Medial Wall Research Articles

FRI350 Prolonged Transient Central Diabetes Insipidus Induced By Traumatic Brain Injury

Abstract Disclosure: R. Marques: None. S. Sharma: None. B.S. Flores Chang: None. A. Sajan: None. Introduction: Central diabetes insipidus (CDI) is a rare complication of traumatic brain injury (TBI). Most cases of CDI due to TBI are transient and resolve within 2-5 days. We report a patient with prolonged transient CDI which lasted for 35 days after sustaining a gunshot wound to the head. Case Description: A 17-year-old male with no past medical history presented after gunshot wound in the head. He had comminuted fractures of the right temporal bone, right zygomatic arch, greater and lesser rings of sphenoid bone, right maxillary sinus, right medial orbital wall, right orbital floor and bilateral frontal sinuses. A computerized tomography of head showed subarachnoid haemorrhage of the frontal lobes as well as subdural haemorrhage of right parietal lobe, right falx cerebri and left cerebral hemisphere. On hospital day 2, he had an intracranial pressure monitor placed which was unremarkable. He underwent right hemicraniectomy with debridement and washout on hospital day 3. Shortly afterwards, his urine output increased to >500 cc/hr with serum sodium of 172 mEq/L [135-145], serum osmolality 307 mOsmol/kg [270-295], and urine osmolality of 117 mOsm/kg [300-900]; consistent with CDI. He was acutely treated with intravenous desmopressin with resolution of hypernatremia. During the next five weeks of his 3-month hospitalization, he continued to have polyuria with specific gravity as low as 1.003 [1.005-1.030], and occasional hypernatremia, with a peak serum sodium of 150 mEq/L. Intranasal desmopressin as well as free water supplementation were given daily to alleviate his polyuria and hypernatremia. Evaluation of anterior pituitary function was normal except for decreased gonadotrophins. His polyuria resolved after five weeks, and labs showed urine osmolality of 530 mOsm/kg with serum sodium 138 mEq/L and urine specific gravity 1.010, consistent with resolution of CDI. Intranasal desmopressin was discontinued. His serum sodium remained stable without desmopressin for the next 7 weeks with serum sodium at discharge of 141 mEq/L. Discussion: The damage of the hypothalamic vasopressin-producing neurons, their axons or the posterior pituitary results in permanent post-TBI CDI. In cases of transient CDI, the pathogenesis is likely related to small vessel damage or inflammatory edema rather than direct neuronal damage. In our case, the patient initially developed hypernatremia and polyuria from acute CDI due to hemicraniectomy with debridement and washout. He continued to have prolonged transient CDI due to the extensive intracranial hemorrhage and edema. The CDI resolved with desmopressin (both intravenous and intranasal) and fluid replacement. Transient CDI is a rare complication intracranial haemorrhage. Our case highlights that the severity of TBI may correlate with the duration of transient CDI. Presentation: Friday, June 16, 2023

Screw Misposition and Detachment During Paranasal Augmentation: A Patient Report With Complication and Management.

Paranasal concavity is esthetically displeasing and interferes with the overall outline of the face. Paranasal augmentation with alloplastic implants is a minimally invasive procedure with significant esthetic effects for paranasal concavity. When fixing the implants, the screws should be placed on the nasofrontal column, but are occasionally mispositioned on the anterior wall of the maxillary sinus. Here, the authors introduce a case of paranasal augmentation in which the self-tapping screw accidentally penetrated through the implant, broke through the anterior and medial walls of the maxillary sinus, and entered the nasal cavity. The screw was located by a computed tomography scan and was successfully removed under a nasal endoscope. The causes of this intraoperative complication were analyzed, emergent management was introduced, and a further preventive strategy was proposed.

Outcomes of orbital decompression for thyroid eye disease over a 10-year period at a tertiary eye care referral center

Background: Orbital decompression is frequently indicated to treat exophthalmos and compressive optic neuropathy, among other indications for thyroid eye disease (TED). This study aimed to evaluate the outcomes of orbital decompression and compare the results by urgency and type of surgery in patients with TED.
 Methods: In this cross-sectional study, we recruited patients with TED who had undergone emergency or elective orbital decompression surgery at a tertiary eye care referral center in Tehran, Iran, between 2010 and 2020. Ophthalmic examination findings, demographic and clinical profiles, and types and outcomes of surgical interventions were reviewed and analyzed.
 Results: Fifty-one orbits of 35 patients with a mean (standard deviation [SD]) age of 36.2 (12.0) years and male-to-female ratio of 23 (66%)/12 (34%) were included. The mean (SD) duration from the diagnosis to the surgery was 41.0 (39.0) months. The surgical method was fat decompression in 1 (2%) orbit; fat and inferior wall decompressions in 2 (4%) orbits; fat, inferior, and medial wall (two-wall) decompressions in 43 (84%) orbits; and fat, inferior, medial, and lateral wall (three-wall) decompressions in five (10%) orbits. Three-wall decompression surgery resulted in significantly lower exophthalmometry readings than those associated with two-wall surgery at all postoperative follow-ups (P < 0.05). Ten (20%) orbits required emergency decompression because of sight-threatening conditions and revealed comparable exophthalmometry readings with electively decompressed orbits at the 1-year visit (P > 0.05). Thirty-seven (73%) orbits required other surgeries within the 1-year follow-up. The mean (SD) exophthalmometry readings before and 1-year after surgery were 26.3 (4.0) and 18.3 (2.7) mm, respectively, with a significant decrease and significant 5.5 (3.3)-mm change from baseline in decompressed orbits (both P < 0.001). Diplopia was reported in 29% (n = 10) of patients less than 2 months postoperatively.
 Conclusions: Emergency or elective orbital decompression significantly reduced exophthalmos in patients with TED within 1 year postoperatively. Three-wall orbital decompression produced the more immediate impact, while two-wall orbital decompression showed the higher effect at a later timepoint. The most common complication was diplopia, while other serious complications occurred infrequently. Further prospective comparative studies involving more participants and longer postoperative follow-up periods are required to verify these preliminary findings.

Sagittal Orientation and Variabilities of the Anatomical Insertional Footprint of the Achilles Tendon: A Cadaveric Study

Category: Hindfoot; Sports Introduction/Purpose: New surgical techniques for Achilles tendon insertional pathology are evolving rapidly. Whether via open surgery, minimally invasive, or endoscopic approaches, more information about the Achilles' insertional footprint is needed to help surgeons with decision making. This study investigated the footprints of the Achilles insertion in sagittal orientation to delineate the anatomical landmarks, safe zones for bone resection3-down surgeries in treating insertional Achilles tendinopathies. Methods: Twenty fresh frozen cadavers were selected excluding insertional Achilles tendon pathology on lateral view x-rays. The calcanei were dissected maintaining the Achilles tendon insertion intact. Dimensions of the posterior tuberosity were recorded and marked to plan for three sagittal cuts (medial, middle, and lateral) (Fig 1 A). Using an oscillating saw (Fig 1 B.), the posterior tuberosity was cut into four pieces (Fig 1 C,E). A trapezoid shape (Fig 1 D) was reconstructed demonstrating relative location of the footprints of the Achilles insertion compared to the boundaries of the tuberosity on each piece (A, most superior point in the posterior tuberosity; B, most superior point in the Achilles insertion; C, most inferior point in the Achilles insertion; D, most inferior point in the posterior tuberosity). Data regarding footprints of the Achilles tendon insertion in the sagittal orientation was analyzed and compared within each trapezoid region and among different regions. Results: AB (calcaneal tuberosity tip to the upper limit of the Achilles insertion) was shortest at the medial cut (9.35mm) and longest at the lateral cut (12.15mm). However, the tendon thickness at the insertion (the distance from the proximal to the distal limits) represented by BC was shortest at the lateral cut (13.19mm) and longest at the middle cut (14.04mm). AD, the distance from the highest to the lowest point of the calcaneal tuberosity, was the longest at the middle cut (41.20mm). AB:BC ratio was highest at the lateral cut and lowest at the medial cut, indicating the safe amount of bone to be resected at the Achilles insertion. Tendon thickness relative to the whole calcaneal tuberosity (BC:CD) was highest at the medial wall (Table1). Conclusion: The sagittal orientation and variability of the Achilles tendon insertion is an under-studied topic in the literature. It needs to be addressed given recent trends towards minimally invasive procedures in treating insertional Achilles pathology. This study precisely delineated the footprint in each region of the insertion by creating a trapezoid pattern to compare the coordinates across these areas. This could lead to future three-dimensional reconstruction of the Achilles insertional footprint and patient- specific instrumentation software directed towards optimizing the management of Insertional Achilles pathology.

An exchange technique in temporomandibular joint (TMJ) arthroscopy to insert a larger operative cannula to facilitate advanced procedures

The paper describes a modification of the surgical technique for temporomandibular joint arthroscopy, using an exchange guide to replace the 2.2 mm cannula with one of 2.9 mm to better facilitate osteoplasty of the medial wall. The procedure is a simple and safe manoeuvre that reduces complications such as fluid extravasation into soft tissues, damage to the articular eminence, and bleeding into the superior joint space. Every oral and maxillofacial surgeon could benefit from this novel method, which reduces the chances of failure when exchanging the working cannulas, the potential morbidity of re-entry, and the duration of surgery.

Location of Local Recurrences Post-Prostatectomy Detected by 18F-DCPFyL and Implications for Salvage Radiotherapy Target Volumes.

The use of prostate-specific membrane antigen (PSMA) PET scans have improved detection of recurrent prostate cancer for biochemical failure post-prostatectomy. The primary aim of this study is to assess the location of local recurrences for PSMA PET positive disease post-prostatectomy relative to anatomical landmarks and to inform salvage radiotherapy contouring guidelines. This is a retrospective study of patients who underwent a staging PSMA PET-CT scan with 18F-DCFPyL tracer. Eligible patients included men with biochemical recurrence (PSA >0.2ng/mL) post-prostatectomy for prostate adenocarcinoma. PSMA positive local disease (GTV) was marked on the CT scan of the PSMA PET/CT, using the PSMA PET scan fused as the secondary dataset. Reference structures were contoured to compare the positional relationship to the GTV local recurrence. Centroids of each GTV position were measured to the closest border of the reference structures and distance measured. Forty-five patients had a local recurrence on PSMA PET, 28/45 with prostate bed recurrence and 17/45 with seminal vesicle bed recurrence. The median age was 72.7 years, median pre-treatment PSA 0.515 ng/ml (0.2-11.1), pT2 in 37.8% and pT3 in 62.2, ISUP G2-3 was 66.7%, ISUP 4-5 29.6%, 67% ECE, 15.4% SV involvement and 40% positive margin. For prostate bed recurrences, 93.6% of GTVs were within 15mm from the inferior border of pubic symphysis (median 3.3mm [-9.8-15.4]), 83.9% within 10mm from the VUA (median 3.3mm [-17.4-15.9]), and 80.6% were greater than 10mm from the most superior slice of the penile bulb (median 16.4mm [1-29.5]). Laterally, 83.9% of recurrences were within 10mm of midline and 41.9% within 5mm (median 3.3mm [-13.56-11.59]) and all were contained within levator, 35.5% within 5mm (median 7.7 [1-22.6]) of the medial muscle border. 29.0% were within 5mm from the anterior edge of the rectal wall (median -7mm [-32.3-0.5]). Seminal vesicle bed recurrences were within 17.5mm of upper border of pubic symphysis for 88.9% of patients (median -4.69mm[-30.8to18.2]), 100% were more than 7.5mm inferiorly from the vas deferens (median-22.1mm[-32.7to-7.7]). Laterally, 100% recurrences were more than 7.5mm medial from obturator internus (median 5.37mm [-23.1to37.8]), and 88.9% were more than 10mm from midline (median 23.1mm [2.0-36.6]). The 18F-DCFPyL PSMA PET local recurrences can provide detailed localization of prostate bed and seminal vesicle recurrences. Our data can inform contouring guidelines for salvage radiotherapy to the prostate bed, particularly when using anatomical landmarks to define cranio-caudal extent of target volumes. For target volume laterally, the medial wall of levator ani would encompass all prostate bed recurrences, and no seminal vesicles recurrences were seen at the medial border of the obturator internus muscle.

The Role of the Transeptal Window in Endoscopic Endonasal Access to the Contralateral Orbit

Abstract Objective This study aimed to objectively compare maneuverability at the contralateral medial orbit when approached through the traditional endoscopic endonasal approach (EEA) and EEA with transeptal window (TW). Study Design Anatomic dissections were performed bilaterally on three latex-injected cadaveric heads. Approaches were performed sequentially; initially, an EEA was fashioned. Binostril access was achieved through a 2-cm posterior septectomy. The second stage pertained to the TW dissection. Area of exposure (AoE), surgical freedom (SF), and angles of attack (AoA) were measured along the contralateral medial orbital wall and compared for each approach. Additionally, the study presents an illustrative case describing the application of the EEA + TW for resection of an intraorbital schwannoma. Results Compared with EEA, EEA + TW yielded a significantly greater AoE along the contralateral medial orbital wall (39.45 vs. 48.45 cm2, respectively; p = 0.002). SF was statistically different between the EEA and EEA + TW (1153.25 vs. 2256.33 cm2, respectively; p = 0.002). AoA in the horizontal plane were significantly broader with the EEA + TW (6.36 vs. 4.9 degrees by EEA; p = 0.015).A 50-year-old male with a right medial extraconal orbital tumor was successfully treated through an EEA using the transeptal corridor to access the medial orbital region. No long-term complications were encountered after 31 months of follow-up. Conclusions EEA + TW is a minimally invasive technique that maximizes exposure and maneuverability within the medial orbital wall, allowing resection of lesions that extend anteriorly. EEA + TW limits disruption of the nasal septum and overcomes the obstacle that intranasal anatomy represents for instrumentation.

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal Approach to the Anterior Cranial Fossa

Abstract Introduction The development of endoscopic techniques has made endoscopic endonasal approaches (EEAs) to the anterior cranial fossa (ACF) increasingly popular. Still, the steps and nuances involved in the approach may be difficult to understand for trainees. Thus, we aim to didactically describe the EEAs to the ACF in an anatomically based, step-by-step manner with supplementary clinical cases. Methods Six cadaveric head specimens were dissected. Endoscopic endonasal Draf I, IIA, IIB, and III frontal sinusotomies, endoscopic endonasal superior ethmoidectomy, and endoscopic endonasal transcribriform and transplanum approaches were modularly performed. The specimens were photodocumented with endoscopic techniques. Results Draf I frontal sinusotomy started with the complete removal of the anteromedial portion of the agger nasi cell, exposing the medial orbital wall, cranial base, and anterior cribriform plate. Draf II frontal sinusotomy proceeded with the removal of the floor of the frontal sinus between the lamina papyracea and the middle turbinate (IIa), and the nasal septum (IIb) until the first olfactory filaments were exposed. Draf III proceeded by creating a superior septal window just below the floor of the frontal sinus. The bone of the ACF bounded by the limbus sphenoidale posteriorly, frontal sinus anteriorly, and the medial orbital walls bilaterally was removed; the cribriform plate was removed; and the crista galli was dissected free from the dural leaflets of the falx cerebri and removed. Conclusion We provide a step-by-step dissection describing basic surgical steps and anatomy of the EEAs to the ACF to facilitate the learning process for skull base surgery trainees.

COMPUTATIONAL MODELING OF A LAYERED AORTIC MEDIAL WALL CONSIDERING EFFECTIVE RESIDUAL STRESSES

We previously developed a simplified finite element (FE) “unit” model to reproduce the mechanical interaction between the smooth muscle layer and elastic lamina (EL) in the aortic media. Nevertheless, whether this simplified FE model can represent the structure of a real medial wall and whether its modeling technique can help in developing a highly sophisticated and structure-based aortic FE model should be determined. Therefore, this study aimed to computationally represent EL buckling in the aortic medial ring at an unloaded state based on the integrated unit models and reproduce transmural variations in EL waviness across the vascular wall. We confirmed that the inner and outer layers of the medial wall were relatively subjected to compressive and tensile residual stresses, respectively, at the unloaded state, implying that the ring model will open spontaneously when it is radially cut. In addition, the residual stresses computed under such a stress-free condition were comparable to the analytically estimated values, partially supporting the validity of our modeling approach. Although further study is still required, the information obtained in this study will greatly improve the understanding of basic aortic physiology and pathophysiology and provide a basis for performing more sophisticated computational modeling of the aortic wall.

Computational Modeling of an Aortic Medial Wall: Effect of Residual Stresses on a Mechanical Behavior of the Aortic Ring

Abstract The aorta is the largest artery in an animal body and is an important organ in the pulsatile flow regulation from the left ventricle. The mechanical and structural characteristics of the aortic media, which are primarily composed of smooth muscle cell layers and elastic laminae (ELs), have profound effects on the physiology and pathophysiology of the aorta. However, many aspects of the aortic tissue remain unknown due to the inherent layered wall structure and the regionally varying residual stresses. This study aimed to computationally represent EL buckling in the aortic medial ring at the unloaded state and reproduce the transmural variation in residual stresses and EL waviness across the vascular wall. A multi-objective optimization technique was applied to a series of simulations with the “unit” structure to obtain an idealized stress distribution throughout the aortic wall thickness. Hence, an appropriate boundary condition given to an initial reference configuration of the aortic ring was successfully identified. As a result, the average “idealized” residual stresses of smooth muscle cell layer and EL were on the order of 20 and −80 kPa, respectively, while EL waviness was ∼1.01 in the unloaded state. Further, it was verified that the ring model with a radial cut will open spontaneously when the inner and outer layers of the medial wall are subjected to relative compressive and tensile residual stresses, respectively, in the unloaded state.

Resection of orbital apex tumours in the medial orbit via four-handed endonasal and transcaruncular approaches.

To report the surgical outcomes of 4-handed endoscopic and transcaruncular approaches for orbital apex tumours located in the medial orbit. This retrospective, observational study included 6 patients (2 males and 4 females; 3 right and 3 left; mean age, 49.5 years; age range, 38-60 years) who underwent excision of an orbital apex tumour in the medial orbit via 4-handed endonasal and transcaruncular approaches. Data on age, sex, affected side, surgical record and complications, and results of pathological examinations, imaging studies, and ophthalmologic examinations were collected. Tumours pathologically corresponded to a cavernous haemangioma in 5 cases and a schwannoma in 1 case. The cavernous haemangioma was completely removed in all cases, while the schwannoma was only debulked because the tumour attached to the surrounding tissues. The medial orbital wall was reconstructed simultaneously in 1 case and 8 days after tumour resection in 1 case. Postoperatively, the visual acuity improved or was maintained in all patients. One patient without medial orbital wall reconstruction showed significant enophthalmos on the affected side after surgery. Another patient without medial orbital wall reconstruction did not obtain binocular single vision field in any direction of gaze after surgery due to severe esotropia. This report indicates that 4-handed endoscopic and transcaruncular approaches are useful for removal of an orbital apex tumour located in the medial orbit. Medial orbital wall reconstruction after tumour resection may be a better option for reducing the risk of postoperative enophthalmos and esotropia.

Pre-clinical investigation of liquid sirolimus for local drug delivery.

Sirolimus is currently being explored as an alternative drug to paclitaxel for the treatment of peripheral artery disease (PAD). To date, sirolimus has only been used as drug coatings for stents and balloons and no studies have yet demonstrated the delivery of sirolimus in liquid form. The purpose of this pilot study was to investigate the feasibility of the delivery of liquid sirolimus into arterial segments in a benchtop peripheral artery bioreactor. The feasibility to deliver liquid therapy was first tested on four drug delivery devices using a fluorescently tagged liquid drug and an ex vivo porcine artery benchtop model. The four devices included the Bullfrog micro-infusion device, ClearWay RX catheter, Occlusion perfusion catheter (OPC), and the targeted adjustable pharmaceutical administration system (TAPAS). Penetration of the fluorescently tagged drug was measured via microscopic imaging and quantification of the depth of drug penetration into all device-treated tissue. Based on the penetration outcome, we then selected a single device to deliver liquid sirolimus into the ex vivo porcine artery model undergoing physiological flow and pressure conditions. The liquid sirolimus-treated arteries were collected from the ex vivo bioreactor at 1- and 24-hour post-delivery and arterial drug retention analyzed by liquid chromatography-tandem mass spectrometry. Fluorescent microscopy demonstrated that drug delivery with the OPC had greater drug penetration into the medial wall as compared to other devices (OPC: 234 ± 161 µm; TAPAS: 127 ± 68 µm; ClearWay: 118 ± 77 µm; Bullfrog: 2.12 ± 3.78 µm; p = 0.098). The results of the ex vivo flow-circuit bench top model showed that the OPC device successfully delivered the liquid sirolimus at 1-hour (5.17 ± 4.48 ng/mg) and 24-hour (0.78 ± 0.55 ng/mg). These results demonstrate for the first time the ability to deliver liquid sirolimus directly to the medial layer of an artery via a liquid delivery catheter.

Three-Dimensional (3D) Analysis of Orbital Morphometry in Healthy Anatolian Adults: Sex, Side Discrepancies, and Clinical Relevance.

Background and objective The complex structural integrity of the orbit is crucial for visual functions. Three-dimensional (3D) reconstructions from radiological images have revolutionized anatomical understanding, eliminating the limitations of two-dimensional (2D) imaging and offering intricate spatial details for complex structures. The aim of this study was to analyze the detailed morphometry of the orbit in healthy Anatolian adults, considering sex, side discrepancies, and clinical relevance using 3D models reconstructed from multidetector computed tomography (MDCT) images. Materials and methods Fifty-six (44.44%) males and 70 (55.56%) females (total: 126, mean age: 48.62) MDCT images were randomly selected and 3D skull models were reconstructed using 3D Slicer software. Measurements were conducted in millimeters (mm) for transverse and vertical diameters, circumference of the orbital opening, orbital wall lengths, as well as intraorbital and extraorbital distances. Results The method of measurements showed high reproducibility of results. The mean values for transverse and vertical diameters, circumference of the orbital opening, medial and lateral wall lengths, roof and floor lengths, and intraorbital and extraorbital distances were 40.23±2.12 mm (p<0.001), 34.94±2.16 mm (p=0.365), 44.74 ±3.02 mm (p<0.001), 46.30±2.69 mm (p<0.001), 51.26±2.91 mm (p<0.001), 49.01±3.22 mm (p<0.001), 126.10±5.71 mm (p<0.001), 19.63±2.35 mm (p=0.026), and 94.09±4.84 mm (p<0.001), respectively. Conclusion The study's high measurement reproducibility contributes significantly to the existing literature and clinical practice. These findings offer specific insights into Anatolian orbital morphometry, aiding in surgical planning, implant placement, and diagnostic assessments. The precise measurement values serve as a reliable reference for clinicians, facilitating the identification of normal and abnormal orbital anatomy and enhancing patient care. We believe this study provides valuable data for craniofacial and ophthalmological research, benefiting both clinical practice and future research endeavors in these fields.

A case of non-ampullary duodenal adenosquamous carcinoma with successful emergency pancreaticoduodenectomy for gastrointestinal hemorrhage

BackgroundAlthough most duodenal carcinomas are pathological adenocarcinomas, a small number of cases have been reported of adenosquamous carcinoma, characterized by variable combinations of two malignant components: adenocarcinoma and squamous cell carcinoma. However, owing to the small number of cases of non-ampullary duodenal adenosquamous carcinoma, there have been no reported cases of emergency pancreaticoduodenectomy for gastrointestinal hemorrhage due to non-ampullary duodenal adenosquamous carcinoma.Case presentationA 66-year-old Japanese male presented to the referring hospital with a chief complaint of abdominal pain, diarrhea, and dark urine that had persisted for 1 month. The patient was referred to our hospital because of liver dysfunction on a blood examination. Laboratory results of the blood on the day of admission showed that total and direct bilirubin levels (12.0 mg/dl and 9.6 mg/dl) were markedly increased. An endoscopic retrograde biliary drainage tube was inserted for the treatment of obstructive jaundice, and imaging studies were continuously performed. Contrast-enhanced computed tomography and endoscopy revealed an ill-defined lesion involving the second portion of the duodenum, predominantly along the medial wall, and measuring 60 mm in diameter. No metastases were observed by positron emission tomography. Pancreaticoduodenectomy was planned based on the pathological findings of poorly differentiated adenocarcinoma. However, 2 days before the scheduled surgery, the patient experienced hemorrhagic shock with melena. Owing to poor hemostasis after endoscopic treatment and poor control of hemodynamic circulation despite blood transfusion, radiological embolization and hemostasis were attempted but were incomplete. An emergency pancreaticoduodenectomy was performed after embolizing the route from the gastroduodenal artery and pseudoaneurysm area to reduce bleeding. The operation was completed using an anterior approach without Kocherization or tunneling due to the huge tumor. The operation time was 4 h and 32 min, and blood loss was 595 mL The pathological diagnosis was adenosquamous carcinoma. The postoperative course was uneventful with 17 day hospital stay and the patient is currently well, with no signs of recurrence 9 months after surgery.ConclusionsThis report presents an extremely rare case of successful emergency pancreaticoduodenectomy for gastrointestinal hemorrhage caused by non-ampullary duodenal adenosquamous carcinoma.

Prevalence of Incidental Maxillary Sinus Anomalies on CBCT Scans: A Radiographic Study.

CBCT significantly impacts dental procedures and has brought significant reforms to our approach to diagnosis and treatment planning despite its limitations in differentiating soft tissues. It is an excellent imaging modality and quickly identifies sinus opacification and provides valuable insight into paranasal sinus pathologies, with considerably lower radiation exposure. The present study aimed to investigate the occurrence of maxillary sinus abnormalities in CBCT scans, identify the frequency, type, and location of these findings, and find the correlation between the distance of periapical lesions and radiographic changes in the maxillary sinus. Two examiners independently evaluated 117 patients to diagnose and classify the cases into different abnormality subtypes. The periapical lesions most closely related to the sinus were recorded. The diameters of the left and right maxillary sinus ostium and the distance of the ostium's lower border to the sinus's osseous floor were recorded. The findings were correlated with the age and gender of these patients. The present study reveals that sixty-one patients were diagnosed with mucosal thickening (52.1%). The sinus wall most affected by mucosal thickening was the maxillary sinus floor, followed by the medial and lateral walls. Of 19 patients with periapical lesions, 15 had maxillary sinus mucosal thickening, which is statistically significant (p = 0.004). The high occurrence of abnormalities in the maxillary sinus emphasizes the importance for the radiologist to comprehensively interpret the whole volume acquired in CBCT images, including the entire sinus. Incidental findings may be considered in the individual clinical context of signs and symptoms, reducing the risk of overestimating the real impact of radiographic findings.

Arsenic trioxide demonstrates efficacy in a mouse model of preclinical systemic sclerosis

BackgroundUncontrolled T-cell activation plays a key role in systemic sclerosis (SSc). Arsenic trioxide (ATO) has immunological effects and has demonstrated potential in preclinical SSc models. In this study, we assessed the efficacy of ATO in Fra2 transgenic (Fra2TG) mice, which develop severe vascular remodeling of pulmonary arterioles and nonspecific interstitial pneumonia-like lung disease, closely resembling human SSc-associated pulmonary hypertension, therefore partially resembling to the SSc human disease.MethodsThe efficacy of ATO in Fra2TG mice was evaluated through histological scoring and determination of cell infiltration. Fibrotic changes in the lungs were assessed by measuring collagen content biochemically, using second harmonic generation to measure fibrillar collagen, and imaging via computed tomography. Cardiovascular effects were determined by measuring right ventricular systolic pressure and vessel remodeling. The mechanism of action of ATO was then investigated by analyzing lung cell infiltrates using flow cytometry and bulk RNA with sequencing techniques.ResultsAfter ATO treatment, the Ashcroft histological score was substantially decreased by 33% in ATO-treated mice compared to control mice. Other investigations of fibrotic markers showed a trend of reduction in various measurements of fibrosis, but the differences did not reach significance. Further cardiovascular investigations revealed convergent findings supporting a beneficial effect of ATO, with reduced right ventricular systolic pressure and medial wall thickness, and a significant decrease in the number of muscularized distal pulmonary arteries in ATO-treated Fra2TG mice compared to untreated Fra2TG mice. Additionally, inflammatory cell infiltration was also markedly reduced in lesioned lungs. A reduction in the frequency of CD4 + and T effector memory cells, and an increase in the percentage of CD4 + T naive cells in the lungs of ATO-treated Fra-2TG mice, was observed when compared to PBS group Fra-2Tg mice. RNA-seq analysis of ATO-treated mouse lungs revealed a downregulation of biological pathways associated with immune activity and inflammation, such as T-cell activation, regulation of leucocyte activation, leucocyte cell–cell adhesion, and regulation of lymphocyte activation.ConclusionsOur results suggest the clinical relevance of ATO treatment in SSc. Using the Fra2TG mouse model, we observed significant lung histological changes, a trend towards a decrease in various fibrotic makers, and a strong reduction in vascular remodeling. The mechanism of action of ATO appears to involve a marked counteraction of the immune activation characteristic of SSc, particularly T-cell involvement. These findings pave the way for further studies in SSc.

Exercise intensities modulate ACE2/MasR/eNOS pathway in male Wistar rat's lung.

Specific exercise intensities could improve lung vascular function by increasing nitric oxide (NO). The ACE2/MasR/eNOS axis is one of the pathways facilitating NO synthesis. This study examines the effect of different intensities of aerobic training on the ACE2/MasR/eNOS axis and histology of lung muscular arteries. Male Wistar rats were used in this study and randomized into control and exercise groups receiving low-, moderate-, and high-intensity training. The training was conducted for 30 min daily, five times a week, for 8 weeks. We observed that different exercise intensities affect the ACE2/MasR/eNOS pathway differently. Compared to control, high-intensity aerobic exercise significantly increased ACE2, Mas receptor (MasR), and eNOS mRNA expressions (p < 0.01). Moderate-intensity exercise significantly increased MasR and eNOS mRNA expressions compared to the control (p < 0.05), and this intensity also increased ACE2 mRNA but not significantly. Low-intensity exercise increased ACE2, MasR, and eNOS mRNA expressions but not significantly. Low-, moderate-, or high-intensity exercises reduced the medial wall thickness of the lung muscular arteries but not significantly. In conclusion, high-intensity exercise may induce NO synthesis in the lung by increasing mRNA expression of ACE2, MasR, and eNOS without decreasing the medial wall thickness of the muscular artery. Thus, high-intensity exercise may be the optimal intensity to improve NO synthesis and vascular function in the lung.

Correlation of the depth, medial wall and opening angle of the bicipital groove and the dimensions of long head of the biceps tendon

Objectives: The aim of this study was to investigate the relationship between the morphological measurements of bicipital groove and long head of biceps tendon and determine the effect of age and gender on these measurements. Methods: The study included 110 patients (60 females, 50 males) aged 18–50 years, who underwent magnetic resonance imaging of the left shoulder between January and December 2020. The patients had stable biceps tendons, and did not have a rotator cuff tear. The bicipital groove morphology was evaluated based on depth, opening angle, medial wall angle and the biceps tendon morphology was assessed based on thickness (anteroposterior length) and width (transverse length). Results: There was no difference between the females and males in terms of age, opening angle and medial wall angle (p&gt;.05). The bicipital groove depth was lower in the females than in the males (p&lt;.001), while the biceps tendon was thicker in the males compared to the females (p&lt;.001). There was no correlation between age and the sizes of bicipital groove and the biceps tendon. A negative correlation was observed between the bicipital groove depth and opening angle (r=-0.55), and a positive correlation between medial wall angle (r=0.51), tendon thickness (r=0.50) and tendon width (r=0.34). Bicipital groove depth had a positive correlation with tendon thickness (r=0.54) in women and tendon width in men (r=0.28). Conclusion: The morphological measurements of bicipital groove and the biceps tendon showed correlations. There were also gender differences in these morphological measurements.

Orbital fractures: Incidence and significance of imaging

Aim: To identify the incidence of various orbital wall fractures, their association with other facial fractures and their clinical significance. Methods: This is a prospective observational study of patients presenting to the emergency department with symptoms of orbital fractures, and were assessed further by CT scan. Results: Radiologic examination reveals a variety of findings in each case. Most of the orbital fractures in our study are comminuted and bilateral. The medial wall is the commonly fractured entity, followed by the floor. Associated findings frequently seen in in this study are zygomatic fractures, nasal bone fractures and hemosinus. Conclusions: Even though orbital floor fractures are relatively less common, diagnosing orbital floor fractures and inferior rectus entrapment are essential in planning surgical intervention. This study also emphasizes the need for CT imaging in every case of orbital injury.

561 A Morphological Review of Medial Malleolar Fractures – a Large Single Centre Series

Abstract Background Medial Malleolus Fractures (MMF) are frequently managed by orthopaedic surgeons and are one of the most treated fractures of the ankle. Many approaches to management are described in the literature however, their morphology is under investigated. Method Patients who had surgical fixation of their MMF were identified from 2012 to 2022. Analysis of their pre-operative, intra-operative and post-operative radiographs was performed. Lauge-Hansen classification was used to characterise ankle fracture morphology and Herscovici classification to characterise MMF morphology. Results A total of 647 patients were identified across a 10-year period who had sustained a medial malleolar fracture. The most common Herscovici fracture in Supination Adduction injuries was a Herscovici D (43.9%, 17/39), in supination external rotation injuries was Herscovici C (52.75%, 259/491), in pronation external rotation injuries was Herscovici C (48.81%, 41/84) and in pronation abduction injuries was Herscovici B (45.45%, 12/33). Medial wall blowout occurred in 19.23%, occurring in supination adduction injuries most commonly (51.28%, 20/39). Herscovici A fractures were significantly more malreduced at time of surgery compared to other fracture types (21.88%, 7/32, p = .003). There was no significant difference in union rates across the classification groups (range 11.67% Herscovici D to 22.86% for Herscovici B). Conclusions Knowledge of the medial malleolar morphology allows greater assessment and planning in their surgical treatment. There was a high rate of medial wall blowout even in the non-adduction fracture types, and this should be assessed to prevent over compression during surgical treatment. Herscovici A fracture malunions may need further investigation and different methods of fixation.