Lateral Films Research Articles

Apparent Proximal Ulna Dorsal Angulation Variation Due to Ulnar Rotation

To investigate the effect of ulna rotation on the apparent proximal ulna dorsal angulation (PUDA). Computed tomography images of 59 ulnas were included in this study, 48 being bilateral specimens and the remaining 11 were unilateral. Three-dimensional models of the entire ulna were obtained, and the ulnas were rotated in 5-degree increments in internal rotation or external rotation from neutral. PUDA, PUDA apex, varus angulation, and varus apex were measured on each ulna. With the ulna in neutral rotation, the mean (95% CI) PUDA was 3.7 (2.9-4.5) degrees, whereas the mean varus angle was 10.5 (9.8-11.1) degrees. The varus angle apex and PUDA apex were 28.9 (27.5-30.2)% and 19.6 (18.7-20.6)% along the total length of the ulna, respectively. As the ulna was rotated externally by 5, 10, and 15 degrees, the PUDA increased by 0.7 (0.5-0.9) degrees, 1.2 (0.9-1.4) degrees, and 1.4 (1.1-1.8) degrees, respectively. Conversely, with internal rotation of 5, 10, and 15 degrees, the PUDA decreased by 0.9 (0.8-1.1) degrees, 2.0 (1.8-2.3) degrees, and 3.3 (2.7-3.9) degrees, respectively. This study demonstrates that small degrees of ulna rotation result in a statistically significant change in the apparent PUDA; however, this may not represent a clinically significant difference. Because of the anatomic variation between patients, it is important to obtain a contralateral film to determine the PUDA for anatomic reduction of the ulna in complex cases. When using a contralateral image, it is important to obtain a true lateral film or consider using 3-dimensional imaging for preoperative planning.

Factors Influencing Serum Homocysteine Levels in Postmenopausal Osteoporotic Females – Comparison to Urinary Collagen Crosslinks –

ABSTRACTPurpose: The correlation between serum levels of homocysteine and bone mineral density remains controversial. The aim of this study was to identify the potential factors associated with the levels of serum total homocysteine (S-Hcy) and urinary N-terminal telopeptide of type I collagen (U-NTX) in female osteoporotic patients.Materials and Methods: This cross-sectional study included 163 female osteoporotic patients, aged between 48 and 91 years, who had never been treated with anti-osteoporosis therapy. Background data including spine and hip bone mineral density, ongoing therapy for the metabolic disease, aortic calcification score as evaluated by lateral lumbar X-ray film, and recent fragility fracture history were obtained. S-Hcy, U-NTX levels, and creatinine clearance were measured.Results: Multiple linear regression analysis revealed a significant correlation between S-Hcy levels and aortic calcification score (p = 0.022), creatinine clearance (p = 0.004), and recent fracture history (within 1 year after fracture) (p = 0.028); conversely, U-NTX levels correlated significantly with total hip bone mineral density (p < 0.0001) and recent fracture history (p = 0.0007).Conclusions: S-Hcy levels had no correlation with bone mineral density, but were associated with the degree of aortic calcification, renal function, and fracture events. These confounding factors should be taken into consideration when the relationship between S-Hcy and bone mineral density is discussed.

Predictive value of hyoid cephalometrics for retroglossal obstruction in patients with obstructive sleep apnoea hypopnea syndrome.

To examine the diagnostic value of hyoid cephalometrics in predicting retroglossal obstruction severity in patients with obstructive sleep apnoea hypopnea syndrome. Ninety-six obstructive sleep apnoea hypopnea syndrome patients diagnosed by polysomnography were recruited. Polysomnography was repeated with a nasopharyngeal tube after eliminating rhinal and palatopharyngeal obstruction. Cervical vertebra lateral films and hyoid cephalometric measurements were obtained, including the distances of the hyoid to the: mental tubercle, prevertebral plane, mental tubercle coronal plane and mental tubercle horizontal plane. The apnoea-hypopnoea index for nasopharyngeal tube polysomnography was significantly correlated with distances from the hyoid to: prevertebral plane (r = 0.350), coronal plane (r = 0.477), horizontal plane (r = 0.529) and mental tubercle (r = 0.560). It was strongly correlated with the hyoid to mental tubercle distance/hyoid to prevertebral plane distance value (r = 0.683), and (hyoid to coronal plane distance plus hyoid to horizontal plane distance)/hyoid to prevertebral plane distance value (r = 0.675). Obstructive sleep apnoea hypopnea syndrome patients with longer hyoid to mental tubercle distances, and/or more inferior and posterior hyoid bone position, are more prone to retroglossal stenosis and obstruction. Hyoid cephalometrics are valuable for predicting retroglossal obstruction severity.

Effects of reduction with different anterior and medial cortical supports on stability after in-tramedullary nailing for unstable intertrochanteric fractures: a biomechanical comparison

Objective To compare the biomechanical stabilities among different combinations of anterior and medial cortical supports after intramedullary nailing for unstable intertrochanteric fractures. Methods Twenty-seven synthesized femur specimens were used to create models of unstable intertrochanteric fracture of type 31A2.1 according to AO/ASIF classification. They were divided into 9 groups (n=3) ac-cording to 9 combinations of anterior and medial cortical supports on the anteroposterior and lateral X-ray films: positive-positive, positive-neutral, positive-negative, neutral-positive, neutral-neutral, neu-tral-negative, negative-positive, negative-neutral, negative-negative groups. After all the fractures were fixated with the newly adapted femoral intertrochanteric nails (FITN), static loadings were applied for tests of fatigue and destruction to investigate the relative displacements and yield loads of the head-neck fragments. Results For the positive-positive, positive-neutral, positive-negative, neutral-positive, neutral-neutral, neutral-negative, negative-positive, negative-neutral, negative-negative groups, the vertical displacements of the head-neck frag-ments under fatigue loading were respectively 5.33±0.58 mm, 7.83±0.29mm, 7.73±0.15 mm, 8.17±0.29 mm, 8.33±1.15 mm, 8.83±0.29 mm, 9.33±0.58 mm, 9.67±1.15 mm and 12.0±1.0 mm, showing significant differences (P<0.05). The smallest displacement was observed in the positive-positive group, significantly smaller than that in any other groups (P<0.05). For the above 9 groups, the yield loads were respectively 4,967±153 N, 4,467±58 N, 3,717±76 N, 2,767±58 N, 2,533±58 N, 2,267±58 N, 1,833±58 N, 1,667±58 N and 1, 333±58 N, showing significant differences between any 2 groups (P<0.05). In the destruction test, bone interface loosening in the femoral head happened in 2 cases, bone interface loosening in the intertrochanteric zone in 15 cases, split fracture at the zone of distal locking nail in 2 cases, and loosening and breakage of the internal fixator in the distal femur in 8 cases. Conclusions The medial cortical support plays a major role and the anterior cortical support plays a secondary role in the stability of unstable intertrochanteric fracture. In the surgical procedure, surgeons should avoid the medial cortical negative support as much as possible. Key words: Hip fractures; Fracture fixation, internal; Biomechanics; Positive cortical; Reduction

Mandibular repositioning in adult patients — an alternative to surgery? A two-year follow-up

Abstract Background Adult patients presenting with skeletal discrepancies may refuse surgical intervention. Materials and methods Thirty-two patients who declined orthognathic correction of their maxillo-mandibular dysplasia and who were without signs of temporomandibular dysfunction (TMD) were offered mandibular repositioning as a non-invasive alternative. Simulating a skeletal correction, it was explained that the approach was based on results described in case reports. Before commencing treatment, initial records, lateral and frontal head films, study casts and photos were obtained (T0) and the mandible was repositioned to camouflage a retrognathic skeletal discrepancy or a mandibular transverse asymmetry by means of an occlusal build-up using Triad™ gel. Results Three months later (T1), 23 patients had adapted to the new occlusion reflected by an absence of functional disturbance and without fracture of the composite occlusal build-up. Mandibular position in these patients was maintained by additional orthodontic treatment and an adjustment of the occlusion to the built-up postured position (T1). The skeletal changes occurring during repositioning were assessed on sagittal and frontal head films while intra-articular changes occurring during a two-year follow-up period (T2) were evaluated on images constructed from CBCT scans. No significant change, either in the direction of relapse or in the direction of further normalisation of condylar position, were observed during the two-year observation period. Conclusion Mandibular repositioning is a non-invasive intervention that may be considered a valid alternative to surgery in selected patients. Morphological variables from the radiographs taken at T0 and the results of the initial clinical evaluation of dysfunction yielded only vague and insignificant indicators regarding the predictability of the adaptation. A CBCT scan at T0 might have contributed to the identification of the patients who would likely accept the repositioning.

Clinical effect of modified open-door laminoplasty with preservation of the unilateral paraspinal muscle ligament com-plex in treating ossification of posterior longitudinal ligament of the cervical spine

Objective To investigate the clinical efficacy of modified open-door laminoplasty with preservation of the unilateral paraspinal muscle ligament complex in treating ossification of posterior longitudinal ligament (OPLL) of the cervical spine. Methods From June 2015 to July 2017, thirty-two patients with OPLL of the cervical spine who underwent modified open-door laminoplasty with preservation of the unilateral paraspinal muscle ligament complex were retrospectively analyzed (modified group). There were 20 males and 12 females with the average age of 61.72±8.41 years (range 46-75 years). The de-compression segment range included three cases of C2-C6, seven cases of C2-C7, eight cases of C3-C6, and fourteen cases of C3-C7. Moreover, twenty-three patients with OPLL of the cervical spine who underwent traditional unilateral open-door laminoplas-ty at the same time were included as controls (control group). The demographics, operation duration, and blood loss volume was recorded. The visual analogue scale (VAS), Japanese Orthopaedic Association scores (JOA), improvement rate of JOA score and neck disability index (NDI) were recorded and analyzed at preoperation, three months after operation, six months af-ter operation and at the final follow-up. The cervical curvature, cervical curvature index (CCI), range of motion (ROM) were measured and statistically analyzed on the lateral X-ray film of the cervical spine. The union rate of the lamina hinge and that of spinous process-lamina was measured on the cross section of the CT scan. Bilateral cervical posterior muscle volume was re-corded and analyzed at cross-section plane on MRI. Axial symptoms, C5 nerve root palsy and other complications were also re-corded. Results All the patients were followed-up for 6 to 18 months (mean, 13.04±4.67 months in control group, 11.81±4.93 months in modified group). At the final follow-up, the JOA, VAS and NDI scores improved from preoperatively 6.09±0.79 to 13.43±1.53, 4.22±1.04 to 2.83±1.15 and 25.48%±3.20% to 8.83%±5.41% in the control group, versus 6.28±1.05 to 13.88±1.48, 4.09±1.00 to 1.16±0.57 and 25.06%±3.24% to 5.66%±2.46% in the modified group. The postoperative JOA score and recovery rate of the two groups was not significantly different, whereas the VAS and NDI scores were significantly reduced in the modified group compared to the control group. The maximum cervical flexion angle, cervical curvature, ROM and CCI of control group were 6.26°±3.31°, 30.17°±4.56°, 11.39°±1.95° and 9.74%±4.05% at the final follow-up, which were reduced significantly compared to pre-op-eration. The maximum cervical flexion angle, cervical curvature, ROM and CCI of modified group were 10.06°±1.93°, 35.03°±5.01°, 17.03°±2.86° and 14.22%±5.00%, and there were no significant differences compared to pre-operation. There were signifi-cant differences among two groups. At the final follow-up, the posterior muscle volume of the two groups at open side was de-creased compared to preoperation, but there was no significant difference between the two groups. At the last follow-up, the posteri-or muscle volume at hinge side was not changed compared to preoperation in modified open-door laminoplasty group, while the vol-ume of the posterior muscle at hinge side in the traditional control group decreased compared to preoperation. The difference was statistically significant. A total of eight patients with axial symptom were present after operation. There were two patients (6%, 2/32) in the modified group and six patients (26%, 6/23) in the control group. The difference of axial symptoms incidence was statisti-cally significant between the two groups. Conclusion Modified open-door laminoplasty with preservation of the unilateral para-spinal muscle ligament complex is an effective technique in treating OPLL of the cervical spine. The technique not only guaran-teed to have good recovery of neurological function and to maintain cervical curvature and range of motion, but also contributed to decrease the occurrence of postoperative axial symptoms. Key words: Cervical vertebrae; Ossification of posterior longitudinal ligament; Decompression, surgical

Treatment of severe distal humeral bone defects with three-dimensional printing technology

To explore the application of three-dimensional (3D) printing technology in precise and individualized surgical treatment of severe distal humeral bone defect. Five patients with severe distal humeral bone defects were treated with customized 3D printing prostheses between December 2010 and December 2015. There were 4 males and 1 female, with an age of 23-57 years (mean, 35 years); and the length of the bone defect was 5-12 cm (mean, 8 cm). The cause of injury was mechanical injury in 2 cases and strangulation in 3 cases. All of them were the open fracture of Gustilo type Ⅲ. There were 2 cases of radial fracture, 1 case of cubital nerve injury, and 3 cases of radial nerve injury. The time from injury to one-stage operation was 6-18 hours (mean, 10 hours). The operation time, intraoperative blood loss, and intraoperative fluoroscopy were recorded. During follow-up, the anteroposterior and lateral X-ray films of the elbow joints were performed to identify whether there was prosthesis loosening; Mayo Elbow Performance Score (MEPS) and upper extremity Enneking score were used to evaluate limb function. The operation time was 140-190 minutes (mean, 165 minutes). The intraoperative blood loss was 310-490 mL (mean, 415 mL). The intraoperative fluoroscopy was 1-3 times (mean, 1.6 times). Five patients were followed up 14-38 months (mean, 21 months). The wound exudate occurred in 1 case and cured after anti-inflammatory local dressing change; the subcutaneous hematoma occurred in 1 case, and improved after color Doppler ultrasound guided puncture and drainage. The MEPS scores and the Enneking scores were all significantly improved when compared with preoperative ones ( P<0.05). Except MEPS score between 6 and 12 months after operation had no significant difference ( P>0.05), there were significant differences in MEPS scores and Enneking scores between the other time points ( P<0.05). During the follow-up, no prosthetic loosening or joint dislocation occurred. 3D printing technology can achieve personalized treatment of severe distal humeral bone defects, obtain relatively good elbow joint function, and has less postoperative complications and satisfactory effectiveness.

Determination of downs hard tissue cephalometric norms for Himachali Mongoloid tribes

ObjectiveThe purpose of this study was (a) to establish hard tissue cephalometric norms for the population of Himachali Mongoloid tribes, (b) to study the sexual dimorphism in hard tissue cephalometric norms of this population and (c) to compare the Himachali Mongoloid norms with the norms established by Downs. Material and methodSixty Himachali Mongoloid subjects were selected on the basis of Angle’s Class I molar relationship, well aligned arches, full complement of teeth, having clinically acceptable facial esthetics, no previous history of Orthodontic treatment, subjects native of the tribal belt of Himachal Pradesh. Lateral head films were traced and Downs cephalometric parameters were recorded. Statistical analysis was done to compare the difference between the established norm and the norm established by Downs for the Caucasian population. ResultSignificant difference was seen in the Angle of convexity, with Himachali Mongoloid tribe population having a more forwardly positioned middle part of the face. This population had less steeper cant of occlusal plane, more acute interincisal angle, more inclined lower incisors in relation to the mandibular and the occlusal plane and more forwardly positioned maxillary incisor in relation to the A-pog line. ConclusionThese findings suggested that ethnic differences in the facial traits exist and awareness of dentofacial pattern of each ethnic group will ensure better success of the treatment in establishing optimal facial harmony.

A reproducible and reliable localization technique for lumbar spine surgery that minimizes unintended-level exposure and wrong-level surgery

Background ContextExposure of unintended levels (defined as a spinal segment outside the intended surgical levels) is unnecessary and potentially adds to operative time and patient morbidity. Wrong-level surgery (defined as decompression, instrumentation, or fusion of a spinal segment not part of the intended surgical procedure) clearly adds to morbidity as well as putting the surgeon at medicolegal risk. PurposeTo describe a localization technique for posterior lumbar spine surgery to minimize both unintended-level exposure and wrong-level surgery. Study DesignConsecutive case series. Patient SampleOne thousand nine hundred and eighty-six consecutive posterior lumbar operations performed from January 2010 to January 2017 using this technique were reviewed. Outcome MeasuresThe primary outcome measure was the incidence of unintended-level exposure and wrong-level surgery. MethodsThis localization technique was consistently used for determination of skin incision, soft tissue dissection, and identification of spinal levels for all patients undergoing posterior lumbar surgery during the time interval noted. Two spinal needles are inserted under sterile technique 3cm lateral to the midline before incision at the approximate cranial and caudal aspects of the anticipated incision based on external landmarks. A cross-table lateral X-ray before incision is obtained and the actual incision is adjusted based on the location of the spinal needles. Once dissection is carried down to the facet capsules, spinal needles are then placed in adjacent facets, and a second cross-table lateral film is obtained to confirm appropriate levels. A retrospective review of all posterior lumbar cases was performed to determine the incidence of unintended-level exposure and wrong-level surgery using this technique. ResultsThere were no wrong-level surgeries during this time period. There were six (0.30%) cases of unintended-level exposure. ConclusionsThe technique described provides surgeons with a reliable, accurate, and easily reproducible method for localizing surgical levels during posterior lumbar spine surgery while minimizing exposure of uninvolved areas. This technique offers distinct advantages over previously proposed protocols and may lead to a widely accepted system for intraoperative spinal level identification.

New Relaxation Mechanism Enabling High-Quality, Laterally Grown Ge on Si

We demonstrate a novel growth technique, metal-catalyzed, lateral epitaxial growth, to grow Ge films laterally on Si with reduced threading dislocation densities (TDD). In contrast to traditional planar film growth on Si, this technique starts with a small crystal nucleation at a specific position on Si followed by Ge lateral film growth. In plan-view and cross-sectional transmission electron microscopy micrographs, high-density threading dislocations were found to be present in the initial growth areas, while the lateral overgrowth areas demonstrated substantially reduced TDD or even defect-free areas. Furthermore, the X-ray diffraction results showed that the films were fully relaxed and mostly pure Ge. Full relaxation and low TDD Ge films are two surprising results given that the growth occurred at a low temperature (375 °C), which cannot be understood with the current misfit dislocation nucleation and glide model of film relaxation. For these reasons, we suggest the presence of a new relaxation mechan...

Treatment of distal radius fractures with dorsal dislocation of Fernandez type IV by open reduction and internal fixation

Objective To report the treatment of distal radius fractures with dorsal dislocation of Fernandez type Ⅳ by open reduction and internal fixation via a combined dorsal and volar approach. Methods A retrospective analysis was conducted of the 14 cases of fresh distal radius fracture with dorsal dislocation of Fernandez type Ⅳ which had been treated by open reduction and internal fixation via a combined dorsal and volar approach at Department of Orthopaedic Trauma, Beijing Jishuitan Hospital from July 2010 to June 2016. All the patients were male, with an average age of 38.4 years (from 27 to 52 years). The time from injury to surgery averaged 6.9 days (from 4 to 10 days). Their injury involved 5 left and 9 right wrists. Follow-up was performed at 1, 2, 3, 6 and 12 months after operation when anteroposterior and lateral X-ray films were taken and functional exercise guidance was provided. At 6 and 12 months after operation, all the patients were evaluated using modified Garland-Werley scoring and Patient Rated Wrist Evaluation (PRWE). Results The patients were followed up for an average of 19.4 months (from 15 to 26 months). Their fractures healed well. Their fracture healing time averaged 3.1 months (from 2 to 4 months). Their modified Garland-Werley scores at 6 and 12 months after surgery were 8.9 points (from 6 to 13 points) and 7.3 points (from 4 to 11 points), respectively; their PRWE scores were 17.9 points (from 12 to 25 points) and 16.5 points (from 11 to 23 points), respectively. None of the patients was inflicted by infection, vascular injury or internal fixation failure. Conclusion The open reduction and internal fixation via a combined dorsal and volar approach can restore the stability of both the dorsal osseous structure of the distal radius and the volar ligament structure of the wrist, facilitating postoperative maintenance of the radiocarpal joint stability, improving the wrist function and leading to satisfactory outcomes. Key words: Radius fractures; Fracture fixation, internal; Ligaments; Surgical approach

Implementation of High Dose-rate Brachytherapy for Cervix Cancer in a Low-income Country

Background:The purpose of this study is to detail the implementation of HDR brachytherapy at the only radiotherapy center in Nicaragua.Methods:Patients are treated with external-beam radiotherapy to 46–50Gy at 2Gy/fraction to the pelvis. A gynecologic examination is performed weekly. Once the cervical os is visualized, brachytherapy is initiated. HDR is delivered in four fractions of 7Gy twice weekly. HDR occurs in two phases: preparation and delivery. Treatment preparation occurs in the procedure room, which includes anesthization, cervical dilation, and brachytherapy applicator placement using fixed-geometry tandem and ring with a rectal blade. The applicator is immobilized and the patient transferred to a stretcher and transported to the treatment delivery room. HDR is performed with the patient on the stretcher to minimize motion. AP and lateral films are taken using portable equipment. Physics staff digitize Point A, rectal point, and bladder point. A standard plan is loaded and approved prescribing 7Gy to Point A. If dose to the rectal or bladder points exceeds the constraint, the applicator is adjusted or vaginal packing is added and films repeated.Results:Nearly 10 years after implementing the HDR program, the center is treating 11–15 women with HDR brachytherapy for cervix cancer daily. Because the procedure is carried out over two separate rooms, patients can be staggered and more treated daily. The rooms turn over every 45 minutes.Conclusions:HDR brachytherapy for cervix cancer has been successfully established in Nicaragua. Significant challenges remain, and there is a role for developed countries to collaborate.

Implementation of High Dose-rate Brachytherapy for Cervix Cancer in a Low-income Country.

The purpose of this study is to detail the implementation of HDR brachytherapy at the only radiotherapy center in Nicaragua. Patients are treated with external-beam radiotherapy to 46-50Gy at 2Gy/fraction to the pelvis. A gynecologic examination is performed weekly. Once the cervical os is visualized, brachytherapy is initiated. HDR is delivered in four fractions of 7Gy twice weekly. HDR occurs in two phases: preparation and delivery. Treatment preparation occurs in the procedure room, which includes anesthization, cervical dilation, and brachytherapy applicator placement using fixed-geometry tandem and ring with a rectal blade. The applicator is immobilized and the patient transferred to a stretcher and transported to the treatment delivery room. HDR is performed with the patient on the stretcher to minimize motion. AP and lateral films are taken using portable equipment. Physics staff digitize Point A, rectal point, and bladder point. A standard plan is loaded and approved prescribing 7Gy to Point A. If dose to the rectal or bladder points exceeds the constraint, the applicator is adjusted or vaginal packing is added and films repeated. Nearly 10 years after implementing the HDR program, the center is treating 11-15 women with HDR brachytherapy for cervix cancer daily. Because the procedure is carried out over two separate rooms, patients can be staggered and more treated daily. The rooms turn over every 45 minutes. HDR brachytherapy for cervix cancer has been successfully established in Nicaragua. Significant challenges remain, and there is a role for developed countries to collaborate.

Surgical Treatment of Malignant Pheochromocytomas in Spine

Surgical Treatment of Malignant Pheochromocytomas in Spine

Headless pressure screw with local complication of PRP for the treatment of intra-articular fracture of old metatarsal

To discuss clinical effects of headless pressure screw with local complication of PRP in treating old metatarsal intra-articular fracture. From January 2010 to June 2016, 7 patients with old metatarsal intra-articular fracture treated by open reduction headless compression screw internal fixation by local application PRP, including 5 males and 2 females, aged from 21 to 52 years old, 5 patients injured by falling down and 2 patients caused by crushing, the time from injury to operation ranged from 3 to 6 weeks. Preoperative anteroposterior, lateral and oblique X-ray film and three-dimensional CT reconstruction were examined, and the results showed 2 patients on the second metatarsal, 2 patients on the third metatarsal, 3 patients on the fourth metatarsal. Regular X-ray as postoperative examination was observed, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle scoring system at the final follow-up was evaluated. Seven patients were followed up from 6 to 17 months. All incisions healed at stage I without joint stiffness, traumatic arthritis and related complications. Imaging examination showed fracture reached bone healing, healing time ranged from 3 to 6 months. No joint stiffness and traumatic arthritis occurred. One of seven patients occurred stiffness of metatarsophalangeal joints. AOFAS score increased from 40.5±4.2 before operation to 85.0±10.5 at 12 months after operation, and 4 patients got excellent results, 2 moderate and 1 poor. The active motion of metatarsophalangeal joint showed dorsal flexion ranged from 35° to 40°, plantar flexion ranged from 25° to 35°. Headless pressure screw with local complication of PRP in treating old metatarsal intra-articular fracture could recover articular surface of metatarsal head, improve metatarsophalangeal joints activity, which do not need the second operation, and could receive good clinical results with early exercise.

Modifications of Midfacial Soft-Tissue Thickness Among Different Skeletal Classes in Italian Children

Background: The anatomical assessment of the arrangement of facial soft tissues has important applications in different fields from orthodontics to plastic surgery. One of the issues concerns the relationship between facial soft tissue thickness and skeletal class. Literature mainly deals with adult populations, whereas very few studies have been focused on children. Objective: This study aims at investigating the relationship between midline facial soft tissue thickness and skeletal classes in Italian pre-treatment orthodontic child patients. Methods: Lateral cephalometric X-ray films were obtained from 220 healthy Caucasoid children (91 males and 129 females), aged between 6 and 18 years (Class I: 41 males and 70 females; Class II: 18 males and 25 females; Class III: 32 males and 34 females). All the films were digitized and 14 soft tissue thicknesses were measured on the midface; in addition, the skeletal class was assessed according to the corrected ANB angle (ANBc). Differences in facial soft tissue thickness according to sex and skeletal class were assessed through two-way ANOVA test (p&lt;0.01). Results: Statistically significant differences according to sex were found for labrale superius, stomion and labrale inferius, with thicker soft tissues in males than in females (p&lt;0.01). Only measurements at labrale superius and gnathion showed statistically significant differences according to skeletal class, with thicker soft tissues in Class III children and thinner ones in Class II children (p&lt;0.01). Conclusion: The limited number of investigations, as well as the differences in protocols, renders the comparison of results from different studies difficult, suggesting further investigations to enlighten this complex and debated anatomical issue.

Treatment of Multidrug-Resistant Tuberculosis Infection in Children.

Treatment of Multidrug-Resistant Tuberculosis Infection in Children.

Overweight and underweight are risk factors for vertebral fractures in patients with type 2 diabetes mellitus.

The aim of this cross-sectional study was to examine the association between body mass index (BMI) and the prevalence of vertebral fracture (VF) in Japanese patients with type 2 diabetes (T2DM). A total of 798 patients with T2DM were enrolled. VF was determined semi-quantitatively using lateral X-ray films. The association between BMI quartiles (Q1: ≤ 21.2kg/m2, Q2: 21.3-23.4kg/m2, Q3: 23.5-25.8kg/m2, Q4: 25.9≤ kg/m2) and the presence of VF was examined. Multiple logistic regression analyses adjusted for age, sex, diabetes duration, hemoglobin A1c (HbA1c), estimated glomerular filtration rate, and albumin showed that Q1, Q3, and Q4 were significantly associated with an increased VF risk compared to Q2, which served as a reference [Q1; odds ratio (OR) = 1.91, 95% confidence interval (CI) 1.24-2.95, p = 0.004, Q3; OR = 1.65, 95% CI 1.07-2.55, p = 0.023, and Q4; OR = 2.18, 95% CI 1.39-3.41, p < 0.001]. Moreover, these associations remained significant after additional adjustment for femoral neck T-score, a bone resorption marker, urinary N-terminal cross-linked telopeptide of type-I collagen, and use of insulin and thiazolidinedione. Our study shows for the first time that both overweight and underweight were associated with the bone mineral density (BMD)-independent risk of VF in patients with T2DM. Therefore, body weight control should be considered as a protective measure against diabetes-related bone fragility.

Case Report: Newborn with Anorectal Malformation

Anorectal malformations are defined by the relationship of the rectum to the sphincter complex and can be classified as high and low anomaly based on whether meconium is present or absent, presence of dimple, anocutaneous reflex, sacral abnormality or presence of meconium in urine. The diagnosis should be made in the delivery room by inspecting the perineum. Meconuria with absence of anal opening invariably indicates a high malformation which requires a colostomy in the newborn period. Low malformations do not become evident until 24 hours when the meconium may show up in the perineal fistula. These defects can be managed by a perineal anoplasty without a colostomy in the newborn period. A prone cross table lateral shoot abdominal film is required if clinical information at 24 hours is insufficient to decide whether a colostomy is needed. We present a case of newborn, day 4 of life, who did not pass meconium since birth, had abdominal distension, vomiting, poor feeding and lethargy since last 2 days. Anal area showed pigmentation with presence of median raphe, anal dimple and slightly formed anal opening. Baby was initially thought as a case of low type imperforate anus. On further evaluation, was found to have meconuria too. Invertogram done showed high type defect. Rest of the examination was normal. Supportive therapy was initiated and baby underwent transverse loop colostomy for high type imperforate anus on day 5 of life. So it is always advisable to confirm the type of anorectal malformation both clinically and by doing required investigation before deciding for any operative intervention like colostomy or anoplasty, as clinical examination and investigation may not correlate in all occasions. Evaluation should also include screening out for associations and other sacral anomalies. BJHS 2018;3(2)6: 500-503.

Numerical Investigation of Film Cooling Enhancement Using an Upstream Sand-Dune-Shaped Ramp

Film cooling enhancement by incorporating an upstream sand-dune-shaped ramp (SDSR) to the film hole exit was numerically investigated on a flat plate under typical blowing ratios ranging from 0.5 to 1.5. Three heights of SDSRs were designed: 0.25D, 0.5D, and 0.75D. The results indicated that the upstream SDSR effectively controlled the near-wall primary flow and subsequent mutual interaction with the coolant jet, which was the main mechanism of the film cooling enhancement. First, a pair of anti-kidney vortices was formed at the trailing ridges of the SDSR, which helped suppress the kidney vortex pair due to the interaction between the coolant jet and the primary flow. Second, a weak separation and a low pressure zone were induced behind the backside of the SDSR, which caused the coolant jet to spread around the film cooling hole and improve the lateral film coverage. With respect to the baseline cylindrical film cooling holes, the effect of the upstream SDSR was distinct under different blowing ratios. Under a low blowing ratio, the upstream SDSR shortened the streetwise film layer coverage in the vicinity of the film hole centerline but increased the span-wise film layer coverage. A relatively optimal ramp height seemed to be 0.5D. Under a high blowing ratio, both the streamwise and span-wise film layer coverages improved in comparison with the baseline case. The film cooling effectiveness improved gradually with increasing ramp height.