Aggregation-Enhanced Photoluminescence and Photoacoustics of Atomically Precise Gold Nanoclusters in Lipid Nanodiscs (NANO2)

The authors designed a structurally stable nano-in-nano (NANO2) system highly capable of bioimaging via an aggregation-enhanced NIR excited emission and photoacoustic response achieved based on atomically precise gold nanoclusters protected by linear thiolated ligands [Au25(SC n H2n+1)18, n = 4-16] encapsulated in discoidal phospholipid bicelles through a one-pot synthesis. The detailed morphological characterization of NANO2 is conducted using cryogenic transmission electron microscopy, small/wide angle X-ray scattering with the support of molecular dynamics simulations, providing information on the location of Au nanoclusters in NANO2. The photoluminescence observed for NANO2 is 20-60 times more intense than that of the free Au nanoclusters, with both excitation and emission wavelengths in the near-infrared range, and the photoacoustic signal is more than tripled. The authors attribute this newly discovered aggregation-enhanced photoluminescence and photoacoustic signals to the restriction of intramolecular motion of the clusters' ligands. With the advantages of biocompatibility and high cellular uptake, NANO2 is potentially applicable for both in vitro and in vivo imaging, as the authors demonstrate with NIR excited emission from in vitro A549 human lung and the KB human cervical cancer cells.

Applying the QUARTZ Trial Results in Clinical Practice: Development of a Prognostic Model Predicting Poor Outcomes for Non-small Cell Lung Cancers with Brain Metastases

AIMS

The role of whole brain radiotherapy (WBRT) in patients with brain metastases from non-small cell lung cancers (NSCLC) has been questioned. However, no reliable criteria exist to identify patients who do not benefit from WBRT. The objective of the current study was to develop a prognostic model to identify such patients whose survival matches that of the Quality of Life after Treatment for Brain Metastases (QUARTZ) study.

MATERIALS AND METHODS

Outcome data of patients with NSCLC with brain metastases undergoing WBRT enrolled in a prospective observational study in a tertiary cancer centre were used to develop a prognostic model. Baseline clinico-radiological factors were used for development of the model. The model was internally validated and calibration accuracy was checked for prediction of 70 day mortality. The generated prognostic model was presented as a nomogram.

RESULTS

The median overall survival of 140 patients enrolled in the study was 166 days (95% confidence interval 108-242 days). The prognostic model identified gender, Karnofsky performance status and epidermal growth factor receptor activating mutation status as significant factors influencing overall survival. The model showed a modest discriminative ability with an optimism-corrected C-index of 0.64. However, model calibration error did reveal a moderate degree of calibration error. The high-risk subgroup identified by the model had a median overall survival of 67 days (95% confidence interval 56-101 days), which was similar to that observed in the QUARTZ trial.

CONCLUSION

This prognostic model derived from traditional clinico-radiological features had a modest ability to identify patients with poor prognosis who may not benefit from WBRT. However, the high-risk subgroup identified using this prognostic model had a survival similar to that observed for patients in the QUARTZ trial.

Pronator teres accessorius: A new variant in flexor antebrachial musculature

Muscles of flexor compartment of forearm have a common origin from medial epicondyle of humerus. Additional bellies of flexor muscles are commonly reported but presence of supernumerary muscles is an infrequent phenomenon. The present study describes an unusual muscle mass in flexor compartment of forearm simulating pronator teres. During routine dissection the upper limb of a 50 years old male cadaver, a supernumerary muscle was found on left side of the upper limb in the flexor compartment. The origin of the muscle was 2cm wide and aponeurotic in nature and attached to an oblique line extending from the inferior surface of the medial epicondyle and the medial surface of the trochlea. It was inserted on an oblique line 2.5cm wide on the radius in area between supinator superiorly and flexor digitorum profundus inferiorly. Existence of accessory muscles, which connect flexor muscles, could be explained embryologically by incomplete cleavage of flexor mass during development. The flexor muscles of the forearm develop from the flexor mass which subsequently divides into two layers: superficial and deep. The deep layer gives rise to flexor digitorum superficialis, flexor digitorum profundus and flexor pollicis longus. These supernumerary muscles are extremely rare entities and probably represent deranged embryological development or the process of atavism in which the anomalous part persist for a longer time in the tree of evolution.

Unusual branching pattern of brachial artery - Embryological basis and clinicoanatomical insight

Variations in the arterial pattern of upper limb are of colossal importance to the surgeons as they are liable to iatrogenic injuries. During routine dissection for undergraduate medical students, an anomaly of brachial artery was discovered. The brachial artery terminated at higher level into ulnar and radial artery. The common interosseus artery took origin arising from radial artery. The ulnar artery did not give any branches in the forearm. Both radial and ulnar artery displayed a superficial course in the forearm. The anatomical knowledge of these variations may be of great help for the clinicians in planning and conducting flap harvesting during reconstructive surgeries and in arteriography.

Adductor accessorius - an unusual supernumerary adductor muscle of thigh

The knowledge of variant anatomy of medial compartment of thigh is extremely important in surgical procedures requiring obturator nerve block. The nerve block is also recommended for providing additional analgesia following major knee surgeries and for relieving painful adductor muscle spasm. The interfascial injection technique is commonly followed in ultrasound guided obturator nerve block. For this procedure it is imperative to identify the adductor muscles on sonography to inject the anesthetic solution in the intermuscular fascial planes. The presence of an additional muscle can prove useful in myocutaneous flap surgeries for reconstruction especially of perineum. We hereby report a case of such an anomalous supernumerary adductor muscle present between adductor brevis and proximal part of adductor magnus, in an adult Indian male cadaver, recorded during routine dissection in Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital. The muscle was innervated by the posterior division of obturator nerve. The morphology, embryological basis and clinical aspects are also discussed.

Early detection of multi-drug resistance and common mutations in Mycobacterium tuberculosis isolates from Delhi using GenoType MTBDRplus assay

PURPOSE

There is scarcity of prevalence data of multi-drug-resistant tuberculosis (MDR-TB) data and common mutations responsible in North India. This study aimed to detect MDR-TB among MDR-TB suspects from Delhi and mutation patterns using GenoType MTBDRplus assay.

MATERIALS AND METHODS

All MDR suspects in five districts of New Delhi were referred to the laboratory from 1 st October 2011 to 31 st December 2012 as per criterion defined by Programmatic Management of Drug Resistant Tuberculosis (PMDT). GenoType MTBDRplus assay was performed on 2182 samples or cultures and mutations in the rpoB gene for rifampicin (RIF) and katG and inhA genes for isoniazid (INH) were analyzed.

RESULTS

A total of 366 (16.8%) MDR-TB cases were diagnosed. MDR rate was found to be 32%, 16.6% and 10.2% during criterion A, B and C respectively. The most common mutation detected for RIF was S531L (59.0%) and for INH was S315T1 (88.3%). Mutations S531L and S315T1 occurred significantly higher in MDR strains as compared to RIF mono-resistant and INH mono-resistant strains, respectively. Average laboratory turn-around time (TAT) for dispatch of result to districts for test conducted on samples was 4.4 days.

CONCLUSION

GenoType MTBDRplus is a useful assay for rapid detection of MDR-TB. The common mutations for RIF and INH were similar to those seen in other regions. However, mutations determining MDR strains and mono-resistant strains differed significantly for both RIF and INH.

Rare atypical vascular pattern of subscapular artery: Anatomico-clinical insight

BACKGROUND AND OBJECTIVE

The use of muscles of scapular region in transposition and reparative surgery has made the anatomical knowledge of axillary artery and its branches imperative. The subscapular arterial tree is frequently used as a source of microvascular grafts to replace damaged or diseased portion of arteries especially in upper and lower limbs. This investigation is aimed to study the variation in branching pattern of the third part of axillary artery.

MATERIALS AND METHODS

Routine educational cadaveric dissection of a young adult Indian male cadaver.

RESULTS

The present article highlights a rare variation of the subscapular artery and its branches. The subscapular artery displayed a unique pattern of trifurcation. Its branches were seen supplying serratus anterior, subscapularis, latissimus dorsi and teres major muscles.

CONCLUSIONS

The study focuses on a new variation of the subscapular artery which could prove useful for interventional radiologists and surgeons in reconstructive surgeries.

Phylogenetic associations with drug-resistant Mycobacterium tuberculosis isolates in a paediatric population

SETTING

Department of Microbiology, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India.

OBJECTIVES

As paediatric tuberculosis (TB) is a surrogate marker for actively transmitted disease in a community, we investigated drug resistance patterns of 97 Mycobacterium tuberculosis complex strains isolated from children and explored their phylogenetic associations.

DESIGN

A total of 111 paediatric patients who attended the out-patient department during the study period 2009-2011 and whose sputum samples were sent to the Microbiology Department for liquid culture and drug susceptibility testing (DST) were included in this study. DST and spoligotyping were performed on cultures positive for M. tuberculosis complex.

RESULTS

DST against four first-line drugs showed that 31 of 97 (32%) strains were pan-susceptible, while 66/97 (68%) were resistant to at least one drug, including 55/97 (56.7%) that were resistant to at least isoniazid and rifampicin (i.e., multidrug-resistant). The majority of the isolates (n = 81/90, 90%) belonged to the principal genetic group 1 strains, the most predominant spoligotyping clusters being spoligotyping international type (SIT)1/Beijing (n = 28), SIT26/CAS1-Delhi (n = 27) and SIT53/T1 (n = 6).

CONCLUSION

The involvement of Beijing and CAS1-Delhi clades in paediatric TB patients suggests that these two lineages play a major role in ongoing active transmission.

Comparison of sorafenib-loaded poly (lactic/glycolic) acid and DPPC liposome nanoparticles in the in vitro treatment of renal cell carcinoma

The objective of this study is to develop and compare several Sorafenib-loaded biocompatible nanoparticle models in order to optimize drug delivery and tumor cellular kill thereby improving the quality of Sorafenib-regimented chemotherapy. Sorafenib-loaded poly (lactic-co-glycolic) acid (PLGA), 1,2-dipalmitoyl-sn-glycero-3-phosphocholine (DPPC) liposomes, and hydrophobically modified chitosan (HMC)-coated DPPC liposomes were evaluated for several characteristics including zeta potential, drug loading, and release profile. Cytotoxicity and uptake trials were also studied using cell line RCC 786-0, a human metastatic clear cell histology renal cell carcinoma cell line. Sorafenib-loaded PLGA particles and HMC-coated DPPC liposomes exhibited significantly improved cell kill compared to Sorafenib alone at lower concentrations, namely 10-15 and 5-15 μM from 24 to 96 h, respectively. At maximum dosage and time (15 μM and 96 h), Sorafenib-loaded PLGA and HMC-coated liposomes killed 88.3 ± 1.8% and 98 ± 1.1% of all tumor cells, significant values compared with Sorafenib 81.8 ± 1.7% (p < 0.01). Likewise, HMC coating substantially improved cell kill for liposome model for all concentrations (5-15 μM) and at time points (24-96 h) (p < 0.01). PLGA and HMC-coated liposomes are promising platforms for drug delivery of Sorafenib. Because of different particle characteristics of PLGA and liposomes, each model can be further developed for unique clinical modalities.

Combined spinal-epidural for labor analgesia with low-dose bupi- vacaine but without any opioid in the spinal component: can we improve upon the traditional?

AIM

To compare the efficacy and safety of combined spinal-epidural (CSE, with the spinal component using low-dose heavy bupivacaine without opioid) with low-dose epidural analgesia in labor.

METHODS

Sixty consenting adult parturients requesting epidural were randomly allocated to two equal groups to receive either low-dose epidural or CSE analgesia. The Epidural Group received 10ml of a mixture of 0.1% bupivacaine and 2 µg/ml fentanyl, followed by a 6 ml first bolus after 10 min if needed (not considered as a top-up). All patients received 8 ml/h continuous background infusion, with patient-controlled top-up bolus of 6 ml with a lock-out interval of 12 min. In the CSE Group, 0.5% (heavy) bupivacaine 2.5 mg was used to produce spinal block (without concomitant use of any opioid), followed by epidural continuous background infusion of 8 ml of 0.1% of bupivacaine and 2 µg/ml of fentanyl, with a similar top-up provision as in the Epidural Group. Primary outcome was total drug consumption during labor, corrected by the duration of labor (ml/h).

RESULTS

Mean total drug consumption during labor was significantly less in the CSE group (9.69 ml/h) than in Epidural group (13.52 ml/h ; P < 0.00 1). CSE also led to significantly faster onset of analgesia and sensory block. There was no significant difference between the two groups with regard to all other variables. Maternal satisfaction was rated as 'excellent' by all subjects.

CONCLUSIONS

CSE using low-dose heavy bupivacaine without opioid required less drug consumption produced faster onset of pain control and sensory block than low-dose epidural analgesia. There were no other significant inter-group differences.

Liposomes tethered to a biopolymer film through the hydrophobic effect create a highly effective lubricating surface

Liposomal coatings are formed on films of a biopolymer, hydrophobically modified chitosan (hm-chitosan), containing dodecyl groups as hydrophobes along the polymer backbone. The alkyl groups insert themselves into the liposome bilayer through hydrophobic interactions and thus tether liposomes, leading to a densely packed liposome layer on the film surface. Such liposomal surfaces exhibit effective lubrication properties due to their high degree of hydration, and reduce the coefficient of friction to the biologically-relevant range. The compliancy and robustness of these tethered liposomes allow retention on the film surface upon repeated applications of shear. Such liposome coated films have potential applications in biolubrication.

Takotsubo Cardiomyopathy: Typical and Atypical Variants, A Two-Year Retrospective Cohort Study

Background

Typical or classical takotsubo cardiomyopathy (TCM) is associated with the characteristic abnormality of a ballooned left ventricular apex with basal segmental hyperkinesis. TCM may not present with the “classical” wall motion abnormalities but can have a variety of segmental wall motion abnormalities. The aim of our work was to assess for any unique identifying factors that can help distinguish typical and atypical variants of TCM.

Methods

We studied 11 consecutive patients between 2010 and 2012 admitted with chest pain, electrocardiographic and cardiac biomarker changes consistent with acute coronary syndrome (ACS) who underwent left heart angiography and were clinically diagnosed to have TCM.

Results

Our study found no specific features distinguishing typical and atypical variants of TCM. In our study, all patients were female and all had excellent outcome. One patient was in fourth decade of life, three patients in fifth and sixth decade of life, while remaining were older. One patient had diabetes mellitus, five had hypertension, four had concurrent coronary artery disease, but no patient had any family history of TCM. Nine of 11 patients had immediate clear-cut stressors. Three patients had normal ECG, two with ST segment elevation, with nine patients having only modest troponin elevations. One patient had an anomalous RCA take-off from the right coronary cusp, otherwise remaining patients had normal anatomy. One patient had only apical involvement, remaining had multiple wall motion abnormalities, and all patients had involvement of the anterior wall. Four patients had apical sparing. No inverted TCM pattern with basal akinesis with normal wall motion in the midventricular and apical regions was found among our patients.

Conclusions

We report that the classification of TCM as typical versus atypical is probably not clinically meaningful. The regional wall motion abnormalities are related to catecholamine excess and to the susceptibility of that particular region to excess catecholamine. We do not know why such differences in regional susceptibility exist, and agree with the other authors that sub-classification would only add to confusion, and a delay in understanding of the disease process.

A rare conglomeration of neurovascular variations in the brachium-antebrachium: clinico-embryological elucidation

During routine dissection in left upper limb in an elderly male cadaver, variations in the arterial and neural pattern were noticed. The undersized brachial artery divided terminally into radial and ulnar artery at a distance of 15.4 cm from the tip of coracoid process, proximal to its usual division in cubital fossa. Additionally, the superior and inferior ulnar collateral artery instead of arising from the brachial artery, emanated from ulnar artery. The course of the median nerve also deserves a brief mention as it crossed the brachial artery from medial to lateral side to position itself laterally in the midbrachium. Coursing further, it shifted from lateral to medial side over the ulnar artery in the distal third of arm, thus placing itself medial to ulnar artery in the cubital fossa. There was also a communication between a medial offshoot of the musculocutaneous nerve and the median nerve 3 cm from the bifurcation of the brachial artery. Although the variations in the origin, termination, course and branching pattern of upper limb vessels and nerves are well documented, but the multitude of disparity in morphology with confusing neurovascular assembly put together in the same limb denotes an outstanding case. An attempt has been made to correlate the present anatomical variations with embryological aspects. Moreover, the clinical inferences of such variations are discussed for planning, performing and analyzing invasive and noninvasive clinical procedures in this region.

Abstract 302: Echocardiographic Parameters in Perioperative Atrial Fibrillation in Cardiac and Non-Cardiac Surgery Patients

Background: We hypothesized that patients with new onset atrial fibrillation (AFib) following cardiac or non-cardiac surgery have similar echocardiographic features, regardless of the type of surgery.

Methods: Study cohort included 4562 consecutive patients without history of atrial fibrillation undergoing general, thoracic or cardiovascular surgeries at a single tertiary academic medical center. Retrospective chart and echocardiogram review was performed. Chi-square, logistic regression, and analysis of variance were performed. Long-term all cause mortality was determined through Social Security Death Index. The study was approved by the institutional IRB.

Results: Post-operative AFib was noted in 24% (275/1141) after cardiac surgery, 1.2 % (10/804) after thoracic non-cardiac surgery, and 0.7% (18/2617) after general non-cardiac non-thoracic surgery (p<0.0001).

On available echocardiograms, 18% (48/264) had LV dilatation and 38% (98/261) had moderate or severe LV dysfunction. The left atrium was dilated in 53% (139/260). Moderate or severe tricuspid regurgitation was noted in 11% (15/128), mitral regurgitation in 28% (45/16), mitral stenosis in 13% (11/82), aortic insufficiency in 27% (37/135), and aortic stenosis in 63% (19/135).

When adjusted for the presence of coronary artery disease, valvular disease, age, and gender, only aortic valve stenosis remained an important independent predictor of post-operative atrial fibrillation in non-cardiac surgery patients, HR=13.9 (95%CI 1.5-132.3, p<0.022).

Conclusion: Despite significantly increased prevalence of new onset AFib after cardiac surgery, pre-existing cardiovascular conditions, specifically aortic valve stenosis, confer an increased risk of post-operative atrial fibrillation rather than the procedure itself. Improved resource utilization can be expected if post-operative ECG monitoring is limited to the high risk patients, identifiable during peri-operative screening. Prospective studies of this important subject are needed.

Histidyl Residues Mediate Electron Transport in Plant Mitochondria

Plant The effect of chemical modification of histidyl residues using diethyl pyrocarbonate (DEP) on plant mitochondrial electron transport was studied. Mitochondrial membranes from potato tubers were isolated and electron flow from NADH to oxygen, NADH to ferricyanide and ascorbate to oxygen were monitored in pro», nee and/or absence of DEP. Measurements were made at various concentrations of DEP and at different pHs either by using an oxygen electrode or spectro-photometrically. The results show that DEP inhibits flow of electrons from NADH to oxygen, however partial electron transport from NADH to ferricyanide and ascorbate to oxygen was unaffected. Maximum inhibition was observed at pH 6.5. The time course of the DEP action revealed a biphasic nature of inhibition. Effects on the levels of reduction of cytochromes b and c by DEP during electron transport indicated that histidyl residues may be present before or at cytochrome b , which are being modified.

Abstract T P320: Echocardiographic and Clinical Parameters Associated with Adverse Long-Term Outcomes in Non-Hemorrhagic Stroke Patients: Prediction Model Development and Validation

Background: and hypothesis: We sought to develop and validate the long-term non-hemorrhagic stroke outcome prediction model based on demographic, clinical, and echocardiographic parameters.

Material and Methods: Univariate and multivariate logistic regression modeling of long-term survival based on demographic, clinical, and echocardiographic data was performed in 325 consecutive non-hemorrhagic stroke subjects (original cohort). ANOVA, chi-square, Kaplan-Meier, and logistic regression tests were employed. Prediction rules were developed and applied to 1305 patients (validation cohort). The study was approved by the institutional IRB.

Results: Only age (hazard ratio 1.6 per decade over 40 years old, 95%CI 1.3-2.2, p<0.001), renal failure (hazard ratio 6.2 95%CI 24.3, p<0.001), and aortic root sclerosis (hazard ratio 2.9 95%CI 1.4-5, p=0.004) were associated with increased all-cause mortality in univariate and multivariate logistic regression analyses. Based on the hazard ratios, risk score was developed with 2 points given for each decade of age over 40 years old, 6 for renal failure, and 3 for aortic root sclerosis. Long-term mortality was compared between 3 groups: low risk (0-5 points), moderate risk (6-10 points), and high risk (more than 11 points).

In the original cohort, Kaplan-Meier mean survival estimates were 60+/-1.4 months in low risk, 45+/-2.2 in moderate risk, and 37.4+/-3.3 months high-risk groups (p<0.001). In the validation cohort, Kaplan-Meier mean survival estimates were 53+/-0.8 months in low risk, 47+/-1.3 in moderate risk, and 33+/-2.1 months high-risk groups (p <0.001). When renal function was removed from the analysis, age and aortic root sclerosis still successfully identified patients with poor long term outcomes: 53+/-0.8 months in low risk, 47+/-1.3 in moderate risk, and 34+/-2.4 months high-risk groups (p <0.001).

Conclusions: In non-hemorrhagic stroke survivors, long-term prognosis can be predicted with prospectively validated model based on age, presence of aortic root sclerosis, and renal dysfunction. Using such simple, readily available model may help the clinician to identify this high-risk patient group with adverse outcomes, enabling appropriate management and resource utilization.

Unusual variation of plantaris muscle-clinical and surgical notes

Plantar muscle is one of the most dis-regarded muscles of the body. However, its injury may be considered in differential diagnosis of painful calf. Variations pertaining to plantaris muscle are rare and therefore infrequently reported in anatomical literature. The present case report endeavors to describe a rare variation of the plantaris muscle. A routine dissection experiment revealed an accessory belly associated with plantaris and a fibrous strand extending from medial belly to the oblique popliteal ligament. Since plantaris is known to be associated with lateral head of gastrocnemius, this accessory belly may be thought of as a supplement for its activity. A clinical insight into the topographical relationship between these accessory bellies and other posterior knee structures will aid diagnosis and alter course of treatment of knee disorders. Moreover, the presence of these muscle variants creates challenges for the radiologists while interpreting MRI/ CT scans. Familiarization with these anatomical anomalies may alert the knee surgeons intraoperatively so that these may be of use for reconstructive purposes.

Multifaceted profile of an unusual paramedian occipital condyle-anatomical and computerised tomographic evaluation

During extensive osteological study of 150 dry skulls in the Department of Anatomy, Vardhman Mahavir Medical college, an unusual Paramedian Occipital (POC) condyle was detected in the occipital bone of a cadaveric skull. The anatomical details of this unusual occipital condyle were carefully studied and its morphometric measurements taken. A coronal multiplanner reformatted image and a volume rendered image were taken to study radiological details and establish significant clinical correlation. Precise understanding of anatomy of craniovertebral junction and its anomalies have become immensely important for the present day surgeon during orthopaedic and neurosurgical procedures of this region . Technical advancements in imaging modalities such as CT and MRI scans further signify the importance of these anatomical variations ,which are often missed in routine examination. Osteological study combined with radiological details of the paramedian occipital condyle in the present case aims to emphasize the importance of bony anomalies in the craniovertebral region and their role in diagnosis and appropriate treatment of neurovascular compression syndromes of craniovertebral junction. The present study highlights anatomical details, clinical relevance and embryological basis of such a rare unusual paramedian occipital condyle.

An unusual array of extensor musculature and tendons of the hand clinico-anatomical insight

Extensor tendon injury is a frequent finding in clinical practice. During a routine dissection class of undergraduate medical students examining the extensor aspect of the right hand, they found an interesting pattern of extensor tendons. The extensor digitorum (ED) exhibited three tendons for the middle and ring fingers. The intermediate tendon of the ED was found to pass to the junctura connecting the tendons of the ring and middle fingers. Additionally the Extensor carpi ulnaris displayed two tendinus slips. The lateral slip was inserted on the base of fifth metacarpal as usual, whereas the medial slip divided into two strands- proximal and distal. Apart from the above findings in the current case specimen, there was an accessory muscle belly for the index finger and the extensor digiti minimi bifurcated into two tendinus slips which gained attachment to the dorsal digital expansion of the little finger. These accessory muscle bellies and tendons could possibly be utilized for tendon reconstructions such as repairs, tenoplasties or tendon transfers.

Unusual architecture of extensor digitorum muscle of hand in conjunction with accessory belly of extensor carpi radialis brevis: a clinico-anatomical insight

The present article highlights an unusual combination of variations of the extensor digitorum and extensor carpi radialis brevis muscles in the dorsum of forearm and hand. The extensor carpi radialis brevis exhibited an accessory musculotendinous belly which inserted into the dorsal digital expansion of index finger. The extensor digitorum showed trifurcation into three distinct parts. Resultant multiple extensor tendon insertion pattern is reported upon highlighting the embryological basis and clinical importance. Knowledge of such anatomical variations adds upon the already existing information in literature and is also of profound interest to the clinician. Anatomical awareness of accessory multiple extensor tendons in the dorsum of hand is essential for successful management of extensor tendon injuries and graft transfer operations.

Intrathoracic intrusion of left lobe of thyroid gland co-existent with absent isthmus: clinico-anatomical considerations

Morphological alterations of thyroid gland are common and result because of disturbed embryogenesis. These may vary from hypoplasia, ectopy to hemiagenesis and genesis of the gland. The authors strive to report an unusual morphological alteration of the left lobe of the thyroid gland. The current study presents a case of unusual extension of the thyroid gland discovered incidentally while dissecting the anterior cervical region of an adult Indian male cadaver. The left lobe displayed medial extension from its inferior angle which overlapped the common carotid artery (CCA). The isthmus was absent; instead a fibrous strand was interposed in between the two lobes with ramification into both the lobes. The relevance of diagnosing such extensions of thyroid gland is immense. It may alter the topographical relationship of thyroid gland with other adjacent cervical structures. Further, it may present abnormal signals upon scintillation scans and may be confused with a tumor mass on MRI scans. Lastly, the presence of lobar extension along with absence of isthmus is a gross morphological variant and in our opinion not to be overlooked by anatomists, ultrasonologists as well as thyroid surgeons. Additionally, the study presents possible embryological explanation for these gross anatomical variations.

Unusual innervation pattern of pectoralis minor muscle-anatomical description and clinical implications

The highlight of the current case study is unique branching pattern of the medial pectoral nerve in relation to the pectoralis minor muscle. In addition, the third thoracic spinal nerve also was observed to penetrate the muscle. The lateral pectoral nerve did not innervate the muscle. The pectoralis minor was observed to be pierced extensively by multiple branches from medial pectoral nerve. Therefore, this study was planned to report this unusual presentation. Such an extensive neural arrangement in relation to pectoralis minor is rather unusual and to the best of our knowledge has been not reported earlier. The possible clinical consequence of much an anomaly could be motor and sensory loss associated with accidental injury of these multiple nerves penetrating the substance of pectoralis minor while performing axillary lymphadenectomy. In accordance to the above case description, the surgeon should be cautioned of these possible neural branches while performing axillary dissection in mastectomy. Additionally, iatrogenic sensory or motor losses may be prevented by appropriate knowledge of these variations.

Abstract 129: Effects of Pulse Pressure and Antihypertensive Therapy on Short and Long Term Outcomes in Stroke Patients

Background: Effects of pulse pressure and benefits of blood pressure lowering with intravenous anti-hypertensive medications and beta-blockers in CVA patients have not been well investigated.

Material and Methods: Demographic, clinical, and echocardiographic data were collected and long-term outcomes (55+/-21 months) were ascertained in 356 consecutive cerebro-vascular accident (CVA) patients. ANOVA, chi-square, Kaplan-Meier, and logistic regression tests were employed. Study was approved by the institutional IRB.

Results: Widened pulse pressure on admission was significantly elevated in CVA patients who expired in the hospital or during the long-term follow-up (62+/-21mmHg for long-term survivors vs. 72+/-20mmHg for hospital deaths vs. 69+/-28 mmHg for long-term deaths, p=0.01). There was a trend towards increased hospital mortality (14% in long-term survivors vs. 25% in hospital deaths vs. 22% in long-term deaths, p=0.110) in CVA patients requiring IV anti-hypertensive therapy. Utilization of beta-blockers was lower in patients who suffered hospital death, but more likely in patients experiencing long-term death (42% use in hospital deaths vs. 48% in long-term survivors vs. vs. 66% in long-term deaths, p=0.003). Beta-blocker use was not predictive of hospital outcomes but was strongly predictive of adverse event long-term events (HR 2.1, 95%CI 1.3-3.4, p=0.002). When adjusted for demographic parameters and co-morbidities in multivariate analysis, pulse pressure and IV anti-hypertensive therapy were not predictive of short or long-term outcomes, while beta-blocker treatment was associated with reduced hospital (0.3, 95%CI 0.1-0.9, p=0.029) but not long-term mortality.

Conclusions: Widened pulse pressure and need for IV anti-hypertensive therapy are not predictive of adverse short- or long-term outcomes when demographics and co-morbidities are accounted for. Effects of beta-blocker therapy on outcomes in CVA patients are complex. Wider beta-blocker use in acute CVA may be associated with better hospital outcomes, while increased long term mortality with beta-blocker therapy may be indicative of poor cardiovascular health leading to adverse outcomes

Unilateral anomalous antebrachial vasculature--a clinico-embryological insight

OBJECTIVES

An important and frequently reported arterial variant of the upper extremity is the superficial ulnar artery (SUA). Although SUA is not an uncommon variation, its presence should be detected timely as any surgical procedure in this region could put this unnaturally present superficial vessel to risk. Therefore, we sought to report this anomaly relating to the brachial arterial branching pattern.

MATERIALS AND METHODS

Through the course of a usual instructive gross anatomy class an arterial variant of the brachial artery was noted. A scrupulous dissection was carried out and the specimen photographed.

RESULTS

The present study reports the unilateral presence of abnormal branching pattern and disposition of antebrachial blood vessels. The brachial artery is seen to branch off into superficial ulnar artery (SUA) and usual radial artery. Interestingly, common interosseous artery (CIA) springs from the radial artery instead of the ulnar artery which is the usual case.

CONCLUSIONS

Simple procedures such as venepuncture and intra arterial injections may become cumbersome and complication prone. The study is a humble attempt to caution the radiologists before interpreting angiographic films and the surgeons before performing reconstructions in this region.

RECURRENT OSTEOID OSTEOMA OF THE LUNATE: A CASE REPORT AND REVIEW OF THE LITERATURE

Osteoid osteoma is a benign tumour of bone that rarely localises in the carpal bones. Its treatment by curettage and bone grafting is considered to be curative and its recurrence is thought to be rare.

We report a case of an osteoid osteoma of the lunate, which recurred seven years after the initial operation. Recurrent osteoid osteoma of the lunate bone has not been reported in the literature. We present this case report for its atypical presentation and diagnostic difficulty and also to alert the readers of the possibility of an osteoid osteoma as a cause of the chronic unexplained wrist pain in young adults.

Effect of varying glucose concentrations during in vitro maturation and embryo culture on efficiency of in vitro embryo production in buffalo

This study was aimed to optimize glucose level at different stages of buffalo in vitro embryo production procedure. Three glucose levels (1.5, 5.6 and 10 mm) along with a control (0 mm) were used at three phases of in vitro fertilisation (IVF) procedure viz. in vitro maturation (IVM), in vitro culture (IVC-I) (12-72 hpi) and IVC-II (72 hpi to 7 dpi). Maturation rate of oocytes was found different under different glucose concentrations, and significantly more number of oocytes reached to MII under 5.6 mm glucose. The glucose levels at each phase (IVM, IVC-I and IVC-II) individually had significant effect on blastocyst rate, and the level used at one phase had significant effect on the outcome of next phase. Complete withdrawal of glucose from any of these stages irrespective of concentrations used at subsequent stage/s resulted in significantly lower number of blastocysts. However, the changing levels of glucose had differential effects during different phases of IVF steps. The most prominent effect of glucose level was observed during IVM. The presence of 5.6 mm glucose at all stages was most effective to yield highest blastocyst rate in buffalo IVF system.

An unusual bifid origin of 1st lumbrical muscle of hand: anatomical and clinical perspectives

Lumbrical muscles are pivotal in execution of fine skillful movements of the hand. Anomalies in their morphology are not uncommon. We report an exceptional bifid origin of first lumbrical muscle of the left upper limb, discovered incidentally in gross anatomy dissection class. The 1st lumbrical was observed to comprise of two heads, the accessory one arising from the tendon of flexor digitorum superficialis of the index finger and the other main belly taking origin as usual from flexor digitorum profundus. The two heads joined to form a common muscle belly and were inserted normally in the dorsal digital expansion. The report highlights the surgical and phylogenetic significance of such variation. Additionally, notification of such muscular variants assumes importance in the event of surgical interventions in this region. Moreover, the anomalous origin, length and volume of the first lumbrical are important parameters for the outcome of operations on the carpal tunnel.

An atypical composition of adductor hallucis co-existent with an accessory plantar muscle and duplication of flexor digiti minimi pedis

Adductor hallucis (AH) is frequently employed in transposition onto the first metatarsal head to alleviate symptoms of hallux valgus. Although tis muscle receives sufficient anatomical description, it is often disregarded in clinical practice. The rare anomalies associated with AH, merit a detailed study owing to its contribution to the treatment of hallux valgus. Additionally, the AH may be employed in plastic and reconstructive surgeries as a graft to cover defects of the foot. Therefore, we sought to report this infrequent anomaly relating to the AH muscle. Through the course of a regular educational gross anatomy class a muscular variant of the plantar musculature was noticed. A meticulous dissection was carried out and the specimen photographed. The oblique head of AH displayed three bellies whereas the transverse head was unremarkable. Another accessory belly was observed taking origin from the fourth metatarsal bone. Additionally, the flexor digiti minimi brevis (FDMB) displayed two bellies medial and lateral. A preoperative radiological assessment of the foot to be operated upon may provide the necessary information and may detect these muscular anomalies. Utilizing these variations to their benefit during operation will shorten the procedure time and may reduce post-operative risks and complications. We report this unique muscular anomaly to alert the foot surgeons and radiologists and plan their procedures accordingly.

Anomalous disposition of profunda femoris artery: a clinicoanatomical appraisal

During educational dissection of the left lower limb of an adult Indian male cadaver, an unusual variation of the branches of the femoral artery and profunda femoris artery (PFA), were observed. The profunda femoris artery and medial circumflex femoral artery took origin from a common arterial trunk from the medial side of femoral artery. The PFA coursed lateral to the femoral vein. The lateral circumflex femoral artery (LCFA) took origin, 1.2 cm proximal to the origin of the latter. The lateral circumflex femoral artery (LCFA) took origin directly from the femoral artery. The femoral vein was constantly medial to the PFA and coursed between it and femoral artery. The great saphenous vein was observed to course medial to the PFA and at its termination coursed anterior to the latter to drain into the femoral vein. Changes in caliber of femoral artery were recorded at the site of origin of the variant branches.

Unusual grooved styloid process in a human skull: morphological details and clinical implications

The temporal Styloid Process is an important anatomical landmark for surgeons while performing skull based surgery, for anaesthetists while injecting local anaesthetic solution and for radiologists during interpretation of CT and MRI scans. Knowledge of morphological variations of the styloid process such as a unique groove on its posterior aspect as seen in the present case not only has great clinical implications but is also of academic interest. The present article describes in detail an unusual groove in the styloid process with an additional anterior angulation at its tip. The morphological features, embryological basis and clinical relevance is discussed in details.

Accessory osseous passages in the vicinity of foramen rotundum in a dry adult human skull: morphological evaluation, embryological correlation and clinical reappraisal

An unusual bony depression with accessory osseous passages in the right side of middle cranial fossa was observed in a dry adult human skull. It was located below the superior orbital fissure and optic canal. The bony depression was divided into two parts ,medial and lateral fossa, by an incomplete oblique bony septum. The foramen rotundum and an accessory bony canaliculus were present in the medial fossa whereas the lateral fossa was blind. The foramen rotundum led as usual into the pterygopalatine fossa . The presence of such an abnormal bony depression in the right middle cranial fossa with accessory osseous passages in the vicinity of the foramen rotundum is highlighted in the present case, with embryological correlation and clinical relevance. Anatomical awareness of such variations in the middle cranial fossa are important for the present day radiologist who interprets imaging for this area, neurosurgeons , who operate in this area in the vicinity of cavernous sinus and anaesthetists, during regional block anaesthesia.

Unilateral anomalous brachial and antebrachial musculature associated with duplication of anterior interosseous nerve: a case report

The present case aims to provide an accurate anatomical description of coexistent accessory heads of flexor pollicis longus in the arm and forearm, extra muscular slips of the accessory belly of flexor pollicis longus to flexor digitorum profundus, and double anterior interosseous nerves. The morphology of the anomalous accessory muscle bellies is correlated with their clinical significance and embryological basis. Knowledge of such muscular and neuroanatomical variants is imperative prior to traumatic evaluation and reconstructive surgery.

Accessory muscle belly of peroneus tertius in the leg--a rare anatomical variation with clinical relevance--utility in reconstructions

We report here a rare muscular anomaly of the lower leg in an adult male cadaver observed during routine cadaveric dissection. Peroneus tertius (PT) is peculiar to man, being a hallmark of bipedal locomotion and erect posture. During the course of gross anatomy dissection, a rare finding of accessory belly of PT muscle was discovered. A meticulous dissection was performed and the observations were noted. The PT displayed two distinct bellies of origin. Both the bellies were substantial in size and were eventually fused close to their insertion at the base of the fifth meta-tarsal bone. Innervation of both the bellies was derived from the deep peroneal nerve. Soft tissue defects of the leg may be effectively covered by local muscles in the vicinity of the wounds. PT has been reliably used in the past for local transposition flaps in the lower extremities. The relations of the superficial nerve and the PT during placement of the anterolateral portal in ankle arthroscopy are vital to avoid inadvertent neuromuscular injuries. The presence of two bellies of the PT muscle has been discussed in the comparative perspective. A precise and detailed knowledge of the anatomical details of the crural muscles is important for performing reconstructive surgeries.

A rare bimuscular conglomeration gluteopiriformis case report

The present paper reports a rare anomalous muscle in the gluteal region, which appears to be a conglomeration of gluteus maximus and piriformis muscles. The muscle was proximally attached to the gluteus maximus and distally merged with the piriformis muscle. The innervation of the anomalous muscle was derived from the inferior gluteal nerve. Recognition of such a muscle variant may facilitate early clinical diagnosis and treatment of patients with symptoms of piriformis syndrome or sciatica of unexplained etiology. Contraction of such an anomalous muscle could lead to altered biomechanics of the piriformis and the gluteus maximus. Such a rare muscle, which morphologically resembles the piriformis and developmentally appears to be a part of gluteus maximus could be a challenging puzzle for the present day surgeon and radiologist.