Three-vessel view of the fetal heart: in utero development of the great vessels

OBJECTIVES: The purpose of our study is to provide reference values for the great vessels obtained from images of the three-vessel view of the fetal heart, with an emphasis on the size discrepancy of the great vessels. METHODS: From February 2003 to May 2003, the main pulmonary artery (MPA), ascending aorta (AA), and SVC were measured in well-dated, nonanomalous fetuses scanned at 14-38 weeks of gestation. RESULTS: The size of each great vessel had a significant positive relationship with advance in gestation (P < 0.001); MPA (mm) = -2.76 + 0.34 x GA, ascending aorta (AA) (mm) = -1.73 + 0.26 x GA - 1.18E - 05 x GA(3), and SVC (mm) = 0.33 + 0.01 x GA(2) - 4.12E - 05 x GA(3). The AA/MPA ratio was significantly decreased with advance in gestation, while the SVC/AA ratio was significantly increased; AA/MPA ratio = -1.24 - 0.03 x GA + 3.88E - 04 x GA(2); P < 0.001, SVC/AA ratio = 0.63 - 5.43E - 03 x GA + 1.96E - 04 x GA(2); P < 0.001. CONCLUSION: On the three-vessel view of the fetal heart, the interpretation of the size discrepancy of the great vessels needs to be adjusted according to fetal growth.     

Isolated full-thickness cervical stromal invasion warrants post-hysterectomy pelvic radiotherapy in FIGO stages IB-IIA uterine cervical carcinoma

OBJECTIVE: To evaluate the potential benefit of postoperative radiotherapy (PORT) in women with isolated full-thickness cervical stromal invasion (FTSI) as an unfavorable pathological finding after radical hysterectomy and pelvic lymph node dissection (PLND) in FIGO stages IB-IIA cervical carcinoma. METHODS: A total of 1868 patients with stages IB-IIA cervical carcinoma underwent radical hysterectomy and PLND between January 1982 and December 2002. Seventy-four of these patients had isolated FTSI without any other unfavorable pathological finding, such as lymph node metastasis, microscopic parametrial involvement, involved resection margin, lympho-vascular space invasion, or large clinical tumor diameter (>4 cm). Forty-one of these patients had no adjuvant treatment (S group) and 33 received PORT (PORT group). Patients with isolated FTSI who received chemotherapy were excluded. Treatment outcomes in the PORT and S groups were compared. RESULTS: Ten-year disease-free survival (DFS) and pelvic-failure-free survival (PFFS) of S group vs. PORT group were 73.2% vs. 92.4% (P=0.038) and 79.8% vs. 97.0% (P=0.044), respectively. According to a Cox proportional hazards model developed by forward, stepwise regression incorporating all prognostic variables, only PORT was marginally significant for DFS (RR 0.234; 95% CI 0.051-1.067; P=0.061) and significant for PFFS (RR 0.055; 95% CI 0.005-0.620; P=0.019). A grade 4 late complication developed in two patients (6%) in PORT group. CONCLUSION: PORT administered to patients with isolated FTSI after radical hysterectomy and PLND improves pelvic control in FIGO stages IB-IIA cervical carcinoma with acceptable morbidity.     

Deep vein thrombosis of the common iliac vein caused by neurogenic heterotopic ossification in the anterior lower lumbar spine of a patient with complete paraplegia due to radiation-induced myelopathy

Context: Deep vein thrombosis (DVT), a frequent complication of spinal cord injury, is occasionally caused by neurogenic heterotopic ossification (NHO). In most cases of NHO, the hip joint is affected. Herein, we present a case of paraplegia following radiation-induced myelopathy that presented with left leg swelling due to DVT in the common iliac vein (CIV) caused by venous compression by NHO on the anterior lower lumbar spine.Findings: A 28-year-old man with complete paraplegia due to radiation-induced myelopathy presented with left lower extremity swelling 6 years after the onset of paraplegia. DVT in the left CIV was observed on computed tomography venography. The left CIV was significantly compressed between the NHO at the anterior longitudinal ligament of the lumbar spine and the right common iliac artery, suggestive of May-Thurner syndrome. Slightly distal to that compressed area, the left CIV was significantly compressed by the large NHO at the anterior longitudinal ligament of the lumbar spine.Conclusions: We believe that such compression of the left CIV would have contributed to the development of DVT. This case shows that DVT might be caused by NHO at the anterior aspect of the lumbar vertebral body, and this may help clinicians identify the main cause of DVT in the leg.     

Long-term outcome in patients with obscure gastrointestinal bleeding after negative capsule endoscopy

AIM:To investigate long-term outcome in obscure gastrointestinal bleeding(OGIB) after negative capsule endoscopy(CE) and identify risk factors for rebleeding.METHODS:A total of 113 consecutive patients underwent CE for OGIB from May 2003 to June 2010 at Seoul National University Hospital.Ninety-five patients(84.1%) with a subsequent follow-up after CE of at least 6 mo were enrolled in this study.Follow-up data were obtained from the patients’ medical records.The CE images were reviewed by two board-certified gastroenterologists and consensus diagnosis was used in all cases.The primary outcome measure was the detection of rebleeding after CE,and factors associated with rebleeding were evaluated using multivariate analysis.RESULTS:Of the 95 enrolled patients(median age 61 years,range 17-85 years),62 patients(65.3%) were male.The median duration of follow-up was 23.7 mo(range 6.0-89.4 mo).Seventy-three patients(76.8%) underwent CE for obscure-overt bleeding.Complete examination of the small bowel was achieved in 77 cases(81.1%).Significant lesions were found in 38 patients(40.0%).The overall rebleeding rate was 28.4%.The rebleeding rate was higher in patients with positive CE(36.8%) than in those with negative CE(22.8%).However,there was no significant difference in cumulative rebleeding rates between the two groups(log rank test;P = 0.205).Anticoagulation after CE examination was an independent risk factor for rebleeding(hazard ratio,5.019;95%CI,1.560-16.145;P = 0.007),regardless of CE results.CONCLUSION:Patients with OGIB and negative CE have a potential risk of rebleeding.Therefore,close observation is required and alternative modalities should be considered in suspicious cases.     

Clinical outcomes of secondary stent-in-stent self-expanding metal stent placement for primary stent malfunction in malignant gastric outlet obstruction

Background

Although a substantial number of patients require secondary stents insertion due to primary stent malfunction in malignant gastric outlet obstruction, data on the outcomes of secondary self-expanding metal stents are sparse.

Aim

To investigate clinical outcomes and factors related with secondary stent malfunction in patients with malignant gastric outlet obstruction given secondary stent-in-stent self-expanding metal stent insertion.

Methods

For this retrospective study, a total 77 patients who underwent secondary stent-in-stent self-expanding metal stent placement for primary stent malfunction in malignant gastric outlet obstruction were enrolled. We compared the effectiveness and complications of secondary covered and uncovered stents and explored the predictive factors for stent malfunction.

Results

Stent-in-stent self-expanding metal stent placements were technically successful in all patients. Both groups also had comparable clinical success rates (covered stent, 87.2% and uncovered stent, 90.0%, P = 1.000). Stent malfunction rates (31.9% and 36.7% respectively, P = 0.805) and median patency time of stent (165 [95% confidence interval: 112–218] and 165 [95% confidence interval: 126–204] days, respectively, P = 0.358) were similar between secondary covered and uncovered stents. Longer patients’ survival time (≥100 days) was associated with increased risk of stent malfunction (odds ratio: 4.598; 95% confidence interval: 1.473–14.355; P = 0.009).

Conclusions

Secondary stent-in-stent self-expanding metal stent placement is feasible and effective treatment for primary stent malfunctions in malignant gastric outlet obstruction. Covered and uncovered stent are equally acceptable in terms of stent-related complications and stent patency, regardless of primary stent type.     

A Study on the Mechanical Properties of an Automobile Part Additively Printed through Periodic Layer Rotation Strategies

In metal product manufacturing, additive manufacturing (AM) is a method that has the advantage of fabricating complex shapes and customized production, unlike existing machining methods. However, owing to the characteristics of the AM process, anisotropy of macrostructure occurs because of various causes such as the scan direction, melting, fusion, and cooling of the powdered material. The macrostructure anisotropy is realized from the scan direction, and when a single layer is stacked in one direction, it is expressed as orthogonal anisotropy. Here, the classical lamination theory is applied to simply calculate the individual orthotropic layers by superimposing them. Through this, the authors analyzed whether the mechanical properties of the product are isotropically expressed with a periodic layer rotation strategy. To determine if the mechanical properties can be reasonably considered to be isotropic, a shock absorber mount for a vehicle was manufactured by AM. The tensile and vibration test performed on the product was compared with the finite element analysis and experimental results. As a result of the comparison, it was confirmed that the macroscopically of the product was considered isotropic as the load-displacement diagram and the fracture location coincided, as well as the natural frequency and mode shape.     

Impact of protocolized postarrest care with targeted temperature management on the outcomes of cardiac arrest survivors without temperature management

IntroductionProtocolized postarrest care that includes targeted temperature management (TTM) improves survival and neurological outcomes in cardiac arrest survivors. Whether the accumulated experience regarding the use of the protocolized approach also benefits patients who did not undergo TTM has yet to be investigated.MethodsAdults (≥18 years old) with nontraumatic cardiac arrest and who survived to intensive care unit (ICU) admission were retrospectively recruited from a single tertiary medical centre from 2006 to 2009 and 2011 to 2017. Patients were excluded if they had traumatic injuries, were pregnant, did not survive to ICU admission, regained clear consciousness within 3 h after the return of spontaneous circulation, or underwent TTM. The sum of TTM cases since 2006 and before the cardiac arrest of each enrolled patient was used as a substitute index for the amount of experience accumulated from the use of protocolized TTM care.ResultsIn total, 802 non-TTM patients were enrolled in the final analysis. The rate of survival to hospital discharge increased from 25.9% in 2006 to 33.3% in 2017. Regarding neurological recovery at hospital discharge, the incidence of favourable neurological function (cerebral performance category: 1 or 2) increased from 10.3% in 2006 to 23.5% in 2017. A multiple logistic regression indicated a significant association between the cumulative TTM case numbers and neurological outcomes in patients who did not receive TTM.ConclusionsThe improvement of neurological outcomes in adult nontraumatic cardiac arrest survivors who did not receive TTM was associated with the cumulative number of cases receiving protocolized TTM care. In the era of TTM, the use of only historical control data might lead to bias, which is caused by overlooking the influence of a more refined protocolized postarrest care that includes TTM.

KEY MESSAGE

• The cumulative number of cases receiving protocolized TTM care, which we used as a substitute index for the amount of experience accumulated from the use of protocolized postarrest care that includes TTM, was associated with the improvement of neurological outcomes in adult nontraumatic cardiac arrest survivors who did not receive TTM.

     

Hypothyroidism risk associated with rheumatoid arthritis: A population-based retrospective cohort study

Studies on the thyroid disease risk in patients with rheumatoid arthritis (RA) associated with comorbidities are limited. This population-based retrospective cohort study investigated the hypothyroidism risk in patients with RA and the role of comorbidities.We used Taiwan National Health Insurance Research Database to identify 16,714 RA patients newly diagnosed in 2000 to 2008 and 66,856 control persons without RA, frequency matched by sex, age, and index year. Incidence and the RA group to controls hazard ratio of hypothyroidism were estimated.The hypothyroidism incidence was 1.74-fold higher in the RA group than in controls (16.6 vs 9.52 per 10,000 person–years), with the Cox method estimated adjusted hazard ratio of 1.67 (95% confidence interval = 1.39–2.00) after controlling for covariates. Near 75% of the study population were women, with the incidence 3.6-time higher than men in both groups. The hypothyroidism incidence increased with age, from 12.1 per 1000 person–years in 20 to 39 years to 20.0 per 1000 person–years in 60+ years in RA patients, higher than that in controls (7.17 vs 10.0 per 1000 person–years, respectively by age). Each comorbidity was related to an increased incidence and higher in the RA group than in controls. Among all comorbidities, stroke exerted the greatest impact in the RA group with an adjusted hazard ratio of 3.85 (95% confidence interval = 1.24–12.0).RA patients have an increased risk of developing hypothyroidism; this risk was pronounced in women and the elderly. RA patients should be closely monitored to prevent the development of hypothyroidism.     

Minimal and Maximal Extent of Band Ligation for Acute Variceal Bleeding during the First Endoscopic Session

Background/AimsThe appropriate number of band ligations during the first endoscopic session for acute variceal bleeding is debatable. We aimed to compare the technical aspects of endoscopic variceal ligation (EVL) in patients with variceal bleeding according to the number of bands placed per session.MethodsWe retrospectively reviewed multicenter data from patients who underwent EVL for acute variceal bleeding. Patients were classified into minimal EVL (targeting only the foci with active bleeding or stigmata of recent bleeding) and maximal EVL (targeting potential bleeding sources in addition to the aforementioned targets) groups. The primary endpoint was 5-day treatment failure. The secondary endpoints were 30-day rebleeding, 30-day mortality, and intraprocedural adverse events.ResultsMinimal EVL was associated with lower rates of hypoxia and shock during EVL than maximal EVL (hypoxia, 0.9% vs 2.9%; shock, 1.3% vs 3.4%). However, treatment failure was higher in the minimal EVL group than in the maximal EVL group (odds ratio, 1.60; 95% confidence interval, 1.06 to 2.41). Age ≥60 years, Model for End-Stage Liver Disease score ≥15, Child-Turcotte-Pugh classification C, presence of hepatocellular carcinoma, and systolic blood pressure <90 mm Hg at initial presentation were also associated with treatment failure. In contrast, 30-day rebleeding and 30-day mortality did not differ between the minimal and maximal EVL groups.ConclusionsGiven that minimal EVL was associated with a high risk of treatment failure, maximal EVL may be a better option for variceal bleeding. However, the minimal EVL strategy should be considered in select patients because it does not affect 30-day rebleeding and mortality.