A haptic training environment for the heart myoblast cell injection procedure

The heart muscle of a cardiac arrest victim continues to accumulate damage throughout its lifetime. This reduces the heart's ability to pump sufficient oxygen and nutrient blood to meet the body's needs. Medical researchers have shown that direct injection of pre-harvested skeletal myoblast cells into the heart can restore some muscle function [1]. This operative procedure usually necessitates the surgeon to open a patient's chest. The open chest procedure is usually a lengthy process and often extends the recovery time of the patient. Alternatively, a high accuracy surgical aid robotic system can be used to assist the thoracoscopic surgery [2][3]. While the robotic surgical method aids faster patient recovery, a less experienced surgeon can potentially cause damage to surrounding tissue.

This paper presents a study into the development of a virtual haptically-enabled heart myoblast injection simulation environment, which can be used to train new surgeons to get hands on experience with the process. The paper also discusses the development of a generic constraint motion technique for needle insertion. Experiments on human performance measures and efficacy, while interacting with haptic feedback training models, are also presented. The experiment involved 10 operators, with each person repeating the needle insertion and injection 10 times. A notable improvement in the task execution time with the number of repetitions was observed. Operators improved their time by up to 300% compared to their first training attempt for a static heart scenario. Under a dynamic heart motion, operator's performance was slightly lower, with the successful rate of completing the experiment reduced from 84% to 75%.

Growth restriction before and after birth increases kinase signaling pathways in the adult rat heart

To investigate the mechanisms for the previously reported development of adult cardiac hypertrophy in male rats following growth restriction, the levels of oxidative stress and activation of signaling kinases were measured in the left ventricle (LV) of adult rat offspring. In experiment one, bilateral uterine vessel ligation to induce uteroplacental insufficiency and growth restriction in the offspring (Restricted) or sham surgery was performed during pregnancy. Litters from sham mothers had litter size either reduced (Reduced Litter), which also restricted postnatal growth, or were left unaltered (Control). In males, Reduced Litter offspring had increased LV phosphorylation of AMPKa, p38 MAPK and Akt compared with Restricted and Controls (P,0.05). In females, both Restricted and Reduced Litter adult offspring had increased LV phosphorylation of p38 MAPK and Akt, however, only Restricted offspring had increased phosphorylation of AMPKa (P,0.05). In addition, only Restricted male offspring displayed LV oxidative stress (P,0.05). Experiment two investigated in mothers exposed to uteroplacental insufficiency or sham surgery the effects of cross-fostering offspring at birth, and therefore the effects of the postnatal lactational environment. Surprisingly, the cross-fostering itself resulted in increased LV phosphorylation of AMPKa and Akt in females and increased phosphorylation of Akt in males compared with Control non-cross-fostered offspring (P,0.05). In conclusion, kinase signaling in the adult LV can be programmed by uteroplacental insufficiency induced growth restriction in a gender-specific manner. In addition, the heart of adult rats is also sensitive to programming following the postnatal intervention of cross-fostering alone as well as by postnatal growth restriction.

Relative deprivation between neighbouring wards is predictive of coronary heart disease mortality after adjustment for absolute deprivation of wards

Background The aims of this study were to assess whether deprivation inequality at small area level in England is associated with coronary heart disease (CHD) mortality rates and to assess whether this provides evidence of an association between area-level and individual-level risk.

Methods Mortality rates for all wards in England were calculated using all CHD deaths between 2001 and 2006. Ward-level deprivation was measured using the Carstairs Index. Deprivation inequality within local authorities (LAs) was measured by the IQR of deprivation for wards within the LA. Relative deprivation for wards was measured as the modulus of the difference between deprivation for the ward and average deprivation for all neighbouring wards.

Results Deprivation inequality within LAs was positively associated with CHD mortality rates per 100 000 (eg, all men β; 95% CI=2.7; 1.1 to 4.3) after adjustment for absolute deprivation (p<0.001 for all models). Relative deprivation for wards was positively associated with CHD mortality rates per 100 000 (eg, all men 1.4; 0.7 to 2.1) after adjustment for absolute deprivation (p<0.001 for all models). Subgroup analyses showed that relative deprivation was independently associated with CHD mortality rates in both affluent and deprived wards.

Conclusions Rich wards surrounded by poor areas have higher CHD mortality rates than rich wards surrounded by rich areas, and poor wards surrounded by rich areas have worse CHD mortality rates than poor wards surrounded by poor areas. Local deprivation inequality has a similar adverse impact on both rich and poor areas, supporting the hypothesis that income inequality of an area has an impact on individual-level health outcomes.

The long life of birds : the rat-pigeon comparison revisited

The most studied comparison of aging and maximum lifespan potential (MLSP) among endotherms involves the 7-fold longevity difference between rats (MLSP 5y) and pigeons (MLSP 35y). A widely accepted theory explaining MLSP differences between species is the oxidative stress theory, which purports that reactive oxygen species (ROS) produced during mitochondrial respiration damage bio-molecules and eventually lead to the breakdown of regulatory systems and consequent death. Previous rat-pigeon studies compared only aspects of the oxidative stress theory and most concluded that the lower mitochondrial superoxide production of pigeons compared to rats was responsible for their much greater longevity. This conclusion is based mainly on data from one tissue (the heart) using one mitochondrial substrate (succinate). Studies on heart mitochondria using pyruvate as a mitochondrial substrate gave contradictory results. We believe the conclusion that birds produce less mitochondrial superoxide than mammals is unwarranted. We have revisited the rat-pigeon comparison in the most comprehensive manner to date. We have measured superoxide production (by heart, skeletal muscle and liver mitochondria), five different antioxidants in plasma, three tissues and mitochondria, membrane fatty acid composition (in seven tissues and three mitochondria), and biomarkers of oxidative damage. The only substantial and consistent difference that we have observed between rats and pigeons is their membrane fatty acid composition, with rats having membranes that are more susceptible to damage. This suggests that, although there was no difference in superoxide production, there is likely a much greater production of lipid-based ROS in the rat. We conclude that the differences in superoxide production reported previously were due to the arbitrary selection of heart muscle to source mitochondria and the provision of succinate. Had mitochondria been harvested from other tissues or other relevant mitochondrial metabolic substrates been used, then very different conclusions regarding differences in oxidative stress would have been reached. ©

Absence makes the heart grow fonder SPOKEN WORD

Absence Makes the Heart Grow Fonder is a female voice (British) saying the proverb where the voice has been manipulated to sound arrhythmic and robotic. A good piece for a non-human (robot or like) saying a proverb that goes to the heart of sentience.

Competition : the heart and soul of sport management

Understanding competition is central to the task of strategy formulation and implementation and it is the link between competition and strategy that was explored in the 2011 Dr. Earle F. Zeigler Lecture. It was argued that strategy, given its centrality to organizational phenomena, and strategy research in particular, provides rich and diverse competitive contexts with the potential to reveal some of the unique properties of sport management. To ascertain the prevalence of sport-related strategy research, three sport management journals were subject to content analysis to identify published manuscripts related to strategy. Before presenting the results, the Lecture considered competition on and off the field, the origins of competitive behavior in sport management and a brief review of the major research themes in the generic strategic management literature. Results revealed that 20 (2.5%) of the 805 manuscripts published in the three journals were strategy focused. Research themes and contexts were presented as well as a bibliometric analysis of the reference lists of the 20 identified strategy manuscripts. This analysis highlighted the journals that are influencing published sport management strategy-related research. It was concluded that strategy research specific to sport management has been sparse to date, yet the role of strategy formulation is central to the role of management and should also be central to sport management scholarship.

Contribution of climate and air pollution to variation in coronary heart disease mortality rates in England

There are substantial geographic variations in coronary heart disease (CHD) mortality rates in England that may in part be due to differences in climate and air pollution. An ecological cross-sectional multi-level analysis of male and female CHD mortality rates in all wards in England (1999–2004) was conducted to estimate the relative strength of the association between CHD mortality rates and three aspects of the physical environment - temperature, hours of sunshine and air quality. Models were adjusted for deprivation, an index measuring the healthiness of the lifestyle of populations, and urbanicity. In the fully adjusted model, air quality was not significantly associated with CHD mortality rates, but temperature and sunshine were both significantly negatively associated (p<0.05), suggesting that CHD mortality rates were higher in areas with lower average temperature and hours of sunshine. After adjustment for the unhealthy lifestyle of populations and deprivation, the climate variables explained at least 15% of large scale variation in CHD mortality rates. The results suggest that the climate has a small but significant independent association with CHD mortality rates in England.

Suboptimal management of cardiovascular risk factors in coronary heart disease patients in primary care occurs particularly in women

Background:  Patients with established coronary heart disease (CHD) are at the highest risk of further events. Despite proven therapies, secondary prevention is often suboptimal. General practitioners (GPs) are in an ideal position to improve secondary prevention.

Aim:  To contrast management of cardiovascular risk factors in patients with established CHD in primary care to those in clinical guidelines and according to gender.

Methods:  GPs throughout Australia were approached to participate in a programme incorporating a disease management software (mdCare) program. Participating practitioners (1258 GPs) recruited individual patients whose cardiovascular risk factor levels were measured.

Results:  The mdCare programme included 12 509 patients (58% male) diagnosed with CHD. Their mean age was 71.7 years (intra-quartile range 66–78) for men and 74 years (intra-quartile range 68–80) for women. Low-density-lipoprotein cholesterol was above target levels in 69% (2032) of women compared with 58% (2487) in men (P < 0.0001). There was also a higher proportion of women with total cholesterol above target levels (76%, 3592) compared with men (57%, 3787) (P < 0.0001). In patients who were prescribed lipid-lowering medication, 53% (2504) of men and 72% (2285) of women continued to have a total cholesterol higher than recommended target levels (P < 0.0001). Overall, over half (52%, 6538) had at least five cardiovascular risk factors (55% (2914) in women and 50% (3624) in men, P < 0.0001).

Conclusion:  This study found less intensive management of cardiovascular risk factors in CHD patients, particularly among women, despite equivalent cardiovascular risk. This study has shown that these patients have multiple risk factors where gender also plays a role.

Mortality disparities between geographic regions : results from a risk percentiles model for coronary heart disease

Background: Planning of disease prevention strategies requires information regarding the distribution of absolute risk in the population to allow targeting of people at high disease risk. It is well known that death rates from coronary heart disease (CHD) are higher in remote areas of Australia compared with major cities. Less well understood is the distribution of the absolute risk of CHD death within the different geographic regions. We present a mathematical model of CHD which projects the lifetime risk of death among individuals in different percentiles of CHD risk. We apply this to model the distribution of CHD risk within different geographic regions.

Methods: Using information from the Framingham1, MRFIT2 and AusDiab3 studies, the Australian population was divided into percentiles of CHD risk within age and gender groups by geographic location. Absolute mortality risk was determined at each percentile using current Australian mortality data. Survival curves were generated for each percentile using these risk estimates. Approximate confidence intervals were derived using bootstrap methods.

Conclusions: The difference in life expectancy at age 25 between those in the lowest decile of CHD risk compared to the highest was 5.8 years (95%CI:4.7,6.7) in major cities compared to 8.5 years (95%CI:7.6,9.7) in remote areas. The difference in risk of premature death (before age 75) was 12% (95%CI:10%,14%) in major cities compared to 33% (95%CI:28%,38%) in remote areas.

Cost effectiveness of a general practice chronic disease management plan for coronary heart disease in Australia

Background. The cost effectiveness of a general practice-based program for managing coronary heart disease (CHD) patients in Australia remains uncertain. We have explored this through an economic model.

Methods. A secondary prevention program based on initial clinical assessment and 3 monthly review, optimising of pharmacotherapies and lifestyle modification, supported by a disease registry and financial incentives for quality of care and outcomes achieved was assessed in terms of incremental cost effectiveness ratio (ICER), in Australian dollars per disability adjusted life year (DALY) prevented.

Results. Based on 2006 estimates, 263 487 DALYs were attributable to CHD in Australia. The proposed program would add $115 650 000 to the annual national heath expenditure. Using an estimated 15% reduction in death and disability and a 40% estimated program uptake, the program’s ICER is $8081 per DALY prevented. With more conservative estimates of effectiveness and uptake, estimates of up to $38 316 per DALY are observed in sensitivity analysis.

Conclusions. Although innovation in CHD management promises improved future patient outcomes, many therapies and strategies proven to reduce morbidity and mortality are available today. A general practice-based program for the optimal application of current therapies is likely to be cost-effective and provide substantial and sustainable benefits to the Australian community.

What is known about this topic? Chronic disease management programs are known to provide gains with respect to reductions in death and disability among patients with coronary heart disease. The cost effectiveness of such programs in the Australian context is not known.

What does this paper add? This paper suggests that implementing a coronary heart disease program in Australia is highly cost-effective across a broad range of assumptions of uptake and effectiveness.

What are the implications for practitioners? These data provide the economic rationale for the implementation of a chronic disease management program with a disease registry and regular review in Australia.