External Branch Research Articles

PILOT STUDY FOR THE CREATION OF A STROKE MODEL IN RABBITS USING ENDOVASCULAR TECHNIQUES

Abstract Introduction Due to the clinical implications of stroke in patients, the “2IQBIONEURO” project promoted by the Interreg VA Spain-Portugal programme (POCTEP) aims to study the treatment of neurological diseases associated with ageing. The aim was to evaluate the feasibility of the technique of selective cerebral artery (CA) embolisation for the creation of a stroke model in rabbits. Methods In 3 rabbits, through a 4Fr introducer in the femoral artery, a 4Fr Cobra catheter and 0.035″ guide was placed in the aortic arch to perform angiography of the brachiocephalic trunk. Under road-mapping, the right common carotid artery was catheterised, and its bifurcation into its external and internal branches was visualised with angiography in an oblique position (90°). With a 1.5Fr microcatheter and 0.008″ microguidewire inserted coaxially, the internal carotid artery was catheterised to perform superselective angiography of the cerebral vasculature. The microcatheter was positioned in the CA for embolisation by injection of PVA (100–200 µm) until stasis was reached as an end point or when reflux occurred. MRI monitoring was performed before and after embolisation (2, 5 and 24 hours). After 24 hours, neurological evaluation and macroscopic postmortem study with tetrazolium were performed. Results Successful occlusion of the CA was achieved in all animals whose lesion was observed on MRI. Conclusions The development of a stroke model in rabbits by selective embolisation of the CA is feasible, and can be used for the preclinical study of stroke.

Вариабельность морфологических и генетических признаков Macrohectopus branickii (Dyb., 1874)

Macrohectopus branickii is the only pelagic amphipod from Lake Baikal. Until now, despite the uniqueness of M. branickii, its genetic diversity at the intraspecific level, as well as its intraspecific morphological diversity, have not been studied. In this work, we present the result of a morphological analysis of intrapopulation variability of the species M. branickii from the northern basin of Lake Baikal, as well as the result of a molecular analysis based on the sequence of a fragment of the mitochondrial Nad5 gene of several individuals of this species from three basins of the lake. The material for the study was collected using a plankton net and trawl from all basins and shores of Lake Baikal at depths of 100-300 m. We measured 21 morphological characters according to the scheme previously proposed in Tikhonova’s work for sexually mature females of M. branickii living on different shores of the northern basin of Lake Baikal. The coefficient of variation of the values of all characteristics was determined. Morphological analysis revealed different degrees of variability in the studied characters for M. branickii. The most variable characters are: the length of 1 segment of the peduncle of the upper antennae; length of 4 and 5 segments of the stalk of the lower antennae; length of gnathopod propodites 2 pairs; width and length of basipodites of the third pair of pereiopods; length of the stalk, external and internal branches of the uropods of the third pair; telson width and length. Analysis of the nucleotide sequences of the Nad5 gene fragment showed their low variability. The haplotype network was reconstructed using the pegas package for the R programming language. M. branickii forms a single panmictic population, consistent with the absence of geographic and environmental barriers in the pelagic zone of the lake.

СЛУЧАИ ВНЕГОРТАННЫХ АНАСТОМОЗОВ МЕЖДУ ГОР-ТАННЫМИ НЕРВАМИ У ВЗРОСЛОГО ЧЕЛОВЕКА

Establishing the topographic features of the nerves of the larynx is an im-portant area of modern medicine due to the frequent surgical intervention on the organs of the neck. It is known that the innervation of the larynx is provid-ed by the superior and recurrent (inferior) laryngeal nerves. The laryngeal nerves, as well as their branches, can form many anastomoses between them-selves inside the organ, which should be taken into account by practicing sur-geons to prevent the development of postoperative complications. So, there are a large number of different variants for the innervation of the muscles and mucous membrane of the larynx due to the presence of intralaryngeal anasto-moses. As for extralaryngeal anastomoses, they are rare and are of great inter-est to both morphologists and practicing surgeons. During surgical interven-tion on the thyroid gland during intraoperative identification of the superior and recurrent laryngeal nerves, the presence of extralaryngeal anastomoses be-tween them can make it difficult to identify the nerves and lead to iatrogenic damage to the latter. This article describes 3 cases of extralaryngeal anastomoses between the nerves of the larynx established during the macroscopic preparation of or-ganocomplexes of the neck of an adult. The 1st case is an anastomosis between the internal and external branches of the superior laryngeal nerve, the 2nd and 3rd are anastomoses between the external branch of the superior laryngeal nerve and the recurrent laryngeal nerve.

Assessment of different classification systems for predicting the risk of superior laryngeal nerve injury during thyroid surgery: a prospective cohort study.

A multitude of anatomical variations have been noted in the external branch of the superior laryngeal nerve (EBSLN). In this study, intraoperative neuromonitoring (IONM) was used to assess the potential value of the different classical EBSLN classifications for predicting the risk of EBSLN injury. In total, 136 patients with thyroid nodules were included in this prospective cohort study, covering 242 nerves at risk (NAR). The EBSLN was identified by observing the cricothyroid muscle twitch and/or typical electromyography (EMG) biphasic waveform. The EBSLNs were classified by Cernea classification, Kierner classification, and Friedman classification, respectively. The EMG parameters and outcomes of vocal acoustic assessment were recorded. The distribution of Cernea, Kiernea, and Friedman subtypes were, respectively, Cernea 1 (40.9%), Cernea 2A (45.5%), Cernea 2B (10.7%), Kierner 1 (40.9%), Kierner 2 (45.5%), Kierner 3 (10.7%), Kierner 4 (2.9%) and Friedman 1 (15.7%), Friedman 2 (33.9%), Friedman 3 (50.4%). The amplitudes of EBSLN decreased significantly after superior thyroid pole operation, respectively, in Cernea 2A (193.7 vs. 226.6μV, P=0.019), Cernea 2B (185.8 vs. 221.3μV, P=0.039), Kierner 2 (193.7vs. 226.6μV, P=0.019), Kierner 3 (185.8 vs. 221.3μV, P=0.039), Kierner 4 (126.8vs. 226.0μV, P=0.015) and Friedman type 2 (184.8 vs. 221.6μV, P=0.030). There were significant differences in Fmax and Frange for Cernea 2A (P=0.001, P=0.001), 2B (P=0.001, P=0.038), Kierner 2 (P=0.001), Kierner 3 (P=0.001, P=0.038), and Friedman 2 (P=0.004, P=0.014). In the predictive efficacy of EBSLN injury, the Friedman classification showed higher accuracy (69.8% vs. 44.3% vs. 45.0%), sensitivity (19.5% vs. 11.0% vs. 14.0%), and specificity (95.6% vs. 89.9% vs. 89.9%) than the Cernea and Kierner classifications. However, the false negative rate of Friedman classification was significantly higher than other subtypes (19.5% vs. 11.0% vs. 14.0%). Cernea 2A and 2B; Kierner 2, 3, and 4; and Friedman 2 were defined as the high-risk subtypes of EBSLN. The risk prediction ability of the Friedman classification was found to be superior compared to other classifications.

NERVE MONITORING IN THYROID SURGERY: A RETROSPECTIVE COHORT STUDY

Background:The proximity of the Recurrent Laryngeal and External Branch of Superior Laryngeal Nerve to the Thyroid Gland has been a key factor for a profound interest of surgeons and clinicians in the clinical outcomes and Vocal changes in the post operative period in the patients undergoing thyroid surgery. The presence of Recurrent Laryngeal nerve in proximity of Thyroid poses a significant risk of damage to the nerve during surgery. The Recurrent Laryngeal Nerve SuppliesLarynx below the level of vocal cords and all the muscles except Cricothyroid. Posterior Cricoarytenoid, the only abductor of vocal cord is also supplied by this nerve. So, any damage to the nerve during surgery causes significant changes in pitch and texture of voice, commonly referred to as hoarseness.Intra-operative Nerve Monitoringwas introduced about 50 years ago and various neuromonitoring methods (glottis pressure method, glottic monitoring method, insertion of needle electrodes invocal cords endoscopically or through cricothyroid membrane, laryngeal palpationmethod, and monitoring via endotracheal tube with surface electrodes) have been utilized. We present a retrospective cohort study to surmise the effect of the use of Intraoperative nerve monitoring devices during Thyroid surgery and compare the clinical outcome in two cohorts. First, the study group where the nerve monitoring was used intraoperatively and the Second, where no intraoperative nerve monitoring was used. All the Patients included in the study underwent Thyroid surgery in the Department of Otorhinolaryngology-Head and Neck Surgery, MBS Hospital, Kota. Methods:This retrospective cohort study includes 100 patients as per the inclusion criteria specified in this article and all the included patients were studied after dividing them into two groups with one group where intraoperative nerve monitoring was used and the other group where no nerve monitoring was used. Each group had 50 patients each. All the patients are regularly documented for with Video Laryngoscopic Examination as a standard. All the data collected from the archives and put to statistical evaluation to analyse the data Age wise, Sex wise, Residential address wise, according to mean Thyroid volume, according to presenting complaints, according to history, according to mean operative time, according to the type of Nerve Injury, according to duration of hospital stay and other parameters as followed in the study. Results: On appropriate statistical analysis of the data, it was seen that there were no demographic variables within groups that ensured statistical similarity in the groups, there was also no statistical correlation of functional preservation attributable to mean Thyroid volume. The incidence of nerve injury was higher in the patients who got themselves operated for the malignancy of thyroid and the revision surgeries. The patients being operated for controlled toxic goitre reported ni nerve injury in the post operative period. The intraoperative nerve monitoring reported lower mean time required to do the surgery. There was a similar incidence of permanent and transient nerve injury in both the cohort groups.

Efektivitas dan Efisiensi Penerapan Sistem Antrian Berbasis Online (SpeedID) Dalam Mengoptimalkan Kualitas Pelayanan di Masa Pandemi Covid-19 Pada PT Bank Pembangunan Daerah Bali Cabang Klungkung

This research aims to analyze the extent of effectiveness and efficiency of applications of Online-Based Queuing System (SpeedID) in optimizing the services quality during the pandemic Covid-19 at Bank BPD Bali Klungkung Branch. This research uses a qualitative descriptive method with a case study approach. Data collection is done by using observation, interview and documentation techniques. Interview informants include internal (staff) and external (customers) Bank BPD Bali Klungkung Branch. Data analysis was carried out with the stages of data reduction, data display, and drawing conclusions using pattern matching techniques. Research results indicate that effectiveness and efficiency of applications of Online-Based Queuing System (SpeedID) in optimizing the service quality during pandemic Covid-19 at Bank BPD Bali Klungkung Branch which is not maximized. It is caused by the disturbance of the program and the goal achievements caused by various obstacles like systems or tissue distractions, still many customers of manual queues, an often over looked time estimate. With these obstacles, it causes optimalization of customer time and ease access service through the Online-Based Queuing System (SpeedID) has not been fully sensed. In addition, improvements are needed from the service side, such as increasing the ability and work discipline in the Teller Unit, as well as reviewing infrastructure procurement and spatial planning, especially in the outdoor waiting room and customer parking.

Emergence and Evolutionary Response of Vibrio cholerae to Novel Bacteriophage, Democratic Republic of the Congo1.

Cholera causes substantial illness and death in Africa. We analyzed 24 toxigenic Vibrio cholerae O1 strains isolated in 2015-2017 from patients in the Great Lakes region of the Democratic Republic of the Congo. Strains originating in southern Asia appeared to be part of the T10 introduction event in eastern Africa. We identified 2 main strain lineages, most recently a lineage corresponding to sequence type 515, a V. cholerae cluster previously reported in the Lake Kivu region. In 41% of fecal samples from cholera patients, we also identified a novel ICP1 (Bangladesh cholera phage 1) bacteriophage, genetically distinct from ICP1 isolates previously detected in Asia. Bacteriophage resistance occurred in distinct clades along both internal and external branches of the cholera phylogeny. This bacteriophage appears to have served as a major driver for cholera evolution and spread, and its appearance highlights the complex evolutionary dynamic that occurs between predatory phage and bacterial host.

Effect of mouse nerve growth factor combined with the exposure of the external branch of superior laryngeal nerve on voice changes after thyroidectomy: a prospective non-randomized controlled trial.

The superior laryngeal nerve (SLN) injury may also affect vocal fold function and voice quality. It is efficient yet simple approach to expose the external branch of the superior laryngeal nerve (EBSLN). Neurotrophic agent mouse nerve growth factor (mNGF) to treat patients after thyroid surgery, and found it had significant efficacy in improving the voice of patients. However, the potential effectiveness and safety of mNGF combined with EBSLN were unclear. In this study, 96 patients who suffered from hoarseness after thyroidectomy at Hangzhou First People's Hospital between January 2018 and October 2019 were screened and divided into the control group and the observation group by patients' choice. In the control group, the SLN was not exposed. In the observation group, the SLN was exposed. The mNGF treatment was administered for observation group once a day at 20 µg each time for 4 weeks. The data of acoustic voice indicators was analysis by univariate analyses. Patients in both groups were followed up for more than 6 months. The rate of SLN damage was compared between two groups. The baseline clinical characteristics of the two groups showed no statistic difference. The results showed that the fundamental frequency was significantly lower 1 month after surgery than 3 days after surgery in both groups. The fundamental frequency perturbation, shimmer, maximum phonation time, highest fundamental frequency, and dysphonia severity index in 1 month after surgery were significantly higher than they were 3 days after surgery (all P<0.001). There was no significant difference in the postoperative harmonic-to-noise ratio between the 2 groups (P=0.426). MNGF combined with the exposure and protection of the EBSLN effectively may prevent voice damage after thyroid surgery.

Morphological study of branches of lateral femoral circumflex artery based on digital subtraction angiography

In this study, the digital subtraction angiography (DSA) data were used to describe the number, course, and distribution of the branches of the lateral circumflex femoral artery (LCFA), in order to provide an imaging basis for the application of the anterolateral thigh flap pedicled with each branch of the LCFA. The number, location, direction, and distribution of the branches of the LCFA were analyzed by selective DSA angiography in 113 patients who needed an anterolateral thigh flap to repair the wound. LCFA usually originates from the deep femoral artery or femoral artery and routinely sends out four main branches: ascending branch, transverse branch, oblique branch, and descending branch. The ascending branch is about 45 °outward and upward with the horizontal axis of the body; the transverse branch is roughly parallel to the horizontal axis of the body to the outside of the thigh or slightly upward or downward; the oblique branch is about 45 °outward and downward to the body's long axis or horizontal axis and gradually turns parallel to the body's long axis; the 5∼10cm at the beginning of the descending branch is parallel to the long axis of the body, and the internal and external branches are separated near the midpoint of the line between the anterior superior iliac spine and the lateral edge of the patella. It is of high reference value to use DSA technology to analyze the morphological characteristics of LCFA.

The feasibility of laryngeal nerve protection during thyroidectomy using sternocleidomastoid intermuscular approach with intraoperative neuromonitoring: a case series and step-by-step description of surgical procedure.

Thyroid surgery is increasingly demanding in terms of cosmetic neck outcomes and protection of anterior neck function, so we have adopted an alternative sternocleidomastoid intermuscular approach (SMIA) for open/conventional thyroidectomy. The protection of recurrent laryngeal nerve (RLN) and external branch of superior laryngeal nerve (EBSLN) is the key and difficult point in thyroid surgery. The aim of this study was to testify the feasibility of RLN and EBSLN functional protection during SMIA thyroidectomy with the intraoperative neuromonitoring. A total of 39 patients and 39 RLN and EBSLNs who underwent monitored SMIA thyroidectomy were included. Thyroid gland is revealed and excised anterior to the cervical sheath between the sternal and clavicular heads of the sternocleidomastoid muscle. Standardized intraoperative neuromonitoring (IONM) procedures and postoperative laryngeal examination were performed to audit the SMIA. Following the four-step method, V1, R1, R2, and V2 were monitored and the signal values were recorded. Statistical analysis was used to evaluate the change of IONM amplitude of RLN, combined with the results of laryngoscopy before and after operation to determine the status of RLN. EBSLN injuries were identified from changes in cricothyroid muscle (CTM) twitch and EMG. SMIA video vignette is detailed. All RLN and EBSLNs [17 on the left and 22 on the right] were monitored in 39 patients [5 men, 34 women; mean age 34.1±8.7 years; mean body mass index 22.5 (±3.0, 17.0-30.8) kg/m2] undergoing SMIA. For RLN of the affected side, we compared the V2 and V1 (1,236±672 vs. 1,240±428, P=0.973), R2 and R1 (1,676±778 vs. 1,656±765, P=0.849) signals separately, and the results were not statistically different (P>0.05). Comparing the V1 (1,240±428 vs. 1,309±395, P=0.601) signals of the bilateral recurrent laryngeal nerve, there was no statistical difference (P>0.05). CTM twitch and EMG were preserved. The SMIA technique appears feasible. RLN and EBSLN are easier to be exposed during thyroid surgery of SMIA, which is beneficial to the neuroprotection during the operation. At the same time, it can protect the anterior cervical function and improve the cosmetic effect after operation.

Prevention of intraoperative injuries of the laryngeal nerves. Literature review and own data

Based on the recent literature data, the analysis has been performed for the causes of the laryngeal nerve injuries and methods of their prevention during thyroid surgery. Literature data demonstrate that over the past 20 years the incidence of the laryngeal nerve injuries remained stable, from 0.1 to 3.0 % and more. It does not tend to decrease despite the introduction of neuromonitoring. The authors presented the peculiarities of monitoring the recurrent nerves and the external branch of the superior laryngeal nerve and options for evaluating its results.&#x0D; Based on own clinical material, the authors performed the comparative assessment of the number and nature of the laryngeal nerve injuries and resulted phonation disorders after surgical treatment of patients with goiter. The first group consisted of 208 patients who underwent only visual identification of recurrent nerves of the larynx during thyroid surgery. To prevent injuries of the external branch of the superior laryngeal nerve, the method of gradual and separate ligation of the superior thyroid artery and its branches on the thyroid capsule was used. The second group involved 201 patients who underwent surgery using intraoperative neuromonitoring of the recurrent and external branches of the superior laryngeal nerve by the author’s method.&#x0D; Analysis of the number of injuries from our own clinical material showed that in the group using intraoperative neuromonitoring they were almost 2.5 times less than in the group of patients who underwent surgeries with visual identification of nerves. It was established that the use of intraoperative neuromonitoring enabled an increase of the number of the identified laryngeal nerves and reduction in the rate of their trauma, laryngeal paresis and phonation disorders. It has been emphasized that intraoperative neuromonitoring does not replace the visual identification of laryngeal nerves, but complements it. In complex cases, its results are crucial for making a technical decision during the surgery.&#x0D; The amended topographic and anatomical proportions of the organs of the anterior part of the neck in different clinical forms of goiter create conditions for intraoperative injuries of the laryngeal nerves. The possibility of their occurrence and their number depend only on the correctness of the surgeon’s actions and their adequacy to the clinical situation. In order to prevent these injuries, the following important requirements for the surgeon and the technology of performing goiter surgery should be considered: knowledge of the anatomy of the anterior, lateral parts of the neck, larynx, superior anterior and posterior mediastinum; possession of elements of technology and sequence of surgery on the thyroid depending on the clinical situation, in particular cervical, thoracic, recurrent goiter, compression syndrome; dry operating field and calm, without haste of performance of operation at adequate lighting. In the complicated situations of tissue differentiation optics should be used as well as an intraoperative intermittent or continuous neuromonitoring.&#x0D;

Injury of the external branch of the superior laryngeal nerve in thyroid surgery

Injury of the external branch of the superior laryngeal nerve is one of the complications in thyroid surgery, the frequency of which varies within very wide limits due to the difficulties in diagnosis. The complaints relate to a change in voice tone, which significantly impairs the quality of life of patients, especially those with voice profession. The most accurate specific method for diagnosis is electroneuromyography but this technique is very difficult to perform and not used in routine practice. To diagnose the lesion of the external branch of superior laryngeal nerve the authors used laryngoscopy, laryngostroboscopy and spectral analysis of the voice, which revealed the frequency of nerve injury and dynamic monitoring of voice recovery in the patient.&#x0D; Objective — to examine the frequency of lesions of the external branch of superior laryngeal nerve in thyroid surgery on the basis of changes in the laryngoscopic picture, spectral analysis of the voice and dynamic monitoring of their recovery during treatment&#x0D; Materials and methods. The study was conducted in the surgical department of the Ukrainian Scientific and Practical Center for Endocrine Surgery, Transplantation of Endocrine Organs and Tissues MOH of Ukraine with involvement of 241 operated patients. Examination of the larynx and voice examination were performed before surgery, on the 2 — 3 days and 6 and 12 months after surgery. Diagnosis was performed using methods: videolaryngoscopy, videolaryngostroboscopy, spectral analysis of the voice.&#x0D; Results. Clinical signs of trauma to the external branch of the superior laryngeal nerve were found in 8 (3.3 %) patients out of 241 operated. Patients received a course of phonopedia and stimulation therapy in the absence of contraindications. Voice recovery over time was recorded in 7 (87.5 %) patients, no voice recovery in 1 (0.4 %).&#x0D; Conclusions. Injury of the external branch of superior laryngeal nerve after surgery on the thyroid gland is a complication after thyroid surgery which does not happen often (3.3 %). This complication is very difficult to detect, considering inconspicuous symptoms, the lack of specificity of the laryngoscopic picture and the peculiarities of diagnostic methods. It is not always possible to fully restore the voice when the external branch of the superior laryngeal nerve is damaged (permanent injury accounts for 0.4 % of the total number of operations on the thyroid gland and 85.0 % of the total number of patients with damage to the external branch of the superior laryngeal nerve), which requires dynamic monitoring of patients and timely treatment administration.&#x0D;

Change of Voice Parameters After Thyroidectomy Without Apparent Injury to the Recurrent Laryngeal or External Branch of Superior Laryngeal Nerve: A Prospective Cohort Study

Background and Objectives The quality of life after thyroidectomy, such as voice change, is considered to be as important as control of the disease. In this study, we aimed to evaluate changes in both subjective and objective voice parameters after thyroidectomy resulting in normal morbidity of the vocal cords.Materials and Method In this prospective cohort study, 204 patients who underwent thyroidectomy with or without central neck dissection at a single referral center from Feb 2015 to Aug 2016 were enrolled. All patients underwent prospective voice evaluations including both subjective and objective assessments preoperatively and then at 2 weeks, 3, 6, and 12 months postoperatively. Temporal changes of the voice parameters were analyzed.Results Values of the subjective assessment tool worsened during the early postoperative follow-up period and did not recover to the preoperative values at 12 months postoperatively. The maximal phonation time gradually decreased, whereas most objective parameters, including maximal vocal pitch (MVP), reached preoperative values at 3–6 months postoperatively. The initial decrease in MVP was significantly greater in patients undergoing total thyroidectomy, and their MVP recovery time was faster than that of patients undergoing lobectomy (p=0.001). Patients whose external branch of the superior laryngeal nerve was confirmed intact by electroidentification showed no difference in recovery speed compared with patients without electroindentification (p=0.102), although the initial decrease in MVP was lower with electroidentification.Conclusion Subjective assessment in voice quality and maximal phonation time after thyroidectomy did not show recovery to preoperative values. Aggravation of MVP was associated with surgical extent and electroidentification.

Large‐Scale Afforestation Enhances Precipitation by Intensifying the Atmospheric Water Cycle Over the Chinese Loess Plateau

AbstractAfforestation is an appropriate approach to control soil erosion, but consumes extra water resources. It also exerts feedbacks on local precipitation, affecting the water availability for water‐limited areas. The Chinese Loess Plateau (LP) has implemented the world's largest afforestation program to mitigate severe soil erosion. However, it remains unclear how the atmospheric water cycle responds to large‐scale afforestation under climate change. Here we show that afforestation elevates precipitation in rainy season by intensifying the atmospheric water cycle over the LP. Results show the upward trend of vegetation coverage fraction increased by 3.15% decade−1 and climatological precipitation increased by 54.62 mm after launching the large‐scale afforestation in 1999. Such afforestation also enhanced evapotranspiration by 22.56 mm. We found the moisture inflow and outflow continuously decreased, but more atmospheric moisture was retained since the rate of decline of inflow was less than that of outflow. Using a dynamic precipitation recycling method, we explored changes in precipitation recycling and components of the atmospheric water budget. The precipitation recycling ratio increased from 9.16 ± 0.35 to 10.18 ± 0.28% after the afforestation. Both external and internal branches of the atmospheric water cycle have been strengthened, and their contributions to the increased precipitation are 84.93% and 15.07%, respectively. The afforestation caused a more humid atmosphere, heightened soil moisture‐vegetation‐precipitation feedback, stronger moisture convergence, and more clouds; these changes favored precipitation generation. This study advances the understanding of how afforestation affects regional climate from a precipitation recycling perspective, further assisting decision‐makers to establish sustainable afforestation strategies.

868 External Carotid Artery Pseudoaneurysm Following Penetrating Trauma Presenting as an Atypical Parotid Mass

Abstract Pseudoaneurysm (PSA) of the external carotid artery (ECA) is a rare but potentially lethal clinical entity, with mortality as high as 30%. PSA of the external carotid artery branch vasculature are found consequent to penetrating trauma; infection; vasculitis; iatrogenic injury; radiation therapy and idiopathic causes. Adequate clinical intervention is warranted to prevent rupture and the subsequent neurologic sequelae or death. Management strategies for head and neck PSA have included open vessel ligation, open direct vessel repair, endovascular embolization of the parent vessel or the pseudoaneurysm itself. While surgery was once the standard treatment for PSA, later endovascular approaches have become effective alternatives with minimal morbidity and high success rates. Here we present a complex case of 37yo man who presented with an atypical parotid mass to the emergency department. History revealed several attendances to the primary care, and the emergency department, due to painful enlargements of the mass. Imaging later identified the mass as a PSA secondary to historical penetrating trauma of the left neck. The clinical presentation and diagnosis of this condition is explored. We discuss the initial unsuccessful endovascular embolization and stenting of the ECA, and the subsequent multi-disciplinary decision for surgical excision months later. This case highlights the importance of obtaining an appropriate history; clinical exam; special investigations to consider the differential diagnoses of parotid mass and specifically the management of PSA in the Head &amp; Neck.

Arterial blood supply of the internal neck organs: anatomy, topography, clinical significance in endocrine surgery

BACKGROUND. Current trends of «fast track surgery» give rise to development of new safe techniques of the thyroid and parathyroid surgery, the purpose of which is to minimize the level of postoperative complications, such as vocal cord palsy, hypoparathyroidism, bleeding. In this regard, it is important for the endocrine surgeon to save «dry operating field», which contributes to the clear visualization of such «thin» structures as the recurrent laryngeal nerve, the external branch of the superior laryngeal nerve and the parathyroid glands. Therefore, the key issue of this surgery is to understand the anatomical and topographic features of the blood supply to the internal neck organs (a complex of neck organs consisting of the thyroid and parathyroid glands, larynx, trachea, esophagus).AIM. To determine the main sources of arterial blood supply of the internal neck organs and their anatomical, topographic features.MATERIALS AND METHODS. The computed tomography protocols of cervical branches of brachiocephalic arteries were analysed in the study. The thickness of the reconstructed sections in the axial, frontal and sagittal planes was 0.35±0.05 mm. The fact of blood supply was confirmed by the anatomical close of the arterial structure to the internal organ and the presence of intramural arterial branches.RESULTS. The course of all cervical branches of the subclavian and common carotid artery was traced among 42 patients. It is noted, that only the inferior, superior thyroid arteries and thyroid ima artery supply internal neck organs with the blood. At the same time, the superior thyroid artery was visualized in all angiograms. However, the inferior thyroid artery was absent in 2.4% of cases. The thyroid ima artery was rarely detected (in 4.8% of patients). In 73.2% of cases, the inferior thyroid artery was detected high at the upper third level of the thyroid lobe and then had a descending course. In 23.2% of cases, the artery was formed at the middle third level of the thyroid lobe and was directed horizontally to the gland. Only in 3.6% of cases, the ascending course was determined in the vessel. The inferior thyroid artery was located on the posterior surface of the thyroid lobe, where it formed glandular branches. On the contrary, the branches of the superior thyroid artery were located mainly along the anterolateral surface of the thyroid gland. The average thickness of the inferior thyroid artery was 2.1±0.5 mm, and the superior thyroid artery was 1.6± 0.7 mm.CONCLUSION. According to the study, arterial blood supply to the internal neck organs is provided mainly by the inferior and superior thyroid arteries. At the same time, the trunk of the inferior thyroid artery is larger than the superior thyroid artery (p=0.032). The inferior thyroid artery forms branches along the posterior surface of the thyroid lobe and from a topographic point of view it is the main source of blood supply to the parathyroid glands. In most cases, the inferior thyroid artery has a descending course, is directed along the posterior surface of the thyroid gland and forms an X-shaped intersection with the recurrent laryngeal nerve.

Approximations to the expectations and variances of ratios of tree properties under the coalescent.

Properties of gene genealogies such as tree height (H), total branch length (L), total lengths of external (E) and internal (I) branches, mean length of basal branches (B), and the underlying coalescence times (T) can be used to study population-genetic processes and to develop statistical tests of population-genetic models. Uses of tree features in statistical tests often rely on predictions that depend on pairwise relationships among such features. For genealogies under the coalescent, we provide exact expressions for Taylor approximations to expected values and variances of ratios , for all 15 pairs among the variables , considering n leaves and . For expected values of the ratios, the approximations match closely with empirical simulation-based values. The approximations to the variances are not as accurate, but they generally match simulations in their trends as n increases. Although En has expectation 2 and Hn has expectation 2 in the limit as , the approximation to the limiting expectation for is not 1, instead equaling . The new approximations augment fundamental results in coalescent theory on the shapes of genealogical trees.

Interface engineering of PtCuMn nanoframes with abundant defects for efficient electrooxidation of liquid fuels

Precise design and synthesis of advanced Pt-based catalysts through modulation of the surface coordination environment at the atomic level are crucial for the industrial application of fuel cells. However, conventional surface engineering approaches are generally multistage processes. Herein, we report a simple one-step method to precisely synthesize a set of ternary PtCuMn nanoframes (multiple-pin and external branch structures) with high-index facets (HIFs) and high defect density via change of alcohol species, structure-directing agent and heating mode. Owing to the high density of abundant coordinatively unsaturated sites and the unique electronic effect of ternary alloys, the prepared PtCuMn nanoframes present excellent performance for methanol electrooxidation (MOR) and formic acid electrooxidation (FAOR). Specifically, the area specific current densities of PtCuMn with multiple-pin nanoframe morphology for MOR and FAOR are approximately 7.76 and 6.68 times higher, respectively, than those of Pt/C. More importantly, the catalysts show more stability compared with Pt/C. This proposed surface engineering approach not only realizes efficient architecture- and defect-controlled PtCuMn nanoframe electrocatalyst, but also provides fundamental insights into the roles of architecture and defects in renewable energy electrocatalysis.

The effect of strap muscle transection on voice and swallowing changes after thyroidectomy in patients without laryngeal nerve injury.

Voice and swallowing symptoms are frequently reported after thyroidectomy even without laryngeal nerve injury. We aimed to evaluate the effect of strap muscle transection on voice and swallowing outcome after thyroidectomy. Group 1 (G1) consisted of 17 patients who had their strap muscles transected during thyroidectomy and group 2 (G2) consisted of 17 patients who had their strap muscles preserved during thyroidectomy. None of the patients had laryngeal nerve injury. Voice impairment scores (VIS) and swallowing impairment scores (SIS) were obtained preoperatively and at 1 week and 1, 3 and 6 months postoperatively. Pre- and postoperative vocal cord examinations were performed for all patients. The external branch of the superior laryngeal nerve (EBSLN) was evaluated by intraoperative cricothyroid muscle electromyography. There was no significant difference in VIS and SIS between the two groups. At postoperative week 1, the VIS and SIS for each group were above preoperative values (G1: p = 0.005 and p = 0.035; G2: p = 0.031, p = 0.346, for VIS and SIS respectively). The VIS and SIS scores at 6 months postoperatively were significantly lower than those of the first week postoperatively (G1: p = 0.04 and p = 0.001; G2: p = 0.022 and p = 0.034 respectively) and similar to preoperative values (G1: p = 0.924 and p = 0.086; G2: p = 0.822 and p = 0.187 respectively). Although voice and swallowing complaints increased in the early postoperative period even without recurrent laryngeal nerve and EBSLN injuries, these symptoms are not related with the strap muscle transection.

Thyroidectomy in Australia 2022: lessons from 21,000 consecutive cases.

In this article, we aim to describe our modern-day approach to total thyroidectomy, detailing the subtle refinements of our technique, as it has evolved over three decades and 21 000 cases. Since Delbridge's seminal paper in 2003, the major changes to our approach include a retrograde approach to the recurrent laryngeal nerve that allows dissection of the distal RLN from fascial bands within the ligament of Berry before medialisation of the thyroid lobe. Routine use of intraoperative nerve monitoring systems has increased our awareness of temporary neuropraxia, facilitated a reduction in the risk of bilateral RLN palsy and improved our identification and preservation of the external branch of the superior laryngeal nerve. The increasing use of advanced energy devices has been associated with a reduction in post-operative haematoma rates. We adopt a low threshold to parathyroid auto-transplantation, unless all glands are assessed to be clearly not at risk, and routinely supplement patients with Caltrate in the immediate post-operative period to minimize the risk of symptomatic hypocalcaemia. Ultimately, when we reflect on the subtle refinements that have contributed to improved outcomes, the fundamental principles of exposure and dissection that have evolved over decades remain the basis of our surgical approach and must continue to do so.