Inadvertent Lead Malposition in the Left Ventricle during Permanent Ventricular Pacing about One Case

Inadvertent Lead Malposition in Left Ventricle is a rare and underdiagnosed incident, which may occur during implantation of cardiac electronic devices and may remain asymptomatic. We reported the case of a 71-year-old man who was implanted with a ventricular single-chamber pacemaker for a slow atrial fibrillation with syncope and whose routine transthoracic echocardiography 23 months after implantation displayed a malposition of the pacemaker lead into the Left Ventricle through a patent foramen oval. The patient was asymptomatic. The electrocardiogram showed right bundle branch block QRS-paced morphology with a positive QRS pattern in V1, a median paced QRS axis on the frontal plane at -120°, a Precordial transition on V5. At the lateral Chest X-ray the lead curved backwards to the spine. Given the age of this old patient who already received oral anticoagulant for Atrial Fibrillation and the Lead malposition discovered 23 months after pacemaker’s implantation, we decided to maintain the lead in LV and continue anticoagulation.

TREATMENT OF 80 CASES OF MALPOSITION OF FETUS BY MOXIBUSTION COMBINED WITH CHINESE DRUGS

On 80 patients with abnormal fetal position, we observed the effects of moxibustioncombined with Chinese herbs on the position of fetus. The results suggest this therapy is practical andeffective.

Arthroscopic treatment of iliopsoas tendinitis after total hip arthroplasty with acetabular cup malposition: Two case reports

BACKGROUND Optimal treatment for iliopsoas tendinitis after total hip arthroplasty(THA)with cup malposition,iliopsoas release alone or with cup revision,is controversial,particularly in young,active patients.Moreover,arthroscopic iliopsoas tendon(IPT)release in these patients has been rarely described,and midterm effects of this procedure on THA longevity and groin pain recurrence remain unclear.We performed arthroscopic IPT release after THA and report midterm outcomes in two young patients with acetabular cup malposition.CASE SUMMARY In the two patients,groin pain started early after THA.Physical examination revealed nonspecific findings,and laboratory tests showed no evidence of infection.Radiography and computed tomography showed reduced acetabular component anteversion angle and anterior cup prominence of more than 16 mm.For therapeutic diagnosis,ultrasonography-guided lidocaine with steroid was injected into the IPT sheath.In both patients,groin pain improved initially but worsened after a few months.Therefore,the patients underwent arthroscopic IPT release under spinal anesthesia.Arthroscopy revealed synovitis with fibrous tissues around the IPT and various lesions related to the implants after THA.IPT tenotomy and debridement with biopsy were performed;histopathologic studies showed chronic inflammation with synovial hyperplasia.Both patients were encouraged to start walking immediately after surgery,and they returned to complete daily function early after surgery.They experienced no recurrence of groin pain or any implant-related problems 5 years postoperatively.CONCLUSION Arthroscopic IPT release for cup malposition produced excellent midterm outcomes without recurrence of groin pain and implant-related problems.

Toric Intraocular Lens Malposition Corrected by Lens Repositioning to Manifest Refractive Cylinder Axis in Patient with Irregular Astigmatism Due to Corneal Scar

A case is presented of a patient with an unexpected poor visual result and subsequent correction following cataract removal surgery via phacoemulsification and intraocular lens implantation using a toric intraocular lens implant (IOL). The initial operation resulted in an uncorrected vision of 20/100 (0.70 logMAR). Retrospective analysis of the patient’s corneal topography revealed irregular astigmatism secondary to remote trauma to the cornea. The cylinder axis on manifest refraction (MR) was significantly different from measured keratometry, so a second procedure was performed to align the cylinder axis of the IOL with the steep axis on MR. This repositioning procedure improved visual outcome to a final uncorrected vision of 20/25 (0.10 logMAR) and best corrected acuity of 20/20 (0.0 logMAR).

Treatment of Bilateral Recurrent Dislocation of Hip Pros-thesis with Malpositioned Well-Fixed Shell: A Case Report

Dislocations of total hip prostheses cause pain and patient dissatisfaction. Recurrent dislocations are difficult to treat mainly when the acetabular metal shell is well-fixed. The purpose of this article was to describe the surgical technique used for the treatment of a bilateral recurrent posterior dislocation after a cementless total hip prosthesis, caused by excessive inclination of acetabular components, in a 72-year-old patient. On both sides, acetabular metal shell, porouscoated, was well-fixed. Revision of the entire acetabular component could be an appropriate therapeutic option because it was malpositioned. Nevertheless, a conservative operation was performed. The metal shell was left in situ and the preexisting polyethylene liner was removed and replaced by a new undersized cross-linked polyethylene liner, then, cemented into the shell and properly oriented. An acetabular cemented augmentation reinforced by 3 cortical screws was associated with the reconstruction. This report suggests that cementation of new liner into a malpositioned well- fixed metal shell associated with an acetabular cemented augmentation is a simple and safe technique for the management of recurrent hip dislocation, for elderly patients in which it is advisable to avoid a major revision hip surgery by medical comorbidities. Nonetheless, further studies with medium-and long-term follow-up are needed to validate this technique.

Usefulness of Free Nipple-Areola Complex Graft for Nipple Malposition after Nipple Sparing Mastectomy

Purpose: This article identifies the advantage and disadvantage of a free nipple areola complex graft (FNACG) for nipple malposition which resulted from tissue-expander insertion and subsequently replaced with an implant after nipple sparing mastectomy (NSM). Methods: The subjects were three such patients treated using FNACG and who were followed up for at least one year postoperatively. The surgical outcome was assessed for symmetry of nipple-areola position, graft take, depigmentation, and shrinkage. Results: In all patients, the graft was accurately transferred to a position to achieve symmetry with the unaffected breast, and there was complete graft take in the areola by simple surgical design and techniques. No depigmentation of the areola was observed. The size of the areola was almost unchanged after grafting in two patients, but areolar shrinkage occurred in one other patient. There was complete graft take in the nipple in one patient and no depigmentation of the nipple was observed. Necrosis occurred at the tip of the nipple in two other patients. These patients had depigmentation, and the height of nipples decreased in proportion to the level of necrosis. Conclusion: FNACG can be a useful method if its advantages and disadvantages are well considered.

Eyelid malposition after orbital fracture surgery

Orbital fractures generally do not cause eyelid malposition.Studies have shown that mostly eyelid malposition is mainly due to the choice of surgical approaches of orbital fracture repair.Approaches are divided into transcutaneous and transconjunctival ones.The application of orbital fracture approaches depends on fractures’range and the surgeons’preferences.Eyelid malposition after orbital fracture surgery is not only an aesthetic concern but also a functional complication,which will cause eyes discomfort,such as corneal exposure and ocular irritation.Some patients may have multiple types of eyelid malposition.In this review,we summarized the surgical approaches of orbital fractures and the complications including scar,ectropion,retraction,entropion,flattening,laceration and lacrimal canaliculus avulsion and notch deformity that associated with eyelid,especially the lower eyelid.Reports revealed that the scar usually occurred in infraorbital incisions compared with subtarsal and subciliary incisions,and the transconjunctival approach had a higher incidence of entropion and flattening,and less ectropion than the transcutaneous approach.Meanwhile,pathogenesis of eyelid malposition after orbital fracture surgery are discussed.Furthermore,to prevent eyelid malposition complications,doctors should choose the appropriate orbital fracture approach according to the patient’s needs,and delicate tissue management,technical expertise,and meticulous hemostasis are necessary.Conservative treatment with taping,lubricating ointment,and steroid for eyelid malposition complications should be performed first,and then surgical intervention when the conservative treatment fails.

Malposition of Central Venous Catheter： Presentation and Management

Central venous catheters （CVCs） are commonly utilized to gain vascular access for varied clinical indications. These include administering drugs, renal replacement therapy, total parenteral nutrition, poor peripheral venous access, cardiac catheterization, and transvenous cardiac pacing.

Differential Diagnosis of Cardiac Malposition by Fetal Echocardiography

To explore the method and operating skill of fetal echocardiography in diagnosing cardiac malposition.Methods 91 consecutive fetuses were studied （control： 50 cases, cardiac malposition ： 41 cases） between 2003 and 2008. The position of fetal heart was evaluated according to the fetal posture and the visceral situs by fetal routine scan- ning. The detailed echocardiography should be performed in the differential diagnosis of cardiac lesions when the heart was found to be abnormal position. Results In the control group, all fetuses were levocardia. 39 cases of cardiac mal- positions were detected by fetal echocardiography, included 25 fetuses with dextrocardia, 6 mesocard, 5 with levover- sion of heart, 3 common heart of conjoined twins and 2 extrathorax heart. Two of dextroversion were missed by fetal routine scanning, but found by autopsy or operation after birth. Conclusions When the abnormal visceral situs was found by fetal routine scanning , there is exceedingly high incidence of cardiac malpositions. Proficiently operating skill of fetal echocardiography is helpful to detect abnormal fetal cardiac position. （ S Chin J Cardiol2009 ; 10 （1） ： 23 -25）

Perforation of levonorgestrel-releasing intrauterine system found at one month after insertion:A case report

BACKGROUND The levonorgestrel-releasing intrauterine system(LNG-IUS)is widely used in contraception,menorrhagia,dysmenorrhea and to prevent endometrial hyperplasia during estrogen supplementation.Perforation is more often seen after early postpartum placement.Perforation of the LNG-IUS occurring one month after placement is rare.CASE SUMMARY A 42-year-old female complained of progressive dysmenorrhea and increased menstrual volume.She was diagnosed with adenomyosis and the LNG-IUS was inserted in her uterine cavity.Routine ultrasound examination one month later revealed that the intra-uterine device(IUD)was not found in the uterine cavity,and further X-ray and pelvic magnetic resonance imaging showed an abnormal signal area in the left posterior region of the uterus.Laparoscopic exploratory surgery was performed and the LNG-IUS was found in the left uterosacral ligament.CONCLUSION Perforation of a LNG-IUS occurring one month after placement is rare,and is more common in inexperienced operators and after early postpartum placement.When the operation is difficult,ultrasound monitoring is recommended to reduce the risk of IUD perforation.For patients with inadequate surgery,postoperative imaging is recommended to detect potential risks as soon as possible.

Anterior lamellar recession for management of upper eyelid cicatricial entropion and associated eyelid abnormalities

AIM：To evaluate the functional and aesthetic outcomes of upper eyelid cicatricial entropion（UCE） correction using anterior lamellar recession（ALR） with addressing the associated conditions including dermatochalasis,brow ptosis,blepharoptosis,and lid retraction.METHODS：Chart review of patients with upper lid cicatricial entropion who had undergone ALR from 2013 to 2016 was reviewed.Success was defi ned as the lack of any lash in contact with the globe,no need for a second procedure,and acceptable cosmesis at the fi nal follow up.RESULTS：Sixty eight patients（97 eyelids） were operated by ALR with simultaneous correction of associated lid problems in each case when necessary.The mean followup time was 17.8 mo（range,6.0-24.0 mo）.Concomitantly,levator tucking was performed in 19 eyelids（19.6%）,upper lid retractor recession in 18 eyelids（18.6%）,and internal browpexy in 31 eyelids（32.0%）.In 95.8% of patients（95%CI：0.85-0.96）,satisfactory functional and cosmetic outcome was achieved with a single surgical procedure.CONCLUSION：Based on the principles of lamellar recession and concurrently addressing the associated lid problems,this approach is an effective and safe treatment of UCE.

Blindly inserted nasogastric feeding tubes and thoracic complications in intensive care

Purpose of review: This article reviews the thoracic complications from malpositioned blindly inserted nasogastric feeding tubes in mechanically ventilated patients in intensive care and the methods to check the position and promote safe placement of the feeding tubes. Recent findings: Malpositioned feeding tubes are not included in risk management databases. The reported incidence is 1-3% and more than half occur in mechanically ventilated patients. Eighty three mechanically ventilated patients were reported with malpositioned nasogastric tubes and 66% of them developed serious thoracic complications. Pneumothoraces accounted for 80% of thoracic complications that were evenly distributed between tubes with and without stylet. Repeated misplacements appear to increase the risk. Non-radiological confirmation of the position of the tube has suboptimal performance. Protocols to place feeding tubes and new technology are promising candidates. Summary: Malpositioned nasogastric feeding tubes are underreported and associated with serious thoracic complications in mechanically ventilated patients. We need more data to answer whether we can afford to prevent them.

THE CLINICAL ANALYSIS ON THERAPEUTIC EFFECT ON 47 CASES OF CERVICAL HEADACHE AND VERTIGO TREATED WITH ACUPUNCTURE,COMBINED WITH LIFTING,ROTATING,PULLING-MANIPULATION AT NECK

The cervical headache and vertigo were treated with acupuncture at Fengchi（GB20）and Wangu（GB 12）and lifting,rotating,pulling-manipulation at neck.The total effective ratewas 91.4％.The therapeutic effects of these two types,malposition type and osteophytosis type,were studied and compared.The results were significantly different in statistics.

Tracheal tube misplacement in the thoracic cavity:A case report

BACKGROUND Penetrating neck injuries require prompt recognition,diagnosis and management of critical airways.This case demonstrates an emergent situation that a“medical negligence”was avoided with the aid of end-tidal carbon dioxide(ETCO2)waveform.CASE SUMMARY We report a case of malposition of the endotracheal tube into the right hemithoracic cavity for cervical knife trauma,resulting in pneumothorax.Tube placement was not confirmed during emergency airway management,and the patient was directly transferred to the emergency operation room.Assisted by ETCO2 and imaging examinations,the anesthetist timely noticed the absence of ETCO2 waveform and resolved this urgent situation before anesthesia induction.CONCLUSION This case emphasizes the necessity of ETCO2 waveform and/or X-ray confirmation of endotracheal intubation even in emergent situations.

A Simple and New Device to Avoid Hepatic Venous Outflow Obstruction in Adult Liver Transplantation

Hepatic venous drainage in liver transplantation may be reduced to the level of caval anastomosis producing an obstruction degree and leading to serious vascular complication such as the acute Budd-Chiari syndrome, which may result in organ loss. Outflow obstruction may be caused by lack of technique in caval anastomosis or by allograft malposition as a consequence of anatomical graft and recipient conditions. Fixation of the round ligament, placement of bowel loops and use of tissue expanders have been described to stabilize graft position during liver transplantation with related procedure complications. We report our experience of a simple homemade device using a surgical glove expander that allowed us to successfully avoid outflow obstruction in all of nine treated patients. No device related complications occurred. In malposed liver allografts, we strongly suggest the use of this simple and safe device to avoid hepatic venous outflow obstruction on condition that the device is early removed within 48 hours.

Research on the Related Factors of the Second Molar Dislocation and Orthodontic Erect Method

The second molar dislocation is more common clinically.To investigate the related factors of the second permanent molar dislocation,and provide reference for the clinical diagnosis and treatment of orthodontics.From the current clinical research,the clinical methods of orthodontic erect secondary molars are also diverse and clinical.The narrower first molar alveolar arch width,smaller ANB angle,and crowded maxillary posterior segment arch are the factors that cause the maxillary second permanent molar dislocation.The narrow alveolar arch width,the smaller SNB angle,the larger ANB angle,and the crowded lower mandibular arch are the factors leading to the dislocation of the mandibular second permanent molar.In addition,for the second mandibular molar malposition,it is particularly important to select the corrective treatment plan.It is especially important to improve the treatment.

Why and How Often Is Revision Surgery Necessary after First Metatarsophalangeal Joint Arthrodeses? A Cohort of 120 Consecutive Cases

Background: Little is known about the rate and reasons for revision after primary Metatarsophalangeal (MTP1) arthrodesis with the latest implants. While it is commonly assumed that nonunion accounts for most reoperations, we hypothesized that malposition is the leading cause of revision. The aim of this study was to determine the rate and reasons for revision after MTP1 arthrodesis using cup- and cone-reamers and the latest locking plate technology. Method: Between 2015 and 2017, 120 consecutive MTP1 fusions in 114 patients were performed with a low profile, pre-contoured titanium dorsal locking plate and a plantar metatarsophalangeal screw. The rate and reasons for revision within a minimum one-year follow-up period (average 16 months [12 - 26]) after index procedures were documented and analyzed. The revision was defined as any reoperation following the index procedure excluding hardware removal. Results: Seventeen of 120 feet (14%) underwent revision. Four patients developed a nonunion (3.3%) and needed revision, and 11 feet (9%) required revision for painful malposition;insufficient extension and excessive valgus accounted for the majority. Two patients required medial sesamoidectomy. No infection or wound healing problems occurred. Twelve patients requested hardware removal. Conclusions: Nonunion revision rate after MTP1 fusion with the latest locking plate technology is low. The leading cause of revision is malposition followed by nonunion. Excessive valgus and insufficient extension account for most symptomatic malposition. A recommendation of 0 - 10 degrees of valgus in the horizontal plane may contribute to diminishing revision rates;no conclusions could be drawn regarding an optimal position in the sagittal plane.

Effects of Enterprise 2 stent-assisted coil embolization for wide-necked intracranial aneurysms

Background:This study analyzed the safety and efficacy of Enterprise 2 stent-assisted coil embolization for wide-necked intracranial aneurysms by examining stent-vessel apposition,operative complications,embolization outcomes,and clinical outcomes.Methods:We retrospectively reviewed the medical records of patients with wide-necked intracranial aneurysms who underwent Enterprise 2 stent-assisted coiling in our hospital from November 2018 to October 2019.Intraoperative VasoCT was performed immediately after stent release in a continuous cohort of patients to observe stent-vessel apposition.Patient demographic,clinical,and imaging data were recorded and analyzed.Results:A total of 106 wide-necked aneurysms in 106 patients were treated.Stent release was successful in all patients.Twenty-one patients were enrolled consecutively for VasoCT scanning,and incomplete stent apposition was observed in 5(23.8%).Perioperative complications occurred in 10 patients(9.4%):cerebral infarction in 6,intraoperative coil prolapse in 1,puncture site pseudoaneurysm in 1,deep vein thrombosis at multiple sites in 1,and transient brainstem mass effect in 1.Among the 95 aneurysms with angiographic follow-up,embolization was satisfactory(Raymond-Roy classifications I and II)in 89(93.7%).Hyperlipidemia was an independent risk factor for incomplete aneurysm occlusion.At the last clinical follow-up,seven patients had a poor clinical outcome(modified Rankin Scale score≥3).Independent risk factors for poor outcomes were preoperative subarachnoid hemorrhage at presentation and cerebral infarction.Conclusion:Enterprise 2 stent-assisted coiling for treatment of wide-necked intracranial aneurysms showed good safety and efficacy;however,incomplete stent apposition can still occur in vessels with a large curvature.Preoperative subarachnoid hemorrhage at presentation and cerebral infarction are the main reasons for poor clinical outcomes after stent-assisted coil embolization.

Tip orientation under real-time point-of-care neck ultrasonic monitoring is advantageous in peripherally inserted central catheter procedures:a retrospective cohort study

Background:We analyzed the success and catheter tip malposition rates of peripherally inserted central catheter(PICC)placement using ultrasonic monitoring.Methods:A total of 564 patients were recruited and assigned to either the intervention or control group.In the intervention group,282 patients underwent ultrasound-guided PICC insertion,which helped to identify the position and depth of the catheter tip.From a total of 9000 patients,282 were selectively chosen to receive the traditional method using body surface measurements(control group).The primary endpoint was the success rate;the secondary endpoint was the catheter tip malposition rate as detected by postprocedure chest radiography.Results:In the intervention group,a total of 94 catheters were in a suboptimal position;26 were too deep,68 were too shallow,and 1 was inserted into the subclavian vein,with success and malposition rates of 66.3%and 0.4%,respectively.In the control group,139 catheters were in a suboptimal position;88 were too deep,51 were too shallow,9 were inserted into the jugular vein,and 2 were inserted into the subclavian vein,with success and malposition rates of 46.8%(P<0.001)and 3.9%(P=0.004),respectively.Significant differences were observed in success and malposition rates between the 2 groups.Conclusion:Ultrasound-guided PICC procedures achieved higher success rates and lower malposition rates.

Malocclusions in Xia Dynasty in China

Background The prevalence of malocclusion in modern population is higher than that in the excavated samples from the ancient times.Presently,the prevalence of juvenile malocclusion in the early stage of permanent teeth is as high as 72.92% in China.This study aimed to observe and evaluate the prevalence and severity of malocclusions in a sample of Xia Dynasty in China,and to compare these findings with the modern Chinese population.Methods The material consisted of 38 male and 18 female protohistoric skulls of Xia Dynasty 4000 years ago.Of 86 dental arches,29 cases had the jaw relationships.Tooth crowding,diastema,individual tooth malposition and malocclusion were studied.Results Of the samples,23.3% showed tooth alignment problems including crowding （8.1%）,diastema （9.3%）,and individual tooth malposition （5.8%）.The prevalence of malocclusion was 27.6%,mainly presented as Angle Class Ⅰ.Conclusions It is indicated that over thousands of years from Neolithic Age （6000-7000 years ago） to Xia Dynasty （4000 years ago）,the prevalence of malocclusion did not change significantly.The prevalence of malocclusion of Xia Dynasty samples was much lower than that of modern population.