Incidental bilateral calcaneal fractures following overground walking with a wearable robotic exoskeleton in a wheelchair user with a chronic spinal cord injury: is zero risk possible?

Many individuals with spinal cord injury (SCI) rely on wheelchairs as their primary mode of locomotion leading to reduced weight-bearing on the lower extremities, which contributes to severe bone loss and increased risk of fragility fractures. Engaging in a walking program may reverse this vicious cycle, as this promotes lower extremity weight-bearing and mobility, which may reduce bone loss and fragility fracture risk. However, fragility fracture risk associated with the use of wearable robotic exoskeletons (WREs) in individuals with SCI needs consideration. A 35-year-old man with chronic complete sensorimotor SCI (neurological level = T6) and low initial bone mineral density enrolled in a 6- to 8-week WRE-assisted walking program after successfully completing an initial clinical screening process and two familiarization sessions with the WRE. However, after the first training session with the WRE, he developed bilateral localized ankle edema. Training was suspended, and a CT-scan revealed bilateral calcaneal fractures, which healed with conservative treatment over a 12-week period. Opportunities for improving clinical screening and WRE design are explored. The relevance of developing clinical practice guidelines for safe initiation and progression of intensity during WRE-assisted walking programs is highlighted. This case of bilateral calcaneal fractures illustrates that aiming for "zero risk" during WRE-assisted walking programs may not be realistic. Although WREs are a relatively new technology, current evidence confirms their potential to greatly improve health and quality of life in individuals with chronic SCI. Hence, ensuring their safe use remains a key priority.

Uncovering labially impacted teeth: apically positioned flap and closed-eruption techniques.

The purpose of this study was to examine the esthetic and periodontal differences between two methods of uncovering labially impacted maxillary anterior teeth: the apically positioned flap and closed-eruption techniques. The sample consisted of 30 patients who were recalled a minimum of three months after orthodontic treatment of a unilateral labially impacted maxillary anterior tooth. Eighteen of the patients had undergone an apically positioned flap (APF) procedure, and the remaining twelve had undergone the closed-eruption (CE) technique. In the CE group, clinical examination showed less width of attached gingiva on the distal surface and increased probing bone level on the facial surface of the uncovered teeth relative to their contralateral controls. Uncovered teeth in the APF group showed more apical gingival margins on the mesial and facial surfaces; greater crown length on the midfacial surface; increased probing attachment level on the facial surface; increased width of attached gingiva on the facial surface; increased probing bone level on mesial, facial, and distal surfaces; and gingival scarring. Radiographic examination showed shorter roots on the uncovered teeth in both groups. Photographic examination revealed vertical relapse of the uncovered teeth in the APF group. We conclude that labially impacted maxillary anterior teeth uncovered with an apically positioned flap technique have more unesthetic sequalae than those uncovered with a closed-eruption technique.

Economic growth in the U.S. dental sector, 1950-1986.

Previous research has shown that over the period 1950 through 1977 the dental sector experienced a faster rate of economic growth than did the economy at large. This study extends the period of analysis through 1986. The findings show that dentistry maintained its economic strength relative to the economy. The annual growth rate for dentistry of 4.8 percent was significantly greater (p less than 0.001) than the 3.3 percent rate for the economy. In addition, inflation has been less in dentistry, and growth in the dental sector was not adversely affected by the economic recession of 1978-1984.

Effects of prolonged epinephrine infusion on blood respiratory and acid-base states in the rainbow trout: Alpha and beta effects.

Rainbow trout were infused continuously for 12h with epinephrine in the presence or absence of alpha-and/or beta-adrenergic blockade to characterize the specific adrenergic mechanisms involved in the control of blood acid-base status and oxygen transport capacity. Infusion of epinephrine, alone, produced a transient respiratory acidosis, as indicated by an increase in carbon dioxide tension and a decrease in whole blood pH, yet arterial oxygen tension was elevated. Red blood cell pH increased by approximately 0.2 pH units during epinephrine infusion and this increase as well as the increase in oxygen tension were prevented by pretreatment with propranolol (a beta-adrenergic antagonist). Epinephrine infusion during alpha-adrenergic blockade caused a prolonged elevation of blood carbon dioxide tension and abolished the increases in hematocrit and hemoglobin concentrations observed during epinephrine infusion alone. Infusion of the alpha-adrenergic agonists phenylephrine (an alpha1 agonist) or clonidine (an alpha2 agonist) caused respiratory acidosis (decreased pH, increased CO2 tension) and a reduction in oxygen tension. Infusion of isoprenaline (a non-specific beta agonist) caused delayed increases in carbon dioxide and oxygen tensions. We speculate that the increased carbon dioxide tension observed during epinephrine infusion is a result of beta-adrenoceptor mediated inhibition of red blood cell bicarbonate dehydration and not branchial convective or diffusive adjustments. The effects of epinephrine on blood O2 tension, content and carrying capacity are discussed with reference to the participation of alpha- and beta-adrenergic mechanisms at the gill, spleen and red blood cell.

Vitamin D3 and the renal handling of phosphate in American eels.

Cholecalciferol (Vitamin D3) increased plasma inorganic phosphate concentration in American eels,Anguilla rostrata, in a dose-dependent fashion. This response was more marked in phosphate loaded fish. In control as well as phosphate loaded eels the hyperphosphatemic response to D3 was associated with a sharp reduction in renal phosphate clearance relative to(14)C-polyethelene glycol (PEG) clearance. Glomerular filtration and urine flow rates were not affected by D3. As renal phosphate clearance, even in phosphate loaded eels, never significantly exceeded that of PEG, it is suggested that D3 reduced the relative clearance rate of phosphate by increasing renal phosphate reabsorption rather than by reducing the tubular secretion of phosphate.

The effects of prolonged epinephrine infusion on the physiology of the rainbow trout, Salmo gairdneri. II. Branchial solute fluxes.

Rainbow trout were infused continuously for 24 h with epinephrine in order to elevate circulating levels to those measured during periods of acute extracellular acidosis (about 5 X 10(-8) mol l-1). Concomitant effects on branchial solute fluxes were evaluated. Epinephrine infusion caused complex and differential adjustments of Na+ and Cl- unidirectional fluxes (influx and efflux) resulting in a significant elevation of the arithmetic difference between Na+ and Cl- net fluxes (JnetNa+-JnetCl-). A significant correlation existed between JnetNa+-JnetCl- and net branchial acid excretion (JnetH+), thereby suggesting a role for epinephrine in piscine acid-base regulation. The stimulation of JnetH+ by epinephrine was due primarily to a reduction in the excretion of titratable acid (JTA) accompanied by non-significant changes in ammonia excretion (JAmm). The results are discussed with respect to a role for epinephrine in regulating acid-base disturbances by interacting with branchial ionic exchange mechanisms.

The effects of prolonged epinephrine infusion on the physiology of the rainbow trout, Salmo gairdneri. I. Blood respiratory, acid-base and ionic states.

Rainbow trout were infused continuously for 24 h with epinephrine in order to elevate circulating levels of this hormone to those measured during periods of acute extracellular acidosis (approximately 5 X 10(-8) mol l-1). Concomitant effects on selected blood respiratory acid-base and ionic variables were evaluated. Infusion of epinephrine caused a transient respiratory acidosis as a result of hypoventilation and/or inhibition of red blood cell (RBC) bicarbonate dehydration. The acidosis was regulated by gradual accumulation of plasma bicarbonate. Even though whole blood pH (pHe) was depressed by 0.16 units, RBC pH (pHi) remained constant, thereby causing the transmembrane pH gradient (pHe-pHi) to decrease. A similar effect of epinephrine on RBC pH was observed in vitro, although the response required a higher concentration of epinephrine (2.0 X 10(-7) mol l-1). We speculate that the release of epinephrine during periods of depressed blood pH is important for preventing excessive shifts in RBC pH and for initiating a series of responses leading to plasma HCO3- accumulation and eventual restoration of blood acid-base status.

The effects of prolonged epinephrine infusion on the physiology of the rainbow trout, Salmo gairdneri. III. Renal ionic fluxes.

Rainbow trout were infused continuously for 24 h with epinephrine in order to evaluate the effects of elevated circulating levels of epinephrine on selected renal variables. Pronounced effects of epinephrine included elevation of urine flow rate and concomitant increases in the excretion of all measured electrolytes (Na+, Cl-, K+, Ca2+, inorganic phosphate) with the exception of ammonium and bicarbonate ions. Significant reductions in the tubular reabsorption of Na+ and Cl- also contributed to enhanced excretion of these ions. Similarly, epinephrine affected the tubular handling of NH4+ and HCO3- with NH4+ secretion decreasing and HCO3- reabsorption increasing. We speculate that the stimulation of HCO3- reabsorption was a consequence of elevated tubular H+ secretion. Such a mechanism may be important to permit plasma HCO3- retention during periods of internal acidosis. The results are discussed with reference to the role of the fish kidney in regulating acid-base disturbances and the possible interactive effects of elevated epinephrine.

Effects of epinephrine on branchial and renal calcium handling in the rainbow trout.

Acute exposure of rainbow trout (Salmo gairdneri) to low external calcium (25 microM) caused an immediate but transient increase in plasma epinephrine concentration that may have been related to a concomitant depression of blood pH. Intra-arterial infusion of epinephrine at normal ambient calcium levels (0.35 mM) for 4 h caused circulating levels of epinephrine to rise from 2.9 X 10(-9) to 8.0 X 10(-8) M but did not affect norepinephrine levels, or branchial unidirectional calcium fluxes. Active (ATP-dependent) calcium transport across basolateral plasma membranes prepared from gill epithelial cells was not affected by pretreatment of fish with epinephrine or by direct application of epinephrine or cAMP, in vitro. Epinephrine infusion elevated urine flow rate, decreased urine pH, and increased urine phosphate levels significantly. Net renal calcium efflux increased significantly as a result of the increased urine flow rate. It is concluded that epinephrine does not stimulate branchial calcium uptake or renal conservation of calcium in rainbow trout at normal external calcium levels and therefore we cautiously suggest that epinephrine is unlikely to be involved in calcium balance during periods of exposure to low external calcium. Instead, epinephrine may play a role in compensating the acid-base disturbances and the increased branchial water influx that are associated with exposure to low ambient calcium.