Challenges of Developing Robust AI for Intrapartum Fetal Heart Rate Monitoring.

Background: CTG remains the only non-invasive tool available to the maternity team for continuous monitoring of fetal well-being during labour. Despite widespread use and investment in staff training, difficulty with CTG interpretation continues to be identified as a problem in cases of fetal hypoxia, which often results in permanent brain injury. Given the recent advances in AI, it is hoped that its application to CTG will offer a better, less subjective and more reliable method of CTG interpretation. Objectives: This mini-review examines the literature and discusses the impediments to the success of AI application to CTG thus far. Prior randomised control trials (RCTs) of CTG decision support systems are reviewed from technical and clinical perspectives. A selection of novel engineering approaches, not yet validated in RCTs, are also reviewed. The review presents the key challenges that need to be addressed in order to develop a robust AI tool to identify fetal distress in a timely manner so that appropriate intervention can be made. Results: The decision support systems used in three RCTs were reviewed, summarising the algorithms, the outcomes of the trials and the limitations. Preliminary work suggests that the inclusion of clinical data can improve the performance of AI-assisted CTG. Combined with newer approaches to the classification of traces, this offers promise for rewarding future development.

Fracture Patients' Attitudes towards Online Health Information & a 'Prescribed' Fracture Website

Introduction Following musculoskeletal injury patient education is essential to help patients understand their treatment. Many attend the orthopaedic fracture clinic with multiple questions related to their diagnosis and treatment. Aim To assess trauma patients' attitudes towards online health information and a specific orthopaedic patient information website. Methods A validated questionnaire was distributed over 5 consecutive clinics, with questions based on previous online experiences & www.myorthoclinic.com. Results One hundred six patients completed the survey. Seventy-one percent trusted the internet whereas 83% trusted the information provided by the website. Eighty-three percent felt encouraged to take action to benefit their health. Eighty-seven percent felt that there was a wide range of information provided. Seventy-two percent agreed that they learnt something new. Discussion Patients attending the trauma clinic have benefited from the 'prescribing' of a dedicated orthopaedic trauma website. This low-cost concept utilises minimal resources, requires little effort to implement and is applicable to all specialties.

Arthrodesis of Little Finger Distal Interphalangeal Joint in Flexion to Regain Sporting Ability.

BACKGROUND: Finger injuries are common in the sport of hurling. Injury to the little finger distal interphalangeal joint (DIPJ) often occurs when a high dropping ball impacts on the outstretched finger. The little finger contributes to approximately 15% of grip strength. Injury therefore results in reduced grip strength and may impair the ability of players to grip or catch a ball. METHODS: Six elite hurlers with post-traumatic arthritis of their non-dominant little finger DIPJ underwent arthrodesis in 30 degrees of flexion. Kirchner wires were inserted for up to 8 weeks to achieve fusion of the joint. Patients were evaluated after recovery using a dynamometer to assess grip strength, the DASH questionnaire and a sport specific questionnaire. RESULTS: All arthrodeses achieved bony union without complication. All patients reported a resolution of their pain and recovery in their ability to catch & retain a ball. Measurements of grip strengths were comparable between hands. DASH scores improved by up to 47 points. All scores were less than 5 at final follow-up. CONCLUSIONS: Grip strength decreases when fingers are immobilized in full extension. In sports that require catching or gripping a ball or a bat, arthrodesis of the DIP joint in flexion can improve grip strength and hand function. Fusion in 30 degrees of flexion for hurlers results in restoration of function and resolution of pain. Little finger DIPJ arthrodesis is a valid method of treating posttraumatic arthritis in ball and bat sports.

Relationship of galectin-3 with obesity, IL-6, and CRP in women.

PURPOSE: To evaluate the association of galectin-3 (Gal3) with obesity and inflammatory status in a cohort of metabolically healthy, predominantly African-American women with varying cardiovascular disease (CVD) risk as determined by CRP levels. METHODS: We assessed the association between BMI and serum levels of Gal3, IL-6, CRP, and adiponectin in metabolically healthy women (N = 97) to determine the overall association between Gal3, obesity, and inflammation in groups at different CVD risk. RESULTS: Obese women had significantly higher serum Gal3 compared to non-obese participants (P = 0.0016), although Gal3 levels were comparable among different classes of obesity. BMI (R 2 = 0.1406, P = 0.0013), IL-6 (R 2 = 0.0689, P = 0.035), and CRP (R 2 = 0.0468, P = 0.0419), but not adiponectin, positively predicted the variance of Gal3 levels in the total study population. However, the predicting effect of BMI (R 2 = 0.2923, P = 0.0125) and inflammation (R 2 = 0.3138, P = 0.038) on Gal3 was only present in women at low/moderate risk of CVD (CRP ≤ 3 µg/mL). CONCLUSIONS: Gal3 is positively correlated with obesity and inflammation in women, while the presence of elevated CVD risk may disturb the strength of Gal3 as a biomarker of inflammation.

The path of screw insertion for stabilization of the scapholunate joint: a cadaveric study.

The aim of this study was to determine the path of screw placement to avoid breaching the articular surface of both lunate and scaphoid bones at the radiocarpal and midcarpal joints. An Acutrak screw was inserted into the right scapholunate joint of ten cadavers starting immediately distal to the tip of the radial styloid and aiming for the tip of the ulnar styloid. The articular surfaces of the scaphoid and lunate bones in all ten cadavers were exposed and examined. A computed tomography (CT) scan of four wrists was performed. Eight of the ten cadavers had no perforation or destruction of the articular surfaces. Screw stabilization of the scapholunate joint can be performed without perforation or destruction of the lunate or scaphoid surfaces. We recommend that if this form of fixation is being used then the screw should be inserted commencing at the radial styloid tip and aiming for ulnar styloid tip, under radiological guidance.

A five-year review of publication productivity among Irish orthopaedic units.

BACKGROUND: The academic productivity of trainees, consultants and institutions is frequently judged by the quantity of articles published in peer-reviewed medical journals. AIM: To assess the publication history of Irish orthopaedic units over a 5-year period, and to identify patterns of publication. METHODS: A PubMed search was performed of each consultant affiliated with each orthopaedic unit in the country for between 2004 and 2008. Publications were classified by individual, institution, publication type and impact factor. RESULTS: Over the 5 years of the study, 239 papers were published from 19 orthopaedic units, in 69 different journals. Fifty-six consultants had at least one senior author publication, with seven consultants having more than ten. Impact factors of the journals targeted varied considerably and reveals an interesting duality among authors when opting for profile or prestige. CONCLUSION: We feel this study represents a comprehensive and novel review of the state of publishing in a surgical specialty.

A new barbed device for repair of flexor tendons.

We split 100 porcine flexor tendons into five groups of 20 tendons for repair. Three groups were repaired using the Pennington modified Kessler technique, the cruciate or the Savage technique, one using one new device per tendon and the other with two new devices per tendon. Half of the tendons received supplemental circumferential Silfverskiöld type B cross-stitch. The repairs were loaded to failure and a record made of their bulk, the force required to produce a 3 mm gap, the maximum force applied before failure and the stiffness. When only one device was used repairs were equivalent to the Pennington modified Kessler for all parameters except the force to produce a 3 mm gap when supplemented with a circumferential repair, which was equivalent to the cruciate. When two devices were used the repair strength was equivalent to the cruciate repair, and when the two-device repair was supplemented with a circumferential suture the force to produce a 3 mm gap was equivalent to that of the Savage six-strand technique.

Overexpression of PAI-1 prevents the development of abdominal aortic aneurysm in mice.

Vessel wall inflammation and matrix destruction are critical to abdominal aortic aneurysm (AAA) formation and rupture. We have previously shown that urokinase plasminogen activator (uPA) is highly expressed in experimental AAA and is essential for AAA formation and expansion. In this study, we examined the effects of overexpression of a natural inhibitor of uPA, plasminogen activator inhibitor-1 (PAI-1), on the development of angiotensin (Ang) II-induced AAA in ApoE-deficient (ApoE(-/-)) mice. Mice were treated with recombinant adenovirus containing either the human PAI-1 gene (Ad5.CMV.PAI-1) or the luciferase gene (Ad5.CMV.Luc) delivered either locally by intra-adventitial injection or systemically by tail vein injection. Our results show that local delivery of the PAI-1 gene completely prevented AAA formation (0 vs 55.6% in Ad5.CMV.Luc controls, P<0.05). In contrast, systemic delivery of the PAI-1 gene did not affect AAA incidence (78 vs 90% in Ad5.CMV.Luc controls, P=0.125). Local delivery of the PAI-1 gene 2 weeks after Ang II infusion prevented further expansion of small aneurysms, but had no significant effect on the progression of larger aneurysms. These data suggest that local PAI-1 gene transfer could be used to stabilize small AAA and reduce the rate of expansion and risk of rupture.

A biomechanical analysis of multistrand repairs with the Silfverskiold peripheral cross-stitch.

We compared the bulking and tensile strength of the Pennington modified Kessler, Cruciate and the Savage repairs in an ex vivo model. A total of 60 porcine tendons were randomised to three groups, half repaired using a core suture alone and the remainder employing a core and peripheral technique. The tendons were distracted to failure. The force required to produce a 3 mm gap, the ultimate strength, the mode of failure and bulking for each repair were assessed. We found that there was a significant increase in strength without an increase in bulk as the number of strands increased. The Cruciate repair was significantly more likely to fail by suture pullout than the Pennington modified Kessler or Savage repairs. We advise the use of the Savage repair, especially in the thumb, and a Cruciate when a Savage is not possible. The Pennington modified Kessler repair should be reserved for multiple tendon injuries.

Mutual mentoring in laparoscopic urology - a natural progression from laparoscopic fellowship.

INTRODUCTION: The objective of this study is to report a novel system of 'mutual mentoring' that overcomes the limited availability of laparoscopic mentors and allows progression from laboratory and fellowship experience into independent clinical practice. PATIENTS AND METHODS: A total of 88 laparoscopic cases were performed during the fellowship. In the first 2 years as consultants, we (AJ and MS) performed 151 cases with mutual mentoring (simple nephrectomy [n = 28], radical nephrectomy [n = 35], nephro-ureterectomy [n = 19], pyeloplasty [n = 31], pelvic LND [n = 21], others [n = 17]). RESULTS: Mutual mentoring has resulted in the successful introduction of laparoscopic services to two hospitals, allowing an exposure to an average of two cases a week. Complication rates are acceptable and objective measures such as conversion rates, operative time and blood loss appear to be improving. CONCLUSIONS: Mutual mentoring allows for a greater through-put of cases, a high level of assistance, advice with intra-operative decisions and the potential to 'share' cases, reducing fatigue and increasing experience. It provides significant moral support in the difficult early days of starting the service. Its disadvantages are that it is time consuming and is geographically restrictive. Mutual mentoring has allowed us to introduce a laparoscopic service at our respective hospitals with high case-load acceptable complication rates.

Longwave infrared (LWIR) coded aperture dispersive spectrometer.

We describe a static aperture-coded, dispersive longwave infrared (LWIR) spectrometer that uses a microbolometer array at the detector plane. The two-dimensional aperture code is based on a row-doubled Hadamard mask with transmissive and opaque openings. The independent column code nature of the matrix makes for a mathematically well-defined pattern that spatially and spectrally maps the source information to the detector plane. Post-processing techniques on the data provide spectral estimates of the source. Comparative experimental results between a slit and coded aperture for emission spectroscopy from a CO(2) laser are demonstrated.

Transperitoneal or extraperitoneal laparoscopic radical prostatectomy: does the approach matter?

PURPOSE: : The greater accuracy of apical dissection and reconstruction in our first 100 patients undergoing transperitoneal laparoscopic radical prostatectomy (TLRP) was not matched by a proportionate increase in the rate of return to normal continence compared with our prior open prostatectomy experience. We postulated that greater bladder dysfunction due to the almost total bladder dissection mandated by TLRP might be responsible and this might be rectified by the adoption of laparoscopic radical prostatectomy using an extraperitoneal approach (ELRP). MATERIALS AND METHODS: : A total of 100 patients undergoing TLRP were compared with 100 undergoing ELRP. The groups were subdivided into halves to investigate the influence of any learning curve effect. All patients had clinical stage T3aN0M0 or less prostate cancer and they were operated on by a single surgeon. RESULTS: : Mean operative time (238.9 vs 190.6 minutes), blood loss (310.5 vs 201.5 ml), postoperative hospitalization (3.8 vs 2.6 nights) and catheterization duration (11.3 vs 10.1 days) were significantly greater in the TLRP group. After the first 50 cases were excluded in each group statistical significance persisted only for operative time (218.3 vs 184.2 minutes) and hospitalization (3.5 vs 2.5 nights). The pad-free rate was significantly lower 3 months following ELRP (80% vs 56%, p = 0.02). The overall 12-month pad-free rate for TLRP and ELRP was 90% and 96%, respectively. The overall 12-month erection rate for TLRP and ELRP was 61% and 82%, respectively. CONCLUSIONS: : ELRP is superior to TLRP with respect to operative time, hospitalization and early continence.

Use of cultured cells of kidney origin to assess specific cytotoxic effects of nephrotoxins.

During drug discovery, assessment of renal safety for a compound is important for further development of a candidate drug. In this study, we describe an in vitro cell-based assay capable of discerning nephrotoxicity. Three cell types, two of kidney origin and one of liver origin, were used to examine the effects of nephrotoxins. The cell types were the porcine normal kidney tubular epithelial cell line (LLC-PK1), the primary human renal proximal tubular epithelial cells (hRPTEC) and the human liver cell line (HepG2). Cytotoxicity was measured using a luciferin/luciferase assay that measures cellular ATP levels. Four known nephrotoxins, 4-aminophenol, cisplatin, cyclosporin A and paraquat, were tested in this cell-based assay to evaluate cytotoxicity on drug exposure. Kidney-derived LLC-PK1 cells and hRPTECs were found to be sensitive to selected nephrotoxins while liver-derived HepG2 cells were insensitive. Human RPTEC cells obtained from three individual donors demonstrated highly reproducible effects on drug exposure. With respect to drug discovery efforts, integration of the cell models described here are valuable for evaluation of nephrotoxic potentials during lead selection and optimization processes.

Sphincterotomy and the treatment of detrusor-sphincter dyssynergia: current status, future prospects.

STUDY DESIGN: Literature review of current treatment options for detrusor-sphincter dyssynergia (DSD) in spinal cord injury. OBJECTIVES: To review the outcomes and complications associated with external sphincterotomy and to summarise the results and complications of alternative treatment options for detrusor-sphincter dyssynergia in spinal cord injury. In addition, we propose a potential alternative future drug treatment for external sphincter dyssynergia based upon recent research on the neuropharmacology of the external urethral sphincter. SETTING: The National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK. METHODS: Medline search from 1966 to 2002 using the words 'external sphincterotomy', 'detrusor-sphincter dyssynergia' and 'neurogenic bladder combined with surgery'. RESULTS: While external sphincterotomy is an effective treatment for DSD, a significant number of men following this procedure continue to have high intrarenal pressures, recurrent urinary infection or troublesome autonomic dysreflexia and a worryingly high proportion demonstrate persistently raised leak point pressures, putting them at subsequent risk of renal damage. Alternative treatments for external sphincter dyssynergia include urethral stents and balloon dilatation, both of which are effective. However, over the long term stents can undergo encrustation and there remains a definite risk of stent migration necessitating stent removal or replacement. Balloon dilatation of the external sphincter is associated with a risk of subsequent stricture formation. Intraurethral Botulinum A toxin seems to be effective though there have been no large randomised studies comparing it against placebo. However, it is not a durable treatment option and it has not found a common place in the treatment of DSD. There is now a considerable amount of experimental data from both animal and human studies to suggest that nitric oxide (NO) is an important physiological inhibitory neurotransmitter in the urethral sphincter, mediating relaxation of the external urethral sphincter. The potential role of sphincter NO augmentation for treatment of DSD is discussed. CONCLUSION: External sphincterotomy remains the mainstay of treatment for urodynamically significant detrusor-sphincter dyssynergia, but in recent years a number of effective, alternative treatment options have become available. While at present there is no effective systemic drug treatment, recent research into external sphincter neuropharmacology suggests that systemic or topical augmentation of external sphincter NO may provide an effective method for lowering sphincter pressure.

Enhanced relaxation of diabetic rabbit cavernosal smooth muscle in response to nitric oxide: potential relevance to erectile dysfunction.

New Zealand white rabbit cavernosal smooth muscle strips (n=6) were mounted in organ baths. Relaxations to nitric oxide (10(-7)-10(-4) mol/l) were measured and the same procedure was repeated on strips from rabbits 6 months after alloxan-induced diabetes (n=6). Transverse cavernosal sections were obtained from the same penises. Low and high resolution autoradiographs were prepared using [(3)H]-L-N(G)-nitroarginine (an index of nitric oxide binding sites) and analysed densitometrically. Histochemical analysis was performed on adjacent sections using NADPH diaphorase (an index of nitric oxide synthase activity). Nitric oxide relaxed control rabbit cavernosal smooth muscle strips in a concentration-dependent manner. Diabetic rabbit cavernosal smooth muscle strips were significantly (P<0.03) more sensitive to nitric oxide (mean IC(50)=3.9 x 10(-6) mol/l). Nitric oxide synthase binding sites were localised to the cavernosal endothelium and smooth muscle. Nitric oxide synthase activity was increased in 6 month diabetic cavernosal smooth muscle. These findings suggest impairments in the L-arginine-nitric oxide pathway may play a role in the pathophysiology of diabetic erectile dysfunction.

Increased nitric oxide accounts for decreased basal vascular tone and responsiveness in the resistance vessels of high-cholesterol-fed rabbits.

The objective of this study was to determine the effects of hypercholesterolemia on basal vascular tone and vascular responses to pharmacologic agents in hindquarter resistance vessels. Blood pressure and hindquarter blood flow were measured in conscious rabbits fed a high cholesterol diet (1%) for 17 weeks (HC) compared to age-matched rabbits fed a normal diet (control). Basal hindquarter blood flow and vascular conductance were significantly higher in HC than in control rabbits. Administration of a non-selective nitric oxide synthase (NOS) inhibitor, L-NAME (100 mg/kg) decreased basal hindquarter blood flow and vascular conductance in a greater magnitude in HC than in control rabbits, thus, abolished the differences in both the flow and conductance between 2 groups, indicating that increased NO was responsible for reduced basal vascular tone in the HC rabbits. L-NIL (30 mg/kg), a selective inducible NOS (iNOS) inhibitor had no effects on either flow or conductance. This result does not support the involvement of iNOS. In separate experiments, animals were anesthetized and instrumented with an extracorporeal circuit to measure perfusion pressure under constant blood flow to the hindquarter vascular bed. In the HC group, vascular responses to acetylcholine, S-nitroso-N-acetyl-penicillamine and phenylephrine were all attenuated when compared to the responses in the control rabbits. These results indicate that local overproduction of NO due to hypercholesteremia could desensitize smooth muscle reactivity, thus causing general vascular hyporesponsiveness to vasoactive agents.