Abstract Objective Static 3-dimensional printing is used for operative planning in cases that involve difficult anatomy. An interactive 3D print allowing deliberate surgical practice would represent ...an advance. Methods Two patients with hypertrophic cardiomyopathy had 3-dimensional prints constructed preoperatively. Stereolithography files were generated by segmentation of chest computed tomographic scans. Prints were made with hydrogel material, yielding tissue-like models that can be surgically manipulated. Septal myectomy of the print was performed preoperatively in the simulation laboratory. Volumetric measures of print and patient resected specimens were compared. An assessment tool was developed and used to rate the utility of this process. Clinical and echocardiographic data were reviewed. Results There was congruence between volumes of print and patient resection specimens (patient 1, 3.5 cm3 and 3.0 cm3 , respectively; patient 2, 4.0 cm3 and 4.0 cm3 , respectively). The prints were rated useful (3.5 and 3.6 on a 5-point Likert scale) for preoperative visualization, planning, and practice. Intraoperative echocardiographic assessment showed adequate relief of left ventricular outflow tract obstruction (patient 1, 80 mm Hg to 18 mm Hg; patient 2, 96 mm Hg to 9 mm Hg). Both patients reported symptomatic improvement (New York Heart Association functional class III to class I). Conclusions Three-dimensional printing of interactive hypertrophic cardiomyopathy heart models allows for patient-specific preoperative simulation. Resection volume relationships were congruous on both specimens and suggest evidence of construct validity. This model also holds educational promise for simulation of a low-volume, high-risk operation that is traditionally difficult to teach.
Abstract Background 3D printing is a promising technique that may have applications in medicine, and there is expanding interest in the use of patient-specific 3D models to guide surgical ...interventions. Objective To determine the feasibility of using cardiac CT to print individual models of the aortic root complex for transcatheter aortic valve replacement (TAVR) planning as well as to determine the ability to predict paravalvular aortic regurgitation (PAR). Methods This retrospective study included 16 patients (9 with PAR identified on blinded interpretation of post-procedure trans-thoracic echocardiography and 7 age, sex, and valve size-matched controls with no PAR). 3D printed models of the aortic root were created from pre-TAVR cardiac computed tomography data. These models were fitted with printed valves and predictions regarding post-implant PAR were made using a light transmission test. Results Aortic root 3D models were highly accurate, with excellent agreement between annulus measurements made on 3D models and those made on corresponding 2D data (mean difference of −0.34 mm, 95% limits of agreement: ± 1.3 mm). The 3D printed valve models were within 0.1 mm of their designed dimensions. Examination of the fit of valves within patient-specific aortic root models correctly predicted PAR in 6 of 9 patients (6 true positive, 3 false negative) and absence of PAR in 5 of 7 patients (5 true negative, 2 false positive). Conclusions Pre-TAVR 3D-printing based on cardiac CT provides a unique patient-specific method to assess the physical interplay of the aortic root and implanted valves. With additional optimization, 3D models may complement traditional techniques used for predicting which patients are more likely to develop PAR.
Background
3D printing (3DP) has enabled medical professionals to create patient-specific medical devices to assist in surgical planning. Anatomical models can be generated from patient scans using a ...wide array of software, but there are limited studies on the geometric variance that is introduced during the digital conversion of images to models. The final accuracy of the 3D printed model is a function of manufacturing hardware quality control and the variability introduced during the multiple digital steps that convert patient scans to a printable format. This study provides a brief summary of common algorithms used for segmentation and refinement. Parameters for each that can introduce geometric variability are also identified. Several metrics for measuring variability between models and validating processes are explored and assessed.
Methods
Using a clinical maxillofacial CT scan of a patient with a tumor of the mandible, four segmentation and refinement workflows were processed using four software packages. Differences in segmentation were calculated using several techniques including volumetric, surface, linear, global, and local measurements.
Results
Visual inspection of print-ready models showed distinct differences in the thickness of the medial wall of the mandible adjacent to the tumor. Volumetric intersections and heatmaps provided useful local metrics of mismatch or variance between models made by different workflows. They also allowed calculations of aggregate percentage agreement and disagreement which provided a global benchmark metric. For the relevant regions of interest (ROIs), statistically significant differences were found in the volume and surface area comparisons for the final mandible and tumor models, as well as between measurements of the nerve central path. As with all clinical use cases, statistically significant results must be weighed against the clinical significance of any deviations found.
Conclusions
Statistically significant geometric variations from differences in segmentation and refinement algorithms can be introduced into patient-specific models. No single metric was able to capture the true accuracy of the final models. However, a combination of global and local measurements provided an understanding of important geometric variations. The clinical implications of each geometric variation is different for each anatomical location and should be evaluated on a case-by-case basis by clinicians familiar with the process. Understanding the basic segmentation and refinement functions of software is essential for sites to create a baseline from which to evaluate their standard workflows, user training, and inter-user variability when using patient-specific models for clinical interventions or decisions.
The informed consent conversation is a key component of patient-centered medicine, a concept that emphasizes the importance of patients actively participating in their care. Studies reveal that many ...informed consent conversations throughout medical practice lack essential elements and leave patients' needs unmet. This review addresses these deficiencies, discusses solutions, and introduces a standardized checklist that values the patient's role in shared decision making during the informed consent conversation. The checklist could be particularly helpful to interventional radiologists and other consulting physicians who usually obtain informed consent early in their encounters with patients.
The postnatal maturation of glutamatergic synapses involves a change in composition and functional contribution of postsynaptic receptors. Developing cortical synapses are dominated by NMDA receptors ...(NMDARs) containing NR2B subunits and are characterized by a low ratio of AMPA/NMDA receptor-mediated current. Synapse maturation is marked by the incorporation of NR2A-containing NMDA receptors and an increase in the AMPA/NMDA current ratio. We show here that NMDARs containing the NR2B subunit regulate glutamatergic transmission at developing synapses by negatively influencing the synaptic incorporation of AMPA receptors (AMPARs). Genetic removal of NR2B leads to increased surface expression and synaptic localization of AMPA receptor subunits and a corresponding increase in AMPAR-mediated synaptic current. Enrichment of synaptic AMPARs, in the absence of NR2B signaling, is associated with increased levels of transmembrane AMPAR regulatory protein (TARP) expression and is blocked by expression of a dominant-negative TARP construct (gamma-2deltaC). These observations suggest that NR2B signaling limits AMPA receptor incorporation at developing synapses by negatively regulating TARP expression and provide a mechanism to explain the maintenance of low AMPA/NMDA ratio at immature glutamatergic synapses.
Successful transcatheter aortic valve replacement (TAVR) requires an understanding of how a prosthetic valve will interact with a patient's anatomy in advance of surgical deployment. To improve this ...understanding, we developed a benchtop workflow that allows for testing of physical interactions between prosthetic valves and patient-specific aortic root anatomy, including calcified leaflets, prior to actual prosthetic valve placement.
This was a retrospective study of 30 patients who underwent TAVR at a single high volume center. By design, the dataset contained 15 patients with a successful annular seal (defined by an absence of paravalvular leaks) and 15 patients with a sub-optimal seal (presence of paravalvular leaks) on post-procedure transthoracic echocardiogram (TTE). Patients received either a balloon-expandable (Edwards Sapien or Sapien XT, n = 15), or a self-expanding (Medtronic CoreValve or Core Evolut, n = 14, St. Jude Portico, n = 1) valve. Pre-procedural computed tomography (CT) angiograms, parametric geometry modeling, and multi-material 3D printing were utilized to create flexible aortic root physical models, including displaceable calcified valve leaflets. A 3D printed adjustable sizing device was then positioned in the aortic root models and sequentially opened to larger valve sizes, progressively flattening the calcified leaflets against the aortic wall. Optimal valve size and fit were determined by visual inspection and quantitative pressure mapping of interactions between the sizer and models.
Benchtop-predicted “best fit” valve size showed a statistically significant correlation with gold standard CT measurements of the average annulus diameter (n = 30, p < 0.0001 Wilcoxon matched-pairs signed rank test). Adequateness of seal (presence or absence of paravalvular leak) was correctly predicted in 11/15 (73.3%) patients who received a balloon-expandable valve, and in 9/15 (60%) patients who received a self-expanding valve. Pressure testing provided a physical map of areas with an inadequate seal; these corresponded to areas of paravalvular leak documented by post-procedural transthoracic echocardiography.
We present and demonstrate the potential of a workflow for determining optimal prosthetic valve size that accounts for aortic annular dimensions as well as the active displacement of calcified valve leaflets during prosthetic valve deployment. The workflow's open source framework offers a platform for providing predictive insights into the design and testing of future prosthetic valves.
No free lunch: Even with a diet heavy on PEARS Hermsen, Joshua L., MD; Ripley, Beth, MD, PhD
The Journal of thoracic and cardiovascular surgery,
07/2017, Letnik:
154, Številka:
1
Journal Article
Hypocretin (orexin) deficiency in human narcolepsy Nishino, Seiji; Ripley, Beth; Overeem, Sebastiaan ...
The Lancet (British edition),
2000, 2000-Jan-01, 2000-01-00, 20000101, Letnik:
355, Številka:
9197
Journal Article
Recenzirano
Alterations in the hypocretin receptor 2 and preprohypocretin genes produce narcolepsy in animal models. Hypocretin was undetectable in seven out of nine people with narcolepsy, indicating abnormal ...hypocretin transmission.
Hypocretins (orexins) are hypothalamic neuropeptides involved in sleep and energy homeostasis. Hypocretin mutations produce narcolepsy in animal models. In humans, narcolepsy is rarely due to ...hypocretin mutations, but this system is deficient in the cerebrospinal fluid (CSF) and brain of a small number of patients. A recent study also indicates increased body mass index (BMI) in narcolepsy. The sensitivity of low CSF hypocretin was examined in 38 successive narcolepsy–cataplexy cases 36 human leukocyte antigen (HLA)‐DQB1*0602‐positive and 34 matched controls (15 controls and 19 neurological patients). BMI and CSF leptin levels were also measured. Hypocretin‐1 was measurable (169 to 376pg/ml) in all controls. Levels were unaffected by freezing/thawing or prolonged storage and did not display any concentration gradient. Hypocretin‐1 was dramatically decreased (<100pg/ml) in 32 of 38 patients (all HLA‐positive). Four patients had normal levels (2 HLA‐negative). Two HLA‐positive patients had high levels (609 and 637pg/ml). CSF leptin and adjusted BMI were significantly higher in patients versus controls. We conclude that the hypocretin ligand is deficient in most cases of human narcolepsy, providing possible diagnostic applications. Increased BMI and leptin indicate altered energy homeostasis. Sleep and energy metabolism are likely to be functionally connected through the hypocretin system.
We explored the role of hypocretins in human narcolepsy through histopathology of six narcolepsy brains and mutation screening of Hcrt, Hcrtr1 and Hcrtr2 in 74 patients of various human leukocyte ...antigen and family history status. One Hcrt mutation, impairing peptide trafficking and processing, was found in a single case with early onset narcolepsy. In situ hybridization of the perifornical area and peptide radioimmunoassays indicated global loss of hypocretins, without gliosis or signs of inflammation in all human cases examined. Although hypocretin loci do not contribute significantly to genetic predisposition, most cases of human narcolepsy are associated with a deficient hypocretin system.
Celotno besedilo
Dostopno za:
DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
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