The efficacy and safety of patient-specific instrumentation in primary total knee replacement: a systematic review and meta-analysis.

INTRODUCTION: Patient-specific instrumentation (PSI) for primary total knee arthroplasty (TKA) surgery has been shown to increase accuracy of component positioning. However, it is unclear whether this also translates to actual benefits for patients in terms of better outcomes (efficacy) or less complications such as revisions (safety). We therefore systematically reviewed the literature to determine the efficacy and safety of PSI in primary TKA. METHODS: Randomized controlled trials comparing PSI to non-PSI in primary TKA were included. A random effects model was used with meta-regression in case of heterogeneity. RESULTS: Forty-three studies were included with a total of 1816 TKA in the PSI group and 1887 TKA in the control group. There were no clinically relevant differences between the PSI-group and non-PSI group regarding all outcomes. There was considerable heterogeneity: meta-regression analyses showed that the year the study was published was an important effect modifier. Early publications tended to show a positive effect for PSI compared to non-PSI TKA, whereas later studies found the opposite. CONCLUSION: Based on evidence of moderate certainty, our study suggested that there were no clinically relevant differences in efficacy and safety between patients treated with PSI TKA and patients treated with non-PSI TKA.

Long-term oncological outcomes of endoscopic full-thickness resection after previous incomplete resection of low-risk T1 CRC (LOCAL-study): study protocol of a national prospective cohort study.

BACKGROUND: T1 colorectal cancer (CRC) without histological high-risk factors for lymph node metastasis (LNM) can potentially be cured by endoscopic resection, which is associated with significantly lower morbidity, mortality and costs compared to radical surgery. An important prerequisite for endoscopic resection as definite treatment is the histological confirmation of tumour-free resection margins. Incomplete resection with involved (R1) or indeterminate (Rx) margins is considered a strong risk factor for residual disease and local recurrence. Therefore, international guidelines recommend additional surgery in case of R1/Rx resection, even in absence of high-risk factors for LNM. Endoscopic full-thickness resection (eFTR) is a relatively new technique that allows transmural resection of colorectal lesions. Local scar excision after prior R1/Rx resection of low-risk T1 CRC could offer an attractive minimal invasive strategy to achieve confirmation about radicality of the previous resection or a second attempt for radical resection of residual luminal cancer. However, oncologic safety has not been established and long-term data are lacking. Besides, surveillance varies widely and requires standardization. METHODS/DESIGN: In this nationwide, multicenter, prospective cohort study we aim to assess feasibility and oncological safety of completion eFTR following incomplete resection of low-risk T1 CRC. The primary endpoint is to assess the 2 and 5 year luminal local tumor recurrence rate. Secondary study endpoints are to assess feasibility, percentage of curative eFTR-resections, presence of scar tissue and/or complete scar excision at histopathology, safety of eFTR compared to surgery, 2 and 5 year nodal and/or distant tumor recurrence rate and 5-year disease-specific and overall-survival rate. DISCUSSION: Since the implementation of CRC screening programs, the diagnostic rate of T1 CRC is steadily increasing. A significant proportion is not recognized as cancer before endoscopic resection and is therefore resected through conventional techniques primarily reserved for benign polyps. As such, precise histological assessment is often hampered due to cauterization and fragmentation and frequently leads to treatment dilemmas. This first prospective trial will potentially demonstrate the effectiveness and oncological safety of completion eFTR for patients who have undergone a previous incomplete T1 CRC resection. Hereby, substantial surgical overtreatment may be avoided, leading to treatment optimization and organ preservation. Trial registration Nederlands Trial Register, NL 7879, 16 July 2019 ( https://trialregister.nl/trial/7879 ).

Evaluating abdominal core muscle fatigue: Assessment of the validity and reliability of the prone bridging test.

The aims of this study were to research the amplitude and median frequency characteristics of selected abdominal, back, and hip muscles of healthy subjects during a prone bridging endurance test, based on surface electromyography (sEMG), (a) to determine if the prone bridging test is a valid field test to measure abdominal muscle fatigue, and (b) to evaluate if the current method of administrating the prone bridging test is reliable. Thirty healthy subjects participated in this experiment. The sEMG activity of seven abdominal, back, and hip muscles was bilaterally measured. Normalized median frequencies were computed from the EMG power spectra. The prone bridging tests were repeated on separate days to evaluate inter and intratester reliability. Significant differences in normalized median frequency slope (NMFslope ) values between several abdominal, back, and hip muscles could be demonstrated. Moderate-to-high correlation coefficients were shown between NMFslope values and endurance time. Multiple backward linear regression revealed that the test endurance time could only be significantly predicted by the NMFslope of the rectus abdominis. Statistical analysis showed excellent reliability (ICC=0.87-0.89). The findings of this study support the validity and reliability of the prone bridging test for evaluating abdominal muscle fatigue.

Kinematic chain-related risk factors in the development of lower extremity injuries in women: A prospective study.

The link between dynamic range of motion (dROM) parameters within the kinematic chain and the development of lower extremity (LE) injury has gained attention; however, very few longitudinal studies have been conducted. Therefore, we wanted to prospectively determine dROM-related risk factors for the development of LE injury. Within this study, 90 female physical education students aged 19.33±0.87 years were tested. Full-body kinematic and vertical ground reaction force (VGRF) parameters were measured during a triple hop jump (THJ). Cox regression analysis was used to identify potential risk factors for the development of LE injury. The injury follow-up was assessed using a weekly online questionnaire and a tri-monthly retrospective control questionnaire. Lower extremity injury was diagnosed by an experienced medical doctor. During the follow-up, 39 percent of the participants were diagnosed with a LE injury. Decreased dROM of the pelvic segment (P=.043) and increased dROM of the knee and ankle joint (P=.041 and P=.028, respectively) in the sagittal plane during landing phase were identified as predictive parameters for the development of LE injury in women. No VGRF parameters were identified as predictive variables. It can be concluded that an altered dROM within the LE kinematic chain was observed within the group at risk for LE injury. More specifically, this group showed reduced proximal dROM that was coupled with increased dROM in the distal segments during a THJ. The THJ can be seen as a practical screening tool for LE injury.

Effect of a Home-based Balance Training Protocol on Dynamic Postural Control in Subjects with Chronic Ankle Instability.

The aim of this study was to establish the presence of postural deficits in subjects with chronic ankle instability (CAI) and to assess the effect of an 8-week balance training program on dynamic postural control. A total of 43 subjects with CAI and 31 controls participated in this case-control study. Participants with CAI performed an 8-week home-based balance training, including 3 sessions a week. As main outcome measure, postural control was quantified after a vertical drop by means of the dynamic postural stability index (DPSI). Perceptual outcomes were documented using the FADI, FADI-Sport and VAS scales. At baseline, subjects with CAI displayed higher anterior/posterior and vertical postural instability, a poorer DPSI, and lower subjective stability scores compared to the control group. After balance training, all subjective stability scores improved significantly, although no changes were noted for the stability indices. In conclusion, subjects with CAI have an impaired postural control. As a treatment modality, balance training exhibits the capability of improving the subjective feeling of instability in subjects with CAI. However, there was no effect on dynamic postural control. Further research on the explanatory mechanisms of balance training is warranted, and other training modalities should be considered.

Effect of tape on dynamic postural stability in subjects with chronic ankle instability.

The objective of our study was to evaluate the effect of taping on the dynamic postural stability during a jump landing protocol in subjects with chronic ankle instability (CAI). For this purpose, 28 subjects with CAI performed a sagittal and frontal plane landing task in a non-taped and taped condition. As main outcome measure, the dynamic postural stability index (DPSI) was calculated. In addition, subjective feelings of instability and perceived difficulty level were assessed. Furthermore, mechanical effectiveness of the tape on the ankle joint was determined by registering 3D kinematics. 3 subjects were excluded based on discomfort during the landing protocol. Study results indicated that the tape reduced plantar flexion and inversion at the ankle at touchdown and range of motion in the landing phase. There was, however, no effect on the DPSI or on its directional subcomponents. Subjective feelings of stability with tape improved significantly, whereas perceived difficulty did not change. In conclusion, our taping procedure did not improve postural control during a sagittal and frontal plane landing task in subjects with CAI. Perceived instability did improve and is considered an important treatment outcome, which suggests that taping could be considered as a treatment modality by clinicians.

Miniature spectrometer and beam splitter for an optical coherence tomography on a silicon chip.

Optical coherence tomography (OCT) has enabled clinical applications that revolutionized in vivo medical diagnostics. Nevertheless, its current limitations owing to cost, size, complexity, and the need for accurate alignment must be overcome by radically novel approaches. Exploiting integrated optics, we assemble the central components of a spectral-domain OCT system on a silicon chip. The spectrometer comprises an arrayed-waveguide grating with 136-nm free spectral range and 0.21-nm wavelength resolution. The beam splitter is realized by a non-uniform adiabatic coupler with its 3-dB splitting ratio being nearly constant over 150 nm. With this device whose overall volume is 0.36 cm(3) we demonstrate high-quality in vivo imaging in human skin with 1.4-mm penetration depth, 7.5-µm axial resolution, and a signal-to-noise ratio of 74 dB. Considering the reasonable performance of this early OCT on-a-chip system and the anticipated improvements in this technology, a completely different range of devices and new fields of applications may become feasible.

Broad-spectral-range synchronized flat-top arrayed-waveguide grating applied in a 225-channel cascaded spectrometer.

We present a new synchronized design for flattening the passband of an arrayed-waveguide grating (AWG) over a broad wavelength range of 90 nm. A wavelength-insensitive 3-dB balanced coupler is designed to be used in duplicate in a Mach-Zehnder interferometer (MZI); the phase deviation created by one of the balanced couplers is cancelled by flipping the other coupler around. This MZI is arranged in tandem with the AWG such that the output signal of the MZI is the input signal of the AWG. We demonstrate a 5-channel, 18-nm-spacing AWG with a 0.5-dB bandwidth of 12 nm over a 90-nm spectral range. A low-loss cascaded AWG system is demonstrated by using the MZI-synchronized flat-top AWG as a primary filter.

Photonic generation of stable microwave signals from a dual-wavelength Al2O3:Yb3+ distributed-feedback waveguide laser.

We report the fabrication and characterization of a dual-wavelength distributed-feedback channel waveguide laser in ytterbium-doped aluminum oxide. Operation of the device is based on the optical resonances that are induced by two local phase shifts in the distributed-feedback structure. A stable microwave signal at ~15 GHz with a -3 dB width of 9 kHz was subsequently created via the heterodyne photodetection of the two laser wavelengths. The long-term frequency stability of the microwave signal produced by the free-running laser is better than ±2.5 MHz, while the power of the microwave signal is stable within ±0.35 dB.

Raman spectroscopy with an integrated arrayed-waveguide grating.

An integrated arrayed-waveguide grating fabricated in silicon-oxynitride technology is applied to Raman spectroscopy. After its validation by reproducing the well-known spectrum of cyclohexane, polarized Raman spectra are measured of extracted human teeth containing localized initial carious lesions. Excellent agreement is obtained between the spectra of healthy and carious tooth enamel measured with our integrated device and spectra recorded using a conventional Raman spectrometer. Our results represent a step toward the realization of compact, hand-held, integrated spectrometers, e.g. for the detection of dental caries at an early stage.

Opportunistic screening of hospital staff using primary colonoscopy: participation, discomfort and willingness to repeat the procedure.

BACKGROUND: Participation in and tolerability of primary colonoscopy screening are presumed to be relatively low. The present study aimed to test its feasibility in a well-informed population of hospital staff using an intensive information campaign, and to identify factors associated with screening colonoscopy rated as uncomfortable. METHODS: Data were collected using standardized forms. RESULTS: Out of 1,090 invited employees (50-65 years), 447 (41.0%) participated. Bowel preparation and colonoscopy were rated as 'somewhat to very uncomfortable' by 79.5 and 21.9%, respectively. 96.3% of participants were willing to repeat colonoscopy in the future. Participants rating colonoscopy as uncomfortable were more likely unwilling to repeat the procedure (OR 8.026, CI 2.667-24.154). Multivariate analysis (age- and gender-adjusted) showed an association of colonoscopy rated as uncomfortable with: abdominal pain during colonoscopy (OR 3.185, CI 1.642-6.178), other pain (OR 2.428, CI 1.335-4.416), flatulence (OR 2.175, CI 1.219-3.881), embarrassment (OR 2.843, CI 1.350-5.989), abdominal pain after colonoscopy (OR 1.976, CI 1.041-3.751), and a prolonged procedure time (OR 1.000, CI 1.000-1.001). CONCLUSIONS: Acceptance of primary colonoscopy screening for colorectal neoplasia was high, although participants with symptoms during and after colonoscopy were more likely to rate colonoscopy as uncomfortable. This type of opportunistic screening procedure is suitable for the introduction of screening programs and may be useful in areas that have no access to population-based screening.

Endoscopic red flags for the detection of high-risk serrated polyps: an observational study.

BACKGROUND AND STUDY AIMS: In routine practice, colonoscopy may fail to prevent colorectal cancer (CRC), especially in the proximal colon. A better endoscopic recognition of serrated polyps is important, as this pathway may explain some of the post-colonoscopy cancers. In this study, the endoscopic characteristics of serrated polyps were examined. PATIENT AND METHODS: This was a cross-sectional, single-center study of all consecutive patients referred for elective colonoscopy during 1 year. The endoscopists were familiarized with the detection and treatment of nonpolypoid colorectal lesions. Serrated polyps were classified into high risk serrated polyps, defined as dysplastic or large (≥ 6 mm) proximal nondysplastic serrated polyps, and low risk serrated polyps including the remaining nondysplastic serrated polyps. Advanced colorectal neoplasms were defined as multiple (at least three),≥ 10 mm in size, high grade dysplastic adenomas or CRC. RESULTS: A total of 2309 patients were included (46.1 % men, mean age 58.4 years), of whom 2.5 % (57) had at least one high risk serrated polyp and 13.9 % (322) had at least one advanced neoplasm. Overall, serrated polyps were more often nonpolypoid than adenomas (16.2 % vs. 11.1 %; P = 0.002). In total, 65 high risk serrated polyps were found, of which 43.1 % (28) displayed a nonpolypoid endoscopic appearance. Patients with advanced neoplasms were more likely to have synchronous high risk serrated polyps than patients without advanced neoplasms: OR 3.66 (95 % CI 2.03 - 6.61, P < 0.001). CONCLUSIONS: High risk serrated polyps are frequently nonpolypoid and are associated with synchronous advanced colorectal neoplasms. Advanced colorectal neoplasms may therefore be considered red flags for the presence of high risk serrated polyps. Detection, diagnosis, and treatment of high risk serrated lesions may be important targets to improve the quality of colonoscopic cancer prevention.

Tuning a racetrack ring resonator by an integrated dielectric MEMS cantilever.

The principle, fabrication and characterization of a dielectric MEMS cantilever located a few 100 nm above a racetrack ring resonator are presented. After fabrication of the resonators on silicon-on-insulator (SOI) wafers in a foundry process, the cantilevers were integrated by surface micromachining techniques. Off-state deflections of the cantilevers have been optimized to appropriately position them near the evanescent field of the resonator. Using electrostatic actuation, moving the cantilevers into this evanescent field, the propagation properties of the ring waveguide are modulated. We demonstrate 122 pm tuning of the resonance wavelength of the optical ring resonator (in the optical C-band) without change of the optical quality factor, on application of 9 V to a 40 µm long cantilever. This compact integrated device can be used for tuning/switching a specific wavelength, with very little energy for operation and negligible cross talk with surrounding devices.

Cardiopulmonary events during primary colonoscopy screening in an average risk population.

BACKGROUND: Large colorectal cancer screening studies using primary colonoscopy have reported a low risk of major complications. Studies on diagnostic and therapeutic colonoscopy have pointed to a frequent occurrence of(minor) cardiopulmonary events, and with the steady increase of colonoscopy screening, it is important to investigate their occurrence in colonoscopy screening. METHODS: This study describes the frequency of bradycardia(pulse rate <60 min-1), hypotension (systolic blood pressure(SB P) <90 mmHg), hypoxaemia (blood oxygenation, SaO2<90%) and ECG changes during colonoscopy screening in an average-risk population (hospital personnel, n=214,mean age 54.0±3.8, 39.3% male), without significant comorbidity) and aims at identifying subject-related and/or endoscopic factors associated with their occurrence. All data were collected prospectively. During 214 consecutive primary screening colonoscopies under conscious sedation(midazolam and pethidine), on top of pulse rate and SaO2,blood pressure and a three-channel ECG were recorded every five minutes. RESULTS: No major complications or relevant ECG changes occurred. Hypoxaemia occurred in 119 (55.6%),hypotension in 19 (8.9%) and bradycardia in 12 subjects(5.6%). In multivariate analysis, the sedation level 3 increased the risk of hypoxaemia (OR 4.8, CI 1.7-13.7), and incomplete colonoscopy (OR 5.3, CI 1.6-18.1) was associated with hypotension. Subjects with bradycardia had a longer mean procedure time (38±12 vs. 29±12 min, p<0.05), which did not turn out as a risk factor in a multivariate analysis. CONCLUSIONS: Mainly procedure-related and not subject-related factors were found to be associated with the occurrence of cardiopulmonary events in primary colonoscopy screening in this relatively healthy screening population.

Highly efficient, low-threshold monolithic distributed-Bragg-reflector channel waveguide laser in Al2O3:Yb3+.

We report the fabrication and performance of a highly efficient, monolithic distributed-Bragg-reflector channel waveguide laser in ytterbium-doped aluminum oxide. The 1 cm long device was fabricated on a standard thermally oxidized silicon substrate and was optically pumped with a 976 nm laser diode. Single-longitudinal-mode and single-polarization operation was achieved at a wavelength of 1021.2 nm. Continuous-wave output powers of up to 47 mW and a launched pump power threshold of 10 mW resulted in a slope efficiency of 67%.

Ultra-narrow-linewidth, single-frequency distributed feedback waveguide laser in Al2O3:Er3+ on silicon.

We report the realization and performance of a distributed feedback channel waveguide laser in erbium-doped aluminum oxide on a standard thermally oxidized silicon substrate. The diode-pumped continuous-wave laser demonstrated a threshold of 2.2 mW absorbed pump power and a maximum output power of more than 3 mW with a slope efficiency of 41.3% versus absorbed pump power. Single-longitudinal-mode and single-polarization operation was achieved with an emission linewidth of 1.70+/-0.58 kHz (corresponding to a Q factor of 1.14 x 10(11)), which was centered at a wavelength of 1545.2 nm.

Closure of the stop-band in photonic wire Bragg gratings.

Photonic Wire Bragg Gratings, made by periodic insertion of lateral rectangular recesses into photonic wires in silicon-on-insulator, can provide large reflectivity with short device lengths because of their large index contrast. This type of design shows a counter-intuitive behaviour, as we demonstrate - using experimental and numerical data - that it can have low or null reflectance, even for large indentation values. We provide physical insight into this phenomenon by developing a model based on Bloch mode theory, and are able to find an analytical expression for the frequency at which the grating does not sustain the stop-band. Finally we demonstrate that the stop-band closing effect is a general phenomenon that may occur in various types of periodic device that can be modeled as transmission line structures.

Review article: Non-alcoholic fatty liver disease in morbidly obese patients and the effect of bariatric surgery.

BACKGROUND: Morbid obesity is strongly associated with non-alcoholic fatty liver disease. The effects of bariatric surgery on liver tests an histological abnormalities after weight loss are controversial. AIM: To review the literature on the prevalence of non-alcoholic fatty liver disease in patients with morbid obesity with respect to laboratory and histopathological parameters and the effect of weight loss on these parameters after bariatric surgery. RESULTS: Standard liver tests do not seem to be a sensitive tool for the assessment and follow-up of non-alcoholic fatty liver disease in obesity. In nearly all patients with morbid obesity, histological abnormalities reflecting non-alcoholic fatty liver disease are present. Bariatric surgery in these patients will decrease the grade of steatosis. However, there are some concerns about the effect of bariatric surgery on hepatic inflammation and fibrosis. In particular, older follow-up studies reported negative results as opposed to more recent studies, which also showed improvement in hepatic inflammation and fibrosis. Unfortunately, most studies had limitations because of the selection of patients. CONCLUSION: Despite limitations in many studies, bariatric surgery seems to be a promising treatment in patients with obesity presenting with non-alcoholic fatty liver disease.

Far-field scattering microscopy applied to analysis of slow light, power enhancement, and delay times in uniform Bragg waveguide gratings.

A novel method is presented for determining the group index, intensity enhancement and delay times for waveguide gratings, based on (Rayleigh) scattering observations. This far-field scattering microscopy (FScM) method is compared with the phase shift method and a method that uses the transmission spectrum to quantify the slow wave properties. We find a minimum group velocity of 0.04c and a maximum intensity enhancement of ~14.5 for a 1000-period grating and a maximum group delay of ~80 ps for a 2000-period grating. Furthermore, we show that the FScM method can be used for both displaying the intensity distribution of the Bloch resonances and for investigating out of plane losses. Finally, an application is discussed for the slow-wave grating as index sensor able to detect a minimum cladding index change of 10(-8), assuming a transmission detection limit of 10(-4).

Nano-mechanical tuning and imaging of a photonic crystal micro-cavity resonance.

We show that nano-mechanical interaction using atomic force microscopy (AFM) can be used to map out mode-patterns of an optical micro-resonator with high spatial accuracy. Furthermore we demonstrate how the Q-factor and center wavelength of such resonances can be sensitively modified by both horizontal and vertical displacement of an AFM tip consisting of either Si(3)N(4) or Si material. With a silicon tip we are able to tune the resonance wavelength by 2.3 nm, and to set Q between values of 615 and zero, by expedient positioning of the AFM tip. We find full on/off switching for less than 100 nm vertical, and for 500 nm lateral displacement at the strongest resonance antinode locations.