The difficulties of recanalization in chronic superior cava vein obstruction by penetrating diagnostic catheter, PTA, and stenting: A case report

Superior vena cava obstruction is caused by a blockage in its blood flow; one of its few causes can be device related. This case follows a patient presented with superior vena cava obstruction following a septal cardiac implant. Endovascular intervention has been associated with more rapid, complete symptom relief and lower complication rates. The use of stenting as first-line therapy has gathered popularity to become standard practice in the past 2 decades. This paper illustrates a successful recanalization with penetrating diagnostic catheter, followed with percutaneous transluminal angioplasty stenting in order to preserve the patency superior vena cava.

Preoperative transcatheter arterial embolization successfully minimizes intraoperative bleeding in juvenile nasopharyngeal angiofibroma even without internal carotid artery branch embolization: A report of two cases

Juvenile nasopharyngeal angiofibroma (JNA) is a histopathologically benign and highly vascular neoplasm of the nasopharynx. Surgery is the treatment of choice for this type of tumor, but its highly vascular nature could result in profuse and uncontrollable bleeding. Preoperative transcatheter arterial embolization offers an effective and minimally invasive modality for reducing intraoperative blood loss. We report 2 cases of JNA in a 17-year-old male and 14-year-old male who underwent preoperative embolization of external carotid artery branch using gelatin sponge slury and polyvinyl alcohol. Even without internal carotid artery branch embolization, both of our reported cases had intraoperative blood loss of 1100 mL and 1300 mL which are less than the previously reported mean blood loss of 1428 mL in patients who underwent both internal and external carotid artery branch embolization.

Massive DVT from the proximal IVC to the pedal vein: Our approach using aspiration mechanical thrombectomy and open surgery thrombectomy

Deep venous thrombosis might present in an acute condition requiring early thrombus removal. Several endovascular and surgical approaches are available with a short treatment time and minimal complications compared to pharmacotherapies. However, due to a lack of evidence, these are not the first treatment choice for deep vein thrombosis. Our case report showed a successful multimodality treatment for an acute-on-chronic massive deep vein thrombosis from the inferior vena cava to the pedal vein. A 47-year-old with chief complaints of cold, significant swelling, and severe pain in her left leg was diagnosed with deep vein thrombosis through Doppler ultrasound and contrast-enhanced computed tomography. The patient received aspiration mechanical thrombectomy with the "kissing catheter" technique, adjunctive stent, percutaneous transluminal angioplasty, and open surgical thrombectomy by Fogarty catheter without recurrence and complication.

Intra-arterial chemotherapy for retinoblastoma: Our first experience in Indonesia

Intra-arterial chemotherapy (IAC) has become the mainstay therapy for retinoblastoma group D and E for the past few decades. However, IAC had never been done in Indonesia before. In this report, we present a case of a 2-year-old girl with recurrent Group D retinoblastoma of the left eye that improved significantly after one session of IAC, the first IAC in Indonesia.

Altered Resting-State Network in Adolescents with Problematic Internet Use

Problematic internet use (PIU) is increasingly recognized as a mental health concern, particularly among adolescents. The resting-state functional connectivity (rsFC) of the triple-network model has been described inconsistently in PIU. Using resting-state fMRI (rsFMRI) and hypothesizing a lower rsFC between default mode (DMN) and central executive networks (CEN) but a higher rsFC within the salience network (SN), this study scrutinized the neural substrates of PIU adolescents. A total of 30 adolescents with PIU and 30 control subjects underwent rsFMRI. The severity of PIU was evaluated by the Internet Addiction Test. Additionally, personality traits as well as emotional and behavioral problems were evaluated by the Temperament and Character Inventory (TCI) and the Strength and Difficulties Questionnaire (SDQ), respectively. Focusing on the DMN, SN, and CEN, we compared rsFC values between PIU and the control. Subsequently, within the combined group of subjects, TCI and SDQ correlation and mediation effects were investigated. Higher rsFC values of the left lateral prefrontal cortex (LPFC(L)) with the left anterior insula (aIns(L)) were observed for PIU than for the control, while rsFCs of the LPFC(L) with the medial PFC (MPFC), LPFC(L), as well as with the right lateral parietal cortex (LP(R)) were lower for PIU. Among these significant group differences, the rsFC between the LPFC(L) and MPFC was mediated by emotional symptoms (standardized β = −0.12, 95% CI −0.29, −0.0052). The dysfunctional attention switching and incentive salience regulated by the SN were implicated as being a neural correlate of PIU, and this relationship would in part be explained by the emotional dysregulation associated with PIU in adolescents.

Changes in residual kidney Pulsatility Index following living donor nephrectomy

OBJECTIVE

Nephrectomy in kidney transplant donors provokes a compensatory hyperfiltration process of the residual kidney, characterized by changes in renal vascular hemodynamics. This research aimed to determine the short-term difference in the pulsatility index (PI) of kidney transplant donors' residual kidney before and after nephrectomy.

METHODS

This is a prospective historical study using secondary data from kidney transplant living donors who have undergone nephrectomy at a tertiary referral hospital in Jakarta, Indonesia, from March 2019 to January 2020. PI of renal, segmental, interlobar, and arcuate arteries of the residual kidneys were measured in the preoperative and day-1, day-7, day-30 postoperative period. The pre- and postoperative PI values were statistically analyzed to examine differences between the groups.

RESULTS

PI of 40 residual kidneys were obtained. There were no significant mean PI changes in the arteries except for the middle interlobar artery (p = 0.049), which showed no significant difference after post hoc analysis.

CONCLUSIONS

There is no significant short-term difference in PI of the residual kidney before and after kidney transplant donor nephrectomy.

ADVANCES IN KNOWLEDGE

Short-term postoperative PI of the residual kidney arteries may not be suitable as a predictor for chronic kidney disease in kidney transplant donors. Other quantitative Doppler ultrasound parameters must be considered.

Diffusion magnetic resonance imaging of normal-appearing white matter in multiple sclerosis: correlation with brain volume and clinical disability

Background

Diffusion magnetic resonance imaging (MRI) abnormalities in multiple sclerosis (MS) are not limited to lesions, but have also been observed in the white matter that appears normal on conventional MRI sequences, known as normal-appearing white matter (NAWM). There is evidence of microstructural processes occurring in the NAWM.

Objective

To assess the correlation between NAWM apparent diffusion coefficient (ADC) and fractional anisotropy (FA) with brain volume and clinical disability in MS.

Methods

Brain MRI from 33 MS patients were included. ADC and FA measurements of the genu, body, and splenium of corpus callosum (CC) were done. ADC and FA values were analyzed to measure their correlation with brain volume from MR volumetry and clinical disability represented by Expanded Disability Status Scale (EDSS).

Results

The mean ADC of CC NAWM was .93 ×10⁻³ mm²/s (±.13 SD), and the mean FA .72 (±.12 SD). ADC and FA of CC NAWM were significantly correlated with the ratio of brain volume to intracranial volume (R = −0,70 and 0,78 respectively), and with EDSS (R = .52 and −.59 respectively).

Conclusion

There were significant correlations between ADC and FA of NAWM with brain volume and EDSS of MS patients. Further longitudinal studies were needed to evaluate the potential of diffusion MRI in the evaluation of MS.

Cone beam CT Angiography-Guided direct puncture embolization for treatment of vascular anomalies in the head and neck region

The use of angiography combined with cone-beam computed tomography (CBCT) in interventional radiology and endovascular surgery is beneficial. The combination of CBCT with digital subtraction angiography (DSA) resulted in a detailed vascular map and its surrounding structures. This paper presents cases of vascular anomalies outside the skull, including malformations and hypervascular tumors, specifically in the head and neck region, which were managed with direct puncture embolization under CBCT guidance. CBCT could facilitate the visualization and identification of the precise puncture site of targeting vessels. No complications were observed in all cases.

Sacrum morphometry and spinopelvic parameters among the Indonesian population using computed tomography scans

This is a cross-sectional study. This study aims to describe the characteristics of sacrum vertebrae and spinopelvic parameters among the Indonesian population and compare them with studies from other populations. This study also intends to determine the sexual dimorphism of sacrum vertebrae and find the correlations between spinopelvic parameters.Morphometry of the sacrum is necessary for designing sacral prosthesis and instrumentations. Knowledge of spinopelvic parameters further supports the prosthesis installation procedure to restore the physiological spinal alignment of the patients. However, previous studies showed varied results among different populations. This is the first study to be conducted among the Indonesian population.Morphometric dimensions of sacrum vertebrae and the spinopelvic parameters (pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis) were analyzed using thin-cut (1 mm) computed tomography images in 150 males and 150 females, aged 25 to 50 years without any spinal pathology.Generally, the size of the sacrum vertebrae was greater in males (P < .05). The sacral index, curvature index, and corporo-basal index were statistically different between genders (P < .001). Lumbar lordosis was the only spinopelvic parameter found significantly greater in females (P < .001). Significant positive correlations between all spinopelvic parameters, except for lumbar lordosis and pelvic tilt, were found in the present study (P < .001).The study serves as the first large series database of sacrum morphometric characteristics and spinopelvic parameters of the Indonesian population. There was significant gender-associated differences in various dimensions of sacrum vertebrae. The sacral index was found to be the most useful parameter for sex determination. There were strong significant positive correlations between various spinopelvic parameters. A comparison of populations revealed morphometric characteristic differences, which is proved to be critical in surgical implications.

Analysis Survival of Breast Cancer with Brain Metastases Treated with Different Fraction Whole Brain Radiotherapy Concomitant with Capecitabine

Introduction: Breast cancer is the second most frequent cancer worldwide. The main therapeutic modality for breast cancer with brain metastases is radiation. Whole Brain Radiotherapy (WBRT) is a treatment that provides moderate doses of radiotherapy to all brain tissue. Capecitabine was found to be effective for the treatment of breast cancer with metastases and its metabolites can cross the BBB in animal models.   Objective: This study aims to determine the response and survival of breast cancer patient with brain metastases treated with different fractionation WBRT combined with capecitabine administration.   Materials and methods: This is a prospective, randomized-blind cohort analytic study. Subjects were randomized into two groups by giving different fraction of WBRT (Group I WBRT 10x3Gy and Group II WBRT 20x2Gy) concomitant with capecitabine 850-1000mg/m2. OS was calculated from brain metastases diagnosis. Median follow-up was 5.6 months.   Results: A total of 22 breast cancer patients with brain metastases participated in this study. Group I obtained results of 5 (45.5%) out of 11 are responding to therapy and median OS was 4.4 months. Whereas in group II found 11 (100%) out of 11 patients responded to therapy and median OS was 9.4 months. The results of statistical analysis showed that there were significant differences of response between the two groups with p value= 0.012. The differences of survival of each group also statistically significant with p value=0.004   Conclusions: WBRT with 20x2Gy concomitant with Capecitabine gives a better response rate and OS.

Internet addiction in adolescents: Development and validation of Internet Addiction Diagnostic Questionnaire (KDAI)

Internet addiction (IA) is an emerging behavioral problem that constitutes a major health threat to vulnerable populations, including adolescents. However, there is a paucity of IA screening tools specifically designed for adolescents, especially in Indonesia. Therefore, the current study developed and validated the IA Diagnostic Questionnaire (KDAI) in adolescents while acknowledging local cultural influences. The KDAI was conceived through extensive literature reviews, expert discussions based on Delphi methods, a face validity study, focus group discussion (N = 31) for initial reliability testing, and a recruited pilot study (N = 385) and main study (N = 643) for exploratory and confirmatory factor analyses, respectively. The multi-sample analyses demonstrated that the KDAI model with the best fit and reliability comprised a seven-factor structure, including withdrawal, loss of control, increase of priority, negative consequences, mood modification, salience, and impairment. These factors were scrutinized against domains of IA Test, and concurrent validity was ascertained. Subsequently, a receiver operating characteristic curve and area under the curve determined a cutoff score of 108 to discern adolescents with IA. Taken together, the KDAI displayed excellent psychometric indices and sensitivity as a screening tool for IA in adolescents.

Forequarter amputation post transarterial chemoembolization and radiation in synovial sarcoma: A case report

INTRODUCTION AND IMPORTANCE

Forequarter amputation or interscapulathoracalis amputation is a major amputation procedure that involves the entire upper extremity, scapula, and a whole or part of the clavicula. Forequarter amputation is commonly used to control bleeding in malignant tumor cases in which no treatment is available for the extremities.

CASE PRESENTATION

We report a case of forequarter amputation in a 25-year-old patient with synovial sarcoma. Transarterial chemoembolization (TACE) and radiation synovial sarcoma were performed in the patient to reduce bleeding. This technique may also be used for treating synovial sarcoma with massive bleeding.

CLINICAL DISCUSSION

Despite forequarter amputation indications in malignant tumor cases and recurrent cancer cases, the effectiveness of this technique remains unclear. The patient was readmitted with a recurrent mass three months after surgery.

CONCLUSION

In this study, TACE and radiotherapy are effective in controlling bleeding preoperatively and intraoperatively in patients with synovial sarcoma.

Validation study of the Indonesian internet addiction test among adolescents

BACKGROUND

Internet addiction is a serious problem that can negatively impact both the physical and mental health of individuals. The Internet Addiction Test (IAT) is the most common used instrument to screen internet addiction worldwide. This study sought to investigate the psychometric properties of an Indonesian version of the IAT.

METHODS

The IAT questionnaire was made the focus of forward translation, expert panel discussions, back translation, an item analysis (30 subjects), a pilot study (385 subjects), and field testing (643 subjects). Factor structure was analysed by exploratory (EFA) and confirmatory factor (CFA) analyses, whereas reliability was measured with Cronbach's alpha coefficient.

RESULTS

Factor analysis revealed that the Indonesian version of IAT, consisted of 3 domains, and had good validity (χ2 p < 0.001; RMSEA = 0.076; CFI = 0.95; SRMR = 0.057, and AIC = 784.63). The Cronbach's alpha score is 0.855. A significant association was also observed between the level of internet addiction with gender (p = 0.027) and the duration of internet use per day (p = 0.001).

CONCLUSION

The Indonesian version of IAT provides good validity and reliability in a three-dimensional model. Therefore, it can be utilised as a tool for screening internet addiction in the Indonesian population.

Bone Growth Capacity of Human Umbilical Cord Mesenchymal Stem Cells and BMP-2 Seeded Into Hydroxyapatite/Chitosan/Gelatin Scaffold in Alveolar Cleft Defects: An Experimental Study in Goat

OBJECTIVE

To evaluate bone regeneration in alveolar defects treated with human umbilical cord-derived mesenchymal stem cells (hUCMSCs), hydroxyapatite/chitosan/gelatin (HA/CS/Gel) scaffold, and bone morphogenic protein-2 (BMP-2) in Capra hircus models.

DESIGN

Randomized posttest-only control group design.

SETTING

Animal Hospital at Bogor Agricultural Institute.

PARTICIPANTS

Healthy and equally treated 24 female Capra hircus/goats.

INTERVENTION

Animals were randomly assigned to 3 experimental group design (iliac crest alveolar bone graft/ICABG [control], HA/Cs/Gel+BMP-2 [Novosys], and HA/Cs/Gel+BMP-2+UCMSCs). Graft materials were implanted in surgically made alveolar defects.

MAIN OUTCOME MEASURES

Postoperative functional score and operating time were assessed. New bone growth, bone density, inflammatory cells recruitment, and neoangiogenesis were evaluated based on radiological and histological approach at 2 time points, week 4 and 12. Statistical analysis was done between treatment groups.

RESULTS

Operating time was 34% faster and functional score 94.5% more superior in HA/Cs/Gel+BMP-2+hUCMSC group. Bone growth capacity in HA/Cs/Gel+BMP-2+UCMSCs mimicked ICABG, but ICABG showed possibility of bone loss between week 4 and 12. The HA/Cs/Gel+BMP-2+UCMSCs showed early bone repopulation and unseen inflammatory cells and angiogenesis on week 12.

DISCUSSION AND CONCLUSION

The HA/Cs/Gel+BMP-2+hUCMSCs were superior in enhancing new bone growth without donor site morbidity compared to ICABG. The presence of hUCMSCs in tissue-engineered alveolar bone graft (ABG), supported with paracrine activity of the resident stem cells, initiated earlier new bone repopulation, and completed faster bone regeneration. The HA/Cs/Gel scaffold seeded with UCMSCs+BMP-2 is a safe substitute of ICABG to close alveolar bone defects suitable for patients with cleft lip, alveolus, and palate.

The Association between Peripheral Th17, Th1, IL-17, and IFN-γ Levels and TACE Response in Patients with Unresectable Hepatocellular Carcinoma with or without Cirrhosis

BACKGROUND

Th17 cells, a subset of CD4+ T cells with the capacity to produce IL-17, were reported to have pro-tumor and anti-tumor effects. Th1 cells are known for their capacity to eliminate tumor cells by producing IFN-γ. Transarterial chemoembolization (TACE) is a treatment of choice for patients with unresectable hepatocellular carcinoma (HCC). Therefore, this study aimed to determine the association between peripheral Th17, Th1, IL-17, and IFN-γ levels and TACE response in patients with unresectable HCC with or without cirrhosis.

METHODS

a prospective cohort study was conducted in Cipto Mangunkusumo Hospital and several affiliated hospitals from June 2015 to January 2019. HCC patients with or without cirrhosis who met the inclusion criteria were included in this study. Blood samples were obtained immediately before TACE and 30 days after TACE. Th1 and Th17 cells were analyzed by flowcytometry, while IL-17 and IFN-γ were examined with ELISA method. TACE response was assessed with mRECIST.

RESULTS

forty-one HCC patients were enrolled in this study. According to mRECIST, 12 patients were assessed as response group (complete and partial response) and 29 patients were assessed as nonresponse group (stable and progressive disease). Levels of Th1 and Th17 increased significantly after TACE in the response group. On the other hand, IL-17 and IFN-γ decreased after TACE in both groups, although not statistically significant. Interestingly, in the response group, a significant increase was found in the number of T cells subset showing both IFN-γ and IL-17 markers on their surfaces, i.e. CD4+/IFN-γ+/IL-17+ T cells.

CONCLUSION

increased circulating Th1, Th17, and CD4+/IFN-γ+/IL-17+ T cells were observed in HCC patients with complete or partial response to TACE.

Torrential bleeding of arteriovenous malformation in hand post-ethanol sclerotherapy: A case report

Embolization or sclerotherapy is considered as the first-line therapy for the management of arteriovenous malformations (AVM) and can be performed directly targeting the nidus. Ethanol is an effective embolic agent; however, some complications may arise. This paper illustrates a case of torrential bleeding following ethanol sclerotherapy in a patient with progressive hand arteriovenous malformations with a poor prognosis and was suggested to be amputated. Direct pressure, tourniquet appliance, and split-thickness skin graft procedure were performed to stop the bleeding successfully. No recurrence of bleeding was reported; and complete alleviation of pain was achieved.

The Effect of Hyperfiltration on Kidney Function in Living Donor Kidney Transplantation: A Prospective Cohort Study

BACKGROUND

living kidney donation is a safe medical procedure. Kidney function after donation is crucial for donors' health and quality of life. Kidney hyperfiltration is a compensatory mechanism, which will preserve kidney function after unilateral nephrectomy. The number of studies regarding hyperfiltration in living kidney donors is limited. Our study aimed to explain kidney hyperfiltration mechanism and evaluate its effect on the kidney function within 30 days after surgery.

METHODS

our study was a prospective cohort study with 46 living-kidney donors participating in the study between April and December 2019. We evaluated main outcomes, the 30-day post-surgery kidney function, which was evaluated by calculating estimated glomerular filtration rate (eGFR) and Urinary Albumin to Creatinine Ratio (ACR). The subjects were categorized into two groups based on their 30-day outcomes, which were the adaptive (eGFR > 60 mL/min/1.73 m2 and/or ACR > 30 mg/g) and maladaptive (eGFR < 60 mL/min/1.73 m2 and/or ACR > 30 mg/g) groups. A series of evaluation including calculating the renal arterial resistive index (RI) and measuring urinary vascular endothelial growth factor (VEGF), neutrophil gelatinase-associated lipocalin (NGAL), and heparan sulfate (HS) levels were performed before surgery and serially until 30 days after surgery. Multivariate analysis with adjustments for confounding factors was done.

RESULTS

forty donors were included and mostly were female (67.5%). The average age and body mass index (BMI) were 45.85 (SD 9.74) years old and 24.36 (SD 3.73) kg/m2, respectively. Nineteen donors (47.5%) had maladaptive hyperfiltration outcomes. The hyperfiltration process was demonstrated by significant changes in renal arterial RI, urinary VEGF, NGAL, and HS levels (p<0.005). There was no significant difference regarding RI, urinary VEGF, NGAL, and HS levels between both groups. Several confounding factors (BMI over 25 kg/m2, familial relationship, age over 40 years old, and arterial stiffness) were significantly influenced by kidney hyperfiltration and outcomes (p<0.05).

CONCLUSION

the hyperfiltration process does not affect the 30-day post-nephrectomy kidney function of the donors. Several other factors may influence the hyperfiltration process and kidney function. Further study is necessary to evaluate kidney function and its other related variables with a longer period of time study duration.

Functional and Radiological Comparison of Umbilical Cord Mesenchymal Stem Cells, Somatotropin, and Hyaluronic Acid Injection for Cartilage Repair in Early Osteoarthritis of the Knee: A Randomized Controlled Trial

The umbilical cord-mesenchymal stem cells (UC-MSC) has been shown to improve the viability of degenerated chondrocytes in knee osteoarthritis (KOA) in cellular level. Additional somatotropin injection also shown clinical improvement in patients. The present trial is conducted to assess the efficacy of umbilical cord mesenchymal stem cells (UC-MSC) in comparison to somatotropin and hyaluronic acid (HA) injection to treat and slow the progression of knee osteoarthritis.

Umbilical cord-derived mesenchymal stem cells for treating osteoarthritis of the knee: a single-arm, open-label study

BACKGROUND

Despite being a common cause of quality-of-life impairment, there are no efficacious therapies that could prevent the progression of knee osteoarthritis (KOA). We conducted an open-label trial of human umbilical cord-derived mesenchymal stem cells (hUC-MSCs) and hyaluronic acid (HA) for treating KOA.

METHODS

This open-label study was conducted from July 2015 to December 2018 at Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Patients diagnosed with KOA were injected three times, comprising of 10 × 106 units of hUC-MSCs in 2-ml secretome implantation and 2-ml hyaluronic acid (HA) injection in the first week, followed with 2-ml HA injection twice in the second and third week.

RESULTS

Twenty-nine subjects (57 knees) were recruited. Seventeen (58.6%) subjects were male, and the mean age was 58.3 ± 9.6 years. Thirty-three (57.9%) knees were classified into Kellgren-Lawrence grade I-II KOA (mild OA). hUC-MSCs significantly decreased pain measured by visual analogue scale in severe KOA from initial to 6th month follow-up [5 ± 2.97 to 3.38 ± 2.44 (p = 0.035)]. The International Knee Documentation Committee score significantly increased at 6th month follow-up (53.26 ± 16.66 to 65.49 ± 13.01, p < 0.001, in subjects with grade I-II and 48.84 ± 18.41 to 61.83 ± 18.83, p = 0.008, in subjects with severe KOA). The Western Ontario and McMaster Universities Osteoarthritis decreased significantly in both groups from initial to 6th month follow-up (from 22.55 ± 15.94 to 13.23 ± 10.29, p = 0.003, and from 27.57 ± 15.99 to 17.92 ± 19.1, p = 0.003, in those with mild and severe KOA, respectively).

CONCLUSIONS

hUC-MSCs could be a potentially new regenerative treatment for KOA. The maximum effect of hUC-MSCs was achieved after 6 months of injection.

LEVEL OF EVIDENCE

Therapeutic level II.

IDENTIA Registry: Incidence of Deep Vein Thrombosis in Medically Ill Subjects at High Risk in Indonesia: A Prospective Study

BACKGROUND

medically ill hospitalized patients are at risk of deep vein thrombosis (DVT) and consequentially have high chances of mortality. In Indonesia, there is disparity in healthcare facility and data on incidence of DVT in this multi-ethnic, geographically unique country with large population are limited. Hence, we determined the incidence of DVT and evaluated mean Wells score among medically ill hospitalized persons at increased risk.

METHODS

in this multicenter, prospective, observational registry in Indonesia, subjects (age >40 years) with acute medical illness (like cancer, acute infection, or severe respiratory disease) confined to bed for >3 days were enrolled between January 2016 and November 2017. Data for medical history, Wells score, and DVT diagnosis with compression ultrasonography (CUS) were recorded. DVT incidence was analyzed in eligible and evaluable groups. Data were analyzed by descriptive method.

RESULTS

out of 360 subjects enrolled, 334 were included in the eligible group for analyses. CUS could not be performed in 26 subjects. Thus, 308 subjects who completed the study were included in the evaluable group. Javanese were predominant in the eligible group and obesity was the most common medical history at presentation. Overall, incidence of DVT in eligible and evaluable patients was 37.1% and 40.3%, respectively. Mean (SD) Wells score and bedridden days were 3 (1.20) and 9 (6.89), respectively.

CONCLUSION

this study indicated that the incidence of DVT is high in medically ill patients in Indonesia and will provide new insights and awareness about DVT in Indonesia.

Trans-arterial embolization of acquired uterine arteriovenous malformation after Cesarean section: A case series

Background

Acquired uterine arteriovenous malformation (AVM) is a rare condition due to traumatic episodes in cesarean section. The patient can suffer from life-threatening hemorrhage or recurrent vaginal bleeding. Establishing this diagnosis is difficult, often misdiagnosed due to lack of information and number of cases. Trans-Arterial Embolization (TAE) procedure is rarely performed in our center. All of the cases were found with history of massive bleeding and diagnosed lately after recurrent bleeding history. Even though promising, one of our cases failed to be managed with TAE. It is important to diagnose early symptoms of AVM in order to prevent the life threatening event.

Case presentation

In these case series, four cases of AVMs after cesarean procedures will be reviewed. One could be diagnosed in less than a month but the other three took several months. The symptom of vaginal bleeding might occur a few weeks after the procedure is done, and most patients need transfusion and hospitalization. Three out of four patients were initially sent to the hospital in order to recover from shock condition, and one patient was sent for a diagnostic procedure. AVMs diagnostic was established with ultrasound with or without angiography. Three of our cases were succeeded by performing TAE procedure without further severe vaginal bleeding. One case failed to be treated with embolization and had to proceed with hysterectomy.

Conclusion

AVM should be considered early-on in patient with abnormal uterine bleeding and history of cesarean section. Embolization is still the first-choice treatment of AVMs, otherwise definitive treatment is hysterectomy in a patient without fertility need, or impossible to perform TAE.

Modified exorotation graft tension for tibial fixation in anterior cruciate ligament reconstruction: a randomized controlled trial

Background: The inability of anterior cruciate ligament reconstruction (ACLR) surgery to reduce tibial internal rotation causes many problems. A large tibial internal rotation will result in a patellofemoral pain syndrome. This study aimed to introduce a new technique of modified exorotation graft tension at tibial fixation to minimize endorotation, reduce tibial internal rotation, and prevent patellofemoral pain syndrome.Methods: This study was a randomized double-blind controlled clinical trial. ACL rupture patients underwent ACLR surgery between December 2014 and Februrary 2015. They were randomized to standard endorotation group or modified exorotation group. Hamstring autograft was used and fixed with an EndoButton® and bioabsorbable interference screw. Tibial tubercle to trochlear grove (TTTG) was used to evaluate rotation, whereas cartilage oligomeric matrix protein (COMP) was employed to analyze cartilage breakdown. The functional outcome was measured using the Kujala score to assess patellofemoral joint function. Evaluations were conducted before the surgery and at 6 months postoperation.Results: A total of 29 subjects were recruited. Sixteen subjects were allocated into the standard endorotation group, and 13 were assigned to the modified exorotation group. The exorotation group demonstrated better results than the endorotation group in all three parameters: TTTG (p=0.028), COMP (p<0.001), and Kujala score (p=0.015).Conclusion: A new technique of modified exorotation direction of graft tension for ACL reconstructive surgery at tibial fixation showed a significant reduction in tibial internal rotation and cartilage breakdown. The proposed method could significantly improve the functional outcome of those with total ACL rupture.

Poor memory performance in aged cynomolgus monkeys with hippocampal atrophy, depletion of amyloid beta 1-42 and accumulation of tau proteins in cerebrospinal fluid

BACKGROUND

Due to their similarities in behavior and disease pathology to humans, non-human primate models are desirable to complement small animals as models for the study of age-related dementia.

MATERIALS AND METHODS

Based on their performance on delayed response task (DRT) tests of memory, aged cynomolgus monkeys were divided into two groups to compare high-performing (n=6) and low-performing (n=6) subjects. Both groups were tested for biomarkers related to Alzheimer's disease and their brains were scanned using structural magnetic resonance imaging.

RESULTS

The subjects with poor DRT performance had evidence of atrophy in the hippocampus and cortical areas, significantly lower cerebrospinal fluid levels of amyloid beta amino acid 1-42 (p<0.001) and higher cerebrospinal fluid total tau levels (p<0.05) compared to the group performing well on the DRT tests.

CONCLUSION

Old, memory-impaired Cynomolgus monkeys may be useful as a spontaneous non-human primate model for investigations of age-related neurodegenerative diseases.