Transvenous embolization of vein of galen aneurismal malformations using the “Chapot pressure cooker” technique

In some vein of galen aneurysmal malformation (VGAM) patients, transvenous embolization (TVE) is an attractive option, but its safety is unclear. Here we report the first two VGAM patients treated using the Chapot “pressure cooker” technique (ChPC). Methods Two patients, one 5-year-old and one 7-year-old, both presented with congestive heart failure in the newborn period and were subsequently treated in the newborn period with multiple, staged TAEs with n-BCA for choroidal VGAMs. Results We achieved progressive reduction in shunting and flow but were unable to accomplish complete closure of the malformation: in both patients, a small residual with numerous perforators persisted. The decision was made to perform TVE using the CHPC. In this technique, a guiding catheter is placed transjugular into the straight sinus (SS). One or two detachable tip microcatheters are advanced to the origin of the SS. Another microcatheter is advanced and the tip placed between the distal marker and the detachment zone of the former. Coils and n-BCA are used to prevent reflux of Onyx. Conclusions In this study, we recognized two important factors of traditional VGAM treatment that may cause interventionalists to consider the ChPC to treat VGAM: (1) without liquid embolic, deployed coils may not occlude the fistula entirely. (2) There is the concern of causing delayed bleeding should the arterial component of the fistula rupture. ChPC ameliorates these issues by offering complete closure of the fistula with liquid embolic material in TVE.

Assessment and Validation of the Internal Gross Tumour Volume of Gastroesophageal Junction Cancer During Simultaneous Integrated Boost Radiotherapy

BackgroundRespiratory motion may introduce errors during radiotherapy. This study aims to assess and validate internal gross tumour volume (IGTV) margins in different regions in gastroesophageal junction (GEJ) tumours during simultaneous integrated boost radiotherapy.MethodsWe enrolled 10 patients in group A and 9 patients in group B. For all patients, two markers were placed at the upper and lower boundaries of tumour before treatment. In group A, within the simulation and every five fractions of radiotherapy, we used 4-dimensional computed tomography (4DCT) to record the intrafractional displacement of the proximal and distal markers. By fusing the average image of each fraction with the simulation image according to the lumbar vertebra, the interfractional displacement could be obtained. We calculated the IGTV margin in the proximal and distal regions of the GEJ tumour. In group B, by referring to the simulation images and cone-beam computed tomography (CBCT) images, the range of tumour displacement in different regions within the GEJ tumour was estimated. We verified the proportion of tumours with marker displacement within the range obtained in group A to estimate the accuracy of the IGTV margin.ResultsThe intrafractional displacement in the cranio-caudal (CC) direction was significantly larger than that in the anterior-posterior (AP) and left-right (LR) directions for both the proximal and distal markers of the tumour. The interfractional displacement in the AP and LR directions was larger than that in the CC direction (p=0.001, p=0.017) according to the distal marker. The IGTV margins for in the LR, AP and CC directions were 9 mm, 8.5 mm and 12.1 mm for proximal marker and 15.8 mm, 12.7 mm and 11.5 mm for distal marker. In group B, the proportions of tumours that fell within the IGTV margin in the LR, AP and CC directions were 96.5%, 91.3% and 96.5% for the proximal marker and 100%, 96.5%, 93.1% for the distal marker.ConclusionsOur study proposed individualized IGTV margins for different regions within GEJ tumours during neoadjuvant radiotherapy. The IGTV margin determined in this study was relatively small and was validated appropriately. It could be a reference in clinical practice.

Intestinal motility distal of a deviating ileostomy after rectal resection with the construction of a primary anastomosis: results of the prospective COLO-MOVE study

Purpose No consensus exists regarding the use of preoperative bowel preparation for patients undergoing a low anterior resection (LAR). Several comparative studies show similar outcomes when a single time enema (STE) is compared with mechanical bowel preparation (MBP). It is hypothesized that STE is comparable with MBP due to a decrease in intestinal motility distal of a newly constructed diverting ileostomy (DI). Methods In this prospective single-centre cohort study, patients undergoing a LAR with primary anastomosis and DI construction were given a STE 2 h pre-operatively. Radio-opaque markers were inserted in the efferent loop of the DI during surgery, and plain abdominal X-rays were made during the first, third, fifth and seventh postoperative day to visualize intestinal motility. Results Thirty-nine patients were included. Radio-opaque markers were situated in the ileum or right colon in 100%, 100% and 97.1% of the patients during respectively the first, third and fifth postoperative day. One patient had its most distal marker situated in the left colon during day five. In none of the patients, the markers were seen distal of the anastomosis. Conclusion Intestinal motility distally of the DI is decreased in patients who undergo a LAR resection with the construction of an anastomosis and DI, while preoperatively receiving a STE.

On-Site–Modified Sheath to Overcome the Undesirable Catheterization of the Profunda Femoris Artery During Antegrade Femoral Access

Purpose: To present a simple method to avoid favored passage of a guidewire into the profunda femoris artery (PFA) after antegrade puncture of the common femoral artery. Technique: A 6-F conventional introducer sheath with a radiopaque distal marker is placed on the nurse’s table with its side port orientated to the 12 o’clock position. A small (2–2.5 mm) oval fenestration is created on the superior aspect of the sheath about 3 cm from its tip with a size 11 surgical blade. The modified introducer is passed over the angled 0.035-inch guidewire into the PFA and gently retrieved until the tip marker is ~3 cm from the femoral bifurcation. The dilator is removed, and the guidewire is withdrawn to the level of the fenestration, manipulated through it, and advanced further into the superficial femoral artery under fluoroscopic guidance. Conclusion: When repeated passage of the guidewire down the PFA persists despite conventional manipulation of the wire or needle, an on-site modification of the sheath is an easy alternative approach for the catheterization of the superficial femoral artery.

Biomarker-based subtyping of depression and anxiety disorders using Latent Class Analysis. A NESDA study

BackgroundEtiological research of depression and anxiety disorders has been hampered by diagnostic heterogeneity. In order to address this, researchers have tried to identify more homogeneous patient subgroups. This work has predominantly focused on explaining interpersonal heterogeneity based on clinical features (i.e. symptom profiles). However, to explain interpersonal variations in underlying pathophysiological mechanisms, it might be more effective to take biological heterogeneity as the point of departure when trying to identify subgroups. Therefore, this study aimed to identify data-driven subgroups of patients based on biomarker profiles.MethodsData of patients with a current depressive and/or anxiety disorder came from the Netherlands Study of Depression and Anxiety, a large, multi-site naturalistic cohort study (n = 1460). Thirty-six biomarkers (e.g. leptin, brain-derived neurotrophic factor, tryptophan) were measured, as well as sociodemographic and clinical characteristics. Latent class analysis of the discretized (lower 10%, middle, upper 10%) biomarkers were used to identify different patient clusters.ResultsThe analyses resulted in three classes, which were primarily characterized by different levels of metabolic health: ‘lean’ (21.6%), ‘average’ (62.2%) and ‘overweight’ (16.2%). Inspection of the classes’ clinical features showed the highest levels of psychopathology, severity and medication use in the overweight class.ConclusionsThe identified classes were strongly tied to general (metabolic) health, and did not reflect any natural cutoffs along the lines of the traditional diagnostic classifications. Our analyses suggested that especially poor metabolic health could be seen as a distal marker for depression and anxiety, suggesting a relationship between the ‘overweight’ subtype and internalizing psychopathology.

Realis and Non-Realis Modalities in Daakie (Ambrym, Vanuatu)

This paper analyzes the system of modality marking in Daakie, an Austronesian (Oceanic) language spoken on Ambrym (Vanuatu). Daakie has a fiveway distinction that expresses both temporal and modal notions. In addition to a realis marker there is a potentialis marker for events that are expected to happen, a distal marker for temporally or modally remote events, a realis negation, and a potentialis negation. These markers are used in main and dependent clauses, where they express factive and negative interpretations

Bmp signaling regulates proximal-distal differentiation of endoderm in mouse lung development

In the mature mouse lung, the proximal-distal (P-D) axis is delineated by two distinct epithelial subpopulations: the proximal bronchiolar epithelium and the distal respiratory epithelium. Little is known about the signaling molecules that pattern the lung along the P-D axis. One candidate is Bone Morphogenetic Protein 4 (Bmp4), which is expressed in a dynamic pattern in the epithelial cells in the tips of growing lung buds. Previous studies in which Bmp4 was overexpressed in the lung endoderm (Bellusci, S., Henderson, R., Winnier, G., Oikawa, T. and Hogan, B. L. M. (1996) Development 122, 1693–1702) suggested that this factor plays an important role in lung morphogenesis. To further investigate this question, two complementary approaches were utilized to inhibit Bmp signaling in vivo. The Bmp antagonist Xnoggin and, independently, a dominant negative Bmp receptor (dnAlk6), were overexpressed using the surfactant protein C (Sp-C) promoter/enhancer. Inhibiting Bmp signaling results in a severe reduction in distal epithelial cell types and a concurrent increase in proximal cell types, as indicated by morphology and expression of marker genes, including the proximally expressed hepatocyte nuclear factor/forkhead homologue 4 (Hfh4) and Clara cell marker CC10, and the distal marker Sp-C. In addition, electron microscopy demonstrates the presence of ciliated cells, a proximal cell type, in the most peripheral regions of the transgenic lungs. We propose a model in which Bmp4 is a component of an apical signaling center controlling P-D patterning. Endodermal cells at the periphery of the lung, which are exposed to high levels of Bmp4, maintain or adopt a distal character, while cells receiving little or no Bmp4 signal initiate a proximal differentiation program.