Anomalous constitution of the brachioradialis muscle: a potential site of radial nerve entrapment

The anatomical relationships of structures in the elbow region in the context of surgical approaches require to be studied carefully and diligently. The main aim of the present study is to report an accessory muscle in the elbow region which was detected during routine anatomical dissection and discuss its clinical importance. The muscle belly measured 4.8 x 2.1cm and it fused with the brachioradialis distally. Proximally, it was seen to blend with the deltoid and the brachialis muscles. The radial nerve was observed to interpose between this accessory muscle and the brachioradialis. This could act as a potential site of compression neuropathy. The present study seeks to elucidate the morphology and potential function of an additional muscle belly in relation to the brachioradialis muscle. A comprehensive knowledge of the anatomical characteristics of brachialis, brachioradialis and radial nerve should prove extremely helpful for the hand surgeons to considerably reduce the risk of injury during operative maneuvers.

Bitendinous insertion of abductor pollicis longus coexistent with a rare accessory antebrachial muscle: clinico-anatomical considerations

Reports of the anomalous orientation of the musculature of the fi rst osseofi brous extensor compartment of the wrist are not uncommon; especially that of Abductor Pollicis Longus (APL) muscle. Such variations can be explained phylogenetically; owing to a synonymous occurrence in primates. In this report, we highlight a unique variation in the APL muscle of the left side in an adult male cadaver. The present anomaly consisted of a bitendinous insertion of APL on the base of the fi rst metacarpal, complemented by an additional muscle belly arising from the fascia covering Extensor Carpi Radialis Longus (ECRL). Such an accessory muscle is speculated to greatly alter kinematics at the wrist and thumb, thus affecting the daily activities of the hand. Such multiple tendons of APL are benefi cial clinically in providing additive support to the fi rst carpo-metacarpal joint and act as effective aids in tendon transfers and reconstructive procedures of the hand. In contrast, they can pose as surgical hazards in post-operative cases of De Quervain's disease. Thus, it is imperative for surgeons and clinicians to acquire a prior substantial knowledge of such anatomical variants of APL before attempting any treatment of this region.

Growth in children with cystic fibrosis-related diabetes

Cystic fibrosis-related diabetes (CFRD) is associated with a shortened life expectancy and greater deterioration in lung function than in CF patients with normal glucose metabolism. There are few published data on how CFRD affects growth in childhood. We carried out a retrospective case controlled study of growth and lung function in 34 children with CFRD attending three specialist centers in London. We found that for the 2 years leading to CFRD diagnosis (at a mean age of 13.1 years), the mean height velocity was significantly less compared to controls: 4.9 (standard deviation-SD 1.6) cm/year vs. 6.0 (SD 1.9) cm/year (P = 0.005). For the 2 years following diagnosis, height velocity remained significantly lower (3.4 (SD 2.2) cm/year vs. 4.4 (SD 2.2) cm/year, P = 0.02). Mean FEV(1) was reduced prior to diagnosis and at diagnosis, but was similar to controls 2 years after diagnosis. This study highlights the compromise in height velocity and lung function that occurs prior to diagnosis of CFRD in children with CF, and a reduction in height velocity should be considered an indicator of impaired glucose metabolism. It would be useful to know whether early treatment with insulin can help promote catch up growth.

A new variant in the brachium musculature with reinforced innervation from a median-musculocutaneous nerve communication

Neural variations of the brachium constitute an important anatomical and clinical entity. Although frequently reported, if accompanied by other anomalies, they deserve special mention in anatomical literature. The goal of this present study is to report a communication between the median (MN) and musculocutaneous nerve (MCN), concomitant with an accessory muscle belly. Interestingly, an important proximal connection between the lateral and medial roots of the MN was also observed. The MCN joined the MN at mid humeral level. The peculiarity of the current report arises due to the presence of a twig passing from the site of communication between the two nerves, to supply the coracobrachialis. Concomitantly, an accessory muscle measuring 5cm in length originating from the short head of biceps brachii, fusing with the coracobrachialis was seen in the mid brachium. The observations of the current study may cause a perplexing situation for anesthetists attempting brachial plexus blocks and for surgeons who operate on this vital anatomical arena.

Abnormal spicules on the inferior aspect of anterior arch of atlas vertebra

Anterior arch of the atlas vertebra is known to exhibit various developmental anomalies. Bony outgrowths, osteophytes, clefts and aplasia of the anterior and posterior arches of the atlas have received special attention by research workers. To the best of our knowledge, not many osteological studies have defined the spicules on the anterior arch of the atlas. The present study describes an abnormal atlas vertebra with 2 spicules on the inferior aspect, 2 additional facets inferior to the superior articular facets and a peculiar facet to the left of the posterior tubercle. These abnormal spicules may cause dysphagia or involve atlanto-occipital movements. Such anomalies may be misinterpreted in routine X rays as a degenerative disease. However, asymptomatic cases remain undetected throughout life. Such anomalies may be important in radiological, clinical, forensic and anthropological studies.

A triplicate obturator foramen

The obturator foramen is a large opening in the hip bone situated below and anterior to the acetabulum. The obturator foramen is enclosed by the obturator membrane, apart from the part above near the obturator groove, where the obturator vessels and nerve pass through. The present study reports multiple openings in the obturator foramen detected incidentally in a left hip bone specimen and discusses its clinical implications. To the best of our knowledge, the occurrence of multiple openings associated with the obturator foramen is rare and has not been reported in any standard textbook of anatomy or in any research study. Anatomical knowledge of the presence of such anomalies may be clinically important for radiologists interpreting skiagrams and surgeons performing operative procedures in the hip region.

An asymmetrical inferior articular process of a lumbar vertebra

The present case report describes the topographical anatomy and radiological study of an asymmetrical inferior articular process of a lumbar vertebra, which was detected during routine osteology teaching of undergraduate medical students. The inferior articular process of the lumbar vertebra on the left side was rudimentary, while that on the right was normal in size. On the left side an additional bony projection was noted anterior to the rudimentary inferior articular process. The difference in height between the inferior articular processes of the two sides may play an important role in the kinematics of the particular joint. The orientation of the facets of the articular processes of the vertebrae are important for axial weight transmission and anomalies involving these can possibly alter the orientation of movements in that particular segment. An asymmetrical inferior articular process may be related to disc prolapse and may be a cause of back pain. In view of the paucity of research reports of anatomicoradiological study of the inferior articular process of a lumbar vertebra in relation to other parts of the vertebra, we, as anatomists, believe that knowledge of anomalies of the inferior articular process may be relevant for academic, anthropological and clinical purposes.

The impact of depression and fluoxetine treatment on obstetrical outcome

INTRODUCTION

This study prospectively followed women over the course of pregnancy to assess the impact of depression and/or antidepressant treatment on obstetrical outcome.

METHOD

Sixty-four outpatient women with an Axis I diagnosis of major depressive disorder or no psychiatric history were followed in each trimester of pregnancy with administration of the CES-D. A subset of the women with depression received treatment with fluoxetine during pregnancy. Subjects with a CES-D score greater than 16 at any time point were further assessed for the presence of an active major or minor depressive episode. Primary outcome variables included infant gestational age, birth weight, Apgar score, and admission to the neonatal intensive care unit.

RESULTS

Analyzable data were available for 62 women. No significant differences were found in outcome variables between those women with exposure to medication and/or prenatal depressed mood and those women without a history of depression.

CONCLUSIONS

In contrast to other studies, our study did not demonstrate an adverse effect of fluoxetine exposure per se on obstetrical outcome. In addition, we did not find a significant impact of depression during pregnancy on obstetrical outcome.

Effects of hypertonic saline, alternate day and daily rhDNase on healthcare use, costs and outcomes in children with cystic fibrosis

BACKGROUND

Daily recombinant human deoxyribonuclease (rhDNase) is an established but expensive treatment in cystic fibrosis (CF). An alternative lower cost therapy is hypertonic saline (HS), which has been shown to improve lung function in short term studies. This study compares the costs and consequences of daily rhDNase with alternate day rhDNase and HS in children with CF.

METHODS

In an open, randomised, crossover trial, 48 children with CF were allocated consecutively to 12 weeks of once daily 2.5 mg rhDNase, alternate day 2.5 mg rhDNase, and twice daily 5 ml 7% HS. Outcomes assessed included forced expiratory volume in 1 second (FEV(1)) and quality of life. All healthcare resource use was prospectively recorded for each patient. Unit costs were collected and combined with resource use data to give the total health service costs per patient for each treatment strategy.

RESULTS

Daily rhDNase resulted in a significantly greater increase in mean FEV(1) than HS (8%, 95% CI 2 to 14) but there was no significant difference in FEV(1) between daily and alternate day rhDNase (2%, 95% CI -4 to 9). Over a 12 week period the mean incremental costs of daily rhDNase compared with HS was pound 1409 (95% CI pound 440 to pound 2318), and the incremental cost of using daily rather than alternate day rhDNase was pound 513 (95% CI - pound 546 to pound 1510).

CONCLUSIONS

Daily rhDNase is more effective than 5 ml 7% HS twice daily delivered by jet nebuliser, but significantly increases healthcare costs. Administering rhDNase on an alternate day rather than a daily basis is as effective, with a potential for cost savings.

Fluoxetine and norfluoxetine concentrations in nursing infants and breast milk

BACKGROUND

This study's goal was to characterize nursing infants' exposure to fluoxetine through breast milk and to identify variables for minimizing such exposure.

METHODS

Nursing women on stable daily doses of fluoxetine were recruited into the study. Breast milk, maternal and infant serum concentrations of fluoxetine and norfluoxetine were determined with high-performance liquid chromatography.

RESULTS

Nineteen nursing women one with a pair of dizygotic twins participated in the study. The women were on stable daily doses of fluoxetine (10-60 mg/day) and all but two took the medication during the last trimester of pregnancy. Fluoxetine was detectable in 30% (n = 6) of the nursing infant sera (< 1-84 ng/mL), whereas norfluoxetine was found in 85% (N = 17) (< 1-265 ng/mL). Peak breast milk concentrations occurred approximately 8 hours after maternal dosing and predicted norfluoxetine concentrations in infant serum. Maternal serum fluoxetine and norfluoxetine concentrations correlated highly with infant norfluoxetine concentrations. A daily maternal fluoxetine dosage of 20 mg or lower was significantly less likely to produce detectable concentrations of either fluoxetine or norfluoxetine in infants compared to higher daily dosages. No adverse effects were reported in any infant.

CONCLUSIONS

Our findings demonstrate that maternal serum and peak breast milk concentrations of fluoxetine and norfluoxetine predict nursing infant serum norfluoxetine concentrations. In nursing women taking 20 mg/day or less of fluoxetine, infant serum concentrations were typically low.

Comparison of hypertonic saline and alternate-day or daily recombinant human deoxyribonuclease in children with cystic fibrosis: a randomised trial

BACKGROUND

Daily recombinant human deoxyribonuclease (rhDNase) is an established but expensive treatment in cystic fibrosis. Alternate-day treatment, if equally effective, would reduce the drug cost. Hypertonic saline improved lung function to the same degree as rhDNase in short-term studies. We compared the effectiveness of daily rhDNase, hypertonic saline, and alternate-day rhDNase in children with cystic fibrosis.

METHODS

In an open cross-over trial, 48 children were allocated in random order to 12 weeks of once-daily rhDNase (2.5 mg), alternate-day rhDNase (2.5 mg), and twice-daily 5 mL 7% hypertonic saline. The primary outcome was forced expiratory volume in 1 s (FEV(1)). Secondary outcomes were forced vital capacity, number of pulmonary exacerbations, weight gain, quality of life, exercise tolerance, and the total costs of hospital and community care.

FINDINGS

Mean FEV(1) increased by 16% (SD 25%), 14% (22%), and 3% (21%) with daily rhDNase, alternate-day rhDNase, and hypertonic saline, respectively. There was no difference between daily and alternate-day rhDNase (2% [95% CI -4 to 9], p=0.55). However, daily rhDNase showed a significantly greater increase in FEV(1) than hypertonic saline (8% [2 to 14], p=0.01). The average difference in 12-week cost between daily and alternate-day rhDNase was pound513 (95% CI -546 to 1510) and that between daily rhDNase and hypertonic saline was pound1409 (440 to 2318). None of the secondary clinical outcomes showed significant differences between treatments.

INTERPRETATION

Hypertonic saline, delivered by jet nebuliser, is not as effective as daily rhDNase, although there is variation in individual response. There is no evidence of a difference between daily and alternate-day rhDNase.

The use of psychotropic medications during breast-feeding

OBJECTIVE

The authors reviewed the risks and benefits regarding the use of psychiatric medications during breast-feeding as they relate to the health and well-being of mothers and their infants. Strategies are discussed to limit infant exposure to a medication while effectively treating the nursing mother.

METHOD

A MEDLINE search of the literature since 1955 was conducted to determine the use of psychotropic medications in breast-feeding women. Search items included each of the categories of psychopharmacologic agents as well as each of the agents in association with nursing, breast-feeding, postpartum, lactation, and breast milk.

RESULTS

No controlled studies on the safety of psychotropic medications in nursing mothers were found. Case reports and small case series for each of the different psychotropic medications serve as the basis for suggested treatment guidelines for the management of psychiatric illnesses in breast-feeding women. Thus, each case needs to be considered on an individual basis, with a thoughtful analysis of the risks and benefits of nursing and exposure of the infant to medication. The baseline clinical status of the infant should also be reviewed.

CONCLUSIONS

Women are vulnerable postpartum to psychiatric disorders and frequently face the need to decide whether to take psychotropic medications while breast-feeding. Should psychiatric medication be indicated, the parents should be provided with the available information regarding the effects of these medications on the neonate. In this way, an informed decision can be made. When psychotropic medication is used during breast-feeding, it is strongly recommended that the infant's pediatrician be involved in monitoring the infant.