Predictors of Outcomes in Endoscopies for Foreign Body Ingestion: A Cross-Sectional Study

BACKGROUND

As foreign body ingestion/food impaction is one of the less common indications for upper endoscopy in adults, few studies have investigated outcomes. We aimed to determine the distribution of ingested items warranting endoscopy and to identify factors associated with successful endoscopic retrieval.

METHODS

We conducted a retrospective, cross-sectional study, identifying all endoscopies performed between June 2006 and June 2018 for foreign body ingestion or food impaction. We performed univariate and multivariate analyses to identify variables associated with endoscopic foreign body visualization and successful removal from the mouth.

RESULTS

Of the 168 endoscopies identified, the ingested item was visualized in 131 (78%) and was removed from the mouth in 88 (52.4%). 6.5% of cases required surgery and 2.4% of cases had a perforation noted. The two most common foreign bodies were food boluses (51.2%) and bones (28.6%). Older patients were more likely to have their ingested foreign body visualized during endoscopy (age ≥ 70 compared to 18-29 adjusted odds ratio [aOR] 8.78; 95% CI 1.62-47.70) and more likely to have it removed from the mouth (aOR 5.57; 95% CI 1.34-22.85). Bones were less likely to be visualized on endoscopy (aOR 0.16; 95% CI 0.04-0.57) but not less likely to be removed successfully (aOR 0.85; 95% CI 0.42-1.72). Foreign bodies visible on radiography were more likely to be identified on endoscopy (aOR 9.07; 95% CI 2.71-30.37) and more likely to be successfully removed (aOR 2.82; 95% CI 1.26-6.32).

CONCLUSIONS

Factors such as age, radiographic visibility, and the suspected foreign body may affect the likelihood that it can be visualized and removed. Future studies should focus on further characterizing complications of foreign body ingestions and the types of patients and objects most at risk.

Supramolecular photochemical synthesis of an unsymmetrical cyclobutane

2-styrylbenzothiazole (1) and cinnamic acid (2) derivatives containing 15-crown-5 ether moieties form a supramolecular assembly in the presence of Ba(2+) cations in acetonitrile. The assembly is stabilized by hydrogen bonding between the heterocyclic N atom of 1 and the proton of the carboxylic group of 2, by sandwich Ba(2+) complex formation between the crown ether moieties of 1 and 2, and by pi-pi stacking interactions. Irradiation of solutions containing these supramolecular complexes leads to highly specific formation of an unsymmetrical cycloadduct. This investigation provides an interesting example of supramolecular control of [2 + 2]-photocyclization in solution.

The Photochemistry of a bis-Crown Ether Based on Benzobis(thiazole) and Its Alkaline Earth Metal Cation Complexes

Irradiation of acetonitrile solutions of the bis-crown ether E,E-2,7-bis[2-(6,7,9,10,12,13,15,16-octahydro-5,8,11,14,17-pentaoxabenzocyclopentadecen-2-yl)vinyl]-benzo[1,2-d;3,4-d']bisthiazole (hereafter, 1) gives efficient E --> Z photoisomerization (initial phi(trans --> cis) = 0.48), leading to lambda(exc)-dependent quasi-photostationary states composed primarily of E,Z and E,E isomer mixtures. Further irradiation gives [2 + 2]-cycloadducts of 1. In the presence of Ba2+ ions, essentially quantitative formation of 2:2 complexes, 1(2) x (Ba2+)2 controls the photochemical outcome. E --> Z photoisomerization of the ligand is entirely suppressed and efficient intramolecular [2 + 2]-photocycloaddition in the complexes leads to cyclobutane dimers of 1 (phiCB = 0.26). The reactivity of 1 in the presence of Mg2+ ions for which 1:2 complex formation dominates gives both cis-trans photoisomerization and enhanced photocycloaddition.

Synthesis and multitopic complex formation of a photochromic bis(crown ether) based on benzobis(thiazole)

2,7-Bis[2-(6,7,9,10,12,13,15,16-octahydro-5,8,11,14,17-pentaoxabenzocyclopentadecen-2-yl)vinyl]-benzo[1,2-d;3,4-d']bisthiazole, 2, with crown ether styryl moieties substituted on a heterocyclic core, was synthesized and its complex forming ability with several metal cations was evaluated in acetonitrile by absorption and fluorescence spectroscopy. The results are compared to those for the analogous ligand possessing a single crown ether styryl moiety. Selective binding of the metal cation at the heterocyclic core of both ligands was observed only for Hg2+. Alkali and alkaline earth cations bind selectively at the crown ether moieties. Stability constants and pure spectra of defined stoichiometry were determined with the use of HYPERQUAD, a least-squares fitting program, and the results were validated in one case by subjecting the titration spectral matrix to singular value decomposition with self-modeling (SVD-SM). The multitopic ligand 2 forms relatively strong 2:2 stoichiometric complexes with K+, among the alkali metal cations, and Ba2+, among the alkaline earth metal cations, and is a promising selective optical sensor for these ions.

Dissecting the photocycle of the bacteriorhodopsin E204Q mutant from kinetic multichannel difference spectra. Extension of the method of singular value decomposition with self-modeling to five components

Kinetic multichannel difference spectroscopy in the visible spectral range of the Glu204 --> Gln(E204Q) site-directed mutant of bacteriorhodopsin revealed five spectrally distinct metastable intermediates, as for the wild type. Due to the perturbation of the extracellular proton release cluster, the late O intermediate accumulates in much higher amounts in this mutant, and the photocycle is not complicated by the pH-dependent branching observed in the wild type protein. This mutant is therefore more amenable than the wild type to the determination of the intermediate spectra with the method of singular value decomposition with self-modeling, developed recently for three components (Zimányi et al. Proc. Natl. Acad. Sci. U.S.A. 1999, 96, 4408-4413, 4414-4419). The method provides the most reliable spectra so far, defining the time evolution of the intermediates essential to the determination of the reaction scheme that describes the photocycle. The analysis confirms published results on this mutant by and large, but revises the locations of the L intermediates in the photocycle. In addition, it allows identification of the pH-dependent transitions of the photocycle, and offers an alternative mechanism for the pH dependence of the yield and kinetics of the late O intermediate.

Intermediate spectra and photocycle kinetics of the Asp96 --> asn mutant bacteriorhodopsin determined by singular value decomposition with self-modeling

Singular value decomposition with self-modeling is applied to resolve the intermediate spectra and kinetics of the Asp96 --> Asn mutant bacteriorhodopsin. The search for the difference spectra of the intermediates is performed in eigenvector space on the stoichiometric plane. The analysis of data at pH values ranging from 4 to 8 and temperatures between 5 and 25 degrees C reveals significant, early partial recovery of the initial state after photoexcitation. The derived spectra are not biased by assumed photocycles. The intermediate spectra derived in the initial step differ from spectra determined in prior analyses, which results in intermediate concentrations with improved stoichiometric properties. Increasingly more accurate photocycles follow with increasing assumed complexity, of which parallel models are favored, consistent with recent, independent experimental evidence.

Singular value decomposition with self-modeling applied to determine bacteriorhodopsin intermediate spectra: analysis of simulated data

An a priori model-independent method for the determination of accurate spectra of photocycle intermediates is developed. The method, singular value decomposition with self-modeling (SVD-SM), is tested on simulated difference spectra designed to mimic the photocycle of the Asp-96 --> Asn mutant of bacteriorhodopsin. Stoichiometric constraints, valid until the onset of the recovery of bleached bacteriorhodopsin at the end of the photocycle, guide the self-modeling procedure. The difference spectra of the intermediates are determined in eigenvector space by confining the search for their coordinates to a stoichiometric plane. In the absence of random noise, SVD-SM recovers the intermediate spectra and their time evolution nearly exactly. The recovery of input spectra and kinetics is excellent although somewhat less exact when realistic random noise is included in the input spectra. The difference between recovered and input kinetics is now visually discernible, but the same reaction scheme with nearly identical rate constants to those assumed in the simulation fits the output kinetics well. SVD-SM relegates the selection of a photocycle model to the late stage of the analysis. It thus avoids derivation of erroneous model-specific spectra that result from global model-fitting approaches that assume a model at the outset.

Clinical and angiographic correlates and prognostic significance of the coronary extent score

The clinical and angiographic correlates and the prognostic significance of the "coronary extent score" in a consecutive series of 313 patients who were catheterized twice were studied. The extent score was defined as the number of 5 to 75% stenosed segments in a 15-segment coding system. The extent score was higher in subgroups of patients with new onset angina at the time of the first angiogram (4.3 +/- 2.4 vs 3.3 +/- 1.9, p less than 0.01), unstable angina at the time of the second angiogram (4.0 +/- 2.0 vs 3.3 +/- 1.9, p less than 0.05) or multifocal progression from the first to the second angiogram (4.0 +/- 2.1 vs 3.3 +/- 1.9, p less than 0.01), suggesting that it is an index of active coronary artery disease. The extent score did not correlate with the number of diseased vessels (r = 0.03), the ejection fraction (r = 0.03), the Friesinger score (r = 0.04) and the Gensini score (r = -0.07) (difference not significant for each). Cox's model was fit to the survival data recorded on a prospective basis after the second angiogram. Independent predictors of survival were ejection fraction (p less than 0.001), extent score (p = 0.001), number of diseased vessels (p = 0.01) and percent of left main luminal stenosis (p less than 0.05). The extent score was also an independent predictor of myocardial infarction and unstable angina. Thus, the extent score, an index of active progressive disease, is an independent predictor of mortality and cardiac events in patients with coronary artery disease.

Undergraduate radiology clerkship: the Universite de Montreal program

At the Université de Montréal, a four-week rotation in radiology is part of the core curriculum for students in their fifth and final year of medicine. The objective of this undergraduate radiology clerkship is to prepare the future physician to use efficiently the resources of radiology and nuclear medicine in patient care. Specific goals and methods used to achieve them are described and analysed.

Progression of obstructive coronary artery disease 5 to 7 years after aortocoronary bypass surgery

Changes in the native coronary circulation were evaluated 5 to 7 years (72 +/- 10 months) after aortocoronary bypass surgery in 108 patients; 104 had had previous angiographic controls between 6 and 18 months following surgery. Coronary artery narrowings were graded on a scale of 0 to 6, 0 being normal, grade 1 and 2, < or = 50%; grade 3, 51-75%; grade 4, 76-90%; grade 5, 91-99% narrowing and grade 6 total occlusion. Progression of disease was significant when a preexisting stenosis increased at least 1 grade or a new lesion > 50% developed. Nongrafted vessels were compared to arteries with patent or occluded grafts. During the first year following surgery, the rate of progression was much higher in grafted arteries with patent or occluded grafts than in nongrafted arteries 157 and 53% vs 9.5% respectively, P < 0.001). During the subsequent period of approximately 5 years, however, grafted arteries did not change, whereas the rate of progression in nongrafted arteries increased from 9.5 to 46%. At 5 to 7 years after surgery, grade 1 and 2 (< or = 50%) narrowings progressed slightly more frequently in grafted arteries because of surgically related events. However, for narrowings > 50% and for new lesions, there was no difference in the rate of progression between grafted and nongrafted vessels. In conclusion, the rate of progression of atherosclerosis in nongrafted coronary arteries is important. At 5 to 7 years after surgery, there is little or no difference in the severity of the disease in the proximal segments of grafted and nongrafted coronary arteries.

Clinical, angiographic, and hemodynamic findings in patients with anomalous origin of the coronary arteries

Clinical and angiographic features of 31 patients with anomalous coronpary artery origin are reviewed. Of 17 aberrant circumflex arteries from the right sinus of Valsalva or artery, each was retro-aortic, six atherosclerotic, and seven irrigated a small area of myocardium. Of seven anomalous right coronary arteries from the left sinus of Valsalva or artery, each was ante-aortic and two atherosclerotic. Aberrant origin of the circumflex or right coronary artery was a benign anomaly. The proximal course of seven aberrant left coronary arteries from the right sinus of Valsalva or right coronary artery was related to clinical events. The anomaly was best demonstrated in the lateral view. In five cases, coronary blood flow during exercise and myocardial metabolism during pacing were assessed. Two had had a previous infarction with nonatherosclerotic arteries. Exercise coronary blood flow was normal in four and low in one patient. Pacing resulted in lactate production in two with atherosclerotic and one without atherosclerotic arteries. We conclude that anomalous left coronpary origin from the right sinus of Valsalva can result in significant myocardial ischemia and infarction.

Aberrant course of the left anterior descending coronary artery assoicated with anomalous left circumflex origin from the pulmonary artery

We have presented a two year nonoperative follow-up of an asymptomatic 14-year-old girl with an unusual anomaly of the coronary arteries. Systolic and diastolic murmurs heard preoperatively did not change following severance of a patent ductus arteriosus. Postoperative selective coronary arteriography revealed (1) anomalous orgin of the left anterior descending artery from the right aortic sinus of Valsalva crossing between the aorta and pulmonary artery, (2) aberrant circumflex artery orgin from the pulmonary artery and (3) collaterals from the left anterior descending and right coronary arteries to the circumflex artery. This combination of coronary anomalies has never been described previously.

Angiographic changes in aortocoronary vein grafts: lack of progession beyond the first year

The angiographic aspect of aortocoronary vein grafts was reviewed three years after operation in 43 patients. These patients had been previously subjected to two selective angiographic studies: two weeks and one year after operation. The review of these angiographic studies suggests that the attrition rate of aortocoronary vein grafts levels off after the first year. Only three occlusions (5.4%) were found on the three-year study in the 55 grafts which were patent on the study conducted at one year. Two of the three occlusions occurred in grafts which had already displayed severe segmental reduction in size after one year. Moreover, the slight to moderate reduction in caliber noted in more than 70% of vein grafts between two weeks and one year after operation did not progress between one and three years. Thus, it appears that fibrous hyperplasia. which is believed responsible for these changes, is a time-limited process, and is not expected to progress after the first year.

Fate of left ventricular contraction following aortocoronary venous grafts. Early and late postoperative modifications

Changes in left ventriclar contraction were studied approximately two weeks and one year after surgery in 87 patients having 131 venous grafts. Nineteen out of 37 or 51% of the ventricular wall motion defects revascularized by patent and intact grafts were improved following surgery. Hypokinesis was improved in 17 out of 24 instances (70%) and a normal contraction was restored in nearly half of the cases. Akinesis was improved in two out of 13 instances (15%). Following inadequate venous grafts, 15 out of 35 or 42% of the normal wall segments and four out of 16 or 25% of the hypokinetic wall segments were worse after surgery and late akinesis was frequent. Aortocoronary bypass surgery is followed by significant improvement as well as deterioration of left ventricular contraction and function. The late result of surgery is determined by the fate of aortocoronary venous grafts.

Criteria for internal mammary artery implantation based on cine coronary arteriography

Preoperative coronary arteriograms were correlated, in a group of 50 patients, with left internal mammary angiograms obtained from 11 to 32 months, with a mean of 17 months, after mammary artery implantation. In all patients in whom the internal mammary artery was patent and considered functional with good angiographic opacification of the anterior descending coronary artery, the preoperative coronary angiogram showed total or subtotal obstruction of the latter vessel, with indirect evidence of decreased flow and pressure distal to the obstruction. This evidence was provided by the presence of a collateral circulation or, in a few cases of subtotal obstruction, delayed opacification of the vessel distal to the obstruction.In patients in whom the internal mammary artery was patent but showed no anastomotic connection with the anterior descending coronary artery or only opacification of small coronary branches, the degree of coronary obstruction was, in most cases, less than 90% of the lumen of the coronary artery in the absence of any collateral circulation or delayed opacification of the vessel distal to the obstruction.Occlusion of the internal mammary artery was seen as often in the presence of total or subtotal obstructions as with lesser degrees of anterior descending coronary artery obstruction, and is believed unrelated to the degree of pre-existing coronary artery disease.Successful internal mammary artery implantation can be related to specific coronary angiographic patterns recognizable before operation; these may serve as reliable criteria for the selection of patients.

Selective coronary angiography using a percutaneous femoral technique

Successful use, in 650 patients over a period of two years, of a percutaneous femoral technique of selective coronary angiography is described. This technique is carried out with the use of mouldable, manually preshaped polyethylene catheters. Preparation of the material and the different steps of the technique are discussed. Excellent flexibility and plastic memory of this catheter material allow easy, rapid and consistent percutaneous insertion and removal of catheters and intubation of the coronary arteries.