Superior End Research Articles

Energy systems and green sourced nanomaterials—A today’s outlook

Owing to current growing demands of environmental friendly energy devices, innumerable green materials/nanomaterials have been applied to design the desired high tech devices. Amongst energy devices, supercapacitors have been ranked distinctively for efficient energy storage competence. Principally, green nanocomposites derived from green or ecological polymers and green nanoparticles have been scrutinized for supercapacitor components. Concerning this, current review has been planned to sketch the energy storage application of green nanocomposites, predominantly for supercapacitors. In this concern, mostly synthetic green polymers (such as polyaniline, polypyrrole, etc.) and their blends with natural polymers (like chitosan) having fine biodegradability, non-toxicity, low cost, and superior device end performance have been found as the noteworthy materials. Additionally, green nanofillers like carbon nanoparticles (carbon nanotube, graphene, etc.) and metal nanoparticles have been processed with green polymers via ecological techniques, like in situ, solution, sonication, mixing, hydrothermal, exfoliation, reduction, etc., to form the anticipated energy device components. In consequence, the designed ecological nanocomposites expectedly had the advantages of low price/weight, superior mechanical/heat resilience, electron transference, capacitance, power/charge density, charge-discharge, sustainability as well as environmentally friendliness for energy related methodological systems. Incidentally, the design and performance challenges towards the application of ecological nanocomposites in energy storage devices have been conversed.

9379 From Diagnosis To Treatment: A Comprehensive Approach To Pregnancy-Related Osteoporosis With Teriparatide

Abstract Disclosure: C. Hubers: None. M. Renzu: None. V. Mehta: None. A. Manzoor Qazi: None. A.M. Satei: None. D.K. Yerasuri: None. Introduction: Pregnancy and lactation related osteoporosis (PLO) is a rare but serious condition with significant consequences for maternal and fetal health. Teriparatide's efficacy in treating this condition is promising, particularly given concerns about bisphosphonate use in this population. Clinical Case: A 26-year-old white female sought evaluation for concerns arising after her first pregnancy. Following delivery via Cesarean section, she experienced acute back pain, instability while walking and frequent falls. A subsequent bone scan showed superior end plate fractures of T9, T11, T12, and L1, while an MRI of the lumbosacral spine showed mild acute to subacute compression deformities involving the superior endplates of the L2-L5 vertebral bodies. Despite having Factor V Leiden disease, her medical history is unremarkable for significant chronic conditions or comorbidities affecting bone health. Bone density scans revealed a Z-score of -2.4 in the lumbar spine and -1.6 in the total hip, with a femoral neck Z-score of -1.3. Her lumbar spine T-score was reported as -2.8, reflecting significant bone mineral density (BMD) loss with a BMI of 20.67. She underwent thorough testing to rule out other potential contributory conditions, such as celiac disease and hemochromatosis, but was eventually diagnosed with PLO. Treatment was initiated with teriparatide, administered as a daily 20 µg subcutaneous injection. The patient demonstrated an excellent response, with marked improvements in pain and enhanced ability to perform daily activities. After treatment with teriparatide, the patient’s c-telopeptide also improved. Discussion: PLO is a very rare manifestation of osteoporosis, mainly affecting women with lower BMI and advanced age. The etiology involves hormonal changes, increased calcium demands during pregnancy and lactation, and decreased BMD. Our patient's history and clinical course highlight a compelling instance of PLO, likely attributed to decreased estrogen exposure secondary to amenorrhea and breastfeeding, resulting in increased bone turnover. While bisphosphonates are often recommended for PLO, concerns about safety in pregnant and lactating women underscore the need for alternative treatments like teriparatide. Potential effects on gestational age, neonatal birth weight, and neonatal calcium levels have been observed in newborns with maternal exposure to bisphosphonates. Teriparatide is a synthetic form of parathyroid hormone that works primarily by stimulating osteoblast activity, leading to increased bone formation and BMD. It also enhances calcium and phosphate absorption in the kidneys and intestines, further contributing to its bone-building effects. Our patient's response to teriparatide emphasizes its potential as a safer option in managing PLO, warranting further research to establish comprehensive management guidelines. Presentation: 6/3/2024

Hybrid III Manikin Lumbar Spine Loading Under Vertical Impact.

Clinical investigations have attributed lumbar spine injuries in combat to the vertical vector. Injury prevention strategies include the determination of spine biomechanics under this vector and developing/evaluating physical devices for use in live fire and evaluation-type tests to enhance Warfighter safety. While biological models have replicated theater injuries in the laboratory, matched-pair tests with physical devices are needed for standardized tests. The objective of this investigation is to determine the responses of the widely used Hybrid III lumbar spine under the vertical impact-loading vector. Our custom vertical accelerator device was used in the study. The manikin spinal column was mounted between the inferior and superior six-axis load cells, and the impact was delivered to the inferior end. The first group of tests consisted of matched-pair repeatability tests, second group consisted of adding matched-pair tests to this first group to determine the response characteristics, and the third group consisted of repeating the earlier two groups by changing the effective torso mass from 12 to 16 kg. Peak axial, shear, and resultant forces at the two ends of the spine were obtained. The first group of 12 repeatability tests showed that the mean difference in the axial force between two tests at the same velocity across the entire range of inputs was <3% at both ends. In the second group, at the inferior end, the axial and shear forces ranged from 4.9-25.2 kN to 0.7-3.0 kN. Shear forces accounted for a mean of 11 ± 6% and 12 ± 4% of axial forces at the two ends. In the third group of tests with increased torso mass, repeatability tests showed that the mean difference in the axial force between the two tests at the same velocity across the entire range of inputs was <2% at both ends. At the inferior end, the axial and shear forces ranged from 5.7-28.7 kN to 0.6-3.4 kN. Shear forces accounted for a mean of 11 ± 8% and 9 ± 3% of axial forces across all tests at the inferior and superior ends. Other data including plots of axial and shear forces at the superior and inferior ends across tested velocities of the spine are given in the paper. The Hybrid III lumbar spine when subjected to vertical impact simulating underbody blast levels showed that the impact is transmitted via the axial loading mechanism. This finding paralleled the results of axial force predominance over shear forces and axial loading injuries to human spines. Axial forces increased with increasing velocity suggesting the possibility of developing injury assessment risk curves, i.e., the manikin spine does not saturate, and its response is not a step function. It is possible to associate probability values for different force magnitudes. A similar conclusion was found to be true for both magnitudes of added effective torso mass at the superior end of the manikin spinal column. Additional matched-pair tests are needed to develop injury criteria for the Hybrid III male and female lumbar spines.

The sphenopterygoid canal and pterygoid foramen.

In human anatomy, there are well-known the foramina of the greater sphenoidal wing, the foramen rotundum, the foramen ovale, the foramen spinosum, as well as the inconstant sphenoidal emissary foramen of Vesalius and the foramen of Arnold. Different canals are found in several species of rodents, such as the alisphenoid and sphenopterygoid (SPC) canals. It was re-explored an archived computed tomography angiogram of a 60 y.o. female case. Bilateral superior recesses of the pterygoid fossae (SRPF) and a right SPC were found. The SRPF on each side penetrated the non-lamellar pterygoid root and superiorly reached the sphenoidal sinus wall. Upper fibres of medial pterygoid muscles were inserted into each SRPF. An unexpected SPC was found on the right side. It opened superiorly on the lateral side of the foramen rotundum and inferiorly at a pterygoid foramen in the superior end of the posterior margin of the lateral pterygoid plate. A sphenoidal emissary vein traversed that SPC to drain into the pterygoid plexus. The SRPF and SPC could also be found in humans. As the sphenoidal emissary veins are surgically relevant, they should not be further regarded as exclusively crossing the foramen of Vesalius but also the SPC.

Reverse 4-Flanged Technique for Intrascleral Fixation of a Foldable Hydrophobic Intraocular Lens in the Absence of Capsular Support Through a 2.2-mm Corneal Incision.

The purpose of this study was to describe a modified technique for sutureless intrascleral intraocular lens fixation in patients without capsular support: the reverse 4-flanged technique. A 2.2-mm corneal incision was made for aphakic patients. The 6-0 polypropylene sutures were threaded through a 30-gauge needle outside the eye. An MDJ injector was employed to insert the intraocular lens into the eye. A suture-needle snare with 7-0 polypropylene was used to exteriorize the superior end of the sutures through the sclerotomy. The 6-0 polypropylene was heated with a cautery to create the flanges. Nine eyes of nine patients underwent the reverse 4-flanged technique. The median follow-up time was 182 days (range 174-195). Best-corrected distance visual acuity improved from 20/400 [hand movement-20/33] to 20/120 [20/400-20/21]. No vitreous hemorrhage, retinal detachment, endophthalmitis, intraocular lens luxation, or flange exposure was recorded during the follow-up. The reverse 4-flanged technique maintains the advantages of the original 4-flanged technique in terms of intraocular lens stability while reducing the incision size and surgical maneuvers performed inside the eye. This modification promises to be a reliable, safe, and relatively simple technique to correct aphakia in the absence of capsular support.

How to Reduce Inferomedial Orbital Wall Fracture Using a Navigation System: Tips and Pearls.

The orbit is a confined space with a defined bony structure. Bony protrusion into the ethmoid or maxillary sinuses by the blowout fracture can displace orbital tissues, including rectus muscles and adjacent fascial septae. Especially, reconstructing the orbit's floor and medial wall can be challenging when the inferomedial strut or posterior bony ledge is affected, leading to a loss of critical anatomic landmarks and support. Correctly positioning an implant in the precise anatomic location can be challenging. Recent updates to the navigation system have addressed this issue. Despite its early application, using a navigation system in these orbital fractures advances plastic surgeons in a way that has more confidence and accuracy in surgical planning. The video demonstrates how these 2 can be combined in an operating room. Intraoperatively, the authors check the superior, anterior, and posterior ends of the medial wall fracture and the posterior end of the floor fracture. A single orbital implant was trimmed and reshaped to match defect measurements. The implant placement was meticulously executed to repair the fracture while ensuring the inferior oblique muscle was not injured. After confirming the correct placement of the implant, it was secured to the inferior orbital rim using a single screw. Depending on the medial orbital wall fracture depth or degree of soft tissue herniation, the authors used an artificial dermal matrix or trimmed absorbable mesh plate to cover the uppermost part of the medial wall fracture to prevent postoperative enophthalmos. Finally, a forced duction test was performed. Our study shows that navigation-assisted inferomedial orbital wall reconstruction using materials readily available in the market is safe and effective.

Correlation between preoperative CT scan of the paraspinal, psoas, and gluteus muscles and postoperative ambulatory status in patients with femoral neck fractures

BackgroundThis study aimed to investigate the relationship between femoral neck fractures and sarcopenia.MethodsThis was a retrospective analysis of 92 patients with femoral neck fractures, from September 2017 to March 2020, who were classified into high ambulatory status (HG) and low ambulatory status (LG) groups. Ambulatory status was assessed before surgery, one week after surgery, at discharge, and during the final follow-up. To evaluate sarcopenia, muscle mass and fatty degeneration of the muscles were measured using preoperative CT. An axial slice of the superior end of the L5 vertebra was used to evaluate the paraspinal and psoas muscles, a slice of the superior end of the femoral head for the gluteus maximus muscle, and a slice of the inferior end of the sacroiliac joint for the gluteus medius muscle. The degeneration of the muscles was evaluated according to the Goutallier classification.ResultsThe cross-sectional area of the gluteus medius and paraspinal muscles was significantly correlated with ambulatory status before the injury, at discharge, and during the final follow-up.ConclusionsMeasurement of the gluteus medius and paraspinal muscles has the potential to evaluate sarcopenia and predict ambulatory status after femoral neck fractures.

Exploring the Frontiers of Non-Destructive Techniques: Shearography, Ultrasound Laser and Thermography

Non-destructive testing (NDT) techniques serve as indispensable tools across diverse industries, facilitating material and component inspection without inflicting damage. This article underscores the paramount importance of NDT methods in enhancing product quality, safety, and cost-effectiveness. Leveraging advanced techniques such as shearography, ultrasonic laser, and thermography, manufacturers can proactively identify defects during the production process, thereby reducing scrap and rework costs while enhancing overall product integrity. Shearography excels in surface defect detection, while ultrasonic laser offers sensitivity without necessitating direct contact, and thermography enables versatile temperature-based inspection. The synergistic coexistence of these techniques within NDT protocols maximizes inspection efficacy, ensuring high-quality and safe outcomes across various industries. By embracing a comprehensive approach to NDT, industries can optimize operational efficiency, minimize risks, and uphold stringent quality standards. In conclusion, the integration of shearography, ultrasonic laser, and thermography in NDT practices represents a cornerstone in maximizing inspection effectiveness and maintaining superior quality end safety standards across industrial sectors.

The Effect of Interbody Cage Parameters on the Rate of Subsidence in Single-Level Anterior Cervical Discectomy and Fusion (ACDF): A Retrospective Analysis of 98 Patients.

Subsidence is arelatively common consequence after anterior cervical discectomy and fusion (ACDF) surgery. This study aimed to identify the effect of radiological and non-radiological risk factors on subsidence after a single-level ACDF surgery with cage and plate. This is a retrospective cohort study of patients who underwent ACDF for radiculopathy or myelopathy at an academic center, University of Kentucky Albert Chandler Hospital, Lexington, Kentucky, United States, between January 2010 and January 2020.Subsidence was defined as the sinking of the interbody cage into the vertebral body at either the superior end plate (SEP) or inferior end plate (IEP) at the ACDF level and was measured manually on lateral standing x-ray. The numerical amount of subsidence was measured in millimeters as the sum of subsidence in the SEP and IEP and was further categorized into subsidence2 and subsidence3 (i.e., presence of subsidence > 2 mm and subsidence > 3 mm, respectively). Multivariateregression analysis was used to assess the effect of variables such as age, gender, body mass index (BMI), tobacco use, follow-up length, cage type, anterior cage height, posterior cage height, anterior cage height ratio, posterior cage height ratio, cage position, cage-end plate interface and cervical alignment on outcomes such as subsidence, subsidence2, and subsidence3. A total of 98 patients were included, of which 46 (47.1%) were male. The mean age of the population was 47.6±8.4 years. Fifty-one patients (52%) experienced subsidence more than 3 mm. Anterior disc height ratio (ADHR) was calculated by dividing the anterior cage height by the anterior disc height (pmADH). The posterior disc height ratio (PDHR) was calculated by dividing the posterior cage height by the posterior disc height (pmPDH). There was no significant correlation between ADHR and PDHR with subsidence, (p=0.93 and 0.56, respectively). Gender, age, BMI, and smoking status did not affect subsidence either. Cage type significantly affected subsidence with a higher subsidence rate in VG2 cages compared to Bengal cages (p=0.05). This study showed that in patients undergoing single-level ACDF with cage and plate, cage size and in particular cage height (if adjusted for individual patients) did not affect subsidence. Other factors such as cage-endplate interface, cage depth in interbody space, and cervical alignment did not significantly affect subsidence either. This might be attributable to the use of an anterior plating system that conducts the force and reduces the stress on the graft-bone interface.

Pelvis-Sacrum-Lumbar Spine Injury Characteristics From Underbody Blast Loading.

Combat-related injuries from improvised explosive devices occur commonly to the lower extremity and spine. As the underbody blast impact loading traverses from the seat to pelvis to spine, energy transfer occurs through deformations of the combined pelvis-sacrum-lumbar spine complex, and the time factor plays a role in injury to any of these components. Previous studies have largely ignored the role of the time variable in injuries, injury mechanisms, and warfighter tolerance. The objective of this study is to relate the time or temporal factor using a multi-component, pelvis-sacrum-lumbar spinal column complex model. Intact pelvis-sacrum-spine specimens from pre-screened unembalmed human cadavers were prepared by fixing at the superior end of the lumbar spine, pelvis and abdominal contents were simulated, and a weight was added to the cranial end of the fixation to account for torso effective mass. Prepared specimens were placed on the platform of a custom vertical accelerator device and aligned in a seated soldier posture. An accelerometer was attached to the seat platen of the device to record the time duration to peak velocity. Radiographs and computed tomography images were used to document and associate injuries with time duration. The mean age, stature, weight, body mass index, and bone density of 12 male specimens were as follows: 65 ± 11 years, 1.8 ± 0.01 m, 83 ± 13 kg, 27 ± 5.0 kg/m2, and 114 ± 21 mg/cc. They were equally divided into short, medium, and long time durations: 4.8 ± 0.5, 16.3 ± 7.3, and 34.5 ± 7.5 ms. Most severe injuries associated with the short time duration were to pelvis, although they were to spine for the long time duration. With adequate time for the underbody blast loading to traverse the pelvis-sacrum-spine complex, distal structures are spared while proximal/spine structures sustain severe/unstable injuries. The time factor may have implications in seat and/or seat structure design in future military vehicles to advance warfighter safety.

Minimally invasive tubular microdiscectomy for recurrent lumbar disc herniation: step-by-step technical description with safe scar dissection

IntroductionRecurrent lumbar disc herniation (RLDH) is one of the most common reasons for re-operation after primary lumbar disc herniation with an incidence ranging from 5 to 23%. Numerous RLDH studies have been conducted; however, no available studies have provided a specific description of the use of the tubular retractor discectomy technique for RLDH emphasizing safe scar dissection. The objective of this study is to describe a detailed step-by-step technique for RLDH.Material and methodsA surgical technique reporting on our experience from the year 2013–2021 in 9 patients with RLDH at the same level and same side was included in the study. Clinical outcomes were assessed using the visual analog score (VAS) for leg pain before and three months after surgery.ResultsA significant improvement was observed between the preoperative and postoperative VASs [mean (SD): 9.2 (1) vs. 1.5 (1)] for all patients. We did not report any incidental durotomy, neurological deficits or mortality in this study. One patient had superficial wound infection. The study is limited by small population, short follow-up and not reporting stability or spondylolisthesis.ConclusionA modified tubular discectomy technique with safe scar dissection is effective for RLDH treatment. Technically, the only scar needed to be dissected is the scar lateral to the exposed normal dura and the scar extended caudally till the level of the superior end plate of the targeted disc space where the scar can be entered ventrally and the disc fragment retrieved. Adherence to the step-by-step procedure described in our study will help surgeons operate with more confidence and minimize complications of recurrent lumbar disc herniation.

Improving Patient Compliance for More Efficient Deep Inspiration Breath Hold Treatment through Innovation and Education.

Visual guidance has been widely proven to improve the reproducibility and stability of Deep Inspiration Breath Hold (DIBH) treatments. Here, we present a quality improvement project by implementing the use of visual guidance in a multi-campus institution to improve clinical efficiency, including the design of a novel mount for the visual aid and the creation of a patient education video to better prepare lung and GI patients for their DIBH treatments. Prior to institution-wide implementation, the clinical feasibility of utilizing visual guidance for DIBH treatments was determined by a pilot study with 10 lung/GI patients. A commercial visual guidance device was used, which consisted of a tablet-like device, attached to a mount affixed to the treatment couch. The device is positioned over the patient's head, displaying the real-time vertical motion of a block with infrared markers on the patient's abdomen. The original mount for the device locks onto the superior end of the treatment couch, which occupies space used for immobilization devices and limits the number of patients eligible for visual guidance when the isocenter is inferior, as for GI patients. A novel in-house mount was designed to overcome this limitation. Also, a patient education video was created to introduce the concept of DIBH and the visual aid device. Visual guidance is offered at the first treatment; its use is optional, and patients may start or stop using it at any time. If the device is not used, the patient relies on audio coaching from the radiation therapists (RTTs), which is the standard practice in our clinic. All 10 patients in the pilot who were offered the visual aid used it, found it helpful and continued to use it throughout their treatment, with no issues reported. The median number of fractions for all 10 patients was 5(3-15). The in-house mount was manufactured from 3D printed and machined components. The treatment couch was 3D scanned, and the mount was designed to clamp laterally on the couch top and align with the indexing indentations. The in-house mount is easy to use and is more versatile than the commercial mount, enabling use for patients with inferior isocenters. Prior to treatment, patients were encouraged to view the <3 min long patient education video that consisted of a combination of animation and real-actor content. Verbal instructions for use were also given by RTTs at the first treatment. Upon successful completion of the pilot study, the use of visual guidance was implemented institution-wide across 5 campuses for all lung and GI DIBH patients, being utilized on an average of 14 patients/week. A quality improvement project was developed and successfully implemented to introduce the use of visual guidance for lung and GI DIBH patients at a large institution, improving the efficiency of DIBH treatment for both the patients and RTTs.

Impact of publisher's commercial or non‐profit orientation on editorial practices: Moving towards a more strategic approach to supporting editorial staff

AbstractThis study was guided by previous research highlighting the significance of journal publishers' commercial or non‐profit orientations in shaping academic editors' perspectives regarding the necessity of enhancing editorial and business practices. There is limited understanding of how the editor–publisher relationship varies based on publishers' commercial orientation. This study revealed five key factors influencing editors' attitudes towards how publishers strive to provide high‐quality publications: (i) availability of high‐quality publication services; (ii) sufficient technological support and access to visibility‐related data; (iii) accessible marketing and indexing services; (iv) access to continuous education for the editorial team; and (v) a balance between editorial autonomy and publisher support in managing the journal. The study indicated that editors partnering with commercial publishers tended to receive more extensive and advanced services, better technological support, and more training opportunities, contributing to the production of superior end products. However, working with commercial publishers resulted in the trade‐off of less editorial independence, which sometimes compromised editors' decision‐making ability and made them feel uncertain about their further involvement. The study's findings highlighted the importance of publishers adopting a more strategic approach to support their editorial staff, while considering the unique needs of each journal.

MRI-based Endplate Bone Quality score independently predicts cage subsidence following transforaminal lumbar interbody fusion

Cage subsidence following transforaminal lumbar interbody fusion (TLIF) has closely correlated with poor vertebral bone quality. Studies have shown better predictive value for cage subsidence by measuring bone density at specific site. However, few studies have been performed to examine the relationship between site-specific MRI bone assessment and cage subsidence in patients who have undergone lumbar interbody fusion. The association between MRI-based assessment of endplate bone quality and cage subsidence after TLIF remains unclear. To study the predictive value of MRI-based endplate bone quality (EBQ) score for cage subsidence following TLIF, using QCT bone densitometry as a reference standard. A retrospective study. A total of 280 adult patients undergoing single-segment TLIF for degenerative lumbar spine disease from 2010 to 2020 at our institution who had pre-operative T1-weighted MRIs. Cage subsidence, disc height, endplate bone quality (EBQ) score, bone mineral density, fusion rate. The retrospective study reviewed patients who underwent TLIF at one institution between March 2010 and October 2020. Cage subsidence was measured with postoperative lumbar X-rays based on the cage protrusion through into the superior or inferior end plate or both by more than 2 mm. The EBQ score was measured from preoperative T1-weighted MRI in accordance with the previously reported method. Cage subsidence was observed in 42 of the 280 patients. Bone densitometry with quantitative computed tomography was visibly reduced in the subsidence group. The mean EBQ scores of the lumbar endplate bone was 4.3±0.9 in nonsubsidence and 5.0±0.6 in subsidence. On multivariate logistic regression, the difference between the two groups was remarkable. Risk of cage subsidence increases significantly with higher EBQ scores (odds ratio [OR]=2.063, 95% confidence interval [CI] 1.365-3.120, p=.001) and was an independent factor in predicting subsidence after TLIF. On receiver operating characteristic curve, the AUC for the EBQ score was 0.820 (95% confidence interval [CI]: 0.755-0.844) and the most suitable threshold for the EBQ score was 4.730 (sensitivity: 76.2%, specificity: 83.2%). Higher EBQ scores measured on preoperative MRI correlated significantly with cage subsidence following TLIF. Performing EBQ assessment prior to TLIF may be a valid method of predicting the risk of postoperative subsidence.

A Cross-Sectional Study of the Olfactory Fossa in Delta State, Nigeria

Introduction:Evaluation of the olfactory fossa (OF) before endoscopic sinus surgery is important in minimizing inadvertent penetration into the anterior cranial fossa. This study assessed the depth of the OF using computed tomography (CT) images of adult Nigerians.Materials and Methods:Cranial CT images were obtained from the database of the radiological unit of a referral center in Delta State, Nigeria, after ethical clearance. The images belonged to 137 female and 199 male adults aged ≥20 years. The depth of OF was measured as the perpendicular distance between the cribriform plate (CP) inferiorly to the superior end of the lateral lamella of the CP on coronal sections. The fossae were classified as Keros Type I (0.1–0.39 cm), Type II (0.4–0.79 cm), and Type III (&gt;0.8 cm). Data collected were analyzed using the Statistical Package for the Social Sciences version 23. Side and gender comparisons of the depth were evaluated using the Student'st-test, while the variations in the OF types were assessed using the Chi-square test. These comparisons were regarded significant whenP&lt; 0.05.Results:The mean OF depth was larger in males (0.543 ± 0.183 cm) than in females (0.527 ± 0.169 cm) (P= 0.018). The prevalence of symmetrical (64.9%) and asymmetrical (35.1%) OF showed significant sex differences (P&lt; 0.05). Type II OF was the most common (77.2%), followed by Type I (15.8%) and Type III (7%).Conclusion:The presence of the deep (Type III) and asymmetric OF in the patients studied emphasizes the importance of their preoperative radiological identification to minimize complications.

Endoscopic appearance of duplicated middle turbinate, case series and literature review.

Duplication of the middle turbinate is an extremely rare condition encountered in rhinology clinic. Knowledge and awareness of the nasal turbinates' variations are important to perform a safe endoscopic surgery and evaluate patients with inflammatory sinus diseases. Case series of two patients who visited rhinology clinic in academic university hospital. Case 1: presented with 6-month history of nasal blockage. Nasal endoscopy revealed bilateral duplication of the middle nasal turbinates. Computed tomography scans showed bilateral medially curved and anteriorly folded uncinate process, and right middle turbinate concha bullosa and its superior end of the middle turbinate was turned medially. Case 2: A 29-year-old gentleman presented with nasal obstruction mainly to the left side for several years. Nasal endoscopy showed bifid right middle turbinate and severe deviated nasal septum to the left. Upon imaging, a sinus computed tomography scan demonstrated a duplication of the right middle turbinates in the form of two middle nasal concha. Different rare anatomical variations can occur at different points during the embryological development. These rare variations include double middle turbinate, accessory middle turbinate, secondary middle turbinate, and bifid inferior turbinate. The appearance of double middle turbinate can be encountered in rhinology clinic only 2% of the time. Upon reviewing the literature, only few case reports were found regarding the double middle turbinate. A double middle turbinate has important clinical implications. Anatomical variation may lead to narrowing in the middle meatus which makes the patient vulnerable to sinusitis or maybe associated with secondary symptoms. We report rare cases of middle turbinate duplication. Awareness of the nasal turbinates' variations is important for detection and management of inflammatory sinus diseases. Further studies are needed to identify the association of other pathology.

Effect of ultrasound pretreatment and microwave vacuum drying in the production of dried poniol fruit

AbstractThis study suggested a combination of microwave and vacuum drying to meet the requirements of preserving the nutritional content of fresh poniol fruit, consuming lower energy, and having a faster drying rate. In this study, the influence of microwave power, vacuum level, and citric acid pretreatment level on the product quality of dried poniol was analyzed. The citric acid pretreatment was conducted in an ultrasonicator bath. The pretreated was dried by changing the microwave power () from 400 to 800 W and the vacuum level () from 300 to 600 mmHg. The quality of the dried product was analyzed in terms of total phenolic content (), antioxidant activity (), total change in color (), and rehydration ratio () of dried poniol fruit. The response range in the sequence was between 22.219–38.361 mg GAE/g, 69.037–92.578 %DPPH inhibition, 23.451–40.148, and 1.38–3.81, respectively, at various combinations of independent variables. The optimal combination of independent variables for maximal recovery of total phenolic content, antioxidant activity, rehydration ratio, and minimal color changes was obtained at 440 W power level, 600 mmHg vacuum, and pretreated with citric acid of concentration .8%. Under the optimum combination of independent variables, the total phenolic content, antioxidant activity, rehydration ratio, and total color change values were 37.904 mg GAE/g, 92.973%, 23.906, and 3.307, respectively. Because of the low temperature in the vacuum process combined with the rapid heating time of microwaves, the results indicate that microwave vacuum drying might be a viable alternative method for improving the quality of dried food products.Practical ApplicationsMicrowave vacuum drying is a technology that uses microwave radiation to generate heat in the absolute pressure range between the triple point of water and atmospheric pressure. Heat is generated in microwave vacuum drying by directly converting electromagnetic energy into kinetic molecular energy. Hence, heat is generated deep inside the product being dried. Because interior temperatures are greater than exterior temperatures, evaporating water is driven to the surface, resulting in higher partial pressure. As a result, the moisture evaporating within the product is released through the pore structure of the macro‐capillary system of the solid material, resulting in a faster drying rate. Since the superficial layer does not dry out completely, the surfaces remain porous. This method results in a superior end product that is also very nutritious with enhanced sensory properties. As a result, this approach is used in the chemical, pharmaceutical, and food industries.

"Insert flipping technique:" An effective way of restoring segmental lordosis and disc height with tall bullet cages.

The study design was a retrospective study. The objectives of the present study are dual; to describe a simple and effective way of restoring intervertebral disc (IVD) height by the "Insert Flip Technique" of cage insertion and to demonstrate effective restoration of IVD height and segmental lordosis (SL) and their influence on the functional outcome postoperatively. IVD height and SL were recorded pre- and postoperatively. Each motion segment was instrumented with pedicle screws to allow segmental stabilization. Patients were called for follow-up at 6 weeks, 3 months, and 1 year postoperatively and were assessed clinically for back pain and leg pain (VAS and Oswestry Disability Index scores recorded).The bullet cages are designed such that they are lordotic in the superior-inferior plane and neutral in the mediolateral plane. Usually, the cage is inserted with superior and inferior surfaces of the cage impacting against superior and inferior end plates of the adjacent vertebral body. However, with the proposed technique, the cages were inserted such that the narrower mediolateral surfaces of the cage engaged with superior and inferior vertebral end plates. The cage was then flipped within the disc space such that the superior-inferior surfaces of the bullet cage impacted against the superior and inferior end plates of the vertebral body to create desired lordosis. There was a significant improvement seen in the postoperative Cobb's angle and disc height after placement of a tall bullet cage compared to the preoperative Cobb's angle and disc height. This modification of technique helped in gaining lordosis with taller bullet cages in minimally invasive surgery transforaminal lumbar interbody fusion with no/minimal complication and also reduced the need for bone resection during insertion of the cage.

Reformatting of Computed Tomography Scans Parallel to the S1 End Plate Increases Visualization of Trans Sacral Pathway in the First Sacral Segment, Especially With Dysmorphism.

To determine whether reformatted computed tomography (CT) scans would increase surgeons' confidence in placing a trans sacral (TS) screw in the first sacral segment. Level 1 trauma center. A retrospective cohort study. There were 50 patients with uninjured pelvises who were reviewed by 9 orthopaedic trauma fellowship-trained surgeons and 5 orthopaedic residents. The overall percentage of surgeons who believe it was safe to place a TS screw in the first sacral segment with standard (axial cuts perpendicular to the scanner gantry) versus reformatted (parallel to the S1 end plate) CT scans. Overall, 58% of patients were believed to have a safe corridor in traditional cut axial CT scans, whereas 68% were believed to have a safe corridor on reformatted CT scans ( P < 0.001). When grouped by dysplasia, those without sacral dysplasia (n = 28) had a safe corridor 93% of the time on traditional scans and 93% of the time with reformatted CT scans ( P = 0.87). However, of those who had dysplasia (n = 22), only 12% were believed to have a safe corridor on original scans compared with 35% on reformatted scans ( P < 0.001). CT scan reformatting parallel to the S1 superior end plate increases the likelihood of identifying a safe corridor for a TS screw, especially in patients with evidence of sacral dysplasia. The authors would recommend the routine use of reformatting CT scans in this manner to provide a better understanding of the upper sacral segment osseous fixation pathways.

Assessment of dose-volume histogram precision for five clinical systems.

To investigate the dependency of dose-volume histogram (DVH) behavior and precision on underlying discretization using shapes and dose distributions with known analytical DVHs for five commercial DVH calculators. DVHs and summary metrics were extracted from all five systems using synthetic cone and cylinder objects for which the true volume and DVH curves were known. Trends in the curves and metrics were explored by varying the underlying voxelization of the CT image, structure set, and dose grid as well by varying the geometry of the structure and direction of a linear dose gradient. Using synthetic structures allowed for comparison with ground truth DVH curves to assess their accuracy while an algorithm was additionally developed to assess the precision of each system. The precision was calculated with a novel algorithm that treats any "stair step" behavior in a DVH curve as an uncertainty band and calculates the width, characterized as a percent difference, of the band for various DVH metrics. The underlying voxelization was additionally changed and DVHs were extracted for two clinical examples. The details of how each system calculated DVHs were also investigated and tendencies in the calculated curves, metrics, and precision were related to choices made in the calculation methodology. Calculation methodology differences that had a noticeable impact on the DVH curves and summary metrics include supersampling beyond the input grids and interpretation of the superior and inferior ends of the structures. Among the systems studied, the median precision ranged from 0.902% to 3.22%, and interquartile ranges varied from 1.09% to 3.91%. Commercial dose-evaluation solutions can calculate different DVH curves, structure volume measures, and dose statistics for the same input data due to differences in their calculation methodologies. This study highlights the importance of understanding and investigating the DVH calculation when considering a new clinical system and when using more than one system for data transfer.