From lab to clinic : towards a virtual reality platform for routine clinical rehabilitation

Background: Recent advances in technology have led to the widespread commercialisation of virtual reality (VR). Many researchers have investigated the use of VR for rehabilitation; however few have extended VR use into routine clinical practice. This is mainly due to systems being too complex and time consuming or too simple to provide necessary information regarding patient function. Aim: Develop a VR platform that can provide an objective measure of patient function and can be integrated into clinical practice with minimal disruption to routine care. Method: Motion analysis is currently the gold standard for non-invasive measurement of human movement and therefore was implemented in this study to provide an objective analysis of function. A bespoke, cluster based protocol was developed and used to create an avatar and three feedback scenarios for standard orthopaedic rehabilitation exercises (step up, sit to stand, weight transfer). A cohort study was carried out in a hospital clinic with 15 control and 15 intervention orthopaedic rehabilitation patients to assess the effectiveness of feedback and the integration of the system into routine practice. Results/Findings: Visual feedback was successfully delivered using motion capture with minimal disruption to routine practice. Further, provision of feedback may have a positive effect on knee sagittal RoM, although larger scale studies are required to confirm these findings. Discussion and Conclusion: Use of a motion analysis protocol which was designed for purpose allowed integration of the system into routine practice. There was minimal disruption to patient care and use of the system may improve functional outcome of orthopaedic rehabilitation patients

Development of a motion analysis protocol for use in routine clinical care

There is widespread agreement that motion analysis is currently the gold standard for measuring human movement in a non-invasive manner [1]. Current commercially available systems, such as Vicon Plug in Gait (PiG, Vicon Motion Systems, Oxford, UK) have been developed over a number of years and are capable of providing a biomechanical analysis which is robust enough to dictate complex treatment plans, such as multi-level surgery [1]. However, due to the vast capabilities of PiG, it is a time consuming and technically complex protocol to deliver. Additionally, there are currently limited options for delivering motion capture using other protocols which vastly limits the use of motion analysis in other aspects of clinical care, such as outpatient rehabilitation. Cluster based marker sets may provide a faster and less technically complex alternative to models such as PiG; however these are currently not commercially available and have thus far been restricted to research environments. Therefore, the aim of this study was to develop a bespoke cluster based motion analysis protocol (Strathclyde Cluster Model; SCM) capable of calculating lower limb kinematics which could be implemented in routine clinical care in order to expand the use of motion analysis beyond research and complex clinical cases. Further aims included an assessment of the kinematic output and reliability of SCM in comparison to PiG. SCM is a motion analysis protocol which has been developed for routine clinical use, such as outpatient rehabilitation and therefore application of markers and participant calibration is quicker and easier than current commercial alternatives. Further, kinematic output and reliability are comparable between SCM and the current clinical gold standard. Therefore, SCM is a suitable alternative for providing an objective assessment of function and outcome in routine clinical practice

Early detection of Pseudomonas aeruginosa – comparison of conventional versus molecular (PCR) detection directly from adult patients with cystic fibrosis (CF)

BACKGROUND: Pseudomonas aeruginosa (PA) is the most important bacterial pathogen in patients with cystic fibrosis (CF) patients. Currently, routine bacteriological culture on selective/non- selective culture media is the cornerstone of microbiological detection. The aim of this study was to compare isolation rates of PA by conventional culture and molecular (PCR) detection directly from sputum. METHODS: Adult patients (n = 57) attending the regional adult CF centre in Northern Ireland, provided fresh sputum following airways clearance exercise. Following processing of the specimen with sputasol (1:1 vol), the specimen was examined for the presence of PA by plating onto a combination of culture media (Pseudomonas isolation agar, Blood agar & McConkey agar). In addition, from the same specimen, genomic bacterial DNA was extracted (1 ml) and was amplified employing two sequence-specific targets, namely (i) the outer membrane protein (oprL) gene locus and (ii) the exotoxin A (ETA) gene locus. RESULTS: By sputum culture, there were 30 patients positive for PA, whereas by molecular techniques, there were 35 positive patients. In 39 patients (22 PA +ve & 17 PA -ve), there was complete agreement between molecular and conventional detection and with both PCR gene loci. The oprL locus was more sensitive than the ETA locus, as the former was positive in 10 more patients and there were no patients where the ETA was positive and the oprL target negative. Where a PCR +ve/culture -ve result was recorded (10 patients), we followed these patients and recorded that 5 of these patients converted to being culture-positive at times ranging from 4–17 months later, with a mean lag time of 4.5 months. CONCLUSIONS: This study indicates that molecular detection of PA in sputum employing the oprL gene target, is a useful technique in the early detection of PA, gaining on average 4.5 months over conventional culture. It now remains to be established whether aggressive antibiotic intervention at this earlier stage, based on PCR detection, has any significant benefits on clinical outcome

Effects of visual feedback on orthopaedic rehabilitation

Currently, functional outcome following total knee arthroplasty (TKA) is not fully restored, with the majority of TKA patients exhibiting lower functional outcome scores than their healthy counterparts [1]. A contributing factor to limited functional outcome may be the nature of the rehabilitation provided as there is still some controversy regarding the most appropriate methods for rehabilitation delivery [2]. Providing patients with visual feedback during rehabilitation has had a positive effect in other patient populations such as stroke survivors [3] and therefore may also improve the efficacy of orthopaedic rehabilitation. The aim of this study was to develop a visual feedback tool based on real time data from 3D motion capture for routine clinical use. Further aims included determining if provision of augmented feedback was acceptable to patients and whether it had a positive effect on functional outcome. Visual feedback using motion analysis was successfully delivered in a routine clinical environment and was widely acceptable to patients. Further, provision of visual feedback appeared to lead to improved knee range of motion in the sagittal plane in comparison to control patients. However, larger scale studies are required to confirm these positive effects

Hepatitis B Virus Prevalence and Mother-to-Child Transmission Risk in an HIV Early Intervention Cohort in KwaZulu-Natal, South Africa

BACKGROUND: HIV and hepatitis B virus (HBV) prevalence are both high in KwaZulu-Natal, South Africa. HIV coinfection negatively affects HBV prognosis and can increase the likelihood of HBV mother-to-child transmission (MTCT). In an early HIV infant treatment intervention cohort of HIV-transmitting mother-child pairs in KwaZulu-Natal, we characterized maternal HBV prevalence and screened infants at risk. METHODS: Infants were treated for HIV MTCT at birth, and combination regimens incidentally active against HBV were initiated within 21 days. Maternal samples (N = 175) were screened at birth for HBV infection (HBV surface antigen [HBsAg]), exposure to HBV (HBV anti-core IgG), and vaccination responses (HBV anti-S positive without other HBV markers). Infants of mothers who were HBV positive were screened for HBsAg at 1 and 12 months. RESULTS: Evidence of HBV infection was present in 8.6% (n = 15) of maternal samples. Biomarkers for HBV exposure were present in 31.4% (n = 55). Evidence of HBV vaccination was uncommon in mothers (8.0%; n = 14). Despite prescription of antiretroviral therapy (ART) active against HBV, HBV DNA was detectable in 46.7% (7/15) of mothers who were HBsAg positive. Three mothers had HBV viral loads >5.3 log10 IU/mL, making them high risk for HBV MTCT. Screening of available infant samples at 1 month (n = 14) revealed no cases of HBV MTCT. At 12 months, we identified 1 HBV infection (1/13), and serologic evidence of vaccination was present in 53.8% (7/13) of infants. DISCUSSION: This vulnerable cohort of HIV-transmitting mothers had a high prevalence of undiagnosed HBV. Early infant ART may have reduced the risk of MTCT in high-risk cases. Current HBV guidelines recommend ART prophylaxis, but these data underline the pressing need to increase availability of birth dose vaccines

Influence of Sex and Age on Muscle Sympathetic Nerve Activity of Healthy Normotensive Adults

As with blood pressure, age-related changes in muscle sympathetic nerve activity (MSNA) may differ nonlinearly between sexes. Data acquired from 398 male (age: 39±17; range: 18-78 years [mean±SD]) and 260 female (age: 37±18; range: 18-81 years) normotensive healthy nonmedicated volunteers were analyzed using linear regression models with resting MSNA burst frequency as the outcome and the predictors sex, age, MSNA, blood pressure, and body mass index modelled with natural cubic splines. Age and body mass index contributed 41% and 11%, respectively, of MSNA variance in females and 23% and 1% in males. Overall, changes in MSNA with age were sigmoidal. At age 20, mean MSNA of males and females were similar, then diverged significantly, reaching in women a nadir at age 30. After 30, MSNA increased nonlinearly in both sexes. Both MSNA discharge and blood pressure were lower in females until age 50 (17±9 versus 25±10 bursts·min-1; P\u3c1×10-19; 106±11/66±8 versus 116±7/68±9 mm Hg; P\u3c0.01) but converged thereafter (38±11 versus 35±12 bursts·min-1; P=0.17; 119±15/71±13 versus 120±13/72±9 mm Hg; P\u3e0.56). Compared with age 30, MSNA burst frequency at age 70 was 57% higher in males but 3-fold greater in females; corresponding increases in systolic blood pressure were 1 (95% CI, -4 to 5) and 12 (95% CI, 6-16) mm Hg. Except for concordance in females beyond age 40, there was no systematic change with age in any resting MSNA-blood pressure relationship. In normotensive adults, MSNA increases after age 30, with ascendance steeper in women

Microneurographic characterization of sympathetic responses during 1-leg exercise in young and middle-aged humans

Muscle sympathetic nerve activity (MSNA) at rest increases with age. However, the influence of age on MSNA recorded during dynamic leg exercise is unknown. We tested the hypothesis that aging attenuates the sympatho-inhibitory response observed in young subjects performing mild to moderate 1-leg cycling. After pre-determining peak oxygen uptake (VO2peak), we compared contra-lateral fibular nerve MSNA during 2 minutes each of mild (unloaded) and moderate (30-40% of the work rate at peak VO2, halved for single leg) 1-leg cycling in 18 young (23±1 years [mean±SE]) and 18 middle-aged (57±2 years) sex-matched healthy subjects. Mean height, weight, resting heart rate (HR), systolic blood pressure (BP) and percent predicted VO2peak were similar between groups. Middle-aged subjects had higher resting MSNA burst frequency and incidence (P<0.001) and diastolic BP (P=0.04). During moderate 1-leg cycling, older subjects’ systolic BP increased more (+21±5 vs.+10±1 mmHg; P=0.02) and their fall in MSNA burst incidence was amplified (-19±2 vs. -11±2 bursts/100heartbeats; P=0.01) but because HR rose less (+153 vs.+192 bpm; P=0.03), exercise induced similar reductions in burst frequency (P=0.25). Contrary to our initial hypothesis, with advancing age, mild to moderate intensity dynamic leg exercise elicits a greater rise in systolic BP and a larger fall in MSNA

A comparison of static and dynamic cerebral autoregulation during mild whole-body cold stress in individuals with and without cervical spinal cord injury: a pilot study

Study design: Experimental study. Objectives: To characterize static and dynamic cerebral autoregulation (CA) of individuals with cervical spinal cord injury (SCI) compared to able-bodied controls in response to moderate increases in mean arterial pressure (MAP) caused by mild whole-body cold stress. Setting: Japan Methods: Five men with complete autonomic cervical SCI (sustained>5y) and six age-matched able-bodied men participated in hemodynamic, temperature, catecholamine and respiratory measurements for 60 min during three consecutive stages: baseline (10 min; 330C water through a thin-tubed whole-body suit), mild cold stress (20 min; 250C water) and post-cold recovery (30 min; 330C water). Static CA was determined as the ratio between mean changes in middle cerebral artery blood velocity and MAP, dynamic CA as transfer function coherence, gain and phase between spontaneous changes in MAP to middle cerebral artery blood velocity. Results: MAP increased in both groups during cold and post-cold recovery (mean differences: 5 to 10 mm Hg; main effect of time: p=0.001). Static CA was not different between the able-bodied vs the cervical SCI group (mean [95% CI] of between-group difference: -4 [-11 to 3] and -2 [-5 to 1] cm/s/mmHg for cold (p=0.22) and post-cold (p=0.24), respectively). At baseline, transfer function phase was shorter in the cervical SCI group (mean [95% CI] of between-group difference: 0.6 [0.2 to 1.0] rad; p=0.006), while between-group differences in changes in phase were not different in response to the cold stress (interaction term: p=0.06). Conclusions: This pilot study suggests that static CA is similar between individuals with cervical SCI and able-bodied controls in response to moderate increases in MAP, while dynamic CA may be impaired in cervical SCI due to disturbed sympathetic control

Left Ventricular Structure and Function in Elite Swimmers and Runners

Sport-specific differences in the left ventricle (LV) of land-based athletes have been observed; however, comparisons to water-based athletes are sparse. The purpose of this study was to examine differences in LV structure and function in elite swimmers and runners. Sixteen elite swimmers [23 (2) years, 81% male, 69% white] and 16 age, sex, and race matched elite runners participated in the study. All athletes underwent resting echocardiography and indices of LV dimension, global LV systolic and diastolic function, and LV mechanics were determined. All results are presented as swimmers vs. runners. Early diastolic function was lower in swimmers including peak early transmitral filling velocity [76 (13) vs. 87 (11) cm ⋅ s-1, p = 0.02], mean mitral annular peak early velocity [16 (2) vs. 18 (2) cm ⋅ s-1, p = 0.01], and the ratio of peak early to late transmitral filling velocity [2.68 (0.59) vs. 3.29 (0.72), p = 0.005]. The diastolic mechanics index of time to peak untwisting rate also occurred later in diastole in swimmers [12 (10)% diastole vs. 5 (4)% diastole, p = 0.01]. Cardiac output was larger in swimmers [5.8 (1.5) vs. 4.7 (1.2) L ⋅ min-1, p = 0.04], which was attributed to their higher heart rates [56 (6) vs. 49 (6) bpm, p &lt; 0.001] given stroke volumes were similar between groups. All other indices of LV systolic function and dimensions were similar between groups. Our findings suggest enhanced early diastolic function in elite runners relative to swimmers, which may be attributed to faster LV untwisting

"Pathogen Eradication" and "Emerging Pathogens": Difficult Definitions in Cystic Fibrosis.

Infection is a common complication of cystic fibrosis (CF) airway disease. Current treatment approaches include early intervention with the intent to eradicate pathogens in the hope of delaying the development of chronic infection and the chronic use of aerosolized antibiotics to suppress infection. The use of molecules that help restore CFTR (cystic fibrosis transmembrane conductance regulator) function, modulate pulmonary inflammation, or improve pulmonary clearance may also influence the microbial communities in the airways. As the pipeline of these new entities continues to expand, it is important to define when key pathogens are eradicated from the lungs of CF patients and, equally important, when new pathogens might emerge as a result of these novel therapies