Normal Anatomy Research Articles

Abdominal ultrasonographic evaluation of the urinary tract, adrenal glands, spleen, hepatobiliary, and gastrointestinal tract in juvenile eastern grey kangaroos (Macropus giganteus).

The purpose of this prospective and anatomic study was to describe the ultrasonographic anatomy of the kidneys, urinary bladder, adrenal glands, spleen, liver, gall bladder, and gastrointestinal tract in healthy juvenile eastern grey kangaroos (Macropus giganteus). As ultrasonographic descriptions are lacking in marsupial species, it was also conducted to develop a systematic approach for abdominal ultrasonographic evaluation in the kangaroo and to provide preliminary quantitative and qualitative references. Ten macropod cadavers (eight eastern grey kangaroos and two swamp wallabies (Wallabia bicolor)) were used for initial dissections and preliminary ultrasonographic examinations. Seven eastern grey kangaroos (four females and three males; mean mass 18kg (±4.5)) were ultrasonographically examined under heavy sedation in lateral recumbency. The gaseous forestomach occupied a large proportion of the entire abdomen ultrasonographically; therefore, the majority of cranial landmarks were based on an intercostal approach comparable to a deep-chested dog. Compared to domestic species, ultrasonographic differences in anatomy include the forestomach, hindstomach, liver orientation, distinguishable adrenal glands, splenic branching, and epipubic bones, all of which were described. The study was limited by the small sample size (7) and weight range (14-25kg). The systematic approach and description of the normal ultrasonographic anatomy of the abdominal organs in the eastern grey kangaroo should provide a foundation for the ultrasonographic diagnosis and interpretation of abdominal disease in this species.

The Application of 3D Anatomy for Teaching Veterinary Clinical Neurology.

Neuroanatomy is always a challenging topic for veterinary students. It is widely accepted that understanding the anatomy of the central nervous system (CNS) is essential to explain many of the pathological processes that affect the brain. Although its study has varied over time to achieve this goal, in human and veterinary medicine it is difficult to find a teaching method that associates normal anatomy with pathological alterations of the brain. For the first time, we have created an educational tool that combines neuroanatomy and neuropathology, using different magnetic resonance (MR) images as a basis and EspINA software as analyzer, to obtain segmented structures and 3D reconstructions of the dog brain. We demonstrate that this combination is an optimal tool to help anatomists to understand the encephalon, and additionally to help clinicians to recognize illness including a multitude of neurological problems. In addition, we have tried to see whether photogrammetry, which is a common technique in other sciences, for example geology, could be useful to teach veterinary neuroanatomy. Although we still need further investigations, we have been able to generate 3D reconstructions of the whole brain, with very promising results to date.

Variant anatomy of non-recurrent laryngeal nerve: when and how should it be taught in surgical residency?

While the performance of a thyroidectomy is generally associated with a low risk of injury to the recurrent laryngeal nerve (RLN), the presence of a non-recurrent nerve (NRLN) increases the risk of this complication. Generally, the intraoperative detection via visual appreciation of variant anatomy of the RLN has been regarded as poor, possibly due to a lack of knowledge of both the normal and aberrant anatomy of the RLN. Articles for the review were searched through PubMed using the search terms and their combinations: "non-recurrent laryngeal nerve," "thyroidectomy," "injury," "palsy," "variant anatomy," and "residency," from January 1, 2000, to December 2022. Papers considered for the review were the articles published in English, with additional classic and articles of surgical importance retrieved from the reference list of papers. Only papers relevant to the scope of the review were considered for this review. The NRLN has been found to be associated with concurrent vascular abnormalities, such as the presence of an aberrant right subclavian artery (ARSA) or an arteria lusoria originating from the aortic arch. However, it seems that both the normal as well as aberrant anatomy of the RLN is currently not emphasized enough during postgraduate surgical training. With the increased use of intraoperative neuromonitoring (IONM), detection of NRLN has become possible through appropriate neural mapping during thyroid surgery, besides other pointers such as visualization during surgery, computerised tomography, and duplex ultrasound scans to visualize the variant vascular anatomy. There is also a possible role for cadaveric courses, either during medical school or in a post-graduate setting-adapted to the student's level to teach the variant anatomy. With the development of newer techniques such as artificial intelligence, there are potential new options for teaching and training anatomy in the near future. Adequate knowledge of the normal and aberrant anatomy of the RLN remains essential for the best outcomes in thyroid surgery, even in the era of the IONM. Moving forward, the knowledge of (aberrant) anatomy should be made an integral part of the core competencies of both medical students and surgical trainees. It is imperative that leaders of the different field work closely together to combine their knowledge towards providing their trainees with the best possible training options.

Graph matching and deep neural networks based whole heart and great vessel segmentation in congenital heart disease

Congenital heart disease (CHD) is one of the leading causes of mortality among birth defects, and due to significant variations in the whole heart and great vessel, automatic CHD segmentation using CT images has been always under-researched. Even though some segmentation algorithms have been developed in the literature, none perform very well under the complex structure of CHD. To deal with the challenges, we take advantage of deep learning in processing regular structures and graph algorithms in dealing with large variations and propose a framework combining both the whole heart and great vessel segmentation in complex CHD. We benefit from deep learning in segmenting the four chambers and myocardium based on the blood pool, and then we extract the connection information and apply graph matching to determine the categories of all the vessels. Experimental results on 68 3D CT images covering 14 types of CHD illustrate our framework can increase the Dice score by 12% on average compared with the state-of-the-art whole heart and great vessel segmentation method in normal anatomy. We further introduce two cardiovascular imaging specialists to evaluate our results in the standard of the Van Praagh classification system, and achieves well performance in clinical evaluation. All these results may pave the way for the clinical use of our method in the incoming future.

Tonotopic fitting of the sound processor cochlear implant in normal cochlea anatomy

Introduction. Cochlear implantation is very effective due to the known tonotopic organization of the cochlea. These data are used in the distribution of signals along the channels of the cochlear implant electrode. The more accurate and natural the stimulation of the auditory nerve fibers, the better the perception of speech, sounds and speech intelligibility.The aim of the study was to compare the clinical and anatomical settings of the cochlear implant processor.Materials and methods. The study included 63 patients aged 2 to 60 years using cochlear implantation system, implants with a standard long electrode array (31.5 mm). All participants underwent computed tomography (CT) of the temporal bones with a step of 0.6 mm or less. CT data were processed using Otoplan and Sliser 3D software. The geometric dimensions of the cochlea, the length of the cochlear canal, the angular position and tonotopic frequency of each electrode were calculated, and a 3D reconstruction of the cochlea and electrode was built.Results. The correction of the frequency filters of the electrodes and the anatomical adjustment of the processor were performed according to the data obtained in the Otoplan program. A comparison was made between the clinical and anatomical setting. After the redistribution of frequency filters, patients noted a more natural sound, improved speech intelligibility. Thus, with anatomical adjustment, an exact correspondence is achieved between the central frequency of each electrode channel and the tonotopic frequency of the cochlear zone, individually determined by computed tomography.Conclusions. A new tool has appeared that allows you to significantly improve the quality and provide an individual approach to setting up processors after cochlear implantation.

Identification of genetic variants and phenotypic characterization of a large cohort of patients with congenital hypopituitarism and related disorders

PurposeCongenital hypopituitarism (CH) disorders are phenotypically variable. Variants in multiple genes are associated with these disorders, with variable penetrance and inheritance. MethodsWe screened a large cohort (N = 1765) of patients with or at risk of CH using Sanger sequencing, selected according to phenotype, and conducted next-generation sequencing (NGS) in 51 families within our cohort. We report the clinical, hormonal, and neuroradiological phenotypes of patients with variants in known genes associated with CH. ResultsWe identified variants in 178 patients: GH1/GHRHR (51 patients of 414 screened), PROP1 (17 of 253), POU1F1 (15 of 139), SOX2 (13 of 59), GLI2 (7 of 106), LHX3/LHX4 (8 of 110), HESX1 (8 of 724), SOX3 (9 of 354), OTX2 (5 of 59), SHH (2 of 64), and TCF7L1, KAL1, FGFR1, and FGF8 (2 of 585, respectively). NGS identified 26 novel variants in 35 patients (from 24 families). Magnetic resonance imaging showed prevalent hypothalamo-pituitary abnormalities, present in all patients with PROP1, GLI2, SOX3, HESX1, OTX2, LHX3, and LHX4 variants. Normal hypothalamo-pituitary anatomy was reported in 24 of 121, predominantly those with GH1, GHRHR, POU1F1, and SOX2 variants. ConclusionWe identified variants in 10% (178 of 1765) of our CH cohort. NGS has revolutionized variant identification, and careful phenotypic patient characterization has improved our understanding of CH. We have constructed a flow chart to guide genetic analysis in these patients, which will evolve upon novel gene discoveries.

Assessing chronic pain in the ankle and foot using Magnetic Resonance Imaging (MRI)

Objectives: Chronic ankle and foot pain is a common and non-specific manifestation of a broad spectrum of osseous and soft tissue pathology in the ankle and foot. MRI can play an important role in the diagnosis of these conditions and help to guide conservative management.
 Aim: The aim of this study was to assess the normal anatomy and anatomical variations, as well as to examine the MRI features that provide vital clues for the diagnosis of painful conditions of the ankle and foot. Another objective was to differentiate these conditions from one another using MRI imaging.
 Methodology: This was a descriptive study of 50 patients presenting with pain in the ankle and foot who underwent MRI examinations at the Department of Radiodiagnosis, Pacific Institute of Medical Sciences from November 2022 to February 2023.
 Results: The most common cause of chronic pain in the ankle and foot in our study was ligament pathology, which was found in 12 (24%) of the 50 patients. Tendon injuries were the next most common cause, present in 10 (20%) patients. Other causes included arthritis, bursitis, osteomyelitis, and ganglion cysts. The most affected age group was 21 to 30 years old.
 Conclusion: MRI is the modality of choice for the evaluation and characterization of various pathologies of the ankle. Most of the conditions can be managed conservatively. This study highlights the importance of MRI in the diagnosis and management of chronic ankle and foot pain.

Impact of pulmonary vein anatomy and ostial dimensions on long-term outcome after single-shot device–guided cryoablation for paroxysmal atrial fibrillation

BackgroundCryoballoon (CB)-guided pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). This observational study aimed to assess the role of individual anatomical characteristics to predict long-term freedom from arrhythmia recurrence after CB-guided PVI for paroxysmal AF (PAF).MethodsThree hundred fifty three consecutive patients (58 ± 11 years, 56% males), undergoing PVI between 2012 and 2018 were analysed. Individual pulmonary vein (PV) anatomy was assessed using preprocedural cardiac magnetic resonance imaging (MRI). For each PV, the cross-sectional area (CSA) was calculated. The impact of PV characteristics and CSA on long-term AF-free survival was evaluated.ResultsAcute PVI was achieved in all patients. Two hundred twenty-three patients (63%) had a normal PV anatomy (2 left- and 2 right-sided PV). Variant PV anatomy was present in 130 patients (37%). During the observation period of 48 months, AF-recurrence was documented in 167 patients (47 %). Patients with AF-recurrence presented with significantly enlarged right-sided PVs and left superior PVs (LSPVs) (p < 0.001). The presence of left common PVs (LCPVs) (n = 75, Log-rank p < 0.001) as well as right variant PVs (n = 35, Log rank p < 0.001) was associated with a significantly impaired long-term AF-free survival rate as compared to patients with normal PV characteristics.ConclusionVariant PV anatomy is a good predictor for AF-recurrence. A correlation between an enlarged CSA of right-sided PVs as well as LSPVs and AF-recurrence was documented.

Incidental Preduodenal Portal Vein Causing Partial Duodenal Obstruction and Hypertrophied Pre-Pyloric Gastric Polyp.

Preduodenal portal vein (PDPV) is a rare congenital anomaly in which the portal vein lies anterior to the duodenum rather than its normal posterior position. It is a known rare cause of duodenal obstruction and can be associated with other anomalies such as malrotation with or without jejunal atresia. Presented is an incidentally found PDPV causing partial duodenal obstruction during exploration for the resection of a gastric mass and placement of open gastrostomy tube for feeding. This was managed with duodenoduodenostomy, re-creating normal anatomy with portal.

V-007 Robotic repair of a bilateral recurrent groin hernia in a kidney transplant patient

Abstract Aim Due to the increased frequency of kidney transplantations and the high incidence of inguinal hernia in men, the coincidence of both features is not uncommon. Material &amp; Methods A 58-year-old male patient with a history of a kidney transplantation in the right fossa due to bilateral shrivel kidneys, presented with a bilateral recurrent incisional hernia. Two years before he had an anterior bilateral groin hernia repair; a Liechtenstein repair on the left side and a partial preperitoneal repair with mesh reinforcement on the right side. Results The case was approached via a robot assisted TAPP (transabdominal preperitoneal) procedure to perform the preperitoneal dissection of the myopectineal orifices. At the region of the right inguinal hernia, the normal anatomy was distorted, due to the extraperitoneal course of the donor ureter which was freed accordingly. A partial mesh excision of the previous mesh was performed. The preperitoneal dissection area was covered with a self-gripping mesh. The postoperative course was uneventful. Conclusions The extraperitoneal course of the ureter in a kidney transplant patient challenges the surgical repair of an inguinal hernia. In primary groin hernias an anterior approach seems best suited, but in case of a recurrence after a previous anterior approach, a laparoscopic approach is a possible though challenging surgical option.

Visual Attention, Bias, and Social Dispositions Toward People With Facial Anomalies: A Prospective Study With Eye-Tracking Technology.

Facial attractiveness influences our perceptions of others, with beautiful faces reaping societal rewards and anomalous faces encountering penalties. The purpose of this study was to determine associations of visual attention with bias and social dispositions toward people with facial anomalies. Sixty subjects completed tests evaluating implicit bias, explicit bias, and social dispositions before viewing publicly available images of preoperative and postoperative patients with hemifacial microsomia. Eye-tracking was used to register visual fixations. Participants with higher implicit bias scores fixated significantly less on the cheek and ear region preoperatively (P = 0.004). Participants with higher scores in empathic concern and perspective taking fixated more on the forehead and orbit preoperatively (P = 0.045) and nose and lips (P = 0.027) preoperativel. Participants with higher levels of implicit bias spent less visual attention on anomalous facial anatomy, whereas participants with higher levels of empathic concern and perspective taking spent more visual attention on normal facial anatomy. Levels of bias and social dispositions such as empathy may predict layperson gaze patterns toward those with facial anomalies and provide insights to neural mechanisms underlying the "anomalous is bad" paradigm.

Repair of a Reverse HAGL: A 2-Portal Technique

Background: Glenohumeral joint stability is reliant on a combination of static and dynamic constraints. Humeral avulsion of the posterior band of the inferior glenohumeral ligament (HAGL) is an exceedingly rare injury. These injuries can be difficult to diagnose and can lead to continued pain, dysfunction, and recurrent instability. There is a paucity of literature regarding surgical management of reverse HAGL lesions. Indications: Many intrasubstance reverse HAGL lesions can be managed nonoperatively with rehabilitation focused on improving shoulder stability. Although the incidence of recurrent instability in patients with reverse HAGL lesions is unknown, the acute detached humeral lesions in athletes are often treated surgically to restore normal shoulder. Technique Description: The patient was placed in a standard beach chair position, and the standard portals were made for a diagnostic shoulder arthroscopy. The anterior portal was the primary viewing portal. Using the initial posterior skin incision, instruments were introduced through the defect from the retracted posterior band of the inferior glenohumeral ligament. Using a combination of the 30° and 70° arthroscope, the HAGL was mobilized from the infraspinatus musculature. Two knotless suture devices (1.8-mm suture anchor, 2.6-mm suture anchor) were used to reduce the reverse HAGL lesion to an anatomical position, and the posterior capsule was closed thereafter. Results: Only case studies and a single case series have been published pertaining to reverse HAGL repair techniques and related outcomes. When diagnosed and treated appropriately, arthroscopic repairs yield promising results with a high percentage of patients returning to prior level of activity or returning to prior participation level in sport. However, outcome data are limited given the rare occurrence of this injury pattern. Discussion/Conclusion: Reverse HAGL pathology can be treated effectively with arthroscopic surgical repair to restore the normal capsular anatomy and prevent recurrent instability and persistent posterior shoulder pain. Using a 2-portal approach with posterior capsular closure is a minimally invasive operation that allows for appropriate management of these rare injuries. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

MRI of Benign Prostatic Hyperplasia: Important Pre- and Posttherapeutic Considerations

New minimally invasive techniques that reduce morbidity while improving lower urinary tract symptoms (LUTS) due to benign prostatic hypertrophy (BPH) have become attractive alternatives for patients, in comparison to traditional techniques such as transurethral resection of the prostate (TURP) and simple prostatectomy. Pre- and postprocedural MRI is not routinely performed for LUTS due to BPH treatments. However, because of the combination of rapidly evolving treatments available for LUTS due to BPH and increasing demand for prebiopsy prostate MRI for detection of clinically significant prostate cancer (PCa), an understanding of procedural techniques and expected changes are important for accurate interpretation of prostate MRI performed after treatment of BPH. The authors discuss the imaging evaluation of LUTS due to BPH and emerging predictors of treatment success. The posttreatment appearance and underlying anatomic changes in the prostate after medical, surgical, and minimally invasive treatments including TURP, simple prostatectomy, laser enucleations and ablations, prostatic urethral lift, water vapor thermal therapy, and prostate artery embolization are detailed. Most procedures reduce prostate volume, notably in the periurethral prostatic tissue. Ablations create areas of necrosis and can distort the normal zonal anatomy between the transition zone and the peripheral zone, and prostate artery embolization creates infarcts in the transition zone. Mechanical prostatic urethral lift devices open the anterior channel at the bladder base but create susceptibility artifacts that can obscure and prevent detection of a lesion in the transition zone. Also discussed are the detection of clinically significant prostate cancer in the postprocedural prostate and imaging of BPH procedure complications such as urethral strictures, abscesses, and hematuria. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material. See the invited commentary by Purysko in this issue.

Evaluation of normal measurements of fourth ventricle by computed tomography

Background: Size of fourth ventricle varies in different pathologies, in the context of enlarged brain ventricles size observed in routine clinical practices, knowledge of the usual range of exact measurement is required. Aims and Objectives: This study is hospital-based observational study to derive normal measurement range of fourth ventricle and correlating it with measurements of cerebrum and age of patients. Materials and Methods: Hospital-based prospective study was conducted in the department of radiodiagnosis in a teaching medical college. Patients with virtually normal study on unenhanced head CT scan of both sex and age groups from 2 year to 60 years, were included in the study. Patients with CT scans showing gross pathological changes affecting the normal anatomy of ventricles were excluded from the study. Results: The mean age of the cases was 37.0±16.88 years. Mean fourth ventricle anterioposterior dimension is 7.5±2.5 mm and transverse dimension is 12±3.1 mm. Anteroposterior diameter of fourth ventricle showed non-significant correlation (r=0.06, P=0.56) with anteroposterior diameter of skull and no significant correlation with (r=0.07, P=0.45) transverse diameter (TD) of skull. AP diameter of fourth ventricle showed a positive correlation with age, which was statistically significant (r2=0.698, P=0.01). TD of fourth ventricle showed slight positive correlation (r=0.202 P=0.048) with anteroposterior diameter of skull and (r=0.142, P=0.168) TD of skull whereas nil with. TD of fourth ventricle showed a positive correlation with age, which was statistically non-significant (r2=0.659, P=0.01). It increases with age. Conclusion: Knowledge of normal measurements helps in assessing, dilated fourth ventricle in various pathologies.

Partial hydatidiform mole and coexistent live fetus with placenta previa: a case report.

Here, we report a case of a 24-year-old Indonesian woman with an ultrasonographic appearance of partial hydatidiform mole with initial placenta covering the internal uterine ostium in the late first trimester which then became marginal placenta previa in the third trimester. The woman decided to continue the pregnancy after considering the risks and benefits. The normal anatomy of the premature infant was vaginally delivered alive with a large and hydropic placenta. Proper diagnosis, management, and monitoring remain challenging as this case is still rarely reported. Although embryos from partial mole forms generally do not survive since the first trimester, our case reported the singleton pregnancy with the coexistent normal fetus and the partial mole characteristic of the placenta. Diploid karyotype, few and focal extent of hydatidiform tissue of placenta, low rate of molar degeneration, and the absence of fetal anemia hypothesized as the factors that influenced survival of the fetus. There were two maternal complications such as hyperthyroidism and frequent vaginal bleeding without subsequent anemia in this patient. A rare case of partial hydatidiform mole coexistent with a live fetus with placenta previa was reported in this study. There were also maternal complications. Thus, prompt and regular monitoring of maternal and fetal condition holds an important role.

Lack of consensus on the definition of severe congenital heart defects for research: A challenge for comparing international studies.

In this issue of Paediatric and Perinatal Epidemiology, Gimeno and colleagues1 examine trends in the survival of children born with severe congenital heart defects (CHD) by gestational age in all of England using administrative hospital data. The main strengths of the study are the use of a national healthcare database that allows for the inclusion of a much larger population in the study than in traditional research using medical records as the primary data source and the almost complete follow-up of the children born with severe CHD. The main limitation is the exclusion of 19.9% of the births due to missing or implausible gestational age, which led to the exclusion of 23.2% of the children with a diagnosis of severe CHD within the study period. Differences in the prevalence of CHD across regions and countries are mainly explained by variations in the inclusion of small ventricular septal defects (VSDs) and access to and waiting time for echocardiography.2, 3 Studies may focus on only severe CHD, which may be ascertained more comparably. However, there is no international consensus on the definition of severe CHD. The study by Gimeno et al. defined severe CHD according to the 2014 definition of the European network of population-based registries for the Epidemiological Surveillance of Congenital Anomalies (EUROCAT)4, 5 and further included all children that had cardiac surgery or intervention within the first 5 years for less severe CHD such as septal defects. In fetal medicine, the definition of major CHD includes all cardiac defects that are lethal or require surgery or cardiac intervention within the first year after birth, and the definition is used when estimating the prenatal detection rates of CHD.6 This definition requires access to follow-up data on survival and surgery within the first year. The population-based study by Gimeno et al.1 included children with surgery or cardiac intervention performed up to 5 years of age which means that more children were included than if the definitions from fetal medicine were applied. The first EUROCAT definition of severe CHD was based on the study on prevalence and perinatal mortality for CHD in Europe from 2000 to 2005.3 After grouping the study cases with a specific ICD code for CHD into three groups based on perinatal mortality, it was clear that all cardiac defects in the most severe group were univentricular heart defects. The group with intermediate perinatal mortality included cardiac defects that could be corrected by surgery to normal anatomy and the less severe group included atrial septal defects (ASD), VSD, and pulmonary valve stenosis. After the study, the EUROCAT Coding and Classification Committee defined the severe CHD subgroup for prevalence and surveillance as the ICD codes for the cardiac anomalies included in the two groups with the highest perinatal mortality. The severe CHD subgroup was revised in 2014 with additional ICD codes for more rare cardiac anomalies with specific ICD codes such as aortic arch anomalies. A recent review of EUROCAT cases for the severe CHD subgroup showed that the cases included with mitral valve insufficiency often had secondary valve insufficiency due to dilatation of the left ventricle. Therefore, in the most recent version of the EUROCAT subgroups published on the EUROCAT website in 2022, the severe CHD subgroup does not include the code for mitral valve insufficiency.4 The advantage of using the EUROCAT definition of severe CHD in research based on healthcare databases is that the classification is based on the ICD codes only. The disadvantage is that healthcare databases may contain inaccurately recorded ICD codes and the coding of CHD is difficult and challenging for noncardiologists. Studies have shown that for 90% of the children with a code for CHD in hospital databases the CHD diagnosis was correct.7-9 As children have ICD codes for every hospital contact, the codes may not be the same from the initial suspected diagnosis around the birth to the follow-up after surgery and some codes may be more unspecified such as Q248 (other specified CHD) and Q249 (unspecified CHD). The study by Gimeno et al.1 included all children with any ICD code up to age 5 years for the specific severe CHD included in the EUROCAT definition. This may result in the inclusion of some children where the diagnosis of severe CHD was a data entry error or later was corrected to a less severe CHD. Other options may be to use the CHD diagnosis given by paediatric cardiologists as the diagnosis for inclusion or set as a requirement that the specific CHD diagnosis is present in more than one hospital contact. A study from Australia showed that by restricting the inclusion of children with multiple diagnoses in separate admissions reduced the over-recording in the hospital databases from 10% to 2% for children with any CHD.6 Researchers using healthcare databases to study children with severe CHD should be aware of the important step of developing the inclusion criteria based on the optimal use of the data available. Frequency lists with ICD codes for each child will be valuable to know the proportion of children with multiple codes for severe CHD and the proportion of children with the codes for unspecified and other specified CHD only before defining the inclusion criteria and the analysis for the study. The lack of an international consensus on the definition of severe CHD for research limits the comparisons across studies and populations. The prevalence of severe CHD in the study by Gimeno et al. was 3.6 per 1000 live births compared to the EUROCAT prevalence of severe CHD at 1.9 per 1000 live births for the same birth years.4 This indicates that around half of the children in the study by Gimeno et al. had septal defects only with an expected high survival rate. For the identification of children with severe CHD in the study by Gimeno et al., 47% had both a diagnostic code (ICD10) and a procedural code, 30% had procedural codes only and 23% had diagnostic codes only.1 Among the children with procedural codes only, a high proportion is expected to have septal defects that are not included in the EUROCAT definition of severe CHD, but there may also be children with severe CHD that are not coded correctly in the hospital databases or have the codes only for unspecified or other specified CHD. The 23% of children included with a diagnostic code only will include children dying before surgery but may also include children with less severe CHD not requiring intervention but have one or more codes for a severe CHD in the hospital databases. Some of them may have the code for mitral valve insufficiency as the study used the older EUROCAT definition of severe CHD. The citizens in Europe seem to be positive about the use of healthcare data for research as long as it is for the common good.10 Many more studies will be published with outcome data for children with severe CHD based on big data from healthcare databases. Classifying severe CHD in healthcare databases based on more variables than the ICD codes is complicated and for every additional variable added, there will be the issue of incomplete data. It would be good if future studies used the same definition of severe CHD to make the outcome for these children comparable across countries. The EUROCAT definition of severe CHD is simple to use as it is based on ICD codes only and is publicly available at the EUROCAT website.4 Ester Garne is a Consultant Paediatrician at Hospital Lillebaelt and associate professor at the University of Southern Denmark. She is the registry leader of the EUROCAT registry for Funen and has been the Chair of the EUROCAT Coding and Classification Committee for 20 years. She has research collaboration with the international networks on cerebral palsy (SCPE and the Australian Cerebral Palsy register) and was a partner in the EU FP7 project EUROmediCAT 2011-2014. She is the clinical coordinator of the EUROlinkCAT study. The main research interests are congenital anomalies and perinatal epidemiology. None. The author declares no conflicts of interest. No new data presented to share, only data from references.

A Novel Direct Pathway of Dural Venous Outflow from the Basilar Venous Plexus via the Diploic Space of the Clivus

The internal jugular vein is the preeminent outflow of the dural venous sinuses in the supine position, while the vertebral venous plexus dominates venous outflow in the upright position. Emissary veins can also be an accessory pathway for this venous egress. To our knowledge, alternative dural venous sinus directly drainage via the diploic space has not been previously reported in the literature. Ten fresh frozen adult cadavers underwent exposure of the basilar venous plexus. The entire plexus, still adhered to the underlying clivus, was removed with its underlying bone and submitted for histological examination following decalcification (Masson Trichrome, 5μm slices). All specimens were found to have direct communications between the basilar venous plexus and underlying diploic space of the clivus i.e., no intermediate clival emissary vein. These were concentrated near the midline and were more numerous over the clivus near the junction of the occipital and sphenoid bones. The endothelium of the venous sinus was continuous at the opening into the diploic space and these openings ranged in size from 500 to 750 μm (mean 650 μm). An improved understanding of cerebral venous drainage can assist clinicians and surgeons in recognizing normal, pathologic, and variant anatomy in this region. Based on our study, direct venous sinus to diploic space drainage offers an additional pathway for venous egress from the intracranium. Therefore, removal of the dura over the clivus during various skull base procedures might be associated with increased venous bleeding from the basilar venous plexus on its deep surface where it interfaces with the clivus.

Minimally Invasive Approach to Decompression for Chiari Malformation Type 1

Objective: Chiari malformation type 1 (CM1) is a congenital hindbrain abnormality characterized by downward displacement of the cerebellar tonsils through the foramen magnum. The widespread accessibility of advanced technologies and imaging modalities has led to an increase in the popularity of minimally invasive (MIS) techniques in cranial and spinal pathologies. Methods: The study was conducted at a university hospital in Bogotá, Colombia. All data were obtained from the database of the hospital’s Neurosurgery Department. After institutional review board approval, the medical records of patients who underwent MIS posterior fossa decompression for CM1 were retrospectively reviewed.Results: Thirty-six patients underwent posterior fossa decompression through a minimally invasive approach during the study period. Nineteen patients met the inclusion criteria and were included in the data analysis. The patients’ chief complaints were headache (78.9%) and neck pain (57.9%). The average surgical time was 158.2 ± 50.5 minutes, with no significant difference in timing among different specialists. The most common postoperative complications were associated with dura closure, including 6 patients with pseudomeningocele and one patient with cerebrospinal fluid leak.Conclusion: Different surgical techniques have been proposed for posterior fossa decompression of CM1. In the present study, we favor a minimally invasive approach to the craniocervical junction to preserve as much of the normal anatomy as possible and avoid alterations in spinal biomechanics.

Emergency pacing via the umbilical vein of a neonate with congenital complete atrioventricular block: a report of two cases.

We report two cases of successful emergency pacing via the umbilical vein in neonates with congenital complete atrioventricular block. The first patient, a neonate with normal cardiac anatomy, underwent emergency temporary pacing via the umbilical vein under echocardiographic guidance. The patient underwent permanent pacemaker implantation on postnatal day 4. The second patient, a neonate with heterotaxy syndrome, underwent emergency temporary pacing through the umbilical vein under fluoroscopic guidance. The patient underwent permanent pacemaker implantation on postnatal day 17.

De Quervain's Disease: A Discourse on Etiology, Diagnosis, and Treatment.

Since Fritz De Quervain first postulated stenosing tenosynovitis within the radial dorsum of the wrist, much research has been conducted to provide further insights. De Quervain's Disease (DQD) is a condition that affects the tendons that control the movement of the thumb, specifically the abductor pollicis longus and extensor pollicis brevis. Numerous studies have shown that structural divergence from normal anatomy is partly related to contingency for developing DQD. Even though this condition was discovered many years ago, its exact etiology remains a subject of debate. Two schools of thought exist, one that contends an inflammatory-mediated pathway and the other degenerative changes. Substantial evidence exists for both theories, thus necessitating further studies into the etiology of DQD. Classically, Finkelstein's and Eichhoff's tests have been used as the physical examinations of choice for clinically diagnosing this condition. However, these tests have been shown to have low specificity, hence, the emergence of the wrist hyperflexion and abduction of the thumb test. Evidence also suggests that ultrasonography may become a critical diagnostic tool, especially to identify anatomical variations before invasive treatment, reducing the risk of further complications. The management of DQD is typically conservative, with escalation to steroid injections before surgery is indicated. Future research into this disease should focus on establishing a clearer picture of how anatomical variations and other pathological and occupational factors may interplay to bring about this condition. While current research has suggested possible novel approaches for diagnosing and treating DQD, more studies are required to gain greater insights into the effectiveness of these interventions.