded of a 2 weeks adaptation period at home and followed by a 3-weeks wash-out period with their ESR. Lower limb angular position and moment, Centre of Pressure (CoP) position, Ground Reaction Forces (GRF) and functional scores were collected in static, on level ground and 12% inclined slope.

RESULTS

MPAs allowed a better posture and a reduction of residual knee moment on positive and/or negative slope compared to ESR. Results also reflect that the MPA2 allows the best control of the CoP in all situations.

CONCLUSIONS

An increased ankle mobility is associated with a better posture and balance on slope. Gait analysis would complete these outcomes.

CLINICAL RELEVANCE

This study compares three MPAs to ESR analysing static posture. Static analysis on level ground and slope represents the challenging conditions people with amputation have to cope with in their daily life, especially outdoors. Having a better understanding of the three MPAs behaviour could help to adequately fit the prosthesis to each patient. Implications for rehabilitation This is a study comparing three MPAs. The static analysis in standard and constraining conditions (slope) reflects the balance of people with amputation in their daily life, especially outdoors. Having a better understanding of the behaviour of each foot could help to adequately fit the prosthesis to each patient.

The influence of a microprocessor-controlled hydraulic ankle on the kinetic symmetry of trans-tibial amputees during ramp walking: A case series

Introduction

Asymmetrical limb loading is believed to cause health problems for lower limb amputees and is exacerbated when walking on slopes. Hydraulically damped ankle-feet improve ground compliance on slopes compared to conventional prosthetic feet. Microprocessor-controlled hydraulic ankle-feet provide further adaptation by dynamically adjusting viscoelastic damping properties.

Method

Using a case series design, gait analysis was performed with four trans-tibial amputees. There were two walking conditions (ramp ascent and descent) and two prosthetic foot conditions (microprocessor-control on and off – MPF-on and MPF-off). Total support moment integral (MIsup) and degree-of-asymmetry were compared across foot conditions.

Results

During ramp descent, the transition of prosthetic ankle moment from dorsiflexion to plantarflexion occurred earlier in stance phase with MPF-on, slowing the angular velocity of the shank. During ramp ascent, the MPF-on dorsiflexion/plantarflexion moment transition occurred later, meaning less resistance to shank rotation in early stance and increasing walking speed by up to 6%. For both slope conditions, sound limb MIsup was universally decreased with MPF-on (4–13% descent, 3–11% ascent).

Discussion

Microprocessor-control of hydraulic ankle-feet reduced the total loading of the sound limb joints, for both walking conditions, for all participants. This may have beneficial consequences for long-term joint health and walking efficiency.

Brightening and Dimming Aftereffects at Low and High Luminance

Adaptation to a spatially uniform field that increases or decreases in luminance over time yields a “ramp aftereffect”, whereby a steady, uniform luminance appears to dim or brighten, and an appropriate non-uniform test field appears to move. We measured the duration of this aftereffect of adaptation to ascending and descending luminance for a wide range of temporal frequencies and luminance amplitudes. Three types of luminance ramp profiles were used: linear, logarithmic, and exponential. The duration of the motion aftereffect increased as amplitude increased, regardless of the frequency, slope, or ramp profile of the adapting pattern. At low luminance, this result held for ascending luminance adaptation, but the duration of the aftereffect was significantly reduced for descending luminance adaptation. This reduction in the duration of the aftereffect at low luminance is consistent with differential recruitment of temporally tuned cells of the ON and OFF pathways, but the relative independence of the effect from temporal frequency is not.

Testing the feasibility of using a conveyor belt to load weanling and nursery pigs for transportation

Transportation is known to be a multi-faceted stressor, with the process of loading being one of the most significant factors impacting the stress to which animals are exposed. This project was designed to determine if using a conveyor to load pigs into the top deck of a simulated straight deck trailer could lower the stress to which pigs and handlers are exposed. Pigs were assigned to either a Control group that were herded up a stationary conveyor ramp into a top deck trailer (2.5 m above the ground); or Conveyor group which were herded onto a mobile conveyor into a top deck trailer. The conveyor was 7.6 m long, 0.9 m wide and rose to 2.5 m high at a 16° slope, and moved 11.3 m/min. Two age groups were tested; Weanling pigs which were moved in groups of 20 (n = 14 groups/treatment) and Nursery pigs which were moved in groups of 10 (n = 15 groups/treatment). Behavior was recorded during loading, including slips and falls, vocalizations, assists, and time to load. Heart rate of 2 sentinel pigs/group and the handler were recorded during loading, and body temperature of the handler after loading. Pigs were held in the simulated trailer for 30 min while heart rate was recorded. After which, they were unloaded and held in a holding pen for an additional 30 min while heart rate was recorded. There were no treatment differences for slips or falls (P < 0.90). Vocalizations were too few to analyze. Both Weanling (2.8 ± 0.7) and Nursery (1.6 ± 0.5) Conveyor pigs needed to be assisted onto the conveyor more than Weanling (1.2 ± 0.4) and Nursery (0.3 ± 0.1) Control pigs (P < 0.06). There was no difference in total loading time between the treatments for any age group (P < 0.15), with Weanling and Nursery pigs loading in 50 to 45 s, respectively. There were no treatment differences for heart rate variability measures (P > 0.10). However, loading increased heart rate of Nursery pigs (204.9 ± 5.7 bpm, P < 0.005), but not Weanling pigs (172.1 ± 9.0 bpm). Nursery pigs had a greater ratio of low frequency to high frequency power during loading (P < 0.02) compared to other phases of the procedure in both Control and Conveyor groups. Heart rate (93.9 ± 1.9 bpm) and body temperature (31.1 ± 0.3°C, eye temperature) of the handler was not affected by treatment (P < 0.26). Based on behavior and physiology, the pigs had similar experiences in both treatments. This study shows that it is feasible to use a conveyor to load pigs, but it may not be advantageous.

Three-dimensional corrective osteotomies of complex malunited humeral fractures using patient-specific guides

BACKGROUND

Corrective osteotomies of malunited fractures of the proximal and distal humerus are among the most demanding orthopedic procedures. Whereas the restoration of the normal humeral anatomy is the ultimate goal, the quantification of the deformity as well as the transfer of the preoperative plan is challenging. The purpose of this study was to provide a guideline for 3-dimensional (3D) corrective osteotomies of malunited intra-articular fractures of the humerus and a detailed overview of existing and novel instruments to enlarge the toolkit for 3D preoperative planning and intraoperative realization using patient-specific guides.

METHODS

We describe the preoperative 3D deformity analysis, relevant considerations for the preoperative plan, design of the patient-specific guides, and surgical technique of corrective osteotomies of the humerus.

RESULTS

The presented technique demonstrates the benefit of computer-assisted surgery for complex osteotomies of the humerus from a preoperative deformity analysis to the creation of feasible surgical procedures and the generation of patient-specific guides.

CONCLUSIONS

A 3D analysis of a post-traumatic deformity of the humerus, 3D preoperative planning, and use of patient-specific guides facilitate corrective osteotomies of complex malunited humeral fractures.

Hemodynamic Ramp Tests in Patients With Left Ventricular Assist Devices

OBJECTIVES

This study tested whether combined invasive hemodynamic and echocardiographic ramp tests can help optimize patient management.

BACKGROUND

Guidelines for optimizing speed and medications in continuous flow ventricular assist device (cfLVAD) patients are mainly based on expert opinion.

METHODS

Thirty-five cfLVAD patients (21 HeartMate II [Thoratec, Pleasanton, California] and 14 HVAD [HeartWare International, Framingham, Massachusetts]) underwent ramp tests with right heart catheterization (including central venous pressure [CVP], pulmonary artery pressure, pulmonary capillary wedge pressure [PCWP], and blood pressure) and echocardiography. Data were recorded at up to 9 speed settings. Speed changes were in steps of 400 revolutions per minute (RPM) for HeartMate II (8,000 to 12,000 RPM) and 100 RPM for HVAD (2,300 to 3,200 RPM) patients.

RESULTS

Only 42.9% of patients had normal CVPs and PCWPs at their original RPM settings. Going from lowest to highest speeds, cardiac output improved by 0.16 ± 0.19 l/min/step (total change 1.28 ± 1.41 l/min) and PCWP decreased by 1.23 ± 0.85 mm Hg/step (total change 9.9 ± 6.5 mm Hg). CVP and systolic blood pressure did not change significantly with RPM. RPM were adjusted based on test results to achieve CVPs and PCWPs as close to normal limits as possible, which was feasible in 56% of patients. For the remainder, results indicated which type of medical management should be pursued.

CONCLUSIONS

Use of combined hemodynamic and echocardiographic ramp tests in patients provides objective means of optimizing RPM, and has the potential to guide medical management. It remains to be tested whether this strategy has a beneficial impact on quality of life or clinical outcomes.

Exploration des cadres de construction des rampes d'accessibilité

Accessibility to buildings promotes social participation through the application of inclusive design. However, architectural frameworks for constructing accessibility ramps are based on scant scientific evidence. This article presents a statement of established standards for construction criteria for accessibility ramps and makes recommendations from the perspective of inclusive design. A literature review was performed using the databases Medline, OTseeker, PsycINFO, and CINAHL (2000 to 2013), combining keywords referring to: universal accessibility, inclusive design, accessibility ramps, biomechanics, obesity, and disabilities. Non-scientific literature was also explored (e.g. building codes). The fifty-eight articles selected were grouped under five themes: 1) ramps and users; 2) materials and climate; 3) visual reference; 4) "wayfinding"; 5) durability, aesthetics and culture. Recommendations encouraging interdisciplinary practice, pegged to inclusive design, are exhibited (e.g. tracking, tilt, contrast).

Loading and Unloading Finishing Pigs: Effects of Bedding Types, Ramp Angle, and Bedding Moisture

Simple Summary

Current guidelines suggest the use of ramps below 20 degrees to load and unload pigs; however, they do not suggest the use of any specific bedding. Bedding types (nothing, feed, sand, wood shavings, and hay) were tested with finishing pigs (70–120 kg) to determine which was most effective in reducing slips, falls, and vocalizations at three ramp angles, two moisture levels, over two seasons. Slips, falls, and vocalizations were summed to establish a scoring system for the types of beddings. Heart rate and the total time it took to load and unload pigs, increased as the slope increased. Bedding, bedding moisture, season, and ramp slope interacted to impact the total time it took for finishing pigs to load and unload the ramp. Selection of the best bedding depends on ramp slope, season, and wetness of bedding.

Abstract

The use of non-slip surfaces during loading and unloading of finishing pigs plays an important role in animal welfare and economics of the pork industry. Currently, the guidelines available only suggest the use of ramps with a slope below 20 degrees to load and unload pigs. However, the total time it takes to load and unload animals and slips, falls, and vocalizations are a welfare concern. Three ramp angles (0, 10 or 20 degrees), five bedding materials (nothing, sand, feed, wood shavings or wheat straw hay), two moistures (dry or wet bedding, >50% moisture) over two seasons (>23.9 °C summer, <23.9 °C winter) were assessed for slips/falls/vocalizations (n = 2400 pig observations) and analyzed with a scoring system. The use of bedding during summer or winter played a role in the total time it took to load and unload the ramp (p < 0.05). Bedding, bedding moisture, season, and slope significantly interacted to impact the total time to load and unload finishing pigs (p < 0.05). Heart rate and the total time it took to load and unload the ramp increased as the slope of the ramp increased (p < 0.05). Heart rates were higher during the summer than winter, and summer heart rates increased as the slope increased (p < 0.05). The current study suggests that several factors should be considered in combination to identify the appropriate bedding for the specific occasion.

Loading and Unloading Weaned Pigs: Effects of Bedding Types, Ramp Angle, and Bedding Moisture

Simple Summary

Current guidelines suggest the use of ramps below 20° to load and unload pigs; they do not suggest the use of any specific bedding. Bedding types (nothing, feed, sand, wood shavings, and hay) were tested with four week old weaned pigs to determine which was most effective in reducing slips, falls, and vocalizations at three ramp angles, two moistures, over two seasons. Slips, falls, and vocalizations were summed to establish a scoring system to evaluate treatments. Scores increased in a linear fashion as ramp slope increased. The amount of time it took to load and unload pigs was affected by bedding type and ramp angle. Overall, the use of selected bedding types minimized slips, falls, and vocalizations and improved animal welfare.

Abstract

The use of non-slip surfaces during loading and unloading of weaned pigs plays an important role in animal welfare and economics of the pork industry. Currently, the guidelines available only suggest the use of ramps below 20° to load and unload pigs. Three ramp angles (0°, 10° or 20°), five bedding materials (nothing, sand, feed, wood shavings or wheat straw hay), two moistures (dry or wet bedding; >50% moisture) over two seasons (>23.9 °C summer, <23.9 °C winter) were assessed for slips/falls/vocalizations (n = 6,000 pig observations). “Score” was calculated by the sum of slips, falls, and vocalizations. With the exception of using feed as a bedding, all beddings provided some protection against elevated slips, falls, and vocalizations (P < 0.01). Providing bedding reduced (P < 0.05) scores regardless of whether the bedding was dry or wet. Scores increased as the slope increased (P < 0.01). Provision of bedding, other than feed, at slopes greater than zero, decreased slips, falls and vocalizations. The total time it took to load and unload pigs was affected by bedding type, ramp angle, and season (P < 0.05). Minimizing slips, falls, and vocalizations when loading and unloading pigs improved animal welfare.

The Effects of Using a Ramp and Elevator to Load and Unload Trailers on the Behavior and Physiology of Piglets

Transport is an inevitable process in the modern U.S. swine industry. The loading process is a novel and potentially stressful experience. This study uses behavior, heart rate and leukocyte counts to compare stress one hour before, during and after loading via ramp or elevator. Piglets were held in a home pen (control (CON)), walked up and down an aisle (handled (HAN)), or walked to a truck and loaded via elevator (ELE) or ramp (RAM). Sitting, feeding and blood parameters did not show a significant treatment by time effect (p > 0.05). Standing behavior did not differ between CON and HAN piglets nor between RAM and ELE piglets (p > 0.05); however, CON and HAN piglets stood more than RAM and ELE piglets during treatment (p < 0.05). After treatment, drinking behavior was increased in RAM piglets (p < 0.05). The heart rate of ELE piglets decreased 6.3% after treatment; whereas the heart rate of RAM piglets remained elevated 2.4% (p < 0.05). In terms of heart rate, loading by elevator appears to be less stressful than loading by ramp.

Environment of care: vertical evacuation concerns for acutely ill patients and others with restricted mobility

This perspective paper was intended to raise awareness and the urgency of needing additional evacuation-related, hospital building design policies. We addressed the challenges to maintain the integrity of exits and inadequate hospital design considerations for individuals with restricted mobility. Hospitals are occupied by people who may have restricted mobility and visitors who are likely unfamiliar with their surroundings. A hospital fire threatens all people in the building, but especially patients in the intensive care unit who are frail and have limited mobility. Evacuating immobile patients is complex, involving horizontal and vertical evacuation approaches. Hospital design must consider the needs of individuals with restricted mobility, who are the most vulnerable in case of a hospital fire. Consequently, we urge that acutely ill patients and others with restricted mobility should occupy units located on the ground floor or Level 2. In addition, when configuring the physical environment of hospitals, providing step-free ground floor access (indoor or outdoor ramps) and evacuation aids for vertical evacuation is crucial. Step-free ground floor access between Level 2 and the ground floor should be wide enough to allow transporting patients on their beds. A standard revision to include these recommendations is desperately needed.

Intermedin (adrenomedullin-2): a novel counter-regulatory peptide in the cardiovascular and renal systems

Intermedin (IMD) is a novel peptide related to calcitonin gene-related peptide (CGRP) and adrenomedullin (AM). Proteolytic processing of a larger precursor yields a series of biologically active C-terminal fragments, IMD(1-53), IMD(1-47) and IMD(8-47). IMD shares a family of receptors with AM and CGRP composed of a calcitonin-receptor like receptor (CALCRL) associated with one of three receptor activity modifying proteins (RAMP). Compared to CGRP, IMD is less potent at CGRP(1) receptors but more potent at AM(1) receptors and AM(2) receptors; compared to AM, IMD is more potent at CGRP(1) receptors but less potent at AM(1) and AM(2) receptors. The cellular and tissue distribution of IMD overlaps in some aspects with that of CGRP and AM but is distinct from both. IMD is present in neonatal but absent or expressed sparsely, in adult heart and vasculature and present at low levels in plasma. The prominent localization of IMD in hypothalamus and pituitary and in kidney is consistent with a physiological role in the central and peripheral regulation of the circulation and water-electrolyte homeostasis. IMD is a potent systemic and pulmonary vasodilator, influences regional blood flow and augments cardiac contractility. IMD protects myocardium from the deleterious effects of oxidative stress associated with ischaemia-reperfusion injury and exerts an anti-growth effect directly on cardiomyocytes to oppose the influence of hypertrophic stimuli. The robust increase in expression of the peptide in hypertrophied and ischaemic myocardium indicates an important protective role for IMD as an endogenous counter-regulatory peptide in the heart.

Muscles do more positive than negative work in human locomotion

Muscle work during level walking and ascent and descent ramp and stairway walking was assessed in order to explore the proposition that muscles perform more positive than negative work during these locomotion tasks. Thirty four healthy human adults were tested while maintaining a constant average walking velocity in the five gait conditions. Ground reaction force and sagittal plane kinematic data were obtained during the stance phases of these gaits and used in inverse dynamic analyses to calculate joint torques and powers at the hip, knee and ankle. Muscle work was derived as the area under the joint power vs time curves and was partitioned into positive, negative and net components. Dependent t-tests were used to compare positive and negative work in level walking and net joint work between ascent and descent gaits on the ramp and stairs (P<0.010). Total negative and positive work in level walking was -34 J and 50 J, respectively, with the difference in magnitude being statistically significant (P<0.001). Level walking was therefore performed with 16 J of net positive muscle work per step. The magnitude of the net work in ramp ascent was 25% greater than the magnitude of net work in ramp descent (89 vs -71 J m(-1), P<0.010). Similarly, the magnitude of the net work in stair ascent was 43% greater than the magnitude of net work in stair descent (107 vs -75 J step(-1), P<0.000). We identified three potential causes for the reduced negative vs positive work in these locomotion tasks: (1) the larger magnitude of the accelerations induced by the larger ground reaction forces in descending compared to ascending gaits elicited greater energy dissipation in non-muscular tissues, (2) the ground reaction force vector was directed closer to the joint centers in ramp and stair descent compared to ascent, which reduced the load on the muscular tissues and their energy dissipating response, and (3) despite the need to produce negative muscle work in descending gaits, both ramp and stair descent also had positive muscle work to propel the lower extremity upward and forward into the swing phase movement trajectory. We used these data to formulate two novel hypotheses about human locomotion. First, level walking requires muscles to generate a net positive amount of work per gait cycle to overcome energy losses by other tissues. Second, skeletal muscles generate more mechanical energy in gait tasks that raise the center of mass compared to the mechanical energy they dissipate in gait tasks that lower the center of mass, despite equivalent changes in total mechanical energy.

The calcium-sensing receptor and its interacting proteins

Seven membrane-spanning, or G protein-coupled receptors were originally thought to act through het-erotrimeric G proteins that in turn activate intracellular enzymes or ion channels, creating relatively simple, linear signalling pathways. Although this basic model remains true in that this family does act via a relatively small number of G proteins, these signalling systems are considerably more complex because the receptors interact with or are located near additional proteins that are often unique to a receptor or subset of receptors. These additional proteins give receptors their unique signalling personalities. The extracellular Ca-sensing receptor (CaR) signals via Galpha(i), Galpha(q) and Galpha(12/13), but its effects in vivo demonstrate that the signalling pathways controlled by these subunits are not sufficient to explain all its biologic effects. Additional structural or signalling proteins that interact with the CaR may explain its behaviour more fully. Although the CaR is less well studied in this respect than other receptors, several CaR-interacting proteins such as filamin, a potential scaffolding protein, receptor activity modifying proteins (RAMPs) and potassium channels may contribute to the unique characteristics of the CaR. The CaR also appears to interact with additional proteins common to other G protein-coupled receptors such as arrestins, G protein receptor kinases, protein kinase C, caveolin and proteins in the ubiquitination pathway. These proteins probably represent a few initial members of CaR-based signalling complex. These and other proteins may not all be associated with the CaR in all tissues, but they form the basis for understanding the complete nature of CaR signalling.

Use of ecotoxicological tools to evaluate the health of New Bedford Harbor sediments: a microbial biomarker approach

We have been investigating microbial communities in sediments from New Bedford Harbor (NBH), Massachusetts, USA, for a number of years. NBH is a U.S. Environmental Protection Agency-designated Superfund site heavily contaminated with polychlorinated biphenyls, polycyclic aromatic hydrocarbons, and heavy metals. Microorganisms are thought to contribute to the fate and distribution of contaminants in NBH through a variety of mechanisms, including direct transformations and formation of soluble and insoluble species. Our more recent research has focused on changes in microbial community structure and function in response to exposure to toxic contaminants, with the ultimate goal of using microbes as ecotoxicological tools. Microbial diversity, as measured by restriction fragment-length polymorphism analysis, changes along pollution gradients, with an apparent increase in diversity at the most contaminated sites, concomitant with an increase in genetic relatedness. Current work on microbial communities examines the presence of arsenic-resistance genes in NBH isolates. In collaboration with the Plymouth Environmental Research Center, Plymouth University, United Kingdom, we have also used more conventional ecotoxicological approaches to examine the health of the NBH biota.

Comparison of the expression of calcitonin receptor-like receptor (CRLR) and receptor activity modifying proteins (RAMPs) with CGRP and adrenomedullin binding in cell lines

1. The calcitonin receptor-like receptor (CRLR) and specific receptor activity modifying proteins (RAMPs) together form receptors for calcitonin gene-related peptide (CGRP) and/or adrenomedullin in transfected cells. 2. There is less evidence that innate CGRP and adrenomedullin receptors are formed by CRLR/RAMP combinations. We therefore examined whether CGRP and/or adrenomedullin binding correlated with CRLR and RAMP mRNA expression in human and rat cell lines known to express these receptors. Specific human or rat CRLR antibodies were used to examine the presence of CRLR in these cells. 3. We confirmed CGRP subtype 1 receptor (CGRP(1)) pharmacology in SK-N-MC neuroblastoma cells. L6 myoblast cells expressed both CGRP(1) and adrenomedullin receptors whereas Rat-2 fibroblasts expressed only adrenomedullin receptors. In contrast we could not confirm CGRP(2) receptor pharmacology for Col-29 colonic epithelial cells, which, instead were CGRP(1)-like in this study. 4. L6, SK-N-MC and Col-29 cells expressed mRNA for RAMP1 and RAMP2 but Rat-2 fibroblasts had only RAMP2. No cell line had detectable RAMP3 mRNA. 5. SK-N-MC, Col-29 and Rat-2 fibroblast cells expressed CRLR mRNA. By contrast, CRLR mRNA was undetectable by Northern analysis in one source of L6 cells. Conversely, a different source of L6 cells had mRNA for CRLR. All of the cell lines expressed CRLR protein. Thus, circumstances where CRLR mRNA is apparently absent by Northern analysis do not exclude the presence of this receptor. 6. These data strongly support CRLR, together with appropriate RAMPs as binding sites for CGRP and adrenomedullin in cultured cells.

CGRP and adrenomedullin binding correlates with transcript levels for calcitonin receptor-like receptor (CRLR) and receptor activity modifying proteins (RAMPs) in rat tissues

1. Putative receptors for CGRP and adrenomedullin have been investigated in the rat. Calcitonin Receptor-Like Receptor (CRLR), in combination with Receptor Activity Modifying Proteins (RAMPs) is hypothesized to bind either CGRP or adrenomedullin. The receptors known as RDC1 and L1 have also been shown to bind CGRP and adrenomedullin respectively. 2. In this study it is shown that rat CRLR cDNA specifies a CGRP receptor when co-transfected with RAMP-1 cDNA and an adrenomedullin receptor when co-transfected with either RAMP-2 or RAMP-3 cDNA in human embryonic kidney 293 cells. 3. CRLR, RAMP, RCD1 and L1 mRNA levels and CGRP and adrenomedullin receptor densities have been measured and correlated with each other in eight rat tissues selected for their distinctive patterns of CGRP and adrenomedullin binding. 4. The data are consistent with the predictions of the CRLR/RAMP model. CGRP binding correlates well with RAMP-1 mRNA levels (R=1.0, P=0.007), adrenomedullin binding shows a tendency to vary with RAMP-2 mRNA levels (R=0.85, P=0.14) and total binding is correlated with CRLR mRNA levels (R=0.94, P=0.03). The data do not support the hypothesis that RDC1 and L1 account for the majority of CGRP and adrenomedullin binding respectively.