Plantar Kinetics During Wheeled Knee Walker Use Compared to Different Assistive Walking Devices in Persons With Type 2 Diabetes Mellitus.

Background: Diabetic patients with foot ulcers are commonly prescribed assistive walking devices to unload the affected foot and promote tissue healing. However, the effect on shear loads to the contralateral foot is unknown. This study investigated the effect of a wheeled knee walker (WKW), compared to common devices, on compressive and shear plantar forces carried by the propulsive foot during walking in patients with type 2 diabetes mellitus. A secondary objective investigated plantar forces' correlations with body weight unloaded (BWU). Methods: Participants walked a maximum of 200 m per condition during normal walking or when using crutches, a standard walker, and a WKW in randomized order. Plantar forces were measured with force plates, and wireless force-sensitive pads measured BWU through the hands. The WKW was instrumented to measure BWU onto the seat and handlebars. Three-dimensional motion capture confirmed gait events. Results: The WKW produced the lowest vertical, braking, propulsive, and medial shear forces but the highest lateral shear force among all conditions. Using crutches or a walker had negligible medial and lateral shear (mean = -6.69 N and -7.80 N), with normal walking producing the highest medial shear. There was a poor relationship between BWU and assistive walking devices and shear force values. Conclusion: A WKW could be the preferred assistive device for unloading a diabetic foot ulcer. The magnitude of lateral force would need further investigation to determine ulceration risk, given patient susceptibility and neuropathy. Clinical Relevance: Understanding shear forces on the propulsive foot is important for minimizing contralateral limb tissue damage risk while treating an ulcer. Different assistive walking devices change walking patterns and affect shear forces on the plantar surface of the foot. Although the WKW minimizes several loading metrics, a clinical trial investigating assistive walking device compliance and wound healing in diabetic foot ulcer patients across devices is needed.

Ketone Bodies Impact on Hypoxic CO2 Retention Protocol During Exercise.

Exogenous ketone esters have demonstrated the capacity to increase oxygen availability during acute hypoxic exposure leading to the potential application of their use to mitigate performance declines at high altitudes. Voluntary hypoventilation (VH) with exercise reliably reduces oxygen availability and increases carbon dioxide retention without alterations to ambient pressure or gas content. Utilizing a double-blind randomized crossover design, fifteen recreational male distance runners performed submaximal exercise (4 × 5 min; 70% VO2 Max) with VH. An exogenous ketone ester (KME; 573 mg⋅kg-1) or iso-caloric flavor matched placebo (PLA) was consumed prior to exercise. Metabolites, blood gases, expired air, heart rate, oxygen saturation, cognition, and perception metrics were collected throughout. KME rapidly elevated R-ß-hydroxybutyrate and reduced blood glucose without altering lactate production. KME lowered pH, bicarbonate, and total carbon dioxide. VH with exercise significantly reduced blood (SpO2) and muscle (SmO2) oxygenation and increased cognitive mean reaction time and respiratory rate regardless of condition. KME administration significantly elevated respiratory exchange ratio (RER) at rest and throughout recovery from VH, compared to PLA. Blood carbon dioxide (PCO2) retention increased in the PLA condition while decreasing in the KME condition, leading to a significantly lower PCO2 value immediately post VH exercise (IPE; p = 0.031) and at recovery (p = 0.001), independent of respiratory rate. The KME's ability to rapidly alter metabolism, acid/base balance, CO2 retention, and respiratory exchange rate independent of respiratory rate changes at rest, during, and/or following VH exercise protocol illustrates a rapid countermeasure to CO2 retention in concert with systemic metabolic changes.

Longitudinal changes in EEG power, sleep cycles and behaviour in a tau model of neurodegeneration.

BACKGROUND: Disturbed sleep is associated with cognitive decline in neurodegenerative diseases such as Alzheimer's disease (AD) and frontotemporal dementia (FTD). The progressive sequence of how neurodegeneration affects aspects of sleep architecture in conjunction with behavioural changes is not well understood. METHODS: We investigated changes in sleep architecture, spectral power and circadian rhythmicity in the tet-off rTg4510 mouse overexpressing human P301L tau within the same subjects over time. Doxycycline-induced transgene-suppressed rTg4510 mice, tTa carriers and wild-type mice were used as comparators. Spectral power and sleep stages were measured from within the home cage environment using EEG electrodes. In addition, locomotor activity and performance during a T-maze task were measured. RESULTS: Spectral power in the delta and theta bands showed a time-dependent decrease in rTg4510 mice compared to all other groups. After the initial changes in spectral power, wake during the dark period increased whereas NREM and number of REM sleep bouts decreased in rTg4510 compared to wild-type mice. Home cage locomotor activity in the dark phase significantly increased in rTg4510 compared to wild-type mice by 40 weeks of age. Peak-to-peak circadian rhythm amplitude and performance in the T-maze was impaired throughout the experiment independent of time. At 46 weeks, rTG4510 mice had significant degeneration in the hippocampus and cortex whereas doxycycline-treated rTG4510 mice were protected. Pathology significantly correlated with sleep and EEG outcomes, in addition to locomotor and cognitive measures. CONCLUSIONS: We show that reduced EEG spectral power precedes reductions in sleep and home cage locomotor activity in a mouse model of tauopathy. The data shows increasing mutant tau changes sleep architecture, EEG properties, behaviour and cognition, which suggest tau-related effects on sleep architecture in patients with neurodegenerative diseases.

Abdominal organ bioengineering: current status and future perspectives.

Organ transplantation represents one of the major milestones of modern medicine and surgical practice in terms of life-years prolonged and quality of life offered for chronic patients. Each year over 100,000 donor organ transplants are performed worldwide. In spite of the rapid advancement and expansion of this niche, it has become a victim of its own success as the donor supply is far oustripped by the demand for replacement organs. Furthermore, current methods only allow for successful transplantation in the setting of life-long, aggressive immunosuppression protocols which enhances the incidence of secondary neoplasm and other associated sequelae. Against this background, recent advances in the fields of regenerative medicine, tissue engineering, and cellular biology have coalesced into a promising new avenue of investigation involving the fabrication of de novo, transplantable organs using autologous cells. Donor organs are stripped of their native cellular material leaving only acellular, extracellular matrix constructs behind. These constructs can then be recellularized with a patient's own cells in order to form transplantable organs that do not require immunosuppression. Furthermore, in theory, these methods could provide a potentially inexhaustible source of organs to meet the growing need for viable transplants. In this review, we describe these methods as well as contemporary successes for various organ systems.

A risk adjusted cost-effectiveness analysis of alternative models of nurse involvement in obesity management in primary care.

OBJECTIVE: Controlled evaluations are subject to uncertainty regarding their replication in the real world, particularly around systems of service provision. Using routinely collected data, we undertook a risk adjusted cost-effectiveness (RAC-E) analysis of alternative applied models of primary health care for the management of obese adult patients. Models were based on the reported level of involvement of practice nurses (registered or enrolled nurses working in general practice) in the provision of clinical-based activities. DESIGN AND METHODS: Linked, routinely collected clinical data describing clinical outcomes (weight, BMI, and obesity-related complications) and resource use (primary care, pharmaceutical, and hospital resource use) were collected. Potential confounders were controlled for using propensity weighted regression analyses. RESULTS: Relative to low level involvement of practice nurses in the provision of clinical-based activities to obese patients, high level involvement was associated with lower costs and better outcomes (more patients losing weight, and larger mean reductions in BMI). Excluding hospital costs, high level practice nurse involvement was associated with slightly higher costs. Incrementally, the high level model gets one additional obese patient to lose weight at an additional cost of $6,741, and reduces mean BMI by an additional one point at an additional cost of $563 (upper 95% confidence interval $1,547). CONCLUSION: Converted to quality adjusted life year (QALY) gains, the results provide a strong indication that increased involvement of practice nurses in clinical activities is associated with additional health benefits that are achieved at reasonable additional cost. Dissemination activities and incentives are required to encourage general practices to better integrate practice nurses in the active provision of clinical services.

A risk-adjusted economic evaluation of alternative models of involvement of practice nurses in management of type 2 diabetes.

AIMS: To determine the cost-effectiveness of alternative models of practice nurse involvement in the management of type 2 diabetes within the primary care setting. METHODS: Linked routinely collected clinical data and resource use (general practitioner visits, hospital services and pharmaceuticals) were used to undertake a risk-adjusted cost-effectiveness analysis of alternative models of care for the management of diabetes patients. These models were based on the reported level of involvement of practice nurses in the provision of clinical-based activities. Potential confounders were controlled for by using propensity score-weighted regression analyses. The impact of alternative models of care on outcomes and costs was measured and incremental cost-effectiveness estimated. The uncertainty around the estimates of cost-effectiveness was illustrated through bootstrapping. RESULTS: Although the difference in total cost between two models of care was not statistically significant, the high-level model was associated with better outcomes (larger mean reductions in HbA(1c)). The upper 95% confidence intervals showed that the incremental cost per 1% decrease in HbA(1c) is only $454, and per one additional patient to achieve an HbA(1c) value of less than 53 mmol/mol (7.0%) is $323. Further analyses showed little uncertainty surrounding the decision to adopt the high-level model. CONCLUSIONS: The results provide a strong indication that the high-level model is a cost-effective way of managing diabetes patients. Our findings highlight the need for effective incentives to encourage general practices to better integrate practice nurses in the provision of clinical services.

Paediatric granular cell tumour of the larynx: case report of laser resection with frozen section.

Granular cell tumours of the larynx are a very rare cause of persistent hoarse or husky voice in children. We report the case of a 13-year-old girl who presented with a three-year history of progressively huskier voice. We discuss the presentation, location and diagnosis of the tumour. In addition, we present a method of surgical treatment of the tumour, involving the hitherto unreported technique of laser excision and frozen section of the lesion.

Bilateral Achilles tendon rupture: a case report.

Bilateral Achilles tendon rupture is a rare injury. We present a case of a 59-year-old gentleman who sustained a bilateral Achilles tendon rupture when the tendon was subjected to normal physiological load. He was treated operatively with V-Y plasty and repair of the tendon with post-operative plaster immobilisation.

Driving practices, risk-taking motivations, and alcohol use among adolescent drivers: a pilot study.

OBJECTIVE: To explore risk-taking motivations, driving practices, and alcohol use in rural adolescent drivers. DESIGN: Descriptive correlational study, that used three self-administered questionnaires: Risk Taking Questionnaire, Driving Practices Questionnaire, and Short Michigan Alcohol Screening Test. METHODS: Test instruments were administered to 23 adolescent drivers, aged 16 to 18 years, recruited by school guidance counselors. RESULTS: Risky driving practices were associated with alcohol use (r = 0.73) and greater risk-taking motivations (r = 0.75). The mean score on the Short Michigan Alcohol Screening Test (4.23) reflected alcoholic tendencies. Male gender was moderately associated with risky driving practice (r = 0.54). CONCLUSION: Drinking alcohol and risky driving may represent a broader risk-taking syndrome. In identifying injury-susceptible individuals, gender may be less useful than identification of driving practices. Injury alone may an indicator of risk-taking behavior, but when injury is combined with alcohol use the index of suspicion increases. Emergency nurses can screen injured adolescents for risk-taking motivations and discuss injury history and perceived injury susceptibility. Awareness is the first step in initiating self-protective measures.

Granulopoietic studies in acute lymphocytic leukemia of children.

Studies have been carried out on the levels of serum and urine colony stimulating activity (CSA) and peripheral blood and bone marrow colony forming cell numbers in children with acute lymphocytic leukemia (ALL) during various phases of their disease. These studies have suggested that serum and urine levels of colony stimulating factor are reduced during the inital or relapse phase of the disease compared to levels found during remission. It has also been found that the number of bone marrow colony forming cells is reduced in relapse or before treatment and elevated during remission while the number of peripheral blood colony forming cells is increased during relapse or before treatment and normal during remission. It has also been shown that mixing of serum or leukemic cells with normal human bone marrow cells inhibits colony formation.

Neuroblastoma in father and son.

A growing literature supports the concept that some cases of neuroblastoma are hereditary. To this we add the first known case, to our knowledge, of neuroblastoma in a parent and child. Various factors, such as the remarkable tendency for this tumor to regress spontaneously, as well as its frequent fatal outcome, have reduced the number of observed familial cases. It is important that siblings and progeny of patients with neuroblastoma be examined to detect possible subclinical neuroblastoma.

Non-hodgkin's lymphoma in children. Correlation of CNS disease with initial presentation.

The clinical and histopathological findings in 26 children with non-Hodgkin's lymphoma without initial marrow involvement are reviewed. A marked male predominance similar to that observed in previous series was noted. Biopsy material was classified according to the recommendations of Rappaport in 22 cases. All have diffuse lymphomas, and 16 of 22 patients had involvement of the mediastinum as part of their initial presentation. Of these 12, 5 developed lymphomatous involvement of the central nervous system prior to the development of leukemic transformation of the bone marrow. This observation suggests that prophylactic therapy against CNS relapse be considered for children with mediastinal non-Hodgkin's lymphoma, even in the absence of initial marrow involvement.

Complications of abdominal exploration and splenectomy in staging children with Hodgkin's disease.

Until alternate diagnostic methods are discovered, the staging procedure seems to be the most reliable method to establish the presence or absence of abdominal involvement in Hodgkin's disease. Our experience with staging laparotomy in 22 children raises serious questions as to both the risk of operation and the prognostic value of a negative abdominal exploration. Routine use of the staging laparotomy may not be justified in clinical Stage IA patients with lymphocyte-predominant cell type. Because of the hazards and limitations of the staging procedure, vigorous attempts would seem to be indicated to identify subcategories of patients in whom the likelihood of intraabdominal involvement is so small as to negate the value of surgical staging.

A multiple chemotherapeutic approach to the management of hepatoblastoma. A preliminary report.

In 1970, a staging based on surgical resectability of hepatic tumors was devised. Adjuvant chemotherapy with vincristine, 5-fluorouracil, and cyclophosphamide has been given to seven recent cases. Objectives of this study were to set up unified clinical staging and followup; to evaluate the effect of combination chemotherapy on survival in advanced disease; and to evaluate early adjunctive combination chemotherapy in surgically resectable lesions to, hopefully, prevent metastasis. Results to date in seven patients are: no change in the poor prognosis of the three female patients presenting with Stage III-IV hepatocellular carcinoma; the three males with Stage I-II hepatoblastoma have done well and survive the free of disease at 47 months, 44 months, and 28 months; one patient with hepatoblastoma had lung metastasis at diagnosis and died at 7 months with tumor. No toxicity was noted with the use of adjunctive combination chemotherapy following major hepatic resection.