Larger Anteroposterior Diameter Research Articles

Combination of an Anti-Vascular Endothelial Growth Factor Tyrosine Kinase Inhibitor and Immunotherapy as a Neoadjuvant Approach in Renal Cell Carcinoma With Associated Inferior Vena Cava Tumor Thrombus: A Single-Center Experience and Review of Literature

Introduction: Renal cell carcinoma (RCC) has a predisposition to vascular invasion that manifest as an inferior vena cava tumor thrombus (IVC TT). Radical nephrectomy with an IVC thrombectomy is associated with high morbidity. We present our single-center experience on the neoadjuvant use of the combination of anti-vascular endothelial growth factor (VEGF) tyrosine kinase inhibitors (TKI) and immune check point inhibitor (IO) for patients with RCC with IVC TT. Patient and Methods: Five patients with RCC and associated IVC TT received a neoadjuvant combination anti-VEGF TKI and IO. The IVC TT reduction was evaluated. The extent of tumor thrombus was defined based on the Mayo Classification, and TT volume was measured by the largest anteroposterior diameter. The safety of therapy, perioperative outcome, and number of patients who were able to undergo definitive surgery are described. Results: Two (40%) had a reduction in IVC TT based on the Mayo Classification. Tumor thrombus volume reduction was seen in all patients (100%). Four of 5 patients (80%) were able to have surgery. Conclusion: The neoadjuvant combination of an anti-VEGF TKI and IO is effective in reducing the extent of IVC TT. Prospective research is needed to characterize the safety, and long-term outcomes of this approach.

Morphometric Variations of the Foramen Lacerum in Dry Skulls and Its Clinical Significance: A Cross-sectional Study

Introduction: The foramen lacerum is located in the middle cranial fossa and transmits a number of nerves and blood vessels. Occlusion can result in the compression of the neurovascular bundle, and the foramen has been reported to be involved in the spread of tumours into the cranium. Aim: The aims of the present study was to describe the morphology of the foramen lacerum and to compare the anatomical parameters on the left and right sides of the skull. Also, the significance of the anatomical parameters in male versus female skulls and right side versus left side of the skull where studied. Materials and Methods: This cross-sectional study was conducted in May and June 2023 using 62 dry skulls (124 foramen lacerum) available in the Department of Anatomy at Gautam Buddha Chikitsa Mahavidyalay, a tertiary care teaching institute in Dehradun, Uttarakhand, India. The anatomical parameters, including the Anteroposterior (AP) and transverse diameters, were recorded using a calibrated digital Vernier caliper. The shape of the foramen was also observed. The mean and standard deviation of the recorded parameters were obtained. Results: Out of the 62 skulls, 41 were males and 21 were females, resulting in a male-to-female ratio of 1.8:1. The mean AP diameter on the Right Side (RT) and Left Side (LT) in males was 6.26 mm and 6.24 mm, respectively, while in females, the mean diameter was 4.97 mm (RT) and 5.4 mm (LT). The mean transverse diameter recorded in the present study was 6.14 mm (RT) and 6.2 mm (LT) in males, while in females, this measurement was 5.88 mm on both sides. The most common shape of the foramen lacerum observed in the study was bilaterally round, in both males and females. Conclusion: There are morphological differences in the AP diameter between male and female skulls, with males having a larger AP diameter on their right side and females having larger AP diameter on their right side. The overall size of the foramen lacerum was smaller in the present study, indicating a higher likelihood of neurovascular bundle compression with age. The recent advances in skull base surgery warrant further and larger studies on this neglected yet important foramen to gather more data on its morphometric variations in different geographical regions.

Febrile urinary tract infection after Double-J stent removal is associated with restenosis after laparoscopic pyeloplasty: A propensity score matched analysis of 503 children

To analyze the association between the febrile urinary tract infection (fUTI) after Double-J (DJ) stents removal and restenosis after laparoscopic pyeloplasty (LP). We retrospectively reviewed the clinical data of patients who were treated with transperitoneal LP for ureteropelvic junction obstruction from 2016 to 2020. Patients were divided into two groups according to whether they developed fUTI after DJ stent removal within 48h. The 1:3 Propensity Score Matched (PSM) method was used to balance confounding variables. 503 patients were included in the study. 28 (5.57%) patients developed fUTI after DJ stent removal. Compared with the non-fUTI group, age was younger, and weight was lower (P<0.05) in the fUTI group. Restenosis occurred in 11 (2.2%) patients, of which six patients developed fUTI after DJ stent removal. The revision surgery rate in the fUTI group was significantly higher than in the non-fUTI group (21.4% vs. 1.1%, P<0.01). After PSM, the results remained consistent. For 492 patients without restenosis, 22 patients developed fUTI. Compared with the non-fUTI group, the larger anteroposterior diameter (APD) and higher APD/cortical thickness (P/C) ratio were observed in the fUTI group at three months and six months postoperatively (P<0.05), but the difference vanished at 12 months and 24 months after surgery (Figure). FUTI after DJ stent removal is not uncommon after LP, and surgeons are often concerned about the possibility of restenosis. In the present study, although our results demonstrated a significant association between them, restenosis patients comprise only about 20% of fUTI patients. Based on our clinical observations, fUTI is often developed in children from 1 to 6 years of age, and the younger patients may be afraid of voiding because of the postoperative pain after DJ stent removal. Besides, intraoperative manipulation of DJ stent removal may lead to transient edema in the anastomotic site, causing the fUTI. For patients who develop fUTI after DJ stent removal but without persistent symptoms, the transient worsening of hydronephrosis during the early postoperative period may not impact long-term outcomes (As shown in Figure). Additional follow-up is needed to prevent the deterioration of renal function. Our result demonstrated that fUTI after DJ stent removal is associated with restenosis after LP. For fUTI patients without restenosis, APD and P/C ratio exhibited transient worsening at three months and six months postoperatively, decreasing gradually during follow-up. Patients who develop fUTI after DJ stent removal should be monitored.

The Effect of Size of Decompressive Craniectomy on Outcome in Deep Spontaneous Intracerebral Hemorrhage

AbstractIntroduction Spontaneous intracerebral hemorrhage (SICH) is one of the most devastating forms of stroke with a mortality of 30 to 40%. We aimed to evaluate the effect of craniotomy size and volume of decompression on surgical outcome, complications, mortality, and morbidity in patients with supratentorial capsuloganglionic bleeds who underwent a decompressive craniectomy (DC) at our institute.Materials and Methods It is a retrospective study done between January 2015 and December 2019. All patients with capsuloganglionic bleeds who had DC and hematoma evacuation were included in the study.Results A total of 55 patients underwent DC for SICH at our hospital during the study period. Mean anteroposterior (AP) diameter of the bone flap was 12.42 cm. The volume of decompression did not influence mortality and morbidity in our study but a larger AP diameter was associated with a higher incidence of hydrocephalus. A smaller craniectomy with an AP diameter of &lt; 12 cm caused a lesser reduction in midline shift (MLS). Persistent postoperative MLS had a significant impact on mortality and its reduction was dependent on the size of craniectomy (p =–0.037)Conclusion DC with a recommended AP diameter of 12 to 13 cm achieves optimal results in terms of reduction in MLS. Larger DC volume carries a higher risk of hydrocephalus and requires close follow-up.

Personalized application of machine learning algorithms to identify pediatric patients at risk for recurrent ureteropelvic junction obstruction after dismembered pyeloplasty.

To develop a model that predicts whether a child will develop a recurrent obstruction after pyeloplasty, determine their survival risk score, and expected time to re-intervention using machine learning (ML). We reviewed patients undergoing pyeloplasty from 2008 to 2020 at our institution, including all children and adolescents younger than 18years. We developed a two-stage machine learning model from 34 clinical fields, which included patient characteristics, ultrasound findings, and anatomical variation. We fit and trained with a logistic lasso model for binary cure model and subsequent survival model. Feature importance on the model was determined with post-selection inference. Performance metrics included area under the receiver-operating-characteristic (AUROC), concordance, and leave-one-out cross validation. A total of 543 patients were identified, with a median preoperative and postoperative anteroposterior diameter of 23 and 10mm, respectively. 39 of 232 patients included in the survival model required re-intervention. The cure and survival models performed well with a leave-one-out cross validation AUROC and concordance of 0.86 and 0.78, respectively. Post-selective inference showed that larger anteroposterior diameter at the second post-op follow-up, and anatomical variation in the form of concurrent anomalies were significant model features predicting negative outcomes. The model can be used at https://sickkidsurology.shinyapps.io/PyeloplastyReOpRisk/ . Our ML-based model performed well in predicting the risk of and time to re-intervention after pyeloplasty. The implementation of this ML-based approach is novel in pediatric urology and will likely help achieve personalized risk stratification for patients undergoing pyeloplasty. Further real-world validation is warranted.

SURGICAL TREATMENT OF SCHWANNOMA IN SUPRAORBITAL REGION: CASE REPORT

Schwannoma is a benign tumor originating from Schwann cells that make up the peripheral nerve sheath. An 11-year-old male referred by ophthalmologist reporting volume increase in right side orbit at a previous trauma site, with no pain complaints. Physical examination showed preserved visual acuity and motility and swelling in the lateral region of the right supraorbital margin. Computed tomography with contrast showed an expansive formation with contrast enhancement. The diagnostic hypotheses were lipoma and Schwannoma. Excisional biopsy was performed by supraorbital superciliary access and the lesion obtained was encapsulated, with elastic consistency, brown and medium staining 3.5 x 2.8 x 1.2 cm, with the largest laterolateral, anteroposterior, and craniocaudal diameters, respectively. Histopathological examination confirmed the Schwannoma diagnosis hypothesis. Patient is currently 6 months postoperatively, has well healed operative wound without sensory or motor deficits and new contrast-enhanced tomography does not show any signs of recurrence of the lesion.

The clinical manifestations of intermittent hydronephrosis and their relationship with renal function in pediatric patients

Most patients with intermittent hydronephrosis have preserved differential renal function (DRF), while others already have impaired DRF at diagnosis. We summarized the clinical manifestations of intermittent hydronephrosis to elucidate what may be related to DRF loss. We retrospectively reviewed patients presenting to our department with unilateral Dietl's Crisis between January 2014 and December 2017. Clinical characteristics were collected, including age of first onset, time of onset, duration of the longest single episodes and whether the patient had prenatally detected hydronephrosis. Ultrasonographic (US) parameters included anteroposterior diameter (APD) during the symptomatic and asymptomatic period. Dynamic renograms (DR) were reviewed to obtain preoperative DRF. A total of 150 patients met the selective criteria. Of the 128 patients whose mother had regular obstetric ultrasounds during pregnancy, 50 (39.06%) had prenatally detected pelvic dilation. The mean age of the first attack was earlier in the prenatally detected hydronephrosis group than in the postnatally detected group (4.58 vs 5.87, p=0.002). The mean preoperative DRF was 41.03% in all of the patients. The patients whose DRFs were below 40% had longer durations of single attacks than those over 40%. The former group also had larger APD during the symptomatic periods than the latter group. The risk of DRF < 40% was higher in the patients whose APD at attack was greater than 35mm (OR=5.111, χ2=12.899, p<0.001). The attack times, waiting time before the surgery and age of the first onset had no association with preoperative DRF. Our study first found that in patients with Dietl's Crisis, the APD during the symptomatic periods and the longest duration of the attack were associated with DRF loss. But the retrospective nature of our study limited us to understand the relationship between DRF and total duration of all attacks. This study revealed that children with prenatal hydronephrosis could develop Dietl's Crisis at early ages. A longer duration of attack and larger APD during the attack were associated with impaired DRF.

Mitral annulus morphometry in degenerative mitral regurgitation phenotypes

Degenerative mitral regurgitation (DMR) is classified into different phenotypes based on the extent of leaflet degeneration. Our aim is to demonstrate that phenotype complexity predicts the extent of structural abnormalities of mitral annulus (MA). Seventy-five patients with DMR and severe valve regurgitation and 23 patients with normal mitral valve were studied using 3D transesophageal echocardiography. Classification of DMR was done by allocating each 3D echocardiography result under five categories: fibroelastic deficiency (FED), FED+, forme fruste, Barlow's disease Mitral annular disjunction (BD MAD)- or BD MAD+. MA was reconstructed in early systole and in end systole. We tested for a trend toward enlargement and flattening of MA in end systole and for a difference in MA dynamics from early systole to end systole with a worsening of DMR phenotype, in the whole spectrum of subjects ranging from controls to BD MAD+. A significant trend was observed toward larger anteroposterior diameter, intercommissural diameter, annulus circumference, and annulus area (P<.001). A reduction was found in annulus height to commissural width ratio (P=.003): This indicates a progressive MA flattening. Prolapse height and prolapse volume tended to be larger (P<.001). Based on the extent of leaflet degeneration, DMR is classified into different phenotypes. As the disease progresses, a related increase in MA size is found, with rounder annular shape, loss of saddle shape, and increase in height and volume of leaflet prolapse. The most pronounced alterations are found in BD MAD+.

P1816Aortic root morphology in bicuspid aortic valve is related to the type of BAV

Abstract Background Dilatation of the ascending aorta associated with bicuspid aortic valve (BAV) is common and has been associated with an increased risk of aortic dissection. However, the causal links between BAV types, aortic valve dysfunction and aorta phenotype are still poorly understood. Our hypothesis is that aortic root dilatation in BAV is an anatomic modification related to the BAV type. Purpose To assess whether the morphology and orientation of the aortic root can be predicted by the type of BAV. Methods 86 patients with BAV without significant valvulopathy (aortic regurgitation &lt;2 and no more than mild stenosis with mean gradient &lt;10mmHg) referred for aortic aneurysm assessment and who had benefited from TTE and CT were studied. Definitions Typical BAVs have a horizontal valve opening (type I L-R and type 0 anteroposterior) while atypical BAVs have a vertical valve opening (type I N-R and type 0 lateral) (Figure). Asymmetry of the root is evaluated in type I BAV using the normalized diameter ND = sinus to commissure diameter/mean of the 3 sinus to commissure diameters. We compared, in the typical (n=64) and atypical (n=22) BAVs, using CT, the asymmetry of the root using the normalized diameter, the orientation of the bicuspid aortic valve opening and the orientation of the largest diameter of the aortic root using the sagittal plane as a reference (Figure). Results Patients with typical and atypical BAVs were comparable for age, sex, weight, height, aortic root surface area and maximum aortic root diameter. Aortic root asymmetric modifications were related to the type of BAV with: – a predominant non coronary sinus dilatation in type I L-R (Non coronary sinus to commissure normalized diameter = 1.02 in Type I l-R vs 0.98 in type I R-N; p=0.0004). – a predominant left coronary sinus dilatation in type I L-N (left coronary sinus to commissure normalized diameter = 1.07 in type I R-N vs 1.01 in type I L-R; p&lt;0.0001). – a significantly larger anteroposterior diameter in type 0 typical BAVs (45mm vs 40mm p=0.02) and a significantly larger lateral diameter in type 0 atypical BAVs (48mm vs 39mm p=0.0003). The orientation of the aortic valve opening is correlated with the type of BAV: Using the sagittal plan as a reference, this angle is 144,9° for the typical BAVs vs 56,6° for the atypical BAVs p&lt;0.0001 (Figure). The orientation of the maximal aortic diameter is correlated with the type of BAV: Using the sagittal plan as a reference, this angle is 64.3° for the typical BAVs and 143,1° for the atypical BAVs p&lt;0.0001 (Figure 1). Figure 1 Conclusion The morphology and orientation of the aortic root in BAVs are strongly correlated with the type of BAV, suggesting anatomical modifications rather than aortopathy.

An automated intravaginal dynamometer: Reliability metrics and the impact of testing protocol on active and passive forces measured from the pelvic floor muscles.

(1) To determine the reliability of an automated dynamometer designed to assess pelvic floor muscle (PFM) strength and resistance to passive elongation. (2) To evaluate the impact of PFM length and rate of tissue elongation on dynamometric outcomes. At each of two sessions, twenty nulliparous women performed three maximum voluntary contractions (MVC) of their PFMs with the dynamometer set to two different anteroposterior (AP) diameters (25 mm, 35 mm). Next, with PFMs relaxed, the arms of the dynamometer opened three times to 40 mm at two speeds (25 mm/s, 50 mm/s). Outcomes included baseline force, peak force, relative peak force, rate of force development (RFD), stiffness and stress relaxation. Repeated-measures ANOVAs were used to test trial, day, and task effects (α = 0.05), and intra-class correlation coefficients (ICCs) were computed. Forces measured on MVC were higher with the larger AP diameter, and passive resistance was higher for the faster rate of tissue elongation. The between-trial reliability of all outcomes was excellent (0.82 < ICC < 0.98) for all measures except for peak force during the passive elongation task (0.56 < ICC < 0.93). Between-day reliability was good to excellent for active and passive RFD (0.75 < ICC < 0.93), stiffness (ICC = 0.77) and relative peak force (0.71 < ICC < 0.87); absolute force (0.11 < ICC < 0.85) and stress relaxation responses (0.19 < ICC < 0.98) tended to be less reliable. The reliability of the dynamometer is adequate for both clinical and research applications. Relative forces were more reliable than absolute forces. Dimensions and rate of tissue elongation should be controlled and reported with all pelvic floor muscle assessments as these parameters impact outcomes.

Relationship between the Degree of Thoracic Deformity and the Angle Formed by a Line Connecting the Sternum and the Spinous Process of the Vertebrae in Individuals with Severe Motor and Intellectual Disorders

[Purpose] The purpose of this study was to examine the relationship between the degree of thoracic deformity (TD) and the angle formed by a line drawn on transverse plane computed tomography (CT) images, connecting the sternum and the spinous process of the vertebrae at the level of the xiphisternum, and the perpendicular line from the floor (ANGLE), in individuals with severe motor and intellectual disorders (SMID). [Subjects] Twenty seven individuals with SMID were examined. [Methods] CT transverse images were acquired at the level of the xiphisternum of each patient. Two protocols were used to measure the anteroposterior (AP) and laterolateral (LL) diameters. The largest AP diameters were measured along a perpendicular line from the floor (protocol 1) and the line from the midline of the sternum to the spinous process of the vertebrae (protocol 2). The largest LL diameters were measured along the lines perpendicular to the AP diameters in each protocol. The ratios of the AP to LL diameters and the difference between the ratios of protocols 1 and 2 (DIFFERENCE) were calculated. [Results] Moderate to good correlation between DIFFERENCE and ANGLE was observed, and DIFFERENCE became larger with increasing ANGLE. [Conclusions] These results show that ANGLE indicates the degree of TD.

Measurements of the Length and Diameter of Main Bronchi on Three-Dimensional Images in Asian Adult Patients in Comparison With the Height of Patients

To measure the length and diameter of the main bronchus using the three-dimensional reconstruction images from the spiral chest computerized tomography scans in Asian adult patients, and to evaluate the relationship between the height of patients and the length and diameter of main bronchi. Prospective observational study. Academic, tertiary care hospital. Two hundred Asian adults undergoing a chest spiral computerized tomography scan. No intervention. The authors measured the anteroposterior and transverse diameters of the mid-portion of the right main bronchus and 2 cm below the carina of the left main bronchus. In addition, the length of both main bronchi was also measured. The length of the left main bronchus was about 3-4 times greater than its right counterpart. The main bronchus of women was oval-shape, with a large anteroposterior diameter, but the main bronchus of men was round-shape. There was no significant correlation between the measurements of main bronchi and the height of patients. The results showed that there is no direct relationship between the length and diameter of main bronchi and the height of patients. The height is not the criterion for choosing DLT size. Therefore, the authors proposed that 3-D images be used to determine the size of the main bronchi. The diameter of main bronchus using the 3-D images can be used to determine the optimal size of the DLT in a clinical setting, although further studies are needed.

The Petrous Portion of the Temporal Bone as Shown on Sonography Between 14 and 40 Weeks' Gestation

The purpose of this study was to examine the feasibility of sonographically identifying, measuring, and constructing nomograms of the fetal petrous bone, the part of the temporal bone that houses the auditory apparatus. A total of 248 consecutive pregnant women between 14 and 40 weeks' gestation were included. During a routine scan using transvaginal or transabdominal sonography, the fetal head was assessed in transverse sections. First, the parotid gland or external ear was identified, followed by the petrous bone. This annular echogenic structure, located medially and superior to the parotid gland or external ear, was measured at its largest anteroposterior diameter. The petrous bone on at least one side was measured; if both sides were visualized easily, both petrous bones were measured. In 247 fetuses, at least one petrous bone was measured. The petrous bone measurement correlated well with the gestational age (R = 0.908; P < .001), biparietal diameter (R = 0.983; P < .001), and femur length (R = 0.913; P < .001). Depiction of the petrous bone is feasible at all gestational ages and correlates well with the gestational age, biparietal diameter, and femur length. The usefulness of the ability to depict this bone in prenatal diagnosis of congenital malformations of the inner ear should be tested in prospective studies.

Three-Dimensional Remodeling of Mitral Valve in Patients With Significant Regurgitation Secondary to Rheumatic Versus Prolapse Etiology

The present study aimed to investigate geometric remodeling of the mitral valve (MV) and to identify the geometric determinants of mitral regurgitation (MR) severity in patients with significant MR secondary to a rheumatic or prolapse etiology. We studied 90 consecutive patients in normal sinus rhythm, including 70 patients showing significant MR (52 with prolapsed/flail and 18 with rheumatic MV) and 20 controls with normal MV without MR. A full volume image was acquired using transesophageal echocardiography, and geometric analysis of the MV leaflet was performed with dedicated software. Areas of the MV annulus and the anterior and posterior leaflets were larger in the rheumatic and prolapsed MV than in the normal controls. No difference was found between the rheumatic and prolapsed MR in those parameters, except that the posterior leaflet area was smaller in rheumatic MR than in prolapsed MR. The leaflet to annulus area ratio was lower and the anterior to posterior leaflet area ratio was higher in the rheumatic MR group than in the prolapsed MR group. A large anteroposterior annulus diameter and small posterior leaflet tenting angle were independently associated with the effective regurgitant orifice area in rheumatic MV, although the leaflet to annulus area ratio was independently associated with the effective regurgitant orifice area in the prolapsed MV. In conclusion, similarities and differences in geometric MV remodeling exist between rheumatic and prolapsed MR. The knowledge of those quantitative differences could open the way to precise planning of surgery tailored to the underlying pathologic entity.

Risk factors for gastric distension in patients with acute appendicitis: a retrospective cohort study

There has been no report on risk factors for gastric distension (GD) when inducing general anesthesia in an emergency situation. The aim of this study was to clarify the risk factors for GD in patients with acute appendicitis at their hospital visit. We reviewed medical records of patients from April 2007 to March 2010 who underwent open appendectomy for acute appendicitis and were diagnosed pathologically. GD was defined as a larger anteroposterior diameter and larger lateral diameter of the stomach than those of the left kidney in computed tomography (CT) imaging. The primary outcome was the presence of GD. Candidate variables such as patient characteristics, physical findings, and CT imaging findings associated with GD were assessed. Time after beginning of abdominal pain was categorized and compared. Determinants with significant univariate association (P<0.20) with the primary outcome were used to construct multivariable logistic regression models. We enrolled 121 patients and divided this cohort into a GD group (44 cases, 36%) and a non-GD group (77 cases, 64%). Results of univariate analysis showed longer duration of time after beginning of abdominal pain (P=0.016), younger age (P<0.001), and more frequent distended small bowel (P<0.001) in the GD group than in the non-GD group. In multivariate analysis, age [odds ratio (OR)=0.939, P=0.002] and time after beginning of abdominal pain (OR=1.807, P=0.031) were shown to be independent risk factors. Younger appendicitis patients with acute abdominal pain for 1 or more days should be treated as patients with high risk for GD.

Prognostic predictors on the efficacy of oral appliance therapy for obstructive sleep apnea syndrome

Objectives: The aim of this study was to identify independent prognostic predictors of the efficacy of oral appliance (OA) therapy for obstructive sleep apnea syndrome (OSAS). Materials and methods: The subjects consisted of 89 patients (77 males and 12 females) in whom OSAS had been treated with an OA. The mean age of the subjects was 52.4 years (range: 20 to 78 years) and mean body mass index (BMI) was 23.9 kg/m2 (range: 17.3 to 32.2 kg/m2). Lateral cephalograms were taken and 15 angle, 15 distance and 5 area measurements were calculated by means of a computerized program. Overnight polysomnography (PSG) was performed before treatment and several months after titration of OA therapy. OA therapy was considered effective if the apnea-hypopnea index several months after titration was under 15 events/h and was reduced to at least 50% of that before treatment. The examined data such as patient age, sex, BMI, data from cephalometric analyses, Epworth sleepiness scale, and data for pretreatment PSG were analyzed statistically, and multivariate logistic regression analysis was performed to clarify predictive variables for treatment outcome. Results: LFH (OR = 0.350; p = 0.035) and McN-A (OR = 0.276; p = 0.057) were selected as independent predictors from the explanatory variables. The predictive accuracy of the calculated logistic regression model was 74.2%. Conclusion: This results show that OA therapy for OSAS is more effective in patients with large anteroposterior diameter of the maxilla and large lower facial height.

Subsidence and Nonunion after Anterior Cervical Interbody Fusion Using a Stand-Alone Polyetheretherketone (PEEK) Cage

BackgroundThe purposes of the present study are to evaluate the subsidence and nonunion that occurred after anterior cervical discectomy and fusion using a stand-alone intervertebral cage and to analyze the risk factors for the complications.MethodsThirty-eight patients (47 segments) who underwent anterior cervical fusion using a stand-alone polyetheretherketone (PEEK) cage and an autologous cancellous iliac bone graft from June 2003 to August 2008 were enrolled in this study. The anterior and posterior segmental heights and the distance from the anterior edge of the upper vertebra to the anterior margin of the cage were measured on the plain radiographs. Subsidence was defined as ≥ a 2 mm (minor) or 3 mm (major) decrease of the segmental height at the final follow-up compared to that measured at the immediate postoperative period. Nonunion was evaluated according to the instability being ≥ 2 mm in the interspinous distance on the flexion-extension lateral radiographs.ResultsThe anterior and posterior segmental heights decreased from the immediate postoperative period to the final follow-up at 1.33 ± 1.46 mm and 0.81 ± 1.27 mm, respectively. Subsidence ≥ 2 mm and 3 mm were observed in 12 segments (25.5%) and 7 segments (14.9%), respectively. Among the expected risk factors for subsidence, a smaller anteroposterior (AP) diameter (14 mm vs. 12 mm) of cages (p = 0.034; odds ratio [OR], 0.017) and larger intraoperative distraction (p = 0.041; OR, 3.988) had a significantly higher risk of subsidence. Intervertebral nonunion was observed in 7 segments (7/47, 14.9%). Compared with the union group, the nonunion group had a significantly higher ratio of two-level fusion to one-level fusions (p = 0.001).ConclusionsAnterior cervical fusion using a stand-alone cage with a large AP diameter while preventing anterior intraoperative over-distraction will be helpful to prevent the subsidence of cages. Two-level cervical fusion might require more careful attention for avoiding nonunion.

Morphological adaptations of incisors in the subterranean Gansu zokor, Myospalax cansus (Rodentia, Spalacidae)

The incisor morphology of rodents varies a good deal among different genera and each structure may have a special evolutionary significance. Some basic and lateral profile measurements of upper and lower incisors which may reflect morphological adaptations of the Gansu zokor (Myospalax cansus, a typical subterranean rodent in northern Asia) and the brown rat (Rattus norvegicus, a typical aboveground rodent that has close body size to the Gansu zokor) were analyzed. GIS (Geographic Information System) software and nonlinear regression were used to analyze incisor lateral profile, allowing the incisors to be viewed as circular arcs with a high degree of accuracy. The results show that: i) zokors have more robust (i.e. larger anteroposterior diameter and transverse diameter values), heavier and longer upper as well as lower incisors than rats; ii) zokors show a significantly higher level of sexual dimorphism (male dominant) than rats on the incisor morphology (including basic and lateral profile measurements) and iii) the upper incisor is heavier than lower incisor in rats, as opposed to zokors, in which the lower incisor is heavier than the upper incisor, indicating that more resources must have been allocated to lower incisors of zokors.

The petrous portion of the temporal bone can be demonstrated by transvaginal ultrasound at 14–16 weeks of gestation

The temporal bone consists of four components: the squamous, petromastoid and tympanic portions, and the styloid process. The petrous part houses the auditory apparatus1. This mass of bone is wedged between the sphenoid and occipital bones in the cranial base1. Complete agenesis of the petrous portion of the temporal bone occurs in Michel aplasia2, a congenital malformation associated with congenital hearing loss. Here we describe, for the first time, the sonographic appearance of the petrous part of the temporal bone in normal pregnancies, between 14 and 16 weeks of gestation, using transvaginal sonography (TVS). Approval for the study was given by the Institutional Review Board (Helsinki Committee Protocol). Thirty-four consecutive pregnant women, between 14 and 16 weeks of gestation, were examined after giving written informed consent to take part in the study. All patients were studied during a routine fetal anomaly scan using TVS, with an endocavitary 5–9-MHz transducer (Voluson 730 Expert; GE Medical Systems, Milwaukee, WI, USA). Patients were included in the study if there was a single fetus without evident or suspected fetal malformations and no family history of congenital hearing loss. The fetal head was assessed in transverse sections with the parotid gland first identified as an echoic structure located medial to the external ear; the petrous bone (an annular echogenic structure located medial and superior to the parotid gland) was then identified and measured in its largest anteroposterior diameter (Figure 1, Videoclip S1). The largest of three measurements was documented. The petrous bone was measured on at least one side of the head in each fetus. The examination time was not prolonged in order to permit measurement of the petrous bone (beyond the short time needed for the measurement itself) and no special attempt was made to measure the bone on both sides. However, bilateral measurements were obtained when both sides were visualized easily. Measurement of the petrous bone (calipers) at 15 weeks of gestation. Ant., anterior; Post., posterior; E, eye. In all 34 fetuses the petrous bone was visualized and measured on at least one side, and in eight patients the petrous bones were visualized and measured bilaterally. The median anteroposterior diameter of the petrous bone was 4.5 (range, 3.5–6.1) mm, and the mean ( ± SD) anteroposterior diameter was 4.59 ± 0.53 mm. This is the first report to describe the normal appearance of the fetal petrous bone. The ability to visualize the petrous bone raises the possibility of prenatal diagnosis of congenital malformations of the inner ear, such as Michel aplasia2. Congenital hearing loss owing to malformation of the inner ear is classified into several types3-5. Some of these malformations are associated with malformations of the temporal bone, specifically the petrous portion, which is reported to be malformed in about 20% of cases of congenital deafness4. We measured the petrous bone at 14–16 weeks of gestation because at later gestational ages measurement of the bone is more difficult and time-consuming. However, we now measure the normal petrous bone at up to 40 weeks of gestation. TVS was used because this is the standard technique used in our institution for a routine fetal anomaly scan at the gestational age considered. However, the petrous bone can also be visualized using transabdominal transducers at 14–16 weeks. SUPPORTING INFORMATION ON THE INTERNET The following supporting information may be found in the online version of this article: Videoclip S1 Videoclip showing measurement of the petrous bone in a 15-week fetus. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. M. Odeh*, E. Ophir*, J. Bornstein*, * Department of Obstetrics and Gynecology, Western Galilee Hospital, Nahariya, Rappaport Faculty of Medicine, Technion, Haifa, Israel

Ultrasonography in patients with ulnar neuropathy at the elbow: Comparison of cross‐sectional area and swelling ratio with electrophysiological severity

The aim of this study was to determine the diagnostic value of ultrasonographic measurements in ulnar neuropathy at the elbow (UNE) and to assess the relationship between the measurements and the electrophysiological severity. The largest anteroposterior diameter (LAPD) and cross-sectional area (CSA) measurements of the ulnar nerve were noted at multiple levels along the arm, and the distal-to-proximal ratios were calculated. Almost all of the measurements and swelling ratios between patients and controls showed statistically significant differences. The largest CSA, distal/largest CSA ratio, CSA at the epicondyle, and proximal LAPD had larger areas under the curve than other measurements. The sensitivity and specificity in diagnosing UNE were 95% and 71% for the largest CSA, 83% and 85% for the distal/largest CSA ratio, 83% and 81% for the CSA at the epicondyle, and 93% and 43% for the proximal LAPD, respectively. There was a statistically significant correlation between the electrophysiological severity scale score (ESSS) and the largest CSA, the CSA at the epicondyle and 2 cm proximal to the epicondyle, and the LAPD at the level of the epicondyle (P < 0.05). None of the swelling ratios showed a significant correlation with the ESSS. The largest CSA measurement is the most valuable ultrasonographic measurement both for diagnosis and determining the severity of UNE.