Endoscopic ultrasound-guided tissue sampling induced pancreatic duct leak resolved by the placement of a pancreatic stent: A case report.

BACKGROUND: Pancreatic ductal leaks complicated by endoscopic ultrasonography-guided tissue sampling (EUS-TS) can manifest as acute pancreatitis. CASE SUMMARY: A 63-year-old man presented with persistent abdominal pain and weight loss. Diagnosis: Laboratory findings revealed elevated carbohydrate antigen 19-9 (5920 U/mL) and carcinoembryonic antigen (23.7 ng/mL) levels. Magnetic resonance imaging of the pancreas revealed an approximately 3 cm ill-defined space-occupying lesion in the inferior aspect of the head, with severe encasement of the superior mesenteric artery. Pancreatic ductal adenocarcinoma was confirmed after pathological examination of specimens obtained by EUS-TS using the fanning method. Interventions and outcomes: The following day, the patient experienced severe abdominal pain with high amylase (265 U/L) and lipase (1173 U/L) levels. Computed tomography of the abdomen revealed edematous wall thickening of the second portion of the duodenum with adjacent fluid collections and a suspicious leak from either the distal common bile duct or the main pancreatic duct in the head. Endoscopic retrograde cholangiopancreatography revealed dye leakage in the head of the main pancreatic duct. Therefore, a 5F 7 cm linear plastic stent was deployed into the pancreatic duct to divert the pancreatic juice. The patient's abdominal pain improved immediately after pancreatic stent insertion, and amylase and lipase levels normalized within a week. Neoadjuvant chemotherapy was then initiated. CONCLUSION: Using the fanning method in EUS-TS can inadvertently cause damage to the pancreatic duct and may lead to clinically significant pancreatitis. Placing a pancreatic stent may immediately resolve acute pancreatitis and shorten the waiting time for curative therapy. When using the fanning method during EUS-TS, ductal structures should be excluded to prevent pancreatic ductal leakage.

Management of post-liver transplantation biliary stricture inaccessible by endoscopic retrograde cholangiopancreatography: A case report.

BACKGROUND: One challenging scenario in the treatment of biliary stricture is that post-liver transplantation (LT) biliary strictures cannot be accessed using endoscopic retrograde cholangiopancreatography (ERCP). Here, we report such a case that was successfully treated using a novel endoscopic technique. CASE SUMMARY: A 60-year-old man presented with obstructive jaundice caused by a post-LT biliary stricture. He underwent LT for compensated alcoholic liver cirrhosis and hepatocellular carcinoma. Laboratory investigations unveiled a cholestatic pattern of abnormalities in liver function and a total bilirubin level of 16 mg/dL. Magnetic resonance cholangiopancreatography revealed a stricture extending from the right intrahepatic bile duct into the common hepatic duct. Severe postoperative deformities made accessing the ampulla of Vater with a side-viewing duodenoscope impossible. Percutaneous transhepatic biliary drainage (PTBD) was performed to treat biliary obstruction. Moreover, to resolve the stricture completely, a fully covered self-expandable metal stent (FC-SEMS) with a novel proximal retrievable string was deployed into the post-LT biliary stricture through the PTBD tract. Before inserting the stent through the PTBD tract, the stent with the distal string was manually inverted to ensure that the distal part with the string became the proximal part for later endoscopic removal. After 6 mo, the FC-SEMS was successfully removed without complications, as the string was pulled out using a forward-viewing gastroscope. CONCLUSION: Deployment and endoscopic removal of an FC-SEMS with a novel proximal string through the PTBD tract may be a viable option for treating post-LT biliary strictures that are inaccessible by ERCP.

Feasibility of artificial intelligence-driven interfractional monitoring of organ changes by mega-voltage computed tomography in intensity-modulated radiotherapy of prostate cancer.

PURPOSE: High-dose radiotherapy (RT) for localized prostate cancer requires careful consideration of target position changes and adjacent organs-at-risk (OARs), such as the rectum and bladder. Therefore, daily monitoring of target position and OAR changes is crucial in minimizing interfractional dosimetric uncertainties. For efficient monitoring of the internal condition of patients, we assessed the feasibility of an auto-segmentation of OARs on the daily acquired images, such as megavoltage computed tomography (MVCT), via a commercial artificial intelligence (AI)-based solution in this study. MATERIALS AND METHODS: We collected MVCT images weekly during the entire course of RT for 100 prostate cancer patients treated with the helical TomoTherapy system. Based on the manually contoured body outline, the bladder including prostate area, and rectal balloon regions for the 100 MVCT images, we trained the commercially available fully convolutional (FC)-DenseNet model and tested its auto-contouring performance. RESULTS: Based on the optimally determined hyperparameters, the FC-DenseNet model successfully auto-contoured all regions of interest showing high dice similarity coefficient (DSC) over 0.8 and a small mean surface distance (MSD) within 1.43 mm in reference to the manually contoured data. With this well-trained AI model, we have efficiently monitored the patient's internal condition through six MVCT scans, analyzing DSC, MSD, centroid, and volume differences. CONCLUSION: We have verified the feasibility of utilizing a commercial AI-based model for auto-segmentation with low-quality daily MVCT images. In the future, we will establish a fast and accurate auto-segmentation and internal organ monitoring system for efficiently determining the time for adaptive replanning.

First Case of Atypical, Generalized Skin Rash after Transarterial Chemoembolization in a Patient with Hepatocellular Carcinoma.

Transarterial chemoembolization (TACE) is a widely used hepatocellular carcinoma (HCC) treatment. Some cases of supraumbilical skin rash after TACE in patients with HCC have been reported. To the best of the authors' knowledge, there are no reports on atypical, generalized rashes caused by doxorubicin systemic absorption after TACE. This paper presents the case of a 64-year-old male with HCC who developed generalized macules and patches one day after a successful TACE procedure. A histology examination of a skin biopsy of a dark reddish patch on the knee revealed severe interface dermatitis. He was treated with a topical steroid, and all skin rashes improved within a week with no side effects. This report presents this rare case with a literature review on skin rash after TACE.

Dose-escalated radiotherapy for clinically localized and locally advanced prostate cancer.

BACKGROUND: Treatments for clinically localized prostate cancer include radical prostatectomy, external beam radiation therapy, brachytherapy, active surveillance, hormonal therapy, and watchful waiting. For external beam radiation therapy, oncological outcomes may be expected to improve as the dose of radiotherapy (RT) increases. However, radiation-mediated side effects on surrounding critical organs may also increase. OBJECTIVES: To assess the effects of dose-escalated RT in comparison with conventional dose RT for curative treatment of clinically localized and locally advanced prostate cancer. SEARCH METHODS: We performed a comprehensive search using multiple databases including trial registries and other sources of grey literature, up until 20 July 2022. We applied no restrictions on publication language or status. SELECTION CRITERIA: We included parallel-arm randomized controlled trials (RCTs) of definitive RT in men with clinically localized and locally advanced prostate adenocarcinoma. RT was dose-escalated RT (equivalent dose in 2 Gy [EQD2] ≥ 74 Gy, lesser than 2.5 Gy per fraction) versus conventional RT (EQD2 < 74 Gy, 1.8 Gy or 2.0 Gy per fraction). Two review authors independently classified studies for inclusion or exclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently abstracted data from the included studies. We performed statistical analyses by using a random-effects model and interpreted them according to the Cochrane Handbook for Systematic Reviews of Interventions. We used GRADE guidance to rate the certainty of the evidence of RCTs. MAIN RESULTS: We included nine studies with 5437 men in an analysis comparing dose-escalated RT versus conventional dose RT for the treatment of prostate cancer. The mean participant age ranged from 67 to 71 years. Almost all men had localized prostate cancer (cT1-3N0M0). Primary outcomes Dose-escalated RT probably results in little to no difference in time to death from prostate cancer (hazard ratio [HR] 0.83, 95% CI 0.66 to 1.04; I2 = 0%; 8 studies; 5231 participants; moderate-certainty evidence). Assuming a risk of death from prostate cancer of 4 per 1000 at 10 years in the conventional dose RT group, this corresponds to 1 fewer men per 1000 (1 fewer to 0 more) dying of prostate cancer in the dose-escalated RT group. Dose-escalated RT probably results in little to no difference in severe RT toxicity of grade 3 or higher late gastrointestinal (GI) toxicity (RR 1.72, 95% CI 1.32 to 2.25; I2 = 0%; 8 studies; 4992 participants; moderate-certainty evidence); 23 more men per 1000 (10 more to 40 more) in the dose-escalated RT group assuming severe late GI toxicity as 32 per 1000 in the conventional dose RT group. Dose-escalated RT probably results in little to no difference in severe late genitourinary (GU) toxicity (RR 1.25, 95% CI 0.95 to 1.63; I2 = 0%; 8 studies; 4962 participants; moderate-certainty evidence); 9 more men per 1000 (2 fewer to 23 more) in the dose-escalated RT group assuming severe late GU toxicity as 37 per 1000 in the conventional dose RT group. Secondary outcomes Dose-escalated RT probably results in little to no difference in time to death from any cause (HR 0.98, 95% CI 0.89 to 1.09; I2 = 0%; 9 studies; 5437 participants; moderate-certainty evidence). Assuming a risk of death from any cause of 101 per 1000 at 10 years in the conventional dose RT group, this corresponds to 2 fewer men per 1000 (11 fewer to 9 more) in the dose-escalated RT group dying of any cause. Dose-escalated RT probably results in little to no difference in time to distant metastasis (HR 0.83, 95% CI 0.57 to 1.22; I2 = 45%; 7 studies; 3499 participants; moderate-certainty evidence). Assuming a risk of distant metastasis of 29 per 1000 in the conventional dose RT group at 10 years, this corresponds to 5 fewer men per 1000 (12 fewer to 6 more) in the dose-escalated RT group developing distant metastases. Dose-escalated RT may increase overall late GI toxicity (RR 1.27, 95% CI 1.04 to 1.55; I2 = 85%; 7 studies; 4328 participants; low-certainty evidence); 92 more men per 1000 (14 more to 188 more) in the dose-escalated RT group assuming overall late GI toxicity as 342 per 1000 in the conventional dose RT group. However, dose-escalated RT may result in little to no difference in overall late GU toxicity (RR 1.12, 95% CI 0.97 to 1.29; I2 = 51%; 7 studies; 4298 participants; low-certainty evidence); 34 more men per 1000 (9 fewer to 82 more) in the dose-escalated RT group assuming overall late GU toxicity as 283 per 1000 in the conventional dose RT group. Based on long-term follow-up (up to 36 months), dose-escalated RT may result or probably results in little to no difference in the quality of life using 36-Item Short Form Survey; physical health (MD -3.9, 95% CI -12.78 to 4.98; 1 study; 300 participants; moderate-certainty evidence) and mental health (MD -3.6, 95% CI -83.85 to 76.65; 1 study; 300 participants; low-certainty evidence), respectively. AUTHORS' CONCLUSIONS: Compared to conventional dose RT, dose-escalated RT probably results in little to no difference in time to death from prostate cancer, time to death from any cause, time to distant metastasis, and RT toxicities (except overall late GI toxicity). While dose-escalated RT may increase overall late GI toxicity, it may result, or probably results, in little to no difference in physical and mental quality of life, respectively.

Reconstruction of Small-Sized Complex Defect on the Foot Dorsum Without Microsurgery: Intrinsic Adipofascial Flap.

Dorsal foot defects are difficult to cover and often require major flap surgery by microsurgeons, even for defects of limited sizes. Intrinsic adipofascial flaps for small-sized complex defects are simple and do not require microsurgery; thus, a flap specialist is unnecessary. This study aimed to assess our institutional experience with this technique and define its role in dorsal foot reconstruction. Nine patients aged 48 to 86 years with soft tissue defects of the dorsal foot were treated with the intrinsic adipofascial flap by rotating the adjacent adipofascial tissues from May 2019 and January 2021 in our institution. Demographic, clinical, and followup data were evaluated. Primary outcomes include flap viability, flap bulkiness, ability to wear shoes, and donor site morbidity. The mean followup period was 24.5 months (range, 10-30 months) and the mean defect size was 6.4 cm2 (range, 3.0-9.0 cm2). Eight flaps survived providing an adequate contour and durable coverage with a thin flap. Among 8 cases of healed flaps, 6 required secondary skin grafts while the other 2 healed spontaneously without additional operation. One patient (defect size: 3.0 cm × 3.0 cm) with underlying diabetes mellitus and peripheral arterial occlusive disease encountered flap total necrosis. Revisional flap surgery was performed to cover the flap total necrosis. In conclusion, the intrinsic adipofascial flap is a relatively simple and suitable method for complex dorsal foot defect reconstruction because it provides minimal donor site morbidity. However, relatively large defect size and comorbidities, such as underlying diabetes mellitus and vascular occlusive disease could accompany a risk of flap necrosis.

Incidence and Risk Factors for Pregnancy-Related de Quervain's Tenosynovitis in South Korea: A Population-Based Epidemiologic Study.

Background: Although pregnant or lactating women have been recognized to be predisposed to de Quervain's tenosynovitis (DQT), there is a lack of epidemiologic evidence. The purpose of this study was to estimate the nationwide incidence of pregnancy-related DQT (PRDQT) and to analyze risk factors using the Korean National Health Insurance (NHI) database. Methods: A retrospective epidemiologic study of pregnant women in South Korea from 2013 to 2017 was conducted using the NHI claims database. Using corresponding diagnostic codes, we identified women diagnosed with DQT during pregnancy or the postpartum period. We calculated the cumulative incidence and analyzed risk factors such as demographics, pregnancy type, delivery method, gestational complications, and comorbidities using multivariate logistic regression analysis. Results: Between 2013 and 2017, 34,342 patients with PRDQT were identified among 1,601,501 pregnant women, representing a cumulative incidence of approximately 2.1%. Age ≥ 30 years, multiple gestation, cesarean delivery, hypertensive disorders in pregnancy, and underlying rheumatoid arthritis were all identified as significant risk factors for the occurrence of PRDQT, whereas diabetic disorders in pregnancy and underlying diabetes mellitus were not. Conclusions: In South Korea, PRDQT was found to affect approximately 2.1 out of 100 pregnant women between 2013 and 2017. The incidence and risk factors identified in this study can be used for clinical consultations and prediction, as well as for development of national health policies.

Iatrogenic radial nerve palsy in the surgical treatment of humerus shaft fracture -anterolateral versus posterior approach: A systematic review and meta-analysis.

BACKGROUND: Although many studies have investigated iatrogenic radial nerve palsy (RNP) in humerus shaft fracture, there is inconsistent evidence on which approach leads to iatrogenic RNP. Moreover, no meta-analysis has directly compared the anterolateral and posterior approaches regarding iatrogenic RNP. METHODS: In this systematic review and meta-analysis, the MEDLINE, Embase, and Cochrane Library databases were searched systematically for studies published before March 30, 2021. We included studies that (1) assessed the RNP in the surgical treatment of humerus shaft fracture and (2) directly compared the anterolateral and posterior approaches regarding the RNP. We performed synthetic analyses of the incidence of iatrogenic RNP and the recovery rate of iatrogenic RNP in humerus shaft fracture between the anterolateral and posterior approaches. RESULTS: Our study enrolled nine studies, representing 1303 patients who underwent surgery for humerus shaft fracture. After exclusion of traumatic RNP, iatrogenic RNP was reported in 35 out of 678 patients in the anterolateral approach and in 69 out of 497 patients in the posterior approach. Pooled analysis revealed that the incidence of iatrogenic RNP was significantly higher in the posterior approach than in the anterolateral approach (OR = 2.72; 95% confidence interval (CI), 1.70-4.35; P < 0.0001, I2 = 0%), but there was no significant difference in the recovery rates of iatrogenic RNP between the two approaches (OR = 1.55; 95% CI, 0.26-9.18; P = 0.63, I2 = 0%). CONCLUSION: In this meta-analysis, the posterior approach showed a higher incidence of iatrogenic RNP than the anterolateral approach in the surgical treatment of humerus shaft fracture. With limited studies, it is difficult to anticipate if any particular approach favors the recovery of iatrogenic RNP.

Rotational osteo-onychocutaneous flap for central polydactyly of the foot: A novel technique for correction of the deformity.

Eccentric location of two nails like eyes of a bird are frequently observed in central polydactyly of the foot. A novel technique of rotational osteo-onychocutaneous (OOC) flap procedure is introduced to correct this deformity. Six children with central polydactyly of the foot who showed eccentric locations of nails were operated by this technique. Four patients were distal phalangeal type, and two middle phalangeal type. Preoperatively the angulation deformity of distal phalangeal type was average 16.8 (range, 2.3-48.0) degrees, and middle phalangeal type 10.3 (range, 2.9-17.7) degrees. The rotational OOC flap procedure was performed at average 24 (range, 12-51) months of age. Cosmetic and radiographic assessments were done after an average of 42 (range, 6-79) months of follow-up. All patients and their parents were satisfied with the cosmetic results. The angulation deformity was improved to average 4.2 (range, 0.5-11.2) degrees in distal phalangeal type, and 5.9 (range, 2.0-9.8) degrees in middle phalangeal type, respectively. Postoperative residual angulation deformity measured by simple radiographs were less than 5° in all patients. Complications such as partial necrosis of the flap were not found. In conclusion, our novel technique of rotational OOC flap procedure resulted in satisfactory outcome for patients with 'eyes of a bird' type toe nail deformity of central polydactyly of the foot. It corrected the angulation and rotational deformity of the toe nail of the main digit without causing any complications.

Long-Term Feasibility of 13.56 MHz Modulated Electro-Hyperthermia-Based Preoperative Thermoradiochemotherapy in Locally Advanced Rectal Cancer.

We evaluated the effect of 13.56 MHz modulated electro-hyperthermia (mEHT) boost in neoadjuvant treatment for cT3-4- or cN-positive rectal cancer. Sixty patients who completed the mEHT feasibility trial (ClinicalTrials.gov Identifier: NCT02546596) were analyzed. Whole pelvis radiotherapy of 40 Gy, mEHT boost twice a week during radiotherapy, and surgical resection 6-8 weeks following radiotherapy were performed. The median age was 59. The median follow-up period was 58 (6-85) months. Total/near total tumor regression was observed in 20 patients (33.3%), including nine cases of complete response. T- and N-downstaging was identified in 40 (66.6%) and 53 (88.3%) patients, respectively. The 5-year overall and disease-free survival were 94.0% and 77.1%, respectively. mEHT energy of ≥3800 kJ potentially increased the overall survival (p = 0.039). The ypN-stage and perineural invasion were possible significant factors in disease-free (p = 0.003 and p = 0.005, respectively) and distant metastasis-free (p = 0.011 and p = 0.034, respectively) survival. Tumor regression, resection margin status, and other molecular genetic factors showed no correlation with survival. Although a limited analysis of a small number of patients, mEHT was feasible considering long-term survival. A relatively low dose irradiation (40 Gy) plus mEHT setting could ensure comparable clinical outcomes with possible mEHT-related prognostic features.

Clinical relationship between distal interosseous membrane thickness measured through magnetic resonance imaging and distal radioulnar joint stability: A retrospective study.

BACKGROUND: Cadaveric studies suggest that a thick part of the distal interosseous membrane (DIOM), known as the distal oblique bundle (DOB), contributes to the distal radioulnar joint (DRUJ)'s stability. We hypothesized that the DIOM thickness, measured through magnetic resonance imaging (MRI), has a clinically significant association with DRUJ stability. METHODS: We retrospectively reviewed patients, from February 2018 to April 2019, who underwent wrist MRI examination with physical examination for DRUJ stability. We evaluated the correlation between their MRI findings (i.e., triangular fibrocartilage complex [TFCC] tears and presence of the DOB) and DRUJ instability. RESULTS: Out of 85 patients with an average age of 42 years, 45 (53%) had foveal TFCC tears, 29 (34%) had a DOB, and 38 patients (45%) had clinical DRUJ instability. Patients with DRUJ instability had a significantly higher incidence of foveal TFCC tears (30/38, vs 15/47, p < 0.001), while DOB was absent (36/38 vs. 20/47, p < 0.001). Among 45 patients with foveal TFCC tears, only 1 out of 13 patients with a DOB had DRUJ instability, whereas 29 out of 32 patients without a DOB had DRUJ instability (p < 0.001). The odds ratio for DRUJ instability was 11.7 (95% CI 2.9-47.5, p = 0.001) for foveal TFCC tear and 54.2 (95% CI 8.2-358.2, p < 0.001) for the absent DOB. CONCLUSIONS: Clinical DRUJ instability was less common when the DOB is present in patients with foveal TFCC tears, which supports DOB's role as a secondary DRUJ stabilizer.

Simple parameters predicting extrahepatic recurrence after curative hepatectomy for hepatocellular carcinoma.

Extrahepatic recurrence (EHR) after curative hepatectomy for hepatocellular carcinoma (HCC) is associated with a poor prognosis. We investigated the features of EHR and identified its predictive factors. This retrospective study included 398 treatment-naive patients who underwent curative hepatectomy for HCC at two tertiary hospitals. Multivariate Cox-regression analysis was performed to identify the variables associated with EHR. EHR was diagnosed in 94 patients (23.6%) over a median follow-up period of 5.92 years, most commonly in the lungs (42.6%). The 5-/10-year cumulative rates of HCC recurrence and EHR were 63.0%/75.6% and 18.1%/35.0%, respectively. The median time to EHR was 2.06 years. Intrahepatic HCC recurrence was not observed in 38.3% of patients on EHR diagnosis. On multivariate analysis, pathologic modified Union for International Cancer Control stage (III, IVa), surgical margin involvement, tumor necrosis, sum of tumor size > 7 cm, and macrovascular invasion were predictive factors of EHR. Four risk levels and their respective EHR rates were defined as follows: very low risk, 1-/5-year, 3.1%/11.6%; low risk, 1-/5-year, 12.0%/27.7%; intermediate risk, 1-/5-year, 36.3%/60.9%; and high risk, 1-year, 100.0%. Our predictive model clarifies the clinical course of EHR and could improve the follow-up strategy to improve outcomes.

In Situ Neurolysis of Ulnar Nerve for Patients With Failed Anterior Subcutaneous Transposition - A Case Series.

BACKGROUND: Various surgical techniques have been attempted to treat patients with failed anterior subcutaneous transposition performed for cubital tunnel syndrome. OBJECTIVE: To analyze intraoperative findings of failed anterior subcutaneous transposition and to report the outcome of in Situ neurolysis of ulnar nerve. METHODS: Patients who, under diagnosis of failed anterior subcutaneous transposition of ulnar nerve, underwent in Situ neurolysis between 2001 and 2018 were included in this study. We excluded patients with follow-up of less than one year, records of traumatic ulnar nerve injury, and concomitant double crush syndrome such as cervical spondylosis causing radicular pain, ulnar tunnel syndrome, or thoracic outlet syndrome. Surgical outcomes were evaluated using visual analog scale (VAS) pain score and Disabilities of the Arm, Shoulder, and Hand (DASH) score, which were assessed before and after surgery. A total of 28 elbows in 27 patients whose average age was 58.5 (range, 31-76) yr were enrolled, and the duration of follow-up was 5.8 (range, 1.0-14.9) yr. RESULTS: The most common pathologic finding identified during operation was severe adhesion of the transposed nerve in all elbows, followed by incomplete decompression of deep flexor-pronator aponeurosis in 26 elbows (93%). The average VAS pain score improved from 4.9 (range, 2-7) to 1.3 (range, 0-5), and the average DASH score from 31.7 (range, 18.1-66.7) to 14.1 (range, 5.0-46.6). Of the 28 elbows, 27 (96.4%) showed improvement of preoperative symptoms. CONCLUSION: In Situ neurolysis of ulnar nerve for patients with failed anterior subcutaneous transposition resulted in satisfactory outcome.

A Novel Protocol for Reducing Intensive Care Utilization After Craniotomy.

BACKGROUND: There is a growing body of evidence suggesting not all craniotomy patients require postoperative intensive care. OBJECTIVE: To devise and implement a standardized protocol for craniotomy patients eligible to transition directly from the operating room to the ward-the Non-Intensive CarE (NICE) protocol. METHODS: We preoperatively identified patients undergoing elective craniotomy for simple neurosurgical procedures with age <65 yr and American Society of Anesthesiologists (ASA) class of 1, 2 or 3. Postoperative eligibility was confirmed by the surgical and anesthesia teams. Upon arrival to the ward, patients were staffed with a neuroscience nurse for hourly neurological examinations for the first 8 h. Patient demographics, clinical characteristics, and outcomes were prospectively collected to evaluate the NICE protocol. RESULTS: From February 2018 to 2019, 63 patients were included in the NICE protocol with a median age of 46 yr and 65% female predominance. Of the operations performed, 38.1% were microvascular decompressions, 31.7% were craniotomy for tumor, 15.9% were cavernous malformation resections, and 14.3% were Chiari decompressions. No patients required transfer to the intensive care unit (ICU). Median length of stay was 2 d. There was an 11.1% overall readmission rate within the median follow-up period of 48 d. Three patients (4.8%) required reoperation at time of readmission within the follow-up period (1 postoperative subdural hematoma, 2 cerebrospinal fluid leak repair). None of these complications could have been identified with a postoperative ICU stay. CONCLUSION: In our pilot trial of the NICE protocol, no patients required postoperative transfer to the ICU.

Diagnosis of Neurogenic Thoracic Outlet Syndrome Based on the Clinical Status.

OBJECTIVES: At our institute, we devised a clinical algorithm for diagnosis of neurogenic thoracic outlet syndrome (TOS). Our approach assisted in the accurate diagnosis and in detection of patients likely to benefit from surgical treatment. The purposes of this study were to propose our diagnostic approach to neurogenic TOS, and to describe the outcomes of surgical and conservative treatment. METHODS: Patients (n = 91) who were suspected to have neurogenic TOS, and therefore, underwent a routine clinical protocol from January 2012 to January 2018 were reviewed. Through the clinical protocol, diagnosis of "true neurologic TOS", "symptomatic TOS", and "not likely TOS" was made. The visual analog scale (VAS) pain score and Disabilities of the Arm, Shoulder and Hand (DASH) score were used to assess the treatment outcomes. Satisfaction with surgery was assessed according to the Derkash classification as excellent, good, fair, or poor. RESULTS: Among 91 patients with presumed neurogenic TOS, 25 patients were "true neurologic TOS", 61 patients were "symptomatic TOS", and five patients were "not likely TOS". Nineteen patients underwent supraclavicular decompression of the brachial plexus whose mean age at the time of surgery was 36.4 years. The VAS average pain score improved from 3.6 to 0.8, and the DASH score improved from 38.4 to 17.1. According to the Derkash classification, ten patients (53%) rated their recovery as excellent, four (21%) as good, and five (26%) as fair. Sixty-seven patients underwent conservative treatment. At the last follow-up visit, their VAS and DASH score were 2.3 and 11.8, respectively. CONCLUSIONS: By using an algorithm, we diagnosed the patients suspected to have neurogenic TOS into three groups based on clinical status. We surgically treated 19 patients using supraclavicular approach, and achieved favorable outcomes.

Is Thumb Proprioception Decreased in Patients With Trapeziometacarpal Joint Osteoarthritis?

Proprioception is thought to be essential for normal joint homeostasis, and its decreased function has been associated with an increased risk of joint diseases. However, only a few studies have been performed on the association between proprioceptive function in the trapeziometacarpal joint (TMCJ) and osteoarthritis. The purpose of this study was to compare TMCJ proprioceptive function in elderly women with radiographic TMCJ osteoarthritis relative to age-matched control women without osteoarthritis. We enrolled 19 women (mean age, 66 years) with symptomatic, radiographic Eaton and Littler grade 2, 3, and 4 TMCJ osteoarthritis and 19 age-matched control women without osteoarthritis. We evaluated thumb proprioception by using a joint-position reproduction test and compared the reposition error (RE) between the groups. We carried out a multivariate analysis for factors potentially associated with increased RE, such as age, body mass index, hand dominance, the presence of diabetes, pain level, and the presence of osteoarthritis. Also, a logistic regression analysis was performed for factors associated with the occurrence of TMCJ osteoarthritis. Patients with TMCJ osteoarthritis had greater RE than did the control patients in the joint-position reproduction test at 20°, 30°, and 40° of thumb palmar abduction. The multivariate analysis indicated that increased RE was associated with the presence of osteoarthritis, but not with the other factors assessed. The occurrence of TMCJ osteoarthritis was associated with increased RE at 20°, 30°, and 40° of thumb palmar abduction. This study showed that decreased proprioceptive function was associated with the presence of osteoarthritis in the TMCJ, although the causality remains unknown. Further studies on the role of proprioception in the pathogenesis of TMCJ osteoarthritis and the potential role of its training for disease prevention or treatment are required.

Influence of Competitive Inclusion of CO2 and N2 on sII Hydrate-Flue Gas Replacement for Energy Recovery and CO2 Sequestration.

This study investigated the structural transformation, guest distributions, and the extent of replacement in CH4 + C3H8-flue gas replacement occurring in sII hydrates via gas chromatography, NMR spectroscopy, and powder X-ray diffraction (PXRD). Simulated flue gas (CO2 (20%) + N2 (80%)) was injected into an sII CH4 (90%) + C3H8 (10%) hydrate for guest exchange. The extent of replacement occurring in CH4 + C3H8-flue gas replacement was much lower than that of CH4 + C3H8-CO2 replacement. Furthermore, 13C NMR spectra and PXRD patterns revealed that unlike CH4 + C3H8-CO2 replacement, CH4 + C3H8-flue gas replacement did not undergo any structural transformation during the replacement (i.e., iso-structural replacement in the sII hydrate). Rietveld refinement of PXRD patterns of gas hydrates after replacement using flue gas injection demonstrated that CO2 molecules occupied both the small (512) and large (51264) cages, whereas N2 molecules occupied only the small (512) cages. CO2 and N2 were not complementary but competitive in replacing CH4 in the small (512) cages, which contributed to the maintenance of the cage stability of the initial sII hydrate and thus, resulted in a lower extent of replacement. The experimental results obtained in this study provide valuable insights on the accurate replacement mechanism and cage-specific guest exchange behavior of sII hydrates using flue gas injection for energy recovery and CO2 sequestration.

Choroidoscleral Interface Irregularity Index: A novel optical coherence tomography-based parameter in patients with epiretinal membrane.

This study aimed to assess the regularity of the choroidoscleral interface (CSI) using a novel parameter, CSI irregularity index, before and after epiretinal membrane (ERM) surgery. This study included 36 patients with idiopathic ERM who underwent pars plana vitrectomy and ERM removal. All subjects underwent ocular examinations at baseline and at 1, 2, 4, and 6 months after surgery. The regular contour of the CSI was found in 14 patients (38.9%); mean CSI irregularity index was 14.84 ± 11.01 in this group. The irregular contour of the CSI was found in 22 patients (61.1%); mean CSI irregularity index was 33.96 ± 20.64 in this group. The CSI irregularity index decreased gradually after ERM surgery, and was correlated with postoperative best-corrected visual acuity. The CSI irregularity index could serve as a surrogate marker to quantitatively represent the CSI morphology. We observed the gradual decrease of the CSI irregularity index after ERM surgery in quantitative manner. This study showed correlations between the CSI irregularity index and visual outcomes after ERM surgery. Our results suggest that the CSI irregularity index might be an intuitive anatomic indicator of the CSI and might be useful as a possible prognostic marker for patients undergoing ERM surgery.

Free Flaps for Soft Tissue Reconstruction of Digits.

Soft tissue reconstruction of the digit is challenging for hand surgeons because it must satisfy both functional and aesthetic requirements. A wide variety of treatment options exist. A free flap can be an alternative solution in some clinical situations. This article has 2 purposes. First, it discusses various considerations for free-flap usage for reconstruction of soft tissue defects of the digits and the available options. Second, it provides more detailed information regarding the 3 commonly used free flaps, namely, the partial toe pulp flap, radial artery superficial palmar branch flap, and arterialized venous flap.

Biomechanical comparison of three tension band wiring techniques for transverse fracture of patella: Kirschner wires, cannulated screws, and ring pins.

PURPOSE: The purpose of this study is to compare biomechanical characteristics of tension band wiring using Kirschner wires (TBWKW), cannulated screws (TBWCS), and ring pins (TBWRP) for transverse fracture of the patella. METHODS: A total of 48 polyurethane synthetic patellae were biomechanically tested. All patellae were osteotomized to create a transverse fracture. Each TBWKW, TBWCS, and TBWRP fixed 16 broken patellae. A specially designed fixation board simulated a knee with 90° flexion. Ten static tests and six dynamic tests were performed on each method. The static test is measuring maximum strength (N) during traction until breakage of the fixation. The dynamic test consisted of measuring the fracture gap (mm) after 10,000 repetitive loading cycles between 100 N and 300 N that simulated actual daily activity. A gap of 2 mm or more was defined as a failure in both tests. RESULT: The failure load was 438.6 ± 138.6 N, 422.2 ± 72.7 N, and 1106.8 ± 230.3 N for TBWKW, TBWRP, and TBWCS, respectively. TBWCS showed a statistically significant difference compared to TBWKW and TBWRP in the static test (p < 0.001). All the groups had no failure in the dynamic test. The mean fracture gap after completion of the dynamic test was 0.3267 ± 0.3395 mm, 0.2938 ± 0.2165 mm, and 0.0360 ± 0.0570 mm for TBWKW, TBWRP, and TBWCS, respectively (p = 0.044). The mean values in the dynamic test showed no statistical difference. There was a significant difference between TBWRP and TBWCS (p = 0.009), but others showed no difference with statistical significance. CONCLUSION: All three methods have sufficient stability at a daily activity. TBWCS showed a better failure load compared with TBWKW and TBWRP. TBWRP showed compatible mechanical characteristics with traditional tension band wiring. TBWRP could be an alternative method for TBWKW.