Newport Hospital

The Cyberknife is a unique instrument for performing frameless stereotactic radiosurgery. Rather than using rigid immobilization, the Cyberknife relies on an image-to-image correlation algorithm for target localization. Furthermore, the system utilizes a novel, light-weight, high-energy radiation source. The authors describe the technical specifications of the Cyberknife and summarize the initial clinical experience.

Fecal microbiota transplantation (FMT) is a promising treatment for recurrent Clostridium difficile infection. We report a case of a woman successfully treated with FMT who developed new-onset obesity after receiving stool from a healthy but overweight donor. This case may stimulate further studies on the mechanisms of the nutritional-neural-microbiota axis and reports of outcomes in patients who have used nonideal donors for FMT.

Of the Orthomyxoviridae family of viruses, only influenza A viruses are thought to exist as multiple subtypes and has non-human maintenance hosts. In April 2011, nasal swabs were collected for virus isolation from pigs exhibiting influenza-like illness. Subsequent electron microscopic, biochemical, and genetic studies identified an orthomyxovirus with seven RNA segments exhibiting approximately 50% overall amino acid identity to human influenza C virus. Based on its genetic organizational similarities to influenza C viruses this virus has been provisionally designated C/Oklahoma/1334/2011 (C/OK). Phylogenetic analysis of the predicted viral proteins found that the divergence between C/OK and human influenza C viruses was similar to that observed between influenza A and B viruses. No cross reactivity was observed between C/OK and human influenza C viruses using hemagglutination inhibition (HI) assays. Additionally, screening of pig and human serum samples found that 9.5% and 1.3%, respectively, of individuals had measurable HI antibody titers to C/OK virus. C/OK virus was able to infect both ferrets and pigs and transmit to naive animals by direct contact. Cell culture studies showed that C/OK virus displayed a broader cellular tropism than a human influenza C virus. The observed difference in cellular tropism was further supported by structural analysis showing that hemagglutinin esterase (HE) proteins between two viruses have conserved enzymatic but divergent receptor-binding sites. These results suggest that C/OK virus represents a new subtype of influenza C viruses that currently circulates in pigs that has not been recognized previously. The presence of multiple subtypes of co-circulating influenza C viruses raises the possibility of reassortment and antigenic shift as mechanisms of influenza C virus evolution.

AIMS: The COVID-19 pandemic required a significant redeployment of worldwide healthcare resources. Fear of infection, national lockdowns and altered healthcare priorities have the potential to impact utilisation of healthcare resources for non-communicable diseases. To survey health professionals' views of the impact of the COVID-19 pandemic on the rate and timing of admission of patients with ST-elevation myocardial infarction (STEMI), the European Society of Cardiology (ESC) administered an internet-based questionnaire to cardiologists and cardiovascular nurses across 6 continents. METHODS AND RESULTS: 3101 responses were received from 141 countries across 6 continents. 88.3% responded that their country was in "total lockdown" and 7.1% in partial lockdown. 78.8% responded that the number of patients presenting with STEMI was reduced since the coronavirus outbreak and 65.2% indicated that the reduction in STEMI presentations was >40%. Approximately 60% of all respondents reported that STEMI patients presented later than usual and 58.5% that >40% of STEMI patients admitted to hospital presented beyond the optimal window for primary percutaneous intervention (PCI) or thrombolysis. Independent predictors of the reported higher rate of delayed STEMI presentation were a country in total lockdown, >100 COVID-19 cases admitted locally, and the complete restructuring of the local cardiology service. CONCLUSION: The survey indicates that the impact of COVID-19 on STEMI presentations is likely to be substantial, with both lower presentations and a higher rate of delayed presentations occurring. This has potentially important ramifications for future healthcare and policy planning in the event of further waves of this pandemic.

Purpose – Both lean and six sigma are key business process strategies which are employed by companies to enhance their manufacturing performance. However, whilst there is significant research information available on implementing these systems in a sequential manner, there is little information available relating to the integration of these approaches to provide a single and highly effective strategy for change in companies. The purpose of this paper is to develop and implement an integrated lean six sigma (LSS) model for manufacturing industry.

A committee assembled by the American Academy of Neurology (AAN) reassessed the evidence related to the care of women with epilepsy (WWE) during pregnancy, including antiepileptic drug (AED) teratogenicity and adverse perinatal outcomes. It is highly probable that intrauterine first-trimester valproate (VPA) exposure has higher risk of major congenital malformations (MCMs) compared to carbamazepine (CBZ), and possibly compared to phenytoin (PHT) or lamotrigine (LTG). It is probable that VPA as part of polytherapy and possible that VPA as monotherapy contribute to the development of MCMs. AED polytherapy probably contributes to the development of MCMs and reduced cognitive outcomes compared to monotherapy. Intrauterine exposure to VPA monotherapy probably reduces cognitive outcomes and monotherapy exposure to PHT or phenobarbital (PB) possibly reduces cognitive outcomes. Neonates of WWE taking AEDs probably have an increased risk of being small for gestational age and possibly have an increased risk of a 1-minute Apgar score of <7. If possible, avoidance of VPA and AED polytherapy during the first trimester of pregnancy should be considered to decrease the risk of MCMs. If possible, avoidance of VPA and AED polytherapy throughout pregnancy should be considered and avoidance of PHT and PB throughout pregnancy may be considered to prevent reduced cognitive outcomes.

BACKGROUND: The role of diet in the etiology of breast carcinoma has been debated for decades. The ecologic approach generally finds that dietary fat is highly associated with breast carcinoma mortality, with fish intake and solar ultraviolet-B (UV-B) radiation, a source of vitamin D, inversely associated. Case-control and cohort studies generally find a variety of chemical, nonfat dietary, environmental, genetic, lifestyle, and reproductive factors to be important. METHODS: An ecologic study was conducted using breast carcinoma mortality rates (1989-1996), dietary supply data, and latitude (an index of solar UV-B radiation) from 35 countries. RESULTS: The fraction of energy derived from animal products (risk) combined with that from vegetable products (risk reduction), followed by solar UV-B radiation and, to a lesser extent, energy derived from alcohol (risk) and fish intake (risk reduction), were found to explain 80% of the variance of breast carcinoma mortality rates. Dietary fat contributed insignificantly in regressions involving the other factors. CONCLUSIONS: It is hypothesized that animal products are associated with risk for breast carcinoma because they are associated with greater amounts of insulin-like growth factor-1 and lifetime doses of estrogen. Vegetable products contain several risk reduction components including antioxidants and phytoestrogens. The association with latitude is very likely because of solar UV-B radiation and vitamin D. Alcohol modulates estrogen's effects on breasts. Fish intake is associated with risk reduction through vitamin D and n-3 oils. These results are consistent with those of many case-control and cohort studies but should be assessed in well designed cohort studies.

A committee assembled by the American Academy of Neurology (AAN) reassessed the evidence related to the care of women with epilepsy (WWE) during pregnancy, including preconceptional folic acid and prenatal vitamin K use and the clinical implications of placental and breast-milk transfer of antiepileptic drugs (AEDs). The committee evaluated the available evidence based on a structured literature review and classification of relevant articles. Preconceptional folic acid supplementation is possibly effective in preventing major congenital malformations in the newborns of WWE taking AEDs. There is inadequate evidence to determine if the newborns of WWE taking AEDs have a substantially increased risk of hemorrhagic complications. Primidone and levetiracetam probably transfer into breast milk in clinically important amounts. Valproate, phenobarbital, phenytoin, and carbamazepine probably are not transferred into breast milk in clinically important amounts. Pregnancy probably causes an increase in the clearance and a decrease in the concentrations of lamotrigine, phenytoin, and, to a lesser extent carbamazepine, and possibly decreases the level of levetiracetam and the active oxcarbazepine metabolite, the monohydroxy derivative (MHD). Supplementing WWE with at least 0.4 mg of folic acid before pregnancy may be considered. Monitoring of lamotrigine, carbamazepine, and phenytoin levels during pregnancy should be considered, and monitoring of levetiracetam and oxcarbazepine (as MHD) levels may be considered. A paucity of evidence limited the strength of many recommendations.

Addiction is a primary, chronic disease involving brain reward, motivation, memory and related circuitry; it can lead to relapse, progressive development, and the potential for fatality if not treated. While pathological use of alcohol and, more recently, psychoactive substances have been accepted as addictive diseases, developing brain science has set the stage for inclusion of the process addictions, including food, sex, shopping and gambling problems, in a broader definition of addiction as set forth by the American Society of Addiction Medicine in 2011.

A committee assembled by the American Academy of Neurology (AAN) reassessed the evidence related to the care of women with epilepsy (WWE) during pregnancy, including the risk of pregnancy complications or other medical problems during pregnancy, change in seizure frequency, the risk of status epilepticus, and the rate of remaining seizure-free during pregnancy. The committee evaluated the available evidence according to a structured literature review and classification of relevant articles. For WWE who are taking antiepileptic drugs (AEDs), there is probably no substantially increased risk (>2 times expected) of cesarean delivery or late pregnancy bleeding, and probably no moderately increased risk (>1.5 times expected) of premature contractions or premature labor and delivery. There is possibly a substantially increased risk of premature contractions and premature labor and delivery during pregnancy for WWE who smoke. WWE should be counseled that seizure freedom for at least 9 months prior to pregnancy is probably associated with a high likelihood (84-92%) of remaining seizure-free during pregnancy. WWE who smoke should be counseled that they possibly have a substantially increased risk of premature contractions and premature labor and delivery.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Understand the challenges in restoring volume and structural integrity in rhinoplasty. 2. Identify the appropriate uses of various homologous grafts and allogenic implants in reconstruction, including: (a) freeze-dried acellular allogenic cadaveric dermis grafts, (b) irradiated cartilage grafts, (c) hydroxyapatite mineral matrix, (d) silicone implants, (e) high-density polyethylene implants, (f) polytetrafluoroethylene implants, and (g) injectable filler materials. 3. Identify the advantages and disadvantages of each of these biomaterials. 4. Understand the specific techniques that may aid in the use these grafts or implants. SUMMARY: This review specifically addresses the use of homologous grafts and allogenic implants in rhinoplasty. It is important to stress that autologous materials remain the preferred graft material for use in rhinoplasty, owing to their high biocompatibility and low risk of infection and extrusion. However, concerns of donor-site morbidity, graft availability, and graft resorption have motivated the development and use of homologous and allogenic implants.

BACKGROUND: Antimicrobial lock therapy has been widely utilized internationally for the prevention and management of intravascular catheter-related bloodstream infections. One of the agents commonly utilized for lock therapy is ethanol. However, a systematic review of adverse events associated with ethanol locks has not been published. METHODS: PubMed was searched to collect articles published from May 2003 through March 2014. The bibliographies of relevant articles were also reviewed. RESULTS: In vitro studies of the mechanical properties of catheters after ethanol immersion have revealed changes predominantly in polyurethane catheters and to a lesser extent in silicone and Carbothane catheters. An elution of polymers from polyurethane and Carbothane catheters has been observed at the ethanol concentrations used in ethanol lock therapy. Ethanol above a concentration of 28% leads to plasma protein precipitation. Ethanol locks were associated with catheter occlusion in 11 studies and independently increased the risk of thrombosis compared with heparin lock in a randomized trial. Six studies noted abnormalities in catheter integrity, including one case leading to catheter embolization. Of note, five of these studies involved silicone catheters. Ethanol lock use was associated with systemic side effects in 10 studies and possible side effects in one additional study. Four studies noted liver function test abnormalities, predominantly transaminase elevation, related to ethanol lock use. However, a prospective study did not find any difference in the risk of doubling the transaminase level above the normal range during use of ethanol locks compared with not using an ethanol lock. CONCLUSIONS: The use of ethanol locks has been associated with structural changes in catheters, as well as the elution of molecules from the catheter polymers. Clinical studies have revealed systemic toxicity, increased catheter occlusion and breaches in catheter integrity.

At the time of writing, about 4.59 billion people use social media with many adolescents using their social media accounts across a myriad of applications and platforms. According to recent statistics, in 2022 individuals spent an average of 151 minutes on social media each day, illustrating the global relevance of social media (Dixon, 2022a,b). One of the pressing questions, internationally, is whether social media use is harmful and/or addictive. This question is of particular importance because many teenagers - and younger adolescents - spend considerable time on these platforms, which have increasingly become an integral part of their lives. Moreover, considering lifespan development, adolescents may be particularly vulnerable to specific features and advertisements shown to them on social media platforms. Growing prevalence of poor mental health in young people has led to recent recommendations in the United States to routinely screen for anxiety in 8-18 year olds, and for depression and suicide risk for adolescents between 12-18 years of age (US Preventive Services Task Force et al., 2022 a,b) - the conditions often accompanying problematic social media use. The present work not only provides insights into the current state of the literature but provides also recommendations.

A novel production process flow is presented here for the manufacture of hollow silicon microneedles using deep reactive-ion etching (DRIE) technology. The patent-pending three-step process flow has been developed to produce multiple arrays of sharp-tipped, hollow microneedles, which facilitate easy insertion and controlled fluid injection into excised skin samples. A bevelled tip and vertical sidewalls for the microneedle have been achieved with good uniformity, despite >45% open etch area. Processing steps and etch challenges are discussed, and preliminary skin testing results are presented, showing effective needle insertion and delivery of fluorescent dye into ex vivo skin from human breast tissue.

A mathematical model was developed to analyze the mechanisms of expiratory asynchrony during pressure support ventilation (PSV). Solving the model revealed several results. 1) Ratio of the flow at the end of patient neural inspiration to peak inspiratory flow (VTI/V(peak)) during PSV is determined by the ratio of time constant of the respiratory system (tau) to patient neural inspiratory time (TI) and the ratio of the set pressure support (Pps) level to maximal inspiratory muscle pressure (Pmus max). 2) VTI/V(peak) is affected more by tau/TI than by Pps/Pmus max. VTI/V(peak) increases in a sigmoidal relationship to tau/TI. An increase in Pps/Pmus max slightly shifts the VTI/V(peak)-tau/TI curve to the right, i.e., VTI/V(peak) becomes lower as Pps/Pmus max increases at the same tau/TI. 3) Under the selected adult respiratory mechanics, VTI/V(peak) ranges from 1 to 85% and has an excellent linear correlation with tau/TI. 4) In mechanical ventilators, single fixed levels of the flow termination criterion will always have chances of both synchronized termination and asynchronized termination, depending on patient mechanics. An increase in tau/TI causes more delayed and less premature termination opportunities. An increase in Pps/Pmus max narrows the synchronized zone, making inspiratory termination predisposed to be in asynchrony. Increasing the expiratory trigger sensitivity of a ventilator shifts the synchronized zone to the right, causing less delayed and more premature termination. Automation of expiratory trigger sensitivity in future mechanical ventilators may also be possible. In conclusion, our model provides a useful tool to analyze the mechanisms of expiratory asynchrony in PSV.

This article reports on two studies that examine the relationship between measurements of activities of daily living (ADL) and cognitive skills performance. Study 1 is a post hoc analysis of ADL improvement scores collected on acute stroke patients who were either given or not given cognitive skills remediation. An examination of individual ADL scores showed significantly higher personal hygiene, bathing, and toilet activity improvement scores for patients receiving cognitive skills remediation. In Study 2, cognitive skills and ADL pre- and posttest scores for stroke patients were measured by occupational therapists, who also implemented an ADL as well as a cognitive skills remediation program as part of the patient's therapy. Some significant positive correlations between initial cognitive skills measurements and ADL outcome were found. The best correlate of patients' ADL performance at discharge was performance on an auditory attention task. Verbal comprehension correlated with overall ADL improvement, and overall cognitive skills improvement correlated with overall ADL improvement. Implications of these two studies are discussed.

The objectives of this study were to investigate if a relationship exists between dental arch width and the vertical facial pattern determined by the steepness of the mandibular plane, and to examine the differences in dental arch widths between male and female untreated adults. Lateral cephalograms and dental casts were obtained from 185 untreated Caucasians (92 males, 93 females) between 18 and 68 years of age with no crossbite, minimal crowding, and spacing. The angle of the mandibular plane (MP) to the anterior cranial base (SN) was measured on cephalograms of each patient. Dental casts were used to obtain comprehensive dental measurements including maxillary and mandibular intercanine, interpremolar, and intermolar widths, as well as the amount of crowding or spacing. The arch widths of males and females were analysed and the differences between them were tested for significance using a Student's t-test. Regression analysis was used to determine the statistical significance of the relationships between MP–SN angle and dental arch width and crowding or spacing. The results showed that male arch widths were significantly larger than those of females (P < 0.05). For both males and females, there was a trend that as MP–SN angle increased, arch width decreased. It was concluded that dental arch width is associated with gender and facial vertical morphology. Thus, using individualized archwires according to each patient's pre-treatment arch form and width is suggested during orthodontic treatment.

INTRODUCTION: Spinal Cord Stimulation (SCS) has become an accepted therapeutic modality for the treatment of intractable pain syndromes, primarily used today in the settings of failed back surgery syndrome, neuropathic back and limb pain. The use of spinal cord stimulators for peripheral nerve field electrostimulation is becoming increasingly recognized as a safe, effective alternative for chronic pain conditions that are refractory to medical management and do not respond to traditional dorsal column stimulation. Advances in technology have allowed for minimally invasive percutaneous placement of multipolar leads with complex programmable systems to provide patient- controlled relief of pain in precisely targeted regions. With these improvements in hardware, the use of Peripheral Nerve Field Stimulation (PNFS) appears to have an untapped potential for providing patients with pain relief for a wider range of underlying conditions than was previously believed possible. We present three cases, each with a different etiology of chronic abdominal pain: one with inguinal neuralgia, one with chronic pancreatitis, and one with pain following liver transplant. Each patient was refractory to conventional medical approaches. For all three patients, PNFS provided significant relief from pain, enabling patients to decrease or discontinue their opioid medications and to enjoy significant improvement in their quality of life. We conclude that PNFS is a safe, effective and minimally invasive treatment that may be used successfully for a wide variety of indications including chronic abdominal pain.

Vertebral augmentation is among the current standards of care to reduce pain in patients with vertebral fractures (VF), yet a lack of consensus regarding efficacy and safety of percutaneous vertebroplasty and kyphoplasty raises questions on what basis clinicians should choose one therapy over another. Given the lack of consensus in the field, the American Society for Bone and Mineral Research (ASBMR) leadership charged this Task Force to address key questions on the efficacy and safety of vertebral augmentation and other nonpharmacological approaches for the treatment of pain after VF. This report details the findings and recommendations of this Task Force. For patients with acutely painful VF, percutaneous vertebroplasty provides no demonstrable clinically significant benefit over placebo. Results did not differ according to duration of pain. There is also insufficient evidence to support kyphoplasty over nonsurgical management, percutaneous vertebroplasty, vertebral body stenting, or KIVA®. There is limited evidence to determine the risk of incident VF or serious adverse effects (AE) related to either percutaneous vertebroplasty or kyphoplasty. No recommendation can be made about harms, but they cannot be excluded. For patients with painful VF, it is unclear whether spinal bracing improves physical function, disability, or quality of life. Exercise may improve mobility and may reduce pain and fear of falling but does not reduce falls or fractures in individuals with VF. General and intervention-specific research recommendations stress the need to reduce study bias and address methodological flaws in study design and data collection. This includes the need for larger sample sizes, inclusion of a placebo control, more data on serious AE, and more research on nonpharmacologic interventions. Routine use of vertebral augmentation is not supported by current evidence. When it is offered, patients should be fully informed about the evidence. Anti-osteoporotic medications reduce the risk of subsequent vertebral fractures by 40-70%. © 2018 American Society for Bone and Mineral Research.

Introduction: Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety. Objective: The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders. Methods: The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented. Results: After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain. Conclusion: The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.