Delineation the anatomy of posterior tibial artery perforator flaps using human cadavers with a modified technique

Background

To delineate the distribution and course layer of the perforator vessels using a modified technique.

Methods

Twelve perforator flaps were obtained from the crura of six fresh adult cadavers. The flaps were randomized into three groups (n = 4 per group): the full-thickness flap group; the deep fascia-free flap group, and the subcutaneous adipose layer-free group. The flaps were smoothened on a silk screen on a batten frame and the isolated flaps were perfused at a perfusion pressure of 140 mmHg for 10 min via the trunk of the posterior tibial artery. Perforator flaps were photographed using a digital camera and radiographed using a mammography device. The imaging data were processed by digital software system.

Results

The mean number of the posterior tibial artery perforator was 4.17 ± 0.94. The three relatively constant perforators varied in the projection points as well as the diameter and the length. The vascular branches and courses of the perforators were clearly visible on the mammograms. Elimination of all the deep fascia or the subcutaneous adipose tissues in the distal portion had no significant impact on the blood supply of posterior tibial artery perforator flaps while the vascular areas of the artery perforators were significantly reduced after the subcutaneous adipose tissue was eliminated in the proximal portion.

Conclusions

We developed an effective modified technique for delineating the vascular territory on perforator flaps of different thicknesses. Our results provide significant guidance for clinical surgeons by providing them with more detailed anatomical knowledge of perforator flaps.

     

Anatomic basis and clinical application of the distally based medialis pedis flaps

Background

Soft-tissue defects of the forefoot are difficult to cover adequately, particularly, although multiple options for reconstruction are available. This study especially focused on the vascularization of the medial side of the foot and the determination of the contribution of the nutrient vessels to medialis pedis flap viability.

Methods

Thirty cadavers were available for this anatomical study. Microdissection was conducted under a microscope, and details of the course and distribution and the communication of the first plantar metatarsal artery with the fascial vascular network of the medial side of the foot were recorded. Clinically, six cases of soft-tissue defects at the forefoot region were reconstructed with distally based medialis pedis flap.

Results

The perforator of the first plantar metatarsal artery pierces in the superficial fascia of the medial aspect of the foot 2.2 ± 0.7 cm proximal to the first metatarsophalangeal joint, vascularize the skin of the medial plantar region. The anatomical study showed that the vasculature pattern could roughly be classified into two types. In terms of clinical application, all flaps completely survived, and one patient had partial loss of skin graft.

Conclusion

The perforators of the medialis pedis flap are presented constant. The forefoot region can be repaired by the distally based medialis pedis flap on the perforator of the medial plantar artery of the hallux or the first plantar metatarsal artery perforator with medial plantar vein, medial plantar cutaneous nerve and nutrient vessels.

     

Study of the tendinous vascularization for the compound radial forearm flap plus flexor carpi radialis tendon

Purpose

The aim of this study was to explore the tendinous vascularization of flexor carpi radialis (FCR) and investigate the anatomical basis for harvesting the compound radial forearm flap (free or pedicled) with the vascularized tendon for the reconstruction of cutaneotendinous defects.

Methods

The area of the radial forearm flap was studied in seventeen forearms of fresh cadavers injected with red latex. A lozenge-shaped flap about 9 cm long and 4 cm wide was raised along the axis of the radial artery. Dissection of the flap was carried out subfascially. We searched perforators going into the flap and the nutritive branches for the tendon sheath of FCR were dissected up to their origin from the radial artery. Their distance from the scaphoid tubercle was recorded.

Results

We found nutritive branches for all the length of the tendon. The mean number of perforators going into the tendon sheath was 9.5 (range 8–12). Constant sizeable branches larger than 0.2 mm were identified from the scaphoid tubercle to the myotendinous junction; their distance from the scaphoid tubercle ranged between 0.5 and 12.5 cm. We found an average 0.8 perforators/cm of tendon (range 0.7–1). The donor sites were always closed primarily.

Conclusions

Nutrient branches of the radial artery for the tendon of FCR were constantly found. Our anatomical findings confirm the possibility of raising a compound radial forearm flap including a sure vascularized tendon of FCR. Its clinical application provides a quick and straightforward single-stage option for the reconstruction of complex cutaneotendinous defects.

     

Transorbital anastomotic pathways between the external and internal carotid systems in children affected by intraocular retinoblastoma

Purpose

It is well known that many anastomoses can join the external carotid system and the ophthalmic artery. However, their frequency has never been reported. Since they can be relevant for interventional radiologists operating in the orbit, we decided to illustrate and determine the frequency of the anastomoses that can be found in children.

Methods

A retrospective study of 443 angiographic procedures (via ophthalmic artery and/or external carotid artery) carried out on 97 children affected by intraocular retinoblastoma was made to investigate the arterial anatomy of 106 orbits.

Results

Anastomoses were observed in 44.33 % of orbits. However, their true frequency is likely much higher as the rate of visualization increased up to 91.11 % of orbits when the angiographic study was extended to the external carotid artery. In order of frequency we detected the following anastomoses: lacrimal artery—middle meningeal artery, lacrimal artery—anterior deep temporal artery, ophthalmic artery—middle meningeal artery, ophthalmic artery—facial artery, supraorbital artery—superficial temporal artery, supratrochlear artery—superficial temporal artery, supraorbital artery—middle meningeal artery, dorsal nasal artery—infraorbital artery, supraorbital artery—zygomaticoorbital artery, lacrimal artery—zygomaticoorbital artery.

Conclusion

When properly searched, anastomoses between the ophthalmic artery and the external carotid artery are almost constant in children. Depending on the clinical scenario, they can represent dangers or valuable alternative routes for collateral circulations and intraarterial chemotherapy.

     

Prevalence of persistent median artery in carpal tunnel syndrome: sonographic assessment

Purpose

This study investigated the frequency of persistent median artery (PMA) in patients with carpal tunnel syndrome (CTS) and controls.

Methods

A total of 84 CTS patient wrists, and 136 wrists of control subjects without CTS, were examined on ultrasonography (US) and color Doppler US (CDUS), and by electrophysiological evaluations. The frequency of PMA in CTS was evaluated.

Results

Of 84 CTS patient wrists, 2 (2.4 %) had a PMA (both on the right side). Of 136 control wrists, 12 (9 %) had a PMA, which was unilateral in eight (three right and five left), and bilateral in two, cases. There was no significant difference between the CTS patient and control groups with respect to the frequency of PMA (P > 0.05).

Conclusions

There was no significant difference between the CTS patient and control groups in the frequency of PMA. We suggest that an ipsilateral PMA does not increase the risk of CTS.

     

A unilateral septal flap based on the anterior ethmoidal artery (Castelnuovo’s flap): CT cadaver study

Objective

We describe our experience for repair septal perforation with a septal flap and we analyse the route of the septal branch of the anterior ethmoidal artery (AEA) in the septum area with a radiological anatomy study in order to perform this flap.

Study design

We carry out a prospective analysis with computed tomography scan in the cadaver heads and we perform an endoscopic technique in the patients.

Methods

Ten nasal cavities were analysed in five adult cadaveric heads and two patients diagnosed with anterior septal perforation were surgically treated. Measurements in the cadaveric heads were obtained from a sagittal plane of the nasal septum. The anterior point corresponds to the projection of the anterior insertion of the middle turbinate in the frontal process of the maxilla over the nasal septum. The posterior point was obtained with a vertical line passing through the entrance of the AEA in the nasal septum.

Results

The mean distance between the anterior point and the posterior point was 7.35 mm with a standard deviation of 0.95 mm. The lowest value was 5.5 mm and the highest value was 8.7 mm. We observed good epithelialisation and closure of the perforation in all patients.

Conclusion

The unilateral septal flap pedicle by anterior ethmoidal artery may be used for small and medium perforations with a pedicle smaller than 1 cm posterior to the axilla.

     

Superficial temporal artery: the “C” shape half-buttonhole configuration as it courses over the zygomatic arch

Purpose

To describe the course and configuration of the superficial temporal artery (STA) around the zygomatic arch.

Methods

Volume rendered 3D reconstructions of computed tomography angiography of 25 healthy patients were performed and analyzed at Duke University Hospitals.

Results

The STA coursed over the zygomatic arch or over the condylar process of the mandible in all cases (25/25 pts, 100 %). The STA courses over the posterior zygomatic arch in 23/25 pts (92 %), creating a characteristic “C” shape half-buttonhole configuration as it embraces the arch. When the STA travels posterior to the zygomatic arch, there is no C shape configuration (2/25 pts, 8 %). The STA bifurcates distal to the zygomatic arch in 24/25 pts (96 %).

Conclusions

The “C” shape half-buttonhole configuration is a useful identifying characteristic of the most common course of the STA—over the posterior zygomatic arch before it bifurcates.

     

A radial artery originating from the thoracoacromial artery

Purpose

The purpose of this case report is to report a rare vascular variation in the upper limbs because of its clinical importance and embryological implication.

Methods

During the educational dissection of a 73-year-old Korean male cadaver`s right upper limb, we found a variant branch which is originated from the thoracoacromial artery.

Results

The variant branch from the thoracoacromial artery ran to the distal forearm in the deep fascia. Because it finally coursed like the radial artery in the forearm and the palm, we defined the variant artery as superficial brachioradial artery (SBRA). In the cubital region a little below the intercondylar line, the brachial artery gave off a small communicating branch to SBRA, and continued as the ulnar artery.

Conclusions

We reported this unique variation and discussed its clinical and embryological implication.

     

A mixed-type intermesenteric trunk as a major contributor to the ascending,transverse, and descending colons: a case report

Purpose

We present a case in which a mixed-type intermesenteric trunk was the major arterial supply for the ascending, transverse, and descending colons.

Methods

We dissected a cadaver of a man aged 74 years that was used for a routine abdominal dissection course of 2nd year medical students.

Results

We observed that a mixed-type intermesenteric trunk supplied the majority of the colon, originating from the inferior mesenteric artery. The vessel was non-tortuous and had a counter clockwise course. It gave branches that supply the marginal artery at the splenic and hepatic flexures and at the transverse colon and finally it anastomosed with the ileocolic artery at the ileocecal junction. Through the intermesenteric trunk, the inferior mesenteric artery supplied the descending, transverse, and ascending colons with contributions from the sigmoidal and ileocolic arteries.

Conclusions

The intermesenteric trunk is an important central connection between the superior and inferior mesenteric arteries. It probably is an embryologic remnant that constituted a longitudinal anastomosis between both mesenteric arteries.

     

Picture perfect—how seeking perfection influences sleep and romantic relationships

Background

Studies have shown that sleep quality is negatively affected by perfectionism. Moreover, partner- or relationship-oriented perfectionism negatively influences relationship quality.

Objective

This paper aims to investigate the association of general perfectionism with sleep quality and relationship quality.

Materials and methods

A study assessing perfectionism, sleep quality, and relationship quality was performed via analyzing online questionnaires completed by 489 German adults from the general population.

Results

Participants with impaired sleep showed a higher level of maladaptive perfectionism (concern over mistakes and doubts, parental expectations, and criticism) than participants with good sleep, whereby the severity of sleep problems was not determining. Relationship quality is affected by perfectionism. However, this association is mediated by sleep quality.

Conclusion

Perfectionism is associated with worse sleep quality but not with worse relationship quality when sleep quality is integrated into the model as a mediator.

     

Patterns of Primary Immunodeficiency Disorders Among a Highly Consanguineous Population: Cairo University Pediatric Hospital’s 5-Year Experience

Introduction

Primary immunodeficiency disorders (PIDs) are heterogeneous disorders that mainly present with severe, persistent, unusual, or recurrent infections in childhood. Reports from different parts of the world indicate a difference between Western and Eastern populations.

Aim

The aim of this study was to report on the different patterns of PIDs and identify subgroup characteristics in a highly consanguineous population in Egypt.

Methods

We performed a retrospective chart review for children below 18 years diagnosed with PID at Cairo University Pediatric Hospital from 2010 to 2014.

Results

Four hundred seventy-six children were diagnosed with PID disorders. Major categories included combined immunodeficiency disorders, which constituted a large proportion (30 %) of cases, along with predominantly antibody disorders (18 %) followed by syndromic combined disorders (16.8 %), phagocytic disorders (13.2 %), immune dysregulation disorders (10.5 %), and autoinflammatory disorders (9 %).

Conclusion

PIDs have different patterns within inbred populations with high consanguinity.

     

Glücklich als Paar – glücklicher Schlaf?

Background

Millions of people share a bed with their partner. Sleep und relationship could possibly influence each other.

Objectives

To identify and discuss connections between relationship and sleep quality.

Methods

Review of the literature in electronic databases.

Results

Conflict and violence in relationships lead to decreases in both partners’ sleep quality. Constructive approaches to resolving conflicts is necessary for good sleep, and vice versa. Women prefer partners with sleep-wake rhythms matching their own and report higher relationship satisfactions when the couple’s chronotypes are compatible.

Conclusions

Sleep and circadian rhythms play important roles in relationships. When treating insomnia, the relationship and the partner’s sleep should be taken into account.

     

Cadaveric study of anterior and posterior elbow endoscopy portals for endoscopic distal biceps repair: comparative anatomy-at-risk

Purpose

The purpose of this study was to describe neurovascular structures-at-risk during establishment of five portals for access to distal biceps tendon (DBT) in cubital fossa, and to establish relative safety of these portal sites for such access. We hypothesized that all five portals are safe for endoscopic DBT exploration.

Methods

Ten fresh frozen cadaveric elbows were dissected after placement of portals at five potential sites (four anterior, one posterior). Nine neurovascular structures (CV, cephalic vein; LCN, lateral cutaneous nerve; LV, leash of vessels; RN, radial nerve; SRN, superficial radial nerve; PIN, posterior interosseous nerve; RA, radial artery; BA, brachial artery; MN, median nerve) were dissected, and their distances from portal sites were measured. Statistical analysis was performed to determine relative portal safety, and risk of injury to neurovascular structures in relation to each portal was analyzed.

Results

Structures that were significantly “at risk” were RA (p = 0.006), SRN (p = 0.002), and PIN (p = 0.004). RA was significantly “at risk” of injury from portal 4 (p = 0.009). Similarly, SRN was “at risk” from portal 3 (p = 0.036), and the PIN was “at risk” from portal 2 (p = 0.003).

Conclusions

Portal 1 (parabiceps portal) was safe for all neurovascular structures, however, portals 2–4 were significantly closer to neurovascular structures. RA, SRN, and PIN were significantly “at risk” as compared to other structures amongst the portals studied. Portal 5 was relatively safe for SRN and PIN.

Clinical relevance

Portals 1 (parabiceps portal) and 5 (distal posterior) can be safely placed for endoscopic access to the DBT. Portal 4 (open distal anterior) may be used after careful open dissection and under direct vision. Portals 2 and 3 are not recommended for elbow endoscopy.

     

Micronized palmitoylethanolamide reduces joint pain and glial cell activation

Objective and design

Temporomandibular disorder (TMD) is a common painful condition in the temporomandibular joint (TMJ). Joint inflammation is believed to be a chief cause of pain in patients with TMD, through the release of pro-inflammatory cytokines that induce peripheral sensitization of nerve terminals followed by microglial stimulation.

Materials and subject

TMJ was induced in rats with the injection of complete Freund’s adjuvant (CFA) emulsion into the left TMJ capsule.

Treatment

The present study would assess the effects of micronized palmitoylethanolamide (m-PEA) on glial activation and trigeminal hypersensitivity.

Methods

Ten mg/kg m-PEA or corresponding vehicle was administered 1 h after CFA and mechanical allodynia and edema were evaluated at 24 and 72 h after CFA injection.

Results

CFA-injected animals showed TMJ edema and ipsilateral mechanical allodynia accompanied by a robust growth in GFAP protein-positive satellite glial cells and activation of resident macrophages in the TG. Moreover, m-PEA administration significantly reduced the degree of TMJ damage and pain, macrophage activation in TG and up-regulation of Iba1.

Conclusions

The results confirm that m-PEA could represent a novel approach for monitoring pain during trigeminal nerve sensitization.

     

Schlafbezogene Interventionen zur Augmentation von Psychotherapie

Background

The neurobiological augmentation of psychotherapy has drawn increasing attention in research on psychotherapy over the past years. In this context, the manipulation of sleep with its beneficial effect on memory formation and underlying neuronal plasticity is of particular interest as a non-invasive intervention.

Objectives

How do sleep and its selective manipulation influence the effectiveness of psychotherapy and how can sleep be used as an intervention to augment learning processes in psychotherapy?

Materials and methods

Important studies that examine the effects of sleep on processes of memory formation and psychotherapy are presented and discussed.

Results

Sleep represents a promising approach to augment the effects of psychotherapy. Sleep patterns are relevant both before and after psychotherapy. Another possibility is the manipulation of sleep and associated neuronal processes, e.?g. by transcranial direct current stimulation (tDCS) or drugs, which might influence learning processes and neuronal plasticity in the context of psychotherapy.

Conclusion

Sleep represents a promising approach to augment psychotherapy. Future studies are needed to further unravel the underlying mechanisms and to test whether this approach can be transferred to clinical practice.

     

Spatial anatomy of the round ligament,gallbladder, and intrahepatic vessels in patients with right-sided round ligament of the liver

Purpose

To analyze the vascular structure of the liver in patients with a right-sided round ligament.

Methods

We reviewed 16 patients with a right-sided round ligament and 3 polysplenia and situs inversus patients with a left-sided round ligament who underwent multidetector row CT with contrast media. The patient population consisted of 13 men and 6 women (mean 62 years). We analyzed the axial and volume-rendered images for the location of the round ligament, gallbladder, portal veins, hepatic veins, and hepatic artery. The following imaging findings for the patients with polysplenia and situs inversus were horizontally reversed.

Results

The prevalence of a right-sided round ligament with and without polysplenia was 75 and 0.11 %, respectively. The gallbladder was located to the right, below, and left of the round ligament in 27.7, 38.8 and 33.3 %, respectively. Independent branching of the right posterior portal vein was noted in 57.8 %. PV4 was difficult to identify in 36.8 %. The middle hepatic vein was located to the left of the round ligament. Two branching patterns for the lateral and medial branches of the right anterior hepatic artery were noted: the common (44.4 %) and separated types (55.5 %). Both of the right anterior hepatic artery and portal vein ramified into two segments; the lateral segment with many branches and the medial segment with a few branches.

Conclusions

The right-sided round ligament divided the right anterior section into the lateral and medial segments based on the portal vein and hepatic artery anatomy.

     

Ethical Assessment of Human Embryonic Stem Cell Research According to Turkish Muslim Scholars: First Critical Analysis and Some Reflections

Background

Turkey, with a Muslim population of officially over 99 %, is one of the few secular states in the Muslim world. Although state institutions are not based on Islamic juridical and ethical norms, the latter play a significant role in defining people’s attitudes towards controversial issues in the modern world, especially when backed by opinions of Muslim scholars living in Turkey. Accordingly, opinions of Muslim scholars undoubtedly have an important effect on bioethical decisions made by institutions and individuals.

Objective(s)

To explore the ethical positions of Muslim scholars living in Turkey and their arguments used in the ethical assessment of embryonic stem cell research; to discuss the biological-moral tensions arising in medical research on human embryos.

Design

Qualitative study.

Setting

Muslim scholars located in different parts of Turkey.

Methods

Qualitative method, involving the collection of opinions of various scholars, by means of 15 individual semi-structured interviews, evaluated using thematic qualitative analysis.

Results

Positions regarding embryonic stem cell research differ among Muslim scholars in Turkey. On the other hand, even where positions are similar, they are often supported by different arguments.

Conclusion

Despite the heterogeneity of the arguments presented, the dominant position considers embryonic stem cell research as morally acceptable.

     

Low radiation dose computed tomography coronary angiography: evaluation of the variations in coronary arteries

Objective

Despite attempts to decrease the radiation dose, coronary computed tomography angiography (CCTA) generally uses higher doses than computed tomography scans of other organs. The purpose of this study was to evaluate the incidence of the variations of the coronary arteries using the adaptive statistical iterative reconstruction technique to perform low-dose coronary computed tomography (CTA).

Methods

Diagnostic CCTA scans were performed in 3433 patients (from November 2010 to January 2015) using an Optima CT660 (GE Healthcare, USA) 64-slice and analyzed retrospectively.

Results

The mean effective dose was 2.1 mSv (1.2–4.9 mSv) for prospective and 4.5 mSv (3.6–9.1 mSv) for retrospective ECG-gated scans. The variations of the coronary arteries (CA) excluding myocardial bridge (MB) were detected in 76 (2.2 %) of the 3433 patients. A myocardial bridge was the most common variation (n = 288, 8.3 %). The second most common variation (n = 13, 17.1 %) was an absence of the left main coronary artery (LMCA) with separate starting points for the left anterior descending (LAD) and left circumflex (LCX) arteries. In addition, there was a rare variation (n = 1, 1.3 %) consisting of the LAD artery originating from the right coronary artery (RCA).

Conclusions

The present retrospective study was conducted using CCTA on patients with a coronary artery variations in Turkey (n = 3433). Our data show that low-dose CCTA can be used to detect common coronary variations.

     

Topography of inferior epigastric artery relevant to laparoscopy: a CT angiographic study

Purpose

The incidence of inferior epigastric artery (IEA) injury is 0.2–2 %. The aim of this study was to trace the position and course of the inferior epigastric artery in the anterior abdominal wall above the inguinal ligament at three important landmarks, i.e., at the mid-inguinal point, Anterior Superior Iliac Spine (ASIS) and umbilicus in abdominal CT Angiograms. The study also correlates the relationship of body build and the position of the inferior epigastric artery.

Methods

In 50 CT Abdominal angiograms, the course of the inferior epigastric artery was traced and distance between the artery and midline was measured at the above landmarks using measurement tool on the picture archival and communication system. The measurements were analyzed using SPSS version 16 and expressed as mean and standard deviation. Mann–Whitney test was used to compare the mean values and ratios in males and females. Linear regression was done to derive formulas by which the position of the inferior epigastric artery could be found.

Results

The mean distance of the inferior epigastric artery from the midline was 5.17 ± 0.93 cm at the level of mid-inguinal point, 4.57 ± 1.05 cm at the level of ASIS and 5.27 ± 1.17 cm at the level of umbilicus. There was a definitive predictive pattern in the course of the artery as seen in correlation and regression analysis.

Conclusion

The security distance for safe trocar placement was 6 cm at the level of ASIS and 9 cm at the level of umbilicus. Preoperative IEA assessment is helpful in reducing injuries to IEA.

     

Anti-allodynic action of the disease-modifying anti-rheumatic drug iguratimod in a rat model of neuropathic pain

Objective

Patients with rheumatoid arthritis experience nociceptive as well as neuropathic pain. The effect of iguratimod (IGU), a disease-modifying anti-rheumatic drug, on neuropathic pain in a rat model of chronic constriction injury (CCI) was examined in this study.

Methods

CCI was induced by making four ligations on the left sciatic nerve. Rats with stable signs of static allodynia were selected 2 weeks after the surgery and drug treatments were started (day 0). The test drugs were orally administered once daily for 15 days. The threshold of mechanical pain response in the hind paw was evaluated by the von Frey hair test in a blinded manner. To observe histological changes in the spinal cord, the L4 region was subjected to immunohistochemical analysis for the detection of microglial cells.

Results

IGU showed an anti-allodynic effect on CCI-induced neuropathic pain at days 6 and 14, but not at 90 min after the first administration of IGU. This effect of IGU was observed until day 21. Furthermore, IGU decreased the number of Iba-1-positive cells, which had been increased at the ipsilateral side of the dorsal horn by CCI.

Conclusions

These results suggest that IGU suppresses neuropathic pain via a different mechanism from that of current therapeutics.