Inferior Third Research Articles

Extended arc of rotation of Latissimus Dorsi Musculocutaneous Flap providing well-vascularized tissue for reconstruction of complete defects of the sternum: An anatomical study of flap pedicle modification.

Deep sternal wound infections (DSWI) following cardiothoracic surgery represent a life quality endangering sequelae and may lead to sternal osteomyelitis. Radical debridement followed by Negative Pressure Wound Therapy (NPWT) may achieve infection control, provide angiogenesis, and improve respiratory function. When stable wound conditions have been established a sustainable plastic surgical flap reconstruction should be undertaken. This study analyses a method to simplify defect coverage with a single Latissimus Dorsi Myocutaneous Flap (LDMF). Preparation of 20 LDMF in ten fresh frozen cadavers was conducted. Surgical steps to increase pedicle length were evaluated. The common surgical preparation of LDMF was compared with additional transection of the Circumflex Scapular Artery (CSA). Alteration of the surgical preparation of LDMF by sacrificing the CSA may provide highly valuable well-vascularized muscle tissue above the sensitive area of the Xiphisternum. All defects could be completely reconstructed with a single LDMF. The gain in length of flap tissue in the inferior third of the sternum was 3.86±0.9 cm (range 2.2 to 8 cm). By sacrificing the CSA in harvesting the LDMF a promising gain in length, perfusion and volume may be achieved to cover big sternal defects with a single flap.

IOLcano Eruption: Eye on Fire With Rubeosis Iridis' Lava Flow

A 40-year-old male presented with visual impairment in the right eye (OD). He had undergone a pars plana vitrectomy for retinal detachment in the OD three years prior. Biomicroscopic examination revealed significant hyperemia, rubeosis iridis, anterior subluxation of the intraocular lens (IOL), and an organized hyphema located in the inferior third of the anterior chamber, characterized by the entrapment of iris tissue between the anterior synechia and the IOL.

The Anatomy of the Frontalis Muscle Revisited: A Detailed Anatomic, Clinical, and Physiologic Study.

There are differing opinions regarding the specific mechanical forces related to contraction of the frontalis muscle and how it exerts its effects on eyebrow motion. The goal of this study was to perform a detailed anatomic and clinical study of the frontalis muscle in cadavers and patients to better define the movement of the frontalis muscle. This study consisted of 4 arms, which included: (1) dynamic ecography to evaluate movement of the frontalis muscle, (2) anatomical study of the relationship between the frontalis muscle and the deep fascia, (3) histological study to define the frontalis muscle attachments, and (4) clinical study to evaluate the action of the frontalis muscle in patients undergoing a temporal facelift. The frontalis muscle was attached, inserted, and adhered to the deep layer of the fascia in the superior cephalic and middle third of the forehead. In the superior cephalic third of the forehead, loose areolar tissue was observed deep to the frontalis muscle and the deep layer of the fascia. Within the middle third of the forehead, the deep layer of the galea was fused with the periosteum and firmly adhered. In the inferior caudal third of the forehead, the frontalis muscle was separated from the deep galeal aponeurosis and interdigitated with the orbicularis muscle. When the frontal muscle end was dissected free from the deep fascia by approximately 1 cm and pulled upward, no movement of the eyebrows was observed. Eyebrow elevation was only achieved by pulling on the inferior part of the muscle. Frontalis muscle movement occurs from the inferior caudal end toward the mid-part of the muscle as it contracts centripetally on its superficial layer, sliding over the deep part strongly attached to the deep fascia.

Catena of Ultisols from southeastern Brazil: Assessing variation within and among pedons

Despite having the second largest territorial extension in Brazil (2,281,135 km2, constituting 26.79% of the country's area), the variability of Ultisols' attributes has not received proportional attention compared to Oxisols (31.61% of the country's area). A very representative catena of Ultisols derived from gneiss in Southeastern Brazil was analyzed to assess the variation of their physical, chemical, magnetic and mineralogical attributes within and among pedons. For that, a complete series of traditional and novel techniques were employed: conventional morphological, physical and chemical analyses, digital morphometrics via X-ray fluorescence spectrometry, magnetic susceptibility analyses and X-ray diffraction. Analyses highlighted how low natural soil fertility varied within and in between soil profiles. The differential concentration of residual elements Zr and Ti, the magnetic susceptibility values and mineralogy data indicated that the Inceptic Hapludult, situated at the inferior third of the catena, received sediments from upslope Ultisol areas. Kaolinite largely predominated in the clay fraction. Digital soil morphometrics allowed for a more objective and detailed assessment of the variation of Ultisols' attributes in the studied catena. It confirmed the field identification of the B/C horizon in the Typic Rhodudult and indicated variation of soil parent material. Enhancing soil variability assessment by combining conventional and digital methods can enrich the knowledge about landscape evolution and help devise better management practices.

Prevention of Dry Socket with Ozone Oil-Based Gel after Inferior Third Molar Extraction: A Double-Blind Split-Mouth Randomized Placebo-Controlled Clinical Trial

Tooth extraction is followed by a sequence of elaborate local changes affecting hard and soft tissues. Dry socket (DS) can occur as intense pain around and in the extraction site, with an incidence from 1-4% after generic tooth extraction to 45% for mandibular third molars. Ozone therapy has gained attention in the medical field because of its success in the treatment of various diseases, its biocompatible properties and its fewer side effects or discomfort than drugs. To investigate the preventive effect of the sunflower oil-based ozone gel Ozosan® (Sanipan srl, Clivio (VA), Italy) on DS, a double-blind split-mouth randomized placebo-controlled clinical trial was conducted according to the CONSORT guidelines. Ozosan® or the placebo gel were put in the socket, and the gels were washed off 2 min later. In total, 200 patients were included in our study. The patient population comprised 87 Caucasian males and 113 Caucasian females. The mean age of the included patients was 33.1 ± 12.4 years. Ozosan reduced the incidence of DS after inferior third molar extraction from 21.5% of the control to 2% (p < 0.001). Concerning the dry socket epidemiology, the incidence was not significantly correlated with gender, smoking or mesioangular, vertical or distoangular Winter's classification. Post hoc power calculation showed a power of 99.8% for this data, with alpha = 0.001.

Comparison between the Flapless Surgical Approach and a Novel Single Incision Access in Terms of Recovery Time and Comfort after Extraction of Impacted Inferior Third Molars: A Randomised, Blinded, Split-Mouth Controlled Clinical Trial

The recent attention to quality of life and oral health care procedures reflects a renewed 'patient-based' approach to dealing with non-life-threatening conditions. In the current study, we proposed a novel surgical approach to the extraction of impacted inferior third molars (iMs3) through a randomised, blinded, split-mouth controlled clinical trial following the CONSORT guidelines. The novel surgical procedure, hereinafter referred to as single incision access (SIA), will be compared with our previously described flapless surgical approach (FSA). The predictor variable was the novel SIA approach, involving access through a single incision without removal of soft tissue, on the impacted iMs3. The primary endpoint was the acceleration of the iMs3 extraction healing time. The secondary endpoints were the incidences of pain and oedema as well as gum health (pocket probing depth and attached gingiva). The study was carried out on 84 teeth of 42 patients with both iMs3 impacted. The cohort was composed of 42% Caucasian males and 58% Caucasian females, aged 23.8 ± 7.9 (17-49) years. We observed faster recovery/wound-healing on the SIA side (33.6 ± 4.3 days) than at the FSA side (42.1 ± 5.4 days; p < 0.05). The FSA approach confirmed the evidence previously detected concerning early post-surgery improvement in terms of attached gingiva and reduced oedema and pain, with respect to the traditional envelope flap. The novel SIA approach follows the early positive post-surgery FSA results.

Microsurgical Anatomy of the Cerebellar Interpeduncular Entry Zones

The cerebellar interpeduncular region, particularly the middle cerebellar peduncle (MCP) and interpeduncular sulcus (IPS) are significant surgical relevance areas due to the high prevalence of vascular and tumoral pathologies, such as cavernomas, arteriovenous malformations, and gliomas. We defined safer access areas of the MCP and the IPS, according to the surface anatomy, involved vessels, and fiber tracts of the cerebellar interpeduncular region. Fifteen formalin-fixed and silicone-injected cadaveric heads and 23 human brainstems with attached cerebellums prepared with the Klingler's technique were bilaterally dissected to study the vascular and intrinsic anatomy. Surface anatomy: The mean length of the IPS was 12.73mm (standard deviation [SD],2.15mm), and the average measured angle formed by the IPS and the lateral mesencephalic sulcus was 144.53°. The mean distance from the uppermost point of the IPS to cranial nerve IV was 2.63mm (SD, 2.84mm). Vascular anatomy: The perforating branches of the superior cerebellar peduncle, IPS, and MCP originated predominantly from the caudal trunk of the superior cerebellar artery. The inferior third of the superior cerebellar peduncle and IPS was the third most pierced by perforating arteries, and for the MCP, was its superior third. Crossing vessels: The branches of the pontotrigeminal vein and the caudal trunk of the superior cerebellar artery crossed the IPS mostly. The superior third of the IPS was the most crossed by arteries and veins. The middle thirds of the IPS and MCP as entry zones might be safer than their superior and inferior thirds due to fewer perforating branches, arterial trunks, and veins crossing the sulcus as fewer eloquent tracts.

Three-dimensional mapping study of pure transverse acetabular fractures

BackgroundTo describe and analyze the morphological characteristics, location and frequency of pure transverse acetabular fracture lines through fracture mapping and quantitative measurements.MethodsTransverse fractures were retrospectively reviewed and analyzed. All computed tomography (CT) data were used for reconstruction and manual reduction. The reductive fracture fragments were graphically overlaid onto a three-dimensional (3D) right hemipelvis template. Then, the fracture lines were accurately depicted onto the surface of the 3D template. The fracture lines were overlapped onto the model to create the 3D fracture map and heatmap. All cases were subdivided into infratectal (62-B1.1), juxtatectal (62-B1.2), and transtectal (62-B1.3) types based on the AO Foundation/Orthopedic Trauma Association (AO/OTA) classification. Some anatomic parameters of the transverse fractures were also analyzed in these 3 groups.ResultsOur study included forty-nine transverse fractures from 32 male and 17 female patients (mean age, 42 years; range 21–74 years) and included 19 type 62-B1.1, 17 type 62-B1.2, and 13 type 62-B1.3 fractures. The average anterior rim fracture angle was 70.0° (± 11.6°), and the posterior rim fracture angle was 92.4° (± 28.5°). The anterior rim fracture angles in 40 cases (40/49, 81.6%) fell within a wide range between 63° and 80°. On the heatmap, the hot zones were located on the highest position of the cotyloid fossa and the narrowed region, and the cold zone was on the inferior third of the articular surface. For type 62-B1.3 fractures, the hot zone was located on the posterior of the acetabular dome. There were no significant differences in anterior rim fracture angle and anterior height among the three patterns (P = 0.071, P = 0.072). Post hoc tests of the posterior rim fracture angle and the posterior height revealed significant differences among fracture subtypes (P < 0.01). The posterior intra-articular fracture line was significantly longer than the anterior intra-articular fracture line in type 62-B1.1 and type 62-B1.2 fractures (P < 0.01).ConclusionThe fracture lines of transverse fractures through the anterior rim were concentrated on the narrowed zone, and the posterior fracture lines were diffusely distributed. The intra-articular fracture line distribution was focused on the superior and middle thirds of the joint surface. The recurrent fracture lines involving the weight-bearing dome mainly converged on the posterior region of the roof.

Bone Marrow Aspirate Concentrate Augmentation May Accelerate Allograft Ligamentization in Anterior Cruciate Ligament Reconstruction: A Double-Blinded Randomized Controlled Trial

To assess the effect of bone marrow aspiration concentrate (BMAC) augmentation on clinical outcomes and magnetic resonance imaging (MRI) findings in anterior cruciate ligament (ACL) reconstruction (ACLR) with bone-patellar tendon-bone (BTB) allografts. A double-blinded, randomized controlled trial was conducted on 80 patients undergoing ACL reconstruction using BTB allografts. Patients were randomized to 2 groups: (1) bone marrow aspirate was collected from the iliac crest, concentrated, and approximately 2.5 mL was injected into the BTB allograft, or (2) a small sham incision was made at the iliac crest (control). MRI was performed at 3 months and 9 months postoperatively to determine the signal intensity ratio of the ACL graft. Seventy-three patients were available for follow-up at 1-year postoperatively (36 BMAC, 37 control). International Knee Documentation Committee (IKDC) scores were significantly greater in the BMAC group versus the control at the 9-month postoperative period (81.6 ± 10.5 vs 74.6 ± 14.2, P= .048). There was no significant difference in the proportion of patients who met the minimal clinically important difference for IKDC between the BMAC and control groups at 9 months (89% vs 85%; P= .7). Three months postoperatively, signal intensity ratio of the inferior third of the ACL graft was significantly greater in the BMAC group versus the control group (3.2 ± 2.2 vs 2.1 ± 1.5; P= .02). Patients who received BMAC augmentation of the BTB allograft during ACL reconstruction demonstrated greater signal intensity scores on MRI at 3 months, suggesting increased metabolic activity and remodeling, and potentially accelerated ligamentization. Additionally, patients in the BMAC group had greater patient-reported outcomes (IKDC) at 9 months postoperatively when compared with those who underwent a standard surgical procedure. There was no significant difference in the proportion of patients who met the minimal clinically important difference for IKDC between the BMAC and control groups at 9 months, suggesting limited clinical significance at this time point. I, randomized control trial.

Subscapularis minor-does it exist?

It has been well established that the subscapularis is divided in two different parts with a tendinous insertion at its superior two-thirds and a muscular attachment on its inferior third. The objective of this cadaveric study was to follow the muscular insertion of the subscapularis medially in order to determine the origin of this inferior muscle insertion and whether a subscapularis minor can be individualized MATERIALS AND METHODS: Twenty-six shoulders from thirteen fresh-frozen cadaveric specimens (5 males and 8 females; mean age, 74.4 years) were dissected in our anatomy lab. The humeral insertion of the subscapularis was then analyzed, and the inferior muscular part of the insertion was identified. The muscle fibers were followed medially until their scapular origin which was recorded as line drawings and photographs. We measured the dimensions of both the humeral insertion and of the scapular origin of the fibers going to the muscular portion. In all cases, the fibres going to the tendinous portion and those going to the muscular portion of the insertion had a different orientation. The fibres going to the muscular portion of the humeral insertion did not originate from the subscapularis fossa but on the glenoid neck and in a depression at the infero-lateral part of the scapular pillar. The mean length of the superior tendinous portion of the humeral insertion was 3.42 cm (± 0.43 cm); the mean length of the inferior muscular portion of the humeral insertion was 1.88 cm (± 0.80 cm). The mean length of the scapular origin in the depression at the infero-lateral part of the scapular pillar of the fibres going to the muscular portion of the humeral insertion was 3.7 cm (± 0.17 cm). The fibres of the subscapularis do not all originate from the subscapularis fossa. An additional origin exists at the inferior part of the glenoid neck and in a depression at the infero-lateral part of the scapular pillar. The fibers which originate at this location all insert on the humerus at the muscular portion of the subscapularis humeral insertion. This portion however does not seem to correspond to the so-called subscapularis minor which has been previously described.

Median 10 years follow-up of patients with covert Cushing\u2019s syndrome: a case series

BackgroundEctopic adrenocorticotropic hormone secretion syndrome occurs in 10% of all patients with adrenocorticotropic-hormone-dependent hypercortisolism. It is usually associated with overt malignancies or with occult and indolent tumors. This study aims to confirm the source of ectopic adrenocorticotropic hormone in four patients with ectopic Cushing’s syndrome over time.Case presentationA 38-year-old Iranian man with Cushing’s syndrome underwent bilateral adrenalectomy since the source of ectopic adrenocorticotropic hormone secretion was not localized and pituitary imaging was normal. A whole-body scan revealed a right-lung tumoral mass with mediastinal lymph node metastasis. The mass was assumed a lung carcinoid tumor with mediastinal adenopathy. Right-lung mid-zone lobectomy and mediastinal lymphadenectomy were done. In a 47-year-old Iranian man with Cushing’s syndrome, whole-body computed tomography scan revealed a pulmonary nodule in the posterior segment of the left lower lobe of the lung. The third case was a 25-year-old Iranian man who presented with symptoms and signs of Cushing’s syndrome. Pituitary magnetic resonance imaging revealed a microadenoma 5 × 9 mm. Whole-body scan showed abnormal focal somatostatin receptors analog avid lesion in the posterior aspect of inferior third of right lung, highly suggestive of ectopic adrenocorticotropic-hormone-producing tumor. The last case was a 43-year-old Iranian woman with Marfan syndrome with a history of mitral and aortic valve replacement and chronic dissection of the aorta, who presented with symptoms and signs of Cushing’s syndrome. She underwent bilateral adrenalectomy 1 year later owing to failure to locate ectopic adrenocorticotropic hormone syndrome. Whole-body scan showed abnormally increased radiotracer uptake in the midline of the skull base and posterior aspect of the middle zone of left hemithorax and bed of left lobe of thyroid.ConclusionThe clinical spectrum of ectopic adrenocorticotropic hormone secretion syndrome is wide, and distinguishing Cushing’s disease from ectopic adrenocorticotropic hormone secretion syndrome is difficult. Initial failure to identify a tumor is common. Pulmonary carcinoid or occult source of ectopic adrenocorticotropic hormone secretion syndrome is usually the cause. In occult cases of ectopic adrenocorticotropic hormone in which the tumor cannot be localized, serial follow-up with serial computed tomography, magnetic resonance imaging, or scintigraphy is recommended for several years until the tumor can be localized and treated.

PERCUTANEOUS RETRIEVAL OF THE SUTURE-ENTRAPPED SWAN-GANZ CATHETER

TOPIC: Cardiothoracic Surgery TYPE: Fellow Case Reports INTRODUCTION: Pulmonary artery catheters (PAC) are used in cardiac surgery to provide critical clinical data. While safe, they are not harmless with multiple associated risks, including surgical entrapment. Causes of include suture snaring and PAC knotting. We present the case of a surgically entrapped PAC that was successfully removed in a percutaneous fashion. CASE PRESENTATION: A 61-year-old man with MV regurgitation presented for surgical repair. A PA catheter was placed through an 8-FR sheath in the RIJ vein. Sternotomy was performed and the patient was placed on central cardiopulmonary bypass with bicaval venous cannulation. The LA was entered through the inter-atrial groove, and MV repair performed. Following both atriotomy closure and venous decannulation, the anesthesia team reported seamless PAC mobility and the chest was closed. On POD1, removal of the PAC was met with resistance. Imaging confirmed normal PAC position without obvious entrapment. The patient was taken to the IR suite where fluoroscopy revealed tethering of the PAC at the inferior third of the SVC. The proximal aspect of the PAC was then cut and the indwelling sheath was replaced with a 9-FR braided sheath over the PAC, which served as 'guide-wire'. A point of obstruction was detected by tactile sensation. The sheath was then upsized to a 10-FR braided vascular sheath. With gentle, simultaneous, back-and-forth maneuvering of the catheter and sheath, the PAC was liberated and removed. Superior venacavogram revealed brisk flow of contrast through the SVC, RA and pulmonary outflow tract with no evidence of injury. Mediastinal tubes were removed on POD2 and the patient was discharged on POD5. DISCUSSION: PACs provide critical data to help guide therapy. In a review of over 15,000 patients, Kaplan et al reported a low risk associated with their use with entrapment constituting only 0.065%-0.1% of cases. The most common reported sites of entrapment are around the atrio-caval and atriotomy closure site. While a re-do sternotomy has been the traditional approach for retrieval, it carries inherent associated risks. Percutaneous options can be considered if the offending suture is sufficiently loose and has not perforated the PAC. This must be performed in a controlled environment with the appropriate resources available for a re-do sternotomy. Clinical surveillance with a repeat TTE in 24-HR are critical. Ultimately prevention is the best therapy with heightened vigilance during surgery to avoid PAC suture entrapment. CONCLUSIONS: A heightened sense of vigilance and recognition are key to the prevention and management of PAC entrapment. Sensible planning, cautious catheter instrumentation and attentive post-procedure assessment are all key to a successful outcome. In the unfortunate situation that this surgical complication does occur, a percutaneous approach for recovery is a viable and safe option to consider as discussed in our report. REFERENCE #1: A heightened sense of vigilance and recognition are key to the prevention and management of PAC entrapment. Sensible planning, cautious catheter instrumentation and attentive post-procedure assessment are all key to a successful outcome. In the unfortunate situation that this complication does occur, a percutaneous approach for recovery is a viable and safe option to consider. REFERENCE #2: Pfeiffer K, Widmann M, Deusch H, Guggenberger H, Duda S, Seboldt H. Inadvertant suture fixation of a Swan-Ganz catheter to the pulmonary artery following heart surgery. Anaesthetist. 1995;44:782–4 REFERENCE #3: Kaplan M, Demirtas M, Cimen S, et al. Swan-Ganz Catheter Entrapment in Open Heart Surgery. J Cardiothorac Surg. 2000;15:313-315. DISCLOSURES: No relevant relationships by Roger Goldman, source=Web Response Consultant relationship with Medtronic Please note: 5 years Added 02/16/2021 by Bob Kiaii, source=Web Response, value=Honoraria Consultant relationship with Johnson and Johnson Please note: 3 Years Added 02/16/2021 by Bob Kiaii, source=Web Response, value=Honoraria Consultant relationship with Boston Scientific Please note: 4 years Added 02/16/2021 by Bob Kiaii, source=Web Response, value=Honoraria Consultant relationship with Edwards Life Sciences Please note: 3 years Added 02/16/2021 by Bob Kiaii, source=Web Response, value=Honoraria Scientific Medical Advisor relationship with Abbott Please note: 6 months Added 02/16/2021 by Bob Kiaii, source=Web Response, value=Honoraria No relevant relationships by David Li, source=Web Response No relevant relationships by AMIR SARKESHIK, source=Web Response

Sinus Augmentation—Expect the Unexpected: Diagnostic Anatomical Study

“Big-nose variant” is an anatomical phenomenon defined as the pneumatization of inferior third of the nasal cavity within the alveolar ridge while simultaneously displacing the maxillary sinus laterally. The purpose of the present study was to assess the prevalence of the big-nose variant phenomenon and suggest a morphology classification system. Diagnostic anatomical evaluation was performed in a tertiary medical center on 321 randomly selected maxillary cone beam computerized tomography scans of patients who presented at an oral and maxillofacial department. Two anatomical categories were defined for anatomical identification: classes for horizontal mesiodistal distribution, and divisions for vertical distribution. Class 2, defined as location of the nasal/sinus border between the distal edge of the canine up to the distal edge of second premolar, was found to be the most prevalent (64.6%). Class 3, defined as location of the nasal/sinus border distal to mesial edge of the first molar, was found in 17.9% of cases. Regarding the divisions category, in 96% and 58.2% of teeth examined, nasal cavity alone was found to be superior to the canine and first premolar, respectively, defined as Division A. In 46.9% and 85.6% of teeth examined, maxillary sinus alone was located above the second premolar and first molar, respectively, defined as Division C. Identifying Class 3 on the paraxial reconstruction is the first step in identifying big-nose variant, with further assurance gained from each determining division. The use of the classes and divisions may enable better maxillary treatment planning, alert surgeons for the unexpected, and avoid complications.

Anatomical Variations of the Peroneus Tertius and Extensor Digitorum Longus Muscles – Case Presentation

Abstract Introduction: The extensor digitorum longus and peroneus tertius muscles have multiple morphological variations. The tendinous slips of these muscles are used as grafts to replace other damaged tendons. Case presentation: We present a unique anatomical variant observed during dissection of a cadaver at the Department of Anatomy and Embryology of the “George Emil Palade” University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Romania. The peroneus tertius muscle was identified on the left lower extremity as originating from the inferior third of the fibula and interosseus membrane. The posterior belly of this muscle joins the muscular belly of the extensor digitorum longus muscle. The tendons of toes II to V detach from the extensor digitorum longus muscle with an additional tendon. This last tendon gives off an accessory tendinous slip; lateral to this, the peroneus tertius muscle tendon is observed. In case of the right lower limb we also noted the peroneus tertius muscle originating from the distal part of the extensor digitorum longus muscle. Regarding the extensor digitorum longus muscle we describe an accessory tendinous slip. Conclusion: The anatomical variation reported in this study is similar to those reported by previous studies, but displays particular characteristics regarding the VI tendon of extensor digitorum longus and the joining of the peroneus tertius and extensor digitorum longus muscles in the left lower extremity.

CENTRAL GIANT CELL GRANULOMA IN A PATIENT WITH NEUROFIBROMATOSIS TYPE 1

<h3>BACKGROUND</h3> Neurofibromatosis type 1 (NF1) is an autosomal dominant, inherited, multisystemic disease caused by a mutation in the NF1 gene. A second mutation in this gene can lead to central giant cell granulomas (CGCGs) in the jaws of patients with NF1. In this case, we describe a patient with NF1 and the presence of a CGCG in the mandible. <h3>CASE REPORT</h3> A 24-year-old female patient with relevant medical/dental history of attention deficit hyperactivity disorder, developmental delay, hypothyroidism, congenital heart defect, NF1, and multiple missing teeth presented to the University of Florida College of Dentistry for implant evaluation. A cone beam computed tomography scan was performed where root resorption on tooth 11 was noted and a well-defined, multiloculated, radiolucent entity in the left parasymphyseal region was seen. This entity extended from tooth 20 beyond the midline and from the alveolar crest to the inferior third of the mandible. The alveolar crest and the buccal cortex were mainly resorbed. The root of tooth 21 was distally displaced without evidence of root resorption. The surrounding bone was sclerotic. A thin septum dividing the lesion from the left mental foramen was noted. Given the radiographic appearance and the history of NF1, a CGCG and neurofibroma were considered as differential diagnoses. Histopathologic evaluation was recommended. <h3>DISCUSSION/CONCLUSIONS</h3> A biopsy confirmed the lesion to be a CGCG. The treatment options suggested by the oral surgeon were (1) nonsurgical: Intralesional injection of corticosteroid or (2) surgical: Enucleation and Curettage (E&C) with likely mandibular resection. Owing to concerns regarding anesthesia, a nonsurgical approach was chosen. The relationship between CGCG and NF1 is rarely seen but is well described in the literature and should be considered as a differential diagnosis in patients with NF1 and tumor-like lesions in the jaws. Intralesional injection of corticosteroids has shown good efficiency in complete remission of CGCGs or substantial shrinkage of the lesion, avoiding large surgical resections.

Post-Traumatic Intraparenchymal Renal Hemorrhages: Correlation between CT and DSA Vascular Findings for Superselective Embolization Procedures.

Background: This study aims to investigate the correlation between computed tomography (CT) and digital subtraction angiography (DSA) findings in patients affected by acute post-traumatic intraparenchymal renal hemorrhages and evaluate their conservative management with superselective embolization. Methods: This retrospective multicenter analysis focuses on patients affected by renal bleedings detected by contrast-enhanced CT and treated with superselective endovascular embolization. CT findings were compared to DSA. Embolization procedural data were analyzed and renal function was evaluated before and after the intervention. Results: Twenty-seven patients were retrospectively evaluated in one year. Compared to DSA, CT showed 96.3% diagnostic accuracy in terms of hemorrhage recognition; concerning the type of vascular lesion, there was discrepancy between CT and DSA in five cases. The technical success rate of embolization was 100%, while primary clinical success was 88.9%. The inferior parenchymal third was the most frequent site of renal injury. Microcoils were the most adopted embolics. Renal function did not change significantly before and after embolization. Conclusions: CT has elevated diagnostic accuracy in detecting post-traumatic intraparenchymal renal hemorrhages; in a small percentage, the type of vascular lesion may differ from the findings observed at DSA. In this scenario, superselective embolization presents high clinical success with a low complication rate.

Retrospective Analysis on Inferior Third Molar Position by Means of Orthopantomography or CBCT: Periapical Band-Like Radiolucent Sign

Background: Orthopantomography (OPG) is usually used as a primary diagnostic radiological exam in the planning of third molar surgery because it is deeply available in dental clinics and has lower radiation doses compared to Cone-beam computed tomography (CBCT). The OPG provides a bi-dimensional image, but several radiological signs have been proposed to study the position of the lower third molar and to predict surgical risks. Methods: Patients were divided into two groups, the OPG with a radiolucent area (D-group) and the OPG without any sign (C-group) in correspondence of inferior wisdom tooth roots. Results: The mean distance between the inferior third molar root and the lingual cortical mandibular bone was −1.09 ± 1.5 mm. The nearness of the root that is less than 1 mm was more frequent in the D-group (84.85%) compared to the C-group (14.58%) with statistical significance (Odd ratio: 32.8) using the Chi-square test. Conclusions: When the root of the impacted inferior third molar is impacted into the lingual cortical plate, a periapical band-like radiolucent sign may appear in the OPG image. It could be useful for the prediction of root position and surgical risks.

Herpes vegetans of the vulva

A 40-year-old woman sought a consultation for a 3-month history of a vulvar tumor. She had a history of HIV infection with unregular therapeutic compliance. Physical examination revealed an exophytic, fleshy yet hard, ulcerated mass located in the inferior third of the left labia majora (Figure 1). Adjacent condyloma were observed. Histologic examination depicted a pseudoepitheliomatous hyperplasia next to an ulcerated epidermis, associated with an inflammatory infiltrate (including plasma cells, neutrophils, and eosinophils) and cytopathic changes (Figures 2 and 3).

Normal range of clivoaxial angle in adults using flexion and extension cervical magnetic resonance imaging scans.

An abnormally decreased clivoaxial angle (CXA) is used during the clinical evaluation for corrective skull base surgery. Published normal ranges of CXA using x-ray, computed tomography, or magnetic resonance imaging (MRI) vary dramatically, especially with neck flexion or extension. The aim of this study was to use high-resolution MRI to determine the normal range of CXA in various neck positions using a reproducible measurement technique. The CXA was measured in 10 healthy volunteers on sagittal T2 SPACE c-spine MRI in supine and prone positions and with the neck both neck and extended. CXA is strictly defined as the angle between a line along the inferior third of the dorsal clival cortex and a line from the superior/posterior cortex of the dens to the posterior/inferior corner of the C2 body. Statistical analysis was performed in all positions and included mean CXA, range, standard deviation (SD), inter-reader agreement, and group comparisons. The mean CXA overall was 156.92° (SD=4.23°; range 134-179°). The mean value for extension CXA was 169.20° (SD=5.81°), and the mean value for flexion CXA was 144.73° (SD=5.71°), the difference being statistically significant (p<0.0001) regardless of supine or prone position. Concordant correlations of reader measurements showed substantial agreement in the supine position at 0.96, with lower agreement in the prone position at 0.87. We report normal ranges for CXA in various neck positions based on 3D T2-weighted MRI, using a reproducible measurement method. There was a significant difference in the CXA values between neck extended and neck flexed positions but not between supine and prone positions.

Flapless Surgical Approach to Extract Impacted Inferior Third Molars: A Retrospective Clinical Study.

This study aimed to compare a flapless surgical approach (FSA) with a traditional envelope flap (traditional approach (TA)). Every patient was treated with two approaches: TA and FSA. The primary outcome variables were both the discomfort during the post-operative convalescence and the correct final recovery of the impacted area. The secondary outcome variable was the average duration of the surgery. Post-operative pain and oedema were recorded. The measurements of soft tissue interface toward the distobuccal edge of the second molar were taken by periodontal probe before surgery (baseline) and 8 weeks after surgery. Statistical software was used to evaluate the data; a p-value < 0.05 was considered statistically significant. Twenty-four teeth of 12 patients (six Caucasian males and six Caucasian females, aged 23 ± 4 (17–30) years) with both lower impacted third molars (Ms3) were analysed. Considering an alpha error 0.05 that sample size allows power from 0.80 to 0.90, depending on the variable evaluated. Concerning attached gingiva, oedema and pain, the linear mixed model resulted in a statistically significant difference between the TA and FSA (p = 0.003; p < 0.01; and p = 0.018, respectively). Conversely, the model did not show a difference (p = 0.322) if pocket probing depth was considered. The FSA procedure was faster (p < 0.05) than the TA procedure (17 min and 8 s (±6 s) vs. 28 min and 6 s (±4 s), respectively). The results suggest that the FSA could be a suitable option for improving the surgical removal of lower Ms3. However, additional randomized controlled trial studies are necessary to confirm the reliability of our procedure and to verify its suitability in more complex Ms3 classifications.