Surgically Implanted Electrodes Enable Real-Time Finger and Grasp Pattern Recognition for Prosthetic Hands.

Currently available prosthetic hands are capable of actuating anywhere from five to 30 degrees of freedom (DOF). However, grasp control of these devices remains unintuitive and cumbersome. To address this issue, we propose directly extracting finger commands from the neuromuscular system via electrodes implanted in residual innervated muscles and regenerative peripheral nerve interfaces (RPNIs). Two persons with transradial amputations had RPNIs created by suturing autologous free muscle grafts to their transected median, ulnar, and dorsal radial sensory nerves. Bipolar electrodes were surgically implanted into their ulnar and median RPNIs and into their residual innervated muscles. The implanted electrodes recorded local electromyography (EMG) with Signal-to-Noise Ratios ranging from 23 to 350 measured across various movements. In a series of single-day experiments, participants used a high speed pattern recognition system to control a virtual prosthetic hand in real-time. Both participants were able to transition between 10 pseudo-randomly cued individual finger and wrist postures in the virtual environment with an average online accuracy of 86.5% and latency of 255 ms. When the set was reduced to five grasp postures, average metrics improved to 97.9% online accuracy and 135 ms latency. Virtual task performance remained stable across untrained static arm positions while supporting the weight of the prosthesis. Participants also used the high speed classifier to switch between robotic prosthetic grips and complete a functional performance assessment. These results demonstrate that pattern recognition systems can use the high-quality EMG afforded by intramuscular electrodes and RPNIs to provide users with fast and accurate grasp control. SUMMARY: Surgically implanted electrodes recorded finger-specific electromyography enabling reliable finger and grasp control of an upper limb prosthesis.

Evaluation of the BD MAX™ MDR-TB assay in a real-world setting for the diagnosis of pulmonary and extra-pulmonary TB.

Tuberculosis in London occurs at a rate of 19 cases per 100,000 population, with a significant proportion diagnosed as extra-pulmonary infection. At Barts Health NHS Trust, our TB rates are much higher than the London average and approximately 60% cases are extra-pulmonary in nature. We evaluated the BD MAX™ MDR-TB assay as a molecular tool for rapid diagnosis of TB. One hundred twenty-eight specimens, encompassing pulmonary (70) and extra-pulmonary (58) infection, were tested using the BD MAX™ MDR-TB assay and compared with smear and liquid culture results, to determine PCR performance. The BD MAX™ MDR-TB assay was also compared with the Xpert MTB/RIF assay, where applicable. TB was successfully detected in 50/66 Mycobacterium tuberculosis culture positive specimens, with additional detections in 2 of the culture negative specimens. The BD MAX™ MDR-TB assay demonstrated higher sensitivity with the pulmonary samples (92%) compared with the extra-pulmonary samples (52%), although the performance with fluids and biopsies demonstrated greater potential than the remaining extra-pulmonary samples. Rifampicin and/or isoniazid resistance was successfully detected by the BD MAX™ in 2/3 samples, where WGS susceptibility results were available. The BD MAX™ MDR-TB assay was comparable with the performance of the Xpert MTB/RIF assay. TB can successfully be diagnosed, in both pulmonary and extra-pulmonary samples, using the BD MAX™ MDR-TB assay.

Examining the effect of spinal cord injury on emotional awareness, expressivity and memory for emotional material.

The prevailing view on the effects of spinal cord injury (SCI) on emotion is that it dampens emotional experience due to a loss of peripheral bodily feedback, with the higher the lesion on the spinal cord the greater the reduction in the intensity of emotional experience. This view persists despite many studies showing an absence of such an emotional impairment in people with SCI. This study specifically aimed to investigate whether total cervical-6 spinal cord transection (i) reduces emotional expressivity and emotional awareness (ii) impairs memory for emotional material. The study contained three groups: 24 patients with SCI, 20 orthopaedic injury control (OIC) patients and 20 young adult controls. A mixed factor design was employed to examine between group and within subject differences. Participants completed the Levels of Emotional Awareness Scale (LEAS), the Berkeley Expressivity Questionnaire (BEQ), and viewed an emotionally arousing slide presentation. Thirty minutes post viewing, participants completed memory tests for the presentation. SCI patients reported greater present levels of emotional expressivity compared with perceived levels prior to their injuries. SCI and OIC groups did not differ on any of the emotional awareness variables. There was also no evidence that SCI leads to impairment in memory for emotional events. This study's findings contradict the mainstream view in the cognitive neuroscience of emotion that SCI dampens emotional experience.

Evaluating the impact of a new pay agreement on New Zealand nursing.

AIM: This paper examines the labour market impact of a new national pay award for nurses implemented in New Zealand in 2004/5 - the Multi-Employer Collective Agreement (MECA). BACKGROUND: The health system in New Zealand is unusual in that, while retaining a public sector system, the focus of pay determination for nurses over the last 20 years has shifted first from national to local pay determination, and then more recently reversed this trend, moving back to a national level pay determination. The shift back to a national pay determination approach in 2004/5 is therefore worthy of examination, both in terms of its labour market impact, and as a case study in the use of national level pay determination. METHODS: The research was conducted in 2007-8. A rapid appraisal method was used, based on key stakeholder interviews, a document and literature review and a review and analysis of available data on the New Zealand nurse labour market, and trends in application rates to schools of nursing were assessed. In addition, interviews with managers of two District Health Boards, and interviews with five non-government employers of nurses, were conducted. RESULTS: Indicators pointing to improvements included: steady (though not rapid) growth in staff numbers; reduced difficulty in recruiting; reduced vacancy rates; and increased application rates to schools of nursing. Managers interviewed in the study supported these positive indications, but some health-care employers not covered by the pay award reported negative knock-on effects (e.g. needing to match DHB rates, increased retention and recruitment difficulties). CONCLUSIONS: Available nurse labour market data provide an incomplete but compelling picture of the positive impacts of the MECA in a period of a very tight labour market. While much of the content of the 2004/5 agreement could be characterized as a 'normal' pay bargaining contract, there were also issues that differentiated it from the norm. In particular, it included an agreement to establish a safe staffing commission to assess the impact and implications of low staffing levels, nursing workload, and to establish guidelines on safe staffing and healthy workplaces.

Spinal cord injury rehabilitation: the experience of women.

STUDY DESIGN: Qualitative study. OBJECTIVES: To develop the knowledge base regarding women's experiences of spinal cord injury (SCI) rehabilitation. SETTING: United Kingdom. METHODS: Qualitative interviews with 10 women from four regional SCI rehabilitation centres were transcribed verbatim and analysed according to grounded theory. RESULTS: The central psychosocial problem identified for women during SCI rehabilitation was vulnerability. Vulnerability was amplified by lack of privacy within the rehabilitation centre, by negative staff interactions (associated with perceived lack of control and lack of respect) and by women's minority status in the rehabilitation setting, which at times left women feeling marginalized and inferior. Vulnerability was contained by: negotiating privacy and space; receiving support and encouragement from staff, other patients and family; and by adopting a positive attitude. CONCLUSION: The SCI rehabilitation environment and interactions within it have the potential to influence significantly, either positively or negatively, women's feelings and behaviours as they begin to negotiate a revised identity as a disabled person. There is a need for further research to be carried out in this area in order that women's needs and concerns can be better understood and clinical practice developed accordingly.

Investigations of complaints and quality of health care.

Malpractice law is frequently justified by the claim that it improves health care services but this belief remains untested. Using a multiple case study in 16 remote rural areas in New Zealand, this study examined the effects of formal quasi-judicial investigations on the quality of health care services. The study found that the fragile local health systems were damaged by the quasi-judicial investigations of the medical disciplinary body and became less efficient and less user-friendly. A few doctors left rural practice and were difficult to replace. The remaining health workers responded to the investigations in a negative manner, losing confidence, enthusiasm and motivation for work; they performed in a less efficient manner, working more slowly, setting up barriers to access, ordering more tests and referring more to secondary care. Complainants also appeared to have been disadvantaged as a consequence of having complained.

Towards a systemic understanding of a hospital waiting list.

Hospital waiting lists are a feature of publicly funded health services that result when demand appears to exceed supply. While much has been written about surgical waiting lists, little is known about the dynamics of radiology waiting lists, which is surprising given that rational treatment, and indeed the medical profession's claim to expertise, rests on establishing a diagnosis. This paper reports the findings of a case study of a problematic ultrasound waiting list. In particular, this paper highlights how the management of the ultrasound waiting list served to subordinate the needs of waiting patients and their general practitioners to the interests and values of radiologists. Radiologist concern to protect specialist expertise from encroachment by outpatient clinicians and sonographers is implicated in the growth of the ultrasound waiting list. It is argued that an adequate understanding of ultrasound waiting lists depends on grasping how radiologists are successful in structuring problems of access in ways that enhance radiologist control over ultrasound imaging. The case study reported helps to shed light on why increasing funding to clear waiting lists proves ineffective.

Betwixt and between: ritual and the management of an ultrasound waiting list.

Hospital waiting lists are a feature of publicly funded health services that results when demand appears to exceed supply. While much has been written about hospital waiting lists, little is known about the dynamics of diagnostic waiting lists, or more generally why hospital waiting lists behave in perverse and often counter-intuitive ways. This paper attempts to address this gap by applying a recent development in critical systems thinking called boundary critique to understand how a particular ultrasound waiting list was managed. A new waiting list metaphor based on waiting lists as ritual forms is proposed.

Decision making in patients with spinal cord damage: afferent feedback and the somatic marker hypothesis.

Damasio has proposed an influential model of human decision making - the somatic marker hypothesis (Damasio AR. Descates' Error. London: Papermac/Macmillan, 1994), where he argues that somatic feedback to the brain influences decision making in man. It is proposed that when choosing between options that differ in relative risk, a somatic marker (e.g. a 'gut feeling') feeds back to the brain and influences cognitive appraisal. In the present study patients who had suffered a complete tetraplegia at the level of the sixth cervical vertebra were compared with matched healthy control subjects. As the spinal injury group have reduced somatic/peripheral feedback via the spinal cord, it was predicted, based on the somatic marker hypothesis, that they may demonstrate riskier behaviour than controls. All subjects completed the Iowa Gambling Task, a computerised card playing game where the player is instructed to try and win as much money as possible over 100 selections from one of four decks. The rules are not disclosed in advance, and the player gradually 'learns' that two of the decks are 'high risk' and lead to significant financial losses. Healthy individuals have previously been shown to learn to avoid the risky decks, whereas patients with medial frontal lobe damage (Bechara A, Damasio AR, Damasio H, Anderson SW. Insensitivity to future consequences following damage to human prefrontal cortex. Cognition 1994;50:7-15) and those with peripheral neuropathy (Bechara A, Tranel D, Wilson J, Heberlein AS, Ross M, Damasio AR, 1998. Impaired decision-making in peripheral neuropathy. Society for Neuroscience Abstracts 24:1176) select an excessive number from the risky decks, and consequently lose money. In the present study there were no significant differences between the spinal sectioned and healthy control groups in either card selection strategy or net financial outcome. This result suggests that in terms of the somatic marker hypothesis, feedback to the brain from the periphery via the cranial vagus and other nerves and the hormonal route may be equally or more influential than afferent feedback transmitted via the spinal cord.

Management challenges faced by managers of New Zealand long-term care facilities.

This article reports on a postal survey of 78 long-term care managers in one region of New Zealand, of whom 45 (58%) responded. Most long-term care managers (73.2%) were middle-aged females holding nursing but not management qualifications. Most long-term care facilities (69%) tended to be stand-alone facilities providing a single type of care (rest home or continuing care hospital). The most prominent issues facing managers were considered to be inadequate funding to match the growing costs of providing long-term care and occupancy levels. Managers believed that political/regulatory, economic and social factors influenced these issues. Despite a turbulent health care environment and the challenges facing managers, long-term care managers reported they were coping well and valued networking.

Educating health managers: the role of SHAPE.

This article highlights the need of health professionals to add management skills to their portfolio, and discusses the role of SHAPE in meeting this need. A list of management-related courses that are available to health professionals is provided.

What role for the general practitioner in child protection?

BACKGROUND: New government guidance on cooperation in child protection confirms the importance of the general practitioner (GP) contribution. While research highlights the concerns of others about their role in the multi-agency process, relatively little is known about the views and experiences of GPs themselves. AIM: To examine the understanding that each of the key professional groups had of its own and each other's roles in child protection to identify those factors seen to enhance or inhibit the effective performance of these roles. METHOD: The research formed part of a larger investigation of the role of health professionals in child protection, which combined case study investigations of child protection networks in three health authority sites with a regional survey of Area Child Protection Committee members. RESULTS: A lack of correspondence was identified between GPs' perception and performance of their role in child protection and the expectations placed upon them by other child protection professionals and government guidance. CONCLUSION: The study identifies the need for more explicit discussion of the nature and extent of the GP role in local interagency child protection networks.

Implementation of analytical technologies in a pharmaceutical development organization--looking into the next millennium.

Managing the implementation of new technology in a pharmaceutical development environment has provided challenges and opportunities to obtain benefits from technologies, e.g. laboratory automation. Successful application of new techniques requires a dedicated resource. Within Pharmaceutical Technologies, this was initially a single person, who has since evolved into a team dedicated to the investigation and development of robotics and non-invasive analytical techniques. Pharmaceutical development is an important interface between research and commercial manufacturing. In research, the success of genomics and combinatorial chemistry will result in a significant increase in the number of development compounds, and this, combined with the desire of commercial manufacturing to move towards parametric release, puts an emphasis on the need for rapid analytical methods. Some ideas on the techniques that will be required to meet these goals will be described together with their impact on automation.

The psychological effects of spinal cord injury: a review.

Spinal cord injury (SCI) usually necessitates considerable changes in the life of an individual, and their family members. SCI may demand difficult psychological adjustment and in addition place great strain on family roles and relationships. Glass (1993) summarises the situation thus: 'The experience of spinal cord injury is one of the most devastating injuries which might affect an individual. The resultant disability, after which normal cognitive function and intellectual ability usually remains, produces not only an inability to move and feel limbs, but also the inability to control the function of internal organs and even, in severe cases, the ability to breathe independently.'1

Diatom analysis in victim's tissues as an indicator of the site of drowning.

The diagnosis of drowning is one of the most difficult in forensic pathology and previously we proposed criteria for a positive tissue analysis according to the qualitative and quantitative diatom investigations. In the positive cases, we studied the reliability of determining the site of drowning by comparing the diatom taxa found in the lung samples with those of the water samples or in the absence of these samples with the results of the water diatom monitoring programme set up in our region. In this study, we present two series of cases, the first is one of 20 corpses who died from accidental or suicidal drowning with known drowning site, and the second of 20 corpses for which the drowning site was unknown. The results showed that a concordance of the abundance of the diatom taxa in tissues compared to the site of drowning and their distribution relative to one another was 65% in the group where the site of drowning was known and 35% in the other group. The concordance of the individual distribution in the lungs of water diatom taxa may be an interesting method to guide the investigations for determining the site of drowning. The two limiting factors are the concentration of diatoms in the lungs and the development of a river monitoring programme in the district of the study.

Going with the grain? General practitioners and the new NHS.

A number of policy initiatives over the last few years have encouraged general practitioners (GPs) to participate in commissioning, as opposed to simply purchasing, health care. This role was reinforced in the white paper, The New NHS. A qualitative study of GPs in two health authorities uncovered not only concerns about the reforms which have since emerged in the medical and general press, but other issues which have been less frequently articulated. There was also evidence of goodwill towards professional colleagues, including those in social services departments. The preference for professional, as opposed to market relationships may help to secure the collaborative ethos desired by government. However, if the concerns the study uncovered are indicative of a more widespread response to the white paper, they suggest the need for careful support of developing Primary Care Groups (PCGs).

Laboratory automation -some perspectives on the challenges in the implementation of the technology in pharmaceutical development.

The intensifying pressure on reducing the development time for new pharmaceutical products is resulting in an increasing need for laboratory automation. A key element for the successful implementation of robotics for drug product analysis is the establishment of a reliable process for interaction of the automation team with its various customers, for example development product team and manufacturing group. The reduction of cycle time for product development appears to be resulting in more stability studies to support NDA/MAA filings for several reasons. Key clinical information may not be available before initiation of the stability studies and simultaneous world-wide development may result in an increase in the number of product strength and pack options.

One hand is better than two: motor extinction of left hand advantage in unilateral neglect.

Severe left visual neglect has previously been shown to reduce when left hand movements in left hemispace were performed simultaneously to a series of cancellation tasks (Robertson and North, Neuropsychologia 30, 553-563, 1992). The present study demonstrates in two separate cases that this advantage associated with left hand activation was eliminated by simultaneous right hand activation, whether carried out in left or right hemispace. This suggests the existence of an extinction phenomenon for motor output which affects perceptual functioning, and a possible theoretical basis for this is discussed.