[Application of a small drainage tube in transoral endoscopic thyroidectomy vestibular approach]

Objective: To examine the feasibility of small drain in transoral endoscopic thyroidectomy vestibular approach (TOETVA). Methods: A prospective research was performed in Department of Oncology Plastic Surgery/Head and Neck Surgery, Hunan Cancer Hospital, from October 2018 to March 2019. Totally 103 patients who met the inclusion and exclusion criteria, signed the operation agreement of TOETVA, had their surgery completed and followed-up over 6 months, were enrolled in analysis. A central venous catheter was used as a drain tube in all cases (outer diameter 1.7 mm, inner diameter 1.0 mm). Visual analogue scale (VAS) was applied for assessing pain scores during the first 24 hours after the operation. Vancouver scar scale (VSS) was used for assessing the scar left by the drainage. The drainage volume (minimum scale:10 ml, approximate read: 1 ml) was recorded every 2 hours during the first postoperative 12 hours, every 4 hours during 12 to 24 hours, every 8 hours during 24 to 48 hours, and once from 48 hours until extubation. The volume of drainage, the cumulative volume and the percentage of cumulative volume accounting for the total volume were calculated. The data of residual volume (subtract the cumulative volume from the total volume) in the postoperative 24, 32 and 40 hours were analyzed, and their upper one-side P(95) was calculated by percentile method. Results: There were 12 males and 91 females. The age was (36.6±9.7) years (range: 18 to 58 years). The intraoperative tube-inserting time was (10.1±2.6) minutes (range: 6 to 18 minutes). The pain score on the first day was 2.7±1.1 (range: 1 to 5). The extubation time was (2.7±0.5) days (range: 2 to 4 days). VSS scores in the postoperative 1(st) month and 6(th) month were 2.9±1.3 (range: 0 to 7) and 0(2)(M(Q(R))), respectively. The size of the scar was 0 (2.5) mm in the postoperative 6(th) month. Sixty-four patients had no visible scars. There were 5 patients who had postoperative drain-related complications (1 for air leakage, 1 for tube blockage, 3 for subcutaneous hydrop, 2 for regional infection), who were all cured after proper treatment. The total volume of drainage for 98 patients without postoperative drain-related complications was (80.1±12.2) ml (range: 58 to 131 ml). The cumulative drainage within 8 hours accounted for (53.8±4.2)% (range: 41.0% to 62.9%) of the total drainage. The volume of residual fluids in the postoperative 32 hours was estimated to (5.8±2.7) ml (range: 0 to 12 ml,P(95)=10.0 ml). Conclusions: The small drain tubecan be applied in TOETVA, providing a satisfied cosmetic appearance and a reliable drainage. The main exudation period of the wound is within 8 hours after the operation. If a residual volume less than 10 ml is considered to be self-absorbable, the shortest safe extubation point for 95% patients without drain-related complications should be 32 hours after the operation.

[A case of using profunda artery perforator flap as an intraoperative salvage for failed deep inferior epigastric artery perforator flap harvesting in autologous breast reconstruction]

On April 11, 2019, a 36-year-old female patient was admitted to Hunan Cancer Hospital. Five years after the modified radical mastectomy for right breast cancer, she planned to undergo scar releasing and reconstruction of right chest wall and free deep inferior epigastric artery perforator (DIEP) flap transfer, right breast reconstruction, and left breast mastopexy. The defect of right chest wall after scar resection was 18 cm×10 cm. During the operation, the vascular pedicle of DIEP flap was accidentally injured, then the profunda artery perforator flap in left inner thigh was designed for salvage. The size of the flap was 20 cm×11 cm, the thickness was 4.5 cm, the length of perforator vessel pedicle was 7.6 cm, and the weight of the flap was 360 g. The right breast defect was repaired with the transferred flap and the deep cavity was filled. The vascular pedicle of profunda artery was anastomosed with the proximal end of the right internal mammary artery. The blood supply of the flap was good during surgery. The left breast mastopexy was completed at the same time, and the donor site of thigh and abdomen was closed directly. The flap survived well and the donor site healed well after surgery. During the follow-up of 7 months post surgery, the appearance and function of thigh donor site were good, no obvious complications were found, and the reconstructed breast was smaller than the contralateral side. This case suggests that the profunda artery perforator flap could be a valuable option as an alternative for DIEP harvesting failure for autologous breast reconstruction.

C-arm orbits for metal artifact avoidance (MAA) in cone-beam CT

Metal artifacts present a challenge to cone-beam CT (CBCT) image-guided surgery, obscuring visualization of metal instruments and adjacent anatomy-often in the very region of interest pertinent to the imaging/surgical tasks. We present a method to reduce the influence of metal artifacts by prospectively defining an image acquisition protocol-viz., the C-arm source-detector orbit-that mitigates metal-induced biases in the projection data. The metal artifact avoidance (MAA) method is compatible with simple mobile C-arms, does not require exact prior information on the patient or metal implants, and is consistent with 3D filtered backprojection (FBP), more advanced (e.g. polyenergetic) model-based image reconstruction (MBIR), and metal artifact reduction (MAR) post-processing methods. The MAA method consists of: (i) coarse localization of metal objects in the field-of-view (FOV) via two or more low-dose scout projection views and segmentation (e.g. a simple U-Net) in coarse backprojection; (ii) model-based prediction of metal-induced x-ray spectral shift for all source-detector vertices accessible by the imaging system (e.g. gantry rotation and tilt angles); and (iii) identification of a circular or non-circular orbit that reduces the variation in spectral shift. The method was developed, tested, and evaluated in a series of studies presenting increasing levels of complexity and realism, including digital simulations, phantom experiment, and cadaver experiment in the context of image-guided spine surgery (pedicle screw implants). The MAA method accurately predicted tilted circular and non-circular orbits that reduced the magnitude of metal artifacts in CBCT reconstructions. Realistic distributions of metal instrumentation were successfully localized (0.71 median Dice coefficient) from 2-6 low-dose scout views even in complex anatomical scenes. The MAA-predicted tilted circular orbits reduced root-mean-square error (RMSE) in 3D image reconstructions by 46%-70% and 'blooming' artifacts (apparent width of the screw shaft) by 20-45%. Non-circular orbits defined by MAA achieved a further ∼46% reduction in RMSE compared to the best (tilted) circular orbit. The MAA method presents a practical means to predict C-arm orbits that minimize spectral bias from metal instrumentation. Resulting orbits-either simple tilted circular orbits or more complex non-circular orbits that can be executed with a motorized multi-axis C-arm-exhibited substantial reduction of metal artifacts in raw CBCT reconstructions by virtue of higher fidelity projection data, which are in turn compatible with subsequent MAR post-processing and/or polyenergetic MBIR to further reduce artifacts.

Multi-body 3D-2D registration for image-guided reduction of pelvic dislocation in orthopaedic trauma surgery

Surgical reduction of pelvic dislocation is a challenging procedure with poor long-term prognosis if reduction does not accurately restore natural morphology. The procedure often requires long fluoroscopic exposure times and trial-and-error to achieve accurate reduction. We report a method to automatically compute the target pose of dislocated bones in preoperative CT and provide 3D guidance of reduction using routine 2D fluoroscopy. A pelvic statistical shape model (SSM) and a statistical pose model (SPM) were formed from an atlas of 40 pelvic CT images. Multi-body bone segmentation was achieved by mapping the SSM to a preoperative CT via an active shape model. The target reduction pose for the dislocated bone is estimated by fitting the poses of undislocated bones to the SPM. Intraoperatively, multiple bones are registered to fluoroscopy images via 3D-2D registration to obtain 3D pose estimates from 2D images. The method was examined in three studies: (1) a simulation study of 40 CT images simulating a range of dislocation patterns; (2) a pelvic phantom study with controlled dislocation of the left innominate bone; (3) a clinical case study investigating feasibility in images acquired during pelvic reduction surgery. Experiments investigated the accuracy of registration as a function of initialization error (capture range), image quality (radiation dose and image noise), and field of view (FOV) size. The simulation study achieved target pose estimation with translational error of median 2.3 mm (1.4 mm interquartile range, IQR) and rotational error of 2.1° (1.3° IQR). 3D-2D registration yielded 0.3 mm (0.2 mm IQR) in-plane and 0.3 mm (0.2 mm IQR) out-of-plane translational error, with in-plane capture range of ±50 mm and out-of-plane capture range of ±120 mm. The phantom study demonstrated 3D-2D target registration error of 2.5 mm (1.5 mm IQR), and the method was robust over a large dose range, down to 5 [Formula: see text]Gy/frame (an order of magnitude lower than the nominal fluoroscopic dose). The clinical feasibility study demonstrated accurate registration with both preoperative and intraoperative radiographs, yielding 3.1 mm (1.0 mm IQR) projection distance error with robust performance for FOV ranging from 340 × 340 mm2 to 170 × 170 mm2 (at the image plane). The method demonstrated accurate estimation of the target reduction pose in simulation, phantom, and a clinical feasibility study for a broad range of dislocation patterns, initialization error, dose levels, and FOV size. The system provides a novel means of guidance and assessment of pelvic reduction from routinely acquired preoperative CT and intraoperative fluoroscopy. The method has the potential to reduce radiation dose by minimizing trial-and-error and to improve outcomes by guiding more accurate reduction of joint dislocations.

[Selection and effects of flap/myocutaneous flap repair methods for the defect after perineum tumor resection]

Objective: To explore the selection and effects of flap/myocutaneous flap repair methods for the defect after perineum tumor resection. Methods: From January 2011 to February 2017, 31 patients with vulvar tumor who were admitted to Hunan Cancer Hospital underwent repair of wound after tumor resection with various flaps/myocutaneous flaps. The patients were composed of 5 males and 26 females, aged 39-76 years, with 27 vulvar cancer and 4 Paget's disease in primary diseases. The size of defects after vulvar tumor radical resection ranged from 8.0 cm×4.5 cm to 27.5 cm×24.0 cm. According to the theory of perforasome, the defects were repaired by the external pudendal artery perforator flap, deep inferior epigastric artery perforator flap, rectus abdominis myocutaneous flap, anterolateral thigh flap, internal pudendal artery perforator flap, gracilis myocutaneous flap, and profunda artery perforator flap based on the specific size and location of perineum and groin where the defect was located. According to the blood supply zone of flap, totally 17 local translocation flaps, 18 axial flaps/myocutaneous flaps, and 7 V-Y advancement flaps were resected, with an area of 7.0 cm×4.0 cm to 21.0 cm×13.0 cm. All the flaps/myocutaneous flaps were transferred in pedicled fashion, and the donor sites were closed without tension. The number of flaps/myocutaneous flaps, wound closure, flaps/myocutaneous flaps survival, and follow-up were observed and recorded. Results: Altogether 42 flaps/myocutaneous flaps were harvested in 31 patients. Two flaps/myocutaneous flaps were used in 11 cases for large circular defect repair. All the defects achieved tension-free primary closure. The blood supply of 32 flaps/myocutaneous flaps was good, while insufficient blood supply was noted in the other 10 flaps/myocutaneous flaps. Seventeen flaps/myocutaneous flaps survived smoothly. Wound dehiscence occurred in 5 flaps/myocutaneous flaps 8 to 14 days postoperatively, which was healed with dressing change. Temporary congestion was noted in 7 flaps/myocutaneous flaps 2 to 5 days postoperatively, which recovered without special treatment. Three flaps/myocutaneous flaps had infection 7 to 15 days postoperatively, two of which recovered after dressing change, while the other one had partial necrosis and received debridement and direct closure. Two flaps/myocutaneous flaps were totally necrotic 8 to 15 days postoperatively, which were repaired with pedicled rectus abdominis myocutaneous flap after debridement. Seven flaps/myocutaneous flaps had partial necrosis 7 to 20 days postoperatively and were healed after dressing change. Twenty-four patients were followed up for 9-38 months. The color of flaps/myocutaneous flaps was similar to that of the surrounding skin, the shape of vulva was natural, the movement of hip joint was not limited, the function of micturition and defecation was not affected, and tumor recurrence was noted in 3 patients. Conclusions: For the complicated large defect after perineum tumor resection, the flexible application of different forms of flaps/myocutaneous flaps to repair according to different areas regains the appearance and function. However, there are many complications, so it is necessary to further strengthen the postoperative care.

[Cell morphological analysis of hepatosplenic T-cell lymphoma gamma-delta type]

Objective: To analyze the cell morphological features of hepatosplenic T-cell lymphoma (HSTCL) gamma-delta (γδ) type, differentiate from acute leukaemia (AL). Methods: This was a retrospective study. The clinical data of four cases of HSTCL γδ type who were treated in Hebei Yanda Ludaopei Hospital from 2009 to 2014 were collected. Their initial morphology diagnoses in other hospitals were all acute leukemia or myelodysplastic syndrome (MDS). Morphological analysis and cytochemical stains to their bone marrow (BM) aspiration and peripheral blood (PB) smears were completed when they had no response to previous chemotherapies, and the morphological reports were compared with results of immunophenotyping, chromosome, and T cell receptor (TCR) gene rearrangement. Results: The percentages of malignant cells in four patients' BM aspirations were 7.6%-40.0%, and in two patients' PB was 9% and 10%, respectively. The morphology of four cases had a very high similarity in Wright's stain. Predominantly medium-sized cells were seen, with rich cytoplasm and frequently one big conspicuous nucleolus. The malignant cells resembled blasts, especially monoblasts, but with coarse granular chromatin, more compact than that in monoblasts. When comparing to malignant myeloblast and lymphoblasts, HSTCL cells were larger and more irregular in cell shape, with more abundant cytoplasm and prominent nuclear irregularity. The cytochemistric stain played an important role in differential diagnosis. HSTCL malignant cells showed non-specific esterase (NSE) negative or focal punctate activity which couldn't be inhibited by sodium fluoride. Periodic acid-Schiff (PAS) stain was negative or positive with a form of coarse granules. The myeloperioxdase (MPO) stain was negative. Conclusion: Malignant cells of HSTCL γδ type have very distinct morphological features of mature lymphocytic neoplasm. The quality of Wright's stain, being short of complete cytochemical stains, lacking of awareness of this disease, and acute leukemia or MDS like appearance in some cases, result in the possibility of diagnostic error as malignant blast, and probably are main causes of misdiagnosis of HSTCL γδ type.

AB1311-HPR RHEUMATIC AND MUSCULOSKELETAL DISEASES MANAGEMENT TOOL HELPS TO IMPROVE TREAT-TO-TARGET THERAPY AND PATIENTS’ ADHERENCE TO TREATMENT

Background:

Many of the rheumatic and musculoskeletal diseases (RMD) are long term, painful, and function affecting, which takes both the doctors and patients a lot of time and effort. The number of Rheumatologists are not sufficient for the huge population of RMD patients in China. The doctor patient ratio is as low as 1:1000. Relatively inadequate medical resources, traffic inconvenience in rural area, and patients’ insufficient understandings of the RMD may cause delayed medical intervention and poor prognosis. Effective RMD patient management tools which provide disease monitoring and enough doctor-patient communication is essential to improve the patients’ adherence to treatment. We designed an RMD management app according to the social, cultural and economic situation of Chinese patients, which helps to facilitate shared decision making and relieve the pressure of insufficient medical resources.

Objectives:

We aim to investigate the effect of RMD patient management app on treat-to-target therapy and patients’ adherence and satisfaction to treatment.

Methods:

An observational survey was administrated using a RMD patient management app. The app was designed and improved by Rheumatologist, orthopedics, nurses, patients, and app technical experts. Patients were offered with a questionnaire in regard to satisfaction with the app and their attitudes about the disease. General therapeutic principles, rehabilitation exercise videos and follow-up information were distributed through the app. Warning signals were sent whenever there was a flag sign of exacerbation. The demographic and clinical data, social and economic status, and drug retention rates of the patients were documented. The survey was designed by clinical experts from relevant departments and developed by both doctors and patients.

Results:

All patients were supervised by the rheumatologist and orthopedist when using the app. In all the patients included, there were cases of rheumatoid arthritis (35.3%), osteoarthritis (32.4%), ankylosing spondylitis (26.5%), and other chronic arthritis (5.8%). The mean age 38.5±15.8 years old, with 52.9% male and 47.1% female. Most of the patients (85.3%) believed that the app was helpful. Young patients were more likely to respond to the survey than older patients. Some patients (79.4%) had increased compliance because the app offered more chances to communicate with the doctors, which increase their understanding and confidence about the disease. Three patients received flag signs of exacerbation much earlier than they could get to the hospital. From the feedback of the patients, we realized that the patient would like to have more information to keep them from stepping on the trap of false advertisement for therapy (which is very commonly seen in China).

Conclusion:

RMD patient need to manage disease activity, daily function and mental state. Insufficient medical resources and patients’ knowledge about the disease may lead to poor adherence and prognosis. RMD patient management tool on app was a feasible and cost-effective approach for data collection and patient education. The app increased treat-to-target therapy and patients’ adherence to treatment.

References:

None.

Disclosure of Interests:

None declared

Cone-beam CT for imaging of the head/brain: Development and assessment of scanner prototype and reconstruction algorithms

PURPOSE

Our aim was to develop a high-quality, mobile cone-beam computed tomography (CBCT) scanner for point-of-care detection and monitoring of low-contrast, soft-tissue abnormalities in the head/brain, such as acute intracranial hemorrhage (ICH). This work presents an integrated framework of hardware and algorithmic advances for improving soft-tissue contrast resolution and evaluation of its technical performance with human subjects.

METHODS

Four configurations of a CBCT scanner prototype were designed and implemented to investigate key aspects of hardware (including system geometry, antiscatter grid, bowtie filter) and technique protocols. An integrated software pipeline (c.f., a serial cascade of algorithms) was developed for artifact correction (image lag, glare, beam hardening and x-ray scatter), motion compensation, and three-dimensional image (3D) reconstruction [penalized weighted least squares (PWLS), with a hardware-specific statistical noise model]. The PWLS method was extended in this work to accommodate multiple, independently moving regions with different resolution (to address both motion compensation and image truncation). Imaging performance was evaluated quantitatively and qualitatively with 41 human subjects in the neurosciences critical care unit (NCCU) at our institution.

RESULTS

The progression of four scanner configurations exhibited systematic improvement in the quality of raw data by variations in system geometry (source-detector distance), antiscatter grid, and bowtie filter. Quantitative assessment of CBCT images in 41 subjects demonstrated: ~70% reduction in image nonuniformity with artifact correction methods (lag, glare, beam hardening, and scatter); ~40% reduction in motion-induced streak artifacts via the multi-motion compensation method; and ~15% improvement in soft-tissue contrast-to-noise ratio (CNR) for PWLS compared to filtered backprojection (FBP) at matched resolution. Each of these components was important to improve contrast resolution for point-of-care cranial imaging.

CONCLUSIONS

This work presents the first application of a high-quality, point-of-care CBCT system for imaging of the head/ brain in a neurological critical care setting. Hardware configuration iterations and an integrated software pipeline for artifacts correction and PWLS reconstruction mitigated artifacts and noise to achieve image quality that could be valuable for point-of-care detection and monitoring of a variety of intracranial abnormalities, including ICH and hydrocephalus.

[Anatomical classification and application of chimeric myocutaneous medial thigh perforator flap in head and neck reconstruction]

Objective: To explore the anatomical classification and application of chimeric myocutaneous medial thigh perforator (MTP) flap in head and neck reconstruction. Methods: From September 2015 to December 2018, the clinical data of 74 patients (62 males and 12 females, age ranging from 31 to 69 years, with a mean age of 50.2 years) with oral tumor, who underwent radical resection in Hunan Cancer Hospital, including 39 cases of tongue carcinoma, 24 cases of gingival carcinoma and 11 cases of buccal cancer, 26 cases of stage T4N1M0, 22 cases of stage T4N0M0,15 cases of stage T3N1M0, and 11 cases of stage T3N2M0 were retrospectively analyzed in this work.The arteries and the veins contributing to MTP were anastomosed respectively with superior thyroid arteries, while the venae comitans were anastomosed with superior thyroid venae veins or internal jugular venae vein. The size of soft tissue defect, the length, width and thickness of free medial thigh flap, the length and source of vascular pedicle were recorded. The flap survival, functional status and donor area recovery were observed. Results: The postoperative defects in size ranged from 4.0 cm×3.5 cm to 9.0 cm×5.5 cm, which were reconstructed by free chimeric myocutaneous MTP flaps. The mean length of MTP flaps was (12.5±0.4) cm, the mean width was (7.2±0.4) cm, the mean thickness was (3.5±0.2) cm. The mean pedicle length was (8.6±0.4) cm. The perforators existed consistently in all cases, and the vascular origins were classified into 6 types. There were 4 cases (5.4%) of the perforating branches originating from femoral artery between the medial femoris and the adductor longus, 6 cases (8.1%) of the perforating branches of the profunda femoral artery from the adductor longus, 16 cases (21.6%) of the perforating branches of the profunda femoral artery from the gracilis, 9 cases (12.2%) of the perforating branches of the profunda femoral artery between the gracilis and the adductor longus, 29 cases (39.2%) of the perforating branches of the profunda femoral artery from the adductor longus, and 10 cases (13.5%) of branches of the profunda femoral artery from the semimembranous muscle. All 74 flaps survived uneventfully. The donor sites and recipient sites were closed directly in all cases. All patients were followed up for 12-36 months with satisfied esthetic and functional results. Only linear scars were left in the donor sites, and the thigh function was not affected. Local recurrence happened in 4 cases, which were treated with radical resection and the left defects were reconstructed with pedicled pectoral major myocutaneous flaps. Conclusion: The chimeric myocutaneous MTP flap has good color match and texture, with abundant tissue, and consistent blood supply, and it can be harvested in various forms while leaving minimal morbidity at donor site, being an idea choice for reconstruction after surgery of oral cancer.

Inhibition of heat shock protein 90 suppresses Bombyx mori nucleopolyhedrovirus replication in B. mori

Heat shock protein 90 (Hsp90) plays a very important role in facilitating the replication of many viruses. Until now, little has been known about the role of Hsp90 in Bombyx mori virus infection. In this study, we explored the role of BmHsp90 in B. mori nucleopolyhedrovirus (BmNPV) replication. We found that BmHsp90 inhibition by geldanamycin (GA) significantly reduced the BmNPV titre, the protein expression level of BmNPV nucleocapsid protein 39 (VP39) and the transcript level of BmNPV genes. Silencing the hsp90 gene in BmN cells by small interfering RNA suppressed BmNPV replication whereas overexpression of hsp90 promoted the replication of BmNPV. After inhibition of Hsp90, the expression of three key genes [signal transducing activator of transcription (stat), suppressor of cytokine signalling protein 2 (socs2), socs6] involved in the Janus kinase/STAT pathway significantly changed, with up-regulation of stat and down-regulation of socs2 and socs6. In addition, the expression of two antiapoptosis genes, BmNPV inhibitor of apoptosis protein1 (BmNPV-iap1) and Bmiap2, was greatly decreased in GA-treated cells, whereas their expression was significantly increased in hsp90-overexpressed silkworm larvae. Our results indicated that inhibition of Hsp90 can suppress BmNPV proliferation in B. mori. Our findings may provide new clues to elucidate the molecular mechanisms of silkworm-virus interactions.

[Value of absolute quantification of myocardial perfusion by PET in detecting coronary microvascular disease in patients with non-obstructive coronaries]

Objective: To compare the incidence of coronary microvascular disease (CMVD) between patients with non-obstructive and obstructive coronary arteries. Methods: We retrospectively analyzed 97 patients with angina pectoris, who underwent the absolute quantitative PET examination of myocardial perfusion and coronary anatomy examination within 90 days. All patients were divided into two groups: non-obstructive group (72 cases, no stenosis ≥50% in all three coronary arteries) and obstructive group (25 cases, at least one coronary stenosis ≥50%; and at least one coronary stenosis<50%). Quantitative parameters derived from PET including rest myocardial blood flow (RMBF), stress myocardial blood flow (SMBF), coronary flow reserve (CFR) and cardiovascular risk factors were compared between the two groups. CMVD was defined as CFR<2.90 and SMBF<2.17 ml·min(-1)·g(-1). Results: Incidence of CMVD was significant higher in the non-obstructive coronary arteries of the obstructive group than in the non-obstructive coronary arteries of non-obstructive group (47.1% (16/34) vs. 25.5% (55/216), χ(2)=6.738, P=0.009) while incidence of CMVD was similar between non-obstructive and obstructive patients ((44% (11/25) vs. 33.3% (24/72), χ(2)=0.915, P=0.339). RMBF ((0.83±0.14) ml·min(-1)·g(-1) vs. (0.82±0.17) ml·min(-1)·g(-1)), SMBF ((2.13±0.60) ml·min(-1)·g(-1) vs. (1.91±0.50) ml·min(-1)·g(-1)) and CFR (2.59±0.66 vs. 2.36±0.47) were similar between the two groups (all P>0.05). Conclusions: CMVD can occur in non-obstructive coronary arteries in both patients with non-occlusive coronary arteries and patients with obstructive coronary arteries. Prevalence of CMVD is significantly higher in patients with obstructive coronary arteries than in patients with non-obstructive coronary arteries. The CMVD severity is similar between the two groups.

Quality of reporting of systematic reviews and meta-analyses of surgical randomized clinical trials

Background

Well designed and conducted systematic reviews are essential to clinical practice. Surgical intervention is more complex than medical intervention when considering special items related to procedures. There has been no cross‐sectional study of the reporting quality of systematic reviews of surgical randomized trials focused on special items relating to surgical interventions.

Methods

A cross‐sectional survey of systematic reviews of surgical randomized trials published in 2007 and 2017 was undertaken via a PubMed search. Quality of reporting was assessed by the PRISMA checklist, with intervention details containing 27 items. Univariable and multivariable linear regression was used to explore factors in the checklist as indicators of reporting quality.

Results

A total of 204 systematic reviews were identified. The median score for the PRISMA checklist was 22 (i.q.r. 20–24), and systematic reviews published in 2017 had a significantly higher median score than those from 2007 (22 (i.q.r. 21–24) versus 20 (17–22); P < 0·001). Among the 27 items, 15 were reported adequately and three were reported poorly (in less than 50 per cent of reports). The proportion of other items reported ranged from 54·4 to 77·9 per cent. In multivariable analysis, systematic reviews published in 2017 (coefficient 0·59, 95 per cent c.i. 0·50 to 0·69) and Cochrane reviews (coefficient 0·67, 0·55 to 0·81) were associated with better reporting.

Conclusion

The quality of reporting of systematic reviews of surgical randomized trials has improved in the past 10 years. Some information relating to specific surgical interventions is, however, still reported poorly.

Image-Guided Robotic K-Wire Placement for Orthopaedic Trauma Surgery

PURPOSE

We report the initial development of an image-based solution for robotic assistance of pelvic fracture fixation. The approach uses intraoperative radiographs, preoperative CT, and an end effector of known design to align the robot with target trajectories in CT. The method extends previous work to solve the robot-to-patient registration from a single radiographic view (without C-arm rotation) and addresses the workflow challenges associated with integrating robotic assistance in orthopaedic trauma surgery in a form that could be broadly applicable to isocentric or non-isocentric C-arms.

METHODS

The proposed method uses 3D-2D known-component registration to localize a robot end effector with respect to the patient by: (1) exploiting the extended size and complex features of pelvic anatomy to register the patient; and (2) capturing multiple end effector poses using precise robotic manipulation. These transformations, along with an offline hand-eye calibration of the end effector, are used to calculate target robot poses that align the end effector with planned trajectories in the patient CT. Geometric accuracy of the registrations was independently evaluated for the patient and the robot in phantom studies.

RESULTS

The resulting translational difference between the ground truth and patient registrations of a pelvis phantom using a single (AP) view was 1.3 mm, compared to 0.4 mm using dual (AP+Lat) views. Registration of the robot in air (i.e., no background anatomy) with five unique end effector poses achieved mean translational difference ~1.4 mm for K-wire placement in the pelvis, comparable to tracker-based margins of error (commonly ~2 mm).

CONCLUSIONS

The proposed approach is feasible based on the accuracy of the patient and robot registrations and is a preliminary step in developing an image-guided robotic guidance system that more naturally fits the workflow of fluoroscopically guided orthopaedic trauma surgery. Future work will involve end-to-end development of the proposed guidance system and assessment of the system with delivery of K-wires in cadaver studies.

[Excision of thyroglossal cyst in children by transverse submentum incision]

Objective:To explore the application of transverse submentum incision in thyroglossal duct cyst surgery. Method:Submentum transverse incision for thyroglossal duct cyst removal in 14 children with thyroglossal duct cyst from January 2014 to December 2017. All cases were performed submentum dermatoglyphic incision, skin incision, subcutaneous tissue, platysma muscle incision, down lifting flap, along the white line incision and separation of banded muscle on both sides, see the mass along the wall of the capsule separated to the attachment of the hyoid bone, ablation of the mucosa of the capsule wall of the hyoid bone attachment, electrotome to break the hyoid bone. The cavity is indeed stopped after bleeding, and the skin is sutured continuously for continuous intradermal suture. The operation time, bleeding volume, severe complications, wound healing time and severe surgical scars were recorded. Close follow-up was performed to observe whether there was infection or recurrence of incisional wound. Parents were informed by telephone to go back to the outpatient clinic. RUTTER Children's Behavior Questionnaire was used to assess the children's psychological status. Vancouver Scar Rating Scale was used to evaluate the children's surgical scars, and to investigate whether parents satisfactory surgical methods. Result:Fourteen cases of thyroglossal duct cyst underwent transverse incision thyroglossal duct cyst excision successfully. The average operative time was 55 minutes, and the standard deviation was 10.5 min, bleeding was less than 10 ml, postoperative hoarseness and weakness of voice, silence became low, wound healing time averaged one week, no serious surgical scars, no wound infection and recurrence. Among the normal children of the same age group, 14 parents were satisfied with the operation. Conclusion:Excision of thyroglossal duct cyst under transverse incision is safe, reliable and satisfactory in appearance.

Factors associated with overall survival and relief of dysphagia in advanced esophageal cancer patients after 125I seed-loaded stent placement: a multicenter retrospective analysis

Iodine-125 (125I) seed-loaded stent placement has served as an effective palliation for malignant esophageal strictures in China. We performed a retrospective study to identify the prognostic factors of this irradiation stent placement in advanced esophageal cancer patients. A total of 201 patients who underwent 125I seed-loaded stent placement were included in this study from June 2012 to March 2016 at five hospitals in China. The Cox regression models adjusted for stratification factors were used, and a stepwise multivariate analysis was performed to predict the overall survival and relief of dysphagia on the basis of pretreatment clinical characteristics, respectively. Three independent prognostic factors were identified for overall survival: histopathological subtype (squamous cell carcinoma vs. adenocarcinoma, hazard ratio [HR] 1.45, 95% confidence interval [CI95%]: 1.01-2.09, P = 0.046), serum total protein (≥66 g/L vs. <66 g/L, HR 0.61, CI95%: 0.48-0.59, P = 0.023), and performance status (<2 vs. ≥2, HR 1.57, CI95%: 1.09-2.08, P = 0.013). Four factors were significantly associated with the relief of dysphagia: T stage (T3 vs. T4, P = 0.003), tumor location (superior vs. inferior, P = 0.049), tumor-node-metastasis classification (IV vs. II, P = 0.025), and age (≥71 years vs. <71 years, P = 0.029). Prognostic factors identified from this analysis can be used to aid clinical decision-making and design future clinical trials.

Determination of Place of Residence Using the Gene Information of Plants Carried by the Human Body

Abstract

Objective To identify the plant species using the DNA sequence of plant pollen from lung tissues of a unidentified body, infer the possible long-term places of residence of the deceased according to the distribution area of the pollen in the lung tissues, therefore narrow the scope of criminal investigation and provide clues for case solving. Methods Lung tissues were extracted from the deceased, total DNA was extracted by the mCTAB method. Gene fragments of the two plant DNA barcodes, matK and rbcL, were acquired using specific primers for amplification, then sequenced. The DNA sequences of target gene fragments were acquired through bioinformatics analysis. The sequences were combined with reference sequence data. Phylogenetic analysis was made to identify the species that the DNA sequences belonged to. The places where the deceased could have lived for a long time were inferred, according to the distribution information of plant species. Results Gene fragments of 32 plant species which belonged to 31 genera of 27 families were in the lung tissues of the deceased. Among them, plants of 9 genera that had certain indicative function were mainly endemic plants from Hainan, Guangdong, Guangxi and Yunnan. These results showed that the deceased may have stayed in these areas for a long time before death. After further investigation, the victim was confirmed to have come from a county in southern Guangxi, which was in accordance with the research results. Conclusion The method of using gene information of plants from lung tissues of human bodies to infer places of residence can assist inference of the places where the deceased could have lived for a long time. The present study may also provide new ideas for locating sources of the corpses in cases with unidentified victims.