Obstruction Score Research Articles

Clinical and pelvic morphologic correlation after subtotal colectomy with colorectal anastomosis for combined slow-transit constipation and obstructive defecation.

The treatment of slow-transit constipation combined with outlet obstruction is controversial. Subtotal colectomy with colorectal anastomosis is regarded as a safe and effective surgical option for refractory constipation. The clinical and morphologic outcomes of patients who underwent subtotal colectomy with colorectal anastomosis for refractory mixed constipation were prospectively evaluated. This study is a nonrandomized, prospective review of gathered data. This investigation was conducted at a tertiary-care GI surgical center in China. The study prospectively included 42 consecutive patients with refractory constipation who were diagnosed with obstructed defecation syndrome combined with slow colon transit. The primary outcomes measured were the Longo obstructive defecation syndrome score and the Wexner constipation scale. The pelvic morphologic changes were determined with defecography before surgery and at 6 and 24 months after surgery. A significant reduction in the Wexner constipation score was observed between baseline (median 24) and 6 months (median 10), which was maintained until 24 months (median 8, compared with baseline, p < 0.01). Improvement in the constipation score was matched by an overall improvement in the Longo obstructive defecation syndrome score at the 6- and 24-month follow-up times (compared with baseline, p < 0.01). In 17 of 21 patients, preexisting intussusception was no longer visible during defecography. Rectoceles were significantly reduced in depth, from 36 mm to 8 mm (p < 0.01), whereas the number of detectable rectoceles was also significantly decreased, from 29 to 7 (p < 0.01). Incomplete evacuation disappeared in 28 of 38 patients. No stenosis was observed at the colorectal posterior side-to-side anastomosis. Most complications were managed conservatively without significant events. This study was performed in selected patients with constipation and did not include a comparison group. Subtotal colectomy with colorectal anastomosis can correct pelvic anatomical disorders in patients with mixed refractory constipation. The clinical improvement of obstructed defecation syndrome after subtotal colectomy with colorectal anastomosis is highly correlated with the morphologic correction of the rectal redundancy.

Effect of Levator Ani Muscle Injury on Primiparous Women During the First Year After Childbirth

The estimated prevalence of levator ani muscle (LAM) injury after vaginal delivery ranges from 13% to 36%. Levator ani muscle injury is associated with pelvic organ prolapse, but its association with stress incontinence is unclear. Differences have been demonstrated between white and Chinese women in structural and pelvic organ mobility. There are limited data on the effect of LAM injury on health-related quality of life. This prospective observational study evaluated the effect of LAM injury on pelvic floor disorders and health-related quality of life in Chinese primiparous women during the first year after delivery. At 8 weeks and 12 months after delivery, women with and without LAM injury were assessed for symptoms of pelvic floor disorders and quality of life using the standardized questionnaire (Pelvic Organ Prolapse Quantification [POP-Q]); translabial ultrasound was used to detect LAM injury. A total of 442 women were recruited in a tertiary obstetric unit during the first trimester from August 2009 to September 2010. Data were analyzed using descriptive analysis, independent-sample t test, nonparametric testing, χ2 test, and 2-sided Fisher exact test. Of the 442 women enrolled, 328 (74.2%) completed the study. At 8 weeks after delivery, LAM injury was detected in 48 women (19.0% [95% confidence interval, 14.2%–23.8%]) with vaginal delivery; 12 months after delivery, the injury persisted in 38 women (79.2%). Eight weeks after delivery, LAM injury was associated with prolapse symptoms, descent at POP-Q Aa and Ba points, and higher Pelvic Organ Prolapse Distress Inventory and Urinary Distress Inventory Obstructive subscale scores. By 12 months, LAM injury was not associated with prolapse symptoms or with either Pelvic Floor Distress Inventory (PFDI) or Pelvic Floor Impact Questionnaire (PFIQ) scores. At both time points, no association was found between stress urinary incontinence, urge urinary incontinence, mixed urinary incontinence, and fecal incontinence with LAM injury. In this prospective cohort, LAM injury persisted 12 months after vaginal delivery in 79% of women who had LAM injury at 8 weeks. Eight weeks after delivery, LAM injury was associated with prolapse symptoms, lower POP-Q Aa and Ba points, and higher Pelvic Organ Prolapse Distress Inventory general and Urinary Distress Inventory Obstructive subscale scores. However, there was no association between LAM injury and stress urinary incontinence, urge urinary incontinence, mixed urinary incontinence, and fecal incontinence at 8 weeks or 12 months after delivery, or prolapse symptoms, PFDI, or PFIQ scores at 12 months after delivery.

Ultrasonography and magnetic resonance cholangiopancreatography correlation in patients with obstructive jaundice

Background: Obstructive jaundice is a condition caused by blockage of the flow of bile out of the liver. This results in an overflow of bile and its by-products into the blood and bile excretion from the body is incomplete. Ultrasound (USG) is used to evaluate patients for biliary stones and cholecystitis. It can detect cystic duct and neck of the gallbladder obstruction as well as distension and inflammation of the gallbladder. It can identify carcinoma of the gallbladder, which is highly malignant and metastasize quickly. Magnetic resonance cholangiopancreatography (MRCP) is a relatively new noninvasive diagnostic technique for direct visualization of the biliary ducts through images similar to those produced in endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography. Objective: To highlight the role of ultrasonography and MRCP as preliminary investigation in patients with obstructive jaundice. Materials and Methods: Thirty patients with complaints of jaundice and clinico-pathological appearance of obstructive jaundice were included in the study. The patients had undergone sonography of abdomen in radiology department and then MRCP study was conducted. Data of patients matching inclusion criteria were recorded after getting informed consent. Result: Of 30 patients, 17 (56.66%) were females and 13 (43.33%) were males. Most common age group of patients was 51–60 years (23.3%) followed by 61–70 years (16.6%). Jaundice was the most frequent symptom (96%) followed by abdominal pain (86.66%). Common bile duct (CBD) was most commonly involved in 50% of cases followed by confluence of right and left hepatic duct and pancreas in 13.33%. Most common obstructive lesions in this study were congenital anomalies of CBD (choledochal cyst) in 30% cases followed by stone in CBD +/- CHD with or without stricture in 19.99% cases. In this study, of 30 cases, 16 (53.33%) were benign lesions and 14 (46.66%) were malignant. Among benign lesions, choledochal cyst was the most common (9/16; 56.25%), especially more among females. However, among malignant lesions, hilar cholangiocarcinoma was most common (5/14), especially among females. USG (30/30) was found to be equally good as MRCP (30/30) in detecting the presence and level of obstruction. In detecting the extent of obstruction, USG could not localize the distal extent of the lesion involving distal CBD (6/30) due to poor patient factors (obesity) and bowel gases. In assessing the cause of obstruction, MRCP (30/30) scored over USG. Conclusion: USG is a cost-effective, noninvasive, and nonionizing easily available preliminary investigation in the evaluation of obstructive jaundice but MRCP scores over USG for evaluation of small hepatic metastasis in the presence of pancreaticobiliary malignancies that may be missed with USG.

Download Sinonasal morbidity following tumour resection with and without nasoseptal flap reconstruction

Sinonasal function can be affected by multiple treatment modalities but surgical techniques, such as the nasoseptal flap or Draf 3 procedure, have been implicated in poor post-treatment function. Prior studies have rarely used comparable populations and this study aims to assess the impact of surgical technique, mainly the nasoseptal flap, on sinonasal function in a group of comparable patients. A prospective cohort of patients undergoing endoscopic surgery for sinonasal and skull base tumours was studied. Patients were analysed according to whether a nasoseptal flap was used. Other treatment factors included; use of the Draf 3, radiotherapy, removal of olfactory apparatus and dural resection. The Sinonasal Outcome Test 22 (SNOT22), a nasal symptom score (NSS), global function score and nasal obstruction scores were recorded pre and post treatment. One hundred and eighteen patients were assessed. Forty-two patients had a nasoseptal flap. Perioperative radiotherapy was higher in the nasoseptal group, as was dural resection and the need to remove the olfactory apparatus. Despite this, there was no significant difference in SNOT22 scores and NSS. Radiotherapy was detrimental to sinonasal function with SNOT22 and NSS. The use of a nasospetal flap in surgery does not affect patient quality of life and sinonasal function after endoscopic tumour resection. Pathology is a better predictor of morbidity, with loss of function from radiotherapy or resection of functional areas such as the olfactory apparatus having a greater impact.

Pharmacodynamic Estimate of Propofol-Induced Sedation and Airway Obstruction Effects in Obstructive Sleep Apnea-Hypopnea Syndrome.

PurposeSedatives must be carefully titrated for patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) as oversedation may lead to disastrous respiratory outcomes. This study aimed to investigate the relations between the effect-site concentration (Ce) of propofol and sedation and airway obstruction levels in patients with OSAHS.Materials and MethodsIn 25 patients with OSAHS, sedation was induced by 2% propofol using target-controlled infusion. Sedation and airway obstruction levels were assessed using the Observer's Assessment of Alertness/Sedation Scale and a four-category scale, respectively. The relationships between propofol Ce and sedation and airway obstruction were evaluated using a sigmoid Emax model. Pharmacodynamic modeling incorporating covariates was performed using the Nonlinear Mixed Effects Modeling VII software.ResultsIncreased propofol Ce correlated with the depth of sedation and the severity of airway obstruction. Predicted Ce50(m) (Ce associated with 50% probability of an effect≥m) for sedation scores (m≥2, 3, 4, and 5) and airway-obstruction scores (m≥2, 3, and 4) were 1.61, 1.78, 1.91, and 2.17 µg/mL and 1.53, 1.64, and 2.09 µg/mL, respectively. Including the apnea-hypopnea index (AHI) as a covariate in the analysis of Ce50(4) for airway obstruction significantly improved the performance of the basic model (p<0.05).ConclusionThe probability of each sedation and airway obstruction score was properly described using a sigmoid Emax model with a narrow therapeutic range of propofol Ce in OSAHS patients. Patients with high AHI values need close monitoring to ensure that airway patency is maintained during propofol sedation.

Adenotonsillar hypertrophy as a risk factor of dentofacial abnormality in Korean children.

No studies for the role of adenotonsillar hypertrophy in development of dentofacial abnormalities have been performed in Asian pediatric population. Thus, we aimed to investigate the relationship between adenotonsillar hypertrophy and dentofacial abnormalities in Korean children. The present study included consecutive children who visited a pediatric clinic for sleep-disordered breathing due to habitual mouth breathing, snoring or sleep apnea. Their palatine tonsils and adenoids were graded by oropharyngeal endoscopy and lateral cephalometry. Anterior open bite, posterior crossbite, and Angle's class malocclusions were evaluated for dentofacial abnormality. The receiver-operating characteristic curve analysis was used to identify age cutoffs to predict dentofacial abnormality. A total of 1,083 children were included. The presence of adenotonsillar hypertrophy was significantly correlated with the prevalence of dentofacial abnormality [adjusted odds ratio = 4.587, 95% CI (2.747-7.658)] after adjusting age, sex, body mass index, allergy, and Korean version of obstructive sleep apnea-18 score. The cutoff age associated with dentofacial abnormality was 5.5 years (sensitivity = 75.5%, specificity = 67%) in the children with adenotonsillar hypertrophy and 6.5 years (sensitivity = 70.6%, specificity = 57%) in those without adenotonsillar hypertrophy. In conclusion, adenotonsillar hypertrophy may be a risk factor for dentofacial abnormalities in Korean children and early surgical intervention could be considered with regards to dentofacial abnormality.

CT pulmonary angiography findings that predict 30-day mortality in patients with acute pulmonary embolism

PurposeStandard computed tomography pulmonary angiography (CTPA) can be used to diagnose acute pulmonary embolism. In addition, multiple findings at CTPA have been proposed as potential tools for risk stratification. Therefore, the aim of the present study is to examine the prognostic value of (I) thrombus distribution, (II) morphometric parameters of right ventricular dysfunction, and (III) contrast reflux in inferior vena cava on 30-day mortality. Material and methodsIn a retrospective, single-center study from 06/2005 to 01/2010 365 consecutive patients were included. Inclusion criteria were: presence of acute pulmonary embolism, and availability of 30-day follow-up. A review of patient charts and images was performed. ResultsThere were no significant differences between the group of 326 survivors and 39 non-survivors in (I) thrombus distribution, and (II) morphometric measurements of right ventricular dysfunction. However, (III) contrast reflux in inferior vena cava was significantly stronger in non-survivors (odds ratio 3.29; p<0.001). Results were independent from comorbidities like heart insufficiency and pulmonary hypertension. ConclusionMeasurement of contrast reflux is a new and robust method for predicting 30-day mortality in patients with acute pulmonary embolism. Obstruction scores and morphometric measurements of right ventricular dysfunction perform poor as risk stratification tools.

An evaluation of factors associated with completion and benefit from pulmonary rehabilitation in COPD

BackgroundPulmonary Rehabilitation (PR) is an important treatment for patients with chronic obstructive pulmonary disease (COPD) but it is not established whether any baseline parameter can predict response or compliance.AimTo identify...

Patient-perceived Satisfaction After Definitive Treatment for Men With High-risk Prostate Cancer: Radical Prostatectomy vs Intensity-modulated Radiotherapy With Androgen Deprivation Therapy

To assess the change in disease-specific health-related quality of life and to evaluate patient-perceived satisfaction after radical prostatectomy (RP) or intensity-modulated radiotherapy (IMRT) with androgen deprivation therapy (ADT) for patients with high-risk prostate cancer (PCA) that has been defined by the European Association of Urology guideline. Between 2006 and 2010, 150 patients with high-risk PCA who underwent either RP (n= 97) or IMRT with ADT (n= 53) were enrolled in this prospective health-related quality of life study. Disease-specific health-related quality of life at baseline, 3, 6, 12, and 24months and patient-perceived satisfaction at 12 and 24months after these treatments were estimated using the Expanded Prostate Cancer Index Composite. Urinary bother and irritation and obstruction scores did not change significantly between both treatment groups throughout the 2-year follow-up. ADT greatly influenced sexual and hormonal functions and bothers in patients who received IMRT with ADT. The patient-perceived satisfaction at 12months after the treatments was approximately 80% in both treatment groups, and there was no significant difference between the 2 groups. At 12months after the treatments, urinary function (P= .001) was identified as the most significant predictor of patient-perceived satisfaction, although it was not associated with the treatment type. The majority of patients with high-risk PCA who received RP or IMRT with ADT reported high patient-perceived satisfaction after the treatments. This study showed that improvement in urinary function might contribute to patient-perceived satisfaction after the treatments.

A prospective two-center study on the associations between microalbuminuria, coronary atherosclerosis and long-term clinical outcome in asymptomatic patients with type 2 diabetes mellitus: evaluation by coronary CT angiography.

This study assessed the associations between microalbuminuria in asymptomatic patients with type 2 diabetes and the presence, extent, and severity of coronary atherosclerosis, as measured by coronary computed tomography angiography (CCTA), and the long-term clinical outcomes. In total, the study enrolled 284 consecutive eligible asymptomatic patients with type 2 diabetes and without known coronary artery disease (CAD), who then underwent CCTA and 24h urine albumin measurements. Microalbuminuria was defined as 30-300mg/day urinary albumin excretion. Obstructive CAD, as measured by CCTA, was defined as maximum intra-luminal stenosis ≥50%. Patients with and without microalbuminuria were compared in terms of obstructive CAD prevalence, and the extent and severity of coronary atherosclerosis. They were evaluated using the following data: coronary artery calcium score (CACS), atheroma burden obstructive score (ABOS), segment involvement score (SIS) and segment stenosis score (SSS). All-cause mortality within a follow-up period of 5years was also compared. Compared to patients without microalbuminuria, patients with microalbuminuria were more likely to have obstructive CAD (p=0.004). Microalbuminuria was associated with higher ABOS (p=0.010), SIS (p=0.029), and SSS (p=0.011), except for CACS (p=0.058). Multivariable analyses adjusted for conventional cardiovascular risk factors revealed that microalbuminuria was an independent predictor of obstructive CAD [odds ratio 2.255, confidence intervals (CI) 1.121-4.538, p=0.023] and all-cause mortality (hazard ratio 3.469, CI 1.319-9.121, p=0.012). In asymptomatic patients with type 2 diabetes, microalbuminuria was associated with increased risk of CAD and poorer clinical outcomes.

GW25-e2172 Obstructive Sleep Apnea and Gensini Score in Suspected Coronary Artery Disease Patients

The relationship between obstructive sleep apnea (OSA) and severity of coronary artery disease (CAD) remains unclear. The present study aimed to determine the association between OSA severity and Gensini score detected by 320-slice coronary CTA in suspected CAD patients. A total of 285 consecutive

Correlation of Clinical and Dosimetric Parameters With Radiographic Lung Injury Following Stereotactic Body Radiotherapy

Radiographic changes occur in over half of patients treated with stereotactic body radiotherapy (SBRT) to the lung, correlating histopathologically with injury. We quantified radiographic density changes (ie, fibrosis) at 3, 6, and 12 months and investigated the relationship between these volumes and clinical and dosimetric parameters. The study population consisted of patients treated with SBRT to the lung for stage I primary lung cancers (n = 39) or oligometastatic lesions (n = 17). Fractionation schemes included 3 fractions of 12, 14, or 18 gray (Gy) and 4 fractions of 12 or 12.5 Gy prescribed to cover 95% of the planning target volume (PTV). Planning computed tomography (CT) scans were rigidly registered to follow-up CT scans obtained at intervals of 3, 6, and 12 months. Fibrotic volumes were contoured on the follow-up scans. Associations between the volume of fibrosis and clinical and dosimetric parameters were investigated using univariate linear regression. Scans were available for 65 and 47 lesions at 6 and 12 months, respectively. Age, years since quitting smoking, and GOLD Global Initiative for Chronic Obstructive Lung Disease score were significantly associated with increasing volume of fibrosis (P < .05). Total dose, dose per fraction, PTV, and volumetric parameters (V0-V55) were also significantly associated with increasing volumes of fibrosis (P < .01). For dosimetric parameters, the effect was largest for V55. Age, significant smoking history, and GOLD score were significantly associated with increasing volumes of fibrosis following SBRT. In a multivariate model adjusted for age and smoking history, V10 through V50 and PTV size remained significant predictors of fibrotic volume. Further, there is a strong dose-response relationship between the volume of lung exposed to a certain dose and the fibrotic volume. The predominant kinetic patterns of fibrosis demonstrate peaking fibrotic volumes at 6 and 12 months. These results provide insight for expectations of fibrosis after SBRT.

Steroid-eluting sinus implant for in-office treatment of recurrent polyposis: a pharmacokinetic study.

Long-term use of systemic glucocorticoid therapy has been associated with hypothalamic-pituitary-adrenal axis suppression and other systemic adverse events. This pharmacokinetic study evaluated the systemic safety and performance of a bioabsorbable sinus implant that gradually releases 1350μg of mometasone furoate directly to the sinus mucosa. A prospective, single-center study treating 5 adult patients with recurrent polyposis after bilateral total ethmoidectomy. Each patient received 2 steroid-releasing implants in-office under local/topical anesthesia. Plasma concentrations of mometasone furoate and cortisol were determined before placement and through 30-day follow-up, which also included endoscopic grading and patient-reported outcomes. Five patients (mean age 46.2 ± 9.2 standard deviation [SD] years; 60% male) underwent successful placement in all 10 ethmoid sinuses. There were no serious adverse events. The plasma concentrations of mometasone furoate were generally below the lower limit of quantification (LLOQ) of the assay (30pg/mL). Cortisol concentrations at follow-up ranged from 3.9 to 5.7mg/dL compared to 4.7mg/dL at baseline. At 1 month, there was a significant improvement in bilateral polyp grade (p = 0.037), nasal obstruction score (p = 0.002), and 22-item Sino-Nasal Outcome Test (SNOT-22) (p = 0.010) compared to baseline. The reported 100% placement success, negligible systemic exposure to mometasone furoate released over time, lack of adrenal suppression, and the absence of serious adverse events suggest that the implant provides a valid and safe option for the in-office treatment of recurrent polyposis. Randomized, controlled, blinded clinical studies are underway to provide further evidence of safety and efficacy.

A novel diagnostic tool for chronic obstructive eustachian tube dysfunction—the eustachian tube score.

The purpose of this study was to introduce a new tool for the diagnosis of chronic obstructive eustachian tube dysfunction (ETD) and as a follow-up tool for eustachian tube therapy using objective and subjective elements. Combined, prospective, retrospective clinical study at a tertiary referral center. Physical examination, history, tympanometry, audiometry, and tubomanometry as well as the seven-item Eustachian Tube Dysfunction Questionnaire (EDTQ-7) were included as diagnostic tests. After initiating the eustachian tube score (ETS), we compared our results of healthy subjects to our data of patients with chronic obstructive ETD. In addition to ETS, an extended test ETS-7 was evaluated, which incorporated two additional items. The test-retest reliability revealed a correlation of 0.82 for the ETS and 0.87 for the ETS-7. ETS-7 receiver operating characteristic analysis, with reference to the EDTQ-7 score, resulted in an area under the curve (AUC) of 0.64. Our analysis considered essential criteria of ETD as comparative tools, which were typical clinical complaints, and at least two of three conditions: a pathologic EDTQ-7, a type B/C tympanometry, and a positive independent expert evaluation. The corresponding AUC was 0.98. Chronic obstructive ETD was identified at a cutoff of 7, with a sensitivity of 96% and a specificity of 96%, using the novel ETS-7. ETS is a valid and reliable instrument in adult patients with chronic obstructive ETD. ETS-7, with a cutoff point of ≤7, should facilitate the diagnosis of ETD and might be valuable as a diagnostic follow-up tool.

Association of Pediatric Obstructive Sleep Apnea Severity with Sleep Endoscopy Findings: A Pilot Study

Objectives: (1) Determine the association of a sleep endoscopy rating scale with pediatric obstructive sleep apnea (OSA) severity. (2) Assess the reliability of this rating scale. Methods: This was a retrospective cohort study of pediatric patients who underwent drug-induced sleep endoscopy (DISE) from January to December 2013 at a tertiary care children’s hospital. DISE recordings were reviewed by 2 blinded senior pediatric otolaryngologists. Severity of obstruction was scored 0, 1, or 2 for no, partial, or complete obstruction at 6 levels: nasal airway, nasopharynx, velum, oropharynx, tongue base, and arytenoids. Ratings at each level were summed for a total score from 0-12. Associations of DISE scores with obstructive apnea-hypopnea index (OAHI) and OSA-18 scores were assessed using linear regression. Interrater and intrarater reliability were calculated using a kappa statistic with linear weighting. Results: Twenty patients were included (mean age 8.4 ± 5.1 years, 55% obese, mean OAHI 16.5 ± 15.6). Associations between OAHI and DISE scores were strongest for the nasopharynx (beta = 12.3, P = .09) and total score (beta = 4.7, P = .06). Associations between OSA-18 and DISE ratings were strongest for the nasopharynx (beta = 11.1, P = .08) and velum (beta = 12.8, P = .07). There was fair-moderate interrater reliability (kappa 0.24-0.63) and moderate-almost perfect intrarater reliability (kappa 0.52-0.88) at individual anatomic sites. Conclusions: Although observed associations did not reach statistical significance, this pilot study suggests clinically important associations between DISE ratings and OSA severity and showed promising interrater and intrarater reliability.

Spiral computed tomographic pulmonary angiography in patients with acute pulmonary emboli and no pre-existing comorbidity: a prospective prognostic panel study.

To investigate the prognostic validity of the right ventricular to left ventricular diameter (RVD/LVD) ratio and Qanadli pulmonary artery obstruction score (PAOS) in hemodynamically stable patients with no pre-existing comorbidities. Sixty-three patients with no previous comorbidity were recruited for this study. The RVD/LVD ratio was calculated based on axial image measurements obtained from contrast-enhanced non-electrocardiography-gated spiral computed tomography (CT) pulmonary angiographic studies. Patients were followed up for 60 days after the initial CT and study variables including demographic data, the RVD/LVD ratio and PAOS were compared between deceased cases and survivors via univariate and multivariate statistical models. The 60-day mortality rate was 22.2%. The deceased and surviving groups were comparable for PAOS, whereas both the median age and RVD/LVD ratio were significantly higher in the first group. In multivariate analysis, however, age was the only significant, independent predictor of 60-day mortality (p = 0.02, Exp(B) = 1.06). At a cut-off age of 63 years the 60-day mortality was predicted with a sensitivity and specificity of 64.3% and 69.4%, respectively. The RVD/LVD ratio and PAOS are not independent predictors of mortality in hemodynamically stable patients with acute PE and no pre-existing comorbidities. • Patients with pulmonary embolism and no pre-existing comorbidity were studied. • The PAOS alone cannot predict mortality in these patients. • Right ventricle strain is not an independent prognostic factor for mortality in pulmonary embolism. • Age is the only independent predictor of death in pulmonary embolism.

Retrospective evaluation of endoscopic stenting of combined malignant common bile duct and gastric outlet-duodenum obstructions.

Malignant dual obstruction in the common bile duct and gastric outlet-duodenum can cause difficulties in palliative treatment. The purpose of this study was to summarize our successful experience with the endoscopic stenting procedure for the palliative treatment of malignant biliary and gastric outlet-duodenum obstruction. Seventeen patients who underwent dual stenting procedures for the common bile duct and duodenum were retrospectively reviewed. The success rate of placement, palliative effect for biliary and duodenal obstruction, incidence of complication and restricture and stent patency were analyzed. Stent placement achieved a 100% success rate. Total bilirubin decreased from 263.4±62.5 to 157.6±25.1 μmol/l, direct bilirubin decreased from 233.2±66.5 to 130.9±27.7 μmol/l and alkaline phosphatase from 534.2±78.7 to 216.3±23.3 IU/l. The differences between the preoperative and postoperative results were statistically significant (P<0.01). The gastric outlet obstruction score increased significantly from 0.9±1.1 to 2.1±0.7 points (P<0.01). The general nutritional status of the patients was improved. No serious complications occurred in any of the patients, and the survival time of patients following stenting ranged between 70 and 332 days with a mean survival time of 192 days. In conclusion, our methodology for combined biliary and enteral stenting is highly effective for the palliation of malignant biliary and gastric outlet-duodenal obstruction.

A new scoring system for upper airway pediatric sleep endoscopy.

Sleep-associated upper-airway obstruction in children is a significant cause of morbidity. Development of a simple, standardized, quantitative technique to assess anatomic causes of sleep-related breathing disorder is important for surgical planning, clinical communication, and research. To design, implement, and evaluate a scoring system to quantify airway obstruction in pediatric drug-induced sleep endoscopy. This study was a retrospective case series conducted at a tertiary pediatric hospital. The patients were children with sleep-related breathing disorder who underwent polysomnography and drug-induced sleep endoscopy. Flexible fiber-optic laryngoscopy was performed. Endoscopic examinations were recorded on video and assessed by 4 independent raters based on a scoring template. Five locations in the upper aerodigestive tract (adenoid, velum, lateral pharyngeal wall, tongue base, and supraglottis) were evaluated on a 4-point scale for minimum and maximum obstruction. Internal reliability was assessed by calculating interrater and intrarater intraclass correlation coefficients (ICCs). For external validation, aggregate and site-specific scores were correlated with preoperative polysomnographic indices. Videos recorded of sleep endoscopies from 23 children (mean age, 2.2 years) were reviewed and rated. Children had an average apnea-hypopnea index of 24.8. Seventy percent of interrater and intrarater ICC values (7 of 10 for each set) were above 0.6, demonstrating substantial agreement. Higher total obstructive scores were associated with lower oxygen saturation nadir (P = .04). The scoring system was also used to quantitatively identify children with multilevel airway obstruction, who were found to have significantly worse polysomnographic indices compared with children with single-level obstruction (P = .02). The proposed scoring system, which is designed to be easy to use and allow for subjectivity in evaluating obstruction at multiple levels, nonetheless achieves good internal reliability and external validity. Implementing this system will allow for standardization of reporting for sleep endoscopy outcomes, as well as aid the practicing clinician in the interpretation of sleep endoscopy findings to inform site-directed surgical intervention in cases of complicated obstructive sleep apnea.

The use of axial diameters and CT obstruction scores for determining echocardiographic right ventricular dysfunction in patients with acute pulmonary embolism.

To evaluate the accuracy of cardiac computed tomography (CT) parameters and pulmonary artery (PA) obstruction (OS) scores in determining the echocardiographic right ventricular dysfunction (RVD) in hemodynamically stable patients with acute pulmonary embolism (PE). A total of 120 patients with acute PE were included in the study. Right ventricle/left ventricle ratio (RV/LV); PA axial diameter; superior vena cava (SVC) axial diameter; and Ghanima, Miller, Qanadli, and Mastora obstruction scores were obtained using CT. RVD was assessed by echocardiography. The patients were divided into two groups based on the presence or absence of RVD. RV/LV ratio, SVC axial diameter, PA axial diameter, and Miller, Qanadli, and Mastora scores were significantly increased in the RVD group. Multivariate logistic regression analysis showed that RV/LV ratio [OR 6.36 (2.02-279.46 95 % CI), p = 0.01] and PA axial diameter [OR 5.02 (1.02-1.26 95 % CI), p = 0.03] were independent predictors of echocardiographic RVD. Predictive values of these parameters were improved when combined with other intragroup cutoff values. A cutoff value for the RV/LV ratio of >1.08 had 81.43 % sensitivity, 52.08 % specificity, 71.3 PPV, and 65.8 NPV for prediction of RVD. Tomographic axial diameters enable more accurate predictions of RVD than OS scores do.

ABSTRACT 749

Background and aims: Base on clinical trials on elective intubation, American Heart Association has recommended that both cuffed and uncuffed endotracheal tube (ETT) are acceptable for infants and children undergoing intubation. However, there are no published comparative studies regarding emergency intubation in infants and children. Aims: To compare the post-extubation upper airway obstruction (UAO) in children aged < 8 years undergoing emergency intubation with cuffed versus uncuffed ETT. Methods: This was a prospective study. Infants and children aged range between 1 month and 8 years, undergoing emergency intubation were enrolled. Every patient was taken care under the standard guideline of ETT care and extubation. Patient’s demographics, durations of intubation, post-extubation UAO (assessed by upper airway obstruction score(UAOS) at 15,30,45 and 60 minute after extubation), extubation failure due to UAO, medication use for treating UAO and reintubation due to UAO were collected. Results: 60 patients were enrolled, 66.6% of cases were male, with age range of 1-62 months. 18 patients (30%) were intubated with cuffed tube. Comparison between patients undergoing intubation with cuffed and uncuffed tube, there was no difference in demographic data, durations of intubation, rate of extubation failure due to UAO, medication use for treating UAO and rate of reintubation due to UAO. The patients undergoing intubation with cuffed tube had a higher UAO score at 15 minute and 60 minute after extubation and used more muscle relaxant. Conclusions: Emergency intubation with cuffed tube in children aged < 8 years tended to injure upper airway more than uncuffed tube, but this may not result in any major clinical complications.