Yellow Arrow Research Articles

S2162 Hemorrhagic Shock Following a Secretin Stimulating Test

INTRODUCTION: Zollinger-Ellison Syndrome (ZES) is a rare disorder resulting from inappropriate gastrin release, which causes acid hypersecretion and the development of peptic ulcer disease (PUD), severe gastroesophageal reflux, and diarrhea. Diagnosing ZES is challenging in the age of PPIs. Furthermore, discontinuing PPI therapy in patients with suspected ZES can be dangerous and even life-threatening. CASE DESCRIPTION/METHODS: A 44 y.o. male with a history of PUD presented for evaluation for ZES. Due to concern for ZES, a secretin-stimulating test was ordered. One week prior to his test he was instructed to stop his PPI and start Ranitidine 450 mg every 6 hours until 24 hours prior to the test. Immediately following the secretin-stimulating test he presented to the emergency room with nausea, vomiting, and profuse watery diarrhea. A pantoprazole infusion at 8 mg/ hr was started. Overnight he became tachycardic and developed about 400cc of hematemesis. His Hbg dropped from 10.3 g/dL to 7.7 g/dL. He subsequently developed hemorrhagic shock requiring intubation and transfer to the ICU. On EGD, he had a large clot in the second portion of the duodenum. He had hematin in the stomach and over 10 ulcers in the duodenum (Image 1). The pantoprazole infusion was increased to 12 mg/hr with no further recurrence of hemorrhage. The secretin stim test returned, confirming the diagnosis of ZES. This was followed up with an Octreotide scan, which revealed increased radiotracer near the second portion of the duodenum, confirming the location of the gastrinoma (Image 2). DISCUSSION: This case illustrates a rare complication of a patient with suspected ZES undergoing a secretin stimulating test. In patient’s with ZES, a secretin stimulating test causes a paradoxical gastrin response to secretin, likely from secretin receptors on tumor cells (Image 3). Furthermore, PPI withdrawal can cause rebound acid secretion, which can lead to exaggerated acid hypersecretion in patient's with ZES. Our patient had an exaggerated response to secretin leading to acid hypersecretion causing PUD, diarrhea, and hemorrhagic shock. Although complications from a secretin stimulating test are rare, in patients with prior UGIB and high suspicion for ZES, a secretin-stimulating test may need to be performed in a controlled hospitalized setting to minimize complication. This case further illustrates how the diagnosis of ZES has become difficult and whether we need to propose new diagnostic criteria to avoid complications in establishing a diagnosis.Figure 1.: Image 1. Large Clot and Multiple Ulcers (Yellow Arrows) in the Duodenum.Figure 2.: Image 2. Markedly increased radiotracer uptake in a soft tissue nodule medial to the second portion of the duodenum, suggestive of a neuroendocrine tumor (confirmed to be gastrinoma by surgical resection).Figure 3.: Image 3. A. In the antrum, exogenous secretin stimulates gastrin secretion directly and concomitantly inhibits gastrin secretion by stimulating somatostatin (SST) secretion, resulting in little or no gastrin release. B. In patients with ZES, because the gastrinoma does not contain functionally coupled SST cells, the effect of secretin is solely to stimulate gastrin secretion from the tumor.

S2766 Sunburn of the Upper GI Tract: A Case of Metastatic Melanoma of the Stomach and Duodenum

INTRODUCTION: Malignant Melanoma is the fifth most common cancer among the population, and it is known to spread to most organs in the body. Severity of this dastardly disease is predicated based on the stage of the cancer. It is one of the most common cancers that can disseminate to the gastrointestinal tract (GIT). To the best of our knowledge as per literary review, there are fewer than 10 reported case reports discussing cutaneous melanoma with metastasis to both stomach and duodenum simultaneously. This case report aims to add yet another example of this phenomenon to the literature. Here, we present a 49-year old female with biopsy proven melanoma of the back, who presented three years later with nausea and vomiting, and was found to have metastasis to the stomach and duodenum. CASE DESCRIPTION/METHODS: Our patient is a 49-year-old female who presented with chief complaints of intractable nausea and vomiting for eight weeks. She was diagnosed with benign superficial spreading melanoma of the back three years prior. Two years later she had a CT chest suggestive of metastatic disease (stage IV), and she was subsequently started on immunotherapy with nivolumab. Given her persistent nausea and vomiting, an EGD was performed which showed three mucosal polypoid nodules, approximately 5–10 mm with tip ulcerations, in the gastric body and multiple mucosal nodules, approximately 5–10 mm, in the duodenum (Figure 1). Biopsies of these nodules showed S-100 and MART-1 positive metastatic melanoma (Figure 2). Genetic sequencing revealed mutations in the following genes: BRAF V600E, PTEN, PD-L1 28-8. DISCUSSION: This case highlights the severity of melanoma and its negative impact on the GIT. Metastatic melanoma of the GIT is a common postmortem finding, however antemortem diagnosis of this lethal disease is quite rare. The most widely used “melanoma markers” are: S-100, HMB-45, and MART-1/Melan-A [6]. It is also important to appreciate that due to their wide differences in sensitivity and specificity, these markers are often tested together to optimize statistical yield. It has been shown that the incidence of metastatic melanoma of the GIT is as follows: Jejunum and ileum 58%, stomach 26%, colon 22%, duodenum 12%, and the least common being to the rectum and anus. GI symptoms in a melanoma patient should always prompt one to explore further endoscopic investigation. In the event of a negative endoscopy in a melanoma patient, one should consider a capsule endoscopy to ensure complete examination of the GIT.Figure 1a.: Mucosal nodules seen in duodenum.Figure 1b.: Mucosal nodule seen in gastric body.Figure 2.: Gastric nodule seen at 100x, stained MART-1 positive (brown). Metastatic infiltration of glands seen (yellow arrows).

A 73-Year-Old With a Linear Rash

A 73-year-old man with a history of bilateral hip replacements developed a unilateral, asymptomatic skin eruption on his left buttock 3 months after a left hip revision. Over the ensuing 3 years, he noticed mild irritation with heat exposure. Hydrocortisone 1% cream provided no benefit. Skin examination revealed linear pink to brown papules with overlying scale, which did not involve his previous surgical scar site (Figure 1). The clinical differential diagnosis included linear lichen planus, lichen striatus, persistent postherpetic granulomatous skin eruption, or other linear skin entities. Punch biopsy showed acantholytic dyskeratosis. A diagnosis of segmental Darier disease (DD) was made (Figure 2).Figure 2Histopathology of the linear rash showed (A) focal acantholysis (black arrows) within the epidermis. B, Acantholysis is occurring just above the basal layer of the epidermis (yellow arrow). There is dyskeratosis with characteristic “corp ronds” (long black arrow) and “grains” (short black arrow). (Hematoxylin and eosin stain [A] 10x original magnification, [B] 20x original magnification.)View Large Image Figure ViewerDownload Hi-res image Download (PPT) DD, a disease of keratinocyte adhesion, presents with grouped keratotic papules that are aggravated by heat and sweating and tends to develop during the third to fourth decades.1Burge S. Wilkinson J. Darier-White disease: a review of the clinical features in 163 patients.J Am Acad Dermatol. 1992; 27: 40-50Abstract Full Text PDF PubMed Google Scholar DD affects the body symmetrically. Segmental DD, however, presents with lesions arranged along the lines of Blaschko (segmental distribution). Diagnosis may be delayed because of the rarity of this entity. DD is an autosomal dominant genodermatosis caused by germline mutations in the ATP2A2 gene, which causes haploinsufficiency of epidermal calcium ATPase.2Sartori-Valinotti J. Peters M. Wieland C. Segmental type 1 Darier disease: a case series highlighting late-onset disease.Br J Dermatol. 2015; 173: 587-589Crossref PubMed Scopus (6) Google Scholar Segmental DD is thought to be caused by genetic mosaicism of the same gene. This mutation leads to keratinocyte discohesion and acantholytic dyskeratosis (rounding up and separation of individual keratinocytes, with accompanying abnormal keratinization), features that can be observed microscopically with skin biopsy (Figure 2).2Sartori-Valinotti J. Peters M. Wieland C. Segmental type 1 Darier disease: a case series highlighting late-onset disease.Br J Dermatol. 2015; 173: 587-589Crossref PubMed Scopus (6) Google Scholar, 3Harboe T. Willems P. Jespergaard C. Mølgaard M. Sørensen F. Bisgaard M. Mosaicism in segmental Darier disease: an in-depth molecular analysis quantifying proportions of mutated alleles in various tissues.Dermatology. 2011; 222: 292-296Crossref PubMed Scopus (15) Google Scholar, 4Pels I. Goodman M. Criteria for the histologic diagnosis of keratosis follicularis (Darier): report of a case with vesiculation.Arch Derm Syphilol. 1939; 39: 438-455Crossref Scopus (7) Google Scholar DD has a chronic course, and the goal of treatment is to limit exacerbations and prevent secondary infections.5Vogt K. Lohse C. El-Azhary R. et al.Kaposi varicelliform eruption in patients with Darier disease: a 20-year retrospective study.J Am Acad Dermatol. 2015; 72: 481-484Abstract Full Text Full Text PDF PubMed Google Scholar

S2491 Small Duct Primary Sclerosing Cholangitis: An Atypical Presentation

INTRODUCTION: Primary sclerosing cholangitis (PSC) is a chronic progressive disease of the liver and biliary tract causing cholestasis, fibrosis, and strictures in intra and extrahepatic bile ducts. Patients are often asymptomatic, but as the disease progress, complications occur and include: recurrent cholangitis, portal hypertension, cirrhosis of the biliary tract, end-stage liver disease, and hepatobiliary malignancies, namely cholangiocarcinoma. Within the entity of PSC, there are two distinct variants: small duct PSC and large duct PSC. Here we present a case of small duct PSC presenting atypically with chronic portal vein thrombosis and a hilar mass. CASE DESCRIPTION/METHODS: 36- year old Pakistani man presented with right upper quadrant abdominal pain, jaundice, and fever. He reported a history of chronic abdominal pain and recurrent jaundice, as well as chronic portal vein thrombosis (PVT) since childhood. The patient was recently hospitalized in another institute for the same complaint for which he had a Computerized tomography (CT) of the abdomen that revealed marked splenomegaly together with evidence of portal vein occlusion with cavernous transformation as well as Intrahepatic biliary ductal dilation with a transition in the common hepatic duct and a hilar mass. The patient underwent endoscopic retrograde cholangiography (ERC) with biopsies obtained through cholangioscopy that were unremarkable. Liver biopsy showed findings consistent with primary sclerosing cholangitis with acute cholangitis and changes secondary to portal vein thrombosis. DISCUSSION: Primary sclerosing cholangitis is a chronic, incurable disease in which the liver and biliary tract become fibrosed, and strictures form in the intra and extrahepatic biliary ducts causing obstruction, portal hypertension, and eventual liver cirrhosis necessitating a liver transplant. MRC is the most frequently used diagnostic tool due to its high specificity and sensitivity. Although ERC is more sensitive, there are added risks and complications (i.e., pancreatitis and bacterial cholangitis) with this technique. When ERC is performed, findings typically include multifocal short annular strictures, which create a "beaded" pattern. Although most patients are shown to have intra and extrahepatic bile duct involvement, a small subset presents with only intra or extrahepatic bile duct involvement. Only a few small duct PSC cases were reported in the literature, and it rarely presents with an inflammatory mass as well as PVT, as in our case.Figure 1.: Portal fibrosis with mild to focal moderate ductular reaction, accompanied by neutrophils.Figure 2.: A Coronal contrast-enhanced CT image through the abdomen shows intrahepatic beading (red arrow) with intervening sites of alternating strictures, mildly dilated, and normal ducts. There is compensatory hypertrophy of the right lobe and caudate lobe of the liver (green arrows).Figure 3.: A Coronal MRCP Image through the liver shows multiple multifocal diffuse intrahepatic and extrahepatic strictures (red arrows) and severely dilated intrahepatic ducts (blue arrows), with a branching-tree appearance. There is extrahepatic beading with intervening sites of a normal, narrow stricture (long red arrow), and mildly dilated extrahepatic ducts (yellow arrow).

Liquid Thermo-Responsive Smart Window Derived from Hydrogel

Summary Buildings account for 40% of global energy consumption, while windows are the least energy-efficient part of buildings. Conventional smart windows only regulate solar transmission. For the first time, we developed high thermal energy storage thermo-responsive smart window (HTEST smart window) by trapping the hydrogel-derived liquid within glasses. The excellent thermo-responsive optical property (90% of luminous transmittance and 68.1% solar modulation) together with outstanding specific heat capacity of liquid gives the HTEST smart window excellent energy conservation performance. Simulations suggested that HTEST window can cut off 44.6% heating, ventilation, and air-conditioning (HVAC) energy consumption compared with the normal glass in Singapore. In outdoor demonstrations, the HTEST smart window showed promising energy-saving performance in summer daytime. Compared with conventional energy-saving glasses, which need expensive equipment, the thermo-responsive liquid-trapped structure offers a disruptive strategy of easy fabrication, good uniformity, and scalability, together with soundproof functionality that opens an avenue for energy-saving buildings and greenhouses.

Heteroleptic Tin-Antimony Sulfoiodide for Stable and Lead-free Solar Cells

Summary The quaternary chalcogenide halides of group IV and V elements have attracted much attention due to their interesting semiconducting properties as well as a suitable band gap for solar cells. Here, for the first time, we report on solar cells using tin-antimony sulfoiodide (Sn2SbS2I3). Sn2SbS2I3 solar cells were fabricated using a chemical single-step deposition process with a solution containing a SbCl3-thiourea complex and SnI2 with the configuration of TiO2 and poly[2,6-(4,4-bis(2-ethylhexyl)-4H-cyclopenta[2,1-b;3,4-b′]dithiophene)-alt-4,7-(2,1,3-enzothiadiazole)] as the electron- and hole-transporting layers, respectively. The best-performing cell exhibits a power conversion efficiency of 4.04% under the illumination of standard AM 1.5G conditions (100 mW cm−2). These unencapsulated cells exhibited good stabilities at 80% relative humidity, 85°C in air, and under illumination, respectively. These results provide guidelines for fabrication of lead-free heteroleptic perovskite solar cells by hosting divalent or combinations of monovalent and trivalent metal cations.

Into the red zone: behind the mask of a cardiology nurse fighting COVID-19

Into the red zone: behind the mask of a cardiology nurse fighting COVID-19

Driver Understanding of the Flashing Yellow Arrow and Dynamic No Turn on Red Sign for Right Turn

Driver Understanding of the Flashing Yellow Arrow and Dynamic No Turn on Red Sign for Right Turn

A case of inverted serrated polyp that mimics a submucosal tumor

A 68-year-old woman underwent colonoscopy because of abdominal discomfort and changing of bowel movements for half a year. A submucosal protruded lesion, 4 mm × 5 mm, with smooth and intact cover mucosa was found at the rectum 4 cm from the anal margin (A). EUS with a miniprobe revealed a heterogenously hyperechoic lesion with clear margins (B, yellow arrow). The lesion was mainly located between the mucosal and submucosal layers, with a maximum size 3.8 × 4.5 mm in diameter. A thin layer of submucosal structure existed beneath the lesion (B, yellow arrow). The physical examination, laboratory examinations, and abdominal and pelvic CT revealed no remarkable findings. Endoscopic submucosal dissection (ESD) was recommended, and the lesion was removed en bloc. Pathologic examination revealed serrated intestinal mucosa within the muscularis mucosal layer, which was consistent with inverted serrated polyps. The lesion also demonstrated the characteristics of low-grade intraepithelial neoplasia. Genetic testing indicated the existence of a BRAF gene mutation. Histopathologic analysis showed the serrated tubular features (C, black arrows) of this lesion and a small area of defective muscularis mucosae (D, yellow box) on top of the protrusion.

Removing top leaves increases yield and nutrient uptake in maize plants

Intraspecific competition for light affects nutrient uptake of maize, especially during the seed filling phase (from the blistering-stage to physiological-maturity). Partial leaf removal only affects the top leaves and improves the light-environment, which could then enhance nutrient uptake during the seed filling phase. However, there is a shortage of quantitative information on the yield effects of such a management measure. A 3-year field trial was conducted to evaluate the impact of different leaf removal treatments (no removal of leaves (D0: control), removal of two leaves (D2), removal of four leaves (D4), and removal of six leaves (D6) from maize-canopy) on total dry matter accumulation, and nitrogen, phosphorus, and potassium uptake at the blistering-stage and physiological-maturity, plus seed number per plant, seed weight, and seed yield at physiological maturity. Compared to D0, at physiological-maturity, D2 significantly increased total dry matter accumulation (by 9%), and uptake of nitrogen (by 5%), phosphorus (by 10%), and potassium (by 4%); while excessive leaf removal treatments considerably reduced dry matter accumulation and nutrient uptake. Importantly, during the seed filling phase of maize, treatment D2 significantly enhanced the uptake of nitrogen, phosphorus, and potassium by 76%, 40%, and 65%, respectively, compared to control. Treatment D2 increased seed number per plant (by 6.4%, from 448 under D0 to 477 in D2) and seed weight (by 5.7%). Relative to control, maize in D2 had 12%, 14%, and 11%, higher seed-yields in 2017, 2018, and 2019, respectively, and it also improved the economic profit when taking into account labor costs. Graphical representation of changes in light transmittance, photosynthesis, nutrient uptake, carbohydrate, and dry matter accumulation in maize plants as affected by different leaf removal treatments. Treatment codes represent no defoliation (D0: control), removal of two leaves (D2), removal of four leaves (D4), and removal of six leaves (D6) from the top of maize canopy. Yellow and green arrows show the light environment and leaf area of maize plants. The black arrows represent the regulating directions of leaf removal treatments on maize growth and development in this paper. The graphical abstract clearly demonstrates the significant improvement of optimum leaf removal treatment (D2) as compared to control (D0). The red and blue arrows show the relevant increase and decrease of the mentioned components between the optimal leaf removal and control.

Tríada de Rigler


 Paciente de 68 años, sin antecedentes quirúrgicos.
 Ingresó a Emergencia con cuadro clínico de oclusión intestinal. Se solicitó radiografía simple de abdomen (solamente se obtuvo en decúbito), observándose la presencia de la tríada radiológica de Rigler, patognomónica del ileo biliar.
 Se señalan los 3 elementos: asas de delgado dilatadas (flecha negra), aerobilia (flecha blanca) y el cálculo calcificado ectópico en la fosa ilíaca derecha (flecha amarilla).
 El íleo biliar es la oclusión intestinal como consecuencia de la migración de un cálculo biliar a través de una fístula bilio-digestiva y su impactación, frecuentemente a nivel de la válvula ileo-cecal. Habitualmente se trata de una fístula colecisto-duodenal, aunque también puede tratarse de una fístula colecisto-colónica.
 El cuadro clínico clásicamente descrito es el de una oclusión intermitente, siendo más frecuente en pacientes añosos, con larga historia de litiasis biliar sintomática.

Left turn crash risk analysis: Development of a microsimulation modeling approach

The use of traffic simulation to analyze complex transportation issues has become common practice in transportation engineering. The further application of microsimulation to the analysis of traffic safety in a systematic, rigorous, and controlled fashion is becoming increasingly viable as simulation models improve and tools for quantifying surrogate safety measures become readily accessible. Using a calibrated traffic microsimulation model and surrogate safety assessment model analysis, this paper examined how the risk for left-turn crashes varied as traffic conditions changed at a signalized intersection.Safety impacts for 750 unique combinations of intersection geometry, traffic, and signal timing parameters were simulated and the number of left-turn conflicts per hour noted. Results of the simulation analyses were used to develop statistical models that expressed the risk of occurrence of a left-turn crash during a given hour as a function of the left-turn phasing mode and prevailing conditions during that hour. The study was motivated by the recent widespread application of the flashing yellow arrow (FYA) which provides the opportunity to vary left-turn phasing mode by time of day—potentially leading to more efficient traffic operations at signalized intersections. In this regard, the study addresses a basic need for tools that predict how the risk for left-turn crashes might vary at a more disaggregated level than that provided by existing crash prediction models, which typically predict yearly totals of left-turn crashes, often based on annual average daily traffic volumes. Potential application of the model to the implementation of a time-variable safety-based left-turn phasing selection scheme using FYA was successfully demonstrated.

THU0601 REFRACTORY ACUTE CORONARY SYNDROME AND CARDIOGENIC SHOCK AS ATYPICAL ONSET OF EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS

Background:Eosinophilic Granulomatosis with Polyangiitis (EGPA) is an ANCA-associated vasculitis, characterized by eosinophilic infiltration in tissues, intravascular and extravascular granuloma formation. It is a rare disease, affecting between 0 and 4 per million population per year. The cardiac involvement occurs in 15-60% of EGPA patients (generally ANCA-negative); it is often insidious, underestimated and it has a poor prognosis. The disease usually shows a prodromal phase characterized by asthma and allergic manifestations.Objectives:We report the case of a young patient with acute coronary syndrome (ACS) complicated by cardiogenic shock as the first manifestation of EGPA.Methods:A 36 year old Indian male patient, with a previous history of asthma, rhinitis, Raynaud syndrome and allergy to ketoprofen, presented to the emergency department with a complaint of chest pain and dyspnea. Cardiac troponin was elevated and he was admitted to intensive care unit with a diagnosis of ACS. The patient conditions rapidly deteriorated due to acute cardiogenic shock and an urgent coronary angiogram was performed. An occlusion of the left main coronary artery was treated with angioplasty and two drug-eluting stents. Echocardiography showed severe left ventricular dysfunction requiring inotropic and intra-aortic balloon pump support. A mild dermatitis after salicylic acid administration resolved with intravenous hydrocortisone 1 g. The thrombophilia screening was negative, as well as cardiovascular risk factors. Over the next days, the clinical conditions rapidly improved with recovery of normal ventricular function on discharge. However, two weeks later he was readmitted with recurrent mandibular and chest pain. Troponin levels were elevated and fluctuated, suggesting recurrent ischemic events. Repeated ECG during angina crisis showed ischemic alterations in different coronary territories. The coronary angiogram detected coronary vasospasm of the circumflex artery, reversible after nitroglycerin (Figure 1). Nitroglycerin and calcium channel blockers were initiated, but did not resolve the vasospastic angina crisis, occurring daily. Laboratory tests revealed eosinophilia (4390 cells/mcl), increased C reactive protein (9.4 mg/l) and positive antinuclear antibodies (1:320). The other serological and immunological tests were negative, including MPO-ANCA and PR3-ANCA. An abdomen and chest CT scan was negative.Figure 1.Coronary angiogram showing coronary vasospasm in the left circumflex artery (panel A, yellow arrow), reversible after nytroglicerin infusion (panel B, yellow arrow)Results:The eosinophilia and the history of asthma rose the suspect of EGPA vasculitis. The patient was treated with intravenous methylprednisolone 250 mg once daily for 3 days, followed by oral prednisone 1 mg/kg/day, with rapid and complete resolution of the recurrent angina episodes. Intravenous cyclophosphamide 10 mg/kg was administered every 2 weeks for 2 times, then 12 mg/kg every 4 weeks. Oral corticosteroid was tapered, with the persistence of a complete remission of the symptoms, after 2 months of immunosuppressive therapy.Conclusion:Coronary involvement in EGPA can mimic atherosclerotic artery disease and can be life threatening, if not promptly recognized. An accurate medical history and complete serological and immunological tests are crucial to detect an atypical onset of EGPA, prompting early immunosuppressive therapy which is pivotal for the patient survival.

Mo1287 LIGATION-ASSISTED ENDOSCOPIC MUCOSAL RESECTION FOR ESOPHAGEAL GRANULAR CELL TUMORS IS SAFE AND EFFECTIVE

Esophageal granular cell tumors (GCTs) are usually asymptomatic and incidentally found, but have malignant potential. Given this, resection is recommended, but optimal technique remains unknown. We present the largest US series of dedicated endoscopic resection using band ligation (EMR-B) of esophageal GCTs. We performed a retrospective analysis, identifying patients diagnosed with esophageal GCTs between 2002-2019 using a prospectively-collected pathology database at our tertiary care referral center. We included those patients who underwent EMR-B of esophageal GCT using the Duette Multi-Band Mucosectomy system. Medical records were queried for patient demographics, endoscopic and pathologic findings, resection technique, adverse events, and follow up. Among 21 patients, median age was 39 years, 16 (76%) were female. Eight (38%) had preceding symptoms attributable to esophageal GCT. Upon endoscopic evaluation, 12 (57%) GCTs were found in the distal esophagus and 4 (19%) in the mid esophagus. Median lesion size was 7mm (IQR 4-8mm). The largest lesion was 12mm. Endoscopic images of esophageal GCTs are presented in Figure 1A-C. Endoscopic ultrasound was used in 15 (71%) cases. Endosonographic appearance of a granular cell tumor is presented in Figure 2. Resection was performed in all 21 patients. Submucosal lift with normal saline was used in 9 (43%). A total of 20/21 (95%) had en bloc resection upon pathologic examination. Post-resection endoscopic appearance is depicted in Figure 1D. The case without complete resection upon review was a 7mm distal esophageal GCT, resected using saline lift followed by EMR. EUS was not used. Upon pathologic evaluation, tumor was focally present at margins. Repeat endoscopy with biopsies in 6 months showed no residual tumor. No patients experienced bleeding, perforation, or stricturing. No patients have had known recurrence of esophageal GCT. EMR-B of esophageal GCTs achieves complete histopathologic resection with minimal adverse events. EMR-B is safe and effective and seems prudent compared with observation for what could be an aggressive and malignant tumor. EMR-B should be considered first-line therapy for esophageal GCT up to 12 mm in diameter.Figure 2Classic EUS appearance of a granular cell tumor (indicated by red arrow), with surrounding submucosal layer (blue dashed line) and muscularis layer (yellow arrow)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Online Survey of Driver Comprehension of the Flashing Yellow Arrow for Right-Turn Signal Indications

This paper presents the results of an online survey of licensed driver comprehension of the right-turn signal displays with a focus on the flashing yellow arrow (FYA) and also including the circular green and red and red arrow. Recruitment postcards were mailed to a random sample of 9,872 residents in Oregon. The online survey yielded 399 responses. The open-ended responses were coded for comprehension and analyzed. The results suggest that FYA for right turns is well understood by Oregon drivers despite its current novelty (only two locations at the time of the research). Importantly, survey respondents were more likely to recognize the yielding requirement of the permissive movement and associate the yielding with pedestrians with the FYA over the circular green (CG) display. The research also confirmed that the expected driver response to the red arrow display for right turns is not well understood (only 52% of the respondents correctly stated the expected driver response). Binary logistic regression modeling revealed that the driver’s age and their educational level were significant factors in comprehension.

Hybrid percutaneous technique guided by ultrasound and fluoroscopy: anatomical bases for sensitive glenohumeral joint neuroablative denervation

IntroductionSince John Hilton (1873), an anatomist physician and British surgeon, joint sensitive innervation had been studied. Understanding this anatomy allows neuroablative joint denervation (NJD) through percutaneous access to the treatment of joint pain in cases of osteoarthritis and shoulder capsulitis, for examples. The shoulder has a rich sensory innervation from mixed nerves, with motor components. Thus, for the NJD the approach should be guided to the sensitive branches of the nerves, avoiding motor sequelae. Suprascapular (SSN), axillary (AN) and lateral pectoral (PLN) nerves are responsible for 98% of sensory innervation of the glenohumeral joint, then represent the most important anatomical target in NDJ procedure.ObjectiveThe aim of this study is to show the anatomical and radiological landmarks for NDJ procedure.Method Dissection of SSN, AN and PLN nerves sensitive branches. Definition of anatomical landmarks of SSN, AN and PLN nerves sensitive branches, by fluoroscopy (FC) and ultrasound (US). NJD was performed on the glenohumeral joint of 8 patients, by cooled radiofrequency (CRF), through percutaneous anatomical accesses using hybrid technique, guided by US and the positioning of the cannulas by bone anatomical references were confirmed by FC. The 8 patients presented joint pain without muscle or tendinous components and without indication of surgical therapy. The visual analogue scale (VAS) and shoulder disability index test were applied before and after the procedure during 6 months. (Figure 1, 2)ResultsThe dissection of SSN, AN and PLN nerves sensitive branches showed the anatomical topography of the sensitive area of the glenohumeral joint innervation. Those anatomical information supported the NDJ procedure in all the 8 patients, were performed feasible and safely, using the hybrid technique (FC and US).Discussion and ConclusionSupported by the anatomical results, the steps of the NDJ procedure were established. The SSN, after passing through the spinoglenoid notch, sends laterally articular sensory branches. Thus, guided by US, the needle tip was placed at the lateral extreme point from the glenoid notch without joint or labrum injury. The AN sends sensory branches after passing through the greater tuberosity inferior margin of the humerus, accessed by US locating the tip of the needle cranially to the posterior humeral circumflex artery and touching the humerus laterally. The PLN sensitive branches go through the caudal and lateral region of the coracoid process, and this area is identified for US guided cannula position. After the cannulas were located, their position was checked by FC, using the bone as reference, and some adjustments could be performed, if necessary. Sensory innervation was properly accessed and NJD procedure was performed without motor innervation damages. Knowledge of anatomical landmarks recognized by dissection or by radiographic or dynamic images such as ultrasound, when combined, can present themselves as tools that contribute to increasing the effectiveness and safety of clinical procedures.Support or Funding Information www.mobissom.com.brA, B, C, D ‐ Suprascapular nerve (SSN); E, F, G, H – Axillary nerve (AN); I, J, K ‐ Lateral pectoral nerve (PL). C, G, J – Ultrasound; D, H, K ‐ Fluoroscopy.1. SSN; 2. M. Infraspinatus1. SSN; 3. Fossa supraspinata; 4. Fossa infraspinataYellow arrow – SSNE. 1. AN (anterior view)F. 1. AN (posterior view); 2. Sensitive branch of ANG. Yellow arrow – NAI. 1. M. pectoralis major; 2. M. pectoralis minor; 3. PL; 4. Sensitive branch of PL.J. Yellow arrow – PLFigure 1Ultrasound.Figure 2

Heterotaxy Syndrome in a Pediatric Cardiac Patient: A Case Report of Rare, Complex Congenital Heart Defects

BackgroundHeterotaxy syndrome, or situs ambiguous, is a multitude of thoracoabdominal congenital irregularities involving organ rearrangements across the body axis. The array of symptoms can be subdivided into either left or right isomerism, which conventionally refers to the anatomy of the designated side presenting bilaterally. While there have been approximately 266 case reports published on heterotaxy syndrome to date, no case report has documented the combination of symptoms seen in our patient, who presents with defects characteristic of both left and right isomerism.PresentationA male infant was delivered early at gestational age 37 weeks and 3 days, due to poor fetal growth. Fetal echocardiogram had been performed prior to delivery and was indicative of complex congenital heart defects, specifically heterotaxy syndrome with dextrocardia, double‐outlet right ventricle with transposed great arteries, a complete atrioventricular canal defect, a large ventricular septal defect and a large common atrium. The suspected defects were confirmed after delivery via echocardiography and cardiac catheterization. Given that heterotaxy can occur by itself or as a secondary feature of another genetic disorder, karyotyping via chromosomal array and chromosomal analysis were performed; however, no chromosomal or genetic abnormalities were identified.Results – Anatomical Features ‐Mirror image dextrocardia with the inferior vena cava and descending aorta located to the left of the spine at the level of the diaphragm ‐There is both a large septum primum and septum secundum defect, which gives rise to essentially a single common atrium, with unrestricted flow across the atrium. The anatomic right atrium is on the patient left, and the anatomic left atrium is on the patient right ‐There are bilateral superior vena cava draining into the anatomic right side of the common atrium is on the patient left. All four pulmonary veins drain into the anatomic left atrium on the patient right. There is also anomalous drainage of the inferior vena cava into the anatomic left atrium is on the patient right ‐The anatomic right ventricular on the patient left gives rise to both the aorta and main pulmonary artery – double‐outlet right ventricle. There is also is transposition of the aorta and main pulmonary artery ‐There is a complete atrioventricular defect with a single common atrioventricular valve with few chordae tendinae attached to the ventricular septum ‐There is severe pulmonary valve stenosis with no appreciable regurgitation. There is no aortic valve stenosis or regurgitation, and the aortic valve is appropriately tri‐leafletConclusionThis form of heterotaxy syndrome partially matches both right and left atrial isomerism. Double‐outlet right ventricle, malposition of the great vessels, and pulmonary and subpulmonary stenosis are typical of right atrial isomerism. In contrast, the common atrioventricular canal defect, bilateral superior vena cava, and anomalous drainage of the inferior vena cava hint at left atrial isomerism. This anatomical case reports highlights the complexity of heart development and highlights the complexity of surgical and long‐term clinical management of heterotaxy syndrome.Cardiac catheterization visualization of dextrocardia and bilateral superior vena cava draining into patients left‐side of common atriumFigure 1Echocardiography visualization of common atrium with small intact septum (yellow arrow), common atrioventricular valve (red arrow), and ventricular septal defect (purple asterisk)Figure 2

Interaction between Autonomous and Microtubule Guidance Systems Controls Cellulose Synthase Trajectories.

The organization of cellulose microfibrils is critical for the strength and growth of plant cell walls. Microtubules have been shown to play a key role in controlling microfibril organization by guiding cellulose synthase complexes [1-4]. However, cellulose synthase trajectories can be maintained when microtubules are removed by drugs, suggesting a separate guidance mechanism is also at play [1, 5, 6]. By slowing down microtubule dynamics, we reveal such a mechanism by showing that cellulose synthase complexes can interact with the trails left by other complexes, causing them to follow the trails or disappear. The stability of the trails, together with the sensitivity of their directions to cellulase treatment, indicates they most likely reflect nascent cellulose microfibrils. Over many hours, this autonomous mechanism alone can lead to a change in the dominant orientation of cellulose synthase trajectories. However, the mechanism can be overridden by the microtubule guidance system. Our findings suggest a dual guidance model, in which an autonomous system, involving interaction between cellulose synthases and microfibrils, can maintain aligned cellulose synthase trajectories, while a microtubule guidance system allows alignments to be steered by environmental and developmental cues.

All-Red Clearance Intervals for Use in the Left-Turn Application of Flashing Yellow Arrows

AbstractIn recent years, agencies across the United States have embraced the implementation of the flashing yellow arrow (FYA) for permissive left turns. Previous research determined that the FYA i...

Safety and Fidelity in Electroconvulsive Therapy (SAFE ECT): A Novel Virtual Reality-Based Training Program in Electroconvulsive Therapy (Phase 1).

Safety and Fidelity in Electroconvulsive Therapy (SAFE ECT): A Novel Virtual Reality-Based Training Program in Electroconvulsive Therapy (Phase 1).