Normal Anatomy Research Articles

Study on Smartphone Vision Syndrome in Smartphone Users: A Prospective Randomised Controlled Study

Introduction: Recent International reports on ocular health shared that diplopia and dry eye are the prevalent ocular disorders caused by overuse of smartphone in young adults. Studies on smartphone usage in young adult’s reports that the smartphone use begins at the age group ranges from 12-18 years old, were the minimum duration of smartphone use per day is 4-6 hours. The association between smartphone use and prevalence of ocular manifestations has recommended the need of health education programs on smartphone use and its ocular impacts. Increasing use of smart devices also can cause acute acquired comitant esotropia in adolescents. Aim: To investigate the influence of smartphone reading on the ocular surface and to compare the influences of smartphone use on ocular symptoms, status of tear film stability and volume assessment. Materials and Methods: This is a prospective randomized controlled study on volunteers who continued reading for 2 hours on different smartphone screens. A total of 100 volunteers above 18 years of age without any ocular diseases had participated in the study. A structured questionnaire was used to collect the details in the present cadaveric case, found that the IMA divided into two terminal branches. The ascending branch emanated the left colic and sigmodal artery whereas the descending branch continued as superior rectal artery. This was similar to type 2 pattern of Yada’s classification. The expert knowledge of normal and variant Anatomy of abdominal aorta is of utmost importance to the interventional Radiologists, laparoscopic Surgeons, and Surgical Oncologist in succeeding surgery with minimal complications. Keywords: Abdominal aorta, Colon, Yada's classification. of smartphone usage and the visual acuity, tear film stability and volume assessment test and Intraocular pressure (IOP) was taken as some of the parameters in the study. Results: The continuous use to smartphone causes various problems, headaches, eye dryness, earache, fatigue, and musculoskeletal manifestations. The visual acuity, tear film stability and tear volume and IOP of both right and left eye was analysed and found to be statistically significant among the control and SPVS group. The ocular manifestations are noted and correlated with the duration of usage. The precautions were recommended further from the results of the study. Conclusion: The prevalence of eye diseases is high in most of the age groups and it is important to educate about the adverse effect of smartphone usage in all categories. The study also suggests about the screen time limitation and usage of smartphones for young adults.

Endovascular treatment of post-thrombotic syndrome of the lower extremities caused by combat trauma. Clinical case

In the course of Russia’s military invasion of Ukraine, gunshot shrapnel wounds of the lower extremities that result in damage to major blood vessels have become a common phenomenon. Their incidence is consistent with the general data on combat‑related vascular injuries. Vascular gunshot injuries can cause significant changes to the normal anatomy and hemodynamics of the extremity as a result of the bullet or shrapnel travelling through the wound channel. Combat trauma of the vascular bundle, either as a primary factor or in combination with other lesions, often causes a serious condition in the wounded that requires urgent surgical intervention]. Injury to the major blood vessels of the lower limbs carries the risk of critical ischemia, which can lead to higher mortality rates, poor limb recovery, and disability. This clinical case demonstrates the endovascular management of a disabling combat‑related vascular injury. The treatment involves the use of modern imaging techniques and minimally invasive surgical procedures. This case highlights the progression of the pathological process after a gunshot shrapnel wound to the soft tissues and major blood vessels. It also shows a change in the normal anatomy of the major blood vessels and the subsequent development of regional hemodynamic disorders of the lower limb after injury. In January 2023, a 51‑year‑old male received a gunshot wound to the soft tissues of the pelvis and right lower limb, as well as a gunshot fracture of the right femur. Immediate post‑evacuation therapy included the management of life‑threatening bleeding by ligating the deep femoral artery and providing external fixation of the gunshot femur fracture. Following the healing of the wounds and the removal of the external fixation device, the injured individual experienced a progressive and notable swelling of the lower limb over a period of 3 months. Subsequently, trophic ulcers appeared on the lower leg. In September 2023, the patient was admitted to the National Military Medical Clinical Centre in Kyiv after developing clinical signs of the post‑thrombotic syndrome. However, further examination revealed the presence of an AV fistula. Consequently, a simultaneous endovascular reconstructive intervention was performed on the arteries and veins of the patient’s lower extremity. Conclusions. A gunshot wound to the major blood vessels can contribute to pathological changes in the normal anatomical structure, resulting in arterial collateral blood circulation or narrowing of blood vessels that can lead to regional hemodynamic disorders. The clinical case exemplifies the importance of using modern imaging techniques for a comprehensive examination of the vascular system and the possibility of minimally invasive treatment for patients with gunshot injuries to the major blood vessels.  

The experience of a tertiary referral center with laparoscopic pyelolithotomy for large renal stones during 18 years

This study aimed to evaluate the outcomes of laparoscopic pyelolithotomy, including its efficacy and feasibility in treatment of large renal stones. All patients who underwent laparoscopic pyelolithotomy operations in a referral center were enrolled from 2003 to 2020. The final analysis included 436 patients. The total stone free rate was 88.3% and the stone-free rate for staghorn/multiple stones versus other types of stones was 81% vs. 91% (P = 0.002). Likewise, the total operation duration was 158 ± 50 and the operation duration for staghorn/multiple stones versus other types of stones was 171 ± 51 min vs. 153 ± 49 min (P < 0.001). The operation duration (169 ± 51 vs. 155 ± 58 vs. 155 ± 42 min) and hospitalization (4.5 ± 2.3 vs. 4.0 ± 2.2 vs. 3.6 ± 1.8) decreased with increasing the surgeons' experience over time. The outcomes of laparoscopic pyelolithotomy for children versus adults versus geriatric patients and in patients with normal versus abnormal kidney anatomy did not reveal statistically significant differences. Laparoscopic pyelolithotomy could be employed as an alternative surgical approach for patients with large kidney stones of any age or with kidney abnormalities provided that appropriate expertise is available to carry out the procedure.

Peculiarities of the parietal bones of the vault of the human skull structure and shape, taking into account sex and craniotype

The development of neurosurgery and the increase in requirements for the performance of surgical approaches performed through the bones of the skull vault lead to the formation of new requests for detailing and clarification of the craniometric characteristics of the parietal bones. The purpose of our study is to establish the features of the shape and other spatial indicators of the parietal bones of the skull of a mature person, taking into account sex and certain types of craniotype. The study was conducted on 130 studied preparations of bone structures of the head of adults from the collected collection of the Department of Normal Anatomy of the Kharkiv National Medical University, in the amount of 82 bone preparations, including isolated parietal bones, as well as 48 tomograms obtained during the examination of patients. The basis for establishing a craniotype is the principle of calculating the cranial index. For statistical analysis, we used the programs Statistica 13.5.0.17 (trial version) and Microsoft Excel of the corporate package MS 365. To establish the peculiarities of the structure and shape of the parietal bones, the following craniometric indicators were determined: the length and width of the parietal tubers, the parietal chord and the arch, calculated the curvature index of the parietal bone. The obtained data were analyzed for mature people of different genders and three established craniotypes. It has been established that brachycephals are characterized by an expanded and expanded form of the parietal bones, which is associated with the predominance of the transverse dimensions of the entire cerebral skull. For mesocephals, the most typical intermediate- average form depending on the values of the cranial index. Dolichocephals have an elongated and narrowed form of the parietal bones, which is combined with general changes in the cerebral skull. Additional linear parameters of the parietal bones are directly dependent on the established craniotype. The dolichocephalic type is characterized by maximum length values of parietal tubers: ¯x =18.43 mm (right) and ¯x =18.24 mm (left) with minimum width parameters: up to ¯x =15.71 mm and ¯x =15.02 mm. Representatives of the brachycranic type are characterized by the minimum indicators of the length of the parietal tubers: from ¯x =12.73 mm to ¯x =12.81 mm and the maximum indicators for the width - ¯x =23.52 mm (right) and ¯x =23.04 mm (left). The parietal chord, like the parietal arch, had a similar trend in the distribution of indicators, namely: an increase from dolichocrania to brachycrania. In men with a dolichocephalic type of skull structure, the average values of these parameters were at the level of ¯x =108.2 mm (right) and 107.6 mm (left) for the parietal chord, and ¯x =114.2 mm and ¯x =113.2 mm for the parietal arcs In men with brachycranic type, the parietal chord reached - ¯x =116.6 mm (right) and ¯x =115.8 mm (left), and the parietal arch reached - ¯x =127.8 mm (right) and ¯x =126.9 mm ( left). In women, a similar principle of size distribution has been established, taking into account a small, 2-3 mm, general decrease in indicators compared to men. The curvature index of the parietal bones was determined: the maximum average values ¯x =83.00-83.58 were obtained in dolichocephals, the minimum values were ¯x =80.56-81.64 in brachycephals. This indicates an increase in the curvature of bones in brachycephals, given that the absolute value of the index is inversely proportional to the degree of curvature. Thus, the obtained data indicate a stable relationship between the craniotype of the skull and additional parameters of the parietal bones.

A Novel Therapeutic Method in Gastro-esophageal Reflux Disease.

Gastro-esophageal reflux disease (GERD/GORD) is a chronic condition in which gastric acid flows backwards up into the esophagus, causing heart burn and a higher disposition to esophageal cancer. The reflux is caused by impairment of the lower esophageal sphincter (LES). Over the past century gastro-esophageal reflux has become the principal gastrointestinal condition of our time. The proton pump inhibitor class of drugs is effective in ameliorating the symptoms of reflux. The cost of investigation of patients in Europe is €100 billion per annum. The cost in days lost from work is €100 billion per annum in Europe. The global cost is 3 times this amount. The proposed device for treating gastro-esophageal reflux is a biodegradable valve that is placed non surgically in the esophago-gastric junction to prevent reflux from the stomach to the esophagus. 50 simulator studies were performed with the patented device to elucidate the most consistent method of insertion and fixation in a human like simulator. The simulator was designed to replicate the normal human gastro-esophageal anatomy and characteristics. Four animal insertions were performed under ethical regulation at Amsterdam Medical Centre, Netherlands. Three cadaveric experiments were performed at Hackensack University Hospital, New Jersey, USA, to verify the positive outcomes of the simulator studies. Successful outcomes of simulator studies and cadaveric experiments allowed the design freeze of a NoReflux device for treating gastro-esophageal reflux disease.

Congenital Vertical Talus

The talus is a very important bone in the foot skeleton. It represents the connection between the leg bones and the other bones of the foot. Its normal anatomy is correlated to its good function. The bone may be exposed to congenital anatomical variations and deformities, including congenital vertical talus (CVT), which affect the shape and movements of the foot. Although CVT is rare, it is important to keep in mind the possibility of CVT when examining a foot defect in newborns to avoid neglecting its treatment and subsequent complications and to avoid extensive surgical intervention.

Outcomes of Guided Personalized Surgery (GPS)-Navigated Reverse Polarity Total Shoulder Joint Replacement in a Low-Volume Hospital.

Introduction Reversepolarity shoulder arthroplasty (RSA) is an evolving surgery, and its indications have expanded over time. Apart from cuff tear arthropathy (CTA), it is recommended for complex proximal humerus fractures in the elderly, inflammatory arthritis, primary osteoarthritis in the elderly, and revision for failed hemiarthroplasty. Glenoid base plate placement and fixation are important to prevent complications, especially glenoid base plate loosening, dislocation, and scapular notching, and to improve longevity. Guided personalized surgery (GPS)-navigated RSA was devised to optimize the glenoid base plate position and fixation. Methodology A retrospective study was carried out in a low-volume district general hospital in England. All the patients who underwent GPS-navigated RSA were included. Their preoperative glenoid version, bone stock, glenoid base plate, and glenoid screw lengths were analysed. Preoperative and post-surgery patient-reported outcomes were gathered using the Oxford Shoulder Score (OSS) at six months and annually thereafter. Results Fourteen patients have undergone GPS-navigated RSA in our institute since 2018. Ten patients were female. All of them had a retroverted glenoid with a mean value of 13.6 degrees. Ten out of 14 patients had an augmented glenoid base plate. This included six eight-degree posterior augmentations, three 10-degree superior augmentations, and one extended cage peg. The follow-up period was six months to five years, depending on the date of surgery, and none of the patients dropped out of follow-up. The OSS revealed statistically significant improvement from preoperative values to six months postoperative, an improvement of 21.64±7.175. It also showed progressive improvement over time during postoperative follow-up, and the three-year mean was 47. The commonest complication was fractures, which happened in four cases. There were no infections or dislocations. Discussion Guided personalized surgery-navigated RSA was performed on selected patients at our institution when they were not suitable for conventional RSA due to distorted glenoid anatomy. Glenoid base plate positioning and fixation are important to optimize the outcome of RSA. Guided personalized surgery navigation is helpful in achieving optimum glenoid base placement, especially when the normal glenoid anatomy is distorted. There were no dislocations, glenoid base plate loosening, or scapular notching in the study group. There were four reported fractures, which was comparable with the published literature.

Exploring the influence of nasal morbidity on quality of life following endoscopic endonasal skull base surgery: a retrospective cohort study of 95 patients

The endoscopic endonasal approach is more disruptive to normal anatomy (particularly nasal mucosa) than the transseptal submucosal microscopic approach. This may result in greater postoperative nasal morbidity, in turn reducing quality of life. We aimed to assess the severity and time course of nasal morbidity, and its impact on quality of life, following endoscopic endonasal skull base surgery in this retrospective cohort study. We identified 95 patients who underwent endoscopic endonasal skull base surgery for anterior skull base pathologies. Nasal-specific questions from the Sino-Nasal Outcome Test-22 (SNOT-22) and the Anterior Skull Base inventory (ASB-12) were combined with quality-of-life questions. Patient demographics, diagnosis, and operative data were collected from electronic records. Age of the cohort ranged from 14–83 years. Time elapsed since surgery ranged from 3–85 months. 85/95 (89%) felt that nasal morbidity associated with surgery was acceptable, given the underlying reason for, and outcome of surgery; 10/95 (11%) did not. 71/95 (75%) reported no change or improvement in olfaction 3-months following surgery. 24/95 (25%) reported a deterioration in olfaction which was mild in 7%, moderate in 7%, and severe in 11%. Nasal crusting, nasal obstruction, and headache were moderately problematic symptoms but improved significantly by 3-month follow-up. Nasal discharge, nasal pain, and nasal whistling were mildly problematic and improved significantly by 3-months. 62/95 (65%) patients reported ‘no change’ in day-to-day activities due to the effects on their nose after surgery. 19/95 (20%) had ‘mild inconvenience’, 8/95 (8%) ‘moderate inconvenience’ and 6/95 (6%) ‘severe inconvenience’. Endoscopic anterior skull base surgery is associated with nasal morbidity. Whilst 35% of patients appreciate a consequent negative impact on day-to-day life, the overwhelming majority feel that nasal morbidity is acceptable, given the wider surgical goals.

Recent Advancements in Pectus Surgery: Crane Lifting, Multiple-Bar Approach, Bridge Stabilization, and Sandwich Technique

PurposeThe most recent procedure for pectus excavatum repair involves crane-powered entire chest wall remodeling, which employs crane lifting, multiple-bar approach, bridge stabilization, and sandwich techniques.This resulted in a paradigm shift in pectus deformity repair from merely lifting the sunken bone to remodeling the chest wall into normal anatomy. MethodsWe analyzed 649 patients who underwent surgery for pectus excavatum or complex combined deformities between March 2018 and January 2022. A crane with sternal wiring or screwing was used to lift the chest wall without using the pectus bar turning power. Multiple bars with bridge connections were placed to eliminate bar displacement. Modified sandwich techniques were applied to relieve the lower coastal flare (flare-buster) and focal protuberance (magic string). ResultsThe mean age of the patients included in the study was 12.2 years (range: 3–45 years). A single bar was used for 202 patients until 2021. For the multiple-bar technique, parallel bars (n = 142), crossbars (n = 166), and crossbars plus upper horizontal bars (XI pattern; n = 139) were used. The overall complication rate was 6.2 %. There was no cases of bar displacement were observed, but other minor complications such as pneumothorax (n = 20, 3.1 %), pleural effusion (n = 7, 1.1 %), and wound infection (n = 5, 0.8 %) were detected. Three patients required reoperation (infection, two: hemorrhage, one). ConclusionsThe crane-powered entire chest wall remodeling technique improved the safety and comprehensiveness of the repair procedure. By incorporating bridge stabilization and the use of multiple bars, we effectively resolved the issues related to bar displacement and incomplete repair. Type of StudyRetrospective Cohort Study. Level of Evidence3.

Comparison of Time to Intubation of a Double-Lumen Endobronchial Tube Utilizing C-MAC® Versus GlideScope® Versus Macintosh Blade: A Randomized Crossover Manikin Study.

Macintosh blade direct laryngoscopy is widely used for endotracheal intubation. It may, however, provide an incomplete view of the glottis in patients with challenging airway anatomy. Consequently, various video laryngoscopes have been developed to enhance the visualization of the glottis and facilitate intubation. Yet, the effectiveness of these video laryngoscopes for intubation using a double-lumen endotracheal tube (DLT), which is longer, larger, and more rigid and has a linear configuration as opposed to the naturally semicircular curvature of a single-lumen endotracheal tube, remains uncertain. We hypothesized that video laryngoscopes would be more efficient for DLT intubation compared to the Macintosh blade in an adult manikin. Ninety-four anesthesia providers, comprising 67 residents, 15 fellows, and 12 attendings, attempted to intubate an adult manikin with normal airway anatomy (Laerdal, Wappingers Falls, NY, USA) using a 37 Fr left-sided DLT. Three different intubation devices were used: the C-MAC® video laryngoscope (Karl Storz GmbH & Co. KG, Tuttlingen, Germany), the GlideScope® video laryngoscope (Verathon Inc., Bothell, WA), and the Macintosh blade direct laryngoscope-were used. Each participant intubated a manikin once with each of the three devices. Participants were randomized via a crossover design with the order of devices determined by using a Latin square design. Time to intubation and the number of failed intubations (esophageal intubation) were compared across the three different devices. Mean times to intubation for the C-MAC®, GlideScope®, and Macintosh blades were 18.57 ± 0.77, 36.26 ± 2.69, and 20.76 ± 0.96 seconds, respectively. There was a statistically significant difference (P<0.001) between the GlideScope® and the other two laryngoscopes. The times for C-MAC® and Macintosh blades were not significantly different. There were two instances of first-attempt failed intubation with the Macintosh. Both the C-MAC® and the Macintosh blades proved more efficient in terms of time to DLT intubation in the manikin with normal airway anatomy, when compared to the GlideScope®. Considering the occurrence of first-attemptfailed intubation, the C-MAC® was the most effective device among the three laryngoscopes for timely successful DLT intubation in the adult manikin. Further studies are needed to confirm these results in human subjects.

The chromatin remodeling protein BRG1 regulates HSC-myofibroblast differentiation and liver fibrosis

Excessive fibrogenic response in the liver disrupts normal hepatic anatomy and function heralding such end-stage liver diseases as hepatocellular carcinoma and cirrhosis. Myofibroblasts, derived primarily from hepatic stellate cells (HSCs), are the effector of liver fibrosis. In the present study we investigated the mechanism by which Brahma-related gene 1 (BRG1, encoded by Smarca4) regulates HSC-myofibroblast transition and the implication in intervention against liver fibrosis. We report that BRG1 expression was elevated during HSC maturation in cell culture, in animal models, and in human cirrhotic liver biopsy specimens. HSC-specific deletion of BRG1 attenuated liver fibrosis in several different animal models. In addition, BRG1 ablation in myofibroblasts ameliorated liver fibrosis. RNA-seq identified IGFBP5 as a novel target for BRG1. Over-expression of IGFBP5 partially rescued the deficiency in myofibroblast activation when BRG1 was depleted. On the contrary, IGFBP5 knockdown suppressed HSC-myofibroblast transition in vitro and mollified liver fibrosis in mice. Mechanistically, IGFBP5 interacted with Bat3 to stabilize the Bat3-TβR complex and sustain TGF-β signaling. In conclusion, our data provide compelling evidence that BRG1 is a pivotal regulator of liver fibrosis by programming HSC-myofibroblast transition.

The alteration of apoptosis-related genes in female pelvic supportive tissues with regard to menopausal status

PurposeWe aimed to compare the expression levels of anti-apoptotic and proapoptotic genes in the parametrium, sacrouterine and round ligaments with respect to menopausal status in women presenting without any indication of pelvic organ prolapse (POP). We hypothesized that apoptosis related gene expressions in female pelvic tissues may be altered during menopause.MethodsThe study groups consisted of pre-menopausal (n = 10) and menopausal (n = 10) females who did not have POP symptoms. Three different types of tissue samples (Parametrium, Round Ligament and Sacrouterine Ligament) were obtained and RNA was isolated from these tissues. After purifying and quantifying RNA samples, qPCR was used to determine the expression levels of anti-apoptotic and pro-apoptotic genes.ResultsBCL-2 gene expression levels were significantly lower in all the tissues of menopausal patients compared to those of premenopausal patients. In comparison to premenopausal patients, the sacrouterine ligament tissue BAD expression level was significantly high (p = 0.035), and the BCL-2/BAD ratio was significantly lower in menopausal patients (p = 0.006).ConclusionApoptosis-related protein levels change during menopause; pro-apoptotic gene expressions decrease and anti-apoptotic gene expressions increase. The significant alteration of BCL-2 and BAD expression in sacrouterine ligament with respect to menopausal status was observed and this suggested that when compared to other pelvic tissues, the sacrouterine ligament, which plays a crucial role for genital organs in restoring normal pelvic anatomy and providing support, could be affected more by menopause.

Central vs peripheral vascular factors determining risk of aortic dissection

Hypertension is the commonest cause of “central” aortic dissection, despite being an “peripheral” arteriole disease. We hypothesised that known regional variations in peripheral organ perfusion, due to variation in arteriole tone, via its effect on differential head and neck vessel flows can alter the risk and location of central aortic dissection. This might help to explain why some hypertensive patients dissect their aorta and others don't despite having similar aortic geometry. We utilised a simple 2D computational fluid dynamic model to test our hypothesis. We hypothesise (1) that variations in “peripheral” organ flow can alter the site of “central” aortic dissection, despite the blood pressure and cardiac output being identical, (2) variations in cardiac output at rest may also help to explain the risk of dissection but not the site of the initial intimal tear, and (3) atrial fibrillation, a known factor for aortic dissection, increases the risk via stroke volume variation. MRI scanning, via regional aortic branch flow quantification, may help to identify individuals who have a family history of dissection/aneurysm, who are normotensive with normal aortic anatomy that have a high potential risk for dissection due to calculated high wall velocity/shear stresses. This may allow selective beta blocker prescriptions in an asymptomatic patient population that is at a predicted high risk of aortic dissection – a hither to unidentified patient subpopulation.

Treatment of Ejaculatory Duct Obstruction by Seminal Vesiculoscopy Assisted Flow Modification.

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory duct cyst. Intraoperative excision of the verumontanum is usually required to expose the ejaculatory ducts. However, preserving the verumontanum structure allows for a better simulation of normal physiological anatomy. Maintaining the verumontanum may increase the risk of postoperative distal ejaculatory duct scarring, leading to recurrent obstruction or reduced semen volume. Therefore, we attempted a novel technique that preserves the verumontanum, which is relatively easier and safer compared to TURED. The following were the procedural steps: 1. A 6F seminal vesiculoscope was introduced through the external urethral orifice to the vicinity of the verumontanum, locating the opening of the affected-side ejaculatory duct and introducing a guidewire into the cyst. This successful step preserved the verumontanum, maximizing the retention of the anti-reflux mechanism in the distal ejaculatory duct. 2. The holmium laser enlarged the affected-side ejaculatory duct opening to 5 mm, decreasing the likelihood of postoperative closure of the ejaculatory duct opening and simplifying the procedure. 3. A window was created within the cyst to access the contralateral seminal vesicle, and then a holmium laser was used to burn and dilate the opening to 5 mm, redirecting the contralateral ejaculatory duct into the cystic cavity. This modification preserved the opening of the healthy-side ejaculatory duct and provided a new outflow passage for semen, reducing the risk of decreased semen volume postoperatively. The patients experienced no complications postoperatively, had shorter hospital stays, and showed improvement in semen volume. Hence, this surgical approach is simple yet effective.

Three-dimensional printing of mitral valve models using echocardiographic data improves the knowledge of cardiology fellow physicians in training.

High fidelity three-dimensional Mitral valve models (3D MVM) printed from echocardiography are currently being used in preparation for surgical repair. We hypothesize that printed 3DMVM could have relevance to cardiologists in training by improving their understanding of normal anatomy and pathology. Sixteen fellow physicians in pediatric and adult cardiology training were recruited. 3D echocardiography (3DE) video clips of six mitral valves (one normal and five pathological) were displayed and the fellows were asked to name the prolapsing segments in each. Following that, three still images of 3D MVMs in different projections: enface, profile and tilted corresponding to the same MVs seen in the clip were presented on a screen. Participating physicians were presented with a comprehensive questionnaire aimed at assessing whether the 3D MVM has improved their understanding of valvular anatomy. Finally, a printed 3D MVM of each of the valves was handed out, and the same questionnaire was re-administered to identify any further improvement in the participants' perception of the anatomy. The correct diagnosis using the echocardiography video clip of the Mitral valve was attained by 45% of the study participants. Both pediatric and adult trainees, regardless of the year of training demonstrated improved understanding of the anatomy of MV after observing the corresponding model image. Significant improvement in their understanding was noted after participants had seen and physically examined the printed model. Printed 3D MVM has a beneficial impact on the cardiology trainees' understanding of MV anatomy and pathology compared to 3DE images.

Discovering Alzheimer’s disease subtypes with imaging and genetic signatures via multi‐view weakly‐supervised deep clustering

AbstractBackgroundThe heterogeneity of neurodegenerative diseases, including Alzheimer’s disease (AD), has hampered precision diagnosis and treatment. Machine learning methods enable the identification of genetically‐explained disease subtypes with distinct brain phenotypes.MethodGene‐SGAN is a novel, multi‐view, weakly‐supervised deep clustering method that jointly considers phenotypic and genetic data, thereby deriving subtypes of disease‐related brain changes with genetic associations. We apply the method to derive subtypes related to AD. Analyses used structural MRIs and whole‐genome sequencing data from the Alzheimer’s Disease Neuroimaging Initiative (1,533 participants, including controls and patients with Mild Cognitive Impairment (MCI) and AD).ResultGene‐SGAN identified four distinct subtypes within MCI/AD: A1, normal anatomy; A2, focal medial temporal lobe (MTL) atrophy; A3, severe atrophy in neocortex and MTL; A4, severe cortical but relatively modest MTL atrophy (Figure 1). The four subtypes reveal significant differences in seven known AD‐related genetic variants (Figure 2). The identified subtype‐associated SNPs not only resemble previous findings, but also suggest genetic protective effects contributing to the observed resilience (A1), potential inflammatory mechanisms underlying subtypes (A2&amp;A3), and the effect of SNPs on atypical atrophy patterns of AD (A4). Clinically, A1 and A3 participants showed the best and the worst cognitive performances (Figure 3). A3 participants had the most abnormal CSF Aβ (p&lt;0.001 vs. A1&amp;A4 and p = 0.039 vs. A2), and exhibited the highest white matter hyperintensity (WMH) volumes (p&lt;0.001 vs. A1&amp;A4 and p = 0.017 vs. A2). However, A2 participants showed significantly higher CSF phospho‐tau than A3 participants (p = 0.019). A4 participants were the youngest group (p&lt;0.001 vs. all other groups), suggesting the inclusion of early onset AD participants, who have a higher prevalence of hippocampal‐sparing variants such as posterior cortical atrophy. The four genetically‐associated subtypes also possess significant differences in a large set of plasma/CSF biomarkers, which are related to distinct biological mechanisms contributing to the heterogeneity of AD.ConclusionDeep learning revealed four morphologic/genetic MCI/AD subtypes. The derived subtypes display distinct neuroanatomical patterns and genetic determinants and also differ in many clinically interpretable biomarkers. These subtypes provide potential for drug discovery and repurposing, optimization of clinical trial recruitment, and personalized medicine based on an individual’s genetic profile.

Extensor Carpi Ulnaris “Turn Around” Ligamentoplasty For Distal Radioulnar Joint Instability

Chronic distal radioulnar joint (DRUJ) instability is a challenging problem of hand surgery practice. The complex motion and function of DRUJ make surgeons give special consideration to pathologies of this joint. DRUJ instability can occur in isolation or associated with dislocations, fractures and malunions of radius and ulna, and ligamentous injuries.1 Untreated DRUJ instability leads to alterations in wrist and forearm kinematics, which can result in loss of function and disability secondary to decreased grip strength, ulnar-sided wrist pain and degenerative changes.2 In case of mild instability in lower-demand patients, nonsurgical management including functional bracing, exercise program could be appropriate in the first-line treatment of chronic DRUJ instability. However, when there is gross DRUJ instability, pain, weakness, and failed nonsurgical management, surgical options should be considered. The common goals of the surgery are to increase stability and decrease pain while preserving wrist and forearm motions. Proper bony alignment is a prerequisite for the stability of the DRUJ. Corrective osteotomy should be performed in case of a malunion accompanying DRUJ instability. However, soft tissue reconstruction is indicated in DRUJ instability with an irreparable triangular fibrocartilage complex (TFCC) when there is no bony malalignment or instability persists following bony correction.3 Several reconstruction techniques have been defined to re-create DRUJ stability. Soft tissue reconstruction procedures can be divided as extra-articular and intra-articular. Extra-articular procedures do not attempt to reconstruct the normal anatomy; however, these techniques create a tether directly between the ulna and radius or indirectly tether the joint using a tenodesis. On the other hand, intra-articular procedures attempt to mimic the normal anatomy by reconstructing the radioulnar ligaments. These intra-articular techniques are usually more complex and technically demanding than the extra-articular techniques. Nakamura described a new technique in patients with chronic DRUJ instability.4 The technique combines both ligament reconstruction and tenodesis using a distally pedicled half-slip of the extensor carpi ulnaris (ECU) tendon graft. In the surgical technique, the graft is first passed through the TFCC remnants, and then through the bone tunnel made from the center of the fovea to the ulnar neck proximally. The ECU half-slip is then anchored to the ulnar fovea with an interference screw.4 The advantages of this technique are reconstruction of the foveal bundle of TFCC by an extra-anatomical way and stabilization of ECU in its groove. However, as the purpose is to reattach the TFCC to the fovea, this technique cannot be performed in cases when there is severe damage to the total structure of the TFCC. Moreover, making bone tunnel can be complicated with fracture or bone tunnel expansion in time which result in recurrent DRUJ instability. We herein would like to present a new technique in the treatment of chronic DRUJ instability using hemi-ECU tendon graft without making a bone tunnel. ANATOMY The bony architecture of the DRUJ leads the joint inherently unstable. Shallower dimension and greater radius of curvature of the sigmoid notch compared with the ulna head result in both rotational and translational motion. This causes natural laxity of the joint. There are 4 types of sigmoid notch morphologies: flat type (42%), C type (30%), S type (14%), and ski slope (14%). Each of these variations of sigmoid notch have variable contribution rates on the stability of DRUJ. A cadaveric study demonstrated that only 20% of DRUJ stability was provided by bony constraints.5 This study shows that the stability of DRUJ is predominantly provided by surrounding soft tissue. Soft tissue stabilizers of DRUJ can be divided into two; dynamic and static. The ECU tendon and the pronator quadratus form the dynamic stabilizers. They act as agonists/antagonists and stabilize the joint during pronation-supination when they are under tension. The static stabilizers of DRUJ are composed of interosseous membrane, ulnocarpal ligaments, joint capsule, and TFCC. The primary static stabilizers of the DRUJ are palmar and dorsal radioulnar ligaments which is a part of TFCC. Recent studies have focused attention on the distal oblique band, the thickened distal portion of the interosseous membrane. This bundle is present in 40% of the cases, and the presence of this bundle results in a significantly more stable DRUJ even TFCC is torn. When the role of soft tissue stabilizers in the stability of DRUJ was examined, the palmar radioulnar ligament was found to provide the greatest restraint to dorsal translocation of the ulna and both interosseous membrane and dorsal-palmar radioulnar ligaments provide restraint to palmar translocation.5 The importance of each soft tissue stabilizer to DRUJ stability was demonstrated by an in vitro kinematic study. Gofton et al found that sectioning all soft tissues altered the DRUJ kinematics.6 However, normal DRUJ motion was observed when the radioulnar ligaments and TFCC were intact. Moreover, near-normal kinematics were observed after sectioning the radioulnar ligaments and preserving the remaining soft tissue constraints. INDICATIONS/CONTRAINDICATIONS The surgical indication for the present technique is chronic, symptomatic, gross DRUJ instability with TFCC foveal detachment. Furthermore, the articular cartilage of DRUJ should be in good condition and, sigmoid notch and ulnar styloid should be competent. The present technique is suitable for wrists with positive, neutral or negative ulnar variance unless there is a bony malalignment. Major symptoms of the patients are pain, mainly during pronation and supination, clicking, weakness, and loss of forearm rotation. Laxity should be assessed with the elbow against a table in forearm neutral, pronation, and supination, and then compared with the uninjured side. The anteroposterior drawer test or stress test is performed by locking the radius and rocking the ulna from the volar to the dorsal (Video 1, Supplemental Digital Content 1, https://links.lww.com/TIO/A59). A positive piano-key test shows DRUJ instability. The technique is contraindicated in case of advanced DRUJ arthrosis, ulnar styloid nonunion, or chronic DRUJ instability with ulnar styloid atrophy. Moreover, any bony malalignment and sigmoid notch incongruity should be addressed before performing this reconstruction procedure. SURGICAL TECHNIQUE The patient is positioned in the supine position under general or regional anesthesia. An upper arm tourniquet is applied. An approximately 8 cm, longitudinal, dorsal skin incision is made over the ECU tendon, starting from the tip of the ulnar styloid continued proximally. The dorsal sensory branch of the ulnar nerve is identified and preserved. ECU tendon sheath is incised, and distally based, ulnar-half ECU tendon graft is harvested (Fig. 1A, B). Next, a soft tissue tunnel is made with a right angle mosquito just beneath the TFCC and around the ulnar styloid (Fig. 2). The tendon graft is taken with mosquito forceps through this soft tissue tunnel and turned around the ulnar styloid (Fig. 3A). The tendon graft is then sutured to itself with pulvertaft weave technique under appropriate tension in neutral rotation (Fig. 3B). The tension and stability of DRUJ is checked with anteroposterior drawer test. Forearm rotation is checked for any limitations.FIGURE 1: A, Half of the ECU tendon is incised distally. B, Distally based partial ECU tendon graft is harvested. ECU indicates extensor carpi ulnaris.FIGURE 2: Soft tissue tunnel is made with a right angle mosquito just beneath the TFCC and around the ulnar styloid. TFCC indicates triangular fibrocartilage complex.FIGURE 3: A, The tendon graft is turned around the ulnar styloid. B, The tendon graft is sutured to itself with the pulvertaft weave technique.The patient is immobilized in a long-arm cast for 3 weeks in neutral rotation. The cast is then removed, and rehabilitation is initiated under the supervision of a hand therapist in the 3rd week (Video 2, Supplemental Digital Content 2, https://links.lww.com/TIO/A60). EXPECTED OUTCOMES The present study demonstrates a new technique using a distally based ECU tendon slip for the stabilization of DRUJ. Stabilization of DRUJ is provided through the stabilization of the distal ulna. In this technique, the ECU tendon acts as a static stabilizer besides its dynamic stabilizer effect. The ECU tendon slip is turned around the ulnar styloid and sutured back onto itself, which provides direct stability on the distal ulna in gross DRUJ instability with complete disruption of soft tissue stabilizers of DRUJ. Moreover, this technique also indirectly increases the stabilization of the DRUJ by tensioning the superficial portion of the radioulnar ligaments and the remaining soft tissue stabilizers in cases with incomplete disruption of soft tissue stabilizers. The major advantages of this technique over others are straightforward technical application and a shorter operation time without a need for a bone tunnel. Thus, this technique avoids the complications related to bone tunnels, such as fracture, expansion of the tunnel, and loosening. This is especially important in osteoporotic patients. Furthermore, there is no need for any implant fixation which avoids implant-related complications. COMPLICATIONS The dorsal sensory branch of the ulnar nerve may be injured during exposure. Rupture of the tendon graft may occur if the graft is not harvested in sufficient thickness. The half thickness of the ECU tendon is appropriate to perform this technique. Infection and recurrent instability could be other possible complications of this procedure.

Impact of choroid plexus size in prenatal diagnosis of normal and abnormal closure of fourth ventricle.

To assess the role of the choroid plexus (CP) of the fourth ventricle (4V) in fetuses with an open 4V and a normal cerebellar vermis. Two groups of patients were recruited in two fetal medicine referral centers. The prospectively collected control group included singleton pregnancies with a normal sonographic examination after first-trimester combined screening for chromosomal abnormalities and normal outcome, recruited in the period between 2019 and 2022. The study group was selected retrospectively by searching our databases to identify all cases with an isolated open 4V and normal anatomy and size of the cerebellar vermis. The inclusion criteria of the study group were: (1) gestational age between 20 and 22 weeks; (2) a brainstem-vermis angle ≥ 18° in the midsagittal plane with an otherwise normal cerebellum and vermis; (3) 4V-CP visible and seen separately from the vermis; (4) absence of other intra- and extracranial anomalies; and (5) available prenatal and/or postnatal magnetic resonance imaging (MRI) data. In 169 cases of the control group, the 4V-CP was seen separately from the cerebellar vermis and was noticed to progressively fill the space caudal to the 4V, between the vermis and brainstem. From 12 to 22 weeks, the surface areas of the vermis and medial portion of the 4V-CP increased progressively with advancing gestation (P < 0.0001). Intra- and interobserver correlation analysis showed good reproducibility for the measurements. Among the cases with an open 4V and a normal vermis, it was retrospectively feasible to visualize the 4V-CP separately from the inferior part of the vermis in 41 fetuses. In five of these cases, the open 4V was due to a small CP. In all 41 fetuses, the diagnosis on MRI was isolated upward rotation of the cerebellar vermis, and no additional anomaly was found. Closure of the 4V is dependent on the 4V-CP and not only the cerebellar vermis. In fact, a small CP may represent another cause of an open 4V. Therefore, separate visualization of the 4V-CP and cerebellar vermis is crucial to improve discrimination between the different causes of an open 4V at the anomaly scan and its clinical implications. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Nasal valve angle or nasal valve groove: Which is more suitable to describe a normal anatomic structure?

The size of the nasal valve angle is often used to assess nasal ventilation. A larger angle of the nasal valve is believed to be more conducive for ventilation, and a small angle is considered unfavorable. However, in more than 30 years of clinical practice, we have experienced that some patients with a normal nasal valve angle have relatively severe subjective or objective nasal ventilation obstruction. By studying the computed tomography data of these patients, we found that the tips of their nasal valves were at a sharp angle, while those of healthy individuals were in an arc shape. A sharp angle at the tip of the nasal valve, therefore, is a risk factor for obstructed nasal ventilation. Herein, we propose that the term “nasal valve groove” may be a more appropriate descriptor for the normal internal nasal valve anatomy, and we hope that more rhinoplasty surgeons will pay attention to how the shape of the tip affects nasal ventilation.

Evaluating Sonographers' Awareness of Artifacts in Renal Ultrasound Scans.

A routine ultrasound scan is used to assess a variety of renal pathological cases. Sonographers face a variety of challenges that may affect their interpretation. Understanding normal organ shapes, human anatomy, physical concepts, and artifacts is required for accurate diagnosis. Sonographers must understand how artifacts appear in ultrasound images in order to reduce errors and improve diagnosis. The purpose of this study is to assess sonographers' awareness and knowledge of artifacts in renal ultrasound scans. Participants in this cross-sectional study were asked to complete a survey containing different types of common artifacts in renal system ultrasound scans. An online questionnaire survey was used to collect the data. The questionnaire targeted radiologists, radiologic technologists, and intern students in Madinah hospitals in the ultrasound department. The total number of participants was 99, with 9.1% being radiologists, 31.3% being radiology technologists, 6.1% being senior specialists, and 53.5% being intern students. There was a significant difference in the participants' knowledge of ultrasound artifacts in the renal system with the total selection of the right artifact in senior specialists at 73% and intern students 45%. There was a direct relationship between age and years of experience in distinguishing artifacts in the renal system scan. A category of participants with the highest age and experience got 92% of the correct selection of artifacts. The study concluded that intern students and radiology technologists have limited knowledge of ultrasound scan artifacts, whereas senior specialists and radiologists have a high level of awareness of the artifacts.