The perioperative utility of 3D printed models in complex surgical care: feedback from 106 cases.

INTRODUCTION: 3D models are an emerging tool for surgical planning, providing an augmented method for the visualisation of a patient's anatomy. As their use increases, more data about the utility of these models is critical to inform budget allocation. This study provides the most comprehensive analysis to date for the use of 3D models in perioperative management. METHODS: 3D models for complex surgical cases in NHS hospitals were delivered alongside a surgeon feedback survey. The survey on the model's utility had been designed alongside the university data analytical team and focused on five areas: surgical planning and diagnosis, economic impact, impact on intraoperative and preoperative time, effect on communication and direct impact on the patient. RESULTS: There were 106 models used by 63 surgeons for complex surgical cases between May 2020 and March 2021, across multiple surgical specialties. The models were reported to have benefits in all perioperative areas, with 92.5% of responses agreeing that the 3D model was a better method for diagnosis and planning than traditional 2D techniques. Benefits were reported on preoperative planning (92.4%), economic savings due to equipment selection (54.4%), reduction in surgical time (41.5%) and surgeon-to-surgeon communication (92.6%). CONCLUSION: 3D models were shown to have a wide range of benefits in a surgical setting. The reduction in surgical time could have the potential to help alleviate surgical backlogs. With more widespread use and optimisation of costs the use of 3D models could become the standard for unusual and complex surgical cases.

Spatial and network analysis of U.S. livestock movements based on Interstate Certificates of Veterinary Inspection.

Livestock movements are a common pathway for the spread infectious diseases in a population. An understanding of livestock movement patterns is needed to understand national transmission risks of highly infectious diseases during epidemics. Social Network Analysis (SNA) is an approach that helps to describe the relationships among individuals and the implications of those relationships. We used SNA to describe the contact structure of livestock movements throughout the contiguous U.S. from April 1st, 2015 to March 31st, 2016. We describe 4 network types: beef cattle, dairy cattle, swine, and small ruminant. Livestock movement data were sourced from Interstate Certificates of Veterinary Inspection (ICVI) while county-level farm demographic data were from the National Agricultural Statistics Service (NASS). In the described networks, nodes are represented by counties and arcs by shipments between nodes; the networks were weighted based on the number of shipments between nodes. For the analyses, movement data were aggregated at the county level and on an annual basis. Measures of centrality and cohesiveness were computed and identification of trade-communities in all networks was conducted. During the study period, a total of 219,042 movements were recorded and beef cattle movements accounted for 63 % of all movements. At least 70 % of U.S. counties were present in each of the networks, but the density of arcs was less than 2% in all networks. In the beef cattle network, counties with high out-degree were strongly correlated (0.8) with the number of beef cows per county while for the dairy cattle network a strong correlation (>0.86) was found with the number of dairy cattle per km2 at the county level. All networks were found to have between 4 and 6 large communities (50 counties or more per community), and were geographically clustered except for the communities in the small ruminant network. Outputs reported in these analyses can help to understand the structure of the contact networks for beef cattle, dairy cattle, swine, and small ruminants. They may also be used in conjunction with simulation modeling to evaluate spread of highly infectious disease such as foot-and-mouth disease at the national level and to evaluate the application of intervention strategies.

Using exceedance probabilities to detect anomalies in routinely recorded animal health data, with particular reference to foot-and-mouth disease in Viet Nam.

The widespread availability of computer hardware and software for recording and storing disease event information means that, in theory, we have the necessary information to carry out detailed analyses of factors influencing the spatial distribution of disease in animal populations. However, the reliability of such analyses depends on data quality, with anomalous records having the potential to introduce significant bias and lead to inappropriate decision making. In this paper we promote the use of exceedance probabilities as a tool for detecting anomalies when applying hierarchical spatio-temporal models to animal health data. We illustrate this methodology through a case study data on outbreaks of foot-and-mouth disease (FMD) in Viet Nam for the period 2006-2008. A flexible binomial logistic regression was employed to model the number of FMD infected communes within each province of the country. Standard analyses of the residuals from this model failed to identify problems, but exceedance probabilities identified provinces in which the number of reported FMD outbreaks was unexpectedly low. This finding is interesting given that these provinces are on major cattle movement pathways through Viet Nam.

Multimodal functional and anatomic imaging identifies preclinical microvascular abnormalities in type 1 diabetes mellitus.

Structural and functional changes in the microcirculation in type 1 diabetes mellitus predict future end-organ damage and macrovascular events. We explored the utility of novel signal processing techniques to detect and track changes in ocular hemodynamics in patients with this disease. Twenty-four patients with uncomplicated type 1 diabetes mellitus and eighteen age- and sex-matched control subjects were studied. Doppler ultrasound was used to interrogate the carotid and ophthalmic arteries, and digital photography was used to image the retinal vasculature. Frequency analysis algorithms were applied to quantify velocity waveform structure and retinal photographic data at baseline and after inhalation of 100% O2. Frequency data were compared between groups. No significant differences were found in the resistive index between groups at baseline or after inhaled O2. Frequency analysis of Doppler flow velocity waveforms identified significant differences in bands 3-7 between patients and control subjects in data captured from the ophthalmic artery (P < 0.01 for each band). In response to inhaled O2, changes in frequency band amplitudes were significantly greater in control subjects compared with patients (P < 0.05). Only control subjects demonstrated a positive correlation (R = 0.61) between changes in retinal vessel diameter and frequency band amplitudes derived from ophthalmic artery waveform data. The use of multimodal signal processing techniques applied to Doppler flow velocity waveforms and retinal photographic data identified preclinical changes in the ocular microcirculation in patients with uncomplicated diabetes mellitus. An impaired autoregulatory response of the retinal microvasculature may contribute to the future development of retinopathy in such patients.

Outcomes of Hybrid Video Assisted Thoracoscopic Surgery for Pulmonary Metastasectomy.

BACKGROUND: Pulmonary metastasectomy is an acceptable treatment option in various metastatic lesions. The role of minimally invasive surgery for metastasectomy remains controversial. We report on a recently described hybrid video-assisted thoracoscopic surgery (hVATS) technique in the community hospital setting. METHODS: Using a retrospective study design, data on 61 patients undergoing 67 resections between April 2000 and January 2008 was collected at a single institution. Patient demographics, pathology, and clinical outcome data were recorded. Kaplan Meier estimates and multivariate Cox regression were used to assess survival and prognostic factors, respectively. RESULTS: Mean patient age was 61.7 years. The majority of lesions were solitary, unilateral, and genitourinary or gastrointestinal in origin (69%). R0 resection was achieved in 97% of cases with the most common operation being lobectomy. Mean length of stay was 4.4 days. Mean follow-up was 39.7 months and 5-year overall survival was 63.2% for the cohort; median survival was not reached. The number of lesions (univariate only) and tumor size over 4 cm influenced overall survival. CONCLUSIONS: Hybrid VATS is a safe and feasible technique in the community medical center setting and warrants additional investigation as an alternative strategy in the management of pulmonary metastases.

Experience using the new GORE Septal Occluder at the margins.

Complex atrial anatomy continues to challenge transcatheter device closure of septal defects. Devices and technology continue to evolve. We report three cases from our institution where the new Gore Septal Occluder was utilized for the closure of a lateral tunnel fenestration, a moderate-sized secundum atrial septal defect and a long tunnel patent foramen ovale. Each case highlights the successful use of this new generation device in challenging circumstances.

Aerobic training-induced improvements in arterial stiffness are not sustained in older adults with multiple cardiovascular risk factors.

There is a well-established relationship between increased arterial stiffness and cardiovascular mortality. We examined whether a long-term aerobic exercise intervention (6 months) would increase arterial compliance in older adults with hypertension complicated by Type 2 diabetes (T2DM) and hyperlipidemia. A total of 52 older adults (mean age 69.3±0.6 years, 30 males and 22 females) with diet/oral hypoglycemic-controlled T2DM, hypertension and hypercholesterolemia were recruited. Subjects were randomly assigned to one of two groups: an aerobic group (6 months vigorous aerobic exercise, AT group) and a non-aerobic group (6 months of no aerobic exercise, NA group). Arterial stiffness was measured as pulse-wave velocity (PWV) using the Complior device. Aerobic training decreased arterial stiffness as measured by both radial (P=0.001, 2-way analysis of variance with repeated measures) and femoral (P=0.002) PWV. This was due to a decrease in arterial stiffness in the AT group after 3 months of training, which was not maintained after 6-month training for either radial (P=0.707) or femoral (P=0.680) PWV. Our findings indicate that in older adults with multiple cardiovascular risk factors, short-term improvements in arterial stiffness became attenuated over the long term.

Closure of multiple fenestrations in an aneurismal atrial septum using overlapping GORE HELEX septal occluders.

Complex atrial septal anatomy can continue to present a challenge for transcatheter closure. We present the successful use of overlapping GORE HELEX atrial septal defect occluders in an adult patient with five distinct fenestrations in an aneurismal septum and how 3D echo can aid device positioning.

Flow-mediated dilatation of the brachial artery is a poorly reproducible indicator of microvascular function in Type I diabetes mellitus.

BACKGROUND: Flow-mediated dilatation (FMD) of the brachial artery is commonly measured as a surrogate marker of endothelial function. Its measurement is, however, technically demanding and reports regarding its reproducibility have not always been favourable. AIM: Two Type I diabetes and control group comparator studies were conducted to assess the reproducibility of FMD and to analyse blood flow data normally discarded during FMD measurement. DESIGN: The studies were sequential and differed only with regard to operator and ultrasound machine. Seventy-two subjects with diabetes and 71 controls were studied in total. METHODS: Subjects had FMD measured conventionally. Blood velocity waveforms were averaged over 10 pulses post forearm ischaemia and their component frequencies analysed using the wavelet transform, a mathematical tool for waveform analysis. The component frequencies were grouped into 11 bands to facilitate analysis. RESULTS: Subjects were well-matched between studies. In Study 1, FMD was significantly impaired in subjects with Type I diabetes vs. controls (median 4.35%, interquartile range 3.10-4.80 vs. 6.50, 4.79-9.42, P < 0.001). No differences were detected between groups in Study 2, however. However, analysis of blood velocity waveforms yielded significant differences between groups in two frequency bands in each study. CONCLUSION: This report highlights concerns over the reproducibility of FMD measures. Further work is required to fully elucidate the role of analysing velocity waveforms after forearm ischaemia.

Comparison of rootMUSIC and discrete wavelet transform analysis of Doppler ultrasound blood flow waveforms to detect microvascular abnormalities in type I diabetes.

The earliest signs of cardiovascular disease occur in microcirculations. Changes to mechanical and structural properties of these small resistive vessels alter the impedance to flow, subsequent reflected waves, and consequently, flow waveform morphology. In this paper, we compare two frequency analysis techniques: 1) rootMUSIC and 2) the discrete wavelet transform (DWT) to extract features of flow velocity waveform morphology captured using Doppler ultrasound from the ophthalmic artery (OA) in 30 controls and 38 age and sex matched Type I diabetics. Conventional techniques for characterizing Doppler velocity waveforms, such as mean velocity, resistive index, and pulsatility index, revealed no significant differences between the groups. However, rootMUSIC and the DWT provided highly correlated results with the spectral content in bands 2-7 (30-0.8 Hz) significantly elevated in the diabetic group (p < 0.05). The spectral distinction between the groups may be attributable to manifestations of underlying pathophysiological processes in vascular impedance and consequent wave reflections, with bands 5 and 7 related to age. Spectral descriptors of OA blood velocity waveforms are better indicators of preclinical microvascular abnormalities in Type I diabetes than conventional measures. Although highly correlated DWT proved slightly more discriminatory than rootMUSIC and has the advantage of extending to subheart rate frequencies, which may be of interest.

Risk factors for seropositivity to bovine coronavirus and bovine respiratory syncytial virus in dairy herds.

A cross-sectional study was conducted to evaluate the association between herd-level characteristics, management routines and farm-level antibody status of bovine coronavirus (BCV) and bovine respiratory syncytial virus (BRSV) in 257 Swedish dairy herds. The possible spatial clustering of positive herds compared with negative herds was also investigated. For each herd, a pooled milk sample from five primiparous cows was analysed for the presence of antibodies to BCV and BRSV. Herd-level information was obtained by a questionnaire. Logistic regression was used to evaluate the association between predictors and antibody status to BCV and BRSV. Large herd size, being located in southern Sweden, and not providing boots for visitors were found to be associated with being antibody-positive to BCV and BRSV. A short distance to the nearest cattle herd was an additional risk factor for BCV. One of the studied areas was suitable for spatial analysis. Positive herds were not spatially autocorrelated when compared with negative herds as estimated by the K-function regarding both BCV and BRSV. This indicates that local factors such as daily visiting milk trucks and wild animals were unlikely to be important sources of infection in this area. Moran's I statistics and semi-variogram showed no evidence of spatial autocorrelation in the residuals, indicating that remaining unidentified factors are not spatially dependent in the areas under study.

Effect of pioglitazone on endothelial function in impaired glucose tolerance.

AIM: Flow-mediated dilation (FMD) is a surrogate marker of endothelial function, which has been proposed as a barometer of vascular health. Impaired microvascular response to reactive hyperaemia is thought to be the mechanism behind reduced shear stress and subsequently impaired FMD, which has been associated with cardiovascular events. This study aims to assess the effect of pioglitazone on the vasculature of patients with impaired glucose tolerance (IGT). MATERIALS AND METHODS: Forty IGT patients with no cardiovascular disease were compared with 24 healthy age- and sex-matched controls. Endothelial function was assessed using FMD of the brachial artery. Adiponectin (ADN) levels were measured and insulin sensitivity was calculated using homeostasis model assessment of insulin resistance (HOMA-IR). A randomised double-blind placebo-controlled trial of the IGT subjects was then performed, with subjects receiving either pioglitazone 30 mg od or matched placebo for 12 weeks before the measurements were repeated. RESULTS: The IGT subjects had a significantly impaired FMD compared with the controls (p < 0.001). Diastolic shear stress (DSS) was also significantly reduced in IGT (p = 0.04). High molecular weight (HMW) ADN was significantly lower in the IGT group than in controls (p = 0.03). On analysis of the IGT group after 12 weeks treatment, FMD was significantly increased in the pioglitazone group compared with placebo (p = 0.03) as was endothelium-independent dilation (EID) (p = 0.03). A significant increase in total ADN (p < 0.001), HMW ADN (p < 0.001) and HMW/total ratio (p = 0.001) occurred in the pioglitazone group compared with placebo. CONCLUSIONS: Pioglitazone improved endothelial function in IGT. Treatment with pioglitazone may reduce the risk of cardiovascular disease in this patient group.

Patterns of contact within the New Zealand poultry industry.

Members of the Poultry Industry Association and the Egg Producers Federation of New Zealand (n=420) were sent a questionnaire asking them to describe the type and frequency of on- and off-enterprise movements relating to feed, live birds and hatching eggs, table eggs and poultry product, and manure and waste litter. Social network analyses were used to describe patterns of contact among poultry enterprises and their associates for these four movement types. The response rate to the survey was 58% (244 out of 420). Network structures for enterprise-to-enterprise movements of feed, live birds and hatching eggs, and table egg and poultry product were characterised by 'hub and spoke' type structures with small-world characteristics. Small worlds were created by network hubs (e.g. feed suppliers and hatcheries) providing goods and services to larger numbers of client farms. In addition to hubs acting as the predominant source of material moving onto farms we identified enterprises acting as bridges between identified small worlds. The presence of these bridges is a concern, since their presence has the potential to facilitate the spread of hazards (e.g. feed contaminants, infectious agents carried within feed) more readily throughout the population. An ability to predict enterprises with these network characteristics on the basis of factors such as shed capacity, enterprise type, geographic location would be useful for developing risk-based approaches to disease prevention, surveillance, detection, response and control activities.

A cross-sectional study of ownership of backyard poultry in two areas of Palmerston North, New Zealand.

AIMS: To determine the proportion of residential land parcels with backyard poultry in an urban and urban-rural fringe area of provincial New Zealand. To document key husbandry and biosecurity practices of owners of backyard poultry, and to identify factors that might assist animal health authorities in locating backyard poultry flocks in the event of an infectious disease emergency. METHODS: A cross-sectional survey was undertaken, in which residents of 449 land parcels in an urban and urban-rural fringe area within and adjacent to the city of Palmerston North, respectively, were visited between February and November 2006. Residents were asked if backyard poultry were kept on the premises. Details recorded for those that kept poultry included the type and number of birds kept, and details of management and biosecurity practices. The geographical distribution of poultry-positive land parcels was assessed for evidence of spatial clustering. RESULTS: Backyard poultry were kept on 3.5 (95% CI=2.1- 5.0)% of land parcels; 1.6 (95% CI=0.7-3.4)% in the urban area and 18.9 (95% CI=11.6-29.3)% in the urban-rural fringe area. There were no significant clusters of poultry-positive land parcels in either area. On all poultry-positive parcels birds were allowed, for at least a portion of the day, to range freely over the property. Three poultry-positive land parcels were within a distance of 1 km of a commercial poultry enterprise in the urban-rural fringe area. Most owners of backyard poultry used feed prepared commercially. CONCLUSIONS: The prevalence of ownership of backyard poultry in this area of New Zealand was low, and varied according to classification of the land, viz urban, or urban-rural fringe. The close proximity of backyard flocks to the single commercial enterprise in the urban-rural fringe area reiterates the importance of strict biosecurity measures on commercial farms. In the event of an infectious disease emergency, it is proposed that a sampling frame of owners of backyard poultry might be rapidly obtained by contacting suppliers of commercial feed.

Colour Doppler ultrasound of the ocular circulation in patients with systemic lupus erythematosus identifies altered microcirculatory haemodynamics.

We assessed whether quantitative analysis of Doppler flow velocity waveforms is able to identify subclinical microvascular abnormalities in SLE and whether eigenvector analysis can detect changes not detectable using the resistive index (RI). Fifty-four SLE patients with no conventional cardiovascular risk factors, major organ involvement or retinopathy were compared to 32 controls. Flow velocity waveforms were obtained from the ophthalmic artery (OA), central retinal artery (CRA) and common carotid artery (CA). The waveforms were analysed using eigenvector decomposition and compared between groups at each arterial site. The RI was also determined. The RI was comparable between groups. In the OA and CRA, there were significant differences in the lower frequency sinusoidal components (P < 0.05 for each component). No differences were apparent in the CA between groups. Eigenvector analysis of Doppler flow waveforms, recorded in proximity of the terminal vascular bed, identified altered ocular microvascular haemodynamics in SLE. Altered waveform structure could not be identified by changes in RI, the traditional measure of downstream vascular resistance. This analytical approach to waveform analysis is more sensitive in detecting preclinical microvascular abnormalities in SLE. It may hold potential as a useful tool for assessing disease activity, response to treatment, and predicting future vascular complications.

Root-MUSIC analysis of nitric oxide-mediated changes in ophthalmic artery blood flow velocity waveforms.

Clinical and experimental studies indicate that structural and functional changes in the microvasculature can predate or accompany risk factors for cardiovascular disease at the earliest stages in the disease process. In the current work, both simulated and actual Doppler ultrasound maximum blood velocity waveform envelopes recorded from the ophthalmic artery were analysed using a root-MUSIC and least squares fitting approach to determine amplitude frequency spectra. Both amplitude and frequency components of noise contaminated simulated waveforms were reliably determined indicating the robustness of the technique. The technique was then used to compare the spectral content of the ophthalmic artery blood velocity waveforms of normal controls in three test states: at baseline, following administration of GTN, a nitric oxide donor, and following administration of L-Name, a nitric oxide inhibitor. Principal components derived from root-MUSIC analysis discriminated between waveforms in baseline and non-baseline test states (p<0.00001) and between GTN and non-GTN test states (p=0.0002).

Elevated CA 125 and ascites: not always malignancy.

BACKGROUND: We present two clinical cases from a single institution where a final diagnosis of cardiac failure was made following the initial finding of ascites and an elevated CA 125 level. In both cases gynaecological malignancy was initially suspected. METHODS: Following negative confirmatory tests for gynaecological malignancy, echocardiography was undertaken. RESULTS: Patient 1 had severe right ventricular dilatation and dysfunction. Patient 2 had biventricular dysfunction with pulmonary hypertension. Both patients responded to standard therapy for heart failure, including loop diuretics.

Thiazolidinediones: effects on insulin resistance and the cardiovascular system.

Thiazolidinediones (TZDs) have been used for the treatment of hyperglycaemia in type 2 diabetes for the past 10 years. They may delay the development of type 2 diabetes in individuals at high risk of developing the condition, and have been shown to have potentially beneficial effects on cardiovascular risk factors. TZDs act as agonists of peroxisome proliferator-activated receptor-gamma (PPAR-gamma) primarily in adipose tissue. PPAR-gamma receptor activation by TZDs improves insulin sensitivity by promoting fatty acid uptake into adipose tissue, increasing production of adiponectin and reducing levels of inflammatory mediators such as tumour necrosis factor-alpha (TNF-alpha), plasminogen activator inhibitor-1(PAI-1) and interleukin-6 (IL-6). Clinically, TZDs have been shown to reduce measures of atherosclerosis such as carotid intima-media thickness (CIMT). However, in spite of beneficial effects on markers of cardiovascular risk, TZDs have not been definitively shown to reduce cardiovascular events in patients, and the safety of rosiglitazone in this respect has recently been called into question. Dual PPAR-alpha/gamma agonists may offer superior treatment of insulin resistance and cardioprotection, but their safety has not yet been assured.