Yellow Arrow Research Articles

Repair of pseudoaneurysm in extra-anatomic aortic arch bypass graft.

Repair of pseudoaneurysm in extra-anatomic aortic arch bypass graft.

Safety and Operational Effectiveness of Protected Only Versus Protected/Permitted Left-Turn Signal Phase

Roadway intersection fatalities account for around 24% of total traffic fatalities each year, with left-turning vehicles associated with most of these crashes. To manage left-turning movements, various left-turn signal phases like protected only (PO), protected/permitted left-turn (PPLT), and flashing yellow arrow (FYA) are currently in use. However, their overall effectiveness has not been well established. The paper evaluates the safety and operational effectiveness of PO over PPLT left-turn signal phase using sample intersections from Louisiana. A total of 151 signalized intersections with uniform left-turn signal phases at all of their approaches were selected. Crash data recorded over five years at those intersections comprising a total of 13,278 crashes, including 1,275 left-turn crashes, were collected. A crash modification factor (CMF) was developed using the negative binomial model (NBM) to assess the safety benefits of PO over PPLT. The Highway Capacity Manual 6th Edition (HCM 6) control delay field measurement technique was used for the operational analysis. The study first developed CMFs for total crashes and only left-turn crashes at various severity levels. CMF of PO over PPLT revealed that PO significantly reduced all severity levels of left-turn crashes by more than 50%, however, it was only able to reduce injury and fatal total crashes. Second, the study found average control delay at PO (50.69 s/vehicle) significantly higher than at PPLT (46.04 s/vehicle). The difference in delay was only significant during the morning peak hour. Overall, from both safety and operation perspectives, the results indicate that PO performs better than PPLT.

Inflammatory Cardiomyopathy: A Multi-modality Imaging Approach For A Timely Diagnosis

Non-ischemic cardiomyopathy (NICM) consists of a heterogeneous group of disorders that result from diverse underlying processes - including infectious, autoimmune, infiltrative, genetic, and otherwise idiopathic. We present a case of inflammatory cardiomyopathy diagnosed by multimodal imaging, including cardiac magnetic resonance (CMR) and positron emission scan with 18F-fluorodeoxyglucose (FDG-PET). A 68-year-old Caucasian male with history of hypertension, hyperlipidemia, chronic kidney disease (stage II), and recent diagnoses of NICM and non-sustained ventricular tachycardia 6 months ago presented to our heart failure clinic to be evaluated for advanced heart failure therapies. CMR showed evidence of non-coronary disease late gadolinium enhancement (LGE) in the basal and mid interventricular septum as well as in both papillary muscles. The LGE extent was 14% of the myocardium. Given results of CMR and rising suspicion for sarcoidosis, our patient underwent FDG-PET, which showed persistent inflammation involving 37% of the left ventricle. The patient underwent endomyocardial biopsy (EMB) of both ventricles at a total of 9 sites using electroanatomic voltage mapping which can identify diseased tissues with low voltage signals. The biopsy results showed minimal focal interstitial edema, but no granulomas or active inflammation. Given the degree of active inflammation on FDG-PET the patient was treated with 3 months of oral prednisone. Subsequent FDG-PET demonstrated complete resolution of inflammation in addition to recovery of ejection fraction from 25% to 49%. This case illustrates the role of FDG-PET resulting in a timely diagnosis even when EMB results were inconclusive. Future studies are needed to determine the outcomes of immunosuppression in these patients. Figure 1. CMR demonstrating late gadolinium enhancement (LGE) in the septum, lateral wall, and the papillary muscles. The yellow arrows point to the areas of LGE. Figure 2. FDG-PET image demonstrating significant active inflammation, correlating to SUV (max) = 3.3 involving 37% of the left ventricle. The yellow arrows point to the areas of increased FDG uptake. Non-ischemic cardiomyopathy (NICM) consists of a heterogeneous group of disorders that result from diverse underlying processes - including infectious, autoimmune, infiltrative, genetic, and otherwise idiopathic. We present a case of inflammatory cardiomyopathy diagnosed by multimodal imaging, including cardiac magnetic resonance (CMR) and positron emission scan with 18F-fluorodeoxyglucose (FDG-PET). A 68-year-old Caucasian male with history of hypertension, hyperlipidemia, chronic kidney disease (stage II), and recent diagnoses of NICM and non-sustained ventricular tachycardia 6 months ago presented to our heart failure clinic to be evaluated for advanced heart failure therapies. CMR showed evidence of non-coronary disease late gadolinium enhancement (LGE) in the basal and mid interventricular septum as well as in both papillary muscles. The LGE extent was 14% of the myocardium. Given results of CMR and rising suspicion for sarcoidosis, our patient underwent FDG-PET, which showed persistent inflammation involving 37% of the left ventricle. The patient underwent endomyocardial biopsy (EMB) of both ventricles at a total of 9 sites using electroanatomic voltage mapping which can identify diseased tissues with low voltage signals. The biopsy results showed minimal focal interstitial edema, but no granulomas or active inflammation. Given the degree of active inflammation on FDG-PET the patient was treated with 3 months of oral prednisone. Subsequent FDG-PET demonstrated complete resolution of inflammation in addition to recovery of ejection fraction from 25% to 49%. This case illustrates the role of FDG-PET resulting in a timely diagnosis even when EMB results were inconclusive. Future studies are needed to determine the outcomes of immunosuppression in these patients. Figure 1. CMR demonstrating late gadolinium enhancement (LGE) in the septum, lateral wall, and the papillary muscles. The yellow arrows point to the areas of LGE. Figure 2. FDG-PET image demonstrating significant active inflammation, correlating to SUV (max) = 3.3 involving 37% of the left ventricle. The yellow arrows point to the areas of increased FDG uptake.

Anterior Spinal Cord Ischemia due to an Acute Aortic Intramural Type B Hematoma

Anterior Spinal Cord Ischemia due to an Acute Aortic Intramural Type B Hematoma

Not Just Blood: Brain Fluid Systems and Their Relevance to Cerebrovascular Diseases.

Not Just Blood: Brain Fluid Systems and Their Relevance to Cerebrovascular Diseases.

Ultrasound-Guided Thoracodorsal Nerve Block for Post-Breast Reconstruction Discomfort.

CASE PRESENTATION A 76-yr-old woman with prediabetes and estrogen receptor–positive breast cancer diagnosed 2 yrs ago underwent a bilateral mastectomy and breast reconstruction with tissue expander and latissimus dorsi flap 1 yr ago. After the procedure, the patient developed constant muscle hyperactivity and a tight band-like feeling in the lateral aspect of the reconstructed breast flap. Subsequently, the tissue expanders were removed without a significant improvement of her symptoms. She denied numbness, tingling, lancinating, electricity-like pain, or pins/needles sensation. She tried physical therapy, a transcutaneous electrical nerve stimulation unit, and oral baclofen without significant relief. Ultrasound-guided thoracodorsal nerve block with 1% lidocaine and 0.25% bupivacaine was performed with consideration for the positive motor symptoms and lack of cutaneous sensory symptoms in the distribution of the latissimus dorsi flap, as illustrated in the Figures 1 and 2. The patient reported 100% relief of symptoms for 5 days and approximately 50% relief of symptoms for 2 wks. Repeated ultrasound-guided injection as per the patient’s request reproduced a similar pattern of symptom relief.FIGURE 1: Ultrasonographic images of the thoracodorsal nerve (yellow arrow) and surrounding structures using an 8- to 15-MHz linear array probe.FIGURE 2: Ultrasonographic-guided perineural block of thoracodorsal nerve using in-plane approach.More than 250,000 women were diagnosed with breast cancer in 2017 and more than 100,000 breast reconstruction procedures were performed.1,2 Latissimus dorsi flaps are frequently used as an option for salvage reconstruction given presence of healthy muscle tissue and consistent vascular supply. As high as 10% of patients who have latissimus dorsi flaps complain of persistent postsurgical pain lasting months or years. Complaints after latissimus dorsi–based reconstruction include abnormal muscle movement, breast deformity, significant muscle tone at rest, and pain, as illustrated in this case.1 Regarding peripheral nerve lesions, intercostobrachial cutaneous, intercostal, and long thoracic nerve injuries are well-known contributors to post–breast surgery pain syndrome.3,4 The thoracodorsal nerve is often underrecognized as the culprit for post–breast surgery pain syndrome. Surgical denervation of the thoracodorsal nerve was proposed but remains controversial because of potential detriments to the reconstruction.1 This case highlights the diagnostic and therapeutic role of ultrasound-guided thoracodorsal nerve blocks for the evaluation and management of post–breast surgery pain and discomfort.

Two-Dimensional Metal–Organic Frameworks with Unique Oriented Layers for Oxygen Reduction Reaction: Tailoring the Activity through Exposed Crystal Facets

Two-Dimensional Metal–Organic Frameworks with Unique Oriented Layers for Oxygen Reduction Reaction: Tailoring the Activity through Exposed Crystal Facets

Machine learning-based phenotyping and risk assessment of hypertrophic cardiomyopathy - linking ECGs, morphology and genotypes

Abstract Funding Acknowledgements Type of funding sources: None. Background Integrating clinical data to distinguish hypertrophic cardiomyopathy (HCM) phenotypes is relevant in clinical practice. Machine learning (ML) can help - deep learning (DL) networks can automate detection and segmentation of 12-lead electrocardiograms (ECGs), whereas unsupervised learning can group patients to compare ECG, imaging and genetic characteristics. The aim is to automate ECG morphology analysis from all 12 ECG leads and multiple beats, and relate this to HCM genotypes and imaging phenotypes. Methods The single-center cohort included phenotype- and genotype-positive (G+) HCM patients (n = 104) and their phenotype-negative relatives (n = 50, 42% G+). All patients had a digital 12-lead ECG, echocardiography, and a magnetic resonance (CMR) study performed. The workflow is shown in Fig 1. A U-Net DL network was used for ECG delineation (P, QRS, T onsets/offsets) for all cardiac cycles. Three heartbeats were selected for each patient based on their morphology, with the aim of capturing beat-to-beat variability. An unsupervised representation learning algorithm was used to fuse ECG data and assess inter-patient similarities. Patients were clustered based on similarities of ECG biomarkers, and compared with regards to genotypes, family history of sudden cardiac death (SCD), history of ventricular arrhythmias/syncope/aborted SCD, implanted defibrillators (ICD), left ventricular (LV) obstruction, maximal wall thickness, late gadolinium enhancement (LGE), and HCM risk-SCD score. Results ML based on ECG biomarkers provided a good separation of HCM patients and relatives (Fig 1A), also showing G- and patients with variants of uncertain significance grouping together (Fig 1B). Clustering resulted in 6 ECG phenogroups (C1-6). C1 and 2 were related to less comorbidities, cardiac remodeling, and HCM risk score, capturing the majority of G- patients. C3 and 4 were related to LV obstruction – where C4 consisted of symptomatic patients with high ICD implantation and event rates, high LGE, and impaired systolic function. C5 captured patients with high comorbidities, extremely remodeled hearts, but no obstruction, whereas C6 patients with positive family history and high arrhythmic events (Fig 1C, Table 1). The average ECG morphology is shown side-by-side for C1 and C5 in Fig 1D – negative T waves, increased R/S wave amplitudes, left axis deviation (LAD) and ST elevation can be recognized as macro-biomarkers in C5 (yellow arrows). Conclusion ML can automate the analysis of complex clinical data, simultaneously taking into account the morphology of all ECG components in all 12-leads, throughout multiple beats, compare it with clinical and imaging data, and identify clinically sensible phenogroups as validated by structural and functional findings, as well as with genotypes and clinical information. Automated and comprehensive cardiac data analysis has diagnostic and research potential to help screen populations and phenotype disease etiologies. Abstract Figure 1: analysis pipeline Abstract Table 1: clinical variables

If echo or magnetic resonance are not enough to assess a patient with congenital heart disease, think of ECG gated computed tomography. Case series from a second level hospital

Abstract Funding Acknowledgements Type of funding sources: None. Background Congenital heart disease (CHD) is evaluated by echocardiogram, and if doubts, there may be necessary other exams, generally magnetic resonance (MRI). Due to radiation concerns, computed tomography (CT) is seldom performed. Depending of different cardiac procedures, radiation exposure to the patients varies, ranged from almost 4 mSv approx. for coronariography alone to 15 mSv approx. if stenting and ventriculography are added. ECG-gated CT can be used in cases of CHD because of its better spatial resolution if other examinations are not enough. Methods We reviewed ECG-gated CT performed at our institution to evaluate patients with CHD (suspected or previously known). Characteristics of the patients and the exams were reported, including other cardiovascular or extracardiac findings. Results There were 5 exams in 4 patients, all of them with contrast. 2 patients were women, 1 of them with two exams (cases No 4 and 5). Mean age was 45.4 years (range 17-59). CT was chosen due to better spatial resolution (including 1 patient which previous MRI was inconclusive), except in one patient, that was performed because of cardiac device that contraindicated MRI. This patient had repeated exams. All of them were in sinusal rhythm. The patient with repeated exams was previously diagnosed of CHD, whereas, in the rest of cases the final diagnosis was made by CT. 3 examinations were retrospective. Coronary arteries were also evaluated in 3 cases (in all prospective studies and one retrospective). Mean radiation exposure was 6.22 mSv (1.2 to 10.7). In prospective studies, it was 1.85 mSv (1.6 and 2.1 mSv) and in retrospective ones were 9.13 mSv (8.2 to 10.7 mSv). There were no complications. In all cases, other cardiovascular findings other than CHD were reported. In 3 cases, other extracardiovascular findings were noted. Characteristics of patients are listed in figure 1 and images from the studies are shown in figure 2. Yellow arrows show the congenital defects. Conclusions Although patients with congenital heart disease are generally evaluated by other imaging techniques, they can be evaluated by ECG-gated CT if necessary, with similar radiation exposure to other cardiac interventional procedures, and coronary angiography and other cardiovascular or extravascular findings can also be assessed. Abstract Table: Characteristics of patients Abstract Figure. Images from exams

Magnetic resonance imaging of Joubert syndrome associated with Dandy-Walker malformation: pathognomonic imaging.

An 8-month-old infant was referred to our institution to investigate psychomotor retardation. The clinical finding found ataxia. An MRI was indicated and performed. Sequence T1 in the axial and coronal plane (A,B) revealed a long thick superior cerebellar peduncle (Yellow arrow) and an interpeduncular fossa (White arrow), reminding the molar tooth sign (MTS). Furthermore, sequence T1 in the sagittal plane (C) showed hypoplasia of the vermis (Red arrow) and global ascension of the tentorium cerebelli (Red star). Finally, the diagnostic of Joubert syndrome associated with Dandy walker malformation was confirmed by pathognomonic imaging. The family patient was informed and received the best medical assistance. Joubert syndrome is a rare recessive ciliopathy, diagnosed by a triad in cross-sectional imaging (Scanner / MRI). (1) thick and straight superior cerebellar peduncles, (2) deep interpeduncular fossa, and (3) hypoplastic/dysplastic vermis forming the

Diagnostic and Therapeutic Utility of Onychoscopy in Subungual Foreign Body.

Dermoscopy is a simple, non-invasive procedure used commonly in the diagnosis of various pigmentary, infectious and papulosquamous disorders. Dermoscopy may also allow identification of indwelling cutaneous foreign bodies with far greater accuracy than with the naked eye and its removal.[1] A 24-year-old female presented with pain over her left index finger for three days. There was a history of trivial trauma with metal pipe brushing the fingertip. There was no discharge or fever. Examination revealed localized brown discoloration of the anterior nail suggestive of subungual hematoma [Figure 1]. She was managed conservatively but reported with persisting pain after two days. An indwelling subungual foreign body was suspected.Figure 1: Brown discoloration of the tip of nail suggestive of subungual hematomaVideo onychoscopy of the nail was performed (Medicam Fotofinder II), which revealed homogenous brown discoloration with some peripheral streaking [Figure 2]. There was also a distinct dark brown discoloration with straight edges and protruding tip suggestive of the presence of a foreign body. Onychoscopy enabled visualization and localization of the foreign body, which was otherwise not seen by the naked eye. The foreign body was gradually removed using a 26-gauge-needle and iris forceps under onychoscopic visualization [Figure 2].Figure 2: Contact Dermoscopy with FotoFinder II Medicam at 70X magnification showing homogenous brown discoloration (black arrow), peripheral streaking (yellow arrow) suggestive of subungual hematoma with distinct dark brown discoloration (green arrow) and protruding tip (blue arrow) suggestive of foreign body. The inset image shows the extracted foreign bodySubungual hematoma may present with various onychoscopic patterns.[2] The foreign body should be distinguished onychoscopically from hematoma by the sharp edges and protruding tip. Performing onychoscopy assisted the diagnosis and smooth extirpation of the foreign body in our case as a safe alternative to surgical intervention. To the best of our knowledge, this is the first case of onychoscopy of a subungual foreign body to be reported. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Phacomatosis pigmentokeratotica.

A 20 yr old female† presented to the department of Dermatology and Sexually Transmitted Diseases, Safdarjung Hospital, New Delhi, India, in February 2019, with progressive asymptomatic brownish-black lesions on the face, neck and chest since birth. Examination revealed yellowish-brown verrucous papules and plaques arranged linearly along the lines of Blaschko on the forehead, nose, right pre-auricular area, neck and chest, suggestive of naevus sebaceous (Fig. 1A and B). Light brown-coloured patch of size 10 × 7 cm with overlying dark brown-to-black macules and papules, suggestive of speckled lentiginous naevus, was present on the left side of the face, extending from forehead to mandibular region (Fig. 2). Biochemical, ophthalmic, neurological and skeletal evaluation revealed no abnormality. Histopathological examination from verrucous plaque showed hyperkeratosis, acanthosis, papillomatosis and follicular plugging in the epidermis. Dermis showed increased number of enlarged sebaceous glands placed abnormally higher, with a few immature hair structures and dilated apocrine glands (Fig. 3). These features were consistent with naevus sebaceous.Fig. 1: (A) Yellowish-brown verrucous papules and plaques arranged linearly along lines of Blaschko, suggestive of naevus sebaceous. (B) Naevus sebaceous over the right pre-auricular area (inset showing similar lesion over anterior chest).Fig. 2: Light brown-coloured patch of size 10 × 7 cm with overlying dark brown-to-black macules and papules, suggestive of speckled lentiginous naevus.Fig. 3: Hyperkeratotic, acanthotic and papillomatous epidermis with follicular plugging. There are an increased number of closely set large sebaceous glands (black arrow) that are placed abnormally higher in the dermis along with a few immature hair structures (yellow arrow). Lower dermis shows dilated apocrine glands (blue arrow) (Hematoxylin and eosin, x100).Phacomatosis pigmentokeratotica (PPK) is a rare form of epidermal naevus syndrome characterized by coexistence of an organoid naevus with sebaceous differentiation along Blaschko’s lines and speckled lentiginous naevus in a checkerboard pattern. Our case represents a rare form of PPK without any extra-cutaneous features. Patients with PPK are at risk of developing basal cell carcinoma and syringocystadenoma papilliferum in naevus sebaceous and malignant melanoma in speckled lentiginous naevus; hence, regular follow up is necessary. The patient was planned for serial surgical excision of naevus sebaceous. Acknowledgment: Authors acknowledge Dr Shruti Sharma, Scientist D, National Institute of Pathology, Indian Council of Medical Research, New Delhi, for providing histopathologic image. Conflicts of Interest: None.

World Health Organization meningioma grade II.

We are presenting to you a magnetic resonance imaging (MRI) finding of a 65 years old female who presented to us with a complains of headache which was over the frontal region and on and off in nature. The patient also complains of imbalance during walking andtingling, numbness and weakness in the left upper and lower extremity. She gives a history of 2 episodes of seizures. Contrast magnetic resonance imaging findings revealed a well-defined extra-axial lesion measuring approximately 4.1*3.9cm (Red arrow and green arrow) in the parafalcine region at the right frontoparietal lobes with mass effect (Blue arrow). In contrast, the lesion shows avid peripheral enhancement with tiny non-enhancing central core features suggesting neoplastic etiology (Yellow arrow), i.e., World Health Organization Meningioma Grade II.Meningiomas, classified as Grade 2 by the World Health Organization, are aggressive tumors with a high recurrence rate that necessitates multiple surgical procedures and can significantly worsen a patient´s neurological condition. The lesion is hyperintense and homo-dense near the coronal suture. She underwent surgical excision of the right frontoparietal parasagittal tumor and is under regular physiotherapeutic and medical management for the residual weakness.

Preperitoneal space, is it an ideal layer for endoscopic sublay repair of ventral hernia?

Preperitoneal space, is it an ideal layer for endoscopic sublay repair of ventral hernia?

Patient effort at a glance

A: Patient with little effort. Top: Volume Controlled Ventilation: airway pressure in cmH2O in yellow, constant flow in L/min in pink. Middle: Pressure controlled ventilation: airway pressure in cmH2O in yellow, decelerating flow in L/min in pink. Bottom: Esophageal pressure in cmH2O. B: Patient with high effort. Top: Volume Controlled Ventilation: airway pressure with convex negative deflection during trigger and first half of inspiration (blue arrow). Middle: Pressure controlled ventilation: airway pressure with negative deflection during the trigger (yellow arrow) and slight convex deflection (green arrow), concave deflection in the flow (orange arrow). Bottom: Convex deflection in esophageal pressure (grey arrow).

Abstract 12030: Impact of High-Resolution Epiaortic Ultrasonographic Imaging on Evaluating Aortic Wall Pathology

Introduction: Innovative imaging modality for preclinical diagnosis of aortic dissection (AD) has been awaited. Hypothesis: We previously reported that synchrotron radiation-based X-ray phase-contrast tomography (XPCT) imaging revealed densitometrical changes in the tunica media in the aortic wall (TM) of AD. To replicate XPCT findings in clinical practice, we investigated the application of high-resolution ultrasound in intraoperative epi-aortic scan (EAS) imaging. Methods: Twelve patients (normal aorta (5), chronic AD (3), acute type-A AD(4)) were selected. Before beginning cardiopulmonary bypass, the mid-ascending aorta was exposed and an EAS was conducted using EPIQ CVx and an eL18-4 transducer. After aortic repairs, the aortic samples of AD were fixed and applied XPCT, to compare ultrasonographic intensity (UI) of EAS and densitometric changes in XPCT in the same samples. Results: In normal aorta, UI remained unchanged throughout the TM (Figure-1A). In chronic AD, high linear changes in the UI in the middle of the TM was observed in the aorta that had not been dissected (yellow arrow in Figure-1B). In acute AD, high linear changes in the UI were clearly observed in the middle of TM, and aortic dissection was observed as an extension of those liner changes (Figure-1C). A line profile of the UI between the intima and the adventitia showed that the UI remained unchanged in normal aorta, and exhibited a high peak in the middle of the TM in chronic and acute AD (Figure-1A,B,C). These results indicated differences in the UI throughout the TM between normal and pathological aortas. These findings were well consistent with changes in the TM of patients with AD, which were obtained using XPCT (Figure-1D,E). Conclusions: High-resolution ultrasonographic imaging could replace XPCT findings in clinical settings and lead to significant improvements in the presymptomatic diagnosis of various aortic wall pathologies, including aortic dissection.

Sonographic appearance of malignant deep endometriosis of the rectum

In a symptomatic, 47-year-old woman with dysmenorrhea, dyschezia, and rectal bleeding, a transvaginal ultrasound demonstrated adenomyosis and an irregular hypoechoic nodule of 31 mm×12 mm×24 mm that infiltrated the anterior rectal wall and caused a retraction compatible with deep infiltrating endometriosis (Figure 1). After an elastography was conducted, the nodule stiffness was observed to be high (Figures 2 and 3). After a transvaginal scan following the intrarectal introduction of a physiological solution (Video), the nodule appeared to infiltrate the submucosa for 3 mm and caused 50% lumen stenosis (Figure 4). Contrary to what is reported for endometriomas, no specific sonographic signs of malignant transformation were evident. Total hysterectomy and partial rectal resection were performed by laparoscopy. Histopathology confirmed adenomyosis and revealed a moderately differentiated endometrioid adenocarcinoma, developed on a deep endometriosis of the rectum. Malignant transformation of endometriosis occurs in 0.7% to 2.5% of women, mainly after 45 years of age. Seventy-five percent of cases involve the ovaries and 25% involve extragonadal sites, mostly the rectum-sigmoid. Figure 2Transvaginal elastography Show full caption The black-marked blue area represents the high-stiffness endometriosis nodule at transvaginal elastography. Xholli. Sonographic appearance of malignant deep endometriosis of the rectum. Am J Obstet Gynecol 2022. View Large Image Figure Viewer Download Hi-res image Figure 3Analysis of the transvaginal elastography Show full caption At elastography analysis the yellow circular area placed in the middle of the nodule proved the presence of high-stiffness tissue with an objective value of 0.05% (in the graphic), whereas the light blue circular area placed in the pericervical tissue showed the presence of soft tissue with an objective value of 0.47%. Xholli. Sonographic appearance of malignant deep endometriosis of the rectum. Am J Obstet Gynecol 2022. View Large Image Figure Viewer Download Hi-res image Figure 4Transvaginal scan Show full caption At transvaginal scan, the nodule marked by the yellow tract infiltrating the submucosa for 3 mm (yellow arrow) narrows the rectal lumen by about 50%. D1 represents the minimum lumen diameter of the affected rectal wall. D2 is the normal rectal lumen diameter. Xholli. Sonographic appearance of malignant deep endometriosis of the rectum. Am J Obstet Gynecol 2022. View Large Image Figure Viewer Download Hi-res image The black-marked blue area represents the high-stiffness endometriosis nodule at transvaginal elastography. Xholli. Sonographic appearance of malignant deep endometriosis of the rectum. Am J Obstet Gynecol 2022. At elastography analysis the yellow circular area placed in the middle of the nodule proved the presence of high-stiffness tissue with an objective value of 0.05% (in the graphic), whereas the light blue circular area placed in the pericervical tissue showed the presence of soft tissue with an objective value of 0.47%. Xholli. Sonographic appearance of malignant deep endometriosis of the rectum. Am J Obstet Gynecol 2022. At transvaginal scan, the nodule marked by the yellow tract infiltrating the submucosa for 3 mm (yellow arrow) narrows the rectal lumen by about 50%. D1 represents the minimum lumen diameter of the affected rectal wall. D2 is the normal rectal lumen diameter. Xholli. Sonographic appearance of malignant deep endometriosis of the rectum. Am J Obstet Gynecol 2022.

Developing Efficiency Attributes for Right-Turn Flashing Yellow Arrow on Impeding through and Opposing Left Phases Using a Multinomial Logit Model

AbstractThe right-turn flashing yellow arrow (FYA) signal display is still considered a new signal practice in the United States. The Manual on Uniform Traffic Control Devices (MUTCD; 2009) allocat...

Grading of "Back Rolls": Guide to Treatment Options.

“Back Rolls,” as the term indicates, are basically fat deposits on the back in the form of rolls. This is a common deformity in women, and concerns were encountered by cosmetic surgeons the world over, especially in patients with massive weight loss due to diet or bariatric surgery and who would like to wear a form hugging costume. The skin–fat envelope of the back normally adheres tightly to the underlying musculoskeletal anatomy of the rib cage. This envelope is held in place by facial attachments that are akin to the “zones of adherence” described by Rohrich et al.1 The extent of fat deposits and number of back rolls, as well as skin laxicity, varies from person to person and also from one side to the other. The rolls surely have a zone of adherence inferiorly over which the tissue fold hangs and medially in the midline. Treatment modalities for back rolls depend on the above-mentioned variables and involve three general approaches: Injection lipolysis in association with weight loss2; Ultrasound-assisted lipectomy with or without skin tightening3; Direct surgical excision of the skin fold4 as an upper back lift. The choice of treatment depends on the specific characteristic of the back roll; hence, a classification to grade the extent of back roll would help in guiding the surgeon to choose the best possible option. Fat deposits in the saddle bag area, abdomen, chest, and submental area have been classified clinically to guide the treatment modality, but unfortunately, we have not come across any published classification system (whether anatomical or clinical) to categorize back rolls. After retrospectively going through the photographs and surgical details of more than 1800 Indian women who have undergone back contouring in the last 17 years, we propose the following classification for categorizing back rolls (Fig. 1):Fig. 1.: Grading of back rolls as seen clinically. A, Left side shows Grade II back roll with a single incomplete indentation, whereas the right side (Grade III) shows two indentations: the lower is complete, whereas the upper is incomplete. Please note that the maximum protrusion of skin fold (yellow arrow) is higher than the inferior indentation (black arrow). B, Grade IV back roll. The maximum protrusion of skin fold (yellow arrow) is lower than the inferior indentation (black arrow). Grade I: Back rolls that appear when the arms are kept by the side and disappear when the arms are raised. Grade II: Back rolls having a single indentation (partial or complete) that reduces when the arm is raised. Grade III: Back rolls with two or more skin indentations with skin pinch of more than 2 cm. The skin fold should not be lower than the inferior tethering point. Grade IV: Back rolls secondary to massive weight loss that have multiple folds with skin pinch less than 2 cm and skin fold lower than the tethering point, or in patients who have undergone prior surgical treatment. A lack of a comprehensive and clinically appropriate classification system prevents an accurate diagnosis, limits the use of treatment algorithm, and makes it difficult to compare treatment outcomes. We believe that this categorization can be used to guide the most appropriate treatment modality for a specific type of back roll that would be ideal. Additional studies are required to validate this classification system in other parts of the world. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No funding has been received for this study.

Understanding the formation of antiphase boundaries in layered oxide cathode materials and their evolution upon electrochemical cycling

Understanding the formation of antiphase boundaries in layered oxide cathode materials and their evolution upon electrochemical cycling