Realist evaluation of Schwartz rounds® for enhancing the delivery of compassionate healthcare: understanding how they work, for whom, and in what contexts.

BACKGROUND: Healthcare work is known to be stressful and challenging, and there are recognised links between the psychological health of staff and high-quality patient care. Schwartz Center Rounds® (Rounds) were developed to support healthcare staff to re-connect with their values through peer reflection, and to promote more compassionate patient care. Research to date has focussed on self-report surveys that measure satisfaction with Rounds but provide little analysis of how Rounds 'work' to produce their reported outcomes, how differing contexts may impact on this, nor make explicit the underlying theories in the conceptualisation and implementation of Rounds. METHODS: Realist evaluation methods aimed to identify how Rounds work, for whom and in what contexts to deliver outcomes. We interviewed 97 key informants: mentors, facilitators, panellists and steering group members, using framework analysis to organise and analyse our data using realist logic. We identified mechanisms by which Rounds lead to outcomes, and contextual factors that impacted on this relationship, using formal theory to explain these findings. RESULTS: Four stages of Rounds were identified. We describe how, why and for whom Schwartz Rounds work through the relationships between nine partial programme theories. These include: trust safety and containment; group interaction; counter-cultural/3rd space for staff; self-disclosure; story-telling; role modelling vulnerability; contextualising patients and staff; shining a spotlight on hidden stories and roles; and reflection and resonance. There was variability in the way Rounds were run across organisations. Attendance for some staff was difficult. Rounds is likely to be a 'slow intervention' the impact of which develops over time. We identified the conditions needed for Rounds to work optimally. These contextual factors influence the intensity and therefore degree to which the key ingredients of Rounds (mechanisms) are activated along a continuum, to produce outcomes. Outcomes included: greater tolerance, empathy and compassion for self and others; increased honesty, openness, and resilience; improved teamwork and organisational change. CONCLUSIONS: Where optimally implemented, Rounds provide staff with a safe, reflective and confidential space to talk and support one another, the consequences of which include increased empathy and compassion for colleagues and patients, and positive changes to practice.

Use of inertial measurement units to assess age-related changes in gait kinematics in an active population.

To study mobility in older populations it can be advantageous to use portable gait analysis systems, such as inertial measurement units (IMUs), which can be used in the community. To define a normal range, 136 active subjects were recruited with an age range of 18 to 97. Four IMUs were attached to the subjects, one on each thigh and shank. Subjects were asked to walk 10 m at their own self-selected speed. The ranges of motion of thigh, shank, and knee in both swing and stance phase were calculated, in addition to stride duration. Thigh, shank, and knee range of movement in swing and stance were significantly different only in the > 80 age group. Regressions of angle against age showed a cubic relationship. Stride duration showed a weak linear relationship with age, increasing by approximately 0.1% per year.

Can FES-rowing mediate bone mineral density in SCI: a pilot study.

STUDY DESIGN: A single case study. OBJECTIVES: To compare proximal tibia trabecular bone mineral density (BMD) of a participant with complete spinal cord injury (SCI), long-termed functional electrical stimulation-rowing (FES-R) trained, with previously reported SCI and non-SCI group norms. To estimate lower limb joint contact forces (JCFs) in the FES-R trained participant. SETTING: UK University and orthopaedic hospital research centre. METHODS: Bilateral proximal tibial trabecular BMD of the FES-R trained participant was measured using peripheral quantitative computerised tomography, and the data were compared with SCI and non-SCI groups. An instrumented four-channel FES-R system was used to measure the lower limb JCFs in the FES-R trained participant. RESULTS: Structurally, proximal tibial trabecular BMD was higher in the FES-R trained participant compared with the SCI group, but was less than the non-SCI group. Furthermore, left (184.7 mg cm(-3)) and right (160.7 mg cm(-3)) BMD were well above the threshold associated with non-traumatic fracture. The knee JCFs were above the threshold known to mediate BMD in SCI, but below threshold at the hip and ankle. CONCLUSION: As pathological fractures predominate in the distal femur and proximal tibia in chronic SCI patients, the fact that the FES-R trained participant's knee JCFs were above those known to partially prevent bone loss, suggests that FES-R training may provide therapeutic benefit. Although the elevated bilateral proximal tibial BMD of the FES-R participant provides circumstantial evidence of osteogenesis, this single case precludes any statement on the clinical significance. Further investigations are required involving larger numbers and additional channels of FES to increase loading at the hip and ankle.

Screw fixation of medial malleolar fractures: a cadaveric biomechanical study challenging the current AO philosophy.

The AO Foundation advocates the use of partially threaded lag screws in the fixation of fractures of the medial malleolus. However, their threads often bypass the radiodense physeal scar of the distal tibia, possibly failing to obtain more secure purchase and better compression of the fracture. We therefore hypothesised that the partially threaded screws commonly used to fix a medial malleolar fracture often provide suboptimal compression as a result of bypassing the physeal scar, and proposed that better compression of the fracture may be achieved with shorter partially threaded screws or fully threaded screws whose threads engage the physeal scar. We analysed compression at the fracture site in human cadaver medial malleoli treated with either 30 mm or 45 mm long partially threaded screws or 45 mm fully threaded screws. The median compression at the fracture site achieved with 30 mm partially threaded screws (0.95 kg/cm(2) (interquartile range (IQR) 0.8 to 1.2) and 45 mm fully threaded screws (1.0 kg/cm(2) (IQR 0.7 to 2.8)) was significantly higher than that achieved with 45 mm partially threaded screws (0.6 kg/cm(2) (IQR 0.2 to 0.9)) (p = 0.04 and p < 0.001, respectively). The fully threaded screws and the 30mm partially threaded screws were seen to engage the physeal scar under an image intensifier in each case. The results support the use of 30 mm partially threaded or 45 mm fully threaded screws that engage the physeal scar rather than longer partially threaded screws that do not. A 45 mm fully threaded screw may in practice offer additional benefit over 30 mm partially threaded screws in increasing the thread count in the denser paraphyseal region.

Species, sex, size and male maturity composition of previously unreported elasmobranch landings in Kuwait, Qatar and Abu Dhabi Emirate.

This paper presents data from the first major survey of the diversity, biology and fisheries of elasmobranchs in the Persian (Arabian) Gulf. Substantial landings of elasmobranchs, usually as gillnet by-catch, were recorded in Kuwait, Qatar and the Emirate of Abu Dhabi (part of the United Arab Emirates), although larger elasmobranchs from targeted line fisheries were landed in Abu Dhabi. The elasmobranch fauna recorded was distinctive and included species that are undescribed, rare and have a highly restricted known distribution. Numerical abundance was dominated by sharks (c. 80%), of which carcharhinids were by far the most important. The milk shark Rhizoprionodon acutus and whitecheek shark Carcharhinus dussumieri together comprised just under half of all recorded individuals. Around 90% of recorded sharks were small (50-90 cm total length, L(T) ) individuals, most of which were mature individuals of species with a small maximum size (<100 cm L(T) ), although immature individuals of larger species (e.g. Carcharhinus sorrah and other Carcharhinus spp.) were also important. The most frequently recorded batoid taxa were cownose rays Rhinoptera spp., an undescribed whipray, and the granulated guitarfish Rhinobatos granulatus. The first size, sex and maturity data for a wide range of Gulf elasmobranch species are presented (including L(T) at 50% maturity for males of four shark species) and include some notable differences from other locations in the Indo-West Pacific Ocean. A number of concerns regarding the sustainability of the fishery were highlighted by this study, notably that most of the batoid species recorded are classed by the IUCN Red List as vulnerable, endangered, data deficient or not evaluated. Despite their considerable elasmobranch landings, none of the three countries sampled have developed a 'Shark Plan' as encouraged to do so under the FAO International Plan of Action: Sharks. Furthermore, Kuwait and Qatar currently report zero or no elasmobranch landings to the FAO.

Phylogenetic and ecological factors influencing the number and distribution of electroreceptors in elasmobranchs.

Electroreception is found throughout the animal kingdom from invertebrates to mammals and has been shown to play an important role in prey detection, facilitating social behaviours, the detection of predators and orientation to the earth's magnetic field for navigation. Electroreceptors in elasmobranchs, the ampullae of Lorenzini, detect minute electric fields and independently process these stimuli, thereby providing spatial information to the central nervous system on the location of a source, often potential prey. The ampullae of Lorenzini are individually connected to a single somatic pore on the surface of the skin, with the spatial separation of each pore directly influencing how electrical stimuli are detected and processed. Pore abundance varies across taxonomic groups resulting in unique species-specific differences. The intricate distribution patterns created by the specific positioning of somatic pores on the head are, however, consistent within families, resulting in patterns that are identifiable at higher taxonomic levels. As elasmobranchs evolved, the electrosensory system became more complex and highly specialized, which is evident by a general trend of increasing pore abundance over time. The elasmobranch electrosensory system has evolved to operate efficiently under the environmental conditions of the particular habitat in which a species lives. For example, reduced pore abundance is evident in oceanic pelagic elasmobranchs, for whom visual cues are thought to be of great importance. Pore abundance and spatial distribution may be influenced by multiple factors including head morphology, phylogeny, feeding behaviour and habitat.

Changes in the structural and material properties of the tibia in patients with spinal cord injury.

STUDY DESIGN: A cross-sectional study. OBJECTIVES: To measure the change of structural and material properties at different sites of the tibia in spinal cord-injured patients using peripheral quantitative computerised tomography (pQCT). SETTING: Orthopaedic research centre (UK). METHODS: Thirty-one subjects were measured--eight with acute spinal cord injury (SCI), nine with chronic SCI and fourteen able-bodied controls. pQCT scans were performed at 2% (proximal), 34% (diaphyseal) and 96% (distal) along the tibia from the tibial plateau. Structural measures of bone were calculated, and volumetric bone mineral density (vBMD) was also measured at all three levels. Muscle cross-sectional area was measured at the diaphyseal level. RESULTS: Structurally, there were changes in the cortical bone; in the diaphysis, the shape of the cross-section changed to offer less resistance to AP bending, and the cross-sectional area of the cortical shell decreased both proximally and distally. There were corresponding changes in vBMD in the anterior aspect of the cortical diaphysis, as well as proximal and distal trabecular bone. Changes in muscle occurred more rapidly than changes in bone. CONCLUSION: There were clear changes of both structure and material at all three levels of the tibia in chronic SCI patients. These changes were consistent with specific adaptations to reduced local mechanical loading conditions. To assess fracture risk in SCI and also to monitor the effect of therapeutic interventions, the structure of the bone should be considered in addition to trabecular bone mineral density.

Is hip muscle strength the key to walking as a bilateral amputee, whatever the level of the amputations?

BACKGROUND: Little data have been reported on the factors that are important in bilateral amputee walking ability especially the role of hip strength. STUDY DESIGN: Observational, case-control study where participants were evaluated at a single point in time. OBJECTIVES: The aim of this study was to investigate the factors involved in bilateral amputee walking ability by assessment of walking speed, perceived exertion, exercise intensity, physiological cost index (PCI) and hip muscle strength. METHODS: For a group of 10 bilateral amputees, with different levels of amputation, and a non-pathological reference group, walking ability was assessed using the two-minute walk test. Hip muscle strength was assessed using isokinetic strength tests. RESULTS: Bilateral amputees were found to have slower walking speeds and increased PCI of walking which were correlated to higher levels of amputation. Peak hip torques were reduced in the amputees, which was only significant for concentric extension torque (p = 0.029), and approaching significance for concentric flexion (p = 0.061) and abduction (p = 0.057). Bilateral amputee peak hip strength suggested a positive trend with increasing walking ability. CONCLUSIONS: Bilateral amputee walking ability was reduced and mainly related to level of amputation. The role of hip strength in bilateral amputee walking ability requires further investigation.

The relationship between physical activity and leg health in the broiler chicken.

1. The relationship between the physical activity and leg health of broiler chickens was assessed on a semi-commercial scale. 2. Three batches of birds (2128 per batch) were raised under two lighting regimes during the photoperiod; either a step-wise change of light intensity alternating between an illuminance of 200 and 10 lx or a constant illuminance of 10 lx. The activity of focal individuals (24 per batch) was observed at 2, 4 and 6 weeks of age, and leg health assessed weekly, based on gait score, the prevalence of burns on the hock and foot pad, and angulation and rotation of the leg at the intertarsal joint. Cortical bone density and thickness and area moments of inertia of the mid-physis tibiotarsus were measured post mortem at 6 weeks of age. 3. The step-wise change in light intensity did not affect overall performance, activity or leg health. 4. An individual bird's activity did not affect its gait score, the prevalence of hock burn or foot pad burn, cortical density or thickness or shape of the tibiotarsus. Sex of the bird was the only factor to affect significantly the area moment of inertia in the horizontal and vertical planes of the tibiotarsus, with females showing a lower moment of inertia for both. No variable had a significant effect on cortical density or thickness. Mean cortical density was low across all birds and may indicate that, when allowed to move freely as much or as little as they choose, broiler chickens do not exercise enough or do not perform the higher impact activities required to affect bone quality. 5. These findings imply that the activity of broiler chickens raised on a semi-commercial scale is unaffected by step-wise changes in light intensity and that other husbandry measures are needed to raise activity and hence improve leg health.

Isolation and characterization of 12 dinucleotide microsatellite loci in the anadromous fish Osmerus eperlanus (L.).

A subtractive hybridization method was used to isolate 12 dinucleotide microsatellite loci for the anadromous European smelt, Osmerus eperlanus (L.). Three to 17 (mean 8.08) alleles per locus were identified in the two populations screened, and observed heterozygosity ranged from 0.067 to 0.933. Loci in both populations showed significant deviations from Hardy-Weinberg expected frequencies. These 12 loci provide a good basis for investigation of O. eperlanus population structure.

The effect of crystallinity on strength development of alpha-TCP bone substitutes.

Alpha phase tricalcium phosphates (alpha-TCP) were produced using a solid-state reaction method and milled for various periods of time. The resulting four materials were alpha-TCPs, ranging in crystalline content. Powders were exposed to X-ray diffraction for material identification as well as for use in crystallinity and purity calculations. Powder particle size was investigated using laser diffraction. Materials were mixed with 2.5% Na(2)HPO(4) solution to initiate the hydration of alpha-TCP to calcium-deficient hydroxyapatite (CDHA). Isothermal calorimetry was performed to observe thermal response of the powders over a period of time. During the reaction process, at various time points up to 216 h, the material was compression tested to observe strength development. Materials proved to be predominantly alpha phase, while amorphous content determined by XRD varied. Reactivity, as measured by isothermal calorimetry, varied with crystallinity of the alpha-TCP powder. Speed of strength development did not change except for the most finely ground powder. In addition, crystal size of the CDHA was changed only in the product formed from the most highly ground material. It is proposed that increasing reactivity of alpha-TCP cements does not result in a corresponding increase in rate of strength development until there is sufficient supersaturation to produce significant crystal nucleation.

In vitro and in vivo biological responses to a novel radiopacifying agent for bone cement.

Iodixanol (IDX) and iohexol (IHX) have been investigated as possible radiopacification agents for polymethylmethacrylate (PMMA) bone cement, to replace the currently used barium sulphate and zirconia. IDX and IHX are both water-soluble iodine-based contrast media and for the last 20 years have been used extensively in clinical diagnostic procedures such as contrast media enhanced computed tomography, angiography and urography. One of the major reasons to remove the current radiopacifying agents is their well-documented cytotoxicity and their potential to increase bone resorption. Using in vitro bone resorption assays, the effect of PMMA particles plus IDX or IHX to induce osteoclast formation and lacunar resorption on dentine slices has been investigated. These responses have been compared with the in vitro response to PMMA particles containing the conventional radiopacifying agents, that is, barium sulphate and zirconia. In parallel, the in vivo reaction, in terms of new bone formation, to particles of these materials has been tested using a bone harvest chamber in rabbit tibiae. In vitro cell culture showed that PMMA containing IHX resulted in significantly less bone resorption than PMMA containing the conventional opacifiers. In vivo testing, however, showed no significant differences between the amounts of new bone formed around cement samples containing the two iodine-based opacifying agents in particulate form, although both led to fewer inflammatory cells than particles of PMMA containing zirconia. Our results suggest that a non-ionic radiopacifier could be considered as an alternative to the conventional radiopacifying agents used in biomaterials in orthopaedic surgery.

Hydration characteristics of alpha-tricalcium phosphates: Comparison of preparation routes.

Alpha tricalcium phosphate ( á -TCP) cement powders were obtained by solid state reaction and milling (M1) and by precipitation from aqueous solution followed by heating (M2). The materials were hydrated to form calcium-deficient hydroxyapatite (CDHA) with a 2.5 wt% solution of Na2 HPO4 (liquid to powder ratio = 0.34 ml/g, temperature = 37.5 degrees C) and subjected to isothermal calorimetry, mechanical compression tests, X-ray powder diffraction, at various times during hydration, as well as scanning electron microscopy (SEM), laser diffraction and gas adsorption. The particle characteristics of the two powders were similar, but M2 exhibited two reaction events in the thermal power curve, while M1 showed a single event. Both reaction events were attributed to á -TCP dissolution and CDHA recipitation. The minimum in the reaction rate response of M2 was probably due to the formation of a passivating product layer. No such layer was formed on the milled M1 due to its rougher surfaces. Both preparations reached a compressive strength of 30-40 MPa after 24 hr.

Water uptake and release from iodine-containing bone cement.

Water uptake and release characteristics of PMMA cement containing the water-soluble contrast media iohexol or iodixanol have been investigated. The water uptake study revealed that iohexol had the highest uptake of water (3.7%) and that iodixanol had an uptake close to that of Palacos R (2.3% and 1.9%). The curves obtained showed the materials to follow classic diffusion theory, with an initial linearity with respect to t(1/2) making it possible to calculate the diffusion coefficients. This showed iohexol to have the lowest diffusion coefficient, Palacos R the highest, and iodixanol close to that of Palacos R. The release study showed that more iohexol than iodixanol was released from the bone cement; the long-term release was above 25 microg/mL for iohexol compared to slightly above 10 microg/mL for iodixanol. A microCT investigation showed that the risk of developing an observable radiolucent zone is negligible.

Bone cement X-ray contrast media: a clinically relevant method of measuring their efficacy.

It is important to compare different contrast media used in bone cement according to their ability to attenuate X-rays and thereby produce image contrast between bone cement and its surroundings in clinical applications. The radiopacity of bone cement is often evaluated by making radiographs of cement in air at an X-ray tube voltage of 40 kV. We have developed a method for ranking contrast media in bone cement simulating the clinical situation, by (1) choosing the same X-ray tube voltage as used in clinical work, and (2) using a water phantom to imitate the effects of the patients' soft tissue on the X-ray photons. In clinical work it is desirable to have low radiation dose, but high image contrast. The voltage chosen is a compromise, because both dose and image contrast decrease with higher voltage. Three contrast media (ZrO(2), BaSO(4), and Iodixanol) have been compared for degree of "image contrast." Comparing 10 wt % contrast media samples at an X-ray tube voltage of 40 kV, ZrO(2) produced higher image contrast than the other media. However, at 80 kV, using a water phantom, the results were reversed, ZrO(2) produced lower image contrast than both BaSO(4) and Iodixanol. We conclude that evaluations of contrast media should be made with voltages and phantoms imitating the clinical application.

Correlations between fitness and heterozygosity at allozyme and microsatellite loci in the Atlantic salmon, Salmo salar L.

The relationship between heterozygosity at genetic markers (six allozyme and eight microsatellite loci), and fluctuating asymmetry (FA), length and weight was investigated in two samples of Atlantic salmon (Salmo salar L.) with different timings of first active feeding (early (EA) and late (LA) salmon). This trait had previously been related to fitness. EA fish show smaller values of FA, are longer, heavier and are more heterozygous at allozyme loci than are conspecific LA fish. Also within both samples, heterozygosity at allozyme loci was inversely related to FA and was positively related to weight and length. However, no significant differences in microsatellite diversity (heterozygosity and mean d2 measurements) were observed between samples (EA vs LA). Furthermore, no association was observed between the variability at microsatellite loci and FA, weight or length within each sample. These results suggest that allozyme loci, in themselves, influence fitness components, rather than associations arising from associative overdominance.

Timing of first feeding and life-history strategies in salmon: genetic data.

To investigate the relationship between genetic composition and some physiological traits of interest (age at smoltification, precocious maturation in male parr) in early and late first feeding Atlantic salmon, genetic variation at 6 isozyme and 8 microsatellite loci was examined. Early and late first feeding salmon showed different allelic and genotypic distributions at both isozyme and microsatellite loci. A positive relation between enzymatic loci heterozygosity and precocious active alimentation and earlier smoltification (S1 cf. S2) were also found.

Ablation of bone, cartilage, and facet joint capsule using Ho:YAG laser.

OBJECTIVE: The objective of this study was to determine of the efficiency of holmium:YAG laser for bone ablation, compared to cartilage and soft tissue of the intervertebral foramen of the lumbosacral spine. BACKGROUND DATA: The holmium:YAG (Ho:YAG) laser has been used for ablation of bulging or prolapsed discs and also has the potential for decompression of the nerve root when there is narrowing of the foraminae (foraminoplasty). It is proposed that laser ablation of bone and ligament of the intervertebral foramen for nerve root decompression using the Ho:YAG laser is able to produce sufficient bone ablation without inducing significant thermal necrosis in surrounding tissues due to its short absorption length, which could result in significant clinical advantages. MATERIALS AND METHODS: Experiments were performed on samples of laminar bone, facet joint capsule, and cartilage for quantitative and qualitative determination of the effect of Ho:YAG ablation on tissue mass loss using a range of pulse energies from 0.5 to 1.5 J/P at 15 pulses/sec. RESULTS: The results showed a significant linear correlation between the mass loss and pulse energy, and between the mass loss and radiant exposure. Electron microscopy and histology showed that the Ho:YAG ablation resulted in a very sharp and clear border with little charring. Applying 0.01 k.J of total energy at two different settings (1.5 J/p, high power, and 0.5 J/p, low power) at 15 pulses/sec, the cross-sectional area/mm(2) of the ablated bone was measured, using light microscopy and the Scion Image analysis program. The ablated areas were 2.28 +/- 0.87 and 1.16 +/- 0.43 mm(2) at high and low power, respectively (p = 0.008).

The effect of irrigation on peak temperatures in nerve root, dura, and intervertebral disc during laser-assisted foraminoplasty.

BACKGROUND AND OBJECTIVE: The Holmium: YAG (Ho: YAG) laser has been used for the ablation of prolapsed discs but alternative techniques are available, and this application remains controversial. It also has potential for the decompression of nerve roots within narrowed foraminae with the technique of endoscopic laser foraminoplasty. Traditional methods of decompression necessitate a major surgical procedure with potential destabilisation of the lumbar spinal segment. Nevertheless, minimally invasive techniques are attractive only if serious complications can be avoided. This study reports the peak temperatures reached in surrounding tissues with and without saline irrigation. STUDY DESIGN/MATERIALS AND METHODS: Investigation of the hypothesis was carried out in excised sheep lumbar spines. T-type thermocouples were used for the measurement of tissue temperatures during laser ablation of nerve root foraminae. The temperature was assessed in the nerve root, dura mater, and disc space. RESULTS: The Ho: YAG laser was effective in widening the foraminae by approximately 1.5 mm with a total energy of 4.60 kJ. This was statistically significant in both vertical and horizontal directions (P < 0.0003 and P < 0.00005, respectively). The mean temperature of the nerve root, dura, and disc space during the procedure was 44 +/- 3.1 degrees C, 42.8 +/- 4.7 degrees C, and 41 +/- 3.4 degrees C respectively. There were transient high peaks seen in the temperature profiles. Using saline irrigation at 27 ml/minutes these temperatures were reduced to 34.1 +/- 1.8 degrees C (P = 0.0002), 34.9 +/- 1.5 degrees C (P = 0.002), and 37.2 +/- 1.2 degrees C (P < 0.014), for nerve roots, dura, and disc space respectively. CONCLUSIONS: Laser ablation of bone and ligament for nerve root decompression using the Ho: YAG laser may offer substantial advantages, but the risk of serious complication may only be avoided if the technique is combined with saline irrigation.

Investigation of bone changes in microgravity during long and short duration space flight: comparison of techniques.

BACKGROUND: Loss of bone mass is a continuing problem in long-term space flight. Although counter-measure programmes have been developed, effective assessment of these programmes is hampered by a lack of monitoring techniques that can be used in-flight. MATERIALS AND METHODS: Three techniques were used to evaluate changes in bone during two missions of 180 and 20 days to the MIR space station, involving three subjects. Dual energy X-ray absorptiometry (DXA) was used before and after flight to measure whole body and regional bone mineral density (BMD). Ultrasonic measurements of velocity (SOS) and broadband attenuation (BUA) of the calcaneus were measured during the 180 day mission and before and after the 20 day mission. Phase velocity of flexural waves in the tibia was also measured on the same days as the ultrasonic measurements of the calcaneus. RESULTS: DXA measurements demonstrated significant variation between different sites in the body for changes in BMD, with the greatest changes occurring in the lumbar spine and proximal femur. There was a trend for increasing phase velocity in the tibia during the 180 mission, but this was not significant. BUA and SOS measurements of the calcaneus showed consistent but divergent patterns of changes during the mission. CONCLUSION: Although in-flight measurements of bone using ultrasound or phase velocity may provide information on the kinetics of bone loss in space flight, the heterogeneity of response in the skeleton means that it is difficult to predict overall bone loss from measurements at one particular site.