Traditional Landmark Research Articles

Ultrasound guided central venous cannulation in infants and children presenting for cardiac surgery

Recent guidelines propose the use of ultrasound assisted central venous cannulation in all cases [1]. Traditional landmark techniques have a success rate of 96%. Complication rates range from 0.3% to 12% according to the experience of the physician and the definition of complications [2]. Our aim was to assess whether ultrasound guidance for central venous cannulation may assist consultant paediatric cardiac anaesthetists, saving time and reducing complication and failure rates in infants and children presenting for cardiac surgery. Approval from our Local Research Ethics Committee was obtained. Patients were randomised into either the landmark technique or the ultrasound groups. Only consultant cardiac anaesthetists performed the cannulations. A Baird site rite II ultrasound machine was used. Time to insertion of a guide wire into the right internal jugular vein was measured. Complications and failures were documented. One hundred and thirty-four patients were recruited, 65 into the landmark group and 69 into the ultrasound group. The ultrasound device was unavailable in 10 patients randomised into the ultrasound group; these patients were excluded from further analysis. The landmark group had 52 successes (80%), six complications (9%: three haematomas and three carotid punctures) and seven failures to cannulate (11%). The ultrasound group had 30 successes (51%), 14 complications (24%: seven haematomas and seven carotid punctures) and 15 failures (25%). Ultrasound guidance did not reduce the time taken to insert a guide wire into the right internal jugular vein, but increased the incidence of failures and complications when used by this group of paediatric cardiac anaesthetists. In different patients, in different settings and with different physicians, the risks of complications or failure of central venous catheterisation vary substantially. Guidelines should concentrate on identifying factors that may predispose to difficulties or complications and encourage the use of ultrasound guidance in those patients or with that particular group of physicians [3].

Postmodern Subjects: On Lyman's Sociology of the Absurd

According to Stanford Lyman, a specter continues to haunt social theory in the United States and that specter is "postmodernism." In Roads to Dystopia,2 Lyman continues3 a critical engagement with postmodern theory?especially that work which has been most influential with, and appropriated by, American sociologists. Although critical of postmodern thought, Lyman is never dismissive of his subject.4 Indeed, Lyman expresses a certain sympathy with some arguments within postmodernism because much is familiar to him.5 In his existentialist sociology of the absurd, an intellectual project first articulated by Lyman and others more than a quar ter century ago,6 several recognizably "postmodern" themes, he maintains, can be found. Lyman accepts that we live in postmodern times, a condition characterized, he suggests, by alienation and despair. It is because of this, however, that he ultimately rejects the postmodernist's response. Reflecting on our present historical condition, Lyman observes that it is "no wonder, then, that the present millennial moment is conceptualized as one 'in between' another, as one whose condition can only be designated as post-modernity, with no name for the age and situation that will follow."7 He concedes that our sense of time, our social and cultural memory, and even our abilities for self-expression, are all subject to ever-increasing fragmen tation. Although our traditional landmarks are now blurred and shifting, Lyman refuses to acquiesce to other claims of postmodernism: namely, that

A redescription of the skull of Euoplocephalus tutus (Archosauria: Ornithischia): a foundation for comparative and systematic studies of ankylosaurian dinosaurs

Euoplocephalus tutusLambe (1902) from the Late Cretaceous of North America, was the first ankylosaurian dinosaur known from significant cranial material. Previous descriptions of this and other members of the Ankylosauria have been constrained by a paucity of material and an extremely apomorphic skull architecture, including the pervasive development of an embossing osseous ornamentation, and the absence of traditional morphological landmarks. A relative abundance of more recently collected and prepared cranial material attributable to Euoplocephalus enables a reappraisal of this taxon (including the type specimen), and permits it to be employed as a morphological representative of the clade. In recognition of previous difficulties encountered due to peculiarities of ankylosaurian anatomy, a fresh descriptive approach is necessitated. Herein, the skull is subdivided into five mutually exclusive topographic regions, within which individual elements are assigned with the assistance of outgroup comparison. Euoplocephalus is characterized by a distinctive pattern of cranial sculpturing across the preorbital area, relatively small, variably fluted teeth lacking a cingulum, a modified palpebral and a shallow nasal vestibule. Among ankylosaurine ankylosaurs, Euoplocephalus is unique in having medially inflected maxillary tooth rows. Osteological evaluation of the type skull of Anodontosaurus lambeiSternberg, 1929 supports its placement into synonymy with Euoplocephalus.

Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department.

To compare ultrasound (US)-guided vs. landmark-guided techniques for central venous access (CVA) in the emergency department. This was a prospective study of consecutive patients enrolled at a university teaching hospital with an annual census of approximately 100,000. On even days patients had CVA with ultrasonic assistance; patients presenting on odd days had CVA via traditional landmark techniques. Ultrasound users were emergency medicine faculty or residents who completed a one-hour training session. A data collection tool with 17 variables was completed for each central line placed. Variables were compared using the independent t-test, Fisher's exact test, and the non-parametric Mann-Whitney U test. Between August 1, 2000, and February 1, 2001, data for 122 subjects (n = 51 for US, and n = 71 for landmark) were collected. Variables with statistically significant differences are as follows. Mean (+/-SD) time from skin puncture to blood flash was 115 (+/-184) seconds for the US group vs. 512 (+/-698) seconds for the landmark group (p < 0.0001). The mean number of CVA attempts in the US group was 1.6 (+/-1.0) vs. 3.5 (+/-2.7) in the landmark group (p < 0.0001). Acute complications were comparable between groups. Comparisons for time, number of CVA attempts, and complications were done specifically for a subset of patients considered to be "difficult stick" due to predefined criteria regarding body habitus or vascular disease. Patients considered to be "difficult sticks" required a significantly longer amount of time (p < 0.001) for CVA via the landmark technique than patients considered to be "difficult sticks" who had CVA with ultrasonic guidance. Time to line placement for the landmark group was 462.7 (+/-627) seconds vs. 93.3 (+/-176) seconds in the US group. Comparing the same subset also revealed an increase in number of required CVA attempts for the landmark technique group. The number of acute complications in the "difficult stick" patients did not show statistical significance (p = 1.00). The landmark group had 60% "difficult sticks," while the ultrasound group had 80%, although the difference was not statistically significant (p = 0.08). Emergency physicians with limited training and experience are able to use ultrasound as an adjunct for central venous access. Ultrasound technology may decrease the number of CVA attempts required to cannulate a central vein and will decrease the amount of time required to cannulate the vein starting from the time when the needle is on the skin, after the ultrasound machine has been set up and turned on. These results are especially true for those patients considered to be "difficult sticks."

Ultrasound Guidance versus the Landmark Technique for the Placement of Central Venous Catheters in the Emergency Department

Abstract Objective: To compare ultrasound (US)‐guided vs. landmark‐guided techniques for central venous access (CVA) in the emergency department. Methods: This was a prospective study of consecutive patients enrolled at a university teaching hospital with an annual census of approximately 100,000. On even days patients had CVA with ultrasonic assistance; patients presenting on odd days had CVA via traditional landmark techniques. Ultrasound users were emergency medicine faculty or residents who completed a one‐hour training session. A data collection tool with 17 variables was completed for each central line placed. Variables were compared using the independent t‐test, Fisher's exact test, and the non‐parametric Mann‐Whitney U test. Results: Between August 1, 2000, and February 1, 2001, data for 122 subjects (n = 51 for US, and n = 71 for landmark) were collected. Variables with statistically significant differences are as follows. Mean (±SD) time from skin puncture to blood flash was 115 (±184) seconds for the US group vs. 512 (±698) seconds for the landmark group (p &lt; 0.0001). The mean number of CVA attempts in the US group was 1.6 (±1.0) vs. 3.5 (±2.7) in the landmark group (p &lt; 0.0001). Acute complications were comparable between groups. Comparisons for time, number of CVA attempts, and complications were done specifically for a subset of patients considered to be “difficult stick” due to predefined criteria regarding body habitus or vascular disease. Patients considered to be “difficult sticks” required a significantly longer amount of time (p &lt; 0.001) for CVA via the landmark technique than patients considered to be “difficult sticks” who had CVA with ultrasonic guidance. Time to line placement for the landmark group was 462.7 (±627) seconds vs. 93.3 (±176) seconds in the US group. Comparing the same subset also revealed an increase in number of required CVA attempts for the landmark technique group. The number of acute complications in the “difficult stick” patients did not show statistical significance (p = 1.00). The landmark group had 60%“difficult sticks,” while the ultrasound group had 80%, although the difference was not statistically significant (p = 0.08). Conclusions: Emergency physicians with limited training and experience are able to use ultrasound as an adjunct for central venous access. Ultrasound technology may decrease the number of CVA attempts required to cannulate a central vein and will decrease the amount of time required to cannulate the vein starting from the time when the needle is on the skin, after the ultrasound machine has been set up and turned on. These results are especially true for those patients considered to be “difficult sticks.”

Use of ultrasound to place central lines

Context: Placement of central venous catheters (CVCs) is an integral part of care for the critically ill patient but is associated with significant morbidity when using the traditional landmark method. The use of real-time ultrasound to guide line placement has been developed in hopes of avoiding this morbidity. Objective: The objectives of this article are 2-fold. The first is to determine the relative effectiveness of the use of real-time ultrasound to place CVCs compared with the use of landmarks alone. The second is to discuss the merits of future study to increase the use of this technology. Data Sources: Medline from 1966 to 2001, personal files, 2 prior systematic reviews, and reference lists of selected articles. Study Selection: Studies were included if: (1) study design was a controlled trial, (2) patients required placement of a CVC, (3) the interventions were real-time ultrasound versus standard landmark-guided line placement, and (4) outcomes included at least 1 of failure to place catheter, success of first attempt, number of attempts, time to catheter placement, or complication rate. Data Synthesis: Eighteen trials were identified. Pooled results showed a significant reduction in failure rate (risk difference, −.12, 95% confidence interval [CI], −.18 to −.06), number of attempts (risk reduction, 1.41, 95% CI, 1.15–1.67), and arterial puncture rate (risk difference, −.07, 95% CI, −.10 to −.03). The number of successful venous cannulations on first attempt were higher using ultrasound (risk difference, .24, 95% CI, .08–.39). No difference was found in time to insertion. Significant heterogeneity of study results was found for most analyses. Subgroup analyses suggested that ultrasound improved outcomes most convincingly using external probes, for internal jugular vein cannulation, and when used by clinicians less experienced at line placement. Conclusions: Adoption of real-time ultrasound to guide CVC placement has the potential to improve successful line placement and minimized complications. It can improve patient safety. However, there are significant cost concerns and the reported adverse events are generally minor and easy to treat. Before creating study protocols to increase usage of this technology, both current usage and cost effectiveness should be determined. Copyright 2002, Elsevier Science (USA). All rights reserved.

Ultraschallgesteuerte Punktionstechnik von zentral-venösen Gefäßen in Ein-Personen-Technik

The traditional anatomic landmark technique usually allows a rapid and easy central venous access but this technique is not always successful and can be associated with severe complications. We developed an ultrasonically guided one-operator-catheterization technique whereas a second operator to place and hold the ultrasound transducer is not necessary. The catheterisation technique consists of 3 functional components: the swivel arm, the ultrasound unit and the conventional Seldinger central venous catheterization technique. As swivel arm we used a device with a 300 mm column with a 700 mm span attached to ultrasound unit. There were 234 catheterizations of the internal jugular vein performed in the period of January 1999 to July 1999. The indication and complication rate for the catheterization procedure was documented. There were 2 plexus irritations and 1 hematoma observed in all performed catheterization procedures which remained without therapeutic consequences. Once the decision for central venous access has been made the safest technique should be applied. The ultrasonically guided catheterization technique allows a fast, safe and convenient central venous access for our patients.

In Vivo Facial Tissue Depth Measurements for Children and Adults

This study reports results of a facial tissue depth measurements project conducted over a two-year period on a modern sample of children and adults of both sexes and varying ages and races. The purpose of this research was to increase available tissue depth data for children and update facial tissue depth measurements for American adults. Most volunteers for this project were patients or visitors to the pediatric clinic at the Louisiana State University Medical Center, School of Dentistry, in New Orleans. Using state of-the-art ultrasound technology, we scanned 551 children and 256 adults at 19 points across the face. Thirteen of the scanned points were traditional landmarks while six others were areas not measured by previous researchers or were points for which very little data exist for both children and adults. For this presentation, we analyzed data for 515 children and 197 adults. Results of Pearson's correlations, analysis of variance, and paired t-tests indicate that age, sex, and race are significant factors when considering tissue depth means for different measurement locations across the human face. These new standards are compared to the work of other researchers. Our results provide valuable assistance in both two-dimensional and three-dimensional facial reproductions and superimpositions.

Early decannulation with bilateral mandibular distraction for tracheostomy-dependent patients.

Obstructive sleep apnea in the neonatal period may originate from a hypoplastic mandibular framework causing retroposition of the base of the tongue and an inadequate hypopharyngeal space. A tracheotomy in childhood is an effective treatment for obstructive sleep apnea, but it is associated with increased morbidity, management problems, and difficulties in social interaction. Tracheostomy-dependent pediatric patients who underwent mandibular distraction were reviewed to determine the effectiveness of this technique in achieving decannulation. A clinical review was completed to determine the status of the tracheostomy after external, unidirectional distraction in tracheostomy-dependent patients. Expansion of the mandibular framework was analyzed using traditional bony landmarks on predistraction and postdistraction lateral cephalograms. The area of the lower face was analyzed, and changes in the position of the hyoid bone were determined. Four patients with tracheostomies underwent an average of 21.3 mm and 20.8 mm of distraction on the left and right hemimandibles, respectively. The average age at the time of distraction was 2.7 years (range, 2.2 to 3.2 years). All patients underwent successful decannulation at an average of 3.8 months (range, 1.5 to 5.5 months) after completion of distraction. The area of the lower face increased 26.9 percent (range, 12.2 to 53.5 percent) after distraction, and the hyoid bone advanced an average of 14.5 mm (range, 8 to 25 mm). Bilateral mandibular distraction is an effective method of expanding the mandibular framework and concomitantly advancing the base of the tongue. The technique provides a tool for early intervention and decannulation in pediatric patients with indwelling tracheostomies secondary to mandibular deficiencies.

Sonographic guidance when using the right internal jugular vein for central vein access.

The intent of this study was to substantiate the advantages of the use of sonographic guidance for central venous access via the right internal jugular vein. Eighty sequential patients requiring central vein access were examined with a hand-held sonography transducer to determine the size, patency, and location of the right internal jugular vein before puncture. Access to the right internal jugular vein was subsequently performed, under sterile conditions, using sonographic guidance. Periprocedural complications were prospectively recorded. Subsequently, we compared our findings with published reports of complications when visible and palpable anatomic landmarks were used for guidance during cannulation of the internal jugular vein. Among these 80 patients, the anatomy of the right internal jugular vein was typical in only 57 (71%). In another 13 patients (16%), sonography showed a medial position of the right internal jugular vein, anterior to the common carotid artery. In three other patients (4%), the right internal jugular vein was positioned laterally by more than 1 cm. In the remaining seven patients (9%), the vein was thrombosed. Its diameter, measured without use of the Valsalva maneuver, also varied, measuring 0.5-2.0 cm. Cannulation was achieved in all 73 patients with a patent right internal jugular vein. One puncture was required in 68 patients (93%); two punctures in three other patients (4%); and three punctures in the remaining two patients (3%). In no case was the common carotid artery inadvertently punctured. Only one periprocedural complication occurred, and it was unrelated to the use of sonographic guidance. Sonographic guidance for central vein access via the right internal jugular vein is safer and more efficient than the traditional landmark approach.

Capturing data from three-dimensional surfaces using fuzzy landmarks.

Anatomical landmarks are defined as biologically meaningful loci that can be unambiguously defined and repeatedly located with a high degree of accuracy and precision. The neurocranial surface is characteristically void of such loci. We define a new class of landmarks, termed fuzzy landmarks, that will allow us to represent the form of the neurocranium. A fuzzy landmark represents the position of a biological structure that is precisely delineated, but occupies an area that is larger than a single point in the observer's reference system. In this study, we present a test case in which the cranial bosses are evaluated as fuzzy landmarks. Five fuzzy landmarks (the cranial bosses) and three traditional landmarks were placed repeatedly by a single observer on three-dimensional (3D) computed tomography (CT) surface reconstructions of pediatric dry skulls and skulls of pediatric patients, and directly on four of the same dry skulls using a 3Space digitizer. Thirty landmark digitizing trials from CT scans show an average error of 1.15 mm local to each fuzzy landmark, while the average error for the last ten trials was 0.75 mm, suggesting a learning curve. Data collected with the 3Space digitizer was comparable. Measurement error of fuzzy landmarks is larger than that of traditional landmarks, but is acceptable, especially since fuzzy landmarks allow inclusion of areas that would otherwise go unsampled. The information obtained is valuable in growth studies, clinical evaluation, and volume measurements. Our method of fuzzy landmarking is not limited to cranial bosses, and can be applied to any other anatomical features with fuzzy boundaries.

Capturing data from three‐dimensional surfaces using fuzzy landmarks

Anatomical landmarks are defined as biologically meaningful loci that can be unambiguously defined and repeatedly located with a high degree of accuracy and precision. The neurocranial surface is characteristically void of such loci. We define a new class of landmarks, termed fuzzy landmarks, that will allow us to represent the form of the neurocranium. A fuzzy landmark represents the position of a biological structure that is precisely delineated, but occupies an area that is larger than a single point in the observer's reference system. In this study, we present a test case in which the cranial bosses are evaluated as fuzzy landmarks. Five fuzzy landmarks (the cranial bosses) and three traditional landmarks were placed repeatedly by a single observer on three-dimensional (3D) computed tomography (CT) surface reconstructions of pediatric dry skulls and skulls of pediatric patients, and directly on four of the same dry skulls using a 3Space digitizer. Thirty landmark digitizing trials from CT scans show an average error of 1.15 mm local to each fuzzy landmark, while the average error for the last ten trials was 0.75 mm, suggesting a learning curve. Data collected with the 3Space digitizer was comparable. Measurement error of fuzzy landmarks is larger than that of traditional landmarks, but is acceptable, especially since fuzzy landmarks allow inclusion of areas that would otherwise go unsampled. The information obtained is valuable in growth studies, clinical evaluation, and volume measurements. Our method of fuzzy landmarking is not limited to cranial bosses, and can be applied to any other anatomical features with fuzzy boundaries. Am J Phys Anthropol 107:113–124, 1998. © 1998 Wiley-Liss, Inc.

Radiographic localization of mandibular anesthesia landmarks

The objective of this study was to assess whether bony landmarks used for the standard inferior alveolar nerve block can be used to accurately determine the position of the mandibular foramen and whether panoramic radiographs are appropriate for this purpose. A total of 11 landmarks from 79 panoramic radiographs and 70 corresponding cases of oblique (45-degree) cephalometric radiographs were examined. Ten measurements of the distance from each landmark to the mandibular foramen, as well as 6 ratios from these distances, were calculated from all radiographs. The results showed that the position of the mandibular foramen was highly individualistic and not consistently related to traditional clinical landmarks. Panoramic radiographs were as good as oblique cephalometric radiographs for the locating of the mandibular foramen. No age or gender correlations were found. It was concluded that the mandibular foramen can be localized in panoramic radiographs but that its relation to bony landmarks is highly variable.

DOES THE USE OF THE ULTRASOUND DEVICE DURING INTERNAL JUGULAR CANNULATION, DECREASE THE INCIDENCE OF COMPLICATIONS IN CHILDREN?

S420 INTRODUCTION: Internal jugular (IJ) vein cannulation is technically more difficult in children than in adults. [1] We hypothesized that the use of the ultrasound device reduces the incidence of complications associated with IJ cannulation in children undergoing cardiac surgery. METHODS: Internal jugular cannulation was performed on 294 patients by anesthesia fellows or attending anesthesiologists using either traditional landmarks method (LM) or the ultrasound device (US). The choice of either method was based on the preference of the attending anesthesiologist. The following data were collected: age, success, number of attempts, cannulation time and the different complications. RESULTS: Of the 294 patients studied, 150 patients were infants and 144 patients older children. The landmark technique was used in 137 patients and the ultrasound technique was used in 157 patients. The number of attempts, cannulation time, the success rate and complications in these infants and children using either the landmark technique or the ultrasound device are shown in Table 1. The complications included, arrhythmias, guidewire kinking, difficulty in threading, arterial and venous hematomas. The significant complications of carotid artery puncture and hematoma formation were specifically evaluated in these patients.Table 1: Landmarks (LM) vs. Ultrasound (US) Technique in Two Groups of ChildrenCONCLUSIONS: There were significantly less complications during internal jugular vein cannulation when ultrasound device was used. The incidence of carotid artery puncture and hematoma formation was also significantly reduced with the use of the ultrasound device in all children. We conclude that the use of ultrasound device during IJ cannulation decreases the overall incidence of complications, especially carotid artery puncture and hematoma formation.

Landmark methods for forms without landmarks: morphometrics of group differences in outline shape

Morphometrics, a new branch of statistics, combines tools from geometry, computer graphics and biometrics in techniques for the multivariate analysis of biological shape variation. Although medical image analysts typically prefer to represent scenes by way of curving outlines or surfaces, the most recent developments in this associated statistical methodology have emphasized the domain of landmark data: size and shape of configurations of discrete, named points in two or three dimensions. This paper introduces a combination of Procrustes analysis and thin-plate splines, the two most powerful tools of landmark-based morphometrics, for multivariate analysis of curving outlines in samples of biomedical images. The thin-plate spline is used to assign point-to-point correspondences, called semi-landmarks, between curves of similar but variable shape, while the standard algorithm for Procrustes shape averages and shape coordinates is altered to accord with the ways in which semi-landmarks formally differ from more traditional landmark loci. Subsequent multivariate statistics and visualization proceed mainly as in the landmark-based methods. The combination provides a range of complementary filters, from high pass to low pass, for effects on outline shape in grouped studies. The low-pass version is based on the spectrum of the spline, the high pass, on a familiar special case of Procrustes analysis. This hybrid method is demonstrated in a comparison of the shape of the corpus callosum from mid-sagittal sections of MRI of 25 human brains, 12 normal and 13 with schizophrenia.

Volumes of frontal lobe subregions in schizophrenia: Relation to cognitive function and clinical symptomatology

Morphometrics, a new branch of statistics, combines tools from geometry, computer graphics and biometrics in techniques for the multivariate analysis of biological shape variation. Although medical image analysts typically prefer to represent scenes by way of curving outlines or surfaces, the most recent developments in this associated statistical methodology have emphasized the domain of landmark data: size and shape of configurations of discrete, named points in two or three dimensions. This paper introduces a combination of Procrustes analysis and thin-plate splines, the two most powerful tools of landmark-based morphometrics, for multivariate analysis of curving outlines in samples of biomedical images. The thin-plate spline is used to assign point-to-point correspondences, called semi-landmarks, between curves of similar but variable shape, while the standard algorithm for Procrustes shape averages and shape coordinates is altered to accord with the ways in which semi-landmarks formally differ from more traditional landmark loci. Subsequent multivariate statistics and visualization proceed mainly as in the landmark-based methods. The combination provides a range of complementary filters, from high pass to low pass, for effects on outline shape in grouped studies. The low-pass version is based on the spectrum of the spline, the high pass, on a familiar special case of Procrustes analysis. This hybrid method is demonstrated in a comparison of the shape of the corpus callosum from mid-sagittal sections of MRI of 25 human brains, 12 normal and 13 with schizophrenia.

Intrapleural Urokinase in the Treatment of Loculated Pleural Effusions

The purpose of this study was to assess the value of intrapleural urokinase (UK) instillations in enhancing tube drainage of loculated, complex pleural effusions. Tube thoracostomy has variable success in the treatment of complex pleural effusions, with limitations because of viscous fluid, improper tube position or kinking, and, most importantly, loculation. In the past, intrapleural administration of streptokinase has been used to lyse locules. In this study, eight patients with nine loculated pleural processes were treated with intrapleural instillations of UK. Six patients had previously undergone unsuccessful conventional tube drainage. Loculation was suggested by persistent fluid despite an adequate trial of simple drainage, radiographic demonstration of septation, or drainage of a volume of fluid far less than expected by a computed tomography scan. After instillation of a UK solution, the tubes were clamped for 30 to 180 min and then placed back to suction. Five pleural cavities with disease 6 to 18 days old showed complete resolution, and clinical improvement occurred. Three pleural processes showed improvement and one showed no improvement, with disease ranging from 23 days to 3 months. No complications were seen. These results suggest that UK instillations may enhance tube drainage of loculated pleural fluid in the early phase, before fibrosis has developed.

An external reference to identify the internal auditory canal in middle fossa surgery.

Traditional middle fossa landmarks, such as the facial hiatus and arcuate eminence, are often unreliable. This study was performed to establish an external reference from which to identify precisely the surgical anatomy of the middle fossa. The head of the malleus was identified from the middle fossa in the temporal bones of 20 adults. The lateral cortex of the temporal squamosa at the zygomatic root was used as the external plane of reference. The head of the malleus was consistently located 18 mm medial to the outer cortex on a line perpendicular to the reference plane. Medial extension of this line through the malleus head bisected the internal auditory canal. We recommend this method to precisely locate the malleus head as the first landmark in the middle fossa. Other structures, such as the geniculate ganglion, internal auditory canal, and superior semicircular canal can then be safely identified. We also present our results using this technique in six consecutive patients undergoing middle fossa surgery during the past 12 months.

Ferdinanda Ongania and the Golden Basilica: A documentation programme in 19th-Century Venice

Abstract The remarkable Ferdinanda Ongania, publisher, bookseller, cultore appassionato, and purveyor of the beauties of Venetian art, was born in Venice, 18th July, 1842 and died in St Moritz on 21st August 1911. When still very young he began working in a bookshop established in Venice in the spring of 1846 by the elder of the Munster brothers. He soon became its director and, in 1871, though not yet thirty, he succeeded the brothers as proprietor. In Venice, which up until the previous decade had belonged to Austria, the bookshop (located under the Procuratie of the Royal Palace toward the Ascensione, no. 72-73, in front of the Basilica of San Marco) had become a traditional landmark for foreign scholars. It held a special importance for young Venetian intellectuals, who met there to read clandestinely Berchet's and Aleardi's patriotic lyrics. In the euphoric, chaotic and rather uncertain climate of the liberation (1866), there was a new rise of interest in Venice. Beginning in the 1870s, Ongania's ent...