Antecubital Fossa Research Articles

SUN-585 A Case of Atypical Myxedema in Hypothyroidism

Background: Myxedema, also known as thyroid dermopathy, is a skin finding in thyroid disease characterized by papules or nodules overlying a non-pitting induration, with atrophy of overlying skin (1). It is more common in Graves’ disease (~4% of patients) but can rarely be seen in hypothyroidism as well (1). Clinical Case: A 33-year-old African American female with past medical history of obesity presented to dermatology clinic for evaluation of a diffuse, non-resolving papulonodular rash on her face, trunk, groin, and buttocks. Biopsy was taken from the right flank, and laboratory studies were obtained. She was started empirically on topical ketoconazole and oral doxycycline. The biopsy showed a positive mucin stain, and psoriasiform hyperplasia with slight spongiosis in the epidermis, consistent with myxedema. Laboratory studies revealed thyroid stimulating hormone (TSH) >100 mcIU/L (reference range, 0.34 - 5.60), free thyroxine (FT4) of 0.34 ng/dL (reference range, 0.58 - 1.64), free triodothyronine (FT3) of 1.2 pg/mL (reference range, 2.0 - 4.4), and thyroid peroxidase antibody level of 274 IU/mL (reference range, 0 - 34), and she was urgently referred to endocrinology clinic. During her endocrinology clinic visit, her review of systems was positive for weight gain, cold intolerance, fatigue, lower extremity edema, rash, intermittent constipation, and hair loss. She had no personal or family history of thyroid disease. Physical exam revealed thick hyperpigmented macerated plaques in the skin folds on her trunk and antecubital fossae. Thyroid was normal in size, with no palpable nodules. Weight was 157 kg, with BMI of 55.9. Hemoglobin A1c was normal at 4.5%. She was started on levothyroxine 250 mcg daily. On follow up two months later, her TSH was 0.99 mcIU/L and FT4 was 1.38 ng/dL. Clinical symptoms of constipation and fatigue had improved, and there was improvement in the rash. Conclusion: Myxedema is caused by accumulation of glycosaminoglycans in the dermis, secreted by fibroblasts. It is hypothesized that destruction of thyroid tissue may release an antigen that cross-reacts with an antigen in the dermis (2). The location is typically pretibial, but case reports exist of myxedema in other locations. Overall, this case is unusual in that skin findings of myxedema were present in a patient with severe hypothyroidism, and in atypical locations.

Comparison of Indices Used to Assess Microvascular Function During Post‐Occlusion Reactive Hyperemia in Humans

Numerous studies have used reactive hyperemia in response to cuff occlusion to assess microvascular function/reactivity. However, there are inconsistencies amongst these studies in regard to the indices used to quantify microvascular function/reactivity. Some studies do not provide accurate details of their analysis, while others report different indices such as peak velocity post occlusion or reactive hyperemic velocity area under the curve (AUC) from cuff release up to varying durations (i.e., 1 min, 2 min or back to baseline). As such, the lack of consistency in the reported indices makes it challenging to compare microvascular function between studies. Moreover, it remains unclear as to which index better characterizes microvascular function. Therefore, to elucidate the marker(s) that better detect differences in microvascular function, we compared young healthy subjects (YH) with normal vascular function (n = 10, age = 21 ± 1 yrs, BMI = 24.4 ± 0.7 kg/m2, mean ± SEM), to patients with type 2 diabetes (T2D), a population known to have impaired vascular function (n = 9, age = 58 ± 11 yrs, BMI = 38.3 ± 8.2 kg/m2). Heart rate (ECG) and brachial artery diameter and blood velocity (duplex Doppler Ultrasound) were measured continuously while subjects laid in supine position. Baseline measures were recorded for 2 min, following which a cuff placed just distal to the antecubital fossa was rapidly inflated to 220 mmHg for 5 min. Measurements were recorded for 30 s prior to and 3 min after cuff release. Microvascular function was quantified using the following indices of mean blood velocity after cuff release: peak velocity, percent change in peak velocity from baseline, and reactive hyperemic velocity AUC to: peak velocity, 10 s, 30 s, 1 min, 2 min and back to baseline. Peak velocity following cuff release was not different between groups (p = 0.70), however, baseline mean blood velocity was higher in T2D patients (T2D: 13.9 ± 1.8 cm/s vs. YH: 9.1 ± 1.7 cm/s; p = 0.04). Thus, we compared the percent change in peak velocity from baseline, which was significantly lower in T2D patients (T2D: 414.9 ± 63.5% vs. YH: 680.1 ± 107.8%; p = 0.03). AUC to peak blood velocity was also significantly lower in T2D (T2D: 289.6 ± 24.4 a.u. vs. YH: 453.73 ± 52.9 a.u.; p = 0.02); however, a shorter time to peak velocity in the T2D group likely contributed (T2D: 6.4 ± 0.8 s vs. YH: 10.2 ± 0.9 s; p = 0.007). To compare a similar duration between the groups, AUC up to 10 s, 30 s, 1 min, 2 min and back to baseline were calculated and these indices were not different between groups (e.g., AUC up to 30 s, T2D: 951.5 ± 84.9 a.u. vs. YH: 1141.0 ± 101.0; p = 0.13). Collectively, these preliminary results suggest that percent increase in peak velocity was able to discern the difference in microvascular function between the healthy and T2D groups whereas other indices were less consistent.Support or Funding InformationSupported by UTA College of Nursing and Health InnovationThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

A cadaveric study on the persistence of the median artery

The median artery is a transitory artery that supplies blood to the forearm and hand of an embryo. This artery regresses at the 8th week of gestation upon the development of the radial and the ulnar arteries. However, the median artery may persist in adults and such persistence can lead to many complications including median nerve compression and related syndromes such as carpal tunnel syndrome, anterior interosseous nerve syndrome and pronator teres syndrome. The persistent median artery has been shown to be highly variable in its origin, and has been shown to arise either from the brachial, radial, ulnar, common interosseous or anterior interosseous arteries. The prevalence of persistent median arteries has a wide range, reported as 1.1% – 27.1%. Studies reporting the prevalence, origin of the persistent median artery and its contribution to the complete or the incomplete palmar arch have been highly variable. Additionally, no study has documented the prevalence of this artery in the population of donated cadavers within the UT Health San Antonio Human Anatomy Program. Furthermore, publications demonstrating the presence of other arterial variations in the upper extremity in association with the presence of the persistent median artery in this donated cadaver population are very limited. Awareness of such anatomical variations is extremely critical for clinicians performing reconstructive surgeries involving the arteries of the upper extremity to optimize patient outcomes.Specific aims of this study are 1. To determine the prevalence and the origin of the persistent median artery in this donated population of cadavers 2. To investigate whether the persistence of a median artery is associated with other arterial variations in the arm & the forearm 3. To elucidate the contribution of the persistent median artery to the complete or incomplete superficial palmar arch. To address these specific aims, 54 upper limbs of donated cadavers were surveyed. Preliminary data suggest the incidence of persistent median artery to be 29.63% (16/54). Furthermore, 25% (4/16) of the upper limbs with a persistent median artery presented with a high division (proximal to the cubital fossa) of the brachial artery into the radial and the ulnar arteries. Additionally, 43.8% (7/16) of these persistent median arteries entered the hand through the carpal tunnel and supplied the digits. 31.3% (5/16) of these persistent median arteries contributed to an incomplete superficial palmar arch and 12.5% (2/16) contributed to a complete superficial palmar arch. We are currently surveying more cadavers. Knowledge provided from this project will allow not only a better understanding of the prevalence of this artery, but also an understanding of clinical correlates that arise due to the presence of the persistent median artery.Support or Funding InformationNoneThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Staphylococcus aureus colonization on antecubital non-exacerbated atopic dermatitis patient compared to healthy children

Atopic dermatitis is chronic pruritic inflammatory skin disease affects one third of children in the world, and the highest number of child`s skin problems in Indonesia. The complex role of the skin microbiome in the pathogenesis of atopic dermatitis is being elucidated. Interaction between skin barrier defects, and immunological factors can change the skin microbiome, and increased Staphylococcus aureus colonization. The aim of this study was to compare the colony of Staphylococcus aureus from antecubital fossa of non-exacerbated atopic dermatitis children to healthy children without history of atopic dermatitis. A comparative observational analytic with cross sectional design, examined antecubital swab culture from 17 non-exacerbated atopic dermatitis patients and 17 controls to investigate the presence of Staphylococcus aureus and density of the colonization. Staphylococcus aureus skin colonization was seen in 5 patients (29.41%) in non-exacerbated atopic dermatitis patients but none in control group (statistically significant with p=0.044), relative risk 2.417. All of positive colonization revealed moderate and heavy bacterial growth (104->105 cfu/cm2). This finding supports previous study that atopic dermatitis prone to colonized with Staphylococcus aureus.

503 Use of a Biodegradable Polyurethane Dermal Matrix to Treat a Facial Burn in a Patient with 90% TBSA Burns

Full thickness facial burns should be treated in a way that honors the best possible outcomes for facial cosmesis and function. In patients with massive burns the options are limited. We present the case of a successful facial autograft using a biodegradable polyurethane matrix prior to graft application. An 11-year-old boy sustaining 90% TBSA full thickness burns after an ATV explosion was treated at our hospital. Spared areas included the left anticubital fossa, bilateral feet, pelvis, and scalp. Unfortunately, the entirety of his face sustained a full thickness burn injury in the accident. He underwent tangential excision of the majority of his burned surfaces in a series of operations that included using the same matrix. On post injury day 8 he had tangential excision of the facial burns with placement of allograft. Three days later, the facial allograft was removed and the biodegradable polyurethane dermal matrix was secured to the face. Ten weeks after placement, sheet autografts were placed over the face. At the time of the operation the matrix appeared salmon pink and adherent. The sheet autografts were applied horizontally across the face in accordance with aesthetic units. Donor sites were taken from several re-harvested areas (including scalp and lower abdomen). There was near 100% take of the facial autografts. With regard to esthetics, the resultant facial autograft appeared pink, healthy, well vascularized, and smooth. The patient had very appropriate facial contour and some functional facial expression. There are small areas of minor ectropion, however this is a common occurrence with facial autografts regardless of dermal substrates utilized. The biodegradable polyurethane dermal matrix is a relatively new product that is composed of three distinct layers, all of which are derived from polyurethane material. The foam layer contacts the wound and is highly porous, an adhesive layer bonds the foam to a sealing membrane which comprises the layer of the product that is exposed to the environment. Of note, the matrix did not desiccate, macerate, and seemed to resist infection. This was distinctly advantageous for our patient with extensive 90% TBSA burns and facilitated a long, but safe, time course between wound excision and definitive grafting. From this case, we observed that utilizing this biodegradable polyurethane dermal matrix as a dermal substrate for facial autografts was feasible, demonstrated excellent early cosmetic results, and also provided long term wound bed protection, and thus more flexibility, to optimize timing of autograft application.

Retrospective analysis of arteriovenous fistula patency and failure in patients on dialysis for end-stage kidney disease in the Gaza strip

BackgroundThe preservation of patent, well-functioning arteriovenous fistulas is one of the most difficult clinical problems in the long-term management of patients undergoing renal dialysis. This study aimed to define the patency and failure rates of fistulas in patients with end-stage kidney disease on dialysis and to examine how fistula failure is managed. MethodsData regarding disease history and long-term patency and failure of hemodialysis arteriovenous fistulas were collected from patients and patients' charts in five dialysis centres in the Gaza strip, including a specialised centre for paediatric dialysis, from May, 2017, to October, 2017, using a specifically designed data collection sheet. Informed written consent was obtained from participants upon enrolment. FindingsData were collected from 606 patients with end-stage kidney disease on dialysis. The mean age was 50·3 (SD 18·6) years and 56% (339 out of 606) were males. The mean age at diagnosis was 45 (19·9) years and at first fistula creation was 46·2 (19·2) years. Hypertension was the most common cause of end-stage kidney disease (34·7%; 210 of 606), followed by diabetes mellitus (26%; 158), and obstructive uropathy (11·6%; 70). Failure of the first fistula was reported for 36% (97 of 267) of females and 31% (105 of 339) of males. The failure rate at 1 month was 21% (43 of 202) for first fistulas and 13% (six of 45) for second fistulas. Hypertension was reported for 77% (156 of 202) of patients who encountered failure. Of first fistulas, failure was reported for 61% (21 of 34) of right distal, 39% (52 of 133) of left distal, 37% (37 of 101) of right cubital, and 31% (91 of 201) of left cubital fistulas, indicating that the site of placement of the first arteriovenous fistula might have had a role in determining failure. The mean time until fistula failure after creation was 0·8 years (SD 2·0, range 0–13) for first fistulas and 0·1 years (0·79, 0–8) for second fistulas. Most fistulas were created as direct arteriovenous fistula anastomoses. Synthetic grafts were used in three cases for first fistulas and in eight cases for second fistulas. The failure rate for synthetic graft fistulas was higher than for direct anastomosis, and the failure rates were 60% (two of three) and 62% (five of eight) for first and second synthetic graft fistulas, respectively. The management of fistula failure involved creating a new fistula in 85·6% (173 of 202) of first fistulas and 49% (22 of 45) of second fistulas. Of the 606 patients, 48 were paediatric patients younger than 18 years, with a mean age of 13 (3·6) years; two-thirds (60·4%, 29 of 48) of these patients were male. Their mean age at diagnosis was 7 years (SD 5·4) and the most prevalent aetiologies were congenital (40%; 20 of 48), obstructive uropathy (21%; ten), and glomerulonephritis (12%; six). Half of these patients (24 of 48) were on dialysis via a central line and all others had arteriovenous fistulas for dialysis. Proximal sites of the right and left upper forearms were preferred over distal sites for the first fistula in most cases, failure was reported in a third (16 of 48) of cases, and the mean duration of fistula patency before failure was 1 year (range 0–8 years). Of the patients who encountered fistula failure, 12 had direct anastomosis fistulas with the right cubital fossa as the preferred site. In five of these cases, failure of the second fistulas was encountered within 3 years. InterpretationHypertension was the major cause of end-stage kidney disease, and this necessitates the proper recognition and management of hypertension, especially among middle-aged people (35–60 years). Female sex, hypertension, distal (versus proximal) placement of fistulas, and operations outside of Ministry of Health hospitals were found to be risk factors for fistula failure. The high failure rates at 1 month are likely to be due to technical issues relating to surgery, as fistulas are not used for dialysis before 1 month. To improve patency, preference should be given to direct anastomosis arteriovenous fistulas rather than synthetic grafts. FundingNone.

Rethinking Intravenous Catheter Size and Location for Computed Tomography Pulmonary Angiography.

IntroductionComputed tomography pulmonary angiography (CTPA) is the test of choice for diagnosis of pulmonary embolism (PE) in the emergency department (ED), but this test may be indeterminate for technical reasons such as inadequate contrast filling of the pulmonary arteries. Many hospitals have requirements for intravenous (IV) catheter size or location for CTPA studies to reduce the chances of inadequate filling, but there is a lack of clinical data to support these requirements. The objective of this study was to determine if a certain size or location of IV catheter used for contrast for CTPA is associated with an increased chance of suboptimal CTPA.MethodsThis was a retrospective chart review of patients who underwent CTPA in the ED. A CTPA study was considered suboptimal if the radiology report indicated it was technically limited or inadequate to exclude a PE. The reason for the study being suboptimal, and the size and location of the IV catheter, were abstracted. We calculated the rate of inadequate contrast filling of the pulmonary vasculature and compared the rate for various IV catheter sizes and locations. In particular, we compared 20-gauge or larger IV catheters in the antecubital fossa or forearm to all other sizes and locations.ResultsA total of 19.3% of the 1500 CTPA reports reviewed met our criteria as suboptimal, and 51.6% of those were due to inadequate filling. Patients with a 20-gauge IV catheter or larger placed in the antecubital fossa or forearm had inadequate filling 9.2% of the time compared to 13.2% for patients who had smaller IVs or IVs in other locations (difference: 4.0% [95% confidence interval, −1.7%–9.7%]). There were also no statistically significant differences in the rates of inadequate filling when data were further stratified by IV catheter location and size.ConclusionWe did not detect any statistically significant differences in the rate of inadequate contrast filling based on IV catheter locations or sizes. While small differences not detected in this study may exist, it seems prudent to proceed with CTPA in patients with difficult IV access who need emergent imaging even if they have a small or distally located IV.

Deep lymphatic anatomy of the upper limb: An anatomical study and clinical implications

BackgroundThe deep and perforating lymphatic anatomy of the upper limb still remains the least described in medical literature. Materials and MethodsSix upper limbs with the axillary tissue were harvested from three unembalmed human cadavers amputated at the shoulder joint. A small amount of 6% hydrogen peroxide was employed to detect the lymphatic vessels around the deep palmar arch, radial and ulnar neurovascular bundles. A 30-gauge needle was inserted into the vessels and they were injected with a barium sulphate compound. Each specimen was dissected, photographed and radiographed to demonstrate deep lymphatic distribution of the upper limb. ResultsContinuing from the deep lymph vessels of the hand, single or multiple deep collecting lymph vessels have been found along the radial, ulnar, anterior and posterior interosseous neurovascular bundles in the forearm, brachial and deep branchial neurovascular bundles in the upper arm. During their courses, lymph nodes were found setting in the trunk of the radial, ulnar and brachial lymph vessels near or in the cubital fossa, and in the axillar. Perforating lymph vessels have been found near the wrist and in the cubital fossa, which linked the superficial and deep lymph vessels. The direction of lymphatic drainage was from the deep to superficial or superficial to deep vessels. ConclusionThe deep lymphatic anatomy of the upper limb has been described. The results will provide an anatomical basis for clinical management, educational reference and scientific research.

Cavernous hemangioma in median nerve in the cubital fossa: a rare cause of a median nerve lesion

Cavernous hemangioma in median nerve in the cubital fossa: a rare cause of a median nerve lesion

Venous vascular malformations and compressive neuropathy

Abstract Background Venous malformations (VMs) are slow flowing congenital vascular malformations that demonstrate continuous growth. They are prone to bleeding and frequent invasion of adjacent structures. It is therefore important to differentiate them from schwannomas, which can appear similar on imaging. Currently, the literature demonstrates only a few examples of pathology misdiagnosed as a schwannoma, and of VMs associated with neurological deficits. We will illustrate the characteristics and management of VMs causing compressive neuropathy in the cervical and upper extremity regions and contrast them against the features of peripheral nerve sheath tumors. Case description Two case reports are presented, one of a 55-year-old woman with a chronic cervical mass due to a venous malformation (VM) originally misdiagnosed as a schwannoma, and another of a 35-year-old man with a vascular malformation of predominantly venous pathology in the antecubital fossa. Both patients were surgically managed. Conclusions Patients presented with chronic pain, weakness and paresthesia. Venous malformations were seen as thinly encapsulated, multilobular, heterogeneously enhancing lesions with internal fluid levels and venous lakes. Post-contrast septate enhancement, intrinsic foci of T1 hyperintensity, phleboliths, T2 hyperintensity, and nodular enhancement of torturous vessels we also noted. MEP, SSEP, and EMG monitoring was used during surgical resection. Both patients had favorable outcomes.

A Proof-of-concept Study Using Quantitative Sensory Threshold Analysis to Compare Two Intraoral Topical Anesthetics

PurposeCTY-5339A is an investigational topical anesthetic spray containing 14% benzocaine/2% tetracaine in a metered canister. Each spray delivers ∼0.2 mL of solution. This double-blind, randomized, crossover study compared the local anesthetic effect of CTY-5339A versus 14% benzocaine alone by using 2 quantitative sensory threshold experimental pain paradigms on the maxillary gingiva: pin prick test pain intensity (PPT PI) and heat pain threshold (HPT). Methods: American Society of Anesthesiology Class 1 and 2 subjects (N = 50) were enrolled in this study. To qualify for the study, subjects were tested on the anterior maxillary gingiva with both PPT and HPT. Subjects had to report a PPT PI of ≥3 on a 0 to 10 numeric pain intensity scale on 1 of 2 consecutive pin pricks separated by 10 s, with at least one score ≥4. After PPT, mean HPT following 2 ramps in the same location had to be ≤ 46.5 °C, with each ramp beginning at 35 °C and an automatic cutoff of 50.6 °C. For treatment visits, subjects were randomly administered either 1 spray of CTY-5339A or 14% benzocaine to the anterior maxillary gingiva within 3 weeks of screening and then the alternative treatment 5 days to 2 weeks later. PPT PI and HPT were recorded immediately before drug application. After drug administration, PPT PI was recorded every minute through 5 min. Commencing at 5 min, PPT PI and HPT were recorded every 5 min through 60 min. For assessment of methemoglobin concentrations, venous blood (5 mL) was drawn from the antecubital fossa both before and 60 min after drug application. Oxygen saturation was recorded via pulse oximetry at baseline and every 10 min. FindingsThe AUCs for pain intensity difference from 0–30 and 0–60 min after PPT and HPT differences were significantly greater (P < 0.0001) for CTY-5339A compared with 14% benzocaine. Multiple time points on the time–action curves for PPT PI difference and HPT difference statistically (P < 0.05) favored CTY-5399A. Methemoglobin and oxygen saturation levels did not change compared with baseline after dosing with either treatment. ImplicationsRecommended doses of CTY-5339A provided significantly more profound and sustained local anesthesia than 14% benzocaine when applied to the maxillary gingiva. Significant changes in methemoglobin or oxygen saturation concentrations did not occur for either drug. ClinicalTrials.gov identifier: NCT03233737.

Estimation of YKL-40 Acute-Phase Protein in Serum of Patients with Periodontal Disease and Healthy Individuals: A Clinical-Biochemical Study.

Objective:YKL-40, an acute-phase protein, is a novel potential inflammatory marker. It is a member of “mammalian chitinase-like proteins.” YKL-40 is secreted by activated neutrophils and macrophages in both acute and chronic inflammation. It is also shown to be produced by vascular smooth muscle and endothelial cells, arthritic chondrocytes, cancer cells, and embryonic and fetal cells. It might play an important role in the initiation or maintenance of pro-inflammatory response. The purpose of the present study was to estimate the concentrations of YKL-40 in the serum of healthy and periodontally affected individuals.Materials and Methods:Serum samples were collected from forty patients of periodontally (Group C) affected sites (probing depth [PD] >5 mm) and gingivitis patients (Group B) affected sites (PD ≤ 3 mm) with bleeding on probing. Comparison with healthy controls was carried out by collecting serum samples from ten healthy volunteers (Group A). 5 ml of blood was collected from the antecubital fossa by venipuncture using a 20G needle with 5 ml syringe and immediately transferred to the laboratory. Serum was extracted from blood and stored at −70°C till the assay procedure, and enzyme-linked immunosorbent assay was performed to determine the concentrations of YKL-40.Results:The mean YKL-40 concentration scores were significantly higher in Group C, i.e. 62.49 ± 8.33 when compared to Group B, i.e. 51.96 ± 4.30 and Group I, i.e. 44.23 ± 4.34, which was statistically significant (P ≤ 0.001). In the present study, mean probing pocket depth was higher in Group C than Group A (P ≤ 0.001). A positive correlation was found between probing pocket depth and concentrations of YKL-40 in serum (r = 0.815), P < 0.001, i.e. when the pocket depth increases, concentration of YKL-40 also increases.Conclusion:In this study the presence of YKL-40 in serum samples was observed both in healthy and chronic periodontitis. In this study, the concentration of YKL-40 was elevated in chronic periodontitis group when compared to healthy group. With increases in the amount of destruction, there is substantial increase in clinical parameter and YKL-40 concentration in serum, which is directly related to pocket depth. This study shows that YKL-40 is a novel biomarker for periodontal disease progression.

Anastomotic pseudoaneurysm of brachioradial artery

Brachioradial (BR) artery also known as “radial artery of high origin” is the most common anatomical variation in the upper extremity arterial system. However, the clinical significance of this variation is rarely recognized in daily practice. This article reports the case of a 40-year-old male patient who presented with anastomotic pseudoaneurysm of an arteriovenous fistula, which had been created between the BR artery and median cubital vein in the antecubital fossa. The patient underwent aneurysm excision with repair of BR artery. Postoperative period was uneventful.

New Viewpoint of Surface Anatomy Using the Curved Sectional Planes of a Male Cadaver.

BackgroundThe curved sectional planes of the human body can provide a new approach of surface anatomy that the classical horizontal, coronal, and sagittal planes cannot do. The purpose of this study was to verify whether the curved sectional planes contribute to the morphological comprehension of anatomical structures.MethodsBy stacking the sectioned images of a male cadaver, a volume model of the right half body was produced (voxel size 1 mm). The sectioned images with the segmentation data were also used to build another volume model. The volume models were peeled and rotated to be screen captured. The captured images were loaded on user-friendly browsing software that had been made in the laboratory.ResultsThe browsing software was downloadable from the authors' homepage (anatomy.co.kr). On the software, the volume model was peeled at 1 mm thicknesses and rotated at 30 degrees. Since the volume models were made from the cadaveric images, actual colors of the structures were displayed in high resolution. Thanks to the segmentation data, the structures on the volume model could be automatically annotated. Using the software, the sternocleidomastoid muscle and the internal jugular vein in the neck region, the cubital fossa in the upper limb region, and the femoral triangle in the lower limb region were observed to be described.ConclusionFor the students learning various medical procedures, the software presents the needed graphic information of the human body. The curved sectional planes are expected to be a tool for disciplinary convergence of the sectional anatomy and surface anatomy.

Anatomic Variation in the Origin and Course of Radial Artery: A Descriptive Cross-Sectional Study

Introduction: The radial artery is commonly originated from the brachial artery in the cubital fossaat the level of the neck of the radius. It is the artery of choice for coronary artery angiography,percutaneous coronary artery intervention, cannulation, and others. Radial artery anomalies likehigh origin, tortuosity, and accessory branches are associated with the failure of such procedures.The main objective of this study is to study the variation in origin and course of the radial artery incadavers.&#x0D; Methods: A descriptive cross-sectional study was conducted in 27 formalin-fixed adult humancadavers in the Department of Anatomy, KIST Medical College and Teaching Hospital, Lalitpur,Nepal, from 2075/4/2 to 2076/4/2. Ethical approval was taken on date 02/04/2075 (IRC No.2074/75/38). Altogether, 53 specimens were enrolled in the study by convenience sampling method.Point estimate at 95% Confidence Interval was done for binary data along with frequency andproportion. The data was analyzed by and Statistical Package for the Social Sciences version 20.&#x0D; Results: Out of of 53 upper limbs, forty-six (86.79%) specimens, the origin of the radial artery wasobserved to be normal in the cubital fossa, 34.5±6.31mm below the level of the intercondylar lineof the humerus with the superficial course. In seven (13.21%) specimens, the radial artery showedvariation in the origin. Among them, variations in origin were found to be from sites like the axilla,upper-middle, and lower part of the arm. One cadaver showed a tortuous radial artery bilaterally.&#x0D; Conclusions: This study concludes that most of the radial artery originates in the cubital fossa fromthe brachial artery with few variations.

Comparison of hyperemic efficacy between femoral and antecubital fossa vein adenosine infusion for fractional flow reserve assessment

IntroductionIntravenous infusion of adenosine via the femoral vein is commonly used to achieve maximum hyperemia for fractional flow reserve (FFR) assessment in the catheterization laboratory. In the era of transradial access for coronary interventions, obtaining additional venous access with sheath insertion in the groin is unpractical and may be associated with a higher risk of bleeding complications. In a vast majority of cases, patients scheduled for the catheterization laboratory are already equipped with peripheral vein access in antecubital fossa vein. However, only limited data exist to support non-central vein infusion of adenosine instead of the femoral vein for FFR assessment.AimTo compare infusion of adenosine via a central versus a peripheral vein for the assessment of peak FFR.Material and methodsWe enrolled 50 consecutive patients with 125 borderline coronary lesions that were assessed by FFR using adenosine femoral and antecubital vein infusion of 140 µg/kg/min.ResultsPhysiological severity assessed with femoral vein adenosine infusion at 140 µg/kg/min was mean 0.82 ±0.09, and with antecubital vein adenosine infusion at 140 µg/kg/min was 0.82 ±0.09. The mean time from initiation of adenosine infusion to maximal stable hyperemia was significantly shorter for 140 µg/kg/min femoral vein infusion as compared to antecubital vein infusion (49 ±19 s vs. 68 ±23 s; p < 0.001). There was a strong correlation between FFR values obtained from 140 µg/kg/min femoral and antecubital vein infusion (r = 0.99; p < 0.001).ConclusionsAntecubital vein adenosine infusion achieved FFR values are very similar to those obtained using femoral vein adenosine administration. However, time to maximal hyperemia is longer with infusion via the antecubital vein.

Right-heart catheterization using antecubital venous access in patients with complex congenital heart defects and Glenn anastomosis.

Right-heart catheterization using the antecubital veins has recently regained attention, and studies demonstrating the feasibility and safety of antecubital access in adults have been published. However, no changes have been observed in the preferred entrance sites in right-heart catheterizations in children with congenital heart diseases. This article is a description of the technique and features of the antecubital venous approach in pediatric patients with complex congenital heart defects and a Glenn anastomosis. The data regarding a right cardiac catheterization through the antecubital fossa veins performed in 18 patients with various clinical indications between January 2014 and August 2017 were reviewed retrospectively and the results were assessed. Ten patients (55%) were male and 8 patients were female. All of the patients but 1 had a complex congenital heart disease with a Glenn anastomosis. One patient had been operated on for a sinus venosus atrial septal defect and an abnormal pulmonary venous return and had a total occlusion of the superior vena cava. A diagnostic catheterization was performed in all cases. Additional procedures consisted of a balloon test occlusion of the pulmonary valve in 2 patients, a superior vena cava-right pulmonary artery anastomosis dilatation in 1, and abnormal veno-venous collateral occlusion with various devices in 2 patients. The antecubital venous approach technique can be performed easily and safely for diagnostic and therapeutic catheterization in patients with complex congenital heart defects. The authors advocate that the antecubital venous approach should be the first site selected for right-heart catheterization, especially in patients with a Glenn anastomosis.

Brachio- Axillary Translocation Fistula with Reverse Saphenous Venous Graft: a New Hope for the Patients of End stage Renal Disease

Native arterio-venous fistula (AVF) are the preferred mode of repeated vascular access for the chronic renal failure patients surviving on hemodialysis because of their easy accessibility, good long term patency, low complication rate and cost-effectiveness. Creation of a fistula between the radial or brachial artery and a suitable adjacent vein is the most commonly practiced option. However the major upper arm veins of the CKD patients are often found thrombosed, cord like and not suitable for AV anastomosis. A 48 years old male patient of chronic kidney disease with a permanent catheter placed in the right subclavian vein was referred to create an AV fistula. On exploration none of the upper limb veins was found suitable for fistula formation. The proximal part of the left GSV was harvested from patient’s left upper thigh and was used to make a connection between left brachial artery at cubital fossa and the left axillary vein. To avoid over flooding of the limb vasculature, partial banding of the left axillary vein was done distal to this anastomosis. When all options in both upper limbs are exhausted, autologous great saphenous grafts may be a very useful tool for the surgeons in creating upper limb AV fistulas in difficult situations&#x0D; Bangladesh Heart Journal 2018; 33(2) : 134-137

Anesthetic potential of lidocaine/prilocaine cream versus placebo before venepuncture

Background: Pain associated with venepuncture has long been accepted as an unavoidable consequence. Many studies show reducing pain during venepuncture after application of prilocaine/lignocaine, but there are few studies that has depicted, the depth of anesthesia produced by prilocaine/lignocaine tends to be too superficial for the reducing the pain during venepuncture. These two scenarios were debatable. Therefore, authors planned a study to assess anesthetic potential of lidocaine /prilocaine cream versus placebo before venepuncture with help of VAS in an adult patient who were drawn blood sample for investigation purposes.Methods: Prospective interventional study. All adult patient for blood sampling from surgery OPD to central laboratory were included in study. Site of venepuncture selected in both control and study group was left cubital fossa. 30 patients selected in study group received lignocaine/prilocaine locally, 30min prior to venepuncture which was later covered with occlusive tape, whereas 30 control group patient received normal saline locally as placebo. The extent of pain was assessed by patient on 10cm visual analogue scale (VAS) with end points of 0 cm rated as no pain and the points of 10cm as intolerable pain.Results: A total of 60 patient were randomly selected who were referred from surgery OPD for blood sampling. Other 30 patient were applied normal saline as placebo and 30 patient with lignocaine and prilocaine cream. In the control group there were 30 patients (5 female and 25 male). In the study group there were 30 patients (8 females and 22 males). The level of pain among study group is as follows: mild 22, moderate 7, worst 1 and in control group: no pain 0, mild 5, moderate 14 and worst pain 1. Statistical analysis between outcome of two groups done by calculating chi-square test. Chi- square test was 20.0263. P value is 0.000168. Hence the result is significant at p &lt;0.05.Conclusions: The present study shows that prilocaine-lidocaine cream reduces the pain of needle puncture in adults and facilitates the procedure of venous blood sampling.

To Determine The Frequency Of Vitamin D Deficiency In Patients With Chronic Hepatitis C

Objective: To determine the frequency of vitamin D deficiency in patients with chronic hepatitis C (CHC) Design: It was a Descriptive and Cross Sectional study Place and Duration of Study: It was carried out in the Medicine Unit of Pakistan Naval Ship SHIFA, Karachi from Nov 29, 2016 to May 29, 2017. Patients and Methods: Approval was sought from Institutional Review Board before carrying out the study. Proper history, clinical examination and appropriate lab investigations were carried out. Standard techniques were used for blood sample collection. Site used for blood collection was antecubital fossa. Sterile method was used for fasting sample and about 10 ml of blood was collected from each patient. Results: A total of 289 patients were included. Strict exclusion and inclusion criteria was used for study cohort. Mean age (years) of study cohort was 34.51+8.32. There were 188 (65.1) male and 101 (34.9) female patients. Patients with CHC who were vitamin D deficient were 74 (25.6). Conclusion: Patients of CHC had high frequency of vitamin D deficiency which suggests that further studies in the region will be conduct in our general population to know the exact statistics which will pave the way for future researchers