Crimson Publishers High Impact Journals

Tuesday, July 5, 2022

Enhancing Overall Equipment Effectiveness (OEE) in Compressor Manufacturing Industries_Crimson Publishers

Enhancing Overall Equipment Effectiveness (OEE) in Compressor Manufacturing Industries by Sripriyan K in Research & Development in Material Science_journal of materials processing technology


Abstract

This paper focuses on the methodology of improving the productivity through overall equipment effectiveness (OEE) with help of lean manufacturing technique in compressor manufacturing industries. For a good manufacturing plant, the most recommended things are quality and efficiency. These two parameters depend on the function of equipment used in the industry. In the current global competitive environment it is of immense importance for manufacturing companies to keep track of, and improve the production performance of their production systems. Production failure includes many reasons, among them improper maintenance and equipment performance are the eye catching reasons. Lean manufacturing techniques is to significantly identify the waste and eliminate it from the manufacturing processes. The OEE calculation is one of the ways to improve the performance. This work has been carried out in 2hp air compressor manufacturing unit for improving OEE with help of 5s techniques using a systematic approach The project has been addressed in three aspects; namely Availability, Performance and Quality which quantify OEE. The investigation result shows that the OEE has been improved from 45.9% to 55.8%.

Keywords: 5S; Overall equipment effectiveness (OEE); Standard operating procedure and Productivity.

Introduction

CThe manufacturing and process industry use Overall Equipment Effectiveness (OEE) as an important Key factor to monitor and control their performance effectiveness. At present the level of competition between firms is increasingly demanding, levels of demand by the customer are more stringent so that only the companies that have the ability to adapt easily to these needs are protruding. Maintenance plays a very important role in the industry, since to be able to produce goods of quality and quantity, and to deliver at the right time according to customer needs; machinery and equipment must operate efficient and accurate. Although it is not always recognized as an important area, maintenance has been widely regarded as a support function that is not productive, since it does not generate cash directly and sometimes relegated for that reason. OEE is a measure used in Total Productive Maintenance (TPM) to indicate how efficiently the machines are working. With the proper implementation of lean tools, the problems can be solved effectively and the productivity can be increased. The paper discusses about the analysis and implementation of lean tools for improving the overall equipment effectiveness and to meet the customer demand by using standard operating procedure and 5S techniques. 5S is a system which helps to organize a workplace for efficiency and optimizes quality and productivity via monitoring an organized environment.

Problem Definition

Data collection is done based on 2 hp air compressor manufacturing unit. The results show that while the setup time is more. Further observation revealed that they are not meeting the customer demand, because there is no proper assembly of workstations it will increases the manufacturing lead time. Another observation is the machine downtime is more because of improper maintenance. This will causes the less productivity. In machine shop there is no proper handling of 5S activity, this causes for more tool searching time for operators. It will also increase the non value added activity for operators in machine shop. Machine utilization also poor because of improper operating procedure. It will causes for less production.

Objectives

a. To reduce the non value added activity for operators in machine shop

b. To improve the overall equipment effectiveness

c. To meet the customer demand

To attain the above objective proper time study has been contacted and observations are noted down. Takt time is calculated and time study is done for each and every activity details are in Tables 1 & 2 [1,2]. The time study is done for each and every activity. Table 2 gives the details about the data collection. This data is tabulated based on average values noted.

Table 1: Takt time calculation.


Table 2: Time study observations.


Results and Discussion

After implementing lean tools OEE is improved 17.7% and productivity also increased from 35 products per shift to 40 products per shift details are in below.

Implementation Of Lean Tools

Different lean tools are identified to improve the OEE and productivity. After identification of lean tools, each tool is implemented as given below [3-6]:

Table 3: Implementation of lean tool.


Figure 1: Implementations of lean tool.


5S: 5S encourages workers to improve their working conditions and helps them to learn to reduce waste. In this paper 5S is one of the most important lean tools used. By using 5S as a tool lot of time is saved. The Table 3 and Figure 1 shows the details of before and after implement of lean tools.

Overall equipment effectiveness:

Overall equipment effectiveness for before implementation

An experimental result shows the compressor manufacturing unit having 45.9% of overall equipment effectiveness before implementation of lean tools details are in Table 4 & 5 and Figure 2. An experimental result shows the compressor manufacturing unit having 55.8% of overall equipment effectiveness before implementation of lean tools details are in Table 6-8 and Figure 3 & 4. After implementing each tool step by step the suitable results are found out and results are discussed as follows. Figure 4 shows the tool searching of operator after the implementation of 5S. By implementing lean tools suitable results are found out. There is reduction in setup time is found out. Table gives the clear picture of how much time is reduced (Table 9 & 10).

Table 4: Production data for before implementation


Table 5: Calculated data for before implementation.


Figure 2: Overall equipment effectiveness for before implementation of lean tool.


Table 6: Downtime calculation for after implementation.


Table 7: Production data for after implementation.


Table 8: Calculated data for after implementation.


Figure 3: Tool searching time (Before).


Figure 4: Tool searching time (Before).


Table 9: Comparison OEE.


Table 10: Results comparison.


Conclusion

This paper was aimed to improvement of investigate the influences of the overall equipment effectiveness in compressor manufacturing unit. To this purpose, Tool Searching time, Downtime, Productivity and OEE are implemented and analyzed. Investigated results are compared before and after implementing the lean tools. The end results shows that 75% reduction of tool searching time, 23% down time reduction, productivity has increased 12.5% and 17.7% increasing the Overall Equipment Effectiveness.

References

  1. Bain N (2010) The consultants guide to successfully implementing 5S.
  2. Singh R, Gohil AM, Shah DB, Desai S (2013) Total productive maintenance (TPM) implementation in a machine shop: a case study. Procedia Engineering 51: 592-599.
  3. Sripriyan K, Janagiraman R (2001) Line balancing technique for labor optimization and productivity improvement in a compressor manufacturing industry. International Journal of Advanced and Innovative Research 4(4): 631.
  4. Matt DT, Rauch E (2009) Implementation of lean production in small sized enterprises. Procedia CIRP 12: 420-425.
  5. Escalante JE (1999) Quality and productivity improvement: a study of variation and defects in manufacturing. Quality Engineering 1(3): 427- 442.
  6. Sripriyan K, Janagiraman R (2018) Analysis and implementation of lean tools for lead time reduction in a compressor manufacturing industry. National Journal of Technology 11(3): 0973-1334.

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Friday, July 1, 2022

Trees and Shrubs Monitoring Using an Ecological Approach: The Conclusion of the Restoration Project of Borgotrebbia Landfill (Northern Italy)_Crimson Publishers

Trees and Shrubs Monitoring Using an Ecological Approach: The Conclusion of the Restoration Project of Borgotrebbia Landfill (Northern Italy) by Cassinari C in Environmental Analysis & Ecology Studies_international journal of environmental sciences


Abstract

Plants growth monitoring in restored landfills are poorly available in literature. These data might be of critical importance for the evaluation and improvement of current and future restoration projects. Our study was focused on the plant’s growth monitoring during a Life project (LIFE10 ENV/IT/000400 NEW LIFE), designed to restore a closed landfill (located in Northern Italy) using reconstituted soils. The growth monitoring was conducted on mortality rate, stress symptoms and phenological cycle completion of 10 plant species (trees and shrubs). Data were acquired during the 12 months following the end of the restoration with an ecological approach, using Landolt’s indices and CSR functional strategy. It was observed that the stress-tolerant and the heliphilous ruderal species were the ones that best adapt to the restored environment (dead plants:0-39%; unhealthy plants: 24-42%), whereas the most competitive species were the ones with highest mortality (17-43%) and stress symptoms (43-51%).

Keywords:Restoration; Landfill; Plant monitoring; Ecological indices; Functional strategy

Introduction

Environmental restoration of degraded lands is one of the most urgent thematic to solve [1] due to world population growth and urban centres expansions, two phenomena causing land degradation and water and land ecosystem imbalances [2]. On a global level, soil consumption and land degradation [3] caused by urbanization proceed at a rate of 30ha day- 1 (ISPRA 2017). In order to fight degradation, during the last decades many environmental restorations took place in the world [4-10].

In urbanized areas, one of the most emblematic examples of degradation are the landfills, where solid wastes are compressed and isolated in order to avoid leachate losses; when the landfills are closed, they are covered with soil and planted, but none monitoring and maintaining are done, so often the closed landfills became a degraded land. Led by this chance, in the last years many closed landfill restoration projects took place [11-25] along with the development of more sustainable methods and technologies for municipal solid wastes management [26]: recycling process, new generation incinerators and bio-digester [27].

Altogether, these topics are increasingly attracting the attention of our society, with a growing number of initiatives for their support and promotion. The EU Biodiversity Strategy aims to ensure by 2020, ecosystems and their services are maintained and enhanced by establishing green infrastructure (strategically planned network of natural and semi-natural areas with other environmental features designed and managed to deliver a wide range of ecosystem services (EU Commission 2016) and restoring at least 15% of degraded ecosystems (EU Commission 2010). Despite all the efforts by different researchers (engineers, biologists, pedologists, chemists, architects) to improve the environmental restoration projects in highly degraded contexts, like landfills, there’s still a lot of work to do. Firstly, the restored areas are to be surveyed by acquiring data through a long-term monitoring; this is the only way to gain knowledge of possible errors occurred during the realization.

Despite the importance of this kind of survey, in many cases it’s not possible to do it, mainly because of founds. Due to this, the data concerning the main environmental components (soil, vegetation, water) of restored areas are low [28-39], especially those regarding restored landfills [17,15,21,22,40]. The main aim of this work was to present an ecological survey of trees and shrubs planted during a Life project (LIFE10 ENV/IT/000400 NEW LIFE; web site: http:// www.lifeplusecosistemi.eu), co-founded by European Union, aimed at restoring a closed landfill located in Piacenza (Emilia Romagna, Italy) using reconstituted soils [28]. The ecological survey, to understand the species’ responses in the new environment, was carried out using the Landolt’s ecological indices [41] functional strategy in accordance with the bioindication principles [42]. This research wants to prove how such simple and cheap methods may grant useful information about the restoration and the plants’ adaptation to restored areas.

Study area

The closed landfill is located in Borgotrebbia, municipal territory of Piacenza (Emilia-Romagna, Italy) near Trebbia River (coordinates: 45°04’13’’ N, 9°39’33’’ E; altitude: 60m) (Figure 1). The area, 20ha wide, is in Trebbia Fluvial Park and, partially, inside a Site of Community Importance (SCI 4010016 Basso Trebbia). The solid urban wastes’ landfill was active between 1972 and 1985. Wastes were buried in a 4-5m layer and then covered with a 20- 30cm cap of degraded soils. In 2012, with the New Life project, the spontaneous vegetation and the soil of the closed landfill were studied [28,43-46] (Figure 2). Several ruderal species of Sellarietea mediae and Artemisietea vulgaris phytosociological classes, typical of degraded environments, were observed. The cap soil had poor water holding capacity, low organic carbon content, it was compacted and with stoniness, its values of clay, total CaCO3, CEC, P2O5, K2O, pH and salinity were used to calculate, in 5 sampling points, LCC [47] & FCC [48] (Figure 1 & Table 1). In this way, the study area soils were described having sever limitation for agricultural use, limiting their use to grazing or wildlife and with low fertility [28,46].

This was in accordance with the lack of more exigent species, like trees and shrubs. The restoration of the closed landfill was made by means of soil restoration by reconstitution. Reconstituted soils were produced by a technology (mcm Ecosistemi Patent), designed to act on two types of soils: on Technosol and degraded soils. By the means of this pedotechnique chemical and mechanical actions were applied to a mixture of degraded soil and environmental and pedological suitable materials such as waste of productive activities (sludge from paper industry and cellulose transformation processes, washing sludge of inert materials and water treatment sediments for drinking water supplies): the mixture was crushed, so the added organic fraction was incorporated into the mineral particles of the soil, then a mechanical compression realized the new reconstituted soil aggregates [46-48].

From October 2014 to August 2017, 10ha of the study area were covered with reconstituted soils 1m deep. Physicochemical properties of the reconstituted soil were performed and so LCC and FCC were calculated in the same previous sample points (Figure 1 & Table 1). The new soils were described having moderate limitations that restrict the choice of plants or that require moderate conservation practices and characterized by a high fertility [46-70], thus confirming other studies on reconstituted soils [28, 45,46,49,50]. From October 2016 to December 2017, over 3,000 trees and shrubs of 16 autochthonous species (Table 2), were planted in the area (Figure 3). All these plants were no more than 2 years old. The 16 species had to improve the ecological conditions and the landscape of the area, they had to produce edible fruits for birds, being the area a resting spot for migratory birds. In order to promote the plants to take roots, cuts of the herbaceous vegetation and a watering program during the drought season were made and still continue.

Figure 1:Geographical localization of the study area.


Figure 2:Closed landfill before environmental restoration.


Figure 3:Tree planting intervention and monitoring area definition.


Table 1:Physical-chemical parameters of landfill soil before (2011) and after (2016) environmental restoration in the 5 sample points (data from Manfredi et al., 2019).

SP sample point; *Data are the average of 3 sub-samples


Table 2:Floristic list of trees and shrubs planted.


Material and Methods

Trees and shrubs’ monitoring were conducted on a monthly basis across 2017 considering 8-400m2 (20x20m)-plots (A, B, C, D, E, F, G and H) homogeneously distributed on the area. In every plot all the species were identified using Pignatti [68] and numbered. For every species, a radar chart with Landolt’s ecological indices (2010) (T, temperature; L, light intensity; F, soil moisture; R, substrate reaction; N, nutrients; H, humus; D, aeration) and a triangular plot with CSR strategy of each species were made to compare the plants ecological needs with the related functional strategy. The functional strategy of each plant was retrieved from recent literature [51].

Monthly the following data were collected in every plot:

A. Number of dead plants (without considering dead plants within 14 days after planting);

B. Number of plants showing stress-related symptoms (leaf yellowing and/or plant pathologies);

C. Number of flowered plants;

D. Number of plants producing fruits.

The % mortality rate was evaluated for every species as follows:

Where M was mortality rate, d was the number of dead plants during 2017 and p was the size of the population in which the dead plants occurred. The % of unhealthy, flowered and fruit-producing plants were calculated in the same way. Data were then organized in a matrix and statistically analyzed with Principal Component Analysis (PCA). PCA was performed using the “vegan” package [52] of R 3.5.1 software (R Development Core Team 2018). Species with less than 8 individuals were excluded from calculations because not significant.

M = d/p * 100

Where M was mortality rate, d was the number of dead plants during 2017 and p was the size of the population in which the dead plants occurred. The % of unhealthy, flowered and fruit-producing plants were calculated in the same way. Data were then organized in a matrix and statistically analyzed with Principal Component Analysis (PCA). PCA was performed using the “vegan” package [52] of R 3.5.1 software (R Development Core Team 2018). Species with less than 8 individuals were excluded from calculations because not significant.

Result

215 plants from 16 different species were planted inside the 8 plots (Table 3). 6 species (Ulmus Minor, Quercus robur, Carpinus betulus, Salix alba, Corylus avellana, Spartium junceum) were represented by less than 8 individuals and so were excluded from the statistical analysis and results.The requirement of the species, based on the ecological indices of [41] were evaluated from the radar charts analysis (Figure 4). The species had similar requirements of temperature (T), light intensity (L) and soil water content (F) being moderately heliophilous, typical of mild weather and tolerating a moderate soil water content. Euonymus europaeus, Rhamnus cathartica, Frangula alnus and Sambucus nigra had a peculiar tolerance for poorly aerated soils (D) (compact soils), Sambucus nigra required a lot of soil nutrients (N) whereas Rhamnus cathartica and Frangula alnus tolerated poorly fertile soils. Frangula alnus was the only species that required elevated amounts of humus (H).

Table 3:Number of monitored plants in the 8 plots. A, B, C, D, E, F, G & H: Plots *Species with less than 8 individuals


Figure 4:Radar charts of ecological indices of Landolt et al. (2010) for every monitored species. Key: T-Temperature; L-Light intensity; F-Soil moisture; R-Substrate reaction; N-Nutrients; H-Humus; D-Aeration.


From CSR triangular graph (Figure 5) it was possible to observe the functional strategies of the species. The CSR strategies were: Cornus mas, Euonymus europaeus and Rhamnus cathartica S/CSR, Rosa canina SR/CSR, Cornus sanguinea CS/CSR and Acer campestre CSR. Frangula alnus (S/SR) and Ligustrum vulgare (S/CS) were the most stress-tolerant species, whereas Sambucus nigra was the most competitive (C/CSR) and Prunus spinosa was the most ruderal (SR/ CSR) [51].<./

All the 10 species showed stress-related symptoms (Figure 6) while mortality didn’t occur in 3 of the 10 species (Acer campestre, Rosa canina, and Ligustrum vulgare) during 2017. Only Cornus sanguinea, Ligustrum vulgare, Frangula alnus were able to produce flowers but only Ligustrum vulgare e Frangula alnus completed their biological cycle by producing mature fruits (Figure 7), this could be due to the unlike time required by the species to reach sexual maturity. From PCA biplot (Figure 8) emerged that the species showing higher mortality and stress rates were the most competitive that required soil nutrients, available water content and a neutral-to-basic pH. The ruderal heliophilous species, requiring well aerated soils, were the ones showing less suffering from the new environment.

Figure 5:CSR strategies of the ten species considered.


Figure 6:Percentage of dead and unhealthy plants.


Figure 7:Percentage of flowered plants and fruitproducing plants.


Figure 8:PCA ordination biplot of species (1. Acer campestre; 2. Rosa canina; 3. Prunus spinosa; 4. Cornus mas; 5. Cornus sanguinea; 6. Ligustrum vulgare; 7. Euonymus europaeus; 8. Rhamnus cathartica; 9. Frangula alnus; 10. Sambucus nigra). Key: T-Temperature; L-Light Intensity; F-Soil Moisture; R-Substrate Reaction; N-Nutrients; H-Humus; D-Aeration; C-Competitor Strategy; S-Stress-Tolerant Strategy; R-Ruderal Strategy; Mortality, Percentage Of Dead Plants; Unhealthy, Percentage of Unhealthy Plants; Flowers, Percentage Of Flowered Plants; Fruits, Percentage Of Plants With Fruits..


Discussion

This study is an example of a simple and effective ecological approach to post-restoration vegetation survey. These data are useful not only to biologists and botanists, but also to all the people involved in planning and evaluation restoration projects. The combined use of traditional (ecological indices) and innovative (CSR functional strategy) methods is successful. Landolt’s indices application allowed to understand that the most fitting species for the reconstituted soil were the ones best tolerating elevated luminous radiation levels (heliophilous) requiring well-aerated and humus-rich soils, like Acer campestre, Rosa canina, Prunus spinosa, Ligustrum vulgare, Rhamnus cathartica and Frangula alnus. Ecological indices confirmed that, being the reconstituted soils well-aerated, non-compacted, rich in organic matter and high fertile.

CSR strategy represents a univocal system applicable to every tracheophyte [51] and as reported for the first time in this study, applicable also to restored areas survey. It can be observed that the most competitive species had more adaptation problems (mortality rate and stress-related symptoms) whereas ruderal and stress-tolerant plants best adapted to the restored environment. This result was confident with the fact that competitive species could live in an environment without stresses (defined as external constraints which limit the rate of dry matter production [53] or disturbances (factors causing plant biomass destruction [53]. Indeed, transferring highly competitive plants from a protected artificial environment, like a nursery, to a non-protected one, like a restored landfill, may have represented the main stress able to affect their survival, health and ability to complete the phenological cycle. So, to improve the overall restoration efficiency, it can be said that stress-tolerant and ruderal species, based on their CSR strategy, had to be chosen rather than competitive ones. Even though nowadays CSR strategy of over 3,000 species is known [51,54-56] there’s still a lot of work to do to define the functional strategy for as many as possible species included herbaceous species, given their importance in anthropic-perturbed ecosystems. Indeed, in synphytosociology (or dynamic phytosociology) [57], is known that the initial stages in a forest formation process are herbaceous species [58,59] and that the same are in environmental restored areas [60,31,55,56]. Further surveys should be carried out on the study area on the whole vegetation system (including herbaceous species). These kinds of surveys, being the key to understand the highly complex dynamics in the restored areas, should be made till the current potential vegetation [61-70] will be reached. Unfortunately, it’s not so, because these monitoring are costly, and they need technicians with specific skills.

Conclusion

This study highlighted how monitoring trees and shrubs growth, using both classic (ecological indices) and modern (CSR functional strategy) methods, may give useful information to improve the interventions efficiency in a restored landfill. Based on the results, it would recommend those involved in environmental restoration projects to select the plants accordingly to their specific CSR functional strategy. In order to obtain better environmental results, autochthonous ruderal and stress-tolerant plants should be used. Moreover, it would like to urge to monitor the post-intervention for at least 20 years [31]. Even though the long-term surveys are time consuming and expensive, are also fundamental to understand the highly complex dynamics underlying the restored areas. Lastly, the use of new technologies and materials, like reconstituted soils, are hoped to be applied to closed landfills restoration, in a world-wide optic, to fight environmental degradation.

Acknowledgement

This research was supported by Life+ project “Recupero ambientale di un suolo degradato e desertificato mediante una nuova tecnologia di trattamento di ricostituzione del terreno” (Life 10 ENV/IT/000400 New Life, http://www.lifeplusecosistemi.eu).

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Thursday, June 30, 2022

Sexual Abuse Identified after Suicide: Case Report_Crimson Publishers

 Sexual Abuse Identified after Suicide: Case Report by Kenan Kaya in COJ Nursing & Healthcare_research in nursing and health


Abstract

Child abuse is a maltreatment of a child under the age of 18 by his or her parent, carer, someone living in their home, or someone working with children. Abuse of a child is anything that causes injury or puts the child in danger of physical injury. Child abuse can be physical, sexual or emotional. Sexual abuse has been reported to be the largest component of suicide attempts in childhood. Between 1950 and 1993, children under the age of 15 had a 4-fold increase in suicide-related deaths among causes of death. In 1994, 6 percent of deaths between 5 and 14 years of age were found to be suicidal. Case; on a 14-year-old girl’s body’s external examination, where dead stiffness continued and purple-colored dead stains began to appear in unprinted areas. It was recorded that the telem was viewed as a parchmented area starting from the middle line, 10cm long and 1.5cm wide in the thickest area. On the outer side of the left knee there was a 3x2cm scar tissue. It was observed that the hymen was 2cm wide and had a notched structure and a partial tear at the level of 7 o’clock. There was no ecchymosis and hemorrhage around the anus and hymen. On the internal examination, a 2.5 centimeter fetus was detected in the uterus between 6-8 weeks of gestation. Only male DNA profiles were detected from the pregnancy material. Toxicological analyzes result in no detectable substance. It was determined that death was caused by mechanical asphyxia, the result of hanging. A 14-year-old girl who has been diagnosed with suicide mortality and pregnancy after autopsy will be examined in the light of literature in terms of child abuse and pregnancy.

Keyword: Death; Suicide; Sexual abuse; Child; Pregnancy

Introduction

Child abuse is the maltreatment of a child under the age of 18 by his or her parent, carer, someone living in their home, or someone working with children. Abuse of a child is anything that causes injury or puts the child in danger of physical injury. Child abuse can be physical, sexual or emotional. The World Health Organization refers to child abuse as “all of the behaviors of an adult, society or state, which harm the general values of the child’s life, health, development, trust, responsibility and skills” [1].

It is stated that child abuse is an important part of sexual abuse among the causes [2]. Between 1950 and 1993, children under the age of 15 had a 4-fold increase in suicide-related deaths among causes of death, and in 1994, 6% of deaths between 5 and 14 years of age were suicide-related [3]. De Wilde and colleagues reported that people who had sexually abused adolescents constituted a high risk group for suicide [4]. According to a study conducted in the United States on the Youth Health Behavior, the proportion of high school students who have experienced sexual harassment has reached 20.9% in Oregon and high-risk behaviors and suicide attempts rates have been found to increase in the group of sexual exploitation, especially during adolescence [5]. In the case report, we aimed to analyze the cause of pregnancy and sexual abuse detected after the autopsy of a 14-year-old girl.

Case Report

On a 14-year-old girl’s body’s external examination, where dead stiffness continued and purple-colored dead stains began to appear in unprinted areas. It was recorded that the telem was viewed as a parchmented area starting from the middle line, 10cm long and 1.5cm wide in the thickest area. On the outer side of the left knee there was a 3x2cm scar tissue. It was observed that the hymen was 2cm wide and had a notched structure and a partial tear at the level of 7 o’clock. Postmortem dilatation was detected in the anal examination. Ecchymosis and hemorrhage were not observed around the anus and hymen. On the internal examination, the stomach was seen as empty, and a 2.5centimeter fetus was detected in the uterus. In the toxicological analysis of the blood taken during the autopsy, there were no foreign substances in the blood, It was determined that the fetus was between 6-8 weeks of gestation, that the pregnancy material was compatible with the male DNA profile, and that the death was caused by mechanical asphyxia the result of hanging. According to the statements taken in the forensic investigation; the girl was hanging in her uncle’s house, the girl was already dead when the rope was cut off, the girl did not finish her primary school, the girl went to work in the cotton field 2 months ago and the girl tried to commit suicide by taking medication a month ago.

Discussion

Childhood suicides have increased in recent years. Sexual abuse of the child has an important place among causes of childhood suicide attempts. In a study conducted in 1993, 177 adolescent cases were examined and a significant relationship was found between physical or sexual abuse and suicide attempt. These cases have been reported to have recurrent suicide attempts [2]. In our case, the child had a history of suicide attempts a month ago, and the child has not been sufficiently observed, and has not been investigated for pregnancy. This shows that child abuse does not take place in the differential diagnosis. Suicide attempts affect family and society negatively; but it should not be forgotten that suicide is a call for help.

In a survey conducted by the National Society for the Prevention of Cruelty to Children (NSPCC), it was determined that the average age of sexually abused children was 10.2 and that 80 percent of these children were girls [6]. The concept of death under the age of ten is sophisticated and undefined, so there is less suicide attempt. It is believed that the developmental process of the concept of death was created at the age of 7-8 [7].

Many studies of sexual trauma show that the rate of exposure of girls to sexual assault is very common. A prevalence study has shown that 12 percent of adolescents are exposed to lifetime sexual abuse and / or assault [8]. In another literature, 76 percent of suicide attempts have been reported to occur in the home environment [9].

A child who has been sexually abused may face different psychosexual problems that affect him/her throughout his/her life. It has been reported that psychological damage caused by abuse causes the self-respect of the child to diminish in some way, and that social relations deteriorate following self-harm [10]. Kilpatrick and colleagues note that the anxieties and fears of sexual abuse (AIDS, sexually transmitted diseases, pregnancy, witnessing in court) are experienced by all victims [11]. The unacceptable nature and sudden onset of your activity lead to excessive fear, lack of control, and increased trauma response [12]. It should be kept in mind that the 14-year-old girl’s pregnancy is interpreted as child abuse, and the reasons for not telling the pregnancy to the family are embarrassment, social and traditional pressure.

In such deaths, hair and similar evidence on the body and clothing in the acute process is important for the identification of the attacker. It is also suggested that (especially if genital, perianal, and anal regions have traumatic symptoms) investigate traumatic symptoms; oral, rectal, and vaginal swabs taken for DNA analysis and antigenic seminal fluid speciation, searching for vaginal and rectal impairments etc. [13,14]. However, in our case about the presence of a 6-8 week fetus, DNA is the most important evidence for finding the identity of the attacker.

Conclusion

According to the law, a girl aged 14 years is guilty of sexual intercourse with her own discretion. Providing adequate support for the child’s protection, protecting the child from the family or community (ethical) pressures associated with possible pregnancies, and building confidence in this issue should be one of the government’s most important tasks.

References

  1. WHO (1999) Guidelines for medico-legal care for victims of sexual violence. Geneva, Switzerland.
  2. Shaunescy K, Cohen JL, Plummer B, Bcrmaii A (1993) Suicidally in hospitalized adolescental relationship tp prior abuse. Am J Orthopsychiatry 63(1): 113-119.
  3. Anonymous (1997) Rates of homicide, suicide and fire-arm related death among children 26 industrialized countries. MMWR Morb Mortal Wkly Rep 46(5): 101-105.
  4. De Wilde, Kienhorst EJ, Diekstra CW, Wolters RF (1994) Social support, life events and behavioral characteristics of psychologically distressed adolescents at high risk for attempted suicide. Adolescence 29(113): 49- 60.
  5. Nelson DE, Higginson GK, Grant Wiley WA (1994) Using the youth risk behavior survey to estimate prevalance of sexual abuse among oregon high school students. J School Health 64(10): 413-416.
  6. Surrey J, Sweet C, Michaels A, Levin S (1990) Reported history of physical and sexual abuse and severity of symptomatology in women psychiatric outpatients. Am J Orthopsychiatry 60(3): 412-417.
  7. Ozdogan B (1988) Child and Play Therapy. Ankara, Turkey.
  8. Council on Scientific Affairs, American Medical Association (1992) Violence against women: relevance for medical practitioners. JAMA 267(23): 3184-3189.
  9. Cirit H, Eğilmez A, Kültür S (1990) Investigation of psychiatric symptomatology and family characteristics in adults whoare attempting suicide. XXVI Scientific Studies of National Congress of Psychiatry and Neurological Sciences. İzmir, Turkey, pp. 547-553.
  10. Zciller B (1982) Physical and psychological abused and delinquent adolescents. Child Abuse Neglet 6(2): 207.
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  13. Yorulmaz C, Bütün C, Dokgöz H, Citici I, Altun G (2003) Death associated with sexual abuse of children. Forensic Sci İnt 136(Suppl 1): 397-398.
  14. Polat O, Yaycı N (2007) Approach to cases of death due to abuse. Child Abuse by All Dimensions. Prevention and Rehabilitation 2: 221-256.

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Wednesday, June 29, 2022

Evaluation of Leg Length Discrepancy (LLD) after Unilateral Total Knee Arthroplasty (TKA) Done for Varus Knee Deformity_Crimson Publishers

Evaluation of Leg Length Discrepancy (LLD) after Unilateral Total Knee Arthroplasty (TKA) Done for Varus Knee Deformity by Ahmed Khalifa A in Researches in Arthritis & Bone Study_Arthritis Open Access Journals


Abstract

Leg Length Discrepancy (LLD) is a major concern in patients undergoing lower limb total joint arthroplasty, it is commonly studied in Total Hip Arthroplasty (THA) literature, however, few studies evaluated this issue in Total Knee Arthroplasty (TKA) patients. In this mini-review, we will mention in brief how to evaluate the LLD associated with LLD as well as reviewing what had been reported about its incidence and the possible effect on clinical outcomes.

Introduction

Varus deformity associated with knee osteoarthritis considered to be the most commonly encountered deformity in patients undergoing Total Knee Arthroplasty (TKA), which is usually associated with varying degrees of medial soft tissue structures contractures, laxity of the lateral soft tissue structures, flexion deformity and medial knee compartment bone erosions [1]. The challenges in performing TKA in a varus arthritic knee include the restoration of mechanical limb alignment after balancing the medial and lateral soft tissue tension by equalizing the flexion and extension gaps [2]. Limb Length Discrepancy (LLD) less than 2cm is usually not noticeable and does not require treatment, however, if the LLD is over 2cm, it is usually noticed by the patients with a tendency to perform a self-compensation mechanism such as walking on the ball of the foot (toe down) or by tilting the pelvis and curving the spine, which eventually may lead to lower back pain, gait abnormalities and even can lead to hip arthritis [3-5]. LLD and its effects on patient function have been discussed in depth in the Total Hip Arthroplasty (THA) literature, although it had been reported with TKA, however, few studies handled this issue with its effects on the clinical outcomes [6,7].

How to assess LLD associated with TKA

Clinically: Apparent or functional leg length (which can be affected due to other causes rather than the TKA such as pelvis or spine problems) can be measured using measuring tape from a fixed point (usually the umbilicus) to a point represented bilaterally in both limb (usually the medial malleolus) [5,8,9], while the true or the anatomical leg length (which represents the actual bony length of the lower limb) can be measured from a separate points on each limb independently (which usually the anterior superior iliac spine “ASIS” proximally and the medial malleolus distally)

Radiologically: Using a full-length (hip to ankle) standing anteroposterior (AP) radiographs of the bilateral lower extremities as a routine during pre- and postoperative evaluation of TKA patients [10-12]. A marker is used to digitally scale the radiograph and the functional length is performed by measuring the distance from the center of the head to a point located at the center of the tibial plafond (Figure 1A) for both sides, while to determine the anatomical length of the limb, the femur and the tibia are measured separately. Anatomical length of the femur is determined by the length of a line connecting the center of the femoral head to the center of the roof of the intercondylar notch (Figure 1B), while the anatomical length of the tibia is determined by the length of a line connecting the center of the tibial plateau to the base of the tibial plafond (Figure 1C). Obtaining these measurements can guide the surgeon to detect if there is a pre- or post TKA LLD, and if present, it will determine its source (Figure 2).

Figure 1:Preoperative radiological measurement of leg length of both lower limbs on long film AP radiograph.
A. Functional length of both limbs.
B. Anatomical length of the femur.
C. Anatomical length of the tibia.


Figure 2:Postoperative long film AP radiograph showing the LLD between the operated and nonoperated limb after TKA.


Will the LLD after TKA affect the clinical outcomes

As we mentioned earlier that the data regarding the effect of LLD on patients having THA is huge but deficient regarding its incidence and secondary effect in the case of patients having TKA, however, few studies discussed this issue. Lang et al. [3] in their study in 2010 on 102 knees performed over a period of seven months, they found that 85 (83.3%) knees showed increase in the limb length after TKA and the average lengthening was 6.3mm (SD: 6.85mm; range, -11.0 to 24.0mm), however, they didn’t correlate this LLD with patients clinical outcomes. A study by Vaidya et al. [13] who reported that LLD after unilateral, not bilateral TKA done for varus knees with osteoarthritis significantly affected the functional outcomes. However, they also noted that 83.3% of the patients in the unilateral group and 46.6% in the bilateral group had LLD. Another study by Tipton et al. [14] in 2015 including 203 patients underwent TKA, 59.1% of the patients included in this study experienced an increase in limb length with an average increase of 0.438cm.
The authors didn’t report on the clinical outcomes as well as the previous study. A recent study by Kim et al. [15] including 148 patients reviewed retrospectively which was divided into two groups with one group including Eighty-one knees having a <15mm LLD, and the other group including 67 knees found to have more than a 15mm LLD, they evaluated the radiographic outcomes, clinical outcomes, patients satisfaction, and perception of LLD were also evaluated. They found a significant difference in the Knee Society function score and the score for the difficulty with ascending the stairs in the Western Ontario and McMaster Universities score between both groups, however, there was no difference in the results of their satisfaction questionnaires. They concluded that the functional outcomes of more than 15mm post-operative LLD after TKA were lower than those of the <15mm LLD. Thus, the reduced post-operative LLD should be considered to improve the functional outcomes of primary TKA.

Conclusion

Although not much studied, LLD related to TKA can occur and surgeons should keep it into account while performing TKA. More studies should be performed to assess the incidence of LLD following TKA as well as its effect on clinical as well as radiological outcomes and if it has any impact on implant survival and rate of revision.

References

  1. Mihalko WM, Saleh KJ, Krackow KA, Whiteside LA (2009) Soft tissue balancing during total knee arthroplasty in the varus knee. J Am Acad Orthop Surg 17(12): 766-774.
  2. Mullaji, Arun B, Shetty, Gautam (2014) Deformity correction in total knee arthroplasty. Asian Heart Institute and Research Center, India.
  3. Lang JE, Scott RD, Lonner JH, Bono JV, Hunter DJ, et al. (2012) Magnitude of limb lengthening after primary total knee arthroplasty. J Arthroplasty 27(3): 341-346.
  4. Khalifa AA (2017) Leg length discrepancy: Assessment and secondary effects. Ortho & Rheum Open Access 6(1): 001-005.
  5. Clark CR, Huddleston HD, Schoch EP, Thomas BJ (2006) Leg-length discrepancy after total hip arthroplasty. J Am Acad Orthop Surg 14(1): 38-45.
  6. Konyves A, Bannister G (2005) The importance of leg length discrepancy after total hip arthroplasty. J Bone Joint Surg Br 87(2): 155-157.
  7. Edeen J, Sharkey P, Alexander AH (1995) Clinical significance of leg-length inequality after total hip arthroplasty. Am J Orthop (Belle Mead NJ) 24(4): 347-351.
  8. McCaw S, Bates B (1991) Biomechanical implications of mild leg length inequality. Br J Sports Med 25(1): 10-13.
  9. Beard D, Andrew JG, Jeya P, John FN (2008) Incidence and effect of leg length discrepancy following total hip arthroplasty. Physiotherapy 94(2): 91-96.
  10. Murray KJ, Azari MF (2015) Leg length discrepancy and osteoarthritis in the knee, hip and lumbar spine. J Can Chiropr Assoc 59(3): 226-237.
  11. Sabharwal S, Kumar A (2008) Methods for assessing leg length discrepancy. Clin Orthop Relat Res 466(12): 2910-2922.
  12. Harvey WF, Yang M, Cooke TD, Segal NA, Lane N, et al. (2010) Association of leg-length inequality with knee osteoarthritis: A cohort study. Ann Intern Med 152(5): 287-295.
  13. Vaidya SV, Patel MR, Panghate AN, Rathod PA (2010) Total knee arthroplasty: Limb length discrepancy and functional outcome. Indian J Orthop 44(3): 300-307.
  14. Tipton S, Sutherland, Schwarzkopf R (2015) Change in limb length after total knee arthroplasty. Geriatr Orthop Surg Rehabil 6(3): 197-201.
  15. Kim SH, Rhee SM, Lim JW, Lee HJ (2016) The effect of leg length discrepancy on clinical outcome after TKA and identification of possible risk factors. Knee Surg Sports Traumatol Arthrosc 24(8): 2678-2685.

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Tuesday, June 28, 2022

Endovascular Treatment of Acute Pulmonary Artery Trunk Embolism Following Thrombosis of Double Inferior Vena Cava_Crimson Publishers

Endovascular Treatment of Acute Pulmonary Artery Trunk Embolism Following Thrombosis of Double Inferior Vena Cava by Tao Zhang Z in Developments in Anaesthetics & Pain Management_Journal of Research and Review


Abstract

A double Inferior Vena Cava (IVC) is a rare disease but can cause venous thrombosis and pulmonary embolism. We herein describe a patient who was admitted for evaluation of syncope. A severe pulmonary trunk embolism was found by computed tomography pulmonary angiography, but ultrasound showed no deep vein thrombosis in the lower extremity. A double IVC accompanied by floating thrombi was found during IVC angiography, and the double IVC converged above the renal veins. A temporary filter was implanted through the right internal jugular vein, and catheter-directed thrombolysis in both the pulmonary artery and IVC was performed. The patient recovered smoothly.

Conclusion: For patients with pulmonary embolism and no thrombosis in the deep veins of the lower extremities, the source of the thrombi should be clarified and the possibility of IVC malformation should be considered.

Keywords: Double inferior vena cava; Vessel anomalies; Pulmonary embolism; Catheter-directedthrombolysis

Introduction

Inferior Vena Cava (IVC) malformations are not common, but they should be carefully identified prior to IVC surgery and retroperitoneal surgery to avoid serious complications. A double IVC is a common type of IVC anomaly. A double IVC can cause anatomical and blood flow abnormalities that lead to thrombosis and secondary Pulmonary Embolism (PE). We herein report our experience with the diagnosis and treatment of a patient with acute pulmonary artery trunk embolism following thrombosis of a double IVC.

Case Report

A previously healthy 46-year-old man was admitted because of sudden-onset syncope 8 hours previously. The patient had suddenly fainted 8 hours prior to presentation with no known cause and lost consciousness; however, he had no convulsions of any limbs and no fecal or urinary incontinence. The syncope lasted for about 3 minutes, and the patient gradually regained his consciousness accompanied by shortness of breath, chest distress, coughing, and expectoration. Examination upon admission revealed type I respiratory failure, and Computed Tomography (CT) pulmonary angiography showed an embolism in the main pulmonary artery; however, ultrasound examination showed no thrombus in the lower extremities (Figure 1). On physical examination, the patient’s blood pressure was 98/45mmHg, his lips were cyanosed, his heart rate was 115beats/min with a regular rhythm, and his respiratory rate was rapid (about 30breaths/min) with coarse respiratory sounds in the bilateral lungs. No swelling was seen in the lower limbs. After admission, blood gas analysis (mask-delivered oxygen at 5L/min) showed the following: pH, 7.30; PO2, 45.40mmHg; PCO2, 36.50mmHg; and SO2, 85.8%. His D-dimer concentration was 3.75mg/L. After treatment with oxygen inhalation, the patient was able to assume a supine position. His PE severity index was 126 points (grade V is defined as >125 points, which indicates very high 30-day mortality risk of (10.0-24.5) %.

Figure 1:Preoperative computed tomography showed thromboembolism in the bilateral main pulmonary arteries (arrow).


Preoperative Analysis

Peripheral thrombolysis or Catheter-Directed Thrombolysis (CDT) after IVC filter placement

The patient had acute pulmonary arterial embolism, and the thrombi were relatively large. They were considered to have been caused by the detachment of large thrombi, but no thrombus was found on an ultrasound examination of the bilateral lower extremities. Because the source of the thrombi was not clear, we were concerned that peripheral thrombolysis may result in a new thrombus that could readily detach and aggravate the PE. Therefore, the patient was scheduled to undergo IVC angiography followed by pulmonary angiography and pulmonary artery CDT.

Source of the thrombi

CT pulmonary angiography showed PE, but no swelling in the lower limbs. The ultrasound examination showed no thrombosis in the deep veins of the lower limbs. The source of the thrombi could not be identified. IVC angiography was therefore performed to determine the source of the thrombi. Because thrombi are usually seen in the IVC system, IVC angiography was the first-choice procedure. If thrombi were present, a filter could be implanted through the superior vena cava.

Operative procedure

Local anesthesia was administered, and the angiography procedure was performed via puncture of the right femoral vein. Angiography showed that the IVC was relatively small in diameter and contained a filling defect. After puncture via the left femoral vein, angiography showed a double IVC (Figure 2A) and thrombosis (floating thrombi) within the IVC. The left and right IVCs merged into one branch above the renal vein. Puncture was performed via the right jugular vein, and a temporary vena cava filter was implanted (Tempofilter II; B. Braun, Melsungen, Germany) (Figure 2B & 2C). The filter was located above the junction of the two IVCs. Pulmonary artery angiography (Figure 3A) and pulmonary artery CDT were performed through the right subclavian vein. IVC CDT was performed through the left femoral vein. The thrombolysis catheter used in this patient was a Uni Fuse (AngioDynamics, Latham, NY, USA).

Figure 2: Angiography showed a double IVC with thrombosis (arrows) in both IVCs.
(A) Angiography via right femoral vein.
(B) Angiography via left femoral vein.
(C) Junction of left and right IVCs, IVC filter (long arrow) and floating thrombi in IVC (short arrow).


Postoperative treatment

After pulmonary arterial CDT and IVC filter placement, the patient was continuously infused with 500,000 IU of urokinase for 10 hours and administered low-molecular-weight dextran daily. Additionally, low-molecular-weight heparin (nadroparin at 100IU/ kg) was injected subcutaneously for anticoagulation treatment. The patient’s respiratory condition gradually improved, and his shortness of breath and chest distress disappeared. After 3 days, his blood pressure was 120/75mmHg, heart rate was 90beats/ min, and blood oxygen saturation returned to 95% to 100%. His oxygen partial pressure was normal on repeated blood gas analysis. Additionally, repeat angiography showed that the pulmonary artery thrombi had disappeared, and his blood flow was smooth (Figure 3B). After 1 month, the IVC filter was removed.

Figure 3: (A) Pulmonary angiography showed a filling defect of the main pulmonary artery (circle).
(B)After thrombolysis, the thrombi in the pulmonary arteries disappeared.
(C)Reexamination by computed tomography pulmonary angiography of the pulmonary arteries at 3 months postoperatively showed no abnormalities.


Follow-up visits

After discharge, the patient received oral warfarin as long-term anticoagulant therapy. CT pulmonary angiography was performed again 3 months after the operation (Figure 3C). The patient was followed up for 2 years, during which time he developed no symptoms such as chest distress or shortness of breath and exhibited no lower limb venous insufficiency.

Discussion

Choice of treatment method

Generally, PE with syncope as the main manifestation is relatively severe. This patient had a massive thromboembolism in the main pulmonary arteries of the bilateral lungs, his medical condition was critical, and the source of the thrombi was unclear. Peripheral thrombolysis may result in a new thrombus in such cases, and peripheral thrombolysis therapy alone may not completely dissolve the thrombus. In our patient, angiography of the IVC was performed first, and a double IVC containing floating thrombi was found. Implantation of an IVC filter was required before thrombolysis therapy to avoid recurrence of the PE. The patient had a double IVC characterized by the joining of two IVCs between the hepatic veins and the renal veins, and thrombi had formed in the bilateral IVCs. The filter was implanted into the trunk of the IVC, and this needed to be performed via the internal jugular vein. Because the patient was young, a temporary filter was required. The Tempofilter II met these requirements.

Pulmonary arterial CDT

The treatment of acute PE includes anticoagulant therapy, thrombolytic therapy, catheter interventional surgery, surgical thrombectomy, implantation of IVC filters, and possibly other measures. The main purpose of percutaneous catheter interventional therapy is to quickly reduce the pulmonary artery pressure, restore right ventricular function, and increase systemic perfusion. In 2014, the European Society of Cardiology (ESC) guideline recommended that CDT [1] may be the first-choice treatment for patients without absolute contraindications for thrombolysis [1]. In 2019, the ESC guideline stated that surgical thrombectomy or CDT could be considered as an alternative to thrombolysis rescue, and the recommendation level was increased from IIb to IIa [2]. In the present case, the patient underwent pulmonary artery angiography via the right subclavian vein and received thrombolysis therapy by means of thrombolysis catheter implantation. After the treatment, his respiration was significantly improved, and his oxygen partial pressure returned to normal as shown by blood gas examination. After 3 days, repeat angiography showed that the pulmonary artery thrombi had disappeared and that the blood flow in the pulmonary arteries was unobstructed. The effect of thrombolysis was satisfactory in this case for two reasons: first, the CDT allowed the drugs to act quickly and intensively, and second, the CDT was conducted within 24 hours of symptom onset.

IVC malformations

The IVC can be divided into four segments: the hepatic segment, suprarenal segment, renal segment, and infrarenal segment. IVC malformations can be divided into three types according to the lesion characteristics:
1. Infrarenal: left-sided IVC, duplication, pre-aortic IVC, and absence of the infrarenal IVC
2. Renal: left retroaortic renal vein and left circumaortic renal collar, accessory left renal vein
3. Suprarenal: absent hepatic IVC with azygos continuation, congenital caval membranes, congenital IVC stenosis or atresia [3,4].

IVC malformations are relatively rare, with an incidence of about 0.3% to 0.6% in the general population [5,6]. Although a large collateral circulation is present, IVC abnormalities can cause obstructions of venous reflux, leading to venous hypertension and blood flow stagnation, eventually resulting in venous thrombosis [3,7]. Some patients visit the hospital because of chronic venous insufficiency and are further diagnosed with an IVC malformation [8,9]. It is generally accepted that congenital IVC malformations should be considered in young patients with spontaneous bilateral deep venous thrombosis, and most such patients have subclinical symptoms [3,6,10]. Contrast-enhanced CT is very effective in the examination of IVC abnormalities. It can reveal the venous extension and the presence of thrombi [6,11]. Duplication is a common IVC anomaly. Notably, embryonic development of the IVC is complicated. There are three pairs of embryonic veins (postcardinal, subcardinal, and supracardinal) that form a complex anastomosis among one another, gradually regressing thereafter to form the final IVC. Failure of regression of both supracardinal veins and failure of formation of adequate connections between the primitive veins are considered reasonable explanations of double IVC formation [6,12,13]. In most cases, the abnormal left IVC is located at the level of the left renal vein, spans the aorta, and connects to the right IVC [14], and it sometimes directly connects to the left renal vein [15]. Double IVCs can be divided into asymmetric and symmetric duplication. In most cases, the right IVC is still the dominant reflux channel [6]. The clinical manifestations of a double IVC include lumbago, thrombosis, and other conditions; some patients are asymptomatic [16]. In patients with a double IVC, clinicians must be vigilant before retroperitoneal surgery; avoid massive hemorrhage, thrombosis, and other complications; determine whether a double IVC is present before IVC filter implantation; and avoid filter-related complications [6,13,17]. In the present case, two IVCs had joined above the renal vein with floating thrombi, and severe PE was present; however, the deep veins of the lower limbs were free of thrombi, and the patient had no symptoms of venous insufficiency, considering that the thrombosis was related to the venous malformation.

Conclusion

Although a double IVC with floating thrombi is rare, clinicians must still be vigilant of the possibility, and it is helpful to formulate a treatment plan. For patients with PE and no swelling in the lower limbs or thrombosis in the deep veins of the lower limbs as shown by ultrasound examination, the source of the thrombi should be clarified. Both the IVC and iliac vein should be considered as potential sources.

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