Anatomical Deformities Research Articles

Hip Dysplasia in Adults: Surgical Correction vs. Conservative Treatment Options

Introduction: Developmental Dysplasia of the Hip (DDH) is an anatomical deformation resulting from abnormal formation of the structures that make up the hip joint. Due to abnormal biomechanics patients with hip dysplasia usually develop radiographic osteoarthritis. Aim of the study: Despite the introduction of screening tests in children, DDH remains an issue among adults. For this group of patients, it is essential to begin treatment as early as possible to prevent early-onset osteoarthritis of the hip joint. In adults it is often too late to implement non-invasive methods such as braces or orthoses. Therefore, in this study, we aim to describe other treatment options for adults with DDH, considering both surgical and non-surgical methods. In the following work, we present both the advantages and complications associated with these surgical methods. Additionally, we describe the non-surgical alternative method of progressive resistance training (PRT) and consider the possibilities of combining it with surgical techniques. We also discuss the potential for pharmacological treatment. Material and Methods: Review of studies available through open-access sources on PubMed, Google Scholar, and the National Library of Medicine. Conclusions: The decision to quickly implement an appropriate treatment plan is crucial for improving the patient's quality of life. The choice of treatment method should consider the patient's age and the severity of the disease. Adults with DDH are most often qualified for surgical procedures, which include periacetabular osteotomy (PAO) and total hip replacement (THR). However, for some patients, surgical procedures may be contraindicated or impossible, and in such cases, other non-invasive methods, such as resistance training or appropriate pharmacotherapy, should be considered. Keywords: hip joint, osteoarthritis, surgery, conservative therapy, hip, Surgical Correction

Monte Carlo dose calculation for photon and electron radiotherapy on dynamically deforming anatomy.

Dose calculation in radiotherapy aims to accurately estimate and assess the dose distribution of a treatment plan. Monte Carlo (MC) dose calculation is considered the gold standard owing to its ability to accurately simulate particle transport in inhomogeneous media. However, uncertainties such as the patient's dynamically deforming anatomy can still lead to differences between the delivered and planned dose distribution. Development and validation of a deformable voxel geometry for MC dose calculations (DefVoxMC) to account for dynamic deformation in the dose calculation process of photon- and electron-based radiotherapy treatment plans for clinically motivated cases. DefVoxMC relies on the subdivision of a regular voxel geometry into dodecahedrons. It allows shifting the dodecahedrons' corner points according to the deformation in the patient's anatomy using deformation vector fields (DVF). DefVoxMC is integrated into the Swiss Monte Carlo Plan (SMCP) to allow the MC dose calculation of photon- and electron-based treatment plans on the deformable voxel geometry. DefVoxMC is validated in two steps. A compression test and a Fano test are performed in silico. Delta4 (for photon beams) and EBT4 film measurements in a cubic PMMA phantom (for electron beams) are performed on a TrueBeam in Developer Mode for clinically motivated treatment plans. During these measurements, table motion is used to mimic rigid dynamic patient motion. The measured and calculated dose distributions are compared using gamma passing rate (GPR) (3% / 2mm (global), 10% threshold). DefVoxMC is used to study the impact of patient-recorded breathing motion on the dose distribution for clinically motivated lung and breast cases, each prescribed 50Gy to 50% of the target volume. A volumetric modulated arc therapy (VMAT) and an arc mixed-beam radiotherapy (Arc-MBRT) plan are created for the lung and breast case, respectively. For the dose calculation, the dynamic deformation of the patient's anatomy is described by DVFs obtained from deformable image registration of the different phases of 4DCTs. The resulting dose distributions are compared to the ones of the static situation using dose-volume histograms and dose differences. DefVoxMC is successfully integrated into the SMCP to enable the MC dose calculation of photon- and electron-based treatments on a dynamically deforming patient anatomy. The compression and the Fano test agree within 1.0% and 0.1% with the expected result, respectively. Delta4 and EBT4 film measurements agree with the calculated dose by a GPR>95%. For the clinically motivated cases, breathing motion resulted in areas with a dose increase of up to 26.9Gy (lung) and up to 7.6Gy (breast) compared to the static situation. The largest dose differences are observed in high-dose-gradient regions perpendicular to the beam plane, consequently decreasing the planning target volume coverage (V95%) by 4.2% for the lung case and 2.0% for the breast case. A novel method for MC dose calculation for photon- and electron-based treatments on dynamically deforming anatomy is successfully developed and validated. Applying DefVoxMC to clinically motivated cases, we found that breathing motion has non-negligible impact on the dosimetric plan quality.

Design and manufacturing of a dynamically deformable liver phantom for radiotherapy

Phantoms representing anatomical deformations are necessary to investigate and improve dynamic treatments. In this study, we aimed to produce a deformable liver phantom by simulating respiratory motion.The dynamically DEformable Liver Phantom (DELP) is designed to create a human-specific respiratory model and to produce synchronised, repeatable motion with this model. For the deformation effect of this movement, an artificial liver was created using silicone material and mold. A stepper motor was used to compress the liver in the inferior direction according to an adjustable respiratory motion. Reference markers (fiducial) placed on the DELP helped to verify the movement and calculate the deformation. In dynamic deformation tests, the greatest amount of deformation was found in the edge region of the silicone liver. The average deformation was 3.45 ± 0.93 mm when 5 mm amplitude movement was applied and 5.98 ± 0.01 mm when 10 mm amplitude movement was applied.DELP is a deformable liver phantom with motion reproducibility. Its performance in radiotherapy application was evaluated using dosimetric equipment.

Insights into the State of the Art of Urogenital Schistosomiasis with a Focus on Infertility.

Schistosomiasis is a neglected tropical disease that affects developing countries worldwide and is caused by several species of parasites from the Schistosoma genus. Chronic infection is characterized by the formation of granulomas around the parasite eggs, the leading cause of pathology. The hepatosplenic clinical form is one of the most common, but urogenital schistosomiasis is another relevant clinical presentation responsible for infertility in men and women. Inflammatory response, anatomical deformations, and endocrine/biochemical changes are involved in the development of infertility. Schistosome parasites can synthesize catechol estrogen-like molecules and affect the sexual hormone balance in their host. Here, we review many aspects of the pathology of urogenital schistosomiasis, specifically infertility, and point to the biochemical and endocrinal elements that must be investigated in the future.

Operative Management of Pediatric Physeal Bar Development and Genu Valgum.

Pediatric orthopedic conditions present unique challenges due to ongoing skeletal growth and development. Managing these cases requires addressing both structural anomalies and functional deficits. This case report discusses a 13-year-old male with recurrent left knee pain exacerbated by physical activity. The patient's history of a left knee infection at 1.5 years of age, possibly septic arthritis or osteomyelitis, underscores the long-term consequences of early pathology on skeletal growth and alignment. Imaging studies revealed a distal lateral femur physis bar and genu valgum, necessitating surgical intervention. The surgery involved medial distal femur hemiepiphysiodesis and lateral distal femur bar excision to correct anatomical deformities and restore optimal limb alignment and function. Postoperative rehabilitation, including targeted exercises to improve quadriceps strength, was crucial for functional recovery and reducing the risk of complications such as medial patellofemoral pain. This case highlights the importance of a multidisciplinary approach in managing complex pediatric orthopedic cases.

Simulating the Morphological Changes of Facial Deformities after Using 3D-printed Polyether Ether Ketone Facial Implants.

Patient-specific implants (PSIs) have been presented as an effective solution for diseases that require reconstruction. PSIs are designed to precisely fit anatomical defects or deformities in terms of shape and size. In addition to the possibility of predicting the results of surgery regarding soft tissue changes. A research sample consisting of 10 patients with facial deformities underwent maxillofacial reconstructive surgery between 2020 and 2021 in the Tishreen University Hospital, Syria. All patients underwent computed tomography scans; then, the design of the required facial implant was carried out, and the three-dimensional soft tissues were reconstructed using the ExoCad 3.0 program based on the computed tomography. The final form of the facial implant was printed from polyether ether ketone, and then surgical work was performed. The patients were followed up after 6 months. Then, a comparison was made between the virtual design and the real result. The absolute difference between the expected soft tissue changes result and the actual result did not exceed three-tenths for all patients, and only two of 10 patients had measurements higher than 20%. This technique can be relied upon with the placement of implants to predict the outcome of the surgical procedure in terms of morphological changes in the facial soft tissues covering PSI polyether ether ketone. Therefore, it is possible to make a virtual design based on the cosmetic requirements of the patient.

DiffuseRT: predicting likely anatomical deformations of patients undergoing radiotherapy

Objective. Predicting potential deformations of patients can improve radiotherapy treatment planning. Here, we introduce new deep-learning models that predict likely anatomical changes during radiotherapy for head and neck cancer patients. Approach. Denoising diffusion probabilistic models (DDPMs) were developed to generate fraction-specific anatomical changes based on a reference cone-beam CT (CBCT), the fraction number and the dose distribution delivered. Three distinct DDPMs were developed: (1) the image model was trained to directly generate likely future CBCTs, (2) the deformable vector field (DVF) model was trained to generate DVFs that deform a reference CBCT and (3) the hybrid model was trained similarly to the DVF model, but without relying on an external deformable registration algorithm. The models were trained on 9 patients with longitudinal CBCT images (224 CBCTs) and evaluated on 5 patients (152 CBCTs). Results. The generated images mainly exhibited random positioning shifts and small anatomical changes for early fractions. For later fractions, all models predicted weight losses in accordance with the training data. The distributions of volume and position changes of the body, esophagus, and parotids generated with the image and hybrid models were more similar to the ground truth distribution than the DVF model, evident from the lower Wasserstein distance achieved with the image (0.33) and hybrid model (0.30) compared to the DVF model (0.36). Generating several images for the same fraction did not yield the expected variability since the ground truth anatomical changes were only in 76% of the fractions within the 95% bounds predicted with the best model. Using the generated images for robust optimization of simplified proton therapy plans improved the worst-case clinical target volume V95 with 7% compared to optimizing with 3 mm set-up robustness while maintaining a similar integral dose. Significance. The newly developed DDPMs generate distributions similar to the real anatomical changes and have the potential to be used for robust anatomical optimization.

Comparative host transcriptomics as a tool to identify candidate biomarkers for immune reactions in leprosy using meta-analysis.

Background Leprosy is no longer considered an imprecation, as an effective multidrug therapy regimen is available worldwide for its cure. However, its diverse clinical manifestations sometimes involve acute inflammatory reactions. These complications result in irreversible nerve damage, neuritis and anatomical deformities that emerge before, during the treatment or after the completion of treatment. Reversal reaction (Type-I) and erythema nodosum leprosum (Type-II) are the leprosy reactions generally seen in patients with lepromatous and borderline forms of leprosy. At present, there is no accurate diagnostic test available to detect these leprosy reactions. Objectives To identify potential biomarkers indicative of Type-I and Type-II leprosy reactions that could help in their early diagnosis. Methods and Results Host-transcriptomics investigations have been utilised in this study to decipher a correlation between host-gene expression-based biomarkers and exacerbation of leprosy reactions. We present a comparative analysis of publicly available host transcriptomics datasets (from Gene Expression Omnibus) related to leprosy reactions. Individual datasets were analysed and integration of results was carried out using meta-analysis. Common differentially expressed genes (DEGs) were identified using the frequentist and Bayesian ratio association test methods. We have identified several genes - ADAMTS5, ADAMTS9, IFITM2, IFITM3, KIRREL, ANK3, CD1E, CTSF, DOCK9 and KRT73 to name a few - which can serve as potential biomarkers for Type-II reaction. Similarly, ACP5, APOC1, CCL17, S100B, SLC11A1 among others may likely serve as biomarkers for Type-I reaction. Limitations The number of datasets related to leprosy reactions found after the systematic search is less (n = 4) and may limit the accuracy of identified biomarker genes. This could be resolved by including more studies in the data analysis. Conclusion We provide a comprehensive list of gene candidates which could be prioritised further in research focusing on immune reactions in leprosy, as they are likely important in understanding its complexities and could be useful in its early diagnosis.

Generalized div-curl based regularization for physically constrained deformable image registration

Variational image registration methods commonly employ a similarity metric and a regularization term that renders the minimization problem well-posed. However, many frequently used regularizations such as smoothness or curvature do not necessarily reflect the underlying physics that apply to anatomical deformations. This, in turn, can make the accurate estimation of complex deformations particularly challenging. Here, we present a new highly flexible regularization inspired from the physics of fluid dynamics which allows applying independent penalties on the divergence and curl of the deformations and/or their nth order derivative. The complexity of the proposed generalized div-curl regularization renders the problem particularly challenging using conventional optimization techniques. To this end, we develop a transformation model and an optimization scheme that uses the divergence and curl components of the deformation as control parameters for the registration. We demonstrate that the original unconstrained minimization problem reduces to a constrained problem for which we propose the use of the augmented Lagrangian method. Doing this, the equations of motion greatly simplify and become managable. Our experiments indicate that the proposed framework can be applied on a variety of different registration problems and produce highly accurate deformations with the desired physical properties.

Dental rehabilitation of a patient with a decrease in bite height due to pathological abrasion of hard tooth tissues (clinical case)

At the present stage of diagnostics and treatment of dental diseases, morphofunctional disorders of the dento-maxillary system associated with a decrease in the height of occlusion are becoming more common. In the scientific literature, this pathological condition is described under the name "occlusion" that decreases. The reasons that cause it include partial or complete loss of teeth, irrational prosthetics and untimely restoration of dentition defects, doctors' mistakes in the restructuring of the masticatory apparatus, and a generalized form of pathological abrasion of hard tooth tissues. The purpose of the study – demonstration of a clinical case of pathological abrasion of hard tissues of teeth with a decrease in bite height, complicated by defects in the dentition. Patient S., 47 years old, applied for orthopedic help with complaints of anatomical deformity, significant abration of teeth on the upper and lower jaws, increased sensitivity to various types of irritants, partial absence of teeth, impaired masticatory function, periodic clicking in the temporomandibular joint, aesthetic and phonetic defects. Based on the data obtained, we established the following diagnosis: generalized form of pathological abrasion of hard teeth tissues, subcompensated form of reduced bite height, complicated by defects in the dentition of the upper jaw – class I according to the Kenedy classification, lower jaw – class III according to the Kenedy classification. The loss of chewing efficiency according to Agapov was 68%. Patient S. was recommended a two-stage orthopedic treatment, which involves preliminary separation of the bite with the help of individual vinyl mouth guards which have an increasing thickness of 2, 4 and 6 mm, made for the lower jaw.The planned treatment period with each of the muscle relaxant splints will be 2 months. Subsequently, 15, 14, 13, 12, 11, 21, 22, 23, 24 will be restored with one-piece metal crowns with ceramic cladding, and the final defects in the lateral areas will be restored with a clasp prosthesis with a locking system of fixation. The included defect of the lateral part of the lower jaw is planned to be restored with a metal-ceramic bridge-like prosthesis with a support on 47, 45, 44, and the worn-out hard tooth tissues will be completely restored with photopolymer material. In patients with a reduction in bite height of more than 2 mm, it is advisable to carry out treatment in two stages. At the first stage, we normalize the occlusal height and rebuild the function of the masticatory muscles. At the second stage, we provide rational prosthetics. Orthopedic rehabilitation with myorelaxing splints of increasing thickness makes it possible to correctly rebuild myostatic reflexes and prevent functional disorders in the TMJ. Any case of complex treatment of patients with a decrease in bite height due to pathological abrasion of the hard tooth tissues deserves the attention of both scientists and dentists in practical health care.

Deformable anthropomorphic pelvis phantom for dose accumulation verification

Objective. The validation of deformable image registration (DIR) for contour propagation is often done using contour-based metrics. Meanwhile, dose accumulation requires evaluation of voxel mapping accuracy, which might not be accurately represented by contour-based metrics. By fabricating a deformable anthropomorphic pelvis phantom, we aim to (1) quantify the voxel mapping accuracy for various deformation scenarios, in high- and low-contrast regions, and (2) identify any correlation between dice similarity coefficient (DSC), a commonly used contour-based metric, and the voxel mapping accuracy for each organ. Approach. Four organs, i.e. pelvic bone, prostate, bladder and rectum (PBR), were 3D printed using PLA and a Polyjet digital material, and assembled. The latter three were implanted with glass bead and CT markers within or on their surfaces. Four deformation scenarios were simulated by varying the bladder and rectum volumes. For each scenario, nine DIRs with different parameters were performed on RayStation v10B. The voxel mapping accuracy was quantified by finding the discrepancy between true and mapped marker positions, termed the target registration error (TRE). Pearson correlation test was done between the DSC and mean TRE for each organ. Main results. For the first time, we fabricated a deformable phantom purely from 3D printing, which successfully reproduced realistic anatomical deformations. Overall, the voxel mapping accuracy dropped with increasing deformation magnitude, but improved when more organs were used to guide the DIR or limit the registration region. DSC was found to be a good indicator of voxel mapping accuracy for prostate and rectum, but a comparatively poorer one for bladder. DSC > 0.85/0.90 was established as the threshold of mean TRE ⩽ 0.3 cm for rectum/prostate. For bladder, extra metrics in addition to DSC should be considered. Significance. This work presented a 3D printed phantom, which enabled quantification of voxel mapping accuracy and evaluation of correlation between DSC and voxel mapping accuracy.

Metformin as adjunctive therapy in combination with multidrug treatment for multibacillary leprosy: A protocol for a randomized double-blind, controlled Phase 2 trial in Indonesia (MetLep Trial).

The clinical management of leprosy is complicated by leprosy reactions (LR) causing irreversible nerve damage and disabilities. LR often require long-term use of corticosteroids causing serious side effects. Adjunct host-directed therapy (HDT) is a potentially attractive strategy in leprosy to prevent LR and associated immunopathology, modulate immunological memory that protects against recurrence, and thereby reduce nerve damage, disability and corticosteroid-associated morbidities. Metformin, a well-tolerated, safe and cheap anti-hyperglycaemic drug, is repurposed as HDT in auto-immune and infectious diseases, like tuberculosis (TB). Metformin use in people with diabetes is associated with reduced risks of TB-infection, progression to active TB, treatment failure and TB-mortality. Given the similarities both mycobacteria share, we hypothesize that among persons with multibacillary (MB) leprosy, adjunctive metformin may prevent/mitigate LR. We will perform a double-blind controlled proof-of-concept trial in which people with newly diagnosed multibacillary leprosy will be randomized (1:1) to metformin hydrochloride 1000mg extended release once daily versus placebo for 24 weeks in addition to standard-of-care WHO MB multidrug therapy (MDT) during 48 weeks. We aim to enrol 166 participants aged between 18 and 65 years, across five clinical sites in two leprosy endemic areas in Indonesia. Primary outcomes are the proportion of participants experiencing a LR and the frequency of (serious) adverse events. Secondary outcomes are the severity and time to first LR, the cumulative corticosteroid usage, and quality of life. The total study follow-up is 48 weeks. LR signify the most important cause of irreversible nerve damage leading to anatomical deformities and disabilities, imposing a social and financial burden on those affected. Our study aims to evaluate the efficacy, tolerability and safety of adjunct metformin added to MDT in persons with multibacillary leprosy, and explore its effects on clinical and immunological outcomes. NCT05243654 (17/02/2022).

Robust tracking of deformable anatomical structures with severe occlusions using deformable geometrical primitives

Background and objective:Surgical robotics tends to develop cognitive control architectures to provide certain degree of autonomy to improve patient safety and surgery outcomes, while decreasing the required surgeons’ cognitive load dedicated to low level decisions. Cognition needs workspace perception, which is an essential step towards automatic decision-making and task planning capabilities. Robust and accurate detection and tracking in minimally invasive surgery suffers from limited visibility, occlusions, anatomy deformations and camera movements. Method:This paper develops a robust methodology to detect and track anatomical structures in real time to be used in automatic control of robotic systems and augmented reality. The work focuses on the experimental validation in highly challenging surgery: fetoscopic repair of Open Spina Bifida. The proposed method is based on two sequential steps: first, selection of relevant points (contour) using a Convolutional Neural Network and, second, reconstruction of the anatomical shape by means of deformable geometric primitives. Results:The methodology performance was validated with different scenarios. Synthetic scenario tests, designed for extreme validation conditions, demonstrate the safety margin offered by the methodology with respect to the nominal conditions during surgery. Real scenario experiments have demonstrated the validity of the method in terms of accuracy, robustness and computational efficiency. Conclusions:This paper presents a robust anatomical structure detection in present of abrupt camera movements, severe occlusions and deformations. Even though the paper focuses on a case study, Open Spina Bifida, the methodology is applicable in all anatomies which contours can be approximated by geometric primitives. The methodology is designed to provide effective inputs to cognitive robotic control and augmented reality systems that require accurate tracking of sensitive anatomies.

New improved model for joint segmentation and registration of multi-modality images: application to medical images

Joint segmentation and registration of images is a focused area of research nowadays. Jointly segmenting and registering noisy images and images having weak boundaries/intensity inhomogeneity is a challenging task. In medical image processing, joint segmentation and registration are essential methods that aid in distinguishing structures and aligning images for precise diagnosis and therapy. However, these methods encounter challenges, such as computational complexity and sensitivity to variations in image quality, which may reduce their effectiveness in real-world applications. Another major issue is still attaining effective joint segmentation and registration in the presence of artifacts or anatomical deformations. In this paper, a new nonparametric joint model is proposed for the segmentation and registration of multi-modality images having weak boundaries/noise. For segmentation purposes, the model will be utilizing local binary fitting data term and for registration, it is utilizing conditional mutual information. For regularization of the model, we are using linear curvature. The new proposed model is more efficient to segmenting and registering multi-modality images having intensity inhomogeneity, noise and/or weak boundaries. The proposed model is also tested on the images obtained from the freely available CHOAS dataset and compare the results of the proposed model with the other existing models using statistical measures such as the Jaccard similarity index, relative reduction, Dice similarity coefficient and Hausdorff distance. It can be seen that the proposed model outperforms the other existing models in terms of quantitatively and qualitatively.

Chest Radiography Pearls in Select Adult Congenital Heart Disease.

Congenital heart disease in adult patients (ACHD) includes individuals with native anatomic deformities and those who have benefited from corrective, ameliorative, or interventional heart and vascular interventions. Congenital heart disease is the most common birth defect, although with interventions most survive into adulthood. Newborns and children with complex congenital heart diseases that feature cyanosis fail to thrive, and once this is identified, heart failure can promptly undergo diagnostic evaluations and treatment. However, patients with simple congenital heart disease and subtle clinical signs and symptoms may escape diagnosis until adulthood or experience changes in their cardiac hemodynamics and physiology in settings such as pregnancy or newly diagnosed arrhythmias. The chest X-ray (CXR) is the most common X-ray among all radiological procedures. Individual features or a constellation of features on a CXR are often present in patients who have congenital heart disease. The ability to recognize these CXR features is a valuable skill for making the diagnosis of ACHD and for following these patients as they age, and can complement echocardiographic findings. When used well to diagnose ACHD, the CXR will be the sharpest arrow in the quiver.

Virtual Reality and Mixed Reality-Assisted Endoscopic DCR in Extremely Complex Lacrimal Obstructions.

To report the techniques and outcomes of virtual reality (VR) and mixed reality (MR)-assisted powered endoscopic dacryocystorhinostomy (DCR) in extremely complex lacrimal drainage obstructions. A prospective, non-randomized clinical study was performed in complex syndromic congenital nasolacrimal duct obstruction (CNLDO) and post-traumatic secondary acquired lacrimal duct obstruction (SALDO) in the setting of Le Fort fractures. All patients underwent preoperative planning in VR and intraoperative planning with a step ahead with MR assistance during the surgery. Surgery was supported by mixed reality intraoperative guidance with the use of the prearranged 3D models and real-time-rendered digital models. Parameters assessed include demographics, clinical presentation, complexities of the nasolacrimal duct obstruction, preoperative and intraoperative utility of VR and MR models, surgical techniques, complications, and outcomes. The technique is described as a proof of concept in challenging situations with Apert syndrome and traumatic SALDOs with gross malposition of the sac, and gross nasal and lacrimal anatomical deformities. The VR models helped the surgeon to assess the details of the altered anatomy preoperatively to plan an appropriate approach. Intraoperatively, MR models were present in the surgeon's view without disturbing the endoscopic procedure. Intermittently, the surgeon could pull any of the models virtually present in the operating room, slice them, rotate them, and intricately study the alterations in a stepwise manner, as the surgery proceeds. Virtual reality and mixed reality-assisted powered endoscopic DCR can be an alternate approach reserved for extremely challenging cases of complex syndromic CNLDOs and post-traumatic SALDOs. 4 Laryngoscope, 134:3508-3515, 2024.

Management of the anatomically complex penile implant candidate through an infrapubic incision: a review of surgical techniques and benefits.

This article provides a comprehensive discussion of 3-piece inflatable penile implant surgery when performed through an infrapubic approach in patients presenting with challenging anatomy or corporal fibrosis. The infrapubic approach is one of the primary approaches for inflatable device placement with excellent long-term functional outcomes. While the literature is rich in descriptions of infrapubic placement in the primary, uncomplicated setting, its role in the management of complex patients presenting to centers of excellence is less elucidated. In uncomplicated cases, the infrapubic approach offers several theoretical advantages including shorter operative time and quicker return to sexual function. In addition to describing specific details of our infrapubic technique and perioperative management, I discuss scenarios in which an infrapubic approach may allow for better exposure for correction of dorsal deformity, facilitate secondary surgical maneuvers such as suprapubic lipectomy, or protect existing incontinence prosthetics already in place. Specific technique and surgical pearls from our prosthetic center of excellence are reviewed for each of these challenging scenarios. Ultimately, prosthetic surgeons should be adept at placing, revising, and removing devices through both approaches so that various forms of anatomical deformity and device failures can be addressed proficiently. In addition to my own clinical reflections, a critical review was performed using the Medline database to support our statements.

Unsuspected Limitations of 3D Printed Model in Planning of Complex Aortic Aneurysm Endovascular Treatment.

Static 3-dimensional (3D) printing became attractive for operative planning in cases that involve difficult anatomy. An interactive (low cost, fast) 3D print allowing deliberate surgical practice can be used to improve interventional simulation and planning. Endovascular treatment of complex aortic aneurysms is technically challenging, especially in case of narrow aortic lumen or significant aortic angulation (hostile anatomy). The risk of complications such as graft kinking and target vessel occlusion is difficult to assess based solely on traditional software measuring methods and remain highly dependent on surgeon skills and expertise. A patient with juxtarenal AAA with hostile anatomy had a 3-dimensional printed model constructed preoperatively according to computed tomography images. Endovascular graft implantation in the 3D printed aorta with a standard T-Branch Cook (Cook® Medical, Bloomington, IN, USA) was performed preoperatively in the simulation laboratory enabling optimized feasibility, surgical planning and intraoperative decision making. The 3D printed aortic model proved to be radio-opaque and allowed simulation of branched endovascular aortic repair (BREVAR). The assessment of intervention feasibility, as well as optimal branch position and orientation was found to be useful for surgeon confidence and the actual intervention in the patient. There was a remarkable agreement between the 3D printed model and both CT and X-ray angiographic images. Although the technical success was achieved as planned, a previously deployed renal stent caused unexpected difficulty in advancing the renal stent, which was not observed in the 3D model simulation. The 3D printed aortic models can be useful for determining feasibility, optimizing planning and intraoperative decision making in hostile anatomy improving the outcome. Despite already offering satisfying accuracy at present, further advancements could enhance the 3D model capability to replicate minor anatomical deformities and variations in tissue density.

Trigeminal cold receptors and airflow perception are altered in chronic rhinosinusitis.

In chronic rhinosinusitis (CRS), nasal obstruction can often be explained by anatomical deformities, polyps, or congested nasal mucosa. However, in cases with little deformity or inflammation, perceived nasal obstruction may result from reduced airflow perception caused by an alteration of the intranasal trigeminal system. The aim of this study was to assess this association. We performed a prospective case-control study of 15 CRS patients, 18 patients with a deviated nasal septum (DNS) and 16 healthy controls. We assessed olfactory function using the Sniffin' Sticks test and Visual Analog Scales (VAS). We used the Trigeminal Lateralization Task (TLT) with eucalyptol and cinnamaldehyde to examine intranasal trigeminal function. Further, we assessed nasal patency with Peak Nasal Inspiratory Flow and VAS. Finally, we measured protein levels of trigeminal receptors (TRPM8, TRPA1 and TRPV1) and inflammatory markers (IL-13, INF-y and eosinophils) in CRS and DNS patients' mucosal biopsies using Western Blots. CRS patients had significantly lower olfactory function than DNS and healthy controls. They also had significantly lower TLT scores for eucalyptol than both other groups. CRS patients had significantly lower nasal patency than controls; for DNS patients this was limited to subjective measures of nasal patency. In line with this, CRS patients exhibited significantly higher levels of sTRPM8-18 than DNS patients. Intranasal trigeminal function is decreased in CRS patients, possibly due to the overexpression of short isoforms of TRPM8 receptors.

A Meta-Analysis for Postoperative Alternations of Aortic Coarctation.

To investigate postoperative vascular changes of patients with coarctation of the aorta (CoA). Literature review of updated articles was performed in June 2023 through the following databases: PubMed, Web of Science, EMBASE, Crohrane Library, CNKI and Wanfang database. All the case-control studies regarding the postoperative changes of vascular structure and function in patients with CoA were analyzed. A total of 596 articles from the above databases were initially identified, with 10 articles being selected for meta-analysis. The analysis showed that weighted mean difference (WMD) of carotid intima-media thickness (cIMT) was 0.07 (95% CI = 0.01~0.13, p < 0.01) and WMD of flow mediated dilation (FMD) was -4.36 (95% CI = -7.49~-1.24, p < 0.01), respectively. The postoperative cIMT of CoA patients was higher than that of the control group, but the postoperative FMD was lower than that of the control group. The operation on CoA patients ameliorates anatomical deformity in the vascular structures. However, intima-media thickening and endothelial malfunction remain as the key postoperative issues.