Pelvic floor muscle training in spinal cord injury and its impact on neurogenic detrusor over-activity and incontinence.

STUDY DESIGN: Two case studies. OBJECTIVES: To determine whether 6 weeks of regular pelvic floor muscle training (PFMT) can improve the strength and endurance of voluntary contractions in incomplete spinal cord injury and reduce neurogenic detrusor over-activity (NDO) and incontinence. SETTING: The London Spinal Cord Injury Centre, Stanmore, London, UK. METHODS: A 6-week programme of PFMT was conducted in two male subjects with stable supra-sacral motor incomplete (AIS C and D) spinal cord injuries. Clinical evaluations before and after training comprised measures of strength and endurance of voluntary pelvic floor contractions both objectively by anal canal-pressure measurements and subjectively using the modified Oxford grading system. NDO was determined by standard urodynamic tests of bladder function and incontinence measured by the International Consultation on Incontinence Questionnaire-Urology. RESULTS: Both subjects improved the strength and endurance of their pelvic floor muscle contractions by over 100% at the end of training. After training, Subject 1 (AIS D) was able to reduce bladder pressure during over-activity almost completely by voluntarily contracting the pelvic floor muscles. Subject 2 (AIS C) achieved a lesser reduction overall after training. Continence improved only in subject 1. CONCLUSION: These case studies provide evidence that a 6-week programme of PFMT may have a beneficial effect on promoting voluntary control of NDO and reduce incontinence in selected cases with a motor incomplete spinal cord lesion.

Plastic physicians: The surgical salamanders of the COVID-19 pandemic.

At the time of writing, coronavirus disease-2019 (COVID-19) has affected 6.42 million people globally and over 380,000 deaths, with the United Kingdom now having the highest death rate in Europe. The plastic surgery department at Leeds Teaching Hospitals put necessary steps in place to maintain an excellent urgent elective and acute service whilst also managing COVID-positive medical patients in the ward. We describe the structures and pathways implemented together with complex decision-making, which has allowed us to respond early and effectively. We hope these lessons will prove a useful tool as we look to open conversations around the recovery of normal activity.

["Flowsecure" artificial urinary sphincter: a new adjustable artificial urinary sphincter concept with conditional occlusion for stress urinary incontinence]. / Esfínter Urinario Artificial "FlowSecure": un nuevo concepto de esfínter artificial regulable y con oclusión condicional para la incontinencia urinaria de esfuerzo.

INTRODUCTION: To spread de concept of a new artificial urinary sphincter with conditional occlusion for stress incontinence. The new prototype was conceived and designed in The Institute of Urology and Nephrology of London by Professor Craggs M. and Professor Mundy A.R. METHODS: The FlowSecure sphincter consists of an adjustable pressure-regulating balloon, a stress relief reservoir, a control pump and valve assembly unit with self-sealing port and a urethral cuff. The pressure regulating balloon determinates de operating pressure of the device; the pressure is adjustable in the range 0-80 cm H2O and can be altered by injection or removal of normal saline through the self sealing port. The stress relief balloon transmits transient intrabdominal pressure to the cuff during periods of stress. An adjustable circular urethral cuff minimises creasing and possible stress fractures. RESULTS: The device is implanted as a one-piece assembly which is pre-filled with sterile saline. The surgical technique is simple and associated with little handling, reducing risk of infection and potential assembly errors. The adjustable pressure regulating balloon in association with the stress relief reservoir enables the cuff occluding pressure to be set at a low range, therefore reducing the risk for atrophy and erosion. DISCUSSION: The new FlowSecure urinary artificial sphincter with conditional occlusion is designed to provide good continence rates adjusting regulating pressures when needed and conceived to reduce the risk of potential complications associated with excessive occluding pressures and mechanical failures.

Three-dimensional MRI of the male urethrae with implanted artificial sphincters: initial results.

The aim of this study was to develop a method for simultaneous 3D visualization of a new type of artificial urethral sphincter (AUS) and adjacent urinary structures. Serial MR tomograms were acquired from seven men after AUS implantation. 3D reconstruction was performed by thresholding original (positive) and inverted (negative) image intensity and by subsequently fusing positive and negative images. Results show that the bladder, cuff and balloons of the AUS of originally high intensity were imaged in 3D by thresholding the positive datasets. The urethrae and corpora cavernosa penis of originally low intensity were displayed in 3D by thresholding the negative datasets. Fusion of the positive and negative datasets allowed simultaneous visualization of the AUS complex and adjacent urinary structures. All the structures of interest were also clearly seen by interactive multiplanar reformatting. Coronal tomographic datasets provided better 3D and reformatted 2D images than sagittal and transverse datasets. This technique offers a simple means for evaluating the complex urethral anatomy and the AUS, and has potential for improved 3D visualization of many other complex morphological and pathological conditions.

Establishing predictive indicators for the status of loaded soft tissues.

Two complementary techniques were employed to assess the soft tissue response to applied pressure. The noninvasive methods involve the simultaneous measurement of the local tensions of oxygen and carbon dioxide (tcPO2 and tcPCO2) and the collection and subsequent analysis of sweat collected from the sacrum, a common site for the development of pressure sores. All tests were performed on able-bodied subjects. Results have indicated that oxygen levels (tcPO2) were lowered in soft tissues subjected to applied pressures of between 40 (5.3 kPa) and 120 mmHg (16.0 kPa). At the higher pressures, this decrease was generally associated with an increase in carbon dioxide levels (tcPCO2) well above the normal basal levels of 45 mmHg (6 kPa). There were also considerable increases, in some cases up to twofold, in the concentrations of both sweat lactate and urea at the loaded site compared with the unloaded control. By comparing selected parameters, a threshold value for loaded tcPO2 was identified, representing a reduction of ~60% from unloaded values. Above this threshold, there was a significant relationship between this parameter and the loaded/unloaded concentration ratios for both sweat metabolites. These parameters may prove useful in identifying those subjects whose soft tissue may be compromised during periods of pressure ischemia.

Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia.

We performed a retrospective review of the case notes of 84 consecutive patients who had suffered a severe (Gustilo IIIb or IIIc) open fracture of the tibia after blunt trauma between 1990 and 1998. All had been treated by a radical protocol which included early soft-tissue cover with a muscle flap by a combined orthopaedic and plastic surgery service. Our ideal management is a radical debridement of the wound outside the zone of injury, skeletal stabilisation and early soft-tissue cover with a vascularised muscle flap. All patients were followed clinically and radiologically to union or for one year. After exclusion of four patients (one unrelated death and three patients lost to follow-up), we reviewed 80 patients with 84 fractures. There were 67 men and 13 women with a mean age of 37 years (3 to 89). Five injuries were grade IIIc and 79 grade IIIb; 12 were site 41, 43 were site 42 and 29 were site 43. Debridement and stabilisation of the fracture were invariably performed immediately. In 33 cases the soft-tissue reconstruction was also completed in a single stage, while in a further 30 it was achieved within 72 hours. In the remaining 21 there was a delay beyond 72 hours, often for critical reasons unrelated to the limb injury. All grade-IIIc injuries underwent immediate vascular reconstruction, with an immediate cover by a flap in two. All were salvaged. There were four amputations, one early, one mid-term and two late, giving a final rate of limb salvage of 95%. Overall, nine pedicled and 75 free muscle flaps were used; the rate of flap failure was 3.5%. Stabilisation of the fracture was achieved with 19 external and 65 internal fixation devices (nails or plates). Three patients had significant segmental defects and required bone-transport procedures to achieve bony union. Of the rest, 51 fractures (66%) progressed to primary bony union while 26 (34%) required a bone-stimulating procedure to achieve this outcome. Overall, there was a rate of superficial infection of the skin graft of 6%, of deep infection at the site of the fracture of 9.5%, and of serious pin-track infection of 37% in the external fixator group. At final review all patients were walking freely on united fractures with no evidence of infection. The treatment of these very severe injuries by an aggressive combined orthopaedic and plastic surgical approach provides good results; immediate internal fixation and healthy soft-tissue cover with a muscle flap is safe. Indeed, delay in cover (>72 hours) was associated with most of the problems. External fixation was associated with practical difficulties for the plastic surgeons, a number of chronic pin-track infections and our only cases of malunion. We prefer to use internal fixation. We recommend primary referral to a specialist centre whenever possible. If local factors prevent this we suggest that after discussion with the relevant centre, initial debridement and bridging external fixation, followed by transfer, is the safest procedure.

Malignant schwannoma in a burn scar.

The malignant potential of a burn scar is well recognized. Epidermal malignancies predominate and sarcomas are a rare finding. The first case of a malignant schwannoma developing in a burn scar is reported, and the management discussed.

A modification of the Kleinert splint for mobilisation of digital flexor tendons.

A modification of the Kleinert dynamic splint is described, whereby the rubber band is looped around the hand, rather than attached to the volar aspect of the wrist or forearm. This alters the direction of traction so that the interphalangeal joints are more effectively mobilised.

A simple and fail safe method for digital tourniquet.

Digital tourniquets are commonly used to provide a bloodless field for surgery to the finger. Such tourniquets, however, are potentially harmful and disastrous consequences occur if they are accidentally left in place. We propose a modification of the rubber glove tourniquet technique that will provide a safe and reliable tourniquet.

Growth and yield characteristics of 'Waldmann's Green' leaf lettuce under different photon fluxes from metal halide or incandescent + fluorescent radiation.

'Waldmann's Green' leaf lettuce (Lactuca sativa L.) was grown either under 84% irradiance from incandescent (In) + 16% from fluorescence (Fl) lamps, or 100% from metal halide (MH) lamps, both at 392 micromoles s-1 m-2 of photosynthetically active radiation (400-700 nm) from 11 to 19 days after seeding. No differences in leaf dry weight, leaf area, relative growth rate (RGR) or photosynthesis (Pn) occurred after 8 days of exposure to these radiation treatments for 20 h day-1. However, a 23% reduction in root dry weight, a 123% increase in stem length and a 61% increase in stem dry weight were found with In + Fl relative to MH radiation. A photosynthetic photon flux (PPF) of 920 micromoles s-1 m-2 from the In + Fl source increased leaf dry weight by 13% and RGR by 21% relative to those at 460 micromoles s-1 m-2 from the same source. From 4 to 8 days of treatment, high PPF did not lower shoot dry gain, but did lower RGR. Photosynthesis and net assimilation rate were lower while leaf area ratio was higher at 460 than at 920 micromoles s-1 m-2 over the 8-day treatment period. When PPF from MH lamps was 400 micromoles s-1 m-2, leaf dry weight was 20% greater than if PPF was 805 micromoles s-1 m-2 after 4 days of treatment, but no differences were detected after 8 days. Relative growth rate increased by 11% during the first 4 days, but declined by 12% during the second 4 days under high- relative to low-PPF MH radiation. Lettuce productivity was stimulated by high PPF from either lamp type from Day 11 to Day 14, but not from Day 15 to Day 19 after seeding.

Effects of incandescent radiation on photosynthesis, growth rate and yield of 'Waldmann's Green' leaf lettuce.

Effects of different ratios incandescent (ln) to fluorescent (Fl) radiation were tested on growth of 'Waldmann's Green' leaf lettuce (Lactuca sativa L.) in a controlled environment. After 4 days of treatment, dry weight, leaf area, relative growth rate (RGR), net assimilation rate (NAR), leaf area ratio (LAR) and photosynthetic rate (Pn) were greater for plants grown at 84 rather than 16% of total irradiance (82 W m-2) from ln lamps. Although leaf dry weight and area were 12-17% greater at 84% ln after the first 8 days of treatment, there were no differences in RGR or Pn between treatments during the last 4 days. If 84% ln was compared with 50% ln, all cumulative growth parameters, RGR, NAR and Pn were greater for 84% ln during the first 4 days of treatment. However, during the second 4 days, RGR was greater for the 50% ln treatment, resulting in no net difference in leaf dry weight or area between treatments. Shifting from 84 to 50% ln radiation between the first and second 4 days of treatment increased plant dry weight, leaf area, RGR and NAR relative to those under 84% ln for 8 days continuously.

Stimulating productivity of hydroponic lettuce in controlled environments with triacontanol.

Triacontanol (1-triacontanol) applied as a foliar spray at 10(-7) M to 4-day-old, hydroponically grown leaf lettuce (Lactuca sativa L.) seedlings in a controlled environment increased leaf fresh and dry weight 13% to 20% and root fresh and dry weight 13% to 24% 6 days after application, relative to plants sprayed with water. When applied at 8 as well as 4 days after seeding, triacontanol increased plant fresh and dry weight, leaf area, and mean relative growth rate 12% to 37%. There was no benefit of repeating application of triacontanol in terms of leaf dry weight gain.

Stimulation of lettuce productivity by manipulation of diurnal temperature and light.

'Salad Bowl' and 'Waldmann's Green' leaf lettuce (Lactuca sativa L.) were exposed to photosynthetic photon flux densities (PPFD) of 444 or 889 micromoles s-1 m-2 for 20 hours day-1 under a diurnal temperature regime of 25 degrees C days/15 degrees nights or 20 degrees days/15 degrees nights. Leaf dry weight of both cultivars was highest under the high PPFD/warm temperature regime and lowest under the low PPFD/cool temperature regime. 'Waldmann's Green' yielded more than did 'Salad Bowl' at 889 micromoles s-1 m-2 and 25 degrees days/20 degrees nights. Under high PPFD, both cultivars yielded better with 25 degrees days/25 degrees nights than with 25 degrees days/20 degrees nights, although relative growth rates were the same under both temperature regimes.

Enhancement of lettuce yield by manipulation of light and nitrogen nutrition.

Several levels of photosynthetic photon flux density (PPFD) were tested for effects on growth of 4 cultivars of lettuce (Lactuca sativa L.) under controlled-environment conditions. Growth of 'Salad Bowl', 'Bibb', and 'Ruby' was greater at 932 micromoles s-1 m-2 than at < or = 644 micromoles s-1 m-2 under a 16-hour photoperiod. Thirty mM NO3- or 5 mM NH4+ + 25 mM NO3- increased leaf dry weight while reducing leaf chlorosis in 'Salad Bowl' and 'Grand Rapids' relative to that with 15 mM NO3-, and reduced leaf purpling in 'Bibb' and 'Ruby' with little or no effect on yield. Continuous illumination with 455 or 918 micromoles s-1 m-2 stimulated yield of 'Salad Bowl' and 'Bibb' when 30 mM N as NH4+ + NO3- was used relative to that with 15 mM NO3-.

Photosynthetic productivity and vibration/acceleration stress considerations for higher plants in bioregenerative systems.

NASA: The food production group of the NASA Closed Ecology Life Support Systems (CELSS) program is conducting research to optimize production of candidate species from each of the major categories of food crop. Studies are underway with soybean, wheat and potato, and leaf lettuce. Our laboratory emphasizes the controlled environment production of leaf lettuce. Our objective is to obtain the greatest possible production of edible lettuce biomass in the smallest possible growing space in the shortest possible time. It is obvious from the lettuce studies that the ability to achieve high photosynthetic productivity is a desirable option for plant production in a bioregenerative life support system. However, another NASA-sponsored project in our laboratory involving effects of mechanical stress on plants is a cause for concern regarding the ability of plants to be productive in a microgravity space environment. Periodic gyratory shaking reduces stem elongation, but also dry weight gain and therefore photosynthetic productivity. We have been conducting mechanical stress research in a controlled environment with soybean, another CELSS candidate species which can provide protein for a vegetarian diet. The seismic disturbances that attend spacecraft acceleration, maneuver, machine operations, and even astronaut activity are a cause for concern, not only for their effects on plant growth and tropisms, but because they have gravity equivalents. Pulses of vibration in space may mimic gravity. Or will they retard tropistic curvature? Many questions remain regarding whether seismic disturbance will be a serious confounding factor for plant research in a microgravity environment.^ieng

Long term study into surgical re-exploration of the 'free flap in difficulty'.

BACKGROUND: Free tissue transfers must survive in order to achieve their surgical goals. There is little consensus about managing the 'failing' free flap, and practice is often guided by anecdote. MATERIAL AND METHODS: We have prospectively collected data about all free flaps performed within our department between 1985 and 2008 (2569 flaps). We identified 327 flaps which were re-explored a total of 369 times. We analysed these flaps with regard to indication for re-exploration, operative findings and outcome. RESULTS: Thirteen percent (327) of free flaps were re-explored. Of these, 291 (83%) had a successful outcome. Successful re-explorations took place at a mean 19h post-op and unsuccessful re-explorations at a mean 56h post-op. Clinical diagnosis prior to re-exploration was confirmed operatively in 91% of cases. CONCLUSION: We have considered the factors that allowed us to achieve the salvage rates described over a prolonged period, and identified two key areas. Firstly, we favour a model for free flap monitoring with clinical judgement at its core. Secondly, we feel the facility to recover patients post-operatively in a specialised, warmed environment, and return them to theatre quickly should the need arise, is essential. These two simple, yet institutionally determined factors are vital for maintaining excellent success rates.

Assessing the influence of field- and GIS-based inquiry on student attitude and conceptual knowledge in an undergraduate ecology lab.

Combining field experience with use of information technology has the potential to create a problem-based learning environment that engages learners in authentic scientific inquiry. This study, conducted over a 2-yr period, determined differences in attitudes and conceptual knowledge between students in a field lab and students with combined field and geographic information systems (GIS) experience. All students used radio-telemetry equipment to locate fox squirrels, while one group of students was provided an additional data set in a GIS to visualize and quantify squirrel locations. Pre/postsurveys and tests revealed that attitudes improved in year 1 for both groups of students, but differences were minimal between groups. Attitudes generally declined in year 2 due to a change in the authenticity of the field experience; however, attitudes for students that used GIS declined less than those with field experience only. Conceptual knowledge also increased for both groups in both years. The field-based nature of this lab likely had a greater influence on student attitude and conceptual knowledge than did the use of GIS. Although significant differences were limited, GIS did not negatively impact student attitude or conceptual knowledge but potentially provided other benefits to learners.

Effects of CO2 and photosynthetic photon flux on yield, gas exchange and growth rate of Lactuca sativa L. 'Waldmann's Green.'

Enrichment of CO2 to 46 mmol m-3 (1000 mm3 dm-3) at a moderate photosynthetic photon flux (PPF) of 450 micromoles m-2 s-1 stimulated fresh and dry weight gain of lettuce leaves 39% to 75% relative to plants at 16 mmol m-3 CO2 (350 mm3 dm-3). Relative growth rate (RGR) was stimulated only during the first several days of exponential growth. Elevating CO2 above 46 mmol m-3 at moderate PPF had no further benefit. However, high PPF of 880-900 micromoles m-2 s-1 gave further, substantial increases in growth, RGR, net assimilation rate (NAR) and photosynthetic rate (Pn), but a decrease in leaf area ratio (LAR), at 46 or 69 mmol m-3 (1000 or 1500 mm3 dm-3) CO2, the differences being greater at the higher CO2 level. Enrichment of CO2 to a supraoptimal level of 92 mmol m-3 (2000 mm3 dm-3) at high PPF increased leaf area and LAR, decreased specific leaf weight, NAR and Pn and had no effect on leaf, stem and root dry weight or RGR relative to plants grown at 69 mmol m-3 CO2 after 8 d of treatment. The results of the study indicate that leaf lettuce growth is most responsive to a combination of high PPF and CO2 enrichment to 69 mmol m-3 for several days at the onset of exponential growth, after which optimizing resources might be conserved.