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The design and selection of lower-limb prosthetic devices is currently hampered by a shortage of evidence to drive the choice of prosthetic foot parameters. We propose a new approach wherein prostheses could be designed, specified, and provided based on individualized measurements of the benefits provided by candidate feet. In this manuscript, we present a pilot test of this evidence-based and personalized process.We previously developed a "prosthetic foot emulator," a wearable robotic system that provides users with the physical sensation of trying on different prosthetic feet before definitive fitting. Here we detail preliminary demonstrations of two possible approaches to personalizing foot design: 1) an emulation and test-drive strategy of representative commercial foot models, and 2) a prosthetist-driven tuning procedure to optimize foot parameters.The first experiment demonstrated large and sometimes surprising differences in optimal prosthetic foot parameters across a variety of subjects, walking conditions, and outcome measures. The second experiment demonstrated a quick and effective simple manual tuning procedure for identifying preferred prosthetic foot parameters.Emulator-based approaches could improve individualization of prosthetic foot prescription. The present results motivate future clinical studies of the validity, efficacy, and economics of the approach across larger and more diverse subject populations.Today, emulator technology is being used to accelerate research and development of novel prosthetic and orthotic devices. In the future, after further refinement and validation, this technology could benefit clinical practice by providing a means for rapid test-driving and optimal selection of clinically available prosthetic feet.

Mechanical testing is the principal method used to quantify properties of commercial prosthetic feet in a controlled and standardized manner. To test feet in a mechanical testing machine without overconstraining the system, tangential shear forces must be minimized. However, there is scant published information comparing techniques for reducing shear forces during mechanical testing. Furthermore, there are no data on variability in linear stiffness across testing sessions.To compare techniques for reducing shear forces during mechanical testing of prosthetic feet and to evaluate variation in linear stiffness across testing sessions.Repeated measures.Force-displacement data were collected at two pylon progression angles, one for the forefoot and one for the heel, and compared across three conditions: roller plate (RoPl), low-friction interface on the shoe (SB), and no method for reducing shear forces (NoSB). Data were collected for a range of commercial prosthetic foot models and sizes. Select data were collected over multiple days to assess variation over test sessions.Differences in stiffness between RoPl and SB test conditions ranged from -0.9% to +2.6% across foot models. By contrast, differences between RoPl and no method for reducing shear conditions ranged from -2.9% to +14.6%. Differences in linear stiffness between test sessions ranged from -2.2% to +3.6%.Methods for reducing shear force in this study demonstrated roughly equivalent effects. Thus, a low-friction interface may be used as a less expensive and less complex method for reducing shear force in prosthetic foot testing. In addition, mechanical testing results were relatively consistent across multiple test sessions, lending confidence to test consistency.

INTRODUCTION AND OBJECTIVE: While primarily associated with prostate cancer pathogenesis, TMPRSS2 has recently been identified as a co-receptor for ACE2, the target protein used by SARSCoV2 for viral entry. This protein is primarily regulated by the androgen receptor, and this mechanism may partly explain the disproportionate burden of disease among males. We hypothesized that the use of androgen modulation therapies (AMT) such as 5-a-reductase inhibitors (5-ARI) and androgen deprivation therapy (ADT) may affect inpatient outcomes among hospitalized men with COVID-19. METHODS: In a single-center retrospective analysis in a large urban hospital system, hospitalized males with laboratory-confirmed diagnosis of COVID-19 and a history of benign prostatic hyperplasia (BPH) and/or prostate cancer was identified from February to June 2020. Men were then stratified by use of specific AMT (ADT or 5- ARI). Baseline patient and hospital characteristics were analyzed using descriptive statistics, and multivariable regression models were used to explore the association of AMT with inpatient mortality, length of hospital stay (LOS), and other ICU outcomes (ICU admission, ICU Length of Stay, Non-Invasive Mechanical Ventilation, Intubation, and ARDS). RESULTS: A total of 396 inpatients were identified, with 130 (32.8%) having prior use of AMT. Of these, a large majority used 5-ARI (n=122, 93.8%). Mean (SD) age of patients was higher for those using AMT (76.5 (10.7) vs. 71.1 (11.8) years;p

Introduction: Guidelines recommend oral anticoagulants (OAC) in high risk atrial fibrillation (HRAF) patients. It has been reported that >40% of such patients are not taking an OAC. We observed that active AF often was not present in patients labeled as having AF (either because of wrong diagnosis or no AF in last 5 years). Hypothesis: We undertook a systematic electronic medical record (EMR) review to determine the presence or absence of active AF to accurately identify HRAF patients requiring an OAC. Methods: We reviewed 6514 patients with presumed AF and 2 or more outpatient visits documented by at least one of: billing diagnosis, EMR encounter diagnosis, EMR problem list, or EKG interpretation. Results: Active AF was noted in 4555/6514 patients (69.7%) after 1959 patients with no prior history of AF or inactive AF were withdrawn from further analysis. In active AF patients, 3869 had HRAF with CHA 2 DS 2 -VASc ≥2. OAC use was statistically higher (p2 DS 2 -VASc ≥3 (79.9%). In HRAF patients not taking an OAC (20.1%), expert review frequently disagreed with that recommendation suggesting that OACs can be taken in up to 92% of HRAF patients. Conclusions: 1) Current registries with un-adjudicated EMR diagnoses over-report the number of HRAF patients not taking an OAC; 2) Expert adjudication of active AF diagnosis identifies a smaller OAC treatment gap than previously described; 3) absolute contraindication or repeated refusal to take an OAC exists in less than 10% of HRAF patients; and, 4) there were no gender differences in OAC use.

INTRODUCTION AND OBJECTIVE:1.4 million U.S. adults identify as transgender. Attitudes and knowledge about fertility preservation among transgender women (male sex at birth, but the gender identify ...

INTRODUCTION AND OBJECTIVES:The risks of secondary penile prosthesis (PP) surgery (revision, replacement or explant) include catastrophic complications such as visceral organ injury, vascular injur...

INTRODUCTION AND OBJECTIVES:Nocturia, waking ≥1 time to void during sleep with each void preceded by sleep, negatively impacts quality of life. Nocturia patients are a heterogeneous cohort due to its multifactorial causes, both urologic and systemic. Urodynamic (UDS) findings in patients with noctur

INTRODUCTION AND OBJECTIVES:No-show appointments weigh heavily, leading to under-utilized resources and decreased productivity for urologists. There is concern that increased lag-time (time between...

INTRODUCTION AND OBJECTIVES:Over 1,500 bladder cancers were diagnosed among US Veterans in 2010, the majority of which were non-muscle invasive bladder cancer (NMIBC). Little is known about NMIBC t...

This study describes the process undertaken by a private health care network to develop and implement an outreach program for rural level III to V trauma centers. The program provided individualized trauma program support to 18 rural out-of-network facilities. A case study and participant satisfaction survey demonstrate the experiences of rural trauma nurse coordinators working with the program. The Trauma Outreach Program presents a solution to enhance the effectiveness of regional trauma systems, lift the burden on rural facilities, and improve care for the injured patient.

Introduction: Target:Stroke recommends pre-mixing intravenous tPA before brain imaging for high likelihood acute ischemic stroke (AIS) patients, allowing the drug to be available immediately after the decision to treat is made. However, premixing tPA is rarely practiced despite potential benefits of improving door-to-needle time. Hypothesis: We describe our experience developing criteria to eliminate avoidable wasting of the drug by identifying patients most likely to benefit from pre-mixed tPA and compare rates of wasted tPA before and after criteria development. We hypothesized this would result in a substantial reduction in wasted tPA. Methods: On 4/1/14, our Comprehensive Stroke Center instituted a series of interventions to reduce door-to-needle times, including pre-mixing tPA for AIS patients presenting within the tPA treatment window. Seven vials of pre-mixed tPA were wasted over the next five weeks, revealing the need for specific criteria to guide the medical decision to order tPA prior to brain imaging. A multi-disciplinary team examined cases of wasted pre-mixed tPA through peer review and determined four would have been avoided if criteria identified patients ineligible for tPA pre-mixing. Revised criteria were implemented for ordering pre-mixed tPA on 6/1/14. Results: Our revised criteria restricted pre-mixing tPA for patients taking anticoagulants, or presenting with a decreased level of consciousness, elevated blood pressure, headache, nausea, vomiting, or advanced stage cancer. Between 6/1/14-6/1/15, there has been one case of non-avoidable wasting, and no cases of avoidable tPA wasting. Conclusions: While pre-mixing tPA does not incur financial risk as drug manufacturers replace unused vials without cost, stroke centers remain wary of wasting the drug. We believe succinct criteria can reduce avoidable tPA waste, allowing health care providers to remain fiscally responsible while ensuring AIS patients are treated as fast as possible.

Background: Acute stroke treatment has been proven to be most effective when performed quickly. The objective of our study was to describe the steps taken to improve time metrics for patients receiving intra-arterial therapy (IAT), and compare metrics before and after implementation of these standardized time saving protocols. Hypothesis: Through streamlining the evaluation and treatment process of IAT, we predict our times between patient arrival, imaging, groin puncture and recanalization will be reduced. Methods: On 6/1/13, we instituted a series of interventions in the Neuro-interventional Surgery department to streamline care, including: requiring the Neuro-interventional team to meet all transferred patients in the CT scanner upon patient arrival, introducing a wheeled stroke cart replete with a stroke tray containing all devices needed to perform the stroke thrombectomy, standardizing the thrombectomy procedure, switching from general anesthesia to conscious sedation for all stroke patients, and no longer shaving the groin or using a foley catheter. We also added an additional biplane INR room, doubling our room capacity. We compared time metrics of patient arrival to CT imaging, imaging to puncture, and puncture to recanalization of acute ischemic stroke patients that received IAT before (1/1/12-5/31/13) and after (6/1/13-5/31/15) the interventions using univariate analysis. Results: Three hundred twenty-two patients received IAT during the study period. Nearly three quarters (73.3%) of the population was transferred from a referring facility. There were significantly less female patients in the post-intervention cohort (59.5% v 48.0%, p=0.04); there were no significant differences in age, race, or initial NIHSS. We found statistically significant reductions in time between patient arrival to imaging (19.2±9.6 v 13.6 ±6.7, p Conclusions: Our initiatives allowed us to refine our process of care, resulting in a significant reduction of time between patient arrival and imaging, imaging and femoral artery access, and groin puncture to recanalization.

Background: Benefits of intravenous tissue plasminogen activator (IV-tPA) are greatest when patients are treated immediately. Our Comprehensive Stroke Center hires Advanced Practice Nurse stroke program coordinators (APN SPC) to respond to the bedside of all acute stroke alert calls. Between 08:00-17:00, an APN SPC works with dedicated on-duty neurologists to rapidly treat acute stroke patients with IV-tPA. Purpose: The purpose of this study was to determine if the presence of an APN SPC decreases door-to-needle (DTN) times in acute stroke patients. Methods: Data were collected by stroke coordinator abstractors from January 1, 2010 to June 14, 2014. DTN times were compared using a Student’s t-test between times when an APN SPC was on duty with times the APN SPC was not present. Patient age, time between symptom onset to hospital arrival, and NIH Stroke Scale (NIHSS) categories were compared between groups using Student’s t-test and chi-squared test. Results: There were 245 patients who received IV-tPA over the study period. Over half (52%, n=127) of patients were treated in the presence of an APN SPC; 48% of patients (n=118) were not treated in the presence of an APN SPC. There were no significant differences in age, time between symptom onset to hospital arrival, or NIHSS values between groups. Median DTN time for patients treated with an APN SPC present was 36 minutes versus 45 minutes for patients treated without an APN SPC present; this 9-minute difference in median DTN time was borderline statistically significant (p=.051). Conclusion: The presence of an APN SPC was associated with reduced median DTN times. The presence of an APN SPC, in addition to an on duty neurologist, may reduce time between door and needle, engendering improvements in patient outcomes.

Background: Improvements in functional outcomes are greatest when intravenous tissue plasminogen activator (IV-tPA) is administered immediately following acute ischemic stroke (AIS). Our study objectives were to describe interventions administered by our Comprehensive Stroke Center to improve door-to-needle (DTN) time, report median DTN times, and determine if interventions influenced functional outcomes and sICH rates. Methods: A DTN task force was created to streamline care of suspected AIS patients; interventions included developing a launch pad for emergent evaluation near registration staffed by a neurologist, physician and stroke program coordinator, transferring patients directly to CT room before entering an ED room, and giving IV-tPA in the CT room. We examined patients that received IV-tPA between 1/1/10 - 6/25/14 and compared median DTN times and discharge mRS over the study period using the Kruskal-Wallis analysis of variance. The chi-square trend test was used to compare proportions of patients receiving IV-tPA in less than 60 minutes. Results: During the study period 245 patients received IV-tPA. There was a significant decrease in median DTN times over time, from 46 minutes in 2010 to 29 minutes in 2014 (p=.001, Graph), and there was a significant trend towards shorter DTN times over time (p Conclusions: Streamlining initial evaluation of suspected AIS patients can reduce DTN times, and was also associated with improvements in functional outcomes at discharge. There was no change in sICH rates.

Lumbar epidural steroid injections are commonly employed in the treatment of degenerative lumbar conditions. The procedure is generally accepted as safe, and few complications have been reported in the literature. An exceedingly rare complication of epidural steroid injection is a spinal epidural hematoma. Although millions of epidural steroid injections have been completed since 19601-3, to our knowledge, there have been no more than fifteen reported cases of epidural hematoma related to epidural steroid injections4-16. A review of these reports reveals that nearly all of the patients involved were taking anticoagulants near the time of injection. In October 2010, the U.S. Food and Drug Administration (FDA) approved the use of a novel anticoagulant called dabigatran (Pradaxa; Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut) for the prevention of stroke in patients with atrial fibrillation. In Europe and Canada, the drug also has been approved for the prevention of thromboembolism in patients undergoing total joint arthroplasty. Dabigatran has experienced a rapid increase in popularity in the orthopaedic community because it has several benefits over enoxaparin and warfarin. Unlike enoxaparin, dabigatran is administered orally. Unlike warfarin, dabigatran has minimal monitoring requirements and few drug-drug and drug-food interactions, and it becomes therapeutic within hours instead of days17. Currently, to the best of our knowledge, there are no known cases in the literature of dabigatran-associated complications after epidural steroid injections. Recent clinical trials involving over 20,000 patients treated with dabigatran did not identify a single case of spinal epidural hematoma17,18. The patient was informed that data concerning the case would be submitted for publicaton, and he provided consent. ### History A seventy-year-old man presented with ongoing symptoms of lower back pain and bilateral leg pain for four months. Neurological examination revealed full motor strength in the …

A 25-year-old Caucasian male underwent orthotopic liver transplantation in June 2000 because of Caroli’s disease.Hewas retransplanted inMay 2001 due to intractable chronic rejection. Retransplantation was performed with a conventional technique using veno-venous bypass, anastomosis between the hepatic artery of the graft and the common hepatic artery of the recipient, and a Roux-en-Y choledochojejunostomy.An episode of acute rejectionwas diagnosedinthesecondpostoperativeweekthat respondedto high-dose steroids, and the patient was discharged 34 days after retransplantation. No significant abnormality in the graft function was detected until June 2003, when the patient developed fever and leukocytosis associated with biochemical signs of cholestasis followed by jaundice; transaminases remained normal or showed minimal increase.Hepatic ultrasonogram revealedmoderate dilatation of the intrahepatic bile ducts with 2 small bilomas, whileDoppler US showed normal intraparenchymal arterial resistive index and systolic acceleration time. Abdominal computed tomography scan confirmed diffuse dilatation of the bile ducts with hypodense areas consistent with biloma (Fig. 1). Selective celiac arteriography showed a complete obstruction of hepatic artery (Fig. 2), while the arteriogram of the superior mesenteric artery demonstrated the presence of compensatory collateral vessels recruited from the jejunal vascular arcade of the Roux