Use of Near-infrared Spectroscopy and Implantable Doppler for Postoperative Monitoring of Free Tissue Transfer for Breast Reconstruction: A Systematic Review and Meta-analysis.

BACKGROUND: Failure to accurately assess the perfusion of free tissue transfer (FTT) in the early postoperative period may contribute to failure, which is a source of major patient morbidity and healthcare costs. This systematic review and meta-analysis aim to evaluate and appraise current evidence for the use of near-infrared spectroscopy (NIRS) and/or implantable Doppler (ID) devices compared with conventional clinical assessment (CCA) for postoperative monitoring of FTT in reconstructive breast surgery. METHODS: A systematic literature search was performed in accordance with the preferred reporting items for systematic reviews guidelines. Studies in human subjects published within the last decade relevant to the review question were identified. Meta-analysis using random-effects models of FTT failure rate and STARD scoring was then performed on the retrieved publications. RESULTS: Nineteen studies met the inclusions criteria. For NIRS and ID, the mean sensitivity for the detection of FTT failure is 99.36% and 100% respectively, with average specificity of 99.36% and 97.63%, respectively. From studies with sufficient reported data, meta-analysis results demonstrated that both NIRS [OR = 0.09 (0.02-0.36); P < 0.001] and ID [OR = 0.39 (0.27-0.95); P = 0.04] were associated with significant reduction of FTT failure rates compared with CCA. CONCLUSIONS: The use of ID and NIRS provided equivalent outcomes in detecting FTT failure and were superior to CCA. The ability to acquire continuous objective physiological data regarding tissue perfusion is a perceived advantage of these techniques. Reduced clinical staff workload and minimized hospital costs are also perceived as positive consequences of their use.

Pervasive wearable device for free tissue transfer monitoring based on advanced data analysis: clinical study report.

Free tissue transfer (FTT) surgery for breast reconstruction following mastectomy has become a routine operation with high success rates. Although failure is low, it can have a devastating impact on patient recovery, prognosis, and psychological well-being. Continuous and objective monitoring of tissue oxygen saturation (StO2) has been shown to reduce failure rates through rapid detection time of postoperative vascular complications. We have developed a pervasive wearable wireless device that employs near-infrared spectroscopy (NIRS) to continuously monitor FTT via StO2 measurement. Previously tested on different models, the results of a clinical study are introduced. Our goal for the study is to demonstrate that the developed device can reliably detect StO2 variations in a clinical setting: 14 patients were recruited. Advanced data analysis was performed on the StO2 variations, the relative StO2 gradient change, and the classification of the StO2 within different clusters of blood occlusion level (from 0% to 100% at 25% step) based on previous studies made on a vascular phantom and animals. The outcomes of the clinical study concur with previous experimental results and the expected biological responses. This suggests that the device is able to correctly detect perfusion changes and provide real-time assessment on the viability of the FTT in a clinical setting.

Streamlining Decision Making in Contralateral Risk-Reducing Mastectomy: Impact of PREDICT and BOADICEA Computations.

INTRODUCTION: Patients with sporadic breast cancer (BC) have low contralateral breast cancer risk (CLBCR; approximately 0.7% per annum) and contralateral prophylactic mastectomy (CPM) offers no survival advantage. CPM with autologous reconstruction (AR) has major morbidity and resource implications. OBJECTIVE: The aim of this study was to review the impact of PREDICT survival estimates and lifetime CLBCR scores on decision making for CPM in patients with unilateral BC. METHODS: Of n = 272 consecutive patients undergoing mastectomy and AR, 252 were included. Five- and 10-year survival was computed with the PREDICT(V2) online prognostication tool, using age and clinicopathological factors. Based on family history (FH) and tumor biology, CLBCR was calculated using validated BODICEA web-based software. Survival scores were correlated against CLBCR estimates to identify patients receiving CPM with 'low' CLBCR (< 30% lifetime risk) and poor prognosis (5-year survival < 80%). Patients with 'high' CLBCR receiving unilateral mastectomy (UM) were similarly identified (UK National Institute of Health and Care Excellence [NICE] criteria for CPM, ≥ 30% lifetime BC risk). Justifications motivating CPM were investigated. RESULTS: Of 252 patients, 215 had UM and 37 had bilateral mastectomy and AR. Only 23 (62%) patients receiving CPM fulfilled the NICE criteria. Of 215 patients, 5 (2.3%) failed to undergo CPM despite high CLBCR and good prognosis. CPMs were performed, at the patient's request, for no clear justification (n = 8), contralateral non-invasive disease, and/or FH (n = 5), FH alone (n = 4) and ipsilateral cancer recurrence-related anxiety (n = 3). CONCLUSION: In the absence of prospective risk estimates of CLBCR and prognosis, certain patients receive CPM and reconstruction despite modest CLBCR, yet a proportion of patients with good prognoses and substantial risk are not undergoing CPM.

Recovery-based Training in Mental Health: Effects on Staff Knowledge and Attitudes to Recovery.

This longitudinal study describes the effects of recovery-based training on staff knowledge and attitudes to recovery. Mental health staff (n = 101) completed the study questionnaire (the Recovery Knowledge Inventory (RKI-20) and Recovery Attitudes' Questionnaire (RAQ-16)) before training and after six months. On the RKI, significant changes between pre- and post-training scores (p < 0.01) were found. On the RAQ, the scores showed significant changes in Factors 1 (p < 0.001) and 2 (p < 0.009). The results indicate a significant difference in confidence using a recovery model of care following training suggesting that recovery-based training positively affects staff knowledge and attitudes to recovery overall.

Viral symbiosis and the holobiontic nature of the human genome.

The human genome is a holobiontic union of the mammalian nuclear genome, the mitochondrial genome and large numbers of endogenized retroviral genomes. This article defines and explores this symbiogenetic pattern of evolution, looking at the implications for human genetics, epigenetics, embryogenesis, physiology and the pathogenesis of inborn errors of metabolism and many other diseases.

Introduction of team-based learning (TBL) at Kilimanjaro Christian Medical University College: experience with the ectoparasites module.

BACKGROUND: Contemporary teaching in sub-Saharan African medical schools is largely through didactic and problem-based approaches. These schools face challenges from burgeoning student numbers, severe faculty shortages, faculty without instruction in teaching methods and severe infrastructure inadequacies. Team-based learning (TBL) is a pedagogy which may be attractive because it spares faculty time. TBL was piloted in a module on ectoparasites at the Kilimanjaro Christian Medical University College (KCMU Co.). METHODS: TBL orientation began six weeks before starting the module. Students were issued background readings and individual and group readiness assessment tests, followed by module application, discussion and evaluation. At completion, student perceptions of TBL were assessed using a 5-point Likert scale evaluating six domains, with a score of 5 being most favourable. Strength of consensus measures (sCns) was applied. Final examination scores were compiled for 2011 (didactic) and 2012 (TBL). RESULTS: About 158 students participated in the module. The mean student scores across the six domains ranged from 4.2 to 4.5, with a high degree of consensus (range 85-90%). The final examination scores improved between 2011 and 2012. CONCLUSIONS: KCMU Co. student perceptions of TBL were very positive, and final exam grades improved. These observations suggest future promise for TBL applications at KCMU Co. and potentially other schools.

Association between Urinary N-Acetyl-Beta-D-Glucosaminidase and Microalbuminuria in Diabetic Black Africans.

Diabetes mellitus is the commonest cause of ESRD worldwide and third most common cause in Nigeria. Recent reports from Nigeria indicate the prevalence of diabetic nephropathy as an aetiology of ESRD is increasing necessitating early diagnosis of diabetic nephropathy. We measured the urinary excretion of N-acetyl-beta-D-glucosaminidase (NAG), NAG/creatinine ratio, urinary protein-creatinine ratio and calculated eGFR in 30 recently diagnosed nonhypertensive diabetics and 67 controls. The age and sex distribution, systolic blood pressure, serum and urinary creatinine were similar for both groups. There was higher urinary excretion of NAG (304 versus 184 µmol/h/L, P < 0.001) and NAG/creatinine ratio (21.2 versus 15.7 µmol/h/L/mmolCr, P < 0.001) in the diabetics than controls. There was a strong correlation between NAG/creatinine ratio and albumin/creatinine ratio (r = 0.74, P < 0.001). A multivariate linear regression model showed a significant linear relationship between NAG/creatinine ratio and albumin/creatinine ratio after adjusting for the effect of blood pressure, age, sex, and serum creatinine. The strong association found between albumin/creatinine ratio and NAG/creatinine ratio perhaps indicates the need for further investigation of the clinical utility of NAG/creatinine ratio as a screening tool for early nephropathy in African diabetics.

Zonal rate model for stacked membrane chromatography part II: characterizing ion-exchange membrane chromatography under protein retention conditions.

The Zonal Rate Model (ZRM) has previously been shown to accurately account for contributions to elution band broadening, including external flow nonidealities and radial concentration gradients, in ion-exchange membrane (IEXM) chromatography systems operated under nonbinding conditions. Here, we extend the ZRM to analyze and model the behavior of retained proteins by introducing terms for intra-column mass transfer resistances and intrinsic binding kinetics. Breakthrough curve (BTC) data from a scaled-down anion-exchange membrane chromatography module using ovalbumin as a model protein were collected at flow rates ranging from 1.5 to 20 mL min(-1). Through its careful accounting of transport nonidealities within and external to the membrane stack, the ZRM is shown to provide a useful framework for characterizing putative protein binding mechanisms and models, for predicting BTCs and complex elution behavior, including the common observation that the dynamic binding capacity can increase with linear velocity in IEXM systems, and for simulating and scaling separations using IEXM chromatography. Global fitting of model parameters is used to evaluate the performance of the Langmuir, bi-Langmuir, steric mass action (SMA), and spreading-type protein binding models in either correlating or fundamentally describing BTC data. When combined with the ZRM, the bi-Langmuir, and SMA models match the chromatography data, but require physically unrealistic regressed model parameters to do so. In contrast, for this system a spreading-type model is shown to accurately predict column performance while also providing a realistic fundamental explanation for observed trends, including an observed increase in dynamic binding capacity with flow rate.

Development and validation of an instrument to assess the risk of developing viral infections in Australian travelers during international travel.

BACKGROUND: Questionnaires are widely used for data collection in travel medicine studies, but there are no validated instruments that are available to researchers in this field. Our objective was to develop and validate a questionnaire to be used in a prospective study designed to estimate the risk of three viral infections in Australian travelers to Asia. METHODS: Qualitative nonexperimental cognitive methods, including cognitive review, task analysis, and cognitive interviews, were selected. A pilot study was performed to assess the instrument in the target population. RESULTS: Recalling dates related to travel or health events was observed and reported to be the most difficult task for travelers. The use of cues embedded into items and provision of memory prompts such as calendars improves the recall of dates during travel. There is a wide spectrum of accommodation, activities, and travel experiences, and item responses that were constructed as lists were useful as memory triggers, particularly for travelers with long and complicated itineraries. Cognitive interviews provided a valuable insight into how travelers used inferential and direct memory to recall travel events and their confidence in the accuracy of these processes. CONCLUSIONS: The development and validation of questionnaires improve the accuracy of the data collected and should be considered an integral part of the methodology of travel-related studies.

Zonal rate model for stacked membrane chromatography. I: characterizing solute dispersion under flow-through conditions.

Conventional models of both packed-bed and stacked-membrane chromatography typically attribute elution band broadening to non-idealities within the column. However, when the column length to diameter ratio is greatly reduced, as in stacked-membrane chromatography, variations in solute residence times within the feed-distribution (inlet) and eluent-collection (outlet) manifolds can also contribute to band broadening. We report on a new zonal rate model (ZRM) for stacked-membrane chromatography that improves on existing hold-up volume models that rely on one plug-flow reactor and one stirred-tank reactor in series to describe dispersion of solute during transport into and out of the column. The ZRM radially partitions the membrane stack and the hold-up volumes within the inlet and outlet manifolds into zones to better capture non-uniform flow distribution effects associated with the large column diameter to height ratio. Breakthrough curves from a scaled-down anion-exchange membrane chromatography module using ovalbumin as a model protein were collected at flow rates ranging from 1.5 to 20 mL min(-1) under non-binding conditions and used to evaluate the ZRM as well as previous models. The ZRM was shown to be significantly more accurate in describing protein dispersion and breakthrough. The model was then used to decompose breakthrough data, where it was found that variations in solute residence time distributions within the inlet and outlet manifolds make the dominant contribution to solute dispersion over the recommended range of feed flow rates. The ZRM therefore identifies manifold design as a critical contributor to separation quality within stacked-membrane chromatography units.

Pathogen quantitation in complex matrices: a multi-operator comparison of DNA extraction methods with a novel assessment of PCR inhibition.

BACKGROUND: Mycobacterium bovis is the aetiological agent of bovine tuberculosis (bTB), an important recrudescent zoonosis, significantly increasing in British herds in recent years. Wildlife reservoirs have been identified for this disease but the mode of transmission to cattle remains unclear. There is evidence that viable M. bovis cells can survive in soil and faeces for over a year. METHODOLOGY/PRINCIPAL FINDINGS: We report a multi-operator blinded trial for a rigorous comparison of five DNA extraction methods from a variety of soil and faecal samples to assess recovery of M. bovis via real-time PCR detection. The methods included four commercial kits: the QIAamp Stool Mini kit with a pre-treatment step, the FastDNA® Spin kit, the UltraClean™ and PowerSoil™ soil kits and a published manual method based on phenol:chloroform purification, termed Griffiths. M. bovis BCG Pasteur spiked samples were extracted by four operators and evaluated using a specific real-time PCR assay. A novel inhibition control assay was used alongside spectrophotometric ratios to monitor the level of inhibitory compounds affecting PCR, DNA yield, and purity. There were statistically significant differences in M. bovis detection between methods of extraction and types of environmental samples; no significant differences were observed between operators. Processing times and costs were also evaluated. To improve M. bovis detection further, the two best performing methods, FastDNA® Spin kit and Griffiths, were optimised and the ABI TaqMan environmental PCR Master mix was adopted, leading to improved sensitivities. CONCLUSIONS: M. bovis was successfully detected in all environmental samples; DNA extraction using FastDNA® Spin kit was the most sensitive method with highest recoveries from all soil types tested. For troublesome faecal samples, we have used and recommend an improved assay based on a reduced volume, resulting in detection limits of 4.25×10(5) cells g(-1) using Griffiths and 4.25×10(6) cells g(-1) using FastDNA® Spin kit.

Scale-up of controlled-shear affinity filtration using computational fluid dynamics.

Controlled shear affinity filtration (CSAF) is an integrated bioprocess that positions a contoured rotor above a membrane affinity chromatography column to permit the capture and purification of a secreted protein product directly from cell culture. Here, computational fluid dynamics (CFD) simulations previously used on a laboratory-scale unit (Francis et al., Biotechnol. Bioeng. 2005, 95, 1207-1217) are extended to study the fluid hydrodynamics and expected filter performance of the CSAF device for rotor sizes up to 140 cm in radius. We show that the fluid hydrodynamics within the rotor chamber of larger-scale CSAF units are complex and include turbulent boundary layers; thus, CFD likely provides the only reliable route to CSAF scale-up. We then model design improvements that will be required for CSAF scale-up to permit processing of industrial feedstock. The result is the in silico design of a preparative CSAF device with an optimized rotor 140 cm in radius. The scaled up device has an effective filtration area of 5.93 m(2), which should allow for complete processing in ca. 2 h of 1000 L of culture harvested from either a perfusion, fed-batch or batch bioreactor. Finally, a novel method for the parallelization of CSAF units is presented for use in bioprocessing operations larger than 1000 L.

Optimizing the rotor design for controlled-shear affinity filtration using computational fluid dynamics.

Controlled shear affinity filtration (CSAF) is a novel integrated processing technology that positions a rotor directly above an affinity membrane chromatography column to permit protein capture and purification directly from cell culture. The conical rotor is intended to provide a uniform and tunable shear stress at the membrane surface that inhibits membrane fouling and cell cake formation by providing a hydrodynamic force away from and a drag force parallel to the membrane surface. Computational fluid dynamics (CFD) simulations are used to show that the rotor in the original CSAF device (Vogel et al., 2002) does not provide uniform shear stress at the membrane surface. This results in the need to operate the system at unnecessarily high rotor speeds to reach a required shear stress of at least 0.17 Pa at every radial position of the membrane surface, compromising the scale-up of the technology. Results from CFD simulations are compared with particle image velocimetry (PIV) experiments and a numerical solution for low Reynolds number conditions to confirm that our CFD model accurately describes the hydrodynamics in the rotor chamber of the CSAF device over a range of rotor velocities, filtrate fluxes, and (both laminar and turbulent) retentate flows. CFD simulations were then carried out in combination with a root-finding method to optimize the shape of the CSAF rotor. The optimized rotor geometry produces a nearly constant shear stress of 0.17 Pa at a rotational velocity of 250 rpm, 60% lower than the original CSAF design. This permits the optimized CSAF device to be scaled up to a maximum rotor diameter 2.5 times larger than is permissible in the original device, thereby providing more than a sixfold increase in volumetric throughput.