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.

Feasibility study for a controllable orthotic knee joint.

PURPOSE: The purpose of this study was to demonstrate the feasibility of producing an orthotic knee joint that could lock and unlock during ambulation for eventual use in a reciprocating gait orthosis (RGO) for severely disabled patients. METHOD: Three prototype orthotic knee joints incorporating braking mechanisms were designed and manufactured to demonstrate their ability to withstand a maximum calculated sagittal plane bending moment of 73 Nm. Each was then subjected to bench trials to test their performance against the required specification. RESULTS: Although all three joints achieved the requirement to sustain the specified externally applied bending moments, the hydraulic disc brake system proved significantly superior and was selected for more comprehensive testing. CONCLUSIONS: The results confirmed the feasibility of utilising a hydraulic braking mechanism within an orthotic knee joint to withstand the knee flexing moments during walking in a lower limb orthosis. This gave the development group confidence to progress to the prototype design phase with the specific aim of eventually incorporating such a joint in an RGO designed for severely disabled patients such as those with complete paraplegia up to level T4 and those with severe neurological dysfunction.

A rehabilitation device data logging system.

PURPOSE: The difficulty of recording service history of rehabilitation devices makes it impractical for prescribing centres to monitor treatment effectively, or implement maintenance and replacement policies that permit safety and economic viability to be fully complementary. An approach to providing such a facility has been investigated, so that specified treatment can be monitored or device replacement matched to the functional activity of the patient. METHODS: A two-channel data logger has been developed that can record, over periods in excess of 12 months, information in an event-monitoring channel; and in the second channel a varying analogue signal at the time an event occurs. In addition a downloading interface allows data to be transferred and then processed in a personal computer during a routine patient visit. RESULTS: Laboratory testing demonstrated that the system recorded events accurately. Field trials verified a battery life exceeding 12 months for continuous routine monitoring of twice daily orthosis application in the event logging channel. The analogue channel was tested by applying known signals to the logger at the time events were monitored, and comparing the output to the input signal. OUTCOME: The feasibility of routinely monitoring the use of rehabilitation devices was successfully demonstrated and production development is now being undertaken.

Performance specification for lower limb orthotic devices.

OBJECTIVE: To establish the range of forces and moments applied to lower limb orthoses during ambulation by routine users. DESIGN: Well-established gait analysis techniques were used to determine the loading at the major joints. It was assumed that the joint moments were transmitted by the orthosis encompassing any particular joint. Two hundred and five assessments of 164 patients were successfully completed by a consortium of four gait laboratories in Europe. The orthosis specification and patient clinical data were also recorded. BACKGROUND: The design and development of orthoses has occurred largely by evolution rather than by formal engineering methods. In particular, formal design has been hampered by a lack of information on the forces and moments applied during ambulation. METHODS: A standard gait analysis procedure was employed to capture the data. In-house biomechanical models were used to calculate the joint loading. Data were normalised with respect to patient weight and leg length. RESULTS: It was found that the median maximum normalised ankle moment transmitted by an ankle foot orthosis was 0.15 and the maximum knee moment was 0.09. The greatest moment transmitted by the hip joint of a hip knee ankle foot orthosis was also 0.09. There was a wide variation in the data due to differences in the impairments of the test subjects. CONCLUSION: It is possible to estimate the loads transmitted by an orthosis using established gait analysis procedures without the need for load measurement transducers. There is now a need both to collect a larger representative dataset and to perform validation studies with transducers.

New technical advances in swivel walkers.

Swivel walkers were commonly prescribed for children with complete thoracic lesion myelomeningocele in the 1970s and 80s, when the incidence of spina bifida in the UK was of the order of 3 per 100,000 live births. The advent of reciprocal walking orthoses provided a more suitable alternative for those with good upper limb and trunk function, and swivel walkers were then used primarily for very young or more severely disabled patients. Pre-natal screening has dramatically reduced the incidence of spina bifida in the UK and subsequently swivel walkers have been used in a wider range of pathology, including spinal muscular atrophy, multiple sclerosis, muscular dystrophy and other neurological conditions that lead to lower limb dysfunction. The detail design of these devices has been adapted to accommodate the specific problems encountered in these conditions. In particular the designs have been updated to: enable very young patients to be more readily fitted at the age of 1 year; allow the walking mechanisms to be conveniently adjusted for easier ambulation when weakness or lack of confidence inhibits performance; permit simple adjustment to a standing frame mode to enhance stability in situations of increased risk; promote manual handling practice that is compatible with the National Health Service (NHS) policy of compliance with relevant regulations. To underpin appropriate prescription and safe supply the NHS Procurement Agency have encouraged the development of a common course for all types of swivel walker.

Reciprocal walking orthosis with composite material body brace: initial development.

Reciprocal walking orthoses are routinely used by thoracic lesion patients for ambulation using crutches. A primary reason for their prescription is to provide therapeutic benefit and improved independence. To achieve this, maximum efficiency of walking and acceptance of the device is necessary to promote long-term compliance. Lateral rigidity in the orthosis influences walking efficiency, but the structural properties of conventional techniques for producing a sufficiently rigid body brace makes them unattractive. Currently patients and clinicians are forced to choose between greater efficiency or cosmesis of the orthosis. Composite materials have the potential to permit the required rigidity in a structure that is less obtrusive. However, their material properties could lead to unsafe forms of failure unless suitable manufacturing methods are devised. It is therefore inappropriate to supply prototypes to patients for field evaluation until laboratory investigation of innovative production methods has ensured that the orthosis is safe. A production technique has been devised that is ostensibly suitable. Prototype body braces have been tested and have been shown to have improved structural properties and safe failure modes. A test programme implemented on a complete concept orthosis has confirmed that improved lateral rigidity can be achieved with a less obtrusive body brace, and that it will behave safely for long enough to permit field evaluation.

Transportable two-dimensional gait assessment: routine service experience for orthotic provision.

PURPOSE: The purpose of the pilot service was to establish the potential of the newly developed system to achieve, in a community setting, more effective orthotic outcomes for patients in whom alignment of ground reaction force is an important treatment objective. METHODS: Twelve visits were arranged to a paediatric community physiotherapy department. Up to six patients at each visit were selected for assessment of their lower limb orthotic prescription. The patient's gait was assessed using the video vector generator to determine alignment of ground reaction force. Where necessary, adjustments to the orthotic set-up were made to achieve more closely the stated objective. At the conclusion a specification of the orthosis was agreed. RESULTS: In only two of 61 assessments that were conducted was it not possible to achieve a useful outcome. CONCLUSIONS: Improvements in biomechanical alignment were achieved in more than 68% of assessments. The pilot service was sufficiently successful for it to be extended to a routine clinical service.

Evaluation of safety and reliability in an infant reciprocal walking orthosis.

In response to new demands for infant walking orthoses consideration was given to the development of a device for this category of patient. A specially developed hip joint with the required structural properties (Woollam et al., 2001) provided an opportunity for this development. Earlier structural assessment, and limited cyclic load testing of key elements of the orthosis (primarily the body brace), confirmed that a safe device for evaluation with patients could, theoretically, be produced. A provisional prototype was therefore designed and manufactured for initial structural testing of the complete infant orthosis (Stallard et al., 2001). Efficiency of walking is strongly influenced by the lateral rigidity of the orthosis. Monitoring the structural performance of the provisional infant design indicated it would equal or improve on the stiffness of that achieved in the adult specification. Additionally, relative strength was comparable with the adult version, which has proven to be safe and reliable in many years of routine prescription. This, together with the limited cyclic testing of the complete orthosis (Stallard et al., 2001), gave confidence that it was safe to proceed with controlled field evaluation of the infant design when supplied as a rehabilitation engineering device within the provisions of an ISO9001 and EN46001 QA System. This additional study of controlled patient use, and further representative cyclic load testing in parallel with the field evaluation, had established the long-term structural safety of the orthosis. Wider application is now to be introduced through completion of the EC (European Community) Medical Devices Directive formalities.

Health care for the elderly: a social obligation.

TOPIC: Ageism in the allocation of health care. PURPOSE: To explore the ethical bases for rationing health care according to age, and to make appropriate recommendations for nursing policy and practice. SOURCES: Published literature. CONCLUSIONS: Limiting access to resources and opportunities for older Americans simply because they are old is clearly a case of ageism. The authors opine that society has an obligation to provide an adequate level of health care to all, rationing on the basis of age is wrong, and nursing policy and practice should support this stance.

Structural design and performance of a rear support walking frame.

Rear support walking frames provide predetermined vertical support for patients with dysfunctional lower limbs that have limited active control; the support is provided through a spring-loaded boom hinged on an upright stanchion mounted at the rear of a wheeled frame within which the patient ambulates. The application of these frames for total-body-involved cerebral palsy patients, in combination with a walking orthosis, has highlighted a number of practical problems that need to be addressed for the system to become fully viable. A composite material prototype walking frame has been developed that permits the patient to be transferred by a single carer without the need to use inappropriate manual handling techniques. The frame has improved structural properties, with stiffness in the sagittal and coronal planes increasing by between 50 and 100 per cent. Evaluation with patients showed that the greater structural stiffness permitted the objective of improved continuity of walking to be achieved. The strength of the frame is such that it can accommodate patients of up to 80 kg, more than twice that possible in the earlier system. Since the structural yield point is approximately twice the maximum working load, the device should not be prone to unacceptable fatigue characteristics. Despite the use of carbon composite materials (which have brittle failure characteristics), the mode of failure is of progressive collapse and is therefore inherently safe. The successful outcome of prototype testing has justified production development. Work is now proceeding on a design that incorporates further improvements in structural performance and ease of manufacture.

Sludge digestion enhancement and nutrient removal from anaerobic supernatant by Mg(OH)2 application.

Anaerobic sludge digestion is a widely adopted process for sludge stabilization. Phosphate removal from anaerobic supernatant is necessary to limit the phosphate returned to the head of the treatment plant, thereby improving the overall treatment efficiency. In this study, magnesium hydroxide (Mg(OH)2) was used to improve the sludge digestion efficiency and to remove phosphorus from anaerobic supernatant. The anaerobic sludge digestion experiment was conducted at a pilot scale, and the results showed that applying Mg(OH)2 to anaerobic sludge digester resulted in a larger reduction in SS and COD, a higher biogas production rate, a lower level of phosphate and ammonia nitrogen concentrations in the sludge supernatant and an improved sludge dewaterability. Research results at both lab scale and pilot scale on phosphorus removal from anaerobic supernatant using Mg(OH)2 showed that a high removal of phosphorus can be achieved through the addition of Mg(OH)2. The required reaction time depends on the initial phosphorus concentration and the Mg(OH)2 dosage.

Postoperative staphylococcal toxic shock syndrome due to pre-existing staphylococcal infection: case report and review of the literature.

Staphylococcal postoperative toxic shock syndrome (PTSS) has been associated with a variety of surgical procedures. It is generally believed that the source of infection is acquired at or near the time of surgery. PTSS has been specifically associated with nasal packing, insertion of hardware, surgical drains, retained foreign materials, and breaks in sterile technique. Although PTSS has been associated with postoperative abscesses, development of PTSS after surgery of a pre-existing source of infection has not been described. We report a case of PTSS that developed after vertebral abscess drainage, and we review the literature to determine the incidence of PTSS due to preexisting staphylococcal infection.