Biomechanical risk factors associated with distal upper extremity musculoskeletal disorders in endoscopists performing colonoscopy.

BACKGROUND AND AIMS: Endoscopists experience upper extremity musculoskeletal injuries. The primary aim of this study was to compare distal upper extremity biomechanical risk factors during colonoscopy with established risk thresholds. Secondary aims were to determine which subtasks during colonoscopy are associated with the greatest risk and to evaluate an intervention to reduce risks. METHODS: Twelve endoscopists performed 2 to 4 colonoscopies while thumb pinch force and forearm muscle loads of extensor carpi radialis (ECR) and flexor digitorum superficialis (FDS) muscles were collected. Peak exertion values were analyzed using amplitude probability distribution functions. An endoscope support device was evaluated during simulated colonoscopy (n = 8). RESULTS: Mean endoscopist age was 42.3 years; 67% were men. Peak thumb pinch force exceeded risk thresholds for pinch force (10 N) and percent of time spent in forceful pinch for all colonoscopy subtasks. Peak ECR and FDS muscle activity exceeded the action limit (10% maximum voluntary contraction [MVC]) in both forearms. Peak left FDS, left ECR, and right ECR activity exceeded the threshold limit value (>30% MVC). Peak left FDS and ECR activity were significantly greater during insertion than during withdrawal (P < .05). Peak right FDS and ECR activity were significantly greater during right colon insertion compared with withdrawal (P < .05). The endoscope support device reduced left ECR muscle activity (P = .02). CONCLUSIONS: Thumb pinch forces and time spent in forceful pinch indicate high-risk exposures during colonoscopy. Left wrist extensor muscle activity exceeded established thresholds with the greatest risk occurring during insertion. An endoscope support device reduced loads to the left wrist extensors.

A special method of dilating tracheal stenosis following tracheostomy.

Several methods can be used to manage tracheal stenosis. For patients unfit for surgery, frequent dilatation with stent placement is the most common treatment. We here describe a simple and effective method using Bakes common bile duct dilators to dilate a tracheal stenosis in a patient with a tracheostomy.

Applying the N-isopropylacrylamide gel dosimeter to quantify dynamic dose effects: A feasibility study.

BACKGROUND: The gel dosimeter is a chemical as well as a relative dosimeter. OBJECTIVE: To evaluate the feasibility of using N-isopropylacrylamide (NIPAM) gel dosimeter to observe the dynamic dose effects and quantification of the respiration, and to help determine the safety margins. METHODS: The NIPAM gel dosimeter combined with the dynamic phantom was used to simulate radiotherapy of lung or upper abdominal tumor. The field set to 4 × 5 cm2, simulate respiratory rate of 4 sec/cycle, and motion range 2 cm. MRI was used for reading, and MATLAB was used for analysis. The 3%/3 mm gamma passing rate > 95% was used as a clinical basis for evaluation. RESULTS: The dynamic dose curve was compared with 4 × 5, 4 × 4, 4 × 3 cm2 TPS, and gamma passing rates were 74.32%, 54.83%, 30.18%. Gamma mapping demonstrated that the highest dose region was similar to the result of the 4 × 4 cm2 TPS. After appropriate selection and comparing that the ⩾ 60% part of the dose curve with TPS, the gamma passing rate was 96.49%. CONCLUSIONS: Using the NIPAM gel dosimeter with dynamic phantom to simulate organ motion during respiration for dynamic dose measurement and quantified the dynamic dose effect is feasible. The results are consistent with clinical evaluation standards.

Using NIPAM gel dosimeter and concentric swing machine to simulate the dose distribu- tion during breathing: A feasibility study.

BACKGROUND: Radiotherapy plays an important role in cancer treatment today. Successful radiotherapy includes precise positioning and accurate dosimetry. OBJECTIVE: To use NIPAM gel dosimeter and concentric swing machine to simulate and evaluate the feasibility of lung or upper abdominal tumor dose distribution during breathing. METHODS: We used a concentric swing machine to simulate actual radiotherapy for lung or upper abdomen tumors. A 4 × 4 cm2 irradiation field area was set and MRI was performed. Next, readout analysis was performed using MATLAB and the 3 mm, 3% gamma passing rate > 95% was used as a basis for evaluation. RESULTS: The concentric dynamic dose curve for a simulated respiratory rate of 3 seconds/breath and 4 × 4 cm2 field was compared with 4 × 4, 3 × 3, and 2 × 2 cm2 treatment planning systems (TPS), and the 3 mm, 3% gamma passing rate was 42.87%, 54.96%, and 49.92%, respectively. Pre-simulation showed that the high-dose region dose curve was similar to the 2 × 2 cm2 TPS result. After appropriate selection and comparison, we found that the 3 mm, 3% gamma passing rate was 97.92% on comparing the > 60% dose curve with the 2 × 2 cm2 TPS. CONCLUSIONS: NIPAM gel dosimeter and concentric swing machine use is feasible to simulate dose distribution during breathing and results conforming to clinical evaluation standards.

Errors in femoral anteversion, femoral offset, and vertical offset following robot-assisted total hip arthroplasty.

The objectives were to determine errors in femoral anteversion (FA), femoral offset (FO), and vertical offset (VO) with robot-assisted total hip arthroplasty (THA) and how consistently these errors are within clinically desirable limits of ±5° and ±5 mm. After preoperative planning, robot-assisted THAs were performed on twelve cadaveric specimens. The error between achieved and planned component placements was used to determine bias (mean error) and precision (SD of error). The percent of the population within clinically desirable limits was determined. Bias of 1.5° and 2.7 mm occurred for FA and VO, respectively. Precision was 1.2° for FA and better than 1.5 mm for FO and VO. The percent of population within clinically desirable limits was at least 95% for FA and at least 99% for FO. With limits of ±7 mm, at least 95% of the population was within these limits for VO. Robot-assisted THA may improve clinical outcomes.

Macrophage expression of E3 ubiquitin ligase Grail protects mice from lipopolysaccharide-induced hyperinflammation and organ injury.

Multiple organ dysfunction caused by hyperinflammation remains the major cause of mortality during sepsis. Excessive M1-macrophage activation leads to systemic inflammatory responses. Gene related to anergy in lymphocytes (Grail) is regarded as an important regulator of T cells that functions by diminishing cytokine production. However, its role in regulating macrophage activation and organ injury during sepsis remains unclear. Our aim was to examine the effects of Grail on macrophage reactivity and organ injury in endotoxemic animals. Wild-type and Grail knockout mice were injected with vehicle or Escherichia coli lipopolysaccharide and observed for 24 h. Changes in blood pressure, heart rate, blood glucose, and biochemical variables were then examined. Moreover, levels of neutrophil infiltration, MMP-9, and caspase 3 were analyzed in the lungs of animals. The expression of pro-inflammatory cytokines in J774A, RAW264.7, and primary peritoneal macrophages stimulated with LPS were also assessed in the presence or absence of Grail. Results indicated that loss of Grail expression enhances the induction of pro-inflammatory cytokines in J774A, RAW264.7, and primary peritoneal macrophages treated with LPS. Furthermore, LPS-induced macrophage hyperactivation was alleviated by ectopic Grail overexpression. In vivo studies showed that Grail deficiency exacerbates organ damage in endotoxemic animals. Levels of neutrophil infiltration, MMP-9, and caspase 3 were significantly increased in the lungs of Grail-deficient endotoxemic mice. Thus, these results suggest that Grail contributes to the attenuation of hyperinflammation caused by activated macrophages and prevents organ damage in endotoxemic mice. We suggest that Grail signaling could be a therapeutic target for endotoxemia.

What are the six degree-of-freedom errors of a robotically-machined femoral cavity in total hip arthroplasty and are they clinically important? An in-vitro study.

Errors during a robot-assisted THA may result in a femoral cavity with position and orientation different than planned. This can lead to a femoral component placement that inaccurately sets a patient's femoral anteversion (FA), femoral offset (FO), and vertical offset (VO). The objectives of this study were to determine the position and orientation errors of robotically-machined femoral cavities in six degrees of freedom and to determine how position and orientation errors translate into errors in the setting of FA, FO, and VO. After creating preoperative plans, robot-assisted THAs were performed on twelve cadaveric specimens. The position and orientation of the machined cavities were compared to those of the planned cavities to determine the errors in six degrees of freedom. Placement of femoral components into the machined cavities was simulated, and the differences in FA, FO, and VO between the simulated and planned component placement were computed. While bias (i.e. mean error) occurred for three of six degrees of freedom in femoral cavities machined by a robotic system, the root mean squared errors (RMSEs) when the placement of femoral component was simulated were limited to 1.9° for FA, 1.0mm for FO, and 2.1mm for VO and were clinically unimportant.

The effect of keyboard key spacing on typing speed, error, usability, and biomechanics, Part 2: Vertical spacing.

OBJECTIVE: The objective was to evaluate the effects of vertical key spacing on a conventional computer keyboard on typing speed, percentage error, usability, forearm muscle activity, and wrist posture for both females with small fingers and males with large fingers. BACKGROUND: Part I evaluated primarily horizontal key spacing and found that for male typists with large fingers, productivity and usability were similar for spacings of 17, 18, and 19 mm but were reduced for spacings of 16 mm. Few other key spacing studies are available, and the international standards that specify the spacing between keys on a keyboard have been mainly guided by design convention. METHOD: Experienced female typists (n = 26) with small fingers (middle finger length < or = 7.71 cm or finger breadth of < or = 1.93 cm) and male typists (n = 26) with large fingers (middle finger length > or = 8.37 cm or finger breadth of > or = 2.24 cm) typed on five keyboards that differed primarily in vertical key spacing (17 x 18, 17 x 17, 17 x 16, 17 x 15.5, and 18 x 16 mm) while typing speed, error, fatigue, preference, forearm muscle activity, and wrist posture were recorded. RESULTS: Productivity and usability ratings were significantly worse for the keyboard with 15.5 mm vertical spacing compared to the other keyboards for both groups.There were few significant differences on usability ratings between the other keyboards. Reducing vertical key spacing,from 18 to 17 to 16 mm, had no significant effect on productivity or usability. CONCLUSIONS: The findings support the design of keyboards with vertical key spacings of 16, 17, or 18 mm. APPLICATIONS: These findings may influence keyboard design and standards.

Pulmonary metastatic gastric cancer mimicking a giant mediastinal cyst.

Cysts and cavities are common radiologic abnormalities. Pulmonary metastasis comprises a rare entity of thoracic cystic diseases. We reported a case of giant cyst at the left anterior mediastinum that was pathologically confirmed as a lung metastasis from previously resected gastric cancer. The cyst was completely removed with wedge resection of the surrounding lung through a left anterior thoracotomy. One should always keep in mind the possibility of an intrathoracic cyst near or at the mediastinal region that may originate from metastatic lesions to the lungs when patients have previous cancer history.

Treatment of empyema and bronchopleural fistula by bovine pericardium and latissimus flap.

Management of empyema with bronchopleural fistula remains a challenge. A 38-year-old man who had bullous emphysema was hospitalized on account of a right-sided necrotizing pneumonia complicated by empyema that mandated a tube drainage. Persistent air leak from the chest tube was noted, and chest computed tomography confirmed an empyema cavity with a suspicious bronchopleural fistula. This complex condition was successfully treated using fibrin glue with buttressed bovine pericardium to seal the fistula, followed by obliteration of the empyema cavity using a pedicled muscle flap of the latissimus dorsi. There was no recurrence of empyema at a follow-up 5 years after this procedure.

Standard uptake value of positron emission tomography in clinical stage I lung cancer: clinical application and pathological correlation.

OBJECTIVES: The aim of this study was to assess the standard uptake value in clinical stage I non-small cell lung cancer (NSCLC) and its correlation with pathological status and prognosis. METHODS: We retrospectively reviewed 674 patients diagnosed with NSCLC between January 2002 and June 2005. Patients with clinical stage I diseases undergone a preoperative positron emission tomography-computed tomography scan followed by anatomic resection. We reviewed the clinical features of 152 patients with an average follow-up of 87 months. RESULTS: We analysed the clinical features of 108 patients with stage I NSCLC and 44 patients with non-stage I NSCLC. There were no statistical differences in age, histological type, location or tumour differentiation between the two groups. In the Stage I group, the patients had lower maximum standard uptake value (SUVmax; 3.80 ± 3.17 vs 5.73 ± 3.65, P = 0.001), lower carcinoembryonic antigen (CEA) levels (2.86 ± 4.80 vs 9.11 ± 17.21 ng/ml, P = 0.027) and smaller tumour size (2.39 ± 0.98 vs 3.73 ± 2.04 cm, P < 0.001). The patients with higher SUVmax had a more advanced pathological stage, poorer tumour differentiation and larger tumour size. A higher SUVmax was an independent factor predicting an advanced pathological stage (SUVmax ≥ 3.3, odds ratio 3.246). The median survival of patients with SUVmax ≥ 3.3 and SUVmax <3.3 were 64.32 and 53.08 months, respectively (P = 0.654). CONCLUSIONS: Higher preoperative 18-fluorodeoxyglucose uptake by a tumour was significantly associated with an advanced pathological stage but not correlated with a poorer prognosis. An aggressive preoperative work-up for occult N2 disease should be emphasized, avoiding inappropriate thoracotomy.

Cystic seminoma with elevated value of carbohydrate antigen 19-9 in tumor fluid mimicking cystic teratoma.

The incidence of cystic lesions of anterior mediastinum is low, which is responsible for approximately 10% of anterior mediastinal tumors. We presented a special case of primary anterior mediastinal tumor with both prominent cystic change and extreme high carbohydrate antigen 19-9 level of cystic fluid here. From the finding of this case report, we suggested that the diagnosis of cystic anterior mediastinal tumors should include both cystic seminoma and mature cystic teratoma.