Does the Level and Complexity of Femur Fracture Determine Intramedullary Peak Pressures During Reamed Femoral Nailing? A Prospective Study.

OBJECTIVES: To investigate femoral intramedullary (IM) pressures during reamed antegrade nailing and to determine whether fracture level and/or complexity affect peak pressures. DESIGN: Prospective, nonrandomized observational cohort. SETTING: Single level I trauma center. PATIENT SELECTION CRITERIA: Patients presenting with femur fractures (OTA/AO 31A3; 32A; 32B; 32C; 33A2; 33A3), requiring antegrade IM nail fixation, were included in this study. Excluded were minors and patients presenting with hemodynamic instability, a reduced level of consciousness and intoxication. Femurs were divided into thirds based on preoperative radiological measurements and allocated to 3 groups based on fracture location: Proximal (A), middle (B), and distal (C) third femur fractures. Fracture complexity was also documented. OUTCOME MEASURES AND COMPARISONS: Peak IM pressures of proximal, middle, and distal third femoral fractures were compared during antegrade femoral IM nail fixation. RESULTS: Twenty-two fractures in 21 patients were enrolled and treated over a 4-month period with a distribution of fracture locations of group A = 12, group B = 6, and group C = 4. Measured mean resting distal IM pressures were significantly higher ( P < 0.05) in proximal fractures (group A: 52.5 mm Hg) than in middle and distal third fractures (group B: 36.6 mm Hg and group C: 27.5 mm Hg). Greatest peak pressures were generated during the first ream in groups A and B, occurring distal to the fracture in all cases. Group A averaged 363.8 mm Hg (300-420), group B 174.2 mm Hg (160-200), and group C 98.8 mm Hg (90-100). There was a significant difference comparing group A with B and C combined ( P < 0.01) and group A with B ( P < 0.05) and C ( P < 0.05]) individually. Group A consisted of 6 comminuted and 6 simple fracture configurations. Mean peak pressures in these subgroups differed significantly: 329 mm Hg (300-370) versus 398 mm Hg (370-430), respectively ( P < 0.05). Complex fractures in study groups B and C did not have significantly different peak pressures compared with simple fractures ( P > 0.05). CONCLUSIONS: Both the fracture location and comminution affect peak IM pressures during reamed antegrade femoral nailing. Proximal, simple fracture configurations resulted in significantly higher pressures when compared with more distal and comminuted fracture configurations. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Drastic reduction of orthopaedic services at an urban tertiary hospital in South Africa during COVID-19: Lessons for the future response to the pandemic.

BACKGROUND: The COVID-19 pandemic has impacted on the global surgery landscape. OBJECTIVES: To analyse and describe the initial impact of the COVID-19 pandemic on orthopaedic surgery at Groote Schuur Hospital, a tertiary academic hospital in South Africa. METHODS: The number of orthopaedic surgical cases, emergency theatre patient waiting times, and numbers of outpatient clinic visits, ward admissions, bed occupancies and total inpatient days for January - April 2019 (pre-COVID-19) were compared with the same time frame in 2020 (COVID-19). The COVID-19 timeframe included initiation of a national 'hard lockdown' from 26 March 2020, in preparation for an increasing volume of COVID-19 cases. RESULTS: April 2020, the time of the imposed hard lockdown, was the most affected month, although the number of surgical cases had started to decrease slowly during the 3 preceding months. The total number of surgeries, outpatient visits and ward admissions decreased significantly during April 2020 (55.2%, 69.1% and 60.6%, respectively) compared with April 2019 (p<0.05). Trauma cases were reduced by 40% in April 2020. Overall emergency theatre patient waiting time was 30% lower for April 2020 compared with 2019. CONCLUSIONS: COVID-19 and the associated lockdown has heavily impacted on both orthopaedic inpatient and outpatient services. Lockdown led to a larger reduction in the orthopaedic trauma burden than in international centres, but the overall reduction in surgeries, outpatient visits and hospital admissions was less. This lesser reduction was probably due to local factors, but also to a conscious decision to avoid total collapse of our surgical services.

Low 30-day mortality in South African orthopaedic patients undergoing surgery at an academic hospital during the first wave of the COVID-19 pandemic: It was safe to perform orthopaedic procedures at our hospital during the first COVID-19 peak.

BACKGROUND:  Initial local and global evidence suggests that SARS-CoV-2-infected patients who undergo surgery, and those who become infected perioperatively, have an increased mortality risk post surgery. OBJECTIVES: To analyse and describe the 30-day mortality, presurgical COVID-19 status and hospital-acquired SARS-CoV-2 infection rates of patients, both SARS-CoV-2-positive and negative, undergoing orthopaedic surgery at a tertiary academic hospital in South Africa (SA) during the first COVID-19 peak. METHODS: This single-centre, observational, prospective study included patients who underwent orthopaedic procedures from 1 April 2020 (beginning of the COVID-19 case increase in SA) to 31 July 2020 (first COVID-19 peak in SA). All patients were screened for COVID-19 and were confirmed positive if they had a positive laboratory quantitative polymerase chain reaction test for SARS-CoV-2 RNA on a nasopharyngeal or oral swab. Thirty-day mortality, presurgical COVID-19 status and hospital-acquired SARS-CoV-2 infection were assessed. RESULTS:  Overall, a total of 433 operations were performed on 346 patients during the timeframe. Of these patients, 65.9% (n=228) were male and 34.1% (n=118) were female. The mean (standard deviation) age was 42.5 (16.8) years (range 9 - 89). Of the patients, 5 (1.4%) were identified as COVID-19 patients under investigation (PUI) on admission and tested positive for SARS-CoV-2 before surgery, and 1 (0.3%) contracted SARS-CoV-2 perioperatively; all survived 30 days post surgery. Twenty-nine patients were lost to follow-up, and data were missing for 6 patients. The final analysis was performed excluding these 35 patients. Of the 311 patients included in the final 30-day mortality analysis, 303 (97%) had a follow-up observation ≥30 days after the operation. The overall 30-day mortality for these patients was 2.5% (n=8 deaths). None of the recorded deaths were of screened COVID-19 PUI. CONCLUSIONS: We report a low 30-day mortality rate of 2.5% (n=8) for patients undergoing orthopaedic surgery at our hospital during the first COVID-19 peak. None of the deaths were COVID-19 related, and all patients who tested SARS-CoV-2-positive, before or after surgery, survived. Our overall 30-day mortality rate correlates with several other reports of orthopaedic centres analysing over similar timeframes during the first peak of the COVID-19 pandemic. Regarding mortality and SARS-CoV-2 infection risk, we can conclude that with the appropriate measures taken, it was safe to undergo orthopaedic procedures at our hospital during the first peak of the COVID-19 pandemic in SA.

Prospective surveillance of breast cancer-related lymphoedema in the first-year post-surgery: feasibility and comparison of screening measures.

PURPOSE: To examine the feasibility of a breast cancer-related lymphoedema (BCRL) screening programme. Additionally, to investigate the efficacy of bioimpedance analysis (BIA) compared to circumferential measurements (CM) in detecting BCRL. METHODS: This was a 12-month prospective feasibility study. Participants were recruited from two diagnostic breast clinics and consented to be screened for BCRL. Pre-surgical assessments were conducted, and participants were followed up at quarterly intervals. BIA and CM measurements were conducted at all time points. An L-Dex score of >10 or a 10-U increase from baseline or a ≥5 % increase in proximal, distal or total percentage volume difference (PVD) from baseline was indicative of BCRL. Information was collected on subjective symptoms, potential risk factors, demographics and medical data. Feasibility was based on uptake and retention. RESULTS: One hundred twenty-six participants were recruited with an attrition rate of 16.2 %. Participants' mean age was 59 years with the majority having stage I (63.9 %), infiltrating ductal carcinoma (87.4 %). 31.6 % were identified as having BCRL, 90.3 % detected by CM and 35.5 % by BIA (p = ≤0.0001). We found no significant correlation between BIA and CM. Participants identified as having BCRL had a higher BMI, a recent injury to their 'at-risk' arm and more lymph nodes excised (p = <0.05). These findings were not evident across all time points. A large percentage of participants had transient BCRL when assessed by a lymphoedema physiotherapist. CONCLUSIONS: BCRL screening is acceptable and valued by breast cancer survivors. Work needs to continue to establish the most effective screening tool and the natural behaviour of BCRL within the first-year post-surgery.

Conditional transitions in gaze dynamics: role of vestibular nuclei in eye-only and eye/head gaze behaviors.

The gaze control system governs distinct gaze behaviors, including visual fixation and gaze reorientations. Transitions between these gaze behaviors are frequent and smooth in healthy individuals. This study models these gaze-behavior transitions for different numbers of gaze degrees of freedom. Eye/head gaze behaviors have twice the number of degrees of freedom as eye-only gaze behaviors. Each gaze behavior is observable in the system dynamics and is correlated with neuronal behaviors in several, coordinated neural centers, including the vestibular nuclei. The coordination among the neural centers establishes a sensorimotor state which maintains each gaze behavior. This study develops a mathematical framework for synthesizing the coordination among neural centers in gaze sensorimotor states and focuses on the role of vestibular nuclei neurons in gaze sensorimotor state transitions.

Social barriers to a theoretical neuroscience.

Social rather than scientific barriers are impeding neuroscience theory. There are plenty of experimental data and mathematical methods to develop a rigorous, mathematical theory in neuroscience. However, structural mathematical efforts are being suffocated by the requirement to produce numbers immediately. Also theoretical development is tied too closely to one experimental group. The social barriers can be addressed by: (1) judging theory by structural accuracy rather than numerical output; (2) recognizing mathematical theory (not just computational modeling) as a method for producing insight into neurobiological phenomena; (3) funding fundamental theoretical neuroscience and (4) recognizing theoretical neuroscientists as neuroscientists.

Differences in virulence between two Candida albicans strains in experimental keratitis.

PURPOSE: To study the differences in disease caused by two wild-type strains of Candida albicans in a model of contact lens-facilitated keratitis in rabbits. METHODS: Two strains, SC5314 and VE175, were examined. Standardized inocula were placed on the debrided corneal surface of one eye in Dutch belted rabbits and covered with a contact lens. A temporary tarsorrhaphy was opened after 24 hours with removal of the contact lens. Six days later, corneas were photographed and animals killed. Corneas were bisected with one half for quantitative isolate recovery and the other for stromal penetration by hyphae. RESULTS: Strain SC5314 was significantly more virulent. The mean hyphal penetration into the cornea was 24.4% +/- 8.5% of the corneal thickness, and in three of six corneas hyphae penetrated through the entire cornea. In contrast, for VE175, the mean hyphal penetration was 2.6% +/- 1.2%. The difference between these two strains was statistically significant (P = 0.0297). Hyphae did not penetrate into the deep layers of the cornea in any of the six rabbits infected with VE175. The grading of clinical disease was consistent with histology, in that strain SC5314 caused more severe infection than VE175 and the difference was statistically significant (P = 0.0048). There was no difference in isolate recovery. CONCLUSIONS: Wild-type strains of C. albicans can differ significantly in virulence as measured by depth of fungal invasion into corneas and clinical evaluation of infection. Further characterization of the intrinsic genetic differences between such strains may help identify factors responsible for fungal virulence.

Sensory and motor interdependence in postural adjustments.

The sensory reafference from a movement depends upon the movement, and the movement chosen depends upon the available senses, as demonstrated by vestibular patients who abandon certain movements. Often, one variable is assumed to be dependent whereas the other is independent; however, sensory and motor dynamics in posture are interdependent as conditions upon each other. This paper applies conditional dynamics to characterize the global structure of interdependence between sensory states and motor strategies in fast postural adjustments. The mathematical formalism incorporates rich but disparate experimental, clinical, and theoretical results about sensory and motor control of posture. The control structures presented include relatively stable anatomical, physiological, and functional structures, both continuous and discrete, leading to a composite functional logic for the coordination of these structures in sensorimotor control. Results include sensorimotor control structures for postural adjustments for healthy subjects and certain types of vestibular patients. The sensorimotor control structures for patients with absent vestibular function suggest implications for management of the deficit.

Identification of head motions by central vestibular neurons receiving linear and angular input.

Most naturally occurring displacements of the head in space, due to either an external perturbation of the body or a self-generated, volitional head movement, apply both linear and angular forces to the head. The vestibular system detects linear and angular accelerations of the head separately, but the succeeding control of gaze and posture often relies upon the combined processing of linear and angular motion information. Thus, the output of a secondary neuron may reflect the linear, the angular, or both components of the head motion. Although the vestibular system is typically studied in terms of separate responses to linear and angular acceleration of the head, many secondary and higher-order neurons in the vestibular system do, in fact, receive information from both sets of motion sensors. The present paper develops methods to analyze responses of neurons that receive both types of information, and focuses on responses to sinusoidal motions composed of a linear and an angular component. We show that each neuron has a preferred motion, but a single neuron cannot code for a single motion. However, a pair of neurons can code for a motion by the relative phases of firing-rate modulation. In this way, information about motion is enhanced by neurons combining information about linear and angular motion.

Timing of secondary vestibular neuron responses to a range of rotational head movements.

Secondary vestibular neurons exhibit a wide variety of responses to a head movement, with the response of each secondary neuron depending upon the particular primary afferents converging onto it. A single head movement is thereby registered in a distributed manner. This paper focuses on implications of afferent convergence to the relative timing of secondary neuron response modulation during rotational movements about a combination of horizontal axes. In particular, the neurons of interest are those that receive input from afferents innervating the vertical semicircular canals, and the movements of interest are those that have a sinusoidal component about one vertical canal axis and a sinusoidal component about another, approximately orthogonal, vertical canal axis. Under these conditions, the present research shows that it is possible for two or more secondary neurons to have a different relative timing of response (i.e., different relative phase of the periodic modulation in firing rate) for different head movements, and for the neurons to switch their order of response for different movements. For particular head movements, those same neurons will respond in phase. From the point of view of the nervous system, the relative timing of neuron responses may tell which movement is taking place, but with certain restrictions as discussed in the present paper. Shown here is that, among those head movements for which the two components of rotation may be at any phase relative to one another and have any relative amplitude, an in-phase response of just two neurons cannot identify a single motion. Two neurons that respond in phase for one motion must respond in phase for an entire range of motions; all motions in that range are thus response-equivalent, in the sense that the pair of neurons cannot distinguish between the two motions. On the other hand, an in-phase response of three neurons can identify a single motion, for certain patterns of primary afferent convergence.

Thioredoxin reductase activity is decreased by selenium deficiency.

Animal thioredoxin reductase is a selenoprotein. In this study, thioredoxin reductase activities in liver, kidney, and brain have been compared in rats fed selenium-deficient and control diets for 14 weeks following weaning. Selenium deficiency caused a decrease in thioredoxin reductase activity from control to 4.5% in liver and 11% in kidney. However, brain thioredoxin reductase activity was not affected by selenium deficiency of this severity. Gold inhibited thioredoxin reductase activity in the liver in a manner typical of its effect on selenoenzymes. Repletion of selenium-deficient rats with injections of selenium caused thioredoxin reductase activity to increase more rapidly in the liver than glutathione peroxidase activity but more slowly than selenoprotein P. These results indicate that thioredoxin reductase activity in liver and kidney is sensitive to selenium nutritional status but that brain thioredoxin reductase activity is less sensitive.

Organizing sensory information for postural control in altered sensory environments.

Healthy human subjects can maintain adequate balance despite distorted somatosensory or visual feedback or vestibular feedback distorted by a peripheral vestibular disorder. Although it is not precisely known how this sensorimotor integration task is achieved, the nervous system coordinates information from multiple sensory systems to produce motor commands differently in different sensory environments. These different ways of coordinating sensory information and motor commands can be thought of as "sensorimotor states". The way the nervous system distributes the monitoring of postural sway among states is analysed in this paper as a logical structure of transitions between states. The form of the transition structure is specified and distinguished from a finite state machine. The hypothesis that the nervous system could use a transition structure to maintain balance is tested by developing transition structures which are consistent with a set of experimental observations of postural control in healthy subjects and three groups of patients with peripheral vestibular disease.

The stomatogastric nervous system: a formal approach.

A discrete mathematical formalism (d-space) which is specifically designed to investigate discrete aspects of behavior is applied to the foregut of decapod crustacea. This approach differs from continuous modeling techniques in that the analysis determines a structure in which the observed behavior of the foregut is constrained. A notation for the implementation of the formalism is developed as well as a coordinate system natural to the functioning of the gastric mill. The formalism is used to organize previous observations that suggest potential courses of further experimental investigation. A detailed analysis of observed chewing modes of the gastric mill is presented, along with a discussion of the overall organization of the interrelationships between these modes. The investigation also addresses the relationship between behavioral modes of a pyloric muscle found in the shrimp Palaemon. Two alternative hypotheses are presented to describe the relationship of the behavioral components of the gastric mill: an interlaced control scheme in which the components are freely exchanged, and a top-down control system where the chewing modes are rigidly separated into packages. Flow through regions of state space in time is found to be important in determining the relations between the discrete behavioral components. The behavior of the foregut, like that of other motor control systems, is shown to fit naturally into the d-space formalism.

Dynamics of the sit-to-stand movement.

The strategies of the sit-to-stand movement are investigated by describing the movement in terms of the topology of an associated phase diagram. Kinematic constraints are applied to describe movement sequences, thus reducing the dimension of the phase space. This dimensional reduction allows us to apply theorems of topological dynamics for two-dimensional systems to arrive at a classification of six possible movement strategies, distinguished by the topology of their corresponding phase portrait. Since movement is treated in terms of topological structure rather than specific trajectories, individual variations are automatically included, and the approach is by nature model independent. Pathological movement is investigated, and this method clarifies how subtle abnormalities in movement lead to difficulties in achieving a stable stance upon rising from a seated position.

The shape of self-motion perception--I. Equivalence classification for sustained motions.

Two completely different motions of a subject relative to the earth can induce exactly the same stimuli to the vestibular, somatosensory and visual systems. When this happens, the subject may experience disorientation and misperception of self-motion. We have identified large classes of motions that are perceptually equivalent, i.e. indistinguishable by the subject, under three sets of conditions: no vision, with vision and earth-fixed visual surround, and with vision during possible movement of the visual surround. For each of these sets of conditions, we have developed a classification of all sustained motions according to their perceptual equivalences. The result is a complete list of the possible misperceptions of sustained motion due to equivalence of the forces and other direct stimuli to the sensors under the given conditions. This research expands the range of possible experiments by including all components of linear and angular velocity and acceleration. Many of the predictions in this paper can be tested experimentally. In addition, the equivalence classes developed here predict perceptual phenomena in unusual motion environments that are difficult or impossible to investigate in the laboratory.

The shape of self-motion perception--II. framework and principles for simple and complex motion.

There have been numerous experimental studies on human perception and misperception of self-motion and orientation relative to the earth, each focusing on one or a few types of motion. We present a formal framework encompassing many types of motion and including all angular and linear components of velocity and acceleration. Using a mathematically rigorous presentation, the framework defines the space of all possible motions, the map from motion to sensor status, the space containing each possible status of the sensors, and the map from sensor status to perceived motion. The shape of the full perceptual map from actual motion to perceived motion is investigated with the framework, using formal theory and a number of published experimental results. Two principles of simple motion perception and four principles of complex motion perception are presented. The framework also distinguishes the roles of physics and the nervous system in the process of self-motion perception for both simple and complex motions. The present rigorous development of the self-motion perception framework allows the scientist to compare and contrast results from many studies with differing types of motion. The six principles formalized here comprise a foundation with which to explain and predict perceptual phenomena, both those observed in the past and those to be encountered in the future. The framework is especially aimed to expand our capacity to investigate complex motions such as those encountered in everyday life or in unusual motion environments.

Forms of early walking.

Children in the first weeks of independent locomotion display a wide variety of walking forms. The walking forms differ in mechanical strategy and concern with balance. Three extreme walking forms are presented: the Twister, who uses trunk twist, the Faller, who uses gravity, and the Stepper, who remains balanced as much as possible. Each walking form is presented as a "d-space", a mathematical format combining continuous and discrete aspects, developed to express the sequence and pattern of a movement without the inappropriate precision of a physical trajectory. The three d-spaces represent analyses of three extreme modes of early walking. They are used to generate the variety of early walking forms and to predict mixtures of mechanical strategies as children mature and converge to more similar walking forms over the first few months of independent locomotion.