Long-term health-related quality of life in living liver donors: A south Asian experience.

AIM: The aim of this study was to evaluate long-term health-related quality of life (HRQOL), changes in lifestyle, and complications in living liver donors at a single transplant center from southern India. METHODS: A total of 64 consecutive living liver donors from 2008 to 2011 were evaluated; 46 of 64 donors completed the short form 36 (SF-36) via telephonic interviews or clinic consultations. Mean follow-up was 48 months (range: 37-84 months). RESULTS: There was no mortality in the donors evaluated. Overall morbidity was 23%, which included wound infections (4.3%), incisional hernia (2.1%), biliary leak (4.3%), and nonspecific complaints regarding the incision site (15.2%). All 46 donors who completed the SF-36 had no change in career path or predonation lifestyle. A total of 40 of 46 (87%) donors had no limitations, decrements, or disability in any domain, while six of 46 (13%) had these in some domains of which general health (GH) was most severely affected. CONCLUSIONS: Living donor hepatectomy is safe with acceptable morbidity and excellent long-term HRQOL with no change in career path or significant alteration of lifestyle for donors.

Better innovate than compromise: a novel hepatic outflow reconstruction technique in pediatric living donor liver transplantation.

Pediatric LDLT using donors with unfavorable vascular anatomy is challenging in terms of donor safety, and complexity of reconstruction in the recipient. We describe an innovative technique of hepatic venous outflow reconstruction involving the recipient RHV, in the presence of a rudimentary RHV in the donor. The postoperative course of the donor and recipient was uneventful with satisfactory venous outflow in both. This technique avoided the use of prosthetic material, an important consideration given the recipient age and requirement for growth. This shows that donors previously considered unsuitable for donation can be utilized safely as long as principles of vascular anastomosis are adhered to. Moreover, it highlights that innovation is sometimes necessary to avoid compromise in donor safety.

Unusual case of acute posteromedial papillary muscle rupture after acute anterior myocardial infarction.

Papillary muscle rupture is now a rare complication of acute myocardial infarction. Posteromedial papillary muscle rupture is more common than anterolateral papillary muscle rupture. The posteromedial papillary muscle is usually supplied from a branch of the right coronary artery. We present a case of posteromedial papillary muscle rupture due to an isolated left anterior descending artery lesion. This was diagnosed on the fifth day post infarction. The patient progressed to mitral valve replacement and coronary artery bypass grafting to the left anterior descending artery. We believe this unusual arterial supply to the posteromedial papillary muscle is due to an apex forming left anterior descending artery coupled with an apically located posteromedial papillary muscle.

Liver transplantation in human immunodeficiency virus-infected patients: procoagulant, but is antithrombotic prophylaxis required?

Liver transplantation (LT) for human immunodeficiency virus (HIV)-positive recipients with end-stage liver disease has become an accepted practice. However, because these patients are increasingly being recognized as prothrombotic, we reviewed their posttransplant thrombotic complications. Because morphological changes might be responsible in part for this prothrombotic state, we also conducted a histopathological review of explants from HIV-positive patients. Between 1990 and 2010, 24 of 3502 recipients (including 23 adults) were HIV-positive at LT. These patients and their postoperative courses were reviewed with a particular focus on vascular complications, risk factors, and outcomes. Another patient in whom HIV was detected 12 years after LT was also examined. Among the 24 HIV-positive LT recipients (17 males and 22 whole liver grafts; median age = 40 years), 5 developed arterial complications [including 3 cases of hepatic artery thrombosis (HAT), 1 case of generalized arteriopathy (on angiography), and 1 case of endoarteritis (on histological analysis)]. Multiple arterial anastomoses were performed in 8 of the 24 recipients, and HAT occurred twice within this anastomosis group. The outcomes of the 3 patients with HAT included retransplantation, biliary stenting for ischemic cholangiopathy followed by retransplantation, and observation only. In addition, 5 separate venous thrombotic events were detected in the 24 recipients during this period. Moreover, the delayed-HIV recipient developed delayed HAT and subsequently ischemic cholangiopathy and was being assessed for retransplantation at the time of this writing. In conclusion, the prothrombotic state associated with combined HIV and liver disease is a cause of morbidity after LT: 8 of the 24 recipients (33%) in this series suffered vascular thrombotic complications. There is a potential increase in the risk of HAT: the rate for the HIV-positive cohort was higher than the rate for historical HIV-negative controls [12% versus 3.2%, P = 0.016 (Fisher's exact test)]. The minimization of complex arterial reconstruction, coagulopathy screening, and risk-adapted antithrombotic chemoprophylaxis appear to be reasonable precautions.

Susceptibility-Weighted MRI as an Imaging Marker for Reperfusion Injury in Acute Ischemic Stroke Following Mechanical Thrombectomy.

Background/Purpose: Following endovascular intervention for stroke, hyperattenuated areas are common in brain parenchyma and it is difficult to differentiate on non-contrast CT whether it is contrast staining or reperfusion hemorrhage. Differentiation between contrast staining from reperfusion hemorrhage is of paramount importance for early initiation of antiplatelets and/or anticoagulants to prevent reocclusion of vessel. This study demonstrates signal characteristics of contrast-staining and reperfusion hemorrhage on susceptibility weighted MRI and its role to differentiate between two. Materials/Methods: Between July 2017 to March 2019, 36 patients who presented with acute ischemic stroke due to large vessel occlusion underwent mechanical thrombectomy. Low-osmolar non-ionic (Iopromide 300 mg/L) iodinated contrast was used in all patients who underwent endovascular intervention. All patients underwent noncontrast CT brain and SWI on 3T MRI within 30 minutes of endovascular intervention. MRI was evaluated by two neuroradiologists. Reperfusion hemorrhage was defined as ECASS criteria II. Symptomatic ICH was defined as hemorrhagic transformation temporally related to a negative shift in NIHSS score >/=4. Results: Out of 36 patients, 15 had hyperattenuated areas in brain on NCCT. Out of 15, 13 patients had blooming on SWI, suggestive of bleed. Two patients had no blooming on SWI, suggestive of contrast staining. Two patients didnot show any hyperdensity on NCCT but blooming on SWI, suggestive of bleed. Conclusion: All patients with hyperdensity on NCCT secondary to bleed showed blooming on SWI whereas those with contrast staining didnot show any signal changes on SWI. Thus, it is possible to differentiate reperfusion hemorrhage from contrast staining using SWI MRI. The significance of SWI in normal CT may be low where a small bleed maynot have any clinical significance.

Metastatic pulmonary adenocarcinoma 6 years after curative resection for ampullary adenocarcinoma. Metastatic disease from initial primary or metachronous tumour?

CONTEXT: With patients surviving longer after pancreatic resection, the challenges now is the management of the unresolved longer-term issues. CASE REPORT: A 53-year-old woman with painless obstructive jaundice, underwent a pylorous preserving pancreaticoduodenectomy for a pT3N0M0 ampullary adenocarcinoma in 2001 (patchy chronic pancreatitis with mucinous metaplasia of background pancreatic duct epithelium and acinar atrophy were noted). Despite adjuvant chemotherapy, at month 54 she required a pulmonary wedge resection for metastatic adenocarcinoma, followed by a pulmonary relapse at 76 months when she underwent 6 neoadjuvant cycles of gemcitabine/capecitabine and a left pneumonectomy. Finally 7 years after the initial Whipple's, a single 18F fluorodeoxyglucose (FDG) avid pancreatic tail lesion led to completion pancreatectomy for a well-differentiated ductal adenocarcinoma with clear resection margins albeit peripancreatic adipose tissue infiltration. On review all resected tumour cells had identical immunophenotype (CK7+/CK20-/MUC1+/MUC2-) as that of the primary. She is currently asymptomatic on follow-up. CONCLUSIONS: These findings suggest that in selected cases even in the presence of pulmonary metastasis, repeat resections could result in long-term survival of patients with metachronous ampullary cancer. Second, even ampullary tumours maybe should be regarded as index tumors in the presence of ductal precursor lesions in the resection specimen. Three distant metastases, particularly if long after the initial tumour, should instigate a search for metachronous tumour, especially in the presence of field change in the initial specimen. Risk-adapted follow-up protocols with recognition of such factors could result in cost-effective surveillance and potentially improved outcomes.

The management of an accessory or replaced right hepatic artery during multiorgan retrieval: results of an angiographic study.

In the presence of anatomical variants such as an accessory or replaced (A/R) right hepatic artery (RHA), a conflict of interest can arise during organ retrieval between liver and pancreatic teams. This angiographic study examines the anatomy of the inferior pancreaticoduodenal artery (IPDA), its relation to the A/R RHA, and the implications for the use of livers and pancreases from multiorgan donors. Gastrointestinal angiograms performed in our institution for unrelated indications were reviewed, and the relevant arteries, their diameters, the distances between origins, the time at which variants were found, and the blood supply to relevant solid organs were recorded. A review of 122 angiograms identified 100 patients in whom both the superior mesenteric artery (SMA) and the celiac axis were cannulated synchronously; these patients composed our study cohort. The IPDA was identified in 95% of the cases. There were 8 patients with a replaced RHA and 4 with an accessory RHA. In all 12, the IPDA had an SMA origin; 3 of these shared a common origin with the A/R RHA on the SMA. In the rest, the mean distance between them was 29 mm (range = 17.8-48.3 mm). All anomalous arteries found were segmental vessels. In conclusion, the A/R RHA incidence in our series was 12%, and no case had an IPDA originating from the A/R RHA. Separate accessory RHA and IPDA origins potentially allow an uncompromised accessory RHA (with its Carrel patch) without risk of prejudice to the pancreatic graft if retrieval is accurately performed. Rarely (3%), there is a common origin between the A/R RHA and the IPDA, and back-bench reconstruction would be required to allow the use of both the liver and pancreas.

Dementia in Kerala, South India: prevalence and influence of age, education and gender.

BACKGROUND: Data on the prevalence of dementia in India with a large and aging population is scant. We studied prevalence of AD and dementia in Kerala, South India, and effects of age, education and gender on it. METHODS: 2-phase survey on 2466 individuals aged > or = 55 years living in community. Men constituted 41%, < 75 years age in 76.9% and education > or = 4 years in 69.6%. Screening (Phase I) using the instrumental activity of daily living scale for the elderly (IADL-E) and the Addenbrooke's cognition examination (ACE). Diagnostic-assessment (Phase II) was in 532 screen-positives and 247 (10%) screen-negatives. RESULTS: 93 (3.77%) > or = 55 years and 81 (4.86%) > or = 65 years of age had dementia. Age adjusted (against US-population in 2000) dementia (and AD) rates were 4.86% (1.91%) in age > or = 55 years and 6.44% (3.56%) in > or = 65 years. Odds for dementia (and AD) were high with increasing-age 5.89 (15.33) in 75-84, 13.23 (25.92) > or = 85 years, and in women 1.62 (2.95); and low 0.27 (0.16) if education was > or = 9 years. Age and low education increased dementia. Age and female gender increased AD. CONCLUSION: Prevalence of dementia and AD is higher than any reported from the subcontinent suggesting that dementia in Kerala in South India is not uncommon. Increasing age increased dementia and AD. Low-education is associated with dementia and female-gender with AD.

Band erosion after laparoscopic gastric banding: a retrospective analysis of 865 patients over 5 years.

BACKGROUND: Gastric band erosion is a well-reported complication after laparoscopic adjustable gastric banding (LAGB). The published literature is limited and inconclusive with regard to its management. The authors therefore reviewed all band erosions detected during a 5-year period in a high-volume bariatric practice. Because a significant proportion of the band insertions (65%) were undertaken by an operator beyond his learning curve, the authors hoped to gain a mature, comprehensive understanding of this significant complication. METHODS: The authors retrospectively reviewed the operative log of the operating theaters in their obesity surgery unit to find all the operations performed on LAGB patients for erosion from January 2003 to December 2007. The clinical notes and electronic records for each patient were reviewed. These data were cross-referenced against the authors' obesity surgery database, and denominator data such as the total number operations performed and demographics were found. Finally, postoperative outcomes were collated from the outpatient follow-up data and telephonic interviews, and the results were analyzed. RESULTS: From January 2003 to December 2007, a single surgeon performed 865 LAGBs in the authors' unit. The authors identified 18 operations performed for LAGB erosions. The 18 patients (one referred from elsewhere, 14 women) formed the final study cohort (median preoperative body mass index [BMI], 46 kg/m(2)). Of the 17 erosions, 15 occurred relatively early in the series. The patients with the 213 Swedish adjustable gastric bands experienced 12 erosions (incidence, 5.6%) compared with 6 erosions with the 652 LAP-BANDs (incidence, 0.9%). The median time to presentation was 7 months (range, 1-60 months). However, 55% of the erosions (n = 10) occurred within the first year, and only 10% occurred after the second year. The most common presenting symptom was pain followed by weight regain. None of the patients experienced peritonitis. After surgical management of the erosion, three patients had a second LAGB and at this writing are well. Of the remaining patients, 11 are well, but 6 of these patients have returned to their previous weight (4 patients were lost to follow-up evaluation). CONCLUSIONS: The overall incidence of LAGB erosions in our series was 1.96%. This incidence fell with increasing experience to 0.5% after the initial 300 bands were excluded from the analysis (3 band erosions in the last 565 band insertions). However, further increases in incidence are likely with a longer follow-up period. The most common presentation was abdominal pain followed by weight regain and port-site sepsis. In the authors' hands, laparoscopic omental plugging and band removal through a separate anterior gastrotomy appear to be effective methods for dealing with band erosions. Band erosion is a significant source of morbidity, with at least one-third of the erosion patients in our series not achieving their final goal of weight loss despite appropriate treatment. This study highlights the need for a future prospective randomized study to clarify the apparent strong influence of band design and construction on the etiopathogenesis of band erosion.

Role of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of solid pancreatic and peripancreatic lesions: is onsite cytopathology necessary?

OBJECTIVES: The reported median diagnostic yield from endoscopic ultrasound (EUS) fine-needle aspiration (FNA) cytology is 78% (range 39-93%). The aim of this study is to describe a single-centre experience in the diagnostic work-up of solid pancreatic and peripancreatic masses without the benefit of an onsite cytopathologist. METHODS: In a consecutive series of 429 EUS examinations performed over a 12-month period by a single operator, 108 were on non-cystic pancreatic or biliary lesions. Data were collected prospectively and the accuracy of FNA was assessed retrospectively using either surgery or repeat imaging as the benchmark in the presence or absence of malignancy. RESULTS: Of the 108 FNAs, 102 (94%) were diagnostic, four were falsely negative (FN) and two were atypical and considered equivocal. There were 78 pancreatic lesions, of which 65 were true positives (TP), 11 true negatives (TN) and two FN, giving an overall accuracy of 97% (76/78). Of nine periampullary lesions, two were TP, six were TN and one was FN, giving an overall accuracy of 89% (8/9). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of EUS-FNA for pancreatic and periampullary lesions combined were 96%, 100%, 100% [95% confidence interval (CI) 95-100%], 85% (95% CI 62-97%) and 97%, respectively. There were 21 bile duct lesions, of which 10 were TP, eight TN, two atypical and one FN, giving an overall accuracy of 86% (18/21). The sensitivity, specificity, PPV, NPV and accuracy of EUS-FNA for biliary lesions were 91%, 100%, 100% (95% CI 69-100%), 91% (95% CI 59-100%) and 95%, respectively. CONCLUSIONS: The diagnostic accuracy of EUS-FNA for pancreatic lesions in our series was 97% and the PPV for the three subgroups of lesion type was 100%; these figures are comparable with the best rates reported in the literature, despite the absence of onsite cytopathology. These rates are potentially a direct result of high-volume practice, dedicated endosonography and cytopathology. These results show that it is possible to achieve high rates of accuracy in places where logistical issues make it impossible to maintain a cytopathologist in the endoscopy suite. In addition, our results contribute to the limited, collective global experience on the effectiveness of EUS-FNA in periampullary and biliary lesions.

Endovascular treatment of psuedoaneurysm arising from common hepatic artery bifurcation with complete disruption of gastroduodenal artery and high flow arterioportal fistula.

Arterio-portal fistulas (APFs) are characterized by anomalous communication between arteries and the portal vein (PV) system. Treatment of APF is imperative as an emergency or if there is development of portal hypertension/heart failure in chronic cases. Both endovascular and surgical managements can be attempted, however since endovascular management carries comparatively low intra and post procedural morbidity it is mostly preferred. This is a case report on endovascular management of post-traumatic pseudoaneurysm arising from bifurcation of common hepatic artery with complete disruption of the gastroduodenal artery and high-flow APF. This report describes the intraprocedure challenges in exclusion of fistula from the circulation, without disruption of portal system and anticipation of recruitment of new collateral feeders to the fistula immediate post exclusion with its embolization, which needs appropriate positioning of the catheter prior to exclusion of the fistula.

Automated neonatal seizure detection mimicking a human observer reading EEG.

OBJECTIVE: The description and evaluation of a novel patient-independent seizure detection for the EEG of the newborn term infant. METHODS: We identified characteristics of neonatal seizures by which a human observer is able to detect them. Neonatal seizures were divided into two types. For each type, a fully automated detection algorithm was developed based on the identified human observer characteristics. The first algorithm analyzes the correlation between high-energetic segments of the EEG. The second detects increases in low-frequency activity (<8 Hz) with high autocorrelation. RESULTS: The complete algorithm was tested on multi-channel EEG recordings of 21 patients with and 5 patients without electrographic seizures, totaling 217 h of EEG. Sensitivity of the combined algorithms was found to be 88%, Positive Predictive Value (PPV) 75% and the false positive rate 0.66 per hour. CONCLUSIONS: Our approach to separate neonatal seizures into two types yields a high sensitivity combined with a good PPV and much lower false positive rate than previously published algorithms. SIGNIFICANCE: The proposed algorithm significantly improves neonatal seizure detection and monitoring.

Intravenous amiodarone for the pharmacological termination of haemodynamically-tolerated sustained ventricular tachycardia: is bolus dose amiodarone an appropriate first-line treatment?

OBJECTIVE: To examine the efficacy of bolus dose intravenous amiodarone for the pharmacological termination of haemodynamically-tolerated sustained monomorphic ventricular tachycardia (VT). DESIGN, SETTING AND PARTICIPANTS: Retrospective case series of consecutive emergency admissions with haemodynamically-tolerated sustained monomorphic VT administered bolus dose intravenous amiodarone 300 mg, according to current UK advanced life support practice guidelines. MAIN OUTCOME MEASURES: Pharmacological termination rates within 20 min and 1 h and incidence of hypotension requiring emergency direct current cardioversion (DCCV) during this period. RESULTS: 41 patients (35 men) of mean (SD) age 68 (10) years, the majority (85%) with ischaemic heart disease and impaired left ventricular function (mean (SD) ejection fraction 0.31 (0.11)), were enrolled in the study. The median VT duration was 70 min (range 15-6000), mean heart rate was 174 (34) bpm and systolic and diastolic blood pressures were 112 (22) and 73 (19) mm Hg, respectively. Pharmacological VT termination occurred within 20 min in 6/41 patients (15%; 95% CI 7% to 29%) and within 1 h in 12/41 patients (29%; 95% CI 18% to 45%). Haemodynamic deterioration requiring emergency DCCV occurred in 7/41 patients (17%; 95% CI 8% to 32%). CONCLUSIONS: Although advocated by advanced life support guidelines, bolus dose intravenous amiodarone was relatively ineffective for acutely terminating haemodynamically-tolerated sustained monomorphic VT with a significant incidence of haemodynamic destabilisation requiring emergency DCCV. Previous studies in the identical clinical setting suggest that alternative antiarrhythmic agents, particularly intravenous procainamide and sotalol, may be superior. A prospective randomised trial is required to determine the optimal drug treatment for stable sustained monomorphic VT in the emergency setting.

Radiologic anatomy of the inguinofemoral region: insights from MDCT.

OBJECTIVE: We set out to reexamine the radiologic anatomy of the inguinofemoral region using volume data sets obtained with an MDCT scanner. MATERIALS AND METHODS: We conducted a systematic prospective review of CT scans of 20 consecutively enrolled patients, 10 men and 10 women chosen retrospectively from our CT database. An experienced radiologist and a senior trainee surgeon conducted an image review to maximize recognition of relevant anatomic detail. RESULTS: The inferior epigastric artery and femoral canal were identified in all planes in all patients. On axial views a spur on the pubic bone was visible in 17 (85%) of the patients, but the inguinal ligament was not reliably identified in any. The round ligament or spermatic cord was visible in only 15 (75%) of 20 patients. In contrast, on coronal and sagittal views, the inguinal ligament, which is vital to reliable identification and accurate classification of groin hernias, was visible in 19 (95%) of the 20 patients. Scans in the sagittal plane best depicted the gutter-like aspect of the ligament, the canal and contents being clearly visible in 95% of the patients. On sagittal views, the internal ring was identifiable in 90% and the round ligament or spermatic cord in 95% of the patients. On coronal images, the internal ring was identified in all and the conjoint tendon in 95% of the patients. The round ligament or spermatic cord was not seen in 10% of the patients. CONCLUSION: MDCT produces images of the inguinal region in detail not possible with previous generations of scanners. In our small series, 100% identification of key anatomic structures was achieved when information from all three views was combined. We found subtle differences between imaging findings and standard anatomic teaching.

Improved neonatal seizure detection using adaptive learning.

In neonatal intensive care units performing continuous EEG monitoring, there is an unmet need for around-the-clock interpretation of EEG, especially for recognizing seizures. In recent years, a few automated seizure detection algorithms have been proposed. However, these are suboptimal in detecting brief-duration seizures (<; 30s), which frequently occur in neonates with severe neurological problems. Recently, a multi-stage neonatal seizure detector, composed of a heuristic and a data-driven classifier was proposed by our group and showed improved detection of brief seizures. In the present work, we propose to add a third stage to the detector in order to use feedback of the Clinical Neurophysiologist and adaptively retune a threshold of the second stage to improve the performance of detection of brief seizures. As a result, the false alarm rate (FAR) of the brief seizure detections decreased by 50% and the positive predictive value (PPV) increased by 18%. At the same time, for all detections, the FAR decreased by 35% and PPV increased by 5% while the good detection rate remained unchanged.

Evolution of stimulus-induced rhythmic EEG discharges in three patients with encephalopathy.

Stimulus-induced rhythmic EEG discharges (SIRDs) is a recently reported phenomenon in critically ill patients and little is known about their evolution. We found SIRDs in three patients with encephalopathy and followed them with serial EEGs. SIRDs appeared between 4 and 13 days after the onset of illness and persisted for 2-3 days. The discharges were elicited by tactile or nociceptive stimuli and lasted for 20-120 s. They were detected in 2/6, 1/3 and 2/11 EEGs performed between 9 and 32, 2 and 4 and 3 and 15 days, respectively, after the onset of illness. Their morphology varied: blunt triphasic waves, rhythmic delta activity and rhythmic sharp wave complexes. The background EEG activity was slowed or suppressed in all. One patient had acute disseminated encephalomyelitis (ADEM) with good recovery and the other two had fatal hypoxic ischemic encephalopathy. SIRDs appear to be a transient phenomena occurring in patients with encephalopathy, appearing hours to few days after the onset of illness. This is the first report of SIRDs in ADEM. Serial EEGs and repeated testing of EEG response to tactile and nociceptive stimuli is required for their detection. Larger number of patients with SIRDs need to be studied to assess their prognostic significance.

Molecular docking and pharmacophore studies of heterocyclic compounds as Heat shock protein 90 (Hsp90) Inhibitors.

Heat Shock Protein 90 was a key molecular chaperone involved in the proteome stability maintenance and its interference in many signaling networks associated with cancer progression, makes it of an important target for cancer therapeutics. The present study aimed to identify potential lead molecule among the selected heterocyclic compounds against Human Hsp90 (PDB: 1YET) through docking using GOLD 3.1 and pharmacophore studies using Discovery studio 2.1. On the basis of the GOLD Fitness scores, the compounds Q1G and T21 showed better binding affinity. Further the analyzed structure pharmacophore results are in consistence with the docking results indicating that both these compounds show antagonistic activity towards HSP90 respectively.

The clinical application of rhBMP-7 for the reconstruction of alveolar cleft.

In this study, radiographic assessment was performed to find out the effectiveness of bone regeneration following the application of recombinant human bone morphogenetic protein 7 (rhBMP-7) for the reconstruction of alveolar cleft defects in 11 cases: nine unilateral and two bilateral alveolar clefs. Reconstruction of the alveolar cleft was performed by using 3.5 mg of rhBMP-7 (Osigraft OP1) on a type I collagen carrier. Radiographs were taken 6 months post operation using a Gendex Intraoral Unit with Agfa Dentus M2 Comfort occlusal film. The amount of bony infill was graded on a Kindelan four-point scale. The patients were followed up for an average of 6.6 years. Based on the radiographic analysis, eight out of the nine unilateral alveolar cleft cases received a score of grade I and one patient had a grade II score, using the Kindelan scale. In the two bilateral alveolar clefts, only one side had bone formation. The radiographic appearance showed a normal trabecular pattern similar to the adjacent bone. Thus, rhBMP-7 was radiographically and clinically successful in regenerating the bone at the alveolar cleft which resulted in shortening of the operation time, absence of donor-site morbidity and a shorter hospital stay. The promising results of this preliminary study should encourage a phase II trial to compare bone grafts with BMP for the reconstruction of alveolar defects.

Improved multi-stage neonatal seizure detection using a heuristic classifier and a data-driven post-processor.

OBJECTIVE: After identifying the most seizure-relevant characteristics by a previously developed heuristic classifier, a data-driven post-processor using a novel set of features is applied to improve the performance. METHODS: The main characteristics of the outputs of the heuristic algorithm are extracted by five sets of features including synchronization, evolution, retention, segment, and signal features. Then, a support vector machine and a decision making layer remove the falsely detected segments. RESULTS: Four datasets including 71 neonates (1023h, 3493 seizures) recorded in two different university hospitals, are used to train and test the algorithm without removing the dubious seizures. The heuristic method resulted in a false alarm rate of 3.81 per hour and good detection rate of 88% on the entire test databases. The post-processor, effectively reduces the false alarm rate by 34% while the good detection rate decreases by 2%. CONCLUSION: This post-processing technique improves the performance of the heuristic algorithm. The structure of this post-processor is generic, improves our understanding of the core visually determined EEG features of neonatal seizures and is applicable for other neonatal seizure detectors. SIGNIFICANCE: The post-processor significantly decreases the false alarm rate at the expense of a small reduction of the good detection rate.

Improvement of an automated neonatal seizure detector using a post-processing technique.

Visual recognition of neonatal seizures during continuous EEG monitoring in neonatal intensive care units (NICUs) is labor-intensive, has low inter-rater agreement and requires special expertise that is not available around the clock. Development of an accurate automated seizure detection system with a low false alarm rate will support clinical decision making and alleviate significantly the workload. However, this is an ongoing difficult challenge for engineers as the neonatal EEG signal is non-stationary and often includes complex patterns of seizures and artifacts. In this study, we show an improvement of our previously developed neonatal seizure detector (developed using heuristic if-then rules). In order to improve the detection accuracy, mean phase coherence as a new feature is used to characterize artifacts and also support vector machine is applied to perform the post-processing step to remove false detections. As a result, the false alarm rate drops 42% (from 2.6 h(-1) to 1.5 h(-1)), whereas the good detection rate reduces only by 4%.