Basilar Artery Bands: Anatomic and Histologic Study with Application to Coiling and Stenting Procedures

BACKGROUND

Internal bands of the basilar artery (BA) have been rarely studied. Because bands could have obvious consequences in patient diagnosis and care, the present multiinstitutional cadaveric study was performed.

METHODS

The intraluminal bands of BAs were studied in 80 cadaveric specimens derived from India (Group 1) and the United States (Group 2). Their orientation within the vessel was recorded. Measurements included the length of the BA, diameter of the BA, intraluminal band length and thickness, and distance of the band to the vertebrobasilar junction. Selected bands were submitted for histologic analysis.

RESULTS

In Group 1, an intraluminal band (all vertically oriented) was identified in 16.6%. The mean length and thickness of the bands were 2.04 mm and 1.33 mm, respectively. These bands were located at a mean distance of 1.74 mm superior to the vertebrobasilar junction. In Group 2, an intraluminal band was identified in 6%. One band was vertically positioned, and 2 were horizontally positioned. The mean length and thickness of the bands were 2.5 mm and 0.9 mm, respectively. These latter bands were located at a mean distance of 2.23 mm superior to the vertebrobasilar junction. Histologically, the bands were essentially extensions of the tunica media and interna of the artery.

CONCLUSIONS

To our knowledge, this study is the first multiethnic study of the prevalence and morphometry of the BA bands. A better understanding of these bands may help reveal their relationship to thrombus and aneurysmal formation and their impact on endovascular procedures.

Osseous deficiencies, pockets, superfluous lateral border thickening in scapula: a rare occurrence

BACKGROUND

Beyond the nutrient and suprascapular foramen, the other foramina, holes or osseous deficiencies, pockets has rarely been reported in scapula. If present, the bony holes or deficiencies may lead to radiolucent areas and may be mistaken for sites of osteolytic destruction related to skeletal metastases, multiple myeloma or others.

CASE REPORT

In the present case of left scapula, unusual osseous deficiencies of different size and shape along with pockets were observed in the body of scapula. The maximum height and width of largest bony deficiency was 35.8 mm and 12.6 mm. There was abnormal osseous thickening beside the lateral border of scapula along with the presence of some spines. Five nutrient foramina, three on the costal and two on the dorsal surface were noticed.

CONCLUSIONS

The present case reports the osseous deficiencies, pockets and extra osseous growth along the lateral border, multiple nutrient foramina altogether in one specimen. Thorough anatomical knowledge of these unusual osseous variations can provide the clinicians, radiologists and forensic experts with better clinical judgement and may add insight to the surgical planning by orthopaedic surgeons.

Setting up a Neurosurgical Skills Laboratory and Designing Simulation Courses to Augment Resident Training Program

BACKGROUND

The surgical skill practice in neurosurgery is being compromised in the recent past owing to the duty time constraint, patient safety concerns, and medico-legal issues. Surgical practice outside the operating room is essential to enhance a resident's operative skills and to gain confidence.

OBJECTIVE

To discuss the experience of establishing an 'in-house neurosurgery skills laboratory' and various training sessions conducted with cadaveric and non-cadaveric simulation modules.

METHODS

A skills laboratory was set up in the existing resident teaching hall with nine workstations. Each station has been equipped with an operating table, surgeon's chair, basic microscope, endoscope, high-speed drill system, and a suction machine. Vascular anastomosis, high-speed drilling, and basic neuroendoscopy were planned on low-cost non-cadaveric modules. Craniotomy and various surgical approaches were designed on cadaveric modules obtained from the anatomy department.

RESULT

A total of 18 residents in divided groups during their initial three semesters had participated in the non-cadaveric simulation courses. Twenty-six residents had participated and 12 sessions were conducted on the cadaveric modules. Three workshops were conducted and 20 residents and faculty members from five other institutions had participated in the cadaveric hands-on training session.

CONCLUSION

A well-equipped skills laboratory provides an opportunity for the residents to acquire operative expertise in a similar atmosphere to that of the operating theater. A structured program comprising various operative practice sessions should be incorporated into the resident training program.

Digastric musculus sternalis

PURPOSE

To report a rare variant muscle.

METHODS

Aberrant muscle was observed in the anterior chest wall musculature during routine cadaver prosection.

RESULTS

Musculus sternalis consisting of two muscular bellies united at an angle by an intermediate tendon was observed anterior to the pectoral major of the left side. The muscle did not have any bony attachment.

CONCLUSIONS

The present case represents a hybrid muscle with superior belly derived from the prepectoral mass and inferior belly from ventral longitudinal muscle column. Clinically, the musculus sternalis may be misinterpreted as a pathological mass or lesion thus its accurate knowledge is significant to radiologists, angiologists and surgeons for better interpretation of mammographic images, safer interventions and for reconstructive surgeries.

Identification of novel pulmonary vein nodes as generators of ectopic arrhythmic foci for atrial fibrillation: an immunohistochemical proof

PURPOSE

The atrial muscle sleeve (AMS) of the pulmonary vein is the most common source of the arrhythmogenic triggers in atrial fibrillation (AF). Anatomical substrate generating these ectopic currents is still elusive. The present study was designed to study the AMS of pulmonary veins with an emphasis on the structural basis which might govern AF initiation and perpetuation.

METHODS

The study was conducted on a longitudinal tissue section of pulmonary vein, taken from 15 human cadaveric nondiseased hearts. Tissue was studied histologically using H&E and Gömöri trichrome stain. The pacemaker channels were identified by immunohistochemistry using monoclonal HCN4 and HCN1 antibodies.

RESULTS

The AMS was identified in each pulmonary vein, located between the tunica adventitia and tunica media. A node-like arrangement of myocytes was seen within the AMS in 30% of veins. It had a compact zone limited by a fibrous capsule and contained much smaller, paler and interconnected myocytes. Outside the capsule, there was a zone of dispersed, singly placed myocytes separating the compact zone from the working myocytes of the AMS. HCN4 and HCN1 antibodies were expressed on the cell membrane of nodal myocytes, while the working myocytes demonstrated none to minimal staining.

CONCLUSION

Pulmonary veins nodes are similar to the specialized cardiac conductive tissue in the histological arrangement of compact and transitional zones, cellular characteristics and the presence of pacemaker channels. They might be the anatomical basis of ectopic arrhythmogenic foci. To our knowledge, these nodes are being described for the first time in human.

Interplay between anisotropy and magnetic exchange to modulate magnetic relaxation behaviors of phenoxo bridged Dy2 dimers with axial β-diketonate co-ligands

A series of Schiff base LH ((E)-2-((pyridin-2-ylmethylene)amino)phenol) supported phenoxo bridged symmetric [Dy2(L)2(hfac)4] (1), [Dy2(L)2(tfac)4] (2) and asymmetric [Dy2(L)2(thd)3(NO3)]·1.5H2O (3) binuclear complexes were isolated using diffrently substituted β-diketonate co-ligands (Hhfac =...

Post-cricoid and Upper Oesophagus Cancers Treated with Organ Preservation Using Intensity-modulated Image-guided Radiotherapy: a Phase II Prospective Study of Outcomes, Toxicity and Quality of Life

AIMS

To prospectively examine the outcomes, toxicity and quality of life (QoL) of patients with post-cricoid and upper oesophagus (PCUE) cancers treated with an organ-preservation approach of (chemo)-radiotherapy using intensity-modulated image-guided radiotherapy (IM-IGRT).

MATERIALS AND METHODS

This phase II prospective study was conducted at a tertiary cancer centre from February 2017 to January 2020. Forty patients with squamous cell carcinoma of PCUE of stage T1-3, N0-2, M0 were accrued. Gross exolaryngeal extension/dysfunctional larynx were major exclusion criteria. Patients received 63-66 Gy in once-daily fractions using volumetric modulated arc therapy with daily IGRT. Outcome measures included disease-related outcomes, patterns of failure, Radiation Therapy Oncology Group toxicities, feeding tube dependency and QoL.

RESULTS

The median follow-up was 22 months. Twenty-six (87.5%) patients had locoregionally advanced disease and 34 (85%) patients received (chemo)-radiotherapy. A complete response was observed in 26 (65%) patients. The 2-year locoregional control, event-free survival and cause-specific survival were 59.6%, 40.2% and 44.8%, respectively. The volume of primary tumour (GTVPvol) exceeding 28 cm³ had inferior overall survival (P = 0.005) on univariate analysis. Multivariable analysis showed GTVPvol and positron emission tomography-computed tomography maximum standardised uptake value to be independently predictive for event-free and overall survival. A feeding tube requirement at presentation was seen in 11 (27.5%) patients, whereas long-term feeding tube dependency at 6 months was seen in 10 (37%) patients. For QoL, a statistical improvement in pain, appetite loss and swallowing was observed over time.

CONCLUSION

Although the outcomes of PCUE cancers remain dismal, the use of state of the art diagnostic modalities, careful case selection and modern radiotherapy techniques improved outcomes as compared with before in this exclusive analysis of PCUE cancers.

Glucagon Like Peptide-1 and Its Receptor in Human Brain: Distribution of Expression, Functional Implications, Age Related Changes & Species Specific Characteristics

Emerging evidence has shown that the Glucagon like peptide-1 (GLP-1) agonist can be used for treating Alzheimer’s disease, but knowledge of its neural targets is limited. To understand the neural substrates of GLP-1, we have done whole brain mapping for GLP-1 and its receptor (GLP-1R), in 30 human brains. GLP-1 expression was studied by immuno-histochemistry and confirmed by western blot method. GLP-1R gene expression was studied by RT-PCR. GLP-1 expression was seen in most of the cortical areas (maximum in frontal, prefrontal & parietal cortex), diencephalon and brainstem, but not in cerebellum. Protein expression studies validated these results. Highest expression of GLP-1R was found in the frontal cortex. The orbito-frontal cortex and cerebellum had negligible expression. Hippocampus demonstrated significant presence of GLP-1R but patchy immunoreactivity to GLP-1. GLP-1R presence in most of the human cortical regions and absence in cerebellum is the major deviation from the animal brain. Sites which might be of interest in Alzheimer’s have been identified. GLP-1 demonstrated age related decline in most of the areas after 5thdecade. At 60yrs GLP-1 was not found in any of the cortical areas except in the prefrontal cortex but it was present in the sub-cortical areas. Age related profiling of GLP-1 in various brain areas has been analysed, which can have important bearing on understanding the Alzheimer’s. This study provides detailed description of GLP-1 and GLP-1R locations by complete human brain mapping for the first time and may lead to novel treatment options targeting the GLP-1 receptors.

Lactobacillus fermentum (MTCC-5898) alleviates Escherichia coli-induced inflammatory responses in intestinal epithelial cells by modulating immune genes and NF-κB signalling

AIM

Dietary intervention using probiotic bacteria has emerged as a promising preventive strategy in addressing foodborne infections or gastrointestinal disorders. This study investigated the immunomodulatory effects of Lactobacillus fermentum (MTCC-5898) on Escherichia coli-induced inflammatory responses in intestinal epithelial cells.

METHODS AND RESULTS

The immune response of intestinal cells (Caco-2) in the presence of probiotic Lact. fermentum was determined during exclusion, competition and displacement of E. coli as the inflammatory agent. To achieve this objective, transcriptional modulation of key immune-related genes (cytokines, pattern recognition receptors and NF-κB), release of cytokines and nuclear translocation of the NF-κB subunit p-65 were studied. Expression of pro-inflammatory cytokines IL-8, TNF-α, IFN-ϒ and IL-23 was high in E. coli-exposed intestinal cells. However, overexpression of these E. coli-induced pro-inflammatory cytokines was prevented by Lact. fermentum during exclusion and competition assays. It also modulated the transcriptional expression of regulatory cytokines (IL-10 and TGF-β), pattern recognition receptors (TLR-2 and TLR-4) and genes associated with master inflammatory regulators (NF-κB and SIGIRR) to reduce E. coli-induced inflammation. The protective effect of Lact. fermentum was further confirmed by suppression of nuclear translocation of cytoplasmic NF-κB subunit (p-65).

CONCLUSION

Lactobacillus fermentum alleviated E. coli-induced inflammatory responses by modulating the NF-κB signalling besides pro-inflammatory and regulatory cytokines expression.

SIGNIFICANCE AND IMPACT OF THE STUDY

Lactobacillus fermentum holds significant promise as a potent nutraceutical that prevents and manages inflammatory gut-associated dysfunctions.

Cadaveric anatomy of the lumbar triangular safe zone of Kambin's in North West Indian population

A three dimensional triangular space ‘the Kambin’s triangle (KT)’ present on the dorsolateral aspect of the intervertebral disc, is considered to be a safe area for transforaminal approaches. It allows access to the exiting and traversing nerve roots, the thecal sac and to the intervertebral disc spaces. Our aim was to calculate the area of the triangle by measuring the height and base at all the intervertebral spaces bilaterally in the lumbar region in North West Indian cadavers and to assess the diameter of circle inscribed within this triangle which will correspond to the size of cannula inserted for the minimally invasive transforaminal approaches in this population. Five randomly chosen adult cadavers were used for this study. After clearing the area, the exiting nerve was identified. The height and base of the bony KTs (n=40) were measured with the help of digital Vernier’s calliper (accuracy 0.02 mm) to calculate the area of the KT. There is a steady increase in the area of the bony KT reaching maximum at the level of L4-5 intervertebral space. Statistically there were no differences in the calculated areas between right and left side. The mean diameter of inscribed circle within the triangle also showed gradual increase from 5.82 mm at L1-2 level, reaching maximum value of 7.26 mm at L4-5 level on the right side while on the left side the values were 5.66 mm and 8.16 mm respectively. Careful anatomical consideration is of utmost importance in transforaminal approaches during surgical or interventional procedures in this region. Cannula having external diameter ranging 6–8 mm is recommended for any interventional approach through Kambin’s space.

Multidimensional dynamic healthcare personnel (HCP)-centric model from a low-income and middle-income country to support and protect COVID-19 warriors: a large prospective cohort study

OBJECTIVES

Healthcare personnel (HCP) are at an increased risk of acquiring COVID-19 infection especially in resource-restricted healthcare settings, and return to homes unfit for self-isolation, making them apprehensive about COVID-19 duty and transmission risk to their families. We aimed at implementing a novel multidimensional HCP-centric evidence-based, dynamic policy with the objectives to reduce risk of HCP infection, ensure welfare and safety of the HCP and to improve willingness to accept and return to duty.

SETTING

Our tertiary care university hospital, with 12 600 HCP, was divided into high-risk, medium-risk and low-risk zones. In the high-risk and medium-risk zones, we organised training, logistic support, postduty HCP welfare and collected feedback, and sent them home after they tested negative for COVID-19. We supervised use of appropriate personal protective equipment (PPE) and kept communication paperless.

PARTICIPANTS

We recruited willing low-risk HCP, aged <50 years, with no comorbidities to work in COVID-19 zones. Social distancing, hand hygiene and universal masking were advocated in the low-risk zone.

RESULTS

Between 31 March and 20 July 2020, we clinically screened 5553 outpatients, of whom 3012 (54.2%) were COVID-19 suspects managed in the medium-risk zone. Among them, 346 (11.4%) tested COVID-19 positive (57.2% male) and were managed in the high-risk zone with 19 (5.4%) deaths. One (0.08%) of the 1224 HCP in high-risk zone, 6 (0.62%) of 960 HCP in medium-risk zone and 23 (0.18%) of the 12 600 HCP in the low-risk zone tested positive at the end of shift. All the 30 COVID-19-positive HCP have since recovered. This HCP-centric policy resulted in low transmission rates (<1%), ensured satisfaction with training (92%), PPE (90.8%), medical and psychosocial support (79%) and improved acceptance of COVID-19 duty with 54.7% volunteering for re-deployment.

CONCLUSION

A multidimensional HCP-centric policy was effective in ensuring safety, satisfaction and welfare of HCP in a resource-poor setting and resulted in a willing workforce to fight the pandemic.

High-dose salvage re-irradiation for recurrent/progressive adult diffuse glioma: healing or hurting?

PURPOSE

To report survival outcomes and identify prognostic factors of salvage re-irradiation (re-RT) in recurrent/progressive glioma.

METHODS

Medical records of patients treated with high-dose re-RT as part of multi-modality salvage therapy for recurrence/progression of adult diffuse glioma from 2010 to 2019 were analyzed retrospectively.

RESULTS

A total of 111 patients developing recurrent/progressive high-grade glioma after adequate upfront treatment at initial diagnosis were included. The first course of radiotherapy (RT) had been delivered to a median dose of 59.4 Gy with an inter-quartile range (IQR) of 54-60 Gy. Median time to recurrence/progression was 4.3 years (IQR = 2.3-7.4 years) while the median time to re-RT was 4.8 years (IQR = 3.6-7.9 years). Re-RT was delivered with intensity-modulated radiation therapy (IMRT) using 1.8 Gy/fraction to a median dose of 54 Gy (IQR = 50.4-55.8 Gy) for a cumulative median equivalent dose in 2-Gy fractions (EQD2) of 104.3 Gy (IQR = 102.6-109.4 Gy). At a median follow-up of 14 months after re-RT, the 1-year Kaplan-Meier estimates of post-re-RT progression-free survival (PFS) and overall survival (OS) were 42.8 and 61.8%, respectively. Univariate analysis identified histological grade at recurrence/progression; histological subtype; disease-free interval (DFI) and time interval between both courses of RT; performance status at re-RT; dose at re-RT and cumulative EQD2; isocitrate dehydrogenase (IDH) mutation; and O⁶-methyl-guanine DNA methyl transferase (MGMT) gene promoter methylation as significant prognostic factors. Preserved performance status, longer DFI, prolonged time interval between both courses of RT, and presence of IDH mutation were associated with significantly improved PFS on multi-variate analysis. However, only performance status retained independent prognostic significance for OS on multi-variate analysis. Post-treatment changes were seen in 33 (30%) patients on follow-up imaging, with higher cumulative dose (EQD2 ≥ 104.3 Gy) being associated with increased risk of post-re-RT pseudo-progression.

CONCLUSION

This clinical audit reports encouraging survival outcomes and identifies key prognostic factors associated with high-dose salvage re-RT in recurrent/progressive glioma.

Surgical anatomy of basal turn in relation to middle cranial fossa and round window as pertaining to middle fossa cochlear implant technique

PURPOSE

The purpose of this investigation was to evaluate the relation of the basal turn of cochlea with middle cranial fossa and round window as pertaining to middle cranial fossa cochlear implant technique.

METHODS

Fifty-four formalin preserved temporal bones were micro-dissected to expose the basal turn. The point (f) was marked on the basal turn of cochlea where there was minimum distance of basal turn of cochlea from the floor of middle cranial fossa (f¹). The f-f¹ distance, the angle (∠smf) and distance of point "f" from the round window (s-f) was measured.

RESULTS

The mean minimum distance between basal turn of cochlea and floor of middle cranial fossa (f-f¹) was 2.0 ± 0.7 mm.The point f was at mean distance (s-f) and angle (∠smf) of 14.7 ± 1.6 mm and 217° ± 13.7° from round window, respectively.

CONCLUSIONS

The information may be helpful for designing appropriate electrode array for middle fossa technique especially for deciding the length of electrode array towards round window, as otherwise electrode may extend into vestibule of inner ear. In the cases where bone thickness between superior part of basal turn of cochlea and middle cranial fossa is < 1.5 mm, surgeon should be extra cautious.

Diffuse Idiopathic Skeletal Hyperostosis: An Anatomical Case Report

Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a noninflammatory disease of unknown cause characterised by osteophytic calcification or ossification of ligaments and enthesis; especially spinal. Authors hereby present a case report of a 65-year-old male cadaver, in whom the fusion of contiguous nine vertebrae from fifth thoracic to first lumbar vertebrae, because of ossification of the Anterior Longitudinal Ligament (ALL) was noticed. The tenth and eleventh thoracic vertebrae seemed to be affected worse, as maximum osseous anterior outgrowth (12 mm) of ossified ALL, ossification of Ligamentum Flavum (LF) and supraspinous ligament was also observed at this level. The Ossification of Anterior Longitudinal Ligament (OALL) along with the involvement of LF has not been classically reported. Ossification of spinal ligaments may cause local thoracic pain, stiffness and slowly progressive myelopathy. Ossified LF at the level of joint between tenth and eleventh thoracic vertebrae may result in compression of spinal cord at this level.

Mucosal-associated invariant T (MAIT) cells are activated in the gastrointestinal tissue of patients with combination ipilimumab and nivolumab therapy-related colitis in a pathology distinct from ulcerative colitis

The aim of this study was to investigate the pathogenesis of combination ipilimumab and nivolumab-associated colitis (IN-COL) by measuring gut-derived and peripheral blood mononuclear cell (GMNC; PBMC) profiles. We studied GMNC and PBMC from patients with IN-COL, IN-treated with no adverse-events (IN-NAE), ulcerative colitis (UC) and healthy volunteers using flow cytometry. In the gastrointestinal-derived cells we found high levels of activated CD8⁺ T cells and mucosal-associated invariant T (MAIT) cells in IN-COL, changes that were not evident in IN-NAE or UC. UC, but not IN-C, was associated with a high proportion of regulatory T cells (T_reg ). We sought to determine if local tissue responses could be measured in peripheral blood. Peripherally, checkpoint inhibition instigated a rise in activated memory CD4⁺ and CD8⁺ T cells, regardless of colitis. Low circulating MAIT cells at baseline was associated with IN-COL patients compared with IN-NAE in one of two cohorts. UC, but not IN-COL, was associated with high levels of circulating plasmablasts. In summary, the alterations in T cell subsets measured in IN-COL-affected tissue, characterized by high levels of activated CD8⁺ T cells and MAIT cells and a low proportion of T_reg , reflected a pathology distinct from UC. These tissue changes differed from the periphery, where T cell activation was a widespread on-treatment effect, and circulating MAIT cell count was low but not reliably predictive of colitis.

The role of contaminations in ion beam spectroscopy with freestanding 2D materials: A study on thermal treatment

As surface-only materials, freestanding 2D materials are known to have a high level of contamination-mostly in the form of hydrocarbons, water, and residuals from production and exfoliation. For well-designed experiments, it is of particular importance to develop effective cleaning procedures, especially since standard surface science techniques are typically not applicable. We perform ion spectroscopy with highly charged ions transmitted through freestanding atomically thin materials and present two techniques to achieve clean samples, both based on thermal treatment. Ion charge exchange and energy loss are used to analyze the degree of sample contamination. We find that even after cleaning, heavily contaminated spots remain on single layer graphene. The contamination coverage, however, clusters in strand-like structures leaving large clean areas. We present a way to discriminate clean from contaminated areas with our ion beam spectroscopy if the heterogeneity of the surface is increased sufficiently enough. We expect a similar discrimination to be necessary in most other experimental techniques.

Anatomy of scalenovertebral triangle: A vade mecum for clinicians

OBJECTIVE OF THE STUDY

The thorough anatomical knowledge of scalenovertebral triangle or Triangle of the vertebral artery and its contents is crucial in various neurosurgical procedures such as scalenotomy, stellate ganglion block, direct isolation of proximal vertebral artery and proximal brachial plexus repair.

MATERIAL AND METHOD

Thirty scalenovertebral triangles of known age and sex were dissected. The morphometry of the triangle and stellate ganglion was done. Various relevant distances were measured for topographical location of neurovascular structures especially stellate ganglion and vertebral artery within the triangle.

RESULTS

The mean height and width of the scalenovertebral triangle was 21.7+5.1mm and 19.4+4.4mm respectively. Vertebral artery originated from subclavian artery within the triangle except in one case (left side) where it originated from aortic arch. The mean minimum distance of stellate ganglion from phrenic nerve, scalenus anterior and vertebral origin was 12.6+4.5mm, 12.26+4mm and 2.3+1.3mm respectively.

CONCLUSIONS

The origin and proximal part of vertebral artery may not be present within the scalenovertebral triangle, thus topographic anatomy of the stellate ganglion is also affected and may cause complications during stellate ganglion block. Stellate ganglion is never located in the lateral or upper third of triangle. Occasionally, the phrenic nerve may cross the triangle, making it unsafe during stellate ganglion block.