Surgical programme at Royal Alexandra Hospital, Sydney, for Papua New Guinea children with congenital heart disease, 1978-1994

Objective : To report the history of the Royal Alexandra Hospital for Children (RAHC) Papua New Guinea (PNG) cardiac surgical programme and describe the selection, preoperative clinical features and postoperative outcome of children with congenital heart disease managed by the programme. Methods : Details for each of the PNG cardiac patients admitted to RAHC following selection by visiting cardiologists between 1978 and 1994 were entered into a database, and analysed and interpreted. Results : A congenital heart defect was confirmed in 165 of the 170 children selected. The male to female ratio was 1:1 and the mean age on admission to RAHC was 5.5 years. Almost all of the children for whom data were available (98%) had a weight for age and 41% had a height for age less than the 3rd centile. One-sixth had delayed milestones. A large number were tachypnoeic, in heart failure, or had pulmonary hypertension on admission. Ventricular septal defect and tetralogy of Fallot were the commonest defects, and lesions such as aortic stenosis, coarctation of the aorta and transposition of the great arteries were absent or rare. Thirty-one (19%) of the children selected initially did not receive surgery because of pulmonary hypertension, or because the lesions did not fall within the programme guidelines for operation. One hundred and twenty-nine children had corrective and four had palliative procedures. Half of the operated children had postoperative complications. Eight children died, all following open-heart procedures, giving a case fatality rate of 6%. Preoperative tachypnoea, hepatomegaly, cardiac failure and pulmonary hypertension were strongly associated with poor outcome. Conclusions : The programme was an arduous exercise for all organizations concerned, but achieved comparatively good short-term outcomes. The experience gained should assist in planning for similar programmes.

Particulate bioglass in the regeneration of alveolar bone in dogs: clinical, surgical and radiographic evaluations

Bone loss, either by trauma or other diseases, generates an increasing need for substitutes of this tissue. This study evaluated Bioglass as a bone substitute in the regeneration of the alveolar bone in mandibles of dogs by clinical, surgical and radiological analysis. Twenty-eight adult dogs were randomly separated into two equal groups. In each animal, a bone defect was created on the vestibular surface of the alveolar bone between the roots of the fourth right premolar tooth. In the treated group, the defect was immediately filled with bioglass, while in the control, it remained unfilled. Clinical evaluations were performed daily for a week, as well as x-rays immediately after surgery and at 8, 14, 21, 42, 60, 90 and 120 days post-operative. Most animals in both groups showed no signs of inflammation and wound healing was similar. Radiographic examination revealed a gradual increase of radiopacity in the region of the defect in the control group. In the treated group, initial radiopacity was higher than that of adjacent bone, decreasing until 21 days after surgery. Then it gradually increased until 120 days after surgery, when the defect became undetectable. The results showed that Bioglass integrates into bone tissue, is biocompatible and reduced the period for complete bone regeneration.

Finite element analysis of pectus carinatum surgical correction via a minimally invasive approach

Pectus carinatum (PC) is a chest deformity caused by a disproportionate growth of the costal cartilages compared to the bony thoracic skeleton, pulling the sternum towards, which leads to its protrusion. There has been a growing interest on using the ‘reversed Nuss’ technique as minimally invasive procedure for PC surgical correction. A corrective bar is introduced between the skin and the thoracic cage and positioned on top of the sternum highest protrusion area for continuous pressure. Then, it is fixed to the ribs and kept implanted for about 2–3 years. The purpose of this work was to (a) assess the stresses distribution on the thoracic cage that arise from the procedure, and (b) investigate the impact of different positioning of the corrective bar along the sternum. The higher stresses were generated on the 4th, 5th and 6th ribs backend, supporting the hypothesis of pectus deformities correction-induced scoliosis. The different bar positioning originated different stresses on the ribs’ backend. The bar position that led to lower stresses generated on the ribs backend was the one that also led to the smallest sternum displacement. However, this may be preferred, as the risk of induced scoliosis is lowered.

Surgical correction of scoliosis: Numerical analysis and optimization of the procedure

A previously developed model is used to numerically simulate real clinical cases of the surgical correction of scoliosis. This model consists of one-dimensional finite elements with spatial deformation in which (i) the column is represented by its axis; (ii) the vertebrae are assumed to be rigid; and (iii) the deformability of the column is concentrated in springs that connect the successive rigid elements. The metallic rods used for the surgical correction are modeled by beam elements with linear elastic behavior. To obtain the forces at the connections between the metallic rods and the vertebrae geometrically, non-linear finite element analyses are performed. The tightening sequence determines the magnitude of the forces applied to the patient column, and it is desirable to keep those forces as small as possible. In this study, a Genetic Algorithm optimization is applied to this model in order to determine the sequence that minimizes the corrective forces applied during the surgery. This amounts to find the optimal permutation of integers 1, ... , n, n being the number of vertebrae involved. As such, we are faced with a combinatorial optimization problem isomorph to the Traveling Salesman Problem. The fitness evaluation requires one computing intensive Finite Element Analysis per candidate solution and, thus, a parallel implementation of the Genetic Algorithm is developed.

Pre-operative tractography of the facial nerve in vestibular schwannomas: inter-observer agreement with surgical findings

Pre-operative diffusion tensor (DT) tractography is currently employed in our institutions. We use it to predict the course of the facial nerve (FN) in the vicinity of vestibular schwannomas (VS) of the cerebellopontine angle (CPA). In this study we were interested to assess the inter-observer reproducibility of this method. Two Neuroradiologists (PMGP and TT) determined independently the location of the FN by tractography and compared the results with in-vivo findings of microsurgery of VS.

Post-surgical wound infections involving Enterobacteriaceae with reduced susceptibility to ß-lactams in two Portuguese hospitals

The post-surgical period is often critical for infection acquisition. The combination of patient injury and environmental exposure through breached skin add risk to pre-existing conditions such as drug or depressed immunity. Several factors such as the period of hospital staying after surgery, base disease, age, immune system condition, hygiene policies, careless prophylactic drug administration and physical conditions of the healthcare centre may contribute to the acquisition of a nosocomial infection. A purulent wound can become complicated whenever antimicrobial therapy becomes compromised. In this pilot study, we analysed Enterobacteriaceae strains, the most significant gram-negative rods that may occur in post-surgical skin and soft tissue infections (SSTI) presenting reduced β-lactam susceptibility and those presenting extended-spectrum β-lactamases (ESBL). There is little information in our country regarding the relationship between β-lactam susceptibility, ESBL and development of resistant strains of microorganisms in SSTI. Our main results indicate Escherichia coli and Klebsiella spp. are among the most frequent enterobacteria (46% and 30% respectively) with ESBL production in 72% of Enterobacteriaceae isolates from SSTI. Moreover, coinfection occurred extensively, mainly with Pseudomonas aeruginosa and Methicillin-resistant Staphylococcus aureus (18% and 13%, respectively). These results suggest future research to explore if and how these associations are involved in the development of antibiotic resistance.

Surgical proven location of the facial nerve in the vicinity of cerebellopontine angle tumours depicted pre-operatively by tractography

Purpose/Introduction: To determine the clinical utility of pre-operative diffusion tensor (DT) tractography of the facial nerve in the vicinity of cerebellopontine angle (CPA) tumours. The location of the facial nerve was established pre-operatively by tractography and compared with in-vivo electrode stimulation during microsurgery of vestibular schwannomas and rare CPA masses (meningiomas and arachnoid cysts).

Fracture toughness determination of adhesive and co-cured joints in natural fibre composites

Adhesive bonding has become more efficient in the last few decades due to the adhesives developments, granting higher strength and ductility. On the other hand, natural fibre composites have recently gained interest due to the low cost and density. It is therefore essential to predict the fracture behavior of joints between these materials, to assess the feasibility of joining or repairing with adhesives. In this work, the tensile fracture toughness (Gc n) of adhesive joints between natural fibre composites is studied, by bonding with a ductile adhesive and co-curing. Conventional methods to obtain Gc n are used for the co-cured specimens, while for the adhesive within the bonded joint, the J-integral is considered. For the J-integral calculation, an optical measurement method is developed for the evaluation of the crack tip opening and adherends rotation at the crack tip during the test, supported by a Matlab sub-routine for the automated extraction of these quantities. As output of this work, an optical method that allows an easier and quicker extraction of the parameters to obtain Gc n than the available methods is proposed (by the J-integral technique), and the fracture behaviour in tension of bonded and co-cured joints in jute-reinforced natural fibre composites is also provided for the subsequent strength prediction. Additionally, for the adhesively- bonded joints, the tensile cohesive law of the adhesive is derived by the direct method.

Tensile behaviour of a structural adhesive at high temperatures by the extended finite element method

Component joining is typically performed by welding, fastening, or adhesive-bonding. For bonded aerospace applications, adhesives must withstand high-temperatures (200°C or above, depending on the application), which implies their mechanical characterization under identical conditions. The extended finite element method (XFEM) is an enhancement of the finite element method (FEM) that can be used for the strength prediction of bonded structures. This work proposes and validates damage laws for a thin layer of an epoxy adhesive at room temperature (RT), 100, 150, and 200°C using the XFEM. The fracture toughness (G Ic ) and maximum load ( ); in pure tensile loading were defined by testing double-cantilever beam (DCB) and bulk tensile specimens, respectively, which permitted building the damage laws for each temperature. The bulk test results revealed that decreased gradually with the temperature. On the other hand, the value of G Ic of the adhesive, extracted from the DCB data, was shown to be relatively insensitive to temperature up to the glass transition temperature (T g ), while above T g (at 200°C) a great reduction took place. The output of the DCB numerical simulations for the various temperatures showed a good agreement with the experimental results, which validated the obtained data for strength prediction of bonded joints in tension. By the obtained results, the XFEM proved to be an alternative for the accurate strength prediction of bonded structures.

Modelling adhesive joints with cohesive zone models: effect of the cohesive law shape of the adhesive layer

Adhesively-bonded joints are extensively used in several fields of engineering. Cohesive Zone Models (CZM) have been used for the strength prediction of adhesive joints, as an add-in to Finite Element (FE) analyses that allows simulation of damage growth, by consideration of energetic principles. A useful feature of CZM is that different shapes can be developed for the cohesive laws, depending on the nature of the material or interface to be simulated, allowing an accurate strength prediction. This work studies the influence of the CZM shape (triangular, exponential or trapezoidal) used to model a thin adhesive layer in single-lap adhesive joints, for an estimation of its influence on the strength prediction under different material conditions. By performing this study, guidelines are provided on the possibility to use a CZM shape that may not be the most suited for a particular adhesive, but that may be more straightforward to use/implement and have less convergence problems (e.g. triangular shaped CZM), thus attaining the solution faster. The overall results showed that joints bonded with ductile adhesives are highly influenced by the CZM shape, and that the trapezoidal shape fits best the experimental data. Moreover, the smaller is the overlap length (LO), the greater is the influence of the CZM shape. On the other hand, the influence of the CZM shape can be neglected when using brittle adhesives, without compromising too much the accuracy of the strength predictions.

Economic analysis of surgical treatment of hip fracture in older adults

OBJECTIVE To analyze the incremental cost-utility ratio for the surgical treatment of hip fracture in older patients.METHODS This was a retrospective cohort study of a systematic sample of patients who underwent surgery for hip fracture at a central hospital of a macro-region in the state of Minas Gerais, Southeastern Brazil between January 1, 2009 and December 31, 2011. A decision tree creation was analyzed considering the direct medical costs. The study followed the healthcare provider’s perspective and had a one-year time horizon. Effectiveness was measured by the time elapsed between trauma and surgery after dividing the patients into early and late surgery groups. The utility was obtained in a cross-sectional and indirect manner using the EuroQOL 5 Dimensions generic questionnaire transformed into cardinal numbers using the national regulations established by the Center for the Development and Regional Planning of the State of Minas Gerais. The sample included 110 patients, 27 of whom were allocated in the early surgery group and 83 in the late surgery group. The groups were stratified by age, gender, type of fracture, type of surgery, and anesthetic risk.RESULTS The direct medical cost presented a statistically significant increase among patients in the late surgery group (p < 0.005), mainly because of ward costs (p < 0.001). In-hospital mortality was higher in the late surgery group (7.4% versus 16.9%). The decision tree demonstrated the dominance of the early surgery strategy over the late surgery strategy: R$9,854.34 (USD4,387.17) versus R$26,754.56 (USD11,911.03) per quality-adjusted life year. The sensitivity test with extreme values proved the robustness of the results.CONCLUSIONS After controlling for confounding variables, the strategy of early surgery for hip fracture in the older adults was proven to be dominant, because it presented a lower cost and better results than late surgery.

Strength prediction and experimental validation of adhesive joints including polyethylene, carbon-epoxy and aluminium adherends

Polyolefins are especially difficult to bond due to their non-polar, non-porous and chemically inert surfaces. Acrylic adhesives used in industry are particularly suited to bond these materials, including many grades of polypropylene (PP) and polyethylene (PE), without special surface preparation. In this work, the tensile strength of single-lap PE and mixed joints bonded with an acrylic adhesive was investigated. The mixed joints included PE with aluminium (AL) or carbon fibre reinforced plastic (CFRP) substrates. The PE substrates were only cleaned with isopropanol, which assured cohesive failures. For the PE CFRP joints, three different surfaces preparations were employed for the CFRP substrates: cleaning with acetone, abrasion with 100 grit sand paper and peel-ply finishing. In the PE AL joints, the AL bonding surfaces were prepared by the following methods: cleaning with acetone, abrasion with 180 and 320 grit sand papers, grit blasting and chemical etching with chromic acid. After abrasion of the CFRP and AL substrates, the surfaces were always cleaned with acetone. The tensile strengths were compared with numerical results from ABAQUS® and a mixed mode (I+II) cohesive damage model. A good agreement was found between the experimental and numerical results, except for the PE AL joints, since the AL surface treatments were not found to be effective.

Shear modulus and strength of an acrylic adhesive by the notched plate shear method (Arcan) and the thick adherend shear test (TAST)

In this work, the shear modulus and strength of the acrylic adhesive 3M® DP 8005 was evaluated by two different methods: the Thick Adherend Shear Test (TAST) and the Notched Plate Shear Method (Arcan). However, TAST standards advise the use of a special extensometer attached to the specimen, which requires a very experienced technician. In the present study, the adhesive shear displacement for the TAST was measured using an optical technique, and also with a conventional inductive extensometer of 25 mm used for tensile tests. This allowed for an assessment of suitability of using a conventional extensometer to measure this parameter. Since the results obtained by the two techniques are identical, it can be concluded that using a conventional extensometer is a valid option to obtain the shear modulus for the particular adhesive used. In the Arcan tests, the adhesive shear displacement was only measured using the optical technique. This work also aimed the comparison of shear modulus and strength obtained by the TAST and Arcan test methods.

Single-lap joints of similar and dissimilar adherends bonded with an acrylic adhesive

In this study, the tensile strength of single-lap joints (SLJs) between similar and dissimilar adherends bonded with an acrylic adhesive was evaluated experimentally and numerically. The adherend materials included polyethylene (PE), polypropylene (PP), carbon-epoxy (CFRP), and glass-polyester (GFRP) composites. The following adherend combinations were tested: PE/PE, PE/PP, PE/CFRP, PE/GFRP, PP/PP, CFRP/CFRP, and GFRP/GFRP. One of the objectives of this work was to assess the influence of the adherends stiffness on the strength of the joints since it significantly affects the peel stresses magnitude in the adhesive layer. The experimental results were also used to validate a new mixed-mode cohesive damage model developed to simulate the adhesive layer. Thus, the experimental results were compared with numerical simulations performed in ABAQUS®, including a developed mixed-mode (I+II) cohesive damage model, based on the indirect use of fracture mechanics and implemented within interface finite elements. The cohesive laws present a trapezoidal shape with an increasing stress plateau, to reproduce the behaviour of the ductile adhesive used. A good agreement was found between the experimental and numerical results.

Smart Adhesive Joints: An overview of recent developments

Adhesive bonding is a viable technique for joining a wide range of materials. However, increasing the lifetime, reducing the costs, and improving the safety of structures are highly demanded nowadays. Hence, the development of new technologies and processes for easy recycle, heal, or self-heal of bonded structures are becoming of great interest for the industry. This paper provides an overview of the current developments in the use of “smart” adhesive technology and introduces the reader to early findings on the use of self-healing materials, thermally expandable particles, and nanoparticles, among others, in adhesives and their potential to increase the reliability of adhesive joints.