Development of a computer-assisted high-pressure Injection device for vertebroplasty

A novel computer-assisted injection device for the delivery of highly viscous bone cements in vertebroplasty is presented. It addresses the shortcomings of manual injection systems ranging from low-pressure and poor level of control to device failure. The presented instrument is capable of generating a maximum pressure of 5000 kPa in traditional 6-ml syringes and provides an advanced control interface for precise cement delivery from outside radiation fields emitted by intraoperative imaging systems. The integrated real-time monitoring of injection parameters, such as flow-rate, volume, pressure, and viscosity, simplifies consistent documentation of interventions and establishes a basis for the identification of safe injection protocols on the longer term. Control algorithms prevent device failure due to overloading and provide means to immediately stop cement flow to avoid leakage into adjacent tissues.

Properties of an injectable low modulus PMMA bone cement for osteoporotic bone

The use of polymethylmethacrylate (PMMA) cement to reinforce fragile or broken vertebral bodies (vertebroplasty) leads to extensive bone stiffening. Fractures in the adjacent vertebrae may be the consequence of this procedure. PMMA with a reduced Young's modulus may be more suitable. The goal of this study was to produce and characterize stiffness adapted PMMA bone cements. Porous PMMA bone cements were produced by combining PMMA with various volume fractions of an aqueous sodium hyaluronate solution. Porosity, Young's modulus, yield strength, polymerization temperature, setting time, viscosity, injectability, and monomer release of those porous cements were investigated. Samples presented pores with diameters in the range of 25-260 microm and porosity up to 56%. Young's modulus and yield strength decreased from 930 to 50 MPa and from 39 to 1.3 MPa between 0 and 56% porosity, respectively. The polymerization temperature decreased from 68 degrees C (0%, regular cement) to 41 degrees C for cement having 30% aqueous fraction. Setting time decreased from 1020 s (0%, regular cement) to 720 s for the 30% composition. Viscosity of the 30% composition (145 Pa s) was higher than the ones received from regular cement and the 45% composition (100-125 Pa s). The monomer release was in the range of 4-10 mg/mL for all porosities; showing no higher release for the porous materials. The generation of pores using an aqueous gel seems to be a promising method to make the PMMA cement more compliant and lower its mechanical properties to values close to those of cancellous bone.

Cement distribution, volume, and compliance in vertebroplasty: some answers from an anatomy-based nonlinear finite element study

STUDY DESIGN: The biomechanics of vertebral bodies augmented with real distributions of cement were investigated using nonlinear finite element (FE) analysis. OBJECTIVES: To compare stiffness, strength, and stress transfer of augmented versus nonaugmented osteoporotic vertebral bodies under compressive loading. Specifically, to examine how cement distribution, volume, and compliance affect these biomechanical variables. SUMMARY OF BACKGROUND DATA: Previous FE studies suggested that vertebroplasty might alter vertebral stress transfer, leading to adjacent vertebral failure. However, no FE study so far accounted for real cement distributions and bone damage accumulation. METHODS: Twelve vertebral bodies scanned with high-resolution pQCT and tested in compression were augmented with various volumes of cements and scanned again. Nonaugmented and augmented pQCT datasets were converted to FE models, with bone properties modeled with an elastic, plastic and damage constitutive law that was previously calibrated for the nonaugmented models. The cement-bone composite was modeled with a rule of mixture. The nonaugmented and augmented FE models were subjected to compression and their stiffness, strength, and stress map calculated for different cement compliances. RESULTS: Cement distribution dominated the stiffening and strengthening effects of augmentation. Models with cement connecting either the superior or inferior endplate (S/I fillings) were only up to 2 times stiffer than the nonaugmented models with minimal strengthening, whereas those with cement connecting both endplates (S + I fillings) were 1 to 8 times stiffer and 1 to 12 times stronger. Stress increases above and below the cement, which was higher for the S + I cases and was significantly reduced by increasing cement compliance. CONCLUSION: The developed FE approach, which accounts for real cement distributions and bone damage accumulation, provides a refined insight into the mechanics of augmented vertebral bodies. In particular, augmentation with compliant cement bridging both endplates would reduce stress transfer while providing sufficient strengthening.

Clinical investigations of polymethylmethacrylate cement viscosity during vertebroplasty and related in vitro measurements

Percutaneous vertebroplasty, comprising an injection of polymethylmethacrylate (PMMA) into vertebral bodies, is a practical procedure for the stabilization of osteoporotic compression fractures as well as other weakening lesions. Cement leakage is considered to be one of the major and most severe complications during percutaneous vertebroplasty. The viscosity of the material plays a key role in this context. In order to enhance the safety for the patient, a rheometer system was developed to measure the cement viscosity intraoperatively. For this development, it is of great importance to know the proper viscosity to start the procedure determined by experienced surgeons and the relation between the time period when different injection devices are used and the cement viscosity. The purpose of the study was to investigate the viscosity ranges for different injection systems during conventional vertebroplasty. Clinically observed viscosity values and related time periods showed high scattering. In order to get a better understanding of the clinical observations, cement viscosity during hardening at different ambient temperatures and by simulation of the body temperature was investigated in vitro. It could be concluded, that the direct viscosity assessment with a rheometer during vertebroplasty can help clinicians to define a lower threshold viscosity and thereby decrease the risk of leakage and make adjustments to their injection technique in real time. Secondly, the acceleration in hardening of PMMA-based cements at body temperature can be useful in minimizing leakages by addressing them with a short injection break.

Shear bond strength of four different esthetic brackets.

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Dentin Bond Strength of Two Recent CAD/CAM-Materials after Storage

Purpose: To investigate the bond strength to dentin of two recent resin-ceramic materials for computer-aided design/computer-aided manufacturing (CAD/CAM) after 24 hours and after six months storage. Methods and Materials: Ninety cylinders were milled out of Lava Ultimate (3M ESPE) and 90 cylinders out of VITA ENAMIC (VITA Zahnfabrik) (dimension of cylinders: ∅=3.6 mm, h=2 mm). All Lava Ultimate cylinders were sandblasted (aluminium oxide, grain size: 27 μm) and cleaned with ethanol, whereas all VITA ENAMIC cylinders were acid-etched (5% hydrofluoric acid) and cleaned with water-spray. According to the three groups of cements used, the cylinders (n=30/resin-ceramic material) were further pretreated with 1) Scotchbond Universal for RelyX Ultimate (3M ESPE), 2) CLEARFIL Ceramic Primer for PANAVIA F2.0 (Kuraray), or 3) no further pretreatment for Ketac Cem Plus (3M ESPE). The cylinders were then bonded to ground human dentin specimens with 1) Scotchbond Universal and RelyX Ultimate (light-cured), 2) ED PRIMER II and PANAVIA F2.0 (light-cured), or 3) no adhesive system; Ketac Cem Plus (self-cured). Shear bond strength (SBS) was measured after 24 hours for 15 specimens/group and after six months (37°C, 100% humidity) for the other 15 specimens/group. SBS-values were statistically analysed with nonparametric ANOVA followed by exact Wilcoxon rank sum tests (α=0.05). Results: SBS of the two resin-ceramic materials and the three cements after 24 hours and after six months storage are shown in Figure 1. The statistical analysis showed that the duration of storage had a significant effect on SBS of Lava Ultimate for all three cements but had no significant effect on SBS of VITA ENAMIC. For Lava Ultimate SBS-values were (MPa; medians after 24 hours/six months): 13.5/22.5 (p=0.04) for RelyX Ultimate, 11.4/5.8 (p=0.0006) for PANAVIA F2.0, and 0.34/0.09 (p=0.04) for Ketac Cem Plus (Fig. 1). For VITA ENAMIC SBS-values were (MPa; medians after 24 hours/six months): 16.0/21.2 (p=0.10) for RelyX Ultimate, 11.4/14.4 (p=0.06) for PANAVIA F2.0, and 0.43/0.41 (p=0.32) for Ketac Cem Plus (Fig. 1). After 24 hours, there was no significant difference in SBS between Lava Ultimate and VITA ENAMIC for all three cements (p≥0.37). After six months, there was no significant difference in SBS between Lava Ultimate and VITA ENAMIC for RelyX Ultimate and Ketac Cem Plus (p≥0.07) whereas for PANAVIA F2.0, SBS was significantly lower for Lava Ultimate than for VITA ENAMIC (p<0.0001). Conclusion: SBS of Lava Ultimate was more affected by six months storage and by the cement used than was VITA ENAMIC.

Interprofessional Education in Anatomy: Learning Together in Medical and Nursing Training

Teamwork and the interprofessional collaboration of all health professions are a guarantee of patient safety and highly qualified treatment in patient care. In the daily clinical routine, physicians and nurses must work together, but the education of the different health professions occurs separately in various places, mostly without interrelated contact. Such training abets mutual misunderstanding and cements professional protectionism, which is why interprofessional education can play an important role in dismantling such barriers to future cooperation. In this article, a pilot project in interprofessional education involving both medical and nursing students is presented, and the concept and the course of training are described in detail. The report illustrates how nursing topics and anatomy lectures can be combined for interprofessional learning in an early phase of training. Evaluation of the course showed that the students were highly satisfied with the collaborative training and believed interprofessional education (IPE) to be an important experience for their future profession and understanding of other health professionals. The results show that the IPE teaching concept, which combines anatomy and nursing topics, provides an optimal setting for learning together and helps nurses and doctors in training to gain knowledge about other health professionals’ roles, thus evolving mutual understanding.

Retention of Root Canal Posts: Effect of Cement Film Thickness, Luting Cement, and Post Pretreatment.

The aim of this study was to investigate the effect of the cement film thickness of a zinc phosphate or a resin cement on retention of untreated and pretreated root canal posts. Prefabricated zirconia posts (CosmoPost: 1.4 mm) and two types of luting cements (a zinc phosphate cement [DeTrey Zinc] and a self-etch adhesive resin cement [Panavia F2.0]) were used. After removal of the crowns of 360 extracted premolars, canines, or incisors, the root canals were prepared with a parallel-sided drill system to three different final diameters. Half the posts did not receive any pretreatment. The other half received tribochemical silicate coating according to the manufacturer's instructions. Posts were then luted in the prepared root canals (n=30 per group). Following water storage at 37°C for seven days, retention of the posts was determined by the pull-out method. Irrespective of the luting cement, pretreatment with tribochemical silicate coating significantly increased retention of the posts. Increased cement film thickness resulted in decreased retention of untreated posts and of pretreated posts luted with zinc phosphate cement. Increased cement film thickness had no influence on retention of pretreated posts luted with resin cement. Thus, retention of the posts was influenced by the type of luting cement, by the cement film thickness, and by the post pretreatment.

Diagenesis of a light, tight-oil chert reservoir at the Ediacaran/Cambrian boundary, Sultanate of Oman

The Al Shomou Silicilyte Member (Athel Formation) in the South Oman Salt Basin shares many of the characteristics of a light, tight-oil (LTO) reservoir: it is a prolifi c source rock mature for light oil, it produces light oil from a very tight matrix and reservoir, and hydraulic fracking technology is required to produce the oil. What is intriguing about the Al Shomou Silicilyte, and different from other LTO reservoirs, is its position related to the Precambrian/Cambrian Boundary (PCB) and the fact that it is a ‘laminated chert‘ rather than a shale. In an integrated diagenetic study we applied microstructural analyses (SEM, BSE) combined with state-of-the-art stable isotope and trace element analysis of the silicilyte matrix and fractures. Fluid inclusion microthermometry was applied to record the salinity and minimum trapping temperatures. The microstructural investigations reveal a fi ne lamination of the silicilyte matrix with a mean lamina thickness of ca. 20 μm consisting of predominantly organic matter-rich and fi nely crystalline quartz-rich layers, respectively. Authigenic, micron-sized idiomorphic quartz crystals are the main matrix components of the silicilyte. Other diagenetic phases are pyrite, apatite, dolomite, magnesite and barite cements. Porosity values based on neutron density logs and core plug data indicate porosity in the silicilyte ranges from less than 2% to almost to 40%. The majority of the pore space in the silicilyte is related to (primary) inter-crystalline pores, with locally important oversized secondary pores. Pore casts of the silica matrix show that pores are extremely irregular in three dimensions, and are generally interconnected by a complex web or meshwork of fi ne elongate pore throats. Mercury injection capillary data are in line with the microstructural observations suggesting two populations of pore throats, with an effective average modal diameter of 0.4 μm. The acquired geochemical data support the interpretation that the primary source of the silica is the ambient seawater rather than hydrothermal or biogenic. A maximum temperature of ca. 45°C for the formation of microcrystalline quartz in the silicilyte is good evidence that the lithifi cation and crystallization of quartz occurred in the fi rst 5 Ma after deposition. Several phases of brittle fracturing and mineralization occurred in response to salt tectonics during burial. The sequences of fracture-fi lling mineral phases (dolomite - layered chalcedony – quartz – apatite - magnesite I+II - barite – halite) indicates a complex fl uid evolution after silicilyte lithifi cation. Primary, all-liquid fl uid inclusions in the fracturefi lling quartz are good evidence of growth beginning at low temperatures, i.e. ≤ 50ºC. Continuous precipitation during increasing temperature and burial is documented by primary two-phase fl uid inclusions in quartz cements that show brines at 50°C and fi rst hydrocarbons at ca. 70°C. The absolute timing of each mineral phase can be constrained based on U-Pb geochronometry, and basin modelling. Secondary fl uid inclusions in quartz, magnesite and barite indicate reactivation of the fracture system after peak burial temperature during the major cooling event, i.e. uplift, between 450 and 310 Ma. A number of fi rst-order trends in porosity and reservoir-quality distribution are observed which are strongly related to the diagenetic and fl uid history of the reservoir: the early in-situ generation of hydrocarbons and overpressure development arrests diagenesis and preserves matrix porosity. Chemical compaction by pressure dissolution in the fl ank areas could be a valid hypothesis to explain the porosity variations in the silicilitye slabs resulting in lower porosity and poorer connectivity on the fl anks of the reservoir. Most of the hydrocarbon storage and production comes from intervals characterized by Amthor et al. 114488 preserved micropores, not hydrocarbon storage in a fracture system. The absence of oil expulsion results in present-day high oil saturations. The main diagenetic modifi cations of the silicilyte occurred and were completed relatively early in its history, i.e. before 300 Ma. An instrumental factor for preserving matrix porosity is the diffi culty for a given slab to evacuate all the fl uids (water and hydrocarbons), or in other words, the very good sealing capacity of the salt embedding the slab.

Encapsulation of caesium-loaded Ionsiv in cement

The microporous material Ionsiv is used for 137Cs removal from aqueous nuclear waste streams. In the UK, Cs-loaded Ionsiv is classed as an intermediate-level waste; no sentencing and disposal route is yet defined for this material and it is currently held in safe interim storage on several nuclear sites. In this study, the suitability of fly ash and blast furnace slag blended cements for encapsulation of Cs-Ionsiv in a monolithic wasteform was investigated. No evidence of reaction or dissolution of the Cs-Ionsiv in the cementitious environment was found by scanning electron microscopy and X-ray diffraction. However, a small fraction (<= 1.6 wt.%) of the Cs inventory was released from the encapsulated Ionsiv during leaching experiments carried out on hydrated samples. Furthermore, it was evident that K and Na present in the cementitious pore water exchanged with Cs and H in the Ionsiv. Therefore, cement systems lower in K and Na, such as slag based cements, showed lower Cs release than the fly ash based cements.

EACTS expert consensus statement for surgical management of pleural empyema

Pleural infection is a frequent clinical condition. Prompt treatment has been shown to reduce hospital costs, morbidity and mortality. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research. The European Association for Cardio-Thoracic Surgery (EACTS) Thoracic Domain and the EACTS Pleural Diseases Working Group established a team of thoracic surgeons to produce a comprehensive review of available scientific evidence with the aim to cover all aspects of surgical practice related to its treatment, in particular focusing on: surgical treatment of empyema in adults; surgical treatment of empyema in children; and surgical treatment of post-pneumonectomy empyema (PPE). In the management of Stage 1 empyema, prompt pleural space chest tube drainage is required. In patients with Stage 2 or 3 empyema who are fit enough to undergo an operative procedure, there is a demonstrated benefit of surgical debridement or decortication [possibly by video-assisted thoracoscopic surgery (VATS)] over tube thoracostomy alone in terms of treatment success and reduction in hospital stay. In children, a primary operative approach is an effective management strategy, associated with a lower mortality rate and a reduction of tube thoracostomy duration, length of antibiotic therapy, reintervention rate and hospital stay. Intrapleural fibrinolytic therapy is a reasonable alternative to primary operative management. Uncomplicated PPE [without bronchopleural fistula (BPF)] can be effectively managed with minimally invasive techniques, including fenestration, pleural space irrigation and VATS debridement. PPE associated with BPF can be effectively managed with individualized open surgical techniques, including direct repair, myoplastic and thoracoplastic techniques. Intrathoracic vacuum-assisted closure may be considered as an adjunct to the standard treatment. The current literature cements the role of VATS in the management of pleural empyema, even if the choice of surgical approach relies on the individual surgeon's preference.

Stable oxygen and carbon isotope compositions of Campanian grainstones and rudstones

Petrographic descriptions and stable oxygen and carbon isotope compositions of microsamples of Campanian-age sediment gravity-flow deposits from Northeast Providence Channel, Bahamas, indicate deep-marine cementation of shallow-marine skeletal grains that were transported to the channel during the Late Cretaceous. Shallow-marine components are represented by mollusks, especially rudists, and shallow-water benthic foraminifers as well as sparse echinoderm and algal grains. The sole evidence of diagenesis in shallow-marine environments consists of micrite envelopes around skeletal grains. Shallow-marine skeletal grains have mean stable isotope values of -3.1 per mil d18O and +2.6 per mil d13C. The d18O values are consistent with precipitation in equilibrium with warm (20°-30°C), shallow-marine water. Deep-marine components are represented by equant calcite spar cements and rip-up clasts of slope sediments. Spar cements, exhibiting hexagonal morphology with scalenohedral terminations, most commonly occur as thin isopachous linings in the abundant porosity. Deep-marine cements have mean stable isotope values of - 1.1 per mil d18O and +2.7 per mil d13C. Deep-marine cements are 18O-enriched relative to shallow-marine skeletal grains, consistent with precipitation in equilibrium with colder (10°-20°C), deep-marine waters. The cement .source during lithification appears to have been dissolution of aragonite and high-magnesium calcite skeletal grains, which made up part of the transported sediment. Interbedded periplatform ooze remains uncemented, or poorly cemented, probably because of lower permeability. Equant spar cements that occur in gravity-flow deposits recovered from Hole 634A have stable isotope compositions similar to spars in Lower and mid-Cretaceous shallow-water limestones exposed on the Bahama Escarpment, to Campanian-Paleocene deep-marine hardgrounds recovered during DSDP Leg 15 in the Caribbean, and to spars in Aptian-Albian talus deposits at the base of the Campeche Escarpment recovered during DSDP Leg 77.