Infrequent Event Research Articles

Perioperative stroke associated in-hospital morbidity and in-hospital mortality in common non-vascular non-neurological surgery

Perioperative stroke in non-vascular, non-neurological surgery is a potential cause of high levels of in-hospital morbidity and mortality. Although, perioperative stroke following non-vascular and non-neurological surgery is a relatively infrequent event; high surgical volume results in thousands of patients experiencing neurological deficits. We aim to determine if perioperative stroke is an independent risk factor for 30-day in-hospital morbidity and mortality following common non-vascular non-neurological surgery. This is a retrospective analysis of 4,264,963 surgical procedures identified in the Nationwide Inpatient Sample (NIS) from the years 2000 through 2011. The exposure of interest was stroke within 30 days of total knee arthroscopy, total hip arthroscopy, lung segmentation and resection, appendectomy, hemicolectomy, cholecystectomy, and lysis of peritoneal adhesions. Study outcomes were in-hospital mortality and in-hospital morbidity. Our study found an in-hospital morbidity, in-hospital mortality, and perioperative stroke rate of 5.5%, 0.8%, and 0.2%, respectively. Multivariable analysis revealed perioperative stroke to be a significant independent predictor (p < 0.001) of length of stay exceeding 14 days (OR = 4.55, 95% CI: 4.21–4.91), cardiovascular complications (OR = 1.96, 95% CI: 1.75–2.19), pulmonary complications (OR = 2.07, 95% CI: 1.89–2.27). The impact of perioperative stroke on in-hospital mortality was (OR = 8.53, 95% CI: 7.87–9.25), whereas cardiovascular complications impact on in-hospital mortality was (OR = 8.36, 95% CI = 7.67–9.10, p < 0.001). This study identified perioperative stroke as an independent predictor of 30-day in-hospital morbidity and mortality following non-vascular, non-neurological surgery.

Respuesta ultrarrápida a la terapia electroconvulsiva en un caso de trastorno psicótico agudo polimorfo.

Existe la errónea percepción de que la Terapia Electroconvulsiva (TEC) debe usarse como último recurso de manejo psiquiátrico y únicamente en casos crónicos y/o refractarios. Esto, entre otras causas, ha llevado a la lamentable disminución de su empleo a lo largo de los últimos tiempos en nuestro medio y en otras latitudes. Sin embargo, las psicosis agudas con síntomas motores de tipo catatoniforme presentan tasas de respuesta de hasta 100% y la TEC debiera, por ende, hallarse en la primera línea de los recursos de tratamiento para estos cuadros, evitando o previniendo, de ese modo, connsecuencias ominosas de la catatonía. A propósito de un cuadro de trastorno psicótico agudo polimorfo sin síntomas de esquizofrenia (F23.0, CIE-10) que presentó remisión completa de síntomas catatónicos y psicóticos luego de una sola sesión de TEC (lo que es, de hecho, un resultado infrecuente), se realiza una revisión de la literatura pertinente. Se concluye que la TEC debiera retomar su relevancia en casos psicóticos agudos de buen pronóstico, en los que su postergación acarreará consecuencias innecesariamente negativas.

Neumonitis por docetaxel, discusión de un caso

&#x0D; &#x0D; &#x0D; La neumonitis intersticial por docetaxel es un evento infrecuente, pero con alto potencial de mortalidad y puede ser potencialmente reversible con el uso de esteroides sistémicos; se considera importante en el diagnóstico diferencial del paciente bajo quimioterapia con síntomas respiratorios. A continuación, se presenta un caso de neumonitis fatal por docetaxel en un paciente con carcinoma de próstata avanzado. Paciente de 80 años de edad con historia de cáncer de próstata de 15 años de evolución, en progresión ósea y ganglionar, y que inició manejo con docetaxel. Después de la aplicación del tercer ciclo presenta disnea de esfuerzos, fiebre, tos seca y deterioro general. Se realizó diagnóstico de neumonitis por docetaxel y se descartaron otras entidades. La neumonitis intersticial por docetaxel es una entidad rara. Los pilares del tratamiento son la suspensión del medicamento, el soporte ventilatorio y el uso de glucocorticoides sistémicos.&#x0D; &#x0D; &#x0D;

Immunohistochemical expression of mismatch repair proteins (MSH2, MSH6, MLH1, and PMS2) in prostate cancer: correlation with grade groups (WHO 2016) and ERG and PTEN status.

The role of DNA MMR genes in prostate cancer (PrCa) is controversial, as genetic alterations leading to microsatellite instability are incompletely defined in these tumors. ERG rearrangements and PTEN loss are concomitant events in PrCa. The aim of this study has been to analyze the immunohistochemical (IHC) expression of MSH2, MSH6, MLH1, PMS2, ERG, and PTEN and their potential association with the grade group (GG) grading system (WHO 2016) and PSA recurrence in a series of 200 PrCa (PSMAR-Biobank, Barcelona, Spain). MSH2, MLH1, PMS2, and PTEN losses were documented in 8%, 5%, 2%, and 36.5%, respectively. ERG expression was found in 48%. MSH6 showed an increase of expression with respect to basal levels in 42.1% of the cases. A statistical association between MSH6 overexpression and GG5 was found (p = 0.0281). ERG-wild-type cases were associated with single MSH2 loss (p = 0.024), and MSH2 and/or MLH1 loss (p = 0.019). The percentage of cases with PTEN loss was 20.5% (8/39) in GG1, 37.6% (53/141) of clustered GG2 to 4, and 60% (12/20) of GG5 (chi-square test, p = 0.01). Thus, PTEN expression loss was statistically more frequent in the upper-grade tumors. PMS2 loss was an infrequent event, but it was statistically associated with shorter time to PSA recurrence (p = 0.011). These results suggest the existence of an alternative non-ERG pathway associated with MSH2 or MLH1 expression loss. MSH6 overexpression could be a marker of aggressiveness in PrCa. The IHC assessment of DNA MMR proteins, ERG and PTEN, could identify different altered PrCa pathways, which could aid patient stratification.

Coronary perforation complicating percutaneous coronary intervention in patients presenting with an acute coronary syndrome: An analysis of 1013 perforation cases from the British Cardiovascular Intervention Society database

BackgroundThe evidence base for coronary perforation occurring during percutaneous coronary intervention in patients presenting with an acute coronary syndrome (ACS-PCI) is limited and the specific role of acute pharmacology in its clinical presentation unclear. Methods and resultsUsing the BCIS PCI database, data were analysed on all ACS-PCI procedures performed in England and Wales between 2007 and 2014. Multiple regressions were used to identify predictors of coronary perforation and its association with outcomes. Propensity score matching was used to evaluate the association between differing P2Y12 inhibitors or glycoprotein inhibitors (GPI) and CP. During 270,329 ACS-PCI procedures, 1013 coronary perforations were recorded (0.37%) with a stable annual incidence. In multiple regression analysis, covariates associated with increased frequency of coronary perforation included age, female gender, CTO intervention, number and length of stents used, and rotational atherectomy use, whilst differing P2Y12 inhibitors were not predictive. Using propensity score matching, use of a GPI was independently associated with tamponade (OR 1.50, [1.08–2.06], p = 0.014). The adjusted odds ratios for all clinical outcomes were adversely affected by coronary perforation. ConclusionsCoronary perforation is an infrequent event during ACS-PCI but is closely associated with adverse clinical outcomes. GPI use was associated with higher rates of tamponade.

Cause investigation of high-mode vortex-induced vibration in a long-span suspension bridge

A significant vortex-induced vibration (VIV) was observed in a suspension bridge under a wind velocity of approximately 6 and 7 m/s, and with a maximum amplitude that exceeded the serviceability limitations. Since the observation of VIV in an operating bridge was an infrequent event, this study investigated the cause of unexpected VIV. A series of wind tunnel tests revealed the main cause of the VIV was temporary screens applied over the guardrails to shield the curing surface during replacement of epoxy-coated pavement. The characteristics of the measured VIV were consistent with those from experimental results in terms of amplitude and lock-in wind speed range. The effect of Scruton numbers on VIV amplitude was examined for several dominant modes with different modal mass and damping ratios. Since the VIV amplitude is sensitive to the inherent damping ratio, the modal damping ratios of the bridge were identified from output-only modal analysis by using the frequency domain decomposition. This approach was efficient in identifying the damping ratios of high modes that were challenging due to weakly excited signals. The damping ratio of the triggered mode for VIV was the lowest among the investigated modes and estimated to be the level of the design-damping ratio.

Prolapse and regurgitation of the four heart valves in a patient with Ehlers-Danlos Syndrome: a case report.

BackgroundThe Ehlers–Danlos Syndrome (EDS) is part of a group of connective tissue diseases that affect the synthesis and processing of collagen leading to alterations in the structure of many tissues and organs.Case summaryHerein, we reported a case of a patient with prolapse of the four cardiac valves. Non-significant regurgitation of the mitral, aortic, and tricuspid valves was observed. The pulmonary regurgitation (PR) was considered significant. Dilatation of the right ventricle with preserved systolic function was also noted. A cardiac magnetic resonance confirmed the findings of the echocardiogram and determined a severe PR (regurgitant fraction of 41%). The physical examination revealed hyperlaxity of the joints, skin hyperelasticity, defects in wound healing, and abdominal hernias suggesting EDS. The stress test did not develop any symptoms or complex arrhythmias. In this patient, the heart team initially decided medical treatment and evolutionary control. At the moment, he remains asymptomatic.DiscussionValvular involvement in EDS is an infrequent event and the compromise of the four cardiac valves is exceptional. The existence of severe PR with a marked increase in ventricular volumes, even in the absence of symptoms, in most cases requires an intervention on the valve. However, in patients with EDS, there are a high rate of complications and interventions should be avoided as much as possible.

Incidence, predictors and cerebrovascular consequences of leaflet thrombosis after transcatheter aortic valve implantation: a systematic review and meta-analysis.

We examined the incidence, the impact of subsequent cerebrovascular events and the clinical or procedural predictors of leaflet thrombosis (LT) in patients undergoing transcatheter aortic valve implantation (TAVI). MEDLINE/PubMed was systematically screened for studies reporting on LT in TAVI patients. Incidence [both clinical and subclinical, i.e. detected with computed tomography (CT)] of LT was the primary end point of the study. Predictors of LT evaluated at multivariable analysis and impact of LT on stroke were the secondary ones. Eighteen studies encompassing 11124 patients evaluating incidence of LT were included. Pooled incidence of LT was 0.43% per month [5.16% per year, 95% confidence interval (CI) 0.21-0.72, I2 = 98%]. Pooled incidence of subclinical LT was 1.36% per month (16.32% per year, 95% CI 0.71-2.19, I2 = 94%). Clinical LT was less frequent (0.04% per month, 0.48% per year, 95% CI 0.00-0.19, I2 = 93%). LT increased the risk of stroke [odds ratio (OR) 4.21, 95% CI 1.27-13.98], and was more frequent in patients with a valve diameter of 28-mm (OR 2.89: 1.55-5.8), for balloon-expandable (OR 8: 2.1-9.7) or after valve-in-valve procedures (OR 17.1: 3.1-84.9). Oral anticoagulation therapy reduced the risk of LT (OR 0.43, 95% CI: 0.22-0.84, I2 = 64%), as well as the mean transvalvular gradient. LT represents an infrequent event after TAVI, despite increasing risk of stroke. Given its full reversal with warfarin, in high-risk patients (those with valve-in-valve procedures, balloon expandable or large-sized devices), a protocol which includes a control CT appears reasonable.

Association between anemia and chronic obstructive pulmonary disease exacerbations in Cartagena Colombia: a prospective cohort study

The presence of anemia in chronic obstructive pulmonary disease is not an infrequent event. Exacerbations of this disease have been associated with an increase in mortality in these patients. It is not clear if the presence of anemia is associated with the risk of exacerbations. To establish the association between anemia and the incidence of outcomes related to exacerbations of chronic obstructive pulmonary disease. Analytical study of a dynamic or open concurrent prospective cohort of patients diagnosed with chronic obstructive pulmonary disease at two health care institutions in Cartagena, Colombia, between July 2010 and July 2011. 43.9% had anemia at the start of follow-up. The cumulative incidence of exacerbations was 63% in the anemic vs. 55.5% in the non-anemic group. The cumulative incidence of recurrence of exacerbations was 30.4% in the anemic vs. 38.8% in the non-anemic group. The rate of hospitalizations for exacerbations was 30.4% in the anemic vs. 33.3% in the non-anemic group. No significant association was established between anemia and the incidence of exacerbations of chronic obstructive pulmonary disease, the incidence of recurrence of first exacerbation, the rate of hospitalizations for chronic obstructive pulmonary disease exacerbations and the recurrence time of the first exacerbation of chronic obstructive pulmonary disease.

Pathologic Features and Clinical Implications of Breast Cancer With HER2 Intratumoral Genetic Heterogeneity.

To review breast cancer with human epidermal growth factor receptor 2 (HER2) genetic heterogeneity (GH), with a focus on clinician interpretation of the results and subsequent management. We retrospectively searched all consecutive invasive breast cancers that underwent HER2 fluorescent in situ hybridization testing and identified cases with HER2 GH. Eleven (0.4%) cases of primary breast tumors with reported HER2 GH were identified over 76 months. HER2-positive tumor cells comprised a mean ± SD of 20% ± 15% of the overall tumor population (range, 5%-50%) and exhibited high levels of amplification (HER2/CEP17 = 5.4 ± 2.9). Three cases had morphologic heterogeneity. Of the four patients who completed neoadjuvant chemotherapy, two had trastuzumab; all showed a partial pathologic response. We identified two cases in which there appeared to be clinical misinterpretation of the HER2 results. HER2 GH is an infrequent event, may contain morphologic heterogeneity, could infer incomplete response to neoadjuvant therapy, and requires adequate communication with treating clinicians.

Droplet combustion and sooting characteristics of UCO biodiesel, heating oil and their mixtures under realistic conditions

The droplet combustion characteristics of conventional heating oil, UCO biodiesel and their mixtures (10 and 20% biodiesel by volume) were examined in a free-falling droplet combustion facility designed to approach the typical temperature and oxygen conditions around individual droplets in real boiler flames. Moreover, and given the importance of avoiding effects due to gravity or convection in this type of experiments, the quite spherical soot shells recorded (infrequent event in free-falling droplet combustion studies) reveal a configuration close to 1-D, even though tests were performed at normal gravity. The droplet combustion characteristics were evaluated at four different oxygen levels (0,3,5 and 10% O2), and comprise droplet size evolution, burning rates and sizing of the occurring soot shells and envelope flames. Results show indistinguishable behaviors between heating oil and their mixtures, whereas biodiesel displays longer initial heating transients and higher quasi-steady burning rates. Even though the UCO biodiesel studied is highly unsaturated, no signs of polymerization were observed for any of the tests. In addition to these combustion characteristics, an aspirating soot probe was used to quantitatively evaluate the propensity to soot of each fuel at different oxygen levels. The amount of collected soot was found to significantly decrease with biodiesel addition, even though similar results were obtained for both mixtures. The practically identical droplet combustion characteristics between heating oil and its mixtures with biodiesel, in addition to the lower propensity to soot of the latter, support the feasibility of using such blends as drop-in replacement for conventional heating oil. The experimental results obtained are thought to constitute a valuable database for the development and validation of modeling tools for the prediction of droplet evaporation and combustion of practical fuels in realistic conditions.

Abstract PD3-12: Central nervous system as first site of relapse in patients with HER2 positive early breast cancer treated in the BCIRG-006 trial

Abstract Introduction: Central Nervous System (CNS) metastases as first site of relapse is seen in 2-3% of patients with HER2+ early breast cancer (EBC) during or after treatment with adjuvant trastuzumab. Data about long-term follow-up outcomes in this population is scarce. Methodology: BCIRG-006 was designed to assess the efficacy and safety of two trastuzumab-based regimens compared to a standard (non-trastuzumab) regimen in the adjuvant treatment of HER2+ EBC. 3,222 patients were randomized to standard AC-T or two trastuzumab-based regimens (AC-TH or TCH). Ten year follow-up outcomes were previously presented; we have used this data to assess the frequency and course of CNS relapses as first site of distant recurrence. DFS and OS in these patients were estimated and compared using the Kaplan-Meier method and Log-Rank test respectively. Univariate and multivariate analyses for DFS were conducted considering patient's age, nodal status, tumor size and estrogen receptor (ER) status in the primary tumor. Results: Of the 3,222 patients randomized, 575 (17.8%) experienced a distant relapse and in 17.5% of these (n=101) CNS was the first site of recurrence. With a median follow-up of 10.3 years, the frequency of CNS relapses did not differ when comparing the trastuzumab containing arms with the control arm (OR 0.86, 95% CI: 0.56-1.33; p= 0.519). No difference was observed either between AC-TH and TCH (OR 1.14, 95% CI: 0.67-1.94; p= 0.704). There were no differences in DFS (HR 1.21, 95% CI: 0.74-1.99; p= 0.621) nor in OS (HR 0.74, 95% CI: 0.43-1.27; p= 0.377) between AC-T, AC-TH and TCH arms. Positive axillary nodes (≥4 nodes) and ER negative status at baseline remained independent risk factors for CNS relapse after univariate and multivariate analysis (HR 0.60, 95% CI: 0.8-0.95; p= 0.007 for nodal status and HR 0.56, 95% CI: 0.37-0.85; p= 0.029 for ER status). Conclusion: Among the pivotal adjuvant trastuzumab trials, BCIRG-006 is the one with the longest median FUP in which data about CNS relapses has been presented. CNS relapse in patients in this trial was an infrequent event. Its frequency and outcomes were similar across the three treatment arms. Patients with ER negative and/or ≥ 4 positive nodes are at higher risk of CNS relapse irrespective of trastuzumab therapy and may be the patient population where research efforts should be focused. BC outcomes in patients with CNS metastases per treatment arm in the BCIRG-006 trial AC-T N=1073 n(%)AC-TH N=1074 n(%)TCH N=1075 n(%)p valueFrequency of CNS relapse37 (3.44%)30 (2.79%)34 (3.16%)0.519 ^Median DFS (months; 95% CI)23.8 (13.3-30.4)19.9 (16.6-25.1)19.9 (15.0-27.2)0.621 ⫲Median OS (months; 95% CI)42.5 (28.3-62.7)53.2 (31.2-103.6)30.3 (23.4-39.0)0.377 ⫲ ^ comparing control vs. trastuzumab-containing arm using Fisher's Exact test. ⫲ comparing control vs. trastuzumab-containing arms using Log Rank test. Citation Format: Chan A, Spera G, Machado A, Fung H, Bee V, Fresco R, Slamon DJ. Central nervous system as first site of relapse in patients with HER2 positive early breast cancer treated in the BCIRG-006 trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD3-12.

Energetics, kinetics and dynamics of self-interstitial clusters in bcc tungsten

ABSTRACTThe configuration, slipping and rotation of self-interstitial atoms cluster along <111> crystal orientation with different sizes in a tungsten are investigated systematically with molecular dynamics. It is found that (I) the SIA clusters with high symmetry are always favoured; (II) the SIA clusters can undergo one-dimensional fast migration along <111> direction, and their migration barriers are no more than 0.07 eV, which is expected due to the strong interaction in the SIA clusters; (III) the rotation energy barriers of the SIA clusters are rather high and they are basically positively correlated with the size of the cluster. For example, the reorientation barrier is 0.66 eV for 1 SIA, 1.2–1.8 eV for SIAn (2 ≤ n ≤ 5) clusters and over 2.7 eV for SIAn (6 ≤ n ≤ 7) clusters. Compared with slipping of SIA clusters, is an infrequent event, especially for larger SIAs cluster, the vast majority SIAs cluster would have already recombination with vacancies or annihilates at surface and grain boundary through slipping before rotation, which explained that there are very low density of SIAs cluster found in the experiment.

Outcomes for Patients Who Contact the Emergency Ambulance Service and Are Not Transported to the Emergency Department: A Data Linkage Study

Objectives: Emergency ambulance services do not transport all patients to hospital. International literature reports non-transport rates ranging from 3.7–93.7%. In 2017, 38% of the 11 million calls received by ambulance services in England were attended by ambulance but not transported to an Emergency Department (ED). A further 10% received clinical advice over the telephone. Little is known about what happens to patients following a non-transport decision. We aimed to investigate what happens to patients following an emergency ambulance telephone call that resulted in a non-transport decision, using a linked routine data-set. Methods: Six-months individual patient level data from one ambulance service in England, linked with Hospital Episode Statistics and national mortality data, were used to identify subsequent health events (ambulance re-contact, ED attendance, hospital admission, death) within 3 days (primary analysis) and 7 days (secondary analysis) of an ambulance call ending in non-transport to hospital. Non-clinical staff used a priority dispatch system e.g. Medical Priority Dispatch System to prioritize calls for ambulance dispatch. Non-transport to ED was determined by ambulance crew members at scene or clinicians at the emergency operating center when an ambulance was not dispatched (telephone advice). Results: The data linkage rate was 85% for patients who were discharged at scene (43,108/50,894). After removal of deaths associated with end of life care (N = 312), 9% (3,861/42,796) re-contacted the ambulance service, 12.6% (5,412/42,796) attended ED, 6.3% (2,694/42,796) were admitted to hospital, and 0.3% (129/42,796) died within 3 days of the call. Rates were higher for events occurring within 7 days. For example, 12% re-contacted the ambulance service, 16.1% attended ED, 9.3% were admitted to hospital, and 0.5% died. The linkage rate for telephone advice calls was low because ambulance services record less information about these patients (24% 2,514/10,634). A sensitivity analysis identified a range of subsequent event rates: 2.5–10.5% of patients were admitted to hospital and 0.06–0.24% of patient died within 3 days of the call. Conclusions: Most non-transported patients did not have subsequent health events. Deaths after non-transport are an infrequent event that could be selected for more detailed review of individual cases, to facilitate learning and improvement.

Discharge Against Medical Advice: A Tertiary Referral Centre Experience

Background: Discharge against medical advice (DAMA) is an infrequent event within hospital. It has been shown this group maybe more likely to have higher rates of readmission and post discharge mortality. Aims: To describe the clinical characteristics, comorbidities, organisational factors, and health outcomes of consecutive patients who DAMA in a large tertiary hospital. Methods: DAMA patients were identified by ICD codes during the period 2012–2017. Inpatient characteristics were sourced from the medical records. Length of hospital stay, 30-day readmission, and mortality rates were included and sourced from the Cardiac and Stroke outcomes. Results: A total of 69 patients were classified as DAMA during the study. The median age was 56 (IQR 47–66). Males were more likely to DAMA (75%). DAMA patients predominantly presented with ACS (64%), CHF (17%), and arrhythmia (13%). The cardiac co-morbidities of this group included prior PCI (28%), ischaemic heart disease (43%), diabetes (52%), heart failure (23%), and renal failure (23%). Indigenous patients accounted for 17% of this group. Additional patient characteristics showed that DAMA patients had a high rate of unemployment (51%), and 38% had a current mental illness. Of interest in a large geographical area, the median distance from home to hospital was 20km (IQR 10–47). This patient group showed a high 30-day readmission rate (45%), but low 30 day mortality rate. Conclusion: The incidence of DAMA is low. DAMA patients have identifiable comorbidities and complex social issues. DAMA does confer a high readmission rate. DAMA patients were more likely to be male and Indigenous.

Event-Triggered Consensus Control for Second-Order Multi-Agent Systems With/Without Input Time Delay

The paper studies the consensus of event-triggered for second-order multi-agent systems (MASs) with or without input time delay. Based on the designed triggering function, a distributed event-triggered control strategy is presented to drive the system to achieve consensus. For each agent, controller update only needs the neighbor's information communication and its own error value, thus continuous communication among agents is not necessary. Communication energy can be saved as the agents send their state information only at infrequent event instants. To demonstrate the asymptotical stability of the closed-loop error system, S-procedure approach is used by combing Lyapunov stability theories with linear matrix inequality (LMI) technique. Two sufficient conditions are derived by solving LMIs for achieving second-order consensus under the cases of with or without input time delay, respectively.Numerical examples are presented to verify the effectiveness of the proposed controllers.

Acute mesenteric venous thrombosis in a pregnant woman at 35\u2009weeks of gestation: a case report and review of the literature

BackgroundMesenteric venous thrombosis (MVT) is an infrequent thrombotic event that can cause devastating intestinal hemorrhagic ischemia. The mortality rate among patients with acute MVT ranges from 20 to 50%. Occurrence of MVT in pregnancy is quite rare. In this case report, we describe a pregnant woman who presented with acute MVT at 35 weeks of gestation.Case presentationOur case was a 26-year-old primigravid woman at 35 weeks gestation. She presented to Guangzhou First People’s Hospital with complaints of abdominal pain, nausea and vomiting. The second day after admission, she complained of more intense abdominal pain, anorexia, vomiting and abdominal distention that were out of proportion to physical signs. An emergency exploratory laparotomy was performed. The entire ileum, part of the jejunum and part of the ascending colon were gangrenous, and thromboembolism was discovered in the corresponding mesenteric veins. The necrotic intestine was resected and an end-to-end jejunum-colon anastomosis was performed. A cesarean section was performed to remove the placenta and fetus, which had expired. Histopathological analysis revealed extensive edema, hemorrhage, inflammatory infiltration and necrosis in the resected bowel, and widespread thrombosis in mesenteric venous lumens.ConclusionThe diagnosis of MVT during pregnancy is very difficult due to its low incidence, and non-characteristic symptoms, signs and laboratory results. MVT may be the underlying cause of severe abdominal pain during pregnancy and should be included in the differential diagnosis of pregnant patients with an acute abdomen.

Structural variation and the development of thick rhyolite lava: A case study of the Sanukayama rhyolite lava on Kozushima Island, Japan

Geological studies of ancient rhyolite lavas are required for understanding flow dynamics because rhyolite lava eruption is an infrequent event. The Pleistocene Sanukayama rhyolite lava is about 130 m thick and located on Kozushima Island, Japan. Vertical sections of the lava are well exposed in the sea cliff and in a dissected valley, providing a good opportunity for the elucidation of the internal structural variations. The vertical lithofacies variations are classified into three zones of pumiceous, obsidian, and crystalline from the top to the base, respectively. The exposed area is considered to correspond to the upper half of the lava. In the boundaries between each zone, the lithofacies are mingled rather than exhibiting gradual change. This indicates that rheological contrasts are arisen within the lava due to differences of vesicularity and/or crystallinity. Various heterogeneous structures are recognized throughout the lava such as obsidian and reddish layers in the pumiceous zone, strongly deformed white-colored bands and a clastic layer in the obsidian zone, and dark-colored bands in the crystalline zone. We demonstrate on the basis of geological evidences and magnetic studies that these heterogeneous structures originated mostly from shear-induced fracturing within the advancing lava. This study indicates that brittle lava fracturing during ductile-brittle transition likely governs the acceleration of rhyolite lava heterogeneity.

Release of circulating tumor cells and cell-free nucleic acids is an infrequent event in synovial sarcoma: liquid biopsy analysis of 15 patients diagnosed with synovial sarcoma

BackgroundSynovial sarcoma is a rare soft tissue tumor which contains the unique SS18-SSX1, SS18-SSX2 – or, rarely, SS18-SSX4 - fusion transcripts. It is well known that some soft tissue tumors, like Ewing sarcomas and myxoid liposarcomas, can spread via the blood with free circulating tumor cells (CTC); this can be detected by several sensitive molecular biology methods. Here we report a study of fifteen synovial sarcoma patients with varied clinical backgrounds.MethodAfter blood withdrawal and nucleic acid isolation, we attempted to detect the SS18-SSX fusion genes from circulating tumor cells or cell-free nucleic acids with nested PCR and droplet digital PCR.ResultsSS18-SSX2 fusion transcript was identified in a small copy number with droplet digital PCR in one case. Nested PCR could not detect any of the fusion transcripts in the examined 15 synovial sarcoma cases.ConclusionsHeretofore two case reports could detect CTCs in synovial sarcoma - in the first paper, the patient was diagnosed with poorly differentiated type while the other had a rare primary gastric synovial sarcoma. However, until now, no other studies have detected CTCs in the peripheral blood of synovial sarcoma patients. Based on our findings, we can conclude that detection of the chimeric SS18-SSX fusion gene after surgical excision and/or chemotherapy/radiotherapy is a rare circumstance and hence in itself is not sufficient for monitoring the tumor recurrence. Therefore, monitoring of other possible biomarkers - for example synovial sarcoma specific miRNAs - is recommended.

Building and Implementing an Operational Plan.

Radiology practices engage in planning processes with varying frequency. Organizational planning can occur on three levels. Strategic planning is an infrequent event occurring every 5-7 years. It is aspirational and is guided by the mission and the vision of the organization. Operational planning is a yearly process in which businesses articulate their goals for the year. Creating a yearly operational plan provides departmental employees with a road map for the upcoming year and helps to tie their daily activities to the larger strategic plan of the organization. Finally, a project plan provides details describing how a specific goal will be met. The differences among these three types of plans (strategic plan, operational plan, and project plan) are described. The article then focuses on operational planning, providing a rationale for building an operational plan and then a description of the method used in the authors' division to build an operational plan. ©RSNA, 2018.