Leaving hip rotation out of a conventional 3D gait model improves discrimination of pathological gait in cerebral palsy: A novel neural network analysis.

BACKGROUND: Complex clinical gait analysis results can be expressed as single number gait deviations by applying multivariate processing methods. The original Movement Deviation Profile (MDP) quantifies the deviation of abnormal gait using the most trusted nine dynamic joint angles of lower limbs. RESEARCH QUESTION: Which subset of joint angles maximises the ability of the MDP to separate abnormal gait from normality? What is the effect of using the best subset in a large group of patients, and in individuals? METHODS: A self-organising neural network was trained using normal gait data from 166 controls, and then the MDP of 1923 patients with cerebral palsy (3846 legs) was calculated. The same procedure was repeated with 511 combinations of the nine joint angles. The standardised distances of abnormal gait from normality were then calculated as log-transformed Z-scores to select the best combination. A mixed design ANOVA was used to assess how removing the least discriminating angle improved the separation of patients from controls. The effect of using the optimal subset of angles was also quantified for each individual leg by comparing the change in MDP to the independent FAQ levels of patients. RESULTS: Removal of hip rotation significantly (p<0.0005) increased the separation of the patient group from normality (ΔZ-score 0.24) and also at FAQ levels 7-10 (ΔZ-score 0.38, 0.27, 0.22, 0.14). The MDP of individual patients changed in a wider range of -4.65 to 1.12 Z-scores and their change matched their independent FAQ scores, with less functional patients moving further from, and more functional patients moving closer to normality. SIGNIFICANCE: In existing gait databases we recommend excluding hip rotation from data used to calculate the MDP. Alternatively, the calculation of hip rotation can be improved by post-hoc correction, but the ultimate solution is to use more accurate and reliable models of hip rotation.

3D printed structures for modeling the Young's modulus of bamboo parenchyma.

Bamboo is a sustainable, lightweight material that is widely used in structural applications. To fully develop micromechanical models for plants, such as bamboo, the mechanical properties of each individual type of tissue are needed. However, separating individual tissues and testing them mechanically is challenging. Here, we report an alternative approach in which micro X-ray computed tomography (µ-CT) is used to image moso bamboo (Phyllostachys pubescens). The acquired images, which correspond to the 3D structure of the parenchyma, are then transformed into physical, albeit larger scale, structures by 3D printing, and their mechanical properties are characterized. The normalized longitudinal Young's moduli of the fabricated structures depend on relative density raised to a power between 2 and 3, suggesting that elastic deformation of the parenchyma cellular structure involves considerable cell wall bending. The mechanical behavior of other biological tissues may also be elucidated using this approach. STATEMENT OF SIGNIFICANCE: Bamboo is a lightweight, sustainable engineering material widely used in structural applications. By combining micro X-ray computed tomography and 3D printing, we have produced bamboo parenchyma mimics and characterized their stiffness. Using this approach, we gained insight into bamboo parenchyma tissue mechanics, specifically the cellular geometry's role in longitudinal elasticity.

Use of Ex Vivo Normothermic Perfusion for Quality Assessment of Discarded Human Donor Pancreases.

A significant number of pancreases procured for transplantation are deemed unsuitable due to concerns about graft quality and the associated risk of complications. However, this decision is subjective and some declined grafts may be suitable for transplantation. Ex vivo normothermic perfusion (EVNP) prior to transplantation may allow a more objective assessment of graft quality and reduce discard rates. We report ex vivo normothermic perfusion of human pancreases procured but declined for transplantation, with ABO-compatible warm oxygenated packed red blood cells for 1-2 h. Five declined human pancreases were assessed using this technique after a median cold ischemia time of 13 h 19 min. One pancreas, with cold ischemia over 30 h, did not appear viable and was excluded. In the remaining pancreases, blood flow and pH were maintained throughout perfusion. Insulin secretion was observed in all four pancreases, but was lowest in an older donation after cardiac death pancreas. Amylase levels were highest in a gland with significant fat infiltration. This is the first study to assess the perfusion, injury, as measured by amylase, and exocrine function of human pancreases using EVNP and demonstrates the feasibility of the approach, although further refinements are required.

Current status of adult spinal deformity.

Purpose To review the current literature for the nonoperative and operative treatment for adult spinal deformity. Recent Findings With more than 11 million baby boomers joining the population of over 60 years of age in the United States, the incidence of lumbar deformity is greatly increasing. Recent literature suggests that a lack of evidence exists to support the effectiveness of nonoperative treatment for adult scoliosis. In regards to operative treatment, current literature reports a varying range of improved clinical outcomes, curve correction, and complication rates. The extension of fusion to S1 compared with L5 and lower thoracic levels compared with L1 remains a highly controversial topic among literature. Summary Most adult deformity patients never seek nonoperative or operative treatment. Of the few that seek treatment, many can benefit from nonoperative treatment. However, in selected patients who have failed nonoperative treatment and who are candidates for surgical intervention, the literature reflects positive outcomes related to surgical intervention as compared with nonoperative treatment despite varying associated ranges in morbidity and mortality rates. If nonoperative therapy fails in addressing a patient's complaints, then an appropriate surgical procedure that relieves neural compression, corrects excessive sagittal or coronal imbalance, and results in a solidly fused, pain-free spine is warranted.

Comparative clinical- and cost-effectiveness of candesartan and losartan in the management of hypertension and heart failure: a systematic review, meta- and cost-utility analysis.

The UK National Health Service (NHS) currently spends in excess of £250 million per annum on angiotensin II receptor blockers (ARBs) for the treatment of hypertension and heart failure; with candesartan currently dominating the market. With the recent introduction of generic losartan, we set out to directly compare the branded market leader to its now cheaper alternative. The primary objectives were to compare the blood pressure (BP) lowering efficacy and cardiovascular outcomes of candesartan and losartan in the treatment of essential hypertension and chronic heart failure, respectively. The secondary objective was to model their comparative incremental cost-effectiveness in a UK NHS setting. The Cochrane Central Register of Controlled Trials (Cochrane Library 2009, issue 2), which contains the Hypertension and Heart Group's specialist register, Medline (1950-February 2010), and Embase (1980-February 2010) were included in the search strategy. Selection criteria were randomised studies of candesartan versus losartan in adults (> 18 years). The main outcome measures were as follows: Hypertension: mean change from baseline in trough (24 h postdose) systolic and diastolic BP. Heart failure: composite of cardiovascular death and hospital admission for management of heart failure. Two reviewers applied inclusion criteria, assessed trial quality, and extracted data. Eight (three of which met inclusion criteria) and zero trials compared candesartan directly with losartan in the treatment of hypertension and heart failure, respectively. A between-treatment difference of -1.96 mmHg [95% confidence interval (CI) -2.40 to -1.51] for trough diastolic BP and -3.00 mmHg (95% CI -3.79 to -2.22) for trough systolic BP in favour of candesartan was observed. Based on this differential, a 10-year Markov model estimates the cost per quality-adjusted life-year gained to exceed £40,000 for using candesartan in place of generic losartan. Candesartan reduces BP to a slightly greater extent when compared with losartan, however, such difference is unlikely to be cost-effective based on current acquisition costs, perceived NHS affordability thresholds and use of combination regimens. We could find no robust evidence supporting the superiority of candesartan over losartan in the treatment of heart failure. We therefore recommend using generic losartan as the ARB of choice which could save the UK NHS approximately £200 million per annum in drug costs.

Prothrombotic and inflammatory effects of intravenous administration of human immunoglobulin G in dogs.

BACKGROUND: Intravenous administration of human immunoglobulin G (hIVIgG) has been suggested to potentiate thromboembolism in dogs, but supportive scientific reports are lacking. OBJECTIVES: To determine if hIVIgG therapy promotes hypercoagulability and inflammation in dogs. ANIMALS: Twelve healthy Beagle dogs. METHODS: Prospective, experimental trial. An hIVIgG/saline solution was infused IV at 1 g/kg BW over 8 hours to 6 dogs, and physiological saline was infused to the other 6 dogs. Blood samples were drawn before, during, and after infusion for serial measurement of indicators of coagulation and inflammation. Data were analyzed by 2-way repeated measures analysis of variance. RESULTS: Dogs administered hIVIgG developed mildly decreased blood platelet concentrations without thrombocytopenia (median, 200 x 10(3)/microL; range, 150-302 x 10(3)/microL; P < .01), leukopenia (median, 3.5 x 10(3)/microL; range, 20-62 x 10(3)/microL; P < .001), and mildly increased plasma total protein concentrations (median, 6.3 g/dL; range, 5.6-6.7 g/dL; P < .001). Administration of hIVIgG was also associated with increases in fibrin/fibrinogen degradation products in all dogs (either 5 microg/mL or 10 microg/dL), thrombin-antithrombin III complexes (median, 7.2 ng/mL; range, 4.9-14.2 ng/mL; P < .001), and C-reactive protein concentrations (median, 2.5 mg/dL; range, 0.5-4.3 mg/dL; P < .01). CONCLUSION AND CLINICAL IMPORTANCE: Administration of hIVIgG to dogs promotes hypercoagulability and an inflammatory state. This should be further evaluated and considered when using hIVIgG in dogs with IMHA or other prothrombotic conditions.

High-dose oral vitamin D3 supplementation in the elderly.

SUMMARY: Daily dosing with vitamin D often fails to achieve optimal outcomes, and it is uncertain what the target level of 25-hydroxyvitamin D should be. This study found that large loading doses of vitamin D(3) rapidly and safely normalize 25OHD levels, and that monthly dosing is similarly effective after 3-5 months. With baseline 25OHD > 50 nmol/L, vitamin D supplementation does not reduce PTH levels. INTRODUCTION: There is concern that vitamin D supplementation doses are frequently inadequate, and that compliance with daily medication is likely to be suboptimal. METHODS: This randomized double-blind trial compares responses to three high-dose vitamin D(3) regimens and estimates optimal 25-hydroxyvitamin D (25OHD) levels, from changes in parathyroid hormone (PTH), and procollagen type I amino-terminal propeptide (P1NP) in relation to baseline 25OHD. Sixty-three elderly participants were randomized to three regimens of vitamin D supplementation: a 500,000-IU loading dose; the loading dose plus 50,000 IU/month; or 50,000 IU/month. RESULTS: The Loading and Loading + Monthly groups showed increases in 25OHD of 58 +/- 28 nmol/L from baseline to 1 month. Thereafter, levels gradually declined to plateaus of 69 +/- 5 nmol/L and 91 +/- 4 nmol/l, respectively. In the Monthly group, 25OHD reached a plateau of ~80 +/- 20 nmol/L at 3-5 months. There were no changes in serum calcium concentrations. PTH and P1NP were only suppressed by vitamin D treatment in those with baseline 25OHD levels <50 and <30 nmol/L, respectively. CONCLUSIONS: Large loading doses of vitamin D(3) rapidly and safely normalize 25OHD levels in the frail elderly. Monthly dosing is similarly effective and safe, but takes 3-5 months for plateau 25OHD levels to be reached.

Equine multinodular pulmonary fibrosis: a newly recognized herpesvirus-associated fibrotic lung disease.

Pulmonary fibrosis and interstitial lung disease are poorly understood in horses; the causes of such conditions are rarely identified. Equine herpesvirus 5 (EHV-5) is a gamma-herpesvirus of horses that has not been associated with disease in horses. Pathologic and virologic findings from 24 horses with progressive nodular fibrotic lung disease associated with EHV-5 infection are described and compared with 23 age-matched control animals. Gross lesions consisted of multiple nodules of fibrosis throughout the lungs. Histologically, there was marked interstitial fibrosis, often with preservation of an "alveolar-like" architecture, lined by cuboidal epithelial cells. The airways contained primarily neutrophils and macrophages. Rare macrophages contained large eosinophilic intranuclear viral inclusion bodies; similar inclusion bodies were also found cytologically. The inclusions were identified as herpesviral-like particles by transmission electron microscopy in a single horse. In situ hybridization was used to detect EHV-5 nucleic acids within occasional macrophage nuclei. With polymerase chain reaction (PCR), the herpesviral DNA polymerase gene was detected in 19/24 (79.2%) of affected horses and 2/23 (8.7%) of the control horses. Virus genera-specific PCR was used to detect EHV-5 in all of the affected horses and none of the control horses. EHV-2 was detected in 8/24 (33.3%) of affected horses and 1/9 (11.1%) of the control horses. This disease has not been reported before, and the authors propose that based upon the characteristic gross and histologic findings, the disease be known as equine multinodular pulmonary fibrosis. Further, we propose that this newly described disease develops in association with infection by the equine gamma-herpesvirus, EHV-5.

Structural and chemical changes in ultra-high-molecular-weight polyethylene due to gamma radiation-induced crosslinking and annealing in air.

Ultra-High-Molecular-Weight-Polyethylene (UHMWPE) is the material of choice for one of the articulating surfaces in many total joint replacements, notably hip and knee prostheses. The various methods used by the orthopaedic biomaterials industry to sterilize and anneal UHMWPE components, and the resulting oxidation and crosslinking, affect the mechanical wear resistance properties in ways still unknown at the microscopic and molecular levels. Transmission electron microscopy and chemical pyrolysis were used to quantify crosslinking induced by gamma irradiation and annealing in air. Changes in lamellar stacking and the amount of crosslinking suggest two types of crosslinking: relatively unstable crosslinks in the amorphous region initially resulting from gamma irradiation which are later replaced by more thermally stable crosslinks resulting from rearrangements at the annealing temperature. Lamellar mobility, the ability of crystalline lamellae to flow in the material, is enhanced during the transition from one type of bond to the other, and this appears to optimize near eight hours of annealing time. Results from decomposition and percent crystallinity measurements provide further support for this theory.

Molecular genetic analysis of haematological malignancies II: Mature lymphoid neoplasms.

Molecular genetic techniques have become an integral part of the diagnostic assessment for many lymphomas and other chronic lymphoid neoplasms. The demonstration of a clonal immunoglobulin or T cell receptor gene rearrangement offers a useful diagnostic tool in cases where the diagnosis is equivocal. Molecular genetic detection of other genomic rearrangements may not only assist with the diagnosis but can also provide important prognostic information. Many of these rearrangements can act as molecular markers for the detection of low levels of residual disease. In this review, we discuss the applications of molecular genetic analysis to the chronic lymphoid malignancies. The review concentrates on those disorders for which molecular genetic analysis can offer diagnostic and/or prognostic information.

Application of growth factor stimulants improves cytogenetic analysis of chronic myeloproliferative disorder patients without alteration to cell lineage or clonality.

Conventional cytogenetic methods rely on culturing bone marrow aspirates to obtain suitable and sufficient mitotic figures for G-banded analysis. Samples from patients with chronic myeloproliferative disorders (CMPD) often have increased failure rates due to reduced growth and poor morphology, all of which hamper the conventional karyotyping investigation. The application of growth factor (GF) stimulants to bone marrow aspirates has been shown to yield significant increases in both the quality and quantity of bone marrow metaphases obtained in 53 CPMD patient samples. All cultures were stimulated using the conditioned supernatant from the human bladder carcinoma cell line 5637, which contains IL-3, IL-6, and G-CSF. Results were assessed qualitatively on G-banded preparations and quantitatively by mitotic index (MI = % dividing cells). To assess whether the application of GF stimulants leads to clonal selection, culture samples from 15 patients were analyzed by fluorescence in situ hybridization, which supported the theory that clonal selection remains unaltered in GF-stimulated cultures. In addition to this immunophenotyping of cells, we demonstrated the lineage of cells propagated under these conditions. Cell markers were chosen to characterize B-lymphoid, T-lymphoid, myeloid, and primitive cell types. Results indicated that T cells were maintained in culture and B-lymphoid markers remained negative. In the myeloid subset, there was an overall reduction in the pan-myeloid markers. We believe this represents the loss of terminally differentiated cells (e.g., neutrophils) in culture. Overall, the study clearly demonstrates that the application of GF stimulants does not alter clonality or cell lineage propagated in these samples and is therefore suitable for application in diagnostic cytogenetic laboratories.

A single common urgent pathway for all colorectal referrals reduces time to diagnosis and treatment.

OBJECTIVE: Guidelines for the urgent referral of patients with suspected colorectal cancer were introduced in 2000. They aimed to facilitate the prompt diagnosis and treatment of patients with symptoms suggestive of malignant disease. Recent assessment of these guidelines has suggested that although they identify 9-14% of patients with colorectal cancer, they may be used inappropriately and may lead to delays in treatment for those patients with cancers whose symptoms do not fit the guidelines. We aimed to assess the effect of introducing a single pathway for all referrals irrespective of indicated urgency. METHOD: All referral letters to a single consultant colorectal surgeon over a 6-month period were coded 'urgent' irrespective of the indicated urgency on the original referral letter. Data was collected prospectively on 47 patients diagnosed with colorectal cancer identified over the trial period. Patient demographics, the mode of presentation, urgency of referral and waiting times were documented. RESULTS: Following the introduction of the common urgent referral pathway, no patient waited longer than 62 days from referral to treatment or 31 days from the decision to treat to first treatment, thus meeting government targets introduced in 2005. CONCLUSION: The introduction of the urgent referral guidelines has accelerated the referral pathway for patients with symptoms suggestive of colorectal cancer, although this is at the expense of the majority of patients who present via conventional pathways. The introduction of a common urgent pathway allows prompt diagnosis and treatment and is of particular benefit for the majority of patients not referred via the 2-week standard. Until a more accurate method of identifying the highest risk patients is implemented, we suggest that all patients are seen on an urgent basis.

Acute anhydrous ammonia intoxication in cattle.

Intoxication with anhydrous ammonia (AA) is a common occupation-related health problem affecting farmers and fertilizer applicators, however, very few descriptions of animal exposure to this toxicant exist. Thieves entered a feedlot and damaged a liquid AA storage tank, resulting in the accidental leakage of gas from a valve. Overnight, 12 cattle were found dead, with a total mortality of 64 cattle out of 260 on the premises dying or euthanized in < 1 week. Signs of affected cattle included blindness, drooling, inappetence, respiratory distress, recumbency, and death. Two cattle were submitted live for diagnostic evaluation 3 days after initial exposure. Gross lesions included corneal ulcers, fibrinonecrotizing rhinitis, hemorrhages within the nasal sinuses, and anterioventral bronchopneumonia. Microscopic lesions consisted predominantly of degeneration and necrosis of superficial epithelium lining nasal passages, trachea, and pulmonary airways. This case illustrates the acute AA effects on cattle, which is likely to be an increasingly encountered problem because of on-farm storage of AA and its access by illicit drug manufacturers.

Visual search and coordination changes in response to video and point-light demonstrations without KR.

The authors examined the observational learning of 24 participants whom they constrained to use the model by removing intrinsic visual knowledge of results (KR). Matched participants assigned to video (VID), point-light (PL), and no-model (CON) groups performed a soccer-chipping task in which vision was occluded at ball contact. Pre- and posttests were interspersed with alternating periods of demonstration and acquisition. The authors assessed delayed retention 2-3 days later. In support of the visual perception perspective, the participants who observed the models showed immediate and enduring changes to more closely imitate the model's relative motion. While observing the demonstration, the PL group participants were more selective in their visual search than were the VID group participants but did not perform more accurately or learn more.

Molecular genetic analysis of haematological malignancies: I. Acute leukaemias and myeloproliferative disorders.

Molecular genetic techniques are now routinely applied to haematological malignancies within a clinical laboratory setting. The detection of genetic rearrangements not only assists with diagnosis and treatment decisions, but also adds important prognostic information. In addition, genetic rearrangements associated with leukaemia can be used as molecular markers allowing the detection of low levels of residual disease. This review will concentrate on the application of molecular genetic techniques to the acute leukaemias and myeloprolferative disorders.