Significant changes in lower limb alignment due to flexion and rotation-a systematic 3D simulation of radiographic measurements.

BACKGROUND: Many radiographic lower limb alignment  measurements are dependent on patients' position, which makes a standardised image acquisition of long-leg radiographs (LLRs) essential for valid measurements. The purpose of this study was to investigate the influence of rotation and flexion of the lower limb on common radiological alignment parameters using three-dimensional (3D) simulation. METHODS: Joint angles and alignment parameters of 3D lower limb bone models (n = 60), generated from computed tomography (CT) scans, were assessed and projected into the coronal plane to mimic radiographic imaging. Bone models were subsequently rotated around the longitudinal mechanical axis up to 15° inward/outward and additionally flexed along the femoral intercondylar axis up to 30°. This resulted in 28 combinations of rotation and flexion for each leg. The results were statistically analysed on a descriptive level and using a linear mixed effects model. RESULTS: A total of 1680 simulations were performed. Mechanical axis deviation (MAD) revealed a medial deviation with increasing internal rotation and a lateral deviation with increasing external rotation. This effect increased significantly (p < 0.05) with combined flexion up to 30° flexion (- 25.4 mm to 25.2 mm). With the knee extended, the mean deviation of hip-knee-ankle angle (HKA) was small over all rotational steps but increased toward more varus/valgus when combined with flexion (8.4° to - 8.5°). Rotation alone changed the medial proximal tibial angle (MPTA) and the mechanical lateral distal femoral angle (mLDFA) in opposite directions, and the effects increased significantly (p < 0.05) when flexion was present. CONCLUSIONS: Axial rotation and flexion of the 3D lower limb has a huge impact on the projected two-dimensional alignment measurements in the coronal plane. The observed effects were small for isolated rotation or flexion, but became pronounced and clinically relevant when there was a combination of both. This must be considered when evaluating X-ray images. Extension deficits of the knee make LLR prone to error and this calls into question direct postoperative alignment controls. LEVEL OF EVIDENCE: III (retrospective cohort study).

Linear correlation between patellar positioning and rotation of the lower limb in radiographic imaging: a 3D simulation study.

PURPOSE: The purpose of this study was to quantify changes in rotation of the lower limb between image pairs based on patellar position. Additionally, we investigated the differences in alignment between centralized patellar and orthograde-positioned condyles. METHODS: Three-dimensional models of 30 paired legs were aligned in neutral position with condyles orthogonal to the sagittal axis and then rotated internally and externally in 1° increments up to 15°. For each rotation, the deviation of the patella and the subsequent changes in alignment parameters were calculated and plotted using a linear regression model. Differences between neutral position and patellar centralization were analysed qualitatively. RESULTS: A linear relationship between lower limb rotation and patellar position can be postulated. The regression model (R2 = 0.99) calculated a change of the patellar position of - 0.9 mm per degree rotation and alignment parameters showed small changes due to rotation. The physiological lateralization of the patella at neutral position was on average - 8.3 mm (SD: ± 5.4 mm). From neutral position, internal rotation that led to a centralized patella was on average - 9.8° (SD: ± 5.2°). CONCLUSION: The approximately linear dependence of the patellar position on rotation allows an inverse estimation of the rotation during image acquisition and its influence on the alignment parameters. As there is still no absolute consensus about lower limb positioning during image acquisition, data about the impact of a centralized patella compared to an orthograde condyle positioning on alignment parameters was provided. LEVEL OF EVIDENCE: IV.

Variety of non-invasive continuous monitoring methodologies including electrical impedance tomography provides novel insights into the physiology of lung collapse and recruitment ­ case report of an anaesthetized horse.

INTRODUCTION: The use of alveolar recruitment maneuvers during general anaesthesia of horses is a potentially useful therapeutic option for the ventilatory management. While the routine application of recruitments would benefit from the availability of dedicated large animal ventilators their impact on ventilation and perfusion in the horse is not yet well documented nor completely understood. CASE HISTORY: A healthy 533 kg experimental horse underwent general anaesthesia in lateral recumbency. During intermittent positive pressure ventilation a stepwise alveolar recruitment maneuver was performed. MANAGEMENT: Anaesthesia was induced with ketamine and midazolam and maintained with isoflurane in oxygen using a large animal circle system. Mechanical ventilation was applied in pressure ventilation mode and an alveolar recruitment maneuver performed employing a sequence of ascending and descending positive end expiratory pressures. Next to the standard monitoring, which included spirometry, additionally three non-invasive monitoring techniques were used: electrical impedance tomography (EIT), volumetric capnography and respiratory ultrasonic plethysmography. The functional images continuously delivered by EIT initially showed markedly reduced ventilation in the dependent lung and allowed on-line monitoring of the dynamic changes in the distribution of ventilation during the recruitment maneuver. Furthermore, continuous monitoring of compliance, dead space fraction, tidal volumes and changes in end expiratory lung volume were possible without technical difficulties. FOLLOW: up The horse made an unremarkable recovery. CONCLUSION: The novel non-invasive monitoring technologies used in this study provided unprecedented insights into the physiology of lung collapse and recruitment. The synergic information of these techniques holds promise to be useful when developing and evaluating new ventilatory strategies in horses.

Open wedge high tibial osteotomy alters patellofemoral joint kinematics: A multibody simulation study.

Changes in lower limb alignment after open-wedge high tibial osteotomy (owHTO) influence joint kinematics. The aim of this study was to investigate the morphological and kinematic changes of the knee joint, in particular the patellofemoral joint, using a multibody simulation model. OwHTO with an open tibial wedge of 6-12 mm (1 mm intervals) was virtually performed on each of 13 three-dimensional (3D) computer-aided design models (CAD models) derived from computer tomography scans of full-leg cadaver specimens. For each owHTO, an individual biomechanical simulation model was built and knee flexion from 5° to 100° was simulated using a multibody simulation model of the native knee. Morphologic and alignment parameters as well as tibiofemoral and patellofemoral kinematic parameters were evaluated. Almost linear changes in tibial tuberosity trochlea groove (TT-TG) (0.42 mm/1 mm wedge height) were observed which led to pathological values (TT-TG > 20 mm) in 3 out of 13 knees. Furthermore, a 6 mm increase in osteotomy wedge height increased lateral patellofemoral rotation by 0.8° (range: 0.39° to 1.11°) and led to a lateral patellar translation of 0.8 mm (range: 0.37-3.11 mm) on average. Additionally, valgisation led to a medial translation of the tibia and a decrease in the degree of tibial internal rotation during knee flexion of approximately 0.3°/1 mm increase in osteotomy wedge height. The increase in TT-TG and the biomechanical effects observed influence patellofemoral tracking, which may increase retropatellar pressure and are potential risk factors for the development of anterior knee pain.

The HEV Ventilator: at the interface between particle physics and biomedical engineering.

A high-quality, low-cost ventilator, dubbed HEV, has been developed by the particle physics community working together with biomedical engineers and physicians around the world. The HEV design is suitable for use both in and out of hospital intensive care units, provides a variety of modes and is capable of supporting spontaneous breathing and supplying oxygen-enriched air. An external air supply can be combined with the unit for use in situations where compressed air is not readily available. HEV supports remote training and post market surveillance via a Web interface and data logging to complement standard touch screen operation, making it suitable for a wide range of geographical deployment. The HEV design places emphasis on the ventilation performance, especially the quality and accuracy of the pressure curves, reactivity of the trigger, measurement of delivered volume and control of oxygen mixing, delivering a global performance which will be applicable to ventilator needs beyond the COVID-19 pandemic. This article describes the conceptual design and presents the prototype units together with a performance evaluation.

Closed-loop ventilation: an emerging standard of care?

The rational for using closed loop ventilation is becoming strong and stronger. Studies are now available supporting the hypothesis that patient outcome is improved by using closed loop ventilation. In the highly sophisticated ICU world driven by the triumvirate of cost-efficiency, quality, and safety, closed loop ventilation will become definitely unavoidable. The challenge is how to make that change effortless, "friendly" and as fast as possible. Introducing novel graphical user interfaces and providing data displays that are pertinent, integrative and dynamic will reduce cognitive resources of the clinician and have the potential to make ventilation safer. They may be the key to adopt closed loop ventilation in everyday practice.

Electrical impedance tomography system based on active electrodes.

Electrical impedance tomography (EIT) can image the distribution of ventilated lung tissue, and is thus a promising technology to help monitor patient breathing to help selection of mechanical ventilation parameters. Two key difficulties in EIT instrumentation make such monitoring difficult: (1) EIT data quality depends on good electrode contact and is sensitive to changes in contact quality, and (2) EIT electrodes are difficult and time consuming to place on patients. This paper presents the design and initial tests of an active electrode-based system to address these difficulties. Our active electrode EIT system incorporates an active electrode belt, a central voltage-driven current source, central analog to digital converters and digital to analog converters, a central FPGA-based demodulator and controller. The electrode belt is designed incorporating 32 active electrodes, each of which contains the electronic amplifiers, switches and associated logic. Tests show stable device performance with a convenient ease of use and good imaging ability in volunteer tests.

Adaptive support ventilation versus conventional ventilation for total ventilatory support in acute respiratory failure.

OBJECTIVE: To compare the short-term effects of adaptive support ventilation (ASV), an advanced closed-loop mode, with conventional volume or pressure-control ventilation in patients passively ventilated for acute respiratory failure. DESIGN: Prospective crossover interventional multicenter trial. SETTING: Six European academic intensive care units. PATIENTS: Eighty-eight patients in three groups: patients with no obvious lung disease (n = 22), restrictive lung disease (n = 36) or obstructive lung disease (n = 30). INTERVENTIONS: After measurements on conventional ventilation (CV) as set by the patients' clinicians, each patient was switched to ASV set to obtain the same minute ventilation as during CV (isoMV condition). If this resulted in a change in PaCO(2), the minute ventilation setting of ASV was readjusted to achieve the same PaCO(2) as in CV (isoCO(2) condition). MEASUREMENTS AND RESULTS: Compared with CV, PaCO(2) during ASV in isoMV condition and minute ventilation during ASV in isoCO(2) condition were slightly lower, with lower inspiratory work/minute performed by the ventilator (p < 0.01). Oxygenation and hemodynamics were unchanged. During ASV, respiratory rate was slightly lower and tidal volume (Vt) slightly greater (p < 0.01), especially in obstructed patients. During ASV there were different ventilatory patterns in the three groups, with lower Vt in patients with restrictive disease and prolonged expiratory time in obstructed patients, thus mimicking the clinicians' choices for setting CV. In three chronic obstructive pulmonary disease patients the resulting Vt was unacceptably high. CONCLUSIONS: Comparison between ASV and CV resulted either in similarities or in minor differences. Except for excessive Vt in a few obstructed patients, all differences were in favor of ASV.

Is there an optimal breath pattern to minimize stress and strain during mechanical ventilation?

BACKGROUND: Inappropriate selection of tidal volume and rate on mechanical ventilators in patients with reduced lung volume may cause lung damage. In spite of this rather recent insight, the optimal breath pattern and the relative importance of elevating end-expiratory lung volume (EELV) are still debated. A recent hypothesis is that lung injury is caused by excessive stress and strain. This paper elaborates on that hypothesis and proposes a new approach to optimizing the breath pattern. METHODS: An index to quantify the impact of positive pressure ventilation on the lungs is defined (Stress-Strain Index, SSI) and calculated as a function of the breath pattern (tidal volume Vt and respiratory rate f) for five different levels of EELV. The breath pattern at which SSI is minimal (mSSI strategy) was compared with three other strategies: the "6 ml/kg Vt," minimal work of breathing and minimal force to breathe, for the different EELV levels. RESULTS: In the mathematical analysis, SSI was mainly determined by EELV and was much higher with low EELV. For each EELV level, a distinct minimum of SSI was found, defined by a particular Vt-f combination. The mSSI strategy yielded lower Vt and higher f (0.252 l and 39 b/min) as compared to the "6 ml/kg Vt" strategy (0.420 l and 17 b/min). CONCLUSION: The EELV is the main determinant of the SSI. For a given EELV, the SSI can be minimized by an optimal Vt-f combination.

Phospholipids occupy the internal lumen of the c ring of the ATP synthase of Escherichia coli.

The occupancy of the central cavity of the membrane-embedded c ring of the ATP synthase of Escherichia coli was investigated with a photo-cross-linking approach. Single cysteine mutants were created at c subunit positions 4, 8, and 11, which are oriented to the inside of the ring. These cysteines were alkylated with reagents carrying a photoactivatable substituent and illuminated. Subunit c and derivatives were then isolated and subjected to mass spectrometric analyses. The most noticeable product, which was found exclusively in irradiated samples, had a mass increase of 719 Da, consistent with a cross-link product between the substituted c subunit and phosphatidylethanolamine. Digestion with phospholipase C converted this product into one with a mass diminished by 126 Da, indicating that the phosphoethanolamine moiety was cleaved off. Hence, the cross-link forms to the diacylglycerol moiety of phosphatidylethanolamine. Control experiments showed that the subunit c-phospholipid adducts were formed in the ATP synthase complex in its natural membrane environment and were not artifacts arising from monomeric c subunits. We conclude therefore that the inner lumen of the c ring is occupied with phospholipids. No evidence was found for an extension of subunit a into this space.

Sequence-specific interactions of nascent Escherichia coli polypeptides with trigger factor and signal recognition particle.

As nascent polypeptides exit the ribosomal tunnel they immediately associate with chaperones, folding catalysts, and targeting factors. These interactions are decisive for the future conformation and destination of the protein that is being synthesized. Using Escherichia coli as a model organism, we have systematically analyzed how the earliest contacts of nascent polypeptides with cytosolic factors depend on the nature and future destination of the emerging sequence using a photo cross-linking approach. Together, the data suggest that the chaperone trigger factor is adjacent to emerging sequences by default, consistent with both its placement near the nascent chain exit site and its cellular abundance. The signal recognition particle (SRP) effectively competes the contact with TF when a signal anchor (SA) sequence of a nascent inner membrane protein appears outside the ribosome. The SRP remains in contact with the SA and downstream sequences during further synthesis of approximately 30 amino acids. The contact with trigger factor is then restored unless another transmembrane segment reinitiates SRP binding. Importantly and in contrast to published data, the SRP appears perfectly capable of distinguishing SA sequences from signal sequences in secretory proteins at this early stage in biogenesis.

The ion channel of F-ATP synthase is the target of toxic organotin compounds.

ATP is the universal energy currency of living cells, and the majority of it is synthesized by the F1F0 ATP synthase. Inhibitors of this enzyme are therefore potentially detrimental for all life forms. Tributyltin chloride (TBT-Cl) inhibits ATP hydrolysis by the Na(+)-translocating ATP synthase of Ilyobacter tartaricus or the H(+)-translocating counterpart of Escherichia coli with apparent Ki of 200 nM. To target the site of this inhibition, we synthesized a tritium-labeled derivative of TBT-Cl in which one of the butyl groups was replaced by a photoactivatable aryldiazirine residue. Upon illumination, subunit a of the ATP synthase becomes specifically modified, and this labeling is suppressed in the presence of the original inhibitor. In case of the Na+ ATP synthase, labeling is also suppressed in the presence of Na+ ions, suggesting an interference in Na+ or TBT-Cl binding to subunit a. This interference is corroborated by the protection of ATP hydrolysis from TBT-Cl inhibition by 105 mM Na+. TBT-Cl strongly inhibits Na+ exchange by the reconstituted I. tartaricus ATP synthase. Taken together these results indicate that the subunit a ion channel is the target site for ATPase inhibition by toxic organotin compounds. An inhibitor interacting specifically with this site has not been reported previously.

Membrane topography of the coupling ion binding site in Na+-translocating F1F0 ATP synthase.

A carbodiimide with a photoactivatable diazirine substituent was synthesized and incubated with the Na(+)-translocating F(1)F(0) ATP synthase from both Propionigenium modestum and Ilyobacter tartaricus. This caused severe inhibition of ATP hydrolysis activity in the absence of Na(+) ions but not in its presence, indicating the specific reaction with the Na(+) binding c-Glu(65) residue. Photocross-linking was investigated with the substituted ATP synthase from both bacteria in reconstituted 1-palmitoyl-2-oleyl-sn-glycero-3-phosphocholine (POPC)-containing proteoliposomes. A subunit c/POPC conjugate was found in the illuminated samples but no a-c cross-links were observed, not even after ATP-induced rotation of the c-ring. Our substituted diazirine moiety on c-Glu(65) was therefore in close contact with phospholipid but does not contact subunit a. Na(+)in/(22)Na(+)out exchange activity of the ATP synthase was not affected by modifying the c-Glu(65) sites with the carbodiimide, but upon photoinduced cross-linking, this activity was abolished. Cross-linking the rotor to lipids apparently arrested rotational mobility required for moving Na(+) ions back and forth across the membrane. The site of cross-linking was analyzed by digestions of the substituted POPC using phospholipases C and A(2) and by mass spectroscopy. The substitutions were found exclusively at the fatty acid side chains, which indicates that c-Glu(65) is located within the core of the membrane.

The two membrane segments of leader peptidase partition one by one into the lipid bilayer via a Sec/YidC interface.

We have addressed the mechanism of insertion of both transmembrane segments (TMs) of leader peptidase, a double-spanning protein, into the Escherichia coli inner membrane. Using photo-crosslinking, the first TM (H1) was shown to insert at a Sec-translocon/YidC interface in a fixed orientation. H1 lost its contacts with the Sec-translocon and gained access to lipids near YidC soon after complete exposure outside the ribosome. Following lipid integration, it moved away from the Sec/YidC insertion site. The second TM (H2) inserted and interacted with SecY and YidC in a similar transient fashion. The data are consistent with a linear integration model in which the TMs of polytopic inner membrane proteins move one by one from a Sec/YidC insertion site into the lipid bilayer. We propose that YidC assists the lipid partitioning of single TMs.

Trigger factor interacts with the signal peptide of nascent Tat substrates but does not play a critical role in Tat-mediated export.

Twin-arginine translocation (Tat)-mediated protein transport across the bacterial cytoplasmic membrane occurs only after synthesis and folding of the substrate protein that contains a signal peptide with a characteristic twin-arginine motif. This implies that premature contact between the Tat signal peptide and the Tat translocon in the membrane must be prevented. We used site-specific photo-crosslinking to demonstrate that the signal peptide of nascent Tat proteins is in close proximity to the chaperone and peptidyl-prolyl isomerase trigger factor (TF). The contact with TF was strictly dependent on the context of the translating ribosome, started early in biogenesis when the nascent chain left the ribosome near L23, and persisted until the chain reached its full length. Despite this exclusive and prolonged contact, depletion or overexpression of TF had little effect on the kinetics and efficiency of the Tat export process.

Targeting, insertion, and localization of Escherichia coli YidC.

YidC was recently shown to play an important role in the assembly of inner membrane proteins (IMPs) both in conjunction with and separate from the Sec-translocon. Little is known about the biogenesis and structural and functional properties of YidC, itself a polytopic IMP. Here we analyze the targeting and membrane integration of YidC using in vivo and in vitro approaches. The combined data indicate that YidC is targeted by the signal recognition particle and inserts at the SecAYEG-YidC translocon early during biogenesis, unlike its mitochondrial homologue Oxa1p. In addition, YidC is shown to be relatively abundant compared with other components involved in IMP assembly and is predominantly localized at the poles of the cell.

Photo-crosslinking analysis of preferential interactions between a transmembrane peptide and matching lipids.

In this study, a novel method is presented by which the molecular environment of a transmembrane peptide can be investigated directly. This was achieved by incorporating a photoactivatable crosslinking probe in the hydrophobic segment of a model transmembrane peptide. When this peptide was incorporated into lipid bilayers and irradiated with UV light, a covalent bond was formed between the crosslinking probe and a lipid. This crosslinking reaction could be visualized by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and the resulting product could be characterized by mass spectrometry. By use of phospholipases, it was demonstrated that the peptide crosslinks to both acyl chains of the lipids. The peptide showed a clear preference to partition into fluid lipids and was excluded from lipids in the gel phase. However, when the peptide was incorporated into bilayers containing two lipid species with different acyl chain lengths, molecular sorting of the lipids around the peptide based on hydrophobic matching was not observed. It is proposed that the size of the transmembrane part plays an important role in the dynamic interactions of membrane proteins with the surrounding lipids and hence in determining whether molecular sorting can occur.

YidC and SecY mediate membrane insertion of a Type I transmembrane domain.

YidC has been identified recently as an evolutionary conserved factor that is involved in the integration of inner membrane proteins (IMPs) in Escherichia coli. The discovery of YidC has inspired the reevaluation of membrane protein assembly pathways in E. coli. In this study, we have analyzed the role of YidC in membrane integration of a widely used model IMP, leader peptidase (Lep). Site-directed photocross-linking experiments demonstrate that both YidC and SecY contact nascent Lep very early during biogenesis, at only 50-amino acid nascent chain length. At this length the first transmembrane domain (TM), which acquires a type I topology, is not even fully exposed outside the ribosome. The pattern of interactions appears dependent on the position of the cross-linking probe in the nascent chain. Upon elongation, nascent Lep remains close to YidC and comes into contact with lipids as well. Our results suggest a role for YidC in both the reception and lipid partitioning of type I TMs.