Defect detection by multi-axis infrared process monitoring of laser beam directed energy deposition

Laser beam directed energy deposition (DED-LB) is an attractive additive manufacturing technique to produce versatile and complex 3D structures on demand, apply a cladding, or repair local defects. However, the quality of manufactured parts is difficult to assess by inspection prior to completion, and parts must be extensively inspected post-production to ensure conformance. Consequently, critical defects occurring during the build go undetected. In this work, a new monitoring system combining three infrared cameras along different optical axes capable of monitoring melt pool geometry and vertical displacement throughout deposition is reported. By combining multiple sensor data, an automated algorithm is developed which is capable of identifying the formation of structural features and defects. An intersecting, thin-walled geometry is used to demonstrate the capability of the system to detect process-induced porosity in samples with narrow intersection angles, which is validated using micro-CT observations. The recorded results indicate the root cause of this process-induced porosity at the intersection, and it is shown that advanced toolpath planning can eliminate such defects. The presented methodology demonstrates the value of multi-axis monitoring for identifying both defects and structural features, providing an advancement towards automated detection and alert systems in DED-LB.

Educational Intervention Reduced Family Medicine Residents' Intention to Request Diagnostic Tests: Results of a Controlled Trial

OBJECTIVE

Dealing with uncertainty is a core competence for physicians. To evaluate the impact of an educational intervention on family medicine residents' (FMRs') intention to request diagnostic tests and their attitudes toward uncertainty.

METHODS

Nonrandomized controlled trial. Intervention group (IG) FMRs participated in interactive "dealing with uncertainty" seminars comprising statistical lessons and diagnostic reasoning. Control group (CG) FMRs participated in seminars without in-depth diagnostic lessons. FMRs completed the Dealing with Uncertainty Questionnaire (DUQ), comprising the Diagnostic Action and Diagnostic Reasoning scales. The Physicians' Reaction to Uncertainty (PRU) questionnaire, comprising 4 scales (Anxiety Due to Uncertainty, Concern about Bad Outcomes, Reluctance to Disclose Uncertainty to Patients, and Reluctance to Disclose Mistakes to Physicians) was also completed. Follow-up was performed 3 months later. Differences were calculated with repeated-measures analysis of variance.

RESULTS

In total, 107 FMRs of the IG and 102 FMRs of the CG participated at baseline and follow-up. The mean (SD) Diagnostic Action scale score decreased from 24.0 (4.8) to 22.9 (5.1) in the IG and increased in the CG from 23.7 (5.4) to 24.1 (5.4), showing significant group difference (P = 0.006). The Diagnostic Reasoning scale increased significantly (P = 0.025) without a significant group difference (P = 0.616), from 19.2 (2.6) to 19.7 (2.4) in the IG and from 18.1 (3.3) to 18.8 (3.2) in the CG. The PRU scale Anxiety Due to Uncertainty decreased significantly (P = 0.029) without a significant group difference (P = 0.116), from 20.5 (4.8) to 18.5 (5.5) in the IG and from 19.9 (5.5) to 19.0 (6.0) in the CG.

CONCLUSION

The structured seminar reduced self-rated diagnostic test requisition. The change in Anxiety Due to Uncertainty and Diagnostic Reasoning might be due to an unspecific accompanying effect of the extra-occupational seminars for residents.

Diagnostic double strike in the emergency room - two cases of complete pancreatic ruptures due to bicycle handlebar injuries on two consecutive days

Background

Pancreatic injuries are rare in cases of blunt abdominal trauma and therefore easily misdiagnosed at time of hospital admission. They are associated with a significantly elevated morbidity and lethality. Bicycle handlebar injuries are the most common cause of pancreatic trauma in children and adolescents.

Case presentation

We report two cases of a 23-year-old Caucasian woman and a 15-year-old Caucasian boy who presented to our clinic with a similar history of a bicycle accident on 2 consecutive days. Both suffered from a fall from a bicycle with bicycle handlebar injury 4 and 6 days prior to admission in our clinic. Emergency distal pancreatectomies were performed in both cases.

Conclusions

Pancreatic injuries must be highly suspected in bicycle handlebar injuries, even if amylase/lipase levels or ultrasound findings seem unremarkable. The best initial strategies are early computed tomography and a quick referral to a level 1 trauma center. Distal pancreatectomy is the treatment of choice in cases of complete rupture of the pancreatic body.

Erratum to: The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

[This corrects the article DOI: 10.1186/s13017-017-0141-6.].

Erratum to: Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

[This corrects the article DOI: 10.1186/s13017-016-0089-y.].

[Clostridium difficile in visceral surgery]

BACKGROUND

For surgeons the early identification of patients with clostridium difficile infections (CDI) is important, because the incidence and virulence of this potentially life-threatening disease are increasing.

OBJECTIVES

The aim of this study was to describe the frequency of CDI among surgical patients, to analyze which treatment was successful and to define which factors were associated with mortality.

METHODS

A retrospective analysis of patients with CDI was performed.

RESULTS

From January 2004 to June 2012 the overall incidence of CDI among all departments at the St. Josef Hospital, Ruhr University Bochum was 0.6 % (1669 out of 301,919 patients). In 2004 the number of surgical patients with CDI was 1 which increased to 41 in 2011. Before the diagnosis of CDI was made 84 % (151 out of 179) of patients had received an antibiotic treatment. Conservative management of CDI was performed with metronidazole in 75 % (134 out of 179), 60 % (107 out of 179) received vancomycin, while 44 % (79 out of 179) received a combination of metronidazole and vancomycin, tygecycline or fidaxomidin. The overall mortality was 7 % (12 out of 179). There was a significant association with mortality for patients with sepsis, readmission to the intensive care unit (ICU), requirement for vasopressor therapy and intubation with mechanical ventilation. In 4 % of patients (7 out of 179) colectomy was carried out. Despite maximum intensive care management, 86 % (6 out of 7) of patients who underwent colectomy ultimately died.

CONCLUSION

Although conservative management is successful for most patients with CDI, the mortality is high for patients who require intensive care management secondary to CDI. Mortality after colectomy for CDI is almost 100 %, mostly because the operation is usually only performed as a last resort in patients with sepsis. The most important risk factor for CDI is a prior antibiotic therapy.

Effects of intra-arterial octreotide on pancreatic texture: a randomized controlled trial

BACKGROUND AND AIMS

Octreotide is suggested to harden the pancreas, thus facilitating the construction of a pancreatic anastomosis and lowering the risk of postoperative fistula. We tested the hypothesis that intra-arterial application of octreotide in the gastroduodenal artery during pancreatectomy may increase pancreatic hardness.

MATERIAL AND METHODS

A single-center, prospective, double-blinded, randomized controlled trial with parallel assignment was conducted. Patients planned for a pancreatoduodenectomy or a total pancreatectomy, who had a palpatory and durometer proven (<40 Shore units) soft pancreas, were assigned to receive intraoperatively either 5 mL 500µg octreotide or 5 mL 0.9% saline solution as a bolus injection in the gastroduodenal artery. Pancreatic hardness was measured before, early, and late after intervention. The investigator performing the durometer measurements and pathologist were masked to group assignment. The primary outcome was increased pancreatic hardness. Analysis was by intention to treat. This trial is registered at http://www.clinicaltrials.gov (ID NCT01400100).

RESULTS

A total of 12 patients received octreotide and 13 received saline solution. Pancreatic hardness marginally increased in the octreotide group: 0.67 ± 2.3 Shore units, whereas it decreased in the control group: -2.15 ± 2.7 Shore units. The difference was statistically significant, p = 0.029 (95% confidence interval = -4.87 to -0.77). Histology did not find any correlate for this clinically irrelevant hardening effect.

CONCLUSIONS

A single bolus application of octreotide did not deliver a clinically relevant increase in pancreatic hardness. Future studies on the hardening effect of octreotide should employ repeated or continuous preoperative administration of this drug.

[Hepaticojejunostomy after pancreatic head resection - technical aspects for reconstruction of small and fragile bile ducts with T-tube drainage]

BACKGROUND

After pancreatic head resection the reconstruction of small and fragile bile ducts is technically demanding, resulting in more postoperative bile leaks. One option for the reconstruction is the placement of a T-tube drainage at the site of the anastomosis.

MATERIAL AND METHODS

Standard reconstruction after pancreatic head resection was an end-to-side hepaticojejunostomy with PDS 5.0, 15-25 cm distally from the pancreaticojejunostomy. For patients with a small bile duct diameter (≤ 5 mm) or a fragile bile duct wall the reconstruction was performed with PDS 6.0 and a T-tube drainage at the side of the anastomosis.

RESULTS

The reconstruction with a T-tube drainage at the site of the anastomosis is technically easy to perform and offers the opportunity for immediate visualisation of the anastomosis in the postoperative period by application of water soluble contrast medium. If a bile leak occurs, biliary deviation through the T-tube drainage can enable a conservative management without revisional laparotomy in selected patients. Whether or not a conservative management of postoperative bile leaks will lead to more bile duct strictures is a subject for further investigations.

CONCLUSION

A T-tube drainage at the site of the anastomosis can probably not prevent postoperative bile leaks from a difficult hepaticojejunostomy, but in selected patients it offers the opportunity for a conservative management resulting in less re-operations. Therefore we recommend the augmentation of a difficult hepaticojejunostomy with a T-tube drainage.

TME quality in rectal cancer surgery

Background

The concept of total mesorectal excision has revolutionised rectal cancer surgery. TME reduces the rate of local recurrence and tumour associated mortality. However, in clinical trials only 50% of the removed rectal tumours have an optimal TME quality. Patients: During a period of 36 months we performed 103 rectal resections. The majority of patients (76%; 78/103) received an anterior resection. The remaining patients underwent either abdominoperineal resection (16%; 17/103), Hartmann's procedure (6%; 6/103) or colectomy (2%; 2/103).

Results

In 90% (93/103) TME quality control could be performed. 99% (92/93) of resected tumours had optimal TME quality. In 1% (1/93) the mesorectum was nearly complete. None of the removed tumours had an incomplete mesorectum. In 98% (91/93) the circumferential resection margin was negative. Major surgical complications occurred in 17% (18/103). 5% (4/78) of patients with anterior resection had anastomotic leakage. 17% (17/103) developed wound infections. Mortality after elective surgery was 4% (4/95).

Conclusion

Optimal TME quality results can be achieved in all stages of rectal cancer with a rate of morbidity and mortality comparable to the results from the literature. Future studies should evaluate outcome and local recurrence in accordance to the degree of TME quality.

Changes in microglial activation within the hindbrain, nodose ganglia, and the spinal cord following subdiaphragmatic vagotomy

Damage to peripheral nerve branches triggers activation of microglia in CNS areas containing motor neuron soma and primary afferent terminals of the damaged fibers. Furthermore, microglial activation occurs in areas containing the soma and terminals of spared nerve branches of a damaged nerve. Because the abdominal viscera are innervated by spinal afferents as well as vagal afferents and efferents, we speculated that spinal nerves might respond like spared nerve branches following damage to vagal fibers. Therefore, we tested the hypothesis that damage to the abdominal vagus would result in microglial activation in vagal structures-the nucleus of the solitary tract (NTS), dorsal motor nucleus of the vagus nerve (DMV), and nodose ganglia (NG)-as well as spinal cord (SC) segments that innervate the abdominal viscera. To test this hypothesis, rats underwent subdiaphragmatic vagotomy or sham surgery and were treated with saline or the microglial inhibitor, minocycline. Microglial activation was determined by quantifying changes in the intensity of fluorescent staining with a primary antibody against ionizing calcium adapter binding molecule 1 (Iba1). We found that subdiaphragmatic vagotomy significantly activated microglia in the NTS, DMV, and NG two weeks post-vagotomy. Microglial activation remained significantly increased in the NG and DMV for at least 42 days. Surprisingly, vagotomy significantly decreased microglial activation in the SC. Minocycline treatment attenuated microglial activation in all studied areas. Our results indicate that microglial activation in vagal structures following abdominal vagal damage is accompanied by suppression of microglial activation in associated areas of the spinal cord.

Complicated sigmoid diverticulitis--Hartmann's procedure or primary anastomosis?

INTRODUCTION

Diverticular disease of the colon is a common condition in developed countries. For perforated diverticulitis Hartmann's procedure is a safe and quick treatment option. But intestinal restoration needs further interventions. This leads to high complication rates and cost. Therefore a critical evaluation of surgical treatment options is necessary.

METHODS

During a period of 18 months 88 patients underwent surgical resection for diverticulitis. Forty patients had emergency surgery. Among those a primary anastomosis was performed in 21 patients. The other 19 patients had interval colostomy. Among 21 patients with primary anastomosis major complications occurred in two patients, vs. twelve in patients with Hartmann's operation (p = 0.03). In the Hartmann group eight patients had major general complications, vs. one patient in the group with primary anastomosis (p = 0.06). The mean hospital stay was 38 days after Hartmann's procedure, vs. 13 days for patients with primary anastomosis (p < 0.01).

CONCLUSION

In emergency surgery for complicated diverticulitis primary anastomosis is not associated with an increased postoperative morbidity. A primary anastomosis reduces the need for further surgical interventions and complex re-operations. Thus, an overall reduction of morbidity, cost, complication rate and hospital stay is possible. Therefore this technique is advantageous for patients and hospitals.

Treatment of complicated intra-abdominal infections in the era of multi-drug resistant bacteria

The management of severe intra-abdominal infections remains a major challenge facing surgeons and intensive care physicians, because of its association with high morbidity and mortality. Surgical management and intensive care medicine have constantly improved, but in the recent years a rapidly continuing emergence of resistant pathogens led to treatment failure secondary to infections with multi-drug resistant bacteria. In secondary peritonitis the rate of resistant germs at the initial operation is already 30%. The lack of effective antibiotics against these pathogens resulted in the development of new broad-spectrum compounds and antibiotics directed against resistant germs. But so far no "super-drug" with efficacy against all resistant bacteria exists. Even more, soon after their approval, reports on resistance against these novel drugs have been reported, or the drugs were withdrawn from the market due to severe side effects. Since pharmaceutical companies reduced their investigations on antibiotic research, only few new antimicrobial derivates are available.

In abdominal surgery you may be in fear that in the future more and more patients with tertiary peritonitis secondary to multi-drug resistant species are seen with an increase of mortality after secondary peritonitis.

This article reviews the current treatment modalities for complicated intra-abdominal infections with special reference to the antibiotic treatment of complicated intra-abdominal infections with multi-drug resistant species.

Health-related quality of life/patient-reported outcomes in relapsed ovarian cancer: Results from a randomized phase III study of trabectedin with pegylated liposomal doxorubicin (PLD) versus PLD alone

5526

Background: In an open-label, multicenter, randomized phase III study comparing the combination of trabectedin and PLD to PLD alone in patients with relapsed ovarian cancer, the combination demonstrated significantly improved progression free survival and response rates, manageable non-cumulative toxicity, and fewer PLD-associated adverse events. We studied the impact of the combination of trabectedin with PLD on the quality of life (QoL)/patient-reported outcomes (PRO) evaluated as part of the trial. Methods: QoL/PRO questionnaires, EORTC-QLQ C30, OV28, and EQ-5D were completed by patients at screening and on Day 1 of every other treatment cycle starting with Cycle 1, and at the end-of-treatment visit. Global health status/QoL, fatigue, rain subscales from QLQ C30, and abdominal pain/GI symptoms scale from OV28 were chosen a priori for primary analyses. Other scales of the three questionnaires were analyzed on a supportive basis. Results: A total of 672 patients were randomized. 663 (98%) completed at least the baseline questionnaires. Median cycles of treatment was 6 (131 days) for the combination arm and 5 (143 days) for the monotherapy arm. Mixed effects models (using a covariance structure of AR[1]) predicting the score at baseline and follow-up scores as a function of treatment, days after baseline, and interaction between treatment and days after baseline showed no significant differences between the treatment arms for any of the prespecified scales. Similar analyses of other scales, including EQ-5D Health Index scores and Health State on the Visual Analog Scale, support the findings. Conclusions: The addition of trabectedin to PLD results in superior efficacy in patients with relapsed ovarian cancer, with no added decrement to overall health status as assessed by PRO.

[Table: see text]

[Intraductal papillary mucinous neoplasms of the pancreas: pro surgical therapy--pro surveillance]

Intraductal papillary mucinous neoplasms (IPMN) are the most common cystic tumours of the pancreas. The preoperative diagnosis of IPMN malignancy is difficult and the majority of IPMN are malignant upon diagnosis. Thus, only the early radical resection of the pancreas with regional lymph node dissection offers the patient a chance for cure. A discussion of the type "to resect or not to resect" should, furthermore, be held only within the walls of high-volume pancreatic centres and patients managed by the "watchful waiting" strategy (mainly branch-duct type IPMN) should all be recruited into large randomised controlled trials aimed to discover reliable diagnostic criteria to differentiate between invasive and non-invasive IPMN. Until then an aggressive surgical approach should be recommended as the standard treatment for all patients with IPMN.

Symptom severity and treatment course of bulimic patients with and without a borderline personality disorder

There are contradictory results concerning the frequency of borderline personality disorder (BPD) in bulimic patients and its impact on eating pathology and treatment outcome. We evaluated 240 patients with bulimia nervosa using EDI-2, SIAB and SCL-90-R. Only a minority of patients had a BPD (13.8%). There were no differences in binging or purging behaviour between patients with and without BPD, but borderline patients had significantly more feelings of ineffectiveness and more disturbances in interoceptive awareness. Bulimic patients with BPD showed significantly more general psychopathology. Although, BPD patients started with higher levels of pathology, there were similar reductions of symptoms over the course of treatment in both groups. Psychotherapy in bulimic patients with a BPD has to focus not only on eating pathology but also on aspects that are caused by the severe personality disturbance.

Clinical outcome of atypical uterine smooth muscle tumors

15028

Background: Smooth muscle tumors of uncertain malignant potential (STUMP) and atypical leiomyomas have increased mitotic activity, cellular atypia and necrosis but the degree is less than that used to define uterine leiomyosarcomas. Our objective is to evaluate the clinical outcome of patients with uterine masses histologically defined as smooth muscle tumors of uncertain malignant potential or atypical leiomyomas. Methods: A thorough search of our institution’s pathology database from 1990 to 2005 was performed. A retrospective chart review was performed to obtain initial and subsequent treatments, documented recurrences and clinical outcomes. Pathology reports and slides were reviewed and the presence of atypia, necrosis and number of mitosis was recorded. Statistical analysis was performed by Student’s T-test. Results: Eighteen patients with a histologic diagnosis of atypical leiomyoma were identified with 14 STUMP, 2 bizarre leiomyomas, 1 myxoid and 1 mitotically active leiomyoma. The mean age of these patients was 41.8 years (range: 25–77) and was significantly younger than those with leiomyosarcoma (mean age was 54 years, p < 0.001). The histologic characteristics of the tumors included the presence of atypia at 50%, necrosis at 82% and mitoses at 94%. The rate of necrosis and number of mitosis was significantly less in the atypical group as compared to the leiomyosarcoma group (p values < 0.05). However the rate of cellular atypia was not statistically different between the two groups. The median follow-up period was 25 months, range 1–138 months. One of the eighteen patients developed a pelvic and pulmonary recurrence at which time a low grade leiomyosarcoma was diagnosed. The recurrence occurred 32 months after the initial diagnosis of a mitotically active leiomyoma. Sixteen patients demonstrated no recurrence or metastatic disease at the time of follow-up. Conclusions: Atypical leiomyomas appear to be diagnosed in younger women which leads to challenging treatment issues involving fertility preservation. While these tumors generally behave in a benign fashion, they have histologic characteristics that may allow for progression or recurrence. Close follow-up is warranted for patients who are diagnosed with atypical leiomyomas and smooth muscle tumors of uncertain malignant potential.

No significant financial relationships to disclose.

Progression-free interval in ovarian cancer and predictive value of an ex vivo chemoresponse assay

The study objective was to determine the effectiveness of a phenotypic chemoresponse assay in predicting response to chemotherapy measured by progression-free interval (PFI) in a retrospective series of ovarian cancer patients whose tumor specimens had been tested with the ChemoFx assay. A statistically significant correlation between assay prediction of response and PFI was observed in 256 cases with an exact or partial match between drug(s) assayed and received. In 135 cases with an exact match, the hazard ratio for progression of the resistant group was 2.9 (confidence interval [CI]: 1.4-6.3; P < 0.01) compared to the sensitive group and 1.7 (CI: 1.2-2.5) for the intermediate compared to the sensitive group. The median PFI for patients treated with drugs assayed as resistant was 9 months, 14 months for those with drugs assayed as intermediately sensitive, and PFI had not been achieved for those with drugs assayed as sensitive. These data indicate that the ChemoFx assay is predictive of PFI in ovarian cancer. As the majority of ovarian cancers display different degrees of response to different chemotherapy agents ex vivo, the incorporation of assay information into treatment selection has the potential to improve clinical outcomes in ovarian cancer patients.

Drop outs from in-patient treatment of anorexia nervosa

OBJECTIVE

Aim of the study was to identify patient characteristics that distinguish drop outs and completers from in-patient treatment for anorexia nervosa.

METHOD

A total of 133 consecutively admitted in-patients with anorexia nervosa (age range 16-50 years; 92.5% women) were analysed using sociodemographic variables as well as measures of psychopathology (SCL-90-R, EDI-2) and interpersonal difficulties (IIP-C). Patients were treated in a multimodal treatment setting, combining cognitive-behavioural and psychodynamic components.

RESULTS

Patients, who reported fewer symptoms, were hospitalized before and had a comorbid depression stayed more often in psychotherapy. Patients dropping out of treatment (31.6%) showed a trend to higher levels of maturity fears. Subtype, age, duration of illness, comorbid personality disorders or previous drop outs were not predictive of dropping out.

CONCLUSION

Addressing the high ambivalence and maturity fears of anorexic patients should be an essential issue in psychotherapy with this patient group.