Moderate Narrowing Research Articles

Incidence of pulmonary vein stenosis in two types of cryoballoon systems.

Currently, two types of cryoballoon (CB) systems are available for catheter ablation of atrial fibrillation (AF). Since the POLARx (Boston Scientific) is softer during freezing than the Arctic Front Advance Pro (AFA-Pro; Medtronic), it tends to go more deeply into the pulmonary vein (PV), risking PV stenosis. Ninety-one patients underwent initial CB ablation for paroxysmal AF (AFA-Pro 56; POLARx 35). Twenty-six from each group were extracted using propensity score matching. The PV cross-sectional area (PVA) was measured by tracing the area within the PV plane at 5-mm intervals from the PV ostium in a distal direction for 20 mm or to the bifurcation in each PV. The PVA was compared before and 3 months after ablation. Time to balloon temperatures of -30 and - 40°C was significantly shorter and the nadir temperature was significantly lower with POLARx than with AFA-Pro. In the left inferior (LI) PV and right superior (RS) PV, the freezing balloon position was significantly deeper in POLARx than in AFA-pro. The freezing position in RSPV with mild to moderate narrowing was deeper than those without (10.2 ± 3.3 mm vs. 8.2 ± 1.8 mm, p = .01). In RSPV, the reduction of PVA tended to be greater with the POLARx than with the AFA-Pro (26.1% ± 14.1% vs. 19.9% ± 10.3%, p = .07). There was no significant difference in the incidence of PV stenosis between POLARx and AFA-Pro. However, if POLARx goes deep into the PVs, we will still have to be careful.

Solanum nigrum Toxicity and Its Neuroprotective Effect Against Retinal Ganglion Cell Death Through Modulation of Extracellular Matrix in a Glaucoma Rat Model.

Purpose: Glaucoma is a complex degenerative optic neuropathy characterized by loss of retinal ganglion cells (RGCs) leading to irreversible vision loss and blindness. Solanum nigrum has been used for decades in traditional medicine system. However, no extensive studies were reported on its antiglaucoma properties. Therefore, this study was designed to investigate the neuroprotective effects of S. nigrum extract on RGC against glaucoma rat model. Methods: High performance liquid chromatography and liquid chromatography tandem mass spectrometry was used to analyze the phytochemical profile of aqueous extract of S. nigrum (AESN). In vitro, {3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide} (MTT) and H2DCFDA assays were used to determine cell viability and reactive oxygen species (ROS) production in Statens Seruminstitut Rabbit Cornea cells. In vivo, AESN was orally administered to carbomer-induced rats for 4 weeks. Intraocular pressure, antioxidant levels, and electrolytes were determined. Histopathological and immunohistochemical analysis was carried out to evaluate the neurodegeneration of RGC. Results: MTT assay showed AESN exhibited greater cell viability and minimal ROS production at 10 μg/mL. Slit lamp and funduscopy confirmed glaucomatous changes in carbomer-induced rats. Administration of AESN showed minimal peripheral corneal vascularization and restored histopathological alterations such as minimal loss of corneal epithelium and moderate narrowing of the iridocorneal angle. Immunohistochemistry analysis showed increased expression of positive BRN3A cells and decreased matrix metalloproteinase (MMP)-9 activation in retina and cornea, whereas western blot analysis revealed downregulation of extracellular matrix proteins (COL-1 and MMP-9) in AESN-treated rats compared with the diseased group rats. Conclusions: AESN protects RGC loss through remodeling of MMPs and, therefore, can be used for the development of novel neurotherapeutics for the treatment of glaucoma.

Efficacy of Marma Chikitsa in pain management of Cervical Spondylosis - A Single Case Study

Cervical spondylosis is a chronic degenerative condition of the cervical spine that affects the vertebral bodies and intervertebral discs of the neck as well as the contents of spinal canal. It is characterized by neck pain radiating to shoulders, arms, head and person is unable to perform daily routine work. Patient aged 47 years came to our institute with the complaint of headache, pain and stiffness in cervical region & pain is radiated to hand, tingling sensation in hand, restricted movement of cervical spine for 6 month. He was diagnosed as case of cervical spondylosis. MRI of cervical spine suggested protrusion at C5-C6 level causing anterior thecal sac compression & bilateral moderate neural foraminal narrowing with left exiting nerve compression. In this case study effect of Marma Chikitsa in pain management of cervical spondylosis is evaluated. This case study shows that pain in cervical spondylosis may be successfully managed by Marma Chikitsa.

Spontaneous Laryngeal Hematoma: A Rare Presentation of Supratherapeutic INR

Introduction: Warfarin is one of the most routinely used drugs for anticoagulation. However, it poses a significant bleeding risk. Incidence of major bleeding events ranges from 0.4-7.2% per year, and that of minor bleeding events can be as high as 15.4% per year. Here we present a rare case of laryngeal hematoma due to supratherapeutic INR. Case description: A 48-year-old male with past medical history of hypertension, Insulin dependent diabetes mellitus, and multiple episodes of deep venous thromboses on chronic anticoagulation with warfarin presented to the emergency department complaining of left sided neck pain and hoarseness of voice that started and progressively worsened since the past 24 hours. He denies any fever, chills, cough, shortness of breath, or dental pain. He was found to be hemodynamically stable with no oxygen requirement. He spoke with a hoarse voice, but no stridor was noted. Tenderness of the left anterior triangle of the neck below the jawline and mild trismus was noted. Laboratory work-up showed stable hemoglobin of 12.2 and a supratherapeutic INR of 9.9. CT of soft tissue neck showed retropharyngeal fluid collection extending from skull base to C7 with mild to moderate supraglottic airway narrowing. Flexible nasopharyngeal endoscopy showed significant collection of secretions with omega shaped epiglottis and retropharyngeal swelling, raising concerns for a hematoma. INR reversal with 2 units of fresh frozen plasma was initiated and patient was transferred to medical intensive care unit. He underwent daily endoscopies for three days; on day 3 significant improvement of the hematoma size was noted. Daily oral Vitamin K for 3 days ensured INR reversal from 9.9 to 1.7. After transferring to floors, the patient was gradually re-started on his anticoagulation and discharged home safely. Discussion: This case exemplified one of the rare but life-threatening complications of supratherapeutic INR. Bleeding into the larynx is a very rare life-threatening complication of chronic anticoagulation with warfarin. Similar case was reported by Cody A. Koch et al in 2010. In 2017 another case was reported which resulted in death from asphyxia before patient was taken to the hospital. A patient with similar presentation and demographics with the index case was reported also in 2019. As per literature, this case will be one of the very few reported cases of Spontaneous laryngeal hematoma due to supratherapeutic INR. Several factors could potentially affect the INR level of patients on chronic warfarin therapy and can cause acute elevation of INR which can lead to several complications including epiglottal hematoma as seen in this case. The index patient has significant history of chronic diarrhea along with OTC Tylenol ingestion for chronic patient both of which can cause INR increase. Thus, high index of suspicion is important especially for patients with comorbidities due to the fragile interaction of warfarin with several common medications and clinical conditions. Epiglottal hematoma can expand and potentially compromise the airway if immediate reversal of supratherapeutic INR is not commenced. Regardless of presentation, every patient who exhibits warfarin-associated upper airway hemorrhage should receive treatment that includes stopping anticoagulation, correcting the coagulopathy quickly, closely monitoring the patient's airway in an intensive setting, and having a low threshold for tracheostomy. Given the predicted difficulty with direct and fiberoptic laryngoscopy, the delayed time course for hematoma clearance, and the potential trauma resulting in further bleeding in an anticoagulated patient, securing the airway via intubation is frequently not desirable. Such cases of non-traumatic hemorrhage may be managed medically or surgically. Spontaneous hemorrhage is usually managed conservatively. Regarding the ideal course of treatment, there is, however, no agreement. Conclusion: There is need for a high index of suspicion for atypical presentations of supratherapeutic INR (including bleeding into the airway) in patients on prolonged anticoagulation with warfarin. The need for immediate reversal and routine INR monitoring in these patients is also emphasized in this clinical vignette.

Rare Association of Takayasu Arteritis and Antiphospholipid Syndrome with Severe Thrombocytopenia

The association of Takayasu arteritis (TA) with antiphospholipid syndrome (APS) has rarely been described in the literature. This paper reports the first documented case of TA and APS in a 24-year-old woman in Bangladesh. This patient had claudication pain in upper and lower limbs for four years and Raynaud’s phenomenon in right hand for eight months. During the course of her illness, she suddenly developed deep vein thrombosis in left superficial femoral, popliteal and posterior tibial veins. Conventional angiography revealed total occlusion of right subclavian artery and 60-70% stenosis of right common iliac artery. CT angiography of right upper limb also supported these findings along with increased wall thickening in the 2nd part of right subclavian artery and moderate narrowing of the 1st part of right axillary artery. She had persistently positive anticardiolipin antibodies in high titers, positive lupus anticoagulant (LA), prolonged activated partial thromboplastin time (APTT) and severe thrombocytopenia. We started high dose prednisolone (1mg/kg daily). Her platelet count increased rapidly. Based on review of 10 case reports, we considered the rare association of TA and APS. Both conditions should be determined promptly for the sake of early institution of the appropriate therapy. Bangabandhu Sheikh Mujib Med. Coll. J. 2023;2(1): 59-63

1041 Recurrent Retropharyngeal Ganglioneuroma in a Pediatric Patient

Abstract Introduction Ganglioneuroma is a rare benign subtype of peripheral neuroblastic tumor that arises from sympathetic ganglion cells. Fewer than 10% of these cases occur in the head and neck and are rarely seen in pediatric patients. Clinical symptoms and treatment are dependent on mass location and extension. The authors present a case of recurrent retropharyngeal ganglioneuroma in a pediatric patient. Report of case(s) Patient is a 2-year-old previously healthy female who presented with progressive snoring and found to have retropharyngeal lymphadenopathy during tonsillectomy. Differential diagnosis included retropharyngeal abscess; however, after no improvement with antibiotics, malignancy was suspected. Pathology results from a needle biopsy confirmed the diagnosis of ganglioneuroma. CT imaging showed extension of mass to bilateral retropharyngeal, posterior mediastinal and paraspinal, and retroperitoneal spaces. Given concerns for significant morbidity with complete resection, patient underwent partial resection of mass, followed by chemotherapy to decrease tumor burden. Patient initially did well, then developed nine-month progressive snoring, positional apnea, persistent stertor, and dysphagia. Sleep study showed severe obstructive sleep apnea (OSA) with apnea hypopnea index (AHI) 74, oxygen nadir 66%, and maximum transcutaneous carbon dioxide (CO2) level of 58 mmHg. Repeat CT imaging showed regrowth of the tumor with large right-sided retropharyngeal mass, mass effect on right oropharynx and associated vasculature, and moderate narrowing of airway. Supplemental oxygen via nasal cannula was initiated as inpatient, due to concerns that noninvasive positive pressure support would further compromise the critical airway. Urgent repeat debulking of the tumor with partial pharyngectomy was completed. Post-operatively, patient's oxygen dependence, stertor, and positional apnea resolved within 24 hours. Repeat sleep study showed considerable improvement with mild OSA, AHI 1.4, oxygen nadir 89%, and maximum transcutaneous CO2 level of 47 mmHg. Her dysphagia and residual mild intermittent snoring are improving with no signs of recurrence of the mass. Conclusion Upper airway obstruction secondary to neck mass in pediatric patients is rare and even less commonly found to be recurrent ganglioneuroma. This case offers further understanding of the complexities of diagnosing and treating insidiously growing retropharyngeal tumors and the prompt management of critically obstructed airways. Support (if any)

The ankle in XLH: Reduced motion, power and quality of life.

X-linked hypophosphatemia (OMIM 307800) is a rare bone disease caused by a phosphate-wasting condition with lifelong clinical consequences. Those affected suffer from bone pain, complex skeletal deformities, impaired mobility and a reduced quality of life. Early osteoarthritis and reduced range of motion of the lower limbs are known pathologies in XLH patients. However, XLH-specific data on the affected compartments such as the ankle joint through the evaluation of radiographic and gait analysis data is still lacking. In this cross-sectional study, patients with genetically verified XLH, age ≥ 16 - 50 years and a complete record of gait analysis and or radiographic analysis data were included. Clinical examination, radiological and gait analysis data were compared to norms using the dataset of our gait laboratory registry. Radiographic analysis included tibial deformity analysis and assessment of osteoarthritis and enthesopathies. Western Ontario and McMaster Universities Arthritis Index (WOMAC), SF36v2, American Orthopedic Foot and Ankle Society score (AOFAS) and the Foot and Ankle Outcome Score (FAOS) were used. Twentythree participants with 46 limbs were eligible for the study. A total of 23 patients (n=46 feet) met the inclusion criteria. Patients with XLH had significantly reduced gait quality, ankle power and plantar flexion (p < 0.001) compared to a historic gait laboratory control group. Ankle valgus deformity was detected in 22 % and ankle varus deformity in 30 % of the patients. The subtalar joint (59.1%) as well as the anterior tibiotalar joint (31.1%) were the main localizations of moderate to severe joint space narrowing. Ankle power was decreased in moderate and severe subtalar joint space narrowing (p < 0.05) compared to normal subtalar joint space narrowing. No lateral or medial ligament instability of the ankle joint was found in clinical examination. Tibial procurvatum deformity led to lower ankle power (p < 0.05). This study showed structural and functional changes of the ankle in patients with XLH. Subtalar ankle osteoarthritis, patient reported outcome scores and clinical ankle restriction resulted in lower gait quality and ankle power.

ODP470 Compressive Goiter with COVID-19: An Unusual Etiology of Respiratory Distress Requiring Endotracheal Intubation with Surgical Resection

Abstract Introduction Gradual enlargement of multinodular goiter (MNG) may compress surrounding structures which may progressively cause complications of tracheal stenosis and airway compromise. Surgical resection remains the gold standard treatment in MNG patients presenting with respiratory distress. In the current global COVID -19 pandemic, compressive goiter should be a differential diagnosis in patients with stable benign thyroid goiter presenting with dyspnea. We present a case of MNG with life threatening airway obstruction during an active COVID-19 infection. Case presentation A 74-year-old female with a history of hyperthyroidism with multi-nodular goiter and recurrent atrial fibrillation status-post ablation, was transferred to the intensive care unit for treatment after being intubated for respiratory distress at a nearby hospital. She was diagnosed with hyperthyroidism about 40 years ago and managed with methimazole. Over the last two years, thyroid ultrasound and prior imaging showed MNG with patent but moderate tracheal narrowing; fine-needle aspiration (FNA) confirmed benign colloid nodules with cystic degeneration. She was pending cardiac clearance for surgery when symptoms acutely worsened two days before admission. On initial assessment, she was hemodynamically stable, afebrile, with oxygen saturation of 86% on room air. She was alert and able to follow commands. On physical examination, she had stridor and thyromegaly was evident with mild tenderness on palpation. Cardiopulmonary examination was remarkable for coarse breath sounds. Labs showed TSH 4.82 (Normal 0.3 - 4.5 ulU/mL), FT4 0.64 (Normal 0.5- 1.26 ng/dL). Respiratory panel test came back positive for SARS-CoV-2. Racemic epinephrine and albuterol nebulizers were administered to help with her symptoms. CT scan of the neck revealed a severe narrowing and mild rightward shift of the trachea by a large multinodular goiter, prompting the decision to intubate for airway protection. CT scan of the chest with contrast demonstrated the large MNG with tracheal stenosis. Her methimazole dose was adjusted. After cardiac clearance, she underwent thyroidectomy through a transcervical approach. Levothyroxine and calcium supplementation were started post-surgery. She was extubated two days after her thyroidectomy. Pathology results showed no evidence of malignancy. Discussion Acute airway obstruction by large MNG requiring emergent airway protection is rare. Typically airway compromise from large otherwise stable benign goiters results from sudden hemorrhage into a cyst, upper respiratory tract infection leading to tracheal edema, or worseningcomorbid conditions. During the COVID-19 pandemic, acute respiratory failure and shortness of breath is typical of worsening disease course. This case highlights the importance of maintaining wider differentials of respiratory failure even and we need to consider worsening of tracheal narrowing with a large goiter due to tracheal edema from SARS- CoV-2 Infection. Thyroidectomy before SARS-CoV-2 infection may have reduced her need for emergent intubation for acute respiratory failure by improving pre existing airway compression. Presentation: No date and time listed

In vivo evaluation of histopathologic findings of vascular damage after mechanical thrombectomy with the Tromba device in a canine model of cerebral infarction.

A novel stent retriever device for in vivo mechanical thrombectomy for acute cerebral infarction has been developed. In this study, we compared the thrombus removal capacity, potential complications, and extent of vessel wall damage of this novel device with those of the Solitaire FR device by performing a histopathologic analysis using an autopsied canine model. Through this experimental evaluation, we aimed to assess the safety and efficacy of the newly developed thrombus removal device for cerebral infarction. Blood clots (autologous thrombus) were injected into 12 canines. Mechanical thrombectomy was performed in six canines using the newly developed Tromba thrombectomy device (experimental group) and in the other six canines using the Solitaire FR thrombectomy device (control group). Angiographic and histopathologic evaluations were performed 1 month after the blood vessels underwent mechanical thrombectomy. In the experimental group, the reperfusion patency was classified as "no narrowing" in five cases and "moderate narrowing (25%-50% stenosis)" in one case. In the control group, the reperfusion patency was classified as "no narrowing" in four cases, "moderate narrowing (25%-50% stenosis)" in one case, and "slight narrowing (less than 25% stenosis)" in one case. In the experimental group, intimal proliferation was observed in only two cases, endothelial loss was observed in two cases, and device-induced medial injury was observed in one case. In the control group, intimal proliferation was observed in two cases, endothelial loss was observed in one case, and thrombosis (fibrin/platelet) was observed in one case. The Tromba thrombectomy device showed no significant difference to the conventional Solitaire device in angiographic and histopathologic evaluations after thrombus removal. The stability and efficiency of the newly developed Tromba device are considered to be high and comparable to those of Solitaire.

S2720 Crohn’s Disease Manifesting as a Jejunal Obstruction at Diagnosis

Introduction: Crohn’s disease is an inflammatory bowel disease caused by transmural inflammation and may affect any portion of the luminal gastrointestinal tract. It is commonly associated with abdominal pain, fatigue, weight loss and diarrhea as the initial presentation. It is vastly uncommon that Crohn’s disease is diagnosed as a bowel obstruction as it initial presentation. We present a gentleman whose initial presentation of Crohn’s disease was a small bowel obstruction from an inflammatory mass. Case Description/Methods: Patient is a 21-year-old male with no significant past medical history who presented to the ED with myalgias, abdominal pain, nausea, and vomiting for one month. He was recently seen at a different hospital for similar symptoms. He underwent EGD which showed Mallory Weiss tears in the esophagus and a gastric emptying study which showed abnormal transit of solids and liquids. He was treated at that time for gastroparesis. On this admission, he had a normal gastric emptying study. He continued to have large amounts of emesis in amounts over one liter in volume. A CT abdomen and pelvis with oral contrast showed marked distention and dilation of the duodenum to the level of the superior mesenteric artery to where there was relative obstruction and moderate narrowing and a stricture in the proximal to mid jejunum with mesenteric nodal prominence. A small bowel series with gastrograffin had similar findings. Patient underwent a laparoscopic small bowel resection where a small bowel mass at the level of the mid jejunum was found, causing focal narrowing and partial obstruction. The mass pathology revealed a central structure with mural thickening and features suggestive of Crohn’s disease. His post operative course was unremarkable, and he followed up with gastroenterology outpatient for evaluation and treatment of his new diagnosis of Crohn’s disease. (Figure) Discussion: Crohn’s disease includes a wide collection of clinical presentations. Small bowel obstruction progresses in moderate to severe cases of Crohn’s, which typically is a chronic issue. To our knowledge, one other case report has been published with the initial presentation of Crohn’s disease manifesting as an obstruction. Our patient had misleading initial work up and isolated jejunal involvement without other intestinal involvement which may have contributed to the delay in his diagnosis.Figure 1.: Left and middle panels reveal the small bowel series with small intestine narrowing and dilatation. Right similarly reveals small bowel dilation and mesenteric nodal prominence.

S2671 Upper Gastrointestinal Bleeding Due to Duodenal Ischemia: A Case Series

Introduction: Duodenal ischemia is a rare entity given dual blood supply from branches of the Celiac axis and Superior Mesenteric artery. However, it may present with clinically significant GI bleeding. We present three cases of duodenal ischemia diagnosed on EGD. Case Description/Methods: Case 1: An 84-year-old lady with heart failure presented with abdominal pain and melena. Vitals were BP 90/55, HR 112. She was cachectic with a mildly tender abdomen. Labs were notable for hemoglobin 6.6 g/dL from baseline of 8.2; BUN 65 mg/dL. CT abdomen noted bowel wall edema involving the duodenum. EGD revealed 5 duodenal ulcers with surrounding erythematous and friable mucosa consistent with ischemia (FigureA). She was discharged in stable condition on pantoprazole BID. Case 2: A 63-year-old lady presented with chest pain and was diagnosed with an inferior STEMI. On presentation vitals were BP 76/50 mmHg and HR 43 bpm. Cardiac catheterization was performed with two drug-eluting stents placed in the right coronary artery. Patient was started on aspirin and clopidogrel and developed melena 3 days later. Hemoglobin dripped from 12.4 to 8.4 g/dL. EGD noted pallor of the gastric body with areas of patchy erythema and erosions within the antrum, in addition to several clean based ulcers with erythema within the duodenal bulb through the second portion (FigureB). Admission CT abdomen showed moderate celiac narrowing. Patient was continued on pantoprazole BID and did not have further bleeding episodes prior to discharge. Case 3: A 63-year-old man with ESRD was admitted with endocarditis, MSSA bacteremia and embolic strokes. On day 9, he suffered PEA arrest and was resuscitated. He subsequently developed melena and shock. Hemoglobin dropped from 9.8 g/dL to 6.6 g/dL. Urgent EGD revealed a diffusely hemorrhagic stomach and the duodenum was noted to have spotty areas of necrosis, erosions and ulcerations within the bulb and second portion ( FigureC). CTA revealed moderate to severe stenosis in the proximal SMA and celiac axis. The patient was transitioned to comfort measures after suffering recurrent embolic strokes during admission. Discussion: Clinicians should maintain a high index of suspicion for duodenal ischemia in patients presenting with upper GI bleeding in the setting of a low-flow state, as illustrated in the above three cases. Management is typically supportive; however prognosis may be poor reflecting patients’ systemic illnesses leading to the process.Figure 1.: Endoscopic images demonstrating duodenal ischemia.

Thermodynamic Stability, Structure, and Optical Properties of Perovskite-Related CsPb2Br5 Single Crystals under Pressure

CsPb2Br5 belongs to all inorganic perovskite-related quasi-two-dimensional materials that have attracted considerable attention due to their potential for optoelectronic applications. In this study, we solve numerous controversies on the physical properties of this material. We show that optical absorption in the visible spectrum and green photoluminescence are due to microcrystallites of the three-dimensional CsPbBr3 perovskite settled on the CsPb2Br5 plates and that carefully cleaned crystal plates are devoid of these features. The high-pressure structural and spectroscopic experiments, performed on the single crystals free of CsPbBr3 impurities, evidenced that the layered tetragonal structure of CsPb2Br5 is stable at least up to 6 GPa. The absorption edge is located in the ultraviolet at around 350 nm and continuously red shifts under pressure. Moderate band gap narrowing is well correlated to the pressure-induced changes in the crystal structure. Although the compressibility of CsPb2Br5 is much higher than for CsPbBr3, the response in optical properties is weaker because the Pb–Br layers responsible for the optical absorption are much less affected by hydrostatic pressure than those built of Cs+ cations. Our study clarifies the confusing data in the literature on the optical properties and thermodynamic stability of CsPb2Br5.

Long-term preservation of metacarpophalangeal joint function in traumatic defects by metatarsophalangeal osteochondral transplantation.

The integrity of the metacarpophalangeal (MCP) joints is essential for finger and hand function. Preservation of range-of-motion is one of the aims in reconstruction of complex injuries to these joints. Osteochondral transplants have shown to be reliable in reconstruction of various joint defects. This series presents three patients with traumatic injuries to four MCP joints, which were reconstructed by seven avascular osteochondral transplants of metatarsophalangeal (MTP) joints. The joints were examined for radiographic signs of resorption or joint space narrowing, and if this would affect the joints' function in the long term. In three patients (40, 45 and 48years) with complex injuries to their MCP joints (one milling, two saw injuries), four joints were reconstructed by three metatarsal head and four osteochondral transplants of the base of the proximal toe phalanges. Beside the joint itself, various soft tissue defects were reconstructed in each patient. The patients were clinically and radiographically examined after 9, 6, respectively, 7years. All patients were satisfied with the result without any pain in the MCP joints. Range-of-motion in the four affected joints rated 25, 60, 75, and 80°, DASH scores rated 13, 29, and 17, respectively. None of the patients complained of problems at their feet. Radiographic examination revealed moderate joint space narrowing in one of the four joints. In another patient, localized osteolysis was found around the screws' heads, so that the screws were removed 7years post-op. Osteochondral transplants for reconstruction of MCP defects are able to preserve function in severely injured joints even in the long term. Joint space narrowing may occur, which is not accompanied by pain, however. Since localized osteolysis can cause screw head prominence, mid-term radiographic follow-up is necessary to prevent damage to the joint. In the long term, remaining bone stock may be adequate for total joint replacement.

Methodological approach to assessing environmental risk (health risk) from air pollution in the Baikal region in a changing climate

The methodological approach to assessing the environmental risk (health risk) from atmospheric pollution in the Baikal region taking into account the changing climate was formulated. It is based on the US EPA's health risk assessment methodology and impurity concentration estimates by solving the adjoint equation for impurities transport and diffusion. The dynamics of health risk for the population of Irkutsk from atmospheric pollution PM10, PM2.5 due to emissions from possible sources located both in the Baikal region and beyond including sources of transboundary pollution in 1980-2050 under various scenarios of climate change was researched. A tendency for a moderate decrease in the considered risk over the past several decades was shown. In the forecast period until 2050, under both climate scenarios, significant changes in the risk were not noted. The spatio-temporal dynamics of the areas of PM10, PM2.5 sources location that create the increased health risk in relation to Irkutsk was studied. The results indicate the moderate narrowing of the increased risk zone for Irkutsk in the first half of the 21st century. In the period until 2050, the main impact on the population health in the Irkutsk area from emission sources located in the southwest, south and southeast is expected. In case of transboundary pollution, the main danger from sources in Kazakhstan, Mongolia, and China is expected. The results are important to develop proposals for ensuring safety for public health, developing health care and planning environmental protection measures in the Baikal and neighboring regions.

Progressive Pulmonary Venous Stenosis and Recurrent Hypoxemic Respiratory Failure in a Lung Transplant Recipient

<h3>Introduction</h3> Pulmonary venous stenosis (PVS) is a rare complication of lung transplant (LT) that typically presents soon after surgery with pulmonary congestion at the site of reduced venous drainage. We describe a case of a 34-year-old LT recipient with an unremarkable initial postoperative course who later developed recurrent hypoxemic respiratory failure due to progressive PVS. <h3>Case Report</h3> The patient underwent an uneventful bilateral LT; he had no evidence of primary graft dysfunction, was extubated the day after LT, and was discharged 10 days later. A month after LT, a chest CT showed moderate narrowing of the right superior pulmonary vein (RSPV); the remaining PVs appeared unremarkable. A subsequent chest CT showed mild right interlobular septal thickening and an incidental left bronchial anastomotic dehiscence. He recovered from dehiscence repair but continued to present with intermittent respiratory failure and bilateral, lower lobe predominant, ground-glass opacities and consolidations. As the location of the consolidations did not correlate with the location of PV narrowing, pulmonary edema from reduced venous drainage was not suspected. However, CT5 months after LT showed increased narrowing of the RSPV as well as narrowing of the right inferior pulmonary vein (RIPV) and left superior and inferior pulmonary veins (LSPV, LIPV); follow-up CT showed complete absence of opacification of the right venous system. In collaboration with interventional cardiology, PV stenting was selected over re-transplant. A 3-D model of the patient's proximal pulmonary vasculature was printed to guide intervention. Angiography at 16 months after transplant revealed occlusion of the RSPV and RIPV, severe stenosis of the LIPV, and moderate-severe stenosis of the LSPV (6-7mm). A transseptal approach was used to perform balloon angioplasty with stenting (Palmaz biliary stents) of the LSPV first and the RIPV 3 months later. The patient was treated with dual anti-platelet therapy, reported significant symptomatic improvement, remains off of supplemental oxygen, and still has stable allograft function 21 months after PV stenting. <h3>Summary</h3> PVS is a well-described postoperative complication of LT; however, progressive stenosis of multiple PVs is unusual. PV stenting can improve venous drainage and relieve pulmonary congestion in patients with progressive PVS.

К оценке экологических рисков от загрязнения атмосферы Арк­тической зоны в условиях изменяющегося климата в ХХI в

The article formulates a methodological approach to assessing environmental risks from atmospheric pollution in the Arctic zone under a changing climate. It is based on the US EPA’s health risk assessment methodology and impurity concentration estimates by solving the adjoint equation for impurities transport and diffusion. The authors investigate the dynamics of health risk from atmospheric pollution PM10, PM2.5 in the areas of five arctic cities due to emissions from potential nearby and remote sources (including sources of transboundary pollution) in 1980—2050 taking into account various scenarios of climate change. The results indicate general tendency towards an increase in the danger of air pollution for humans in the forecast period until 2050 against the background of climate changes. The authors study the spatio-temporal dynamics in the location areas of PM10, PM2.5 sources that create the highest health risk in relation to Arkhangelsk. The results show the moderate narrowing of the high-risk zone in the first quarter of the XXI century and some upward trend in risk in the second quarter of this century. In the period up to 2050, the main impact on public health in the Arkhangelsk region is expected from emission sources located in the west and southwest. At the same time, the authors prove a tendency towards an increase in the influence of sources located in the southwestern and southern directions. In case of transboundary pollution, sources in the Scandinavian states, Baltics, the countries of Eastern and Central Europe, Ukraine and Belarus pose a danger. The results are important to develop proposals for ensuring the environmental safety in Arctic when planning the spatial development of the Russian Arctic zone and other country territories.

Flush Flow Behaviour Affected by the Morphology of Intravascular Endoscope: A Numerical Simulation and Experimental Study.

Background: Whilst intravascular endoscopy can be used to identify lesions and assess the deployment of endovascular devices, it requires temporary blockage of the local blood flow during observation, posing a serious risk of ischaemia.Objective: To aid the design of a novel flow-blockage-free intravascular endoscope, we explored changes in the haemodynamic behaviour of the flush flow with respect to the flow injection speed and the system design.Methods: We first constructed the computational models for three candidate endoscope designs (i.e., Model A, B, and C). Using each of the three endoscopes, flow patterns in the target vessels (straight, bent, and twisted) under three different sets of boundary conditions (i.e., injection speed of the flush flow and the background blood flowrate) were then resolved through use of computational fluid dynamics and in vitro flow experiments. The design of endoscope and its optimal operating condition were evaluated in terms of the volume fraction within the vascular segment of interest, as well as the percentage of high-volume-fraction area (PHVFA) corresponding to three cross-sectional planes distal to the microcatheter tip.Results: With a mild narrowing at the endoscope neck, Model B exhibited the highest PHVFA, irrespective of location of the cross-sectional plane, compared with Models A and C which, respectively, had no narrowing and a moderate narrowing. The greatest difference in the PHVFA between the three models was observed on the cross-sectional plane 2 mm distal to the tip of the microcatheter (Model B: 33% vs. Model A: 18%). The background blood flowrate was found to have a strong impact on the resulting volume fraction of the flush flow close to the vascular wall, with the greatest difference being 44% (Model A).Conclusion: We found that the haemodynamic performance of endoscope Model B outperformed that of Models A and C, as it generated a flush flow that occupied the largest volume within the vascular segment of interest, suggesting that the endoscope design with a diameter narrowing of 30% at the endoscope neck might yield images of a better quality.

RAPID RECOVERY FROM MYCOBACTERIUM TB EPIGLOTTITIS REQUIRING ENDOTRACHEAL INTUBATION

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Laryngeal Tuberculosis (LTb) currently accounts for <1% of all Tb cases. Patients most often present with dysphonia, weight loss, and typically respond well to targeted antimicrobial regimens [1]. To our knowledge, there is minimal data regarding time to liberation from mechanical ventilation and the efficacy of corticosteroids in LTb. We present a case of LTb in a 37-year-old immunocompetent female requiring endotracheal intubation with a subsequent rapid recovery. CASE PRESENTATION: A 37-year-old female presented to the Emergency Department for a 2-week history of dyspnea, and 3 months of intermittent fevers, weight loss, and dysphonia. She had no known past medical history. The patient was febrile, tachycardic, and hypoxic requiring 100% oxygen via non-rebreather mask. Physical exam was remarkable for respiratory distress and mild stridor. Laboratory studies found a leukocytosis of 18.3 K/μL with a neutrophilic predominance to 84%. HIV screening was negative. A CXR revealed bilateral interstitial opacities. Chest CT angiography found diffuse, bilateral centrilobular nodules, tree-in-bud opacities, and bilateral upper lobe cavitary lesions measuring up to 3.9cm (Image 1). Contrast-enhanced Neck CT demonstrated marked swelling of the epiglottis and moderate narrowing of the airway (Image 2). Nebulized racemic epinephrine, albuterol, ipratropium, and IV dexamethasone resulted in mild improvement of her stridor. Transnasal flexible fiberoptic laryngoscopy revealed an enlarged epiglottis with >50% obstruction of the supraglottic airway. She underwent endotracheal intubation for airway protection, and a flexible bronchoscopy was performed. Bronchoalveolar lavage fluid analysis revealed 95% neutrophils, cultures grew Mycobacterium tuberculosis, and cytology was negative for malignant cells. Rifampin, isoniazid, pyrazinamide, ethambutol (RIPE), and pyridoxine were initiated. She also received dexamethasone 6mg IV daily for seven days. Twelve days after intubation, the patient was extubated without signs of stridor. DISCUSSION: LTb has two categories: primary, in which bacteria seed the larynx directly, and secondary, via invasion by advanced pulmonary Tb [1]. Diagnosis is often a combination of visualization of laryngeal lesions via laryngoscopy, tissue culture, and laryngeal histopathology [1]. A review of the literature identified 13 cases of LTb requiring mechanical ventilation, all via tracheostomy. Time to decannulation ranged from 2-6 months, with one case reporting 2 weeks [2]. Data regarding the efficacy of corticosteroids in LTb with airway compromise is limited. However, a recent retrospective study found steroid use in pulmonary Tb with acute respiratory failure to be beneficial [3]. CONCLUSIONS: When treated with appropriate antimicrobials along with consideration to adjunct corticosteroid use, LTb patients may demonstrate a rapid recovery obviating the need for tracheostomy. REFERENCE #1: Benwill JL, Sarria JC. Laryngeal tuberculosis in the United States of America: a forgotten disease. Scand J Infect Dis. 2014;46(4):241-249. doi:10.3109/00365548.2013.877157 REFERENCE #2: Gupta R, Fotedar S, Sansanwal P, et al. Obstructing mass lesion of epiglottis: it can be tubercular. Indian J Tuberc. 2008;55(2):100-103. REFERENCE #3: Yang JY, Han M, Koh Y, et al. Effects of Corticosteroids on Critically Ill Pulmonary Tuberculosis Patients With Acute Respiratory Failure: A Propensity Analysis of Mortality. Clin Infect Dis. 2016;63(11):1449-1455. doi:10.1093/cid/ciw616 DISCLOSURES: No relevant relationships by Nathaniel Allison, source=Web Response No relevant relationships by Christopher Lee, source=Web Response No relevant relationships by John Prudenti, source=Web Response No relevant relationships by Lourdes Sanso, source=Web Response

S2165 A Breath-Taking Case of Esophageal Dilation

Introduction: Esophageal dilation is rarely associated with shortness of breath. In this abstract, we present a case of severe esophageal dilation likely due to achalasia which resulted in airway obstruction. Case Description/Methods: An 80 year old man with past medical history congestive heart failure and hypothyroidism presented with a worsening neck mass and difficulty breathing. He endorsed weight gain, abdominal distension and bloating. He denied stridor, nausea, vomiting, or regurgitation. He noted dysphagia to solids for the last two years; however, he was able to swallow liquids. An esophagram obtained two years prior showed distal narrowing of the esophagus with proximal dilation. The neck was bulging to the right with significant neck fullness. There was no abdominal distension. CT neck revealed a distended esophagus compressing and mild to moderate narrowing of the subglottic airway. The gaseous distended esophagus protruded into the right anterior neck. EGD revealed severe dilation in the upper and middle third of the esophagus. There was also severe esophagitis dissecans in the entire middle and lower esophagus with an area of black mucosal discoloration in the middle of the esophagus. ANA, Anti-Scl-70 Ab, T. Cruzi IgG Ab were negative. Discussion: In the case described, the patient's shortness of breath was caused by heart failure exacerbation but also likely due to esophageal dilation causing compression on the airway. His history of distal esophageal narrowing two years prior and EGD without signs of mechanical obstruction of the distal esophagus suggest his esophageal dilation was likely due to achalasia. Unfortunately, the patient deteriorated clinically and transitioned to hospice cares shortly thereafter. He died several weeks later. Achlasia is associated with respiratory complaints typically in the form of aspiration. Retained esophageal products can cause symptoms of cough, sore throat, hoarseness, and wheezing. Esophageal dilation can result from achalasia or pseudoachalasia. EGD is useful to differentiate between these two entities. Barium esophagram and esophageal manometry are also useful in establishing the diagnosis of achalasia. Due to the severity of the patient's condition in the above case, barium esophagram and esophageal manometry were not performed. The black esophagus noted on EGD was likely due to ischemia as a result of severe dilation.Figure 1.: CT neck shows a distended esophagus compressing the trachea and adjacent structures.

Partial arthroscopic trapeziectomy and stabilisation by ligamentoplasty: Outcomes in patients younger than 60 years

BackgroundThumb carpometacarpal joint (TCMJ) osteoarthritis is the fourth leading cause of referral to elective hand surgery. None of the available techniques has proved superior over the others. Some techniques carry unacceptable risks for younger patients, such as loss of strength and shortening of the thumb column after total trapeziectomy, or wear and loosening after total arthroplasty. Our objective was to assess outcomes after partial arthroscopic trapeziectomy (PAT) combined with suspensionplasty using the abductor pollicis longus (APL) tendon in patients younger than 60years of age. HypothesisPAT combined with suspensionplasty using the APL tendon in patients younger than 60years would restore strength in the medium-term without further surgery. Material and methodsWe retrospectively included consecutive patients operated between 2007 and 2017, in a single centre, and aged less than 60years. All patients had isolated TCMJ osteoarthritis stage 1 to 3 according to Eaton and Glickel classification that remained symptomatic despite optimal conservative treatment. We collected pain intensity, range of motion, strength, the Nelson Hospital Score (NHS), and the Patient-Rated Wrist Evaluation (PRWE) score. Radiographs were reviewed. ResultsWe included 27 patients, of whom 6 had surgery on both thumbs, yielding 33 thumbs for the analysis. Mean follow-up was 64.7months (range: 10.6–136.5months). Pain intensity, grip strength, and key-pinch strength were significantly improved (p<0.001), with no difference between men and women. No differences were found for the Kapandji score (p=0.2) or TCMJ hyperextension (p=0.06). At last follow-up, the mean NHS was 83.2±19.4 and the mean PRWE was 15.4±17.9. Mean sick leave duration was 5.4weeks (range: 1–24weeks). Only 2 patients, both in manual jobs, were unable to return to work. The radiographs at last follow-up showed the development of moderate TCMJ narrowing in 14 patients and evidence of scapho-trapezio-trapezoid (STT) osteoarthritis in 10 patients. No patient experienced complex regional pain syndrome or injury to the sensory branch of the radial nerve. A single patient required further surgery for persistent pain. DiscussionPatients younger than 60years who are treated with this minimally invasive technique are likely to experience sustained improvements in both strength and pain intensity. Total trapeziectomy and pyrocarbon implant has also been evaluated in younger patients, who experienced pain relief and strength gains but had lower levels of satisfaction and developed complications inherent in the implants. The short time off work and low morbidity make our technique a procedure of choice in younger patients. To build on this study, a comparison of PAT and arthroplasty would be of interest. Level of evidenceIV.