Distal Point Research Articles

LENGTH CHANGE OF THE ILIOFEMORAL LIGAMENT DURING TESTS FOR ANTERIOR MICROINSTABILITY OF THE HIP JOINT: A CADAVERIC VALIDITY STUDY.

There is little information to support the use of clinical tests to assess for microinstability of the hip joint. The purpose of this study was to use a string model to describe and compare length changes of the iliofemoral ligament in the test positions commonly used to assess hip ligament laxity. Twelve hip joints from nine cadavers (4 male; 5 female) with lifespans of 57-84 years of age were studied. A string model representing the medial and lateral arms of the iliofemoral ligament was secured to the proximal and distal attachment points. The amount of length change of the string model was compared in four test positions: 1) external rotation, 2) hyperextension-external rotation 3) abduction-extension-external rotation, and 4) adduction--extension-external rotation. For the medial arm, the greatest change occurred in the adduction-extension-external rotation position (12.7mm). This was significantly greater than the external rotation (5.1mm; p=0.002) and abduction-extension-external rotation position (1.9mm; p<0.001). The lateral arm also had the greatest excursion in the adduction-extension-external rotation position (16.6mm). This length change was significantly greater than the external rotation position (8.6mm; p=0.002), the hyperextension-external rotation (11.1mm; p=0.047), and the abduction-extension-external rotation position (5.6mm; p<0.001). Tests used for hip instability cause various levels of tension through the iliofemoral ligament. The combination of hip extension and external rotation increased the length change of string model and was maximized with hip adduction. The least amount of change occurred with the addition of hip abduction to extension and external rotation. Clinicians may use the information to help interpret tests for instability of the hip and may consider the combined position of hip extension, external rotation, and adduction to elucidate involvement of the iliofemoral femoral ligament. 2b; Exploratory cohort study with good reference standards.

Testing landmark redundancy for sex-based shape analysis of the adult human os coxa.

To test the individual effectiveness of common landmarks used in sex estimation of whole adult coxal bones in sex-based shape analysis and propose a method to determine how many principal components of sex-based shape to include for discriminant function analysis. Three-dimensional models (NextEngine desktop laser scanner) of left and right os coxae from 396 individuals (William Bass Skeletal Collection, Forensic Anthropology Centre, University of Tennessee, Knoxville, TN) were subjected to shape analysis using 32 landmarks (Landmark 3.6, Institute for Data Analysis and Visualization). Each landmark was individually removed and subjected to a new principal component analysis to identify the effect omitting a landmark has on PC1/PC2 ordination. Landmarks that poorly discriminated sex-based shape were considered redundant for analysis on sex estimation. This study identified 17 landmarks that represent sex-based shape of right and left coxal bones most effectively, these are: the anterior superior iliac spine; posterior superior iliac spine; posterior inferior iliac spine; iliac crest; apex of the auricular surface; greater sciatic notch; ischial spine; superior, inferior and distal points on ischial tuberosity; superior, inferior and midpoint on the symphyseal face; arcuate eminence; ischiopubic ramus; posterosuperior and anterosuperior points on the acetabular rim. The first and second PCs of the 17-landmark configuration correctly predicted sex in 98.5% of cases; better than a 32-landmark configuration (96%) and better than previous landmark studies on whole coxal bone sex-based shape. These 17 landmarks represent more meaningful data for sex-based shape analysis in PC1 and 2 and concentrate meaningful sex-based shape data to the first five PCs that make up over 50% of the total shape variance.

P51-T A new approach to the radial nerve conduction block determination in the upper arm

Background There are technical limitations in the radial nerve studies in the upper arm using surface electrodes. One of the limitations is that stimulation at the axilla and Erb‘s point stimulates the entire brachial plexus along with the radial nerve. Material and methods Twenty-one healthy volunteers, 55 patients with compressive neuropathies of the radial nerve in the spiral groove and 22 patients with complete radial nerve injuries were studied. Control group (65 radial nerves) consisted of healthy subjects and patients with the undamaged side. Stimulation was carried out at: (1) the distal part of lateral brachium (distal point); (2) Erb’s point (proximal point); (3) the middle part of medial brachium – median and ulnar nerves (additional point). CMAP area recorded from the extensor digitorum was analyzed. Conduction block (CB) in percentage was calculated using the formula: ((distal CMAP + additional CMAP) − (proximal CMAP)) × 100/(distal CMAP + additional CMAP). Results In control group and patients with complete nerve injury CB was not registered (4.2 ± 9.8% and −1.7 ± 11.7% respectively), whereas in patients with compressive radial nerve neuropathy CB was 61.2 ± 11.2% (P Conclusion Median and ulnar nerves stimulation in the middle part of medial brachium is recommended as an additional brachium diagnostic point for radial nerve CB determination.

P16-S Isolated lower-leg pain and A-wave studies: A case report

An isolated lower-leg pain without neurological manifestations is an important problem in clinical practice. A-wave has been found in many cases but its significance remains unclear. We described a case of a 29-year-old woman, a bank employee, complaining of the lower-leg pain in the calf muscle on the left side. It continued over a year causing discomfort, excruciating muscle pain, accompanied by episodes of shooting pains that would appear in the morning and on sitting at desk at work for a long time. The pains disappeared during a walk. Intensity of the pain was 3.0 points when assessed on the visual analogue scale and 4.0 points on the DN4 questionnaire. Neurological investigations revealed only a Lasegue sign (60°) on the left side. Lumbosacral spine MRI showed a diffuse dorsal protrusion of the intervertebral discs L4-L5 2.1 mm, L5-S1 2.3 mm. Nerve conduction studies demonstrated normal motor and sensory conduction velocities in peroneal, tibial and sural nerves. No changes were recorded in the H-reflex studies. F-wave studies at distal and proximal point stimulation of the left tibial nerve showed the presence of the A-wave immediately before the F-wave. After month of regular visits to the swimming pool and the vascular medicines treatment, the patient observed that lower-leg pain significantly decreased. Conclusion The isolated lower-leg pain has been regarded as a neuropathic one with its source in the S1 root on the left side. This observation indicates clinical importance of studying and analyzing of A-waves in the lower limbs pain.

Analysis on acupoint selection rules of acupuncture for Alzheimer's disease based on complex network

To explore the acupoint selection rules of acupuncture for Alzheimer's disease (AD) in modern clinical practice by complex network technology. The relevant articles of clinical trials were retrieved from CNKI published before December 2017. Using Microsoft Excel 2010, the database was established. Using Gephi 0.8.2 software, the complex network mode was built and its topological structure was analyzed. Finally, 81 articles were eligible and 114 acupoint prescriptions were extracted. The constructed complex network of acupoint prescriptions for AD was characteristics as small world effect and scale-free property, the crucial acupoints included Baihui (GV 20), Sishencong (EX-HN 1), Fengchi (GB 20), Yintang (GV 29), Shenmen (HT 7), Shenting (GV 24), Zusanli (ST 36), Fenglong (ST 40) and Taichong (LR 3). In acupoint combination, Baihui (GV 20), Neiguan (PC 6), Shenmen (HT 7) and Sanyinjiao (SP 6) were the most common, and the combination of the distal and nearby points was predominant. Using k-core for acupoint optimization, 29 core acupoints were screened and they were mostly located on the governor vessel and the head and neck, with the highest use frequency. 82.76% of acupoints were specific acupoints and the influential points were dominant. Using community structure partition, these acupoints were classified into two groups, i.e. deficiency syndrome and excess syndrome. The selection of local acupoints is the first choice in acupuncture treatment for AD. The combination of distal and nearby points is the most common and the special points are the core. In clinical practice, the great consideration is provided on mind regulation, integration of disease and symptoms, the mutual treatment of the primary and the secondary as well as the deficiency and the excess.

Accuracy of Length of Virtual Stents in Treatment of Intracranial Wide-Necked Aneurysms

Background and PurposePrecise stent deployment is important for successful treatment of intracranial aneurysms by stent-assisted coiling (SAC). We evaluated the accuracy of virtual stents generated using commercial stent planning software by comparing the length of virtual and actually deployed intracranial laser cut stents on three-dimensional digital subtraction angiography (3D-DSA) images.MethodsWe retrospectively analyzed the data of 75 consecutive cases of intracranial wide-necked aneurysms treated with the SAC technique using laser cut stents. Based on 3D-DSA images acquired by C-arm CT, stent sizing and placement were intraoperatively simulated by a commercial software application. The difference in length of the stents was estimated by measuring proximal discrepancies between the end points of the virtual and actually deployed stents on fused pre-procedural and post-procedural 3D-DSA images. Discrepancies between distal stent end points were manually minimized. The Kruskal–Wallis test was applied to test whether stent location, type, and length had an effect on difference in length between virtual and real stent.ResultsThe median difference in length between virtual and real stents was 1.58 mm with interquartile range 1.12–2.12 mm. There was no evidence for an effect of stent location (p = 0.23), stent type (p = 0.33), or stent length (p = 0.53) on difference in length between virtual and real stents.ConclusionsStent planning software allows 3D simulation of laser cut stents overlain on 3D-DSA images of vessels and may thus be useful for stent selection and deployment of laser cut stents during stent-assisted coiling of intracranial aneurysms.

Front crawl arm stroke trajectories of physically impaired swimmers: A preliminary study

Summary Introduction This study evaluated three-dimensional kinematic parameters of the front crawl stroke in physically impaired swimmers across a range of functional classification levels. Facts and Results Eight highly-trained competitive swimmers (5 male and 3 female) from IPC classes S5 to S9 performed 50 m maximal front crawl trials while being video-taped by six cameras (four under- and two above water). The most distal point of the right upper limb was manually digitised at 50 Hz to allow three-dimensional reconstruction of the limb's trajectory through the water. Conclusion The stroke presented large inter-swimmer variability, reflecting individual characteristics and severity of the impairment. The swimmers who combined shallow and narrow stroke movements produced a shorter trajectory. This study provides swimmers and coaches with an overview of the kinematic characteristics of a range of physically impaired swimmers.

Estimation of the Humerus Length by its Proximal Segments: A South Indian Anatomical Study

Introduction To determine the morphometric data of the proximal segments of the humerus in the South Indian population, and to obtain the regression equations that will enable us to predict the whole length of humerus. Materials and Methods The present study included 166 dried adult human humeri. Their lengths were measured by using the osteometric board. The seven proximal segment lengths of the humeri were assessed by using a digital Vernier caliper (Mitutoyo Corporation 150 mm/6 inch, model number 500-196-20, Kawasaki, Japan). Results The mean humerus length in the present study was 30.75 ± 2.03 cm on the right side and 30.27 ± 2.28 cm on the left side. The comparison between the right and left sides of the proximal segments of the humerus did not yield statistically significant results (p &gt; 0.05). The present study observed that the relationship between the dimensions of the proximal segments of the humerus and the length of humerus were strong (p = 0.00). The oblique length between the most proximal and distal points over the anatomical neck was the best parameter to predict the length of humerus (the Pearson coefficient was 0.78 for the right side and 0.77 for the left side). Conclusion The simple regression formulae, which were derived in this study, are helpful in the estimation of the length of the humerus. The formulae can be used in forensic investigations, in which the stature of a person has to be determined and only bone fragments are available. The morphometric data of the present study have implications in archaeological and anthropological studies. The data are enlightening to orthopedicians, when planning reconstructive surgeries of the proximal end of the humerus in the South Indian population.

Vaping During Pregnancy Results in Arterial Stiffness in Offspring

Electronic cigarettes (Ecigs) are promoted as effective smoking cessation tools, and consequently widely used among pregnant women who are motivated to quit tobacco cigarette smoking. Emerging evidence demonstrates that Ecigs can be dangerous to cardiovascular health. Babies born to women who vape represent a uniquely vulnerable population for this type of exposure, because they may be adversely impacted during a critical developmental period. It is unknown if cardiovascular harm potential of Ecigs without nicotine is conferred to offspring of vaping mothers. Pulse wave velocity (PWV) provides an indirect measure of arterial stiffness (with stiffer vessels having higher PWV) and can be useful for characterizing cardiovascular disease progression.Sprague‐Dawley rat dams were exposed to either nicotine‐free Ecig vapor (Ecig0, Joyetech eGrip OLED using 5‐sec puffs @17.5 W) or ambient air. Exposure consisted of 20 puffs over 1‐hour each day, 5 days/week, and resulted in an average daily TPM of ~120 mg/m3. Maternal exposure started on gestational day 2 and continued until pups were weaned (postnatal day 21). Pups were never directly exposed. Left common carotid arteries (LCCA) of 4‐month old pups (n=5 per group) were noninvasively imaged via Doppler ultrasound. PWV was measured using the regional transit‐time (TT) method (PWV=Δd/Δt; where d is distance between proximal (downstream to aortic arch) and distal (upstream of bifurcation) points on the LCCA, and t is the arrival time of pulse wave upstroke relative to R‐wave peak on ECG). Repeated (≥3) measurements were made for each variable and averaged. TT measurements were performed using a Vevo2100 ultra high frequency ultrasound platform with heart rate monitoring system (VisualSonics Inc, Toronto, ON, Canada). Results were processed using VisualSonics analysis software.Left common carotid arterial PWV (mean ± SD) in the Ecig0 group (6.6 ± 2 m/s) was significantly higher (p&lt;0.01) than in the air control group (3.2 ± 0.7 m/s).Offspring exposed to nicotine‐free Ecig vapor in utero had higher PWV than controls, indicating stiffer arteries and an increased risk for cardiovascular disease. Further studies will determine the long‐term implications of this vascular impairment. Clinicians and policy‐makers need to be aware of these risks to discourage pregnant women from using Ecigs (with or without nicotine).Support or Funding InformationWVU Cancer Institute Philip R Dino Innovative Research Grant (IMO); APS STRIDE Fellowship (JO); AMIF: NIH S10RR026378, P20RR016440, P30GM103488, P20RR016440, P30GM103488 and U54GM104942 (SM)This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Reassessing shelter dogs' use of human communicative cues in the standard object-choice task.

Unlike other animal species, domesticated pet dogs reliably use a range of human communicative cues to find a hidden reward in the object-choice task. One explanation for this finding is that dogs evolved skills for understanding human communicative behaviour during and as a result of human domestication. However, contrary to this domestication hypothesis, Udell et al. found domesticated shelter dogs failed to locate a hidden reward using a human’s distal point cue, a cue pet dogs easily use. Hare et al., however, suggested the unorthodox methods used in Udell et al.’s object-choice task resulted in the shelter dogs failing to use human cues. In support of this, Hare et al. found that shelter dogs could use a human communicative pointing cue when tested with a standard object-choice task method. Yet in contrast to Udell et al., Hare at al. used a much simpler proximal cue that cannot exclude success based on stimulus enhancement rather than an understanding of the cue’s communicative nature. We therefore addressed this issue by testing shelter dogs’ abilities to use a range of proximal and distal human communicative cues in a standard object-choice task. We found shelter dogs could use proximal cues that may involve stimulus enhancement, but they continuously failed to use distal cues that excluded this possibility. Object-choice tasks with dogs typically involve non-vocalised human cues. We tested if vocalising would help shelter dogs to use distal cues. We found shelter dogs could use a vocalised distal continuous cue when the subject’s name was called during cue presentation. It is therefore possible that vocalised cues help domesticated dogs learn about non-vocalised human communicative cues. Overall our results do not support that domesticated dogs’ understanding of human communicative cues is a direct result of the domestication process.

QUADRICEP TENDON TURNDOWNS FOR MPFL RECONSTRUCTION: AN ANATOMICAL DIFFERENCE BETWEEN THE ORIGINS OF THE QUADRICEP TENDON AND MPFL ON THE PATELLA

Background: Quadriceps tendon (QT) turndowns are an alternative method for medial patellofemoral ligament (MPFL) reconstruction, with several distinct advantages: 1. Avoids the use of patella bone tunnels, which have been associated with patella fracture, 2. Avoids the use of separate incision for hamstring tendon harvest, and 3. Avoids the use of allograft tissue, which adds a significant cost. The disadvantage of the Quad Tendon graft is that the most distal reflection point on the patella may not duplicate the patella origin of the native MPFL. The purpose of this study was to determine whether a QT graft for MPFL reconstruction is anatomically analogous to the native MPFL origin in a skeletally immature population. Methods: Three skeletally immature cadaveric knee specimens (ages 10 and 11, 11) were dissected to reveal the MPFL and QT origins on the patella. The proximal and distal extent of the MPFL was marked on the medial border of the patella. The medial aspect of the quad tendon was reflected as far as possible in both a medial and distal position on the patella, to function as the MPFL graft. The distance was measured between the midpoint of the patellar origin of the MPFL in the coronal plane, and the most distal aspect of the patellar origin of the reflected quad tendon. Results: In the 10, 11, and 11 year-old specimens, the distance between the midpoint of MPFL patellar origin and the QT patellar origin was 3.4 cm, 4.3, and 3.7 mm. In all cases, the QT reflected origin was at least 7 mm anterior to the to native MPFL origin on the medial border of the patella. Conclusion: A disparity exists between the patellar origin of the MPFL and the patellar origin of the quad tendon, with the patellar origin of the MPFL being more medial, more distal, and more posterior than the reflected patellar origin of the QT graft. Surgeons performing MPFL reconstructions may find this anatomically valuable as they attempt to duplicate the normal anatomy of the patella stabilizers during surgical reconstruction. While the QT remains a good graft choice for MPFL reconstruction, attachment of the QT graft at the native origin of the MPFL may better reproduce the anatomy of the MPFL. Figures: [Figure: see text][Figure: see text]

Direct and indirect effects of joint torque inputs during an induced speed analysis of a swinging motion

This study proposed a method to quantify direct and indirect effects of the joint torque inputs in the speed-generating mechanism of a swinging motion. Linear and angular accelerations of all segments within a multi-linked system can be expressed as the sum of contributions from a joint torque term, gravitational force term and motion-dependent term (MDT), where the MDT is a nonlinear term consisting of centrifugal force, Coriolis force and gyroscopic effect moment components. Direct effects result from angular accelerations induced by a joint torque at a given instant, whereas indirect effects arise through the MDT induced by joint torques exerted in the past. These two effects were quantified for the kicking-side leg during a rugby place kick. The MDT was the largest contributor to the foot centre of gravity (CG)’s speed at ball contact. Of the factors responsible for generating the MDT, the direct and indirect effects of the hip flexion-extension torque during both the flight phase (from the final kicking foot take-off to support foot contact) and the subsequent support phase (from support foot contact to ball contact) were important contributors to the foot CG’s speed at ball contact. The indirect effect of the ankle plantar-dorsal flexion torque and the direct effect of the knee flexion-extension torque during the support phase showed the largest positive and negative contributions to the foot CG’s speed at ball contact, respectively. The proposed method allows the identification of which individual joint torque axes are crucial and the timings of joint torque exertion that are used to generate a high speed of the distal point of a multi-linked system.

Evaluation of the diameter of the distal radial artery at the anatomical snuff box using ultrasound in Japanese patients.

Catheter angioplasty or angiography via the distal access point of the radial artery (dRA), located at the anatomical snuff box, is a less invasive strategy for coronary intervention attracting considerable attention. Determining the diameter of the dRA is necessary to minimize the risk of artery occlusion and safely perform catheter intervention. This was a retrospective observational study including patients who underwent coronary angiography or coronary intervention at Aomori Kyoritsu Hospital, Aomori, Japan, between February 2018 and August 2018. The diameter of the dRA and the conventional access point of the radial artery (cRA) at the wrist of the patients were measured using ultrasound prior to angiography or interventional procedure. A total of 120 patients were analyzed. In male patients, the diameters of the cRA and dRA were 2.62 ± 0.60mm and 2.04 ± 0.43mm, respectively. In females, these diameters were 2.44 ± 0.51mm and 1.96 ± 0.44mm, respectively. Overall, the dRA was statistically significantly smaller than the cRA. However, variations were observed, with eight patients (6.7%) having a larger dRA than cRA. The diameter of the dRA indicated only that of the cRA. A multivariate analysis did not reveal factors associated with vessel diameter. The size and anatomy of the dRA varied considerably. Thus, it is difficult to predict the actual diameter of the artery. Customized selection of the size of the sheath and site of intervention is essential for each patient to safely perform ultrasound examination prior to cannulation.

Esophageal Blood Flow May Not Be Directly Influenced by Anastomotic Tension: An Exploratory Laser Doppler Study in Swine.

Anastomotic tension has been linked to leakage and stenosis in esophageal surgery in both adults and children. We aimed to determine the effects of esophageal topography, operative technique, and anastomotic tension on esophageal blood flow. We divided and reanastomosed the esophagi at the carinal level with increasing levels of anastomotic tension in piglets (n = 10) and sham controls (n = 4). We examined esophageal blood flow pre- and postoperatively using laser Doppler flowmetry at the anastomosis and two predetermined proximal and distal points. Blood flow in relation to distance from the anastomosis was examined by multivariate linear regression. Thoracotomy alone did not influence perfusion at the carinal level in shams (Δ = 3.13 laser Doppler units, 95% confidence interval: -3.4 to 9.7, p = 0.2686). We constructed a (F[5,134] = 6.34, p < 0.0001) multinomial regression model based on distance to the anastomotic site and pre-/postoperative measurements (adjusted R 2 = 0.1624). Tissue blood flow was higher distant to the carina, but lower postoperatively and not influenced by the tension resulting from the extent of resection (F[1, 8] = 1.134, p = 0.318). Esophageal blood flow is higher at greater distances to the carinal level and hampered by esophageal division and reanastomosis. The extent of resection has less influence than previously assumed. Therefore, leakage and stenosis after esophageal anastomosis may not solely be caused by insufficient anastomotic blood flow.

Evaluation of presence of proximal contacts on recently inserted posterior crowns in different health sectors in Riyadh City, Saudi Arabia.

Background:For the successful outcome of the rehabilitation of the teeth with crown, the proximal contact points play a significant role hence the aim of the present study was to evaluate the presence of proximal contacts on recently inserted crowns in posterior teeth.Methods and Materials:The cross-sectional study was conducted on recently inserted posterior crowns. Clinical assessment of proximal contact points on crowns was made with dental floss, the floss was wrapped around the index fingers of both hands and was passed through the crowns mesial and distal contact points and was categorized as acceptable, open contact points, and tight contact points.Results:In the present study 401 crowns were examined to assess proximal contacts on 788 proximal surfaces. It was found that 522 (66.2%) crowns were in normal proximal contact, 144 (18.3%) showed open proximal contacts, 122 (15.5%) showed tight proximal contacts.Conclusion:Regarding the assessment of proximal contacts, the study showed that a significant number of crowns had open or tight proximal contacts. Specialists and residents were able to perform better in providing the optimum proximal contacts.

Are stainless steel elastic nails the solution to heavier children with femoral shaft fractures?

Background: The use of titanium elastic intramedullary nails for the treatment of femoral shaft fractures, in children weighing ≥45 kg, has been questioned due to the increased rates of malunion. Our aim was to see if the mechanical properties of stainless steel elastic nails provided enough fracture stability to justify their use in heavier children. Materials and Methods: Twenty pediatric femoral Sawbones®, fixed with titanium or stainless steel elastic nails, were tested. The bending stiffness and moments of the constructs were calculated at increasing loads, along with the angle of fracture deformation. From these estimates of maximum permitted body weight for each nail type were extrapolated. Results: Steel nails created significantly stiffer constructs than titanium in both the coronal and sagittal planes (P < 0.0001). Steel nails allowed bigger sagittal bending moments before losing acceptable alignment, compared to titanium (P < 0.0001). However, in the coronal plane, the difference was not statistically significant (P = 0.457). The estimated body weights extrapolated in the sagittal plane were 45 and 61 kg, in titanium and steel, respectively. In the coronal plane, they were 42 and 44 kg. Discussion: As steel has nearly twice the Young's modulus of titanium, it seems logical that fractures fixed with steel nails would be stiffer and fail at higher loads. However, it is unclear why steel did not outperform titanium in the coronal plane. A theory was proposed that unequal nail slip from the insertion sites might be a contributing factor to these findings. Conclusion: Pediatric femoral shaft fractures fixed with elastic steel nails provide significantly stiffer constructs than those fixed with titanium. However, there is an increased risk of malunion in the coronal plane, in children weighing ≥45 kg, regardless of material used, possibly due to unequal nail slip at the distal entry points.

EUS-specific stents: Available designs and probable lacunae.

Interventional EUS has seen exponential growth in its indications and applications in the last decade.[1,2,3] Dedicated endoscopic devices for EUS-guided interventions are still limited. Up until recently, the tools used have been borrowed from other procedures such as ERCP. In interventional EUS, the linear-array echoendoscope allows a needle to be advanced under EUS-guidance from the upper gastrointestinal lumen to the biliary, pancreatic, or another adjacent intestinal lumen. Real-time puncture can be performed and provide the possibility of EUS-guided transluminal drainage (EUS-TLD). Plastic stents and conventional self-expandable metallic stents (SEMSs) were initially used but present several limitations due to their design.[1,4,5] They lack lumen-to-lumen anchorage and present migratory risks in the absence of stricture to hold them in place. Plastic stents are associated with potential pneumoperitoneum and bile peritonitis, whereas fully-covered SEMS (FCSEMS), despite preventing bile leak, will not maintain secure apposition between two nonadherent organs. Furthermore, their length often exceeds the anatomical requirement of a shorter transluminal anastomosis and predisposes them to obstruction as well as difficult positioning. With the rise in new EUS-guided interventional techniques, new tools, in particular, new stent designs have evolved to facilitate the various applications. A few EUS-specific stents have now become available for EUS-TLD.[4,5] We hereby review the stent designs and discuss lacunae to be addressed to improve the efficacy, safety, and ease of procedures.

Epidemiological Pattern of Closed Femoral Shaft Fractures in a Regional Tertiary Hospital in Enugu, Nigeria

Background: The femur is the longest and strongest tubular bone in the human body. The femoral shaft is the portion of the bone between 5 cm distal to the lesser trochanter and 6 cm proximal to the most distal point of the medial femoral condyle. Femoral shaft fractures often result from high energy forces. These fractures occur mostly among young adults. Objective: This was to determine the epidemiological pattern of closed femoral shaft fractures in a regional tertiary hospital in Enugu, Nigeria. Method: The study was a prospective study over a 12 month period (June 2015-May 2016) at National Orthopaedic Hospital, Enugu. Following ethical approval and written informed consent, patients were consecutively recruited. The patients were clinically and radiographically evaluated at presentation. The diagnosis of closed femoral shaft fractures were made from the physical examination finding of absent open wound communicating with the fracture hematoma in the thigh and anteroposterior (AP) and lateral x-rays of the affected thigh confirming the fracture pattern. The data collected included patients’ demographics, the cause of injury, the side of injury and anatomic site of the injury among other parameters. The data were collected using well designed and structured proforma. Results: A total of 52 femoral shaft fractures in 50 patients were included and analyzed using SPSS version 20.0. The age range of the patients is 18 - 85 years with a median age of 39.1 ± 14.9 years. The most commonly affected age group is 21 - 30 years. There was male preponderance with a male to female ratio of 2.3:1. Majority of the fractures (76.9%) resulted from road traffic crashes most commonly following motor vehicular accident (36.5%). Majority of the fractures (92.3%) are unilateral with right side to left side ratio of 1.2:1. Majority of the patients (51.9%) had Winquist Hansen grade III type of fracture. The most common associated injury is fractures of tibia/fibula followed by fracture of the neck of the ipsilateral femur. All the patients were treated operatively using either locked intramedullary nailing technique or plating technique. Majority of the patients (59.6%) were discharged between 10th and 29th day post-operatively. Conclusion: From the results of this study, it is concluded that most of the closed femoral shaft fractures were caused by high energy trauma from road traffic crashes. It is therefore recommended that proper education of motorists on good use of roads and strict adherence to traffic rules will significantly help in preventing the occurrence of these fractures in our environment.

The better choice for measuring the gonial angle of different skeletal malocclusion types: Orthopantomograms or lateral cephalograms?

The aim of this study was to highlight the current dilemma of gonial angle measurement on orthopantomograms and lateral cephalograms of adults with different skeletal malocclusion types. The sample consisted of 50 Class I, 50 Class II and 50 Class III (25 males and 25 females for each group) orthopantomograms and cephalograms obtained from previously treated orthodontic patients. For each malocclusion group, the angle between TweedÂ’s mandibular plane and the tangent from the line running along the gonion to the distal point of the condyle was measured on the right and left sides on orthopantomograms and the superimposed images of the mandible on cephalograms. Paired t-test demonstrated no significant difference between the values of gonial angles determined by cephalograms and orthopantomograms in Cl I patients. Pearson correlation also showed a high correlation between gonial angle values measured on the two diagnostic tools in Cl I patients. In Cl II and Cl III patients, statistical analysis showed a significant difference between the gonial angles defined by cephalograms and orthopantomograms. Orthopantomograms can be used for determining gonial angle as accurately as cephalograms in Cl I patients. Hovewer, orthopantomograms are not appropriate tools for measuring the gonial angle in Cl II and Cl III patients.

Gastrointestinal manifestations in patient with Common Variable Immunodeficiency Syndrome (CVID): A Case Report

A 57 yo male with a background history of common variable Immunodeficiency syndrome (CVID) on Immunoglobulin Infusion (Kiovig) 40mg three weekly was referred for investigation of diarrhoea and follow up from previous history of colonic polyps. Colonoscopy showed an irregular looking ileocaecal valve (ICV) with an adjacent flat polyp (Paris IIa). Biopsies showed low grade dysplasia. There was also a duodenal polyp noted on gastroscopy and biopsy again showed low grade dysplasia. In light of the findings of upper and lower gastrointestinal tract polyps, a small bowel capsule endoscopy (SBCE) was arranged. This showed an irregular area of mucosa in the proximal small bowel with significant ulceration and inflammation (Figure 1). There were also multiple scattered lymphagiectasias and lymphoid hyperplasia in the distal small bowel (Figure 2). Anterograde double ballon enteroscopy (ADBE) was subsequently performed to the distal jejunum about 8 weeks after the SBCE. The duodenal polyp seen at gastroscopy was visualised during ADBE (Figure 3). In addition, two diminutive (<3mm) jejunal sessile polyps were encountered and excised (Figure 4). There was no evidence of ulcerative enteritis as seen on SBCE. The enteritis features initially visualized on the SBCE was thought to be a transient phenomenon possibly related to his CVID background. However, for completion, the distal point of enteroscopy insertion was marked and a repeat SBCE performed immediately after recovery from the ADBE. This again showed the known duodenal polyp as well as 2 further diminutive small bowel polyps and minimal distal patchy enteritis only, with complete resolution of the previously observed ulcerative jejunitis. The jejunal polyps’ histology was reviewed at a histology multidisciplinary meeting, there were no adenomatous or hamartomatous features and biopsies were thought to have non-specific changes only. The patient was referred for polyp resection and further follow up and surveillance will be arranged based on histology.