El Camino Hospital

To assess patency and characterize anatomical patterns of restenosis following percutaneous transluminal angioplasty (PTA) of cephalic arch stenosis (CAS) from patients with hemodialysis arteriovenous fistulas who were enrolled in the ArterioVeNous Stent Graft in the TreatmEnt of Venous OutfloW Stenosis in Arteriovenous Fistula Access Circuits (AVeNEW) trial. Among 280 patients enrolled in AVeNEW, patients with CAS randomized to PTA were identified. Clinical data and fistulograms were reviewed through 730 days. Kaplan-Meier curves were used to estimate target lesion primary patency (TLPP) and access circuit primary patency (ACPP). The cephalic vein arch was segmented into 3 regions: proximal, arch, and terminus. Recurrence patterns were characterized by comparing the site of index stenosis with the site of restenosis using Sankey diagrams. Seventy patients with CAS were treated with PTA. Two ruptures and 2 unsuccessful PTAs yielded a modified intention-to-treat group of 66 patients. TLPP and ACPP were equivalent at the 180-, 365-, and 730-day time points: 39.5%, 13.2%, and 5.6%, respectively. Regarding post-PTA restenosis, 15 patients were censored, leaving 51 patients for analysis. Terminus stenoses recurred at the terminus. Arch region stenoses often recurred in the arch region; however, 6 (20%) of 30 formed a new terminus stenosis. PTA has a high technical successful rate for treating CAS; however, TLPP and ACPP were poor; their equivalence indicates CAS drives circuit failure. Recurrence at the index site of stenosis was the most common, although PTA of stenosis in the arch region induced a new site of stenosis at the terminus region in some patients. Proximal stenoses exhibited variable recurrence patterns.

Abstract Regardless of the high recurrence rate, copers manage the damage after a sprain. Copers do not experience ankle instability and continue their daily activities. However, it is unclear whether copers can use movement strategies similar to people without an ankle sprain. Identifying movement strategies can improve efficacy and prevent unwanted effects during training. Therefore, we aimed to compare the kinematics and muscular activities of the lower limbs during half squats and gait between copers and healthy controls. Ten copers (7 men, 3 women; age = 21.6 ± 1.1 years) and 10 controls (6 men, 4 women; age = 22.5 ± 2.8 years) were included in the cross-sectional study. We compared angles of the thigh, shank, and foot calculated from inertial measurement units and muscle activities of the biceps femoris long head, rectus femoris, gastrocnemius, and tibialis anterior between copers and controls during half squats and gait. For half squats, copers demonstrated thigh restriction with an effect size of 0.67–1.35, whereas we observed no significant differences in the shank and foot angles in the descending phase. Copers demonstrated less activity with an effect size of 0.61–1.58 in all four muscles. Copers showed lower activities of the rectus femoris and tibialis anterior during the same period of thigh restriction. For gait, there were no significant differences in lower limb angles and muscle activities between copers and controls. Copers may restrict thigh rotation unintentionally, leading to less muscle activity during half squats. Removing unconscious restrictions using sensor-based quantitative feedback can enable copers to obtain more efficient training. Our results suggest that assessing the limb movements of copers is important for efficient training, even if they do not experience instability to continue with their daily activities.

Introduction: Neuroendocrine tumors (NETs) are epithelial tumors that arise from neuroendocrine cells of the digestive system. Within the digestive system, the majority occur in small intestine (45%). Diagnosis is usually made accidentally during a routine workup or from the patient experiencing symptoms from the tumor. We report a difficult-to-diagnose unsuspected NET of the ileum in a young, otherwise healthy individual. Case Description/Methods: A 57-year-old female with a history of hypertension and hyperlipidemia presented to the emergency department with multiple episodes of dark stools one day prior to admission. A CT angiogram showed high density fluid in the small bowel with no active bleeding. Overnight, the patient had a near syncopal episode. A repeat CT angiogram showed active bleeding within the small intestine. However, on angiogram, no active bleeding was noted. The following day, an MR enterography showed thickening of the segment of the small intestine that had shown active bleeding on the repeat CT angiogram. During laparoscopy, the surgeon identified what felt to be a tumor in the distal ileum. Pathology revealed a well-differentiated neuroendocrine tumor (Figure 1). Discussion: NETs are the most common type of small bowel neoplasms. They are divided into duodenal NETs and distal NETs of the jejunum and ileum. Lymph node metastasis occurs in about 60% of cases of duodenal NET. Liver metastasis occurs in less than 10% of duodenal NET cases and about 20% of cases of distal NET of the jejunum and ileum. The stage of the disease has a large impact on prognosis. The 10-year survival rate is 95% for patients with localized NETs and 10% for those with distant metastasis. Distal NETs of the jejunum and ileum have a poorer prognosis because of their tendency to metastasize. The annual incidence of NETs has increased over the past five years to forty to fifty cases per million, largely due to better diagnostic tools. For duodenal NETs, upper gastrointestinal endoscopy with biopsy is the most sensitive diagnostic test. Several genetic markers are being evaluated as diagnostic tools. Treatment depends on the size of the NET. Small (≤ 1 cm) duodenal NETs can be resected endoscopically. Larger duodenal NETs (≥ 2 cm) or lymph node metastasis should be treated surgically. Systemic chemotherapy is not recommended for well-differentiated NETs. In conclusion, this case describes difficulties in diagnosing NETs of the ileum and highlights the need for improvements in diagnosis and management of NETs.Figure 1.: Ulcerated submucosal mass in distal small bowel measuring 2.8x1.8 cm.

Purpose: To compare physicians’ ability to read Alberta Stroke Program Early CT Score (ASPECTS) in patients with a large vessel occlusion within 6 hours of symptom onset when assisted by a machine learning-based automatic software tool, RAPID ASPECTS, compared with their unassisted score. Materials and Methods: 50 baseline CT scans selected from two prior studies (CRISP and GAMES-RP) were read by 3 experienced neuroradiologists who were provided access to a follow-up MRI. The average ASPECT score of these reads was used as the reference standard. Two additional neuroradiologists and 6 non-neuroradiologist readers then read the scans both with and without assistance from the RAPID ASPECTS software and reader improvement was determined. The primary hypothesis was that the agreement between typical readers and the consensus of 3 expert neuroradiologists would be improved with RAPID-assisted vs. unassisted reads. Agreement was based on the percentage of the individual ASPECT regions (50 cases, 10 regions each; N=500) where agreement was achieved. Results: Typical non-neuroradiologist readers agreed with the expert consensus read in 72% of the 500 ASPECTS regions, evaluated without software assistance. The automated software alone agreed in 77%. When the typical readers read the scan in conjunction with the software, agreement improved to 78% (P<0.0001, test of proportions). RAPID ASPECTS alone achieved correlations for total ASPECT scores that were similar to the expert readers who had access to the follow-up MRI scan to help enhance the quality of their reads. Conclusion: Typical readers had statistically significant improvement in their scoring of scans when the scan was read in conjunction with the automated RAPID ASPECTS software, achieving agreement rates that were comparable to neuroradiologists.

The sensitivity of suspicious lung nodules biopsied by currently available techniques is suboptimal. Robotic-assisted navigation bronchoscopy (RANB) is a novel method for biopsying lung nodules. Our study objective was to determine the sensitivity for malignancy and overall diagnostic accuracy for RANB when combined with cone beam CT (CBCT) for secondary confirmation. 52 consecutive patients were prospectively enrolled. Demographic data, nodule characteristics, procedural information, and follow-up results were obtained. Mean patient age was 66, with the majority Caucasian (73%) females (65%) with a similar number of never (46%) and former (46%) smokers. 15 patients had a history of cancer and 3 had a prior thoracic surgery. 59 total nodules were included as 7 patients had two nodules biopsied. Mean nodule diameter was < 2cm in all dimension with the majority solid (41, 70%) and located in the upper lobes (left: 22, 37%; right: 17, 29%). Bronchus sign was absent (32, 54%) or present (27, 46%) in a similar number. All nodules were successfully reached with nine (15%) requiring minor directional changes after initial cone beam CT. A tissue diagnosis was obtained in 83% (49/59) of biopsied nodules, with malignancy (31, 65%) most common. Including all biopsy results and follow-up imaging, we obtained an 84% (31/37) procedural sensitivity for malignancy and an overall 86% (51/59) diagnostic yield. RANB with CBCT increases sensitivity for malignancy and diagnostic accuracy of lung nodule biopsies. Combining these modalities has the potential to shift the diagnostic approach to pulmonary nodules.