[Automated two-point discrimination (TPD) for phantom pain : Effect of a 3­week automated therapy based on TPD for a transtibial amputee with phantom pain]. / Automatisierte Zweipunktdiskrimination bei Phantomschmerzen : Effekt einer 3­wöchigen automatisierten Therapie auf der Basis der Zweipunktdiskrimination (ZPD) bei einem unterschenkelamputierten Patienten mit Phantomschmerzen.

There is preliminary evidence that phantom pain is associated with disturbed organization of the sensory cortex and that this organization can be normalized with two-point discrimination (TPD) training. In this case study, a reduction in phantom pain and painful phantom sensation during a test period of 19 days, was achieved using an automated TPD procedure. In a patient with a transtibial amputation, pain levels decreased from a mean of 2.3/10 on the visual analog scale (VAS) to 1.3/10 (VAS) and the painful phantom sensation level decreased from a mean 3.7/10 (VAS) to 2.0/10 (VAS). These results show a positive trend, but are (except of the nocturnal pain attacks) rather of limited clinical relevance.

Therapists and patients perceptions of a mixed reality system designed to improve trunk control and upper extremity function.

A prototype system aimed at improving arm function and trunk control after stroke has been developed that combines mixed-reality (MR) feedback with a mobile seat system (Holoreach). The purpose of this study was to assess the usability of Holoreach in a rehabilitation setting from both the patient and therapist perspective. Ten therapists (eight physiotherapists and two occupational therapists) used the device in their regular therapy programs for fifteen stroke patients with trunk control issues. Each patient received four individual therapy sessions with the device performed under the supervision of the therapist. Therapists and patients kept therapy diaries and used customized questionnaires. At the end of the study two focus groups were conducted to further assess usability. Generally, the prototype system is suitable for training trunk and arm control. The therapists expressed overall positive views on the impact of Holoreach. They characterized it as new, motivating, fresh, joyful, interesting, and exciting. All therapists and 80% of the patients agreed with the statement that training with Holoreach is beneficial for rehabilitation. Nonetheless, improvements are required in the hardware and software, and design. The prototype system contributes at various levels to the rapidly evolving advances in neurorehabilitation, particularly regarding the practical aspect of exercise delivery.

Deep Learning-Based Image Registration in Dynamic Myocardial Perfusion CT Imaging.

Registration of dynamic CT image sequences is a crucial preprocessing step for clinical evaluation of multiple physiological determinants in the heart such as global and regional myocardial perfusion. In this work, we present a deformable deep learning-based image registration method for quantitative myocardial perfusion CT examinations, which in contrast to previous approaches, takes into account some unique challenges such as low image quality with less accurate anatomical landmarks, dynamic changes of contrast agent concentration in the heart chambers and tissue, and misalignment caused by cardiac stress, respiration, and patient motion. The introduced method uses a recursive cascade network with a ventricle segmentation module, and a novel loss function that accounts for local contrast changes over time. It was trained and validated on a dataset of n = 118 patients with known or suspected coronary artery disease and/or aortic valve insufficiency. Our results demonstrate that the proposed method is capable of registering dynamic cardiac perfusion sequences by reducing local tissue displacements of the left ventricle (LV), whereas contrast changes do not affect the registration and image quality, in particular the absolute CT (HU) values of the entire CT sequence. In addition, the deep learning-based approach presented reveals a short processing time of a few seconds compared to conventional image registration methods, demonstrating its application potential for quantitative CT myocardial perfusion measurements in daily clinical routine.

A novel assistive therapy chair to improve trunk control during neurorehabilitation: Perceptions of physical therapists and patients.

A prototype assistive therapy chair (T-Chair) that induces exercise stimuli to improve trunk control and standing and walking early after stroke has been developed. The aim of this study was to assess its usability in a rehabilitation setting. Eleven physical therapists (PTs) integrated the T-Chair into the therapy programs of 15 patients post stroke. Each patient performed on average four individual therapy sessions on the T-Chair under the PTs' supervision. Usability was assessed using questionnaires, therapy diaries and focus group interviews with PTs'. Among PTs', 64% had generally a positive view on the T-Chair. Physical therapists recognized the potential for unsupervised therapy. Generally, patients reacted positively and enjoyed training. The T-Chair has the potential to become an adequate training tool for patients with an intermediate trunk control after stroke. Further development and usability testing are required to provide a therapeutic device allowing for an intensive therapy early post stroke.

Determination of a sagittal plane axis of rotation for a dynamic office chair.

OBJECTIVE: This study investigated the location of the axis of rotation in sagittal plane movement of the spine in a free sitting condition to adjust the kinematics of a mobile seat for a dynamic chair. BACKGROUND: Dynamic office chairs are designed to avoid continuous isometric muscle activity, and to facilitate increased mobility of the back during sitting. However, these chairs incorporate increased upper body movement which could distract office workers from the performance of their tasks. A chair with an axis of rotation above the seat would facilitate a stable upper back during movements of the lower back. The selection of a natural kinematic pattern is of high importance in order to match the properties of the spine. METHOD: Twenty-one participants performed four cycles of flexion and extension of the spine during an upper arm hang on parallel bars. The location of the axis of rotation relative to the seat was estimated using infrared cameras and reflective skin markers. RESULTS: The median axis of rotation across all participants was located 36 cm above the seat for the complete movement and 39 cm for both the flexion and extension phases, each with an interquartile range of 20 cm. CONCLUSION: There was no significant effect of the movement direction on the location of the axis of rotation and only a weak, non-significant correlation between body height and the location of the axis of rotation. Individual movement patterns explained the majority of the variance. APPLICATION: The axis of rotation for a spinal flexion/extension movement is located above the seat. The recommended radius for a guide rail of a mobile seat is between 36 cm and 39 cm.

Inclination-dependent changes of the critical shoulder angle significantly influence superior glenohumeral joint stability.

BACKGROUND: The critical shoulder angle combines the acromion index and glenoid inclination and has potential to discriminate between shoulders at risk for rotator cuff tear or osteoarthritis and those that are asymptomatic. However, its biomechanics, and particularly the role of the glenoid inclination, are not yet fully understood. METHODS: A shoulder simulator was used to analyze the independent influence of glenoid inclination during abduction from 0 to 60°. Spindle motors transferred tension forces by a cable-pulley on human cadaveric humeri. A six-degree-of-freedom force transducer was mounted directly behind the polyethylene glenoid to measure shear and compressive joint reaction force and calculate the instability ratio (ratio of shear and compressive joint reaction force) with the different force ratios of the deltoid and supraspinatus muscles (2:1 and 1:1). A stepwise change in the inclination by 5° increments allowed simulation of a critical shoulder angle range of 20° to 45°. FINDINGS: Tilting the glenoid to cranial (increasing the critical shoulder angle) increases the shear joint reaction force and therefore the instability ratio. A balanced force ratio (1:1) between the deltoid and the supraspinatus allowed larger critical shoulder angles before cranial subluxation occurred than did the deltoid-dominant ratio (2:1). INTERPRETATION: Glenoid inclination-dependent changes of the critical shoulder angle have a significant impact on superior glenohumeral joint stability. The increased compensatory activity of the rotator cuff to keep the humeral head centered may lead to mechanical overload and could explain the clinically observed association between large angles and degenerative rotator cuff tears.

Marfan syndrome--a diagnostic challenge caused by phenotypic and genetic heterogeneity.

OBJECTIVES: Marfan syndrome (MFS) is an autosomal dominant inherited connective tissue disorder caused by mutations in the fibrillin-1 (FBN1) gene with variable clinical manifestations in the cardiovascular, musculoskeletal and ocular systems. METHODS: Data of moleculor genetic analysis and a catalogue of clinical manifestations including aortic elastic parameters were mined in order to (i) assess aortic abnormality before and during medical treatment, and to (ii) identify novel correlations between the genotype and phenotype of the disease using hierarchical cluster analysis and logistic regression analysis. A score measure describing the similarity between a patient's clinical symptoms and a characteristic phenotype class was introduced. RESULTS: A probabilistic model for monitoring the loss of aortic elasticity was built on merely aortic parameters of 34 patients with classic MFS and 43 control subjects showing a sensitivity of 82% and a specificity of 96%. The clinical phenotypes of 100 individuals with classical or suspected MFS were clustered yielding four different phenotypic expressions. The highest correlation was found between FBN1 missense mutations, which manifested as ectopia lentis, skeletal major and skin minor criteria, and two out of four clustered phenotypes. The probability of the presence of a missense mutation in both phenotype classes is approximately 70%. CONCLUSIONS: Monitoring of aortic elastic properties during medical treatment may serve as additional criterion to indicate elective surgical interventions. Genotype-phenotype correlation may contribute to anticipate the clinical consequences of specific FBN1 mutations more comprehensively and may be helpful to identify MFS patients at risk at on early stage of disease.

Moderate effect of preoperative blood transfusions on pancreas allograft survival in rats and dogs.

Treatment of type I diabetes by early pancreas transplantation requires the availability of a safe and effective transplantation technique. With the currently available immunosuppressive drugs it is difficult to obtain long-term pancreatic allograft survival. In this respect pancreas grafts compare unfavorably with heart or kidney grafts. Using a relatively simple and safe subcutaneous transplantation technique we investigated the effect of blood transfusions combined with low-dose immunosuppressive drugs in rats and dogs in order to attain an immunosuppressive schedule of low toxicity. Subcutaneous pancreas transplantation appeared to be a feasible technique, with long-term graft survival in syngeneically transplanted rats and autotransplanted dogs. Only a moderate prolongation of pancreatic allograft survival by blood transfusions was demonstrated in both models. In rats one or three preoperative donor-specific blood transfusions significantly prolonged pancreas graft survival to 23 +/- 15 and 29 +/- 15 days, respectively, compared with 12 +/- 2 days in untreated controls. Low-dose cyclosporine (15 mg/kg on the day of operation) led to improved graft survival in nontransfused recipients (17 +/- 4 days), however, this treatment could not further prolong graft survival in transfused animals (34 +/- 20 days). In dogs, treated postoperatively with azathioprine and prednisolone, three preoperative third-party blood transfusions led to 29 +/- 19 days of pancreas graft survival, which was not significantly different from nontransfused controls (17 +/- 5 days). These results indicate that, in rats as well in dogs, pancreatic allografts are less sensitive to the immunomodulating effect of blood transfusions than heart and kidney grafts.

Intraoperative hemodynamics in liver transplantation comparing orthotopic with heterotopic transplantation in the pig.

The intraoperative hemodynamic changes and several graft function parameters were studied comparing orthotopic liver transplantation with auxiliary partial liver transplantation (APLT) in the pig. Thirty-one Yorkshire pigs (ca. 25 kg b.w.) were randomly allocated to OLT (n = 16) or APLT (n = 15). During the construction of portal anastomosis the median cardiac output dropped to 67% of the initial value in OLT and to 49% in APLT (P less than 0.02). Median duration of the portal flow interruption was shorter in APLT: 15 min versus 48 min in OLT (P less than 0.002). After unclamping of the aorta, the median systolic blood pressure dropped to 75 mmHg in OLT and to 90 mmHg in APLT (P less than 0.02). APLT is less time-consuming: median duration of transplantation was 128 min versus 165 min in OLT (P less than 0.002). SGOT levels were lower in APLT than in OLT (median SGOT on the first postoperative day 67 was IU/L versus 177 IU/L, P less than 0.002). It is concluded that APLT is a shorter procedure than OLT with a shorter portal flow interruption, being less offensive to the recipient.

Sensitivity of mitochondrial peptidyl-prolyl cis-trans isomerase, pyridine nucleotide hydrolysis and Ca2+ release to cyclosporine A and related compounds.

Prooxidants activate a specific Ca2+ release pathway from mitochondria. Here we investigate the inhibitory potency of cyclosporine A and six related compounds with respect to peptidyl-prolyl cis-trans isomerase (PPIase), pyridine nucleotide hydrolysis and Ca2+ release. Whereas the absolute inhibitory potency of the compounds varies by about three orders of magnitude, a given compound is always most effective on PPIase, followed by pyridine nucleotide hydrolysis, and least effective in Ca2+ release inhibition. The data show that pyridine nucleotide hydrolysis is a prerequisite but not a consequence of Ca2+ release. They also strongly suggest that PPIase participates in the Ca2+ release mechanism from intact mitochondria by regulating the intramitochondrial NAD+ glycohydrolase, and thereby ascribe a physiological function to the protein. Furthermore, a complete lack of correlation between the inhibitory potencies described here and the reported immunosuppressive activities of the drugs is evident.

Calvarial "doughnut lesions": clinical spectrum of the syndrome, report on a case, and review of the literature.

Many pathologic fractures, lumps on the head, elevated serum alkaline phosphatase (ALP) levels, and dental caries are the main characteristics of the rare autosomal dominantly inherited calvarial "doughnut lesions" (MIM 126550). We report the sporadic case of a 16-year-old patient who has had 10 pathologic fractures between age 6 weeks and 15 years. An elevated serum ALP level was found at age 11 and skull lumps at age 15; radiography showed frontal and parietal round radiolucencies surrounded by sclerotic bone comparable to doughnuts. Magnetic resonance imaging (MRI) showed skull lesions at an early stage. Because the findings are reminiscent of osteogenesis imperfecta (OI), collagen types I, III, and V were analyzed in fibroblasts and shown to be normal in terms of quantities, proportions, electrophoretic mobility, and thermostability. Thus, this rare syndrome can be distinguished from OI by collagen analysis and MRI of the skull at an early stage, even before palpable skull lesions appear.

Segmental pancreas transplantation from living related and cadaver donors: a clinical experience.

Between July 25, 1978, and January 25, 1981, 20 segmental pancreas transplants from 14 cadaver (cad) and six related (rel) donors were performed. All but two recipients had previously received renal allografts for treatment of end-sage diabetic nephropathy. The grafts were placed intraperitoneally-13 with open ducts, 4 with prolamine-injected ducts, and 3 with silicone rubber-injected ducts. At this writing six patients have functioning grafts (3 silicone, 3 open duct) at less than 1 (cad), 2 (cad), 3 (rel), 15 (cad), 20 (rel), and 31 (cad) months. Five open-duct grafts failed for technical reasons. Two prolamine-injected grafts lost function between 1 and 3 months; biopsy specimens showed severe fibrosis. The others lost function between 2 and 4 months. Three patients died 1 to 3 months after transplantation. Metabolic test results were normal or nearly normal in most recipients with functioning grafts. Splenectomy was required in one related donor; there were no other complications of donation. Technical problems and rejection are impediments to application of pancreas transplantation, but a sustained correction of the metabolic defect has been achieved in a few patients, and the effect on secondary complications are studied.

Dose-response effects of atropine on pancreatic secretory response to intravenous cerulein in dogs.

In conscious dogs with gastric and pancreatic fistulas, we studied the effect of i.v. atropine in doses ranging from 1.8 to 29 nmol/kg/h on the pancreatic secretory response to i.v. cerulein in doses ranging from 3.7 to 118 pmol/kg/h. Cerulein was given with an i.v. background infusion of secretin (20.5 pmol/kg/h), started 1 h before the lowest dose of cerulein was given. Secretin alone did not stimulate pancreatic protein output above basal. Doses of 7 and 29 nmol/kg/h of atropine significantly (p less than 0.05) decreased the protein output during secretin. A dose of 29 nmol/kg/h, but not lower doses, of atropine significantly inhibited the bicarbonate response to secretin. A dose of 3.7 pmol/kg/h and all higher doses of cerulein significantly stimulated bicarbonate and protein output above the value observed during secretin alone. None of the three doses of atropine given had any significant effect on the incremental bicarbonate and protein responses to cerulein. Secretin and cerulein did not alter basal heart rate; only the highest dose (29 nmol/kg/h) of atropine significantly increased heart rate. These findings are compatible with the hypothesis that cholinergic nerves do not alter the effect of exogenous cerulein, a CCK analogue, on pancreatic bicarbonate and protein secretion in dogs.

Metabolic effects of a fat- and carbohydrate-rich meal in rats.

To investigate meal-induced changes in hepatic fat and carbohydrate metabolism in rats, hepatic venous, portal venous, and aortal plasma levels of several metabolites as well as changes in hepatic glycogen and lactate content were measured during and after the first nocturnal meal following a 12-h fast. The rats were fed a diet with about 46%, 41%, and 13% of the total energy (approximately 16.5 kJ/g) derived from carbohydrates, fats, and protein, respectively. During the later part of the meal and thereafter, plasma triglyceride level increased in all blood vessels. After a transient initial decrease, portal venous and aortal nonesterified fatty acid (NEFA) levels, net hepatic NEFA uptake, and hepatic beta-hydroxybutyrate (BHB) production increased and reached fasting (meal onset) values by 30 min after the meal. Although liver glycogen did not change significantly, the liver released glucose continuously. The liver initially accumulated lactate and maintained a high lactate concentration despite switching from lactate uptake to net release of lactate around 10 min into the meal. Taken together, these data indicate that hepatic glycolysis, gluconeogenesis, and considerable fatty acid oxidation occur concurrently in rat liver during and after a fat- and carbohydrate-rich meal. The findings are relevant to contemporary hypotheses of the metabolic control of eating and, in particular, to hypotheses linking hepatic fatty acid oxidation to postprandial satiety.

Review of Chrysomya rufifacies (Diptera: Calliphoridae).

The taxonomy, distribution, bionomics, and medical and veterinary importance of C. rufifacies are reviewed and summarized. Late instars are beneficial as predators of the maggots of pathogen-transmitting and myiasis-producing flies, but strains from parts of Australia, India, and Hawaii are harmful as secondary myiasis agents. The effects of invasions, possible competition, and displacement of native calliphorids are discussed. The developmental duration of the immature stadia at different temperatures are reviewed. The primary literature (274 papers) dealing with this fly is given and cross-referenced by subject to serve as a reference to research entomologists and governmental agencies involved in the control of this livestock parasite in the Americas and Australia.

Spatial analysis of the distribution of Ixodes dammini (Acari: Ixodidae) on white-tailed deer in Ogle County, Illinois.

The pattern of infestations of Ixodes dammini on white-tailed deer in Ogle County in Illinois was studied through examinations of hunted deer from 1988 to 1990. The Illinois Geographic Information System mapped the spatial distribution of tick infestations on deer and related it to a known endemic focus for I. dammini and Borrelia burgdorferi (Castle Rock State Park), and to a major waterway (Rock River). Second-order neighborhood analysis was used to analyze the spatial distribution of deer around Castle Rock State Park. More than 25% of deer were infested. All deer were clustered around CRSP, but the clustering resulted mostly from clustering of infested deer around CRSP. CRSP is apparently the only important source of tick infestations in Ogle County. Clustering of infested deer did not change during the 3-yr study period. The dispersion pattern of ticks on deer was aggregated, with twice and three times as many ticks collected from bucks as from does and from fawns, respectively. More male ticks than female ticks were collected from infested deer. Of 59 ticks removed from harvested deer in 1990, 5.1% tested positive for B. burgdorferi.

Antegrade pyelography, percutaneous nephrostomy and ureteral perfusion (Whitaker test) for the renal transplant recipient.

Ureteral obstruction is a serious complication in renal transplant recipients. The diagnosis may be difficult with standard methods of investigation, and definite treatment may, therefore, be delayed. This paper describes the indications, the technique, and the experience with antegrade pyelography, ureteral perfusion and percutaneous drainage in 18 patients with suspected urinary obstruction. Though invasive, these methods proved to be a safe, fast and accurate means for evaluating the location and significance of ureteral obstruction. For initial treatment in obstruction, percutaneous nephrostomy is the method of choice. Surgery should be delayed until recovery of renal function with decreasing serum creatinine is demonstrated. Patients with persistent or rising serum creatinine (greater than 250 mumol./l.) did not benefit from surgical relief of obstruction.

Effect of venous drainage to the vena cava and denervation on endocrine function of pancreatic segments in dogs.

IVGTTs and OGTTs (0.5 g/kg glucose) were performed in 36 normal dogs (group N) and one to two weeks postoperatively in 22 dogs after partial pancreatectomy [( ppx ] group I); nine dogs after ppx and pancreatic venous drainage to the inferior vena cava (group II); nine dogs after ppx and pancreatic denervation (group III); and in seven dogs after ppx , venous drainage to the vena cava, and denervation (group IV). Fasting glucose and insulin were in the same range in all dogs. In IVGTT peak insulin levels were diminished by ppx , but total insulin secretion was similar in all dogs. Systemic venous drainage and denervation had no effect on glucose tolerance, peak insulin, and total amount of insulin appearing in the peripheral circulation. In groups II and IV, there was a linear correlation between individual K values and the area under the insulin curve, whereas there was no such correlation in groups I and III. In OGTTs , glucose tolerance and the total amount of insulin were equal in groups I through IV but diminished compared to group N. Venous transposition resulted in an early increase of insulin secretion and a late insulin peak. Thus, glucose load and islet cell mass are the determinants of glucose tolerance and insulin secretion in this model. Neither drainage of the pancreatic blood to the vena cava nor denervation have measurable influence on magnitude and effectivity of fasting and stimulated insulin secretion.

Importance of construction sites as foci for urban Culex in northern Illinois.

Expanding urbanization in America has created many new artificial sources which serve as focal points for urban, opportunistic and disease-vectoring mosquitoes. One such urban source, building construction sites, has received little attention despite a growing construction industry. During the summer of 1985, 522 unfinished buildings, 90% as single-family homes, were surveyed for water accumulation, larval mosquito occurrence and density, and species involved. Sump-pits and basements proved to be the most abundant sites of water accumulation of unfinished homes in the later stages of completion with Culex restuans and Cx. pipiens dominating the collections from these sites. Buildings at early stages of construction were much less productive, probably due to sun-exposure. Factors which favor mosquito colonization such as reduced illumination and temperatures, and increased organic content are discussed. Various cultural and insecticidal controls of mosquitoes breeding at construction sites are suggested.