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Purpose: The purpose of this study is to investigate the effect of the deformity angular ratio (DAR) on intra-operative neuromonitoring (IONM) signal changes during posterior spinal fusion (PSF) without vertebral column resection (VCR). Methods: Retrospective review of severe pediatric spinal deformity patients treated with PSF without VCR or three-column osteotomy from 2008 to 2018. Exclusion criteria were prior instrumentation, lack of IONM, and incomplete radiographic data. Coronal DAR (C-DAR), sagittal DAR (S-DAR), and total DAR (T-DAR) were calculated and compared between patients with IONM signal loss and those without. Results: Two hundred and fifty-three patients met inclusion criteria. Forty-seven of two hundred and fifty-three (19%) patients had IONM signal loss. Intra-operative wake-up test was performed in seven cases; three of seven (43%) had a neurological deficit on wake-up test. All neurological deficits resolved at a mean of 41 days postop. IONM loss was associated with increased kyphosis (p= 0.003) and was not associated with Cobb angle (p= 0.16). S-DAR (p= 0.03) and T-DAR (p= 0.005) were associated with IONM signal loss but C-DAR was not (p= 0.06). Increased incidence of IONM signal loss was seen with S-DAR > 7 (p= 0.02) or T-DAR > 27 (p= 0.02). Twenty-four of ninety-two (26%) patients with S-DAR > 7 had IONM signal loss compared to twenty-three of one hundred and sixty-one (14%) with S-DAR ≤ 7 (OR, 2.1; 95% CI, 1.1–4.0). Seven of sixteen (44%) patients with T-DAR > 27 had signal loss compared to forty of two hundred and thirty-seven (17%) patients with T-DAR ≤ 27 (OR, 3.8; 95% CI, 1.3–10.9). Conclusion: Patients with S-DAR > 7 or T-DAR > 27 have a higher risk of IONM loss during pediatric PSF even in the absence of a VCR or three-column osteotomies.

Background: Stress-view radiographs are frequently obtained to evaluate supination-external rotation (SER) variant ankle fractures. Measurement of the ankle medial clear space (MCS) is a surrogate of medial structure integrity as part of overall ankle stability. Measurement of the lateral talus displacement with respect to the incisura may be a sensitive and specific method to assess joint subluxation.Methods: Retrospective review of acute SER-variant isolated lateral malleolar fractures with gravity stress views (GSVs) were performed for 103 patients. GSV analysis was performed with standardized measurements of the MCS, superior clear space (SCS), and 2 new novel measurements of lateral talus subluxation (LTS). Decision for surgery was obtained by surgeons who reviewed masked injury radiographs for predictive performance analysis of the LTS vs MCS.Results: MCS, SCS, and LTS measurements were performed on 103 patients. Mean MCS, SCS, and LTS within the operative group was increased. MCS ≥5 mm and LTS >4 mm had equal sensitivity (95%), with higher specificity for LTS (75% vs 60%). Receiver operating characteristic analysis demonstrates an area under the curve of 0.786 for MCS ≥5 mm vs 0.918 for LTS >4 mm.Conclusion: We found LTS to be superior to MCS for medial ankle structure stability on gravity stress views of SER-variant ankle fractures. We propose this as a useful tool for clinicians to consider when evaluating SER-variant ankle fractures.Level of Evidence: Level II, prospective comparative study of radiographs.

Reconfigurable platforms such as field-programmable gate arrays (FPGAs) are widely used as an optimized platform with fast design time. New features such as dynamic reconfiguration make the bitstream vulnerable to clone/modification attacks which raise a security concern in today’s heterogeneous computing architecture. A widely adopted countermeasure is by providing a secure boot mechanism as root-of-trust to authenticate the unmodified firmware to prevent attackers from manipulating it. In this work, we propose an automated security-aware design flow scheme by integrating the logic-locking scheme for secure boot in Xilinx FPGAs. The proposed design implements FPGA-based logic obfuscation, with a pre-boot in-field device authentication scheme implemented using ARM TrustZone enabled with Trusted Platform Modules (TPM) key provisioning. This scheme constructs security features that can protect the IPs during the design process and integrates the primitives with FPGAs secure boot process and enhances bitstream security.

The upper ocean salinity in the eastern subpolar North Atlantic undergoes decadal fluctuations. A large fresh anomaly event occurred during 2012–2016. Using the ECCOv4r4 state estimate, we diagnose and compare mechanisms of this low salinity event with those of the 1990s fresh anomaly event. To avoid issues related to the choice of reference salinity values in the freshwater budget, we perform a salt mass content budget analysis of the eastern subpolar North Atlantic. It shows that the recent low salt content anomaly occurs due to the circulation of anomalous salinity by mean currents entering the eastern subpolar basin from its western boundary via the North Atlantic Current. This is in contrast to the early 1990s, when the dominant mechanism governing the low salt content anomaly was the transport of the mean salinity field by anomalous currents. On decadal time scales, the eastern subpolar North Atlantic shifts between a salty and fresh upper ocean. Between 2012 and 2016, there was a large event which freshened this region more than at any other time in over a century. A similar event occurred in the early 1990s, but with a smaller magnitude. We use a numerical model of the ocean to figure out why these events occurred. Our study shows that there were two different mechanisms at play. The recent event occurred because a lot of fresh water came in from the west by the mean currents. The 1990s event occurred because ocean currents shifted and brought fresh water from outside the region. Two fresh anomalies observed in the eastern subpolar North Atlantic upper ocean during 1992–2017 share similar spatial characteristicsSalt budget analysis shows the 2012–2016 fresh anomaly in the upper 1,000 m occurs due to transport of anomalous salinity by mean currentsIn contrast, the fresh anomaly in the 1990s is due to anomalous circulation of the mean salinity field Two fresh anomalies observed in the eastern subpolar North Atlantic upper ocean during 1992–2017 share similar spatial characteristics Salt budget analysis shows the 2012–2016 fresh anomaly in the upper 1,000 m occurs due to transport of anomalous salinity by mean currents In contrast, the fresh anomaly in the 1990s is due to anomalous circulation of the mean salinity field

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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjsurg.2006.08.023 Byline: Ali Siddiqui (a), Edward Livingston (b), Sergio Huerta (b) Keywords: Laparoscopic Roux-en-Y gastric bypass surgery; Open Roux-en-Y gastric bypass surgery; Morbid obesity; Super obesity; Decision support techniques Abstract: The aim of this study was to compare laparoscopic Roux-en-Y gastric bypass (LGBP) with open Roux-en-Y gastric bypass (OGBP) to determine which approach resulted in better clinical outcomes and cost effectiveness in patients with morbid obesity. Author Affiliation: (a) Division of Gastroenterology, VA North Texas Health Care System and University of Texas Southwestern Medical School, Dallas, TX, USA (b) Division of GI/Endocrine Surgery, VA North Texas Health Care System and University of Texas Southwestern Medical School, 5323 Harry Hines Blvd., Dallas, TX 75390, USA Article History: Received 12 May 2006; Revised 7 August 2006

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Multicenter retrospective review.

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Percutaneous cholecystostomy tube (PTGBD), endoscopic retrograde cholangiopancreatography with transpapillary gallbladder drainage (TP), and endoscopic ultrasound-guided transmural gallbladder drainage (EGBD) using lumen-apposing metal stents (LAMS) have been offered for gallbladder decompression for acute cholecystitis in high-risk surgical patients. Yet, there are limited data comparing these therapies. Our aim was to compare the safety and efficacy of EGBD to TP and PTGBD for gallbladder drainage. We retrospectively collected high-risk surgical patients from six centers with acute cholecystitis who underwent gallbladder drainage by EGBD, TP, or PTGBD. Data included technical success (gallbladder drainage), clinical success (acute cholecystitis resolution), adverse events (AE), and follow-up. From 2010 to 2016, 372 patients underwent gallbladder drainage, with 146 by PTGBD, 124 by TP, and 102 drained by EGBD. Technical (98% vs. 88% vs. 94%; p= 0.004) and Clinical (97% vs. 90% vs. 80%; p< 0.001) success rates were significantly higher with PTGBD and EGBD compared to TP. PTGBD group had statistically significantly higher number of complications as compared to EGBD and TP groups (2 0% vs. 2% vs. 5%; p= 0.01). Mean hospital stay in the EGBD group was significantly less than TP and PTGBD (16 vs. 18 vs. 19 days; p= 0.01), while additional surgical intervention was significantly higher in the PTGBD group compared to the EGBD and TP groups (49% vs. 4% vs. 11%; p< 0.0001). EGBD with LAMS is an effective and safer alternative to TP and PTGBD for treatment of patients with acute cholecystitis who cannot undergo surgery. EGBD with LAMS has significantly lower overall AEs, hospital stay, and unplanned admissions compared to PTGBD. Trial registration: ClinicalTrials.gov Identifier: NCT01522573.

Gastrocutaneous fistula after gastrostomy tube removal may persist for a prolonged period. We present a case of a 58-year-old woman with a GCF that had persisted for 5 months following [...]

To use subharmonic imaging (SHI) to depict the vascularity of pancreatic masses compared to contrast‐enhanced endoscopic ultrasound (EUS) and pathologic results. Sixteen patients scheduled for biopsy of a pancreatic mass were enrolled in an Institutional Review Board–approved study. Pulse‐inversion SHI (transmitting/receiving at 2.5/1.25 MHz) was performed on a LOGIQ 9 system (GE Healthcare, Milwaukee, WI) with a 4C transducer, whereas contrast harmonic EUS (transmitting/receiving at 4.7/9.4 MHz) was performed with a radial endoscope (GF‐UTC180; Olympus Corporation, Tokyo, Japan) connected to a ProSound SSD α‐10 scanner (Hitachi Aloka, Tokyo, Japan). Two injections of the contrast agent Definity (Lantheus Medical Imaging, North Billerica, MA) were administrated (0.3–0.4 and 0.6–0.8 mL for EUS and SHI, respectively). Contrast‐to‐tissue ratios (CTRs) in the mass and an adjacent vessel were calculated. Four physicians independently scored the images (benign to malignant) for diagnostic accuracy and inter‐reader agreement. One patient dropped out before imaging, leaving 11 adenocarcinomas, 1 gastrointestinal stromal tumor with pancreatic infiltration, and 3 benign masses. Marked subharmonic signals were obtained in all patients, with intratumoral blood flow clearly visualized with SHI. Significantly greater CTRs were obtained in the masses with SHI than with EUS (mean ± SD, 1.71 ± 1.63 versus 0.63 ± 0.89; P= .016). There were no differences in the CTR in the surrounding vessels or when grouped by pathologic results (P> .60). The accuracies for contrast EUS and SHI were low (<53%), albeit with a greater κ value for SHI (0.34) than for EUS (0.13). Diagnostic accuracy of contrast EUS and transabdominal SHI for assessment of pancreatic masses was quite low in this pilot study. However, SHI had improved tumoral CTRs relative to contrast EUS.

Endoscopic placement of fully covered self-expanding metal stents (FCSEMS) to treat malignant dysphagia in patients with esophageal cancer significantly improves dysphagia; however, these stents have a high migration rate. To determine whether FCSEMS fixation using an endoscopic suturing device treated malignant dysphagia and prevented stent migration in patients with locally advanced esophageal cancer receiving neoadjuvant therapy when compared to patients with FCSEMS placement alone. A review of patients with locally advanced esophageal cancer who underwent FCSEMS placement at 3 centers was performed. Patients were divided into two groups: Group A (n= 26) was composed of patients who underwent FCSEMS placement with suture placement, and Group B (n= 67) was composed of patients with FCSEMS placement alone. There were no significant differences between Groups A and B in demographics, and tumor characteristics. The technical success rate for stent placement was 100 %. There was no difference between Groups A and B in the median stent diameter and stent lengths. Mean dysphagia score obtained at 1 week after stent placement had improved significantly from baseline (2.4 and 1, respectively, p< 0.001). Patients had a median follow-up of 4 months. Immediate adverse events were mild chest discomfort in 4 patients in Group A and 2 patients in Group B (p= 0.05), and significant acid reflux in 3 patient in Group A compared to 2 patients in Group B (p= 0.1). The stent migration rate was significantly lower in Group A compared to compared to Group B (7.7 vs 26.9 %, respectively, p= 0.004). There was a delayed perforation in 1 patient and 1 death due to aspiration pneumonia in Group B. Fixation of esophageal FCSEMSs by using an endoscopic suturing device in patients receiving neoadjuvant therapy was shown to be feasible, safe, and relatively effective at preventing stent migration compared to those who had stent placed alone.

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Despite the significant advances in the medical research and treatment methods, the rate of mortality associated with cardiovascular disease (CVD) is continuously rising and it remains the leading cause of death worldwide. There are several treatment methods for CVD and associated complications that have been considered till now. The current treatment methods cannot produce rapid cure, but could prevent or reduce the progression of this devastating disease. In the current article, we have summarized the use of various pharmacological agents viz. HMG-CoA reductase inhibitors (statins), antihypertensive, thrombolytic and anticoagulation agents that are currently being used for the management of CVD which targets different biochemical or molecular events. Based on our article, more research in this field is advocated which will provide the rapid and effective treatment methods in order to avoid fatal complications associated with CVD.

Computed tomography (CT) is the primary imaging modality for initial evaluation of pancreatic cancer (PC). Endoscopic ultrasound (EUS) has a higher sensitivity for detection of PC and is better especially for lesions<3 cm. It should be the next step if the CT scan is indeterminate, or negative in the presence of high suspicion of PC based on clinical and laboratory data. EUS-guided fine-needle aspiration (FNA) should be performed for lesions found on EUS after negative or indeterminate CT, for borderline resectable pancreatic cancer (BRPC) and unresectable cancer, or if the patient is being considered for neoadjuvant or palliative chemotherapy. EUS elastography and contrast-enhanced harmonic EUS are new and promising EUS technologies that may detect lesions missed by other modalities and may help guide EUS-FNA to target lesions.

We report a retrospective analysis of patients with malignant biliary obstruction in whom a newly released fully silicon-covered, WallFlex, self-expandable metal stent (CSEMS) was placed for biliary decompression.

Abstract: Background: Endoscopic ultrasound (EUS)-guided biliary drainage (EUSBD) has been described as a viable alternative to percutaneous transhepatic cholangiography (PTC) in patients in whom ERCP has been unsuccessful. The purpose of our study was to assess the utility of EUSBD using a newly released, fully covered, self-expanding, biliary metal stent (SEMS) for palliation in patients with an obstructing malignant biliary stricture. Methods: We collected data on all patients who presented with obstructive jaundice and who underwent transduodenal EUSBD after a failed ERCP. Eight patients presented with biliary obstruction from inoperable pancreatic cancer or cholangiocarcinoma. Reasons for failed ERCP were duodenum stenosis, high-grade malignant stenosis of the common bile duct, periampullary tumor infiltration, failure to access the common bile duct, and periampullary diverticulum. EUS was used to access the common bile duct from the duodenum after which a guidewire was advanced upwards toward the liver hilum. The metal stent was then advanced into the biliary tree. Technical success was defined as correct stent deployment across the duodenum. Clinical success was defined as serum bilirubin level decreased by 50% or more within 2 weeks after the stent placement. Results: Technical and clinical success was achieved in all eight patients. No stent malfunction or occlusion was observed. Complications included one case of duodenal perforation, which required surgery, and one case of self-limiting abdominal pain. Conclusions: EUSBD with a fully covered SEMS in whom ERCP is unsuccessful is effective for palliation of biliary obstruction. The limitations of our study are that we had a small number of patients and a limited follow-up time.

The long-term use of angiotensin converting enzyme (ACE) inhibitors may reduce the risk of developing colorectal cancer (CRC).

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) may be employed for procurement of a tissue diagnosis in a minimally invasive fashion. In many cases, EUS-FNA excludes the need for more invasive diagnostic procedures when a tissue diagnosis is required. In patients with esophageal neoplasms, EUS-FNA is a safe and accurate tool for the preoperative diagnosis of metastatic spread to the paraesophageal and celiac lymph nodes. EUS-FNA is also increasingly recognized as an accurate, cost-effective and safe means of evaluating and staging patients with lung cancer. EUS-FNA is useful in providing tissue confirmation of cancer in cases in which bronchoscopy or computed tomography-guided approaches has been non-diagnostic. EUS-guided therapies are paving the way for therapeutic/interventional EUS. The interventional endoscopist will now play a more central role in the diagnosis and treatment of various gastrointestinal malignancies by delivering antitumor agents.

The aims of this study were to examine the ability of the antioxidant N-acetylcysteine (NAC) and mesalamine (5-ASA) alone and in combination to affect TNBS-induced colitis in rat. Three days following induction of TNBS colitis rats were randomized to receive daily intracolonic treatment with NAC, 5-ASA, and NAC plus 5-ASA for 5 or 8 days. At the end of the treatment period macroscopic and microscopic colonic injuries were scored. Myeloperoxidase (MPO) activity and cytokine gene expression were measured in colonic tissues. Results indicated that treatment with NAC plus 5-ASA caused a significantly greater reduction in colonic injury than either agent alone. Furthermore, combination therapy inhibited significantly MPO activity and inflammatory cytokine gene expression in the distal colon of TNBS-treated animals. The beneficial effects of NAC plus 5-ASA on reduction of colonic injury and promotion of healing were most evident after 8 days of treatment.The aims of this study were to examine the ability of the antioxidant N-acetylcysteine (NAC) and mesalamine (5-ASA) alone and in combination to affect TNBS-induced colitis in rat. Three days following induction of TNBS colitis rats were randomized to receive daily intracolonic treatment with NAC, 5-ASA, and NAC plus 5-ASA for 5 or 8 days. At the end of the treatment period macroscopic and microscopic colonic injuries were scored. Myeloperoxidase (MPO) activity and cytokine gene expression were measured in colonic tissues. Results indicated that treatment with NAC plus 5-ASA caused a significantly greater reduction in colonic injury than either agent alone. Furthermore, combination therapy inhibited significantly MPO activity and inflammatory cytokine gene expression in the distal colon of TNBS-treated animals. The beneficial effects of NAC plus 5-ASA on reduction of colonic injury and promotion of healing were most evident after 8 days of treatment.

Patients with nonerosive gastroesophageal reflux disease often have relatively low esophageal acid exposure and respond suboptimally to gastric acid suppression. In these patients, other constituents of gastric contents may induce esophageal symptoms. We have demonstrated that gastric contents can cause heartburn when the gastric pH > 4. (Aliment Pharm Ther 14:129–134, 2000). The aim of this study was to determine relative sensitivities to chenodeoxycholic and ursodeoxycholic acids, and 0.1 N HCl, administered as provocative perfusion tests. Patients with functional heartburn and healthy control subjects were evaluated. Patients underwent a modified Bernstein acid infusion test and esophageal Barostat balloon distention. Time and volume to pain were recorded. Barostat balloon distention was performed using our standard protocol. Stepwise distentions were performed and pain was recorded. Sensitivity to chenodeoxycholic acid (Cheno) and Ursodeoxycholic acid (Urso) were assessed similarly to the Bernstein test using 2 mM concentrations of each, followed immediately by 5 mM if no pain was reported with 2 mM. Volume of bile acid infusion and length of time until pain was induced were assessed and compared to the same endpoints for acid sensitivity. ldquoTotalrdquo time and ldquototalrdquo volume to induce pain were calculated for Cheno and Urso. Least-squares means were generated and two-tailed t-tests and regression analyses were performed (P < 0.05 level of significance). Ten functional heartburn patients and six healthy controls were evaluated (3 M, 13 F; age range, 19 to 56 years). Since five of six controls had pain with acid infusion (hypersensitive), all subjects were analyzed as one group. Only three subjects (all controls) had no pain with infusion of 2 mM Cheno and received the follow-up infusion of 5 mM. These same three subjects tolerated the maximum infusion (150 ml and 15 min) of 5 mM Cheno. Nine subjects did not have pain with 2 mM Urso and received the follow-up infusion of 5 mM Urso (five functional heartburn, four controls). Significantly more subjects tolerated the maximum bile acid infusion of 2 mM Urso vs 2 mM Cheno (nine vs three; P < 0.05, Chi-square test). The pain threshold (volume and time) for Urso was significantly higher than that for Cheno and acid (P < 0.05), and the pain threshold for Cheno was significantly higher than that for acid (P < 0.05). Conclusions are as follows: (1) Bile acids differ in their ability to induce pain. (2) Changing bile acid composition by treatment with Urso may change symptom presentation and symptom severity in patients with bile acid-induced esophageal pain.

Non-alcoholic fatty liver disease (NAFLD) is a widespread chronic liver disease. It is considered a multifactorial disorder that can progress to liver fibrosis and cause a worldwide public health concern. Coffee consumption may have a protective impact on NAFLD and liver fibrosis. However, the evidence from the previous studies is inconsistent. This meta-analysis summarizes available literature.

• Ocular blood flow was determined using radioactive strontium 85 microspheres after an alkali (sodium hydroxide [NaOH]) burn to the eye. With 20 μL of NaOH, blood flow was significantly increased in the iris, ciliary processes, and choroid from two through four hours. This correlated well with the sustained increase in intraocular pressure (IOP) seen after a 20-μL burn. A 50-μL burn increased blood flow at one hour, but it returned toward normal levels beyond two hours. In general terms, there appeared to be a meaningful correlation between IOP changes and altered blood flow following ocular alkali burns. The blood flow changes paralleled those occurring after the topical application of prostaglandins and supported the concept that ocular blood flow dynamics are mediated by prostaglandins.

Syphilitic proctitis is a rare disease that usually presents as proctitis, ulcer, and neoplasm but lacks pathognomonic clinical symptoms. It is thus difficult to diagnose and may be treated inappropriately. We report a 31-year-old man who had a hard, ulcerated mass that occupied the rectal and sigmoid colon wall and mimicked a tumor. Fortunately, a biopsy of the mass demonstrated Treponema pallidumorganisms consistent with syphilitic proctitis. The patient was successfully treated with intravenous benzyl penicillin, resulting in improvement in his proctitis.

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