Heart sounds: Past, present, and future from a technological and clinical perspective - a systematic review.

The high prevalence of cardiac diseases around the world has created a need for quick, easy and cost effective approaches to diagnose heart disease. The auscultation and interpretation of heart sounds using the stethoscope is relatively inexpensive, requires minimal to advanced training, and is widely available and easily carried by healthcare providers working in urban environments or medically underserved rural areas. Since René-Théophile-Hyacinthe Laennec's simple, monoaural design, the capabilities of modern-day, commercially available stethoscopes and stethoscope systems have radically advanced with the integration of electronic hardware and software tools, however these systems are largely confined to the metropolitan medical centers. The purpose of this paper is to review the history of stethoscopes, compare commercially available stethoscope products and analytical software, and discuss future directions. Our review includes a description of heart sounds and how modern software enables the measurement and analysis of time intervals, teaching auscultation, remote cardiac examination (telemedicine) and, more recently, spectrographic evaluation and electronic storage. The basic methodologies behind modern software algorithms and techniques for heart sound preprocessing, segmentation and classification are described to provide awareness.

Do Articular Surfaces of Dual Mobility Hips Have More Wear and Friction? An In Vitro Investigation.

BACKGROUND: Larger head-to-neck ratio of dual mobility (DM) hip arthroplasties provide greater range of motion/less risk of dislocation, but raise concerns for high wear and friction. We measured in vitro, the wear rates of contemporary DM hips with highly cross-linked ultra high molecular weight polyethylene (UHWMPE), where it came from, and their frictional torques. METHODS: Hip simulators were used to compare the wear of DM to fixed-bearing (FB) designs of 2 different implants. Each of 8 different configurations underwent millions of simulated walking cycle tests, some as full DM, some as FB controls, some DM with the outer-articulation deliberately immobilized, and some the inner. Wear and 3-dimensional-frictional torques were measured and friction independent of size was deduced. RESULTS: The DM hips produced lower wear and friction-torque than the FB hips. The DM wear during walking gait comes mostly from the smaller inner articular surface. If the outer surface was immobilized, the wear and torque of the inner alone would be small, but the full DM (inner and outer free-to-move) wear and torque were smallest of all. Friction measurements expectedly showed larger hips having higher frictional torques, but the DM showed the lowest, again because its motion was mostly the smaller inner articulation; smaller than even a modern fixed-bearing hip. CONCLUSION: The DM hips appear to combine the benefits of greater range of motion and less impingement of larger hips, with the lower wear and friction of smaller FB hips, with some benefits compromised if the outer or inner articulations are immobilized.

Predictors of Reinfection in Prosthetic Joint Infections Following Two-Stage Reimplantation.

BACKGROUND: Two-stage reimplantation is an effective treatment for periprosthetic joint infection (PJI). Many factors are involved in the variable success of this procedure. The purpose of this study is to examine the relationship between patient risk factors, comorbidities, and the pathogen on reinfection rates following two-stage reimplantation. METHODS: We evaluated 158 patients treated for PJI from 2008-2019. Only patients who had completed a two-stage exchange were included. Patient demographics, comorbidities, laboratory values, time-to-reimplantation, pathogen, antibiotic sensitivities, host status, and reinfection rates were assessed. Multivariate analysis was performed to identify correlation between risk factors and reinfection. A P-value < .05 was considered statistically significant. RESULTS: 31 patients experienced a reinfection (19.6%). There was a statistically significant association between infection with Methicillin Sensitive Staphylococcus Aureus (MSSA) and reinfection (P = .046). Patients with a reinfection also had a significantly greater median serum C-reactive protein (CRP) level (12.65 g/dL) at the time of diagnosis compared to patients without a reinfection (5.0 g/dL) (P = .010). Median Erythrocyte Sedimentation Rate (ESR) (56 in no re-infection and 69 in re-infection) and time-to-reimplantation (101 days in no reinfection and 141 days in reinfection) demonstrated a trend toward an association with re-infection but were not statistically significant (P = .055 and P = .054 respectively). CONCLUSION: As the number of arthroplasties continue to rise, PJIs are increasing proportionately and represent a significant revision burden. Elevated C-reactive protein (CRP) levels and Methicillin Sensitive Staphylococcus aureus (MSSA) infection were strongly associated with failure of a two-stage reimplantation. While not statistically significant with our numbers, there were strong trends toward an association between elevated Erythrocyte Sedimentation Rate (ESR), longer time-to-reimplantation, and reinfection.

Optimal designs and surgical technique for hip and knee joint replacement: The best is yet to come!

Over the last three decades, there have been significant advancements in knee and hip replacement technology. The implants and the surgical technology we now have to aid in their implantation are advancing and improving functional outcomes and survivorship. Despite these advancements, there are still issues with patient satisfaction, functional limitations, and early revisions due to instability and aseptic loosening. This article reviews the state of current technology in hip and knee replacement implant design and surgical technique, and reviews some of the current implant designs and surgical technologies that may be able to solve some of the most common issues in the knee and hip replacement surgery.

New materials for hip and knee joint replacement: What's hip and what's in kneed?

Over the last three decades there have been significant advancements in the knee and hip replacement technology that has been driven by an issue in the past concerning adverse local tissue reactions, aseptic and septic loosening. The implants and the materials we utilize have improved over the last two decades and in knee and hip replacement there has been a decrease in the failures attributed to wear and osteolysis. Despite these advancements there are still issues with patient satisfaction and early revisions due to septic and aseptic loosening in knee replacement patients. This article reviews the state of current implant material technology in hip and knee replacement surgery, discusses some of the unmet needs we have in biomaterials, and reviews some of the current biomaterials and technology that may be able to solve the most common issues in the knee and hip replacement surgery.

Surface nano-modification by ion beam-assisted deposition alters the expression of osteogenic genes in osteoblasts.

Biomaterials with enhanced biocompatibility are favored in implant studies to improve the outcomes of total joint replacement surgeries. This study tested the hypothesis that nano-structured surfaces for orthopedic applications, produced by the ion beam-assisted deposition method, would enhance osteointegration by altering the expression of bone-associated genes in osteoblasts. The ion beam-assisted deposition technique was employed to deposit nano-films on glass or titanium substrates. The effects of the ion beam-assisted deposition produced surfaces on the human osteosarcoma cell line SAOS-2 at the molecular level were investigated by assays of adhesion, proliferation, differentiation, and apoptosis on coated surfaces versus uncoated cobalt-chrome, as the control. Ion beam-assisted deposition nano-coatings enhanced bone-associated gene expression at initial cell adhesion, proliferation, and differentiation compared to cobalt-chrome surfaces as assessed by polymerase chain reaction techniques. Increased cell proliferation was observed using a nuclear cell proliferation-associated antigen. Moreover, enhanced cell differentiation was determined by alkaline phosphatase activity, an indicator of bone formation. In addition, programmed cell death assessed by annexin V staining and flow cytometry was lower on nano-surfaces compared to cobalt-chrome surfaces. Overall, the results indicate that nano-coated surfaces produced by the ion beam-assisted deposition technique for use on implants were superior to orthopedic grade cobalt-chrome in supporting bone cell adhesion, proliferation, and differentiation and reducing apoptosis. Thus, surface properties altered by the ion beam-assisted deposition technique should enhance bone formation and increase the biocompatibility of bone cell-associated surfaces.

Effects of carbon addition on wear mechanisms of CoCrMo metal-on-metal hip joint bearings.

The wear behaviors of biomedical CoCrMo prosthetic alloys containing various amounts of carbon were investigated using a standard hip joint simulator in a simulated body fluid. A few chunks and punctate σ-phase precipitates were observed in the low-carbon (LC) alloy; these were responsible for the abrasion and run-in wear. Increasing the carbon content led to greater precipitation of globular M23C6-type carbides. As a result, lower wear loss was observed in the high-carbon (HC) alloy. However, the Student's t-test analysis on wear loss indicated that there was no significant difference in wear loss between the LC-LC and HC-HC combinations. Surface fatigue caused by torn-off of Mo-rich carbides was the dominant wear mechanism in the HC alloy. Further, Cr-rich carbides prevent three-body abrasion and increase the wear resistance.

Simultaneous measurement of friction and wear in hip simulators.

We propose and have evaluated a method to measure hip friction during wear testing on a popular multi-station hip simulator. A 6-degree-of-freedom load cell underneath the specimen sensed forces and torques during implant wear testing of simulated walking. This included internal-external and adduction-abduction rotations which are often neglected during friction testing on pendulum-type machines. Robust mathematical analysis and data processing provided friction estimates in three simultaneous orthogonal rotations, over extended multi-million cycle wear tests. We tested various bearing couples including metal-on-plastic, ceramic-on-plastic, and metal-on-metal material couples. In one test series, new and intentionally scratched CoCrMo 40-mm-diameter femoral heads were tested against conventional ultrahigh-molecular-weight polyethylene, highly cross-linked, and highly cross-linked with vitamin E versions. The scratching significantly increased friction and doubled the wear of all groups. Before scratching, friction levels for the aforementioned plastic groups were 0.056 ± 0.0060, 0.062 ± 0.0080, and 0.070 ± 0.0045, respectively, but after scratching increased to 0.088 ± 0.018, 0.076 ± 0.0066, and 0.082 ± 0.0049, respectively, all statistically significant increases (p = 0.00059, 0.00005, 0.0115, respectively). In another test series of 44-mm femoral head diameter hips, metal-on-plastic hips with conventional ultrahigh-molecular-weight polyethylene showed the lowest friction at 0.045 ± 0.0085, followed by highly cross-linked with 0.046 ± 0.0035 (not significantly different). In a ceramic-on-plastic design with conventional ultrahigh-molecular-weight polyethylene, higher friction 0.079 ± 0.0070 was measured likely due to that ceramic surface being rougher than usual. Metal-on-metal hips were compared without and with a TiN coating, resulting in 0.049 ± 0.014 and 0.097 ± 0.020 friction factors, respectively (statistically significant, p < 0.001), and the coating wore away on all coated hips eventually. Higher friction mostly correlated with higher wear or damage to femoral heads or implant coatings, except for the highly cross-linked wear resistant ultrahigh-molecular-weight polyethylene which had slightly higher friction, confirming the same finding in other independent studies. This type of friction measurements can help screen for clamping and elevated wear of metal-on-metal and resurfacing total hip replacements, surgical malpositioning, and abraded and otherwise damaged surfaces.

Antibiotic-tolerant Staphylococcus aureus Biofilm Persists on Arthroplasty Materials.

BACKGROUND: The continued presence of biofilm may be one cause of the high risk of failure observed with irrigation and débridement with component retention in acute periprosthetic joint infection (PJI). There is a poor understanding of the role of biofilm antibiotic tolerance in PJI. QUESTIONS/PURPOSES: (1) Do increasing doses of cefazolin result in decreased viable biofilm mass on arthroplasty materials? (2) Is cefazolin resistance phenotypic or genotypic? (3) Is biofilm viability a function of biofilm depth after treatment with cefazolin? (4) Is the toxin-antitoxin system, yoeB expression, associated with antibiotic stress? METHODS: Methicillin-sensitive Staphylococcus aureus biofilm was cultured on total knee arthroplasty (TKA) materials and exposed to increasing doses of cefazolin (control, 0.5, 1.0, 10.0, 100.0 µg/mL). Quantitative confocal microscopy and quantitative culture were used to measure viable biofilm cell density. To determine if cefazolin resistance was phenotypic or genotypic, we measured minimum inhibitory concentration (MIC) after exposure to different cefazolin concentrations; changes in MIC would suggest genotypic features, whereas unchanged MIC would suggest phenotypic behavior. Finally, quantitative reverse transcription-polymerase chain reaction was used to quantify expression of yoeB levels between biofilm and planktonic bacteria after exposure to 1 µg/mL cefazolin for 3 hours. RESULTS: Although live biofilm mass was reduced by exposure to cefazolin when compared with biofilm mass in controls (39.2 × 10(3) ± 26.4 × 10(3) pixels), where the level after 0.5 µg/mL exposure also showed reduced mass (20.3 × 10(3) ± 11.9 × 10(3) pixels), no further reduction was seen after higher doses (mass at 1.0 µg/mL: 5.0 × 10(3) pixels ± 1.1 × 10(3) pixels; at 10.0 µg/mL: 6.4 × 10(3) ± 9.6 × 10(3) pixels; at 100.0 µg/mL: 6.4 × 10(3) ± 3.9 × 10(3)). At the highest concentration tested (100 µg/mL), residual viable biofilm was present on all three materials, and there were no differences in percent biofilm survival among cobalt-chromium (18.5% ± 15.1%), polymethylmethacrylate (22.8% ± 20.2%), and polyethylene (14.7% ± 10.4%). We found that tolerance was a phenotypic phenomenon, because increasing cefazolin exposure did not result in changes in MIC as compared with controls (MIC in controls: 0.13 ± 0.02; at 0.5 µg/mL: 0.13 ± 0.001, p = 0.96; at 1.0 µg/m: 0.14 ± 0.04, p = 0.95; at 10.0 µg/m: 0.11 ± 0.016, p = 0.47; at 100.0 µg/m: 0.94 ± 0.047, p = 0.47). Expression of yoeB after 1 µg/mL cefazolin for 3 hours in biofilm cells was greater in biofilm but not in planktonic cells (biofilm: 62.3-fold change, planktonic cells: -78.8-fold change, p < 0.001). CONCLUSIONS: Antibiotics are inadequate at complete removal of the biofilm from the surface of TKA materials. Results suggest that bacterial persisters are responsible for this phenotypic behavior allowing biofilm high tolerance to antibiotics. CLINICAL RELEVANCE: Antibiotic-tolerant biofilm suggests a mechanism behind the poor results in irrigation and débridement for acute TKA PJI.

Using a surrogate contact pair to evaluate polyethylene wear in prosthetic knee joints.

With recent improvements to the properties of ultra-high molecular weight polyethylene (UHMWPE) used in joint replacements, prosthetic knee and hip longevity may extend beyond two decades. However, it is difficult and costly to replicate such a long in vivo lifetime using clinically relevant in vitro wear testing approaches such as walking gait joint simulators. We advance a wear test intermediate in complexity between pin-on-disk and knee joint simulator tests. The test uses a surrogate contact pair, consisting of a surrogate femoral and tibial specimen that replicate the contact mechanics of any full-scale knee condyle contact pair. The method is implemented in a standard multi-directional pin-on-disk wear test machine, and we demonstrate its application via a two-million-cycle wear test of three different UHMWPE formulations. Further, we demonstrate the use of digital photography and image processing to accurately quantify fatigue damage based on the reduced transmission of light through a damage area in a UHMWPE specimen. The surrogate contact pairs replicate the knee condyle contact areas within -3% to +12%. The gravimetric wear test results reflect the dose of crosslinking radiation applied to the UHMWPE: 35 kGy yielded a wear rate of 7.4 mg/Mcycles, 55 kGy yielded 1.0 mg/Mcycles, and 75 kGy (applied to a 0.1% vitamin E stabilized UHMWPE) yielded 1.5 mg/Mcycles. A precursor to spalling fatigue is observed and precisely measured in the radiation-sterilized (35 kGy) and aged UHMWPE specimen. The presented techniques can be used to evaluate the high-cycle fatigue performance of arbitrary knee condyle contact pairs under design-specific contact stresses, using existing wear test machines. This makes the techniques more economical and well-suited to standardized comparative testing.

Pulse lavage is inadequate at removal of biofilm from the surface of total knee arthroplasty materials.

In acute periprosthetic infection, irrigation and debridement with component retention has a high failure rate in some studies. We hypothesize that pulse lavage irrigation is ineffective at removing biofilm from total knee arthroplasty (TKA) components. Staphylococcus aureus biofilm mass and location was directly visualized on arthroplasty materials with a photon collection camera and laser scanning confocal microscopy. There was a substantial reduction in biofilm signal intensity, but the reduction was less than a ten-fold decrease. This suggests that irrigation needs to be further improved for the removal of biofilm mass below the necessary bioburden level to prevent recurrence of acute infection in total knee arthroplasty.

Honorary authorship in biomedical journals: how common is it and why does it exist?

BACKGROUND: The number of coauthors in the medical literature has increased over the past 50 years as authorship continues to have important academic, social and financial implications. AIM AND METHOD: The study aim was to determine the prevalence of honorary authorship in biomedical publications and identify the factors that lead to its existence. An email with a survey link was sent anonymously to 9283 corresponding authors of PubMed articles published within 1 year of contact. RESULTS: A completed survey was obtained from 1246 corresponding authors, a response rate of 15.75%. One-third (33.4%) admitted that they had added authors who did not deserve authorship credit. Origin of the study from Europe and Asia (p ≤ 0.001 and 0.005, respectively), study type as case report/case series (p=0.036) and increasing number of coauthors were found to be the associated factors on multivariate analysis. Journal impact factor was also found to be associated with honorary authorship (mean journal impact factor was 4.82 (SD 6.32) for those who self-reported honorary authorship and 5.60 (SD 7.13) for those who did not report unjust authorship, p=0.05). In retrospect, 75% of the authors indicated that they would remove unjustified names from the authorship list. Reasons for adding honorary authors were complimentary (39.4%), to avoid conflict at work (16.1%), to facilitate article acceptance (7.2%), and other (3.6%). CONCLUSIONS: Honorary authorship is relatively common in biomedical publications. Researchers should comply with the International Committee of Medical Journal Editors' criteria for authorship.

Titanium implant with nanostructured zirconia surface promotes maturation of peri-implant bone in osseointegration.

The goal of the experiment outlined in this article is to improve upon noncemented methods of arthroplasty for clinical application in elderly patients. This was done by determining whether titanium implants with a novel nanostructured zirconia surface, which was created by ion beam-assisted deposition, would prevent impaired osseointegration of intramedullary implants in 1-year-old rats receiving a protein-deficient diet. Specifically, we asked whether the implant with the nanostructured zirconia surface would increase expression of markers of bone maturation within the remodeling of peri-implant woven bone. The control implants, which were made of commercially pure titanium, had a polished surface ex vivo but are known to acquire a microstructured titania surface in vivo. Ten 1-year-old rats received experimental implant (group A) and 10 had control (group B) implants. Ten 3-month-old rats received normal protein diet and the control implant (group C). Animals were euthanized 8 weeks after implantation, and transverse sections of femur-implant samples were used for histology, micro-computed tomography and immunohistochemical evaluations. In group B, the expression of α2ß1 and α5ß1 integrins, which are known to mediate osteoblast adhesion, glycosaminoglycans, heparan sulfate and chondroitin sulfate, was less than half of that in group C. Important to this study, the zirconia surface used in group A prevented these deficiencies. Therefore, these results indicate that nanostructured zirconia surface created on clinical implants by ion beam-assisted deposition may prevent impaired osseointegration in elderly patients by promoting quicker maturation of peri-implant woven bone.

Total knee arthroplasty with a computer-navigated saw: a pilot study.

BACKGROUND: Computer-aided surgery aims to improve implant alignment in TKA but has only been adopted by a minority for routine use. A novel approach, navigated freehand bone cutting (NFC), is intended to achieve wider acceptance by eliminating the need for cumbersome, implant-specific mechanical jigs and avoiding the expense of navigation. QUESTIONS/PURPOSES: We determined cutting time, surface quality, implant fit, and implant alignment after NFC of synthetic femoral specimens and the feasibility and alignment of a complete TKA performed with NFC technology in cadaveric specimens. METHODS: Seven surgeons prepared six synthetic femoral specimens each, using our custom NFC system. Cutting times, quality of bone cuts, and implant fit and alignment were assessed quantitatively by CT surface scanning and computational measurements. Additionally, a single surgeon performed a complete TKA on two cadaveric specimens using the NFC system, with cutting time and implant alignment analyzed through plain radiographs and CT. RESULTS: For the synthetic specimens, femoral coronal alignment was within ± 2° of neutral in 94% of the specimens. Sagittal alignment was within 0° to 5° of flexion in all specimens. Rotation was within ± 1° of the epicondylar axis in 97% of the specimens. The mean time to make cuts improved from 13 minutes for the first specimen to 9 minutes for the fourth specimen. TKA was performed in two cadaveric specimens without complications and implants were well aligned. CONCLUSIONS: TKA is feasible with NFC, which eliminates the need for implant-specific instruments. We observed a fast learning curve. CLINICAL RELEVANCE: NFC has the potential to improve TKA alignment, reduce operative time, and reduce the number of instruments in surgery. Fewer instruments and less sterilization could reduce costs associated with TKA.

Does vitamin E-stabilized ultrahigh-molecular-weight polyethylene address concerns of cross-linked polyethylene in total knee arthroplasty?

Concerns about reduced strength, fatigue resistance, and oxidative stability of highly cross-linked and remelted ultrahigh-molecular-weight polyethylene (UHMWPE) have limited its clinical acceptance for total knee arthroplasty. We hypothesized that a highly cross-linked UHMWPE stabilized with vitamin E would have less oxidation and loss of mechanical properties. We compared the oxidation, in vitro strength, fatigue-crack propagation resistance, and wear of highly cross-linked UHMWPE doped with vitamin E to γ-inert-sterilized direct compression-molded UHMWPE (control). After accelerated aging, the control material showed elevated oxidation, loss of small-punch mechanical properties, and loss of fatigue-crack propagation resistance. In contrast, the vitamin E-stabilized material had minimal changes and exhibited 73% to 86% reduction in wear for both cruciate-retaining and posterior-stabilized total knee arthroplasty designs. Highly cross-linked vitamin E-stabilized UHMWPE performed well in vitro.

In vitro response of the natural cadaver knee to the loading profiles specified in a standard for knee implant wear testing.

The purpose of this study was to examine how a natural knee responds to the inputs of a total knee replacement testing standard developed by the International Organization for Standardization (ISO). This load control standard prescribes forces to be used for wear testing of knee replacements independent of implant size or design. A parallel ISO standard provides wear testing inputs that are displacement based instead of force based. Eight fresh frozen cadaveric knees were potted and tested in a 6 degree of freedom knee simulator using the load-control standard. The resulting displacements during load-control testing were compared to the prescribed displacements of the ISO displacement standard. At half the tibial torque prescribed by the load standard there was three times more average internal tibial rotation (20.3 degrees) than is prescribed by the displacement standard (5.7 degrees). The AP motion resulting from load testing was much different than is specified by the displacement standard. All eight knees had anterior tibial translation with respect to the femur during swing phase while the displacement standard specifies posterior tibial displacement. The variation in these motions among knees and their difference from the ISO displacement standard may be one factor that explains why wear results of total knee replacements based on ISO load or displacement testing frequently do not agree with each other or with clinical retrievals.

Ion beam-induced amorphous-to-tetragonal phase transformation and grain growth of nanocrystalline zirconia.

Nanocrystalline zirconia has recently attracted extensive research interest due to its unique mechanical, thermal and electrical properties as compared with bulk zirconia counterparts, and it is of particular importance for controlling the phase stability of different polymorphs (amorphous, cubic, tetragonal and monoclinic phases) in different size regimes. In this work, we performed ion beam bombardments on bilayers (amorphous and cubic) of nano-zirconia using 1 MeV Kr2+ irradiation. Transmission electron microscopy (TEM) analysis reveals that amorphous zirconia transforms to a tetragonal structure under irradiation at room temperature, suggesting that the tetragonal phase is more energetically favorable under these conditions. The final grain size of the tetragonal zirconia can be controlled by irradiation conditions. A slower kinetics in the grain growth from cubic nanocrystalline zirconia was found as compared with that for the tetragonal grains recrystallized from the amorphous layer. The radiation-induced nanograins of tetragonal ZrO2 are stable at ambient conditions and maintain their physical integrity over a long period of time after irradiation. These results demonstrated that ion beam methods provide the means to control the phase stability and structure of zirconia polymorphs.

Rotating platform versus fixed-bearing total knees: an in vitro study of wear.

One of the assumed benefits of mobile bearings is the reduction of UHMWPE wear. However, to date, such benefit has not been categorically proven. To test the hypothesis that rotating platform total knee arthroplasty would have less wear than a fixed-bearing of the same design, this in vitro study compared the wear and kinematics (which influence wear) of one type of mobile with fixed-bearing tibial components of otherwise identical design. We tested four fixed bearing (FB) and four rotating platforms (RP) on force control knee simulators using identical ISO standard force inputs and simulated soft tissue restraint for 6 million walking cycles. The internal/external rotations peaked just before toe off, reaching an average maximum of 7 degrees internal (tibial rotation) in the RP, 1.5 times that of the FB, which peaked at approximately 4.5 degrees internally. Two of the RP specimens showed infrequent and mostly temporary dislocations of the UHMWPE insert. The wear rate for the FB averaged 8.14 +/- 2.63 mg/million cycles and the RP averaged 6.78 +/- 1.74 mg/million cycles. Both were very low wear rates compared with most other implants tested similarly in the same laboratory. We concluded polyethylene wear was similar for both designs.

Alveolar Echinococcosis induced liver failure: salvage by liver transplantation in an otherwise uniformly fatal disease.

A technically difficult liver transplant was performed in a 68-yr-old male with Alveolar Echinococcosis causing end-stage liver disease. The pathology was extensive and included hepatic artery thrombosis, Budd-Chiari syndrome, and right hemidiaphragm invasion necessitating resection of this portion of diaphragm and direct donor cava anastomosis to the right atrium. The patient is now 21 months since transplant disease free with normal liver function.

Lotus effect in engineered zirconia.

Patterned micro- and nanostructured surfaces have received increasing attention because of their ability to tune the hydrophobicity and hydrophilicity of their surfaces. However, the mechanical properties of these studied surfaces are not sufficiently robust for load-bearing applications. Here we report transparent nanocrystalline ZrO 2 films possessing combined properties of hardness and complete wetting behavior, which are expected to benefit tribology, wear reduction, and biomedical applications where ultrahydrophilic surfaces are required. This ultrahydrophilic behavior may be explained by the Wenzel model.