Accessory Muscle Research Articles

Unusual bilateral variation of the flexor digitorum accessorius longus muscle and its relation on tarsal tunnel syndrome.

During standard anatomical dissection for a medical anatomy course, we encountered an unusual bilateral variant of a unipennate flexor digitorum accessorius longus (FDAL) muscle, a supernumery muscle of the deep posterior leg and medial ankle. We documented the muscles course and measured the diameter and length of the FDAL muscle belly, as well as the full length of its tendinous attachments. On both right and left legs, the FDAL originated from the proximal posterior fibula and distal one-third of the flexor hallucis longus muscle. The tendon had a distal attachment on the flexor digitorum longus (FDL) tendon and traveled with the FDL tendon as it inserted on the third distal phalanx. The left FDAL full length was 42.54cm; the length of the muscle belly was 16.26cm; and the circumference of the muscle belly was 4.44cm. The right FDAL full length was 44.20cm; the length of muscle belly was 12.06; and the circumference (belly) was 4.44cm. Surrounding musculature and neurovasculature follow standard anatomical courses. This anatomical documentation provides opportunities for clinicians to consider mechanical influences of the FDAL on plantar foot function and further consider the accessory ankle muscles that have the potential to cause compressive neuropathies such as tarsal tunnel syndrome.

A severe case of Israeli spotted fever with pleural effusion in Italy

BackgroundThe most common Italian rickettsiosis is Mediterranean Spotted Fever (MSF). MSF is commonly associated with a symptom triad consisting of fever, cutaneous rash, and inoculation eschar. The rash is usually maculopapular but, especially in severe presentations, may be petechial. Other typical findings are arthromyalgia and headache. Herein, we describe for the first time an unusual case of Israeli spotted fever (ISF) associated with interstitial pneumonia and pleural effusion in which R. conorii subsp. israelensis was identified by molecular methods in the blood, as well as in the pleural fluid.Case presentationA 72-year-old male presented with a 10-day history of remittent fever. On admission, the patient’s general condition appeared poor with confusion and drowsiness; the first assessment revealed a temperature of 38.7°, blood pressure of 110/70 mmHg, a blood oxygen saturation level of 80% with rapid, frequent, and superficial breathing using accessory muscles (28 breaths per minute), and an arrhythmia with a heart rate of 90 beats per minute. qSOFA score was 3/3. Chest CT revealed ground-glass pneumonia with massive pleural effusion. Petechial exanthema was present diffusely, including on the palms and soles, and a very little eschar surrounded by a violaceous halo was noted on the dorsum of the right foot. Awaiting the results of blood cultures, broad-spectrum antibiotic therapy with meropenem 1 g q8h, ciprofloxacin 400 mg q12h, and doxycycline 100 mg q12h was initiated. Doxycycline was included in the therapy because of the presence of petechial rash and fever, making us consider a diagnosis of rickettsiosis. This suspicion was confirmed by the positivity of polymerase chain reaction on whole blood for R. conorii subsp. israelensis. Thoracentesis was performed to improve alveolar ventilation. R. conorii subsp. israelensis was again identified in the pleural fluid by PCR technique. On day 4 the clinical condition worsened. Blood exams showed values suggestive of secondary hemophagocytic lymphohistiocytosis; 4 out of 8 diagnostic criteria were present and empirical treatment with prednisone was started resulting in a gradual improvement in general condition.ConclusionsIsraeli spotted fever may be a severe disease. A high index of suspicion is required to promptly start life-saving therapy. Pleural effusion and interstitial pneumonia may be part of the clinical picture of severe rickettsial disease and should not lead the physician away from this diagnosis.

Low lysophosphatidylcholine induces skeletal muscle myopathy that is aggravated by high-fat diet feeding.

Obesity alters skeletal muscle lipidome and promotes myopathy, but it is unknown whether aberrant muscle lipidome contributes to the reduction in skeletal muscle contractile force-generating capacity. Comprehensive lipidomic analyses of mouse skeletal muscle revealed a very strong positive correlation between the abundance of lysophosphatidylcholine (lyso-PC), a class of lipids that is known to be downregulated with obesity, with maximal tetanic force production. The level of lyso-PC is regulated primarily by lyso-PC acyltransferase 3 (LPCAT3), which acylates lyso-PC to form phosphatidylcholine. Tamoxifen-inducible skeletal muscle-specific overexpression of LPCAT3 (LPCAT3-MKI) was sufficient to reduce muscle lyso-PC content in both standard chow diet- and high-fat diet (HFD)-fed conditions. Strikingly, the assessment of skeletal muscle force-generating capacity ex vivo revealed that muscles from LPCAT3-MKI mice were weaker regardless of diet. Defects in force production were more apparent in HFD-fed condition, where tetanic force production was 40% lower in muscles from LPCAT3-MKI compared to that of control mice. These observations were partly explained by reductions in the cross-sectional area in type IIa and IIx fibers, and signs of muscle edema in the absence of fibrosis. Future studies will pursue the mechanism by which LPCAT3 may alter protein turnover to promote myopathy.

Features of electromyography threshold of the respiratory muscles during incremental exercise test

In this study, we aimed to examine the electromyography threshold (EMGT) of the respiratory muscle and accessory respiratory muscles. Sixteen healthy men underwent an incremental exercise test at 15 W/minute to the end point. Expired gases and electromyograms of the respiratory and lower limb muscles were measured. The breakpoints for the EMG and expired gas data were analyzed using a segmented regression model. EMGT of the sternocleidomastoid and diaphragm was significantly more delayed than the ventilation threshold (VT) (287.94 s, 288.15 s vs. 185.5 s, p = 0.028 and 0.044, respectively). The EMGT of respiratory muscles and VT were not related, though EMGT of rectus femoris and vastus lateralis correlated with VT (r = 0.854, p < 0.001; r = 0.657, p = 0.011, respectively). EMGT of respiratory muscles may be influenced by multiple factors, such as central command and afferent input of mechanical stimulation from muscles, in addition to VT-induced changes in metabolic dynamics.

A cadaveric analysis of anatomical variations of the anterior belly of the digastric muscle.

The anterior belly of the digastric muscle (ABDM) presents highly variable and frequent anatomical variations. Since the ABDM functions as a landmark for clinical procedures involving the submental region, it is important to have a comprehensive understanding of its variations. In this study, we sought to improve our knowledge of ABDM variations in the ethnically diverse whole-body donor population in Northern California. Specific aims were: (1) to determine the frequency of ABDM and anterior belly (AB) accessory muscle variations in cadavers donated to the UC Davis Body Donation Programme, (2) to classify these variations identified in this population using the previously proposed nomenclatures by Yamada (1935) and Zlabek (1933), and (3) to investigate the innervation and arterial supply to the representative ABDM and AB accessory muscle variations. During the 2018 and 2019 gross anatomy dissection laboratories at the UC Davis School of Medicine, the submental regions of 48 cadavers were examined and classified. Fifteen (31.2%) cadavers presented ABDM and AB accessory muscle variations. These variations were clearly categorised using the morphology of the ABDMs and attachments of the AB accessory muscles. We also identified three previously unreported types of variations, two of which presented the fusion of right and left ABDMs and one presenting an ectopic tubercle beneath the mandibular symphysis to which a pair of AB accessory muscles were attached. Anterior belly of the digastric muscle variations were found in 1 in 3 individuals in the local Northern California population. Knowledge of the prevalence and common patterns of ABDM variations in the general population would be valuable information when an operation or examination is performed in the submental region.

Tarsal Tunnel Syndrome: An Ultrasound Pictorial Review.

Tarsal tunnel syndrome may be idiopathic or may be caused by various conditions: bone disease, thickening of the retinaculum, hematoma, or iatrogenic nerve damage; tendinopathy or tenosynovitis; the presence of supernumerary muscles such as an accessory soleus, peroneocalcaneus internus, or accessory flexor digitorum muscle; bone or joint disorders; expansile tumors or cysts; and venous aneurysm or kinking of the tibial artery. The purpose of this article is to describe and illustrate most of the causes of tarsal tunnel syndrome, as diagnosed by ultrasound, which is a practical, inexpensive method.

Demographic characteristics of duane syndrome patients with synergistic divergence and accessory fibrotic extraocular muscles

Imaging studies report accessory fibrotic muscles in approximately 2.5% of patients with strabismus. Synergistic divergence is a rare form of ocular motility characterized by simultaneous divergence in attempted adduction. This study describes demographic predilections of Duane syndrome patients diagnosed with accessory fibrotic muscles or synergistic divergence.

An Accessory Muscle of the Posterior Compartment of Leg of Clinical Significance: A Cadaveric Case Report

An Accessory Muscle of the Posterior Compartment of Leg of Clinical Significance: A Cadaveric Case Report

Does diaphragm ultrasound improve the rapid shallow breathing index accuracy for predicting the success of weaning from mechanical ventilation?

BackgroundThis prospective study investigated whether taking into account diaphragmatic excursion (DE) measured by ultrasonography would improve the performance of the rapid shallow breathing index (RSBI) to predict extubation success or failure. ObjectivesThe aim of the study was to compare the new composite index named the rapid shallow diaphragmatic index (RSDI), and the RSBI measured during a spontaneous breathing trial regarding their ability to predict the need for re-intubation at 72 h. MethodsOne hundred mechanically ventilated patients underwent daily 30-min spontaneous breathing trials (SBTs) under pressure support ventilation of 6 cm H2O and end-expiratory pressure of 0 cm H2O until the SBT was considered successful and followed by extubation. The performances of RSBI (respiratory rate/tidal volume) and of the ratio RSBI/DE measured at 5 and 25 min of the successful SBT were compared in terms of area under the receiver operating characteristics curve (AUC), for predicting extubation success at 72 h. As secondary analysis, extubation and weaning success at 7 d were also considered. As exploratory analyses, predictive indices incorporating both clinical characteristics, the DE, and ultrasound diaphragm thickening fraction (DTF) were investigated. ResultsRSBI and RSBI/DE showed AUCs with 95% confidence intervals consistently extending below 0.50, either at the 5th (0.55 [0.36–0.74] and 0.55 [0.34–0.75], respectively) or at the 25th minute of SBT (0.49 [0.27–0.71] and 0.50 [0.29–0.68], respectively) for predicting weaning success at 72 h or at 7 d (5th min: 0.53 [0.37–0.70] and 0.54 [0.37–0.70], respectively; 25th min: 0.54 [0.37–0.71] and 0.55 [0.39–0.71], respectively). An exploratory index incorporating the accessory respiratory muscle activity, DE, DTF, and respiratory rate at 5th min of SBT showed AUCs for predicting extubation success at 7 d in the 78 patients with DTF measurement (0.77 [0.64–0.90]) that were significantly higher than that of the RSBI (P = 0.017) and RSBI/DE (P < 0.001) in the same respective populations. ConclusionsThe RSBI and the ratio RSBI/DE failed to predict weaning success when measured during an SBT performed under minimal pressure support. Predictive indices incorporating ultrasound DE and DTF may merit further investigation.

Scaling of axial muscle architecture in juvenile Alligator mississippiensis reveals an enhanced performance capacity of accessory breathing mechanisms.

Quantitative functional anatomy of amniote thoracic and abdominal regions is crucial to understanding constraints on and adaptations for facilitating simultaneous breathing and locomotion. Crocodilians have diverse locomotor modes and variable breathing mechanics facilitated by basal and derived (accessory) muscles. However, the inherent flexibility of these systems is not well studied, and the functional specialisation of the crocodilian trunk is yet to be investigated. Increases in body size and trunk stiffness would be expected to cause a disproportionate increase in muscle force demands and therefore constrain the basal costal aspiration mechanism, necessitating changes in respiratory mechanics. Here, we describe the anatomy of the trunk muscles, their properties that determine muscle performance (mass, length and physiological cross‐sectional area [PCSA]) and investigate their scaling in juvenile Alligator mississippiensis spanning an order of magnitude in body mass (359 g–5.5 kg). Comparatively, the expiratory muscles (transversus abdominis, rectus abdominis, iliocostalis), which compress the trunk, have greater relative PCSA being specialised for greater force‐generating capacity, while the inspiratory muscles (diaphragmaticus, truncocaudalis ischiotruncus, ischiopubis), which create negative internal pressure, have greater relative fascicle lengths, being adapted for greater working range and contraction velocity. Fascicle lengths of the accessory diaphragmaticus scaled with positive allometry in the alligators examined, enhancing contractile capacity, in line with this muscle's ability to modulate both tidal volume and breathing frequency in response to energetic demand during terrestrial locomotion. The iliocostalis, an accessory expiratory muscle, also demonstrated positive allometry in fascicle lengths and mass. All accessory muscles of the infrapubic abdominal wall demonstrated positive allometry in PCSA, which would enhance their force‐generating capacity. Conversely, the basal tetrapod expiratory pump (transversus abdominis) scaled isometrically, which may indicate a decreased reliance on this muscle with ontogeny. Collectively, these findings would support existing anecdotal evidence that crocodilians shift their breathing mechanics as they increase in size. Furthermore, the functional specialisation of the diaphragmaticus and compliance of the body wall in the lumbar region against which it works may contribute to low‐cost breathing in crocodilians.

EARLY PULMONARY REHABILITATION APPROACH TOWARDS COMPLICATED CASE OF ACUTE RESPIRATORY FAILURE: ENHANCING QUALITY OF LIFE

Acute Respiratory failure often refers to the inability of the body system to maintain optimum arterial and tissue oxygen levels or to optimally expel out carbon dioxide. It is, therefore, hypoxemic or hypercapnia in nature or both depending on the root pathogenesis. A 72-year-old female patient was admitted to the hospital with complaints of breathlessness at rest with NYHA grade 4, dry cough (nonproductive), and orthopnea. The patient is a known case of Diabetes Mellitus type 2 for the last 5 years. On the day of examination patients were breathless using accessory muscles for respiration. The patient was tachypnea. The chest expansion, as well as excursion, was significantly reduced. On auscultations in Coarse crackles were heard. X-ray showed pneumonitis changes. ABG showed respiratory acidosis without compensation initially. Physiotherapy intervention included patients and their family members counseling, airway clearance techniques, energy conservation methods, and adaptation to complex positions with the maintenance of Spo2. Outcome measures have shown enhancement in functional independence and bedside daily activities. Pulmonary Rehab with efficient family counseling is effective in the overall improvement of the patient’s condition with acute respiratory failure.

Responses in knee joint muscle activation patterns to different perturbations during gait in healthy subjects

PurposeTo compare the responses in knee joint muscle activation patterns to different perturbations during gait in healthy subjects. ScopeNine healthy participants were subjected to perturbed walking on a split-belt treadmill. Four perturbation types were applied, each at five intensities. The activations of seven muscles surrounding the knee were measured using surface EMG. The responses in muscle activation were expressed by calculating mean, peak, co-contraction (CCI) and perturbation responses (PR) values. PR captures the responses relative to unperturbed gait. Statistical parametric mapping analysis was used to compare the muscle activation patterns between conditions. ResultsPerturbations evoked only small responses in muscle activation, though higher perturbation intensities yielded a higher mean activation in five muscles, as well as higher PR. Different types of perturbation led to different responses in the rectus femoris, medial gastrocnemius and lateral gastrocnemius. The participants had lower CCI just before perturbation compared to the same phase of unperturbed gait. ConclusionsHealthy participants respond to different perturbations during gait with small adaptations in their knee joint muscle activation patterns. This study provides insights in how the muscles are activated to stabilize the knee when challenged. Furthermore it could guide future studies in determining aberrant muscle activation in patients with knee disorders.

A RANDOMIZED COMPARATIVE CLINICAL EVALUATION OF HARIDRADI LEHA AND VASADI KASHAYA IN THE MANAGEMENT OF TAMAKA SHWASA (BRONCHIAL ASTHMA)

Tamaka Shwasa in Ayurveda is analogous to Bronchial Asthma due to similarity in causative and precipitating factors, onset, pathogenesis and symptoms. An estimated 300 million people worldwide suffer from asthma, with 250,000 annual deaths attributed to the disease. The Objective is to evaluate and compare the efficacy of Haridradi Leha with and without Vasadi Kashaya in the management of Tamaka Shwasa. Total 30 patients were registered for the present study. The patients of group A were administered Haridradi Leha in a dose of 20 grams BD (Bis in die i.e., twice daily) in empty stomach orally with lukewarm water for 21 days. The patients of group B were administered Haridradi Leha (20 grams BD) and Vasadi Kashaya (50 ml BD) with Anupana (co-administers with medicine) of honey orally for 21 days. There are highly significant results (p value: p&lt;0.01, p&lt;0.001) in breathlessness, cough, body position, wheezing in a day, wheezing in night, heart rate in both group but quantity of sputum, respiratory rate, use of accessory muscle and mental status shows highly significant result only in Group B. Both groups have highly significant result in peak expiratory flow rate (PEFR) and forced expiratory volume in one second (FEV1). Both the Haridradi Leha and Vasadi Kashaya are highly effective in the management of Tamaka Shwasa. Haridradi Leha along with Vasadi Kashaya provided better relief than Haridradi Leha alone in most of the sign and symptom of the disease at significant level.

Rehabilitation Effects of Acupuncture on the Diaphragm Dysfunction in Chronic Obstructive Pulmonary Disease: A Systematic Review.

IntroductionDiaphragm dysfunction is a significant extrapulmonary effect in chronic obstructive pulmonary disease (COPD), which is manifested by changes in diaphragm structure and reduced diaphragm strength. Acupuncture is a traditional rehabilitation technique in China, which has been used in rehabilitation for COPD. But whether acupuncture can improve the diaphragm function of COPD patients remains to be verified.ObjectiveThe objective of this study was to evaluate the rehabilitation effects of acupuncture on diaphragm dysfunction in patients with COPD.MethodsThe authors retrieved in CNKI, VIP, SinoMed, PubMed, Ebsco, Web of Science, from inception to November 2020, for relevant randomized control trials. Two researchers independently screened the articles and extracted the data. The quality of the included studies was evaluated by Physiotherapy Evidence Database scale. The primary outcome measures were maximal inspiratory pressure and the scale for accessory respiratory muscle mobilization, the secondary outcome measures were pulmonary function-related indicators and arterial blood gas indicators.ResultsNine articles were finally obtained. Seven studies added acupuncture to standard treatment for patients with diaphragm dysfunction in COPD and found statistically significant changes in the maximum inspiratory pressure and the scale for accessory respiratory muscle mobilization. Two studies have proved that use acupuncture combined with other Traditional Chinese Medicine methods in the rehabilitation for COPD can effectively improve the diaphragm strength and diaphragmatic motor performance. Seven studies showed that acupuncture has obvious improvement in pulmonary ventilation function. Seven studies reported significant differences in arterial blood gas pre- to post-intervention.ConclusionThis systematic review found that acupuncture can effectively enhance the diaphragm strength, relieve respiratory muscle fatigue, it can also play a promoting role in improving lung function, hypoxia, and carbon dioxide retention, as well as preventing and alleviating respiratory failure. The generalizability of these results is limited by the design of the included studies.

Comparison of effectiveness of metered dose inhaler with spacer and jet nebulizer in children aged 5–14 years with acute exacerbation of asthma

Background: Asthma is a common and potentially serious chronic disease that imposes a substantial burden on patients, their families, and community. The main treatment of an acute exacerbation includes inhaled short-acting β2-agonists (SABA). The aim of this of study was to compare the effectiveness of metered dose inhaler (MDI) with spacer and jet nebulizer for delivering SABA in children aged 5-14 years presenting to the emergency department with acute asthma. Subjects and Methods: One hundred subjects were randomly assigned to receive salbutamol by an MDI with spacer or a nebulizer at fixed intervals. The parameters such as respiratory rate, heart rate, use of accessory muscles, auscultatory findings, peak expiratory flow rate (PEFR), development of tremor, pCO2 on venous blood gas, need for hospital admission, and duration of stay in the emergency department were compared between two groups. Statistical tests used were Student's t-test, Chi-square test, and Fisher's exact test. Results: Clinical improvement in the form reduction of respiratory rate, use of accessary muscles, wheeze, and PEFR was comparable between two groups. Increase in heart rate in children with MDI with spacer group was significantly lower (P &lt; 0.001) than that of nebulizer group at all time intervals during the study period. No significant difference was observed for the need of pediatric intensive care unit admission, duration of stay in emergency department, and adverse events between two groups. Conclusions: In children aged 5-14 years presenting to the emergency department with acute exacerbation of asthma, the efficacy of MDI with spacer for delivering SABA was comparable with that of nebulizer.

Pulmonary Embolism in a Patient with Well’s Score of Zero

Pulmonary embolism is a condition in which a blood clot blocks a vessel in the lungs. It is a venous thromboembolism that is common and sometimes may prove to be life threatening. Well’s score/Well’s criteria calculates the risks of developing deep vein thrombosis and subsequently pulmonary embolism. Well’s score is based on clinical symptoms of DVT (leg swelling, pain with palpation)(3.0 points each), other diagnosis less likely than pulmonary embolism (3.0 points each), heart rate more than 100 (1.5 points each), immobilization or surgery in the last four weeks (1.5 points each), previous DVT/PE (1.5 points each), hemoptysis (1.0 points), malignancy (1.0 points). If the patient scores 3 or higher there is a high risk of DVT. 1 or 2 score is a moderate risk of DVT. In patients with moderate or higher probability for DVT (cut-off scores of 2), the Well’s score was able to detect patients at risk of developing DVT with a sensitivity of 67% and specificity of 90%. We hereby present a 40-year-old lady with no significant past medical history, who presented to the emergency department with sudden onset of non-radiating right sided chest pain and shortness of breath worsened with walking. Patient denied smoking, recent travels, OCP, recent surgeries, immobilization, previous DVT, pulmonary embolism, hemoptysis, malignancy, miscarriages, lupus. No family history of coagulopathies. Vitals were stable with Blood pressure of 101/60 mmHg, heart rate of 77 beats/minute, afebrile, Respiratory rate of 18, saturating 99% on room air. On examination no leg swelling or tenderness noted, no Intercostal Retraction, no use of accessory muscles, lungs clear to auscultation bilaterally. Venous Doppler study was unremarkable. Chest x ray did not show any cardio-pulmonary disease. The Well’s score came out to be zero with pulmonary embolism very low in the differential. We decided to do CT chest which showed small pulmonary emboli involving bilateral lower lobe sub-segmental pulmonary arteries. D-dimer came out to be 1938. All the rest of the labs and the coagulation factors were within normal limits. We started the patient on lovenox subQ 60 mg Q12 hourly with improvement in the shortness of breath. Patient was discharged on Xarelto. The possibility of DVT should still be considered if the patient presents with shortness of breath with zero Well’s Score.

Gelsolin and dCryAB act downstream of muscle identity genes and contribute to preventing muscle splitting and branching in Drosophila

A combinatorial code of identity transcription factors (iTFs) specifies the diversity of muscle types in Drosophila. We previously showed that two iTFs, Lms and Ap, play critical role in the identity of a subset of larval body wall muscles, the lateral transverse (LT) muscles. Intriguingly, a small portion of ap and lms mutants displays an increased number of LT muscles, a phenotype that recalls pathological split muscle fibers in human. However, genes acting downstream of Ap and Lms to prevent these aberrant muscle feature are not known. Here, we applied a cell type specific translational profiling (TRAP) to identify gene expression signatures underlying identity of muscle subsets including the LT muscles. We found that Gelsolin (Gel) and dCryAB, both encoding actin-interacting proteins, displayed LT muscle prevailing expression positively regulated by, the LT iTFs. Loss of dCryAB function resulted in LTs with irregular shape and occasional branched ends also observed in ap and lms mutant contexts. In contrast, enlarged and then split LTs with a greater number of myonuclei formed in Gel mutants while Gel gain of function resulted in unfused myoblasts, collectively indicating that Gel regulates LTs size and prevents splitting by limiting myoblast fusion. Thus, dCryAB and Gel act downstream of Lms and Ap and contribute to preventing LT muscle branching and splitting. Our findings offer first clues to still unknown mechanisms of pathological muscle splitting commonly detected in human dystrophic muscles and causing muscle weakness.

Anatomical work-up of an individual with multiple muscular variants on both forearms

Muscular variants of the forearm are common and frequently cause neurovascular compression syndromes, especially when interfering with the compact topography of the carpal tunnel or the Canalis ulnaris. Here, we report on a male body donor with multiple muscular normal variations on both forearms. The two main findings are (1) an accessory variant muscle (AVM) on the right forearm originating from the M. brachioradialis, the distal radius, and the M. flexor pollicis longus. It spanned the wrist beneath the Fascia antebrachia and inserted at the proximal phalanx of the digitus minimus. (2) Moreover, we found a three-headed palmaris longus variant on the left arm with proximal origin tendon and a distal, trifurcated muscle belly, with separated insertions at the palmar aponeurosis, the flexor retinaculum, and, in analogy to the accessory muscle on the contralateral arm, at the base of the proximal phalanx of the digitus minimus. We found a considerable thickening of the left-hand median nerve right before entering the carpal tunnel indicative of a possible chronic compression syndrome adding clinical relevance to this anatomical case. We also discuss the notion that both, the AVM and the contralateral three-headed palmaris variant are developmental descendants of the M. palmaris longus. Additionally, we found a previously not recorded variant of the M. palmaris brevis on the left hand.

Hemodynamics of the sternocleidomastoid measured with frequency domain near-infrared spectroscopy towards non-invasive monitoring during mechanical ventilation.

Mechanical ventilation (MV) is used to assist spontaneous breathing in critically ill patients in the intensive care unit (ICU). MV is a cornerstone of critical care medicine but it is now known that inspiratory muscle dysfunction due to injury, disuse, and/or atrophy during MV plays a major role in outcomes for these patients. For example, prolonged MV is strongly correlated with dysfunction of the sternocleidomastoid (SCM), an accessory inspiratory muscle that has been linked to weaning failure from MV. Hemodynamic monitoring of the SCM may provide an important non-invasive and real-time means to monitor MV. In this work, we first conducted multi-layer Monte Carlo simulations to confirm the ability of near infrared light to detect changes in the oxygenation of the SCM over wide ranges of skin tones and adipose layer thicknesses. We then optimized a custom digital frequency domain near-infrared spectroscopy (FD-NIRS) system for continuous 10 Hz measurements of the SCM at 730 nm and 850 nm. A healthy volunteer study was conducted (N=10); subjects performed sets of isometric neck flexions of the SCM. Substantial changes in oxyhemoglobin + oxymyoglobin (oxy[Hb + Mb]), deoxyhemoglobin + deoxymyoglobin (deoxy[Hb + Mb]), and total hemoglobin + myoglobin (total[Hb + Mb]) were observed during sustained and intermittent isometric flexions. There were notable sex differences observed in the magnitude of hemodynamic changes (∼2x larger changes in males for oxy[Hb + Mb] and deoxy[Hb + Mb]). The magnitude of hemodynamic changes when taking into account µs' changes during flexions was ∼ 2-2.5x larger as compared to assuming constant scattering (CS), which is a common assumption used for continuous wave (CW) NIRS methods. This study suggests that FD-NIRS provides improved accuracy for hemodynamic monitoring of the SCM compared to CW-NIRS, and that FD-NIRS may provide value for SCM monitoring during MV.

Validation of Songklanagarind Pediatric Triage Model in the Emergency Department; a Cross-Sectional Study.

Introduction:An effective triage needs to consider many factors, such as good triage protocol, experienced triage nurses, and patient factors. This study aimed to evaluate the validity of Songklanagarind Pediatric Triage (SPT) for triage of pediatric patients in the emergency department (ED) and identify the factors associated with triage appropriateness. Methods:This study was done in two phases. In the first phase, a team of emergency physicians, a pediatric emergency physician, and a pediatric critical care physician developed SPT model by considering and combining Emergency Severity Index (ESI), Pediatric Assessment Triangle (PAT), Pediatric Canadian Triage and Acuity Scale (PaedCTAS), and Pediatric Septic Shock early warning signs protocol of the hospital as the core concept. In the second phase, a prospective observational study was conducted in the ED of Songklanagarind Hospital, which is a tertiary university hospital in southern Thailand, from September to October 2019 to evaluate the accuracy of the developed triage model. Results: A total of 520 pediatric patients met the inclusion criteria. The pediatric triage model had sensitivity and specificity values of 98.28% and 26.24%, respectively, and positive and negative predictive values of 27.67% and 98.15%, respectively, in prediction of death, hospitalization, and resource utilization. The rates of appropriate triage, over-triage, and under-triage were 68.8%, 28.5%, and 2.7%, respectively. Significant factors associated with appropriateness of triage were underlying disease of the respiratory system (OR = 4.16, 95%CI: 1.75‒9.23), fever (OR = 0.60, 95%CI: 0.41‒0.88), dyspnea (OR: 6.38, 95%CI: 2.51‒16.22), diarrhea (OR = 0.26, 95%CI: 0.09‒0.73), oxygen saturation <95% (OR = 3.18, 95%CI: 1.09‒9.27), accessory muscle use during breathing (OR = 3.67, 95%CI: 1.09‒12.41), and wheezing or rhonchi (OR = 6.96, 95%CI: 3.14‒15.43). Conclusion:SPT showed good correlation of hospital admission rates and resource utilization with pediatric triage level of urgency. However, further efforts are needed to decrease the rates of over- and under-triage.