Post-traumatic cerebral infarction (PTCI) is a secondary insult which causes global cerebral hypoxia or hypoperfusion after traumatic brain injury, and carries a remarkable high mortality rate. PTCI is usually caused by blunt brain injury with gross hematoma and/or brain herniation. Herein, we present the case of a 91-year-old male who had sustained PTCI following a low-energy penetrating craniocerebral injury due to a nail without evidence of hematoma. The patient survived after a decompressive craniectomy, but permanent neurological damage occurred. This is the first case of profound PTCI following a low-energy penetrating craniocerebral nail injury and reminds clinicians of possibility this rare dreadful complication for care of head-injured patients.
Brain ; Brain Edema ; Brain Injuries ; Cerebral Infarction* ; Craniocerebral Trauma* ; Decompressive Craniectomy ; Hematoma ; Humans ; Hypoxia, Brain ; Male ; Mortality

BACKGROUNDSpine surgery using computer-assisted navigation (CAN) has been proven to result in low screw misplacement rates, low incidence of radiation exposure and excellent operative field viewing versus the conventional intraoperative image intensifier (CIII). However, as we know, few previous studies have described the learning curve of CAN in spine surgery.

METHODSWe performed two consecutive case cohort studies on pedicel screw accuracy and operative time of two spine surgeons with different experience backgrounds, A and B, in one institution during the same period. Lumbar pedicel screw cortical perforation rate and operative time of the same kind of operation using CAN were analyzed and compared using CIII for the two surgeons at initial, 6 months and 12 months of CAN usage.

RESULTSCAN spine surgery had an overall lower cortical perforation rate and less mean operative time compared with CIII for both surgeon A and B cohorts when total cases of four years were included. It missed being statistically significant, with 3.3% versus 4.7% (P = 0.191) and 125.7 versus 132.3 minutes (P = 0.428) for surgeon A and 3.6% versus 6.4% (P = 0.058), and 183.2 versus 213.2 minutes (P = 0.070) for surgeon B. In an attempt to demonstrate the learning curve, the cases after 6 months of the CAN system in each surgeon's cohort were compared. The perforation rate decreased by 2.4% (P = 0.039) and 4.3% (P = 0.003) and the operative time was reduced by 31.8 minutes (P = 0.002) and 14.4 minutes (P = 0.026) for the CAN groups of surgeons A and B, respectively. When only the cases performed after 12 months using the CAN system were considered, the perforation rate decreased by 3.9% (P = 0.006) and 5.6% (P < 0.001) and the operative time was reduced by 20.9 minutes (P < 0.001) and 40.3 minutes (P < 0.001) for the CAN groups of surgeon A and B, respectively.

CONCLUSIONSIn the long run, CAN spine surgery decreased the lumbar screw cortical perforation rate and operative time. The learning curve showed a sharp drop after 6 months of using CAN that plateaued after 12 months; which was demonstrated by both perforation rate and operative time data. Careful analysis of the data showed CAN is especially useful for less experienced surgeon to reduce perforation rate and intraoperative time, although further comparative studies are anticipated.

Background/Aims: Anti-reflux mucosal ablation (ARMA) is a promising endoscopic intervention for proton pump inhibitor (PPI)-dependent gastroesophageal reflux disease (GERD). However, the effect of ARMA on esophageal motility remains unclear. Methods: Twenty patients with PPI-dependent GERD receiving ARMA were prospectively enrolled. Comprehensive self-report symptom questionnaires, endoscopy, 24-hour impedance-pH monitoring, and high-resolution impedance manometry were performed and analyzed before and 3 months after ARMA. Results: All ARMA procedures were performed successfully. Symptom scores, including GerdQ (11.16 ± 2.67 to 9.11 ± 2.64, P = 0.026) and reflux symptom index (11.63 ± 5.62 to 6.11 ± 3.86, P = 0.001), improved significantly, while 13 patients (65%) reported discontinuation of PPI. Total acid exposure time (5.84 ± 4.63% to 2.83 ± 3.41%, P = 0.024) and number of reflux episodes (73.05 ± 19.34 to 37.55 ± 22.71, P < 0.001) decreased significantly after ARMA. Improved esophagogastric junction (EGJ) barrier function, including increased lower esophageal sphincter resting pressure (13.89 ± 10.78 mmHg to 21.68 ± 11.5 mmHg, P = 0.034), 4-second integrated relaxation pressure (5.75 ± 6.42 mmHg to 9.99 ± 5.89 mmHg, P = 0.020), and EGJ-contractile integral(16.42 ± 16.93 mmHg · cm to 31.95 ± 21.25 mmHg · cm, P = 0.016), were observed. Esophageal body contractility also increased significantly (distal contractile integral, 966.85 ± 845.84 mmHg · s · cm to 1198.8 ± 811.74 mmHg · s · cm, P = 0.023). Patients with symptom improvement had better pre-AMRA esophageal body contractility. Conclusions ARMA effectively improves symptoms and reflux burden, EGJ barrier function, and esophageal body contractility in patients with PPIdependent GERD during short-term evaluation. Longer follow-up to clarify the sustainability of ARMA is needed.

Background/Aims: Anti-reflux mucosal ablation (ARMA) is a promising endoscopic intervention for proton pump inhibitor (PPI)-dependent gastroesophageal reflux disease (GERD). However, the effect of ARMA on esophageal motility remains unclear. Methods: Twenty patients with PPI-dependent GERD receiving ARMA were prospectively enrolled. Comprehensive self-report symptom questionnaires, endoscopy, 24-hour impedance-pH monitoring, and high-resolution impedance manometry were performed and analyzed before and 3 months after ARMA. Results: All ARMA procedures were performed successfully. Symptom scores, including GerdQ (11.16 ± 2.67 to 9.11 ± 2.64, P = 0.026) and reflux symptom index (11.63 ± 5.62 to 6.11 ± 3.86, P = 0.001), improved significantly, while 13 patients (65%) reported discontinuation of PPI. Total acid exposure time (5.84 ± 4.63% to 2.83 ± 3.41%, P = 0.024) and number of reflux episodes (73.05 ± 19.34 to 37.55 ± 22.71, P < 0.001) decreased significantly after ARMA. Improved esophagogastric junction (EGJ) barrier function, including increased lower esophageal sphincter resting pressure (13.89 ± 10.78 mmHg to 21.68 ± 11.5 mmHg, P = 0.034), 4-second integrated relaxation pressure (5.75 ± 6.42 mmHg to 9.99 ± 5.89 mmHg, P = 0.020), and EGJ-contractile integral(16.42 ± 16.93 mmHg · cm to 31.95 ± 21.25 mmHg · cm, P = 0.016), were observed. Esophageal body contractility also increased significantly (distal contractile integral, 966.85 ± 845.84 mmHg · s · cm to 1198.8 ± 811.74 mmHg · s · cm, P = 0.023). Patients with symptom improvement had better pre-AMRA esophageal body contractility. Conclusions ARMA effectively improves symptoms and reflux burden, EGJ barrier function, and esophageal body contractility in patients with PPIdependent GERD during short-term evaluation. Longer follow-up to clarify the sustainability of ARMA is needed.

Background/Aims: Anti-reflux mucosal ablation (ARMA) is a promising endoscopic intervention for proton pump inhibitor (PPI)-dependent gastroesophageal reflux disease (GERD). However, the effect of ARMA on esophageal motility remains unclear. Methods: Twenty patients with PPI-dependent GERD receiving ARMA were prospectively enrolled. Comprehensive self-report symptom questionnaires, endoscopy, 24-hour impedance-pH monitoring, and high-resolution impedance manometry were performed and analyzed before and 3 months after ARMA. Results: All ARMA procedures were performed successfully. Symptom scores, including GerdQ (11.16 ± 2.67 to 9.11 ± 2.64, P = 0.026) and reflux symptom index (11.63 ± 5.62 to 6.11 ± 3.86, P = 0.001), improved significantly, while 13 patients (65%) reported discontinuation of PPI. Total acid exposure time (5.84 ± 4.63% to 2.83 ± 3.41%, P = 0.024) and number of reflux episodes (73.05 ± 19.34 to 37.55 ± 22.71, P < 0.001) decreased significantly after ARMA. Improved esophagogastric junction (EGJ) barrier function, including increased lower esophageal sphincter resting pressure (13.89 ± 10.78 mmHg to 21.68 ± 11.5 mmHg, P = 0.034), 4-second integrated relaxation pressure (5.75 ± 6.42 mmHg to 9.99 ± 5.89 mmHg, P = 0.020), and EGJ-contractile integral(16.42 ± 16.93 mmHg · cm to 31.95 ± 21.25 mmHg · cm, P = 0.016), were observed. Esophageal body contractility also increased significantly (distal contractile integral, 966.85 ± 845.84 mmHg · s · cm to 1198.8 ± 811.74 mmHg · s · cm, P = 0.023). Patients with symptom improvement had better pre-AMRA esophageal body contractility. Conclusions ARMA effectively improves symptoms and reflux burden, EGJ barrier function, and esophageal body contractility in patients with PPIdependent GERD during short-term evaluation. Longer follow-up to clarify the sustainability of ARMA is needed.

Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is predominantly an inherited cardiomyopathy with typical histopathological characteristics of fibro-fatty infiltration mainly involving the right ventricular (RV) inflow tract, RV outflow tract, and RV apex in the majority of patients. The above pathologic evolution frequently brings patients with ARVD/C to medical attention owing to the manifestation of syncope, sudden cardiac death (SCD), ventricular arrhythmogenesis, or heart failure. To prevent future or recurrent SCD, an implantable cardiac defibrillator (ICD) is highly desirable in patients with ARVD/C who had experienced unexplained syncope, hemodynamically intolerable ventricular tachycardia (VT), ventricular fibrillation, and/or aborted SCD. Notably, the management of frequent ventricular tachyarrhythmias in ARVD/C is challenging, and the use of antiarrhythmic drugs could be unsatisfactory or limited by the unfavorable side effects. Therefore, radiofrequency catheter ablation (RFCA) has been implemented to treat the drug-refractory VT in ARVD/C for decades. However, the initial understanding of the link between fibro-fatty pathogenesis and ventricular arrhythmogenesis in ARVD/C is scarce, the efficacy and prognosis of endocardial RFCA alone were limited and disappointing. The electrophysiologists had broken through this frontier after better illustration of epicardial substrates and broadly application of epicardial approaches in ARVD/C. In recent works of literature, the application of epicardial ablation also successfully results in higher procedural success and decreases VT recurrences in patients with ARVD/C who are refractory to the endocardial approach during long-term follow-up. In this article, we review the important evolution on the delineation of arrhythmogenic substrates, ablation strategies, and ablation outcome of VT in patients with ARVD/C.
Anti-Arrhythmia Agents ; Arrhythmogenic Right Ventricular Dysplasia ; Cardiomyopathies ; Catheter Ablation ; Catheters ; Death, Sudden, Cardiac ; Defibrillators ; Epicardial Mapping ; Follow-Up Studies ; Heart Failure ; Humans ; Prognosis ; Recurrence ; Syncope ; Tachycardia ; Tachycardia, Ventricular ; Ventricular Fibrillation

BACKGROUND AND OBJECTIVES: The differences between electromagnetic-based mapping (EM) and impedance-based mapping (IM) in 3D anatomical reconstruction have not been fully clarified. We aimed to investigate the anatomical accuracy between EM (MediGuide™) and IM (EnSite Velocity™) systems. METHODS: We investigated 15 consecutive patients (10 males, mean age 58±9 years) who underwent pulmonary veins (PVs) isolation for paroxysmal atrial fibrillation (PAF). Contrast-enhanced computed tomography (CT) image of the left atrium (LA) was acquired before ablation and the 3D geometry of the LA was constructed using EM during ablation procedure. We measured the 4 PV angles between the main trunk of each PV and the posterior LA after field scaling. Additionally, the posterior LA surface area was measured. The variables were compared to those of CT-based geometry. A control group of 40 patients who underwent conventional PVs isolation using IM were also evaluated. RESULTS: The actual and relative changes of EM and CT-based geometry in all PV angles and posterior LA were significantly smaller compared to those of IM and CT-based geometry. Intraclass correlation coefficient (ICC) between EM and CT-based geometry were 0.871 (right superior pulmonary vein [RSPV]), 0.887 (right inferior pulmonary vein [RIPV]), 0.853 (left superior pulmonary vein [LSPV]), 0.911 (left inferior pulmonary vein [LIPV]), and 0.833 (posterior LA). On the other hand, ICC between IM and CT-based geometry were 0.548 (RSPV), 0.639 (RIPV), 0.691 (LSPV), 0.706 (LIPV), and 0.568 (posterior LA). CONCLUSIONS: Image integration with EM enables high accurate visualization of cardiac anatomy compared to IM in PAF ablation.
Atrial Fibrillation ; Atrial Flutter ; Catheters ; Fluoroscopy ; Hand ; Heart Atria ; Humans ; Magnets ; Male ; Pulmonary Veins

Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is predominantly an inherited cardiomyopathy with typical histopathological characteristics of fibro-fatty infiltration mainly involving the right ventricular (RV) inflow tract, RV outflow tract, and RV apex in the majority of patients. The above pathologic evolution frequently brings patients with ARVD/C to medical attention owing to the manifestation of syncope, sudden cardiac death (SCD), ventricular arrhythmogenesis, or heart failure. To prevent future or recurrent SCD, an implantable cardiac defibrillator (ICD) is highly desirable in patients with ARVD/C who had experienced unexplained syncope, hemodynamically intolerable ventricular tachycardia (VT), ventricular fibrillation, and/or aborted SCD. Notably, the management of frequent ventricular tachyarrhythmias in ARVD/C is challenging, and the use of antiarrhythmic drugs could be unsatisfactory or limited by the unfavorable side effects. Therefore, radiofrequency catheter ablation (RFCA) has been implemented to treat the drug-refractory VT in ARVD/C for decades. However, the initial understanding of the link between fibro-fatty pathogenesis and ventricular arrhythmogenesis in ARVD/C is scarce, the efficacy and prognosis of endocardial RFCA alone were limited and disappointing. The electrophysiologists had broken through this frontier after better illustration of epicardial substrates and broadly application of epicardial approaches in ARVD/C. In recent works of literature, the application of epicardial ablation also successfully results in higher procedural success and decreases VT recurrences in patients with ARVD/C who are refractory to the endocardial approach during long-term follow-up. In this article, we review the important evolution on the delineation of arrhythmogenic substrates, ablation strategies, and ablation outcome of VT in patients with ARVD/C.

BACKGROUND AND OBJECTIVES: The differences between electromagnetic-based mapping (EM) and impedance-based mapping (IM) in 3D anatomical reconstruction have not been fully clarified. We aimed to investigate the anatomical accuracy between EM (MediGuide™) and IM (EnSite Velocity™) systems. METHODS: We investigated 15 consecutive patients (10 males, mean age 58±9 years) who underwent pulmonary veins (PVs) isolation for paroxysmal atrial fibrillation (PAF). Contrast-enhanced computed tomography (CT) image of the left atrium (LA) was acquired before ablation and the 3D geometry of the LA was constructed using EM during ablation procedure. We measured the 4 PV angles between the main trunk of each PV and the posterior LA after field scaling. Additionally, the posterior LA surface area was measured. The variables were compared to those of CT-based geometry. A control group of 40 patients who underwent conventional PVs isolation using IM were also evaluated. RESULTS: The actual and relative changes of EM and CT-based geometry in all PV angles and posterior LA were significantly smaller compared to those of IM and CT-based geometry. Intraclass correlation coefficient (ICC) between EM and CT-based geometry were 0.871 (right superior pulmonary vein [RSPV]), 0.887 (right inferior pulmonary vein [RIPV]), 0.853 (left superior pulmonary vein [LSPV]), 0.911 (left inferior pulmonary vein [LIPV]), and 0.833 (posterior LA). On the other hand, ICC between IM and CT-based geometry were 0.548 (RSPV), 0.639 (RIPV), 0.691 (LSPV), 0.706 (LIPV), and 0.568 (posterior LA). CONCLUSIONS Image integration with EM enables high accurate visualization of cardiac anatomy compared to IM in PAF ablation.

Purpose: Active surveillance (AS) is one of the management options for patients with low-risk and select intermediate-risk prostate cancer (PC). However, factors predicting disease reclassification and conversion to active treatment from a large population of pure Asian cohorts regarding AS are less evaluated. This study investigated the intermediate-term outcomes of patients with localized PC undergoing AS. Materials and Methods: This cohort study enrolled consecutive men with localized non-high-risk PC diagnosed in Taiwan between June 2012 and Jan 2023. The study endpoints were disease reclassification (either pathological or radiographic progression) and conversion to active treatment. The factors predicting endpoints were evaluated using the Cox proportional hazards model. Results: A total of 405 patients (median age: 67.2 years) were consecutively enrolled and followed up with a median of 64.6 months. Based on the National Comprehensive Cancer Network (NCCN) risk grouping, 70 (17.3%), 164 (40.5%), 140 (34.6%), and 31 (7.7%) patients were classified as very low-risk, low-risk, favorable-intermediate risk, and unfavorable intermediate-risk PC, respectively. The 5-year reclassification rates were 24.8%, 27.0%, 18.6%, and 25.3%, respectively. The 5-year conversion rates were 20.4%, 28.8%, 43.6%, and 37.8%, respectively. A prostate-specific antigen density (PSAD) of ≥0.15 ng/mL2 predicted reclassification (hazard ratio [HR] 1.84, 95% confidence interval [CI] 1.17–2.88) and conversion (HR 1.56, 95% CI 1.05–2.31). A maximal percentage of cancer in positive cores (MPCPC) of ≥15% predicted conversion (15% to <50%: HR 1.41, 95% CI 0.91–2.18; ≥50%: HR 1.97, 95% CI 1.1453–3.40) compared with that of <15%. A Gleason grade group (GGG) of 3 tumor also predicted conversion (HR 2.69, 95% CI 1.06–6.79; GGG 3 vs 1). One patient developed metastasis, but none died of PC during the study period (2,141 person-years). Conclusions AS is a viable option for Taiwanese men with non-high-risk PC, in terms of reclassification and conversion. High PSAD predicted reclassification, whereas high PSAD, MPCPC, and GGG predicted conversion.