Differences in Anatomy and Kinematics in Asian and Caucasian TKA Patients: Influence on Implant Positioning and Subsequent Loading Conditions in Mobile Bearing Knees

The objective of our study was to determine the mechanical stress conditions under tibiofemoral loading with an overlay of knee kinematics in deep flexion on two different mobile bearing designs in comparison to in vivo failure modes. This study investigates the seldom but severe complication of fatigue failure of polyethylene components at mobile bearing total knee arthroplasty designs. Assuming a combination of a floor-based lifestyle and tibial malrotation as a possible reason for a higher failure rate in Asian countries we developed a simplified finite element model considering a tibiofemoral roll-back angle of 22 degrees and the range of rotational motion of a clinically established floating platform design (e. motion FP) at a knee flexion angle of 120 degrees in order to compare our results to failure modes found in retrieved implants. Compared to the failure mode observed in the clinical retrievals the locations of the occurring stress maxima as well as the tensile stress distribution show analogies. From our observations, we conclude that the newly introduced finite element model with an overlay of deep knee flexion (lateral roll-back) and considerable internally rotated tibia implant positioning is an appropriate analysis for knee design optimizations and a suitable method to predict clinical failure modes

Reflections on a 'virtual' practice development unit: changing practice through identity development

Aims. This paper draws together the personal thoughts and critical reflections of key people involved in the establishment of a ‘virtual’ practice development unit of clinical nurse specialists in the south of England. Background. This practice development unit is ‘virtual’ in that it is not constrained by physical or specialty boundaries. It became the first group of Trust-wide clinical nurse specialists to be accredited in the UK as a practice development unit in 2004. Design and methods. The local university was asked to facilitate the accreditation process via 11 two-hour audio-recorded learning sessions. Critical reflections from practice development unit members, leaders and university staff were written 12 months after successful accreditation, and the framework of their content analysed. Findings and discussion. Practice development was seen as a way for the clinical nurse specialists to realize their potential for improving patient care by transforming care practice in a collaborative, interprofessional and evolutionary manner. The practice development unit provided a means for these nurses to analyse their role and function within the Trust. Roberts’ identity development model for nursing serves as a useful theoretical underpinning for the reflections contained in this paper. Conclusions. These narratives provide another example of nurses making the effort to shape and contribute to patient care through organizational redesign. This group of nurses began to realize that the structure of the practice development unit process provided them with the means to analyse their role and function within the organization and, as they reflected on this structure, their behaviour began to change. Relevance to clinical practice. Evidence from these reflections supports the view that practice development unit participants have secured a positive and professional identity and are, therefore, better able to improve the patient experience

Preparing clinical-grade myeloid dendritic cells by electroporation-mediated transfection of in vitro amplified tumor-derived mRNA and safety testing in stage IV malignant melanoma

BACKGROUND: Dendritic cells (DCs) have been used as vaccines in clinical trials of immunotherapy of cancer and other diseases. Nonetheless, progress towards the use of DCs in the clinic has been slow due in part to the absence of standard methods for DC preparation and exposure to disease-associated antigens. Because different ex vivo exposure methods can affect DC phenotype and function differently, we studied whether electroporation-mediated transfection (electrotransfection) of myeloid DCs with in vitro expanded RNA isolated from tumor tissue might be feasible as a standard physical method in the preparation of clinical-grade DC vaccines. METHODS: We prepared immature DCs (IDCs) from CD14(+ )cells isolated from leukapheresis products and extracted total RNA from freshly resected melanoma tissue. We reversely transcribed the RNA while attaching a T7 promoter to the products that we subsequently amplified by PCR. We transcribed the amplified cDNA in vitro and introduced the expanded RNA into IDCs by electroporation followed by DC maturation and cryopreservation. Isolated and expanded mRNA was analyzed for the presence of melanoma-associated tumor antigens gp100, tyrosinase or MART1. To test product safety, we injected five million DCs subcutaneously at three-week intervals for up to four injections into six patients suffering from stage IV malignant melanoma. RESULTS: Three preparations contained all three transcripts, one isolate contained tyrosinase and gp100 and one contained none. Electrotransfection of DCs did not affect viability and phenotype of fresh mature DCs. However, post-thaw viability was lower (69 ± 12 percent) in comparison to non-electroporated cells (82 ± 12 percent; p = 0.001). No patient exhibited grade 3 or 4 toxicity upon DC injections. CONCLUSION: Standardized preparation of viable clinical-grade DCs transfected with tumor-derived and in vitro amplified mRNA is feasible and their administration is safe

DINÂMICA EM SUPERFÍCIE, VOLUME, BIOMASSA E CARBONO NAS FLORESTAS PLANTADAS BRASILEIRAS: 1990-2016

O objetivo do trabalho foi quantificar a dinâmica em superfície e dos estoques de volume de madeira, biomassa e carbono nas plantações florestais brasileiras. Dados sobre a extensão dessas florestas por diferentes instituições embasaram as estimativas para o período 1990-2016 para os principais gêneros utilizados em plantações florestais no Brasil. As produtividades foram simuladas com programas computacionais da EMBRAPA. Fatores de expansão de biomassa, razão de raízes, massa específica e teores de carbono de literatura foram aplicados. A área de florestas plantadas aumentou para 10,212 milhões ha (ano de 2016) em relação a área de 4,934 milhões ha (para o ano de 1990). O volume de madeira comercial cresceu de 774 milhões m3 em 1990 para 1,999 bilhão de m3 em 2016. A biomassa apresentou mudança de 457 milhões t em 1990 a 1,246 bilhão t em 2016. Os estoques de carbono apontaram 210 milhões t em 1990 e 575 milhões t em 2016. Eucalyptus contribuía com 60% da área plantada em 1990, passando a 74% em 2016 e sua participação em volume, biomassa e carbono aumentou de 52, 57 e 58%, em 1990, para 67, 71 e 71% em 2016, respectivamente. O gênero Pinus pouco cresceu em área plantada, perdendo participação relativa. Outros gêneros têm participação modesta, mas vêm observando-se uma tendência de crescimento nos últimos anos. Concluiu-se que houve grande crescimento em área, volume, biomassa e carbono nas plantações florestais brasileiras nos 26 anos, em que as remoções de CO2 atmosférico equivalente nesse período foram da ordem de 1,338 bilhão t, as quais se devem pelo aumento da área plantada e pela maior produtividade dos povoamentos

DINÂMICA EM SUPERFÍCIE, VOLUME, BIOMASSA E CARBONO NAS FLORESTAS NATIVAS BRASILEIRAS: 1990-2015

Avaliou-se a dinâmica em área e em estoques de volume de madeira, biomassa e carbono nas florestas nativas do Brasil no período 1990 a 2015. A fonte utilizada para o trabalho foi o Relatório FRA2015 (Avaliação dos Recursos Florestais) submetido pelo Serviço Florestal Brasileiro à FAO (Organização das Nações Unidas para Alimentação e Agricultura). Os dados publicados foram analisados criticamente, deduções dos parâmetros empregados foram realizadas e alguns ajustes nos cálculos foram efetivados. A área de florestas nativas no Brasil decresceu no período de 25 anos, de 542 M ha para 486 M ha, o que corresponde a 10% da superfície inicial computada em 1990. As maiores perdas de áreas florestais ocorreram nos biomas Amazônia e Cerrado que representaram 85% do total e 56 M ha em todo o País, sendo equivalente à superfície do Estado da Bahia. O estoque volumétrico de madeira foi reduzido em 8,45% no período avaliado, de 103 G m3 para 95 G m3, com maior perda no bioma Amazônia (79%). A biomassa total seca estocada nas florestas também decresceu 8,44%, de 126 G t para 115 G t, com maior redução na Amazônia (79%). O estoque de carbono caiu de 63 G t para 58 G t, expressando uma perda de 8,40% que se deu em maior intensidade no bioma Amazônia (80%). Concluiu-se que as reduções em volume, biomassa e carbono são atribuídas à diminuição da cobertura florestal em todos os biomas e que tais reduções implicaram em emissões de gases de efeito estufa

The effects of nationality differences and work stressors on work adjustment for foreign nurse aides

<p>Abstract</p> <p>Background</p> <p>The main purpose of this study was to discuss the nationality differences of foreign nurse aides and the effect of work stressors influencing work adjustment. And of helping them adapt to Taiwanese society, we summarized the difficulties that foreign nurse aides face in Taiwan.</p> <p>Methods</p> <p>The subjects included 80 foreign nurse aides from the Philippines, Indonesia, and Vietnam who worked in long-term care facilities in Tao Yuan County. We recruited volunteers at the participating facilities to complete the anonymous questionnaires. The return rate of the questionnaire was 88.75%. The validated instruments of Hershenson's (1981) and Schaefer and Moos (1993) were adopted to measure work stressors and work adjustment, respectively. A forward-backward translation process was used in this study.</p> <p>Results</p> <p>Indonesian foreign nurse aides respect their work, and are better workers than Vietnamese and Filipino nurse aids in many respects, which shows how the nationality of the foreign nurse aides might affect work adjustment. The stress created from patient care tasks influenced the foreign nurse aides' personal relationships at work and also affected their attitude when they performed their tasks. In addition, pressure from their supervisors might have affected their work skills, work habits, personal relationships, self-concepts or work attitudes. Moreover, a heavy workload and improper scheduling might have affected the personal relationships and work attitudes of the foreign nurse aides. It was found that work stressors had a significant correlation with work adjustment.</p> <p>Conclusions</p> <p>The results of the present study indicate that training programs are important factors for work adjustment among foreign nurse aides. Furthermore, celebration and leisure activities could be provided to release them from work stressors. More effort should be put into improving the working environment, namely providing a more supportive and enriching atmosphere. Based on these findings, we have a better understanding of how to assist foreign nurse aides in the future.</p

Métodos de quantificação do estoque de carbono na biomassa de Nectandra grandiflora Nees em remanescente de Floresta Ombrófila Mista

Atualmente, observa-se que a capacidade de sobrevivência das florestas naturais é fortemente afetada pelas mudanças climáticas, em que a quantificação do carbono é um quesito fundamental para a seleção de espécies adequadas para climas futuros. Dessa forma, este trabalho teve como objetivo aplicar e avaliar métodos de quantificação do estoque de carbono na biomassa para a espécie arbórea Nectandra grandiflora em um fragmento de Floresta Ombrófila Mista Montana no estado do Paraná, Brasil. As biomassas úmidas do fuste, galhos, folhas e raízes foram obtidas de 30 árvores e, posteriormente, convertidas em secas para a determinação dos teores e dos estoques de carbono. Ademais, fatores de expansão de biomassa e razões de raízes foram calculados, bem como equações alométricas de simples e dupla entradas, em função do diâmetro e da altura, foram ajustadas visando fundamentar os seis métodos de quantificação de carbono aplicados, os quais foram avaliados pelo índice de concordância de Willmott, critério de informação de Akaike e erro quadrático médio. Houve maior acurácia em efetuar a quantificação do carbono com equações alométricas de simples entrada combinadas com teores médios ou ponderados de carbono. Ao passo que o uso da biomassa do fuste associada aos fatores de expansão, razão de raízes e teores médio de carbono foram os menos indicados para a quantificação do elemento. A divulgação dos indicadores de biomassa e de teor de carbono torna a Nectandra grandiflora uma espécie potencial para programas de reflorestamentos e de restauração de ecossistemas

Making space for disability in eco-housing and eco-communities

There is continued failure to build homes for diverse and disabled occupancy. We use three eco-communities in England to explore how their eco-houses and wider community spaces accommodate the complex disability of hypotonic Cerebral Palsy. Using site visits, video footage, spatial mapping, field diary observations, surveys and interviews, this paper argues that little attention has been paid to making eco-communities and eco-houses accessible. There are, we argue, three useful and productive ways to interrogate accessibility in eco-communities, through understandings of legislation, barriers and mobility. These have three significant consequences for eco-communities and disabled access: ecological living as practised by these eco-communities relies upon particular bodily capacities, and thus excludes many disabled people; disabled access was only considered in relation to the house and its thresholds, not to the much broader space of the home; and eco-communities need to be, and would benefit from being, spaces of diverse interaction

Down-titration of biologics for the treatment of rheumatoid arthritis: A systematic literature review

Biologic therapies have improved the management of rheumatoid arthritis (RA) and the treat-to-target approach has resulted in many patients achieving remission. In the current treatment landscape, clinicians have begun considering dose reduction/tapering for their patients. Rheumatology guidelines in Asia, Europe, and the United States include down-titration of biologics but admit that the level of evidence is moderate. We conducted a systematic literature review to assess the published studies that evaluate down-titration of biologics in RA. The published literature was searched for studies that down-titrated the following biologics: abatacept, adalimumab, certolizumab, etanercept, golimumab, infliximab, rituximab, and tocilizumab. Eligible studies included randomized controlled trials (RCTs), non-RCTs, observational, and pharmacoeconomic studies. The outcomes of interest were (1) efficacy and health-related quality of life, (2) disease flares, and (3) impact on cost. Eleven full-text publications were identified; only three were RCTs. Study results suggest that dosing down may be an option in many patients who have achieved remission or low disease activity. However, some patients are likely to experience a disease flare. Across the studies, the definition of disease flare and the down-titration criteria were inconsistent, making it difficult to conclude which patients may be appropriate and when to attempt down-titration. Studies have evaluated the practice of dosing down biologic therapy in patients with RA; however, a relatively small number of RCTs have been published. Although down-titration may be an option for some patients in LDA or remission, additional RCTs are needed to provide guidance on this practice

Cognitive behavioural therapy with optional graded exercise therapy in patients with severe fatigue with myotonic dystrophy type 1:a multicentre, single-blind, randomised trial

Background: Myotonic dystrophy type 1 is the most common form of muscular dystrophy in adults and leads to severe fatigue, substantial physical functional impairment, and restricted social participation. In this study, we aimed to determine whether cognitive behavioural therapy optionally combined with graded exercise compared with standard care alone improved the health status of patients with myotonic dystrophy type 1. Methods: We did a multicentre, single-blind, randomised trial, at four neuromuscular referral centres with experience in treating patients with myotonic dystrophy type 1 located in Paris (France), Munich (Germany), Nijmegen (Netherlands), and Newcastle (UK). Eligible participants were patients aged 18 years and older with a confirmed genetic diagnosis of myotonic dystrophy type 1, who were severely fatigued (ie, a score of ≥35 on the checklist-individual strength, subscale fatigue). We randomly assigned participants (1:1) to either cognitive behavioural therapy plus standard care and optional graded exercise or standard care alone. Randomisation was done via a central web-based system, stratified by study site. Cognitive behavioural therapy focused on addressing reduced patient initiative, increasing physical activity, optimising social interaction, regulating sleep–wake patterns, coping with pain, and addressing beliefs about fatigue and myotonic dystrophy type 1. Cognitive behavioural therapy was delivered over a 10-month period in 10–14 sessions. A graded exercise module could be added to cognitive behavioural therapy in Nijmegen and Newcastle. The primary outcome was the 10-month change from baseline in scores on the DM1-Activ-c scale, a measure of capacity for activity and social participation (score range 0–100). Statistical analysis of the primary outcome included all participants for whom data were available, using mixed-effects linear regression models with baseline scores as a covariate. Safety data were presented as descriptives. This trial is registered with ClinicalTrials.gov, number NCT02118779. Findings: Between April 2, 2014, and May 29, 2015, we randomly assigned 255 patients to treatment: 128 to cognitive behavioural therapy plus standard care and 127 to standard care alone. 33 (26%) of 128 assigned to cognitive behavioural therapy also received the graded exercise module. Follow-up continued until Oct 17, 2016. The DM1-Activ-c score increased from a mean (SD) of 61·22 (17·35) points at baseline to 63·92 (17·41) at month 10 in the cognitive behavioural therapy group (adjusted mean difference 1·53, 95% CI −0·14 to 3·20), and decreased from 63·00 (17·35) to 60·79 (18·49) in the standard care group (−2·02, −4·02 to −0·01), with a mean difference between groups of 3·27 points (95% CI 0·93 to 5·62, p=0·007). 244 adverse events occurred in 65 (51%) patients in the cognitive behavioural therapy group and 155 in 63 (50%) patients in the standard care alone group, the most common of which were falls (155 events in 40 [31%] patients in the cognitive behavioural therapy group and 71 in 33 [26%] patients in the standard care alone group). 24 serious adverse events were recorded in 19 (15%) patients in the cognitive behavioural therapy group and 23 in 15 (12%) patients in the standard care alone group, the most common of which were gastrointestinal and cardiac. Interpretation: Cognitive behavioural therapy increased the capacity for activity and social participation in patients with myotonic dystrophy type 1 at 10 months. With no curative treatment and few symptomatic treatments, cognitive behavioural therapy could be considered for use in severely fatigued patients with myotonic dystrophy type 1. Funding: The European Union Seventh Framework Programme