Midline Position Research Articles

P51. The effect of structural spinal deformities on the effectiveness of spinal cord stimulators

BACKGROUND CONTEXT Neural modulation via spinal cord stimulators (SCS) has become an accepted technique for the treatment of a variety of chronic pain syndromes. A concept akin to the placement of these devices (regardless of manufacturer) in most cases is the desire to ensure accurate midline positioning of the paddle lead in the thoracic spine. Midline positioning allows for flexibility of unilateral or bilateral coverage of pain patterns in patients. The presence of structural spinal deformities such as scoliosis or kyphosis often implies some degree of coronal, sagittal and rotatory deformity. To date, no study has examined the relationship of thoracic scoliosis/kyphosis and outcomes after permanent SCS placement. PURPOSE This study looks to ascertain if the presence of structural thoracic deformities affects outcomes of permanent SCS placement. STUDY DESIGN/SETTING This retrospective chart review included patients who underwent permanent SCS placement at our suburban hospital. Spinal imaging for each patient was reviewed, and scoliosis and thoracic kyphosis angles were recorded. The effect of each structural deformity on the change in NRS, ODI, and narcotic medication usage from baseline was analyzed. PATIENT SAMPLE Only patients with lumbar radiculopathy who were treated with a SCS placed by a fellowship trained orthopedic surgeon or neurosurgeon were included in our study. Patients who had previous SCS placed, were having other surgeries while having their SCS placed, or did not have spinal imaging taken that allowed the angular measurement of structural curves were excluded. OUTCOME MEASURES For each patient, demographic information, numerical rating system (NRS) pain scores, Oswestry Disability Index (ODI) scores, and narcotic medication usage as reported by our online state narcotic drug monitoring program were recorded at baseline and after permanent stimulator placement. METHODS Spinal imaging for each patient was reviewed, and scoliosis and thoracic kyphosis angles were recorded. The effect of each structural deformity on the change in NRS, ODI, and narcotic medication usage from baseline was analyzed. RESULTS A total of 100 patient charts were included in our cohort. Sixty percent of our population was female, with a roughly even age distribution ranging from 37 to 90 years of age. The average scoliotic Cobb angle was 11.0 degrees and kyphotic scoliotic angle was 39.2 degrees. Overall, 43% of our cohort had scoliosis and 30% had thoracic kyphosis. There was no significant difference in change in NRS scores, ODI scores, or narcotic usage between patients with scoliosis and those without scoliosis (p=0.86, p=0.81, p=0.64) or patients with kyphosis and those without (p=0.71, p=0.31, p=0.62). Univariate linear regression analysis showed that scoliotic angle and kyphotic angle were not significant predictors of change in NRS score (p=0.46, p=0.12), ODI score (p=0.48, p=0.06), or narcotic usage (p=0.93, p=0.56). Multivariate linear regression also showed that scoliotic angle and kyphotic angle were not significant predictors of NRS (p=0.482, p=0.304), ODI (p=0.116, p=0.161), or narcotic pain usage (p=0.644, p=0.735) either. CONCLUSIONS Spinal cord stimulators can be effective options for treating lumbar back pain and radiculopathy, even in patients with structural deformities such as thoracic scoliosis or kyphosis. Our study suggests that the presence of structural deformities does not adversely affect outcomes of permanent SCS placement and as such should not preclude this population from benefiting from such therapies. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Introducing and Reviewing a Novel Mutation of ROBO3 in Horizontal Gaze Palsy with Progressive Scoliosis from a Chinese Family

Horizontal gaze palsy with progressive scoliosis (HGPPS) is an autosomal recessive disorder caused by ROBO3 gene mutations. To date, the number of confirmed HGPPS cases caused by gene mutations is estimated at 76. However, HGPPS caused by ROBO3 gene mutation has not been reported in the Chinese population. In this study, the clinical data, brain imaging features, somatosensory evoked potentials (SEP), and ROBO3 gene mutations were obtained for two Chinese patients with HGPPS. The proband was an 11-year-old boy. He developed horizontal eye movement disorder at the age of 1year and scoliosis at the age of 11years. Two eyeballs fixed in the midline position were revealed by neurological examination. A dorsal cleft in the pons and a butterfly-shaped medulla were shown by brain magnetic resonance imaging. Again, most corticospinal bundles did not cross in the brainstem, as revealed by diffusion tensor imaging. SEP confirmed that most somatosensory projections were uncrossed. The proband's 7-year-old brother exhibited similar clinical manifestations and imaging features. The brothers had compound heterozygous mutations c.3165G>A (p.W1055X) and c.955G>A (p.E319K) of the ROBO3 gene. The c.3165G>A mutation is a novel nonsense mutation that has not been previously reported. This study reports the first two cases of HGPPS carrying a novel ROBO3 gene mutation in patients from a Chinese family, thereby expanding the disease spectrum. Reports from the literature show that missense mutation is the most common mutational type in the ROBO3 gene. Early ROBO3 gene detection is required for patients exhibiting early-onset eyeball movement disorder to confirm HGPPS disease.

Head midline position for preventing the occurrence or extension of germinal matrix-intraventricular haemorrhage in preterm infants.

Head position during care may affect cerebral haemodynamics and contribute to the development of germinal matrix-intraventricular haemorrhage (GM-IVH) in very preterm infants. Turning the head toward one side may occlude jugular venous drainage while increasing intracranial pressure and cerebral blood volume. It is suggested that cerebral venous pressure is reduced and hydrostatic brain drainage improved if the infant is cared for in the supine 'head midline' position. To assess whether head midline position is more effective than other head positions for preventing (or preventing extension) of GM-IVH in very preterm infants (< 32 weeks' gestation at birth). We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 9), MEDLINE via PubMed (1966 to 12 September 2019), Embase (1980 to 12 September 2019), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 12 September 2019). We searched clinical trials databases, conference proceedings, and reference lists of retrieved articles. Randomised controlled trials (RCTs) comparing caring for very preterm infants in a supine head midline position versus a prone or lateral decubitus position, or undertaking a strategy of regular position change, or having no prespecified position. We included trials enrolling infants with existing GM-IVH and planned to assess extension of haemorrhage in a subgroup of infants. We planned to analyse horizontal (flat) versus head elevated positions separately for all body positions. We used standard methods of Cochrane Neonatal. For each of the included trials, two review authors independently extracted data and assessed risk of bias. The primary outcomes were GM-IVH, severe IVH, and neonatal death. We evaluated treatment effects using a fixed-effect model with risk ratio (RR) for categorical data; and mean, standard deviation (SD), and mean difference (MD) for continuous data. We used the GRADE approach to assess the certainty of evidence. Three RCTs, with a total of 290 infants (either < 30 weeks' gestational age or < 1000 g body weight), met the inclusion criteria. Two trials compared supine midline head position versus head rotated 90° with the cot flat. One trial compared supine midline head position versus head rotated 90° with the bed tilted at 30°. We found no trials that compared supine versus prone midline head position. Meta-analysis of three trials (290 infants) did not show an effect on rates of GM-IVH (RR 1.11, 95% confidence interval (CI) 0.78 to 1.56; I² = 0%) and severe IVH (RR 0.71, 95% CI 0.37 to 1.33; I² = 0%). Neonatal mortality (RR 0.49, 95% CI 0.25 to 0.93; I² = 0%; RD -0.09, 95% CI -0.16 to -0.01) and mortality until hospital discharge (typical RR 0.50, 95% CI 0.28 to 0.90; I² = 0%; RD -0.10, 95% CI -0.18 to -0.02) were lower in the supine midline head position. The certainty of the evidence was very low for all outcomes because of limitations in study design and imprecision of estimates. We identified one ongoing study. We found few trial data on the effects of head midline position on GM-IVH in very preterm infants. Although meta-analyses suggest that mortality might be reduced, the certainty of the evidence is very low and it is unclear whether any effect is due to cot tilting (a co-intervention in one trial). Further high-quality RCTs would be needed to resolve this uncertainty.

A history of the path towards imaging of the brain: From skull radiography through cerebral angiography

This publication reviews the steps in the path towards obtaining a complete image of the brain. Up to the 1920s, plain X-ray films could demonstrate only calcified tumors, shifts in midline position of a calcified pineal gland due to a mass in the cranium, or foreign metallic objects within the skull. Walter Dandy reported in 1918 that he visualized cerebral ventricles by introducing air as a contrast agent through a trocar into one of the occipital lobes or the right frontal horn of the ventricular system. Dandy localized lesions that distorted or shifted the ventricles. In 1920, Dandy placed air by lumbar puncture into the spinal subarachnoid space that could visualize the brain and entire ventricles. Antonio Egas Moniz with the assistance of his neurosurgeon colleague, Almeida Lima, obtained X-ray images of cerebral arteries of dogs and decapitated human heads from corpses after injecting strontium bromide into their carotid arteries. Satisfied by these experiments, Moniz injected strontium bromide directly into carotid arteries of five patients which failed to show intracranial vessels. In the sixth patient, intracranial arteries were outlined but that patient died of cerebral thrombosis presumably due to the hyper-osmolality of that contrast agent. Finally, on June 18, 1927, Moniz injected 22% sodium iodine into a 20-year-old man and obtained clear visualization of his carotid artery and intracerebral branches after temporarily occluding the artery with a ligature. Direct percutaneous puncture of the cervical carotid artery remained the primary technique unto the 1960s to visualize intracranial blood vessels until Seldinger’s technique was introduced in 1953. Computerized axial tomography (CAT) and magnetic resonance imaging (MRI) replaced cerebral arteriography for localizing tumors and epidural or subdural hemorrhage. However, angiography is used currently for embolization of aneurysms and removal of thrombi or emboli in patients with acute stroke.

Hedgehog Signaling Regulates Epithelial Morphogenesis to Position the Ventral Embryonic Midline.

Despite much progress toward understanding how epithelial morphogenesis is shaped by intra-epithelial processes including contractility, polarity, and adhesion, much less is known regarding how such cellular processes are coordinated by extra-epithelial signaling. During embryogenesis, the coelomic epithelia on the two sides of the chick embryo undergo symmetrical lengthening and thinning, converging medially to generate and position the dorsal mesentery (DM) in the embryonic midline. We find that Hedgehog signaling, acting through downstream effectors Sec5 (ExoC2), an exocyst complex component, and RhoU (Wrch-1), a small GTPase, regulates coelomic epithelium morphogenesis to guide DM midline positioning. These effects are accompanied by changes in epithelial cell-cell alignment and N-cadherin and laminin distribution, suggesting Hedgehog regulation of cell organization within the coelomic epithelium. These results indicate a role for Hedgehog signaling in regulating epithelial morphology and provide an example of how transcellular signaling can modulate specific cellular processes to shape tissue morphogenesis.

Comparative analysis of panoramic radiography and cone-beam computed tomography in treatment planning of palatally displaced canines

The objective of this research was to compare the predictive value of panoramicradiographs (PRs) and cone-beam computed tomography (CBCT) scans for the estimation of root resorption, spontaneous eruption of a canine, and time for orthodontic traction. CBCT scans and PR images of 88 patients (27 male and 61 female; aged between 11 and 44years) with 106 palatally displaced maxillary canines were retrieved from a database. Predictive values of several radiographic parameters, including the 3-dimensional angle of the canine, were analyzed using the area under the curve and multiple regression analysis. The angle to the midline and canine position category had a discriminative ability for root resorption of the central incisors with area under the curve values of 0.63 (95% confidence interval, 0.56-0.79) and 0.83 (95% confidence interval, 0.75-0.91), respectively. PR measurements were not reliable predictors of resorptions, except severe resorptions, of the lateral incisors and the premolars. The measurements describing the position of the canine in relation to the midline could predict spontaneous eruption of the canine, regardless of the imaging method. The canine angle to the midline assessed on CBCT was significantly associated with traction time of the canine, producing the following equation: canine traction time=49.6 - 0.24×canine angle to the midline (r2=0.360). Only severe resorptions of roots can be predicted with PRs. The use of CBCT is indicated in cases of impacted canines.

Anatomic Relationship of Bony Structures in Pedicle-Rib Unit and its Significance

The pedicle-rib unit is regarded as an expanded pedicle and is a new approach to thoracic pedicle fixation. Previous studies were mostly focused on anatomic, radiographic, and biomechanical assessment. However, there is no study on anatomic relationship of bony structures in the pedicle-rib unit. This article investigates the anatomic relationships between transverse process, pedicle, rib, and corresponding vertebrae body in the pedicle-rib unit, so as to improve the clinical safety of pedicle-rib unit screw placement. Forty-five normal dry adult cadaver specimens were included. Anatomic parameters were measured. Anatomic parameters were 1) the anatomic relationship between the transverse process and the pedicle (the distance from the horizontal center line of the transverse process to the center and the superior and inferior border of the pedicle); 2) the anatomic relationship between the transverse process and the rib (the overlap portion between the costal neck and the transverse process); 3) the anatomic relationship between the transverse process and the vertebral body (the relative position of the horizontal midline of the transverse process and the vertebral body); and 4) the anatomic relationship between the pedicle and the rib (the overlap portion between the costal neck and the pedicle). The midline of the transverse process was located within the range of the superior and inferior borders of the pedicle in the thoracic spine. The distance between the midline of the transverse process and the center of the pedicle was the closest at T6 and T7, but the farthest at T11 and T12. The anterolateral part of the transverse process was mostly covered by rib from T1 to T8, but it was less covered from T9 to T12. The midline of the transverse process corresponded to the upper third or middle third of the vertebral body. The pedicle is completely or mostly overlapped by the rib from T1 to T9 on the anterolateral side, but from T10 to T12, the rib overlapped the pedicle partially. The pedicle-rib unit is a three-dimensional anatomic structure. The pedicle, transverse process, and rib are not completely in the same plane, and their positions vary in different segments. Pedicle-rib unit screw fixation is anatomically feasible. Setting the screw in the upper-middle thoracic spine is safer than setting it in the lower thoracic spine.

Effect of highly cross-linked hyaluronic acid in synovitis of knee osteoarthritis

Purpose: The purpose of this study is to compare the synovial thickening by US evaluation, before and after Intra-articular highly cross-linked HA injection in OA knee patients. Methods: 107 knees in 73cases OA patients were underwent US measurement of synovial thickening before intra-articular injections of highly cross-linked HA, at 4 weeks and at 3 months after injections. The US were performed with the knee flexion 30° and probe in longitudinal midline position at suprapatellar pouch. All knees were classified by Kellgren-Lawrence (KL) radiographic staging. Comparison of synovial thickening before & after Intra articulation highly cross-linked HA injection were analyzed. Results: The overall synovial thickening was significantly decreased after highly cross-linked HA injection at 4 weeks (p=0.01) but significantly increased after highly cross-linked HA injection at 3 months (p=0.047). In different group of knee OA. At 4 weeks after highly cross-linked HA injection, the synovial thickening was significantly decrease only in KL II (p=0.01) but not significantly different in KL III (p=0.96) & IV (p=0.83). At 3 months after highly cross-linked HA injection, the synovial thickening were not significantly different in KL II (p=0.058) & III (p=0.127). The synovial thickening in KL IV was significantly increase (p=0.02). Conclusions: Highly cross-linked hyaluronic acid injection can prevent structural damage by controlling inflammation in early stage knee OA. For advanced OA, it provides pain relief by better viscoselastic properties.

Evaluation of the maxillary midline, curve of the upper lip, smile line and tooth shape: a prospective study of 140 Caucasian patients

BackgroundA number of reference patterns such as the interincisal line, curve of the upper lip, width of the smile or shape of the teeth have been studied in different populations. Determining the frequency of different smile aesthetic parameters in a European Caucasian population and exploring possible gender differences is important in order to obtain predictable treatment outcomes.MethodsPhotographs were obtained under resting and forced smiling conditions in 140 individuals (70 males and 70 females) with a mean age of 20.1 ± 4.3 years. Different variables were recorded, including the position of the maxillary interincisal midline in relation to the facial midline, the arc and width of the smile, and the shape of the teeth. The data were processed using the SPSS version 15.0 statistical package, with application of the chi-squared test and a confidence level of 95%. The statistical power was 80%, and the level of significance 5% (α = 0.05).ResultsA total of 94.3% of the sample presented a maxillary interincisal midline coinciding with the facial midline, and 80% had a consonant smile line. The curve of the upper lip was upwards in 47.1% of the cases, followed by a straight curve in 41.4%. Most of the subjects (84.3%) presented a medium smile line with tooth exposure to the second premolar (61.4%). There were no significant differences between males and females.ConclusionsThe integration of aesthetic criteria is needed in order to guarantee satisfactory and predictable dental treatment outcomes. There were no statistically significant differences between males and females. The maxillary interincisal midline coincided with the facial midline, with a consonant smile arc and a medium smile line, upward lip curve and oval tooth shape.

Impacted maxillary canines and their relationship with lateral incisor resorption: a cone beam computed tomography (CBCT) study

Abstract Objective The spatial position of a canine can affect the level of proximal root resorption and the success of orthodontic treatment. The aim of this study was to examine the mesiodistal and vertical position of impacted maxillary canines and to assess their relationship with the lateral incisor by using cone beam computed tomography (CBCT). Material and method One hundred and sixty-nine CBCT scans of patients presenting with maxillary impacted canines were included in the study. The buccopalatal, mesiodistal (classified as sectors I, II, III, IV from distal to mesial) and vertical (cervical, middle, apical) position of the maxillary impacted canines were determined. The positional effect on the morphology (width, length, and depth) and resorption was assessed on the roots of the maxillary lateral incisors. Obtained data were statistically analysed by using Student t-test, the Mann Whitney U and Chi-Square tests. Results Of the maxillary impacted canines, the 34.72% that had associated resorption on the adjacent lateral incisors were buccally positioned, and 65.28% were palatally positioned. While 45.58% of sector I impacted maxillary canines were buccally positioned, 68.31% of sector IV impacted maxillary canines were palatally positioned. Furthermore, there was a statistical significance between the mesiodistal position and palatal or buccal maxillary canine impaction (p &lt; 0.05). In addition, the vertical position of the impacted maxillary canines was also related to their mesiodistal and buccopalatal positions (p &lt; 0.05). Conclusion While all maxillary impacted canines had the potential to cause lateral incisor resorption, there was no close relationship related to the canine’s buccopalatal, mesiodistal and vertical position. Nevertheless, if an impacted maxillary canine migrated towards the midline, the buccopalatal and vertical position of the tooth changed from buccal to palatal and cervical to apical, respectively.

Early Progressive Maxillary Changes with Nasoalveolar Molding: Randomized Controlled Clinical Trial.

Quantitative assessment of 3-dimensional progressive changes of the maxillary geometry in unilateral cleft lip palate (UCLP) with and without nasoalveolar molding (NAM). The study was designed as a prospective 2-arm randomized controlled clinical trial conducted in parallel. Forty infants with nonsyndromic UCLP were randomly assigned into a NAM-treated group (n = 20) and non-NAM treated group (n = 20). A total of 120 laser-scanned maxillary casts were collected and blindly analyzed via a modified algorithm at T0 (initial visit; baseline), T1 (after 3 wk; first interval), and T2 (after 6 wk; second interval). The main outcome measures were the amount and rate of cleft gap changes, the midline position, and the transverse, sagittal, and vertical growth through intervals. More than 50% of the cleft gap (56.42%; P < 0.001) was reduced in the first 3 wk of alveolar molding (AM). The end point of the AM was obtained in 6 wk (86.25%; P < 0.001); then, the kinks of the greater segment were noticed. The AM effect decreased as far as posterior; the anterior arch width reduced slightly (1.23%; P < 0.001), while the middle and posterior arches increased slightly (P > 0.999 and P = 0.288, respectively). The posterior arch width was the least changing and was considered a baseline, while the anterior was the pivot of the segment rotation. Both groups showed different patterns of segment rotation and sagittal growth. The non-NAM treated group showed a slight increase in cleft gap length, arch width, and midline position. Based on this study, it was concluded that the NAM treatment is effective in minimizing cleft severity and realigning maxillary segments without the deterioration of the transverse and vertical arch growth. Near follow-up visits are recommended to monitor the rapid gap reduction within the first 3 wk. Further trials are recommended to compare the outcomes regarding the sagittal growth to reference values (ClinicalTrials.gov NCT03029195). The results of this study will help clinicians understand nasoalveolar molding biomechanics that may improve the treatment outcomes for patients with unilateral cleft lip and palate. The trial data can be a valuable guide to the qualitative and quantitative predictive virtual molding in computer aided design-simulated nasoalveolar molding therapy. The modified algorithm can be used by researchers to quantify the rate, the sequence, and the direction of the maxillary segments movement in unilateral cleft lip and palate.

Left-right asymmetric heart jogging increases the robustness of dextral heart looping in zebrafish

Building a left-right (L-R) asymmetric organ requires asymmetric information. This comes from various sources, including asymmetries in embryo-scale genetic cascades (including the left-sided Nodal cascade), organ-intrinsic mechanical forces, and cell-level chirality, but the relative influence of these sources and how they collaborate to drive asymmetric morphogenesis is not understood. During zebrafish heart development, the linear heart tube extends to the left of the midline in a process known as jogging. The jogged heart then undergoes dextral (i.e. rightward) looping to correctly position the heart chambers relative to one another. Left lateralized jogging is governed by the left-sided expression of Nodal in mesoderm tissue, while looping laterality is mainly controlled by heart-intrinsic cell-level asymmetries in the actomyosin cytoskeleton. The purpose of lateralized jogging is not known. Moreover, after jogging, the heart tube returns to an almost midline position and so it is not clear whether or how jogging may impact the dextral loop. Here, we characterize a novel loss-of-function mutant in the zebrafish Nodal homolog southpaw (spaw) that appears to be a true null. We then assess the relationship between jogging and looping laterality in embryos lacking asymmetric Spaw signals. We found that the probability of a dextral loop occurring, does not depend on asymmetric Spaw signals per se, but does depend on the laterality of jogging. Thus, we conclude that the role of leftward jogging is to spatially position the heart tube in a manner that promotes robust dextral looping. When jogging laterality is abnormal, the robustness of dextral looping decreases. This establishes a cooperation between embryo-scale Nodal-dependent L-R asymmetries and organ-intrinsic cellular chirality in the control of asymmetric heart morphogenesis and shows that the transient laterality of the early heart tube has consequences for later heart morphogenetic events.

Concept of neuroprotective NICU

Neurodevelopmental outcomes are of paramount importance for every clinician as the survival rates of term and preterm babies have continued to improve. We aim to provide a framework for developing a Neuroprotective Neonatal Intensive Care Unit (NICU) by describing five main domains below. We achieve this in our NICU by a multidisciplinary team consisting of neonatologists, respiratory therapist, occupational therapist, physiotherapist, social worker, pharmacist, and a dietician. This approach needs to be individualised for each unit based on the resources and services available.I. Neuro assessment: clinical neuro assessment remains the most important tool with strong predictive value for long-term outcomes. It is important to develop other tools of assessment like comfort and pain scoring. We use COMFORTneo scale as a standard of care.1 Neuroimaging is another important factor as part of the assessment. We have a local guideline to decide on the frequency and the timing of the neuroimaging such as cranial ultrasound and MRI.II. Neuroprotection: antenatal magnesium sulphate and antenatal steroids have become an established treatment in most units.2 Interventions like total body cooling have significantly improved the outcomes for babies with hypoxic ischemic injury. One challenge faced in these babies is the ability to provide active cooling during transport when these babies are born outside cooling centres. Optimal nutrition is another important element for the developing brain. We developed neonatal nutritional guidelines in collaboration with the clinical pharmacist and a dietician. Introduction of starter parenteral nutrition bags for out of hours use in line with evidence-based feeding guidelines are known to improve the outcomes. We practice the golden hour protocol for all babies born before 28 weeks gestation and have introduced intraventricular haemorrhage (IVH) prevention bundles3 for the same cohort of babies. Even though individual components of these bundles do not have strong evidence, there is some benefit when these interventions are offered as a bundle. Our care bundle involves midline positioning, using log roll, minimal handling, maintaining normothermia, avoiding IV boluses, and maintaining normal CO2 levels etc.III. Neuromonitoring: tools like amplitude-integrated electroencephalogram (aEEG), near-infrared spectroscopy (NIRS), and onsite MRI are gaining popularity. eEEG should be routinely used in hypoxic ischemic encephalopathy (HIE) babies when available. All team members should be trained in its application and interpretation. NIRS is a developing modality used by only a few units to monitor the cerebral oxygenation. We have recently started to pilot these machines.IV. Neurodevelopment: the environment of the NICU has been shown to affect the developing brain. Strategies should be developed to optimise babies sleeping by reducing lighting and noise levels. We use positioning tools like boundaries and midliners as part of their neurodevelopment.V. Neurointervention: we use therapeutic techniques like auditory, tactile, visual, and vestibular (ATVV) stimulation.4 It is an evidence-based technique used to increase alertness in medically stable preterm infants. We use Prechtl's Qualitative Assessment of General Movements observational tool.5 It is the most predictive tool (98% sensitivity) for detecting cerebral palsy. This helps provide targeted treatment at an earlier stage.

Outcomes in two patients with vocal fold palsy who underwent revision arytenoid adduction surgery.

This study investigated the position of adduction thread attachment, pulling direction and fixation position in revision arytenoid adduction surgery performed in two patients with left vocal fold palsy in whom satisfactory speech improvement had not been obtained by arytenoid adduction and type 1 thyroplasty. Revision arytenoid adduction surgery was performed with the vocal fold in the midline position in both cases. A type 1 thyroplasty procedure was subsequently added in one case because of worsened quality of speech following arytenoid adduction. Although the arytenoid adduction procedure is conceptually well established, there is still room for debate concerning the actual surgical procedures used. The technique described in this report is effective, suggesting that it is worthy of recognition as an index procedure.

Application of ultrasound monitoring for evaluation of neonatal peripherally inserted central catheter tip localization in newborns

Objective To investigate the value of ultrasound in the localization of peripherally inserted central catheter (PICC) in neonates. Methods A retrospective analysis of the PICC catheterization was conducted at Department of Neonatology, Beijing Chaoyang District Maternal and Child Healthcare Hospital from June 2017 to December 2018.The ultrasound monitoring was performed immediately after PICC catheterization.The probe was placed into the midline position of the lower xiphoid or the subclavian parasternal line for scanning, and it would be the PICC if a high-echo equal sign was observed by ultrasound.It was believed that the PICC was successfully placed when ultrasound detected that the PICC tip was located in the junction of inferior vena cava or superior vena cava in the right atrium. Results (1)Among 112 infants with PICC catheterization, 103 cases (92.0%) were accurately placed, 9 cases (8.0%) were not placed in the ideal site, among them, 2 cases were too deep, 4 cases were too shallow and 3 cases were catheter heterotopia.The tip position was accurate after the readjustment under ultrasound monitoring in those patients whose the first ultrasound showed the tip position was not ideal.(2)The PICC indwelling time was as short as 2 days (removed due to severe arrhythmia) and as long as 56 days with an average of (15.1±10.7) days.(3)The catheter-related complications occurred in 3 cases with an incidence of 2.7%. Conclusions Using ultrasound to determine the PICC tips position is accurate and reliable, which is worthy of extensive application in the neonatal wards. Key words: Ultrasound; Peripherally inserted central catheter; Infant, newborn

Live Imaging and Analysis of Muscle Contractions in Drosophila Embryo.

Coordinated muscle contractions are a form of rhythmic behavior seen early during development in Drosophila embryos. Neuronal sensory feedback circuits are required to control this behavior. Failure to produce the rhythmic pattern of contractions can be indicative of neurological abnormalities. We previously found that defects in protein O-mannosylation, a posttranslational protein modification, affect the axon morphology of sensory neurons and result in abnormal coordinated muscle contractions in embryos. Here, we present a relatively simple method for recording and analyzing the pattern of peristaltic muscle contractions by live imaging of late stage embryos up to the point of hatching, which we used to characterize the muscle contraction phenotype of protein O-mannosyltransferase mutants. Data obtained from these recordings can be used to analyze muscle contraction waves, including frequency, direction of propagation and relative amplitude of muscle contractions at different body segments. We have also examined body posture and taken advantage of a fluorescent marker expressed specifically in muscles to accurately determine the position of the embryo midline. A similar approach can also be utilized to study various other behaviors during development, such as embryo rolling and hatching.

Effects of arm weight and target height on hand selection: A low-cost virtual reality paradigm.

We evaluated the ability of a virtual reality (VR) system to reliably detect the reaching frequency midline position of a user; the distinguishing plane between free-choice use of the left and right hand. The paradigm utilized the Leap Motion Hand Tracker along with a custom script written in C# and was realized through a Unity3D application. Stimuli appeared in random locations on the computer screen and required the participant to reach with the hand of their choice to contact them with a virtually coupled hand inside the virtual space. We investigated the effects of two manipulations of effort on the free-choice reaching of either the left or right hand. We varied the height of target positions and applied an additional weight to the non-dominant, left hand. We observed main effects of height and weight on reaching frequency midline positions across the group. We found increased use of the dominant hand as stimuli height increased, as well as a significant increase in overall use of the dominant, right hand when a weighted-glove was worn by the non-dominant, left hand. Our results are in line with previously published research on hand selection from similar paradigms, supporting the use of our VR paradigm in future experiments and applications.

Esophageal position, measured luminal temperatures, and risk of atrioesophageal fistula with atrial fibrillation ablation

Despite improvement in catheter ablation for atrial fibrillation (AF), ability to recognize and prevent esophageal injury remains challenging. We hypothesized that esophageal course may impact esophageal heating, as measured through ablation, and thereby, risk of injury. We evaluated all patients undergoing first-time AF ablation with preprocedural computed tomography (CT) imaging from 2014 to 2016 at our institution, focusing on esophageal position at the left atrial (LA)/pulmonary vein junction. Esophageal luminal temperatures (ELTs) were analyzed by esophageal course. In exploratory work by investigation of published reports of atrioesophageal fistula (AEF), we evaluated for a relationship between esophageal course and risk of AEF. Of 68 patients, 48.5% had midline, 36.8% leftward, and 14.7% rightward esophageal positions. Of 20 patients (29% of cohort) with esophageal confinement-defined as a midline or leftward position relative to the LA, vertebrae, and aorta, with luminal distortion-14 had leftward position. No significant differences in patient or procedure characteristics were noted between confinement and nonconfinement cohorts. The average peak ELT was significantly higher in those with confinement (36.9°C vs 36.2°C, P<0.05) and confinement with a left-sided esophagus (37.1°C vs 36.2°C, P<0.05). There was a significant correlation between esophageal confinement and risk of AEF (odds ratio [OR]: 2.7, 95% confidence interval [CI]: 1.2-6.2, P<0.01). Approximately one-third of patients undergoing AF ablation display leftward esophageal course along the ablation zone on preprocedure CT imaging, with a significant portion exhibiting esophageal confinement. In those with confinement, higher peak ELTs are noted with ablation. Esophageal confinement may be a risk factor for development of AEF.

Are panoramic radiographs good enough to render correct angle and sector position in palatally displaced canines?

The early interceptive treatment of palatally displaced canines (PDCs) has for decades been based on their position in panoramic radiographs. In the 1990s, cone-beam computed tomography (CBCT) started to become popular in cases with PDCs. The aims of this prospective study were to evaluate the agreement of PDC sector position and angle to midline between panoramic radiographs and CBCT scans. PDC sector and angle to midline were measured in panoramic radiographs and CBCT scans in 58 consecutive patients with 64 PDCs. Kappa with linear weighting was used to assess the agreement between the measurements of PDC sector position and Bland-Altman limits of agreement to assess the agreement between the PDC angular measurements in the 2 methods. PDC sector position and angle to midline had systematically higher values in panoramic radiographs compared with those in the CBCT scans. The agreement of sector position between the methods was fair: weighted kappa 0.36 (95% CI 0.24-0.49). The mean difference in angle was almost 7° (95% CI 5.9°-7.9°) higher in panoramic radiographs compared with CBCT. Panoramic radiographs overestimate PDC sector and angle to midline position, compared with the use of CBCT scans, but clinically the differences are quite modest. Panoramic radiographs could be considered good enough for rendering PDC position when the need for 3D information is not crucial for treatment planning.

Supine vs. Prone Position With Turn of the Head Does Not Affect Cerebral Perfusion and Oxygenation in Stable Preterm Infants ≤32 Weeks Gestational Age.

Intraventricular hemorrhage (IVH) is a frequent major damage to the brain of premature babies ≤32 weeks gestational age, and its incidence (20–25%) has not significantly changed lately. Because of the intrinsic fragility of germinal matrix blood vessels, IVH occurs following disruption of subependymal mono-layer arteries and is generally attributed to ischemia-reperfusion alterations or venous congestion, which may be caused by turn of the head. Therefore, supine position with the head in a midline position is considered a standard position for preterm infants during their first days of life. We asked whether a change in body position (supine vs. prone) linked with a turn of the head by 90° in the prone position would change blood flow velocities and resistance indices in major cerebral arteries and veins of stable premature babies at two different time points (t0, day of life 2, vs. t1, day 9). Moreover, we assessed cerebral tissue oxygenation (cStO2) by near-infrared spectroscopy and determined correlations for changes in velocities and oxygenation. Twenty one premature infants [gestational age 30 (26–32) weeks] with sufficiently stable gas exchange and circulation were screened by ultrasonography and near-infrared spectroscopy. Peak systolic and end-diastolic blood flow velocities in the anterior cerebral arteries (29 ± 6 m/s vs. 28 ± 7 peak flow at t0, 36 ± 8 vs. 35 ± 7 at t1), the basilar artery, the right and the left internal carotid artery, and the great cerebral vein Galen (4.0 ± 0.8 m/s vs. 4.1 ± 1.0 maximum flow at t0, 4.4 ± 0.8 vs. 4.4 ± 1.0 at t1) did not show significant differences following change of body and head position. Also, there were no differences in cStO2 (83 ± 7% vs. 84 ± 7 at t0, 76 ± 10 vs. 77 ± 11 at t1) and in vital signs such as heart rate and blood pressure. We conclude that change in body position with turn of the head in the prone position does not elicit significant alterations in cerebral blood flow velocities or in oxygenation of cerebral tissues. Maturational changes in arterial flow velocities and cStO2 are not correlated. For this subgroup of premature infants at low risk of IVH our data do not support the concept of exclusive preterm infant care in supine position.