Background. Pigmented villonodular synovitis (PVNS) is a rare benign tumor affecting large joints and prompts excision to prevent local destruction of the joint. The purpose of this case report is to describe two differing surgical approaches for management of PVNS of the hip in patients requiring concomitant treatment for additional hip pathology. Methods. This report discusses the presentation, clinical and radiographic findings, and operative management of two contrasting cases of PVNS of the hip. Case 1 describes a 31-year-old female with localized PVNS in addition to a labral tear treated with arthroscopic labral repair followed by tumor excision via a mini-open incision. Case 2 describes a 29-year-old male with more diffuse PVNS in addition to a cam deformity managed with open surgical dislocation of the hip, tumor excision, and restoration of the femoral head/neck junction. Results. This report demonstrates two cases of successful excision of PVNS of the hip in addition to addressing concomitant hip pathology in both cases. Conclusions. Open surgical dislocation of the hip or arthroscopic surgery with a mini-open incision may be used in appropriately selected patients to successfully excise PVNS lesions in addition to addressing concomitant hip pathology. Pigmented villonodular synovitis (PVNS) is a rare benign proliferation of synovium involving the joints, bursae, or tendon sheaths . PVNS isLesional excision and synovectomy is the treatment of choice for PVNS and can be performed through an open or arthroscopic approach . While tThe unique aspect of this case report is that both described patients with PVNS lesions required additional treatment for hip pathology beyond tumor excision alone. The purpose of this article is to describe two differing surgical approaches for management of PVNS of the hip in patients requiring concomitant treatment for additional hip pathology. Case 1 describes a patient with PVNS and a labral tear treated with tumor excision through a mini-open incision following arthroscopic labral repair. Case 2 describes a patient with PVNS and a cam deformity managed with open surgical dislocation of the hip, tumor excision, and restoration of the femoral head/neck junction.A 31-year-old woman with a history of right hip developmental dysplasia (DDH) presented with insidious onset of right hip pain, present for several years but significantly worsening over the year prior to presentation. The pain was exacerbated by prolonged sitting and walking and was associated with popping of the hip. Her physical exam was notable for a positive right anterior impingement sign and pain in the right groin exacerbated with log roll, Stinchfield, resisted psoas, and fan kick maneuvers.Initial radiographs revealed right hip dysplasia and stigmata of femoroacetabular impingement (FAI), with the right hip exhibiting a cross-over sign Figures . MagnetiAfter discussion of the treatment options, the patient elected to undergo right hip arthroscopy with labral repair and possible mini-open incision for mass excision. The patient understood the likelihood of persistent dysplasia requiring osteotomy surgery at a later date after initial management of the tumor.During the surgery, anterolateral and mid anterior portals were established with the right leg in traction. The labrum was repaired arthroscopically with suture anchor fixation.The mass within the right hip joint was deemed inaccessible through the arthroscope and rather removed safely and en bloc via a separate mini-open incision along the Smith-Peterson interval. This approach has been described previously for treatment of FAI , 9. An iThe mass was located in the posterior-inferior aspect of the capsule. The nodular mass and stalk were excised sharply en bloc  and sentThe capsule, fascia over the TFL, subcutaneous tissue, and skin were then closed in separate layers along with the portal sites. A sterile dressing was placed over the hip, and a HipRAP was applied for gentle compression. The patient's weight-bearing was protected postoperatively, and a labral repair hip arthroscopy physical therapy protocol was initiated, along with use of a continuous passive motion (CPM) machine.A 29-year-old male presented with left groin pain that began in adolescence but had been worsening over a two-year period. The pain was exacerbated with activities and was associated with locking and catching, with a history of a number of severe locking episodes in which he was unable to walk for several minutes. Physical exam was notable for pain in the left groin with passive hip rotation, as well as restrictions in range of motion. Outside hospital radiographs were largely unremarkable but did reveal a left-sided cam deformity . A MRI rThe patient elected to undergo a surgical dislocation of the left hip with mass excision and labral/chondral treatment, as an arthroscopic approach or anterior mini-open incision would likely not provide adequate circumferential hip access for excision of the large mass tethering the inferior femoral neck.With the patient under general anesthesia, a surgical dislocation of the left hip was performed using the technique described by Ganz et al.  Figure . The synIn addition to removal of the mass, the femoral head/neck junction was reshaped due to the presence of a cam deformity. Using a combination of osteotomes and a burr, the gentle waist of the femoral head and neck junction was reconstituted. Offset templates were used to verify extent of decompression needed. The retinacular vessels were identified and protected at all times, and gentle continuous irrigation was performed to exposed cartilage surfaces of the acetabulum and femur throughout. Bone wax was applied to the exposed bony surfaces after offset correction. The hip was reduced, and a very nice labral seal could be seen through the peripheral compartment.The labrum was well reduced and stable onto the bony rim. The capsulotomy was closed without undue tension and with partial thickness (nonarticular sided) bites in interrupted fashion. The trochanteric flip osteotomy was reduced and fixed with screws. The trochanteric bursa was closed over the screws, and the subvastus approach to the femur was closed. The patient's weight-bearing was protected immediately postoperatively, and a surgical hip dislocation postoperative protocol was followed.The authors report two contrasting cases of PVNS of the hip in addition to concomitant hip pathology treated successfully using different approaches. While both lesions were located in the posterior-inferior aspect of the capsule, the patient's tumor in Case 1 was smaller and easily accessible via a mini-open approach following labral repair via hip arthroscopy, obviating the need for a larger incision. The patient's mass in Case 2 was larger and would have been difficult to visualize and excise using a minimally invasive approach. Furthermore, treatment of the large cam deformity could be performed concurrently through the open dislocation approach.While PVNS is a benign lesion, it can be locally invasive and destructive and may require complete removal to minimize risk of recurrence. Thus, the patient in Case 2 elected for a more extensive procedure with surgical dislocation of the hip in order to ensure complete excision of the tumor. Additionally, both patients had concomitant hip pathology that required attention and treatment at the time of surgery.This report demonstrates that PVNS of the hip must be managed on a case-by-case basis, as multiple factors, such as size and location of the lesion as well as additional hip pathology, can influence surgical management. A recent report by Shoji et al. describes two young patients (<30 years old) with advanced PVNS of the hip, both with evidence of radiographic joint-space narrowing at the time of presentation . InsteadBoth arthroscopic and open procedures have been successful in preventing recurrence of PVNS of the hip , 5. HoweHowever, due to limitations in exposure during arthroscopy, surgical dislocation of the hip is still required to excise certain lesions, especially large lesions in the posterior-inferior capsule, as in Case 2. As stated previously, many cases of PVNS already have significant secondary joint damage by the time of diagnosis and treatment. A recent systematic review by Levy et al. found a high revision rate in patients undergoing surgery for PVNS (about 1 in 4 patients) . While tThis case report demonstrates that patients with PVNS tumors and concomitant hip pathology may be successfully treated using multiple techniques. There are myriad factors that determine which technique should be used, but location and size of the lesion, additional hip pathology, surgeon experience and expertise, and patient preference should all play a role in the decision-making process. Further research is necessary to determine whether surgical approach to PVNS affects long-term outcomes and progression to secondary osteoarthritis.Excision of PVNS of the hip is necessary to halt progression and local destruction of the joint. Patients with PVNS lesions of the hip may have additional hip pathology that must be addressed at the time of surgery. Open surgical dislocation of the hip or arthroscopic surgery with a mini-open incision may be used in appropriately selected patients to successfully excise PVNS lesions in addition to addressing concomitant hip pathology.


Radiation-induced breast angiosarcoma is a severe but rare late complication in the breast-preserving management of breast cancer through surgery and radiotherapy . Often t In recent decades breast-preserving surgery with adjuvant radiotherapy has replaced mastectomy as the standard treatment of breast cancer in the initial stages . Breast A woman of 62 years of age came to our centre’s Breast Unit in December 2014 following the appearance of skin lesions in the lower quadrants of her left breast. Her medical history included arterial hypertension, procedures in both upper limbs for osteomyelitis, and the 2006 treatment for a medullary carcinoma in the left breast, stage IA, by lumpectomy and axillary dissection , having required adjuvant radiotherapy afterwards, which had been administered without incident.A mammogram was performed which returned with a result of BIRADS 2, for which reason excision under local anaesthetic was conducted resulting in dermal angiosarcoma and changes attributable to radiotherapy. The tumour was 1 cm and occupied the reticular dermis with positive immunohistochemistry at CD31, CD34, absence of HHV8, and high rate of proliferation (80%).In the first review, the patient again had multiple skin lesions in the inferior-internal and superior-external quadrants of the left breast. After having ruled out the existence of deep plane invasion by CT scan, it was decided to first remove the lesions under local anaesthetic. Having obtained the same result , a bilateral mastectomy was subsequently performed after discussing the case with the Tumour Committee. The mastectomy and the postoperative period occurred without incident in May 2015. In the right breast no pathological findings were observed; in the left breast a focus of angiosarcoma was observed at the level of the deep dermis and subcutaneous tissue of 1 cm in diameter, probably radiation induced. The immunohistochemistry study was positive for CD31, CD34, FLI1 and there was evidence of four mitosis every 10 CGA as well as an increased Ki67.In August 2015, the patient returned for consultation following the appearance of tumours in the left mastectomy scar. Five lesions  were removed under local anaesthetic, again obtaining the result of angiosarcoma positive for CD31, CD34, ERG, and MYC which contacted the resection borders.In the Tumour Committee, it was decided to proceed with removal of all the affected skin together with plastic surgery and the completion of a flap to close off the affected skin. An MRI was performed which showed an absence of deep plane infiltration. In October 2015 a radical excision was performed including the pectoralis major muscle, fascia of the rectus, and fascia of the serratus anterior preserving the free edge of the latissimus dorsi . Reconstet al [One of the risks associated with the use of radiotherapy is the secondary development of malignant tumours. It is the cause for debate when compared to the breast-preserving management of breast cancer consisting of surgery and adjuvant radiotherapy . Althouget al  reportedde novo (primary angiosarcomas) or as a complication of radiotherapy or chronic lymphoedema [Angiosarcoma is a highly aggressive vascular tumour characterised by a rapid proliferative pattern and a tendency to infiltrate any organ in the body. Mammary angiosarcomas may appear phoedema . Classicphoedema . Angiosaphoedema .Contrary to what occurs in primary angiosarcoma of the breast, which usually appears in women aged 30–50 years, radiation-induced angiosarcoma affects older women (with a median age of 67–71 years) about 10.5 years after radiotherapy as treatment of primary breast cancer (the median onset latency varies from 5–10 years). It has been proposed that with radiotherapy doses greater than 50 Gy, cellular apoptosis occurs; however, with doses below this level, DNA damage and genomic instability occur. Probably because of this, the secondary sarcomas appear at the edges of the radiation fields where the radiotherapeutic dose is more heterogeneous .et al [The pathogenesis of radiation-induced breast angiosarcoma is unclear. It is believed that radiation triggers both genomic instability and a mutation of relevant oncogenes. All molecular studies carried out on radiation-induced angiosarcomas present inactivation of the p53 gene as well as the expression and amplification of the MYC oncogene in the 8q24 region , althouget al  speak inRadiation-induced angiosarcoma usually affects the cutaneous dermis, although occasionally it may develop in the parenchyma. Initially, it may resemble a haematoma (flat violaceous lesions), i.e. appear in the form of reddish purple multifocal nodules or adopt the appearance of eczema . When tuWhen examined with ultrasound, these lesions present variable characteristics, being able to adopt a hypoechoic, hyperechoic, or heterogeneous appearance with or without posterior acoustic shadowing . RadiogrThe histological diagnosis of moderately or poorly differentiated radiation-induced angiosarcomas is relatively straightforward. It shows factor VIII and PECAM-1 (CD31) immunostaining positive malignant endothelial cells  which foet al [The treatment of choice is aggressive surgery  with a vet al  report iet al .It has been postulated that the adjuvant use of hyperfractionated and accelerated radiotherapy could achieve a better control of the disease after surgery . In the The prognosis of primary mammary angiosarcomas is directly related to histological grade and size . AdvanceRadiation-induced angiosarcomas of the breast are a rare and aggressive type of tumour which we must suspect before the appearance of erythematous nodules in a breast previously exposed to radiation therapy. Its treatment of choice is aggressive surgery, i.e. it involves removal of the pectoral muscle and needs subsequent reconstruction to achieve free margins. In advanced or inoperable cases, good responses to taxanes and liposomal doxorubicin chemotherapy have been described. The overall prognosis is poor, worsening in the case of poorly-differentiated tumoursThe authors declare that there are no conflicts of interest.All of the authors participated in the bibliography compilation. STV was responsible for the preparation of the manuscript. All authors approved the final version of the manuscript.


Biomarker quest for Alzheimer’s disease (AD) has gone a long way by studying various anatomical, physiological and biochemical parameters for detecting disease onset and predicting prognosis. Almost all the studies converge on the single hypothesis of the amyloid and Tau pathway. Recently, vascular hypothesis has evolved drawing attention towards a complex dynamic anatomical and physiological entity, neuro-vascular (NV) unit. Pathological changes at this level, altering the normal physiology such as auto-regulation and dynamics of blood brain barrier have been hypothesized as a probable basis for AD. This paper attempts to review the existing data on the vascular hypothesis and the current trends in analyzing the NV unit in AD.This review initially focuses on the cerebral NV coupling followed by the retinal neurovascular coupling that mirrors the cerebral pathophysiology. The pathophysiology and the potential tools to diagnose AD at the level of NV unit are analyzed. Further, it examines the drawbacks in existing methods for analyzing the same.None of the current studies have emphasized the importance of studying the complex dynamic NV unit as a whole. This review strongly recommends the combination of vascular and neuro-glial parameters using objective methods for estimating the physiological and pathological changes in the NV unit.This review highlights the importance of retina for non-invasive estimation of the same. Also, novel algorithms for retinal image analysis have been proposed. The purpose of this review is to highlight the importance of retinal findings in neurodegenerative disorders and to create awareness among the neuroophthalmologists, of the potential benefits of ophthalmological tools in screening dementia patients. The pathobiology underlying AD has been understood in a reasonable number of ways. Even after a century of its known existence, the amyloid-tau hypothesis takes the lead –2. The pIn this review, the PUBMED search engine was used.Period of review: 1976 to 2016.Optical coherence tomography and Alzheimer’s diseaseRetina and dementia.Neurovascular coupling and Alzheimer’s disease.Search terms used:Both human as well as animal model studies are included. A total of 626 results were found and relevant articles highlighting the role of neurovascular coupling were selected. Recently two review articles were published on similar lines ,5. Howev2 that act on the vascular smooth muscle or pericytes, leading to alteration in vessel diameter thus regulating the blood flow [NV unit is an anatomical structure complex comprising of the neuron, glia and the blood vessel which auto-regulates blood flow through the NV coupling phenomenon. Blood supply to the brain is majorly through large intracranial vessels, internal carotid arteries, middle cerebral arteries, anterior cerebral arteries, posterior cerebral arteries, vertebral arteries and the basilar artery. These large arteries branch out to wrap the brain surface under the pia mater, thus called pial vessels; which in turn give rise to arterioles called parenchymal vessels that penetrate the brain parenchyma. These different blood vessels are regulated by different mechanisms. Large intracranial vessels are regulated by the autonomic nervous system ,7, whereood flow –18.Understanding the NV unit and coupling opened up gateways to explore the dynamic interactions underlying the normal physiological processes like memory, cerebral auto-regulation during sensory stimulus and motor task, and also in imaging techniques like blood oxygen level dependent signal(BOLD) fMRI . This reIn the late 1980’s a series of studies were published hypothesizing the role of blood flow dysregulation and cerebral hypoperfusion in AD ,21. CereCholinergic innervation is the drive for neuronal excitability in the hippocampal region which is lost in AD due to degeneration of Nucleus basalis of Meynert (NBM) . ElectriThickening of basement membrane and accumulation of amyloid beta in the capillaries are observed in the mouse models of AD. In addition, smooth muscle cells involved in vascular contractility also show abnormal constrictions and degeneration ,28.Attwell et al. in 2010  showed sWith this complex pathobiology of AD, studying, analyzing and quantifying these dynamic changes at three distinct and integrated structures are critical tasks. Further diagnosing the disease based on these parameters remains a major hurdle as the diagnostic tool should have moderate sensitivity, specificity and preferably be noninvasive.The available diagnostic tools are Single Photon Emission Computer Tomography (SPECT), Transcranial Doppler (TCD) and Near Infrared Spectroscopy (NIRS). SPECT is the commonly used technique to assess regional cerebral blood flow ; but it Retina, an embryological derivative of the central nervous system (CNS), is a layered structure considered to be anatomical and physiological simulant of the CNS . With thHaving an understanding about the physiological phenomenon of NV coupling in the retina and brain, it can be speculated that retina can mirror the dysregulatory mechanisms observed in NV unit of brain.Structural changes are evident in the inner plexiform layer (IPL), ganglion cell layer (GCL) and retinal nerve fiber layer (RNFL) of patients with AD and Mild Cognitive Impairment (MCI) . HoweverRNFL thinning was also demonstrated in few studies. Among a group of nine AD cases and eight age matched controls, significant thinning of the RNFL mainly in the superior quadrant was shown in AD patients . RNFL laAbnormalities of central retinal vessels and choroidal circulation are appreciated in AD pathophysiology. Venous diameter, blood velocity and blood flow differed significantly in AD cases . FurtherChoroid vasculature which is the main source of nourishment to the outer retina, including photoreceptor cells and Retinal Pigment Epithelium (RPE) was also abnormal in AD. Using Spectral Domain Optical Coherence Tomogram (SD OCT) and the Enhanced Depth Imaging (EDI) technique, subfoveal, temporal, nasal, superior, and inferior choroidal thinning was shown in mild to moderate AD patients . This thOptical Coherence tomogram (OCT) is used to study retina. Spectral domain OCT, analyses individual layers with great precision. The doppler technology as an add-on to the Spectral OCT can be used to visualize changes in blood flow in the retinal circulation . EnhanceHaving briefly described the existing literature on the individual components of the NV unit, we now highlight the lacunae in the knowledge of NV unit as a whole in AD and stress the importance of analyzing the unit holistically through studies contradicting the above results. It is shown that in a cohort of 21 AD patients and 21 controls, the mean peri-papillary RNFL thickness in all 4 quadrants were similar in AD and control subjects. The central subfield retinal thickness in the two groups did not differ either , contrasThe aim of this review article is to highlight the need for evaluating the NV unit as a whole rather than the individual changes at the level of individual structures within the unit, like the nerve or the blood vessel. Analyzing this complex structure in real time is indeed a tedious exercise. Retinal changes are not only specific to neurodegenerative diseases, they are also evident in eye diseases such as glaucoma, and age related macular degeneration, systemic diseases and cardiovascular disorders. The fact is that all these studies have considered a single structure in the complex NV unit and tried to correlate with the cognitive changes. None of these studies had combined vascular parameters with the neuro-glial interactions. Though neuro-glial interaction is itself a complex phenomenon in its own, it can still be studied. Combining all the parameters would be highly beneficial. This multi-parametric analysis will aid us in gaining more insights into the pathophysiology of the disease process in the retina and also will overcome the major hurdle of low sensitivity and specificity. Thus this article proposes the merging of different parameters; RNFL with any of the topographical parameters estimated objectively using automated softwares, can significantly differentiate patients with AD from control group. Later, using high end OCT, quantification of oxygen saturation in human retinal vasculature can be attempted. The geometry of individual cell scan is studied using Ultra High Resolution-OCT and the specific protein or chemical composition can be determined using Molecular imaging OCT.Thus, this review can serve as a bird’s eye view on the afore discussed problems and limitations associated with the individual parameter assessment and it also emphasizes a tangible solution of combining different approaches in a holistic way.


Functional lateralization is highly replicable trait of human neural system. Many previous studies have indicated the possibility that people with attention-deficits/hyperactivity-disorder (ADHD) and autism spectrum disorder (ASD) show hemispheric asymmetry in atypical neural function. However, despite the abundance of relevant studies, there is still ongoing controversy over this issue. In the present mini-review, we provide an overview of the hemispheric asymmetry in atypical neural function observed in fNIRS studies on people with these conditions. Atypical neural function is defined as group-difference in the task-related concentration change of oxygenated hemoglobin. The existing fNIRS studies give support to the right-lateralized atypicalty in children with ADHD. At the same time, we did not find clear leftward-lateralization in atypical activation in people with ASD. On the basis of these, we discuss the current states and limitation of the existing studies. Functional near-infrared spectroscopy (fNIRS) was introduced into the scientific community as a neuroimaging tool ~20 years ago  pooled across wide neural regions, fNIRS measures hemodynamic response  with relatively high spatial resolusion. Second, the concentrations of oxygenated-/deoxygenated hemoglobin (oxyHb/deoxyHb) measured by fNIRS reflect aspects of hemodynamic response that are different from the indicators used in other neuroimaging techniques  approach, in which neighboring channels are grouped into single ROI and the averaged levels of oxyHb in channels within ROI are analyzed as the main indicators of neural activation. In this approach, corresponding channels in the left and right hemisphere are usually integrated into left/right ROI. The other approach is channel-wise analysis, in which a primary statistical test is conducted for each channel. It is unclear at this point which of these two approaches is more advantageous for detecting lateralized patterns in atypical activation. Channel-wise analysis is more sensitive to highly localized group-differences than the ROI approach, and thus might be more suitable for detecting signs of lateralization in atypical function. The main problem of the channel-wise approach is how to set the significance threshold. Apparently, a large number of statistical tests leads to inflation of the false-positive rate, while a conventional method for adjusting the threshold, e.g., Bonferroni's procedure, is sometimes too stringent.The second issue also relates to the analytic procedure. There are several problems in the group comparisons of fNIRS results. First, due to morphological variations in cortical structure, the location and depth of the cortical region through which the infrared light passes might differ between people with and without developmental disorders. Second, it is often noted that children with ADHD/ASD show larger bodily and facial movements than matched controls during experimental tasks, which might introduce group-differences in the level of artifacts and consequently influence the results. Especially problematic is the artifact of skin blood perfusion accompanying facial muscle contractions (Takahashi et al., The third point is the scarcity of fNIRS studies on resting state activation (Medvedev, The fourth is the potential confound of medication. The number of studies recruiting only drug-naïve patients is relatively few and participants in the patient group are taking various kinds of medications in majority of the studies. Fuethremore, several fNIRS studies reviewed above have shown that short-term administration of drugs such as methylphenidate changed the pattern of cortical activation in children with ADHD (Nagashima et al., In this mini-review, we gave a brief overview of the findings of fNIRS studies about lateralization in atypical neural function in people with ADHD and ASD. The existing studies generally support rightward-lateralization in atypical function in children with ADHD. At the same time, we did not find clear pattern of the leftward-lateralization in atypical function for people with ASD. Nevertheless, lateralization in atypical neural function might have been obscured by factors such as sample heterogeneity and particular method of analysis.HD conceived this study. HD and KS wrote the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Understanding of the olfactory neural circuits has progressed beyond analysis of how odor information from the external environment is processed in the brain. While spatially-organized sub-circuits were found to exist up to the olfactory bulb (OB), the arrangement in the olfactory cortex (OC), especially in its representative piriform cortex (PC), appears diffuse and dispersed. An emerging view is that the activity of OC neurons may not simply encode odor identity but rather encode plastic odor information such as odor value. Although many studies support this notion, odor value can be either positive or negative, and the existence of sub-circuits corresponding to individual value types is not well explored. To address this question, I introduce here two olfactory areas other than the PC, OB and olfactory tubercle (OT) whose analysis may facilitate understanding of functional sub-circuits related to different odor values. Peripheral and centrifugal inputs to the OB are considered to relate to odor identity and odor value, respectively and centrifugal inputs to the OB potentially represent different odor values during different behavioral periods. The OT has spatially-segregated functional domains related to distinct motivated and hedonic behaviors. Thus, the OT provides a good starting point from which functional sub-circuits across various olfactory regions can be traced. Further analysis across wide areas of the olfactory system will likely reveal the functional sub-circuits that link odor identity with distinct odor values and direct distinct odor-induced motivated and hedonic behaviors. Animals utilize sensory systems to understand the environment in which they live. A straightforward question for understanding sensory neural circuits is how sensory inputs are processed in the circuits. In answering this question, our understanding of olfactory neural circuits has been remarkably advanced by the identification of odorant receptors, axonal convergence of olfactory sensory neurons expressing a given odorant receptor, and the resulting formation of odor maps in the olfactory bulb  is spatially the widest area among various areas of the OC and has been supposed to be the functional representative of the OC. In contrast to the topographically-organized projection of olfactory sensory neurons to the OB, axonal projection of OB principal neurons to the PC is diffuse and dispersed , which I discuss in the following sections.As the first relay of olfactory information processing, the OB receives odor information from the external environment. Odor input is transferred from olfactory sensory neurons in the olfactory epithelium to mitral/tufted cells, the principal projection neurons in the OB, through synapses in the glomerular neuropils (Shepherd et al., The centrifugal inputs from the OC have a strong impact on OB function. These inputs modulate mitral/tufted cell activity in the OB: when activated, they potentiate the inhibition of odor-evoked mitral cell activity by inhibitory interneurons (Boyd et al., The contribution of centrifugal inputs to structural reorganization of the OB neural circuit hints at the information they convey. An outstanding characteristic of the olfactory system is that neurogenesis continues throughout life (Lepousez et al., The contribution of centrifugal inputs to the structural reorganization that occurs during at least two different behaviors provides an opportunity to reveal the information conveyed by the centrifugal inputs. Because food is a typical reward for animals, centrifugal inputs after food eating might represent a positive value. On the other hand, because electrical shock is a strong punishment for animals, centrifugal inputs during and after electrical shock might represent a negative value. This notion fits with the observation that glutamatergic centrifugal projection to the OB regulates food intake behavior under the control of endocannabinoid signaling (Soria-Gómez et al., A related question in considering functional sub-circuits concerns the spatial organization of the centrifugal inputs. It is not yet known whether specific value information originates in specific populations of PC neurons, or whether specific value information is transmitted to specific populations of OB interneurons and modulates the activity of specific populations of mitral/tufted cells. An anatomical study showed that the boutons of centrifugal axons of individual PC neurons were distributed in a patchy but not diffuse pattern in the OB (Matsutani, By definition, the OC is the brain region which receives the direct projection of OB principal neurons. The OC consists of various areas other than the PC, including the anterior olfactory nucleus, OT, nucleus of LOT, cortical amygdala and entorhinal cortex (Luskin and Price, The ventral striatum is known to direct motivated behaviors and hedonic liking (Berridge and Kringelbach, A receptor agonist in the anterior medial shell of the nucleus accumbens elicited appetitive eating behavior, whereas the same microinjections in the posterior medial shell induced fearful defensive treading (Reynolds and Berridge, Sub-regional segregation of function in the ventral striatum has been identified. For example, microinjections of an AMPA/kainate receptor antagonist or GABAThe OT receives massive axonal projection from various cortical regions, including other areas of the OC (Haberly and Price, Understanding the functional olfactory circuit starts with an analysis of how odor inputs from the external environment are transferred and processed in higher-order olfactory neural circuits. In addition, recent analyses have begun to focus on the circuit mechanisms that encode odor values and conduct odor-induced motivated and hedonic behaviors. The OB provides a good platform for understanding the link between odor inputs and odor value. The peripheral and central inputs to the OB are considered to relate to odor identity and odor value, respectively, and the existence of spatially-organized odor maps in the OB may help to dissect the possible spatial organization of odor value-based centrifugal inputs. The OT is considered to possess functional domains related to distinct motivated and hedonic behaviors, and to provide a good starting point from which functional sub-circuits across various olfactory regions can be traced.While the anatomical and functional organization of the PC appears diffuse and dispersed, recent studies suggest heterogeneity in PC neurons. Output neurons from the PC to different areas of the orbitofrontal cortex were differently distributed in the PC along the dorsal-ventral axis (Chen et al., MY wrote the manuscript.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Wastewater is increasingly viewed as a resource, with anaerobic digester technology being routinely implemented for biogas production. Characterising the microbial communities involved in wastewater treatment facilities and their anaerobic digesters is considered key to their optimal design and operation. Amplicon sequencing of the 16S rRNA gene allows high-throughput monitoring of these systems. The MiDAS field guide is a public resource providing amplicon sequencing protocols and an ecosystem-specific taxonomic database optimized for use with wastewater treatment facility samples. The curated taxonomy endeavours to provide a genus-level-classification for abundant phylotypes and the online field guide links this identity to published information regarding their ecology, function and distribution. This article describes the expansion of the database resources to cover the organisms of the anaerobic digester systems fed primary sludge and surplus activated sludge. The updated database includes descriptions of the abundant genus-level-taxa in influent wastewater, activated sludge and anaerobic digesters. Abundance information is also included to allow assessment of the role of emigration in the ecology of each phylotype. MiDAS is intended as a collaborative resource for the progression of research into the ecology of wastewater treatment, by providing a public repository for knowledge that is accessible to all interested in these biotechnologically important systems.Database URL: http://www.midasfieldguide.org Wastewater treatment is one of the largest biotechnological industries in the world. Wastewater itself is increasingly viewed as a resource with a growing focus on the recovery of inorganic resources, such as nitrogen and phosphorus, and bioenergy. As such, anaerobic digester technology is increasingly being implemented at full-scale treatment plants, primarily for the conversion of solid waste to methane gas for energy, giving the potential for net-energy production from wastewater treatment . As withRecent advances in sequencing technology now make high throughput analyses of complex microbial communities with 16S rRNA gene sequencing possible. This allows high-resolution monitoring over time, permitting correlation analyses with operational parameters for the identification of key phylotypes in full-scale wastewater treatment and biogas systems ,4. Of suIn this report, we present the expansion of the MiDAS field guide to include the organisms of the anaerobic digestion community. This includes an updated taxonomy and online profiles for the abundant organisms of full-scale anaerobic digester systems. In addition, the most abundant influent wastewater organisms are also incorporated, allowing for an assessment of the influence of migration on described phylotypes, which is critical to understanding their ecology. Coverage of the influent wastewater, activated sludge and anaerobic digester communities gives a holistic view of the microbial ecology of wastewater treatment facilities.The MiDAS taxonomy is a curated version of the SILVA taxonomy , with MiCandidatus Fermentibacteria for the mesophilic ADs .The searchable online MiDAS database allows users to link genus level names, obtained with the use of the MiDAS taxonomy, to available information on their distribution and likely function in wastewater systems. Online MiDAS profiles are provided for the abundant genera of the influent wastewater, activated sludge and associated anaerobic digesters, based on extensive in-house surveys . The curDescription fields; otherwise it is assumed that the fermentative organisms mediate the breakdown of complex organics. The Acetogenesis field in MiDAS uses the microbiological definition of the trait. Acetogenesis is routinely applied to broadly describe the synthesis of acetate. However, this definition is somewhat misleading as several metabolic strategies result in acetate production , Aalborg University, the Innovation Fund Denmark (EcoDesign-MBR and NomiGas) [grant number 09-067230 and 1305-00018B] and, the Danish Council for Independent Research [grant no. 4093-00127A].Conflict of interest. None declared.Supplementary DataClick here for additional data file.


Non-communicable diseases (NCDs) continue to pose threats to human health and development worldwide. Though preventable, NCDs kill more people annually than all other diseases combined. The four major NCDs namely cardiovascular diseases, chronic respiratory diseases, diabetes and cancers share common modifiable risk factors. In order to prevent and control NCDs, Ghana has adopted the World Health Organisation Package for Essential NCD (WHO-PEN) intervention, to be piloted in selected districts before a nationwide scale-up. We assessed the capacity of these facilities for the implementation of the WHO-PEN pilot.We conducted a cross-sectional health facility-based survey using a multistage sampling technique. We collected data on human resource, equipment, service utilization, medicines availability and health financing through interviews and observation. Descriptive data analysis was performed and expressed in frequencies and relative frequencies.In all, 23 health facilities comprising two regional hospitals, three district hospitals, nine health centres and nine Community-based Health Planning and Services (CHPS) compounds from three regions were surveyed. All the hospitals had medical officers whilst 4 (44.4%) of the health centres had physician assistants. Health financing is mainly by the National Health Insurance Scheme (NHIS). None of the health facilities had spacers and only one health centre had oxygen cylinder, glucometer and nebulizer.Gaps exist in the human resource capacity and service delivery at the primary care levels, the focus of WHO-PEN intervention. Adequately equipping the primary health care level with trained health workers, basic equipment, medications and diagnostics will optimize the performance of WHO-PEN intervention when implemented. Non-communicable diseases (NCDs) continue to be a major public health problem worldwide posing threats to human health and development. They are the leading cause of death worldwide killing more than 36 million people each year , 2. The WHO estimates that up to 80% of NCDs are preventable through lifestyle changes . The fouThe WHO-PEN intervention is a prioritized set of cost-effective interventions that provides clinical decision support for assessment and management of NCDs at the primary care level in low resource settings . It is dGhana has therefore adopted this tool with a strategy of piloting it in selected health facilities and ultimately scaling up to cover the whole country. Since the successful implementation of this intervention will largely depend on the readiness of the health facilities, there is the need to determine the capacity of the health facilities in order to identify existing and potential gaps that may hamper the smooth deployment of the package. Our study therefore responded to this need with the objective of assessing human resource capacity, equipment, service utilization, medicines availability and health financing.We conducted a cross-sectional health facility-based survey from 9th June to 28th June 2013 in three districts in Ghana, a West African country with a population of 24,658,823 . Ghana cThe health system is organized at different levels from the lowest level of care called the Community-based Health Planning and Services (CHPS) compound which are manned by Community health nurses, through health centres which are manned by medical assistants, then district hospitals which are manned by medical officers and provide general medical services, regional hospitals which provide some level of specialized services and the teaching hospitals. Each region has one regional hospital. There are three teaching hospitals, one in each zone. Approximately 58% of the population live within 30 minutes of a health facility with urban households having better geographical access (78.5%) compared to their rural counterparts (42.3%) .In each of the selected regions, the regional hospital was purposively selected to reflect facilities with high caseload, high cadre of personnel and advanced case-management skills. In each of the selected districts, the district hospital was selected in addition to three health centres and three Community-based Health and Planning Services (CHPS) zones in order to reflect the referral system. The health centres and the CHPS zones were purposively selected based on their distances from the district hospital which served as the main referral centre in the district: one near and one far from the hospital and a third one in between these two.The assessment had approval of the authorities of the Ghana Health Service as part of the responsibilities of the NCD Control Programme. Permission was also sought from the respective Regional Health Directors, District Directors of Health Services as well as the medical directors and heads of the health facilities. All of them willingly agreed for their facilities to be included for data collection. Trained health workers collected data from each of the selected districts through a combination of self-administered questionnaires and interviews. The authorities of the facilities and key personnel who could provide information were trained and given self-administered questionnaires to obtain information on human resource, infrastructure and equipment, service utilization, referrals, medicines and health financing. The survey team reviewed the completed questionnaires with the respondents to ensure that the questionnaires were properly filled. Where necessary, the responses to the questions were validated by observation and inspection of the facilities. A rapid assessment tool for primary healthcare facility capacity assessment for NCDs was adapted and used for data collection. All the facilities, except one regional hospital returned the completed questionnaire.We performed descriptive statistical analysis and expressed categorical variables as frequencies and relative frequencies. Data was entered cleaned and analysed using Epi Info version 7.In all, 24 health facilities from the three regions were surveyed. These include two regional hospitals, three district hospitals, nine health centres and nine CHPS. All the CHPS compounds have at least a trained nurse or health assistant manning them. At the health centres however, four (44.4%) out of the nine had medical assistants. Trained nurses, mostly midwives, were managing the rest. All the district hospitals had at least one medical officer in charge. The regional and teaching hospitals had physician specialists and other specialist doctors delivering care. Other categories of staff working in all the primary health care setting included laboratory technicians, pharmacy assistants or dispensing technicians, and community and public health nurses. In 5 out of the 9 (56%) health centres, there were health promoters who were involved in giving health education in the communities through house-to-house and other engagements such as school and church programmes.Basic equipment for managing NCDs were not readily available in most of the health facilities particularly the primary health care level. None of the CHPS centres had functional glucometers, oxygen cylinders or nebulizers and only 1 out of the 9 (11%) health centres had these equipment. There was no functional spacer in any of the health facilities . All theThe two regional hospitals had almost all the essential medicines for managing NCDs . The CHPAll the facilities surveyed had medical registers where patients’ attendance records were documented. The patients’ folders were retrieved each time they visited the facilities using their unique folder identification numbers. None of the facilities had a registry (computerized version) of patients’ records.Attendance of the patients to the facilities was largely by “walk–in” in all the facilities. A few 8 (34.8%) facilities use both ‘walk-in’ and ‘appointment’ system where patients call and book appointments for attendance. This appointment system usually works in the CHPS compounds where the health workers are in direct contact with the community members. Most of these appointments are not formalized and are based on the availability of the health worker. All the health facilities provided some education and counseling of patients on risk factors for NCDs. A few, 8 (34.8%) of the 24 health facilities were performing clinical breast examination.All the lower health facilities were able to refer patients to a higher level. The lower facilities usually used other means of transporting patients apart from an ambulance. Some were able to arrange for ambulance to transport patients. Feedback on referred patients from the referral centres was a major challenge mentioned by all the primary health care facilities.Ghana has a National Health Insurance Scheme (NHIS) as part of the health financing schemes and those who register by paying a premium are eligible to benefit under the scheme. All the 23 health facilities are accredited by the NHIS. Services and medications that are covered by the NHIS are therefore paid for through the NHIS except for individuals who do not have valid National Health Insurance cards.The WHO-PEN is designed to deliver low-cost, high-impact interventions through the primary health care approach. This requires prioritization of resources geared towards adequately equipping the primary health care facilities and providing the required capacity to deliver care. From the results, the health facilities lacked the capacity required for the smooth implementation of the WHO-PEN intervention. Inadequate capacity of primary healthcare facilities to serve NCD-related health needs have been widely reported , 13, 14.Despite the fact that some basic equipment were found in all the facilities, some vital equipment were also missing. Capacity of the health facilities was strong in the area of health financing. This is largely due to the NHIS, which covers treatment of most diseases Ghanaians are afflicted with . With reSystems for managing patients’ information for continuity of care were inadequate in all the facilities surveyed. None of the facilities had a database of their patients that could facilitate follow up. Patients were referred when necessary, however feedback from the referral centres and adequate record on the patients were challenges. The records of the patients were not kept with sufficient care to enable tracking of their progress. This has effect on effective implementation of the WHO-PEN intervention. Since NCDs require long-term care and tracking of patients’ progress, having a good data management system in place would have been an added advantage.The results also highlight the unavailability of essential medicines required for adequate management of NCDs at the various levels of care. The availability of the medicines reflected the capacity of the different levels of care. Since the different levels of health facilities have been mandated to cater for severity and complexity of diseases commensurate with their manpower expertise, the lower levels of care such as the CHPS compounds and the health centres did not have most of the medications available. The two regional hospitals had almost all the essential drugs available sometimes or always. The unavailability of glucose injectablesand salbutamol inhaler at the lower levels of care means that emergency situations such as hypoglycaemia and acute asthmatic attacks may not be managed as promptly as required. This has the potential for causing needless deaths.Capacity of the health facilities was strong in the area of health promotion as all were providing some education of risk factors for NCDs and a few were providing screening for breast lesions through clinical breast examination. Though most of the lower levels of care did not show evidence of availability of health education materials, awareness creation was done through other means employed by the health promoters.Although the study provides the opportunity for strengthening the baseline capacity of selected health facilities for prevention and management of NCDs, it is important to note that strong capacity does not necessarily imply optimal care. Also, the capacity of these facilities may change over time. Thus, there is the need for a follow-up and periodic assessment of the facilities and the impact of WHO-PEN intervention on NCDs control. The adoption of the WHO-PEN intervention will also set the stage for a more holistic approach to NCD control. It has been argued that health facility-based measures alone may not be enough to achieve the needed effects for priority NCDs . There iThe preparedness of the health facilities for the implementation of WHO-PEN intervention is unsatisfactory. Apart from health financing, which seems to be uniform and somewhat adequate due to the NHIS, major gaps in the human resource capacity, availability of medications, diagnostics, equipment and medical information management system are likely to hamper the smooth implementation of the WHO-PEN intervention. Adequately addressing these gaps and other potential needs of the health facilities will optimize the implementation of the package.


Thepostoperative course was uneventful, and the patient was discharged 8 dayslater. At 9-month follow-up a coronary computed tomography angiography confirmedthe viability of all of the grafts, and one year after the operation the patientremained asymptomatic. It comprises the fifth Brazilian case of a coronarysurgery in a patient with situs inversus totalis and the firstone of the country of a coronary artery bypass surgery without the use of thecardiopulmonary bypass in this condition.A 76-year-old man with  In levocardia the apex of the heart is situated on the left side ofthe body, and in dextrocardia the apex of the heart is on the right side.Situs inversus associated to dextrocardia is also termed assitus inversus totalis, with cardiac apex and atrial chambersas well as abdominal organs being a mirror image of the normal anatomy.Situs inversus totalis is a rare condition with an incidence of1:10.000 in the population. Individuals with this condition commonly survive longenough to develop atherosclerotic coronary artery disease (CAD), with an incidencesimilar to the general population, and then may also undergo interventional orsurgical procedures when indicated. There are very few reports about coronary arterybypass surgery in patients with this condition in the world, and less than a halfdozen cases in Brazil-5. As far as we know, this isthe first report of an off-pump coronary artery bypass grafting in a patient withsitus inversus totalis in Brazil.The This study was performed after written informed consent from the patient and approvalby the Ethics Committee of the João de Freitas Regional Hospital .situs inversustotalis - that was found during the military service recruitment - andhypertension was admitted with a three month story of chest pain associated todyspnea on moderate efforts despite optimized pharmacological therapy. The chestroentgenogram was normal except for dextrocardia and an abdominal computedtomography (CT) confirmed a situs inversus totalis (A 76-year-old man (73 kg and 169 cm) with a diagnosis of  totalis  and 1B.  totalis . Thepatsitus solitus.After induction of general anesthesia, the procedure was initiated through amedian sternotomy, with the surgeon standing on the right side of the patient toopen the chest. Besides presenting with a good contractile performance, weobserved that the heart presented with an exact mirror image of a normallypositioned heart: the apex of the heart on the right, the right atrium on theleft, the pulmonary artery on the right side of the aorta and the left ventricleon the right. Then after, with the surgeon standing on the left side of thepatient, the right internal mammary artery (RIMA) was harvested in the standardmanner as pedicle. The pericardium was then opened and deep pericardial tractionsutures were placed to adequately expose both lateral and posterior walls of theheart. With these technical arrangements the visualization of the coronaryarteries was feasible enough to perform the anastomosis without using mechanicalstabilizers - careful manual stabilization plus transient and minimal inotropicsupport assured hemodynamic stability during the operation in this case. Threedistal anastomoses were performed, the RIMA was anastomosed to the left anteriordescending artery (LAD) and the two saphenous vein grafts to the first obtusemarginal branch and to the posterior descending artery PDA, . The surThe patient's postoperative course was uneventful, he remained stable without theneed for inotropic support and was weaned from mechanical ventilation after afew hours of his arrival at the cardiac intensive care unit. There were nosurgical and medical complications during his time in hospital and he wasdischarged home 8 days later. At a 9-month follow-up the patient had undergone aCT coronary angiography that confirmed the viability of all of the grafts . At a onsitus inversus totalis is a rare congenitalabnormality characterized by the development of visceral organs on the opposite sideof its topography, like a mirror image. Hieronymus Fabricius (1537 - 1619) was anItalian anatomist and surgeon who first described situs inversus in1606,4. The combination of a rarecondition such as dextrocardia and situs inversus totalis with acardiac disease has been reported sporadically in medical literature, generallyrelated to congenital anomalies, and recent reports regarding to atherosclerotic CADhas emerged. Patients with this condition are so vulnerable to be affected by CADthan general population, but the few number of only recently reported cases may beresulted from advances in life expectancy of the population in combination withmedical advances in diagnostic and therapeutic fields, and more importantly, withthe rarity of this condition by itself.Dextrocardia with situsinversus were reported by Grey and Cooley, in 1981, and by Irving etal., in 1982,5. Previously, Richardson etal., in 1974, described a case of a ventricular aneurysm resection after myocardialinfarction in a patient with persistent ventricular tachycardia .The first cases of coronary artery bypass surgery in patients with  published the first report of coronary artery bypassgrafting using the RIMA in situs inversus totalis, and thiscase marked the first Brazilian report of coronary bypass surgery in this kindof patient. Only 14 years later, Rosa et al., in 2002, reported the second case inthe country, performing a triple-vessel revascularization with CPB utilizingRIMA and two saphenous vein grafts. Pego-Fernandes et al. reported a case in whichthey performed an on-pump quintuple coronary artery bypass grafting and Saadi etal.reported another case in which they performed a triple on-pump coronary bypassgrafting. In these three operations, the only change in the surgical setup wasthe surgeon standing in the left side of the patient, not altering the rest ofthe scenario. On the other hand, the surgical setup in these situations may becompletely modified when the complexity requires. The Brazilian experience issummarized in In 1988, Abensur et al. were the first to publish a case of acoronary artery bypass surgery with the off-pump technique, in which bothmammary arteries (the free LIMA anatomosed to the in situ RIMA)and a saphenous vein graft were sequentially anastomosed. After that report, afew number of authors have published similar cases, with some differences intheir technical options. These data are presented in The first cases of Grey and Cooley were reported in 1981, but using the CPBcircuit. Twenty years later, Tabry et al., in 2010, in which they performed aright anterior small thoracotomy (11 cm in length) to access the chest andmobilize the RIMA in a skeletonized fashion. Distal anastomosis to the LADartery was achieved by the standard beating-heart technique and the surgeonstanding on the right side of the patient. The authors claimed more complete andnormal view of the operative field using such technique and arrangement. Su etal.,in 2013, described an off-pump triplevessel coronary bypass surgery with apartial sternotomy incision (10 cm in length), in which the surgeon performedthe distal anastomosis standing on the left side of the operating table andafter chose the right side to perform the proximal anastomosis because of thebetter exposure of the ascending aorta.Although not widely diffused in our country, minimally invasive techniques can beemployed in these cases, like demonstrated only by a couple of authors. Thefirst report was described by Romano et al.situs inversus condition. Besides of our report, wefound 15 patients operated without the use of CPB. In 2 of them there was no clearmention about the surgeon side. In 5 patients, the operations were performed withthe surgeon standing on the right side of the patient, in another 5 on the left sideand in 3 the surgeon stood on both sides. Bonde & Campalani strongly recommendedperforming the surgery from the left side, but some authors simply felt at ease toperform in this way. Chakravarthy et al. reported a series of two cases, in thefirst standing on the right side, but in the second case they chose to switch thepositions, concluding that such cases brought extra technical problems even ifstanding on the left side. Chakravarthy et al. and Su et al. performed the distalanastomosis standing on the left side and the proximal anastomosis on the rightside. Su et al.experienced better exposure of the ascending aorta during the proximal anastomosis.Another authors advocated operating on the right side while feeling comfortableperforming such operations. Bonde & Campalani, Abdullah &Mazalanand Chakravarthy et al., even with different positions, experienceddifficulties during exposure and anastomosis of the PDA with some hemodynamicinstability, which obligated the first to convert the case to on-pump procedure.One of the most important facts in these cases is related to the best position of thesurgeon on the operating table specially when considering off-pump procedures, dueto the natural challenges during beating-heart operations and the mirrored operativefield in the situs inversus totalis, with thesurgeon standing on the left side of the patient being the unique change in thetechnical arrangement for the procedure that occurred without any complication. Wechose to use the RIMA once the left one would not reach properly the LAD artery andwould cross over the mediastinum. We have found that using deep pericardial tractionsutures with minimal inotropic support allowed to us to obtain good exposure of thelateral and posterior walls of the heart without inducing hemodynamic instability.The postoperative course was uneventful, the patient was discharged home eight dayslater and one year after the operation he remained in good clinical condition and nofurther complication. A CT coronary angiography confirmed the viability of allgrafts 9 months after the surgery.Although not using CPB, we performed a triple coronary artery bypass surgery in apatient with dextrocardia and


The rapid progress of robotic technique provides new opportunities for the biomedical and healthcare engineering. For instance, a micro-nano robot allows us to study the fundamental problems at cellular scale owing to its precise positioning and manipulation ability; the medical robot paves a new way for the low invasive and high efficient clinical operation; and rehabilitation robot is able to improve the rehabilitative efficacy of patients. This special issue aims at exhibiting the latest research achievements, findings, and ideas in the field of robotics in biomedical and healthcare engineering, especially focusing on the upper/lower limb rehabilitation, walking assistive robot, telerobotic surgery, and radiosurgery.Currently, there is an increasing population of patients suffering from limb motor dysfunction, which can be caused by nerve injuries associated with stroke, traumatic brain injury, or multiple sclerosis. Past studies have demonstrated that highly repetitive movement training can result in improved recovery. The robotic-assisted technique is a novel and rapidly expanding technology in upper/lower limb rehabilitation that can enhance the recovery process and facilitate the restoration of physical function by delivering high-dose and high-intensity training. This special issue covers several interesting papers addressing these challenges. X. Tu and coworkers introduced an upper limb rehabilitation robot powered by pneumatic artificial muscles which cooperates with functional electrical stimulation arrays to realize active reach-to-grasp training for stroke patients. The dynamic models of a pneumatic muscle and functional electrical stimulation-induced muscle are built for reaching training. By using surface electromyography, the subject's active intent can be identified. Finally, grasping and releasing behaviors can be realized by functional electrical stimulation array electrodes. C. Guo and coworkers proposed an impedance-based iterative learning control method to analyze the squatting training of stroke patients in the iterative domain and time domain. Patient's training trajectory can be corrected by integrating the iterative learning control scheme with the value of impedance. In addition, the method can gradually improve the performance of trajectory tracking by learning the past trajectory tracking information and obtain specific training condition of different individuals. The paper demonstrated an effective control methodology in dealing with repeated tracking control problems or periodic disturbance rejection problems. Apart from these works, J. Li and coworkers designed an open-structured treadmill gait trainer for lower limb rehabilitation; T. Sun and coworkers proposed a method for detecting the motion of human lower limbs including all degrees of freedoms via the inertial sensors, which permits analyzing the motion ability according to the rehabilitation needs.Other biomedical and healthcare robots included in this special issue cover a range of interesting topics, such as walking assistive robot, telerobotic surgery, and radiosurgery. To improve the walking ability of the elderly, the walker-type rehabilitation robot has become a popular research topic over the last decade. C. Tao and coworkers proposed a hierarchical shared control method of the walking-aid robot for both human motion intention recognition and the obstacle emergency-avoidance method based on the artificial potential field. In the implementation, the human motion intention is obtained from the interaction force measurements of the sensory system composed of force sensing registers and a torque sensor. Meanwhile, a laser-range finder forward is applied to detect the obstacles and try to guide the operator based on the repulsion force calculated by artificial potential field. The robot realizes obstacle avoidance while keeping partially the operators' original walking intention. X. Li and coworkers demonstrated a general framework for robot-assisted surgical simulators for a more robust and resilient robotic surgery. They created a hardware-in-the-loop simulator platform and integrated the simulator with a physics engine and a state-of-the-art path planning algorithm to help surgeons acquire an optimal sense of manipulating the robot instrumental arm. Eventually, they achieved autonomous motion of the surgical robot. For coping with the workspace issue during the application of Linac system during radiosurgery, a specialized robotic system was presented by Y. Noh et al. The design and implementation of the robotic system were elaborated. All of these works showed comparative advantages versus classical approaches and will hold great potential for providing insights on the practical and systematic design of robots that serve for broad applications in biomedical and healthcare engineering.The objectives of the special issue were reached in terms of advancing the state of the art of robotic techniques and addresing the challenging problems in biomedical and healthcare engineering. Several critical problems in these areas were addressed, and most of the proposed contributions showed very promising results that outperform existing studies. Some of the proposed approaches were also validated from patients' perspectives, which show the applicability of these techniques in realistic environments.


Aim of the present study is to expand our knowledge of the anatomy of the 11th cranial nerve and discuss the clinical importance and literature pertaining to accessory nerve duplication. We present one case of duplicated spinal accessory nerve in a patient undergoing neck dissection for oral cavity cancer. The literature review confirms the extremely rare diagnosis of a duplicated accessory nerve. Its clinical implication is of great importance. From this finding, a further extension to our knowledge of the existing anatomy is proposed. Cervical lymphadenectomy or neck dissection is a commonly performed procedure concerning the management of head and neck cancer. A major complication associated with this surgery constitutes the injury to the spinal accessory nerve in addition to injury to the great vessels and lymphatic vessels . SuccessThe spinal accessory nerve (SAN) is unique in that it shares its innervation from both the medulla and the spinal cord. The cranial fibers, which originate from the nucleus ambiguus in the medulla, are designated to innervate the laryngeal muscles. The spinal component is composed of fibers from the anterior horn cells of the upper five or six cervical vertebrae. These spinal fibers enter the posterior cranial fossa via the foramen magnum, merge with the cranial fibers, and then exit through the jugular foramen along with the fibers of the glossopharyngeal and vagus nerves. The SAN branches off passing deep into the posterior belly of the digastric muscle to supply the sternocleidomastoid. Finally, it transverses the posterior triangle of the neck, superficial to the prevertebral fascia, and terminates with its branches in the deep surface of the trapezius muscle. Some studies have also documented innervation of the upper trapezius directly from the cervical plexus .Spinal accessory nerve can be a cause of scapular winging and shoulder dysfunction. Despite the use of nerve-sparing surgery, the frequency of shoulder morbidity after modified radical or selective neck dissection remains high. A high incidence of shoulder morbidity may be because of the unrecognized anatomical patterns and branching of CN XI. The most common etiology by far is iatrogenic damage (75%) secondary to surgical procedures involving the posterior triangle of the neck. These are often recognized perioperatively. Understanding anatomical variations of the spinal accessory nerve is therefore of crucial importance to avoid iatrogenic injury , 3.We report a single case of duplicated SAN on the left side in a patient undergoing neck dissection and discuss the clinical implications, management, and literature pertaining to SAN duplication.A 62-year-old Caucasian male presented at the Otolaryngology-Head and Neck Surgery Department of the 417 Army Share Fund Hospital of Athens with an abnormal lesion of the oral cavity on the left side. The lesion was observed one year ago after a dental surgery was performed. It appeared as a painful, nonhealing ulcer, which displayed gradual growth. Regarding his medical history, he suffered from arterial hypertension, managed with angiotensin II receptor blocker. He had no known allergies and used to be a heavy smoker ten years ago (30 pack-years) and a social drinker. Biopsy of the lesion showed squamous cell carcinoma of the internal surface of the posterior third of the body of the mandible, clinically staged as T3N2bM0 after cranial and cervical MRI  has documented two cases (1.8%) where the nerve was found duplicated, one intracranially and one extracranially . KnowledSAN injury results in loss of motor function of the trapezius muscle and primarily leads to shoulder dysfunction and shoulder pain. The shoulder syndrome after neck dissection was first described by Erwing and Martin in 1952, and it includes constant shoulder pain, shoulder tilt and drop, winged scapula, difficulty of shoulder retraction, restriction in anterior flexion movement and active abduction movements at shoulder joint, and abnormal electromyography findings .The type of neck dissection has major impact on the shoulder dysfunction. Modified radical neck dissection (MRND) increases shoulder morbidity when compared to Selective neck dissection. The frequency of postoperative morbidity of SAN was 46.7% for radical neck dissection, 42.5% for selective neck dissection, and 25% for modified neck dissection in a study. Modified neck dissection has similar regional control rates to more comprehensive operations in appropriately selected patients and significantly reduces the risk of functional disability , 6.As the exact role of cervical nerve innervation of the trapezius muscle is still unclear, the nerves should be preserved whenever possible . The safThe identification of anatomical variations of CN XI branching in the neck provides invaluable information to surgeons seeking to preserve the motor branches of the nerve during neck dissection.


The damage to health caused by intimate partner violence demands effective responses from healthcare providers and healthcare systems worldwide. To date, most evidence for the few existing, effective interventions in use comes from high-income countries. Gupta et al. provide rare evidence of a nurse-delivered intimate partner violence screening, supportive care and referral intervention from a large-scale randomised trial in Mexican public health clinics. No difference was found in the primary outcome of reduction in intimate partner violence. There were significant short-term benefits in safety planning and mental health (secondary outcomes) for women in the intervention arm, but these were not sustained.This important study highlights the challenges of primary outcome choices in such studies, and further challenges for the sustainability of healthcare systems and healthcare provider interventions. These challenges include the role of theory for sustainability and the risk that baseline measures of intimate partner violence can wash out intervention effects. We emphasise the importance of studying the processes of adaptation, integration and coordination in the context of the wider healthcare system.https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0880-yPlease see related article:  Violence against women, especially intimate partner violence (IPV), is a global pandemic. Evidence for the range of severe health impacts has galvanised national and international governments to include health system reform in the suite of policy responses to this form of violence . HoweverBMC Medicine [A new study published in Medicine  clearly This cluster-randomised controlled trial of 42 large public health clinics in Mexico City  trained The primary outcome of the study was to reduce IPV in the past year. The investigators included safety behaviours, challenging reproductive coercion, mental wellbeing and use of community resources as secondary outcomes. The study measured these pre-specified outcomes at three points, from baseline up to 15 months . While tThe study by Gupta et al.  raises aStudies of women’s behaviours over the many stages of their transition to safety  suggest There is also an issue of bedevilling in IPV trials. Methodological considerations have encouraged investigators to measure the baseline level of violence in both arms of a study. Ethical guidelines have required them to offer modest support to identified women in the comparison arm. There is growing evidence that simply asking women about IPV can result in a Hawthorne effect; raising the level of consciousness of some women from pre-contemplation to contemplation, or even a higher level of action . The invAdvancing this complex field of healthcare interventions also argues for longer-term follow-up of both women and providers to see whether there is sustained provider behaviour change and whether the ‘seed’ planted in the woman’s mind at the time of intervention might have germinated after 24 or 36 months (if not immediately). Gupta et al. recommend such work, which must also explore factors beyond the individual provider and the woman, and investigate the organisational and systems changes that may have been important at different levels of the healthcare system to support a wider and more integrated systems-wide response to IPV.Interventions for IPV in healthcare settings are complex and require a sound theoretical basis to explain their hypotheses or logic models and to promote their implementation and sustainability. Healthcare providers work in complex systems and hierarchies, and specific adjustments may be required within the organisation and management structure to integrate IPV interventions and sustain changes in work practices , 14. CooIt is critical to understand the broader systems context in which healthcare interventions operate in LMI countries , as the focus of previous studies has primarily been on the effectiveness of the intervention rather than the processes of adaptation, coordination and integration. We strongly recommend long-term intervention trials that follow women beyond the healthcare setting, to understand their coping mechanisms and use or non-use of the formal and informal support services available in their communities. As we have done in healthcare interventions in high income countries, we also recommend theory-driven investigation, including a strong focus on the sustainability of healthcare system responses and healthcare provider interventions in LMI countries , 18. Com