Amnesia is a well-documented complication following surgical repair of anterior communicating artery (ACoA) aneurysms. 3D MRI has clarified that it is primarily caused by infarction of the subcallosal artery, the largest unpaired perforating branch of the ACoA. Bilateral infarction of the columns of the fornix, a core component of the Papez circuit, has been identified as the anatomical basis of such amnesia. Another perforating artery prone to surgical injury is the recurrent artery of Heubner (RAH), which arises from the A1 to A2 junction of the anterior cerebral artery and is usually present bilaterally. When RAH infarction co-occurs with subcallosal artery infarction during ACoA aneurysm surgery, memory impairment may be accompanied by reduced processing speed and a worse long-term outcome. We report a 63-year-old man who underwent surgical clipping for a ruptured ACoA aneurysm. 3D-MR images obtained 10 months postoperatively revealed bilateral infarctions in the subcallosal artery territory, including the columns of the fornix, as well as a right-sided infarction in the RAH territory. Clinical correlation showed that these findings matched the patient’s paradoxical cognitive profile, confirmed by formal neuropsychological testing 5 years after clipping. He demonstrated a dissociation between exceptionally gifted-level intellectual ability and comparatively lower scores in memory and processing speed. His full-scale intelligence quotient (IQ) was 144, with a verbal IQ of 156 and working memory of 150, while his general memory score was 115 and processing speed was 110. Although these latter scores fell within the high-average range, they represented a meaningful decline relative to his potential. This profile supports a dual circuit model: Subcallosal artery infarction disrupts the Papez circuit, impairing memory, while RAH infarction contributes to inefficiency through frontostriatal disconnection. This case of paradoxical giftedness with memory decline underscores the value of 3D MR imaging in revealing memory decline masked by cognitive reserve.

Abstract Post-mastectomy pain syndrome (PMPS) is a prevalent long-term complication after breast cancer surgery, affecting about 25–40 % of survivors. Its causes are diverse, including surgical injury, adjuvant treatment, and individual vulnerability, yet these insights have not translated into consistent management. Conventional pharmacological therapies provide only modest benefit, while nerve blocks, cryoneurolysis, radiofrequency techniques, and surgical innovations such as autologous fat grafting or nerve reconstruction show encouraging but still limited evidence. Neuromodulation strategies and complementary approaches, including rehabilitation and psychosocial support, further illustrate the diversity of available options. Despite these advances, fewer than half of affected patients receive targeted interventions, and clinical practice varies widely across regions. This narrative review aims to raise clinical awareness of PMPS and to provide an evidence-based reference for practicing clinicians, it summarizes the latest findings on risk factors, preventive measures, and therapeutic options. We contend that PMPS should be recognized as a significant oncological and surgical challenge, warranting systematic management in routine follow-up.

BACKGROUND: Modern armed conflicts evolve rapidly, resulting in changes in combat scenarios, tactical settings, and military medicine. This, in turn, influences the prevalence of combat-related surgical injuries, with a significant effect on the scope and type of surgical care provided during the early stages of casualty evacuation. The medical evacuation support system established at the beginning of the military operation is currently facing new challenges. These include providing medical care throughout a lengthy prehospital phase as well as the need for specialty care and military medical examination for the increasing number of light casualties in the active army. AIM: This work aimed to assess the prevalence of combat-related surgical injuries as well as the type and scope of surgical care in various combat scenarios of a modern regional conflict. METHODS: Data on casualties that required surgical treatment were pooled and analyzed for several forward medical facilities of individual medical battalions, including those of reinforced combat teams, during a modern armed conflict. RESULTS: Modern warfare is evolving rapidly, as evidenced by the fact that three-fourths of patients admitted to tertiary care were injured as a result of unmanned aerial vehicle attacks. Changes in combat conditions have significantly altered the prevalence of combat-related surgical injuries and the type of surgical care provided. The longer time to casualty evacuation for specialty surgical care is the most significant change influencing the current medical evacuation support system. Other changes, including the decreased proportion of severe and extremely severe wounds (by 15.4%), the increased proportion of minor wounds (by 49.9%), the decreased incidence of penetrating wounds (by 45.2%), and the increased incidence of isolated wounds (by 53.2%), facilitate secondary and tertiary casualty evacuation. CONCLUSION: The changes discussed above are primarily associated with a longer time to casualty evacuation for specialty surgical care. These changes signify a new, significant challenge for tactical medicine during a lengthy prehospital phase. Specialized military hospitals for light casualties deployed in a combat area and its immediate vicinity have reduced the need for casualty evacuation to rear military medical facilities.

Surgical injury to the labium minus neurovascular bundle (NVB) can result in severe iatrogenic, ischemic, and neurological complications, including labium minus posterior nerve neuropathy and pudendal nerve neuralgia. The objectives are to identify the anatomical distribution of the neurovascular bundle (NVB) within the labium minus and to develop a new surgical intervention to protect the labia minora from severe complications. Additionally, to answer the study question: "Can preservation of the labia minora NVB reduce severe surgical complications?" Anatomical dissection of the labia minora was performed on ten adult female fresh cadavers (group I) and twenty living women (group II). Pictorial documentation was obtained from both groups. The study's findings established the role of the labium minus NVB in ischemic and neurological complications. Anatomical dissection in group I showed that the perineal NVB enters the posterior-inferior labium minus, on average, 1.2cm from the midline, then courses upwards and bifurcates to create the labial inferior branch, which runs horizontally within the labial base, and the superior branch, which also runs horizontally and below the labial free margin. Multiple anastomoses between themain branches of NVB run vertically. The deep femoral neurovascular bundle connects to the superior labial NVB. The labium minus NVB pathway is a complex network with multiple anastomoses. A newly developed and clinically tested surgical intervention effectively eliminates ischemic and neurological complications of the labia minora. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Temporomandibular disorder (TMD) pain originates from muscular or intracapsular disorders, with the latter being represented by arthralgia. The aim of this study was to investigate the effects of photobiomodulation therapy (PBMT) on nociceptor activity, proinflammatory cytokine expression, neuropeptide expression, and tissue alterations in temporomandibular joint (TMJ) discs following unilateral injury in rats. Disc injury was induced via surgical access to the TMJ under general anesthesia. Forty rats were divided into four groups (n = 10 each). Group 1: surgical injury to the articular disc with PBMT; Group 2: sham surgery with PBMT; Group 3: surgical injury to the articular disc without PBMT; and Group 4: naïve (control). Ten PBMT sessions were conducted with a GaAs laser at a wavelength of 904nm and an energy density of 6J/cm². TMJs were analyzed for histological and histomorphometric parameters to evaluate tissue changes and protein levels of substance P (SP), transient receptor potential vanilloid 1 (TRPV-1), calcitonin gene-related peptide (CGRP), interleukin-6 (IL-6), interleukin-1 beta (IL-1β), and tumor necrosis factor-alpha (TNF-α). Statistical analysis was performed by ANOVA with Tukey's post-hoc test (p < 0.050 indicating a significant difference). The results revealed increased expression of SP, TRPV-1, CGRP, IL-6, IL-1β, and TNF-α following TMJ injury, with significantly lower levels after PBMT than in the other groups, leading to an improvement in the initial phases of tissue repair. These findings suggest that PBMT effectively modulates nociceptive activity and reduces proinflammatory cytokine expression, optimizing tissue regeneration and improving the treatment of TMD.

Acutely performed proximal row carpectomy (PRC) is a viable alternative to open reduction internal fixation for perilunate and/or lunate dislocations, offering comparable outcomes with fewer postoperative complications. Studies report good motion, low complication, and reoperation rates. However, limited research exists on acute PRC for perilunate dislocations (PLDs), warranting further investigation into its functional outcomes. A retrospective chart review was conducted on adult patients who underwent acute PRC for PLDs and perilunate fracture-dislocations (PLFDs) at a single institution (2010-2022). Inclusion criteria encompassed patients aged above 18 years with perilunate or lunate dislocation/fracture-dislocation treated with PRC within 21 days post-injury, among other criteria. Fourteen patients met our inclusion criteria. Patient-reported outcomes (PROs) were collected through phone surveys and final clinic visits, using Patient-Rated Wrist Evaluations (PRWEs), Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), visual analog scale (VAS) pain scores, and return-to-work statuses. Surgical approaches, patient demographics, and injury characteristics were analyzed. In our cohort (average age 49.4 years), injuries were due to motor vehicle collisions (57%) and falls (43%). Proximal row carpectomy was performed within an average of 5.6 days post-injury, and patients were contacted an average of 68.0 months post-surgery. Return-to-work rates were favorable, with 35.7% returning without restrictions and 35.7% with restrictions. Patient-reported outcomes, encompassing VAS (1.31), QuickDASH (20.5), and PRWEs (24.5), demonstrated favorable results. This study provides novel insights into the outcomes of acute PRC for perilunate and lunate dislocations, expanding on limited existing literature. It highlights PRC as a viable intervention for PLDs and PLFDs, demonstrated by substantial return-to-work rates and positive PROs.

Radial sensory nerve to anterior interosseous nerve transfer for symptomatic neuromas- clinical outcomes and a transfer classification system.

Getting nervous: the origins and evolution of NAP8.

Intraoperative Sino-Atrial Node Mapping in Left Atrial Isomerism: A Proof-of-Concept Study to Avoid Surgical Injury.

The endoscopic transorbital approach (ETOA) provides minimally invasive access to the skull base, but its orbital trajectory raises concern for subclinical optic nerve or retinal injury. We assessed the structural safety of ETOA using high-resolution optical coherence tomography as an objective neuro-ophthalmic tool, focused mainly on patients without orbital involvement. From 41 consecutive ETOA cases (2017-2024), 16 patients had analyzable baseline and approximately 12-month postoperative imaging and were included: a Group A without orbital involvement (n = 10) and a Group B with orbital or optic nerve involvement but interpretable scans (n = 6). Macular ganglion cell layer (GCL) and peripapillary retinal nerve fiber layer (RNFL) thickness were measured with spectral-domain optical coherence tomography. Paired analyses were prespecified for the Group A; the Group B was summarized descriptively. The contralateral eye served as an internal control. Across all 16 patients, no structural or functional deterioration attributable to surgery was observed. In the Group A, GCL thickness in the operated eye decreased slightly from 81.0 µm to 80.5 µm (mean change -0.5 µm), as well as in the contralateral eye used as control (-0.2 µm). RNFL thickness in the operated eye increased from 96.4 µm to 97.3 µm (mean change +0.9 µm), while the contralateral eye decreased (-1.2 µm). These changes were not statistically significant and remained within physiological variability (±2 µm for GCL; ±3 µm for RNFL). Visual acuity, visual fields, color vision, and pupillary responses were preserved, with no signs of functional impairment. In the Group B, the operated eye showed RNFL thinning (≈-7.7 µm), while GCL remained stable. This was attributed to preexisting optic neuropathy or resolution of preoperative disc edema rather than surgical injury. Importantly, functional outcomes (visual acuity, visual fields, color vision, and pupillary responses) improved or remained stable. ETOA does not induce subclinical retinal or optic nerve injury at late follow-up. The approach demonstrated structural and functional safety, particularly in patients without orbital involvement (Group A), where preservation of visual integrity is imperative. These findings support the neuro-ophthalmic safety of the transorbital corridor and justify larger prospective studies.

The great saphenous vein (GSV) is widely used in vascular surgery, especially for coronary artery bypass grafting (CABG). However, surgical injury and arterial (high) cyclic stretch induce vascular dysfunction in vein grafts. Here, we found that surgical injury induces vascular dysfunctions. Upon adhering to injured vessels, platelets release platelet-derived microvesicles, which serve as potent and persistent mediators of vascular dysfunction. RNA sequencing analysis revealed that zinc ion deficiency plays a vital role in vascular dysfunction. Of note, platelet membrane cloaked Zn-MOF nanoparticles (ZIF-8) alleviate injury-induced vascular dysfunction. To counteract the vascular dysfunction caused by surgical injury and high cyclic stretch in vein grafts, we developed an electrospun polycaprolactone (PCL) external stent loaded with zinc oxide (ZnO) (PCL–ZnO stent). Electrospun PCL external stents containing varying ZnO concentrations (0 wt%, 1 wt%, 3 wt% or 5 wt% ZnO) were fabricated and implanted around vein grafts. Vascular remodeling was assessed by histology, immunofluorescence and RNA sequencing. Moderate ZnO loading (3 wt%) suppressed neointimal hyperplasia to preserve appropriate venous arterialization as confirmed by hematoxylin and eosin (H&E) staining and increased expression of smooth muscle cell phenotypic markers including α-SMA and Calponin. RNA-seq data verified that Zn2+ mediates the regulation of genes involved in proliferation, inflammation and metabolism. Gene set enrichment analysis of RNA-seq data from PCL-3 wt% ZnO-treated vein grafts at 2 weeks revealed significant upregulation of gene sets associated with lipid biosynthesis and cholesterol homeostasis. Pathway enrichment analysis of differential metabolites identified significant perturbations in purine metabolism, amino sugar/nucleotide sugar metabolism, galactose metabolism, and glycerophospholipid metabolism. These results indicated that moderate ZnO incorporation (3 wt%) in external stents effectively modulated local biological responses by suppressing pathological cell proliferation without inducing apoptosis, thereby promoting proper venous arterialization. PCL-3 wt% ZnO stent may be a successful material for clinical use in alleviating intimal hyperplasia and promoting functional arterialization of grafted veins.

Peroral endoscopic myotomy (POEM) recently has been reported as minimally invasive therapy for esophageal achalasia requires general anesthesia. Postoperative nausea and vomiting (PONV) is one of the most common adverse events after general anesthesia. Although PONV is associated with adverse consequences undergoing POEM, little has been known about the incidence and risk factors. We evaluated the incidence of PONV undergoing POEM as well as the relationship between incidences and anesthetic agents. This prospective double-blind study comprised 60 patients with American Society of Anesthesiologist physical status I or II who were undergoing POEM with inhaled anesthesia or TIVA. Patients were interviewed by two experienced anesthesiologists about incidence of PONV in accordance with a categorical verbal rating scale (VAS) and PONV Intensity Scale. The primary outcome was the incidence of PONV undergoing POEM between the two groups. In addition, we observed postoperative outcomes including bleeding at surgical site, mucosal injury, and patients’ satisfaction. The incidence of PONV after POEM within first 6 hours was significant lower in the TIVA group than in the sevoflurane group (46.4% vs 76.7%, p=0.025). Additionally, it was observed that number of patients who experienced postoperative complications, such as surgical site injury, mucosal injury, heart burn, pneumoperitoneum, and emphysema, was higher in TIVA group (44.4%) compared with in sevoflurane group (26.7%), but it was insignificant (p=0.130). These data suggest that TIVA could be considered as a good method to prevent PONV during early postoperative period (within 6 hours) after POEM.

Increased use of operative vaginal birth (OVB; forceps and vacuum) has been proposed as a strategy to avoid cesarean birth(CB) among individuals who elect a trial of labour after CB (TOLAC). The relative maternal safety of OVB and CB in individuals with a TOLAC is poorly understood. To summarize the available evidence and methodologic quality of the literature on the use of OVB versus CB in the second stage of labor with a focus on maternal morbidity in individuals with a TOLAC. We searched OVID MEDLINE, EMBASE, and Web of Science after 1950 to August 8, 2023. Experimental and observational studies of individuals with a TOLAC having had OVB compared with CB in the second stage of labor. Relevant characteristics (participant information, OVB and CB distribution, and comparative estimates of maternal morbidity) were abstracted. Findings were summarized narratively, with results presented in tabular form to highlight key comparisons. Five cohort studies conducted in the USA, Israel, or Australia were included. Higher rates of surgical injuries (9/87, 10.3% vs. 19/788, 2.4%), cystotomy (12/486, 2.5% vs. 4/743, 0.5%), and ureter injury (1/486, 0.2% vs. 1/743, 0.1%) were reported with second-stage CB compared with OVB. Rates of composite maternal morbidity were elevated with OVB, but higher rates of endometritis and wound complications were documented with second-stage CB compared with OVB. All studies were at high risk of bias. Optimal management of individuals requiring operative birth following a TOLAC remains unclear.

BACKGROUND:Complex regional pain syndrome (CRPS) is a debilitating and painful condition accompanied by sensory, autonomic, trophic, and/or motor abnormalities. Although CRPS is rare in the general population, the prevalence among individuals at higher risk, particularly posttraumatic and postsurgical patients, remains unknown. This study aims to provide a benchmark that quantifies CRPS prevalence in high-risk groups, and offers insights on potential predictors of developing CRPS.METHODS:We conducted a systematic review and meta-analysis to identify studies reporting prevalence of CRPS after an inciting event (eg, fracture, surgery), specifically 12-month and 24-month prevalence (primary outcomes), as well as 3-month and 6-month prevalence (secondary outcomes). Estimates from individual studies were transformed using double-arcsine transformation, and the resulting estimates with 95% confidence interval (CI) were pooled in a meta-analysis using a random-effects model.RESULTS:We included 214 articles with data from 2491,378 participants worldwide (35 countries), of which 16,873 had CRPS. The pooled 12-month and 24-month global prevalence was 3.04% (95% CI, 2.64–3.48) and 6.46% (95% CI, 5.46–7.53), respectively. Subgroup analysis and meta-regression were performed to understand the impact of population-dependent (mechanism of injury, type of CRPS), contextual-dependent (socioeconomic status), and methodological-dependent (study design, publication year) factors. The 12-month prevalence was higher in countries with a high human development index (HDI) compared to those with a medium or very high HDI, was higher in participants with a traumatic inciting injury only versus those with surgical injury only or traumatic/surgical injury, and was higher in prospective versus retrospective studies. Meta-regression analysis showed that publication year was a significant moderator, with more recent articles reporting lower 12-month prevalence.CONCLUSIONS:This study provides a benchmark of the global prevalence of CRPS, which anesthesiologists and pain specialists can use to prioritize early diagnosis and identify those at the highest risk for CRPS.

Background: Extra-articular distal humerus fractures (EDHFs) are common in both younger and older adults, presenting clinical challenges related to fracture complexity and patient comorbidities. This study compares the triceps-splitting and paratricipital surgical approaches to determine which method optimizes clinical outcomes over a 6-month follow-up period. Materials and Methods: In this prospective cohort study, 120 patients with radiographically confirmed EDHF were assigned to undergo either the triceps-splitting or paratricipital approach. Each patient was assessed at baseline, 3 months, and 6 months postoperatively for surgical site infection, nerve injury, pain (using a 10-point visual analog scale), and range of motion (using a universal goniometer). Data were analyzed via Chi-square test, Fisher’s exact test, and Kruskal–Wallis test. Results: Baseline characteristics, including age, gender, and hospital stay, did not differ significantly between groups. At 6 months, patients who underwent the paratricipital approach reported significantly lower pain levels and demonstrated fewer limitations in extension compared to the Triceps-Splitting group. While infection and nerve injury rates were low and similar in both cohorts, the paratricipital approach showed a lower necessity for reoperation and reduced postoperative complications. Conclusions: Both the triceps-splitting and paratricipital approaches effectively manage EDHF. However, the paratricipital technique may confer advantages in terms of pain reduction, triceps function preservation, and lower reoperation rates. Surgeons should consider individual patient factors and fracture characteristics when selecting the optimal surgical approach.

Crush nerve injury model in the rat sciatic nerve: A comprehensive review and validation of various methods.

Georg von Békésy’s initial observations of inner-ear vibrations were carried out at the apex of human-cadaver cochleae but contemporary studies have focused on responses at the base of the cochlea of live rodents. Apical cochlear recordings have proven difficult to achieve because opening the otic capsule often produces surgical injury and experimental artifacts. Using optical coherence tomography, I recorded mechanical responses to click stimuli at the organ of Corti (OoC) in the intact chinchilla cochlea at sites with characteristic frequencies (CFs) around 500 Hz. In general, OoC velocity responses to clicks consist of two segments: an initial component with a band-pass tuning centered at around 500 Hz, and a later component with low-pass characteristics. Spectral analysis of the transient responses revealed that responses had greater amplitudes and wider frequency bandwidth near the Hensen’s cells region than in the proximity of the basilar membrane, their frequency selectivity increased with stimulus level and death, and CF changes were negligible postmortem. Noise analysis, using Wiener kernels, indicates that click responses contain nonlinearities absent in first-order Wiener kernels. Click responses were well approximated by a frequency independent delay followed by a minimum-phase filter. The average length of the delay was approximately 1.1 ms.

Introduction. To date, diagnostic criteria for nosocomial pneumonia after open heart surgery have not been developed. The sensitivity and specificity of generally accepted criteria have not been studied, the presence of which may be due to a number of other reasons associated with surgical injury. Chest X-ray does not always reveal this complication due to postoperative chest changes. Focused lung ultrasound with color Doppler mapping seems to be a promising method for verifying pneumonia in this category of patients, not inferior to computed tomography. Brief description . Three cases of ultrasound examination are presented, demonstrating lung parenchyma changes that are characteristic and uncharacteristic for nosocomial pneumonia. Discussion. Focused lung ultrasound with color Doppler mapping is an informative and safe method for diagnosing pneumonia after open heart surgery.

BackgroundNonunion occurs in about 10% of fracture cases, which leads to secondary surgical injury and economic burden for patients.PurposeOur study aimed to confirm the effects of miR-376a-3p/WWTR1 on fracture healing.MethodsThrough bioinformatics analysis, we found that miR-376a-3p was highly expressed in patients with fracture nonunion. We confirmed the interaction of miR-376a-3p and WWTR1 by using RT-qPCR, RNA immunoprecipitation, and Dual-Luciferase assay. Rescue experiment was used to explore the effects of miR-376a-3p/WWTR1 on human bone marrow mesenchymal stem cells (hBMSCs) differentiation into osteoblasts.ResultsWe confirmed that miR-376a-3p was up-regulated in fracture nonunion patients by a retrospective study of clinical data of fracture patients. In vitro experiments showed that inhibiting the miR-376a-3p would increase the expression of WWTR1. It was found in the induction of the hBMSCs differentiation assay that inhibition of miR-376a-3p or overexpression of WWTR1 could increase the level of ALP, Runx2, and OSX in cell supernatant, which reflected the increased differentiation of hBMSCs into osteoblasts. And rescue experiment confirmed that miR-376a-3p inhibits differentiation of hBMSCs through targeted regulating WWTR1.ConclusionWe revealed the regulatory role of miR-376a-3p/WWTR1 in fracture nonunion by inhibiting osteogenic induction, which provides the possibility that miR-376a-3p may be a new underlying target for fracture nonunion prediction and therapy.

Repetitive transcranial magnetic stimulation (rTMS) is recommended as a third-line treatment for chronic neuropathic pain. Because of its non-invasive nature and limited side effects, it is considered a good therapeutic option. rTMS efficacy on chronic neuropathic pain has been demonstrated in numerous quantitative studies. However, there are no qualitative studies to support these quantitative data. Included patients presented with peripheral neuropathic pain related to polyneuropathy (n = 6), radiculopathy (n = 3) and traumatic or surgical nerve injury (n = 3). The target of the rTMS was the primary motor cortex. We conducted a longitudinal qualitative study consisting of two separate semi-structured interviews for all 12 participants from four different French multidisciplinary pain centres, one before starting treatment and the other after 2 months of rTMS treatment. Two separate manual analyses by two researchers were carried out, as were software analysis and data triangulation. Our study revealed an overall positive impression about rTMS treatment, with improvements in pain and activities of daily living. However, most participants felt that information on this treatment was inadequate because of difficulties in understanding the treatment mechanism. These difficulties frequently led to misrepresentations about the treatment, which could result in secondary fears, particularly in relation to the fear of cognitive capacity loss. The results suggest possible areas for improvement, both in clinical practice and in care organisation. Information provided to patients could be optimised, with a focus on more personalised care, considering preliminary representations and fears, so as to further encourage adherence to treatment. Furthermore, it is necessary to train healthcare staff in order to optimise the care pathway for patients suffering from intractable chronic pain and to limit the risks of delays in treatment. rTMS treatment showed overall positive effects on pain and quality of life. Many participants lacked clear understanding of the treatment mechanism, leading to fear and misinformation. Improvements are needed in patient education and healthcare staff training to support therapy compliance and optimise care.