Normal Anatomy Research Articles

Imaging and video of late preterm delivery by midline laparotomy due to incarcerated uterus: A case report and literature review of a rare but morbid condition.

Incarcerated gravid uterus (IGU) is a rare and serious obstetric complication. IGU is defined as the entrapment of the gravid uterus between the pubic symphysis and the sacral promontory. The incidence of IGU is 1 in 3000-10 000 cases. IGU is associated with significant obstetric complications, including preterm labor, intrauterine fetal death, growth restriction, renal failure, uterine ischemia/rupture and thrombosis. Here, we present the case of a primigravida with urinary retention at 14 weeks. On transabdominal ultrasound at 19+5/7 weeks the cervix was difficult to visualize, and the anterior uterine wall appeared thickened. The bladder was elongated superior to the uterus and the placenta was low-lying. Initially the patient was managed with intermittent self-catheterization, and subsequently indwelling catheterization was required from 22 weeks. At 30 weeks, the patient was transferred to a tertiary center and magnetic resonance imaging (MRI) was preformed due to challenging visualization of the cervix on ultrasound and the patient's continued symptoms of constipation and recurrent urinary infections. The MRI found a retroflexed gravid uterus, with vagina and endocervix displaced anteriorly and compressed by the gravid uterus. The findings were consistent with an incarcerated uterus. The patient subsequently had positive urinary cultures for Pseudomonas and rising creatinine. Given the obstructive uropathy and associated morbidity and mortality, a plan for elective pre-term delivery at 33+6/7 weeks was made. Delivery was by midline laparotomy, normal anatomy was restored after manual evacuation of the fundus from below the sacral promontory, and an uncomplicated lower segment transverse uterine cesarean section was performed.

The Difficult Cholecystectomy: What You Need to Know.

This review discusses the grading of cholecystitis, the optimal timing of cholecystectomy, adopting a culture of safe cholecystectomy, understanding the common error traps that can lead to intraoperative complications and how to avoid them. The Tokyo Guidelines, AAST, Nassar and Parkland scoring systems are discussed. The patient factors, physiologic status and operative findings that predict a difficult cholecystectomy or conversion from laparoscopic to open cholecystectomy are reviewed. With laparoscopic expertise and patient conditions that are not prohibitive, early laparoscopic cholecystectomy is recommended. This is ideally within 72 hours of admission but supported up to the seventh hospital day. The majority of bile duct injuries (BDI) are due to misidentification of normal anatomy. Strasberg's four error traps and the zones of danger to avoid during a cholecystectomy are described. The review emphasizes the importance of a true critical view of safety (CVS) for identification of the anatomy. In up to 15% of operations for acute cholecystitis, a CVS cannot be achieved safely. Recognizing these conditions and changing your operative strategy are mandatory to avoid harm. The principles to follow for a safe cholecystectomy are discussed in detail. The cardinal message of this review is "under challenging conditions, BDI can be minimized via either a subtotal cholecystectomy or top-down cholecystectomy if dissection in the hepatocystic triangle is avoided." (28) The most severe biliary/vascular injuries usually occur after conversion from laparoscopic cholecystectomy. Indications and techniques for bailout procedures including the fenestrating and reconstituting subtotal cholecystectomy are presented. Seven to ten percent of cholecystectomies for acute cholecystitis currently result in subtotal cholecystectomy.

Prenatal cardiac findings and 22q11.2 deletion syndrome: Fetal detection and evaluation.

Clinical features of 22q11.2 microdeletion syndrome (22q11.2DS) are highly variable between affected individuals and frequently include a subset of conotruncal and aortic arch anomalies. Many are diagnosed with 22q11.2DS when they present as a fetus, newborn or infant with characteristic cardiac findings and subsequently undergo genetic testing. The presence of an aortic arch anomaly with characteristic intracardiac anomalies increases the likelihood that the patient has 22q11.2 DS, but those with an aortic arch anomaly and normal intracardiac anatomy are also at risk. It is particularly important to identify the fetus at risk for 22q11.2DS in order to prepare the expectant parents and plan postnatal care for optimal outcomes. Fetal anatomy scans now readily identify aortic arch anomalies (aberrant right subclavian artery, right sided aortic arch or double aortic arch) in the three-vessel tracheal view. Given the association of 22q11.2DS with aortic arch anomalies with and without intracardiac defects, this review highlights the importance of recognizing the fetus at risk for 22q11.2 deletion syndrome with an aortic arch anomaly and details current methods for genetic testing. To assist in the prenatal diagnosis of 22q11.2DS, this review summarizes the seminal features of 22q11.2DS, its prenatal presentation and current methods for genetic testing.

A perforation of a duodenal diverticulum in a 97-year-old patient after total gastrectomy and Roux-en-Y reconstruction: a case report.

Most duodenal diverticula (DD) are asymptomatic and rarely develop perforations. Perforation is the most serious complication of DD and often requires emergency surgery. A 97-year-old woman who had undergone total gastrectomy and Roux-en-Y reconstruction 30years ago was referred to our department with chief complaints of abdominal pain and fever during her hospitalization after femoral neck fracture surgery in the orthopedic department. Contrast-enhanced computed tomography showed free air and residue in the abdominal cavity and right retroperitoneum, and an emergency laparotomy was performed. The abdominal cavity was mildly contaminated, and a 6-cm DD with a 1-cm perforation in the wall of the diverticulum on the contralateral side of the mesentery of the duodenum was found. Diverticulectomy and duodenal closure were performed and a drainage tube was placed. The patient experienced no complications and was transferred to the orthopedic department on postoperative day 10. Reports of perforation of DD after gastrectomy are very rare. Particular attention should be paid to perforation of DD after Billroth-II and Roux-en-Y reconstructions as they involve the formation of a duodenal stump that differs from the normal anatomy and may be highly invasive surgical procedures, depending on the degree of inflammation and fistula formation.

Dedication to Morphology (to the 70th Anniversary of the Birth of Professor I.V. Gaivoronsky)

In February 2024, Professor Ivan Vasilyevich Gaivoronsky, Doctor of Sciences in Medicine, the prominent Russian morphologist, Head of the Department of Normal Anatomy at S.M. Kirov Military Medical Academy, celebrated the 70th anniversary. Ivan Vasilyevich was born on February 2, 1954 in the town of Kadievka, Voroshilovgrad region. In 1979, he graduated with a gold medal from S.M. Kirov Military Medical Academy; within its walls, he came a long way from an adjunct to the Head of the Department of Normal Anatomy, which he has headed for more than 35 years. Ivan V. Gavoronsky is a member of the Presidium of the All-Russian Scientific Medical Society of Anatomists, Histologists and Embryologists and Chairman of its St. Petersburg branch, a member of the Coordinating Council responsible for the field of education “Health and Medical Sciences” and its educational and methodological commission in anatomy and anthropology, Chairman of the dissertation council in the specialties Anatomy and Anthropology, Pathological Anatomy and Forensic Medicine, created at S.M. Kirov Military Medical Academy. Professor Ivan V. Gaivoronsky focused his attention on the development of modern aspects of the collateral circulation issues, the state of various parts of the vascular bed under normal conditions and under the influence of various extreme factors, innovative technologies for preparing and preserving anatomical sections for educational purposes, medical craniology, the study of individual and typological features of the human body, applied issues, dictated by the needs of practical medicine, the history of anatomy, and the improvement of the educational process in the departments of morphological profile. He created a scientific morphological school, which trained 11 doctors and 60 candidates of medical sciences. For significant contribution to the development of Russian science and modernization of the educational process, Professor IvanV. Gaivoronsky was twice awarded the Russian Government Prize in the field of education; he was awarded the honorary titles “Honored Scientist of the Russian Federation” and “Honored Figure of Russian Higher Education”, academician of the Russian Military Medical Academy, Honorary Doctor of the Russian Military Medical Academy; he was awarded the Order of Honor and a medal of the Order for Merits to the Fatherland, II degree.

The double-headed accessory iliacus muscle: a case report.

Numerous accessory muscles are present in the human body, many of which are clinically significant. We present a case of an anomalous accessory iliacus composed of two heads, whose occurrence and anatomical location indicate a high probability of causing femoral nerve compression. During a routine dissection of the posterior abdominal wall of a xx-year-old cadaver, a double headed accessory muscle was noted, measured and photographed. In addition to the normal anatomy of dissected structures from the posterior abdominal wall, an accessory iliacus muscle composed of superficial and deep heads was identified. In addition, the inferior roots of the divided femoral nerve located between the heads was found to follow an unusual course. It is important to be aware of morphological variability around structures such as double-headed accessory iliacus muscle presented in this study, due to their association with neurovascular bundles and hip joint. The reported atypical morphology is not widely known in the literature but might be of great clinical significance, therefore knowledge of such variability might be regarded in order to diagnose properly and introduce accurate treatment.

Professor I.V. Gaivoronsky — an outstanding domestic scientist-anatomist and teacher

On February 2, 2024, the prominent Russian morphologist, head of the department of normal anatomy at the Kirov Military Medical Academy to MD, Dr. Sci. (Med.) Professor Ivan V. Gaivoronsky. Ivan V. was born in the town of Kadievka, Voroshilovgrad region, in 1954.
 On February 2, 2024, a prominent Russian morphologist, Professor Ivan V. Gaivoronsky became the head of the Department of Normal Anatomy at the Kirov Military Medical Academy to Doctor of Medical Sciences. Ivan V. was born in the town of Kadievka in the Voroshilovgrad region in 1954.
 In 1973, after graduating from the Starooskolsky Medical School, he entered the Kirov Military Medical Academy, from which he graduated in 1979 with a gold medal. He then studied in an adjunct course at the Department of Normal Anatomy. After completing his studies and defending his dissertation within the walls of his native alma mater, he worked his way up from a teacher to the head of one of the oldest departments, the Department of Normal Anatomy, which he has headed for 35 years. Professor I.V. Gaivoronsky pays great attention to solving modern scientific problems of morphology: collateral circulation, medical craniology, morphology of a gunshot wound, applied problems according to the needs of surgical practice, study of individual and typical characteristics of the human body, development of innovative technologies for the production and preservation of anatomical preparations for scientific and educational purposes, and improvement of the educational process in the departments of morphological profile and history of anatomy. He created a scientific morphological school, which trained 11 doctors and 63 medical science candidates. Professor I.V. Gaivoronsky is the author of polymer embalming technology, which has radically changed the principle of teaching fundamental medical disciplines. Thanks to the development of numerous innovative areas, numerous scientific studies, and use of the latest equipment in the educational process, the Department of Normal Anatomy of the Kirov Military Medical Academy, under the leadership of Professor I.V. Gaivoronsky, became one of the best methodological and scientific centers in the Russian Federation, dealing with the most pressing problems of modern morphology. For his great contribution to the development of domestic science and the organization of the educational process, Professor I.V. Gaivoronsky was twice awarded the Government of the Russian Federation Prize in the field of education. He was awarded the honorary titles “Honored Scientist of the Russian Federation” and “Honored Worker of the Higher School of the Russian Federation”, Academician of the Russian Military Medical Academy, and Honorary Doctor of the Kirov Military Medical Academy. He was also awarded the Order of Honor and the Medal of the Order for Services to the Fatherland, II degree.

Bystander-application of a novel nasal swab optimized for drug delivery is safe and non-traumatic for the general population

ObjectiveThe PN Naloxone Nasal Swab (Pocket Naloxone Corp., Bethesda, MD) is a swab optimized for drug delivery and intended for use by non-medical personnel for the emergency treatment of opioid overdose. The aim of this study (PNC-20-003) is to determine the safety of this nasal swab in a real-world environment. MethodsThis was a single-institution, quantitative-qualitative prospective trial performed at an outpatient clinic. Patients with normal or abnormal nasal structure were recruited. A non-medically trained individual placed the nasal (soaked in fluorescein dye) on each side of the patient’s nose. Endoscopy with recording was performed before and after swab placement. An independent reviewer rated degree of staining, mucosal bleeding, and trauma at nasal subsites. ResultsVideos from 32 nasal cavities (16 participants) were reviewed. All cavities had high intensity staining at the septum and the inferior turbinate. No patients had staining within the middle meatus, agger nasi, or olfactory regions. In patients with normal anatomy, obstructive nasal anatomy or prior nasal surgery, all cavities had staining near the nasal septum. Only 7 cavities (22%) had minor bleeding defined as ooze that stopped in 1-2minutes, and 3 (9%) had minor trauma defined as mucosal disruption less than 5mm. There were no significant differences in comparing pre- and post-swab nasal cavity, trauma, or bleeding exams. ConclusionsThese study results showed that this swab is atraumatic to the nasal mucosal membranes when administered by non-medical personnel. Analysis suggests contact with targeted sites for drug absorption regardless of anatomy.

Imaging Features of Arrhythmogenic Cardiomyopathies.

Arrhythmogenic cardiomyopathy (ACM) is a genetic disease characterized by replacement of ventricular myocardium with fibrofatty tissue, predisposing the patient to ventricular arrhythmias and/or sudden cardiac death. Most cases of ACM are associated with pathogenic variants in genes that encode desmosomal proteins, an important cell-to-cell adhesion complex present in both the heart and skin tissue. Although ACM was first described as a disease predominantly of the right ventricle, it is now acknowledged that it can also primarily involve the left ventricle or both ventricles. The original right-dominant phenotype is traditionally diagnosed using the 2010 task force criteria, a multifactorial algorithm divided into major and minor criteria consisting of structural criteria based on two-dimensional echocardiographic, cardiac MRI, or right ventricular angiographic findings; tissue characterization based on endomyocardial biopsy results; repolarization and depolarization abnormalities based on electrocardiographic findings; arrhythmic features; and family history. Shortfalls in the task force criteria due to the modern understanding of the disease have led to development of the Padua criteria, which include updated criteria for diagnosis of the right-dominant phenotype and new criteria for diagnosis of the left-predominant and biventricular phenotypes. In addition to incorporating cardiac MRI findings of ventricular dilatation, systolic dysfunction, and regional wall motion abnormalities, the new Padua criteria emphasize late gadolinium enhancement at cardiac MRI as a key feature in diagnosis and imaging-based tissue characterization. Conditions to consider in the differential diagnosis of the right-dominant phenotype include various other causes of right ventricular dilatation such as left-to-right shunts and variants of normal right ventricular anatomy that can be misinterpreted as abnormalities. The left-dominant phenotype can mimic myocarditis at imaging and clinical examination. Additional considerations for the differential diagnosis of ACM, particularly for the left-dominant phenotype, include sarcoidosis and dilated cardiomyopathy. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Deep reinforcement learning and convolutional autoencoders for anomaly detection of congenital inner ear malformations in clinical CT images.

Detection of abnormalities within the inner ear is a challenging task even for experienced clinicians. In this study, we propose an automated method for automatic abnormality detection to provide support for the diagnosis and clinical management of various otological disorders. We propose a framework for inner ear abnormality detection based on deep reinforcement learning for landmark detection which is trained uniquely in normative data. In our approach, we derive two abnormality measurements: Dimage and Uimage. The first measurement, Dimage, is based on the variability of the predicted configuration of a well-defined set of landmarks in a subspace formed by the point distribution model of the location of those landmarks in normative data. We create this subspace using Procrustes shape alignment and Principal Component Analysis projection. The second measurement, Uimage, represents the degree of hesitation of the agents when approaching the final location of the landmarks and is based on the distribution of the predicted Q-values of the model for the last ten states. Finally, we unify these measurements in a combined anomaly measurement called Cimage. We compare our method's performance with a 3D convolutional autoencoder technique for abnormality detection using the patch-based mean squared error between the original and the generated image as a basis for classifying abnormal versus normal anatomies. We compare both approaches and show that our method, based on deep reinforcement learning, shows better detection performance for abnormal anatomies on both an artificial and a real clinical CT dataset of various inner ear malformations with an increase of 11.2% of the area under the ROC curve. Our method also shows more robustness against the heterogeneous quality of the images in our dataset.

Anatomical variations in the superficial venous system of the neck: an image-based study using contrast-enhanced computed tomography.

The superficial venous system (SVS) of the neck receives blood from the face and oral cavity. The SVS comprises the anterior jugular vein (AJV), external jugular vein (EJV), and facial vein (FV). Comprehensive knowledge of the normal anatomy and potential variations in the venous system is valuable in surgical and radiological procedures. This study aimed to update the anatomic knowledge of the SVS using a radiographic approach, which is a beneficial data source in clinical practice. Contrast-enhanced computed tomography images of the neck of patients with head and neck cancer treated between 2017 and 2020 were retrospectively evaluated. Each side of the neck was counted separately. A total of 302 necks of 151 patients were enrolled in this study. The medial AJV was absent in 49.7% (75/151) of the patients on the left side, which was significantly greater than the 19.2% (29/151) on the right (p < 0.001). The left AJV drained into the right venous system in 6.6% (10/151) of the necks. In 48.3% (146/302) of the necks, the FV did not flow into the internal jugular vein but rather into the EJV or AJV; these findings were significantly more frequent than those reported in previous studies. The diameters of the veins were significantly larger when they received blood from the FV than when they were not connected to the FV. These findings indicate that the AJV has a rightward preference during its course. The course of the FV is diverse and affects the diameter of connected veins.

External auditory canal reconstruction using a novel mastoidoplasty technique during canal wall down mastoidectomy: how I do it.

While mastoid obliteration techniques have received much attention in decreasing the disadvantages associated with the resultant mastoid cavity from canal wall down procedures, techniques for an anatomically normal looking ear canal reconstruction to increase the feasibility of hearing aid fitting are less commonly discussed as an alternative. Our mastoidoplasty technique basically utilises an inferiorly based periosteal flap with or without temporalis muscles and fascia to obliterate the epitympanum and reconstruct the external auditory canal (EAC). Stay sutures are used to keep them in place. For larger cavities, demineralized bone matrix (DBM) is used to obliterate the mastoid cavity and support the neo-EAC. The concept of our mastoidoplasty potentially provides a very useful alternative in recreating a near normal ear canal anatomy avoiding cavity problems as well as facilitating hearing aid fitting with canal type hearing aids after canal wall down mastoidectomy.

Limited Relationship Between Echocardiographic Measures and Electrocardiographic Markers of Left Ventricular Size in Healthy Children.

Pediatric ECG standards have been defined without echocardiographic confirmation of normal anatomy. The Pediatric Heart Network Normal Echocardiogram Z-score Project provides a racially diverse group of healthy children with normal echocardiograms. We hypothesized that ECG and echocardiographic measures of left ventricular (LV) dimensions are sufficiently correlated in healthy children to imply a clinically meaningful relationship. This was asecondary analysis of a previously described cohort including 2170 digital ECGs. The relationship between 6 ECG measures associated with LV size were analyzed with LV Mass (LVMass-z) and left ventricular end-diastolic volume (LVEDV-z) along with 11 additional parameters. Pearson or Spearman correlations were calculated for the 78 ECG-echocardiographic pairs with regression analyses assessing the variance in ECG measures explained by variation in LV dimensions and demographic variables. ECG/echocardiographic measurement correlations were significant and concordant in 41/78 (53%), though many were significant and discordant (13/78). Of the 6 ECG parameters, 5 correlated in the clinically predicted direction for LV Mass-z and LVEDV-z. Even when statistically significant, correlations were weak (0.05-0.24). R2 was higher for demographic variables than for echocardiographic measures or body surface area in all pairs, but remained weak (R2 ≤ 0.17). In a large cohort of healthy children, there was a positive association between echocardiographic measures of LV size and ECG measures of LVH. These correlations were weak and dependent on factors other than echocardiographic or patient derived variables. Thus, our data support deemphasizing the use of solitary, traditional measurement-based ECG markers traditionally thought to be characteristic of LVH as standalone indications for further cardiac evaluation of LVH in children and adolescents.

Prevalence of eosinophilic gastrointestinal diseases in children with short bowel syndrome: A single center study.

Patients with short bowel syndrome (SBS) have multiple risk factors for eosinophilic gastrointestinal diseases (EGIDs) including increased risk for intestinal dysbiosis and food allergy compared to their counterparts with normal anatomy. However, there is limited data on the prevalence of EGIDs in children with SBS. We aimed to define the prevalence of EGIDs in an SBS cohort and its association with different risk factors via a retrospective chart review of patients with SBSat Children's National Hospital. The prevalence of eosinophilic esophagitis in our SBS cohort was 10%, eosinophilic gastritis was 4.9%, and eosinophilic enteritis was 4.9%. SBS patients with history of allergy or atopy were more likely to have esophageal and intestinal eosinophilia on biopsy than patients without allergy. The prevalence of EGIDs in our SBS cohort is significantly higher than in the general population and may be associated with allergic polarization.

Outcomes of Soft Versus Bony Canal Wall Reconstruction with Mastoid Obliteration.

To compare recidivism rates, audiometric outcomes, and postoperative complication rates between soft-wall canal wall reconstruction (S-CWR) versus bony-wall CWR (B-CWR) with mastoid obliteration (MO) in patients with cholesteatoma. Retrospective chart review. Tertiary neurotologic referral center. Ninety patients aged ≥18 years old who underwent CWR with MO, either S-CWR or B-CWR, for cholesteatoma with one surgeon from January 2011 to January 2022. Patients were followed postoperatively for at least 12 months with or without second-look ossiculoplasty. Tympanomastoidectomy with CWR (soft vs. bony material) and mastoid obliteration. Recidivism rates; conversion rate to CWD; pre- versus postoperative pure tone averages, speech reception thresholds, word recognition scores, and air-bone gaps; postoperative complication rates. Middle ear and mastoid cholesteatoma recidivism rates were not significantly different between B-CWR (17.3%) and S-CWR (18.4%, p = 0.71). There was no significant difference in pre- versus postoperative change in ABG (B-CWR, -2.1 dB; S-CWR, +1.6 dB; p = 0.91) nor in the proportion of postoperative ABGs <20 dB (B-CWR, 41.3%; S-CWR, 30.7%; p = 0.42) between B-CWR and S-CWR. Further, there were no significant differences in complication rates between B-CWR and S-CWR other than increased minor TM perforations/retractions in B-CWR (63% vs. 40%, p = 0.03). Analysis of recidivism rates, audiometric outcomes and postoperative complications between B-CWR with MO versus S-CWR with MO revealed no significant difference. Both approaches are as effective in eradicating cholesteatoma while preserving relatively normal EAC anatomy and hearing. Surgeon preference and technical skill level may guide the surgeon's choice in approach.

Role of Polyunsaturated Fatty Acids (PUFAs) and Eicosanoids on Dry Eye Symptoms and Signs.

Polyunsaturated fatty acids (PUFAs) generate pro- and anti-inflammatory eicosanoids via three different metabolic pathways. This study profiled tear PUFAs and their metabolites and examined the relationships with dry eye (DE) and meibomian gland dysfunction (MGD) symptoms and signs. A total of 40 individuals with normal eyelids and corneal anatomies were prospectively recruited. The symptoms and signs of DE and MGD were assessed, and tear samples (from the right eye) were analyzed by mass spectrometry. Mann-Whitney U tests assessed differences between medians; Spearman tests assessed correlations between continuous variables; and linear regression models assessed the impact of potential confounders. The median age was 63 years; 95% were male; 30% were White; and 85% were non-Hispanic. The symptoms of DE/MGD were not correlated with tear PUFAs and eicosanoids. DE signs (i.e., tear break-up time (TBUT) and Schirmer's) negatively correlated with anti-inflammatory eicosanoids (11,12-dihydroxyeicosatrienoic acid (11,12 DHET) and 14,15-dihydroxyicosatrienoic acid (14,15, DHET)). Corneal staining positively correlated with the anti-inflammatory PUFA, docosahexaenoic acid (DHA). MGD signs significantly associated with the pro-inflammatory eicosanoid 15-hydroxyeicosatetranoic acid (15-HETE) and DHA. Several relationships remained significant when potential confounders were considered. DE/MGD signs relate more to tear PUFAs and eicosanoids than symptoms. Understanding the impact of PUFA-related metabolic pathways in DE/MGD may provide targets for new therapeutic interventions.

Parameter characteristics in intranasal drug delivery: A key to targeting medications to the olfactory airspace

BackgroundThe nose is a viable pathway for topical drug delivery to the olfactory cleft for treatment of obstructive smell loss and nose-to-brain drug delivery. This study investigates how variations in nasal vestibule morphology influence intranasal spray drug transport to the olfactory cleft and olfactory roof/bulb regions. MethodsThe unilateral nasal vestibule morphology in three healthy subjects with healthy normal nasal anatomy was classified as Elongated (Subject DN001), Notched (Subject DN002), and Standard (Subject DN003). Computational fluid and particle dynamics modelling were used to simulate nasal airflow and drug particle transport to the olfactory cleft and olfactory roof/bulb regions in each subject-specific nasal cavity. To evaluate highest drug depositions in these regions, the particle transport simulations involved extensive parameter combination analyses: 6 inspiratory flow rates mimicking resting to sniffing (10-50 L/min); 5 spray release locations (Top, Bottom, Central, Lateral, and Medial); 5 head positions (Upright, Tilted Forward, Tilted Back, Supine, and Mygind); 3 particle velocities (1, 5, and 10 m/s); 350,000 μm-particles (1-100 μm) and 346,500 nanoparticles (10-990 nm). FindingsParticle size groups with highest depositions in olfactory cleft: DN001 left = 28.4% at 11–20 μm, right = 75.3% at 6-10 μm; DN002 left = 16.8% at 1-5 μm, right = 45.3% at 30-40 nm; DN003 left = 29.1% at 21-30 μm, right = 15.9% at 6-10 μm. Highest depositions in olfactory roof/bulb: DN001 left = 6.5% at 11–20 μm, right = 26.4% at 11–20 μm; DN002 left = 3.6% at 1-5 μm, right = 2.6% at 1-5 μm; DN003 left = 2.8% at 21-30 μm, right = 1.7% at 31-40 μm. InterpretationDN001 (Elongated nasal vestibule) had the most deposition in the olfactory regions. Micron-particles size groups generally had better deposition in the olfactory regions.

The position, orientation, and relative size of the fibularis longus tubercle in normal patients: A weightbearing CT assessment.

The fibularis longus attaches to the base of the first metatarsal at the fibularis/peroneus longus tubercle (FLT/PLT). Theoretically, differences in FLT morphology may reflect changes in the function of the fibularis longus. This study defines the normal limits of the FLT position, orientation, and size in patients with morphologically normal foot anatomy. A retrospective analysis of 131 feet without deformity in 72 patients undergoing weightbearing CT (WBCT) at a single center was conducted. The position and morphology of the FLT was assessed with novel measurements including tubercle-floor distance, tubercle-metatarsal angle, and the angle between the floor and a line bisecting the FLT (bisecting angle). Roundness of the FLT was compared to a triangle limiting its shape (triangular ratio), with lower values indicating increasing roundness. We also report relative size of the FLT to the first metatarsal (X/Y ratio), and relative size of the first metatarsal and FLT to the second metatarsal (XY/Z ratio). There were no significant side to side differences for any measurement (p > 0.05). Mean values were: tubercle-floor distance 28.02 ± 2.63 mm, tubercle-metatarsal angle 32.7 ± 6.32 degrees, bisecting angle 65.58 ± 6.27 degrees, triangular ratio 0.69 ± 0.04, X/Y ratio 1.13 ± 0.20, and XY/Z ratio 3.44 ± -0.72. Bisecting angle strongly correlated with tubercle-metatarsal angle (Pearson correlation 0.840, p < 0.001) suggesting FLT rotation occurred independent of foot position. ICC was >0.943 for all measurements. This study reports the morphology of the FLT in individuals with normal feet. This normative data may be used in future studies examining differences between groups of patients with foot pathology, helping us better understand the role of fibularis longus in the development and treatment of foot disorders.

A Rare Cause of a Continuous Murmur in a Newborn.

We describe what we believe to be the first reported case of a neonate with right coronary ostial atresia with the right coronary artery originating from the left circumflex coronary artery, in conjunction with a right coronary artery to right ventricle fistula in a patient with otherwise normal cardiac anatomy. This was found following an evaluation for a continuous murmur at 2 weeks of life with elevated troponin and abnormal electrocardiogram. Thus far the child has required no intervention and is asymptomatic at 17 months of age, but he will require long-term follow-up to monitor the size of the fistula and potential for myocardial insufficiency.

Robotic-assisted uterine transposition followed by anatomic pelvic repositioning for a patient with intramural fibroids and rectal cancer

To report the first described case of robotic-assisted utero-ovarian transposition followed by anatomic repositioning in the pelvis and cervico-vaginal anastomosis in a woman with uterine fibroids, which was performed for fertility preservation in the context of pelvic radiation for rectal cancer. Description of technique and live-action narrated surgical footage showing uterine transposition and repositioning. 36 year-old woman with a new diagnosis of cT3N2M0 rectal adenocarcinoma, planned for neoadjuvant chemotherapy and pelvic radiation, who desired fertility preservation permissive of future pregnancy. Transvaginal ultrasound revealed a 5-cm posterior leiomyoma and normal endometrial cavity. The patient elected for utero-ovarian transposition prior to chemoradiation. The patient included in this video gave consent for publication and posting of the video online including social media, the journal website, scientific literature websites and other applicable sites. Per institutional guidelines, IRB review was not required. Robotic-assisted utero-ovarian transposition was performed in an inpatient setting two weeks following ovarian stimulation and oocyte retrieval. She was given GnRH agonist for menstrual suppression after oocyte retrieval. The uterus and adnexa were transposed en bloc to the upper abdomen, with perfusion via retroflected infundibulopelvic ligaments. Intravenous indocyanine green (ICG) was administered intraoperatively to visualize uterine perfusion. Three weeks postoperatively, the patient underwent surgical management of small bowel obstruction, which was successfully managed with laparoscopic adhesiolysis. The patient subsequently completed chemoradiation, and had complete response of rectal tumor. She therefore elected for surveillance. Seven months following transposition, and two months following completion of treatment, the patient underwent uncomplicated robotic-assisted utero-ovarian anatomic repositioning in the pelvis with cervico-vaginal anastomosis. Chromopertubation confirmed tubal patency. Restoration of normal pelvic anatomy, resumption of reproductive physiology RESULTS: At her 4-month postoperative visit, the cervix and vagina were normal in appearance. The patient reported return of spontaneous menses and sexual activity without complication. This case is unique due to the presence of bulky intramural uterine fibroids. The described technique may be useful for select cancer patients, who desire to carry a pregnancy following pelvic radiation for cancer treatment, and demonstrates that patients considering utero-ovarian transposition need not be excluded solely based on presence of uterine fibroids.