Is there a bone-nail specific entry point? automated fit quantification of tibial nail designs during the insertion for six different nail entry points

Intramedullary nailing is the standard fixation method for displaced diaphyseal fractures of tibia. Selection of the correct nail insertion point is important for axial alignment of bone fragments and to avoid iatrogenic fractures. However, the standard entry point (SEP) may not always optimise the bone-nail fit due to geometric variations of bones. This study aimed to investigate the optimal entry for a given bone-nail pair using the fit quantification software tool previously developed by the authors. The misfit was quantified for 20 bones with two nail designs (ETN and ETN-Proximal Bend) related to the SEP and 5 entry points which were 5 mm and 10 mm away from the SEP. The SEP was the optimal entry point for 50% of the bones used. For the remaining bones, the optimal entry point was located 5 mm away from the SEP, which improved the overall fit by 40% on average. However, entry points 10 mm away from the SEP doubled the misfit. The optimised bone-nail fit can be achieved through the SEP and within the range of a 5 mm radius, except posteriorly. The study results suggest that the optimal entry point should be selected by considering the fit during insertion and not only at the final position.

Automated fit assessment of intramedullary nail designs during insertion

Modern intramedullary nails, which are utilised for the treatment of bone fractures, need to be designed to fit the anatomy of the patient population. Traditional and recent semi-automated approaches for quantifying the anatomical fit between bones and nail designs suffer from various drawbacks. This thesis proposed an automated comprehensive nail design validation method. The developed software tool was utilised to quantify the anatomical fit of four commercial nail designs. Furthermore, the thesis demonstrated the existence of a bone-nail specific nail entry point. The developed method is of great benefit for the implant manufacturing industry as a nail design validation tool.

Patient Variability in Sciatic Nerve Branch Point Distance Using Ultrasound Guided Localization

Background and Objectives: Improved ultrasound and needle technology make popliteal sciatic nerve blockade a popular anesthetic technique and imaging to localize the branch point of the common peroneal and posterior tibial components is important because successful blockade techniques vary with respect to injection of the common trunk proximally or separate injections distally. Nerve stimulation, ultrasound, cadaveric and magnetic resonance studies demonstrate variability in distance and discordance between imaging and anatomic examination of the branch point. The popliteal crease and imprecise, inaccessible landmarks render measurement of the branch point variable and inaccurate. The purpose of this study was to use the tibial tuberosity, a fixed bony reference, to measure the distance of the branch point. Method: During popliteal sciatic nerve blockade in the supine position the branch point was identified by ultrasound and the block needle was inserted. The vertical distance from the tibial tuberosity prominence and needle insertion point was measured. Results: In 92 patients the branch point is a mean distance of 12.91 cm proximal to the tibial tuberosity and more proximal in male (13.74 cm) than female patients (12.08 cm). Body height is related to the branch point distance and is more proximal in taller patients. Separation into two nerve branches during local anesthetic injection supports notions of more proximal neural anatomic division. Limitations: Imaging of the sciatic nerve division may not equal its true anatomic separation. Conclusion: Refinements in identification and resolution of the anatomic division of the nerve branch point will determine if more accurate localization is of any clinical significance for successful nerve blockade.

Geometric Generalizations of the Power of Two Choices

A well-known paradigm for load balancing in distributed systems is the``power of two choices,''whereby an item is stored at the less loaded of two (or more) random alternative servers. We investigate the power of two choices in natural settings for distributed computing where items and servers reside in a geometric space and each item is associated with the server that is its nearest neighbor. This is in fact the backdrop for distributed hash tables such as Chord, where the geometric space is determined by clockwise distance on a one-dimensional ring. Theoretically, we consider the following load balancing problem. Suppose that servers are initially hashed uniformly at random to points in the space. Sequentially, each item then considers d candidate insertion points also chosen uniformly at random from the space,and selects the insertion point whose associated server has the least load. For the one-dimensional ring, and for Euclidean distance on the two-dimensional torus, we demonstrate that when n data items are hashed to n servers,the maximum load at any server is log log n / log d + O(1) with high probability. While our results match the well-known bounds in the standard setting in which each server is selected equiprobably, our applications do not have this feature, since the sizes of the nearest-neighbor regions around servers are non-uniform. Therefore, the novelty in our methods lies in developing appropriate tail bounds on the distribution of nearest-neighbor region sizes and in adapting previous arguments to this more general setting. In addition, we provide simulation results demonstrating the load balance that results as the system size scales into the millions.

Mutational activation of niche-specific genes provides insight into regulatory networks and bacterial function in a complex environment

The genome of the plant-colonizing bacterium Pseudomonas fluorescens SBW25 harbors a subset of genes that are expressed specifically on plant surfaces. The function of these genes is central to the ecological success of SBW25, but their study poses significant challenges because no phenotype is discernable in vitro. Here, we describe a genetic strategy with general utility that combines suppressor analysis with IVET (SPyVET) and provides a means of identifying regulators of niche-specific genes. Central to this strategy are strains carrying operon fusions between plant environment-induced loci (EIL) and promoterless 'dapB. These strains are prototrophic in the plant environment but auxotrophic on laboratory minimal medium. Regulatory elements were identified by transposon mutagenesis and selection for prototrophs on minimal medium. Approximately 106 mutants were screened for each of 27 strains carrying 'dapB fusions to plant EIL and the insertion point for the transposon determined in approximately 2,000 putative regulator mutants. Regulators were functionally characterized and used to provide insight into EIL phenotypes. For one strain carrying a fusion to the cellulose-encoding wss operon, five different regulators were identified including a diguanylate cyclase, the flagella activator, FleQ, and alginate activator, AmrZ (AlgZ). Further rounds of suppressor analysis, possible by virtue of the SPyVET strategy, revealed an additional two regulators including the activator AlgR, and allowed the regulatory connections to be determined.

The identification of genes important in pseudomonas syringae pv. phaseolicola plant colonisation using in vitro screening of transposon libraries

The bacterial plant pathogen Pseudomonas syringae pv. phaseolicola (Pph) colonises the surface of common bean plants before moving into the interior of plant tissue, via wounds and stomata. In the intercellular spaces the pathogen proliferates in the apoplastic fluid and forms microcolonies (biofilms) around plant cells. If the pathogen can suppress the plant’s natural resistance response, it will cause halo blight disease. The process of resistance suppression is fairly well understood, but the mechanisms used by the pathogen in colonisation are less clear. We hypothesised that we could apply in vitro genetic screens to look for changes in motility, colony formation, and adhesion, which are proxies for infection, microcolony formation and cell adhesion. We made transposon (Tn) mutant libraries of Pph strains 1448A and 1302A and found 106/1920 mutants exhibited alterations in colony morphology, motility and biofilm formation. Identification of the insertion point of the Tn identified within the genome highlighted, as expected, a number of altered motility mutants bearing mutations in genes encoding various parts of the flagellum. Genes involved in nutrient biosynthesis, membrane associated proteins, and a number of conserved hypothetical protein (CHP) genes were also identified. A mutation of one CHP gene caused a positive increase in in planta bacterial growth. This rapid and inexpensive screening method allows the discovery of genes important for in vitro traits that can be correlated to roles in the plant interaction

The Anatomy of the Thoracic Spinal Canal Investigated with Magnetic Resonance Imaging

BACKGROUND: We investigated, with magnetic resonance imaging, the distance of the dura mater to the spinal cord in patients without spinal or medullar disease at the 2nd, 5th, and 10th thoracic segments.METHODS: Fifty patients in the supine position underwent magnetic resonance imaging. Medial sagittal slices of the 2nd, 5th, and 10th thoracic segments were measured for the relative distances using the 1.5-T superconducting system (Gyroscan Intera, Philips Medical Systems, Best, the Netherlands). In 10 patients, the angles relative to the tangent at the insertion point on the skin were measured.RESULTS: The posterior dural-spinal cord distance is significantly greater at the midthoracic region (5th thoracic = 5.8 +/- 0.8 mm) than at the upper (2nd thoracic = 3.9 +/- 0.8 mm) and lower thoracic levels (10th thoracic = 4.1 +/- 1.0 mm) (P < 0.015). There were no differences between interspaces T2 and 110. There was no correlation between age and the measured distance between the dura mater and the spinal cord. The entry angle of the needle at T2 was 9.0 degrees +/- 2.5 degrees; at T5, 45.0 degrees +/- 7.4 degrees; and at T10, 9.50 degrees +/- 4.2 degrees.CONCLUSIONS: This study demonstrated that there is greater depth of the posterior subarachnoid space at the T2, T5, and T10 levels. The greater distance was found at T5. (Anesth Analg 2010;110:1494-5)

Anatomia da coluna vertebral torácica em auxílio de ressonância nuclear magnética

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

EVA: Laparoscopic instrument tracking based on endoscopic video analysis for psychomotor skills assessment

INTRODUCTION: The EVA (Endoscopic Video Analysis) tracking system a new tracking system for extracting motions of laparoscopic instruments based on non-obtrusive video tracking was developed. The feasibility of using EVA in laparoscopic settings has been tested in a box trainer setup. METHODS: EVA makes use of an algorithm that employs information of the laparoscopic instrument's shaft edges in the image, the instrument's insertion point, and the camera's optical centre to track the 3D position of the instrument tip. A validation study of EVA comprised a comparison of the measurements achieved with EVA and the TrEndo tracking system. To this end, 42 participants (16 novices, 22 residents, and 4 experts) were asked to perform a peg transfer task in a box trainer. Ten motion-based metrics were used to assess their performance. RESULTS: Construct validation of the EVA has been obtained for seven motion-based metrics. Concurrent validation revealed that there is a strong correlation between the results obtained by EVA and the TrEndo for metrics such as path length (p=0,97), average speed (p=0,94) or economy of volume (p=0,85), proving the viability of EVA. CONCLUSIONS: EVA has been successfully used in the training setup showing potential of endoscopic video analysis to assess laparoscopic psychomotor skills. The results encourage further implementation of video tracking in training setups and in image guided surgery.

Análisis molecular de sistemas génicos implicados en la homeostasis de níquel y eficiencia simbiótica en Rhizobium leguminosarum

Los suelos ultramáficos, que poseen elevadas concentraciones de níquel, cobalto y cromo de manera natural, son fuente de bacterias resistentes a altas concentraciones de metales. Se realizó la caracterización físico-química de seis suelos ultramáficos del suroeste europeo, seleccionándose un suelo de la región de Gorro, Italia, como el más adecuado para aislar bacterias endosimbióticas resistentes a metales. A partir de plantas-trampa de guisante y lenteja inoculados con suspensiones de ese suelo, se obtuvieron 58 aislados de Rhizobium leguminosarum bv. viciae (Rlv) que fueron clasificados en 13 grupos según análisis de PCR-RAPDs. Se determinó la resistencia a cationes metálicos [Ni(II), Co(II), Cu(II), Zn(II)] de una cepa representante de cada grupo, así como la secuencia de los genomas de las cepas que mostraron altos niveles (UPM1137 y UPM1280) y bajos niveles (UPM1131 y UPM1136) de tolerancia a metales. Para identificar mecanismos de resistencia a metales se realizó una mutagénesis al azar en dicha cepa mediante la inserción de un minitransposón. El análisis de 4313 transconjugantes permitió identificar 14 mutantes que mostraron una mayor sensibilidad a Ni(II) que la cepa silvestre. Se determinó el punto de inserción del minitransposón en todos ellos y se analizaron en más detalle dos de los mutantes (D2250 y D4239). En uno de los mutantes (D2250), el gen afectado codifica para una proteína que presenta un 44% de identidad con dmeF (divalent efflux protein) de Cupriavidus metallidurans. Cadena arriba de dmeF se identificó un gen que codifica una proteína con un 39% de identidad con el regulador RcnR de Escherichia coli. Se decidió nombrar a este sistema dmeRF, y se generó un mutante en ambos genes en la cepa Rlv SPF25 (Rlv D15). A partir de experimentos de análisis fenotípico y de regulación se pudo demostrar que el sistema dmeRF tiene un papel relevante en la resistencia a Ni(II) y sobre todo a Co(II) en células en vida libre y en simbiosis con plantas de guisante. Ambos genes forman un operón cuya expresión se induce en respuesta a la presencia de Ni(II) y Co(II). Este sistema se encuentra conservado en distintas especies del género Rhizobium como un mecanismo general de resistencia a níquel y cobalto. Otro de los mutantes identificados (D4239), tiene interrumpido un gen que codifica para un regulador transcripcional de la familia AraC. Aunque inicialmente fue identificado por su sensibilidad a níquel, experimentos posteriores demostraron que su elevada sensibilidad a metales era debida a su sensibilidad al medio TY, y más concretamente a la triptona presente en el medio. En otros medios de cultivo el mutante no está afectado específicamente en su tolerancia a metales. Este mutante presenta un fenotipo simbiótico inusual, siendo inefectivo en guisantes y efectivo en lentejas. Análisis de complementación y de mutagénesis dirigida sugieren que el fenotipo de la mutación podría depender de otros factores distintos del gen portador de la inserción del minitransposón. ABSTRACT Ultramafic soils, having naturally high concentrations of nickel, cobalt and chrome, are potential sources of highly metal-resistant bacteria. A physico-chemical characterization of six ultramafic soils from the European southwest was made. A soil from Gorro, Italy, was chosen as the most appropriated for the isolation of heavy-metal-resistant endosymbiotic bacteria. From pea and lentil trap plants inoculated with soil suspensions, 58 isolates of Rhizobium leguminosarum bv. viciae (Rlv) were obtained and classified into 13 groups based on PCR-RAPDs analysis. The resistance to metallic cations [Ni(II), Co(II), Cu(II), Zn(II)] was analyzed in a representative strain of each group. From the results obtained in the resistance assays, the Rlv UPM1137 strain was selected to identify metal resistance mechanism. A random mutagenesis was made in UPM1137 by using minitransposon insertion. Analysis of 4313 transconjugants allowed to identify 14 mutants with higher sensitivity to Ni(II) than the wild type strain. The insertion point of the minitransposon was determined in all of them, and two mutants (D2250 and D4239) were studied in more detail. In one of the mutants (D2250), the affected gene encodes a protein with 44% identity in compared with DmeF (divalent efflux protein) from Cupriavidus metallidurans. Upstream R. leguminosarum dmeF, a gene encoding a protein with 39% identity with RcnR regulator from E. coli was identified. This protein was named DmeR. A mutant with both genes in the dmeRF deleted was generated and characterized in Rlv SPF25 (Rlv D15). From phenotypic and regulation analysis it was concluded that the dmeRF system is relevant for Ni(II) and specially Co(II) tolerance in both free living and symbiotic forms of the bacteria. This system is conserved in different Rhizobium species like a general mechanism for nickel and cobalt resistance. Other of the identified mutants (D4239) contains the transposon insert on a gene that encodes for an AraC-like transcriptional regulator. Although initially this mutant was identified for its nickel sensitivity, futher experiments demonstrated that its high metal sensitivity is due to its sensitivity to the TY medium, specifically for the tryptone. In other media the mutant is not affected specifically in their tolerance to metals. This mutant showed an unusual symbiotic phenotype, being ineffective in pea and effective in lentil. Complementation analysis and directed mutagenesis suggest that the mutation phenotype could depend of other factors different from the insertion minitransposon gene.

Insertional mutagenesis and marker rescue in a protozoan parasite: cloning of the uracil phosphoribosyltransferase locus from Toxoplasma gondii.

Nonhomologous integration vectors have been used to demonstrate the feasibility of insertional mutagenesis in haploid tachyzoites of the protozoan parasite Toxoplasma gondii. Mutant clones resistant to 5-fluorouracil were identified at a frequency of approximately 10(-6) (approximately 2 x 10(-5) of the stable transformants). Four independent mutants were isolated, all of which were shown to lack uracil phosphoribosyl-transferase (UPRT) activity and harbor transgenes integrated at closely linked loci, suggesting inactivation of the UPRT-encoding gene. Genomic DNA flanking the insertion point (along with the integrated vector) was readily recovered by bacterial transformation with restriction-digested, self-ligated total genomic DNA. Screening of genomic libraries with the recovered fragment identified sequences exhibiting high homology to known UPRT-encoding genes from other species, and cDNA clones were isolated that contain a single open reading frame predicted to encode the 244-amino acid enzyme. Homologous recombination vectors were exploited to create genetic knock-outs at the UPRT locus, which are deficient in enzyme activity but can be complemented by transient transformation with wild-type sequences--formally confirming identification of the functional UPRT gene. Mapping of transgene insertion points indicates that multiple independent mutants arose from integration at distinct sites within the UPRT gene, suggesting that nonhomologous integration is sufficiently random to permit tagging of the entire parasite genome in a single transformation.

The catheter to vein ratio and rates of symptomatic venous thromboembolism in patients with a peripherally inserted central catheter (PICC): a prospective cohort study.

BACKGROUND: Peripherally inserted central catheters (PICCs) are a common vascular access device used in clinical practice. Their use may be complicated by adverse events such as venous thromboembolism (VTE). The size of the vein used for PICC insertion and thus the catheter to vein ratio is thought to be a controllable factor in the reduction of VTE rates in patients who have a PICC. However, an optimal catheter to vein ratio for PICC insertion has not previously been investigated to inform clinical practice. OBJECTIVES: To determine the effect of the catheter to vein ratio (proportion of the vein measured at the insertion point taken up by the catheter) on rates of symptomatic VTE in patients with a PICC and identify the optimal ratio cut-off point to reduce rates of this adverse event. METHOD: Adult patients waiting for PICC insertion at a large metropolitan teaching hospital were recruited between May and December 2013. Vein diameter at the PICC insertion site was measured using ultrasound with in-built callipers. Participants were followed up at eight weeks to determine if they developed symptomatic VTE. RESULTS: Data were available for 136 patients (50% cancer; 44% infection; 6% other indication for PICC). Mean age was 57 years with 54% males. There were four cases of confirmed symptomatic VTE (two involving the deep veins, one peripheral vein and one pulmonary embolism). Receiver operator characteristic (ROC) analysis determined that a 45% catheter to vein ratio was the ideal cut off point to maximise sensitivity and specificity (AUC 0.761; 95% CI 0.681-0.830). When a ratio of 46% or above was compared to one that was less than or equal to 45% using a log binomial generalised linear model it was found that participants with a catheter to vein ratio >45% were 13 times more likely to suffer VTE (relative risk 13, p=0.022; CI 1.445-122.788). CONCLUSION: It was found that a 45% catheter to vein ratio was the optimal cut off with high sensitivity and specificity to reduce the risk of VTE. However, further research is needed to confirm these results as although adequately powered; the number of cases of VTE was comparatively small, resulting in wide confidence intervals.

Lack of fifth anchoring point and violation of the insertion of the rotator cuff during antegrade humeral nailing: pitfalls in straight antegrade humeral nailing.

Antegrade nailing of proximal humeral fractures using a straight nail can damage the bony insertion of the supraspinatus tendon and may lead to varus failure of the construct. In order to establish the ideal anatomical landmarks for insertion of the nail and their clinical relevance we analysed CT scans of bilateral proximal humeri in 200 patients (mean age 45.1 years (sd 19.6; 18 to 97) without humeral fractures. The entry point of the nail was defined by the point of intersection of the anteroposterior and lateral vertical axes with the cortex of the humeral head. The critical point was defined as the intersection of the sagittal axis with the medial limit of the insertion of the supraspinatus tendon on the greater tuberosity. The region of interest, i.e. the biggest entry hole that would not encroach on the insertion of the supraspinatus tendon, was calculated setting a 3 mm minimal distance from the critical point. This identified that 38.5% of the humeral heads were categorised as 'critical types', due to morphology in which the predicted offset of the entry point would encroach on the insertion of the supraspinatus tendon that may damage the tendon and reduce the stability of fixation. We therefore emphasise the need for 'fastidious' pre-operative planning to minimise this risk.

Automated fit quantification of tibial nail designs during the insertion using computer three-dimensional modelling

Intramedullary nailing is the standard fixation method for displaced diaphyseal fractures of the tibia. An optimal nail design should both facilitate insertion and anatomically fit the bone geometry at its final position in order to reduce the risk of stress fractures and malalignments. Due to the nonexistence of suitable commercial software, we developed a software tool for the automated fit assessment of nail designs. Furthermore, we demonstrated that an optimised nail, which fits better at the final position, is also easier to insert. Three-dimensional models of two nail designs and 20 tibiae were used. The fitting was quantified in terms of surface area, maximum distance, sum of surface areas and sum of maximum distances by which the nail was protruding into the cortex. The software was programmed to insert the nail into the bone model and to quantify the fit at defined increment levels. On average, the misfit during the insertion in terms of the four fitting parameters was smaller for the Expert Tibial Nail Proximal bend (476.3 mm2, 1.5 mm, 2029.8 mm2, 6.5 mm) than the Expert Tibial Nail (736.7 mm2, 2.2 mm, 2491.4 mm2, 8.0 mm). The differences were statistically significant (p ≤ 0.05). The software could be used by nail implant manufacturers for the purpose of implant design validation.