A longitudinal-torsional mode ultrasonic needle for deep penetration into bone.

This work presents a longitudinal-torsional (L-T) composite mode ultrasonic needle device for deep bone penetration. The L-T needle is a geometrically modified version of an L-mode needle whose efficacy as a prototype ultrasonic bone biopsy device has been previously demonstrated by the authors. Finite element analysis (FEA) aided in the design of the L-T needle, with the aim of maximising the achievable torsional displacement while matching the longitudinal displacement achieved by the L-mode needle. Experimental modal analysis (EMA) of the fabricated ultrasonic device was used to identify the modal parameters and validate the FEA model. Harmonic analysis then provided an insight into how the inherent nonlinearities of the high-power transducer are affected by incorporating the geometrical features that degenerate the L mode into an L-T mode. High power characterisation shows that the longitudinal displacement amplitude of the L-T mode needle is larger than that of the L-mode needle. Comparative penetration tests in fresh Wistar rat skull were evaluated by investigating cell death and cell survival. The region of statistically significant cell death was small for both devices, with the combined axial and shear motion of the L-T device causing increased osteocyte necrosis within this region. Nevertheless, the results suggest a promising environment for post-operative healing. It is shown how this technology offers a potential technique for a surgical approach to the petrous apex, an application that requires a deep penetration into bone.

Incorporating direct metal laser sintered complex shaped Ti-6Al-4V components in ultrasonic surgical devices.

Additive manufacturing (AM) offers opportunities to design more complex shapes of the Ti-6Al-4V parts commonly used in high-power ultrasonic surgical devices. Moreover, AM metal printing will be essential to the realization of miniature ultrasonic devices incorporating internal structures for minimally invasive surgical procedures. However, it is necessary first to verify the ultrasonic vibrational behavior of devices with three-dimensional (3D) printed metal parts. Therefore, two different prototype devices are fabricated, with CNC machined mill annealed and 3D printed Ti-6Al-4V parts. Both devices, an ultrasonic bone needle and a miniature ultrasonic scalpel, incorporate complex geometries but can be manufactured using subtractive processes so that the comparative effects of 3D printing on the vibrational performance of the devices can be elucidated. The metal microstructure is investigated through measurements of longitudinal and shear acoustic velocities and scanning electron microscopy. Comparisons of electrical impedance, frequency and modal responses, and the vibrational response at increasing levels of excitation enable evaluation of the efficacy of incorporating 3D printed Ti-6Al-4V parts. Results show that whereas the bone needle exhibited comparable vibrational responses for the measurement techniques used, the 3D printed bone cutting device exhibited a more dense modal response and developed cracks at high excitation levels.

Emergency Food Provision for Children and Families during the COVID-19 Pandemic: Examples from Five U.S. Cities.

As lockdown and school closure policies were implemented in response to the coronavirus, the federal government provided funding and relaxed its rules to support emergency food provision, but not guidance on best practices for effectiveness. Accordingly, cities developed a diverse patchwork of emergency feeding programs. This article uses qualitative data to provide insight into emergency food provision developed in five cities to serve children and families. Based on our qualitative analysis, we find that the effectiveness of local approaches appears to depend on: (i) cross-sector collaboration, (ii) supply chains, and (iii) addressing gaps in service to increased risk populations.

Farm to School Activities and Student Outcomes: A Systematic Review.

Farm to school programs (F2SPs) operate in 42% of school districts and are supported in part through federal and state policies as well as philanthropic funding. Although research evaluating the effects of farm to school-related activities on student outcomes is growing, a systematic review of the results and thus a synthesis of implications for future programming have not occurred. The primary objective of this systematic literature review is to summarize and evaluate studies on student outcomes associated with farm to school-related activities up to 1 September, 2017. Four databases spanning 4 research disciplines were used to identify full-text, English-language studies. Twenty-one studies were reviewed: 7 explicitly investigated F2SPs, and 14 evaluated the impact of school-based interventions that were relevant to activities reported in the 2013 and/or 2015 Farm to School Census. All of the F2SP studies (n = 7) and 85.7% of farm to school-related activity studies (n = 12) were multicomponent, and there was a wide variety of implemented intervention components across the reviewed studies. Results from F2SP and farm to school-related activity studies consistently show positive impacts on food and nutrition-related knowledge; most studies also suggest a positive relation between farm to school-related activities and healthy food selection during school meals, nutrition self-efficacy, and willingness to try fruits and vegetables. The impact of farm to school activities on fruit and vegetable consumption and preferences is unclear. The most common F2SP study limitations were study designs that preclude causal inference, outcome measurement with no reported or limited psychometric testing, lack of long-term outcome evaluation, and challenges related to quantifying intervention implementation. These findings underscore the need for more conclusive evidence on the relation between farm to school-related activities and changes in fruit and vegetable consumption.

The natural history of vascular and other complications in patients treated with nilotinib for chronic myeloid leukemia.

Although second-generation tyrosine kinase inhibitors (TKIs) show superiority in achieving deep molecular responses in chronic myeloid leukemia in chronic phase (CML-CP) compared with imatinib, the differing adverse effect (AE) profiles need consideration when deciding the best drug for individual patients. Long-term data from randomized trials of nilotinib demonstrate an increased risk of vascular AEs (VAEs) compared with other TKIs, although the natural history of these events in response to dose modifications or cessation has not been fully characterized. We retrospectively reviewed the incidence of nilotinib-associated AEs in 220 patients with CML-CP at 17 Australian institutions. Overall, AEs of any grade were reported in 95 patients (43%) and prompted nilotinib cessation in 46 (21%). VAEs occurred in 26 patients (12%), with an incidence of 4.1 events per 100 patient-years. Multivariate analysis identified age (P = .022) and dyslipidemia (P = .007) as independent variables for their development. There was 1 fatal first VAE, whereas the remaining patients either continued nilotinib (14 patients) or stopped it immediately (11 patients). Recurrent VAEs were associated with ongoing therapy in 7 of 14 who continued (with 2 fatal VAEs) vs 1 of 11 who discontinued (P = .04). Nineteen of the 23 evaluable patients surviving a VAE ultimately stopped nilotinib, of whom 14 received an alternative TKI. Dose reduction or cessation because of VAEs did not adversely affect maintenance of major molecular response. These findings demonstrate that in contrast to other AEs, VAEs are ideally managed with nilotinib cessation because of the increased risk of additional events with its ongoing use.

Ultrasonic Needles for Bone Biopsy.

Bone biopsy is an invasive clinical procedure, where a bone sample is recovered for analysis during the diagnosis of a medical condition. When the architecture of the bone tissue is required to be preserved, a core-needle biopsy is taken. Although this procedure is performed while the patient is under local anaesthesia, the patient can still experience significant discomfort. Additionally, large haematoma can be induced in the soft tissue surrounding the biopsy site due to the large axial and rotational forces, which are applied through the needle to penetrate bone. It is well documented that power ultrasonic surgical devices offer the advantages of low cutting force, high accuracy, and preservation of soft tissues. This paper reports a study of the design, analysis, and test of two novel power ultrasonic needles for bone biopsy that operate using different configurations to penetrate bone. The first utilizes micrometric vibrations generated at the distil tip of a full-wavelength resonant ultrasonic device, while the second utilizes an ultrasonic-sonic approach, where vibrational energy generated by a resonant ultrasonic horn is transferred to a needle via the chaotic motion of a free-mass. It is shown that the dynamic behavior of the devices identified through experimental techniques closely match the behavior calculated through numerical and finite-element analysis methods, demonstrating that they are effective design tools for these devices. Both devices were able to recover trabecular bone from the metaphysis of an ovine femur, and the biopsy samples were found to be comparable to a sample extracted using a conventional biopsy needle. Furthermore, the resonant needle device was also able to extract a cortical bone sample from the central diaphysis, which is the strongest part of the bone, and the biopsy was found to be superior to the sample recovered by a conventional bone biopsy needle.

The incidence and natural history of dasatinib complications in the treatment of chronic myeloid leukemia.

Dasatinib has shown superiority over imatinib in achieving molecular responses (MRs) in chronic phase chronic myeloid leukemia but with a different toxicity profile, which may impact its overall benefit. Reported toxicities include pleural effusions and pulmonary hypertension, and although the incidence of these events is well described, response to therapy and impact of dose modifications on toxicity has not been comprehensively characterized in a real-world setting. We retrospectively reviewed the incidence of dasatinib adverse events in 212 chronic phase chronic myeloid leukemia patients at 17 Australian institutions. Adverse events were reported in 116 patients (55%), most commonly pleural effusions (53 patients, 25%), which was the predominant cause of permanent drug cessation. Age and dose were risk factors for pleural effusion (P < .01 and .047, respectively). Recurrence rates were higher in those who remained on 100 mg compared with those who dose reduced (P = .041); however, recurrence still occurred at 50 mg. Patients who developed pleural effusions were more likely to have achieved MR4.5 after 6 months of dasatinib than those without effusions (P = .008). Pulmonary hypertension occurred in 5% of patients, frequently in association with pleural effusion, and was reversible upon dasatinib cessation in 6 of 7 patients. Dose reductions and temporary cessations had minimal impact on MR rates. Our observations suggest that by using the lowest effective dose in older patients to minimize the effusion risk, dose modification for cytopenias, and care with concomitant antiplatelet therapy, the necessity for permanent dasatinib cessation due to toxicity is likely to be minimal in immunologically competent patients.

Psychiatric diagnoses and cognitive impairment in pediatric multiple sclerosis.

BACKGROUND: Pediatric multiple sclerosis (MS) represents approximately 5% of the MS population; information regarding clinical features is slowly accumulating. Cognitive and psychiatric impairments frequently occur, but remain poorly understood. OBJECTIVES: To describe psychiatric diagnoses among children with MS referred for psychiatric assessment and their relation to cognitive impairment. METHODS: Forty-five pediatric MS patients (aged 8 to 17 years) were referred for outpatient psychiatric evaluation including a psychiatric interview (K-SADS), a clinician-based global assessment of functioning (Children's Global Assessment Scale, CGAS), a neurologic examination including the Expanded Disability Status Scale (EDSS), and a neuropsychological test battery. RESULTS: The most common categories of psychiatric diagnoses were anxiety disorders (n=15), attention deficit hyperactivity disorder (ADHD, n=12), and mood disorders (n=11). Cognitive impairment was classified in 20/25 (80%) of patients meeting criteria for a psychiatric disorder versus 11/20 (55%) of those without psychiatric disorder (p=0.08). Those diagnosed with anxiety or mood disorder had the highest frequency of cognitive impairment, with a significantly higher rate when compared with those with psychiatric diagnoses in other categories (p=0.05). CONCLUSIONS: A variety of psychiatric diagnoses can occur in children with pediatric MS. Many of these children also had cognitive impairment, particularly those in the mood and anxiety groups.

Postictal psychosis in temporal lobe epilepsy: risk factors and postsurgical outcome?

PURPOSE: Postictal psychosis (PIP) occurs in ∼7% of patients with temporal lobe epilepsy (TLE). The aims of this study were to identify risk factors that may predispose patients to developing PIP and determine whether the severity of PIP predicts postsurgical outcome. METHODS: We compared 20 patients with a history of TLE+PIP to 60 age-matched TLE patients without any psychiatric history (TLE-only), with respect to pre-surgical clinical and neuropsychological variables. Group differences in postsurgical psychiatric, histopathological, cognitive and seizure outcomes were also examined. KEY FINDINGS: TLE+PIP patients were significantly less likely to have localised ictal epileptiform activity than the TLE controls (p=0.05) and were significantly more likely to have a positive family psychiatric history than TLE controls (p=0.04). Other pre-surgical clinical and neuropsychological variables did not distinguish between the groups. Patients with two or more PIP episodes had significantly increased odds of developing de novo psychopathology within 4 years of surgery, after controlling for comorbid pre-surgical psychiatric status and a history of SGTCS (OR: 9.11, 95% CI: 1.53-54.10, p=0.02). A history of PIP did not significantly predict other postsurgical outcomes (seizure freedom (ILAE=1) or cognitive outcome). SIGNIFICANCE: Our results suggest that more widespread or diffuse brain abnormalities as reflected by pre-surgical EEG findings and positive genetic determinants may contribute to the development of PIP. Furthermore, patients with recurrent PIP episodes who undergo TLE surgery are at increased risk of developing de novo psychiatric disorders, particularly mood disorders. This has implications for pre-operative counselling and highlights a need for postsurgical psychiatric monitoring for these patients.

Predicting and preventing psychopathology following temporal lobe epilepsy surgery.

Less than 3% of temporal lobe epilepsy (TLE) surgical outcome studies have investigated the psychiatric sequelae and morbidity associated with surgery. This is disproportionate to the extent of the problem. Variable prevalence rates have been reported for post-surgical depression, anxiety, and interictal psychosis. Until recently, very few studies distinguished de novo postoperative presentations from pre-existing conditions, making it difficult to accurately assess the impact of TLE surgery on psychiatric morbidity. Predictors of de novo postoperative presentations have proved elusive. This current review summarizes the findings from a systematic literature review of the psychiatric morbidity associated with TLE surgery including newly published follow-up data from our own series of 280 surgical patients. A framework for future research, possible pathophysiological mechanisms, and translational models are also discussed.

Predictors of psychiatric and seizure outcome following temporal lobe epilepsy surgery.

PURPOSE: Neurosurgery is an effective therapy for selected individuals with medically refractory temporal lobe epilepsy (TLE). De novo psychopathology may complicate the postsurgical outcome. Our aims were to identify predictors of de novo psychiatric and seizure outcome following TLE surgery. METHODS: Medical records of 280 patients who underwent TLE surgery were reviewed. Preoperative and postoperative psychiatric diagnoses were identified, in addition to information on seizure recurrence and neuropsychological status. Logistic regression analysis was used to identify predictors of having a de novo psychiatric diagnosis and remaining seizure-free within 4 years following surgery. KEY FINDINGS: One hundred five patients (38%) had significant psychiatric problems within 4 years following TLE surgery. Fifty-one patients (18%) developed de novo psychopathology; half of cases presented within 6 months and 90% of psychopathologies persisted 6 months or longer. A preoperative history of secondary generalized tonic-clonic seizure(s) (SGTCS) was an independent predictor of de novo psychopathology (odds ratio [OR] 2.73, 95% confidence interval [CI] 1.14-6.59, p = 0.02). From patients with available seizure data, 49% (127 of 258) remained seizure-free for 4 years after surgery. Patients with a history of SGTCS (OR 0.47, 95% CI 0.25-0.90, p = 0.02) and those with a preoperative psychiatric diagnosis (OR 0.53, 95% CI 0.28-0.98, p = 0.04) were significantly less likely to remain seizure-free. SIGNIFICANCE: De novo psychopathology is a significant complication of TLE surgery. Inclusion of neuropsychiatric assessments in the presurgical evaluation may lead to increase in the power of prognostic models used to predict the neurologic outcome of TLE surgery.

An investigation of co-speech gesture production during action description in Parkinson's disease.

INTRODUCTION: Parkinson's disease (PD) can impact enormously on speech communication. One aspect of non-verbal behaviour closely tied to speech is co-speech gesture production. In healthy people, co-speech gestures can add significant meaning and emphasis to speech. There is, however, little research into how this important channel of communication is affected in PD. METHODS: The present study provides a systematic analysis of co-speech gestures which spontaneously accompany the description of actions in a group of PD patients (N = 23, Hoehn and Yahr Stage III or less) and age-matched healthy controls (N = 22). The analysis considers different co-speech gesture types, using established classification schemes from the field of gesture research. The analysis focuses on the rate of these gestures as well as on their qualitative nature. In doing so, the analysis attempts to overcome several methodological shortcomings of research in this area. RESULTS: Contrary to expectation, gesture rate was not significantly affected in our patient group, with relatively mild PD. This indicates that co-speech gestures could compensate for speech problems. However, while gesture rate seems unaffected, the qualitative precision of gestures representing actions was significantly reduced. CONCLUSIONS: This study demonstrates the feasibility of carrying out fine-grained, detailed analyses of gestures in PD and offers insights into an as yet neglected facet of communication in patients with PD. Based on the present findings, an important next step is the closer investigation of the qualitative changes in gesture (including different communicative situations) and an analysis of the heterogeneity in co-speech gesture production in PD.