Numerous studies have found that obstructive sleep apnea (OSA) causes or exacerbates dementia, including Alzheimer disease and vascular dementia. However, the evidence is often conflicting. Moreover, no study has investigated the effect of surgical treatment for OSA on dementia.This retrospective cohort study analyzed data from the Korea National Health Insurance Corporation. A total of 125,417 participants (age 40 years or older) with a new diagnosis of OSA between 2007 and 2014 were included. The participants were classified into two groups: those who underwent uvulopalatopharyngoplasty (UPPP group, n = 12,664) and those who underwent no surgical treatment (no surgery group, n = 112,753). Propensity score matching by age and sex was used to select the control group of 627,085 participants. Mean follow-up duration was 4.6 ± 2.3 years. The primary endpoint was newly diagnosed Alzheimer dementia, vascular dementia, or other types of dementia.Compared with the control group, the hazard ratio (HR) and 95% confidence interval of dementia was calculated for patients with OSA. In the no-surgery group, the incidence of Alzheimer disease (HR 1.30 [1.22-1.38]), vascular dementia (HR 1.20 [1.05-1.36]), and other types of dementia (HR 1.35 [1.20-1.54]) was significantly higher than those among the control group. In the UPPP group, the incidence of Alzheimer disease (HR 1.08 [0.80-1.45]), vascular dementia (HR 0.58 [0.30-1.12]), and other types of dementia (HR 1.00 [0.57-1.77]) was similar to control levels.Uvulopalatopharyngoplasty may have a preventive effect on dementia in patients with OSA.
We introduce a novel approach for stereo confidence estimation, called ConFormer, leveraging the Transformer architecture.Recent confidence estimation methods commonly adopt convolutional neural networks (CNNs) and learned confidence features with limited receptive fields, thereby having limited capability to model global contexts.Benefiting from global understanding and the long-range dependencies of the attention mechanism, we effectively learn confidence features that take into account global relationships through the Transformer networks.Specifically, in the disparity feature extraction module, we extract global confidence features that encode global interactions with self-attentionusing a global pooling transformer. To complementlocal information and capture fine details, we additionally incorporate local prior features into the pooling transformer with an injection scheme.We further extract color confidence features using Transformer blocks to model the global interaction of the color image. The output confidence features from disparity and colorimage are effectively fused in a weighted attention mannerin fusion networks.Experimental results demonstrate that this model outperforms thestate-of-the-art CNN-based methods on various benchmarks.
ERCP in patients with surgically altered anatomy continues to be challenging. In patients with Roux-en-Y reconstruction, the target site is difficult to reach; the success rates are reported to be as low as 60%.1Wright B.E. Cass O.W. Freeman M.L. ERCP in patients with longlimb Roux-en-Y gastrojejunostomy and intact papilla.Gastrointest Endosc. 2002; 56: 225-232Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar The use of balloon-assisted enteroscopy (BAE) has improved the success rate of ERCP in patients with surgically altered anatomy.2Katanuma A. Yane K. Osanai M. et al.Endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy using balloon-assisted enteroscope.Clin J Gastroenterol. 2014; l7: 283-289Crossref Scopus (14) Google Scholar The reported success rates of ERCP with BAE range from 64.1% to 98%.3Yamauchi H. Kida M. Okuwaki K. et al.Short-type single balloon enteroscope for endoscopic retrograde cholangiopancreatography with altered gastrointestinal anatomy.World J Gastroenterol. 2013; 19: 1728-1735Crossref PubMed Scopus (49) Google Scholar, 4Shimatani M. Matsushita M. Takaoka M. et al.Effective ''short'' double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: a large case series.Endoscopy. 2009; 41: 849-854Crossref PubMed Scopus (184) Google Scholar, 5Shah R.J. Smolkin M. Yen R. et al.A multicenter US experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video).Gastrointest Endosc. 2013; 77: 593-600Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar, 6Itokawa F. Itoi T. Ishii K. et al.Single- and double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y plus hepaticojejunostomy anastomosis and Whipple resection.Dig Endosc. 2014; 26: S136-S143Crossref PubMed Scopus (63) Google Scholar, 7Yane K. Katanuma A. Osanai M. et al.Successful removal of a pancreatic duct stone in a patient with Whipple resection, using a short single-balloon enteroscope with a transparent hood.Endoscopy. 2014; 46: E86-E87Crossref PubMed Scopus (4) Google Scholar In this video, we describe successful balloon overtube-assisted ERCP with single-operator cholangioscopy, laser lithotripsy, and stent placement in a patient with surgically altered anatomy (Video 1, available online at www.VideoGIE.org). An 86-year-old woman with a history of gastric cancer, earlier distal gastrectomy with Roux-en-Y reconstruction, bilateral deep venous thrombosis of the lower limbs with inferior vena cava filter, atrial fibrillation, hypertension, diabetes mellitus type II, and GERD presented with abdominal pain, jaundice, and leukocytosis. A CT scan demonstrated multiple large bile duct stones. All options for intervention, including enteroscopy-assisted ERCP, surgery, percutaneous drainage, and EUS-guided drainage, were discussed with the patient. She was deemed a poor candidate for surgical intervention or percutaneous intervention. EUS-guided drainage is an accepted alternative for biliary drainage in patients with long-limb anatomy, depending on available expertise. However, given the rate of adverse events with EUS-guided hepaticogastrostomy, we reserve this technique as a salvage therapy if enteroscopy is unsuccessful.8Martins F.P. Rossini L.G. Ferrari A.P. Migration of a covered metallic stent following endoscopic ultrasound-guided hepaticogastrostomy: fatal complication.Endoscopy. 2010; 42: E126-E127Crossref PubMed Scopus (99) Google Scholar, 9Ogura T. Masuda D. Takeuchi T. et al.Fistula formation after EUS-guided hepaticogastrostomy.Gastrointest Endosc. 2016; 84: 365Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 10Okuno N. Hara K. Mizuno N. et al.Stent migration into the peritoneal cavity following endoscopic ultrasound-guided hepaticogastrostomy.Endoscopy. 2015; 47: E311Crossref PubMed Scopus (38) Google Scholar, 11Wang K. Zhu J. Xing L. et al.Assessment of efficacy and safety of EUS-guided biliary drainage: a systematic review.Gastrointest Endosc. 2016; 83: 1218-1227Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar After obtaining the patient's informed consent, we elected to perform double-balloon ERCP. Lithotripsy through a colonoscope has previously been reported in long-limb anatomy.12Baron T.H. Saleem A. Intraductal electrohydraulic lithotripsy by using SpyGlass cholangioscopy through a colonoscope in a patient with Roux-en-Y hepaticojejunostomy.Gastrointest Endosc. 2010; 7: 650-651Abstract Full Text Full Text PDF Scopus (17) Google Scholar In this case, an initial attempt with a colonoscope was unsuccessful because of extensive diverticulosis of the small intestine causing sharp angulations in the bowel. There are also previous video case reports on the use of spiral enteroscopy as a conduit for metal stent placement13Samarasena J.B. Huang J.Y. Chin M. et al.Altered anatomy ERCP with spiral overtube-assisted stent placement.Gastrointest Endosc. 2016; 84: 738Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar and double-balloon–assisted ERCP with direct cholangioscopy and electrohydraulic lithotripsy.14Sato T. Kogure H. Nakai Y. et al.Electrohydraulic lithotripsy under double-balloon endoscope–assisted direct cholangioscopy for treatment of choledocholithiasis in a patient with Roux-en-Y gastrectomy.VideoGIE. 2018; 3: 113-114Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Although our video demonstrates similar techniques, our case is unique in that we used laser lithotripsy and a commercially available single-operator cholangioscope, along with placement of a 10F plastic stent directly through the balloon overtube. The native papilla was reached by use of a double-balloon enteroscope (EN-450T5; Fujinon, Tokyo, Japan). The double-balloon overtube was not modified and had a diameter of 16 mm and a length of 1350 mm (TS-13149; Fujifilm, Tokyo, Japan). Cannulation of the bile duct was achieved with a Cotton Cannulatome (6-5F × 320 cm; Cook Medical Inc, Bloomington, Ind) and a 600-cm guidewire (Metro Wire; Cook Medical). A cholangiogram demonstrated multiple large filling defects in the bile duct, measuring up to 2 centimeters (Fig. 1A). A 7F stent was placed because of a concern for cholangitis, and a needle-knife sphincterotomy was performed with the stent in place to aid in future access (Fig. 1B). Two months later, the patient returned for single-balloon ERCP for stone extraction. Single-balloon enteroscopy was chosen over double-balloon to allow for removal of the endoscope through the overtube (Fig. 2A). The single-balloon overtube was not modified and had an outer diameter of 13.2 mm and a total length of 1400 mm (ST-SB1; Olympus Corp, Tokyo, Japan). The major papilla was reached with the single-balloon enteroscope (SIF-Q180; Olympus), and the stent was removed through the overtube. The endoscope was replaced to its position in the duodenum through the overtube, and guidewire access of the bile duct was obtained. The papilla was dilated to 15 mm with a controlled radial expansion balloon; however, this alone did not allow for extraction of the large stones. The endoscope was then removed from the overtube while the guidewire was left in place in the bile duct. The Spyglass DS digital cholangioscope (Boston Scientific, Marlborough, Mass) was advanced through the overtube, over the guidewire, directly into the bile duct (Figs. 2B and C). Extensive laser lithotripsy was performed at a power setting of 1.2 joules and 10 hertz for 12 watts of power (Fig. 2D) by use of a Holmium laser (VeraPulse P20; Lumenis Ltd, Yokneam, Israel). Owing to the inherent challenges of removing stones with an enteroscope, the goal was for complete stone fragmentation to simplify the extraction process (Fig. 2E). After fragmentation, stone fragments were subsequently removed by use of an extraction balloon (Multi-3V plus; Olympus). A plastic stent was placed over the guidewire under direct fluoroscopic guidance through the overtube without the use of an endoscope. This allowed for placement of a 10F stent, which otherwise would not fit through the channel of an enteroscope. After 3 months, repeated single-balloon ERCP was performed to clear the bile duct of all stones. No stone fragments were seen on the cholangiogram, suggesting that any remaining fragments had passed spontaneously (Fig. 2F). Several balloon sweeps were performed and confirmed complete clearance of the bile duct. The time to reach the papilla for each procedure was 15 to 20 minutes, and the total procedure time ranged from 1 hour to 3 hours. At her 3-month follow-up visit, the patient had normal liver test results and no abdominal pain. ERCP in surgically altered anatomy is challenging. However, large bile duct stones can be successfully managed with balloon enteroscopy-assisted ERCP. Use of the balloon overtube allows for direct cholangioscopy over a guidewire allowing for intraductal lithotripsy to be performed. All authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI5ZGMxNDk4YjRjZWZkNGUzMTYwZGUzZDM0MmZhOGMxYSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NjU1NzkwfQ.F8424OjGtSPYKOX5guqJx3SmE13rBQkjxlkororAFy2R2WckCTTqnPlgJ36zecDHHlLhAgLoylq_i-WNYOaRAHL_zuMMYb8l5GLOPMDreW6MpnZhSFkQ5oSYNUuGG394hNfACTFx2dflPx6UhBgz0LWWqQn9yzdgDzNrmvTUd17zp7ls4a9aCvuplydltz5pAZHpQ0OBsVOH75LkqV3kxVzrrrRG3DpFFQBCNrTR5uUH41v41IvbX0QZSsOKs8X2Fym_yFhj0SdnOY5h1dq4pd9kkcQ1WfXCkowdJKsr9_LbCc9GJej0YI-lsPc7hxzTjafuzPP6SgzjOw9k2aRBEQ Download .mp4 (65.09 MB) Help with .mp4 files Video 1Summary of balloon overtube-assisted cholangioscopy and laser lithotripsy of large bile duct stones. Download .docx (.02 MB) Help with docx files Video Script
Strictly maintaining the steam temperature can be difficult due to heating value variation to the fuel source, time delay changes in the main steam temperature, the change of the dynamic characteristics in the reheater. Up to the present time, PID controller has been used to operate this system because of its implementational advantages. However, it is very difficult to achieve an optimal PID gain with no experience, since the gain of the PID controller has to be manually tuned by trial and error. This paper focuses on tuning of the PID controller with disturbance rejection using immune network algorithm. To decide the performance of response, an ITSE (integral of time weighted squared error) is used in this paper.
Objective To perform a meta‐analysis on the distribution and characteristics of the obstructive site in patients with obstructive sleep apnea (OSA) using data from a variety of published studies that evaluated the obstruction with drug‐induced sleep endoscopy (DISE). Methods A literature search was performed to identify studies in which DISE was used to identify the obstruction site in adult patients with OSA, and the obstruction site was described in sufficient detail. Four items were evaluated in the meta‐analysis: the obstruction site, closing direction of the soft palate, degree of closure, and percentage of single‐level obstructions. Results A total of 2,950 patients from 19 studies were included. In the two‐level classification system, the rate of obstruction was 91.6% for the soft palate and 58.0% for the tongue base. In the four‐level classification system, the rate of obstruction was 84.1% for soft palate, 32.8% for the tonsil, 51.6% for the tongue base, and 34.3% for the epiglottis. The soft palate closed in the anteroposterior direction at a rate of 44.4% and in the concentric direction at a rate of 46.5%. The rate of a closure of 75% or more was 69.3% for the soft palate and 56.8% for the hypopharynx. The percentage of single‐level obstructions was 42.5%. Conclusion The soft palate is obstructed in most patients with OSA, and the tongue base is obstructed in half of the patients. In addition, multilevel obstructions including the tonsil, lateral pharyngeal wall, or epiglottis are common; thus, these areas must be checked carefully. Level of Evidence NA Laryngoscope , 129:1235–1243, 2019
'%3e%3cg id='b'%3e%3cpath id='a' stroke='%23000' stroke-width='2' d='M-6-25H6m-12 3H6m-12 3H6'/%3e%3cuse xlink:href='%23a' y='44'/%3e%3c/g%3e%3cpath stroke='%23fff' d='M0 17v10'/%3e%3ccircle r='12' fill='%23cd2e3a'/%3e%3cpath fill='%230047a0' d='M0-12A6 6 0 0 0 0 0a6 6 0 0 1 0 12 12 12 0 0 1 0-24z'/%3e%3c/g%3e%3cg transform='rotate(-123.69)'%3e%3cuse xlink:href='%23b'/%3e%3cpath stroke='%23fff' d='M0-23.5v3M0 17v3.5m0 3v3'/%3e%3c/g%3e%3c/svg%3e)