Orthopedic injuries associated with jet-skis (personal watercrafts): A review of 127 inpatients.

BACKGROUND: Personal watercrafts (PWC) account for a disproportionate amount of water based injuries. Current literature suggests those with less PWC experience are more at risk for injury. Previous studies have not specifically evaluated the orthopedic implications of PWC usage or how various mechanisms of injury (MOI) contribute to different injury patterns. HYPOTHESIS: PWC injuries will frequently require orthopedic intervention. The presence of an orthopedic injury will result in increased injury severity score (ISS), hospital and intensive care unit (ICU) length of stay (LOS). Patients visiting our region will have less PWC experience and so are more prone to serious injuries. MATERIALS AND METHODS: Retrospective cohort study at a single Level 1 trauma center of admitted patients sustaining PWC injuries from 02/2004-03/2017. The following were studied: demographics, mechanism, season, ISS, hospital and ICU LOS, follow-up, fracture characteristics and management. RESULTS: Hundred and twenty-seven patients were admitted due to PWC injury, 66 (52.0%) sustained an orthopedic injury, totaling 103 fractures (48 [46.6%] lower extremity, 26 [25.2%] upper extremity, 14 [13.6%] vertebral, 11 [10.7%] pelvic ring and 4 [3.9%] acetabulum). The mean age of orthopedic patients was 29 years (range 8-62). Handle bar injuries were significantly associated with open fractures, (13 of 25 open fractures, 3 of which became infected). Injuries occurring during the winter were associated with a higher ISS, yet more injuries occurred in the summer. A patient being a "visitor" to the region did not influence ISS. The mean LOS was 12.6 days for orthopedic patients. Eighteen orthopedic patients (27.3%) required ICU admission and 36 (54.5%) patients required orthopedic surgery (mean 2.11 operations). DISCUSSION: A majority of PWC injuries resulted in extremity fractures with a moderate percentage requiring orthopedic surgery. Correlations between PWC experience and injury incidence can provide information for increased safety. LEVEL OF EVIDENCE: IV; retrospective.

Do contamination of and exposure to chicken meat and water drive the temporal dynamics of Campylobacter cases?

Campylobacteriosis, the most frequent bacterial enteric disease, shows a clear yet unexplained seasonality. The study purpose was to explore the influence of seasonal fluctuation in the contamination of and in the behaviour exposures to two important sources of Campylobacter on the seasonality of campylobacteriosis. Time series analyses were applied to data collected through an integrated surveillance system in Canada in 2005-2010. Data included sporadic, domestically-acquired cases of Campylobacter jejuni infection, contamination of retail chicken meat and of surface water by C. jejuni, and exposure to each source through barbequing and swimming in natural waters. Seasonal patterns were evident for all variables with a peak in summer for human cases and for both exposures, in fall for chicken meat contamination, and in late fall for water contamination. Time series analyses showed that the observed campylobacteriosis summer peak could only be significantly linked to behaviour exposures rather than sources contamination (swimming rather than water contamination and barbequing rather than chicken meat contamination). The results indicate that the observed summer increase in human cases may be more the result of amplification through more frequent risky exposures rather than the result of an increase of the Campylobacter source contamination.

Increasing Access to Cost Effective Home-Based Rehabilitation for Rural Veteran Stroke Survivors.

INTRODUCTION: An estimated 750,000 Americans experience a stroke annually. Most stroke survivors require rehabilitation. Limited access to rehabilitation facilities has a pronounced burden on functional outcomes and quality of life. Robotic devices deliver reproducible therapy without the need for real-time human oversight. This study examined the efficacy of using home-based, telerobotic-assisted devices (Hand and Foot Mentor: HM and FM) to improve functional ability and reduce depression symptoms, while improving access and cost savings associated with rehabilitation. METHODS: Twenty stroke survivors performed three months of home-based rehabilitation using a robotic device, while a therapist remotely monitored progress. Baseline and end of treatment function and depression symptoms were assessed. Satisfaction with the device and access to therapy were determined using qualitative surveys. Cost analysis was performed to compare home-based, robotic-assisted therapy to clinic-based physical therapy. RESULTS: Compared to baseline, significant improvement in upper extremity function (30.06%, p= 0.046), clinically significant benefits in gait speed (29.03%), moderate improvement in depressive symptoms (28.44%) and modest improvement in distance walked (30.2%) were observed. Participants indicated satisfaction with the device. Home-based robot therapy expanded access to post-stroke rehabilitation for 35% of the people no longer receiving formal services and increased daily access for the remaining 65%, with a cost savings of $2,352 (64.97%) compared to clinic-based therapy. CONCLUSION: Stroke survivors made significant clinically meaningful improvements in the use of their impaired extremities using a robotic device in the home. Home-based, robotic therapy reduced costs, while expanding access to a rehabilitation modality for people who would not otherwise have received care.

Adult Intestinal and Multivisceral Transplantation: Experience From a Single Center in the United Kingdom.

Cambridge is one of two designated adult intestinal transplant centers in the United Kingdom and has performed 60 transplants on 54 patients since 2007; 52% of these were undertaken in the last 3 years. This increasing trend is in contrast with that reported worldwide; 27% were small bowel grafts (SBT), 15% modified multivisceral (MMVT), and 58% multivisceral (MVT). Median recipient age was 47 years; the female-to-male ratio was 27/33. Primary diseases included visceral arterial thromboses (17%), Crohn's disease (17%), motility disorders (12%), visceral venous thromboses (12%), familial adenomatous polyposis (FAP)/desmoids (8%), alcoholic cirrhosis (3%), nonalcoholic fatty liver disease (3%), ulcerative colitis (2%), and other (15%). Indications for transplant included intestinal failure-associated liver disease (IFALD) (27%), loss of central venous access (17%), FAP/desmoid disease (5%), extensive portomesenteric venous thrombosis (PMVT) (20%), widespread mesenteric arterial ischemia (WMAI) (13%), re-transplant (8%), and other (10%). Overall 1-year/5-year patient survival rates were 77%/62%. One-year/5-year patient survival rates were 92%/83%, 85%/65%, and 71%/33% for SBT, MMVT, and MVT. One-year/5-year survival rates for patients with IFALD, PMVT, and other indications who underwent MVT were 80%/20%, 65%/55%, and 55%/35%. The greatest proportion of patient deaths occurred during the first year after transplant (50% in year 1, 23% in year 2, 9% in year 3, 5% in year 4, and 14% in year 5), particularly in the MVT group. Referrals to our United Kingdom center are increasing, and the indications for transplant are becoming more diverse. Our patient survival rates remain comparable with figures reported worldwide.

Preimplant Normothermic Liver Perfusion of a Suboptimal Liver Donated After Circulatory Death.

Livers retrieved after circulatory death are associated with an increased incidence of primary nonfunction, early allograft dysfunction, and biliary strictures. The authors report a case of preimplant normothermic perfusion of a suboptimal liver from a 57-year-old donor after circulatory death who had been hospitalized for 9 days; predonation alanine transaminase level was 63 IU/L, and the period from withdrawal of life-supporting treatment to circulatory arrest was 150 minutes. After 5 hours of static cold storage, the liver was subject to normothermic machine perfusion with a plasma-free red cell-based perfusate. Perfusate lactate level fell from 7.2 to 0.3 mmol/L within 74 minutes of ex situ perfusion, at which point perfusate alanine transaminase level was 1152 IU/L and urea concentration was 9.4 mmol/L. After 132 minutes, normothermic perfusion was stopped and implantation begun. After transplantation, the patient made an uneventful recovery and was discharged on day 8; liver biochemistry was normal by day 19 and has remained normal thereafter. Donor common bile duct excised at implantation showed preservation of peribiliary glands, and cholangiography 6 months posttransplantation showed no evidence of cholangiopathy. Preimplant ex situ normothermic perfusion of the liver appears to be a promising way to evaluate a marginal liver before transplantation and may modify the response to ischemia.

Campylobacter spp. Prevalence and Levels in Raw Milk: A Systematic Review and Meta-Analysis.

Campylobacteriosis is the leading bacterial gastrointestinal disease internationally, contributing significantly to the enteric illness burden. Cases have been associated with the consumption of raw milk, a behavior that has garnered attention recently. Estimates of the prevalence and levels of Campylobacter spp. in raw milk are lacking, which hinders risk assessment attempts. This article is a systematic review and meta-analysis of reported prevalence and levels of zoonotic Campylobacter spp. in the raw milk of cows, goats, and sheep in Canada, the United States, Europe, Australia, and New Zealand. The relevant literature was reviewed, and trained reviewers examined the results for inclusion of articles in the meta-analysis. Relevant data (prevalence and/or level of Campylobacter in raw milk, country of origin, animal species, sample source, Campylobacter species identified, etc.) were extracted, and a meta-analysis was performed in Stata v. 12 (Metaprop command). The weighted mean prevalence of Campylobacter spp. in raw milk samples was 1.18%. Subgroup analyses were conducted to examine how prevalence varied by study characteristics, with the highest prevalence values in studies from the United Kingdom (by country, 6.4%), about cows (by animal species, 1.3%), and including samples taken from inline filters (by sample source, 1.75%) and in studies that included species that are not pathogenic to humans (by Campylobacter species, 1.14%). Two articles each included a single Campylobacter level, 0.16 ± 0.3 and approximately 0.047 most probable number per ml. Despite a relatively low prevalence, consumption of raw milk is inherently risky because no treatment has been used to inactivate pathogens. This potential risk further supports maintaining regulations to limit the sales of raw milk.

Successful transplantation of kidneys from elderly circulatory death donors by using microscopic and macroscopic characteristics to guide single or dual implantation.

Most kidneys from potential elderly circulatory death (DCD) donors are declined. We report single center outcomes for kidneys transplanted from DCD donors over 70 years old, using preimplantation biopsy Remuzzi grading to inform implantation as single or dual transplants. Between 2009 and 2012, 43 single transplants and 12 dual transplants were performed from elderly DCD donors. Remuzzi scores were higher for dual than single implants (4.4 vs. 3.4, p < 0.001), indicating more severe baseline injury. Donor and recipient characteristics for both groups were otherwise similar. Early graft loss from renal vein thrombosis occurred in two singly implanted kidneys, and in one dual-implanted kidney; its pair continued to function satisfactorily. Death-censored graft survival at 3 years was comparable for the two groups (single 94%; dual 100%), as was 1 year eGFR. Delayed graft function occurred less frequently in the dual-implant group (25% vs. 65%, p = 0.010). Using this approach, we performed proportionally more kidney transplants from elderly DCD donors (23.4%) than the rest of the United Kingdom (7.3%, p < 0.001), with graft outcomes comparable to those achieved nationally for all deceased-donor kidney transplants. Preimplantation biopsy analysis is associated with acceptable transplant outcomes for elderly DCD kidneys and may increase transplant numbers from an underutilized donor pool.

When one becomes more: minimum renal artery length in laparoscopic live donor nephrectomy.

BACKGROUND: Laparoscopic donor nephrectomy may convert short main arteries into multiple arteries, increasing the technical challenge of implantation. We evaluated our experience to identify factors predictive of multiple arteries after laparoscopic nephrectomy. METHODS: All laparoscopic nephrectomies from the start of our program in November 2002 until June 2013 were studied, and preoperative imaging reviewed for donor artery length and multiplicity together with operative findings. RESULTS: A total of 287 consecutive laparoscopic live donor nephrectomies (64 right and 223 left nephrectomies) were studied. Renal artery length was measured from preoperative donor magnetic resonance or computed tomography angiogram and nephrectomy performed using a laparoscopic stapling device. Nine left kidneys with a single artery (6, 7, 9, 10, 11, 12, 13, 14, and 16 mm in length) and five right kidneys with a single artery (5, 13, 15, 20, and 26 mm) on imaging resulted in multiple renal arteries at implantation. Complex renal vein anatomy was associated with multiple arteries following retrieval. CONCLUSION: A main renal artery length of more than 16 mm on the left and 26 mm on the right is unlikely to result in multiple arteries to implant. The possibility of multiple arteries should be borne in mind when the donor renal artery is short.

In situ normothermic regional perfusion for controlled donation after circulatory death--the United Kingdom experience.

Organs recovered from donors after circulatory death (DCD) suffer warm ischemia before cold storage which may prejudice graft survival and result in a greater risk of complications after transplant. A period of normothermic regional perfusion (NRP) in the donor may reverse these effects and improve organ function. Twenty-one NRP retrievals from Maastricht category III DCD donors were performed at three UK centers. NRP was established postasystole via aortic and caval cannulation and maintained for 2 h. Blood gases and biochemistry were monitored to assess organ function. Sixty-three organs were recovered. Forty-nine patients were transplanted. The median time from asystole to NRP was 16 min (range 10-23 min). Thirty-two patients received a kidney transplant. The median cold ischemia time was 12 h 30 min (range 5 h 25 min-18 h 22 min). The median creatinine at 3 and 12 months was 107 µmol/L (range 72-222) and 121 µmol/L (range 63-157), respectively. Thirteen (40%) recipients had delayed graft function and four lost the grafts. Eleven patients received a liver transplant. The first week median peak ALT was 389 IU/L (range 58-3043). One patient had primary nonfunction. Two combined pancreas-kidney transplants, one islet transplant and three double lung transplants were performed with primary function. NRP in DCD donation facilitates organ recovery and may improve short-term outcomes.

Encapsulating peritoneal sclerosis--correlation of radiological findings at CT with underlying pathogenesis.

Encapsulating peritoneal sclerosis (EPS) is a rare entity most commonly associated with peritoneal dialysis (PD). Several imaging features at computed tomography (CT) are common to many diseases; however, appreciation of the features unique to this condition interpreted with the appropriate clinical findings is crucial to diagnosis.

Occult invasive aspergillosis infection following multivisceral transplantation.

Patients undergoing multivisceral transplantation are particularly susceptible to post-operative infections due to immunosuppression and the inclusion of bowel in the transplanted graft. These patients typically receive broad-spectrum antimicrobial and antifungal agents as prophylaxis and treatment. However, evidence for this is limited due to the small number of patients undergoing the procedure. We present a case of occult disseminated invasive aspergillosis infection in a patient who underwent multivisceral transplantation.

Infectious aortitis in a liver transplant recipient.

The development of an abdominal aortic aneurysm secondary to infectious aortitis following solid organ transplantation is a rare event that in the absence of surgical intervention, can lead to uncontrolled sepsis, catastrophic hemorrhage and death. Arterial allografts have been a viable surgical option for the past 30 years, although operative modalities have undergone a paradigm shift in recent years. We describe the first case in the literature of a liver transplant recipient who developed an infrarenal aortic aneurysm secondary to Salmonella bacteraemia, which was treated successfully with aortic allograft transplantation.

A radiologist's guide to small bowel and multivisceral transplantation.

This review will describe the indications for the various small bowel containing transplants. The importance of early referral will be highlighted. Radiologists play a central role in assessing these complex patients prior to transplantation. Furthermore, in the postoperative period, radiologists play an important part in diagnosing and treating complications.

Estimates and relationships between aboveground and belowground resource exchange surface areas in a Sitka spruce managed forest.

Our knowledge of the nature of belowground competition for moisture and nutrients is limited. In this study, we used an earth impedance method to determine the root absorbing area of Sitka spruce (Picea sitchensis (Bong.) Carr.) trees, making measurements in stands of differing density (2-, 4- and 6-m inter-tree spacing). We compared absorbing root area index (RAI(absorbing); based on the impedance measure) with fine root area index (RAI(fine); based on estimates of total surface area of fine roots) and related these results to investment in conductive roots. Root absorbing area was a near-linear function of tree stem diameter at 1.3 m height. At the stand level, RAI(absorbing), which is analogous to and scaled with transpiring leaf area index (maximum stomatal pore area per unit ground area; LAI(transpiring)), increased proportionally with basal area across the three stands. In contrast, RAI(fine) was inversely propotional to basal area. The ratio of RAI(absorbing) to LAI(transpiring) ranged from 7.7 to 17.1, giving an estimate of the relative aboveground versus belowground resource exchange areas. RAI(absorbing) provides a way of characterizing ecosystem functioning as a physiologically meaningful index of belowground absorbing area.

Cambridge-Miami score for intestinal transplantation preoperative risk assessment: initial development and validation.

INTRODUCTION: Preoperative quantification of survival after transplantation would assist in assessing patients. We have developed a preliminary preoperative scoring system, called the Cambridge-Miami (CaMi) score, for transplantation of the small intestine either alone or as a composite graft. METHODS: The score combines putative risk factors for early-, medium-, and long-term survival. Factors included were loss of venous access and impairment of organs or systems not corrected by transplantation. Each factor was scored 0-3. A score of 3 indicated comorbidity approaching a contraindication for transplantation, that which might lead to but was not currently an adverse risk factor scored 1, and that presenting a definite but moderate increase in risk scored 2. The preoperative scores of 20 patients who had received intestinal transplants either isolated or as part of a cluster graft, who had either been followed up postoperatively for at least 10 years, or died within 10 years were compared with their survivals. RESULTS: Postoperative survival and CaMi score inversely correlated when analysed using Spearman test (r(s) = -0.82; P = .0001). A score of <3 associated with survival > or =3 years (12/12 patients) and >3 with survival of <6 months (4/4). Patient Kaplan-Meier (KM) survival curves for patients grouped according to CaMi score became significantly different from group 0 to group 3. Using this as a threshold score patients grouped as either >2 or <3 had significantly different survival rates (log-rank; P = .0001), KM median survival hazard ratio (HR) = 6, and rate of death KM HR = 5. Receiver-operator characteristics indicate a high degree of accuracy for prediction of death with an area under the curve (C statistic) at 3 years of 0.98, at 5 years of 0.82, and at 10 years of 0.65. CONCLUSION: This initial validation suggested that the preoperative CaMi score predicted postoperative survival.

Visual cortex activation in kinesthetic guidance of reaching.

The purpose of this research was to determine the cortical circuit involved in encoding and controlling kinesthetically guided reaching movements. We used (15)O-butanol positron emission tomography in ten blindfolded able-bodied volunteers in a factorial experiment in which arm (left/right) used to encode target location and to reach back to the remembered location and hemispace of target location (left/right side of midsagittal plane) varied systematically. During encoding of a target the experimenter guided the hand to touch the index fingertip to an external target and then returned the hand to the start location. After a short delay the subject voluntarily moved the same hand back to the remembered target location. SPM99 analysis of the PET data contrasting left versus right hand reaching showed increased (P < 0.05, corrected) neural activity in the sensorimotor cortex, premotor cortex and posterior parietal lobule (PPL) contralateral to the moving hand. Additional neural activation was observed in prefrontal cortex and visual association areas of occipital and parietal lobes contralateral and ipsilateral to the reaching hand. There was no statistically significant effect of target location in left versus right hemispace nor was there an interaction of hand and hemispace effects. Structural equation modeling showed that parietal lobe visual association areas contributed to kinesthetic processing by both hands but occipital lobe visual areas contributed only during dominant hand kinesthetic processing. This visual processing may also involve visualization of kinesthetically guided target location and use of the same network employed to guide reaches to visual targets when reaching to kinesthetic targets. The present work clearly demonstrates a network for kinesthetic processing that includes higher visual processing areas in the PPL for both upper limbs and processing in occipital lobe visual areas for the dominant limb.

Functional magnetic resonance imaging and transcranial magnetic stimulation: effects of motor imagery, movement and coil orientation.

OBJECTIVE: To compare fMRI activations during movement and motor imagery to corresponding motor evoked potential (MEP) maps obtained with the TMS coil in three different orientations. METHODS: fMRI activations during executed (EM) and imagined (IM) movements of the index finger were compared to MEP maps of the first dorsal interosseus (FDI) muscle obtained with the TMS coil in anterior, posterior and lateral handle positions. To ensure spatial registration of fMRI and MEP maps, a special grid was used in both experiments. RESULTS: No statistically significant difference was found between the TMS centers of gravity (TMS CoG) obtained with the three coil orientations. There was a significant difference between fMRI centers of gravity during IMs (IM CoG) and EMs (EM CoG), with IM CoGs localized on average 10.3mm anterior to those of EMs in the precentral gyrus. Most importantly, the IM CoGs closely matched cortical projections of the TMS CoGs while the EM CoGs were on average 9.5mm posterior to the projected TMS CoGs. CONCLUSIONS: TMS motor maps are more congruent with fMRI activations during motor imagery than those during EMs. These findings are not significantly affected by changing orientation of the TMS coil. SIGNIFICANCE: Our results suggest that the discrepancy between fMRI and TMS motor maps may be largely due to involvement of the somatosensory component in the EM task.

Fel d 4, a cat lipocalin allergen.

BACKGROUND: Cat allergy is unique among allergy to mammals in that the major allergen Fel d 1 is a uteroglobin-like protein and not a lipocalin. The biochemical spectrum of the cat allergens is thus uncertain, particularly with regard to the role that a cat lipocalin protein may play in sensitization to cats in allergic individuals. OBJECTIVE: To analyse cDNA encoding a lipocalin allergen and the corresponding recombinant allergen at both the molecular and immunological levels. METHODS: A submandibular salivary gland cDNA expression library was constructed and screened for clones producing IgE-binding polypeptides. cDNA encoding a lipocalin allergen and its corresponding recombinant allergen were analysed. RESULTS: An IgE binding molecule with high sequence identity to the boar salivary lipocalin and the horse lipocalin Equ c 1 allergen was isolated and designated, Fel d 4. Serum from 62.96% of cat-allergic subjects examined had measurable IgE antibody to Fel d 4 but typically at low levels. Despite this in 47% of sera the anti-Fel d 4 IgE titres were higher than the anti-Fel d 1 titres. IgE binding to the lipocalin allergen could be blocked by an allergen extract from cow and to a lesser degree by extracts from horse and dog. CONCLUSION: Fel d 4 is a lipocalin allergen produced by the cat, which binds IgE at relatively high frequency in cat-sensitive individuals. The allergen provides not only a means for investigating differences in the immune response to lipocalin allergens from that found for other mammalian species but also an important reagent for the diagnosis of cat allergy.

Disordered sensorimotor transformations for reaching following posterior cortical lesions.

Preparation for reaches to visual targets depends on sensorimotor transformations (SMT) between target and limb coordinate systems. To examine neural substrates for SMT, we studied 19 individuals with focal lesions of the visual association cortices and white matter and 11 control subjects without brain lesions. SMT were assessed by measuring accuracy of reaches to remembered locations of visually presented targets. Results showed abnormally large SMT errors in all individuals with inferior parietal lobule (IPL) lesions and some subjects with lesions of the temporo-occipital regions and in occipital area 19. Types of abnormal errors (direction or distance) varied between subjects with similar lesions, e.g. IPL. Patterns of abnormality included dissociations of distance and direction errors and of constant and variable errors. These findings are compatible with the hypothesis of different systems for guiding distance and direction of reaches distributed among structures in superior and inferior visual association cortex.