Robotic versus freehand CT-guided radiofrequency ablation of pulmonary metastases: a comparative cohort study.

PURPOSE: Radiofrequency ablation (RFA) is a curative treatment option for small lung metastases, which conventionally involves multiple freehand manipulations until the treating electrode is satisfactorily positioned. Stereotactic and robotic guidance has been gaining popularity for liver ablation, although has not been established in lung ablation. The purpose of this study is to determine the feasibility, safety, and accuracy of robotic RFA for pulmonary metastases, and compare procedures with a conventional freehand cohort. METHODS: A single center study with prospective robotic cohort, and retrospective freehand cohort. RFA was performed under general anesthesia using high frequency jet ventilation and CT guidance. Main outcomes were (i) feasibility/technical success (ii) safety using Common Terminology Criteria for Adverse Events (iii) targeting accuracy (iv) number of needle manipulations for satisfactory ablation. Robotic and freehand cohorts were compared using Mann-Whitney U tests for continuous variables, and Fisher's exact for categorical variables. RESULTS: Thirty-nine patients (mean age 65 ± 13 years, 20 men) underwent ablation of 44 pulmonary metastases at single specialist cancer center between July 2019 and August 2022. 20 consecutive participants underwent robotic ablation, and 20 consecutive patients underwent freehand ablation. All 20/20 (100%) robotic procedures were technically successful, and none were converted to freehand procedures. There were 6/20 (30%) adverse events in the robotic cohort, and 15/20 (75%) in the freehand cohort (P = 0.01). Robotic placement was highly accurate with 6 mm tip-to-target distance (range 0-14 mm) despite out-of-plane approaches, with fewer manipulations than freehand placement (median 0 vs. 4.5 manipulations, P < 0.001 and 7/22, 32% vs. 22/22, 100%, P < 0.001). CONCLUSIONS: Robotic radiofrequency ablation of pulmonary metastases with general anesthesia and high frequency jet ventilation is feasible and safe. Targeting accuracy is high, and fewer needle/electrode manipulations are required to achieve a satisfactory position for ablation than freehand placement, with early indications of reduced complications.

Exploring Kinetic and Kinematic Finger Individuation Capability in Children With Hemiplegic Cerebral Palsy.

While fine manual dexterity develops over time, the extent to which children show independent control of their digits in each hand and the impact of perinatal brain injury on this individuation have not been well quantified. Our goal in this study was to assess and compare finger force and movement individuation in 8-14 year old children with hemiplegic cerebral palsy (hCP; n = 4) and their typically developing peers (TD; n = 10). We evaluated finger force individuation with five independent load cells and captured joint movement individuation with video tracking. We observed no significant differences in individuation indices between the dominant and non-dominant hands of TD children, but individuated force and movement were substantially reduced in the paretic versus non paretic hands of children with hCP (p < 0.001). In TD participants, the thumb tended to have the greatest level of independent control. This small sample of children with hCP showed substantial loss of individuation in the paretic hand and some deficits in the non-paretic hand, suggesting possible benefit from targeted training of digit independence in both hands for children with CP.

Starting CT-guided robotic interventional oncology at a UK centre.

OBJECTIVE: A commercially available CT-guided robot offers enhanced abilities in planning, targeting, and confirming accurate needle placement. In this short communication, we describe our first UK experience of robotic interventional oncology procedures. METHODS: We describe the device, discuss installation, operation, and report upon needle insertion success, accuracy (path deviation; PD and tip deviation; TD), number of adjustments, complications, and procedural success. RESULTS: Nine patients (seven males), median age 66 years (range 43-79) were consented for biopsy or ablation between March and April 2021. Needle placement in biopsy was more accurate than ablation (median 1 vs 11 mm PD and 1 vs 20 mm TD) and required fewer adjustments (median 0 vs 5). No complications arose, and all procedures were successful (diagnostic material obtained or complete ablation at follow-up). CONCLUSION: Short procedure times and very high levels of accuracy were readily achieved with biopsy procedures, although tumour ablation was less accurate which likely reflects higher procedural complexity. ADVANCES IN KNOWLEDGE: Achieving highly accurate robotic biopsy with is feasible within a very short time span. Further work is required to maximise the potential of robotic guidance in tumour ablation procedures, which is likely due to higher complexity giving a longer learning curve.

Hand function development of children with hemiplegic cerebral palsy: A scoping review.

PURPOSE: Hemiplegic cerebral palsy (hCP) typically impacts sensorimotor control of the hand, but comprehensive assessments of the hands of children with hCP are relatively rare. This scoping review summarizes the development of hand function for children with hCP. METHODS: This scoping review focused on the development of hand function in children with hCP. Electronic databases (PubMed, PEDro, Web of Science, CINAHL, and SpringerLink) were searched to identify studies assessing hand function in children with hCP. The search was performed using keywords (e.g., "hemiplegia"). An iterative approach verified by two authors was used to select the studies. Articles which reported quantitative data for children with hCP on any items of a specified set of hand evaluations were included. Measures were sorted into three categories: quantitative neuromechanics, clinical assessments, and clinical functional evaluations. RESULTS: Initial searches returned 1536 articles, 131 of which were included in the final review. Trends between assessment scores and age were examined for both hands. CONCLUSION: While several studies have evaluated hand function in children with hCP, the majority relied on clinical scales, assessments, or qualitative descriptions. Further assessments of kinematics, kinetics, and muscle activation patterns are needed to identify the underlying impairment mechanisms that should be targeted for treatment.

High Compliance Pneumatic Actuators to Promote Finger Extension in Stroke Survivors.

Compliant pneumatic systems are well suited for wearable robotic applications. The actuators are lightweight, conformable to irregular shapes, and tolerant of uncontrolled degrees of freedom. These attributes are especially desirable for hand exoskeletons given their space and mass constraints. Creating active digit extension with these exoskeletons is especially critical for clinical populations such as stroke survivors who often have great difficulty opening their paretic hand. To achieve active digit extension with a soft actuator, we have created pneumatic chambers that lie along the palmar surface of the digits. These chambers can directly extend the digits when pressurized. We present a characterization of the extension force and passive flexion resistance generated by these pneumatic chambers across a range of joint angles as a function of cross-sectional shape, dimension, and wall thickness. The chambers were fabricated out of DragonSkin 20 using custom molds and were tested on a custom jig. Extension forces created at the end of the chamber (where fingertip contact would occur) exceeded 3.00 N at relatively low pressure (48.3 kPa). A rectangular cross-section generated higher extension force than a semi-obround cross-sectional shape. Extension force was significantly higher (p < 0.05) for actuators with the highest wall thickness compared to those with the thinnest walls. In comparison to previously used polyurethane actuators, the DragonSkin actuators had a much higher extension force for a similar passive bending resistance. Passive bending resistance of the chamber (simulating finger flexion) did not vary significantly with actuator shape, wall thickness, width, or depth. The flexion resistance, however, could be significantly reduced by applying a vacuum. These results provide guidance in designing pneumatic actuators for assisting finger extension and resisting unwanted flexion in the fingers.

Neuromechanics and Energetics of Walking With an Ankle Exoskeleton Using Neuromuscular-Model Based Control: A Parameter Study.

Powered ankle exoskeletons that apply assistive torques with optimized timing and magnitude can reduce metabolic cost by ∼10% compared to normal walking. However, finding individualized optimal control parameters is time consuming and must be done independently for different walking modes (e.g., speeds, slopes). Thus, there is a need for exoskeleton controllers that are capable of continuously adapting torque assistance in concert with changing locomotor demands. One option is to use a biologically inspired, model-based control scheme that can capture the adaptive behavior of the human plantarflexors during natural gait. Here, based on previously demonstrated success in a powered ankle-foot prosthesis, we developed an ankle exoskeleton controller that uses a neuromuscular model (NMM) comprised of a Hill type musculotendon driven by a simple positive force feedback reflex loop. To examine the effects of NMM reflex parameter settings on (i) ankle exoskeleton mechanical performance and (ii) users' physiological response, we recruited nine healthy, young adults to walk on a treadmill at a fixed speed of 1.25 m/s while donning bilateral tethered robotic ankle exoskeletons. To quantify exoskeleton mechanics, we measured exoskeleton torque and power output across a range of NMM controller Gain (0.8-2.0) and Delay (10-40 ms) settings, as well as a High Gain/High Delay (2.0/40 ms) combination. To quantify users' physiological response, we compared joint kinematics and kinetics, ankle muscle electromyography and metabolic rate between powered and unpowered/zero-torque conditions. Increasing NMM controller reflex Gain caused increases in average ankle exoskeleton torque and net power output, while increasing NMM controller reflex Delay caused a decrease in net ankle exoskeleton power output. Despite systematic reduction in users' average biological ankle moment with exoskeleton mechanical assistance, we found no NMM controller Gain or Delay settings that yielded changes in metabolic rate. Post hoc analyses revealed weak association at best between exoskeleton and biological mechanics and changes in users' metabolic rate. Instead, changes in users' summed ankle joint muscle activity with powered assistance correlated with changes in their metabolic energy use, highlighting the potential to utilize muscle electromyography as a target for on-line optimization in next generation adaptive exoskeleton controllers.

A survey of veterinarians' knowledge, attitudes and practices regarding an emerging disease: Coccidioidomycosis in Washington State.

Coccidioides immitis is an emerging fungal pathogen in Washington State (WA). While the geographical boundaries of C. immitis in WA have not been well characterized, human infections have resulted from exposure in the south-central region of the state. Since 2010, only one dog has been identified as a probable locally acquired animal case, despite pilot canine serological surveys from south-central WA revealing a 9.8% seroprevalence. On the suspicion that clinical animal cases may be underdiagnosed and/or underreported, we assessed WA veterinarians' knowledge, attitudes and practices regarding coccidioidomycosis. All veterinarians with active licenses in WA were invited to complete a self-administered, web-based survey from November 2018 to January 2019. Four hundred and twenty-five of 2,211 (19.2%) veterinarians returned the survey and were eligible for inclusion in the final analysis. Nearly, all respondents (98.8%) had heard of coccidioidomycosis, but only 31.5% and 25.6% knew that locally acquired animal and human cases, respectively, had been reported in WA. Only half (52.6%) of participants knew that the disease was reportable. Fewer than 20% of respondents reported confidence that their knowledge of coccidioidomycosis was up to date, and 76.9% "never" or "rarely" considered the risk of disease in their patients. A statistically significant predictor of a high knowledge score (≥70%), however, included practicing in endemic counties where the Washington State Department of Health had previously delivered outreach and education services. While the results suggest some success with these activities, it is clear that information on the emergence of coccidioidomycosis is not adequately reaching veterinary practitioners in WA. The data support that more frequent CE opportunities, and dissemination of public health communications through veterinary-specific modalities, would help fill the knowledge gap. In turn, improved diagnosis and reporting of animal cases would assist in our overall understanding the epidemiology of coccidioidomycosis in WA.

A Platform for Rehabilitation of Finger Individuation in Children with Hemiplegic Cerebral Palsy.

The brain injury that results in cerebral palsy CP may adversely affect fine motor control of the hand. The degradation of manual dexterity in the fingers profoundly impacts overall functionality of the upper limb, yet research efforts to facilitate rehabilitation of finger individuation in children with CP have been limited. This study describes the development of an integrated hardware and software platform for training and evaluating finger individuation. A pneumatically actuated glove provides extension assistance or flexion resistance independently to each digit in concert with playing a virtual reality keyboard. This setup enables intensive and efficient practice of fine motor control of either or both hands. Bimanual training options range from mirror movements to fully independent motions and rhythms in each hand, thereby enabling maintenance of the proper level of challenge. Additionally, an instrument was created to provide assessment of individuated fingertip force generation in order to evaluate effectiveness of the training. Preliminary data were obtained from children both with and without CP using this tool.

Using information literacy to teach medical entrepreneurship and health care economics.

OBJECTIVE: Entrepreneurship and innovative product design in health care requires expertise in finding and evaluating diverse types of information from a multitude of sources to accomplish a number of tasks, such as securing regulatory approval, developing a reimbursement strategy, and navigating intellectual property. The authors sought to determine whether an intensive, specialized information literacy training program that introduced undergraduate biomedical engineering students to these concepts would improve the quality of the students' design projects. We also sought to test whether information literacy training that included active learning exercises would offer increased benefits over training delivered via lectures and if this specialized information literacy training would increase the extent of students' information use. METHODS: A three-arm cohort study was conducted with a control group and two experimental groups. Mixed methods assessment, including a rubric and citation analysis, was used to evaluate program outcomes by examining authentic artifacts of student learning. RESULTS: Student design teams that received information literacy training on topics related to medical entrepreneurship and health care economics showed significantly improved performance on aspects of project performance relevant to health care economics over student design teams that did not receive this training. There were no significant differences between teams that engaged in active learning exercises and those that only received training via lectures. Also, there were no significant differences in citation patterns between student teams that did or did not receive specialized information literacy training. CONCLUSIONS: Information literacy training can be used as a method for introducing undergraduate health sciences students to the health care economics aspects of the medical entrepreneurship life cycle, including the US Food and Drug Administration regulatory environment, intellectual property, and medical billing and reimbursement structures.

Examining the Potential for Agricultural Benefits from Pollinator Habitat at Solar Facilities in the United States.

Of the many roles insects serve for ecosystem function, pollination is possibly the most important service directly linked to human well-being. However, land use changes have contributed to the decline of pollinators and their habitats. In agricultural landscapes that also support renewable energy developments such as utility-scale solar energy [USSE] facilities, opportunities may exist to conserve insect pollinators and locally restore their ecosystem services through the implementation of vegetation management approaches that aim to provide and maintain pollinator habitat at USSE facilities. As a first step toward understanding the potential agricultural benefits of solar-pollinator habitat, we identified areas of overlap between USSE facilities and surrounding pollinator-dependent crop types in the United States (U.S.). Using spatial data on solar energy developments and crop types across the U.S., and assuming a pollinator foraging distance of 1.5 km, we identified over 3,500 km2 of agricultural land near existing and planned USSE facilities that may benefit from increased pollination services through the creation of pollinator habitat at the USSE facilities. The following five pollinator-dependent crop types accounted for over 90% of the agriculture near USSE facilities, and these could benefit most from the creation of pollinator habitat at existing and planned USSE facilities: soybeans, alfalfa, cotton, almonds, and citrus. We discuss how our results may be used to understand potential agro-economic implications of solar-pollinator habitat. Our results show that ecosystem service restoration through the creation of pollinator habitat could improve the sustainability of large-scale renewable energy developments in agricultural landscapes.

Aqueous Plasma Pharmacy: Preparation Methods, Chemistry, and Therapeutic Applications.

Plasma pharmacy is a subset of the broader field of plasma medicine. Although not strictly defined, the term aqueous plasma pharmacy (APP) is used to refer to the generation and distribution of reactive plasma-generated species in an aqueous solution followed by subsequent administration for therapeutic benefits. APP attempts to harness the therapeutic effects of plasma-generated oxidant species within aqueous solution in various applications, such as disinfectant solutions, cell proliferation related to wound healing, and cancer treatment. The subsequent use of plasma-generated solutions in the APP approach facilitates the delivery of reactive plasma species to internal locations within the body. Although significant efforts in the field of plasma medicine have concentrated on employing direct plasma plume exposure to cells or tissues, here we focus specifically on plasma discharge in aqueous solution to render the solution biologically active for subsequent application. Methods of plasma discharge in solution are reviewed, along with aqueous plasma chemistry and the applications for APP. The future of the field also is discussed regarding necessary research efforts that will enable commercialization for clinical deployment.

Percutaneous transhepatic cholangiography for choledocholithiasis after laparoscopic gastric bypass surgery.

INTRODUCTION: Gallstones are a common condition in bariatric patients after a laparoscopic Roux-en-Y gastric bypass (LRYGB). The management of ductal stones is challenging due to the altered gastrointestinal anatomy. Various techniques have been reported to manage bile duct stones. PRESENTATION OF CASE: We present the successful percutaneous trans hepatic management of common bile duct stones after LRYGB. One year after a LRYGB for morbid obesity, a 59-year-old female presented with acute cholecystitis. One month after laparoscopic cholecystectomy a 1cm calculus was found within the distal CBD and patient underwent a percutaneous trans hepatic cholangiography under local anesthetic. This involved a right sided anterior segmental duct puncture. With the sphincter dilated to 10mm, a balloon catheter was used to push the stone into the duodenum leaving an internal- external drain. Patient recovered completely at follow up. DISCUSSION: Patients with morbid obesity have a higher incidence of gallstones. After LRYGB, the altered anatomy does not allow the conventional endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. Various techniques have been reported as means of managing bile duct stones in LRYGB patients. These include a double balloon enteroscope-assisted ERCP, laparoscopic transgastric ERCP, laparoscopic or open biliary surgery and interventional radiology. We report a non-surgical approach using percutaneous transhepatic technique under local anesthetic that resulted effective and could be applied more extensively. CONCLUSION: Due to the increase of global obesity, bariatric centers need to strategically plan resources such as interventional radiology in order to manage post LRYGB choledocholithiasis safely, efficiently and in a cost effective manner.

NMR-based characterization of the acute metabolic effects of weathered crude and dispersed oil in spawning topsmelt and their embryos.

Oil spill responders require information on the relative toxicity of dispersed and un-dispersed oil in order to make informed decisions regarding the use of chemical dispersants during spill events. Toxicity of the water-accommodated fraction (WAF) and the chemically-enhanced WAF (CEWAF; via the dispersant Corexit 9500) of weathered Prudhoe Bay crude oil was investigated using adult and embryonic topsmelt; topsmelt are an ecologically important atherinid in California bays and estuaries and an important indicator species. Following 96-h exposures, metabolite profiles were measured using 1D (1)H nuclear magnetic resonance (NMR) spectroscopy and compared via principal component analysis. Similar metabolic profiles were obtained between WAF- and CEWAF-exposed adults and embryos. Although metabolic changes, for the adults lacked significance, significant increasing and decreasing metabolic changes were observed for embryos directly exposed. Furthermore, no mortality was observed for embryos, exposed to WAF and normal development occurred, whereas CEWAF exposed embryos lead to mortality and cardiovascular abnormalities. Observed toxicological information, specifically for developing fish, can aide resource managers in the relative risk of treating oil spills with dispersant.

Metabolic responses produced by crude versus dispersed oil in Chinook salmon pre-smolts via NMR-based metabolomics.

Crude oil spills from tankers remain a serious threat along coastal California. Resource managers require information on the acute toxicity of treated and untreated oil, and their sublethal effects on wildlife. This investigation compared the toxic actions of the water-accommodated fraction (WAF) and the chemically-enhanced WAF (CEWAF; Corexit 9500) of Prudhoe Bay crude oil in pre-smolt Chinook salmon (Oncorhynchus tshawytscha) via nuclear magnetic resonance (NMR)-based metabolomics. Metabolite profiles from muscle samples, after 96h exposures, were measured using 1D (1)H NMR and compared via principal component analysis. It was determined that both WAF and CEWAF produced similar profiles in which amino acids, lactate and ATP comprised the highest intensity signals. Overall, metabolic substrates and growth measurements did not show residual effects of short-term exposure on long-term development. In conclusion, the 96h LC(50)s indicate dispersant application significantly decreased hydrocarbon potency and identified metabolites may be bio-indicators of hydrocarbon stress from hydrocarbon exposure.

Characterization of the metabolic actions of crude versus dispersed oil in salmon smolts via NMR-based metabolomics.

With maritime transport of crude oil from Alaska to California, there is significant potential for a catastrophic spill which could impact migrating salmon. Therefore, this study compared the lethal and sublethal metabolic actions of the water-accommodated fraction (WAF) and the chemically enhanced WAF (CEWAF, via Corexit 9500) of Prudhoe Bay crude oil in smolts of Chinook salmon (Onchorhyncus tshawytscha). After 96-h exposure to the CEWAF, the resulting LC50 was some 20 times higher (i.e., less toxic) than that of the WAF. Muscle and liver samples from surviving fish were collected and low-molecular weight metabolites were analyzed using one-dimensional (1)H and projections of two-dimensional (1)H J-resolved NMR. Principal component analysis (PCA), employed to analyze NMR spectra and identify most variance from the samples, revealed age-related metabolic changes in the fish within the replicated studies, but few consistent metabolic effects from the treatments. However, ANOVA results demonstrated that the dose-response metabolite patterns are both metabolite- and organ-dependent. In general, exposure to either WAF or CEWAF resulted in an increase of amino acids (i.e., valine, glutamine and glutamate) and a decrease of both organic osmolytes (i.e., glycerophosphorylcholine) and energetic substrates (i.e., succinate). The simultaneous increase of formate and decrease of glycerophosphorylcholine in the liver, or the decrease of glycerophosphorylcholine in muscle, may serve as sensitive sublethal biomarkers for WAF or CEWAF exposures, respectively. In conclusion, dispersant treatment significantly decreased the lethal potency of crude oil to salmon smolts, and the NMR-based metabolomics approach provided a sensitive means to characterize the sublethal metabolic actions.

Interstudy reproducibility of three-dimensional volume-selective fast spin echo magnetic resonance for quantifying carotid artery wall volume.

PURPOSE: To assess the interstudy reproducibility of a three-dimensional volume-selective, fast spin echo (FSE) magnetic resonance technique for the assessment of carotid artery wall volume, which is a marker for total carotid plaque volume. MATERIALS AND METHODS: Interstudy reproducibility was evaluated in 10 subjects with evidence of carotid artery atherosclerotic disease on carotid Doppler ultrasonography. Subjects were scanned twice with an interscan time of one hour to four days. The carotid artery was imaged in cross-section, and the total carotid arterial wall volume (TWV) was calculated by subtraction of the total carotid lumen volume from the total outer carotid vessel volume. RESULTS: The mean carotid TWV for the scans was 741 and 734 mm3, respectively, with no significant difference (mean difference 7 mm3; P = 0.5). The time for each study was approximately 20 minutes. The standard deviation of the differences between the measurements was 33 mm3, yielding an interstudy coefficient of variation of 4.4%. Sample size calculations showed that 16 patients would enable this difference in plaque volume over time to be detected with 80% power at a P value of 0.05. CONCLUSION: Volumetric analysis with CMR of carotid artery plaques using a three-dimensional volume-selective FSE is efficient with good interstudy reproducibility, and is well suited for longitudinal studies of progression of carotid atheroma with reasonable sample sizes.