Internal Muscle Research Articles

Body stiffness and damping depend sensitively on the timing of muscle activation in lampreys.

Unlike most manmade machines, animals move through their world using flexible bodies and appendages, which bend due to internal muscle and body forces, and also due to forces from the environment. Fishes in particular must cope with fluid dynamic forces that not only resist their overall swimming movements but also may have unsteady flow patterns, vortices, and turbulence, many of which occur more rapidly than what the nervous system can process. Has natural selection led to mechanical properties of fish bodies and their component tissues that can respond very quickly to environmental perturbations? Here, we focus on the mechanical properties of isolated muscle tissue and of the entire intact body in the silver lamprey, Ichthyomyzon unicuspis. We developed two modified work loop protocols to determine the effect of small perturbations on the whole body and on isolated segments of muscle as a function of muscle activation and phase within the swimming cycle. First, we examined how the mechanical properties of the whole lamprey body change depending on the timing of muscle activity. Relative to passive muscle, muscle activation can modulate the effective stiffness by about two-fold and modulate the effective damping by >10-fold depending on the activation phase. Next, we performed a standard work loop test on small sections of axial musculature while adding low-amplitude sinusoidal perturbations at specific frequencies. We modeled the data using a new system identification technique based on time-periodic system analysis and harmonic transfer functions (HTFs) and used the resulting models to predict muscle function under novel conditions. We found that the effective stiffness and damping of muscle varies during the swimming cycle, and that the timing of activation can alter both the magnitude and timing of peak stiffness and damping. Moreover, the response of the isolated muscle was highly nonlinear and length dependent, but the body's response was much more linear. We applied the resulting HTFs from our experiments to explore the effect of pairs of antagonistic muscles. The results suggest that when muscles work against each other as antagonists, the combined system has weaker nonlinearities than either muscle segment alone. Together, these results begin to provide an integrative understanding of how activation timing can tune the mechanical response properties of muscles, enabling fish to swim effectively in their complex and unpredictable environment.

T2-weighted signal intensity-selected volumetry for prediction of pathological complete response after preoperative chemoradiotherapy in locally advanced rectal cancer.

To evaluate the diagnostic value of signal intensity (SI)-selected volumetry findings in T2-weighted magnetic resonance imaging (MRI) as a potential biomarker for predicting pathological complete response (pCR) to preoperative chemoradiotherapy (CRT) in patients with rectal cancer. Forty consecutive patients with pCR after preoperative CRT were compared with 80 age- and sex-matched non-pCR patients in a case-control study. SI-selected tumor volume was measured on post-CRT T2-weighted MRI, which included voxels of the treated tumor exceeding the SI (obturator internus muscle SI + [ischiorectal fossa fat SI - obturator internus muscle SI] × 0.2). Three blinded readers independently rated five-point pCR confidence scores and compared the diagnostic outcome with SI-selected volumetry findings. The SI-selected volumetry protocol was validated in 30 additional rectal cancer patients. The area under the receiver-operating characteristic curve (AUC) of SI-selected volumetry for pCR prediction was 0.831, with an optimal cutoff value of 649.6 mm3 (sensitivity 0.850, specificity 0.725). The AUC of the SI-selected tumor volume was significantly greater than the pooled AUC of readers (0.707, p < 0.001). At this cutoff, the validation trial yielded an accuracy of 0.87. SI-selected volumetry in post-CRT T2-weighted MRI can help predict pCR after preoperative CRT in patients with rectal cancer. • Fibrosis and viable tumor MRI signal intensities (SIs) are difficult to distinguish. • T2 SI-selected volumetry yields high diagnostic performance for assessing pathological complete response. • T2 SI-selected volumetry is significantly more accurate than readers and non-SI-selected volumetry. • Post-chemoradiation therapy T2-weighted MRI SI-selected volumetry facilitates prediction of pathological complete response.

Size, History-Dependent, Activation and Three-Dimensional Effects on the Work and Power Produced During Cyclic Muscle Contractions.

Muscles undergo cycles of length change and force development during locomotion, and these contribute to their work and power production to drive body motion. Muscle fibers are typically considered to be linear actuators whose stress depends on their length, velocity, and activation state, and whose properties can be scaled up to explain the function of whole muscles. However, experimental and modeling studies have shown that a muscle's stress additionally depends on inactive and passive tissues within the muscle, the muscle's size, and its previous contraction history. These effects have not been tested under common sets of contraction conditions, especially the cyclic contractions that are typical of locomotion. Here we evaluate the relative effects of size, history-dependent, activation and three-dimensional effects on the work and power produced during cyclic contractions of muscle models. Simulations of muscle contraction were optimized to generate high power outputs: this resulted in the muscle models being largely active during shortening, and inactive during lengthening. As such, the history-dependent effects were dominated by force depression during simulated active shortening rather than force enhancement during active stretch. Internal work must be done to deform the muscle tissue, and to accelerate the internal muscle mass, resulting in reduced power and work that can be done on an external load. The effect of the muscle mass affects the scaling of muscle properties, with the inertial costs of contraction being relatively greater at larger sizes and lower activation levels.

Is there Relationship between Pectoralis Minor Muscle Length and Shoulder Rotator Muscles Strength?

Problem Statement: In joint movement, agonist and antagonist muscle strength, as well as the length and the shortness of these muscles is an important parameter. Muscle shortness is one of the factor that responsible of sports injuries. Shoulder is one of the most injured joint in Judo. In this joint, determination of the relationship between muscle shortness and agonist-antagonist muscles strength will be effective to increase muscle strength, sportive performance and prevent sports injuries. Purpose of Study: This study was conducted to determine the relationship between pectoralis minor (PM) muscle length and shoulder internal(IR)/external(ER) rotation isokinetic muscle strength in Judo athletes. Methods: The study included 80 (56 males, 24 female) professional Judo athletes aged between 14-25 (mean 17,31±2,51). Isokinetic muscle strength was assessed by ISOMED 2000® device. Pectoralis minor length was evaluated using a flexible tape measure in resting position. The assessments were made bilaterally. Findings and Results: There was a strong and statistically significant correlation between the PM length and the shoulder IR and ER peak torque values at both angular velocities and both sides (p <0,01). Conclusions and Recommendations: It was determined that the relationship between the length of the PM muscle and the internal and external rotator muscle strength of Judo athletes. Therefore, we think that by increasing shoulder muscle strength to enhance sportive performance, stretching exercises for PM muscle shortening should be added to training programs.

Evaluating indices of lipid and protein content in lesser snow and Ross's geese during spring migration

ABSTRACTAssessing nutrient stores in avian species is important for understanding the extent to which body condition influences success or failure in life‐history events. We evaluated predictive models using morphometric characteristics to estimate total body lipids (TBL) and total body protein (TBP), based on traditional proximate analyses, in spring migrating lesser snow geese (Anser caerulescens caerulescens) and Ross's geese (A. rossii). We also compared performance of our lipid model with a previously derived predictive equation for TBL developed for nesting lesser snow geese. We used external and internal measurements on 612 lesser snow and 125 Ross's geese collected during spring migration in 2015 and 2016 within the Central and Mississippi flyways to derive and evaluate predictive models. Using a validation data set, our best performing lipid model for snow geese better predicted TBL (root mean square error [RMSE] of 23.56) compared with a model derived from nesting individuals (RMSE = 48.60), suggesting the importance of season‐specific models for accurate lipid estimation. Models that included body mass and abdominal fat deposit best predicted TBL determined by proximate analysis in both species (lesser snow goose, R2 = 0.87, RMSE = 23.56: Ross's geese, R2 = 0.89, RMSE = 13.75). Models incorporating a combination of external structural measurements in addition to internal muscle and body mass best predicted protein values (R2 = 0.85, RMSE = 19.39 and R2 = 0.85, RMSE = 7.65, lesser snow and Ross's geese, respectively), but protein models including only body mass and body size were also competitive and provided extended utility to our equations for field applications. Therefore, our models indicated the importance of specimen dissection and measurement of the abdominal fat pad to provide the most accurate lipid estimates and provide alternative dissection‐free methods for estimating protein. Published 2018. This article is a U.S. Government work and is in the public domain in the USA.

Online Learning of Joint-Muscle Mapping Using Vision in Tendon-Driven Musculoskeletal Humanoids

The body structures of tendon-driven musculoskeletal humanoids are complex, and accurate modeling is difficult, because they are made by imitating the body structures of human beings. For this reason, we have not been able to move them accurately like ordinary humanoids driven by actuators in each axis, and large internal muscle tension and slack of tendon wires have emerged by the model error between its geometric model and the actual robot. Therefore, we construct a joint-muscle mapping (JMM) using a neural network (NN), which expresses a nonlinear relationship between joint angles and muscle lengths, and aim to move tendon-driven musculoskeletal humanoids accurately by updating the JMM online from data of the actual robot. In this study, the JMM is updated online by using the vision of the robot so that it moves to the correct position (Vision Updater). Also, we execute another update to modify muscle antagonisms correctly (Antagonism Updater). By using these two updaters, the error between the target and actual joint angles decrease to about 40% in 5 min, and we show through a manipulation experiment that the tendon-driven musculoskeletal humanoid Kengoro becomes able to move as intended. This novel system can adapt to the state change and growth of robots, because it updates the JMM online successively.

86: Evidence-based physical examination techniques for the diagnosis of pelvic floor myofascial pain: A systematic review

Levator ani (LA) and obturator internus (OI) myofascial pain is common in patients presenting with chronic pelvic pain. These patients often have co-existing pelvic floor symptoms, but there is limited data on the best method(s) to diagnose myofascial pain in these patients. The objective of our study is to systematically review the literature for examination techniques used to identify LA and OI myofascial pain in patients with pelvic floor symptoms and chronic pelvic pain. A comprehensive literature search was performed using strategies to identify the concepts of pelvic floor disorders, myofascial pain, and diagnosis in Ovid Medline 1946-, Embase 1947-, Scopus 1960-, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and Cochrane Database of Systematic Reviews. Articles were screened by three authors and included if they contained a description of a pelvic myofascial physical examination. Data was extracted and analyzed utilizing a data sheet developed a priori. Fifty-three studies met our inclusion criteria: 2 randomized controlled trials, 6 prospective cohort studies, 8 retrospective cohort and case-control studies, 19 cross sectional studies and 18 general review or expert opinion articles. The majority of studies used a single digit (64%, 34/53) to perform transvaginal palpation (77%, 41/53) of the levator ani (89%, 47/53) and obturator internus (42%, 25/53) muscles and used a patient-reported scale to assess tenderness (53%, 28/53; Table). Physical examination methods for evaluating pelvic musculature for presence of myofascial pain varied significantly and were often undefined. While some agreement exists on which muscles to assess and use of (0-10) pain scales, there is little consensus on methods to identify muscles or muscle palpation techniques. Future work to standardize a reliable and reproducible examination is needed.

Image Quality Assessment of 2D versus 3D T2WI and Evaluation of Ultra-high b-Value (b=2,000 mm/s2) DWI for Response Assessment in Rectal Cancer.

The purpose of this IRB-approved, retrospective study was to compare image quality between 2D and high-resolution 3D, T2-weighted (T2WI) magnetic resonance imaging (MRI) sequences and to investigate the additional value of ultra-high b-value diffusion-weighted imaging (DWI; b=2,000 mm/s2) for both rectal cancer staging and evaluating treatment response. From 12 February to 24 August 2016, 26 consecutive patients (22 males, four females; mean age: 61.9±14.0 years) with histologically-proven rectal cancer. In total 31 examinations [12 prior to and 19 after chemoradiation (CRT)] were included. The patients underwent pelvic MRI on a 3.0-T scanner (Magnetom Skyra, Erlangen, Germany). Three radiologists (3, 4, and 5 years of experience in MRI, respectively) independently assessed all images and rated the image quality of DWI (b=800 mm/s2), apparent diffusion coefficient map, DWI (b=2,000 mm/s2), 3D sagittal T2WI, 3D axial T2WI, 2D sagittal T2WI, and 2D axial T2WI of each patient, respectively. In addition, signal intensity ratios (SIR) were calculated between rectal cancer and obturator internus muscle (background) in all patients after CRT on DWI (b=2,000 mm/s2) and correlated with histopathological regression grade (RG). Tumor delineation was significantly better by 2D T2WI than 3D T2WI both before and after CRT (before CRT: Z=-3.2, p=0.02; after CRT: Z=-4.408, p<0.001; all: Z=-5.192; p<0.001) and was the preferred method, although image quality ratings were not significantly different (3D sagittal: 4.00±0.48; 2D sagittal: 4.03±0.34, p=0.713; 3D axial: 3.85±0.61, 2D axial: 3.78±0.64, p=0.537). Independent t-test showed significantly higher SIR between those with RG 1 or 2 (moderate response: mean score=2.02) and those with RG 3+4 (good response: mean score=0.8) (t=3.044, p=0.011). In those with RG 4 (complete response), SIR of b2000 was 0.946 compared to a 1.41 average of the whole cohort. In two patients, tumor was invisible on b2000 following CRT (RG 3 and 4, respectively). Interobserver agreement was mostly good (κ≥0.6) regarding image quality assessment, except for poor agreement (κ=0.4) in DWI (b2000) between the two less-experienced readers. In conclusion, 3D T2WI might be useful for evaluating response to neoadjuvant therapy in a comprehensive, cost-effective protocol, where 2D imaging seems to be preferable. In addition, DWI (b2000) may be beneficial in assessing both the primary and the residual tumor after CRT in rectal cancer and SIR may be helpful in assessing response to CRT.

Dry Needling for Female Chronic Pelvic Pain: A Case Series

Background: Chronic pelvic pain (CPP) is a debilitating condition often associated with lumbopelvic or hip dysfunction because of the involvement of the deep hip rotators. Dry needling (DN) has been shown to reduce pain and improve function in other chronic, musculoskeletal conditions but as we are aware, its use in those with CPP has not been described. Study Design: Case series. Case Description: Two women, 72 and 62 years of age, were referred to physical therapy with CPP. The patients reported substantial functional limitations secondary to pelvic pain and previous treatments had been unsuccessful. In both patients, familiar pain was elicited with palpation of pelvic floor muscles, particularly obturator internus. Dry needling treatment to obturator internus was a primary focus of treatment in both women with secondary DN to their pelvic floor and gluteal muscles in addition to traditional physical therapy interventions. Outcomes: Patient A demonstrated resolution of symptoms, increased range of motion, and improved mobility after 7 treatments. Her Hip Outcome Score improved from 45.31 to 97.06. Patient B reported resolution of her pelvic pain by the fifth treatment. Her Modified Oswestry Disability Index improved from 46% to 2% and her Pelvic Floor Disability Index score improved by 62.5 points. Discussion: Both patients demonstrated substantial improvement following physical therapy with focused DN to the obturator internus, pelvic floor, and gluteal muscles. These outcomes suggest that physical therapy management using DN may prove to be a powerful treatment technique for patients with CPP. Further evaluation of DN in treating pelvic pain is warranted.

Muscles of the trunk and pelvis are responsive to testosterone administration: data from testosterone dose–response study in young healthy men

Testosterone dose-dependently increases appendicular muscle mass. However, the effects of testosterone administration on the core muscles of the trunk and the pelvis have not been evaluated. The present study evaluated the effects of testosterone administration on truncal and pelvic muscles in a dose-response trial. Participants were young healthy men aged 18-50years participating in the 5α-Reductase (5aR) Trial. All participants received monthly injections of 7.5mg leuprolide acetate to suppress endogenous testosterone production and weekly injections of 50, 125, 300, or 600mg of testosterone enanthate and were randomized to receive either 2.5mg dutasteride (5aR inhibitor) or placebo daily for 20weeks. Muscles of the trunk and the pelvis were measured at baseline and the end of treatment using 1.5-Tesla magnetic resonance imaging. The dose effect of testosterone on changes in the psoas major muscle area was the primary outcome; secondary outcomes included changes in paraspinal, abdominal, pelvic floor, ischiocavernosus, and obturator internus muscles. The association between changes in testosterone levels and muscle area was also assessed. Testosterone dose-dependently increased areas of all truncal and pelvic muscles. The estimated change (95% confidence interval) of muscle area increase per 100mg of testosterone enanthate dosage increase was 0.622cm2 (0.394, 0.850) for psoas; 1.789cm2 (1.317, 2.261) for paraspinal muscles, 2.530cm2 (1.627, 3.434) for total abdominal muscles, 0.455cm2 (0.233, 0.678) for obturator internus, and 0.082cm2 (0.003, 0.045) for ischiocavernosus; the increase in these volumes was significantly associated with the changes in on-treatment total and free serum testosterone concentrations. In conclusion, core muscles of the trunk and pelvis are responsive to testosterone administration. Future trials should evaluate the potential role of testosterone administration in frail men who are predisposed to falls and men with pelvic floor dysfunction.

Effects of low frequency pulsed electrical stimulation on tongue muscles in nasopharyngeal carcinoma patients after radiotherapy

Objective To study the effect of low frequency electric stimulation on tongue muscles in nasopharyngeal carcinoma (NPC) patients after radiation therapy. Methods Forty-three nasopharyngeal carcinoma patients with dysphagia after radiation therapy were randomly divided into a control group of 21 and a test group of 22. The control group received low frequency electric stimulation on external tongue muscles for 15 minutes a day while the test group received low frequency electric stimulation on external tongue muscles for 20 minutes a day, 5 days a week for 4 weeks. Before and after the treatment, the range of motion of tongues was evaluated. Results Before the treatment, there was no significant difference between the two groups in all the measurements (P>0.05). After the treatment, the protraction of the tongue improved significantly in both groups, with a significantly more improvement in the test group than in the control group. Significant improvement was observed in the side-to-side movement of the tongue in the test group, but not in the control group after the treatment. However, no significant improvement was observed in the up-and-down motion of the tongue in both groups after the treatment (P>0.05). Conclusion Low frequency electric stimulation on internal and external tongue muscles can improve the protractive and side-to-side motion of the tongue in NPC patients after radiotherapy. Key words: Nasopharyngeal carcinoma; Radiation therapy; Motion dysfunction of tongue; Dysphagia; Electric stimulation

Morphological fine tuning of the feeding apparatus to proboscis length in Hesperiidae (Lepidoptera).

The form and function of the hesperiid feeding apparatus was studied in detail. The butterflies in the family Hesperiidae are of particular interest because the longest proboscis ever recorded in Papilionoidea was found in the Neotropical genus Damas. We focused on the functional morphology by comparing proboscis morphology as well as size and composition of both the stipes pump and the cibarial suction pump in skippers with short and extremely long proboscis. Results revealed that all studied Hesperiidae have the same proboscis micromorphology and sensilla endowment regardless of the proboscis length. However, the numbers of internal muscles of the proboscis, the morphology of the stipes pump as well as the pumping organs for nectar uptake are related to the proboscis length. We conclude that the low number of tip sensilla compared to proboscis length is responsible for remarkably longer manipulation times of long-proboscid species during flower visits. The organs for proboscis movements and nectar uptake organs are well tuned to the respective proboscis length and are accordingly bigger in species with a proboscis that measures twice the body length.

Injury to the perineal branch of the pudendal nerve in men: Outcomes from surgical resection of the perineal branches.

The objective is to report the outcome of an anterior surgical approach to treat neuroma of the perineal branch of the pudendal nerve (PBPN). An IRB-approved prospective study enrolled 14 consecutive male patients from 2011 through 2015 who had symptoms of perineal/scrotal pain. Each patient had a successful, diagnostic, pudendal nerve block. The surgical procedure was resection of the PBPN and implantation of the nerve into the obturator internus muscle. Mean age at surgery was 50±15years. Median duration of pain symptoms was 5.5years (range 1.2-42.9years). Mechanisms of injury was exercise (6/14), prostatectomy (4/14), and falls (4/14). Outcomes were the Male Pudendal Pain Functional Questionnaire (MQ), and the Numeric Pain Rating Scale (NPRS). The mean postoperative follow-up was 26±14months. The MQ demonstrated that after surgery, patients overall had significantly less disability due to pudendal pain (P<.03). The NPRS revealed that pain significantly improved (P<.004). Resection of the PBPN and implantation of this nerve into the obturator internus muscle significantly relieved men's pelvic pain disability.

When Radiation Proctitis Gets Way Complicated

Radiotherapy is an essential treatment modality for prostate cancer. However, radiation proctitis (RP) is a common complication, with 40% developing rectal hemorrhage. Previous successful experiences in treating cystitis has led to the use of formalin as a treatment modality. Although there have been few published reports of formalin use for RP in the literature, most results show that it is safe and effective. Unusual complications such as fistulae, anal stenosis and colitis have been rarely reported. A 61-year-old man with medical history of prostate cancer status-post radiation therapy completed 6 months ago presented with a 2-week history of rectal bleeding and tenesmus. He denied fever, use of antibiotics, weight loss or previous GI bleeding. Digital rectal exam was painful and with evidence of blood clots. Initial labs showed iron deficiency anemia. Patient underwent colonoscopy which showed a large erythematous ulcerated lesion that extended from anal verge up to 10cm and covered 70% of diameter (Figure 1). Histologic exam was consistent with RP and negative for rectal carcinoma. Initially, patient was provided with supportive management with hydration and steroid enemas. However, he developed progression of symptoms with intractable rectal bleeding requiring multiple blood transfusions as well as severe rectal pain. Pelvic MRI showed bilaterally myositis of the obturator internus and pectineus muscles suggestive of radiation induced myositis. Given severity of symptoms, General Surgery proceeded with rectal instillation of 4% formalin which was unsuccessful for which diverting Loop Colostomy was performed. Patient showed improvement of symptoms until a few days later when he developed hematochezia, fever and leukocytosis. Abdominal CT revealed inflammatory colitis suggestive of formalin-induced colitis which resolved with antibiotics and hydration. Follow up colonoscopy was performed for possible re-connecting surgery which showed anal canal stenosis with 99% of lumen occluded (Figure 2). Patient was referred to Colorectal surgeon whom performed multiple dilations with resolution of stenosis. In this case, anal stenosis and colitis were a complication of formalin instillation as therapy for RP. Both complications are very rare and few cases have been published in which a clinical scenario mirroring our patient presentation and outcome are described. Awareness of rarely described complications is essential for early recognition and treatment.Figure: Large erythematous ulcerated lesion.Figure: Anal canal stenosis.

Antagonist Inhibition Control in Redundant Tendon-Driven Structures Based on Human Reciprocal Innervation for Wide Range Limb Motion of Musculoskeletal Humanoids

The body structure of an anatomically correct tendon-driven musculoskeletal humanoid is complex, and the difference between its geometric model and the actual robot is very large because expressing the complex routes of tendon wires in a geometric model is very difficult. If we move a tendon-driven musculoskeletal humanoid by the tendon wire lengths of the geometric model, unintended muscle tension and slack will emerge. In some cases, this can lead to the wreckage of the actual robot. To solve this problem, we focused on reciprocal innervation in the human nervous system, and then implemented antagonist inhibition control (AIC)-based on the reflex. This control makes it possible to avoid unnecessary internal muscle tension and slack of tendon wires caused by model error, and to perform wide range motion safely for a long time. To verify its effectiveness, we applied AIC to the upper limb of the tendon-driven musculoskeletal humanoid, Kengoro, and succeeded in dangling for 14 min and doing pull-ups.

Comparative anatomy on 3-D MRI of the urogenital sinus and the periurethral area before and during the second stage of labor during childbirth.

To describe the observable MRI changes in the urogenital sinus during the second stage of labor and delivery by comparing the changes in the positions of the anatomical structures of the maternal perineum using MRI-based vector 3-D models. Seven pregnant women underwent 3-D MRI sequences using a Philips 1T Panorama open MRI during the pre-labor period and during the second stage of labor. A 3-D vector reconstruction platform (BABYPROGRESS, France) enabled the transformation of volumes of 2-D images into finite element meshes. The polygonal meshes labeled with the principal components of the urogenital sinus were used as part of a biomechanical study of the pressure exerted on the perineum during fetal descent. The expansion of the urogenital sinus was observed in all patients. Qualitative stretching was observed toward the rear and bottom of the iliococcygeus, pubococcygeus, puborectalis and obturator internus muscles. Significant length differences were measured along the iliococcygeus and pubococcygeus muscles but not along the tendinous arch of the levator ani or the puborectalis muscle. The inversion of the levator ani muscle curvature was accompanied by the transmission of pressure generated during fetal descent to the pubic muscle insertions and the descent of the tendinous arch of the levator ani. Mechanical pressures responsible for the tensioning of the constituent muscles of the urogenital sinus were qualitatively identified during the second stage of labor. MRI-based vector 3-D models allow the quantitative assessment of levator ani muscle stretching during labor, but 2-D MRI is not sufficient for describing perineal expansion. Vector 3-D models from larger scale studies have the potential to aid in the calibration of a realistic simulation based on the consideration of the reaction of each muscular element. These models offer perspectives to enhance our knowledge regarding perineal expansion during childbirth as a risk factor for postpartum perineal defects.

"A clinical study of ‘bilva patra kwath avagahan sweda’ in the management of arsha in garbhini with special reference to 1st And 2nd-degree internal hemorrhoids."

Haemorrhoids are uncomfortable, very common during pregnancy due to various causes. The haemorrhoidal plexus get dilated and inflamed resulting in formation of haemorrhoids. If not treated at proper time may cause bleeding and protrusion of the haemorrhoids. In such a condition, surgical and para-surgical procedures have limitations and use of internally ushna and tikshna kalpas are contraindicated in Garbhini. Keeping in view these problems BILVA Patra Kwath Avgahan sweda karma in Charak Chikitsa sthana - 14/47 was selected to evaluate the effect of Avgahan sweda karma in relieving the signs and symptoms of haemorrhoids. Bilva patra kwath sitz bath was given to the GARBHINI patient suffering from haemorrhoids. Present study has been done on 10 patients and an effort has been made to derive safe, easy accessible treatment in pregnancy. A BILVA patra kwath Avgahan sweda, which has proven Anti-inflammatory7 property relieves venous congestion, relieves spasm of internal sphincter muscles. Assessment done on the basis of criteria, resulting into PR bleeding and significant reduction in size of piles mass without any untoward side effect in pregnancy.

Mobergellans from the early Cambrian of Greenland and Labrador: new morphological details and implications for the functional morphology of mobergellans

AbstractNew morphological features of the mobergellan Discinella micans (Billings, 1871) from the lower Cambrian (Stage 4) of Northeast Greenland and southern Labrador are described. The new features include: (1) the morphology of the larval shell, which is shown to be cap-shaped, subcircular, and with impressions of the internal muscle attachment scars; (2) a range of unusual shell deformations (changes in growth direction resulting in thickened shells, partial detachment of shell laminae and subsequent regrowth, internal projections of shell material increasing the depth of the shell by up to 150%, disturbances and irregular fusion of muscle scars). In addition, we provide new details about the variability in number and shape of the anteriormost internal muscle scars, which often fuse and may vary in number from one to three (resulting in nine to 11 scars in total). Together the new observations provide additional strength for the hypothesis that mobergellan shells represent opercula of an as yet unknown tubular organism.

Obturator Internus Muscle Endometriosis with Nerve Involvement: a Rare Clinical Presentation

Study ObjectiveTo describe our surgical approach in a rare case of deep infiltrating endometriosis of the obturator internus muscle with obturator nerve involvement. DesignA step-by-step surgical explanation using video and literature review (Canadian Task Force Classification III). SettingEndometriosis can be pelvic or rarely extrapelvic and is classically defined as the presence of endometrial glands and stroma outside the uterine cavity [1,2]. Pain along the sensitive area of the obturator nerve, thigh adduction weakness and difficulty in ambulation are extremely rare presenting symptoms [2–4]. PatientWe report a case of a 32-year-old patient who presented with cyclic leg pain in the inner right thigh radiating to the knee caused by a cystic endometriotic mass in the obturator internus muscle with nerve retraction. The patient provided informed consent to use the surgical video. Institutional review board approval was obtained. InterventionsPelvic magnetic resonance imaging was performed and confirmed a nodular lesion of about 2.3 cm with high signal on T1WI and T2WI and without fat suppression on T2FS inside the right obturator internus muscle, suggesting an endometriotic lesion (Fig. 1). Surgical removal of the mass was performed using the laparoscopic approach. A normal pelvic cavity was found, and the retroperitoneal space was dissected. A mass located within the right obturator internus muscle, below the right iliac external vein, behind the corona mortis vein, and lateral to the right obturator nerve was identified. The whole region was inflamed, and the nerve was partially involved. Dissection was performed carefully with rupture of the tumor, releasing a chocolatelike fluid (Fig. 2), and the cyst was removed. Pathology examination was consistent with endometriosis. Patient improvement was observed, with pain relief and improved ability for right limb mobilization. No recurrence of endometriosis was found at the follow-up visit 6 months later. Measurements and Main ResultsThe obturator nerve is responsible for motor and sensitive innervation of the joins and internal muscles of thigh and knee as well as the innervation of skin in the internal thigh. Pain along the sensitive area of the obturator nerve at the time of menstruation, thigh adduction weakness, difficulty ambulating, or paresthesia can be presenting symptoms with the involvement of the obturator nerve [5]. Besides paresthesia, our patient presented all the symptoms. The suspected diagnosis of obturator internus muscle endometriosis with retraction of the obturator nerve was confirmed by laparoscopic surgery and pathological examination of the excised tissue. To our knowledge, only 4 cases of endometriosis involving the obturator nerve have been described (according to MEDLINE searched in January 2017) [5–8]. The laparoscopic approach provided an excellent access to the retroperitoneal space, allowing fine dissection of the obturator nerve and the surrounding structures with complete removal of the cystic mass. ConclusionWe report a rare case of endometriosis with a single mass located inside the right obturator internus muscle with neuronal involvement of the obturator nerve. The fundamental role of laparoscopy was clearly demonstrated for the diagnosis and treatment of our patient.

Muscle MRI findings in a one-year-old girl with merosin-deficient congenital muscular dystrophy type 1A due to LAMA2 mutation: A case report

The objective of the present study was to characterize the muscle magnetic resonance imaging (MRI) features of a 1-year-old girl with merosin-deficient congenital muscular dystrophy type 1A (MDC1A). Beginning as an infant, this patient exhibited severe hypotonia and proximal weakness, as well as delays in developmental milestones. Her serum creatine kinase levels at 3 months, 8 months and 1 year were 2,959, 1,621 and 1,659 U/l, respectively. Brain MRI indicated symmetric, mild T1WI low, mild T2WI and FLAIR high radial patterns in the white matter of the Cornu posterius of the ventricular lateral. Gene sequencing demonstrated a heterozygous frame-shift mutation in the LAMA2 gene, consisting of an AG deletion at nucleotides 2049-2050 (LAMA2 c.2049_2050delAG). Lower limb muscle MRI presented obvious fatty infiltration of the muscles and muscle atrophy during the early stage of the disease. The gluteus maximus, erector spinae, vastus intermedius, vastus lateralis, adductor magnus, soleus and gastrocnemius muscles were involved, whereas the piriformis, obturator internus, pectineus, adductor longus, adductor brevis and sartorius muscles presented mild or no involvement. Fatty infiltration of the erector spinae was observed during the early stage of the disease. As an additional tool in the differential diagnosis of muscle disorders, muscle MRI can delay the need for muscle biopsy.