Anatomical Approach Research Articles

Modified Anatomical Anterior Cruciate Ligament Reconstruction with Flat Semitendinosus Graft and C-shaped Tibial Canal

Every year, approximately 400,000 patients undergo anterior cruciate ligament (ACL) reconstruction surgery in the United States, accounting for almost 50% of all knee surgeries in the country. Recent studies have demonstrated that the ACL is a ribbon-like structure with a C-shaped tibial insertion and a flat femoral origin. This article introduces a modification of an ACL reconstruction technique. The modification renders the procedure easily reproducible with standard surgical instruments. We will describe a surgical technique modification that goes beyond the standard round bone tunnels and adopts a more anatomical approach using a C-shaped tibial canal and a flat femoral canal using a flat semitendinosus (semi-T) graft. The use of a semi-T graft better reproduces the ribbon-like ACL anatomy. The semi-T graft, a flat femoral canal, and a C-shaped tibial canal provide increased bone-tendon contact surface area and decreased diffusion length, resulting in improved tendon-bone healing. The modification proposed by our team makes the anatomical ribbon-like ACL graft, C-shaped tibial canal, and the flat femoral canal technique feasible in every orthopaedic operating room and mitigates costly specialized instrument.

A detailed anatomical approach to taxonomically problematic endemic Seseli L. (Apiaceae) taxa in Türkiye.

In this study, the vegetative anatomical features of the taxa, which were previously named as Seseli gummiferum subsp. ilgazense A.Duran, Ö.Çetin & M.Öztürk and S. paphlagonicum Pimenov & Kljuykov, were compared with a closely related species, S. resinosum Freyn & Sint., which is also endemic in Türkiye. The root, the stem, the leaf segment, the petiole, and the rachis parts were examined anatomically and explained in detail for the first time to discuss the results of recent morphological and molecular studies with the anatomy of the taxa. The results show that S. gummiferum subsp. ilgazense and S. paphlagonicum have anatomically similar characters. However, in terms of the same characters, these taxa quite differ from a closely related species, S. resinosum. The most prominent different characters can be listed as the shape of stems, petioles and rachis, the presence of sclereids in the roots, the collenchyma arrangement of stems and petioles, the surface view of rachis and the sclerenchyma above floem in the stems and rachis. This revisional and detailed descriptive study highlights the importance of anatomy in the taxonomy of Apiaceae, and it is obvious that it will assist future taxonomic research in the genus. RESEARCH HIGHLIGHTS: Vegetative anatomical characters are also taxonomically important as well as the fruit anatomy in the family Apiaceae. The vegetative anatomy supports the molecular data that, the taxa named as S. gummiferum in Türkiye seem to be S. paphlagonicum.

Knee cartilage change on magnetic resonance imaging: Should we lump or split topographical regions? A 2-year study of data from the osteoarthritis initiative.

We challenge the paradigm that a simplistic approach evaluating anatomic regions (e.g., medial femur or tibia) is ideal for assessing articular cartilage loss on magnetic resonance (MR) imaging. We used a data-driven approach to explore whether specific topographical locations of knee cartilage loss may identify novel patterns of cartilage loss over time that current assessment strategies miss. We assessed 60 location-specific measures of articular cartilage on a sample of 99 knees with baseline and 24-month MR images from the Osteoarthritis Initiative, selected as a group with a high likelihood to change. We performed factor analyses of the change in these measures in two ways: (1) summing the measures to create one measure for each of the six anatomically regional-based summary (anatomic regions; e.g., medial tibia) and (2) treating each location separately for a total of 60 measures (location-specific measures). The first analysis produced three factors accounting for 66% of the variation in the articular cartilage changes that occur over 24 months of follow-up: (1) medial tibiofemoral, (2) medial and lateral patellar, and (3) lateral tibiofemoral. The second produced 20 factors accounting for 75% of the variance in cartilage changes. Twelve factors only involved one anatomic region. Five factors included locations from adjoining regions (defined by the first analysis; e.g., medial tibiofemoral). Three factors included articular cartilage loss from disparate locations. Novel patterns of cartilage loss occur within each anatomic region and across these regions, including in disparate regions. The traditional anatomic regional approach is simpler to implement and interpret but may obscure meaningful patterns of change.

Transmaxillary approach to the Orbit: Applying An Anatomical Approach for the Dissection of the Orbital floor

Background: There are multiple approaches for the anatomical and surgical dissection of the orbit, these approaches are made through the walls of the orbit. The most common approach is through the roof of the orbit. In recent years the anatomical transmaxillary approach to the orbit has gained significance, most notably because of its present and future surgical applications. The aim of this study is to provide a guide for the anatomical dissection of the orbit through the transmaxillary approach. Results: ten orbits were dissected through the transmaxillary approach. The orbits were dissected following a five steps procedure, and the anatomy was illustrated with high quality images. Conclusions: a detailed guide for the anatomical dissection of the orbit through the transmaxillary approach was conceived. This guide is meant to be easy to reproduce and serve the reader as a tool to further his anatomical knowledge of the region, increasing the precision and safety of future surgical procedures. KEYWORDS: Orbit, Anatomy, Dissection, Regional anatomy, maxillary sinus.

Anatomic Approach to Common and Uncommon Manifestations of Thoracic Leukemias with Radiologic-Pathologic Correlation.

Leukemias are hematopoietic malignancies characterized by the production of abnormal leukocytes in the bone marrow. Clinical manifestations arise from either bone marrow suppression or leukemic organ infiltration. Lymphadenopathy is the most common direct manifestation of intrathoracic leukemia. However, leukemic cells may also infiltrate the lungs, pleura, heart, bones, and soft tissues. Pulmonary complications in patients with leukemia typically include pneumonia, hemorrhage, pulmonary edema, and sequelae of leukemia treatment. However, pulmonary abnormalities can also be related directly to leukemia, including leukemic pulmonary infiltration. The direct, non-treatment-related effects of leukemia on intrathoracic structures will be the focus of this imaging essay. Given the typical anatomic approach for image interpretation, an organ-based depiction of common and less common intrathoracic findings directly caused by leukemic involvement is presented, emphasizing imaging findings with pathologic correlations. Keywords: Leukemia, Pulmonary, Thorax, Soft Tissues/Skin, Hematologic, Bone Marrow © RSNA, 2023.

Acute impact of the vein of marshall ethanol infusion on newly-formed lesion and mitral line block in persistent atrial fibrillation ablation

Abstract Catheter ablation in persistent atrial fibrillation (PeAF) has limited success. Strategies beyond pulmonary veins isolation failed to demonstrate improvement of long-term rhythm maintenance. The vein of Marshall (VoM) is a promising therapeutic target because it contains triggers and autonomic parasympathetic and sympathetic activity implicated in arrhythmogenesis of AF. Moreover, as the VoM colocalizes with the trajectory of the "mitral isthmus", alcohol infusion into the vein facilitates bidirectional block across the line eliminating protected epicardial connections (1,2). Purpose We evaluated acute impact on lesion formation post-VOM-ETHO and the mitral line block validation after an approach including VOM-ETHO, pulmonary vein isolation (PVI), roof-line, mitral line (ML) and cavo-tricuspid isthmus line in a population of PeAF patients (Figure 1). We aimed also to report procedural outcomes after a short follow-up period. Methods After a detailed electroanatomical map of the left atrium (LA) (filter at 0.05-0.5 mV if the patient was in sinus rhythm or 0.05-0.3 mV in the case of AF), we thus proceeded with the VoM-ETHO using the technique previously described (3,4). LA map was thus repeated to assess the extension of the newly-formed low voltage area (LVA). According to the newly-formed LVAs, mitral isthmus ablation was completed endocardially. PVI, roof-line and cavo-tricuspid isthmus line were performed to complete the ablation setting. Bidirectional block across line was then validated during pacing from left atrial appendage. In case of persistence of conduction through the mitral line due to epicardial gaps, additional ablations were applied in the "anchored wall" or in the "free-wall" of the great cardiac vein (GCV). Results Twenty-one PeAF patients (67±6 years; 67% male) underwent ablation. The medium value of basal LA-LVAs was 3.1±63.8 cmq and the newly-formed LVAs after the VoM-ETHO procedure was 12.35±67.28 cmq. All patients had bidirectional block validated across the roof-line. Bidirectional block of the ML was achieved in 19/21 patients: in 12/21 patients after endocardial line only and in 9/21 after epicardial gaps ablations into the coronary sinus. The ML procedural time was 11.3±65.9 minutes. No major complications occurred. One patient had mild pericardial effusion due to VoM perforation with a spontaneous resolution. After a short follow-up period (6±63 months), no relapse of AF was observed in 19/21 (90%) patients. 12/21 patients were free from antiarrhythmic drugs (AADs). Interestingly, recurrences happened in patients in whom bidirectional block of the mitral line was not achieved. Conclusions VoM ethanol ablation added to PVI and linear lesions in the context of a methodical and anatomical approach seems to have promising results in PeAF patients. This strategy seems to be safe and reproducible. A favourable outcome depended on the interventional setting completion and the procedural end-points validation is crucial.

Efficacy and safety of percutaneous left stellate ganglion block in patients with refractory electrical storm: our five years experience

Abstract Background Neuromodulation by percutaneous stellate ganglion block (PSGB) with local anaesthetic has proven its antiarrhythmic effect suitable for an emergency setting. Purpose To assess the efficacy and safety of PSGB performed with an anterior anatomical approach in patients with refractory electrical storm. Methods Patients with electrical storm were enrolled from November 2017 to December 2022. Left PSGB (PLSGB) was performed after failure of at least one intravenous antiarrhythmic drug. Its repetition or a continuous infusion of the local anaesthetic were considered in selected cases. Clinical data, characteristics of the block and complications were collected. The efficacy was evaluated by comparing the number of arrhythmias treated with ATP or DC-shocks by external or internal defibrillator in the hour before the block with that in the hour after the block. Per-patient efficacy was assessed by comparing the number of ATP/shocks in the 12 hours before the first procedure with that in the 12 hours after the last one. Results 37 patients were enrolled: 76% male, mean age 65 years; 11 with dilated cardiomyopathy, 18 with chronic ischemic heart disease, 11 with ST-elevation myocardial infarction, 3 with non-ST-elevation myocardial infarction, 1 with arrhythmogenic right ventricular cardiomyopathy and 1 with drug intoxication. A total of 62 PLSGBs were performed: 19 for ventricular tachycardia (VT), 26 for ventricular fibrillation (VF) and 17 for both VT and VF episodes; 15 on intubated patients, 4 in extracorporeal circulation, 14 in refractory cardiac arrest, 7 in cardiogenic/septic shock, 28 on patients on single antiplatelet therapy, 11 on dual antiplatelet therapy, 33 on anticoagulant therapy. PLSGBs were performed during intravenous infusion of antiarrhythmics (amiodarone in 30, lidocaine in 37 procedures). The local anaesthetic used was lidocaine in 27/62 PLSGB, bupivacaine in 6/62 and both in 29/62. The per-procedure analysis showed a significant reduction of the number of ATP/shocks in the hour after PLSGB compared with the hour before [0 (0-0) vs 5 (1-8) p<0.001]. Similarly, in the per-patient analysis, the number of ATP/shocks significantly decreased in the 12 hours after the PLSGB compared with that in the 12 hours before [0 (0-1.3) vs 7 (4.8-12.5) p<0.001]. No complications occurred. Conclusions This case series reports our five years experience in performing PLSGB for antiarrhythmic purpose and it confirms its efficacy and safety in the treatment of refractory electrical storm. In particular, the anatomical approach requires few tools and can be easily performed at the bedside.

Modified gastrocnemius splitting anatomic approach to the tibial plateau. Medium-term evaluation

BackgroundPosterior tibial plateau fractures, including avulsion fractures of the posterior cruciate ligament (PCL) insertion, represent a challenge for the orthopedic trauma surgeon. These injuries have gained a new perspective both diagnostically and therapeutically after the regular use of multiplanar computed tomography. In the herein study, we describe the outcome of patients sustaining a tibial plateau fracture with posterior articular involvement treated by open reduction and internal fixation (ORIF) using our modified gastrocnemius splitting anatomic approach. MethodsThis observational retrospective descriptive study was conducted at Complejo Medico de la Policia Federal Argentina Churruca-Visca. All patients were treated by ORIF by our team through our modified gastrocnemius splitting anatomic approach, and followed-up for a minimum of 12 months. ResultsA total of 18 patients sustaining plateau fracture were treated by this approach. Satisfactory tomographic reduction with articular gap and/or step-off <2 mm was achieved in 16. The mean time to the return to activities of daily living was 192.2 days. ConclusionThe modified gastrocnemius splitting anatomic approach represents a good alternative for the management of tibial plateau fractures involving the posterior quadrants.

Perspectives of Medical Organizations, Organ Procurement Organizations, and Advocacy Organizations About Revising the Uniform Determination of Death Act (UDDA).

The Uniform Law Commission paused work of the Drafting Committee to Revise the Uniform Determination of Death Act (UDDA) in September 2023. Thematic review was performed of comments submitted to the Uniform Law Commission by medical organizations (MO), organ procurement organizations (OPO), and advocacy organizations (AO) from 1/1/2023 to 7/31/2023. Of comments from 41 organizations (22 AO, 15 MO, 4 OPO), 34 (83%) supported UDDA revision (50% OPO, 33% MO recommended against revision). The most comments addressed modifications to "all functions of the entire brain, including the brainstem" (31; 95% AO, 75% OPO, 47% MO), followed by irreversible versus permanent (25; 77% AO, 50% OPO, 40% MO), accommodation of brain death/death by neurologic criteria (BD/DNC) objections (23; 100% OPO, 80% MO, 32% AO), consent for BD/DNC evaluation (18; 75% OPO, 47% MO, 36% AO), "accepted medical standards" (13; 36% AO, 33% MO, 0% OPO), notification before BD/DNC evaluation (14; 100% OPO, 53% MO, 9% AO), time to gather before discontinuation of organ support after BD/DNC determination (12; 60% MO, 25% OPO, 9% AO), and BD/DNC examiner credential requirements (2; 13% MO, 0% AO, 0% OPO). The predominant themes were that the revised UDDA should include the term "irreversible" and shouldn't (1) stipulate specific medical guidelines, (2) require notification before BD/DNC evaluation, or (3) require time to gather before discontinuation of organ support after BD/DNC determination. Views on other topics were mixed, but MO and OPO generally advocated for the revised UDDA to take a functional approach to BD/DNC, not require consent for BD/DNC evaluation, and not require opt-out accommodation of BD/DNC objections. Contrastingly, many AO and some MO with religious affiliations or a focus on advocacy favored the revised UDDA take an anatomic approach to BD/DNC or eliminate BD/DNC altogether, require consent for BD/DNC evaluation, and require opt-out accommodation of BD/DNC objections. Most commenting organizations support UDDA revision, but perspectives on the approach vary, so the Drafting Committee could not formulate revisions that would be agreeable to all stakeholders.

A simple formula to control posterior tibial slope during proximal tibial osteotomies

BackgroundHigh tibial osteotomy surgery is a widely successful joint-preserving procedure which alters the hip-knee-ankle axis which can delay the progression of osteoarthritis; however, conventional osteotomy surgical procedures do not adequately control the posterior tibial slope.This study aimed to determine the key variables influencing posterior tibial slope during high tibial osteotomy and provide a simple means of implementing the findings during pre-operative planning. MethodsA virtual cohort of twenty-eight proximal tibia geometries of knee osteoarthritis patients was used in the study. Firstly, absolute posterior tibial slope values were contrasted using anatomical and posterior mechanical axis measurement approaches. Secondly, the influence of variables affecting posterior tibial slope change during osteotomy surgery was investigated using 3D preoperative planning surgical simulation and analytical modelling. FindingsThere was a poor correlation (R2 = 0.38) between the different clinical measurements of posterior tibial slope; with an average of 7.0 ± 1.3° and 14.8 ± 2.2° respectively.An analytical solution for the change in posterior tibial slope was derived based on the hinge axis angle and the osteotomy opening angle. For three different opening angles (6°, 9° and 12°) and seven different hinge axis orientations (−30° to +30°), the results obtained were identical for the analytical model and the 3D preoperative planning. InterpretationThis study determined that the key variables affecting posterior tibial slope during high tibial osteotomy are the osteotomy opening angle and the hinge axis orientation. The derived formula provides a simple means of determining the change in posterior tibial slope resulting from a particular surgical approach.

Research Progress of the Anatomical Structure of the Surgical Approach for Oblique Lumbar Interbody Fusion

Oblique Lumbar Interbody Fusion (OLIF) is a newly developed minimally invasive lumbar interbody fusion procedure used to treat a variety of degenerative lumbar spine diseases. The OLIF procedure has the advantages of less trauma, less bleeding, faster recovery, significant indirect decompression, large bone graft area, high fusion rate, and preservation of posterior column structures, but it needs to be performed under the condition of familiarity with the patient's anatomical approach to avoid injury to nerves, blood vessels, and other structures. In this paper, we review the new clinical advances in the application of anatomy for OLIF surgery in terms of the abdominal wall, blood vessels, lumbar major muscle, window between blood vessels and lumbar major muscle, nerves, and ureter.

Interventional Radiotherapy (Brachytherapy) for Nasal Vestibule: Novel Strategies to Prevent Side Effects.

We were able to identify two different strategies to reduce dose to the treatment volume, including the implantation technique (the implant can be interstitial, endocavitary or mixed and the catheters may be placed either using the Paris system rules or the anatomical approach) and the dose distribution within the implant (the most commonly used parameter to consider is the dose non-uniformity ratio). We subsequently propose two novel strategies to reduce dose to organs at risk, including the use of metal shields for fixed organs as in the case of the eyes and the use of a mouth swab to push away mobile organs, such in the case of the mandible. We used two different algorithms to verify the values namely the TG-43 and the TG-186. We provided an accurate literature review regarding strategies to reduce toxicity to the treatment volume, underlining the pros and cons of all implantation techniques and about the use dose non-uniformity ratio. Regarding the innovative strategies to reduce the dose to organs at risk, we investigated the use of eye shielding and the use of swabs to push away the mandible by performing an innovative calculation using two different algorithms in a series of three consecutive patients. Our results show that the dose reduction, both in the case of the mandible and in the case of eye shielding, was statistically significant. Proper knowledge of the best implantation technique and dose non-uniformity ratio as highlighted by existing literature is mandatory in order to reduce toxicity within the treatment volume. With regard to the dose reduction to the organs at risk we have demonstrated that the use of eye shielding and mouth swab could play a pivotal role in clinical practice; in fact, they are effective at lowering the doses to the surrounding organs and do not require any change to the current clinical workflow.

Distinct Circuits From the Central Lateral Amygdala to the Ventral Part of the Bed Nucleus of Stria Terminalis Regulate Different Fear Memory

BackgroundThe ability to differentiate stimuli that predict fear is critical for survival; however, the underlying molecular and circuit mechanisms remain poorly understood. MethodsWe combined transgenic mice, in vivo transsynaptic circuit-dissecting anatomical approaches, optogenetics, pharmacological methods, and electrophysiological recording to investigate the involvement of specific extended amygdala circuits in different fear memory. ResultsWe identified the projections from central lateral amygdala (CeL) protein kinase C δ (PKCδ)–positive neurons and somatostatin (SST)-positive neurons to GABAergic (gamma-aminobutyric acidergic) and glutamatergic neurons in the ventral part of the bed nucleus of stria terminalis (vBNST). Prolonged optogenetic activation or inhibition of the PKCδCeL-vBNST pathway specifically reduced context fear memory, whereas the SSTCeL-vBNST pathway mainly reduced tone fear memory. Intriguingly, optogenetic manipulation of vBNST neurons that received the projection from PKCδCeL neurons exerted bidirectional regulation of context fear, whereas manipulation of vBNST neurons that received the projection from SSTCeL neurons could bidirectionally regulate both context and tone fear memory. We subsequently demonstrated the presence of δ and κ opioid receptor protein expression within the CeL-vBNST circuits, potentially accounting for the discrepancy between prolonged activation of GABAergic circuits and inhibition of downstream vBNST neurons. Finally, administration of an opioid receptor antagonist cocktail on the PKCδCeL-vBNST or SSTCeL-vBNST pathway successfully restored context or tone fear memory reduction induced by prolonged activation of the circuits. ConclusionsTogether, these findings establish a functional role for distinct CeL-vBNST circuits in the differential regulation and appropriate maintenance of fear.

An Analysis of Foot Morphology Using a Self-Designed Foot Scanner in Preparing Custom-Made Footwear: An Anatomical Approach

Foot morphology and morphometry knowledge is vital in several domains. 60% of the population has foot pain due to ill-fitting footwear. There is no standard device or parameters to evaluate the arches of the foot, and most of the research to assess the arches of the foot. Aim of the study: The study aimed to develop a hodoscope (foot scanner) device to evaluate the arches of the foot. The study's objective was to prepare custom–made footwear based on foot morphology. The study included 849 (405 males and 444 females) participants aged between 25 and 45. Podoscope was used to evaluate the arches of the foot. Based on the evaluation, 62 participants were provided with custom-made footwear based on the morphometry of the foot. The statistical analyses were performed using SPSS software. Wilcoxon Signed Ranks Test was used to analyze the pain scale based on positive ranks, with a statistically significant p-value (&lt; 0.001). Results: 44.19% of men and 47.97% of women had a normal arch foot. 33.08% of men and 28.82% of women had a flat arch, and 22.71% of men and 23.19% of women had a high arch foot. The present study identified foot problems (forefoot, midfoot and hindfoot) using a self-designed podoscope and attempted to design custom–made footwear based on foot morphometry. The quality of the footwear was acceptable and cost-effective. Custom-made footwear based on foot morphology will benefit individuals with foot problems. KEYWORDS: Foot Morphology, Self-Designed Foot Scanner, Custom-Made Footwear, Podoscope.

Aesthetic transaxillary subpectoral placement of vagus nerve stimulator in children and young adults: A technical note

IntroductionVagus nerve stimulation (VNS) is a neuromodulation therapy for drug-resistant epilepsy (DRE), refractory status epilepticus, and treatment-resistant depression. The lead is tunneled into the subcutaneous space and connected to the generator, which is usually implanted in a subcutaneous pocket below the clavicle. Surgical complications in the chest region include skin breakdown or infection. An alternative approach is to perform a subclavear subpectoral implantation. In our surgical series, we report a new aesthetic implantation method for VNS generators in children and young patients: the transaxillary subpectoral placement. Materials and methodsFrom May 2021 to May 2023, 10 vagus nerve stimulation generators were placed subpectorally with a transaxillary approach by the authors. We considered operative time, surgical complications such as blood loss, infections, device migration, pain, and adverse events at follow-up. ResultsIn this surgical series, we reviewed all cases of subpectoral implantation of VNS generators in children and young adults at our institution in the last 2 years. All patients were treated with subpectoral Sentiva 1000 (Livanova PLC) insertion with axillary access by a neurosurgeon and a pediatric surgeon. The operative time was slightly longer compared to the traditional subcutaneous implant. All generators reported impedances within the optimal range. Blood loss was not significant and no other perioperative complications were reported. Patients and families were highly satisfied with the outcomes in terms of comfort and aesthetic results after surgery and at the last follow-up. No cases of infection occurred, and no malfunctions or displacements of the generator were registered at clinical follow-up. ConclusionThe transaxillary subpectoral placement of theVNS generator is an aesthetic and anatomic approach, which provides several benefits to children and young adults.

Comparative Metabolomics in Single Ventricle Patients after Fontan Palliation: A Strong Case for a Targeted Metabolic Therapy.

Most studies on single ventricle (SV) circulation take a physiological or anatomical approach. Although there is a tight coupling between cardiac contractility and metabolism, the metabolic perspective on this patient population is very recent. Early findings point to major metabolic disturbances, with both impaired glucose and fatty acid oxidation in the cardiomyocytes. Additionally, Fontan patients have systemic metabolic derangements such as abnormal glucose metabolism and hypocholesterolemia. Our literature review compares the metabolism of patients with a SV circulation after Fontan palliation with that of patients with a healthy biventricular (BV) heart, or different subtypes of a failing BV heart, by Pubmed review of the literature on cardiac metabolism, Fontan failure, heart failure (HF), ketosis, metabolism published in English from 1939 to 2023. Early evidence demonstrates that SV circulation is not only a hemodynamic burden requiring staged palliation, but also a metabolic issue with alterations similar to what is known for HF in a BV circulation. Alterations of fatty acid and glucose oxidation were found, resulting in metabolic instability and impaired energy production. As reported for patients with BV HF, stimulating ketone oxidation may be an effective treatment strategy for HF in these patients. Few but promising clinical trials have been conducted thus far to evaluate therapeutic ketosis with HF using a variety of instruments, including ketogenic diet, ketone esters, and sodium-glucose co-transporter-2 (SGLT2) inhibitors. An initial trial on a small cohort demonstrated favorable outcomes for Fontan patients treated with SGLT2 inhibitors. Therapeutic ketosis is worth considering in the treatment of Fontan patients, as ketones positively affect not only the myocardial energy metabolism, but also the global Fontan physiopathology. Induced ketosis seems promising as a concerted therapeutic strategy.

Anatomical approach to PCNL: concept of ideal puncture zone in a 3D perspective.

To describe a concept of ideal 'puncture zone' as against any single ideal 'puncture tract' for percutaneous nephro-lithotomy (PCNL) and present our results. Through this narrative, we aim to reduce the gaps in inter-understanding of an erstwhile description of ideal tract and real-life puncture making. The puncture zone principle was applied for our novel puncture making technique during PCNL. The largest imaginary cone that can fit into a respective calyx, with its tip in the pelvis defines the 'puncture zone' for that calyx. This concept allows fine-tuning of the ideal puncture tract based upon the desired corresponding manipulation zone and also shifts the focus of puncture making to infundibulum anatomy from the tip of calyx. The surgical technique and retrospective review of 136 cases done between 2015 and 2021 using this concept are presented. Primary outcome included stone-free rate, pseudo-aneurysm and blood transfusion at 3months of follow-up. 33 cases had multiple (> 3) stones, 21 only calyceal/infundibular stones, eight partial staghorn and 12 were complete staghorn stones. Mean stone size was 29 ± 15 (Range: 5-53) mm. Complete clearance was achieved in 127 cases, four of which required two tracts. Blood transfusion was required in one case. No pseudo-aneurysms were encountered. The puncture zone concept has provided good results in our hands. It may help easier understanding of PCN puncture making and provides a background for reconciliation between description of an ideal tract and practical puncturing techniques used by different surgeons.

FORMATION OF PROFESSIONAL COMPETENCE OF HIGER MEDICAL EDUCATION STUDENTS USING INTEGRATED AND BINARY LESSONS IN TEACHING CLINICAL DISCIPLINES

The mission of higher education institution is to support teachers in the development of pedagogical skills. This is especially relevant for the teaching staff of medical educational institutions, where it is necessary to master the method of teaching the discipline and the educational process itself, since the vast majority of teachers do not have special education.&#x0D; The purpose of the study was to outline the advantages of conducting integrated and binary classes in the teaching of the discipline "Neurology" with the aim of forming the professional competence of students.&#x0D; Materials and methods. Analysis of scientific and methodical literature and generalization of own practical experience of conducting classes were used in the study.&#x0D; Results. Topics from the "General Neurology" module include knowledge of topical neurology: the principles of the structure and functioning of all parts of the nervous system, so the built-in interactive anatomical atlas allows students of higher medical education to improve their knowledge of human anatomy online. SECTRA anatomical tables have large interactive screens with an indication system that provides interaction with images of the human body obtained by computer or magnetic resonance imaging. Classes are conducted by two teachers, whose task is to present the studied material from different points of view: anatomical approach and clinical thinking. A significant role is played by the psychological and methodical compatibility of the teachers preparing the binary class. In the process of preparation, teachers analyze the actual material on the topic, determine the motivation of the researched topic, take into account the scope and level of students' knowledge of the disciplines, identify interdisciplinary connections between the studied disciplines, choose the most rational form of the lesson. In our own experience, the inclusion of such technologies in the educational process is an important step that expands the possibilities of assimilation of information for those seeking education. The use of this high-tech equipment in combination with clinical understanding of pathological processes significantly increases the effectiveness of providing educational services to students of higher medical education.&#x0D; Conclusion. Binary classes held jointly by the teachers of the Department of Nervous Diseases and the Department of Anatomy with Clinical Anatomy and Operative Surgery of the Poltava State Medical University showed that they are of great interest to both students and teachers. Such experience contributes to a deeper and better assimilation of educational material compared to traditional forms.

Pattern analysis for the diagnosis of inflammatory skin lesions in domestic animals: An overview.

Pattern analysis of inflammatory skin diseases is a technique that offers a systematic approach to the histologic diagnosis of skin diseases. First introduced to human dermatopathology in the 1970s, it was widely adopted by veterinary pathologists for the histologic diagnosis of skin diseases in animals. As the inflammatory pattern reflects, to varying extents, aspects of the underlying disease pathogenesis, its use has contributed to the recognition of novel skin diseases in domestic animals, particularly in dogs and cats. Alternative diagnostic approaches used in human dermatopathology, such as "tissue-reaction pattern" and a purely "anatomic approach" have not been as widely used in veterinary pathology. However, veterinary pathologists often combine pattern analysis with anatomic and etiologic factors. This overview outlines the technique, introduces the patterns, and discusses advantages and limitations of pattern analysis in veterinary diagnostic dermatopathology. While molecular analytic techniques and image informatics will undoubtedly prove to be revolutionary in many areas of diagnostic pathology, it is recognized in both human and veterinary arenas that the light microscopic interpretation of hematoxylin and eosin-stained tissue sections will remain the mainstay of routine dermatopathology diagnosis for the foreseeable future.

Regional variations in patient selection and procedural characteristics for cryoballoon ablation of atrial fibrillation in the cryo global registry

BackgroundCryoballoon ablation is a well-established anatomical approach for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Although widely adopted, regional variations in standards of care have not been well characterized.MethodsPatients with AF were enrolled in the Cryo Global Registry (NCT02752737) from May 2016 to Sept 2021 at 128 sites in 37 countries and treated with cryoballoon ablation according to local clinical practice. Baseline patient and procedural characteristics were summarized for 8 regions (Central Asia & Russia, East Asia, Europe, Middle East, North America, South Africa, South America, and Southeast Asia). Serious procedure-related adverse events (SAEs) were evaluated in a subset of patients with ≥ 7 days of follow-up.ResultsA total of 3,680 patients undergoing initial PVI for AF were included. Cryoballoon ablation was commonly performed in patients with paroxysmal AF. Mean age ranged from 47 ± 12 years in the Middle East to 64 ± 11 years in East Asia. Mean procedure time was ≤ 95 min in all regions. Average freeze duration ranged from 153 ± 41 s in Southeast Asia to 230 ± 29 s in Central Asia & Russia. Acute procedural success was ≥ 94.7% in all geographies. In 3,126 subjects with ≥ 7 days of follow-up, 122 procedure-related SAEs were reported in 111 patients (3.6%) and remained low in all regions. One procedure-related death was reported during data collection.ConclusionsDespite regional variations in patient selection and procedural characteristics, PVI using cryoballoon ablation was performed with high acute success and short procedural times around the world.Clinical trial registrationhttps://clinicaltrials.gov/ct2/show/NCT02752737Graphical