Perioperative pain management is one of the most challenging issues for patients with spinal neoplasms. Inadequate postoperative analgesia usually leads to severe postsurgical pain, which could cause patients to suffer from many other related complications. Meanwhile, there is no appropriate analgesic strategy for patients with spinal neoplasms.This is a protocol for a randomized double-blind controlled trial to evaluate the effect of esketamine combined with pregabalin on postsurgical pain in spinal surgery. Patients aged 18 to 65 years scheduled for spinal neoplasm resection will be randomly allocated into the combined and control groups in a 1:1 ratio. In the combined group, esketamine will be given during the during the surgery procedure until 48-h postoperative period, and pregabalin will be taken from 2 h before the surgery to 2 weeks postoperatively. The control group will receive normal saline and placebo capsules at the same time points. Both groups received a background analgesic regimen by using patient-controlled intravenous analgesia (containing 100 μg sufentanil and 16 mg ondansetron) until 2 days after surgery. To ensure the accuracy and reliability of this trial, all the researchers and patients will be blinded until the completion of this study. The primary outcome will be the proportion of patients with acute moderate-to-severe postsurgical pain  during the 48-h postoperative period. The secondary outcomes will include the maximal VAS scores (when the patients felt the most intense pain over the last 24 h before being interviewed) at 0–2 h, 2–24 h, 24–48 h, and 48–72 h after leaving the operating room and 24 h before discharge; the incidence of acute moderate-to-severe postsurgical pain at each other time point; chronic postsurgical pain assessment; neuropathic pain assessment; and the incidence of drug-related adverse events and other postoperative complications, such as postoperative delirium and postoperative nausea and vomiting (PONV).The aim of this study was to evaluate the effect of esketamine combined with pregabalin on acute postsurgical pain in patients undergoing resection of spinal neoplasms. The safety of this perioperative pain management strategy will also be examined.ClinicalTrials.gov NCT05096468. Registered on October 27, 2021The online version contains supplementary material available at 10.1186/s13063-023-07178-3. Pain is one of the most common complications for patients undergoing surgery. According to previous studies, almost 80% of patients undergoing spinal surgery suffer from acute postoperative pain , and oveOne of the most challenging issues during the perioperative period is providing appropriate pain control measures to enhance the recovery of patients. Over the last decade, opioids have been the most commonly used drug in perioperative pain management strategies. However, the administration of opioids could be compounded by aspects of misuse, overdose, and addiction. Furthermore, clinical adverse events such as nausea and vomiting and respiratory depression have limited the use of opioids. In 2016, the American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRAPM) jointly published consensus guidelines for acute pain management. These guidelines indicate that ketamine  and pregd-aspartate (NMDA) receptor activation [The mechanisms underlying postsurgical pain might be peripheral and central sensitization because of nerve injury and inflammatory responses at the operative site. Previously, researchers have suggested that central pain sensitization might be related to N-methyl-tivation . Ketamintivation . S-Ketamtivation . UnfortuAt the same time, gabapentinoids  have gained more attention from researchers for their significant effect on neuralgia. These compounds can inhibit the modulation of neuronal excitability by blocking α2–δ subunits of presynaptic, voltage-dependent calcium channels, which are upregulated in central sensitization processes . A meta-Thus, we designed a randomized controlled study to explore the analgesic effects of a combination of esketamine and pregabalin after resection of spinal neoplasms to investigate whether the combined therapy could improve postoperative analgesia. The fundamental aim of this study was to find an effective and safe analgesic treatment to help patients undergoing spinal surgery and provide a new perspective regarding perioperative pain management strategies.ClinicalTrials.gov on October 27, 2021 (NCT05096468). All participants or their legal representatives will provide written informed consent after screening and before randomization.This study will be a single-center, randomized, double-blind, controlled trial with two parallel study arms. This equivalence trial aims to evaluate the analgesic effects of esketamine in combination with pregabalin after resection of spinal neoplasms. The enrolled subjects will be randomly allocated into the combined group  and the control group  in a 1:1 ratio. This study was approved by the Institutional Review Board of Beijing Tiantan Hospital, Capital Medical University, Beijing, China (KY-2021-081-02). This study (protocol version 1.4/date 2021.10.08) was registered on The recruitment of this trial will be conducted in Beijing Tiantan Hospital from 1 December 2021 to 31 August 2022, and the follow-up will be until 31 December 2022. Based on the electronic medical records of the hospital, potential participants will be individually screened after admission. Almost 100 patients underwent surgery in the spinal neurosurgery department at Beijing Tiantan Hospital in 1 month, and the proportion of patients with spinal neoplasms was nearly 60% in this population. The sample size is only 90 for our study. Therefore, the predicted 8-month duration of this study is enough to complete the recruitment. No extra measures will be taken to recruit a sufficient number. Participants meeting the eligibility criteria will be visited by the research staff to sign informed consent forms and provide baseline information. The flow chart of the study is shown in Fig. Patients meeting the following inclusion criteria and not meeting the exclusion criteria at the time of randomization will be considered for enrollment.Scheduled to undergo elective resection of spinal neoplasmsAge between 18 and 65 years oldASA I–IIISigned informed consentPrevious adverse reaction to ketamine, S-ketamine, or pregabalinA diagnosed history of severe chronic pain Long-term medical history of analgesic treatment (gabapentin/opioids/ketamine)Aphasia or inability to cooperate with the pain assessmentsA diagnosed history of hepatic and renal dysfunctionA diagnosed history of psychiatric disorderThe patient was treated with gabapentin/pregabalin in the last 3 monthsDrug use disorder2Body mass index > 35 kg/mPregnancy or lactationPatients will be randomized 1 day before surgery using blocked, stratified randomization by independent research staff to 1 of 2 treatment groups (the combined group or the control group) after study enrollment. We will randomize the patients in a 1:1 ratio in blocks of four. The randomized allocation list will be generated by using a real-time, online system on the day before surgery. The randomization results will be maintained by independent researchers who will not participate in any other work of this study to guarantee allocation blinding. The presence of moderate or severe preoperative pain will be used as a basis for the stratification of patients .Allocation concealment will be achieved using study capsules and intravenous infusions with identical appearance for placebo and drugs. All the trial drugs will be provided by a medicine company  with no other contribution to this trial. The appearance of all trial capsules  will be the same. Esketamine will be diluted to a concentration of 0.5 mg/ml with normal saline. Colorless 50-ml syringes containing clear esketamine or placebo  solution will be prepared in a blinded manner by an independent research assistant. The randomization code will be marked on the syringes and the drug bottles of the study capsules. Only the study investigator who assigns participants to interventions will be unblinded to the treatment assignment. All other study researchers will be blinded to the treatment assignment, including responsible anesthesiologists and the neurosurgeons in charge of the patients, the outcome assessors, data analysts, and other relevant investigators.In the combined group, the patients will be given both esketamine and pregabalin during the perioperative period. The patients will receive 2 capsules of pregabalin  1~2 h before the surgery and 1 capsule twice daily during the 7-day postoperative period , followed by dose reduction to 1 capsule once daily for 7 days . At the same time, patients will be administered a bolus dose of 0.5 mg/kg esketamine after the induction of anesthesia and then receive continuous intravenous infusion at 0.12 mg/kg ·h (2 μg/kg ·min) during the 48-h postoperative period.In the control group, the patients will be given the same number of placebo capsules as the combined group at the same time points , alongside a normal saline bolus after induction of anesthesia and intravenous saline infusion for the 48-h postoperative period.Perioperative anesthesia management will be standardized. After entering the operating room, the patients will be given standard electrocardiography monitoring. Anesthesia will be induced with propofol, sufentanil, and rocuronium/cisatracurium. Total intravenous anesthesia depends on target-controlled infusions and will be chosen to maintain anesthesia with propofol and sufentanil and keep the bispectral index between 40 and 60. Remifentanil will be prohibited in this study. For the potential impact on the evaluation of the operation, nerve block will not be considered. In addition, local wound infiltration (0.5% ropivacaine 20 ml) will be permitted before skin suturing if required by the surgeon. All the participants will be given the usual postoperative analgesia therapy by postoperative patient-controlled intravenous analgesia  with a lockout period of 15 min, 100 ml total), which will include 100 μg sufentanil and 16 mg ondansetron during the 2-day postoperative period. In the ward, all patients will receive parecoxib sodium (40 mg IV BID) or flurbiprofen axetil (50 mg IV BID) to receive the standard postoperative analgesic for at least 3 days. If the patients are experiencing moderate or severe pain (VAS score ≥ 40 mm), rescue analgesia will be given, including 0.5 μg sufentanil IV in the postanesthesia care unit (PACU) or 1 tablet Tylox (contained 325 mg acetaminophen and 5 mg oxycodone per tablet) in the ward. If the pain persists, the patients will receive 1 dose of 50 to 100 mg of intramuscular tramadol. All analgesic doses and names will be clearly recorded.All of the participants will receive conventional postoperative care in the ward. The postoperative treatment will not be changed whether the patients enter the trial. The interventions of this trial are a combination of analgesic management added to the basic analgesic treatment, which will help the patients to get more comfortable feelings. The interventions are common drugs in the clinic, and the dosages are lower. Thus, the patients will be at low risk during the interventional period. Therefore, there is no anticipated harm or special posttrial care for the participants.The assessment of outcomes will be performed by two independent researchers. The results during hospitalization will be collected by the investigators through bedside interviews. The collection of postdischarge outcomes will be performed by telephone interview.The primary outcome was the proportion of patients with acute moderate-to-severe postsurgical pain during the 48-h postoperative period (defined as a VAS score ≥ 40 mm). The schedule of enrollment, intervention, and assessments is presented in Fig. Acute pain assessment: the maximal VAS score (when the patients felt the most intense pain over the last 24 h before being interviewed) 0–2 h, 2–24 h, 24–48 h, 48–72 h after leaving the operating room and 24 h before discharge; the incidence of acute moderate-to-severe postsurgical pain at each other time point (defined as the VAS score ≥ 40 mm)Subacute or chronic pain assessment: The incidence of postsurgical pain was assessed by a number rating scale (NRS: 0~10) at 1 month and 3 months (defined as an NRS score > 3)Neuropathic pain assessment: the short-form McGill pain questionnaire-2 (SF-MPQ-2) scores at 1 month and 3 months postoperativelyTotal opioid consumption within the 48 h period after surgeryEffective or noneffective button presses for PCIAQuality of anesthesia emergence evaluated by a 15-item quality of recovery scale (QoR-15) on POD3 and at dischargeThe incidence of psychotic side effects  was determined using the Brief Psychiatric Rating Scale (BPRS) and Clinician-Administered Dissociative States Scale (CADSS) at 2 h after surgery, POD1, POD2, and POD3Adverse events included drug-related  and operation- or anesthesia-related complications, the incidence of PONV, and the incidence of postsurgical delirium at 2 h after surgery, POD1, POD2, and POD3Other outcomes: perioperative depressive/anxious symptoms assessed by the Patient Health Questionnaire 9 (PHQ-9) and Generalized Anxiety Disorder scale (GAD-7) on POD3, at discharge, and 1 month and 3 months after surgerySecondary outcomes include the following:All the clinical information will be recorded in the unified case report forms designed specifically for this project and other paper documents, including informed consent forms and the protocol. After the follow-up is completed, the research paper documents will be locked in a single secure office in Beijing Tiantan Hospital, and the key will be kept by only the primary investigator and trial manager. Research data will be coded with a unique trial ID number, and no personal identifiers will be contained in the research data. The trial ID number that links identifying information to study subjects will be accessible only to the study investigators. The data will be entered into an enciphered electronic database after completion of this study. Only the principal investigator will know the password of this electronic database. All of the paper materials and the electronic database will be managed by the principal investigator until the study is complete.t tests, Mann–Whitney U tests, and chi-square or Fisher’s exact tests as appropriate. We will use the modified intension-to-treat (mITT) analysis to report our results, and we will use per-protocol (PP) analysis to perform the sensitivity analysis. The methods for estimating effects and 95% CIs will be reported in our outcomes. Sensitivity analyses will be applied to determine the statistical nature of the missing data. A two-sided P value of 0.05 was considered statistically significant for the primary outcome. Because of the repeated measurement, the Holm–Bonferroni method will be used to adjust the P value for secondary outcomes. Statistical analysis will be implemented using SPSS version 23.0 software and Stata version 14.0.Continuous data will be described as the mean with standard deviation (SD) or median with interquartile range (IQR) based on its distribution. The histogram and Kolmogorov–Smirnov tests will be used to evaluate the normality of the data distribution. Categorical variables will be summarized as counts and percentages. The primary outcome is categorical and will be analyzed by using the chi-square test or Fisher’s exact test. Regarding the secondary outcomes, based on the type of each variable, the difference between groups will be analyzed using P values of 0.05).According to a previous randomized controlled trial that investigated the effect of combined ketamine and pregabalin on persistent postoperative pain, the prevalence of moderate-to-severe acute postoperative pain at 24 h after surgery was 42% in the combined group and 78% in the control group . Among pBecause of the low-risk interventions, the short-term duration, and the small sample size, there are no interim analyses planned.This is a single-site study designed, performed, and coordinated at Beijing Tiantan Hospital. There is no steering committee or adjudication committee. Day-to-day running and management of the trial are based on the regular meeting and led by the chief investigator . The study team meets via a teleconference or face-to-face at least twice a month. The content of regular meetings includes the following: (1) study investigators report the process of the trial, including recruitment, informed consent, assessment, and intervention procedures according to protocol; (2) trial managers raise the problems during the performance of the study; and (3) principal investigators provide oversight for all aspects of the trial and give support to study investigators in each link.In agreement with the Institutional Review Board (IRB) of Beijing Tiantan Hospital, a DSMB was not appointed for this study. Because this study is a short-term study, the interventional drugs of this trial are conventional clinical analgesics with safe dosages. The risks of the interventions are minimal. Moreover, enrolled subjects in this study are adjunctive to routine treatment through the spinal neurosurgery department in Beijing Tiantan Hospital. The population in this trial will be monitored carefully during hospitalization, and regular perioperative treatment will not be altered by study participation. Two knowledgeable anesthesiologists and a spinal neurosurgeon were responsible for the safety of this study. Once adverse events are suspected, they will be asked to diagnose whether the suspected adverse event is related to interventions and will guide the next treatments for safety measures when indicated. The study team will submit the annual tracking reports to IRB institutions to upload the process information of the study once a year. If there is any modification in this trial, the trial manager will need to submit the application in a timely manner, and the IRB will approve if it is feasible.The follow-up investigators will pay close attention to the subjects during the intervention. If any adverse events (AEs) occur, the responsible investigator will report to the principal researcher immediately. If AEs are common and the patients’ symptoms are mild, we will supply thorough symptomatic support and treatments with close monitoring. If AEs become severe, the intervention will be stopped at once, professional doctors from various fields to immediately help the patients. Based on the relationships between AEs or serious adverse events (SAEs) and the drugs being assessed in this study, the project management team will consider whether unblinded allocated interventions are needed. If the AEs are so serious that they might impact regular clinical treatment and threaten patient safety, the research team will perform the emergency unblinding process and report the interventions to the surgeon in charge of the subjects at once. All AEs will be followed up until resolution. All adverse events will be documented in the final written report of this study and will be reported to the Institutional Review Board by the principal investigator.Patients and the public were not involved in the trial design. Participants will have access to the findings of the study on request.This proposed study will measure the efficacy and safety of esketamine combined with pregabalin on postsurgical pain in patients undergoing elective resection of spinal neoplasms. The participants will receive esketamine from the beginning of surgery until 48 h postoperation, along with a total dose of 150 mg pregabalin for 1 week postoperatively  followed by a reduced dose of 75 mg pregabalin for the next week (POD 8~14). Both acute and chronic postoperative pain will be assessed during the 3 months after surgery. Other complications and safety outcomes will also be observed.The primary concern is the potential inadequate analgesia in the control group after the surgery. The PCIA device is not a regular part of the therapeutic regimen during the postoperative period in this study hospital. As a result, we designed a usual PCIA procedure for all the participants to ensure basic postoperative analgesic treatment. If the participants experienced a moderate or severe level of pain, rescue analgesia was administered. The secondary concern is in regard to active placebo for the preoperative pregabalin capsule. In 2017, Hah’s team designed a randomized clinical trial to evaluate the effects of perioperative gabapentin on pain resolution in a mixed surgical population [The choice of the dosages of these two trial drugs was deliberate. Based on a related meta-analysis , intraveIn conclusion, this study is a randomized controlled trial to explore a better method to treat postsurgical pain. The expected outcome is that perioperative esketamine combined with pregabalin can safely and effectively relieve postsurgical pain, and the results of this study can expand the understanding of perioperative pain management.ClinicalTrials.gov on October 27, 2021 (NCT05096468). The first participant will be recruited on December 1, 2021. The conclusions of this study will be published in peer-reviewed journals.This study was approved by the Institutional Review Board of Beijing Tiantan Hospital, Capital Medical University, Beijing, China, on November 20, 2021 (KY-2021-081-02). It was registered on Additional file 1. CONSORT 2010 Flow Diagram.


Falciform ligament appendagitis is an extremely rare disorder, which is characterized by hematogenous or nonhematogenous inflammatory changes in the fat appendage that is contiguous with the falciform ligament. The imaging and clinical features of this condition are similar to those of epiploic appendagitis, especially when caused by torsion of the fatty appendage . We report 2 cases of falciform ligament appendagitis with localized epigastric pain. The ultrasound imaging features of the 2 cases presented here were an oval hyperechoic mass contiguous with the falciform ligament and increased echogenicity of the surrounding inflammatory fat. Both patients were managed conservatively with symptomatic treatment alone. Understanding the imaging features of this falciform ligament appendagitis is important, because ultrasound is often the first choice for noninvasive imaging of acute abdomen. As there is limited detailed literature on falciform ligament appendagitis comparing high-frequency linear probes with CT and MRI, we consider this case report to add valuable information on this poorly reported condition. The first diagnosis of falciform ligament appendage torsion (FLAT) using CT and ultrasound was reported by Coulier et al. in 2001 Case 1: A 25-year-old man was referred to our emergency room with persistent epigastric pain. His body mass index (BMI) was 18.5 kg/m2. Ultrasound and abdominal X-ray done at local clinic a few hours prior did not identify the cause. Palpation revealed localized tenderness on the epigastric area without guarding or rebound tenderness. Blood tests revealed a white blood cell (WBC) count of 10,720/ μL and a C-reactive protein (CRP) value of 0.13 mg/dL. For the ultrasound examinations, we used Aplio 400  with a 14L5 linear probe set at 10-MHz frequency. Ultrasound revealed an oval-shaped hyperechoic mass, which had a hypoechoic rim and was adjacent to the falciform ligament, and increased echogenicity and disturbance of the surrounding fat  with a 12L5 linear probe set at 8-MHz frequency. Ultrasound revealed an oval-shaped hyperechoic mass, which had a hypoechoic rim and was adjacent to the falciform ligament, and inflammation of the surrounding fat  the disease itself is rare, 2) it may have been missed on an ultrasound, and (3) it resolves spontaneously and patients do not return to the hospital. Among the studies on FLA, the most common imaging reported to have been used were ultrasound and CT  it may hGiven the anatomic location, a lesion in the falciform ligament is located at a close distance from the ultrasound probe; therefore, the use of a regular 3.5-MHz convex probe alone would make it difficult to notice the lesion. Given that both the patients were slightly leaner than standard body weight, we were able to use a high-frequency linear probe set at 8-10-MHz frequency. For mildly obese patients in whom this linear probe cannot be used, we recommend the 6-MHz high frequency convex probe. Thus, when FLA is suspected, the use of a high-frequency probe may improve diagnostic performance. In case 2, follow-up ultrasound demonstrated gradual shrinkage of the hyperechoic mass and reduction of the surrounding inflammatory fat until complete resolution . There hCT classically demonstrates FLA as an area of fat density with a thin peripheral rim of hyperattenuation, with or without the classical central dot corresponding to a thrombosed vein The diagnosis of infarcted ligamentum teres hepatis lipoma by MRI has only been reported in one case A few cases of surgical treatment for FLAT had been reported Written informed consent was procured from the patients for publication of this case.Ultrasound interpretation and manuscript writing: DM, CT and MRI interpretation: MS, and clinical diagnosis: YFThe Fukuoka Tokushukai Medical Center Research Ethics Committee has confirmed that no ethics approval was required. All procedures were in accordance with the ethical standards of the responsible institutional and national committee on human experimentation and with the Helsinki Declaration of 1975 and its late amendments.Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.Not applicable.


The use of COVID-19 convalescent plasma (CCP) for the treatment of SARS-CoV-2 infection in pregnancy is intriguing in view of its safety profile in pregnancy and historical precedence of the use of plasma for other viral illnesses. This study aimed to evaluate the use of CCP in pregnant women with early COVID-19 infection.This is a retrospective case series study. We have included seven pregnant women admitted with early COVID-19 infection to a tertiary care hospital, Latifa Maternity Hospital in Dubai, United Arab Emirates between 12 February and 04 March 2021 and who consented to receive COVID-19 convalescent plasma as part of their treatment plan. Main outcomes measured were clinical and radiological features, laboratory tests, WHO clinical progression scale pre and post treatment, and maternal, fetal outcomes. COVID-19 clinical severity was classified according to the NIH guidelines for criteria of SARS-CoV-2. For the radiological features, a modified chest X-ray scoring system was used where each lung was divided into 6 zones . Opacities were classified into reticular, ground glass, patchy and dense consolidations patterns.Seven pregnant women with early COVID-19 were enrolled in this study, their mean age was 28 years (SD 3.6). Four had comorbidities: 2 with diabetes, 1 with asthma, and 1 was obese. Five patients were admitted with a WHO clinical progression score of 4  and 2 with a score of 5 . Upon follow up on day 10, 6 patients had a WHO score of 1 or 2 (asymptomatic/mild symptoms) indicating clinical recovery. Adverse reactions were reported in 2 patients, one reported a mild skin rash, and another developed transfusion related circulatory overload. All patients were discharged alive.CCP seems to be a promising modality of treating COVID-19 infected pregnant women. However, further studies are needed to ascertain the efficacy of CCP in preventing progressive disease in the management of COVID-19 infection in pregnant women. The pharmaceutical management of COVID-19 pregnant women poses a dilemma to obstetricians in terms of maternal and fetal safety profiles of the currently available medication regimens for COVID-19 infections.Coronavirus infection 2019 caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was declared a global pandemic in early 2020 by the World Health Organization (WHO) [Pregnant women are especially considered a high-risk group when compared to the general population in view of the physiological immune modulation and changes in pulmonary function associated with pregnancy itself . Among pDespite the higher risk of disease severity in pregnant women, currently available pharmaceutical regimens for COVID-19 infection poses a dilemma to obstetricians in terms of their unknown maternal and fetal safety profiles.Convalescent plasma has been used since the 1918 flu epidemic, 2015 SARS epidemic and more recently during the MERS (Middle East Respiratory virus) and the Ebola virus epidemics [This is one of the few studies on the favorable outcome of the early use of convalescent plasma (CCP) in pregnant women with moderate COVID-19. We describe seven pregnant women with early COVID-19 infection treated with COVID-19 convalescent plasma (CCP) early rather than later in the course of the illness aiming to prevent further progression and complications in this vulnerable group. Adequate randomized controlled clinical trials are required to further study the efficacy of this modality of treatment as standard of care for early COVID-19 infection in pregnancy.This study aims to evaluate the use of covid-19 convalescent plasma as a treatment option in pregnant women with moderate covid-19 infection early in the course of the disease.This is a retrospective case series study.This study was conducted in a tertiary care hospital, the Latifa Women and Children Hospital in Dubai, United Arab Emirates between 12 February and 04 March 2021. During the COVID-19 pandemic, this public maternity hospital was the only hospital in Dubai that accepted pregnant COVID-19 infected patients.Seven pregnant women that were admitted with moderate disease , with coA data collection tool was formulated including clinical and radiological features, laboratory tests, maternal and fetal outcomes and WHO disease severity score pre and post treatment . We adopCollection of plasma from recovered COVID-19 patients was approved by Dubai Scientific Research Ethics Committee (DSREC) of Dubai Health Authority (DHA) as part of treatment for COVID-19 infection, including for pregnant patients . CCP uniThe FDA and AABB had issued at the end of March 2020 their recommendation and guidelines for blood facilities to start manufacturing such products under controlled conditions and recommended health care facilities to evaluate its effectiveness and safety. However, implementation first started on August 23rd 2020 when the FDA issued an Emergency Use Authorization (EUA) for the use of convalescent plasma in the treatment of hospitalized patients with COVID-19. This was later revised in February 2021 to authorize only the use of high titer COVID-19 convalescent plasma for the treatment of hospitalized patients with COVID-19 early in the course of the disease , 17.All seven pregnant patients with moderate COVID-19 signed a written consent and received 1-2 units of convalescent plasma.Presented with fever, body aches and headache for 2 days. On admission her BP was 123/70 mmHg, respiratory rate of 21-22, O2 saturation of 98% and afebrile but tachycardic with a pulse of 110-120. Chest examination revealed bilateral crepitations in the lung bases. Chest X-ray revealed bilateral perihilar haziness and lower 2 zones reticular infiltrates  levels on admission were negative . All the COVID-19 pregnant women received CCP therapy within the first 5 days from onset of symptoms: 4 on day 5, 2 on day 4, and 1 on day 2 (Table Post CCP transfusion adverse reactions were reported in 2 out of 7 cases: one developed possible TACO (transfusion related circulatory overload) but clinically there was a suspicion of worsening COVID-19 pneumonia, and one developed a mild skin rash . Only one patient with a relatively more severe disease was hospitalized for 10 days  (Table The absolute lymphocyte count showed a positive response with a rate of change by 57.8%, ferritin by 39.9% while LDH, CRP, IL-6, Procalcitonin and D-dimer showed a decline in values as depicted in Fig. The first 5 cases in the series received convalescent plasma units which were considered of low titer as per the cutoff levels of the different testing modalities used by the blood bank in our facility Table . In the The concept behind this modality of treatment is that this plasma contains a higher dose of immunoglobulins against the SARS-CoV-2 virus and this provides passive immunity to patients affected by this virus. Normally, patients affected by COVID-19 infection may take 2-3 weeks to develop an adequate antibody response. Hence, providing these antibodies to patients early in the course of the disease aids in neutralizing the virus, decreasing its entry into cells and theoretically enhances more rapid elimination of the virus [Pregnancy is a unique clinical situation where even though they are a higher risk population, the current pharmaceutical interventions, most of which are still experimental, pose a dilemma to use for both clinicians and the patients in terms of their safety profile for the mother and developing fetus.Convalescent plasma is a blood byproduct and has been widely used before in pregnancy when needed. Good quality evidence on CCP safety and efficacy is lacking so far in COVID-19 infected pregnant women. However, in other viruses such as varicella zoster virus and rabies virus, immunoglobulins have been used in pregnancy to prevent illness progression in these infections with established maternal and fetal safety .Recently, a systematic literature review was done which is the first of its kind to study convalescent plasma for pregnant women with COVID-19 infection. It found only 12 out of 79 records were relevant and these were mostly case reports on 12 pregnant patients. Despite its significant limitations and poor study quality, the conclusion was that the literature seems to indicate that the use of convalescent plasma even for severe cases of COVID-19 infection in pregnant women proves beneficial to both mothers and fetuses [Initially convalescent plasma was thought to be of use in severe COVID-19 infection which would usually be late in the course of the disease. Since then, studies in the non-pregnant population have pointed that this route of management may not prove effective because by then organ damage has started through the now understood acute inflammatory response associated with COVID-19 infection . ConsequThe documented associated risks are low and include allergic reactions, TACO, TRALI, transmission of viral infections such as HIV, HBV, and thrombotic/thromboembolic and cardiac events .In our case series of 7 patients, all were either in the second or third trimester with WHO clinical score of 4 or 5. They had initial low COVID-19 IgG levels and were in their early stage of disease between the second to fifth day of symptom onset. Five cases received 2 units of CCP, while 2 of them received 1 unit of CCP due to the development of TACO in one case and worsening COVID-19 course in another. However, none of the cases progressed to critical illness and all of them were discharged in a stable condition. It was our observation that patients who received CCP with high antibody titers had a more favorable course of illness in terms of the positive change in WHO clinical progression score and length of stay as compared to those who received low titer CCP. Only 1 patient had TACO after the first CCP transfused which is a known adverse effect of plasma products.We agree that like other immune deficiency states, pregnancy although not a pathologic state, is physiologically associated with a depletion in B-cell immune response rendering our patients more at risk to viral illnesses and their complications. Similar to the findings of Rodionov and colleagues, who studied convalescent plasma in 14 patients with varying immunodeficiency conditions, we anticipate that pregnant women may benefit from convalescent plasma for the same reason .A more recent prospective cohort study on convalescent plasma in pregnant patients came to the conclusion that despite the lack of abundant evidence supporting the use of convalescent plasma for pregnant women with covid-19, current data suggests an improvement in both laboratory and ventilatory parameters .Moreover, another study which aimed to analyze the conflicting data coming from the WHO and FDA regarding covid convalescent plasma concluded that upon reviewing 30 randomized controlled trial, indicators of efficacy point to the use of higher titer plasma units . On the We are amongst the first few to publish a case series on the use of CCP in pregnant women with moderate COVID-19 illness within the first 5 days from onset of symptoms. We started this study even before WHO gave its recommendation to use it early in the disease course in the general population and in our case series has shown a favorable outcome. Our study is however limited by the small sample size and lack of follow up of the IgG antibody levels post CCP treatment.Nevertheless, adequately powered randomized controlled trials are still needed to prove the efficiency of this modality of treatment and whether we can suggest this treatment as standard of care for early COVID-19 infection in pregnancy.


Groups 1, 2, and 3, Tetric N-Ceram composite bonded to Biodentine with Tetric N-bond, Xeno V+, Bond Force bond, respectively. Group 4, 5, and 6, Filtek Z350 bonded to Biodentine with the same three adhesives. The specimens were placed in distilled water for 24 hours and tested for the SBS in a universal testing machine at a crosshead speed of 1 mm/min. The test data were listed in a table and independent samples t-test and analysis of variance (ANOVA) were conducted as a part of the statistical analysis.  Forty-eight acrylic blocks having central holes with a nominal diameter of 4 mm and a depth of 2 mm were prepared. The holes of the acrylic blocks were filled with Biodentine, which was prepared following the guidelines provided by the manufacturer. Then, the specimens were divided into six groups ( The Tetric N bonding agent achieved the highest SBS followed by Bond Force, and Xeno V and highly significant difference was found. On the other hand, an overall increase in the SBS values of the Tetric N-Ceram resin was noticed in comparison with the Filtek Z350 and the differences was statistically significant. Although the specimens failed in adhesive, cohesive and mixed fracture modes but the cohesive was found to be the dominant failure mode in all groups.  Among the tested bonding agents and resin composites, the Tetric N-Ceram composite bonded by Tetric N-bond self-etch adhesive with the Biodentine showed the highest SBS compared to the other combinations. Biodentine was presented as a dentine coating material that is used in deep cavities to reduce the bulk of filling material and protect the pulp. It is recommended for using it underneath restorative resin composites and a repair material for endodontic applications due to its favorable biocompatible, bioactive, and biomineralizing characteristics , 2. TricBiodentine can infiltrate through the dentinal tubules and show ability to crystallize while adhering with dentine, thereby improving bonding . The adhthgeneration bonding agents are now available in the market and these are also known as single-solution or all-in-one products. It is important to gain further understanding about performance of the products in terms of accomplishing etching, priming, and bonding/sealing using a single solution. Furthermore, it is necessary to evaluate the bonding efficacy of these newer simplified bonding agents to provide some guidance to the dentists and dental technicians for selecting the best alternative adhesive material from a large pool of bonding materials available commercially. Bonding quality can be enhanced by selecting suitable combinations of dental adhesives, application techniques, and curing strategies.Evolution of the dental adhesive systems can be identified in terms of elemental composition in the materials with their internal chemistry, application procedure, and clinical performance –10. 7thgResin composites have been the material of choice for esthetic restorations in anterior and posterior teeth due to the advances made in their chemical, physical, and mechanical properties. Despite their improved characteristics, the composites have an intrinsic characteristic of shrinkage during the curing process as monomers transform from free floating molecules to rigid polymeric chains . This coLimited information is available in the literature on the bond strength between the resin composites and the Biodentine with different boning agents; hence, their bonding mechanism is not fully understood. The study aimed to determine the SBS between resin-based composites and Biodentine using three types of 7th generation bonding agents.The null hypotheses stated that (1) no significant differences would be present in terms of SBS between the three adhesive systems for a particular resin composite and (2) no significant differences would be present between the two resin composites for a particular adhesive system.Forty-eight acrylic blocks having central holes with a nominal diameter of 4 mm and a depth of 2 mm were prepared. Biodentine were prepared following the manufacturer's guidelines and placed in the hole of each acrylic block as shown in The specimens were kept at 37°C with 100% humidity for 24 hours to facilitate setting. Two types of composites: nanohybrids resin, Tetric-N ceram, and nanofilled resins, FiltekZ350 and three commercially available types of seventh generation bonding agents, Tetric N-bond, Xeno V+, and Bond Force were tested in this study. The adhesive systems and the resin composites considered in this study and their chemical compositions are presented in n = 8) based on different combinations of resin composites and adhesives (The specimens were separated into six groups (dhesives .The corresponding bonding agents are applied to Biodentine according to manufacturer instructions as shown in 2). Each composite cylinder was also cured for an additional 40 seconds after removal from the mold. Polymerization was completed by light curing for 40 seconds in a curing unit  in N by the adhesion area A.r is the radius of the central hole.The force required to debond the restorative material was recorded in Newton (N) and the bond strength The failure modes were identified under a low magnification (×25) light microscope to assess the performance of different combinations of adhesive and resin composite systems. Three failure modes were assessed: pure adhesive, cohesive within Biodentine or resin composite, and mixed failure with adhesive and cohesive types. Fracture behavior was analyzed by an independent researcher who was completely unaware about the experimental groups during sample preparation to avoid any bias.t-test and analysis of variance (ANOVA) were conducted as a part of the statistical analysis using IBM SPSS 21 software. A two-way ANOVA was used to determine the effects of the adhesive systems and restorative materials on the SBS and their interactions with a significance level set at P ≤ 0.05.The test data were listed in a table and independent samples The mean values and standard deviations of SBS for all groups are shown in The results clearly demonstrated that the highest mean SBS was recorded for Group 1, in which Tetric N-Ceram composite was bonded to the Biodentine with Tetric N bond (13.59 MPa), while the lowest mean SBS was recorded for Group 6, in which FiltekZ350 composite was bonded to the Biodentine with Xeno V (6.33 MPa).On the other hand, there was an overall increase in the SBS values of Group 1, Group 2, and Group 3 that Tetric N-Ceram resin composite bonded with the three different bonding agents in comparison with Group 4, Group 5, and Group 6 in which the FiltekZ350 resin composite was used and the difference was statistically significant . The Tetth generation adhesive systems  was evaluated. To the author's best knowledge, no studies were reported on the SBS of the combination of resin composites and adhesives considered here. For each of the resin composites, significant differences in SBS were found among the three bonding agents studied here. Therefore, the first null hypothesis was rejected. Again, for each of the bonding agent, the resin composites showed significant difference in bond strength. Thus, the second hypothesis was also rejected.The most critical factors that determine the clinical success of a dental restoration could be the bonding strength between the restorative resin materials and the enamel or dentin, as well as the strength between the restorative material and the cavity liner. In this study, the SBS of two resin composites (Tetric N-Ceram and Filtek Z350 XT) and Biodentine with three 7In this study, the mean SBS values ranged between 6.33 and 13.59 MPa, which was lower than the range of bond strength 17–20 MPa) recommended for producing strong restoration without any gap at the boundary . The low MPa recoSince there was no indication of the resin structure attached to the Biodentine, this indicated that the bond created with the composite resins might be purely micromechanical . In addiThe SBS results found in this study was higher than the findings of Altunsoy et al. (1.69 MPa)  and DeepBased on the SBS results obtained in this study, there were statistically significant differences between Tetric N-ceram and FiltekZ350 XT, with the former showing higher bond strength values. The variation in composition of the two resin composites along with the nanohybrid structure in Tetric N-Ceram might explain the difference in the SBS. Furthermore, high concentrations of TEGDMA diluent monomer in the FiltekZ350XT might have increased its shrinkage, therefore decreasing the bond strength since Kim et al. reported high volumetric shrinkage with Z350XT when compared to several bulk-fill resin-based composites (RBCs) . GovindaMean SBS values of all groups were ranked as follows: Group 1 > Group 4 > Group 2 > Group 5 > Group 3 > Group 6. Based on the results of six combinations of bonding agents and restorative materials, Tetric N-bond self-etch and Tetric N-Ceram composite (Group 1) was recommended for obtaining the strongest bond ensuring the long-term clinical success.thgeneration bonding agents are easy to handle and apply. The traditional steps of bonding process such as etching, priming, and bonding agent application can be carried out in one step leading to a significant reduction in the application time and improve consistency and quality of the restoration with fewer errors related to technical procedures. Therefore, the bonding system was expected to show lower failure rates in clinical applications.The 7thgeneration bonding agents can be categorized as strong , intermediate strong (pH of approximately 1.5), and mild self-adhesives (pH of approximately 2.0) [The 7ely 2.0) . Bond Foely 2.0) . This maely 2.0)  concludeely 2.0) . The strely 2.0) . These fIn general, adhesive failure indicates poor bonding between the resin, Biodentine, and adhesive but stronger bonding was defined by cohesive failure , 35. In in vitro in order to ensure experiments conducted under controlled conditions, which is a standard technique commonly accepted by the dentistry research community. However, this experimental condition might not accurately replicate the clinical situation in vivo.The SBS tests were carried out after storing in distilled water for only 24 hours. However, conducting SBS tests after subjecting the bonding systems to different physical, mechanical, or thermal aging , 36, 37 In this study, only 24 hours was permitted to set the Biodentine with resin composites and this might be responsible for the overall poor strength lower than the minimum strength requirement. Carretero et al. found improved adhesion between nanohybrid composite and Biodentine at 24 h when compared to a shorter setting time (12 min). Therefore, it was suggested to consider longer setting time for Biodentine . Future The results of this study offered a recommendation for the dentists and clinicians to select a specific bonding system for dental restoration in order to ensure long-term clinical performance and patient's satisfaction.th generation bonding agents  used for bonding two esthetic resin composite materials  to Biodentine, the combination of Tetric N-Bond with Tetric-N Ceram has been recommended due to the highest SBS. A reliable bonding system can be beneficial when used for esthetic purpose leading to a long-term clinical success of the restoration due to the improved restoration stability.Within the limitations of the study, it was concluded that among the three commercially available 7


Mobile games can be effective and motivating tools for promoting children’s health.We aimed to determine the comparative use of 2 prototype serious games for health and assess their effects on healthy lifestyle knowledge in youth aged 9-16 years at risk for type 2 diabetes (T2D).Diabetic Jumper (n=7), Ari and Friends (n=8), or a control game (n=8). All participants completed healthy lifestyle and T2D knowledge questionnaires at baseline, immediately after game play, and 4 weeks after game play. Game attitudes and preferences were also assessed. The primary outcome was the use of the game .A 3-arm parallel pilot randomized controlled trial was undertaken to determine the feasibility and preliminary effectiveness of 2 serious games. Feasibility aspects included recruitment, participant attitudes toward the games, the amount of time the participants played each game at home, and the effects of the games on healthy lifestyle and T2D knowledge. Participants were allocated to play In terms of feasibility, we were unable to recruit our target of 60 participants. In total, 23 participants were recruited. Participants generally viewed the games positively. There were no statistical differences in healthy lifestyle knowledge or diabetes knowledge over time or across games. Only 1 participant accessed the game for an extended period, playing the game for a total of 33 min over 4 weeks.It was not feasible to recruit the target sample for this trial. The 2 prototype serious games were unsuccessful at sustaining long-term game play outside a clinic environment. Based on positive participant attitudes toward the games, it is possible to use these games or similar games as short-term stimuli to engage young people with healthy lifestyle and diabetes knowledge in a clinic setting; however, future research is required to explore this area.Australia New Zealand Clinical Trials Registry ACTRN12619000380190; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377123 As the prevalence of type 2 diabetes (T2D) in New Zealand’s younger population increases, the challenge of designing effective and engaging ways and means of preventing the disease also increases ,2. RecenOne game that was developed to promote knowledge of the interaction of physical activity behaviors and diet with blood glucose, and knowledge of blood glucose monitoring in young people with T2D resulted in promising outcomes ,10. In aA 3-arm parallel pilot randomized controlled trial (RCT) was undertaken in Auckland, New Zealand between April and September 2019. Eligible participants were aged between 9 and 16 years, had a family history of T2D, were overweight or obese for their age according to the Cole International cutoff points for BMI, or had been told by their doctor that they were at risk for T2D. Eligible participants were also required to have access to an Android device, be able to provide assent (if under the age of 16 years) or consent (if 16 years or older), be able to speak and understand English, and live in the Auckland region. Eligible parents or caregivers were over the age of 18 years, could provide written informed consent on behalf of the child (if the child was under 16 years old), and could speak and understand English.Ethics approval was obtained from the University of Auckland Human Participants Ethics Committee (ref# 022616). The Consolidated Standards of Reporting Trials (CONSORT) guidelines for reporting parallel group RCTs were followed  Multime.Participants were recruited from April to September 2019 through posts on websites and social media  by the University of Auckland and affiliates, and paid Facebook and Google advertisements that targeted Auckland parents. Specifically, we included 7 weeks of continuous Facebook advertising, 4 weeks of continuous Google advertising, and 3 to 4 separate posts on Twitter and Facebook. We also placed recruitment flyers in waiting rooms or reception areas of community centers and businesses in the health or youth sector . Participants were also recruited through face-to-face contact by the research assistant attending 14 separate community events and talking to parents, or through a trusted third party such as a community program. After 3 months of low recruitment, our approach was updated to include schools as potential third parties. Three schools were approached, and one consented to be involved. Further, the steering committee made 3 amendments to the trial in a bid to reduce barriers to participation and meet recruitment targets. We updated the study eligibility criteria so that participants no longer required access to an Android device and were no longer restricted to living in the Auckland region. Additionally, advertising materials no longer mentioned that we were targeting overweight/obese children for this intervention . These aAri and Friends, Diabetic Jumper, and Doodle Jump (control game). Participants were randomized in a 1:1:1 ratio, using a computer-generated random sequence with block randomization involving block sizes of 3 created by the study statistician. Immediately after the initial game play and 4 weeks after the meeting, the children completed the online healthy lifestyle and T2D questionnaires again, with additional questions on game attitudes and preferences  was adapted from a Doodle Jump open-source platform  and of sweet foods and drinks on their energy levels. Moreover, questions about healthy lifestyle and T2D were interspersed in the game , which cDoodle Jump did not have any information on T2D or healthy lifestyle behaviors. The object of the game was similar to Diabetic Jumper, with the aim to use platforms to continue jumping upwards without falling. Children allocated to the control game also played for 15 min per session.The control game The primary outcome was the number of hours played over a 4-week period recorded via the game software. Secondary outcomes were assessed via questionnaires 15 min (±5 min) after game play during the baseline session and at the 4-week follow-up. Secondary outcomes included (1) change in healthy lifestyle knowledge from baseline, (2) change in diabetes-specific knowledge from baseline, and (3) attitudes and preferences assessed using open-ended and free-text questions regarding the games. The questionnaires were designed specifically for this study and contained the same healthy lifestyle and T2D questions that boosted power levels in the games. Specifically, there were 18 multiple-choice questions about healthy lifestyles  and 9 true/false questions about T2D. Questions about specific healthy lifestyle topics featured in different levels of the 2 intervention games. For example, level 1 in both games contained questions about physical activity and diabetes, level 2 contained questions about nutrition and diabetes, and the remaining 4 levels contained other healthy lifestyle topics. See Our recruitment target was 60 participants, with 20 participants per study arm. As this was a pilot trial, our recruitment target was not powered to detect significant differences between groups. Study data were collected using REDCap, and all analyses were performed using SAS version 9.4 (SAS Institute). Baseline and follow-up variables were summarized according to group and descriptive summary statistics provided. The change from baseline in continuous outcomes was analyzed using ANOVA for normally distributed data and the Kruskal-Wallis test for nonnormally distributed data.Diabetic Jumper, 8 to Ari and Friends, and 8 to the control game. Participants identified predominantly as Samoan (n=15) and Tongan (n=6), and their BMI ranged from 22 to 46 kg/m2. See In terms of feasibility, we were unable to recruit our target of 60 participants. In total, 23 participants  were recruited between April and September 2019 through direct methods . Four paDiabetic Jumper thrice in the first evening and twice the next day .All participants played the games during the initial visit . Only 1 participant accessed the game after the testing session. The participant played P=.93) or the 4-week follow-up (P=.10).The mean correct scores for diabetes knowledge ranged from 4.6 to 6.6 (51%-73%) for each game at baseline, 5.6 to 6.0 (62%-66%) at the 15-min follow-up, and 5.3 to 6.6 (58%-73%) at the 4-week follow-up . There wP=.86) or the 4-week follow-up (P=.64).The mean correct scores for healthy lifestyle behavior knowledge ranged from 9.4 to 10.5 (52%-58%) for each game at baseline, 10.4 to 11.4 (57%-63%) at the 15-min follow-up, and 9.1 to 11.3 (50%-63%) at the 4-week follow-up . There wAri and Friends, 5 of the 8 (63%) participants indicated that the controls were easy to use and that the game was fun, but only 2 of the 8 (25%) participants said that they would recommend the game to their friends.For Diabetic Jumper, 6 of the 7 (85%) participants indicated that the controls were easy to use and the game was fun, and 3 of the 7 (42%) participants indicated that they would recommend the game to their friends.For Overall, 16 of the 23 (69%) participants reported that their parents allowed them to play video games in general “a bit” or “a lot,” and 13 of the 23 (56%) participants reported that their parents restricted their video game play to some extent. Moreover, 10 of the 23 (43%) participants were unsure if their parents would allow them to play the games from the study.Overall, this pilot trial sought to determine the feasibility and preliminary knowledge effects of using 2 prototype serious games for health to improve healthy lifestyle knowledge in youth aged 9-16 years at risk for T2D. The results showed no evidence of improved healthy lifestyle or diabetes knowledge immediately after playing the games or after 4 weeks. Despite all participants playing the games for the allocated 15 min and the mostly positive feedback about each of the 2 games, only 1 participant played the game after leaving the clinic, and this participant played only during the following 2 days. These results coupled with low participant numbers indicated that the games were not engaging enough to result in sustained play and that the intervention methodology was not feasible. However, there may still be potential for using these games in a clinic setting as tools with which to engage youth in healthy lifestyle and T2D knowledge alongside individual clinical advice.The operation of the 2 prototype games and the method of data extraction from the games were successful. There were no technical issues experienced in either of the games, and extraction of data on play duration, question answers, and food choices from the game software was achieved without any issues. Moreover, the children enjoyed playing both games. In combination, these 3 outcomes indicated that the games were reliable tools to briefly engage with young people who are at risk of diabetes or with diabetes. These outcomes align with the purpose of diabetes-based games for health, making the learning of glycemic control practices engaging and fun . ContrarPrevious studies involving games for health with hard-to-reach populations, such as youth at risk for diabetes, have ranged from case studies (n=1) to large experimental studies n=200) . Larger 0 . LargeWe propose 2 primary reasons for why the recruitment methods in this trial were not as successful as those in previous trials involving games for health. First, there was a teacher strike  and a naKey strengths of this trial include the considerable formative work to develop the games, the RCT design, and the objective collection of game play directly via the game software. One design limitation that hindered recruitment was having 2 consent processes when recruiting through a school. The school principal consented to conducting research on school grounds during or after school time with the pupils. Due to the age of the participants, parents also consented to participate or for a school or YMCA staff member to be present in lieu of the parent. Consequently, children were responsible for taking the consent forms home to their parents and returning the signed forms to a staff member. Forms were subsequently lost or forgotten and never returned. These consent processes were designed to remove the burden from parents having to attend baseline sessions and to keep their children involved. Unfortunately, the children received the burden of looking after the form. It is possible that recruitment could have been more successful with an alternative process  to ease the burden on the participant dyad.Three potential sources of bias should be noted. First, parents, caregivers, or staff members were present during the clinic-type sessions. The presence of authority figures might have influenced participants’ attitudes and preferences toward the games in a bid to be polite, please the authority figure, or behave oneself. This “effort to please” could explain why attitudes and preferences were positive, yet the games were not played during follow-up. Second, the eligibility criteria stipulated that participants had to have access to an Android device, not necessarily that they had to own one themselves. Devices were predominantly owned by parents or elder siblings, and the children might not have the opportunity to use the devices at home, limiting their opportunity to play the games. Third, the research assistant read the questions aloud to many of the younger participants who were struggling to read themselves. The results showed no evidence of change in knowledge, indicating that any unintentional inflection was undetected by the limited sample size or, more likely, was indicative that the participants did not understand the questions at all and guessed.The original purpose of the 2 prototype games was for children to play them while waiting with their parents to see the doctor . InitialIt was not feasible to recruit the target sample for this trial. Our 2 prototype serious games were unsuccessful at sustaining long-term play outside a clinic environment. Based on positive participant attitudes toward the games, it is possible to use these games or similar games as short-term stimuli to engage young people with healthy lifestyle and diabetes knowledge in a clinic setting; however, future research is required to explore this area.


Interstitial pregnancy is a rare type of ectopic pregnancy with a high risk of massive hemorrhage on rupture as compared to ectopic on other sites. The mortality rate for the ruptured interstitial pregnancy is high. Therefore, early diagnosis of such pregnancy before the rupture occurs facilitates appropriate management and avoids life-threatening complications. With the advancement in diagnostic imaging modalities, early diagnosis and more conservative management for interstitial pregnancy have become possible. Here, we report a case of primigravida diagnosed with interstitial pregnancy with ultrasonography and successfully managed with a single dose of methotrexate. Therefore, among all the ectopic pregnancies, interstitial pregnancy is associated with the highest risk of massive hemorrhage if rupture occurs with a mortality rate of 2-2.5%.3 There exists a challenge differentiating interstitial pregnancy from eccentrically implanted intrauterine pregnancy.4 Therefore, it is imperative that the radiologist and the treating doctor be aware of the diagnostic criteria of this rare condition for timely diagnosis to avoid life-threatening complications and mortality. We report a case of interstitial pregnancy diagnosed timely with ultrasonography in a 20-year-old primigravida successfully managed with a single dose of systemic methotrexate.Implantation of a blastocyst into the interstitial portion of the fallopian tube results in an interstitial pregnancy. It is a rare phenomenon accounting for 2-4% of all ectopic pregnancies.1/7 weeks of gestation with complaints of per vaginal spotting for the last three days. She did not have any other complaints at the presentation. Her vital parameters and per abdominal examination findings were normal. There was no active bleeding on per speculum examination and on bimanual examination, uterus was 6-8 weeks size, fornices were free and non-tender. The transvaginal sonography (TVS) showed a gestational sac of 71/7 weeks without a fetal pole or cardiac activity, eccentrically placed in uterine fundus towards the right side surrounded by thin myometrium; suggestive of interstitial pregnancy. Her human Chorionic Gonadotropin (hCG) value at admission was 4479mIU/ml.A 20-year-old primigravida presented to the emergency room of the Department of Obstetrics and Gynecology, B.P. Koirala Institute of Health Sciences at 72). For monitoring, she was kept in the ward and β hCG was repeated on day 4 and day 7 which was 3679 and 2244 respectively. She did not develop any symptoms while she was admitted to the ward and the β hCG values were in decreasing trend. Also, her residence was nearby the hospital and she was compliant to follow up.Thus, she was discharged with advice to follow up with the β hCG report on day 11. She was also advised to report to the emergency room if she experiences any symptoms suggestive of rupture. The β hCG value on day 11 was 1111 mIU/ml. The ultrasonography (USG) was repeated after two weeks which showed irregular gestational sac-like structure placed eccentrically in the fundus without cardiac activity, suggestive of interstitial pregnancy with embryonic demise  Empty uterine cavity; (b) Gestational sac separated <1 cm from the most lateral edge of the uterine cavity, and (c) Thin myometrial layer surrounding the gestational sac.3 If the interstitial pregnancy ruptures, laparotomy for the repair of defect or hysterectomy, in difficult cases, is often needed. Successful laparoscopic management for ruptured interstitial pregnancies is also being reported increasingly. Nevertheless, the route of surgery depends on the surgical expertise and availability of the facilities.Different surgical and non-surgical treatment modalities are available for the management of interstitial pregnancy. However, the choice of management depends on the patient's symptoms, hemodynamic stability, time of diagnosis, size of pregnancy, clinical expertise as well as the desire for fertility preservation.6The facilities for assessment of pregnancy at an earlier gestation, high-resolution transvaginal sonography, availability of quantitative β hCG level have enabled us to detect ectopic pregnancy before rupture occurs and manage them conservatively. Our patient also presented to us in the seventh week. Because of early presentation and diagnosis, conservative management was a feasible option for our patient. Conservative management may again be surgical or medical. Conservative surgical management includes laparoscopic resection of the pregnancy and involved tube with preservation of the uterine architecture.7 Dilatation and curettage under ultrasound guidance followed by a single dose of systemic methotrexate is also reported as a fertility-preserving method of management.8 However, conservative management should only be offered to those patients with radiological diagnosis of interstitial pregnancy, who do not have risk factors for immediate rupture and are hemodynamically stable. Also, close ultrasonographic and β hCG follow-up and good clinical acumen are must for conservative management.3 As our patient fulfilled all these criteria and was compliant to follow up, she proved to be an ideal candidate for conservative management. Also, there is always some risk of uterine rupture at the site of cornual repair in subsequent pregnancy.9Conservative medical management uses methotrexate through various routes like systemic, injection into the sac under ultrasound guidance through transvaginal or transabdominal route, hysteroscopic injection into the sac, or combined local and systemic route.7 In our patient, β hCG normalized after eight weeks and gestational sac in TVS disappeared at 22 weeks of treatment. During the course of treatment, she did not develop any complications, resumed menses after two months of treatment, and had regular cycles. However, she always had a concern regarding the persistence of the gestational sac for a long duration even after normalization of β hCG. We had counseled her at the start of treatment that resolution of the gestational sac may even take up to six months based on the literature. It took five months for the sac to disappear in her case. She was then advised that she can plan her next pregnancy after 6 months and visit for an early pregnancy checkup once she conceives again.Following Methotrexate treatment serum β hCG is reported to normalize by two months but gestational sac may be visible in USG for up to 4 months.Early detection of interstitial pregnancy allows for conservative management with Methotrexate in the hemodynamically stable patient if proper follow-up with β hCG and TVS can be done and emergency surgical management is available in case the need arises. Conservative management not only prevents the morbidity associated with anesthesia and surgical procedure but also avoids uterine scar and risk of rupture of the scar in the subsequent pregnancy. Having said so, the prerequisites and facility for proper follow-up should be ensured before deciding for conservative management.


This paper presents the design, optimisation and fabrication of a mechanically robust 3D printed microfluidic device for the high time resolution online analysis of biomarkers in a microdialysate stream at micro-litre per minute flow rates. The device consists of a microfluidic channel with secure low volume connections that easily integrates electrochemical biosensors for biomarkers such as glutamate, glucose and lactate. The optimisation process of the microfluidic channel fabrication, including for different types of 3D printer, is explained and the resulting improvement in sensor response time is quantified. The time resolution of the device is characterised by recording short lactate concentration pulses. The device is employed to record simultaneous glutamate, glucose and lactate concentration changes simulating the physiological response to spreading depolarisation events in cerebrospinal fluid dialysate. As a proof-of-concept study, the device is then used in the intensive care unit for online monitoring of a brain injury patient, demonstrating its capabilities for clinical monitoring. As a result, it is not possible to resolve local changes in analytes such as neurotransmitters or metabolic biomarkers in the immediate aftermath of tissue damage. Current research is focussed on developing tools to accurately measure dynamic changes in these analytes with high temporal resolution in order to aid clinical decision-making and to allow medical intervention to be administered earlier.Chemical changes in the body can provide essential information on tissue physiology and pathology and can guide patient treatment protocols.ex vivo for compounds of interest. Analysis is traditionally carried out offline, in discrete samples, which results in poor temporal resolution. Another consequence of offline analysis is that concentrations are averaged within a sample; for dynamic changes that are fast compared to the sampling period this results in attenuation of the signal. Online microdialysis,3 where the dialysate is analysed either continuously or near-continuously using an automated flow-injection sampling method, has been developed to overcome these issues. Combined with online analysis systems, online microdialysis provides high time resolution suitable for resolving dynamic changes in metabolite and neurotransmitter levels.7 Online microdialysis has been coupled with various high-frequency flow injection analytical techniques including electrochemical biosensors,13 capillary and microchip electrophoresis16 and liquid chromatography mass spectrometry.19 A recent development from flow-injection analysis is to carry out measurements in the dialysis stream continuously, improving the time resolution further still.24 Due to the availability of commercial FDA-approved probes, online microdialysis has been used in various clinical situations including monitoring of traumatic brain injury,24 bowel ischemia13 and free flap surgery.12Microdialysis is a sampling technique that can be used to locally monitor the metabolic state of tissue. This technique allows collection of molecules from a target tissue, creating a dialysate stream that is analysed −1). Traditionally, microfluidic devices have been fabricated with materials such as PDMS, thermoplastics or glass using soft lithography, micro-thermoforming, micro-milling or injection moulding techniques.27 Among these methods, PDMS-based soft lithography is still the most commonly used in the field of microfluidics due to its capacity to build very small channels, its low cost and its ease of fabrication. Although PDMS-based microfluidic devices have been used extensively in proof-of-concept studies for a wide range of applications,31 there are a range of challenges associated with them. Firstly, due to its elasticity, PDMS lacks mechanical robustness and micro-channels made of PDMS can deform under pressure, causing irregular flow, leaks to occur or air bubbles to become trapped, all perturbing the sample stream. This lack of robustness also makes it difficult to build secure and precise connections between PDMS-based microfluidic devices and other components. Therefore, expertise is required to handle and operate PDMS microfluidic devices making them impractical for non-experts, such as clinicians. Secondly, considerable expertise is required to reproducibly manufacture PDMS microfluidic devices in large quantities.Microfluidic devices are particularly well suited for online analysis of dialysate streams as they provide the low internal volumes required for high time resolution at the low flow rates typically found with microdialysis  techniques as these offer many advantages over PDMS-based soft lithography.34 SDs have been associated with the development of secondary damage and have been shown to independently predict poor patient outcome.37 The electrophysiological and chemical signatures of SDs have been recorded both in animal models41 and clinically.43 The occurrence of an SD wave is reflected in the local tissue by a transient increase in the extracellular levels of potassium and glutamate, coupled with a simultaneous decrease in glucose and increase in lactate, indicating a high energy demand.43 When we have used online microdialysis clinically,24 the metabolic response to an SD appears to take place on a slower timescale and exhibits a lower amplitude than when recorded with small implanted biosensors.38 Predominantly this is because the delicate PDMS-based microfluidic analysis system is protected in a metal box on a large trolley behind the patient’s bed and, to allow patient movement, the system is connected to the patient by one metre of low-volume tubing.24 However, due to Taylor dispersion, this connection tubing creates dispersive blurring of sharp changes in metabolite concentration,44 which in some cases lowers the amplitude of the transient changes below the limit of detection of the sensors, preventing the detection of an SD event.Online microdialysis combined with a 3D printed microfluidic device is particularly applicable for monitoring traumatic brain injury patients in the intensive care unit (ICU), where it is essential to have a sturdy system providing high temporal resolution. The injured human brain spontaneously undergoes spreading depolarisation (SD) events, which are associated with rapid neurochemical changes. An SD consists of a mass depolarisation of all neuronal cells, propagating like a wave over the cortex.45 while enabling them to be easily replaced if necessary. The main challenges in building this lab-on-a-chip platform are therefore to incorporate the smallest microfluidic channel possible with secure, reusable low-volume connections for both the dialysate and the sensors. Optimisation of the size of the 3D printed channel and the resulting improvement in analyser response time are presented, together with characterisation of the fastest pulses the device can resolve. As a proof-of-concept experiment, the device is employed within the current system in the ICU for online monitoring of a brain injury patient, demonstrating its capabilities for clinical monitoring.Here, we describe an improved lab-on-a-chip analysis system that is mechanically robust enough to be positioned closer to a patient and fast enough to measure the dynamic chemical changes associated with SDs, including those of the rapidly changing neurotransmitter glutamate. It consists of a 3D printed microfluidic device with low internal volume to analyse the dialysate stream. It incorporates a system for precisely positioning biosensors for analytes such as glutamate, glucose and lactate in the centre of the dialysate flow stream allowing a fast responseAspergillus niger and lactate oxidase from Aerococcus viridans were purchased from Sekisui Diagnostics. l-Glutamate oxidase from Streptomyces sp. was purchased from Cosmo Bio Co. Polyurethane (Texin 985) was purchased from Bayer. All other chemicals were obtained from Sigma-Aldrich and were of at least ACS reagent grade.Glucose oxidase from 46 Briefly, a 50 μm Teflon insulated platinum wire  and a 50 μm polyester insulated silver wire  were threaded through a 27G hypodermic needle. A flame was used to expose the metal at each end of the wires and the top ends were connected to contact pins via conventional electrical wires using conductive silver epoxy (RS Components Ltd). The internal volume of the needle was filled with epoxy resin (Robnor Resinlab Ltd) and left to cure at room temperature overnight. The sharp end of the needle was then cut and sanded down to expose the microelectrode discs at the tip. The blunt needle was then polished further with alumina slurries . The platinum disc acted as the working electrode and the silver disc was made into a Ag|AgCl reference electrode by dipping the needle tip in a chloridising solution (BASi) for 5 s and then in a 1 M hydrochloric acid solution for 20 s. The needle shaft was connected to an electrical wire using conductive silver epoxy glue and acted as the counter electrode. The working electrode surface was assessed using cyclic voltammetry.Biosensors used in this study were based on combined needle electrodes.47 To fabricate biosensors, two layers were systematically added onto the electrode surface, as shown in m-phenylenediamine) (poly(mPD)) film was electropolymerised onto the working electrode surface by placing the needle tip into a 100 mM solution of mPD in 10 mM PBS at pH 7.4 and holding the working electrode at 0.7 V for 20 minutes. Cyclic voltammetry was used to assess the coating. A second layer consisting of a hydrogel was then added to immobilise enzymes onto the electrode surface, as described elsewhere.47 Full details are given in the ESI.Our fabrication method uses hydrogels to give high enzyme loading.vs. Ag|AgCl and to record biosensor output currents. All signals in this study were recorded with a sampling frequency of 200 Hz and a 10 Hz low-pass filter.In-house high-performance potentiostats connected to a PowerLab (ADInstruments) were used to hold the working electrode at +0.7 V in vitro studies, in-house concentric microdialysis probes  were constructed using Spectra/Por microdialysis hollow fibres. Full details of the fibres used are given in the ESI.†Both clinical and in-house microdialysis probes were used. For clinical studies, a CMA70 brain microdialysis probe , MDialysis, Sweden) was used. For PDMS chips were fabricated using PDMS silicone elastomer and curing agent  in the ratio 9 : 1. The mixture was poured onto a positive SU8 master  and placed in the oven at 65 °C for 1 h, after bubbles were removed using a desiccator. Once cured, holes were pierced for the inlet/outlet tubing and for the sensors. The base of each chip was made by semi-curing the PDMS mixture before assembling the two parts and placing them in the oven at 65 °C overnight to fully cure.x- and y-directions and 50 to 100 μm resolution in the z-direction according to its technical datasheet. However, the true resolution depends on several other parameters such as the printing material used and the geometry of the part. Here, the material loaded in the Ultra 3SP was the “ABS white”, which is known for its toughness and mechanical stability. The second printer tested to print the microfluidic chips was the Objet 30, which uses Polyjet technology. This involves jetting layers of curable liquid photopolymer onto a build tray and instantly curing them with UV. To build intricate features such as a microfluidic channel, it deposits soluble support material (SUP706), which is removed afterwards by bathing the part in a 2% (w/v) sodium hydroxide solution. This printer has an accuracy of 100 μm, although this can vary depending on the geometry of the part, the size, orientation and material used. For our microfluidic chips, the material used with this printer was VeroClear (RGD810), which allows transparency as well as dimensional stability and surface smoothness.In this study, two different printers using distinct technologies were tested to print the hard microfluidic flow-cells: the Ultra 3SP and the Objet 30. The Ultra 3SP uses a scan, spin and selectively photocure technology, which projects images from a digital light source to selectively cure a vat-contained photopolymer voxel by voxel. It provides 100 μm resolution in the The chips 3D printed with the Ultra 3SP were rinsed with IPA and water. They were then placed in a UV oven for 30 s on each side. This post-curing stage was carried out to make the chips harder and more stable, especially around the sensor inserts, which were subjected to friction. The chips printed with the Objet 30 were first cleaned with a water jet to remove most of the Electrode holders were 3D printed with the Objet 260 Connex 3D printer because it can print materials with different rigidity on the same component. Here, the main part was made from hard VeroWhitePlus (RGD835) and the softer tip was made of TangoBlack (FLX973). Once printed, the holders were washed with a water jet to remove all 52 built with LabSmith components. It consisted of a computer-programmed bread-board mounted with two 20 μl pumps, two 1 ml reservoirs and two 3-way valves. Each reservoir contained a different concentration of the analyte(s) of interest. By varying the flow rate of each pump, different analyte concentrations were generated while maintaining a constant total flow rate of 2 μl min−1.Sensor calibration and testing was done using an automated microfluidic workstationThe microfluidic workstation was assembled using polyetheretherketone (PEEK) 150 μm i.d., 360 μm o.d. tubing (Kinesis). The extension tubing used for the microdialysis experiment was fluorinated ethylene propylene (FEP) 120 μm i.d., 1/32″ o.d. tubing (Kinesis). The same extension tubing (one metre long) was used for the clinical experiment.Patients requiring emergency craniotomy for the treatment of vascular and traumatic brain injuries were identified and research consent was obtained from legally authorised representatives. Study data was anonymised and securely stored. All human research procedures were approved by the appointed UK Research Ethics Committee and were conducted in accordance with the Declaration of Helsinki.peri-lesion tissue around the injury core. The probe was externalised through the scalp and secured using double stay sutures.Upon completion of surgery, a clinical microdialysis probe was inserted into the cortex. The aim was to place the probe in the 24 A continuous 21-channel EEG recording was also acquired. Arterial blood pressure was continuously recorded and blood gases, glucose and electrolytes were documented periodically.In addition to the microdialysis data, electrocorticography (ECoG) data was also collected as previously described.Patients were sedated and treated according to King’s College Hospital protocols.et al.,23 which, though lacking the necessary temporal resolution for this application, provides a secure way of inserting sensors into the microfluidic channel. It consists of two distinct parts: the biosensor-enclosing holders and the microfluidic chip .Two 3D printers (Ultra 3SP and Objet 30) were tested to optimise fabrication of the microfluidic channel. For each printer, the microfluidic flow-cell was printed with different channel dimensions and in different orientations in order to obtain the best spatial resolution. Indeed, one of the biggest challenges in 3D printing microstructures is that the dimensions of the printed parts differ from that specified in the design file. For the Objet 30, an inkjet printer, this deviation from the specified dimensions was mostly caused by the asymmetry of the part being printed; creating an uneven distribution of weight around the microchannel that resulted in distortions. For the Ultra 3SP, a stereolithography (SLA) printer, the vat of liquid polymer precursor around the part helped support the weight; in this case dimension errors mainly occurred due to shrinkage of the ABS white during cooling. To address these issues, a CT scan  was used to assess and measure the printed channel. The design files were then amended depending on actual dimensions achieved with each printer/orientation and reprinted iteratively to optimise the channel spatial resolution. For cost and time effectiveness, this optimisation process was first done on shorter microfluidic chips containing one biosensor insert only. The smallest functional microfluidic channels obtained from both the Objet 30 (chip 1) and the Ultra 3SP (chip 2) are featured in Ideally, the microfluidic channel should be circular to provide minimum dispersion. Both rectangular and circular channels were designed and compared in this study. Channels that were circular in the design file were found to collapse more frequently than rectangular ones. Furthermore, prints for rectangular channels appeared in practice with rounded corners. Therefore, the design dimensions presented in z-axis. This was to be expected, as accuracy is always greater in the horizontal xy-plane. However, for the Objet 30, printing the chip with the channel vertical resulted in distortions along the channel and around the sensor inserts, which appeared flattened. These effects were accentuated when printing the longer chips required for more than one sensor, and were presumably due to insufficient or uneven support around the vertical axis. This issue was resolved by printing the chip with the channel horizontal and accounting for the lower accuracy of the z-direction in the design file dimensions. Typically, the channel height defined in the design file had to be 20% larger than the one aimed at in the final print to compensate for this shrinkage. Printing the channel in the xy-plane helped to minimise feature deformations.For the Ultra 3SP, the optimum printing orientation was found to be with the channel built along the vertical −1 in the three different 3D-printed chips featured in 24 shown in These chips were then tested to study the effect of the channel size on the sensor response time to a change in concentration. As chip dimensions vary between different materials and different printing orientations, the design of the sensor holder was adapted for each flow-cell in order to ensure a leak free connection and to run a fair comparison test. T90 time response of the sensing platform being more than 3 times smaller for chips 1 and 2 than for chip 3, as seen in the inset table of T90 response time reduced by 68% for chip 2 and 76% for chip 1. The slow response of the PDMS chip reflects both the compliance of PDMS chip (leading to expansion of channel dimensions) and the great practical difficulty of making near zero dead volume connections between tubing and channels in the PDMS.The sensor responses recorded in the optimised 3D printed chips 1 and 2 were extremely reproducible as shown by the standard deviation traces in T90 of 8.9 ± 0.2 s at 2 μl min−1 (chip 1). However, these tests were run in shorter flow cells made for one sensor only. Longer versions of this channel were found to be extremely hard to clear of the Of the two printers tested, the smallest channel was achieved with the Objet 30 giving the fastest response time to the 2 mM lactate step with a tmin) below which the current response will not reach its full amplitude. To find this threshold, the plateau durations of the current responses were plotted against the durations of the corresponding generated pulses, as shown in To further characterise the temporal resolution of the sensing platform, 2 mM lactate pulses of different durations were generated with our high-precision microfluidic workstation and current responses were recorded for a lactate sensor placed in position 1 of the analysis chip. Due to Taylor dispersion acting along the microfluidic channel, concentration changes recorded downstream at the sensors were broadened compared to the upstream pulses, as illustrated in in vitro using the microfluidic workstation and recorded with our high time resolution analyser incorporating sensors for glutamate, glucose and lactate. Glucose and lactate levels were mimicked based on SD events previously recorded in brain dialysate of TBI patients by Rogers et al.24 This study showed that the simultaneous drop in dialysate glucose and rise in lactate levels triggered by an SD wave occurred on a 5-minute timescale and a 100 μM-amplitude scale on average. Transient extracellular glutamate increases occurring with the onset of an SD have been measured in animal models on a 10 μM scale.48 Basal tonic levels of brain extracellular glutamate vary greatly depending on the measurement technique employed but in vivo microdialysis and voltammetry studies have recorded concentrations between 1 and 30 μM, with the majority between 1 and 5 μM.49T90 of the 10 μM glutamate rises displayed in 50 making the system a promising tool to study the neurochemical mechanisms behind decision making.SD-like physiological events were simulated n = 7 10-minute measurements spread across the recording period), a high level compared to previous reports.49 During the first 3 days of monitoring, glucose levels were 0.4 ± 0.1 mM , which is on the lower end of the range previously measured in injured human brains.24 On day 4, glucose levels were elevated to 1.5 ± 0.5 mM . Throughout the whole monitoring period, lactate levels were stable at 1.6 ± 0.4 mM , which is high compared to what was previously recorded in patients.24 All three metabolite levels recorded here suggest the microdialysis probe was positioned in injured brain tissue. The patient was also monitored for electrophysiology and no SD event was detected in the whole dataset. However, a spontaneous rise in glutamate concentration was detected on day 4 of the monitoring period and this data is shown in 6 These chemical changes, although looking characteristic of a secondary insult to the brain, did not coincide with an ECoG event (such as an SD), or with a transient change in arterial blood pressure. Although the origin of this event is unknown, it may reflect a different sort of secondary insult to the injured human brain. Indeed, a drop in extracellular glucose levels typically reflects an unmet energy demand while an increase in glutamate levels could be associated with pathophysiological membrane depolarisation.51As a proof-of-concept experiment, our new lab-on-a-chip device was used to monitor a patient with an intracerebral haemorrhage (ICH). Brain chemical monitoring was carried out for 4 days continuously using the device described here. Local glutamate, glucose and lactate levels were monitored successfully. Calibration of the sensors in the microfluidic channel was performed automatically every two hours, a period chosen as a balance between calibration integrity and loss of clinical data. This showed that all three sensors were working during their whole period of use, demonstrating the mechanical and analytical robustness of the device. Unlike our previous PDMS chip, the new 3D printed analyser is not affected by movement of the device as the sensors are securely enclosed and locked in the channel. Hence, coupled with wireless electronics, the mechanical robustness and small size of this platform would allow it to be positioned closer to the patient, reducing the length of dialysate tubing required to connect the probe outlet to the analyser, minimising dispersion of concentration changes and improving the temporal resolution within the clinic further still. It would also reduce the delay with which physiological events are detected, allowing the medical team to make critical decisions earlier to potentially minimise the spread of the injury and to prevent the development of secondary brain injury.via tubing extensions of different lengths. T90 response time for the lactate change in two configurations with different connection tubing lengths. The first configuration “by patient bedside” reproduces the current hospital setup where the analyser is placed on a trolley, connected to the probe outlet via a 1 m length of extension tubing (120 μm i.d.). In the “by patient head” configuration, the probe outlet tubing was cut so that the analyser was 5 cm away from the point where the probe would exit the brain, simulating a situation where the analyser would be placed on or around the patient’s head. As shown in T90 system response time by 48%. Importantly, for clinical use the standard deviations are much smaller, making the system more reproducible.To evaluate these potential improvements on delay and temporal resolution, a clinical microdialysis probe was placed in a stirred beaker in which the lactate concentration was increased from 0 to 2 mM. The outlet of the microdialysis probe was connected to the analyser T90 response time of 16.6 ± 0.45 s. This test proves that the performance of the system is now being limited by the clinical microdialysis probe. When our analyser is coupled with a low-volume in-house built microdialysis probe instead, it is significantly faster. Indeed, this extremely high time resolution integrated device would enable the detection of physiological events occurring in the tissue surrounding the probe within half a minute.The same experiment was also carried out with an in-house built microdialysis probe in the “by patient head” configuration to evaluate the performance of our optimised flow-cell analyser with a sampling system that has a lower outlet-tubing diameter and hence a higher temporal resolution. The current response generated from the lactate concentration increase is shown in 38 it even approaches the fast timescale of SD-induced transient glutamate changes recorded using implanted biosensors.48 Simultaneous rapid changes in physiological levels of glutamate, glucose and lactate mimicking dialysate levels seen during SD events were successfully recorded. As a proof-of-concept experiment, the device was used in the ICU to monitor a patient with severe acute brain injury for 4 days continuously, demonstrating the suitability of the device for long-term monitoring. For the first time, a dynamic glutamate change was detected in a living human brain in real time. By careful design, it was possible to incorporate simple screw-type connections for inlet/outlet tubings and to secure sensors reproducibly in the microfluidic channel making the device easy to operate by a non-expert, ideal for clinical monitoring. The mechanical robustness of this new device also allows analysis to occur closer to the patient, removing the need for a bedside trolley and minimising dispersion down the connection tubing. Results presented here show that this would drastically reduce the delay of the system and improve the temporal resolution. The portability of the device is a huge advantage for its use in the ICU where the current wired monitoring systems prevents patient mobility and is cumbersome around routine clinical care. This device shows great promise for clinical monitoring and has potential for use in numerous clinical applications.We have presented the development and optimisation of a new, mechanically and analytically robust, 3D printed microfluidic analyser for monitoring of dynamic concentration changes in a flow stream with high temporal resolution. Using this new device it is possible to resolve transient metabolite concentration changes as short as 8 s. This high time resolution is perfectly suited for monitoring the dynamic changes in glucose and lactate seen in the injured brain;SI