Deep brain stimulation of the subthalamic nucleus in Parkinson disease 2013-2023: where are we a further 10 years on?

Deep brain stimulation has been in clinical use for 30 years and during that time it has changed markedly from a small-scale treatment employed by only a few highly specialized centers into a widespread keystone approach to the management of disorders such as Parkinson's disease. In the intervening decades, many of the broad principles of deep brain stimulation have remained unchanged, that of electrode insertion into stereotactically targeted brain nuclei, however the underlying technology and understanding around the approach have progressed markedly. Some of the most significant advances have taken place over the last decade with the advent of artificial intelligence, directional electrodes, stimulation/recording implantable pulse generators and the potential for remote programming among many other innovations. New therapeutic targets are being assessed for their potential benefits and a surge in the number of deep brain stimulation implantations has given birth to a flourishing scientific literature surrounding the pathophysiology of brain disorders such as Parkinson's disease. Here we outline the developments of the last decade and look to the future of deep brain stimulation to attempt to discern some of the most promising lines of inquiry in this fast-paced and rapidly evolving field.

Preoperative predictors of success after transvaginal rectocoele repair.

PURPOSE: Determine predictors of success for transvaginal rectocoele repair (TVRR). Primary aim is to establish predictors of successful treatment analysing patients' characteristics, baseline symptoms, pelvic floor test results and pre-operative conservative treatment. METHODS: Retrospective single institution study in a tertiary referral centre for pelvic floor disorders. 207 patients underwent TVRR for symptomatic rectocoele. Information about symptoms related to obstructive defaecation, anal incontinence and vaginal prolapse, results of pelvic floor investigations, multimodality conservative management and variation in surgical technique have been recorded. Symptom related information have been collected at surgical follow-up. RESULTS: 115 patients had residual symptoms after surgical repair of rectocoele, while 97 were symptoms free. Factors associated with residual symptoms after surgical repair are previous proctological procedures, urge AI symptoms, absence of vaginal bulge symptoms, use of transanal irrigation and having a concomitant enterocoele repair during procedure. CONCLUSION: Factors able to predict a less favourable outcome after TVRR in patients with concomitant ODS are previous proctological procedures, presence of urge AI, short anal canal length on anorectal physiology, seepage on defaecating proctography, use of transanal irrigation, absence of vaginal bulge symptoms and enterocoele repair during surgery. These information are important for a tailored decision making process and to manage patients' expectations before surgical repair.

Pulmonary Barotrauma in a BUD/S Candidate Following Shallow Dives Using the MK 25 Rebreather.

Pulmonary barotrauma of ascent is a well-recognized risk of compressed air diving in the civilian and military diving communities. Chest imaging is a beneficial adjunct to clinical evaluation in screening select individuals for fitness to dive, evaluating dive-related injuries, and safely returning individuals to diving duty. We present a case of a 26-year-old male U.S. Navy Ensign and Basic Underwater Demolition/SEAL (BUD/S) candidate who experienced pulmonary barotrauma following two shallow dives to a maximum depth of 18 feet of seawater using the MK-25 100% oxygen rebreather. A chest radiograph showed a left upper lobe peripheral wedge-shaped opacity abutting the pleural surface. A subsequent computerized tomography (CT) scan of the chest showed multifocal areas of peripheral pulmonary hemorrhage associated with small pneumatoceles. Two months after the diving injury, chest CT showed resolution of the pulmonary hemorrhage and pneumatoceles. Diving-related pulmonary barotrauma occurs most often secondary to breath-holding on ascent by inexperienced divers and is one of the most common diving injuries seen in BUD/S candidates. The risk of pulmonary barotrauma may be decreased through adequate training and thorough medical screening to include assessing for symptoms of infection before every dive. In cases of acute pulmonary barotrauma, chest radiographs may be used to screen for thoracic injury. Chest CT with inspiratory and expiratory sequences should be used to screen dive candidates on a case-by-case basis and to evaluate lung injury and predisposing pulmonary conditions following pulmonary barotrauma.

Chemical Modifications for a Next Generation of Nucleic Acid Aptamers.

In the past three decades, in vitro systematic evolution of ligands by exponential enrichment (SELEX) has yielded many aptamers for translational applications in both research and clinical settings. Despite their promise as an alternative to antibodies, the low success rate of SELEX (∼30 %) has been a major bottleneck that hampers the further development of aptamers. One hurdle is the lack of chemical diversity in nucleic acids. To address this, the aptamer chemical repertoire has been extended by introducing exotic chemical groups, which provide novel binding functionalities. This review will focus on how modified aptamers can be selected and evolved, with illustration of some successful examples. In particular, unique chemistries are exemplified. Various strategies of incorporating modified building blocks into the standard SELEX protocol are highlighted, with a comparison of the differences between pre-SELEX and post-SELEX modifications. Nucleic acid aptamers with extended functionality evolved from non-natural chemistries will open up new vistas for function and application of nucleic acids.

Transvaginal rectocoele repair for the surgical treatment of a "symptomatic" rectocoele when conservative measures fail: A 12 year experience of 215 patients.

BACKGROUND: Conservative measures are first-line treatment for a "symptomatic" rectocoele, while surgery to correct the anatomical defect may be considered in selected cases. The standard repair offered in our trust is a native tissue transvaginal rectocoele repair (TVRR) combined with levatorplasty. The primary aim of the study was to conduct a retrospective study to assess the outcome of this procedure, while secondary aims were to assess whether specific characteristics and symptoms were associated with response to surgery. METHODS: We conducted a retrospective review of 215 patients who underwent TVRR in a single tertiary referral center between 2006 and 2018. In total, 97% of patients had symptoms of obstructive defecation syndrome (ODS) and 81% had a feeling of vaginal prolapse/bulge. We recorded in-hospital and 30 days post-operative complications and pre- and post-operative symptoms. KEY RESULTS: The majority of patients selected for surgery had rectocoele above 4 cm or medium size with contrast trapping. Mean length of hospital stay was 3.2 days. The in-hospital complication rate was 11.2% with the most common complications being urinary retention (8.4%). Mean length of follow-up was 12.7 months (SD 13.9, range 1.4-71.5) with global improvement of symptoms reported in 87.9% cases. Feeling of vaginal bulge improved in 80% of patients while ODS-related symptoms improved in 58% of cases. CONCLUSIONS & INFERENCES: The data suggest that TVRR might be a valid option in patients with rectocoele when conservative treatment has failed. Overall patient satisfaction is good, with improvement of ODS symptoms.

Manned validation of a US Navy Diving Manual, Revision 7, VVal-79 schedule for short bottom time, deep air decompression diving.

INTRODUCTION: The US Navy air decompression table was promulgated in 2008, and a revised version, calculated with the VVal-79 Thalmann algorithm, was promulgated in 2016. The Swedish Armed Forces conducted a laboratory dive trial using the 2008 air decompression table and 32 dives to 40 metres' seawater for 20 minutes bottom time resulted in two cases of decompression sickness (DCS) and high venous gas emboli (VGE) grades. These results motivated an examination of current US Navy air decompression schedules. METHODS: An air decompression schedule to 132 feet seawater (fsw; 506 kPa) for 20 minutes bottom time with a 9-minute stop at 20 fsw was computed with the VVal-79 Thalmann algorithm. Dives were conducted in 29°C water in the ocean simulation facility at the Navy Experimental Diving Unit. Divers dressed in shorts and t-shirts performed approximately 90 watts cycle ergometer work on the bottom and rested during decompression. VGE were monitored with 2-D echocardiography at 20-minute intervals for two hours post-dive. RESULTS: Ninety-six man-dives were completed, resulting in no cases of DCS. The median (IQR) peak VGE grades were 3 (2-3) at rest and 3 (3-3) with limb flexion. VGE grades remained elevated two hours post-dive with median grades 1 (1-3) at rest and 3 (1-3) with movement. CONCLUSIONS: Testing of a short, deep air decompression schedule computed with the VVal-79 Thalmann algorithm, tested under diving conditions similar to earlier US Navy dive trials, resulted in a low incidence of DCS.

Revision of Total Knee Arthroplasties Performed in Young, Active Patients with Posttraumatic Arthritis and Osteoarthritis.

Rates of total knee arthroplasty (TKA) in younger patients are rising significantly. A recent study performed at our institute illustrated the excellent survivorship of TKAs in patients younger than 55 years at a mean follow-up period of 25 years. This study reports on the 25 knees in this series that required revision surgery. Twenty-five revisions were performed in 24 patients. Indication for revision, clinical outcomes, and radiographs were reviewed at their most recent follow-up. Revisions were performed in 5 cases of infection, 2 cases of fracture/trauma, 17 cases of wear/loosening, and 1 case of instability. The average duration from primary TKA to revision surgery for the 25 knees was 12.5 years (range, 2-26 years). Follow-up was obtained in 24 of 25 TKAs. Nine of the 24 patients (10 knees) had died at the time of follow-up. The average duration from revision surgery to follow-up examination for the remaining knees was 10.5 years. Using the Knee Society scoring system, the average knee score was 89.0 points and the average functional score was 75.6 points. The mean Tegner activity score was 4.6 which exceeded the mean score for unrevised TKAs (2.9). The average range of motion was 119 degrees. None of the knee radiographs showed evidence of component loosening. Young patients who undergo TKA that require revision surgery had good mid-term clinical outcomes. This information is important in completing the clinical picture and outcomes associated with young patients undergoing TKA.

Beginning with the End-User in Mind: Application of Kern's Six-Step Approach to Design and Create a Literary Journal for Healthcare Students.

This article was migrated. The article was marked as recommended. Expression through the arts has been shown to improve resilience and enhance patient care amongst healthcare trainees. This is all the more relevant when considering that many healthcare students feel that insitutions lack an outlet for articstic and creative expression. The creation of a student-run literary review is one possible strategy to allow learners to engage in artistic expression and mitigate rising burnout rates. Utilizing the Kern six-step model for curriculum development, we present a novel, replicable, and stepwise approach to designing a forum for artistic engagement in the form of a literary review.

Necrotizing Fasciitis as a Complication of a Continuous Sciatic Nerve Catheter Using the Lateral Popliteal Approach.

OBJECTIVE: Necrotizing fasciitis is an infection of the soft tissue that is characterized by rapidly spreading inflammation and subsequent necrosis. It is a rare complication of peripheral nerve blocks. We report a rare case of necrotizing fasciitis after placement of a peripheral nerve catheter. CASE REPORT: A 58-year-old woman presented for an elective right second metatarsal resection and received a sciatic nerve catheter for postoperative pain control. On postoperative day 7, clinical examination and imaging supported the diagnosis of necrotizing fasciitis. CONCLUSIONS: Multiple reports have been published of necrotizing fasciitis after single-shot peripheral nerve block injections, neuraxial anesthesia, and intramuscular injections. This case highlights the potential for the rare complication of necrotizing fasciitis after peripheral nerve catheter placement.

Comprehensive multiphase NMR spectroscopy of intact ¹³C-labeled seeds.

Seeds are complex entities composed of liquids, gels, and solids. NMR spectroscopy is a powerful tool for studying molecular structure but has evolved into two fields, solution and solid state. Comprehensive multiphase (CMP) NMR spectroscopy is capable of liquid-, gel-, and solid-state experiments for studying intact samples where all organic components are studied and differentiated in situ. Herein, intact (13)C-labeled seeds were studied by a variety of 1D/2D (1)H/(13)C experiments. In the mobile phase, an assortment of metabolites in a single (13)C-labeled wheat seed were identified; the gel phase was dominated by triacylglycerides; the semisolid phase was composed largely of carbohydrate biopolymers, and the solid phase was greatly influenced by starchy endosperm signals. Subsequently, the seeds were compared and relative similarities and differences between seed types discussed. This study represents the first application of CMP-NMR to food chemistry and demonstrates its general utility and feasibility for studying intact heterogeneous samples.

A streamlined protocol for the use of the semi-sitting position in neurosurgery: a report on 48 consecutive procedures.

The semi-sitting position has lost favor among neurosurgeons partly due to unproven assumptions of increased complications. Many complications have been associated with this position; the most feared: venous air embolism and paradoxical air embolism. We report on this retrospective study of the outcome over 4 years of 48 neurosurgical patients operated on consecutively using a standardized protocol: 41 (85%) in the semi-sitting position, and seven (15%) in the prone position. Procedures included: tumor resection (34), posterior fossa decompression (12), cyst resection (1) and resection of arteriovenous malformation (1). Pre-operative workup was standardized. Vigilant intra-operative observation was done by an experienced neuroanesthetist. Pertinent data was extracted from surgical records. Of the 48 patients, 10 (20.8%) were found to have a patent foramen ovale (PFO) on trans-esophageal echocardiography. Of these, four (40%) patients underwent procedures in the semi-sitting position while six (60%) did not. A clinically significant venous air embolism (VAE) was detected during 2 of the 41 semi-sitting procedures (4.9%). Neither patient suffered any obvious sequelae. No other morbidity was encountered associated with surgical position. Our study suggests that a model similar to ours is effective in preventing major complications associated with the semi-sitting position. The semi-sitting position is a safe, practical position that should be considered in appropriate cases. The fear of dreadful complications seems unwarranted.

Comprehensive multiphase NMR spectroscopy: basic experimental approaches to differentiate phases in heterogeneous samples.

Heterogeneous samples, such as soils, sediments, plants, tissues, foods and organisms, often contain liquid-, gel- and solid-like phases and it is the synergism between these phases that determine their environmental and biological properties. Studying each phase separately can perturb the sample, removing important structural information such as chemical interactions at the gel-solid interface, kinetics across boundaries and conformation in the natural state. In order to overcome these limitations a Comprehensive Multiphase-Nuclear Magnetic Resonance (CMP-NMR) probe has been developed, and is introduced here, that permits all bonds in all phases to be studied and differentiated in whole unaltered natural samples. The CMP-NMR probe is built with high power circuitry, Magic Angle Spinning (MAS), is fitted with a lock channel, pulse field gradients, and is fully susceptibility matched. Consequently, this novel NMR probe has to cover all HR-MAS aspects without compromising power handling to permit the full range of solution-, gel- and solid-state experiments available today. Using this technology, both structures and interactions can be studied independently in each phase as well as transfer/interactions between phases within a heterogeneous sample. This paper outlines some basic experimental approaches using a model heterogeneous multiphase sample containing liquid-, gel- and solid-like components in water, yielding separate (1)H and (13)C spectra for the different phases. In addition, (19)F performance is also addressed. To illustrate the capability of (19)F NMR soil samples, containing two different contaminants, are used, demonstrating a preliminary, but real-world application of this technology. This novel NMR approach possesses a great potential for the in situ study of natural samples in their native state.