Osseointegrated total knee replacement connected to a lower limb prosthesis: 4 cases

Background and purpose — Osseointegrated implants are an alternative for prosthetic attachment in individuals with amputation who are unable to wear a socket. However, the load transmitted through the osseointegrated fixation to the residual tibia and knee joint can be unbearable for those with transtibial amputation and knee arthritis. We report on the feasibility of combining total knee replacement (TKR) with an osseointegrated implant for prosthetic attachment. Patients and methods — We retrospectively reviewed all 4 cases (aged 38–77 years) of transtibial amputations managed with osseointegration and TKR in 2012–2014. The below-the-knee prosthesis was connected to the tibial base plate of a TKR, enabling the tibial residuum and knee joint to act as weight-sharing structures. A 2-stage procedure involved connecting a standard hinged TKR to custom-made implants and creation of a skin-implant interface. Clinical outcomes were assessed at baseline and after 1–3 years of follow-up using standard measures of health-related quality of life, ambulation, and activity level including the questionnaire for transfemoral amputees (Q-TFA) and the 6-minute walk test. Results — There were no major complications, and there was 1 case of superficial infection. All patients showed improved clinical outcomes, with a Q-TFA improvement range of 29–52 and a 6-minute walk test improvement range of 37–84 meters. Interpretation — It is possible to combine TKR with osseointegrated implants.

Immunodeficiencies, pathogens and sex in upper respiratory diseases

In the first part of this thesis the association of different forms of sinonasal diseases and plasma concentrations of C3, C4, immunoglobulins, immunoglobulin G subclasses, C4A and C4B gene numbers were studied in 287 adult patients and 150 sex-matched adult controls. Patients were well characterized and stratified into groups using strict clinical criteria and females and males were also studied as separate groups. Severe primary antibody antibody deficiencies were rare in patients coming to sinonasal operations. Female patients had more recurrent sinusitis and other mucosal infections and males had more nasal polyposis. Upregulation of complement activity was seen in acute rhinosinusitis patients (high levels of plasma C3, C4, and complement classical pathway activity CH50) and male patients coming to sinonasal operations (high levels of plasma C3 and C4). In females, total and partial C4B deficiencies and lower levels of IgG1 and IgG3 were associated with rhinosinusitis leading to sinonasal operations. C4A deficiencies were found to predispose to severe chronic rhinosinusitis in females and males. In female patients with chronic or recurrent rhinosinusitis with nasal polyposis C4B deficiencies seem to predispose to the disease, but in males with a similar disease C4B deficiencies seem to be protective. This suggests a different pathophysiology between sexes in this form of sinonasal disease. In the second part of this thesis work 213 children coming to elective tonsillectomy were studied and compared with 155 randomly selected school children. An association with recurrent upper respiratory tract infections and hypersensitivity disorders was seen especially in children under 7 years of age. However, this association was not seen in levels of specific IgE to respiratory allergens in the same age group. Both symptomatic respiratory allergy and specific IgE to respiratory allergens became more common in boys than girls over 7 years of age. We were able to show that although both rhinoviruses and bacterial pathogens were found in the tonsils, no association between their presence and clinical forms of tonsillar disease was seen. The ability of GAS to bind complement regulators FH and C4BP did not differ between strains causing tonsillar diseases or septicemia, suggesting that other virulence mechanisms of the bacteria are more important.

Nutrient loss and water quality under extensive grazing in the upper Burdekin river catchment, North Queensland

Increased sediment and nutrient losses resulting from unsustainable grazing management in the Burdekin River catchment are major threats to water quality in the Great Barrier Reef Lagoon. To test the effects of grazing management on soil and nutrient loss, five 1 ha mini-catchments were established in 1999 under different grazing strategies on a sedimentary landscape near Charters Towers. Reference samples were also collected from watercourses in the Burdekin catchment during major flow events.Soil and nutrient loss were relatively low across all grazing strategies due to a combination of good cover, low slope and low rainfall intensities. Total soil loss varied from 3 to 20 kg haˉ¹ per event while losses of N and P ranged from 10 to 1900 g haˉ¹ and from 1 to 71 g haˉ¹ per event respectively. Water quality of runoff was considered moderate across all strategies with relatively low levels of total suspended sediment (range: 8-1409 mg lˉ¹), total N (range: 101-4000 ug lˉ¹) and total P (range: 14-609 ug lˉ¹). However, treatment differences are likely to emerge with time as the impacts of the different grazing strategies on land condition become more apparent.Samples collected opportunistically from rivers and creeks during flow events displayed significantly higher levels of total suspended sediment (range: 10-6010 mg lˉ¹), total N (range: 650-6350 ug lˉ¹) and total P (range: 50-1500 ug lˉ¹) than those collected at the grazing trial. These differences can largely be attributed to variation in slope, geology and cover between the grazing trial and different catchments. In particular, watercourses draining hillier, grano-diorite landscapes with low cover had markedly higher sediment and nutrient loads compared to those draining flatter, sedimentary landscapes.These preliminary data suggest that on relatively flat, sedimentary landscapes, extensive cattle grazing is compatible with achieving water quality targets, provided high levels of ground cover are maintained. In contrast, sediment and nutrient loss under grazing on more erodable land types is cause for serious concern. Long-term empirical research and monitoring will be essential to quantify the impacts of changed land management on water quality in the spatially and temporally variable Burdekin River catchment.

Optimal irrigation planning in river basin development: The case of the Upper Cauvery river basin

The study deals with the irrigation planning of the Cauvery river basin in peninsular India which is extensively developed in the downstream reaches and has a high potential for development in the upper reaches. A four-reservoir system is modelled on a monthly basis by using a mathematical programming (LP) formulation to find optimum cropping patterns, subject to land, water and downstream release constraints, and applied to the Cauvery basin. Two objectives, maximizing net economic benefits and maximizing irrigated cropped area, considered in the model are analysed in the context of multiobjective planning and the trade-offs discussed.

A theory of the upper critical field in antiferromagnetic superconductors

A generalized Ginzburg-Landau approach is used to study the nonmonotonic temperature dependence of the upper critical field H c 2(T) in antiferromagnetic superconductors RE(Mo)6S8; RE = Dy, Tb, Gd. It is found that electrodynamic effects incorporated through screening and indirect coupling between the staggered magnetization M Q (T) and superconducting order parameter psgr cannot explain the observed nonmonotonicity. This suggests that the direct coupling between the two order parameters should be considered to understand the experimental results, a finding which is consistent with recent microscopic calculations.

Does gait speed indicate prosthetic walking potential following lower limb amputation?

Background: Gait speed is an indicator of walking ability, morbidity and mortality; and is a reliable, valid and sensitive outcome measure commonly used in the rehabilitation setting. Gait speed is a quick and efficient assessment method; yet, to date, there has been little investigation of its potential use in populations with lower limb amputation.

Upper Valley Jewish Community Hanover, New Hampshire collection, undated, 1984-1996

The Upper Valley Jewish Community (UVJC) is an egalitarian congregation on the campus of Dartmouth College. The congregation hosts a Hebrew School and publishes the newsletter, "The Jewish Connection." This collection consists of several issues of the publication, "The Jewish Connection," as well as other miscellaneous invitations and programs for a variety of events.

The upper respiratory tract is a natural reservoir of haemolytic Mannheimia species associated with ovine mastitis

Lamb suckling has been suggested to be an important way of infecting a ewe's udder with different bacteria, including Mannheimia haemolytica. To test the potential role of lambs in transferring Mannheimia species to the ewe’s udder, the restriction endonuclease cleavage patterns of isolates obtained from nasopharyngeal swabs were compared with those obtained from cases of mastitis. Sterile cotton swabs were used to collect nasopharyngeal samples from 50 ewes and 36 lambs from three flocks. M. haemolytica and Mannheimia glucosida as well as haemolytic Mannheimia ruminalis-like organisms were detected in the upper respiratory tract of lambs and ewes. Comparison of the restriction endonuclease cleavage patterns of the isolates suggested that the M. haemolytica isolates obtained from different milk samples from ewes with mastitis were more clonal than those obtained from the nasal swabs. However, some nasal isolates within both Mannheimia species had restriction endonuclease cleavage patterns identical to those obtained from milk samples from ewes with mastitis, indicating that lambs may have a role in transferring these organisms to the udder. More clonality was observed between the M. glucosida isolates than between M. haemolytica isolates.

Variation in the Understanding of Lutheranism and Its Implications for Religious Education : Meaning Discernment of Students and Teachers in Finnish Upper Secondary Schools

The study investigated variation in the ways in which a group of students and teachers of Evangelical Lutheran religious education in Finnish upper secondary schools understand Lutheranism and searched for educational implications for learning in religious education. The aim of understanding the qualitative variation in understanding Lutheranism was explored through the relationship between the following questions, which correspond to the results reported in the following original refereed publications: 1) How do Finnish students understand Lutheranism? 2) How do Finnish teachers of religious education constitute the meaning of Lutheranism? 3) How could phenomenography and the Variation Theory of Learning contribute to learning about and from religion in the context of Finnish Lutheran Religious Education as compared to religious education in the UK? Two empirical studies (Hella, 2007; Hella, 2008) were undertaken from a phenomenographic research perspective (e.g., Marton, 1981) and the Variation Theory of Learning (e.g., Marton & Tsui et al. 2004) that developed from it. Data was collected from 63 upper secondary students and 40 teachers of religious education through written tasks with open questions and complementary interviews with 11 students and 20 teachers for clarification of meanings. The two studies focused on the content and structure of meaning discernment in students and teachers expressed understandings of Lutheranism. Differences in understandings are due to differences in the meanings that are discerned and focused on. The key differences between the ways students understand varied from understanding Lutheranism as a religion to personal faith with its core in mercy. The logical relationships between the categories that describe variation in understanding express a hierarchy of ascending complexity, according to which more developed understandings are inclusive of less developed ones. The ways the teachers understand relate to student s understandings in a sequential manner. Phenomenography and Variation Theory were discussed in the context of religious education in Finland and the UK in relation to the theoretical notion of learning about and from religion (Hella & Wright, 2008). The thesis suggests that variation theory enables religious educators to recognise the unity of learning about and from religion, as learning is always learning about something and involves simultaneous engagement with the object of learning and development as a person. The study also suggests that phenomenography and variation theory offer a means by which it is possible for academics, policy makers, curriculum designers, teachers and students to learn to discern different ways of understanding the contested nature of religions. Keywords: Lutheranism, understanding, variation, teaching, learning, phenomenography, religious education

The heat capacity of liquid carbon disulfide + acetonitrile, especially near the upper critical solution temperature

The heat capacity Cp of the binary liquid system CS2 + CH3CN has been studied. This system has an upper critical solution temperature To ≈ 323.4 K and a critical mole fraction of CS2xo ≈ 0.5920. Measurements were made both for mixtures close to and far away from the critical region. The heat capacity of the mixture with x = xo exhibits a symmetric logarithmic anomaly around Tc, which is apparently preserved even for compositions in the immediate vicinity of xc. For compositions far away from xc, only a normal rise in Cp over the covered temperature range is observed.

Early post-operative mortality after major lower limb amputation: A systematic review of population and regional based studies

OBJECTIVE: Lower limb amputation is often associated with a high risk of early post-operative mortality. Mortality rates are also increasingly being put forward as a possible benchmark for surgical performance. The primary aim of this systematic review is to investigate early post-operative mortality following a major lower limb amputation in population/regional based studies, and reported factors that might influence these mortality outcomes. METHODS: Embase, PubMed, Cinahl and Psycinfo were searched for publications in any language on 30 day or in hospital mortality after major lower limb amputation in population/regional based studies. PRISMA guidelines were followed. A self developed checklist was used to assess quality and susceptibility to bias. Summary data were extracted for the percentage of the population who died; pooling of quantitative results was not possible because of methodological differences between studies. RESULTS: Of the 9,082 publications identified, results were included from 21. The percentage of the population undergoing amputation who died within 30 days ranged from 7% to 22%, the in hospital equivalent was 4-20%. Transfemoral amputation and older age were found to have a higher proportion of early post-operative mortality, compared with transtibial and younger age, respectively. Other patient factors or surgical treatment choices related to increased early post-operative mortality varied between studies. CONCLUSIONS: Early post-operative mortality rates vary from 4% to 22%. There are very limited data presented for patient related factors (age, comorbidities) that influence mortality. Even less is known about factors related to surgical treatment choices, being limited to amputation level. More information is needed to allow comparison across studies or for any benchmarking of acceptable mortality rates. Agreement is needed on key factors to be reported.

Lower limb amputation in Northern Netherlands: Unchanged incidence from 1991-1992 to 2003-2004

Background Investigating population changes gives insight into effectiveness and need for prevention and rehabilitation services. Incidence rates of amputation are highly varied, making it difficult to meaningfully compare rates between studies and regions or to compare changes over time. Study Design Historical cohort study of transtibial amputation, knee disarticulation, and transfemoral amputations resulting from vascular disease or infection, with/without diabetes, in 2003-2004, in the three Northern provinces of the Netherlands. Objectives To report the incidence of first transtibial amputation, knee disarticulation, or transfemoral amputation in 2003-2004 and the characteristics of this population, and to compare these outcomes to an earlier reported cohort from 1991 to 1992. Methods Population-based incidence rates were calculated per 100,000 person-years and compared across the two cohorts. Results Incidence of amputation was 8.8 (all age groups) and 23.6 (≥45 years) per 100,000 person-years. This was unchanged from the earlier study of 1991-1992. The relative risk of amputation was 12 times greater for people with diabetes than for people without diabetes. Conclusions Investigation is needed into reasons for the unchanged incidence with respect to the provision of services from a range of disciplines, including vascular surgery, diabetes care, and multidisciplinary foot clinics. Clinical relevance This study shows an unchanged incidence of amputation over time and a high risk of amputation related to diabetes. Given the increased prevalence of diabetes and population aging, both of which present an increase in the population at risk of amputation, finding methods for reducing the rate of amputation is of importance.

Short and long term mortality rates after a lower limb amputation

Objective To determine mortality rates after a first lower limb amputation and explore the rates for different subpopulations. Methods Retrospective cohort study of all people who underwent a first amputation at or proximal to transtibial level, in an area of 1.7 million people. Analysis with Kaplan-Meier curves and Log Rank tests for univariate associations of psycho-social and health variables. Logistic regression for odds of death at 30-days, 1-year and 5-years. Results 299 people were included. Median time to death was 20.3 months (95%CI: 13.1; 27.5). 30-day mortality = 22%; odds of death 2.3 times higher in people with history of cerebrovascular disease (95%CI: 1.2; 4.7, P = 0.016). 1 year mortality = 44%; odds of death 3.5 times higher for people with renal disease (95%CI: 1.8; 7.0, P < 0.001). 5-years mortality = 77%; odds of death 5.4 times higher for people with renal disease (95%CI: 1.8; 16.0,P = 0.003). Variation in mortality rates was most apparent in different age groups; people 75–84 years having better short term outcomes than those younger and older. Conclusions Mortality rates demonstrated the frailty of this population, with almost one quarter of people dying within 30-days, and almost half at 1 year. People with cerebrovascular had higher odds of death at 30 days, and those with renal disease and 1 and 5 years, respectively.

Steady mixed convection stagnation-point flow of upper convected Maxwell fluids with magnetic field

The steady MHD mixed convection flow of a viscoelastic fluid in the vicinity of two-dimensional stagnation point with magnetic field has been investigated under the assumption that the fluid obeys the upper-convected Maxwell (UCM) model. Boundary layer theory is used to simplify the equations of motion. induced magnetic field and energy which results in three coupled non-linear ordinary differential equations which are well-posed. These equations have been solved by using finite difference method. The results indicate the reduction in the surface velocity gradient, surface heat transfer and displacement thickness with the increase in the elasticity number. These trends are opposite to those reported in the literature for a second-grade fluid. The surface velocity gradient and heat transfer are enhanced by the magnetic and buoyancy parameters. The surface heat transfer increases with the Prandtl number, but the surface velocity gradient decreases.