Local Institutional Research Articles

Does Positioning of Cervical Disc Arthroplasty Implant Affect Postoperative Outcome

Abstract INTRODUCTION Cervical disc arthroplasty (CDA) is a surgical option for patients with cervical radiculopathy symptoms that have failed conservative management. CDA has a lower incidence of adjacent segment disease as well as reoperation rates. Proper surgical technique is critical for success of CDA surgery. The aim of this study was to investigate whether implant positioning has an impact on the outcomes of CDA surgery. METHODS Following local Institutional Review Board (IRB) approval, a retrospective study was conducted on consecutive patients undergoing CDA with the Mobi-C implant (Zimmer Biomet, IN) between January 2016 and December 2018. Immediately postoperative lateral and AP radiographs were assessed by 3 spine surgeons for implant positioning. Our scoring criteria included rotational, sagittal, and coronal placement as well as size matching. AP and lateral radiographs were scored independently and the overall postoperative score was calculated as the sum of the 2 scores. The overall postoperative score was correlated with 5 patient reported outcomes measures (PROMS); Visual Analogue Scale (VAS) arm, VAS neck, Neck Disability Index (NDI), and Short Form 12 Physical health (SF12-P) and mental health (SF12-M). RESULTS Radiographs of 85 patients, and 110 levels, that underwent CDA were assessed. Of those, 41 patients were excluded from the PROMS analysis due to inadequate follow-up. Inter-rater reliability for radiographic assessment was good to excellent. Mean follow-up was 8 mo and ranged from 6 to 24 mo. The overall implant positioning scores showed strong correlation with NDI and SF12-P outcomes measures at latest follow up (P = .007, P = .028, respectively). CONCLUSION Proper implant sizing and implant rotational and translational positioning have a significant impact on functional and disability outcomes of patients undergoing CDA surgery. Further research is warranted to investigate other parameters that affect the outcomes of CDA surgery.

Single-Item Versus Multiple-Item Headache Ratings in Service Members Seeking Treatment for Brain Injury.

Headaches are the most common complaint after traumatic brain injury (TBI) and a significant cause of morbidity and disability among military personnel. Currently, there are a several measures which can assess headache disability, but there is a significant burden to assess each individual symptom given this heterogeneous polymorbid population. The objective of this proposed study was to validate the single headache item from the Neurobehavioral Symptom Inventory (NSI) compared to the 6-item Headache Impact Test (HIT-6). Participants included consecutive treatment-seeking outpatients at the Brain Injury Rehabilitation Service at the Brooke Army Medical Center from August 2007 to January 2010 who were administered a battery of assessment measures at initial intake, as part of usual care. Archival record review was conducted using procedures approved by the local Institutional Review Board. Inclusionary criteria included completion of both the HIT-6 and NSI. Participants with a cut-off score of >22 on the NSI Validity-10 were excluded in a post hoc analysis to validate findings among those who passed validity screen. The Pearson correlation between the single-item NSI headache measure and the HIT-6 revealed at least 64% shared variance in this military sample (r = 0.8, p < 0.001), indication a high association between the two measures. The NSI single-item headache measure adequately captured headache severity in this military cohort. Use of the single-item NSI headache measure may minimize survey burden on participants whose primary complaint is not headaches, or who present with multiple symptoms. Future studies are needed to validate the single-item headache measure in other samples.

Evaluating the Fit of Co-management for Small-Scale Fisheries Governance in Timor-Leste

Fisheries co-management is an increasingly globalised concept, and a cornerstone of the Voluntary Guidelines for Securing Sustainable Small-scale Fisheries in the Context of Food Security and Poverty Eradication. Timor-Leste is a politically young country in the relatively rare position of having underexploited fisheries that can be leveraged to improve coastal livelihood outcomes and food security. The collaborative and decentralised characteristics of co-management appeal to policymakers in Timor-Leste with provisions for co-management and customary laws applied to resource use incorporated into state law in 2004, and again in 2012. The first fisheries co-management pilots have commenced where management arrangements have been codified through tara bandu, a process of setting local laws built around ritual practice that prohibits nominated activities under threat of spiritual and material sanctions. To date, however there has been little critical evaluation of the suitability of co-management or tara bandu in the Timor-Leste fisheries context. To address this gap, we adapt the interactive governance framework to review the ecological, social and governance characteristics of Timor-Leste’s fisheries to explore whether co-management offers a valid and viable resource governance model. We present two co-management case studies and examine how they were established, who was involved, the local institutional structures, and the fisheries governance challenges they sought to address. Despite their relative proximity, the two sites contrasted in local ecology and fishery type; community institutions were starkly different but equally strong; and one site had tangible economic benefits to justify compliance, where the other had marginal and anecdotal fishery gains. In our review of the broader governance landscape in Timor-Leste, we see co-management as a useful mechanism to govern small-scale fisheries, but there is a need to connect legitimised local institutions with hierarchical governance of higher and external influences. Initial successes with implementing tara bandu incorporating a small marine closure have stimulated other communities to implement no-take zones - one universally popular but very limited interpretation of co-management. However, we highlight the need for a set of guiding principles to ensure legitimate community engagement, and avoid external appropriation that may reinforce marginalization of certain user groups or customary power hierarchies.

Acupuncture for chronic neck pain with sensitive points: study protocol for a multicentre randomised controlled trial

IntroductionChronic neck pain is a challenging condition to treat in clinical practice and has a considerable impact on quality of life and disability. According to the theory of traditional Chinese...

The Industrial School for Jewish Girls, Sambir (1925–1939): A Local Institutional Description

The Industrial School for Jewish Girls, Sambir (1925–1939): A Local Institutional Description

Ischemic Stroke in Pontine and Corona Radiata: Location Specific Impairment of Neural Network Investigated With Resting State fMRI.

Objective: This study aims to investigate location-specific functional remodeling following ischemic stroke in pons and corona radiata.Methods: This study was approved by the local Institutional Review Board. Written consent was obtained from each of the participants prior to the MRI examination. Thirty six subjects with first ever acute ischemic stroke in pons (PS, n = 15, aged 62.8 ± 11.01 years) or corona radiata (CRS, n = 21, aged 59.33 ± 13.84 years) as well as 30 age and sex matched healthy controls (HC, n = 30, aged 60 ± 6.43 years) were examined with resting state functional magnetic resonance imaging (rs-fMRI). Regional homogeneity (ReHo) and degree centrality (DC) were calculated using a voxel-based approach. Intergroup differences in ReHo and DC were explored using a permutation test with a threshold-free cluster enhancement (PT TFCE, number of permutations = 1,000, family-wise error rate (FWER) < 0.05).Results: ReHo and DC alterations were identified in distributed anatomies for both PS and CRS groups. DC mainly increased in the bilateral anterior and posterior cingulate cortex, the inferior frontal-orbital gyrus, and decreased in the bilateral cuneus, calcarine, and the precuneus, while ReHo mainly decreased in the precentral and the postcentral gyri, inferior parietal lobules, precuneus, posterior cingulate cortex, and the superior occipital gyrus. PS and CRS groups were not significantly different in ReHo or DC (FWER > 0.05).Conclusions: Focal ischemic stroke in pons or corona radiata leads to extensive alterations in the functional network centrality. IS-induced network remodeling is more anatomy-specific than pathway-specific, which may underpin the clinicotopographical profiles during the disease dynamic. Approaches targeting neural pathway and functional connectivity may shed light on a better characterization and management innovation of ischemic stroke.

Renal cystic lesions characterization using spectral detector CT (SDCT): Added value of spectral results.

To evaluate the added value of spectral results derived from Spectral Detector CT (SDCT) to the characterization of renal cystic lesions (RCL). This retrospective study was approved by the local Institutional review board. 70 consecutive patients who underwent abdominopelvic SDCT and had at least one RCL were included. 84 RCL were categorized as simple, complex or neoplastic based on attenuation values on single-phase post-contrast images. Attenuation values were measured in each lesion on standard conventional CT images (stCI) and virtual monoenergetic images of 40keV and 100keV. A spectral curve slope was calculated and intra lesional iodine concentration (IC) was measured using iodine-density maps. Reference standard was established using histopathologic correlation, prior and follow-up imaging. Analysis of variance (ANOVA) was used to compare between the groups. Mean attenuation values for benign simple and complex RCL differed significantly (42 ± 16 vs 8 ± 3 HU; p < 0.001). IC was almost identical in benign simple and complex RCL (0.23 ± 0.04 mg ml-1 vs 0.24 ± 0.04 mg ml-1), while IC in neoplastic RCL was significantly higher (2.10 ± 0.08 mg ml-1 ; p < 0.001). The mean spectral curve slope did not differ significantly between simple and complex RCL (0.30 ± 0.03 vs 0.33 ± 0.05) but was significantly higher in neoplastic RCL (2.60 ± 0.10; p < 0.001). Spectral results of SDCT are highly promising in distinguishing benign complex RCL from enhancing neoplastic RCL based on single-phase post-contrast imaging only. SDCT can assist in differentiating between benign complex and neoplastic renal cystic lesions.

Deconstructing institutional roles in climate change adaptation: The case of local public institutions in drought-prone districts of Sidama, Southern Ethiopia

Local institutions play pivotal role in climate change adaptation though less attention has been given to them compared with other components of adaptation. The conventional approach to study local institutional roles focuses on how institutions can support climate change adaptation with little emphasis to other institutional dimensions. Thus, the current study deconstructs the conventional institutional roles in climate change adaptation to reframe them on broader institutional dimensions inspired by Young (2002). Data were collected from households, experts and community leaders on institutional frontiers of local public local institution. The study used mixed methods to analyse the data. The findings indicated that despite the presence of institutional set ups, most of the national policy provisions had not been implemented at local levels due to various reasons. Further, even the implemented policies had limited success because of lack of participation in policy making processes, absence of policy implementation guidelines and limited institutional capacity. The study also revealed very weak coordination among institutions working on climate change adaptation. As the result, climate adaptation policy implementation lack continuity, monitoring and evaluation system, and failed to yield transformative changes to the farmers. Therefore, there is an urgent need to participate, capacitate, and synergize local institutions, and establish policy monitoring and evaluation system so that national policy provisions can yield intended results.

Tilapia fish skin as a new biologic graft for neovaginoplasty in Mayer-Rokitansky-Kuster-Hauser syndrome: a video case report

To describe a McIndoe procedure technique for surgical management of Mayer-Rokitansky-Kuster-Hauser syndrome with the use of Nile tilapia skin as a scaffold for the proliferation of new vaginal epithelium. Surgical video article. Local Institutional Review Board approval and written permission from the patient were obtained. There were no conflicts of interest. University hospital. A 17-year-old woman who presented at our gynecology department with the complaint of primary amenorrhea. At physical examination, she had a phenotypically normal vulva with no vaginal canal. Magnetic resonance imaging of the abdomen and pelvis revealed normal ovaries and absence of uterus and vaginal canal. No other congenital malformations were found. Karyotype was 46,XX. The McIndoe procedure involved only a vaginal approach. Labia minora were separated, and a transverse midline incision of 3cm was made. The vesicorectal space was progressively dissected. Blunt dissection was performed initially with digital separation of tissues. The neovagina was then inspected with the introduction of a vaginal speculum, allowing for review of hemostasis. Blunt dissection was continued with the aid of the speculum, to reach the appropriate vaginal dimensions. Subsequently, a vaginal acrylic mold covered with two pieces of processed and sterilized tilapia fish skin was inserted and accommodated into the newly created cavity. The external side of the tilapia skin, which maintained its grayish coloration after the removal of the scales, stayed in contact with the acrylic mold, while the white internal side of the tilapia skin, which was previously attached to the fish's muscle, stayed in contact with the walls of the neocavity. The mold was held in position by four multifilament polyglactin 1.0 sutures in the labia majora, thus preventing expulsion. Anatomic data, such as measurement of the final canal length, and histomorphologic analysis, 180days after surgery. The patient remained on bed rest for 9days, after which the tilapia fish skin had been partially reabsorbed. After this time, the acrylic mold was removed. A larger plastic mold was then inserted and the patient was advised to wear it day and night for the first postoperative month. The vaginal mold had to be worn each night until normal sexual intercourse was possible. The final canal length 180days after surgery was between 8 and 9cm. For the histopathologic analysis, fragments of the lateral vaginal wall were removed 180days after surgery and showed the presence of stratified squamous epithelium with five cell layers, ectasic blood vessels, and occasional desquamated epithelial cells. The procedure described offered this patient an anatomic and functional neovagina by means of a simple, safe, easy, effective, quick, and minimally invasive procedure. Limitations include the experimental nature of this study, based on a single case report with no long-term outcome results. The tilapia fish skin is a low-cost and widely available biomaterial.

How participating in an international community of psychoanalysts can offset local psychoanalytic institutes’ insularities and enliven practice

ABSTRACTIn this article the author attempts to show how participating in an international community of psychoanalysts can have a transformative effect on a psychoanalyst’s training and practice. The article focuses on the beneficial consequences for candidates of being involved in the International Psychoanalytical Studies Organization (IPSO), due to certain felicitous specificities of this organization, though much of what is discussed can be applied to being involved in other organizations. At the level of training, insular tendencies and local institutional dynamics can limit candidates to a restricted range of thinking, combined with emotional entanglements, which may curtail their intellectual freedom. The breadth of differences in approaches to training that IPSO exposes candidates to, and the fact that this takes place outside of their home institute and its hierarchies, is potentially an antidote to this. At the level of practice, psychoanalysis is a rewarding but also arduous profession that exposes its practitioners to many hardships, the extent of which is sometimes minimized or denied. IPSO embodies a spirit that marries intense intellectual interest for psychoanalysis with an enthusiastic attitude towards sharing good times with colleagues. The author posits that this libidinal investment is paramount to surviving and enjoying our work.

Previous Adaptation Period Modulates Pregnancy Swimming Neuroprotective Effects on the Offspring Following Neonatal Hypoxic‐Ischemic Brain Injury

Neonatal hypoxic‐ischemic encephalopathy (HI) is one the main causes of neurological damage in newborns. Pregnancy has emerging as a feasible therapeutic window for preventing central nervous system damage and has been shown to decrease early and long‐term HI consequences. However, experimental literature is conflicting and point that variables, such as a previous adaptation period to the exercise (before mating) has decisive impact on swimming consequences to the injured offspring's brain.Briefly, the adaptation period consisted of exposing female rats to 7 days (with increasing time exposure ‐ from 5 to 20 minutes) to a tank (200 cm diameter) filled with water at 32°C. After mating, from gestational day 0 to 21, pregnant rats were submitted to 20min/day of swimming or remained in the standard cages. After birth, seven‐days‐old rats were subjected to the Levine‐Rice HI model (right common carotid artery occlusion followed by 8% O2/60min). Western blotting was used to assess protein expression of GFAP (astrocytic reactivity), cytochrome c and cleaved caspase 3 (apoptotic markers) was performed in hippocampus 24h after HI. Animals were divided into 8 experimental groups, according adaptation, swimming and. Behavioral analysis was performed from PND45 and included sensorimotor and cognitive testing. Histological analysis assessed structural brain damage volumes of hemisphere and hippocampus. This study was approved by the local Institutional Animal Care and Use Committee (UFRGS #33497)Non‐parametric tests showed significant increase in astrogliosis in non‐adapted HI animals only. Swimming decreased apoptotic cell death despite adaptation period. Cylinder test evidenced HI effects (increasing the use of the ipsilateral forepaw in HI animals). No effects of swimming nor adaptation were observed in the test. In the open field testing, only HI animals whose mothers where adapted previously to the injury had increased locomotion and swimming reversed the HI effects on the test. Hemisphere and hippocampus were preserved only in the HI group whose mothers swam and were adapted before mating. In summary, the adaptation period has a major role on pregnancy swimming effects following HI and must be considered in future studies and the mechanisms involved in such modulation need to be further explored.Support or Funding InformationThis study was supported by CNPq, FAPERGS and CAPES ‐ Brazil.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Progesterone Induces Neuroprotection in a Model of Neonatal Hypoxic‐Ischemic Brain Injury

Neonatal hypoxic‐ischemic encephalopathy (HI) is a major cause of neurologic deficits in newborns. Since administration of progesterone (PROG) has shown neuroprotective effects in adult models of nervous system injury, we evaluated the effects of PROG in a model of neonatal HI.Seven‐days‐old rats (n=6) were subjected to a surgery for ligation of the common right carotid artery followed by exposure to an hypoxic atmosphere (8% of oxygen) for 60 min. PROG (10 mg/kg) was administered before and/or after HI. Rats were euthanized one week after HI and their brains were processed for histology or Western blot analysis. Hemispheric and hippocampal volumes were measured and apoptotic cells were counted in the CA1 and CA3 areas of the hippocampus. Proteins involved in cell death and survival (caspase‐3 and Akt) were also analyzed. This study was approved by the local Institutional Animal Care and Use Committee (UFRGS #26669; HCPA #140578).The hemispheric and hippocampal lesion caused by HI was reduced by PROG treatment. The number of apoptotic cells in CA1 and CA3 areas was also decreased by PROG administration. Expression of p‐Akt was unaffected by HI but was significantly increased in the hippocampus of PROG‐treated animals. Moreover, administration of PROG reduced hippocampal cleaved caspase‐3 expression.In summary, PROG administration reduced brain damage and neuronal apoptosis in neonatal animals submitted to HI. This neuroprotective effect is probably related to the capability of PROG in regulating caspase‐3 and Akt signaling pathways.Support or Funding InformationThis study was supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq‐Brazil), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES‐Brazil), Pró‐Reitoria de Pesquisa (PROPESQ/UFRGS‐Brazil), and Fundo de Incentivo à Pesquisa e Eventos do Hospital de Clínicas de Porto Alegre (FIPE/HCPA‐Brazil).This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Modeling Trading Behavior in the Japanese Stock Market During QE Tapering and Post-QE Exit

This study investigates the trading dynamics between institutional, foreign and retail investors during QE and post-QE exit in the Japanese stock market. A theoretical framework is developed to classify all transactions into trading, short-selling or information flow. Using weekly data from 2014 to 2015, our results show: Firstly, during QE tapering, there is short-selling by foreign retail investors. There is also information flow from Foreign Retail Sales to Local Institutional Sales as well as Foreign Retail Purchases to Local Retail Purchases. Net buyers are local and foreign institutional investors; Secondly, in post-QE exit, there is short-selling by foreign institutional investors. Moreover, Foreign Institutional Purchases is found to precede Local Retail Purchases. Net sellers are local and foreign retail investors. Hence, it can be concluded that foreign investors are dominant player during QE tapering and post-QE period. As a policy suggestion, both local and foreign investors should be provided with more incentive to trade in the local bourse. The regulator should also ensure timely disclosure of material public information by listed firms to ensure a level playing field for all market participants.

The Epidemiology of Acute Respiratory Distress Syndrome Over 3 Years and Reclassifying Severity after 48 Hours: A Prospective Observational Cohort Study

Background: We examined the incidence and etiologies of ARDS in a tertiary care referral center. Our focus was on factors associated with hospital mortality and determining whether the reclassification of severity after ARDS onset would help to predict clinical outcomes. Methods: Clinical variables and ventilator settings was recorded in the first two weeks after ARDS onset. Disease severity was reclassified 48 hours after enrollment (ie, day 3), and cases where clinical variables still fulfilled the Berlin criteria were regarded as nonresolving ARDS. Findings: Screening was performed on a total of 9,256 patients that used invasive mechanical ventilators during the three-year study period. Among them, 1,034 patients fulfilled ARDS criteria. Overall hospital mortality was 57·7 %. The hospital mortality rates of different severity on day 3 were as follows: resolved (42·1 %), mild (47·9 %), moderate (62·4 %), and severe (76·1 %) (p<0·001). Day 3 reclassification of ARDS outperformed day 1 classification in predicting hospital mortality by the area under the receiver operating characteristic curve. Patients who were older, had lower PaO2/FiO2, or higher PEEP on day 1 were significantly associated with nonresolving ARDS. Age, body mass index, influenza pneumonia, SOFA score, and peak inspiratory pressure on day 3 were associated with hospital mortality. Interpretation: Hospital mortality rates was significantly different between resolved and nonresolving ARDS patients on day 3. Our findings indicated that the reclassification of severity after ARDS onset could improve predictions of clinical outcomes and help to identify cases warranting aggressive clinical intervention and additional rescue therapies. Funding Statement: The authors state: None. Declaration of Interests: On behalf of all authors, the corresponding author states that there are no conflicts of interest. Ethics Approval Statement: The local Institutional Review Board for Human Research approved this study (CGMH IRB No. 102–1729B), and the need for informed consent was waived.

The effect of environmental attitudes and policies on separate waste collection: the case of Insular Italy

This paper investigates the factors determining waste management performance by comparing two Italian regions, Sicily and Sardinia. Using data from official records at the municipal level, the recentered influence function regression is implemented to evaluate the territorial divide in separate waste collection rates between the regions. Then, the divide is disentangled into administrative and spatial components. The administrative component evaluates the effectiveness of the strategic policies set by the regional authority and their implementation by municipalities. The spatial component captures the presence of spatial contagion effect and considers citizens’ pro-environmental behaviours. The main results show that Sardinia has achieved better performance because of its advantages of extrinsic motivations, citizens’ pro-environmental attitudes, local institutional quality, and synergy between citizens and local governments. In Sicily, the weakness of local institutions makes citizens’ participation difficult and generates citizens’ indifference towards environmental issues, explaining most of the failures in the regional waste management.

Mini-invasive transvaginal repair of isthmocele: a video case report

To describe our technique for transvaginal treatment of isthmocele. Surgical video article. Local Institutional Review Board approval for the video reproduction was obtained. A scientific institute. A 26-year-old patient complaining of abnormal uterine bleeding and pelvic pain was referred to our gynecological clinic for secondary infertility. At transvaginal ultrasound examination, a cesarean scar defect of 22 × 11mm was identified, with a residual myometrial thickness over the defect of 2mm. Isthmocele excision and myometrial repair was performed transvaginal, under regional anesthesia. Before surgery, a hysteroscopy was performed to identify the dehiscence of the cesarean scar on the anterior wall of the uterus and to confirm the presence of the isthmocele and its distance from the external os. Then an incision was made at the anterior cervicovaginal junction and the bladder was dissected away until the anterior peritoneal reflection was identified. Hysteroscopic guidance by transillumination was used to identify the exact position and the limits of the isthmocele. The fibrotic tissue was then removed, and the myometrial defect was closed with interrupted sutures by using 2-0 Vicryl, engulfing the myometrial fibers that would tend to slide laterally. The vaginal mucosa was then sutured with interrupted Vicryl 2-0 sutures. At the end of the procedure, a hysteroscopy was performed to visualize the correction of the defect and to prove the continuity of the cervical canal with the uterine cavity. Repair of isthmocele and relief of symptoms. The postoperative course was uneventful, and the patient was discharged the day after surgery. At 1-month follow-up pelvic ultrasound showed complete anatomic repair of the uterine defect. The patient was asymptomatic with no more postmenstrual bleeding. She is satisfied with the treatment and is still trying for pregnancy. Symptomatic isthmocele can be treated surgically via a hysteroscopic, laparoscopic, or vaginal approach, depending on the clinical findings and the skill set and comfort level of the surgeon. Unfortunately, there is no consensus about the ideal surgical approach. The hysteroscopic approach has been demonstrated to be effective for the treatment of abnormal uterine bleeding; however, it does not strengthen the uterine wall and it has a risk of bladder injury. The laparoscopic approach provides good anatomic results, but it requires general anesthesia and may be associated with bladder injury. The transvaginal approach appears to be a feasible, effective, and safe modality to repair the uterine defect and to restore the original thickness of the myometrium. It is a minimally invasive, scarless, and low-cost procedure. It ensures quick recovery and a relatively pain-free postoperative course with early return to normal function.

Model of Community Empowerment of Springs Preservation in Arjuna Mountains

The research objectives were (1) to examine the determinants of community empowerment towards the revegetation of Arjuna mount forests; (2) assessing the influence of geography and soil conditions on the revegetation of Arjuna mount forests; (3) reviewing the effect of Arjuna mount forest revegetation on the preservation of spring water sources and (4) formulating a model for empowering communities around the forest towards sustainable conservation of springs. The research method was descriptive quantitative, with research populations around the forest and springs, namely Leduk, Jatiarjo and Dayurejo Village, Prigen District, Pasuruan Regency, East Java. The research sample was determined by cluster sampling and data analysis using SEM (structural equation modeling). The results showed that (1) the variable of community empowerment with factors human resources, economic, social, local institutions, facilities and infrastructure have a very significant effect on revegetation of Gunung Arjuna forest; (2) geographic and soil variables have a very significant effect on forest revegetation; (3) forest revegetation variables have a very significant effect on the preservation of spring resources; and (4) the local institutional factors, facilities and infrastructure have a higher influence than other factors. The institutional and facilities and infrastructure factors of the forest community can be a model of empowering the community around the forest towards the success of revegetation and preservation of the area around the source of the spring, and was the novelty of this dissertation research.

Can we IMPROVE cardiovascular outcomes through phosphate lowering in CKD? Rationale and protocol for the IMpact of Phosphate Reduction On Vascular End-points in Chronic Kidney Disease (IMPROVE-CKD) study

IntroductionPatients with chronic kidney disease (CKD) are at heightened cardiovascular risk, which has been associated with abnormalities of bone and mineral metabolism. A deeper understanding of these abnormalities should facilitate...

Idiopathic Ventricular Fibrillation and Otherwise Normal Electrocardiograms

Background: Idiopathic ventricular fibrillation (IVF) in patients with normal baseline electrocardiograms (ECGs) is a rare disease. Little information is available on the clinical features and long-term follow-up of out-of-hospital cardiac arrest (OHCA) survivors presenting with true IVF and 12-lead ECGs that remain normal over time. Objective: To define the clinical and ECG characteristics, as well as long-term clinical outcomes of a large cohort of survivors of OHCA due to true IVF. Methods: OHCA survivors with VF as the presenting rhythm, normal baseline and follow-up ECGs with no signs of cardiac channelopathy including early repolarization or atrioventricular (AV) conduction abnormalities, and without structural heart disease were included in a registry. Results: A total of 245 OHCA survivors with IVF (median age: 38 years; males 59%) were recruited from 25 centres. All had normal baseline and follow-up ECGs, and no evidence of structural heart disease. An implantable cardioverter-defibrillator (ICD) was implanted in 226 patients (92%), while 18 patients (8%) were treated with drug therapy only. Over a median follow-up of 63 months (interquartile range: 25-110 months), 12 patients died (5%); in 4 of them (1.6%) the lethal event was of cardiac origin. Patients treated with antiarrhythmic drugs (AADs) only had a higher rate of cardiovascular death compared to patients who received an ICD (16% vs. 0.4%, p=0.001). The ECG and echocardiogram of all patients remained unchanged over time. Fifty-two patients (21%) experienced an arrhythmic recurrence. Age ≤ 16 years at the time of the first ventricular arrhythmia was the only predictor of arrhythmic recurrence on multivariable analysis (HR 0.41, 95% CI 0.18-0.92, p=0.03). Discussion: OHCA survivors of true IVF with normal baseline and follow-up ECGs frequently have arrhythmic recurrences, but a good prognosis when treated with an ICD. Children are a category of IVF patients at higher risk of arrhythmic recurrences. Funding: The study was supported by a grant of the Swiss Heart Foundation. Declaration of Interest: G.C. has received a research grant from the Swiss National Foundation. P.L. has received speaker fees and research grants from Boston Scientific, Abbott and Medtronic Research support from UCLH Biomedicine NIHR. F.L. is consultant and has received research support from Medtronic Plc, Abbott, Boston Scientific and Microport. S.B. has received speaker’s bureau from Medtronic and Microport. C.P. has received research grant from Biotronik and Biosense Webster. P.B. is consultant for Biotronik. A.A. is consultant to Abbott, Biosense Webster, Daiichi-Sankyo, Boston Scientific, Medtronic, Microport-CRM; and has received speaker fee from Daiichi-Sankyo, Boston Scientific, Medtronic, Microport-CRM Ethics Approval Statement: Data were collected in accordance with regulations set by the local Institutional Ethics Committee and/or Institutional Review Board.

Laparoscopic Removal of an Abdominal Pregnancy in the Pelvic Sidewall

To describe the presentation, diagnosis, and management of a patient with abdominal pregnancy and to illustrate the laparoscopic technique used to manage this patient. A descriptive study approved by our local Institutional Review Board. Consent was given from the patient. A university hospital in Ashdod, Israel. On May 15th 2018, a gravida 3, para 2, 37-year-old asymptomatic patient was referred to our hospital's gynecologic emergency department due to a suspected ectopic pregnancy. The patient had no relevant medical or surgical history. Her obstetric history consisted of 2 spontaneous vaginal deliveries with no other significant gynecologic history. Her menses were regular every month. Her last menstrual period was 6 weeks before presentation. Her β-human chorionic gonadotropin (hCG) level measured on the day before presentation was 24,856 IU/L. Physical examination was unremarkable except for a small amount of brownish vaginal discharge. A transvaginal ultrasound (TVUS) exam on presentation did not demonstrate an intrauterine gestational sac, but revealed a gestational sac and a fetus next to the right adnexa, with a crown-rump length of 1.3 cm, consistent with 7+3 gestational weeks. There was a minimal amount of fluid in the pouch of Douglas. Owing to an extrauterine pregnancy with high β-hCG value, laparoscopic operative management was chosen. On entrance to the abdominal cavity, a normal uterus and 2 ovaries and fallopian tubes were observed. A small to moderate amount of blood was present in the pouch of Douglas. a 3- to 4-cm distension was noted over the right uterosacral ligament. Following delicate probing of the area, moderate to severe bleeding commenced, which was initially controlled with local pressure and oxidized regenerated cellulose. An intraoperative TVUS identified an abdominal pregnancy in the right pelvic sidewall. The gestational sac was completely dissected and removed following ureterolysis and separation of the right ureter from the specimen. Local injection of vasopressin was also used. The β-hCG level before surgery of 19,008 IU/L decreased to 6339 IU/L on postoperative day 1. The patient was discharged in good condition on postoperative day 2. A final histopathological report confirmed a gestational sac. This patient referred for a tubal ectopic pregnancy was eventually diagnosed with an abdominal pregnancy and was treated operatively with complete excision of the abdominal pregnancy, which was located at the right pelvic sidewall. Abdominal pregnancy is a rare type of ectopic pregnancy with a reported incidence of 1:10,000 to 1:30,000 pregnancies, and accounts for approximately 1% of ectopic pregnancies [1]. It carries a high risk for maternal morbidity and mortality. Many different locations at different gestational ages have been reported in the literature, including the pouch of Douglas, pelvic sidewall, bowel, broad ligament, omentum, and spleen [2-4]. These varied locations and the rarity of this type of pregnancy make diagnosis and treatment challenging. The location of the growing fetal tissue may endanger the patient's life if it impinges on vital anatomic structures. In the present case, the gestational sac was very close to the right ureter, and we opted to surgically excise the gestational sac in its entirety.