Anatomical Location Research Articles

Ectopic thyroid adenoma diagnosed in a Senegal seabream (Diplodus bellottii, Steindachner 1882): Towards an accurate diagnosis.

Thyroid tissue in teleosts is located mainly in the pharyngeal region, usually reaching other adjacent anatomical locations. Herein, a nodular lesion located in the left operculum of a Senegal seabream (Diplodus bellottii) was surgically excised and sent for microscopical evaluation. Microscopically, the lesion presented irregular borders and consisted in columnar epithelial cells arranged in a tubulopapillary pattern, surrounding a central lumen filled with acellular, acidophilic and homogeneous, material ('colloid'). To determine the lesion's histogenesis, immunohistochemistry was performed employing antibodies for AE1/AE3, CK7, thyroglobulin and vimentin. The neoplastic cells presented low mitotic index and positive immunolabelling for CK7 and thyroglobulin. Therefore, a diagnosis of ectopic thyroid adenoma was made. Herein, the successful employment of antibodies classically used in mammals for accurate diagnosis of thyroid disorders is described. Proliferation of thyroid tissue in fish may reflect environmental and physiological imbalances, making the study and correct diagnosis of these tumours in this species important.

The Association of HIF-1α/rs2057482 Polymorphism with Idiopathic Scleritis in a Chinese Han Population

ABSTRACT Background To investigate the association of hypoxia-inducible factor-1α (HIF-1α), Janus tyrosine kinase-signal transducer and activator of transcription (JAK-STAT) gene polymorphisms with idiopathic scleritis in a Chinese Han population. Methods Ten single nucleotide polymorphisms (SNP) of HIF-1α, tyrosine kinase 2 (TYK2), signal transducer and activator of transcription 3 (STAT3), signal transducer and activator of transcription 4 (STAT4), and retinoid-related orphan nuclear receptors-γ (ROR-γ) were selected for this study. A total of 496 idiopathic scleritis patients and 1009 controls were genotyped by the MassARRAY platform and iPLEX Gold Genotyping Assay. The allele and genotype frequencies were analyzed by Chi-square test and Fisher's exact test. Stratified analyses were performed based on gender and anatomic locations of idiopathic scleritis. Results The frequencies of CC genotype (p = 6.18 × 10−4, Pc = 0.04, OR = 0.67,95%CI = 0.53–0.84) and C allele (p = 7.08 × 10−4, Pc = 0.04, OR = 0.71,95%CI = 0.58–0.87) for HIF-1α/rs2057482 were found significantly lower in idiopathic scleritis patients when compared to healthy controls. Stratified analysis depending on gender showed significant decreased frequencies of CC genotype (CC: p = 4.04 × 10−4, Pc = 0.02, OR = 0.54, 95%CI = 0.39–0.76) and C allele (C: p = 1.62 × 10−4, Pc = 0.01, OR = 0.58, 95%CI = 0.44–0.77) in male patients. Stratification analysis of rs2057482 according to location of scleritis did not show any significant difference between three subgroups and healthy controls. Conclusion This study showed association between polymorphism of HIF-1α/rs2057482 and susceptibility to idiopathic scleritis in Han Chinese male patients.

Solitary Fibrous Tumors: A Rare Tumor Arising from Ubiquitous Anatomical Locations.

Solitary Fibrous Tumors (SFTs) are uncommon mesenchymal tumors of fibroblastic/myofibroblastic origin that stem from various anatomical sites. Most SFTs are asymptomatic and noticed incidentally by various imaging modalities. Although SFTs were initially identified in the pleura and erroneously considered to originate solely from serosal layers, extrapleural SFTs have been reported more commonly than their pleural counterparts. Imaging features are similar in different anatomical locations and are mainly related to the tumor's size and collagen content, characteristically displaying low signal intensity on Magnetic Resonance Imaging (MRI). Smaller tumors typically exhibit uniform enhancement, yet necrotic regions may become evident as the tumor size increases, resulting in heterogeneous enhancement. Less than 30% of SFTs demonstrate unfavorable clinical outcomes regardless of their histological features, warranting surgery as the preferred treatment with long-term follow-up. In this article, we have reviewed the clinical manifestations and imaging features of SFTs, discussed their differential diagnosis based on anatomical site, and provided diagnostic pearls.

Elder Mistreatment Documentation by Prehospital Clinicians: An Analysis of the National Emergency Medical Services Information System Database

Objectives Elder mistreatment (EM), encompassing abuse and neglect, is a significant public health issue, affecting up to 10% of community-dwelling older adults annually. Elder mistreatment is a growing concern with a higher prevalence in institutional settings and substantial associated healthcare costs. Prehospital clinicians (PHCs) such as emergency medical technicians and paramedics are uniquely positioned to detect and report EM during their interactions with older adults in their homes. The objective of the study is to describe the rate and characteristics of EM documented by PHCs using the National Emergency Medical Services Information System (NEMSIS) database. Methods This study analyzed data from NEMSIS, which includes standardized information about PHC emergency response encounters across the United States. In 2018, 22,532,890 activations were included from 9,599 agencies in 43 states and US territories. Elder mistreatment was identified using specific International Classification of Diseases (ICD) codes related to EM. Demographic data, injury location, and associated physical findings were also examined. Results Out of 9,605,522 EMS encounters for patients aged ≥60, EM was coded in 1,765 encounters (0.02%). Most EM cases were listed as the cause of injury (64%), followed by the clinician’s first impression (25.4%). Physical abuse was the most common type of mistreatment reported (20.8%), followed by sexual abuse (18.2%), neglect (9.7%), and psychological/emotional abuse (0.34%). The median age of patients with documented EM was 72, and 62.3% were female. The most common anatomic locations of injuries were the lower extremities, head, and upper extremities. Conclusions Despite the high prevalence of EM, PHCs infrequently document EM in their encounters with older adults. Additional training and comprehensive protocols are needed to improve the identification and reporting of EM, mainly elder neglect. Empowering PHCs through education and protocol development can significantly impact the detection and intervention of EM.

Pleomorphic adenoma of hard palate: Review of updated literature and "case report".

Pleomorphic adenoma (PA) is a rare benign tumor mainly affecting the major salivary glands, known for its diverse histological appearances that can mimic malignancies. When it occurs in the hard palate it present diagnostic and management challenges compared to other sites due to the anatomical location and potential proximity to critical structures. This case reports a rare presentation PA starting as an ulcer, alongside a review of rare cases of PA reported in last 5 years. We aim to highlight clinical challenges and emphasize the need for awareness in diagnosis of this diverse entity amongst the clinicians before reaching a definitive conclusion. A 41-year-old female reported an asymptomatic large swelling on the right side of the posterior palatal region. Clinical diagnosis revealed a firm, rubbery, and non-tender swelling of approximately 4 cm × 4 cm diameter. A triangular incisional biopsy was performed to confirm the diagnosis. The histopathological evaluation confirmed the presence of a PA with a well-encapsulated and compressed salivary gland. A wide surgical dissection was made to remove the entire encapsulated tumor mass, including the mucoperiosteum and eroded bone of the palate. The borderline of the tumor was carefully identified in the surrounding healthy tissue. The hemostasis was obtained using a simple interrupted suture. The diagnosis of PA is difficult as it usually involves extensive squamous and mucous metaplasia, confusing it with malignant disorders. Histopathological and clinical examinations are important for differentiating this lesion from other tumors. Complete surgical excision is reported as the first line of treatment.

Investigation of the Clinical Value of Four Visualization Modalities for Congenital Heart Disease.

Diagnosing congenital heart disease (CHD) remains challenging because of its complex morphology. Representing the intricate structures of CHD on conventional two-dimensional flat screens is difficult owing to wide variations in the pathologies. Technological advancements, such as three-dimensional-printed heart models (3DPHMs) and virtual reality (VR), could potentially address the limitations of viewing complex structures using conventional methods. This study aimed to investigate the usefulness and clinical value of four visualization modalities across three different cases of CHD, including ventricular septal defect, double-outlet right ventricle, and tetralogy of Fallot. Seventeen cardiac specialists were invited to participate in this study, which was aimed at assessing the usefulness and clinical value of four visualization modalities, namely, digital imaging and communications in medicine (DICOM) images, 3DPHM, VR, and 3D portable document format (PDF). Out of these modalities, 76.4% of the specialists ranked VR as the best for understanding the spatial associations between cardiac structures and for presurgical planning. Meanwhile, 94.1% ranked 3DPHM as the best modality for communicating with patients and their families. Of the various visualization modalities, VR was the best tool for assessing anatomical locations and vessels, comprehending the spatial relationships between cardiac structures, and presurgical planning. The 3DPHM models were the best tool for medical education as well as communication. In summary, both 3DPHM and VR have their own advantages and outperform the other two modalities, i.e., DICOM images and 3D PDF, in terms of visualizing and managing CHD.

Survival analysis and prognostic nomogram for patients with cholangiocarcinoma after radical resection in Asia

BackgroundCCA has a poor prognosis. Different anatomical subtypes are characterized by distinct clinical features, surgical options, and prognoses, which can potentially impact survival outcomes following radical resection. In addition to the malignancy of CCA itself, clinical staging and treatment methods are the main factors that can affect survival. This study aims to update a more reliable prediction model for the prognosis of CCA based on different anatomical locations. MethodsA total of 1172 CCA patients (305 iCCA, 467 pCCA, and 400 dCCA) who underwent surgical resection between 2015 and 2022 were included in the analysis. The covariates included in the analysis were age, sex, tumor diameter, differentiation grade, T stage, N stage, M stage, neural invasion, cancer thrombus, history of hepatitis B or biliary calculi, and receipt of adjuvant chemotherapy. The data were randomly divided into training (80 %) and validation cohort (20 %). ResultsWe developed a nomogram of the sensitive model and calculated concordance indices of different constructed prognostic survival models. Meanwhile, we validated the effectiveness of the nomogram model and compared it with the TNM system through decision curve analysis (DCA) and internal cohort validation. The nomogram model had a better net benefit than the TNM system at any given threshold for iCCA, pCCA, and dCCA, regardless of their location. ConclusionsWe have updated the prognostic model for OS in CCA patients who underwent radical resection according to the different tumor locations. This model can effectively predict OS and has the potential to facilitate individual clinical decision-making.

Unsupervised pattern identification in spatial gene expression atlas reveals mouse brain regions beyond established ontology

The rapid growth of large-scale spatial gene expression data demands efficient and reliable computational tools to extract major trends of gene expression in their native spatial context. Here, we used stability-driven unsupervised learning (i.e., staNMF) to identify principal patterns (PPs) of 3D gene expression profiles and understand spatial gene distribution and anatomical localization at the whole mouse brain level. Our subsequent spatial correlation analysis systematically compared the PPs to known anatomical regions and ontology from the Allen Mouse Brain Atlas using spatial neighborhoods. We demonstrate that our stable and spatially coherent PPs, whose linear combinations accurately approximate the spatial gene data, are highly correlated with combinations of expert-annotated brain regions. These PPs yield a brain ontology based purely on spatial gene expression. Our PP identification approach outperforms principal component analysis and typical clustering algorithms on the same task. Moreover, we show that the stable PPs reveal marked regional imbalance of brainwide genetic architecture, leading to region-specific marker genes and gene coexpression networks. Our findings highlight the advantages of stability-driven machine learning for plausible biological discovery from dense spatial gene expression data, streamlining tasks that are infeasible by conventional manual approaches.

Intraoperative Acetabular Fractures in Primary Total Hip Arthroplasty Management and Functional Outcomes.

Intraoperative acetabular fracture (IAF) is a non-common complication of primary total hip arthroplasty (THA). Despite the prevalence of intraoperative periprosthetic fractures are increasing, little has been written about this type of fracture. The main objective is to analyze possible risk factors, treatment options and functional outcomes associated with IAF. Between 2006 and 2020, 4 senior arthroplasty surgeons performed 5540 uncemented primary THA. We reviewed our Total Joint Registry and found 18 cases with an IAF. We analyzed demographic factors, medical history, preoperative diagnose, acetabular cups designs, anatomic location of the fracture, treatment, associated complications and functional outcomes. The minimum duration of follow-up was 12 months. The prevalence of an IAF was 0,3%. All the acetabular cups were hemispherical modular. The most frequent acetabular cup associated with an IAF was the CSF Plus (JRI). In two cases the acetabular components were judged to be stable and no additional treatment was done. In the other sixteen patients, various surgical procedures were carried out. Almost 30% of patients that sustained an IAF had some complication during their follow up. Moreover, poor functionality outcomes were obtained (12.1 ± 4.1). in the final follow up accordance to Postel Merle d'Aubingé score. Although IAF is a rare complication of THA, maintaining a high index of suspicion is important as they can be difficult to identify. Still with an adequate early treatment they have poor functionality and high risk of associated complications.

A Decade of Insights: Reevaluating the Use of the Flexible-Fiber CO2 Laser in Brain Tumor Surgery-Efficacy, Challenges, and Lessons Learned.

The introduction of flexible fiber technology in the early 2000s revitalized the interest in the CO2 laser for neurosurgical applications, making it suitable for microsurgical procedures. Despite its widespread use, specific indications for the CO2 laser in neurosurgery remains undefined. This study evaluates the efficacy and limitations of the CO2 laser in brain tumor surgery. This retrospective observational single-center study analyzed the use of the CO2 laser in intracranial neoplasm surgeries from 2011 to 2021. A total of 94 patients were assessed, focusing on demographics, tumor characteristics, surgical duration, complications, and laser-specific issues. We used a five-tiered scoring system to assess laser effectiveness in both debulking and dissection tasks; with resection extent assessed following established guidelines. The CO2 laser was highly effective in debulking solid tumors, achieving a 76.5% gross total resection rate, while being less effective in softer, highly vascularized tumors. The average effectiveness scores for dissection (2.6±0.8) were significantly lower than for debulking (3.2±1.2). Two major complications were directly associated with laser use. Effectiveness improved over time, particularly in the latter half of the study, and varied across tumor types, with notable utility in meningiomas and vestibular schwannomas but lower scores in glial tumors. The CO2 laser is a valuable tool in neurosurgery, especially for solid tumors in specific anatomical locations. Careful patient selection is crucial, and the laser complements rather than replaces conventional surgical tools. Ongoing technological advancements suggest broader future applications in neurosurgery.

Research progress on the role and mechanism of circular RNA in drug resistance of head and neck squamous cell carcinoma.

Drug resistance in tumors constitutes a significant obstacle to tumor therapy. Head and neck squamous cell carcinoma (HNSCC) presents a major challenge due to its deep anatomical location, limited space, and complex structure. These factors complicate surgical procedures and hinder the effectiveness of chemoradiotherapy, leading to poor prognosis and reduced quality of life. However, there is hope in the form of circular RNAs (circRNAs), non-coding RNA molecules with a closed-loop structure that exhibits superior stability and resistance to degradation compared to linear RNAs. Recent advances in high-throughput sequencing and bioinformatics technology revealed that circRNAs participate in tumor proliferation, invasion, migration, and drug resistance. This review aims to summarize current research progress on the involvement of circRNAs in drug resistance of HNSCC and provide valuable insights for the prevention and mitigation of drug resistance in HNSCC.

Chordoma: Site-Wise Predilections and Pathological Tenets

Abstract Background: Chordomas are rare tumours of presumptive notochordal origin, mostly occurring in the axial skeleton of the body. These tumours are slow growing but are locally invasive neoplasms. Diagnosis requires qualification of the radiological, histopathological, and immunohistochemical criteria. Management predominantly comprises surgical resection with negative margins. Objective: Our study aimed to analyse the clinico-pathological spectrum of these rare chordoma cases visiting our tertiary care institute. Materials and Methods: The study was retrospective, comprising chordoma cases reported histopathologically between January 01, 2013, and August 31, 2023 (a total period of 10.5 years). Clinico-radiological data were recorded. Histopathological diagnosis was separately reviewed by two pathologists. All data were statistically analysed. Results: In total, 41 chordoma cases were received, with a mean age of 43.2 + 17.4 years (6–72 years). Male:female ratio was 1.2:1. Spheno-occipital region chordomas (27 cases) were most common, followed by sacrococcygeal (8 cases) and vertebral (6 cases) chordomas. Symptoms varied with location. However, the commonest presenting complaint was pain. These region-wise chordoma categories were statistically compared in terms of patients’ age, male:female ratio, symptomatic duration, tumour size, histopathological tumour type, and recurrence on follow-up. Of these, only patients’ age and tumour size were found to be statistically significant (P value was 0.011 and 0.0004, respectively). Conclusion: Clinico-pathological parameters vary with the anatomical location of chordoma. We present the experience of this rare tumour in terms of clinico-radiopathological features visiting our tertiary care institute in northern India.

Adipose stem cells are sexually dimorphic cells with dual roles as preadipocytes and resident fibroblasts

Cell identities are defined by intrinsic transcriptional networks and spatio-temporal environmental factors. Here, we explored multiple factors that contribute to the identity of adipose stem cells, including anatomic location, microvascular neighborhood, and sex. Our data suggest that adipose stem cells serve a dual role as adipocyte precursors and fibroblast-like cells that shape the adipose tissue’s extracellular matrix in an organotypic manner. We further find that adipose stem cells display sexual dimorphism regarding genes involved in estrogen signaling, homeobox transcription factor expression and the renin-angiotensin-aldosterone system. These differences could be attributed to sex hormone effects, developmental origin, or both. Finally, our data demonstrate that adipose stem cells are distinct from mural cells, and that the state of commitment to adipogenic differentiation is linked to their anatomic position in the microvascular niche. Our work supports the importance of sex and microvascular function in adipose tissue physiology.

Multimodal and Repeated Localization of Primary Hand Motor Function to the Lateral Postcentral Gyrus in a Case of Frontal Motor Area Brain Metastasis

BACKGROUND AND IMPORTANCE: The human motor homunculus is a well-known topographical map of the functional-anatomical relationships of the precentral gyrus. Within this homunculus, the primary hand motor area is considered one of the least plastic functional-anatomical relationships. Only a few cases in the literature describe relocation of functional hand representation away from the classical anatomical location. These cases have been reported in the context of children, primary gliomas, or arteriovenous malformations. CLINICAL PRESENTATION: Here, we describe a unique case where the area of lowest hand motor stimulation threshold (ie, hand motor representation) was found in the postcentral gyrus in an older adult with a metastasis in the premotor area of the brain. This localization was based on intraoperative cortical stimulation–evoked motor potentials and confirmed with electrophysiological phase reversal and MRI-based neuronavigation. This mapping was repeated and consistent 2 months later during a reoperation for recurrence. In addition, the remapped anatomical location was found in an area that was active during finger tapping on preoperative functional MRI. CONCLUSION: These findings suggest that neuroplastic remapping of hand motor cortex to the postcentral gyrus can occur in brain metastases even in adults. This has implications for planning tumor resections and interventional neurorehabilitation strategies, and it suggests that the motor homunculus may have more plastic potential in adulthood than previously recognized.

Has the energy poverty crisis fuelled a rise in hot water bottle burn injuries within the United Kingdom?

IntroductionThere are an estimated 10 million hot water bottles (HWB) currently in use within the United Kingdom (UK), and HWB related burn injuries represent a significant resource burden to UK Burns Services. These injuries can be caused through a variety of mechanisms including scalds sustained when filling the bottle or scalds from leaking or rupture. The fuel poverty crisis started in February 2022 leading to an estimated six-fold increase in alternative sources of heating, in particular hot water bottles. In this study, we wish to understand the impact that this may have had upon burn injuries sustained by these products. MethodsAll hot water bottle (HWB)-related injuries sustained January 2014 - February 2023 were retrieved from the UK International Burn Injury Database (IBID). Data were collected on patient demographics, injury mechanism, anatomical location, and clinical outcomes. The data were collated and analysed; statistical analysis was performed using R StudioTM. Patient levelling costs were also incorporated to enable translation of these data into healthcare costs. ResultsA total of 5944 HWB-related burn injuries were recorded in the IBID database in England and Wales, from 2014 to 2023, with a mean of 594 (SD 146.2) burn injuries annually, costing an estimated £ 12.7 million. There were 423 burn injuries sustained from HWB in winter 2022 compared to 295 in winter 2021, representing a 43.4 % increase over one year, with a corresponding increase of 43.1 % in the number of patients managed in an outpatient setting. The largest increase in burn incidence between winter 2021 and winter 2022 was seen in children (0–16 years old) and older adults (greater than 65 years old) with a rise of 60.3 % (n = 41) and 68.5 % (n = 37) respectively. ConclusionOur epidemiological study on hot water bottle (HWB)-related burn injuries within the United Kingdom has shown that the dramatic rise in fuel prices, which sparked the fuel poverty crises, has coincided with a 43.4 % increase in HWB burns incidence on the health service in that year alone. This alarming rise in HWB-related injuries highlights the continued need for targeted public awareness campaigns to ensure a safe and proper use of these devices.

346. ESOPHAGOGASTRIC JUNCTION SIEWERT II TUMORS, A CHALLENGE FOR THE SURGEON: RESULTS OF TRANSHIATAL EXTENDED GASTRECTOMY VS. IVOR LEWIS ESOPHAGECTOMY

Abstract Background Esophagogastric junction (EGJ) Siewert type II tumors pose unique challenges in terms of adequate surgical treatment due to their anatomical location and potential for abdominal and mediastinal lymph node metastasis. The optimal surgical approach for these tumors remains a topic of debate, with options including transhiatal extended gastrectomy or transthoracic esophagectomy. Understanding the different outcomes associated with these surgical interventions is crucial for informed decision-making and patient-tailored management. The aim of this study was to compare the perioperative and oncological outcomes of these two surgical technique to access which could be the treatment of choice for Siewert II type tumours. Methods This study is a retrospective non-randomized cohort study from a single center. We reviewed the data of all the patients who underwent surgery for EGJ Siewert type II tumors between December 2014 and February 2023. The patients were divided into two groups: those who underwent transthoracic esophagectomy were assigned to “TE group” (72 patients) and those who underwent transhiatal extended gastrectomy were assigned to “TEG group” (21 patients). Results Patients in the TEG group were older (p=0.011) and in worst clinical condition (Charlson Comorbidity Index 4.15±1.78 vs. 4.95±1.46, p=0.064). The tumour stage at the diagnosis was more advanced in the TE group (p=0.004), and upfront surgery was infrequent in this group (p<0.001). The average duration of surgery was higher in the TE group (p<0.001). No difference was seen in the tumour length (p=0.924), implying a statistically significant difference in the proximal margin length (p<0.001), and distal margin length (p<0.001), with a R0 resection rate higher in the TE group (93.1% vs. 66.7%, p=0.002). The higher rate of R1 resection in the TEG group was mainly due to proximal margin infiltration. No difference was seen in the number of harvested lymph nodes (p=0.339). Overall postoperative complications rates were similar (p=0.144). No differences were found in the length of ICU stay (p=0.676) and in hospital stay (p=0.075). At a median follow up of 20 months, there were no statistical differences in Overall Survival and Disease-Free Survival at 5 years. Conclusion Our data suggests that transthoracic esophagectomy for EGJ Siewert type II tumors should be the treatment of choice for patients in good clinical condition, but transhiatal extended gastrectomy could be a good choice for patients presenting in worse clinical condition. A multidisciplinary approach is essential for optimal patient care, and the selection of the surgical technique should be based on a thorough evaluation of the patient's condition and tumor characteristics

Quantification of eosinophils in the lower gastrointestinal tract of adults: a review of surgical specimens with normal histology from the Free State province, South Africa.

Eosinophils are normal residents of the gastrointestinal tract (GIT). They are noted in small numbers with significant variation between anatomic locations. An idiopathic increase of eosinophils is known as eosinophilic gastrointestinal disease (EGID). EGIDs are a heterologous group of disorders that produce a range of enteric and colonic syndromes. Their incidence has been increasing worldwide. Our study aimed to quantify eosinophils in each segment of the GIT in surgical specimens with normal histology to facilitate the histological diagnosis of EGID. Similarly, we aimed to describe the effect of race and gender on gastrointestinal eosinophil numbers. A retrospective, quantitative comparative study was performed. We assessed 360 surgical specimens with normal histology from the lower gastrointestinal tract of African and Caucasian adults from the Free State Province, South Africa. The number of eosinophils per mm² was counted. Overall, comparable eosinophil values were noted for both males and females, and African and Caucasian South Africans. However, Caucasians recorded a higher concentration of eosinophils in the appendix and the left colon. Eosinophils were most numerous in the lamina propria, with only small numbers present in the epithelium. Our results show that the South African population has similar eosinophil distribution trends to international studies. However, South Africans had far fewer eosinophils than Japanese and North American adults in each segment. Specific eosinophil reference ranges were formulated to quantify reference ranges of eosinophils in the lower GIT, allowing for the accurate diagnosis of EGIDs in our population in future.

Advent of oral medications for the treatment of hereditary angioedema.

Hereditary angioedema (HAE) is a rare genetic disorder characterized by unpredictable, debilitating episodes of submucosal and/or subcutaneous tissue swelling, which may be life-threatening depending on anatomic location. The two primary management strategies for HAE are ready access to effective on-demand treatment in all patients and the prevention of attacks (short-term prophylaxis [STP] and long-term prophylaxis [LTP]) in appropriate patients. All approved on-demand and most LTP medications require subcutaneous or intravenous administration. Injection-related challenges include trypanophobia (fear of needles), difficulty with self-administration, injection-site reactions (e.g., pain, erythema, bleeding, bruising), and anxiety-all contributing to poor compliance and administration delays. Oral HAE treatments may improve outcomes by reducing treatment barriers. To review oral therapies, approved or in development, for on-demand treatment and/or prevention of HAE attacks. To provide a comprehensive review, data was obtained from publicly available resources through a targeted PubMed literature review and supplemented by information provided on company websites (search cutoff of May 31, 2024). Berotralstat, an oral plasma kallikrein (PKa) inhibitor, is approved for LTP. Sebetralstat, another PKa inhibitor, is the investigational first oral on-demand HAE treatment to complete a phase 3 trial. Deucrictibant, an oral bradykinin B2 receptor antagonist, has completed phase 2 trials for on-demand therapy and LTP. Several other oral PKa inhibitors (ATN249, VE-4666, and VE-4062) are in early development for LTP. Substantial advances have been made in the development of oral treatments for HAE. These treatments have the potential to improve and optimize clinical outcomes, satisfaction, and quality of life among patients with HAE.

11. Cervicogenic headache and occipital neuralgia.

Cervicogenic headache (CEH) and occipital neuralgia (ON) are headaches originating in the occiput and that radiate to the vertex. Because of the intimate relationship between structures based in the occiput and those in the upper cervical region, there is significant overlap between the presentation of CEH and ON. Diagnosis starts with a headache history to assess for diagnostic criteria formulated by the International Headache Society. Physical examination evaluates range of motion of the neck and the presence of tender areas or pressure points. The literature for the diagnosis and treatment of CEH and ON was searched from 2015 through August 2022, retrieved, and summarized. Conservative treatment includes pain education and self-care, analgesic medication, physical therapy (such as reducing secondary muscle tension and improving posture), the use of TENS (transcutaneous electrical nerve stimulation), or a combination of the aforementioned treatments. Injection at various anatomical locations with local anesthetic with or without corticosteroids can provide pain relief for a short period. Deep cervical plexus block can result in improved pain for less than 6 months. In both CEH and ON, an occipital nerve block can provide important diagnostic information and improve pain in some patients, with PRF providing greater long-term pain control. Radiofrequency ablation of the cervical facet joints can result in improvement for over 1 year. Occipital nerve stimulation (ONS) should be considered for the treatment of refractory ON. The treatment of CEH preferentially consists of radiofrequency treatment of the facet joints, while for ON, pulsed radiofrequency of the occipital nerves is indicated. For refractory cases, ONS may be considered.

Understanding the anatomy of pelvic fascia: implications for regional anesthesia.

The fascia, a continuous structure around the whole body across various anatomical locations, remains underexplored in regional anesthesia. The pelvic fascia is a particularly controversial and complicated anatomical structure. It holds significant relevance not only for surgeons but also in the realms of regional anesthesia and pain management. Many regional nerve blocking techniques in the pelvis are closely related to fascial anatomy, such as fascia iliaca compartment block, circum-psoas block, inferior hypogastric plexus block, and ganglion impar block. The continuity of fascia and interfascial spaces profoundly influences both the efficacy of blockades and the incidence of complications. A thorough understanding of pelvic fascia anatomy is crucial for understanding the potential pathways and barriers for spread of local anesthetics, enhancing analgesia, and minimizing side effects. Currently, a systematic discussion of pelvic fascia from the perspective of regional anesthesia and pain therapy is notably absent. This narrative review aims to consolidate knowledge on the anatomy of pelvic fascia pertinent to regional anesthesia and pain management, detailing relevant pelvic nerves, and associated peripheral nerve blocking techniques.