Anterior Aspect Research Articles

Dysfunctions associated with the intraparietal sulcus and a distributed network in individuals with math learning difficulties: An ALE meta-analysis.

Math learning difficulty (MLD) is a learning disorder characterized by persistent impairments in the understanding and application of numbers independent of intelligence or schooling. The current study aims to review existing neuroimaging studies to characterize the neurobiological basis in MLD for their quantity and arithmetic dysfunctions. We identified a total of 24 studies with 728 participants throughthe literature. Using the activation likelihood estimate (ALE) method, we found that the most consistent neurobiological dysfunction in MLD was observed in the right intraparietal sulcus (IPS) with distinct patterns of the anterior and posterior aspects. Meanwhile, neurobiological dysfunctions were also observed in a distributed network includingthe fusiformgyrus, inferior temporal gyrus, insula, prefrontal cortex, anterior cingulate cortex, and claustrum. Our results suggest a core dysfunction in the right anterior IPS and left fusiform gyrus with atypically upregulated functions in brain regions for attention, working memory, visual processing, and motivation, serving as the neurobiological basis of MLD.

Geometry of hydrogel rectal spacer placement and risk of MRI-identified rectal wall infiltration.

312 Background: The use of rectal spacers in the management of localized prostate cancer treated with definitive radiotherapy has become ubiquitous in recent years. However, pre-treatment MRIs often identify varying degrees of hydrogel involvement within the rectal wall. In the present study, we evaluate the geometry of spacer placement and its association with radiological rectal wall infiltration. Methods: We identified all patients who underwent hydrogel rectal spacer placement in preparation for 5-fraction prostate SBRT from 1/2020 to 9/2021. Two specialty trained body radiologists evaluated all MRIs independently. Scans were evaluated for the following spacer parameters: spacer thickness, prostate-rectal distance, symmetry, and degree of rectal wall infiltration. Prostate-rectal distance was measured at the level of the prostatic apex, midgland, and base. Symmetry of the rectal spacer was measured using right or left lateralization from midgland. Degree of rectal wall invasion was categorized as follows: none, muscularis, submucosal, and intraluminal. Results: A total of 336 patients underwent MRI following hydrogel rectal spacer placement from 1/2020 to 9/2021. Patients were excluded from MRI if they had AICD/pacemaker, foreign body, or patient refusal. In those patients with any rectal wall invasion, gel thickness as measured at the base (11 vs. 10 mm, p = 0.02), midgland (14 vs. 10 mm, p < 0.001), and apex (12 vs. 8 mm, P < 0.001) was significantly larger than those patients without invasion. This translated into significantly larger distances between the posterior aspect of the prostate and anterior aspect of the rectum at the level of the apex (12 vs. 8 mm, p < 0.001) and midgland (13 vs. 11, p < 0.001), but not at the base (14 vs. 14 mm, p = 0.5). There was no association seen with asymmetrical spacer placement and rectal wall invasion (p = 0.7). Subgroup analysis of patients with more extensive invasion into the muscularis or submucosa confirmed significantly larger gel thickness at all prostate levels, as well as a larger prostate-rectal distance at the level of the apex and midgland. Significant associations remained consistent with both independent radiological evaluations. Conclusions: Hydrogel spacer rectal wall infiltration was associated with increased axial gel thickness, specifically at the level of the prostatic midgland and apex. Rectal wall infiltration was not associated with lateralization of gel. Rectal infiltration may be a result of surplus hydrogel placed particularly in the region where the potential space between the prostate and the rectum is limited.

A new circuit underlying the renewal of appetitive Pavlovian responses: Commentary on Brown and Chaudhri (2022).

A new circuit underlying the renewal of appetitive Pavlovian responses: Commentary on Brown and Chaudhri (2022).

Three Zone Scanning Protocol For Lung Ultrasound: An Anatomical Basis.

Lung ultrasound is rapidly gaining popularity based on point of care ease of use, diagnostic fidelity and lack of ionizing radiation. This was particularly notable at the beginning of the COVID-19 pandemic, where concerns of contamination of the x-ray department led to a reluctance to order frequent chest x-rays. Early COVID-19 lung involvement is of a bronchopneumonia, and patches of consolidation adjacent to the chest wall were easily detectable by ultrasound. A large number of proposed scanning protocols were advocated and are often complex and largely based on traditional stethoscope examination or access points on the chest wall rather than the underlying lung anatomy. A surgical understanding of lung anatomy and related surface anatomy has led us to develop a simplified three zone scanning protocol in 2013. The anterior zone corresponds to the upper lobe, and the posterior zone is divided between upper lobe and lower lobe. The relationship between lung lobes and the surface of the chest wall provides the anatomical basis for a simple three scanning zone lung ultrasound protocol.

A Newly Discovered Dural Venous Sinus of the Skull Base: The Anterior Petroclinoid Sinus

Neurosurgeons must master microanatomy and its variants that occur at the skull base. To the best of our knowledge, we describe a previously unreported dural venous sinus (DVS) within the anterior petroclinoid fold and discuss its potential surgical relevance. Fifteen latex-injected human cadaveric heads (30 sides) underwent skull base dissection using a surgical microscope. The anterior petroclinoid fold was opened in search of evidence of an embedded DVS. When identified, this sinus was documented, photographed, and measured with microcalipers. An anterior petroclinoid sinus (APCS) was identified in 67% of sides. These DVSs had a mean diameter of 0.65 mm and a length ranging from 8 to 15 mm (mean: 12.5 mm). The APCS ran from the anterior aspect of the cavernous sinus, arising just lateral (60%), posterior (20%), or medial (20%) to the anterior clinoid process, to the superior petrosal sinus (65%) or the posterior aspect of the cavernous sinus (35%), at the level of the posterior clinoid process. Along the course of the APCS, the oculomotor nerve was located medially at the oculomotor porus. Although slightly more common and larger on the right side, there was no statistically significant side difference. An improved knowledge of variant DVSs can lower the risk of intraoperative complications and increase our understanding of the venous outflow from the cavernous sinus. Future neuroimaging techniques might also seek to identify the APCS. This is the first description of a DVS contained within the anterior petroclinoid fold.

Cellulitis with a poor clinical course in an immunocompromised patient

A 60-year-old man with a history of stage IV colorectal cancer treated with second-line chemotherapy and EGFRI (epidermal growth factor receptor inhibitor) therapy, presenting redness, swelling, pain and warm skin, secondary to skin wounds on the thigh. He was diagnosed as soft tissue infection (cellulitis) of left lower limb and treated with oral Amoxicillin-clavulanate for 10 days without clinical improvement. The patient was admitted with increased edema accompanied by intense pain up to the knee. Vancomycin and ceftriaxone were initiated. Eco-doppler was negative for deep venous thrombosis and the soft tissue ultrasound showed thickening and de-structuring of the subcutaneous cellular tissue with 7mm. collections affecting the anterior aspect of the thigh. Surgical debridement and sampling abscess for microbiology was performed. Gram stain showed septate fungal hyphae. Forty-eight hours of incubation aerobic agar plates and fungal subculture showed colonies with a brownish center and white edges. Microscopic morphology showed oval conidia with truncated bases and large cleistothecia (Fig. 1). The preliminary result was reported as Scedosporium spp. and it was confirmed by the National Center for Microbiology (Majadahonda, Madrid) as Scedosporium apiospermum. The in vitro antifungal susceptibility testing was performed by the broth dilution method as per the Subcommittee on antifungal susceptibility testing (AFST) of ESCMID European committee for antimicrobial susceptibility testing (EUCAST) 2008 guidelines. The MICs of the isolate were: amphotericin B 16 mg/L; voriconazole 2 mg/L: itraconazole >8 mg/L; posaconazole 2 mg/L; terbinafine >16 mg/L; anidulafungin 2 mg/L and micafungin 0.12 mg/L. The patient started empirical treatment with amphotericin B (liposomal) 3mg/kg intravenous (IV) daily and voriconazole 6mg/kg IV q12 h, two doses (load) then 4 mg/kg IV q12 h. After fungal identification the patient continued with voriconazole IV for 2 weeks, followed by oral voriconazole 200mg q12 h as an outpatient until 6 weeks achieving complete resolution.

Role of aquaporins in corneal healing post chemical injury

Aquaporins (AQPs) are transmembrane water channel proteins that regulate the movement of water through the plasma membrane in various tissues including cornea. The cornea is avascular and has specialized microcirculatory mechanisms for homeostasis. AQPs regulate corneal hydration and transparency for normal vision. Currently, there are 13 known isoforms of AQPs that can be subclassified as orthodox AQPs, aquaglyceroporins (AQGPs), or supraquaporins (SAQPs)/unorthodox AQPs. AQPs are implicated in keratocyte function, inflammation, edema, angiogenesis, microvessel proliferation, and the wound-healing process in the cornea. AQPs play an important role in wound healing by facilitating the movement of corneal stromal keratocytes by squeezing through tight stromal matrix and narrow extracellular spaces to the wound site. Deficiency of AQPs can cause reduced concentration of hepatocyte growth factor (HGF) leading to reduced epithelial proliferation, reduced/impaired keratocyte migration, reduced number of keratocytes in the injury site, delayed and abnormal wound healing process. Dysregulated AQPs cause dysfunction in osmolar homeostasis as well as wound healing mechanisms. The cornea is a transparent avascular tissue that constitutes the anterior aspect of the outer covering of the eye and aids in two-thirds of visual light refraction. Being the outermost layer of the eye, the cornea is prone to injury. Of the 13 AQP isoforms, AQP1 is expressed in the stromal keratocytes and endothelial cells, and AQP3 and AQP5 are expressed in epithelial cells in the human cornea. AQPs can facilitate wound healing through aid in cellular migration, proliferation, migration, extracellular matrix (ECM) remodeling and autophagy mechanism. Corneal wound healing post-chemical injury requires an integrative and coordinated activity of the epithelium, stromal keratocytes, endothelium, ECM, and a battery of cytokines and growth factors to restore corneal transparency. If the chemical injury is mild, the cornea will heal with normal clarity, but severe injuries can lead to partial and/or permanent loss of corneal functions. Currently, the role of AQPs in corneal wound healing is poorly understood in the context of chemical injury. This review discusses the current literature and the role of AQPs in corneal homeostasis, wound repair, and potential therapeutic target for acute and chronic corneal injuries.

A comparative clinical study on the efficacy of Nityanand Ras with (or) without Jeernakarkaruka Nasya in Hypothyroidism

Hypothyroidism also known as underactive thyroid gland, where the gland fails to produce enough thyroid hormones to meet the demands of physical body. The thyroid gland is a small approximately two inches butterfly shaped gland, situated in the anterior aspect of the throat regulates the way the body uses its energy, including the way how one’s heart beats. The normal functioning of this organ is very crucial for the metabolic homeostasis of the body. The rapid changes in the lifestyle and stressful life events are leading to the major disturbance of the normal metabolic functions of the human body, in Ayurveda the signs and symptoms of Hypothyroidism may be superficially compared to Atihraswa (dwarfism) and Atisthula (Obesity), but apart from this also, based on the other visible signs and symptomatology, the disease may be understood and treated accordingly. It is also can be considered as an Santarpanotta Vikara, since most of the Santarpanotta Vikara’s share common etio-pathogenesis. The Panchakarma treatment is known for removing the morbidity deeply from the body, and restores metabolic homeostasis. With this approach the current study was designed to observe the efficacy of Nityananda Ras, which is indicated in the Shlipada Adhikara of Bhaishajya Ratnavali, in the management of HT, and also in comparison with Nasya Karma, since the nasal administration of medicine is the best root for the elimination of the diseases of Head and neck. This research has shown the Nityanand Ras, is found effective and in the Nasya with Jeerna Karakaruka Swarasa group patients the results were encouraging in comparing with Nityanand Ras.

Atypical Cervical Potts Spine with Multiple Level Epidural Collection: A Case Series of Three Patients.

Cervical Pott's constitutes about 10% of all Pott's spine cases. In tuberculous spondylitis, initially there occurs destruction of vertebral bodies and further progression may result in adjacent abscesses, leading to cord compression. Objective is to excise the diseased focus and to provide spinal stability. We are presenting 3 rare cases of cervical Pott's spine with epidural collection at multiple levels in the cervical region without significant vertebral body destruction that were followed up for a period of 1 year postoperatively. Patients underwent single-level corpectomy and decompression from anterior aspect. In all three cases, we were able to decompress the cord and remove all the collections and also achieved spinal stabilization. Patients had a gradual and complete recovery of motor power within 6 months to 1 year after surgery. Technique used allows accurate visual assessment of the extent of the disease and allows complete decompression of the cord at multiple levels in cervical spine without causing much instability.

Endoscopic ultrasound to the rescue of pancoast tumour.

Dear Editor, A 48-year-old male presented with a two-month history of right-sided shoulder pain with right arm radiation and significant weight loss. A radiograph showed an opacity in the right upper zone. A 34 × 45 × 52 mm mass in the apex of the right lung was seen on contrast-enhanced computed tomography (CECT) [Figure 1a]. Magnetic resonance imaging (MRI) for local staging showed involvement of the right subclavian artery and nerve roots [Figure 1b]. A percutaneous biopsy was planned, but no safe window was available due to the clavicle and multiple vessels on the anterior aspect. Because of the proximity of the lesion to the oesophagus, the patient was referred for endoscopic ultrasound (EUS)-guided biopsy. EUS confirmed the findings of prior imaging [Figure 1c]. An initial attempt at EUS-guided fine-needle aspiration (FNA) with 22-G needle failed as the tumour was very hard. Hence, FNA of visualised subcarinal lymph nodes was performed with a 22-G needle followed by FNA of the tumour with a 19-G needle [Figure 2a]. After the procedure, the patient was observed for four hours and was discharged after confirming the absence of pneumothorax on chest radiograph. A final diagnosis of non-small cell carcinoma was made on pathological [Figure 2b] and cytological examination based on visualisation of clusters of large polygonal cells with round-to-oval vesicular pleomorphic nuclei with no evidence of malignancy in the mediastinal nodes. Because of an unresectable lesion, the patient was planned for a combination of induction chemotherapy and radiotherapy.Figure 1: (a) Contrast-enhanced computed tomography (CECT) of thorax showing a mass in the apex of the right lung. (b) Magnetic resonance imaging (MRI) showing involvement of the right subclavian artery (large arrow) and nerve roots of C8, T1, and T2 (small arrows), (c) Transoesophageal endoscopic ultrasound (EUS) showing a hypoechoic irregular lung mass located on top on lung parenchyma (asterisk) and encasing the subclavian artery anteriorly (arrow)Figure 2: (a) Endoscopic ultrasound-guided fine needle aspiration from lung mass, (b) Haematoxylin and eosin (H and E) staining of core lung mass biopsy, suggestive of non-small cell carcinoma of the lung (arrow)EUS has an established role in tissue acquisition from mediastinal lymph nodes, but data on EUS-guided sampling from lung mass remains limited. Transbronchial needle aspiration (TBNA) and endobronchial ultrasound-guided needle aspiration (EBUS-FNA) are the preferred modalities for the diagnosis and staging of lung cancer.[1] However, the tumour’s location at the apex of the lung makes them inaccessible to TBNA or EBUS-FNA. In such cases, tumours close to the oesophagus may be amenable to transoesophageal EUS-guided FNA. It also has the advantage of simultaneous sampling of mediastinal lymph nodes and other organs like the liver and adrenal for assessment of metastasis.[1] The present case highlights the utility of EUS for diagnosing lung tumours at inaccessible sites. A recent multicentric study from Italy reported the efficacy and safety of EUS-guided tissue sampling as a minimally invasive procedure for the diagnosis and staging of peri-oesophageal parenchymal lung lesions.[2] However, transoesophageal FNA from lung mass may be rarely associated with pneumothorax[3] and haemoptysis.[4] Hence, a check X-ray should be done to rule out pneumothorax before discharging the patient. Keeping in mind the possibilities of complications, EUS-FNA of the lung lesions should be done in centres with the availability of pulmonologist to immediately address the adverse events. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

SJLA_2024_A18: Persistent Complex Seroma Treated by Capsulectomy and Argon Beam Coagulator

Background: Seroma formation is one of the most common events following ventral hernia repair. When mesh is used for the repair of larger and more complex incisional hernias, the risk of seroma formation increases. The mesh onlay technique, which requires more extensive dissection, is associated with an even greater incidence of seroma formation. Treatment options for postoperative seromas include observation for spontaneous resolution, percutaneous aspiration, closed suction drainage, abdominal binders, and sclerosant. Methods: The aim of this report is to present a definitive management of a very challenging case of abdominal wall chronic complex seroma following herniorrhaphy with mesh approached by open capsulectomy and scarification of the remnant pseudocapsule. Results: Our patient is a 60 years-old male a status post low anterior resection with covering loop ileostomy for rectal cancer. His diverting stoma was taken off after completing the adjuvant chemotherapy treatment. Seven months later, the patient has developed an enlarging midline incisional hernia. This hernia was subsequently repaired by primary fascial closure with suprafascial onlay polypropylene mesh. Postoperatively, he developed a subcutaneous seroma which was initially treated with an abdominal binder without success. Over the following 3 months of observation, seroma was increasing in size. Discussion: Having recovered his acute condition, surgical intervention was planned. The patient underwent an excision and evacuation of the complex seroma and pseudocapsule. A 12-cm midline incision was made in line with the previous incision used for the hernia repair. The pseudocapsule of the seroma was encountered when the subcutaneous tissue was incised. The incision was carried superior, inferior, and laterally, and the capsule was exposed. The seroma opening sinus was expanded and fluid was evacuated. There were some fibrous dead tissues and coagulated dark blood. The anterior and lateral aspects of the pseudo capsule were excised. Furthermore, the posterior aspect was cleaned carefully using the curettage instrument without affecting the integrity of the mesh which was looking healthy and intact and without causing injury to the intraabdominal contents. Argon beam coagulator was used to scarify the remaining posterior aspect attaching to the mesh. Hemostasis was secured, and the wound was closed over a Jackson–Pratt drain. A pressure dressing and abdominal binder were applied. Conclusion: Factors leading to seroma following incisional herniorrhaphy are poorly understood. Many options are available for treating complicated abdominal wall seroms. capsulectomy and scarification of the remnant pseudocapsule were good option for the treatment of persistence complex seroma.

Pseudoxanthoma Elasticum: A Case Report

BACKGROUND: Pseudoxanthoma elasticum (PXE) is a rare, genetic, metabolic disease with autosomal recessive inheritance caused by mutations in the ABCC6 gene. The lack of functional ABCC6 protein leads to ectopic mineralization that is most apparent in the elastic tissues of the skin, eyes, and blood vessels. Dermatologic manifestations consist of small yellow papules on the nape and sides of the neck and in flexural areas that coalesce into reticulated plaques resembling the cobblestone aspect, and then the skin becomes loose and wrinkled. Histopathologic findings provide characteristic clues such as short, fragmented, clumped, and calcified mid-dermal elastic fibers. CASE PRESENTATION: A 27-year-old Albanian female was referred to the dermatology clinic with skin complaints for approximately 17 years. On physical examination, we observed “cobblestone pattern” lesion located in the anterior, lateral, and posterior aspects of the neck, bilateral axillary, inguinal, antecubital, and popliteal regions, and periumbilical area. A biopsy was performed and the histopathology confirmed the typical changes in the dermis because of ectopic mineralization. The funduscopy revealed the “peau d’orange” aspect, bilateral angioid streaks but no neovascularization. Carotid echography showed minimal intimate thickening with flow acceleration but without significant stenosis of the right common carotid artery (ACC). Different laboratory exams were conducted that resulted within the normal range. CONCLUSION: There is no specific treatment, and therapeutical management is based on prevention, tracking, and follow-ups to increase surveillance of clinical complications through a multidisciplinary team. The dermatologist is usually the first who faces Pseudoxanthoma elasticum manifestations. Therefore, the dermatologist should provide the patient with the best therapeutical and preventive approaches.

Tibial avascular necrosis in a trimalleolar ankle fracture

Fractures involving the distal tibia and fibula are challenging to treat, and can have debilitating sequelae. While many fractures can be treated conservatively, open reduction with internal fixation for displaced or unstable variants is the standard of care. Complications in treatment of these complex fractures are relatively common and often unavoidable. The authors present the case study of a 49 year-old female who underwent open reduction with internal fixation of a closed Danis Weber type-B trimalleolar ankle fracture and suffered avascular necrosis of the anterior lateral tibial plafond. This patient underwent successful trimalleolar ankle fracture fixation surgery, and subsequently suffered collapse of the anterior lateral aspect of the tibia 14 weeks following her index procedure. This case study lends an example of avascular necrosis causing devastating osseous collapse despite timely and robust fracture fixation.

Retroperitoneal Caecum and Looped Retroperitoneal Appendix - A Rare Cadaveric Finding

Caecum is the initial blind part of large intestine normally located in the right iliac fossa. It receives terminal part of ileum on its posteromedial wall. Vermiform appendix is attached to caecum below the attachment of ileum. Variations in the position of caecum have been reported which can be attributed to its development. However variations in the appendix are very rare and most often reported as a finding during surgery. This article reports a cadaveric finding where terminal ileum was opening on to the anterior aspect of caecum. The vermiform appendix was U-shaped and it was fixed to pelvic brim at the bend. This anatomical variation may be of interest to the surgeons operating in the region. A rare finding of appendix which is U shaped not reported so far.

Extensive Eccrine Squamous Syringometaplasia Mimicking Squamous Cell Carcinoma on Histopathology

Eccrine Squamous Syringometaplasia (ESSM) is a histologically distinctive skin eruption occurring predominantly in acral or intertriginous areas presenting as erythematous macules, papules or patches. It is a response of eccrine ducts and glands to any injury or inflammation. The cuboidal epithelium of eccrine ducts and glands undergoes metaplasia and transforms to keratinised squamous epithelium in ESSM. Other types of metaplastic changes encountered are squamous, mucinous and adenomatous. In squamous syringometaplasia, the metaplastic squamous cells form lobules and florid types can pose a diagnostic dilemma, which if not well understood may lead to an erroneous diagnosis of neoplasia. Literature suggests ESSM as a condition associated with another pathogenic stimuli or therapy; however florid ESSM is very rare. Hereby, the authors present a case report of a 43- year- old male who presented florid ESSM mimicking well-differentiated Squamous Cell Carcinoma (SCC). The present case presented with a non healing elevated lesion on anterior aspect of right leg with itching. Similar lesions were not present in any other part of the body. The patient did not have history of any systemic disease or drug intake. The lesion was excised and sent for histopathology. On gross examination the skin showed irregular thickening and foci of erosion. Microscopy showed acanthotic, hyperkeratotic epidermis and dermal ESSM. There were irregular clusters of metaplastic squamous cell in dermis, resembling invasive islands of SCC. Meticulous examination revealed lobulated architecture of ESSM, lack of individual cell keratinisation/significant atypia or mitosis. The present report highlights the significance of histopathological diagnosis of benign squamous proliferations which can mimic malignancy and cause undue stress to the patient.

POL Reconstruction: a Necessity or an Accessory

The MCL is the knee ligament that is most commonly injured but is quite often neglected in terms of in-depth research and understanding. This is due to the belief in good healing abilities that there is a belief that MCL injuries are almost certain to be cured conservatively. Commonly, recurrent rupture after ACL reconstruction is due to neglect of MCL rupture. This prompted researchers and orthopedic sports surgeons to think about the importance of the MCL, initiate in-depth research on the MCL, and initiate repair of the ligament. Surgical indications include high-grade MCL injuries, valgus instability that persists on conservative therapy, and low-grade MCL injuries with other ligamentous injuries. The MCL consists of the superficial MCL (sMCL), deep MCL (dMCL) and the Posterior Oblique Ligament (POL).It stabilizes the medial of the knee against the valgus and rotation. The sMCL attachment to the femur covers the EM (Epicondyle Medial) and has a long attachment proximal to the tibia distally. The course of the dMCL has a sloping path from its attachment at the posterior distal of EM to the anterior distal of the proximal tibia. The posterior oblique ligament consists of three arms: the superficial, central (tibial), and capsular. The central arm is the largest and thickest part of the POL. The POL attachment to the medial condyle of the femur is somewhat more posterior and proximal than the EM or posterior and distal to the adductor tubercle, extending to the distal aspect of the semimembranosus tendon and is a thickening of the posterior medial capsule, with a distinct attachment to the medial meniscus. It is fused anteriorly with the sMCL but can be identified by the orientation of the fibers. The sMCL biomechanics found tension in the anterior aspect of the ligament when flexed about 90 degrees and externally rotated. In the posterior part of the sMCL, tension during full extension and internal rotation. The anterior part of the dMCL relaxes at 0-30 degrees and tension at an angle of 60 degrees to full flexion, while the posterior part of the dMCL relaxes more when flexed at 0-100 degrees. The POL is the posterior part of the MCL complex, which will be tensioned during Full Extension and internal rotation. The MCL complex is different in its response to changes in length to the extension, flexion, and knee rotation. The MCL is not isometric. The role of POL, which is quite prominent in the medial corner of the posterior knee, holds the movement of internal rotation, so this ligament is not accessory. Rupture of POL requires reconstruction to maintain the internal rotation stability of the knee joint. Furthermore, in performing reconstruction, the POL must be tightened and fixed in full knee extension and neutral rotation to reproduce its anatomical length and prevent over-tightening.

From simple neck pain to the diagnosis of Langerhans cell histiocytosis in the thyroid gland

Introduction. Langerhans cell histiocytosis (LCH), as a hematopoietic neoplasm, is a clonal proliferation of Langerhans dendritic cells. A comprehensive clinical examination is sometimes crucial for detecting rare adult diseases, such as LCH with concomitant autoimmune thyroid disease. Case report. A 43-year-old female patient first presented for an endocrinology consultation due to front neck pain and swelling accompanied by fatigue and malaise. The physical examination revealed an enlarged right thyroid gland lobe of extremely firm consistency that was painfully tender on palpation. Echosonographic findings confirmed that the right thyroid gland lobe was enlarged and was not clearly demarcated from the surrounding tissue while exhibiting pronounced parenchyma inhomogeneity characterized by reduced echogenicity of the anterior aspect and pronounced hypoechoicity of the posterior aspect, permeated with fibrous bands and calcifications. The structure of the left thyroid lobe was pseudonodular, with the characteristics of a chronic inflammatory process. Biohumoral findings indicated chronic auto-immune thyroiditis and primary hypothyroidism. Medical history, clinical findings, and personal and family predisposition to malignancy confirmed the need for accelerated additional diagnosis. Fine-needle aspiration biopsy was indicative of atypia of undetermined significance involving Hurthle cells, nuclear overlaps, anisocytosis, anisonucleosis, and the presence of nuclear incisions. Analyses performed after thyroidectomy pointed to the fibrous form of chronic thyroiditis, with suspected monoclonal proliferation of histiocytic and/or lymphoid cells. Immunohistochemical findings confirmed Hashimoto?s thyroiditis and LCH. As the post-operative course was favorable, the patient was prescribed L-thyroxine replacement therapy, along with continuous and systematic monitoring for histiocytosis. Conclusion. Histiocytosis should be suspected more often, given the high incidence of autoimmune thyroid disease in adulthood. A timely LCH diagnosis largely determines the outcome.

LIGHTENING STROKE RESULTING INTO LICHTENBERGS FLOWER: A RARE CASE REPORT

Background:Occupational hazards are consequences and risks associated with particular occupation. Farmers working in the fields are at various risks like snake bite, injuries sustained from agricultural equipment, inhalation of pesticides, electrocution and lightening injuries. In a thunderstorm and rainy season,person working in an open area and that too in a farm, is at utmost risk of getting electrocuted from lightening injury due to less insulation to the electric current in the wet surrounding. Metallic heavy agricultural machineries, irrigated fields and lack of awareness are other factors that makes one prone to get stroked by a lightening arc. Case History:Atwenty-three-year-old male farmer was found dead while working in the fields of rice in the afternoon. As per the family he went for cultivating seedlings of rice plants in the fields full of water. He was taken to the emergency department of our facility where he was declared brought dead after initial examination and resuscitation. The body was sent for medicolegal examination in the Mortuary. On external examination, mud was present over the body and clothes at places, the lower and underwear were torn at places.Characteristic arborescent patterned burns to lighteningi.e., Filigree burn were found over the left lateral aspect of lower abdomen and anterior aspect of upper two third of left thigh. Conclusion:Meticulous examination and sceptical eye of autopsy surgeon, meteorological department report, reconstruction of events and findings over the body can converge upto the cause and manner of death.

Examination of the Effect of Short-term Whole Body Vibration Training on Flexibility, Endurance and Dynamic Balance In Healthy Young People: A Randomized Controlled Study

Objective: To investigate the effect of short-term (3 weeks) whole body vibration training (WBVT) in healthy young people. Materials and Methods: Seventy six healthy individuals (mean age=22.55±1.22 years, 41 females and 35 males) were included in the study. Participants were randomly divided into two groups as WBVT group (n=41) and control group (n=35). WBVT, consisting of 14 exercises for the trunk and lower extremities, was applied to the WBVT group 3 times a week for 3 weeks. The control group did not receive any training. Flexibility, lower extremity endurance, trunk endurance and dynamic balance respectively; measured with sit and reach test, sit and stand test, Biering Sorensen tests, lateral bridge and shuttle, Y balance test. All measurements were made at baseline and at the end of the 3rd week. Results: After 3 weeks, in WBVT group, curl up test (p=0.023), chair stand test (p=0.015) and Y balance test were perfomed on right anterior (p=0.003), right posteromedial (p=0.001), right posterolateral (p=0.001), left anterior (p=0.001), left posterolateral (p=0.000), and left posteromedial (p=0.000) aspects were significant. In the control group, the results in the right anterior (p=0.019) and left anterior (p=0.025) aspects of the Y balance test were significant. When the delta values were compared, the difference in the right (p=0.018) and left (p=0.006) posterolateral directions of the Y balance test; it was significant in favor of the WBVT group. Conclusion: It was observed that short-term whole body vibration training had positive effects on trunk flexor endurance and dynamic balance in healthy young people. New insights into the use of musculoskeletal rehabilitation and sports training programs can be provided by WBVT. Further studies are needed to examine the effectiveness of whole-body vibration training by comparing different loads, volumes and types.

Dermoid cyst of pancreas: A report of an unusual case

Introduction: Pancreatic dermoid cyst is a rare, benign germ cell tumour and part of differential diagnosis for cystic neoplasm of pancreas, where it shows a slight preference for the pancreatic head. Case Report: We report a case of dermoid cyst of pancreas in a 17-year-old female patient. Patient presented with epigastric pain, anorexia and lump in epigastric region. CECT showed a well marginated cystic lesion with tiny speck of calcification in wall and fatty component anteriorly in epigastric region in midline and towards right arising from anterior aspect of head of pancreas. The fat planes surrounding the lesion are normal. The CBD was seen lying on posterior aspect of the lesion. Conclusion: Pre-operative diagnosis is difficult and it is usually diagnosed intraoperatively or by histopathological examination of the specimen.