Individual Anatomy Research Articles

Abstract P3-19-18: Feasibility and short term toxicity of a consecutively delivered 5-fraction stereotactic body radiotherapy in early stage breast cancer patients receiving accelerated partial breast irradiation

Abstract Background: For early stage breast cancer, breast conservation is an appealing option for many women. Interest in reducing the duration and volume of RT has continued in the form of accelerated partial breast irradiation (APBI). Recent work demonstrates that for appropriately selected patients, APBI yields equivalent rates of ipsilateral breast tumor recurrence (IBTR) with improvements in patient rated cosmesis compared to whole breast radiotherapy. When using external beam radiotherapy for APBI, appropriate techniques to reduce setup uncertainty and overall treatment volume are critical to reduce long term adverse cosmesis. Stereotactic body radiotherapy (SBRT) is an attractive technique to deliver APBI because of its excellent accuracy and potentially superior sparing of uninvolved breast tissue. We report here the initial results of our IRB-approved prospective clinical trial investigating feasibility, safety, and cosmetic outcomes of daily, 5-fraction SBRT for APBI in women meeting ASTRO consensus suitability criteria for partial breast irradiation. Methods: We enrolled twenty patients with early stage breast cancer after lumpectomy who met APBI suitability. During lumpectomy, a breast surgeon placed a bioabsorbable 3D fixed array tissue marker (BioZorb™, Hologic, Marlborough, MS) for enhanced visualization of the cavity boundaries. We defined the clinical target volume (CTV) as the delineable cavity plus a 1 cm isotropic expansion. We placed a 3mm isotropic planning target volume (PTV) expansion around the CTV. We treated each woman with 3000cGy delivered in 5 consecutive, daily, free-breathed fractions in either prone or supine positioning depending on individual anatomy. Patient treatment position was free-breathing in the prone position for 17 patients and supine in 3 patients using triggered imaging and fiducial tracking. A maximum PTV of 124cc was allowed to minimize incidence of fat necrosis. Plans used 10MV flattening filter free (FFF) beams delivered on a Varian Edge linear accelerator. We documented the following: adverse events (CTCAE 4.0), causality of the event to SBRT, and nurse- and patient- scored cosmesis (i.e., 1=excellent, 2=good, 3=fair, 4=poor) at pre-treatment baseline, 1 month post-treatment, and at each proceeding 6 month interval. We also clinically surveilled for disease recurrence. Results: We completed accrual and treatment of twenty patients. At time of submission, fourteen patients had completed 6-month follow-up, and eight patients had completed 12-month follow-up. No patients experienced grade ≥3 toxicity. Adverse events reported were mostly grade 1. Eighty-five percent of patient-scored cosmesis were excellent or good at baseline, with no evidence of deterioration at 1-month post-treatment (Baseline = 1.9, 1 month = 1.9; p = 0.914). Eighty-five percent of nurse-scored cosmesis reports were excellent or good at baseline, with no evidence of deterioration between baseline and 1-month post-treatment (Baseline = 1.95, 1 month = 1.90; p = 0.564). Eighty-six percent of patients had excellent or good patient- and nurse-scored cosmesis at 6 months, with either mean score of 1.71. Eighty-eight percent of patients had excellent or good patient- and nurse-scored cosmesis at 12 months, with mean cosmesis score of 1.50 and 1.63, respectively. Local control follow-up is immature, but no patients developed IBTR. Conclusions: Our study demonstrated that consecutive daily 5-fraction breast SBRT for APBI is a safe, efficient, well-tolerated, and cosmetically favorable means of delivering partial breast irradiation in suitable women. As follow-up duration matures, we will report long term cosmetic outcome and recurrence. Citation Format: Yilan Liu, Christopher Veale, Diana Hablitz, Helen Krontiras, Michael Christian Dobelbower, Rachael Lancaster, Markus Bredel, Catherine Parker, Kimberly Keene, Evan Thomas, Drexell Hunter Boggs. Feasibility and short term toxicity of a consecutively delivered 5-fraction stereotactic body radiotherapy in early stage breast cancer patients receiving accelerated partial breast irradiation [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-19-18.

Tips and Tricks for Facial Toxin Injections with Illustrated Anatomy.

After studying this article, the participant should be able to: 1. Recognize facial muscle contraction direction and muscle morphology based on skin surface movements and facial rhytides. 2. Classify different muscle contraction patterns and target respectively with the recommended dosage and injection technique. 3. Apply the presented injection techniques to the patients' individual anatomy with greater precision and without affecting adjacent muscles or causing other adverse events. Facial muscular anatomy has recently gained increased attention, with new investigative methodologies and new injection techniques arising on the market. These recent advancements have increased our understanding about the functional anatomy of facial muscles and have changed the way health care professionals see and understand their interplay during various facial expressions and in determining facial shape. This new anatomical understanding of facial muscles and their interaction has resulted in superior neuromodulator treatment outcomes with fewer side effects and with increased precision. The latter is of greatest importance, as all facial muscles act as a unit and connect with each other. It is therefore paramount to target during neuromodulator treatments only the muscle responsible for the aesthetic effect desired and not other adjacent muscles, which can have different or even antagonistic effects. Conventional anatomy was previously limited to two-dimensional explanations of muscle locations without incorporating their detailed action or their three-dimensional location of extent. The "new" anatomy incorporates those novel concepts and, once understood, will help health care providers to understand better and to "read" the underlying muscular anatomy based on the wrinkle status and based on the change in skin surface landmarks based on the actions of the underlying musculature. The following article summarizes tips and tricks, pearls and pitfalls, and dos and don'ts during facial neuromodulator injections along with a guide toward adverse event management and patient outcome assessment with special focus on the underlying anatomy.

Source imaging of high-density visual evoked potentials with multi-scale brain parcellations and connectomes

We describe the multimodal neuroimaging dataset VEPCON (OpenNeuro Dataset ds003505). It includes raw data and derivatives of high-density EEG, structural MRI, diffusion weighted images (DWI) and single-trial behavior (accuracy, reaction time). Visual evoked potentials (VEPs) were recorded while participants (n = 20) discriminated briefly presented faces from scrambled faces, or coherently moving stimuli from incoherent ones. EEG and MRI were recorded separately from the same participants. The dataset contains raw EEG and behavioral data, pre-processed EEG of single trials in each condition, structural MRIs, individual brain parcellations at 5 spatial resolutions (83 to 1015 regions), and the corresponding structural connectomes computed from fiber count, fiber density, average fractional anisotropy and mean diffusivity maps. For source imaging, VEPCON provides EEG inverse solutions based on individual anatomy, with Python and Matlab scripts to derive activity time-series in each brain region, for each parcellation level. The BIDS-compatible dataset can contribute to multimodal methods development, studying structure-function relations, and to unimodal optimization of source imaging and graph analyses, among many other possibilities.

Tractography-Based Surgical Targeting for Thalamic Deep Brain Stimulation: A Comparison of Probabilistic vs Deterministic Fiber Tracking of the Dentato-Rubro-Thalamic Tract.

The ventral intermediate (VIM) thalamic nucleus is the main target for the surgical treatment of refractory tremor. Initial targeting traditionally relies on atlas-based stereotactic targeting formulas, which only minimally account for individual anatomy. Alternative approaches have been proposed, including direct targeting of the dentato-rubro-thalamic tract (DRTT), which, in clinical settings, is generally reconstructed with deterministic tracking. Whether more advanced probabilistic techniques are feasible on clinical-grade magnetic resonance acquisitions and lead to enhanced reconstructions is poorly understood. To compare DRTT reconstructed with deterministic vs probabilistic tracking. This is a retrospective study of 19 patients with essential tremor who underwent deep brain stimulation (DBS) with intraoperative neurophysiology and stimulation testing. We assessed the proximity of the DRTT to the DBS lead and to the active contact chosen based on clinical response. In the commissural plane, the deterministic DRTT was anterior (P < 10-4) and lateral (P < 10-4) to the DBS lead. By contrast, although the probabilistic DRTT was also anterior to the lead (P < 10-4), there was no difference in the mediolateral dimension (P = .5). Moreover, the 3-dimensional Euclidean distance from the active contact to the probabilistic DRTT was smaller vs the distance to the deterministic DRTT (3.32 ± 1.70 mm vs 5.01 ± 2.12 mm; P < 10-4). DRTT reconstructed with probabilistic fiber tracking was superior in spatial proximity to the physiology-guided DBS lead and to the empirically chosen active contact. These data inform strategies for surgical targeting of the VIM.

Visualizing the Individual Arterial Anatomy of the Face Through Augmented Reality- A Useful and Accurate Tool During Dermal Filler Injections.

BackgroundThe arterial anatomy of the face is extremely variable. Despite numerous cadaver dissections and anatomical descriptions, the exact location of the superficial facial arteries remains unpredictable. This ignorance is a determining factor in the pathophysiology of intravascular filler injections, potentially causing skin necrosis and blindness.ObjectivesThe main objective of this study is to evaluate the accuracy of an augmented reality (AR) application that visualizes the individual arterial anatomy of the face.MethodsA workflow was developed during which a magnetic resonance angiography (MRA) mapped the superficial arteries of the face. The images were further processed into an AR image that was visualized on the patient’s face using a specifically designed smartphone application. The accuracy of the AR image and the position of each individual artery were analyzed using duplex ultrasound (US).ResultsA total of 216 facial arteries were visualized in 20 patients. The superficial temporal (100%), supratrochlear (92.5%), facial (75%), and angular (82.5%) arteries were visualized the most. The inferior labial (17.5%), dorsal nasal (22.5%), and supraorbital (42.5%) arteries were the most difficult to visualize through MRA. The average deviation between the artery visible on the AR image and the location assessed by US was 0.30 mm (standard deviation = +/− 0.66 mm). There were no complications reported.ConclusionsThe combination of a risk-free MRA to map the individual arteries of the face and the processing into an AR image may be considered as a useful and accurate tool during dermal filler injections to potentially minimize the risk of intravascular filler injections.

Functional Alignment Philosophy in Total Knee Arthroplasty - Rationale and technique for the varus morphotype using a CT based robotic platform and individualized planning.

Introduction: Alignment techniques in total knee arthroplasty (TKA) continue to evolve. Functional alignment (FA) is a novel technique that utilizes robotic tools to deliver TKA with the aim of respecting individual anatomical variations. The purpose of this paper is to describe the rationale and technique of FA in the varus morphotype with the use of a robotic platform. Rationale: FA reproduces constitutional knee anatomy within quantifiable target ranges. The principles are founded on a comprehensive assessment and understanding of individual anatomical variations with the aim of delivering personalized TKA. The principles are functional pre-operative planning, reconstitution of native coronal alignment, restoration of dynamic sagittal alignment within 5° of neutral, maintenance of joint-line-obliquity and height, implant sizing to match anatomy and a joint that is balanced in flexion and extension through manipulation of implant positioning rather than soft tissue releases. Technique: An individualized plan is created from pre-operative imaging. Next, a reproducible and quantifiable method of soft tissue laxity assessment is performed in extension and flexion that accounts for individual variation in soft tissue laxity. A dynamic virtual 3D model of the joint and implant position that can be manipulated in all three planes is modified to achieve target gap measurements while maintaining the joint line phenotype and a final limb position within a defined coronal and sagittal range. Conclusion: Functional alignment is a novel knee arthroplasty technique that aims to restore constitutional bony alignment and balance the laxity of the soft tissues by placing and sizing implants in a manner that it respects the variations in individual anatomy. This paper presents the approach for the varus morphotype.

Posterior Cloaca: Multicenter Experience of a Very Rare and Unusual Anorectal and Genitourinary Malformation.

Posterior cloacal malformations (PCMs) are distinguished from classical cloacal malformations by the posterior location of the common opening in the perineum. We aim to describe our experience of management of these rare and complex malformations. This study was a retrospective chart review of all patients with PCM who underwent treatment at Kalawati Saran Children's Hospital (KSCH), New Delhi, and Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, between 2013 and 2021. Individual anatomical variations and their impact on the clinical presentation, management, and final outcome (cosmesis and function) were recorded and analyzed. During the study period, four girls with a median age of 2 (range: 0-5) years presented to us with PCM. Three patients were referred to KSCH as ambiguous genitalia whereas one patient was born at SGPGIMS with an antenatal diagnosis of "urorectal septal defect." On examination, three patients had the urogenital sinus (UGS) opening immediately anterior to the normally located anal opening (2 orifices), whereas one had a single orifice at the normal location of the anus with the UGS opening in the anterior rectal wall. Associated anomalies included: (a) hydrocolpos (n = 3), which was managed by a tube vaginostomy; (b) urethral duplication with dorsal atretic urethra (n = 3); (c) uterine didelphys (n = 1); (d) bilateral grade 5 vesicoureteric reflux (n = 1); and (e) vaginal calculus (n = 1). Total urogenital mobilization (anterior sagittal approach) with feminizing genitoplasty was performed for patients with UGS and normal anus (n = 3). In the patient with a single opening at the normal location of the anus, posterior sagittal ano-recto-urethro-vaginoplasty was performed. At a median follow-up of 24 months, three patients are continent for urine and stool, whereas one patient is yet to be toilet trained. PCMs are unusual complex malformations that necessitate meticulous clinical examination, detailed diagnostic workup, and multistaged surgical management. Management should be tailored as per each individual patient's anatomy and clinical presentation for an optimal outcome.

Statistical Shape Modeling of Biventricular Anatomy with Shared Boundaries.

Statistical shape modeling (SSM) is a valuable and powerful tool to generate a detailed representation of complex anatomy that enables quantitative analysis and the comparison of shapes and their variations. SSM applies mathematics, statistics, and computing to parse the shape into a quantitative representation (such as correspondence points or landmarks) that will help answer various questions about the anatomical variations across the population. Complex anatomical structures have many diverse parts with varying interactions or intricate architecture. For example, the heart is a four-chambered anatomy with several shared boundaries between chambers. Coordinated and efficient contraction of the chambers of the heart is necessary to adequately perfuse end organs throughout the body. Subtle shape changes within these shared boundaries of the heart can indicate potential pathological changes that lead to uncoordinated contraction and poor end-organ perfusion. Early detection and robust quantification could provide insight into ideal treatment techniques and intervention timing. However, existing SSM approaches fall short of explicitly modeling the statistics of shared boundaries. In this paper, we present a general and flexible data-driven approach for building statistical shape models of multi-organ anatomies with shared boundaries that captures morphological and alignment changes of individual anatomies and their shared boundary surfaces throughout the population. We demonstrate the effectiveness of the proposed methods using a biventricular heart dataset by developing shape models that consistently parameterize the cardiac biventricular structure and the interventricular septum (shared boundary surface) across the population data.

Mathematical modeling of high-flow extra-intracranial bypass in the treatment of a complex cerebral aneurysm

Intracranial aneurysms (IAs) pose a high risk of spontaneous subarachnoid hemorrhage. In the most complex cases, the only way to exclude the aneurysm from the circulation is to perform a high-flow extracranial-to-intracranial bypass, thus creating a new bloodstream. This avoids severe ischemic complications; however, it requires careful consideration of individual anatomy and hemodynamic parameters. Computational fluid dynamics (CFD) can be of great help in planning such a surgery by creating 3D patient-specific models of cerebral circulation. Assessment of the perspectivity of high-flow extracranial-to-intracranial bypass planning using computational modeling. In this research work, we have applied the CFD methods to a patient with a giant thrombosed IA of the internal carotid artery (ICA). Preoperative CTA images and Gamma Multivox workstation were used to create a 3D model with current geometry and three additional models: Normal anatomy (no IA), Occlusion (with ligated ICA), Virtual bypass (with bypass and ligated ICA). The postoperative data were also available. Boundary conditions were based on PC-MRI measurements. Calculation of hemodynamics was conducted with a finite element package ANSYS Workbench 19. The results demonstrated an increase in the blood flow on the affected side by more than 70% after the virtual surgery and uniformity of flow distribution between the affected and contralateral sides, indicating that the treatment is likely to be efficient. Later, postoperative data confirmed that. The study showed that virtual preoperative CFD modeling could significantly simplify and improve surgical planning.

Surgical approach for Obstructive Sleep apnea patients

Obstructive sleep apnea (OSA) is a chronic disease that requires long-term, continuous treatment. Considering the prevalence of sleep apnea and serious health-related sequelae, various medical and surgical treatments have been developed to achieve various therapeutic goals according to individual anatomy and patient compliance. Although CPAP treatment should be the preferred treatment, many patients cannot continue this treatment and alternative treatment is needed. Surgical treatment should be aimed at resolving the obstruction of the nose, palatal, retrolingual, and hypopharynx, or should be performed in the direction of increasing adherence to positive pressure therapy. In this review, the author will introduce various surgical approaches currently used when non-surgical treatment for sleep apnea did not yield positive results, and present research on the treatment results.

Evaluation of Anatomoradiological Findings on Trigeminal Neuralgia Patients Using Computed Tomography and Cone-Beam Computed Tomography.

The study aimed to establish and evaluate anatomoradiological landmarks in trigeminal neuralgia patients using computed tomography (CT) and cone-beam CT. CT images of 40 trigeminal neuralgia (TN) and 40 healthy individuals were retrospectively analyzed and enrolled in the study. The width and length of the foramen rotundum (FR), foramen ovale (FO), foramen supraorbitale, and infraorbitale were measured. The distances between these foramen, between these foramen to the median plane, and between the superior orbital fissure, FO, and FR to clinoid processes were also measured bilaterally. Variations were evaluated according to groups. Significant differences were found for width and length of the foramen ovale, length of the foramen supraorbitale, and infraorbitale between TN and control subjects (p < 0.05). On both sides, FO gets narrower and the length of the infraorbital and supraorbital foramen shortens in the TN group. In most of the control patients, the plane which passes through the infraorbital and supraorbital foramen intersects with impression trigeminale; 70% on the right-side, and 67% in the left-side TN groups. This plane does not intersect with impression trigeminale and deviates in certain degrees. The determination of specific landmarks allows customization to individual patient anatomy and may help the surgeon achieve a more selective effect with a variety of percutaneous procedures in trigeminal neuralgia patients.

Endoscopic ultrasound-guided biliary drainage-current status and future perspectives.

Endoscopic retrograde cholangiopancreatography (ERCP) with stenting is the treatment modality of choice for patients with benign and malignant bile duct obstruction. ERCP could fail in cases of duodenal obstruction, duodenal diverticulum, ampullary neoplastic infiltration or surgically altered anatomy. In these cases percutaneous biliary drainage (PTBD) is traditionally used as a rescue procedure but is related to high morbidity and mortality and lower quality of life. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a relatively new interventional procedure that arose due to the development of curvilinear echoendoscope and the various endoscopic devices. A large amount of data is already collected that proves its efficacy, safety and ability to replace PTBD in cases of ERCP failure. It is also possible that EUS-BD could be chosen as a first-line treatment option in some clinical scenarios in the near future. Several EUS-BD techniques are developed EUS-guided transmural stenting, antegrade stenting and rendezvous technique and can be personalized depending on the individual anatomy. EUS-BD is normally performed in the same session from the same endoscopist in case of ERCP failure. The lack of training, absence of enough dedicated devices and lack of standardization still makes EUS-BD a difficult and not very popular procedure, which is related to life-threatening adverse events. Developing training models, dedicated devices and guidelines hopefully will make EUS-BD easier, safer and well accepted in the future. This paper focuses on the technical aspects of the different EUS-BD procedures, available literature data, advantages, negative aspects and the future perspectives of these modalities.

Effects of laser interstitial thermal therapy for mesial temporal lobe epilepsy on the structural connectome and its relationship to seizure freedom.

Laser interstitial thermal therapy (LITT) is a minimally invasive surgery for mesial temporal lobe epilepsy (mTLE), but the effects of individual patient anatomy and location of ablation volumes affect seizure outcomes. The purpose of this study is to see if features of individual patient structural connectomes predict surgical outcomes after LITT for mTLE. This is a retrospective analysis of seizure outcomes of LITT for mTLE in 24 patients. We use preoperative diffusion tensor imaging (DTI) to simulate changes in structural connectivity after laser ablation. A two-step machine-learning algorithm is applied to predict seizure outcomes from the change in connectomic features after surgery. Although node-based network features such as clustering coefficient and betweenness centrality have some predictive value, changes in connection strength between mesial temporal regions predict seizure outcomes significantly better. Changes in connection strength between the entorhinal cortex (EC), and the insula, hippocampus, and amygdala, as well as between the temporal pole and hippocampus, predict Engel Class I outcomes with an accuracy of 88%. Analysis of the ablation location, as well as simulated, alternative ablations, reveals that a more medial, anterior, and inferior ablation volume is associated with a greater effect on these connections, and potentially on seizure outcomes. Our results indicate (1) that seizure outcomes can be retrospectively predicted with excellent accuracy using changes in structural connectivity, and (2) that favorable connectomic changes are associated with an ablation volume involving relatively mesial, anterior, and inferior locations. These results may provide a framework whereby individual pre-operative structural connectomes can be used to optimize ablation volumes and improve outcomes in LITT for mTLE.

Sex difference in tDCS current mediated by changes in cortical anatomy: A study across young, middle and older adults

IntroductionThe observed variability in the effects of transcranial direct current stimulation (tDCS) is influenced by the amount of current reaching the targeted region-of-interest (ROI). Age and sex might affect current density at target ROI due to their impact on cortical anatomy. The present tDCS simulation study investigates the effects of cortical anatomical parameters (volumes, dimension, and torque) on simulated tDCS current density in healthy young, middle-aged, and older males and females. MethodologyIndividualized head models from 240 subjects (120 males, 18–87 years of age) were used to identify the estimated current density (2 mA current intensity, 25 cm2 electrode) from two simulated tDCS montages (CP5_CZ and F3_FP2) targeting the inferior parietal lobule (IPL) and middle frontal gyrus (MFG), respectively. Cortical parameters including segmented brain volumes (cerebrospinal fluid [CSF], grey and white matter), cerebral-dimensions (length/width &length/height) and brain-torque (front and back shift, petalia, and bending) were measured using the magnetic resonance images (MRIs) from each subject. The present study estimated sex differences in current density at these target ROIs mediated by these cortical parameters within each age group. ResultsFor both tDCS montages, females in the older age group received higher current density than their male counterparts at the target ROIs. No sex differences were observed in the middle-aged group. Males in the younger age group had a higher current density than females, only for the parietal montage. Across all age groups, CSF, and grey matter volumes significantly predicted the current intensity estimated at the target sites. In the older age group only, brain-torque was a significant mediator of the sex difference. ConclusionsOur findings demonstrate the presence of sex differences in the simulated tDCS current density, however this pattern differed across age groups and stimulation locations. Future studies should consider influence of age and sex on individual cortical anatomy and tailor tDCS stimulation parameters accordingly.

Challenging Visualization of Sentinel Lymph Nodes in Upper Urinary Tract Urothelial Carcinoma.

Purpose: The purpose of this study was to assess the possibility of detecting sentinel lymph nodes (SLNs) and to perform analysis of lymphatic outflow in patients with suspicion of upper tract urothelial carcinoma (UTUC) with the use of a radioisotope-based technique. Methods: During 2018–2021, a prospective study was conducted on 19 patients with the suspicion of UTUC and for whom diagnostic ureterorenoscopy (URS) was planned. Technetium-99m (99mTc) nanocolloid radioactive tracer injection and a tumor biopsy were performed for staging procedures. Three-dimensional (3D) reconstruction and fusion of images were performed for better localization of lymph nodes (LNs). Detection of SLNs and the analysis of the radiotracer outflow was conducted with the use of single-photon emission-computed tomography/computed tomography (SPECT/CT) lymphangiography. Results: The mean age of the patients was 73.4 years; 7 (36%) were male. Pathological staging from the biopsy was T0—8 (42%), Ta—7 (36%), T1—4 (21%). SLNs were detected in two of 19 cases (10%). In one patient a single SLN (5.3%) was visualized, and in another case (5.3%), multiple (double) radioactive lymph nodes were visualized. In 17 out of the 19 (89.5%) cases, no lymphatic outflow was observed, and out of these five cases (26.3%) of gravitational leakage of injected radiotracer to the retroperitoneal space was noted. Conclusions: We demonstrated that detection of SLNs in the upper urinary tract is possible yet challenging. Radiotracer injection in the upper urinary tract during ureterorenoscopy is difficult to perform, and the expected result of injection is unsatisfactory. Lymphatic outflow from the tumor site to the first LNs in our studied group of patients is visible in 10.5% of cases. SPECT/CT lymphangiography in cases of UTUC may provide valuable information about a patient’s individual anatomy of the lymphatic system and the position of the first lymph nodes draining lymph with potential metastatic cells from the tumor.

Ureter-first Approach and Reduction of Pelvis: Standardizing Handling of Ureteropelvic Junction During Pyeloplasty

ObjectiveTo present our “ureter-first” approach as a standardized step-wise incision-making technique to deal with all types of uretero-pelvic junction (UPJ) anatomy during pyeloplasty. Pyeloplasty is a common surgery performed for UPJ obstruction, with Anderson-Hynes’ pyeloplasty being the commonest. However, there is great variability in handling UPJ and incision-making among the surgeons with no detailed standardized description that can be followed in all cases, notwithstanding broad descriptions of incision lines. We underscore this aspect of pyeloplasty and present our universal technique with a goal to minimize surgical errors. MethodsA standardized step-by-step handling of UPJ and sequential incision-making was developed for pyeloplasty. It avoids unwarranted loss of any pelvis tissue before confirming individual UPJ anatomy, emphasizes preservation of lower lip of pelvis and minimizes tension on anastomosis. This standardized technique was uniformly used in all cases over 5 years. The peri-operative and functional outcome results are presented. ResultsFifty-one consecutive cases were done using ureter-first approach. UPJ was >1 cm in eight cases. Three of these had UPJ >2 cm. Eight other cases had a low-insertion below level of kidney while three had high insertion of ureter. There were no cases which were deemed to be done under tension or unsatisfactory repair by the surgeon. There were no failures requiring any kind of redo repair at mean follow up of 39 months. ConclusionA uniform standardized approach saves the surgeon from unwarranted or wrongly designed incisions on the pelvis and thus has the potential to reduce surgical mistakes.

Multichannel anodal tDCS over the left dorsolateral prefrontal cortex in a paediatric population

Methodological studies investigating transcranial direct current stimulation (tDCS) over the left dorsolateral prefrontal cortex (lDLPFC) in paediatric populations are limited. Therefore, we investigated in a paediatric population whether stimulation success of multichannel tDCS over the lDLPFC depends on concurrent task performance and individual head anatomy. In a randomised, sham-controlled, double-blind crossover study 22 healthy participants (10–17 years) received 2 mA multichannel anodal tDCS (atDCS) over the lDLPFC with and without a 2-back working memory (WM) task. After stimulation, the 2-back task and a Flanker task were performed. Resting state and task-related EEG were recorded. In 16 participants we calculated the individual electric field (E-field) distribution. Performance and neurophysiological activity in the 2-back task were not affected by atDCS. atDCS reduced reaction times in the Flanker task, independent of whether atDCS had been combined with the 2-back task. Flanker task related beta oscillation increased following stimulation without 2-back task performance. atDCS effects were not correlated with the E-field. We found no effect of multichannel atDCS over the lDLPFC on WM in children/adolescents but a transfer effect on interference control. While this effect on behaviour was independent of concurrent task performance, neurophysiological activity might be more sensitive to cognitive activation during stimulation. However, our results are limited by the small sample size, the lack of an active control group and variations in WM performance.

Is leaning trees of Vatica pauciflora (Korth.) Blume related to their crown architecture?

Vatica pauciflora (Korth.) Blume (Dipterocarpaceae) or locally known as resak rawa is an important tree. It is categorized as vulnerable regarding the IUCN (International Union for Conservation of Nature) Red List of Threatened Species. We can find the resak rawa tree collection in the Bogor Botanic Gardens, which serves as a place for research and tourism. Due to the diversity in individual tree anatomy within species, understanding correlation among individual tree traits, particularly crown architecture and tree leaning, is of great interest. That will be important because the leaning trees and crown architecture will affect the risk level to the safety of visitors. We can also use the architecture of the tree crown to understand the factors that influence tree growth. This study aims to investigate the correlation between the leaning trees and the crown architecture of V. pauciflora. Eight heritage trees of the species in the Bogor Botanic Gardens at the age of 54–105 years old were purposely, sampled in this study. The variables observed were height, trunk and crown diameter, leaning tree, live crown ratio, and direction of the main branches. The results show that crown shapes will follow the leaning trees with a correlation of 0.97. The main branches will be longer in the direction of the leaning trees (y=0.9956x+11.312; R²=0.9431). Suggestions to the management of V. pauciflora are to provide information boards to visitors and pruning the crown in the direction of the leaning trees is needed. The findings could be used to formulate mitigation measures as to the risk and safety of visitors.

Upper instrumented level selection in adult deformity surgery

Adult spinal deformity can be a challenging entity to treat surgically. Determining where to place the upper instrumented level in the fusion construct has been an area of great interest within the research community as well as in practice. There are multiple factors that need to be taken into account including the individual patient's anatomy, radiographic parameters, surgical techniques, and cervicothoracic or thoracolumbar junctional levels when determining where to end a fusion. Considering these aspects will decrease the risk of complications at this level post-operatively.

Distal instrumented level selection in adult deformity surgery

Adult spinal deformity surgery has many aspects that need to be considered prior to and during surgery for the best long-term outcome. Determining where to place the lower instrumented level in the fusion construct can be a difficult decision. There are multiple factors that need to be taken into account including the individual patient's anatomy, the mechanical concept of a fusion mass, surgical techniques, and junctional levels particularly the L5-S1 level when determining where to end a fusion. Understanding these concepts will decrease the risk of complications at this level post-operatively.