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In recent years, wellness initiatives across various health professions have prompted national pharmacy organizations to prioritize pharmacist well-being. Pharmacy residency programs present ideal platforms to foster wellness practices among new pharmacy practitioners. By describing the components and implementation of the Resident Wellness Program at an academic medical center, we aim to guide other institutions in facilitating wellness activities for pharmacy trainees.The Resident Wellness Program was implemented in 2019 and provides pharmacy residents with a structured framework of wellness activities intended to promote mental and physical health and prevent burnout. Feedback surveys and written reflections have provided initial evidence of the program's value in enhancing resident well-being.A qualitative analysis of surveys and reflections highlights the program's positive impact, with more than 90% of participants indicating that the program met their needs and promoted self-development. Perspectives from residents and administrators identified key strengths, including the structured nature of sessions and diversity of wellness topics. Opportunities for improvement include teaching participants to apply practical wellness strategies and refining topics to align with residents' interests. As the program evolves, a formal analysis via standardized surveys and an assessment of longitudinal impact will support continued enhancement.The implementation of a pharmacy resident wellness program provides an opportunity to promote well-being and work performance. By engaging in similar initiatives, other institutions can mirror the commitment of national pharmacy organizations and contribute to a culture of wellness among pharmacy residents and the greater pharmacy workforce.

We investigated the incidence of invasive fungal infections (IFIs) and other infectious complications in patients receiving venetoclax and hypomethylating agent therapy for acute myeloid leukaemia (AML). This retrospective, multicentre cohort study included adult patients with AML who received at least one cycle of venetoclax and either azacitidine or decitabine between January 2016 and August 2020. The primary outcome was the incidence of probable or confirmed IFI. Secondary outcomes included antifungal prophylaxis prescribing patterns, incidence of bacterial infections, and incidence of neutropenic fever hospital admissions. Among 235 patients, the incidence of probable or confirmed IFI was 5.1%. IFI incidence did not differ significantly according to age, antifungal prophylaxis use, or disease status. In the subgroup of patients with probable or confirmed IFIs, six (50%) were receiving antifungal prophylaxis at the time of infection. The overall incidence of developing at least one bacterial infection was 33.6% and 127 (54%) patients had at least one hospital admission for febrile neutropenia. This study demonstrated an overall low risk of developing probable or confirmed IFI as well as a notable percentage of documented bacterial infections and hospital admissions due to neutropenic fever.

Objectives Aesthetic and functional outcomes after oncoplastic breast-conserving surgery (BCS) are directly related to the patients' quality of life (QoL). The Breast Cancer Treatment Outcome Scale (BCTOS) is a validated but burdensome questionnaire for the assessment of these outcomes. The aim of the study was to strengthen and focus the BCTOS instrument by reducing the number of items and subscales without loss of information and validity. Methods This study used a dataset of 871 patients with stage 0 – III breast cancer, from a prospective cohort study, who underwent BCS. We investigated correlations and other criteria of homogeneity of the BCTOS items to identify redundancies. An exploratory factor analysis was used to remodel the item-factor structure. Correlation and linear regression analysis with validated QoL subscales assessed the convergent and discriminant validity of the modified BCTOS structure. Results The factor analysis revealed two distinct subscales for aesthetic and functional outcomes. It was possible to reduce the 22 items of the original BCTOS to 12 items, thus the “BCTOS-12”. The two new scales had very good internal consistency: Cronbach's α = 0.86 for the new Aesthetic Status subscale and α = 0.81 for the new Functional Status subscale. Bootstrapping confirmed the item-factor structure for all 10,000 samples, remarkably. Conclusion The modified BCTOS questionnaire with only 12 items (BCTOS-12) is shorter, easier to interpret, and shows good validity.

Breast cancer is the leading cause of death from cancer in women and the most common cancer in the world [1]. To date, many patients with estrogen-receptor-positive (ER+) breast cancer are overtreated with chemotherapy when the rationale for adjuvant chemotherapy is based on clinicopathologic parameters. Different studies were able to demonstrate that a 21-gene expression assay (Oncotype DX® Genomic Health, Redwood City, CA) can predict the benefit from adjuvant chemotherapy in ER+ breast cancers [2, 3] and provide additional prognostic information independent of clinicopathological features [4]. Data from all patients with ER+ Her2neu− breast cancer undergoing Oncotype DX® testing between 2011 and 2014 at a tertiary referral center in Germany were analyzed. Oncotype DX® was performed in 69 cases, in 2 cases data were missing and in 3 cases Oncotype DX® could not be performed by the company. The results showed a low risk in 39 cases, an intermediate risk in 22 cases and a high risk in 3 cases. Based on Oncotype results, treatment recommendations were changed in 39 of 64 patients (61%). Before Oncotype DX® testing, chemotherapy was recommended in 67 patients, afterwards only in 25 patients. Data from 44 of 67 patients were matched to controls for stage, tumor grade, menopausal and hormone receptor status. Within a mean observation time of 19.7 months, cancer recurrence was observed in two patients. Oncotype DX® testing can be recommended for risk-tailored chemotherapy. Results should be validated in larger prospective studies.

Genome-wide-association studies (GWAS) have identified numerous single nucleotide polymorphisms (SNPs) that are associated with an increased risk of breast cancer. Most of these studies were conducted primarily in postmenopausal breast cancer patients. Therefore, we set out to assess whether or not these breast cancer variants are also associated with an elevated risk of breast cancer in young premenopausal patients.In 451 women of European ancestry who had prospectively enrolled in a longitudinal cohort study for women diagnosed with breast cancer at or under age 40, we genotyped 44 SNPs that were previously associated with breast cancer risk. A control group was comprised of 1142 postmenopausal healthy women from the Nurses' Health Study (NHS). We assessed if the frequencies of the adequately genotyped SNPs differed significantly (p≤0.05) between the cohort of young breast cancer patients and postmenopausal controls, and then we corrected for multiple testing.Genotyping of the controls or cases was inadequate for comparisons between the groups for seven of the 44 SNPs. 9 of the remaining 37 were associated with breast cancer risk in young women with a p-value0.05: rs10510102, rs1219648, rs13387042, rs1876206, rs2936870, rs2981579, rs3734805, rs3803662 and rs4973768. The directions of these associations were consistent with those in postmenopausal women. However, after correction for multiple testing (Benjamini Hochberg) none of the results remained statistically significant.After correction for multiple testing, none of the alleles for postmenopausal breast cancer were clearly associated with risk of premenopausal breast cancer in this relatively small study.

Data extraction form designed to extract trial level data. (DOC 494 kb)

Breast-conserving therapy is considered to be the standard treatment for early breast tumors (T1–T2). In up to 82 % of breast-conserving surgery, tumor cells were still found to be present at or near the cut edge of the surgical specimen after surgery. Thus, it is of clinical need to identify tumors at high probability for reexcision in the preoperative setting. A total of 686 patients with invasive or in situ breast cancers and primary breast-conserving surgery were included. In 169 cases (24.6 %), breast-conserving therapy was either incomplete or the presence of residual tumor could not be assessed. By univariate analysis, the following parameters were associated with increased probability for reexcision: carcinoma in situ component next to the invasive tumor (p

Breast cancer is the leading cause of death from cancer in women and the most common cancer in the world [1]. To date, many patients with estrogen-receptor-positive (ER+) breast cancer are overtreated with chemotherapy when the rationale for adjuvant chemotherapy is based on clinicopathologic parameters. Different studies were able to demonstrate that a 21-gene expression assay (Oncotype DXData from all patients with ER+ Her2neu- breast cancer undergoing Oncotype DXOncotype DX

In Graz, a lot of activities concerning the implementation of mobile phones in physics teaching have been carried out on different levels during the last years. These activities can be regarded as exemplary for the common progress in the field of teaching and learning with digital media: Videos of experiments, motion analysis, measurements with internal sensors, WhatsApp and finally the technology of the smartphone itself. All of the presented results have been developed and partially evaluated within final theses on different levels.

PurposeGenome-wide-association studies (GWAS) have identified numerous single nucleotide polymorphisms (SNPs) that are associated with an increased risk of breast cancer. Most of these studies were conducted primarily in postmenopausal breast cancer patients. Therefore, we set out to assess whether or not these breast cancer variants are also associated with an elevated risk of breast cancer in young premenopausal patients.MethodsIn 451 women of European ancestry who had prospectively enrolled in a longitudinal cohort study for women diagnosed with breast cancer at or under age 40, we genotyped 44 SNPs that were previously associated with breast cancer risk. A control group was comprised of 1142 postmenopausal healthy women from the Nurses' Health Study (NHS). We assessed if the frequencies of the adequately genotyped SNPs differed significantly (p≤0.05) between the cohort of young breast cancer patients and postmenopausal controls, and then we corrected for multiple testing.ResultsGenotyping of the controls or cases was inadequate for comparisons between the groups for seven of the 44 SNPs. 9 of the remaining 37 were associated with breast cancer risk in young women with a p-value ConclusionAfter correction for multiple testing, none of the alleles for postmenopausal breast cancer were clearly associated with risk of premenopausal breast cancer in this relatively small study.

The fallopian tube has been implicated as a site of origin of sporadic and BRCA1-related ovarian cancer. To investigate if Ki-67 or p53 is altered in BRCA1 mutation carriers, we have studied the expression of these markers in morphologically normal mucosa in the fallopian tube and fimbriae.Prophylactic adnexectomy specimens from 24 patients (eight BRCA1 mutation carriers, eight non-mutation carriers, and eight with unknown BRCA1 status), were scored by automated image analysis for the amount of Ki-67 and wild-type p53 expression. All patients had a history of breast cancer and a family history of breast or ovarian cancer.In the fimbriae, a median of 0.42 % Ki-67 and 0.04 % p53-positive epithelial cells was present, compared to a median of 0.36 % for Ki-67 and 0.05 % for p53 in the fallopian tube. Ki-67 expression decreased significantly with age (r = -0.45, p = 0.028). In contrast, p53 expression was not age-dependent for the whole group of patients (r = 0.25, p = 0.25). Subgroup analysis revealed a difference for p53 expression of the BRCA1 mutation carriers with respect to age (median 0.039 vs. 0.082 % for age less or greater than 50.5 years). Consequently, the p53/Ki-67 ratio showed an age-dependent increase, which was accelerated in the BRCA1-positive patients.Ki-67 and p53 expression varies in morphologically normal tubal epithelial cells depending on age and BRCA1 mutation status. This may reflect an altered and age-dependent DNA repair in BRCA1 mutation carriers and may be related to increased risk of ovarian cancer arising in the fallopian tube.

Pre- and perinatal complications have been implicated in the onset and clinical expression of Tourette syndrome albeit with considerable inconsistencies across studies. Also, little is known about their role in co-occurring obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity disorder (ADHD) in individuals with a tic disorder. Therefore, we aimed to investigate the role of pre- and perinatal complications in relation to the presence and symptom severity of chronic tic disorder and co-occurring OCD and ADHD using data of 1113 participants from the Tourette International Collaborative Genetics study. This study included 586 participants with a chronic tic disorder and 527 unaffected family controls. We controlled for age and sex differences by creating propensity score matched subsamples for both case-control and within-case analyses. We found that premature birth (OR=1.72) and morning sickness requiring medical attention (OR=2.57) were associated with the presence of a chronic tic disorder. Also, the total number of pre- and perinatal complications was higher in those with a tic disorder (OR=1.07). Furthermore, neonatal complications were related to the presence (OR=1.46) and severity (b=2.27) of co-occurring OCD and also to ADHD severity (b=1.09). Delivery complications were only related to co-occurring OCD (OR=1.49). We conclude that early exposure to adverse situations during pregnancy is related to the presence of chronic tic disorders. Exposure at a later stage, at birth or during the first weeks of life, appears to be associated with co-occurring OCD and ADHD.

In recent years, circulating miRNAs have attracted a great deal of attention as promising novel markers for various diseases. Here, we investigated their potential to serve as minimally invasive, early detection markers for breast cancer in blood plasma. We profiled miRNAs extracted from the plasma of early stage breast cancer patients (taken at the time-point of diagnosis) and healthy control individuals using TaqMan low-density arrays (TLDA). Selected candidates identified in the initial screen were further validated in an extended study cohort of 207 individuals including 127 sporadic breast cancer cases and 80 healthy controls via RT-qPCR. Four miRNAs (miR-148b, miR-376c, miR-409-3p and miR-801) were shown to be significantly upregulated in the plasma of breast cancer patients. ROC curve analysis showed that the combination of only three miRNAs (miR-148b, miR-409-3p and miR-801) had an equal discriminatory power between breast cancer cases and healthy controls as all four miRNAs together (AUC = 0.69). In conclusion, the identified miRNAs might be of potential use in the development of a multimarker blood-based test to complement and improve early detection of breast cancer. Such a multimarker blood test might for instance provide a prescreening tool, especially for younger women, to facilitate decisions about which individuals to recommend for further diagnostic tests.

Breast cancer is the most common tumor in women with Li-Fraumeni Syndrome (LFS), an inherited cancer syndrome associated with germline mutations in the TP53 tumor suppressor gene. Their lifetime breast cancer risk is 49% by age 60. Breast cancers in TP53 mutation carriers recently have more often been reported to be hormone receptor and HER-2 positive by immunohistochemistry and FISH in small series. We seek to complement the existing small literature with this report of a histopathologic analysis of breast cancers from women with documented LFS. Unstained slides and paraffin-embedded tumor blocks from breast cancers from 39 germline TP53 mutation carriers were assembled from investigators in the LFS consortium. Central histology review was performed on 93% of the specimens by a single breast pathologist from a major university hospital. Histology, grade, and hormone receptor status were assessed by immunohistochemistry; HER-2 status was defined by immunohistochemistry and/or FISH. The 43 tumors from 39 women comprise 32 invasive ductal carcinomas and 11 ductal carcinomas in situ (DCIS). No other histologies were observed. The median age at diagnosis was 32 years (range 22-46). Of the invasive cancers, 84% were positive for ER and/or PR; and 81% were high grade. Sixty three percent of invasive and 73% of in situ carcinomas were positive for Her2/neu (IHC 3+ or FISH amplified). Of the invasive tumors, 53% were positive for both ER and HER2+; other ER/PR/HER2 combinations were observed. The DCIS were positive for ER and HER2 in 27% of the cases. This report of the phenotype of breast cancers from women with LFS nearly doubles the literature on this topic. Most DCIS and invasive ductal carcinomas in LFS are hormone receptor positive and/or HER-2 positive. These findings suggest that modern treatments may result in improved outcomes for women with LFS-associated breast cancer.

In this study, we analyzed a "variant of uncertain significance" (VUS) located in exon 23 of the BRCA2 gene exhibited by six members of five distinct families with hereditary breast cancer (BC). The variant was identified by DNA sequencing, and cDNA analysis revealed its co-expression with wild-type mRNA. We analyzed co-occurrence with other pathological mutations in BRCA1/2, performed a case-control study, looked for evolutionary data and used in-silico analyses to predict its potential clinical significance. Sequencing revealed an in frame deletion of 126 nucleotides in exon 23, leading to a deletion of 42 amino acids (c.9203_9328del126, p.Pro2992_Thr3033del). All of the VUS-carriers suffered from either BC or ovarian/pancreatic cancer. No other definite pathologic mutation of BRCA genes was found in the five families. The identified deletion could not be observed in a control cohort of 2,652 healthy individuals, but in 5 out of 916 (0.5%) tested BC families without a bona fide pathogenic BRCA1/2 mutation (P = 0.0011). According to these results, the in frame deletion c.9203_9328del126 is a rare mutation strongly associated with familial BC. In summary, our investigations indicate that this BRCA2 deletion is pathogenic.

Hypertensive disorders are the most common medical problem encountered during pregnancy due to defective angiogenesis during placental development. Vascular endothelial growth factor (VEGF) is one of the angiogenic growth factors that stimulates angiogenesis. The recombinant form of its soluble receptor VEGF receptor-2 (sVEGFR-2) has anti-angiogenic activity. However, there is a paucity of information on serum VEGF and sVEGFR-2 concentrations in different sub-groups of hypertensive disorders during pregnancy. In this cross-sectional study, we evaluated the concentrations and the diagnostic utility of VEGF and sVEGFR-2 in gestational hypertension (GH, n=90), pre-eclampsia (PE, n=180), eclampsia (n=90) and control (n=180) pregnancy at different gestations. VEGF levels were significantly higher in PE and eclamptic (median=19.53 pg ml(-1); 60.36 pg ml(-1), P=0.0001) groups as compared with the control ones (median=18 pg ml(-1)). But, the serum sVEGFR-2 levels were found to be significantly decreased from GH to eclampsia groups (median=5196; 3972 pg ml(-1)) as compared with control groups (median=7417 pg ml(-1)). As the gestation advanced, there was an inverse association in the serum concentrations of sVEGFR-2 among the control, GH, PE and eclampsia groups. At both 34 and >34 weeks of gestations, higher sensitivity and specificity were observed for sVEGFR-2 in differentiating GH (50.8, 50%; 76.6, 76.6%), PE (63, 63%; 90, 90%) and eclampsia (65, 66.6%; 90, 90%) from the control pregnancy. This upregulation of VEGF and downregulation of sVEGFR-2 concentrations in different study groups may be due to hypoxia and could be involved intimately in the pathogenesis of these disorders. This study may contribute in understanding etio-pathogenesis of different hypertensive disorders during pregnancy.

Background: Cancer registries worldwide are vital to determine cancer burden, plan cancer control measures, and facilitate research. Population-based cancer registries are a priority for LMICs by the UICC; the National Cancer Registry Program (NCRP) of India oversees 28 such registries. A primary function of registries is to combine data for the same individual from multiple sources. For other disease cohorts where cancer is an outcome of interest, registries can potentially connect information by linking datasets together. Barriers to successful registration and linkages include systems in which cancer is not a notifiable disease, no universal unique individual identifier exists, and lack of trained personnel. This study utilizes technology and infrastructure to develop better linkages, surveillance, and outcomes. Aim: To assess the feasibility of linking large cohorts designed for cardio-metabolic disease research with cancer registries in New Delhi and Chennai; determine additional steps required for linkage accuracy and completeness; and develop detailed protocols for future applications. Methods: A pilot protocol for linkage between a large diabetes cohort and cancer registries in Delhi and Chennai was developed using MatchPro, a probabilistic record linkage program developed for cancer registries. Probabilistic software links datasets together in the presence of uncertainty (eg misspelled or abbreviated names) to identify record pairs with high probability of representing the same individual. For this study, algorithms were developed to address unique aspects of names and demographics in India. The software and algorithms focused on: detecting duplicates in cancer registries; and linking registries with external files from diabetes cohorts. In Delhi, 3 1-year datasets covering 3 years (2010, 2011, 2012) were linked with the diabetes cohort; in Chennai, the linkage included 3 5-year datasets covering 15 years (2000-04, '05-'09, '10-'14). The unique ID (Aadhaar) is not collected or linked systematically between different systems at this point in time. Results: Linkage attempts yielded potential matches ranked according to probabilistic scores; highest scores were reviewed to determine true matches. In Chennai, this process yielded: (2010-2014) 21% self-reported (SR) cases matching perfectly, 36% requiring follow-up, 13 nonreported (NR) cases found; 2005-2009: 33% SR cases matched perfectly, 1 NR case found; 2000-2004: 1 NR case. Also, 2 training workshops on data linkages and software were held. Conclusion: Linkages between cancer registries and other data sources are feasible in LMICs using probabilistic record linkage software augmented by manual matching. Future efforts to use existing epidemiologic resources (cohorts) and cancer research infrastructure (registries and clinical centers) can enhance research including understanding shared risk factors and pathophysiologic mechanisms e.g., between cancer and other NCD.

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.

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.Routine educational cadaveric dissection of a young adult Indian male cadaver.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.The study focuses on a new variation of the subscapular artery which could prove useful for interventional radiologists and surgeons in reconstructive surgeries.

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.

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.

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.

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.

Purpose: To study the influence of clipping PTV from body contour on plan quality and deliverability in build-up region for superficial target. Methods: Five previously treated patients of post-operative carcinoma of parotid were re-planned for IMRT (6MV X-rays, sliding window technique, five fields and 60Gy/30 fractions) using eclipse treatment planning system (TPS) by keeping dose volume constraints and all other parameters constant, only PTV was clipped from body contour by 0mm, 1mm, 2mm and 3mm respectively. Planned fluence was transferred to previously scanned solid water phantom by placing I’matriXX array at 0.5cm depth (2mm slab+3mm inherent). Fluence was delivered by Varian CL2300C/D linac at 99.5cm source to detector distance. Measured fluence was compared with TPS dose plane using 2D gamma evaluation using 3%/3mm DTA criteria. Total MU (monitor unit) required to deliver a plan was also noted. For plan quality, PTV, maximum-dose, minimum-dose, coverage index (CI=PTV volume covered by prescription dose/PTV) and heterogeneity index HI=D5/D95 were analyzed using dose volume histogram (DVH). Results: The Result of gamma function analysis for I’matriXX and TPS were 97.63±1.79%, 97.48±0.99, 98.08±0.89% and 98.01±0.78% at 0.5cm build-up depth for 0, 1, 2 and 3mm PTV clipping, respectively. I’matriXX measured dose was higher compared to TPS. Total MU required for delivering a plan were 552±61, 503±47, 436±24 and 407±22. Maximum-dose to PTV was 6635.80±62.01cGy, 6635.80±40.60cGy, 6608.43±51.07cGy and 6564.20±28.51cGy. Similarly, minimum-dose to PTV was 3306.23±458.56cGy, 3546.57±721.01cGy, 4591.43±298.81cGy and 4861.90±412.40cGy. CI was 0.9347±0.020, 0.9398±0.021, 0.9448±0.022 and 0.9481±0.021. Similarly, HI was 1.089±0.015, 1.084±0.014, 1.078±0.009 and 1.074±0.008 for 0, 1, 2 and 3mm PTV clipping, respectively. Conclusion: Gamma function analysis resulted in almost similar results. However, I’matriXX was overestimating the dose compared to TPS. MU required to deliver a plan decreases with increase in PTV clipping. CI, PTV minimum-dose and plan homogeneity increases with increase in PTV clipping from skin.

The aim of the current study is to report an unusual occurrence of a retroaortic left renal vein in an adult male cadaver of Caucasian origin. This unusual variant was discovered during the course of preclinical educational training programme for undergraduate medical students. The vascular anomaly was dissected and the surrounding adnexa carefully studied for associated variations. Subsequently, morphometry was performed on the specimen to measure certain important parameters. The left renal vein was found to emerge from lower part of renal hilum and traversed posterior to abdominal aorta and finally terminated into Inferior vena cava. Additionally, the left renal artery was higher in position and originated from the abdominal aorta at the level of upper border of body of Ist lumbar vertebra. This type of anomaly is very important as it may be associated with varicocoele. Furthermore, in preoperative planning for nephrectomy, partial nephrectomy and living donor nephrectomy, the surgeons should keep in mind the possibility of this vascular anomaly. It is also stated that left renal vein appears to be at the centre of a huge venous network which makes the nephrectomy hazardous and permits the spread of infectious material and neoplasms.

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.

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.

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.

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.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.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.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.

Dear Sirs,The estimated relative cerebral blood volume (rCBV) is asemiquantitative parameter that correlates with tissue vas-cularisation. High-grade gliomas are characterised by anincreased macrovasculature and microvasculature, andtherefore associated with an increased rCBV [1]. In neuro-oncology, high rCBV is used to distinguish tumoral fromnon-tumoral increase in lesion size, e.g, pseudoprogressionand radiation necrosis from real tumour progression.However, in high-grade glioma an increase in rCBVwithout tumour progression can also be observed in (non-convulsive) status epilepticus, as we will describe below.A 45-year-old woman was admitted to our hospitalbecause of a complete paresis of the right arm and motorspeech impairment. Thirteen years before she had beentreated for an anaplastic oligodendroglioma of the lefttemporal lobe with surgery followed by radiotherapy(59.4 Gy) and chemotherapy (6 cycles of procarbazine,CCNU, vincristin). Every 6 months a magnetic resonanceimaging (MRI) scan of the brain was performed showing apost-surgery cyst and local subtle enhancement, whichremained stable over this period (Fig. 1a). Dynamic sus-ceptibility contrast (DSC) perfusion-weighted MR imaging[T2*w gradient echo echo-planar imaging with repetitiontime of 2,000 ms; 60 phases; contrast bolus injection after10 phases at 5 ml/s of 12 ml of Gadovist 1.0 (BayerSchering Pharma) followed by 20 ml 0.9% NaCl; preloadbolus of 3 ml of Gadovist 1.0 (Bayer Schering Pharma)5 min prior to DSC perfusion imaging] performed5 months before admission showed rCBV ratios of 1.09(insular L) and 1.18 (occipital L) (Fig. 1d). One weekbefore admission, she had woken up with a headache, aparesis of her right arm and an increased speech impair-ment. In the following days her headache subsided and herparesis was fluctuating. On admission she showed a mixedaphasia, right hemianopia and a complete paresis of herright arm. An electroencephalogram (EEG) showed clearepileptic discharges located left centroparietal withoutclinical corresponding symptoms. A MRI scan of the brainshowed cortical swelling with extensive cortical enhance-ment of the left temporal lobe (Fig. 1b), and perfusion-weighted imaging showed rCBV ratios of 2.24 (insular L)and 1.64 (occipital L) (Fig. 1e), suggesting tumour pro-gression. The patient was treated with anti-epileptic drugsfollowed by an improvement of clinical symptoms. Arepeat MRI made 2 months later showed a decrease ofenhancement (Fig. 1c) and of rCBV ratios (1.07 insular Land 0.78 occipital L) (Fig. 1f) to near-baseline values,indicating the increase in contrast enhancement and rCBVwas not due to tumour progression.

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.

Our goal is to identify subgroups of women undergoing breast-conserving therapy (BCT) who are at increased risk for requiring a secondary surgical procedure, and to identify tumor and patient profiles that will allow surgeons to anticipate the need for taking larger margins when removing the tumor. One hundred female patients who had palpable, invasive carcinomas of the breast, and had undergone a primary BCT, were included in the study. Of these, all women (n = 25) who had incomplete resections, or questionable margins of resection, had to undergo re-excisions. Patients who had multifocal disease, accompanying ductal carcinoma in situ, involvement of regional lymph nodes, high-grade breast cancer (Grade 3 vs. 1/2), lympho-vascular invasion or negative hormone-receptor-status, were significantly more likely to have undergone incomplete removal of tumor tissue—these patients thus required a secondary surgery. The clinical and pathological predictors described above indicate that surgery in breast cancer patients meeting these criteria require larger safety margins to minimize the incidence rate of re-excision at a later date.

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.

The capillaries of placental villi play a very important role in the feto-maternal exchange of gases and nutrients. A morphological change in their structure may lead to the impairment of placental function. In this study an attempt has been made to find out the morphological and morphometric features of the capillaries in full term placental villi of non smoking mothers as well as active and passive smoking mothers under an electron microscope.A total number of 163 placentae from active, passive and nonsmoking mother (n = 61+42+60) were processed for electron microscopic study. The ultrathin sections were examined under electron microscope and images were recorded. Morphometry and statistical analysis were carried out with the help of software.The study revealed that the endothelial cells of stromal capillaries of the placental villi were oedematous and the cytoplasm was rich in dilated endoplasmic reticulum, mitochondria, fibrils and fine filaments in both groups of the smokers' placenta in comparison to control. Morphometric analysis showed a significant reduction in the perimeter of the stromal capillary of the tertiary villi of placenta in both active and passive smokers from mean value of 71.65 ± 47.82 µ to mean value of 59.77 ± 29.72 µ (p = 0.07) and 49.49 ± 20.94 µ (p = 0.0005) respectively. In case of passive smoker, area of the capillary (µm²) reduced significantly (p = 0.00004) from mean value of 266.29 ± 331.86 µm² to 116.64 ± 83.62 µm² whereas the number of capillary per villus increased significantly (p = 0.046) from mean value 2.42 ± 1.84 to 4.2 ± 3.16. The thickness of basement membrane of the endothelial cells of stromal capillaries of the placenta increased significantly in active as well as passive smokers (p = 0.00001).The ultrastructural changes noticed in the endothelial cells of placental villi may be due to hypoxia resulting from tobacco consumption either in active or passive form by the pregnant mothers. Thus, targeted therapy may be implicated for hypoxia, which is one of the major cause of the life threatening disorders of pregnancy.

Hydatidiform moles have a high incidence rate in Asian countries like India. The molecular pathway leading to the pathogenesis and progression of hydatidiform moles is not yet understood. This study aimed to investigate the biological significance of Bcl-2 and p53 in complete hydatidiform moles (CHMs) as well as their influence on disease progression in the Indian population.Archival tissues from 35 patients with CHMs and 35 age-matched controls were examined for Bcl-2 and p53 expressions by immunohistochemistry.Bcl-2 was found to be immunolocalised in the cytoplasm of the syncytiotrophoblast, whereas p53 was observed in both the nucleus and cytoplasm of the syncytiotrophoblast and cytotrophoblasts. In CHMs, Bcl-2 was detected in 23 percent of patients and p53 nuclear expression, in 66 percent. A significant decrease in Bcl-2 expression was observed in CHMs (p-value is 0.015), and the down-regulation of Bcl-2 significantly correlated with higher nuclear expression of p53 (p-value is 0.002), indicating an inverse association between the two proteins (p-value is 0.0001). However, no correlation was found between the clinical progress of patients with CHMs and p53 and those with Bcl-2 protein expression.The current study demonstrated the significance of Bcl-2 and p53 in the pathogenesis of CHMs but did not reveal any association with disease progression.

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.

The topography of the neurovascular structures in the antebrachium assumes relevance during surgical approaches in this region. The aim of the present case report was to describe the clinical importance of a bifid brachioradialis with the superficial branch of radial nerve entrapped between the two slips. The insertion of the two slips was unusual and merits a special documentation in anatomy literature. We propose that the superficial branch of radial nerve could possibly be subjected to compression resulting in the neurological symptoms of varying magnitude. A precise working knowledge of the nerves and muscles of the antebrachium and elbow region is vital for the operating surgeons to avoid post-operative complications.

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.

Variations in the venous architecture of the retro peritoneum is not uncommon, mostly those of Inferior Vena Cava (IVC). In this report we describe an extremely rare anatomical entity, where the IVC is formed by the union of the right common iliac vein and the left internal iliac vein. This is associated with a parallel venous channel which is the upward continuation of the left external iliac vein, which finally drains into the IVC at the level of renal veins. Awareness of such unusual variation of abdominal venous channels is helpful during retroperitoneal and laparoscopic surgeries of the abdomen, in staging of abdominal neoplasm, in radiological interpretation as well as therapeutic intervention in cases of recurrent pulmonary embolism.

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.

Several instances of accessory musculature of the upper extremity are now recognized. During regular dissection class of undergraduate medical students, we observed an important anatomic variation pertaining to the flexor pollicis longus muscle (FPL) in the left upper limb of an adult male cadaver. An accessory muscle belly extending from the deep aspect of flexor digitorum superficialis (FDS) to the tendon of the FPL was observed in the flexor surface of the antebrachium. The description of Gantzer's muscle (GM) is well elucidated in anatomical archives and is described as an accessory muscle extending from the superficial to the deep flexors of the digits.

Anomalous extensive attachment of temporalis muscle covering the mandibular incisure is rarely reported in literature. Such variations of temporalis muscle are of immense significance in operative procedures of maxillo-facial region, utilization of temporalis muscle fl ap and accurate interpretation of radiographs.Dissection of the head and neck region during the course of undergraduate teaching programme revealed unduly extensive attachment of temporalis muscle fibres in the left side in an adult Indian male cadaver. The temporal and infra-temporal regions were carefully dissected to delineate the temporalis muscle with special emphasis on the branches of maxillary artery and mandibular nerve. The morphological details of the temporalis muscle were recorded and appropriate photographs taken.The mandibular notch was 3.1 cm wide. The extra fleshy fibres of the temporalis muscle completely occupied the mandibular notch and further descended for insertion onto the coronoid process, and external and internal surfaces of the ramus of mandible. The masseteric nerves and vessels pierced the anomalous fibres of temporalis muscle in the mandibular notch.The present study highlights the morphological details of an unduly extensive attachment of temporalis muscle and discusses its importance in reconstructive procedures of maxillo-facial region. Detailed information of the variations of temporalis muscle is also important in accurate interpretation of modern imaging procedures.

Apoptosis plays a central role in organ development, homeostasis and immune defence in multicellular organisms and is strictly controlled in part by members of Bcl-2 family. The Bcl-2 is a pro-survival molecule identified through its involvement in B-cell lymphomas. The aim of the study was to evaluate the incidence of apoptosis in the human placenta at different stages of pregnancy and to correlate it further with Bcl-2 expression. A total of 96 placental samples from first trimester, mid-trimester and uncomplicated term pregnancies were collected (n = 32 + 32 + 32). M30 cyto death monoclonal antibody was used to identify apoptotic cells. The apoptosis index of first trimester placentae was 2.33 ± 1.70, mid- trimester was 1.77 ± 1.36 and term placenta was 1.15 ± 0.21. Bcl-2 protein was found immunolocalized in the cytoplasm of syncytiotrophoblast. Apoptosis index was significantly reduced in term cases as compared with first trimester (P0.002) and mid-trimester placentae (P = 0.01). On the contrary, Bcl-2 expression was significantly higher at term cases than in first trimester (P0.0001) and mid-trimester cases (P0.001). The present study divulges the importance of apoptosis in permitting normal physiological turnover of villous trophoblast and also exhibits the contribution of bcl-2 in maintaining syncytial integrity throughout normal pregnancy.

Interesting observations were discovered in a liver specimen during routine educational dissection class. Accessory fissures were observed on the visceral surface of the liver. One fissure was observed to delineate an accessory lobe from the quadrate lobe distorting the configuration of the quadrate lobe. The other fissure was seen demarcating the caudate lobe from its process. These fissural variations are detectable by ultrasonography and adequate knowledge of the normal morphology of the liver may prevent erroneous diagnosis of a focal intrahepatic lesion. We undertook the task of reporting this rare anomaly of this vital organ so that the operating surgeons and radiologists are cautioned adequately before striving to approach the liver.