Outer Third Research Articles

Innervation of nociceptors in intact human menisci along the longitudinal axis: semi-quantitative histological evaluation and clinical implications

BackgroundThe mechanism of pain after meniscus injury remains unknown. After injury, some individuals suffered from acute pain, while others suffer from delayed pain. A precise nociceptor distribution pattern may provide the answer to this question.MethodsTwenty-two intact menisci (paired medial and lateral menisci) were obtained from 11 patients with a mean age of 28.45 years. All menisci were sectioned into five parts: the anterior horn, anterior body, middle body, posterior body, and posterior horn. Two paired menisci were stained by a modified gold chloride method. All other specimens were stained by H&E staining and were subjected to immunohistochemical staining to detect substance-P (SP). Under a microscope, measurements were made in 10 consecutive visual areas at 400x magnification. SP-positive fibres were determined using a three-grade scale, and the mean number of SP-positive fibres was assessed.ResultsNerve fibres and nociceptors stained by H&E and modified gold chloride were found mainly in the vascular outer third of the menisci as observed under a microscope; the positive area was wider in the anterior and posterior horns. There were more SP+ fibres in the anterior horn and posterior horn than in the anterior body, middle body, or posterior body (p < 0.05). Regarding the bodies, the mean number of substance-P fibres was greater in the anterior body or posterior body than in the middle area (p < 0.05). No significant differences were found between the number of substance-P nerve fibres in the anterior horn vs the posterior horn or in the anterior body vs the posterior body of all menisci (p > 0.05). No significant differences were observed in the same location between the paired medial and lateral menisci in all areas of the menisci (p > 0.05).ConclusionThe density of nociceptors decreased along the longitudinal axis of the meniscus from both horns to the middle part of the body, which may guide future diagnostic methods and rehabilitation protocols.

Numerical Investigation of the Aeroelastic Behavior of a Wind Turbine with Iced Blades

Wind turbines installed in cold-climate regions are prone to the risks of ice accumulation which affects their aeroelastic behavior. The studies carried out on this topic so far considered icing in a few sections of the blade, mostly located in the outer part of the blade, and their influence on the loads and power production of the turbine are only analyzed. The knowledge about the influence of icing in different locations of the blade and asymmetrical icing of the blades on loads, power, and vibration behavior of the turbine is still not matured. To improve this knowledge, multiple simulation cases are needed to run with different ice accumulations on the blade considering structural and aerodynamic property changes due to ice. Such simulations can be easily run by automating the ice shape creation on aerofoil sections and two-dimensional (2-D) Computational Fluid Dynamics (CFD) analysis of those sections. The current work proposes such methodology and it is illustrated on the National Renewable Energy Laboratory (NREL) 5 MW baseline wind turbine model. The influence of symmetrical icing in different locations of the blade and asymmetrical icing of the blade assembly is analyzed on the turbine’s dynamic behavior using the aeroelastic computer-aided engineering tool FAST. The outer third of the blade produces about 50% of the turbine’s total power and severe icing in this part of the blade reduces power output and aeroelastic damping of the blade’s flapwise vibration modes. The increase in blade mass due to ice reduces its natural frequencies which can be extracted from the vibration responses of the turbine operating under turbulent wind conditions. Symmetrical icing of the blades reduces loads acting on the turbine components, whereas asymmetrical icing of the blades induces loads and vibrations in the tower, hub, and nacelle assembly at a frequency synchronous to rotational speed of the turbine.

Comparison of the effectiveness of oblique and transverse incisions in the treatment of fractures of the middle and outer third of the clavicle

Iatrogenic supraclavicular nerve injury is frequent during surgical repair of clavicle fractures through a transverse incision. The use of an oblique incision may be a potential approach to avoiding this complication. This study compared the clinical effectiveness of oblique and transverse incisions in the treatment of fractures in the middle and outer thirds of the clavicle. This prospective observational study included patients with fracture of the mid-to-outer third of the clavicle between August 2011 and August 2016. We allocated the patients into 2 groups based on their choice of treatment: oblique incision (n = 62) and transverse incision (n = 64). We compared the following parameters between the 2 groups: operative time, intraoperative blood loss, postoperative fracture healing time, incision size, clinical complications, postoperative subjective satisfaction, and shoulder function. Operative time, postoperative fracture healing time, postoperative shoulder function (Constant-Murley and disabilities of the arm, shoulder and hand [DASH] scores), and clinical complications did not differ significantly between groups (all P > .05). The oblique incision group had less intraoperative blood loss (41.4 ± 16.4 vs. 65.3 ± 10.4 mL, P < .001) and smaller surgical incisions (3.6 ± 1.6 vs. 10.3 ± 2.6 cm, P < .001). The oblique incision group showed better outcomes for postoperative satisfaction (85.5% vs. 64.1%, P = .015), absence of shoulder numbness at the last follow-up (89.3% vs. 70.3%, P = .010), and satisfaction with the scar (90.3% vs. 3.1%, P < .001). Oblique incisions have several advantages over transverse incisions: less bleeding, smaller incisions, less iatrogenic injury to supraclavicular nerves, and higher patient satisfaction. These 2 approaches have equivalent effects on recovery of shoulder joint function.

Presynaptic NMDARs and astrocytes ally to control circuit-specific information flow.

The entorhinal cortex (EC) conveys spatial, limbic, and sensory information to the hippocampus, which performs critical brain functions, including learning and memory processes and spatial information coding. Axons from superficial [layer (L)2] EC neurons make excitatory synapses onto granule cells (GCs) of the hippocampal dentate gyrus (DG), which prepare the information for further processing in other hippocampal regions (1). Afferents from the lateral and medial perforant path (LPP and MPP, respectively) convey different aspects of information to the DG, with the former related more to sensory information, and the latter to spatial location and limbic signals related to attention and motivation. They also have distinct patterns of input, contacting the outer (LPP) or middle (MPP) third of the molecular layer of the DG, and exhibit different functional properties (1, 2). The mechanistic bases of these differences are unknown and represent a challenge to understand circuit-specific biological computations as well as susceptibility to pathological insults. In PNAS, Savtchouk et al. (3) identify presynaptic N -methyl-d-aspartate receptors (pre-NMDARs) as a source of the differences in information processing between MPP and LPP fibers. Previous work by the group (4) demonstrated that glutamate released by astrocytes enhances the strength of PP-GC synapses. The effect seemed to be mediated by pre-NMDARs, which increased the probability of transmitter release and contained the glutamate receptor subunit GluN2b. However, the work made no distinction between LPP and MPP contributions and left unsolved an apparent incongruence: GluN2b subunits confer high voltage-dependent Mg2+ block to NMDAR channels, but pre-NMDARs at PP-GC synapses could be activated without previous depolarization or in the absence of action potential firing in the axons. The current work (3) demonstrates that this is possible because of the additional presence in the receptor channel of the atypical GluN3a subunit, which largely relieves NMDAR … [↵][1]1To whom correspondence may be addressed. Email: arodmor{at}upo.es. [1]: #xref-corresp-1-1

Efficiency of thoracoscopic palpation in localizing small pulmonary nodules.

The thoracoscopic localization of small and deep pulmonary nodules can be challenging. We conducted this study to evaluate the efficiency of thoracoscopic palpation in tumor detection. The subjects of this study were 229 patients with a collective 267 indeterminate pulmonary nodules ≤ 15mm in diameter, in the outer third of the lung field. The nodules were localized by palpation using the forefinger or a metal suction probe. Based on the distance from the pleura-to-tumor size ratio (D/S), the nodules were classified into group A (D/S = 0), group B (0 < D/S ≤ 1), and group C (D/S > 1). The median tumor diameter was 10mm. All 267 nodules were palpable and resected with negative margins via thoracoscopic wedge resection. The majority of the deep nodules had no pleural change (11%, 86%, and 100% in groups A, B, and C, respectively; P < 0.01). The median margins were 15, 16, and 14mm in groups A, B, and C, respectively. In four patients (1.5%) with relatively short margins (2-7mm), an additional intraoperative wedge resection was performed. Thoracoscopic palpation was effective for tumor detection when the nodules were located in the outer third of the lung.

Three-dimensional assessment of proximal contact enamel using optical coherence tomography

ObjectiveThe purpose of this study was to detect and investigate the association of enamel microcracks with demineralization at proximal contact areas of premolars, using 3D swept-source optical coherence tomography (SS-OCT). MethodsExtracted maxillary and mandibular premolars (n=50 each), without any visible tooth cracks, were examined for demineralization of interproximal contact areas, using the International Caries Detection and Assessment System (ICDAS). SS-OCT was used to evaluate demineralization and detect microcracks. Demineralization progression was divided into 4 types by depth: 0 for sound enamel and Type I, II, and III for enamel demineralization penetrating into the outer third, the middle third, and the inner third of the enamel thickness, respectively. Enamel microcracks were classified according to the predominant crack pattern: Type O, no cracks; Type A, subsurface microdefects; Type B, enamel microcrack running along the direction of the enamel prism; Type C, enamel microcrack running transverse to the enamel prism direction; and Type D, a combination of patterns A, B, and C. SS-OCT findings were confirmed by confocal laser scanning microscopy observation. ResultsMicrocracks confined within the superficial enamel in proximal contact areas were seen as bright lines on SS-OCT. There were significant positive correlations among ICDAS codes, demineralization levels, and microcrack distribution (p≤0.001). The mesial side of maxillary premolars showed significantly more demineralization (n=36) and microcracks (n=27) than that of the mandibular premolars (n=20 and n=14, respectively; p<0.001). SignificanceThe presence of microcracks within the superficial enamel in proximal contact areas could be determined using SS-OCT, and correlated with the level of demineralization. 3D SS-OCT is a valuable diagnostic tool for comprehensive assessment of microstructural changes related to enamel demineralization and crack development.

Accuracy of tactile assessment in order to detect proximal cavitation of caries lesions in vitro.

Discriminating non-cavitated from cavitated proximal lesions without tooth separation is only limitedly possible using visual-radiographic assessment alone. We evaluated how additional tactile assessment might increase the accuracy of this discrimination in vitro. Surface integrity of 46 primary molars with proximal lesions extending radiographically into outer third of dentin (ICDAS-codes: 2 n = 34, 3 n = 8 and 5 n = 4) were mounted in groups of two in manikin heads and independently assessed by three examiners using visual-radiographic and additional tactile assessment using a cow-horn-ended explorer with or without gingival displacement. After examination, lesion surfaces were evaluated for possible damage using scanning-electronic microscopy. Analysis of variance (ANOVA) was performed for evaluating if tactile assessment and gingival displacement significantly affected accuracy. Tactile assessment significantly increased sensitivity of detecting cavities (p < 0.001, ANOVA), but decreased specificity (p < 0.05). Sensitivities/specificities varied between 33 (8)%/96 (1)% and 86 (6)%/84 (5)%. Gingival displacement had no significant impact on accuracy (p > 0.05). Scanning-electron microscopy revealed no cavitation. In vitro, tactile assessment of proximal surfaces was useful and safe. Analysis of the cavitation level by using a cow-horn-ended probe might be leading to useful information in addition to bitewing assessment under clinical circumstances.

Accuracy of the DIAGNOcam and bitewing radiographs in the diagnosis of cavitated proximal carious lesions in primary molars.

To evaluate the diagnostic abilities of near-infrared light transillumination (using the DIAGNOcam) and bitewing radiographs in detecting cavitated proximal carious lesions in primary molars. The study was a cross-sectional analytical, clinical study. The proximal surfaces of primary molars of healthy 5- to 8-year-old children were radiographically screened for the presence of carious lesions in the enamel or outer third of dentin (D1). Two trained and calibrated examiners evaluated the depth of caries in bitewing radiographs and DIAGNOcam images and then verified the presence of cavitation by direct visual examination using the "International Caries Detection and Assessment System" after temporary tooth separation. A total of 236 proximal lesions were included in the study. Most of the clinically cavitated lesions (51.9%) were D1 radiographically and in outer dentin lesions (scores 3 and 4) by the DIAGNOcam (37% and 48.1%, respectively). Although DIAGNOcam showed higher sensitivity (0.852) compared to the radiographs (0.519), it showed slightly less specificity (0.569) compared to the radiographs (0.579). However, DIAGNOcam showed higher value of the area under the curve (AUC = 0.722; P < 0.001) compared to the radiographic method (AUC = 0.561; P = 0.308). The DIAGNOcam showed higher sensitivity and better accuracy than bitewing radiographs in diagnosing cavitated proximal lesions in primary molars and can be generally considered as an alternative to radiographs to detect cavitation without the hazards of ionizing radiation in children.

APPLICATION OF COMPUTER MICROTOMOGRAPHY IN THE STUDY OF MORPHOSTRUCTURAL PECULIARITIES OF HARD TISSUES OF TEETH IN EARLY FORMS OF CARIOUS LESIONS

Aim. The research was designed to assess the capabilities of the microcomputer tomography method with the subsequent image analysis and determination of the mineral optical density of demineralized areas to improve the early diagnosis of fissure caries of permanent molars after the eruption.Materials and methods. Using a high-resolution X-ray microtomograph “Skyscan 1176” (“Bruker”, Belgium) followed by post-processing and analysis of the obtained tomograms, 75 molars of children aged 8-11 were removed by orthodontic indications. Of the total number of teeth removed, research groups were formed – teeth without signs of demineralization and teeth with carious lesions in the stage of white, light brown, brown and black spots. In the reconstructed 2D and 3D images were identified the zones in the outer (0.05-0.5 mm), middle (0.75-1.25 mm) and inner (1.5-2.0 mm) thirds of the thickness of the enamel layer followed by the computation in the CTvox program (3.3.0-1403, Bruker-micro CT) of the averaged X-ray (mineral) density indicators.Results. According to the tomograms of the teeth of the studied groups, the average indicators of the mineral optical density of the intact teeth enamel were identified as well as the average indicators of teeth with various types of carious lesions within the enamel. The following sequence was revealed in descending order of the parameters of optical density: healthy enamel (2.47±0.12 g/cm3) – caries in the white spot stage (2.41±0.11 g/cm3) – caries in the light brown spot stage (2.32±0.07 g/cm3) – caries in the brown spot stage (2.18±0.12 g/cm3) – caries in the black spot stage (1.81±0.12 g/cm3). Identifying the correlations between the color of carious lesion and mineral density of tooth enamel broadens the understanding of the mechanisms of the development of caries pathogenesis and contributes to the improvement of therapeutic and preventive measures aimed at improving caries resistance.Conclusion.The use of microcomputer tomography in combination with other special methods characterizes fissure caries as a sequential, gradually progressing destructive process of hard tooth tissues (from focal demineralization to cavity formation), which establishes the relationship between the intensity of internal disturbances and external damage.

Comparison Between Stereotactic Radiotherapy and Sublobar Resection for Non-Small Cell Lung Cancer

The aim of this study was to compare outcomes of primary treatment with stereotactic body radiation therapy (SBRT) versus sublobar resection (SLR) for clinical stage I non-small cell lung cancer (NSCLC) in patients with medical comorbidities. Consecutive patients who underwent SBRT (n= 106) or SLR (100 wedge resection, 41 segmentectomy) because of medical comorbidities associated with stage I NSCLC were enrolled. Lesions located in the outer third of the lung field on computed tomography were defined as external, and others were defined as internal. A propensity score-matched analysis was also performed that compared SBRT and SLR results. Charts were reviewed to determine local tumor recurrence, disease-specific survival (DSS), and overall survival (OS). A propensity score-matched analysis, recurrence-free survival (RFS) became significant in favor of surgery (p= 0.036). For large nodules of greater than 2.0 cm in diameter, RFS was significantly better in the surgery group (p= 0.042). No significant differences in OS, DSS, or RFS were observed with small nodules of less than 2.0 cm in diameter. In the external group, a higher recurrence rate was seen for SBRT group. For internal group, there was no statistical difference between each treatment. Local recurrence rate was higher in the SBRT group (p= 0.0082) in the external group. In a matched comparison of stage I NSCLC in patients with medical comorbidities, RFS was in favor of surgery comparing SBRT, but there were no significant differences in OS or DSS. The tumor size and tumor location should be considered before deciding whether to perform SBRT or surgery.

Micro-invasive interventions for managing non-cavitated proximal caries of different depths: a systematic review and meta-analysis.

The aim of this study was to further evaluate the caries-arresting effectiveness of micro-invasive interventions for non-cavitated proximal caries and analyze their efficacy for caries lesions of different depths. Randomized clinical trials (RCTs) of micro-invasive interventions for non-cavitated proximal caries were included in this study. We searched the Cochrane Library, PubMed, Embase, and Web of Science on May 25, 2017, without restrictions. After duplicate study selection, data extraction, and risk of bias assessment, a meta-analysis of the odds ratios (OR) with 95% confidence intervals (95% CIs) and a publication bias analysis were conducted using Stata 12.0. After 2195 citations were screened, 8 citations of seven studies with follow-up periods from 12 to 36months were included. The subgroup analysis showed that resin infiltration and resin sealant, but not glass ionomer cement (GIC), could reduce the caries progression rate (resin infiltration: OR = 0.15, 95% CI 0.09 to 0.24; resin sealant: OR = 0.33, 95% CI 0.19 to 0.58; GIC: OR = 0.13, 95% CI 0.01 to 2.65). Further analysis of their efficacies for caries lesions of different depths indicated that resin infiltration could arrest progression of enamel caries and caries around the enamel-dentin junction (EDJ) (enamel: OR = 0.05, 95% CI 0.01 to 0.35; EDJ: OR = 0.07, 95% CI 0.01 to 0.70). However, when the outer third of the dentin was involved, resin infiltration yielded significantly different results compared with the control group (OR = 0.42, 95% CI 0.16 to 1.10). Resin sealant seemed to be ineffective regardless of the caries depth (enamel: OR = 0.62, 95% CI 0.13 to 3.00; EDJ: OR = 0.44, 95% CI 0.09 to 2.15; dentin: OR = 0.43, 95% CI 0.07 to 2.63). Resin infiltration is effective in arresting the progression of non-cavitated proximal caries involved in EDJ, while the therapeutic effects of resin sealant for different caries depths still needs to be further confirmed. Based on existing evidence, dentists should carefully select appropriate micro-invasive interventions according to the different depths of non-cavitated proximal caries.

The many ways to mend your liver: A critical appraisal.

In the latter half of the 20th century, our understanding of mammalian liver regeneration was shaped by the manner of compensatory hyperplasia occurring after a partial rat liver resection. This response involves almost all hepatocytes and thus is unlikely to be the outcome of the multiple cycling of a small stem cell population. It was most intense in the outer third of lobule, the location closest to the afferent arterial blood supply. With the advent of heritable genetic labelling techniques, usually applied to mice, hitherto unrecognized hepatocytes with clonogenic potential have been discovered, contributing to homoeostatic renewal and/or regenerative responses after tissue loss. This review combines observations from cell lineage tracing studies with other data to summarize the Four proposed anatomical locations for hepatocyte stem cells: the periportal zone, the pericentral zone, a randomized distribution and finally within the intrahepatic biliary tree. As in other endodermal-derived tissues, it appears that there are both homoeostatic stem cells and regenerative stem cells, while some normally homoeostatic stem cells can become more active to boost regeneration.

Real-time Doppler ultrasound to identify vessels and guide needle placement for gynecologic interstitial brachytherapy

PurposeDoppler ultrasound (US) gives real-time information regarding anatomy and blood vessel location to guide needle placement for gynecologic interstitial (IS) brachytherapy (BT). We retrospectively assessed Doppler US images for vessel quantity, size, and distribution in cervical cancer patients undergoing high-dose-rate BT at our institution. Methods and MaterialsEleven consecutive patients undergoing IS high-dose-rate BT implants for cervical cancer between 2015 and 2017 were included. Transrectal Doppler US was used for real-time image guidance. US images were retrospectively evaluated. Vessel quantity, size, and distribution at superior and inferior levels of the cervix were recorded. Correlation of vessel quantity with tumor size and International Federation of Gynecology and Obstetrics stage was evaluated. ResultsAverage vessel quantity was 4.2 in the inferior cervix and 3.8 in the superior cervix (range 1–11). Median vessel diameter was 2 mm in the inferior cervix and 2 mm in the superior cervix (range 1–6 mm). The most common location was posterolateral (3:00–5:00 and 7:00–9:00), outer third (78% of vessels inferiorly, 64% of vessels superiorly). Vessel quantity was correlated to initial tumor size superiorly (p = 0.04, paired t-test) but not inferiorly (p = 0.31, paired t-test). There was no correlation between vessel quantity and International Federation of Gynecology and Obstetrics stage (p > 0.05, analysis of variance). Doppler US was successfully used to guide needle placement away from visualized blood vessels with no incidents of hemorrhage in these patients. ConclusionsDoppler US is a useful tool to guide needle placement for IS BT for cervical cancer. Vessel quantity varied with increased vessel quantity seen higher in the cervix for larger tumors. Vessels were most commonly distributed in the outer third of the posterolateral cervix.

Use of ARFI elastography in the prediction of placental invasion anomaly via a new Virtual Touch Quantification Technique

We aimed to evaluate the efficiency of placental elasticity in predicting a placental invasion anomaly with the Virtual Touch Quantification (VTQ) technique. Pregnant women in the third trimester with suspected placental invasion anomaly were enrolled into the research (n = 58). The placenta was evaluated and divided into three equal parts as foetal edge (inner 1/3 of placenta), maternal edge (outer 1/3 of placenta) and the central part (central 1/3 of placenta). Shear wave velocity (SWV) measurements were used in the elastographic evaluation of placentas by VTQ. We performed the measurements at the different regions of placenta for sampling the variety areas of the placenta. Acoustic Radiation Force Impulse (ARFI) Elastography scores were significantly higher in the group in which an invasion was detected during the surgery of patients with preoperative placental invasion suspicion. A significant difference in the measurements of the inner, central and outer third of the placenta between the groups was found (p < .001). In this study, we have shown higher SWV scores of placental measurements of the patients with preoperative suspected anomalies and an invasion detected during their surgery. These findings may reflect an event at the tissue elasticity level and we hope that the use of the VTQ technique may contribute to an early prediction of placental invasions before surgery in the future via new research.Impact statementWhat is already known on this subject? Placenta invasion anomalies (PIA’s) are characterized by haemorrhages which can threat the mother’s life. Placental invasion anomalies are among the most important causes of maternal mortality and morbidity. Early diagnosis is very important condition in reducing the mortality and morbidity. Gray scale ultrasonography (US) is mostly used in early diagnosis of PIA’s. Acoustic radiation force impulse elastography (ARFI) is a new elastographic ultrasonography technic. We aimed to evaluate a new method in the early diagnosis of PIA’s using ARFI technique. There is no study in the diagnosis of PIA’s by ARFI in the literature to our knowledge. We think that this original study will contribute to the literature.What do the results of this study add? We showed the accuracy of ARFI in determination of PIA’s. ARFI scores were significantly higher in the group in which invasion was detected during surgery of patients with preoperative placental invasion suspicion.What are the implications are of these findings for clinical practice and/or further research? Our findings may reflect an event at the tissue elasticity level and we hope that the use of VTQ technique may contribute to early predict of placental invasions before surgery in the future via new researches. Early diagnosis of placental invasion anomalies may reduce mortality and morbidity.

Identification of causative variants in TXNL4A in Burn-McKeown syndrome and isolated choanal atresia

Burn-McKeown syndrome (BMKS) is a rare syndrome characterized by choanal atresia, prominent ears, abnormalities of the outer third of the lower eyelid, structural cardiac abnormalities, conductive and sensorineural hearing loss, and cleft lip. Recently, causative compound heterozygous variants were identified in TXNL4A. We analyzed an individual with clinical features of BMKS and her parents by whole-genome sequencing and identified compound heterozygous variants in TXNL4A (a novel splice site variant (c.258-2A>G, (p.?)) and a 34 bp promoter deletion (hg19 chr18:g.77748581_77748614del (type 1Δ) in the proband). Subsequently, we tested a cohort of 19 individuals with (mild) features of BMKS and 17 individuals with isolated choanal atresia for causative variants in TXNL4A by dideoxy-sequence analysis. In one individual with BMKS unrelated to the first family, we identified the identical compound heterozygous variants. In an individual with isolated choanal atresia, we found homozygosity for the same type 1Δ promoter deletion, whilst in two cousins from a family with choanal atresia and other minor anomalies we found homozygosity for a different deletion within the promoter (hg19 chr18: g.77748604_77748637del (type 2Δ)). Hence, we identified causative recessive variants in TXNL4A in two individuals with BMKS as well as in three individuals (from two families) with isolated choanal atresia.

Inhale to Breathe Away Pelvic Floor Pain and Enjoy Intercourse

Pain during intercourse (dyspareunia) and involuntary contraction of the outer third of the vagina (vaginismus) affect between 6.5% and 45% of women. The behavioral approach often includes exhaling to the pain or anticipated discomfort. The common instruction is to exhale in anticipation or sensing discomfort, which paradoxically increases pelvic floor tension and discomfort. Thus, clinicians need to instruct patients to practice what seems initially counterintuitive. The appropriate breathing strategy is to teach effortless diaphragmatic (abdominal) breathing in which the pelvic floor relaxes and descends during inhalation and begin the insertion during inhalation. Do not press or insert during exhalation, and continue to breathe until the discomfort has faded out; then insert slightly more during the next inhalation phase. For clinicians, it is important to point out that this process is most successful when the person feels safe and is given enough time to allow the pelvic floor to relax as monitored by lower abdominal electromyography. This concept is illustrated in a case report of a young woman who successfully experienced intercourse after more than two years of marriage.

The Neurobiology and Psychiatric Perspective of Vaginismus: Linking the Pharmacological and Psycho-Social Interventions.

Vaginismus is an involuntary muscle contraction of the outer third of vaginal barrel causing sexual penetration almost impossible. It is generally classified under sexual pain disorder (SPD). In Diagnostic and Statistical Manual, 5th edition (DSM-5), it is classified under the new rubric of Genito-Pelvic Pain/Sexual Penetration Disorder. This fear-avoidance condition poses an ongoing significant challenge to the medical and health professionals due to the very demanding needs in health care despite its unpredictable prognosis. The etiology of vaginismus is complex: through multiple biopsycho- social processes, involving bidirectional connections between pelvic-genital (local) and higher mental function (central regulation). It has robust neural and psychological-cognitive loop feedback involvement. The internal neural circuit involves an inter-play of at least two-pathway systems, i.e. both "quick threat assessment" of occipital-limbic-occipital-prefrontal-pelvic-genital; and the chronic pain pathways through the genito-spinothalamic-parietal-pre-frontal system, respectively. In this review, a neurobiology root of vaginismus is deliberated with the central role of an emotional-regulating amygdala, and other neural loop, i.e. hippocampus and neo-cortex in the core psychopathology of fear, disgust, and sexual avoidance. Many therapists view vaginismus as a neglected art-and-science which demands a better and deeper understanding on the clinico-pathological correlation to enhance an effective model for the bio-psycho-social treatment. As vaginismus has a strong presentation in psychopathology, i.e. fear of penetration, phobic avoidance, disgust, and anticipatory anxiety, we highlighted a practical psychiatric approach to the clinical management of vaginismus, based on the current core knowledge in the perspective of neuroscience.

MA10.06 Centrality Definition in Non-Small Cell Lung Cancer. Predictor For Occult Mediastinal Lymph Node Involvment

Central tumor location is considered as an independent risk factor for occult mediastinal metastases in patients with non-small cell lung cancer (NSCLC) after negative computerized tomography (CT) and integrated positron emission tomography/CT. However, the distinction between a central and a peripheral tumor has not been codified, some authors consider any tumor in the innerthird of the hemithorax to be central, and others in the inner twothirds. The objective of this study is to identify the best centrality tumor definition for detecting occult mediastinal metastasis. We retrospectively reviewed our thoracic surgery database for cases between January 2011 and December 2015. It was identified patients with potentially operable NSCLC screened by CT and PET/CT and they were classified according to tumor location in the inner third, middle third or outer third. The prevalence of occult mediastinal lymph node metastases was analyzed in relation to tumor location. Statistical analysis for best centrality definition was performed. Univariable analysis was performed using the Fisher exact test and multivariable analysis using logistic regression. A total of 359 patients with clinical operable NSCLC were included in our study. Seventy-five (20.9%) tumors were located in the inner third, 137 (38.2%) in the middle third and 147 (40.9%) in the outer third. It was detected 23 patients with N2 disease and negative TC and PET/CT, 8/38 (21.1%) in the inner third, 6/121 (5.0%) in the middle third and 9/122 (7.4%) in the outer third. Defining centrality as tumor located in the inner third of the hemithorax the incidence of occult N2 was 21.1% and 6.2% for central and peripheral tumor respectively. And defining centrality as tumor located in the inner two-thirds the incidence of occult N2 was 8.8% for central tumors and 7.4% for peripheral. Univariable analysis shows statistical differences in occult N2 involvement between central or peripheral defining central lesion as inner third (p=0.002), but not for central definition of internal two-thirds (p=0.651). In multivariable analysis considering centrality possible definition, histology, Clinical T factor and Clinical N1 affection, only inner third as centrality definition was statistical significance predictor factor for occult mediastinal lymph node involvement (p= 0.027). Considering the results of our study the best definition for central tumor location is limited to the inner third of the hemithorax. Given the low rate of occult N2 disease in the middle third location, the systematic evaluation of the mediastinum by ecobronchoscopy and/or mediastinoscopy in this group of patients is not justified.

ED08.01 Surgery of Early-Stage NSCLC

ED08.01 Surgery of Early-Stage NSCLC

Identification of a new-to-science cyanobacterium, Toxifilum mysidocida gen. nov. & sp. nov. (Cyanobacteria, Cyanophyceae).

Cyanobacteria occupy many niches within terrestrial, planktonic, and benthic habitats. The diversity of habitats colonized, similarity of morphology, and phenotypic plasticity all contribute to the difficulty of cyanobacterial identification. An unknown marine filamentous cyanobacterium was isolated from an aquatic animal rearing facility having mysid mortality events. The cyanobacterium originated from Corpus Christi Bay, TX. Filaments are rarely solitary, benthic mat forming, unbranched, and narrowing at the ends. Cells are 2.1×3.1μm (width×length). Thylakoids are peripherally arranged on the outer third of the cell; cyanophycin granules and polyphosphate bodies are present. Molecular phylogenetic analysis in addition to morphology (transmission electron microscopy and scanning electron microscopy) and chemical composition all confirm it as a new genus and species we name Toxifilum mysidocida. At least one identified Leptolyngbya appears (based on genetic evidence and TEM) to belong to this new genus.