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Introduction The insertion of a foreign body in the urethra is an uncommon urological emergency. A wide variety of inserted objects have been described, presenting either asymptomatically or with lower abdominal discomfort and lower urinary tract symptoms. Sexual experimentation and gratification as well as mental disorders are considered the main underlying causes. The aim of this report is to present the case of a USB wire self-insertion and its challenging urological management. Case Presentation A 15-year-old male patient presented to his local Accident and Emergency department with gross haematuria following self-insertion of the knotted cable of a USB wire into his urethra in the context of sexual experimentation. Endoscopic approach via rigid cystoscopy and optical urethrotomy was not effective. A suprapubic catheter was inserted, and the patient was urgently transferred to our hospital for tertiary management. Following radiological assessment to confirm the position of the wire, a longitudinal peno-scrotal incision over the palpable foreign body was made. Urethrotomy revealed the knotted cable in the proximal aspect of the penile urethra, which was cut and removed. Urethra was subsequently closed over a urethral catheter. Postoperative recovery was uneventful, and patient was discharged home with oral antibiotics. Urethral catheter was removed following normal fluoroscopic assessment of the urethra two weeks later. Conclusions The management of a foreign urethral body can be challenging and usually requires tertiary expertise to achieve optimal outcomes. Poor initial management could potentially lead to devastating long-term complications such as urethral strictures and fistulas.

The signal transduction enzyme phospholipase D1 (PLD1) hydrolyzes phosphatidylcholine to generate the lipid second-messenger phosphatidic acid, which plays roles in disease processes such as thrombosis and cancer. PLD1 is directly and synergistically regulated by protein kinase C, Arf and Rho GTPases, and the membrane lipid phosphatidylinositol-4,5-bisphosphate (PIP2). Here, we present a 1.8 A-resolution crystal structure of the human PLD1 catalytic domain, which is characterized by a globular fold with a funnel-shaped hydrophobic cavity leading to the active site. Adjacent is a PIP2-binding polybasic pocket at the membrane interface that is essential for activity. The C terminus folds into and contributes part of the catalytic pocket, which harbors a phosphohistidine that mimics an intermediate stage of the catalytic cycle. Mapping of PLD1 mutations that disrupt RhoA activation identifies the RhoA-PLD1 binding interface. This structure sheds light on PLD1 regulation by lipid and protein effectors, enabling rationale inhibitor design for this well-studied therapeutic target. A structural study of one of two human phospholipase D enzymes, hPLD1, helps define the determinants of substrate recognition, the highly regulated enzymatic activity, as well as activation by PIP2 and RhoA.

Background: Robotic-arm assisted surgery aims to reduce manual errors and improve the accuracy of implant positioning and orientation during total hip arthroplasty (THA). The objective of this study was to assess the surgical team’s learning curve for robotic-arm assisted acetabular cup positioning during THA. Methods: This prospective cohort study included 100 patients with symptomatic hip osteoarthritis undergoing primary total THA performed by a single surgeon. This included 50 patients receiving conventional manual THA and 50 patients undergoing robotic-arm assisted acetabular cup positioning during THA. Independent observers recorded surrogate markers of the learning curve including operative times, confidence levels amongst the surgical team using the state-trait anxiety inventory (STAI) questionnaire, accuracy in restoring native hip biomechanics, acetabular cup positioning, leg-length discrepancy, and complications within 90 days of surgery. Results: Cumulative summation (CUSUM) analysis revealed robotic-arm assisted acetabular cup positioning during THA was associated with a learning curve of 12 cases for achieving operative times ( p < 0.001) and surgical team confidence levels ( p < 0.001) comparable to conventional manual THA. There was no learning curve of robotic-arm assisted THA for accuracy of achieving the planned horizontal ( p = 0.83) and vertical ( p = 0.71) centres of rotation, combined offset ( p = 0.67), cup inclination ( p = 0.68), cup anteversion ( p = 0.72), and correction of leg-length discrepancy ( p = 0.61). There was no difference in postoperative complications between the two treatment groups. Conclusions: Integration of robotic-arm assisted acetabular cup positioning during THA was associated with a learning curve of 12 cases for operative times and surgical team confidence levels but there was no learning curve effect for accuracy in restoring native hip biomechanics or achieving planned acetabular cup positioning and orientation.

Presented is an assessment of the effects of changes in global human for the regulation of Functional Electrical Stimulation (FES) revived sit-to-stand (STS) using three nonlinear control methods. The techniques are the Sliding Mode Control (SMC), Feedback Linearized Control (FLC), and Back Stepping Control Approach. Literature indicates the necessity of improving the system of which applications control has shown such ability. The analytical STS model uses the four segments. Six order polynomial was harnessed for trajectory planning. The work was aimed at relaxing the effect of the variation in human masses such that there will be no need changing parameters when using the device for different subjects. The results indicated the ability of the control schemes to curtail the perturbations and to regulate the system with minimal errors while maintaining the stability as well. Responses closeness to the desired transition trajectories during the movement and without any disturbance are evident from the results obtained. It was also accomplished within the recommended settings of the stimulation parameters with high levels of robustness, which are highly greater than that of a 2% error margin usually considered. Therefore, indicating the likelihood of the methods for the FES induced STS system for greater performance with the BSC being the best.

Presented is the application of the Feedback Linearisation Control (FLC) method for compensation of variations in human masses for the restoration of sit-to-stand movement function with the aid of Functional Electrical Stimulation. According to literature, enhancement of the control system of such arrangements, which is one of the promising techniques employed is required to attain the desired goal. Hence, improving the system by making it more accurate and robust with aim ushering such devices towards clinical acceptance. The FLC approach is employed, and effort is made to investigate the effect of global human mass distribution as obtained in the literature. The plant is modelled by using the Newton-Euler and Euler-Lagrange methods for the segment dynamics, and the muscles model is adopted from the previous works. The plant for the study is the paraplegic subject and for sit-to-stand movement revival. The control system tries to maintain the stimulation current optimum during the entire process. Results show remarkable improvements with a drastic reduction in the stimulation current, the rate of change in the stimulation current, and the tracking error. Therefore, the system would have a drastic enhancement in accuracy and delayed attainment of fatigue.

Purpose The primary objective of this study was to determine the surgical team’s learning curve for robotic-arm assisted TKA through assessments of operative times, surgical team comfort levels, accuracy of implant positioning, limb alignment, and postoperative complications. Secondary objectives were to compare accuracy of implant positioning and limb alignment in conventional jig-based TKA versus robotic-arm assisted TKA. Methods This prospective cohort study included 60 consecutive conventional jig-based TKAs followed by 60 consecutive robotic-arm assisted TKAs performed by a single surgeon. Independent observers recorded surrogate markers of the learning curve including operative times, stress levels amongst the surgical team using the state-trait anxiety inventory (STAI) questionnaire, accuracy of implant positioning, limb alignment, and complications within 30 days of surgery. Cumulative summation (CUSUM) analyses were used to assess learning curves for operative time and STAI scores in robotic TKA. Results Robotic-arm assisted TKA was associated with a learning curve of seven cases for operative times (p = 0.01) and surgical team anxiety levels (p = 0.02). Cumulative robotic experience did not affect accuracy of implant positioning (n.s.) limb alignment (n.s.) posterior condylar offset ratio (n.s.) posterior tibial slope (n.s.) and joint line restoration (n.s.). Robotic TKA improved accuracy of implant positioning (p

Presented was an investigation on the performance of the feedback linearization control (FLC) method for the FES induced STS movement application in paraplegia. Improving the operation condition of the FES induced movement is one of the challenges currently receiving attention by so many scholars in the field. The Newton-Euler and Euler-Lagrange methods are utilised to check its correctness together with the muscle model proposed by Ferrarin and Pedotti. The FLC was evaluated for the system with and without fatigue disturbance. Although the fatigue disturbance was introduced in the system, results revealed that the cumulative current, cumulative rate of change in current the cumulative rate of change in current, RMSE, tracking error, cumulative tracking error and the level of the control signal, were by far better for the FL than that of the PID control technique with wide margins. Therefore, results portrayed that the FL control system the tendency to annul the effects of the effect of fatigue with higher capability over the gain scheduling based PID control method. It also indicates superiority in terms of system stability.

Patient dissatisfaction after total knee arthroplasty (TKA) is a concern. Surgical error is a common, avoidable cause of failed TKA. Correct femoral and tibial component sizing improves implant longevity, clinical outcomes, knee balance, and pain scores. We hypothesized that preoperative three-dimensional (3D) templating for robot-assisted TKA (RA-TKA) is more accurate than two-dimensional (2D) digital templating. Prospectively collected data from 31 RA-TKAs were assessed to determine accuracy pertaining to implant sizing and positioning. All cases undergoing RA-TKA undergo preoperative CT-scans as per protocol. Three blinded observers retrospectively templated these knees for TKA using standard radiographs. We compared whether 2D templating was as accurate as CT-guided templating. Postoperative radiographs were then evaluated for sizing and positioning. Intraclass correlation coefficients (ICCs) and the effect of learning curve were assessed. Preoperative femoral component 3D templating and retrospective blinded 2D templating accuracies were 96.6% and 52.9%, respectively (χ 2: 17.965; odds ratio [OR]: 24.957, 3.250–191.661; p

Afforestation in semi-arid regions can potentially enhance the global carbon sink by increasing the terrestrial biomass. However, the survival of planted forests under such extreme environmental conditions is not guaranteed a priori, and critically depends on the surface–atmosphere exchange of energy. We investigate the pine forest Yatir in Israel, an example of a man-made semi-arid ecosystem, by means of large-eddy simulations. We focus on the interaction between surface–atmosphere exchange and secondary circulations that couple the isolated forest to the surrounding shrubland. The large-eddy simulations feature a grid resolution that resolves the forest canopy in several layers, and are initialized by satellite data and Doppler lidar, eddy-covariance and radiosonde measurements. We perform three large-eddy simulations with different geostrophic wind speeds to investigate the influence of those wind speeds on the surface–atmosphere exchange. We reproduce the measured mean updrafts above the forest and mean downdrafts above the shrubland, which increase in strength with decreasing geostrophic wind speed. The largest updrafts emerge above the older, denser part of the forest, triggering secondary circulations. The spatial extent of these circulations does not cover the entire forest area, although we observe a reduced aerodynamic resistance in the regions of updraft. Our simulations indicate that the enhanced surface–atmosphere exchange of the Yatir forest is not sufficient to compensate for the increased net radiation, due to the lower albedo of the forest with respect to the surroundings, resulting in higher air temperatures inside the forest. However, the difference between the forest and shrubland temperatures decreases with increasing geostrophic wind speed due to reduction in the aerodynamic resistance.

PURPOSE/OBJECTIVE(S) Previous studies have suggested that the dose immediately outside the PTV may impact the incidence of distant metastases after stereotactic body radiation therapy (SBRT) for patients with early-stage non-small cell lung cancer. In particular, Diamant et al have reported a correlation between the mean EQD2 of a 30mm shell around the PTV and both local control and the rate of distant metastases in lung SBRT patients. In this study, we review this parameter and others in a series of patients with radiographically presumed or biopsy proven early-stage non-small cell lung cancer treated at our institution with SBRT between 2014 and 2019. MATERIALS/METHODS We reviewed the dosimetry, local control and rate of distant metastases for a series of 155 patients with 165 lesions treated with SBRT at our institution. Dosimetric parameters obtained included the prescribed dose, minimum and mean doses to the PTV, conformity index, and the mean EQD2 to a 30mm shell around the PTV, as reported by Diamant et al. Time to local progression and distant metastasis were defined from date of last fraction of SBRT to date of event, with event-free patients censored at last radiographic follow-up. All plans were calculated in the Varian Eclipse treatment planning system using the AAA algorithm and treated on conventional Linac with either IMRT or VMAT delivery. Analysis of the data was performed using IBM SPSS for Windows (version 27), with analysis of time to event via Kaplan-Meier method. Univariate analysis of outcomes based on the above dosimetric parameters was performed utilizing the log-rank test. A P-value < 0.05 was considered to be statistically significant. RESULTS No significant correlation was seen between the mean EQD2 dose to a 30mm shell around the PTV and either the local control or the rate of distant metastases in these patients. Positive predictors of reduced incidence of distant metastases were the prescribed dose of 54 Gy (vs 45-50 Gy, P < 0.01) and PTV < 22 cc (vs. ≥ 22 cc, P = 0.01). In the 45-50 Gy cohort, PTV mean dose ≥ 53 Gy (vs. < 53 Gy, P = 0.04) was associated with reduced incidence of distant metastases. Improved local control was also noted with prescribed dose of 54 Gy (vs 48-50 Gy, P = 0.01). In the 45-50 Gy cohort, PTV mean dose ≥ 53 Gy (vs. < 53 Gy, P = 0.03) was associated improved local control. No additional factors examined were significantly correlated with local control. CONCLUSION We failed to replicate the correlation of the rate of distant metastases with dose outside the PTV as reported by Diamant et al. Higher prescribed and mean dose to the PTV was correlated with both local control and reduced incidence of distant metastases. References.

The Campbell CSAT3 sonic anemometer is one of the most popular instruments for turbulence measurements in basic micrometeorological research and ecological applications. While measurement uncertainty has been characterized by field experiments and wind-tunnel studies in the past, there are conflicting estimates, which motivated us to conduct a numerical experiment using large-eddy simulation to evaluate the probe-induced flow distortion of the CSAT3 anemometer under controlled conditions, and with exact knowledge of the undisturbed flow. As opposed to wind-tunnel studies, we imposed oscillations in both the vertical and horizontal velocity components at the distinct frequencies and amplitudes found in typical turbulence spectra in the surface layer. The resulting flow-distortion errors for the standard deviations of the vertical velocity component range from 3 to 7%, and from 1 to 3% for the horizontal velocity component, depending on the azimuth angle. The magnitude of these errors is almost independent of the frequency of wind speed fluctuations, provided the amplitude is typical for surface-layer turbulence. A comparison of the corrections for transducer shadowing proposed by both Kaimal et al. (Proc Dyn Flow Conf, 551–565, 1978) and Horst et al. (Boundary-Layer Meteorol 155:371–395, 2015) show that both methods compensate for a larger part of the observed error, but do not sufficiently account for the azimuth dependency. Further numerical simulations could be conducted in the future to characterize the flow distortion induced by other existing types of sonic anemometers for the purposes of optimizing their geometry.

The paper presented an evaluation using the Back Stepping control (BSC) for the regulation of Functional Electrical Stimulation (FES) aided sit-to-stand (STS) motion restoration by investigating the effect of human mass distribution across the world. The study focused on eradicating or reducing to the minimum the tasks of changing the control system parameters when applying the device for different subjects. The comparison was made with the Proportional Integral Derivative (PID) based gain scheduling based control approach. Results do indicate the robustness of the BSC control method as it portrays that despite the alteration of the masses to the extremes the control system was able to keep the tracking error approaching zero or very close to the desired with and without changes. It outperformed the PID based gain scheduling control scheme. It also operates within the permissible limits specified. Hence, it reveals the effectiveness of the BSC scheme for solving the problem of continuous readjustments making the equipment universal. It, therefore, relieve the burden of the necessity of changing the control variables continuously. The study is novel because the BSC has never been evaluated on four segments based induced STS movement in paraplegia model. The universal human mass distribution has also not been considered using the control scheme on the model

The work presented an enhanced trajectory planning for better handling of Functional Electrical Stimulation (FES) actuated revival of sit-to-stand (STS) manoeuvre. Currently there the problem of lack of FES aided devices as results of the failures of the proposed equipment to pass clinical tests. Employing control systems techniques have been yielding fruitful results. Literature indicated that further enhancement of trajectory planning could help in achieving milestones towards better performances. Continuous and coupled with bump-free trajectories are some essential properties for better control systems designs for such systems. The proposed trajectory planning utilises the six-order polynomial. Comparisons are made with the five and seven order polynomials. The fifth order polynomials give an insight of the performance of the system with lower order polynomials while the seventh order gave that of the higher order counterparts. It was employed to enhance the desired movement trajectories. Obtained results portrayed that the trajectory planning achieved are continuous and the tendencies of the appearances of jerks or spikes are eliminated. Others are an improvement on execution time by 11%, reducing the upper and lower bound terminal velocities by 16.9% and 20.9% accordingly. Thus, these indicate the possibilities of realisations of higher performance control systems for the induced movement tasks.

Presented is an evaluation of the sliding mode controller (SMC) for regulation of Functional Electrical Stimulation (FES) induced sit-to-stand (STS) movement considering a global human mass variation. It is aimed at the elimination of the retuning issue associated with control systems for different subjects. Results show that despite the changes in mass the control system maintained the tracking error close to zero; that is close to the desired, and without any disturbance scenario, it was also achieved within the suitable specifications. Thus, it shows that the SMC system can be employed to solve the issue of universality; therefore relieving the necessity of altering the control parameters always.

ObjectivesThe primary objective of this study was to compare accuracy in restoring the native centre of hip rotation in patients undergoing conventional manual total hip arthroplasty (THA) versus robotic-arm assisted THA. Secondary objectives were to determine differences between these treatment techniques for THA in achieving the planned combined offset, component inclination, component version, and leg-length correction.Materials and MethodsThis prospective cohort study included 50 patients undergoing conventional manual THA and 25 patients receiving robotic-arm assisted THA. Patients undergoing conventional manual THA and robotic-arm assisted THA were well matched for age (mean age, 69.4 years (sd 5.2) vs 67.5 years (sd 5.8) (p = 0.25); body mass index (27.4 kg/m2(sd 2.1) vs 26.9 kg/m2(sd 2.2); p = 0.39); and laterality of surgery (right = 28, left = 22 vs right = 12, left = 13; p = 0.78). All operative procedures were undertaken by a single surgeon using the posterior approach. Two independent blinded observers recorded all radiological outcomes of interest using plain radiographs.ResultsThe correlation coefficient was 0.92 (95% confidence interval (CI) 0.88 to 0.95) for intraobserver agreement and 0.88 (95% CI 0.82 to 0.94) for interobserver agreement in all study outcomes. Robotic THA was associated with improved accuracy in restoring the native horizontal (p < 0.001) and vertical (p < 0.001) centres of rotation, and improved preservation of the patient’s native combined offset (p < 0.001) compared with conventional THA. Robotic THA improved accuracy in positioning of the acetabular component within the combined safe zones of inclination and anteversion described by Lewinnek et al (p = 0.02) and Callanan et al (p = 0.01) compared with conventional THA. There was no difference between the two treatment groups in achieving the planned leg-length correction (p = 0.10).ConclusionRobotic-arm assisted THA was associated with improved accuracy in restoring the native centre of rotation, better preservation of the combined offset, and more precise acetabular component positioning within the safe zones of inclination and anteversion compared with conventional manual THA.

The role for extra-articular procedures in addition to ACL reconstruction to restore rotational stability is debated. We use lateral extra-articular tenodesis (LEAT) for patients that meet criteria. Our null hypothesis was that there would be no difference between two groups of patients that were treated with ACL reconstruction alone or ACL reconstruction with LEAT according to criteria. A prospectively collected database of patients that were treated primarily according to the presence of a high-grade pivot shift with LEAT at the time of ACL reconstruction was propensity-matched with a group of patients that underwent ACL reconstruction alone. Minimum follow-up was 2 years. Stratified variable analysis of the groups was also performed. There were 218 and 55 patients in the ACL reconstruction group and ACL reconstruction with LEAT group, respectively. There were 125 patients and 46 patients after propensity matching with a median follow-up of 52 months and 27 months, respectively. Post-operative Lysholm score (P = 0.005), Tegner activity index (P = 0.003) and time to return to sport (P

Introduction The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) review (2017) of acute non-invasive ventilation (aNIV) revealed a high inpatient mortality of 35.3%, reflecting the British Thoracic Society (BTS) aNIV audit findings of 2011–2013. The Plant study (2000) demonstrating the effectiveness of ward-based aNIV was limited to patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with modest acidosis. However the NCEPOD report found that aNIV was increasingly used to treat non-COPD and severely acidotic (pH Methods Retrospective analysis of consecutive ward-based aNIV episodes from 2014–2018 in a large university teaching hospital was undertaken. aNIV is delivered by a physiotherapy led team with strict inclusion criteria (acute hypercapnic respiratory failure from AECOPD with modest acidosis [pH 7.25 to 7.35], without new consolidation on chest x-ray, haemodynamic instability or multi-organ failure), in a standard level one respiratory ward without enhanced nursing ratios. Patients outside these criteria, who are deemed appropriate for escalation, are referred to critical care, and if not are then discussed with a respiratory consultant for ward-based aNIV. Results Our cohort (n=549) were mainly COPD patients (76.5%), had a higher mean pH (7.27) and fewer new consolidation on chest x-ray (30%), versus the NCEPOD cohort (69.1% COPD, mean pH 7.23% and 40.7% with consolidation). Our inpatient mortality was significantly lower at 13.8% compared to 35.3% in the NCEPOD cohort and 34% in the 2013 BTS audit cohort. Subset analysis showed that aNIV patients with modest acidosis and no consolidation had a mortality of 9.5%, as opposed to 22% for those with severe acidosis and/or consolidation. Conclusion Our study demonstrates that judicious case selection for ward-based aNIV leads to a lower mortality. Patients with more complex illness and adverse features (i.e. consolidation, severe acidosis) should be managed in a higher care setting than a general respiratory ward. This highlights the need for wider access to higher dependency areas across acute hospitals.

Introduction This is the first study to use Structured Light Plethysmography (SLP) in patients with confirmed Pompe disease (PD) to look at respiratory function. PD or Glycogen storage disease 2 is an autosomal recessive metabolic disorder due to deficiency of the lysosomal enzyme acid alpha glucosidase. The resultant accumulation of glycogen affects various tissues including muscles, causing muscle weakness and, in many patients, ventilatory failure. SLP is a non-invasive, non-contact technique, utilising the movement of the thoraco-abdominal (TA) wall to measure a range of breathing-related parameters. A structured light grid is projected on to the thorax and abdomen as the subject breathes and a 5 min dynamic recording is made. Methods 16 patients (Mean [SD] Age (years)=53.0 [12.7]; M:F=4:12) with adult onset PD performed sitting and supine SLP for 5 min (Pneumacare, Ely, UK) as well as routine respiratory muscle function. SLP parameters included Phase Angle (PA), which is a measure of thoraco-abdominal synchronicity. The routine parameters measured included sitting and supine Vital Capacity (VC), Maximal Inspiratory Pressure (MIP), Maximal Expiratory Pressure (MEP) and Sniff Nasal Inspiratory Pressure (SNIP), using Ultima system (MedGraphics UK) to ATS/ERS 2005 standards. Results Complete data was obtained in 12 patients and showed overall reduced ( Conclusions We have demonstrated that PA by SLP can be used to monitor respiratory muscle strength in PD, since it shadows SNIP and MIP across the clinical range. There could be a potential role of using SLP for assessing respiratory muscle function in other neurological conditions especially where standard respiratory muscle function testing is challenging.

Introduction Full video polysomnography (PSG) remains the gold standard for the diagnosis of sleep disorders including sleep-disordered breathing (SDB). However, it is resource intensive and not widely available. Most UK sleep centres use domiciliary cardiorespiratory studies for evaluation of SDB. The aim of our study was to assess the impact of faster access to PSG on our sleep service. Method Domiciliary oximetry and cardiorespiratory studies (Embletta) are undertaken to investigate SDB in our sleep service, based in a university teaching hospital receiving more than 1000 sleep referrals/year. PSG±multiple sleep latency tests are performed for symptomatic patients with normal cardiorespiratory studies, or where there is a suspicion of non-respiratory sleep disorder (NRSD). However, because of lack of ring-fenced PSG beds (PSGs undertaken in elective neurology ward beds), the average capacity is limited to two PSGs/month. In collaboration with a neighboring hospital having a sleep laboratory with four dedicated PSG beds daily, we introduced a change in our pathway whereby we could directly access their PSG service. Retrospective data was collected for the year preceding (November 2015 – October 2016) and following (November 2016 – October 2017) the change. Results Although the total number of sleep clinic referrals remained largely unchanged over the two years, the number of PSG referrals increased threefold. The median waiting time for PSG reduced significantly from 455 to 77 days. The proportion of cases where PSG revealed a definitive diagnosis (SDB or NRSD) rose from 23% to 55%. In 24% of cases in the second year PSG revealed significant SDB which was missed on previous cardiorespiratory studies. Conclusion Referring to a sleep laboratory with dedicated PSG beds greatly reduced waiting times and led to increased utilization of PSG in our diagnostic pathway. Consequently, this reduced our overall diagnostic waits and enhanced our diagnostic accuracy – not only for NRSD but also in identifying SDB missed on previous cardiorespiratory studies. Non-diagnostic cardiorespiratory studies, suspicion of NRSD, and persistent symptoms despite treatment should lead to PSG evaluation. Regional networks can be established to gain easier access to PSG, enhancing the diagnostic capability of sleep services.

Aims The primary aim of this study was to determine the surgical team’s learning curve for introducing robotic-arm assisted unicompartmental knee arthroplasty (UKA) into routine surgical practice. The secondary objective was to compare accuracy of implant positioning in conventional jig-based UKA versus robotic-arm assisted UKA. Patients and Methods This prospective single-surgeon cohort study included 60 consecutive conventional jig-based UKAs compared with 60 consecutive robotic-arm assisted UKAs for medial compartment knee osteoarthritis. Patients undergoing conventional UKA and robotic-arm assisted UKA were well-matched for baseline characteristics including a mean age of 65.5 years (sd 6.8) vs 64.1 years (sd 8.7), (p = 0.31); a mean body mass index of 27.2 kg.m2 (sd 2.7) vs 28.1 kg.m2 (sd 4.5), (p = 0.25); and gender (27 males: 33 females vs 26 males: 34 females, p = 0.85). Surrogate measures of the learning curve were prospectively collected. These included operative times, the Spielberger State-Trait Anxiety Inventory (STAI) questionnaire to assess preoperative stress levels amongst the surgical team, accuracy of implant positioning, limb alignment, and postoperative complications. Results Robotic-arm assisted UKA was associated with a learning curve of six cases for operating time (p Conclusion Robotic-arm assisted UKA was associated with a learning curve of six cases for operating time and surgical team confidence levels but no learning curve for accuracy of implant positioning. Cite this article: Bone Joint J 2018;100-B:1033–42.

Functional Electrical Stimulation (FES) can be used to revive movement functions of the human body to a certain degree which was lost due to occurrences of the nervous system disorders resulting from accidents or diseases. It can also be employed for gait rehabilitation as well as therapy. Control systems could be employed to improve on the FES-induced motion, and the closed-loop was targeted due to its advantages. Based on the papers reviewed, studies have shown that the linear control schemes are popular for movement restoration in the lower limb, but mostly for continuous standing contributing to mainly the stance phase. Therefore, a myriad of limitations was observed which include: the need for using improved sensors, re-tuning for every subject, tests conducted using patient with more straightforward ailments, complexity in implementation and most importantly is the issue of stability. The swing phase of gait movement and the full walking motion have more complex dynamics and coupled with the nature of the plant (human with nervous system disorder and the neuromuscular structure) could render the linear control method obsolete or unsuitable. Hence, there is a need to investigate other techniques such as the nonlinear and intelligent control methods.

Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) is a life-threatening hypersensitivity reaction which is usually triggered by medications and carries a high mortality. It is typically characterized by a nonspecific flu-like prodrome, followed by round macular or patchy dusky erythematous lesions of the skin that coalesce and develop into bullae, resembling painful thermal burns. Additionally most patients will have mucus membrane involvement. SJS and TEN are a continuum of the same disease entity, whereas SJS is the less severe form of the spectrum with

UN General Assembly explicitly recognized the human right to water and sanitation which is also essential to achieve target six of sustainable development goals. This descriptive type of cross sectional study was carried out to observe knowledge, attitude and practice on hygiene and sanitation in a selected rural area with a sample size of 247 which was purposively selected. The age structure of the respondents showed that 47.4% belonged to 34-48 years and43.3% belonged to 19-33 years’ age group with mean age 35.53 ± 9.11. Among the respondents 78.1% were Muslim, 62.8% and 37.2% were female and male respectively. Study revealed that of the respondents 56.3% thought germ free water as safe, 11.7% opined it as smell free,14.2% replied it as both smell and germ free but 17.8% didn’t know about it. About sanitation, 48.2% mentioned hygienic latrine, 11.3% mentioned clean environment and 28.3% did not know about it. Among them 49.0% respondents cleaned drinking glass by only water, 32.0% by soap/detergent with water. Of them 80.6% cleaned water storage container by only water and 13.8%by soap/detergent along with water. Among respondents 36.8% had under five children in family, 30.4% defecated in open place, 6.4% used latrine for defecation and 30.4% didn’t use soap after bottom cleaning. There was significant association between education and knowledge on sanitation and safe water (p=< 0.001).Bangladesh Poverty Reduction Strategy has included water and sanitation as an important issue which has got due attention by stakeholders and international development organizations.

FES induced movements from indication is promising due to encouraging results being obtained by scholars. The kinematic model usually constitute the initial phase towards achieving the segmental dynamics of any rigid body system. It can be used to ascertain that the model is capable of achieving the desired goal. The dynamic model builds on the kinematic model and is usually mathematically cumbersome depending on the number of degrees-of-freedom. This paper presents a kinematic model applicable for human sit-to-stand movement scenario that will be used to obtain the dynamic model the FES induced movement in a later study. The study shows that the 6 DOF conceptualized sit-to-stand movement can be achieved conveniently using 4 DOF. The 4 DOF has an additional joint compared to similar earlier works which makes more it accurate and flexible. It is more accurate in the sense that it accommodates additional joint i.e. the neck joint whose dynamics could be captured. And more flexible in the sense that if future research uncover more contributions by the segments it can be easily incorporated including that of other segments e.g. the trunk, neck and upper limbs.

The objective is to perform a systematic review and meta-analysis of the literature on the long-term results of hearing preservation after vestibular schwannoma resection.Ovid/Medline, PubMed, Embase, and the Cochrane library from January 1980 to January 2015.Inclusion criteria: age ≥18 years, minimum 10 patients in the treatment group, hearing preserving microsurgery, no previous radiation treatment, serviceable hearing at immediate postop follow-up, hearing outcomes reported using Gardner Robinson or the American Academy of Otolaryngology-Head and Neck Surgeons hearing grading scales, and average follow-up of 5 years. Preoperative, immediate postoperative, and last follow-up audiograms were required. Exclusion criteria included neurofibromatosis type 2 patients and surgery for salvage therapy or decompression.Quality evaluated using Methodological Index for Non-Randomized Studies.Meta-analysis was performed using R v3.2.2, Metafor package v 1.9-7. Cohen's D was used to determine effect size. Ten reports had at least 5-year follow-up and used standardized hearing grading scales. The systematic review found that if hearing was preserved at Class A or B at early postop visit, the chance of preserving hearing at 5 years was excellent. Those who maintained speech discrimination score ≥ 89% at the early postoperative follow-up had better long-term hearing preservation. The meta-analysis reveals that only preoperative and postoperative pure-tone average was associated with long-term hearing preservation.Long-term (5 yr) hearing durability rates are generally very good. Most studies do not report patient and tumor characteristics, therefore precluding combining studies for meta-analysis. Only preoperative and postoperative postoperative pure-tone average was associated with long-term hearing durability.

Objectives/Hypothesis The mechanical properties of normal auricular cartilage provide a benchmark against which to characterize changes in auricular structure/function due to genetic defects creating phenotypic abnormalities in collagen subtypes. Such properties also provide inputs/targets for auricular reconstruction scaffold design. Several studies report the biomechanical properties for septal, costal, and articular cartilage. However, analogous data for auricular cartilage are lacking. Therefore, our aim in this study was to characterize both whole-ear and auricular cartilage mechanics by mechanically testing specimens and fitting the results to nonlinear constitutive models. Study Design Mechanical testing of whole ears and auricular cartilage punch biopsies. Methods Whole human cadaveric ear and auricular cartilage punch biopsies from both porcine and human cartilage were subjected to whole-ear helix-down compression and quasistatic unconfined compression tests. Common hyperelastic constitutive laws (widely used to characterize soft tissue mechanics) were evaluated for their ability to represent the stress-strain behavior of auricular cartilage. Results Load displacement curves for whole ear testing exhibited compliant linear behavior until after significant displacement where nonlinear stiffening occurred. All five commonly used two-term hyperelastic soft tissue constitutive models successfully fit both human and porcine nonlinear elastic behavior (mean R2 fit >0.95). Conclusions Auricular cartilage exhibits nonlinear strain-stiffening elastic behavior that is similar to other soft tissues in the body. The whole ear exhibits compliant behavior with strain stiffening at high displacement. The constants from the hyperelastic model fits provide quantitative baselines for both human and porcine (a commonly used animal model for auricular tissue engineering) auricular mechanics. Level of Evidence NA Laryngoscope, 125:E262–E268, 2015

Background Open fractures of the lower limb represent a complex and varied array of injuries. The BOAST 4 document produced by BAPRAS and the BOA provides standards on how to manage these patients, and NICE have recently produced additional guidance. We aimed to assess concordance with these standards in a large cohort representative of UK orthoplastic centres. Methods Patients admitted to the orthoplastic units at Norfolk and Norwich University Hospital and Royal Stoke University Hospital with open lower limb fractures between 2009 and 2014 were included. Data was gathered from notes and endpoints based on the BOAST 4 document. Results In total, 84 patients were included across the two sites, with 83 having their initial debridement within 24 h (98.8%). Forty-two patients had a documented out-of-hours initial surgery. Of these, 10 (23.8%) had an indication for urgent surgery. This pattern was consistent across both hospitals. A plastic surgeon was present at 33.3% of initial operations. Of 78 patients receiving definitive soft tissue cover, 56.4% had cover within 72 h and 78.2% within 7 days. Main reasons for missing these targets were transfer from other hospitals, plastic surgeons not present at initial operation and intervening critical illness. Conclusions This study has identified key areas for improving compliance with the national BOAST 4 and NICE standards. Out-of-hours operating is occurring unnecessarily and time targets are being missed. The development of dedicated referral pathways and a true orthoplastic approach are required to improve the management of this complex set of injuries.

This study determines segmental dynamics parameters based on subject specific method. Five hemiplegic patients participated in the study, two men and three women. Their ages ranged from 50 to 60 years, weights from 60 to 70 kg and heights from 145 to 170 cm. Sample group included patients with different side of stroke. The parameters of the segmental dynamics resembling the knee joint functions measured via measurement of Winter and its model generated via the employment Kane’s equation of motion. Inertial parameters in the form of the anthropometry can be identified and measured by employing Standard Human Dimension on the subjects who are in hemiplegia condition. The inertial parameters are the location of centre of mass (COM) at the length of the limb segment, inertia moment around the COM and masses of shank and foot to generate accurate motion equations. This investigation has also managed to dig out a few advantages of employing the table of anthropometry in movement biomechanics of Winter’s and Kan...

Objective To determine whether patients with semicircular canal dysplasia have mutations in CHD7. Background CHARGE syndrome is a nonrandom clustering of congenital anomalies, including ocular coloboma, heart defects, choanal atresia or stenosis, retarded growth and development, genital hypoplasia, and inner and outer ear anomalies including deafness. Semicircular canal dysplasia has been included as a major diagnostic criterion for CHARGE syndrome. Mutations in the gene CHD7 on chromosome 8q12.1 are a major cause of CHARGE syndrome, but the extent to which patients with semicircular canal dysplasia have CHD7 mutations is not fully understood. Study design Cross-sectional analysis of CHD7 in 12 patients with semicircular canal dysplasia and variable clinical features of CHARGE syndrome. Results We identified 6 CHD7 mutations, 5 of which occurred in patients who fulfilled Verloes' diagnostic criteria for typical CHARGE syndrome, and three of which were previously unreported. Of the 3 remaining CHD7 mutation-positive patients, one had atypical CHARGE by diagnostic criteria. Four MRI records were available, which revealed 2 patients with cochlear nerve aplasia and 1 patient with Chiari 1 malformation. Conclusion These data provide additional evidence that CHD7 mutations are a significant cause of semicircular canal atresia in children with full or partial CHARGE syndrome.

The sections on the face, neck, and brow include descriptions of facelift, neck lift, and open brow lift techniques, anesthesia, treatment goals, procedural approaches, complications, management, preoperative and postoperative care, rehabilitation, recovery, and outcomes. The approach to facial rejuvenation the midface and periorbital area is detailed. These operations are often and easily performed entirely with the use of local anesthesia and mild oral sedation. There are very high satisfaction rates.

Most hand traumas and elective surgical disorders of the hand can be treated quickly, easily, inexpensively, and effectively in an outpatient clinic. Although many surgeons prefer general anesthesia, the senior author routinely uses local anesthesia without sedation almost exclusively for carpal and cubital tunnel release, fasciectomy, arthrodesis, arthroplasty, synovectomy, and trauma, including the repair of tendons, nerves, ligaments, fractures, and soft tissue defects. After completing more than 10,000 procedures, the authors have found great benefits through the use of local anesthesia, which are detailed in the article.

The evolution of liposuction has been multidisciplinary. The tumescent variant was developed using dilute local lidocaine and epinephrine and was meant to specifically exclude additional intravenous sedation, regional or general anesthesia, and intravenous fluids. Clinical pharmacology, pathophysiology, and safety studies are reviewed in this article. Tumescent formulations for varied anatomic sites are discussed, as well as other indications for tumescent anesthesia.