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Background: Tendinopathies of the rotator cuff muscles, biceps tendon and pectoralis major muscle are common causes of shoulder pain in athletes. Overuse insertional tendinopathy of pectoralis minor is a previously undescribed cause of shoulder pain in weightlifters/sportsmen. Objectives: To describe the clinical features, diagnostic tests and results of an overuse insertional tendinopathy of the pectoralis minor muscle. To also present a new technique of ultrasonographic evaluation and injection of the pectoralis minor muscle/tendon based on use of standard anatomical landmarks (subscapularis, coracoid process and axillary artery) as stepwise reference points for ultrasonographic orientation. Methods: Between 2005 and 2006, seven sportsmen presenting with this condition were diagnosed and treated at the Cape Shoulder Institute, Cape Town, South Africa. Results: In five patients, the initiating and aggravating factor was performance of the bench-press exercise (hence the term "bench-presser's shoulder"). Medial juxta-coracoid tenderness, a painful active-contraction test and bench-press manoeuvre, and decrease in pain after ultrasound-guided injection of a local anaesthetic agent into the enthesis, in the absence of any other clinically/radiologically apparent pathology, were diagnostic of pectoralis minor insertional tendinopathy. All seven patients were successfully treated with a single ultrasound-guided injection of a corticosteroid into the enthesis of pectoralis minor followed by a period of rest and stretching exercises. Conclusions: This study describes the clinical features and management of pectoralis minor insertional tendinopathy, secondary to the bench-press type of weightlifting. A new pain site-based classification of shoulder pathology in weightlifters is suggested. [ABSTRACT FROM AUTHOR]

Machine learning-based interatomic potentials enable accurate materials simulations on extended time- and length scales. ML potentials based on the atomic cluster expansion (ACE) framework have recently shown promising performance for this purpose. Here, we describe a largely automated computational approach to optimizing hyperparameters for ACE potential models. We extend our openly available Python package, XPOT, to include an interface for ACE fitting, and discuss the optimization of the functional form and complexity of these models based on systematic sweeps across relevant hyperparameters. We showcase the usefulness of the approach for two example systems: the covalent network of silicon and the phase-change material Sb 2 Te 3 . More generally, our work emphasizes the importance of hyperparameter selection in the development of advanced ML potential models.

Machine-learning (ML)-based interatomic potentials are increasingly popular in material modeling, enabling highly accurate simulations with thousands and millions of atoms. However, the performance of machine-learned potentials depends strongly on the choice of hyperparameters-that is, of those parameters that are set before the model encounters data. This problem is particularly acute where hyperparameters have no intuitive physical interpretation and where the corresponding optimization space is large. Here, we describe an openly available Python package that facilitates hyperparameter optimization across different ML potential fitting frameworks. We discuss methodological aspects relating to the optimization itself and to the selection of validation data, and we show example applications. We expect this package to become part of a wider computational framework to speed up the mainstream adaptation of ML potentials in the physical sciences., (© 2023 Author(s). All article content, except where otherwise noted, is licensed under a Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).)

Purpose/Aim of the study: To assess if corneal epithelium can be cultured ex vivo from corneas eviscerated due to irretrievable trauma, according to a cell culture method that made use of autologous platelet-rich plasma (A-PRP) as culture substrate. To compare corneal epithelium cultured ex vivo from corneas eviscerated following trauma using A-PRP combined with Dulbecco's modified Eagles medium (DMEM), versus DMEM alone., Materials and Methods: This was a laboratory case-controlled study of human corneal cells cultured in a mixture of A-PRP and DMEM, versus DMEM alone from six eviscerated corneas. A 100 explants were created, of which 50 explants were plated on A-PRP-gel construct combined with DMEM and 50 controls were placed in serum-free DMEM alone. Donor patients received systemic antibiotics prior to evisceration., Results: Confluent epithelium in monolayers could be cultured when donor limbal biopsies were placed in a mixture of A-PRP culture medium and DMEM. No growth was observed when corneas were placed in serum-free DMEM medium only (p < 0.05). No bacterial infection was observed in cultures., Conclusions: This study demonstrated that A-PRP is a viable and effective alternative to bovine serum for the ex vivo expansion of limbal epithelial cells. It also shows that eviscerated corneas are a viable source of donor tissue for this purpose in South Africa where access to tissue banks is limited.

The purpose of this study was to analyse the intermediate-term results of an arthroscopic procedure to debride and resurface the arthritic glenoid, in a middle-aged population, using an acellular human dermal scaffold. Between 2003 and 2005, thirty-two consecutive patients underwent an arthroscopic debridement and biological glenoid resurfacing for glenohumeral arthritis. The diagnoses included primary osteoarthrosis (28 patients), arthritis after arthroscopic reconstruction for anterior instability (1 patient) and inflammatory arthritis (3 patients). All shoulders were assessed clinically using the Constant and Murley score, and results graded according to Neer's criteria. Statistical analysis was performed to determine significant parameters and associations. A significant improvement (P < 0.0001) in each parameter of the subjective evaluation component (severity of pain, limitation in daily living and recreational activities) of the Constant score was observed. The Constant and Murley score increased significantly (P < 0.0001) from a median of 40 points (range 26-63) pre-operatively to 64.5 (range 19-84) at the final assessment. Overall, the procedure was considered as "successful outcome" in 23 patients (72%) and as a "failure" in 9 patients (28%). According to Neer's criteria, the result was categorized as excellent in 9 (28%), satisfactory in 14 (44%) and unsatisfactory in 9 (28%). Within the unsatisfactory group, there were five conversions to prosthetic arthroplasty. A standard magnetic resonance imaging was performed on 22 patients in the successful outcome group; glenoid cartilage was identified in 12 (thick in 5, intermediate in 1, thin in 6) and could not be identified in 10 patients (complete/incomplete loss in 5, technical difficulties in 5). Overall, five complications included transient axillary nerve paresis, foreign-body reaction to biological material, inter-layer dissociation, mild chronic non-specific synovitis and post-traumatic contusion. Dominance of affected extremity and generalized disease (diabetes, rheumatoid arthritis, generalized osteoarthritis) was associated with an unsatisfactory outcome (P < 0.05). Arthroscopic debridement and biological resurfacing of the glenoid is a minimally invasive therapeutic option for pain relief, functional improvement and patient satisfaction, in glenohumeral osteoarthritis, in the intermediate-term.

Objective: To establish whether honey and silver-impregnated dressings used by wound-healing practitioners are cytotoxic in vitro to human skin keratinocytes and dermal fibroblasts., Method: Human keratinocyte and fibroblast tissue cultures were established in vitro. Untreated cultures served as controls (group I). Small dressing implants of monofloral, medicinal honey (L-Mesitran) (group 2) and nanocrystalline silver (Acticoat) (group 3) were placed in test wells and co-cultured with each of the two cell lines. Morphological changes, including cell toxicity, were assessed using inverted microscopy, trypan blue staining and the Rosdy and Clauss cell toxicity scoring system., Results: Untreated cultures consisting of both keratinocytes and fibroblasts (group 1) were established in 90% of all cases. In group 2, cultures with honey-impregnated implants, cell proliferation remained present at two and four months. Cell viability remained intact and cell toxicity was not evident at four months after continuous tissue culture. In group 3, marked toxicity was observed with high non-viability staining and cell-scoring counts compared with groups 1 and 2 (p<0.05). This demonstrates that the silver interfered with epidermal cell proliferation and migration, implying that it contains cytotoxic material., Conclusion: The honey-based product showed excellent cytocompatibility with tissue cell cultures compared with the silver dressing, which demonstrated consistent culture and cell toxicity. Further studies are needed to assess if these comparative in-vitro findings should influence a clinician's choice of wound dressing.

Objectives: To review a single-centre experience with stent-graft treatment of penetrating carotid artery injuries and long-term follow-up., Methods: All stable patients with carotid artery injuries presenting between August 1998 and February 2009 were considered for endovascular treatment. Patients were selected based on clinical and radiological criteria and data were prospectively collected. Follow-up was conducted clinically, angiographically and by telephonic contact. Endpoints were stroke, death and any other stent-graft-related complications., Results: A total of 128 patients were treated, of whom only 19 were selected for endovascular management. The recorded technical success rate was 100%, with one early stroke and one non-stent-graft-related procedural death. A further four patients were lost to follow-up. The remaining 14 patients had a mean follow-up of nearly 4 years. No stent-graft-related late deaths, strokes or other complications were reported, although one instance of late stent-graft occlusion was documented., Conclusion: Endovascular management of penetrating carotid artery injuries is safe and the long-term outcomes justify a more liberal application of this technique in selected patients.

Objective: To review our management of penetrating innominate artery injuries by open and endovascular techniques., Methods: Data regarding patient demography, clinical presentation, investigations, associated injuries, pathology, management, complications and mortality, were collected on patients treated at a single centre over 18 years., Results: 39 innominate artery injuries were treated. There were 36 men and three women, with a mean age of 27 years (range 18-49). Thirty-eight injuries were due to stabwounds and one was the result of a gunshot wound. The most common clinical presentations were shock (47%) and haematoma(42%). Twenty-three patients had associated injuries. The most common pathology was false aneurysm in 21 patients followed by 13 actively bleeding injuries, 4 arteriovenous fistulas and 1 arterial occlusion. Thirty-four patients underwent surgical and five endovascular repair. Overall survival was 79%. The stroke rate for surviving patients was 6%. Patients treated with endovascular stenting had shorter hospital and intensive care unit stays than those treated with surgery., Conclusions: Innominate artery injuries have high rates of morbidity and mortality. A vascular surgical approach with pre-operative angiography, when possible and careful surgical planning by a dedicated team promotes better surgical results. Endovascular and hybrid procedures can become the method of choice when treating stable patients.

The suprascapular nerve is responsible for most of the sensory innervation to the shoulder joint and is potentially at risk during surgery. In this study, 31 shoulders in 22 cadavers were dissected to investigate the sensory innervation of the shoulder joint by the suprascapular nerve, with special reference to its sensory branches. In 27 shoulders (87.1%), a small sensory branch was observed that splits off from the main stem of the suprascapular nerve proximal (48.2%), inferior (40.7%), or distal (11.1%) to the transverse scapular ligament. This percentage is considerably higher than has been previously found. In 74.2% of the shoulders, an acromial branch was also found, originating just proximal to the scapular neck, running to the infraspinatus tendon. These cadaveric results indicate that sensory branches to the shoulder joint are more common and numerous than previously described and therefore should be considered in shoulder surgery and nerve blocks to this area.

Background: The management of penetrating subclavian artery injuries poses a formidable surgical challenge. The feasibility of stent graft repair is already established. General use of this modality is not widely accepted due to concerns regarding the long-term outcome in a generally young patient population. We review our stent graft experience to examine long-term outcomes., Methods: All patients with penetrating subclavian artery injuries were evaluated for stent graft repair. Patients were excluded when hemodynamically unstable or unsuitable on other clinical and angiographic grounds. Patients were followed prospectively for early (<30 days) and late (>30 days) complications. Clinical and telephone evaluation, Doppler pressures, duplex Doppler, and angiography (when indicated), were used to asses patients at follow-up. Outcomes were recorded as technical success of procedure, graft patency, arm claudication, limb loss, the need for open surgical repair, the presence or absence of other complications, and death., Results: Fifty-seven patients underwent stent graft treatment during the 10-year period. Mean age was 34, and 91% were men. There were 53 stab wounds and four gunshot injuries. Pathology included false aneurysms (n = 42), arteriovenous fistula (n = 12), and three arterial occlusions. Early complications: One patient (2%) had a femoral puncture site injury which was managed with open surgical repair. One patient died early due to multiple organ failure related to concomitant injuries. Three patients (5%) presented with graft occlusion and nonlimb threatening ischemia in the first week after treatment. All three patients were managed successfully with a second endovascular intervention. Late complications: Twenty-five (44%) of the 57 patients with subclavian artery injuries were followed-up with a mean duration of 48 months. Two patients died as a result of fatal stab wounds months after their first injuries. Five patients (20%) and three patients (12%) presented with angiographically significant stenosis and occlusions, respectively. The stenotic lesions were successfully managed with endovascular intervention, and the occluded lesions were managed conservatively. No patient experienced life or limb loss or any incapacitating symptoms at the end of the study period. There was no need for conversion to open surgery., Conclusions: This study has reaffirmed the feasibility and safety of stent graft repair in treating stable patients with selected penetrating subclavian artery injuries. The results of this study also confirmed acceptable long-term follow-up without any limb or life threatening complications. We conclude that endovascular repair should be considered the first choice of treatment in stable patients with subclavian artery injuries.

The coracoid process forms an important part of scapular-glenoid construct and is involved in many surgical procedures on the glenohumeral joint. The unique three-dimensional orientation of each coracoid pillar makes radiographic imaging difficult. Congenital variations and minimal traumatic/iatrogenic changes in this orientation can predispose to subcoracoid impingement. We performed a quantitative and statistical analysis of the osseous anatomy of the coracoid process in 101 scapulae; the purpose was to determine the anatomical variations and gender-specific differences in the length, breadth, thickness, vertical and horizontal projections, and triplane angulations of each individual coracoid pillar. All parameters were measured in reference to the glenoid plane to ensure surgical and radiological applicability. The mean dimensions of the inferior coracoid pillar were 31.1 x 16.6 x 9.9 mm and that of the superior coracoid pillar were 41.7 x 14.2 x 8.4 mm (medial)/6.6 mm (lateral). The mean maximal harvestable coracoid length measured 19.0 mm. The mean angular orientation of the inferior coracoid pillar, with reference to the glenoid, measured 51.2 degrees (axial), 126.1 degrees (sagittal), and 134.6 degrees (coronal), and that of the superior coracoid pillar measured 146.1 degrees (axial) with an interpillar angulation of 84.9 degrees (axial). A statistically significant gender difference (P < 0.05) was found in the lengths, breadths, and projections of each coracoid pillar. We used data from this study to devise two new radiographic views (for imaging individual coracoid pillars), to calculate dimensions and orientation of internal fixation/prosthetic hardware during surgery, and conceptualize a geometric model to explain the role of measured parameters in coracoid impingement syndrome.

Conventional techniques of internal fixation of displaced fractures of the greater tuberosity may be insufficient in presence of comminution. A new surgical technique of internal fixation using a double-row of suture-anchors is described. Long-term results of this technique are evaluated in 21 patients with an isolated, displaced and comminuted greater tuberosity fracture at an average of 3.5 years (range 1-5 years) after surgery. The average age of the patients in the study was 51 years (range 17-93 years). Twenty fractures healed without post-operative displacement. The result was rated as excellent in 8, good in 10, satisfactory in 2 and unsatisfactory in 1 patient. Post-operative bicipital impingement in two patients and reaction to fixation material in one patient resulted in persistent, severe pain in the rehabilitation period, necessitating additional surgery.

The suprascapular notch is a common location for entrapment of the suprascapular nerve. Open surgical procedures for excision of the transverse scapular ligament are associated with pain relief and functional improvement. Arthroscopic procedures have been described for decompressing ganglion cysts, which compress the nerve at the spinoglenoid notch. However, there is no description of an arthroscopic procedure for decompression of the nerve at the suprascapular notch, and this is probably related to unfamiliarity with the complex anatomy of the region. The technique described herein is based on standard anatomic landmarks and utilization of these as reference points for arthroscopic orientation and reproducibility. The acromioclavicular joint, conoid ligament, and coracoid process are stepwise reference landmarks leading to the suprascapular notch. Arthroscopic identification of structures around the notch is necessary before ligament resection. A new suprascapular portal, in combination with an accessory portal, is described for retraction, blunt dissection, nerve stimulation, and ligament resection. Key instruments include a 4-mm arthroscope of standard length (160 mm), with a 70 degree angled lens for adequate visualization and a calibrated probe to guide and limit dissection.

Arthroscopic glenohumeral interposition arthroplasty is performed with the patient placed in the lateral decubitus position. Standard posterior, anterior, and anterosuperior portals are created, a routine diagnostic arthroscopy is performed, and the joint is débrided with the use of an arthroscopic shaver. An arthroscopic burr is used to resect prominent osteophytes, to alter the version of the glenoid if necessary, and to create microfractures on the glenoid surface. Next, 3 absorbable sutures are passed percutaneously with a 30 degrees angled suture grasper from 3 different sites posteriorly through the posterior capsular-labral tissue and into the anterior portal cannula, where they are isolated by means of the suture saver kit. The prepared interposition membrane/tissue (GRAFTJACKET Regenerative Tissue Matrix, Wright Medical Technology, Inc., Arlington, TN) is tagged with the 3 sutures in the anterior cannula before it is introduced into the joint. Three additional sutures are attached to the membrane anteriorly at 1, 3, and 5 o'clock positions and are isolated with suture savers. The membrane is next introduced into the joint through the anterior cannula and is aligned with the glenoid rim. The anterior sutures are rerouted through the anterior capsular-labral tissue with a 70 degrees angled suture grasper, and they are retrieved through the anterior cannula. Intra-articular nonsliding knots are used anteriorly to anchor the interposition tissue to the anterior glenoid labrum and capsule. The posterior sutures are knotted intra-articularly, or they may be tied extra-articularly; the proximal and distal posterior sutures are retrieved subcutaneously out through the skin tract of the posterior portal and are knotted with the suture present in this portal, with the use of nonsliding knots. Stability of the interposition tissue is assessed by movement of the glenohumeral joint through its entire range of motion. The postoperative protocol consists of early passive exercises, active exercises after 3 weeks, and muscle-strengthening exercises after 6 weeks.

The morphology of the anterior and posterior internal vertebral venous plexus (IVVP) in human fetuses between 21-25 weeks of gestational age is described. The results are compared to the findings of a previous morphological study of the IVVP in the aged. The morphological pattern of the anterior IVVP in the fetus is very similar with the anterior IVVP in the aged human. In contrast, the posterior IVVP in the fetus lacks the prominent transverse bridging veins that are present in the aged lower thoracic and the lumbar posterior IVVP. The background of these morphological differences is unclear. Maybe the thoracolumbar part of the posterior IVVP is subject to "developmental delay," or the observed differences in the aged may result from functional and age-related factors that trigger this part of the vertebral venous system during (erect) life. The observed age related morphological differences of the posterior IVVP support the concept of the venous origin of the spontaneous spinal epidural hematoma (SSEH)., (Copyright 2005 Wiley-Liss, Inc.)

Although pancreatic beta-cells are capable of adapting their mass in response to insulin requirements, evidence has shown that a dietary insult could compromise this ability. Fetal malnutrition has been linked to low birth weight and the development of type 2 diabetes later in life, while reduced beta-cell mass has been reported in adult rats fed a high-fat diet (HFD). Reported here are the effects of exposure to a HFD, during different periods of gestation, on neonatal rat weight and beta- and alpha-cell development. The experimental groups were composed of neonatal offspring obtained from Wistar rats fed a high-fat (40% as energy) diet for either the first (HF1), second (HF2), or third (HF3) week, or all three (HF1-3) weeks of gestation. Neonatal weights and circulating glucose and insulin concentrations were measured on postnatal day 1, after which the pancreata were excised and processed for histological immunocytochemical examination and image analysis. HF1 and HF2 neonates were hypoglycemic, whereas HF1-3 neonates were hyperglycemic. Low birth weights were observed only in HF1 neonates. No significant differences were detected in the circulating insulin concentrations in the neonates, although beta-cell volume and numbers were reduced in HF1-3 neonates. beta-cell numbers also declined in HF1 and HF3 neonates. alpha-cell volume, number and size were, however, increased in HF1-3 neonates. alpha-cell size was also increased in HF1 and HF3 neonates. In neonates, exposure to a maternal HFD throughout gestation was found to have the most adverse effect on beta-cell development and resulted in hyperglycemia.

Objective: To review blunt traumatic abdominal wall hernias (TAWHs) in our institution., Method: Retrospective review of blunt abdominal trauma cases over a 6-month period., Results: Four patients with TAWH were identified. The mean age was 36 years. Three had been involved in vehicular collisions, and 1 had been assaulted with a large stone. All were diagnosed on presentation, 3 by computed tomography scan and 1 clinically. Two were repaired as emergencies, and 1 was repaired after 4 months. The 4th patient refused surgery., Conclusion: This uncommon injury requires a high index of suspicion and a low threshold for intervention. CT scan offers the best imaging potential.

Transcription factors play an important role during pancreatic development ensuring normal differentiation of the islet endocrine cells. In mature beta-cells, expression of specific transcription factors is essential in maintaining normal beta-cell function.

Background: Endovascular aneurysm repair (EVAR) (using an Federal Drug Association-approved AneuRx device) compared to conventional surgical repair of abdominal aortic aneurysm (AAA) previously rendered favourable outcomes regarding post-operative pain, avoidance of laparotomy, and rapid rehabilitation and hospital discharge in high-risk patients, including octagenarians., Objectives: To assess the safety, reduction in aneurysm-related deaths, and interim survival data up to 72 months after AAA exclusion by endoluminal endografts (EVAR)., Design: We carried out an open, controlled, prospective, multidisciplinary EVAR study for the period 1998 to 2003 (six years). In the earlier part of the study, EVAR was compared with previously published results of conventional open aneurysmectomy surgery., Setting: Heart Unit, Panorama Medi-Clinic, Parow, South Africa., Participants: We recruited adult male and female patients presenting with AAA and fulfilling the inclusion criteria for endovascular repair, as recommended by the consensus 2003 meeting of the Vascular Association of South Africa (VASSA). All patients were offered open surgery as an alternative and were entered into the VASSA EVAR trial registry. Pre-operatively, AAA anatomy was assessed by spiral-computed tomography (CT), and selectively with conventional angiography and intravascular ultrasound (IVUS). Informed consent was obtained in accordance with the recommendations of the Senate of Surgery Paper 2, Ethical Guidelines, Great Britain and Ireland. Patients underwent EVAR by a multidisciplinary interventional team., Interventions: Two hundred and seven adult patients with AAA were assessed. Forty-four of the 207 (21.2%) were excluded from EVAR because of irreversible comorbid factors and complex aneurysm morphology. One hundred and sixty-three patients (78%), with a mean age of 70.7 years (range 60-91 years), underwent EVAR (1998-2003). Five patients were lost to follow-up (3%). Median AAA diameter was 56.9 mm and ASA ratings were I, 1.2%; II, 15.9%; III, 57%; IV, 22.6%; and V, 2.4%. EVAR was performed in high- and low-risk categories of both sexes. Most patients were in ASA groups III and IV. DEVICES DEPLOYED: EVAR was performed using a selection of endografts over 72 months- AneuRx (Medtronic) 47; Talent (Medtronic) 49; Vanguard three; Zenith (Cook) one; Powerlink (Endologix) 62; and other, one., Results: Thirty-day outcome: successful deployment 99%, primary stent patency 97%, surgical conversion 0.6%, procedural or intra-operative mortality 1.2%, 30-day mortality 4.3%, endoleaks 1.84%, and secondary intraprocedural endovascular interventions 24.5%. Perioperative mortality was 3.1% (one aneurysm related). One patient had suspected endograft infection. Late mortality was 21.4% (35 patients due to co-morbidities, and one was aneurysm related). Follow-up was a median of 28.3 months (range 1-69 months). In 163 patients, two persisting endoleaks (1.2%) were detected. Endotension was detected in 3/163 (1.8%) with average sac increase of 0.8 cm. Conversion to open surgery was needed in one patient (0.6%). Co-morbidities that contributed to late mortality included multi-organ failure, ischaemic heart disease (IHD), cardiomyopathy, renal failure, stroke and cancer. One procedural rupture was fatal (0.6%). Two late ruptures occurred; one was successfully endostented and the other patient died after a failed surgical intervention (0.6%). Endovascular repair of AAA is more expensive than conventional surgery. Introduction of the Endologix stent has reduced operative time from 120 to 60 minutes in un complicated patients. Newer-generation aortic stents allow better control of negative remodeling and stent migration., Conclusion: A multidisciplinary team can safely perform EVAR, with a low 30-day mortality rate in selected patients graded ASA II-IV and with favourable aortic aneurysm morphology. About 22% of patients with AAA are not suited for EVAR. Persisting late endoleaks occurred in 1.2% of the cohort study and were not device specific. Life-long follow-up post EVAR is a prerequisite to detect late device failure, endoleaks and aneurysm-sac enlargement, and to assure the durability of these midterm results. Short-term aneurysm rupture prevention is a predictable outcome in high-risk groups.

The primary objective of this cadaveric study was to review the morphological variations of the anatomy of the human carotid artery bifurcation relevant to carotid endarterectomy (CEA) and carotid artery stent-supported angioplasty (CSSA). We quantify carotid bifurcation plaque morphology. Results showed that the angle of deviation at the origin of the internal carotid artery (ICA), in relation to the common carotid artery (CCA), measured a mean of 21.8 degrees with a range from seven to 45 degrees. This anatomical finding is important for the interventionalist concerned with insertion of a carotid stent. The angle of the ICA origin may be an independent risk factor for early atherosclerotic changes at the ICA bulb. Carotid bifurcation plaque was observed in a small, random cohort of seven out of 13 cadavers, and contributed to a mean stenosis of 15.2% (range 5.0-34.8%). Plaque morphology (n = 7) showed haemorrhage (29%), superficial thrombosis (57%), calcification (71%), areas of focal necrosis (71%), neovascularisation (14%) and infiltrates (29%). Ulcerations were not detected. Although four out of 13 patients (31%) died of a cerebrovascular accident, the cause of cerebral apoplexy was thought not to be associated with the carotid bifurcation pathology. 'Re-boring' of occluding plaque, as in CEA, offers potential volumetric anatomical advantage over CSSA within the carotid bifurcation and bulb. In conclusion, precise and applied knowledge of carotid bifurcation anatomy is critical to reduce technical complications during CEA or CSSA. This information may reduce potential dangers of iatrogenic thrombo-embolism and ensuing neurologic deficits. Patients with low-grade carotid stenosis, evidence of focal plaque necrosis, are at risk of spontaneous plaque cap rupture, distal thromboembolism and stroke.

Endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) is an established alternative option to conventional surgery for AAA, provided optimal anatomical morphology of the aneurysm sac, neck and outflow exists. In most documented series of EVAR, type-II endoleak occurrence is a universal procedural drawback. This is referred to as the Achilles heel of EVAR. This morphological study, addressing predominantly non-aneurysmal aortic anatomy, reveals the dyssynchronous origins of the renal ostia, ectopia of the superior mesenteric artery and median sacral artery, variations in the length of the infrarenal abdominal aorta, multiple mainstem renal arteries, and the presence of accessory renal arteries (in 13% of cadavers). Such potential vascular anomalies need careful consideration pre-operatively prior to EVAR. In a prospective, clinical study of EVAR in 163 patients over 60 months, using four different aortic stent devices, we demonstrated an intraprocedural type-II endoleak rate, before exclusion, of 3% (5/163). Most were related to patent lumbar arteries. An active policy of intraprocedural aneurysm pressure sac measurement and angiography was used to demonstrate type-I and type-II endoleaks, focusing on the applied anatomy of aortic side branches and variations. Selective intraprocedural coil embolisation and thrombin injection into the sac was utilised to thrombose persisting and large lumbar arteries that predisposed to retroleaks. We recorded a low incidence of persisting type-II endoleaks using this proactive treatment strategy by addressing variant aortic morphology and patent lumbar arteries during EVAR. One aneurysm-related death (0.6%) was observed due to late rupture after EVAR, and a single intraprocedural death was related to unpredictable aneurysm rupture. In conclusion, comprehensive anatomical knowledge of the abdominal aorta and its main collateral side branches, including variations, is a fundamental prerequisite if satisfactory and predictable results are to be achieved after EVAR, especially regarding prevention, diagnosis and treatment of type-II endoleaks. Intraprocedural aneurysm sac pressure monitoring, coil embolisation and the use of injection of thrombin into the aneurysm sac of selected patients is useful in reducing the incidence of post-EVAR type-II persisting endoleaks.

Objectives: To focus attention of the clinician on the anatomy and (patho)physiology of the vertebral venous system, so as to offer a tool to better understand and anticipate (potential) complications that are related to the application of percutaneous vertebroplasty and kyphoplasty., Background: Percutaneous vertebroplasty and kyphoplasty are newly developed, minimally invasive techniques for the relief of pain and for the strengthening of bone in vertebral body lesions. With the clinical implementation of these techniques, a number of serious neurologic and cardiopulmonary complications have been reported in the international medical literature. Most complications appear to be related to the extrusion of bone cement into the vertebral venous system., Methods: The literature about complications of percutaneous vertebroplasty and kyphoplasty is reviewed, and the anatomic and (patho)physiologic characteristics of the vertebral venous system are reported. Based on what is currently known from the anatomy and physiology of the vertebral venous system, the procedures of percutaneous vertebroplasty and kyphoplasty are analyzed, and suggestions are made to improve the safety of these techniques., Conclusions: Thorough knowledge of the anatomic and (patho)physiologic characteristics of the vertebral venous system is mandatory for all physicians that participate in percutaneous vertebroplasty and kyphoplasty. To reduce the risk of cement extrusion into the vertebral venous system during injection, vertebral venous pressure should be increased during surgery. This can be achieved by operating the patient in the prone position and by raising intrathoracic venous pressure with the aid of the anesthesiologist during intravertebral instrumentation and cement injection. Intensive theoretical and practical training, critical patient selection, and careful monitoring of the procedures, also taking into account patient positioning and intrathoracic and intra-abdominal pressures, will help to facilitate low morbidity outcomes in these very promising minimally invasive techniques.

The major salivary glands include the paired parotid, submandibular and sublingual glands. Salivary glands act as accessory digestive glands and produce a secretion referred to as saliva. Saliva has lubricating, cleansing, digestive and antimicrobial properties. The parotid is the largest salivary gland and saliva is secreted into the mouth via the parotid duct (Stensen's duct). The submandibular gland lies inferior to the body of the mandible and is susceptible to sialolithiases. Drainage is via the duct of the submandibular gland (Wharton's duct) into the floor of the mouth on either side of the lingual frenulum. The sublingual glands are situated under the mucosa in the floor of the mouth, on the sides of the tongue. These glands are in relationship to important nerves in the surrounding tissue. Disease processes such as chronic intraparenchymal sialolithiasis and neoplastic changes frequently mandate surgical removal of the underlying salivary gland. Detailed, applied knowledge of anatomy on a regional basis is required to avoid inadvertent nerve damage during surgery and resulting litigation.

Context: The use of foetal tissue is an emotive issue and attempts are being made to find suitable alternative replacements. A duct ligated pancreas resembles day 16-17 post-coitum foetal pancreas tissue, both being predominantly endocrine structures., Objective: The aim of this study was to quantify the metabolic changes occurring in chemically induced diabetic rats over a 30 day period following transplantation of duct ligated tissue beneath the renal capsule., Setting: Thirty normal Sprague-Dawley laboratory rats., Design: The rats were grouped as transplant recipients (A), untreated diabetic (B), untreated normal (C), sham operated controls (D) and donors of duct ligated pancreatic tissue (E)., Interventions: Groups A and B received 60 mg/kg streptozotocin via a tail vein rendering them diabetic. Groups D and E underwent mid-line laparotomy under general anaesthesia with pancreatic duct ligation procedures performed on E in addition., Main Outcome Measures: Blood glucose was monitored daily in Groups A, B, C and D, and exogenous insulin was administered in Groups A and B as required. Glucose tolerance tests were performed on day 3.5 and after 30 days in Groups A (just prior to unilateral nephrectomy), B, C and D. In addition, in Group A, they were repeated one week after the removal of the grafted tissue. The removed grafts were processed for histological examination., Results: The metabolic profile of the transplant recipients compared favourably with that of normal animals., Conclusion: A chemically or mechanically manipulated pancreas may respond to exogenous insulin therapy by undergoing some degree of regeneration or owing to the pluripotent stem cells thought to reside in the pancreas. Although insulin positive tissue was evident at the graft site, morphometric assessment, however, found no significant increase in the insulin secreting tissue in the pancreas compared to the untreated diabetic controls.

Choking on aspirated food or a foreign body (i.e. meat, mushroom, coin, chewing gum and a balloon) is a common cause of laryngeal obstruction, particularly in those persons who are intoxicated by alcohol or who have bulbar palsy (degeneration of motor neurons in the brain stem nuclei of the glossopharyngeal and vagal nerve). The rima glottis in the larynx is an important site where aspirated food or material becomes lodged, thereby causing laryngeal obstruction (choking). Because the lungs still contain air, intentional compression thrusts to the abdomen (Heimlich manoeuvre) will theoretically expel air from the lungs and dislodge the entrapped food or other material. The manoeuvre can also be used to expel aspirated water from the airways in cases of near drowning. The manoeuvre has been found to be successful as an emergency adjunct measure in removing food blocking the airway.

Background: This study evaluated a single-centre experience with endovascular repair of traumatic arteriovenous fistula in the cervicothoracic region., Methods: Endovascular repair of 27 traumatic cervicothoracic arteriovenous fistulas was attempted between August 1998 and December 2001. Patients with active bleeding or end-organ ischaemia were excluded. Follow-up was accomplished with clinical, duplex Doppler and arteriographic evaluation after 1 month and then every 3 months., Results: Twelve patients with a major vessel injury were treated by stent-graft placement. Vessels involved were the subclavian (eight), common carotid (three) and internal carotid (one) arteries. Subclavian artery side branches were embolized in three of the eight patients. Four patients developed early type 4 endoleaks but all resolved. Treatment with stent-grafts was ultimately successful in all 12 patients. Three patients were lost to follow-up. During mean follow-up of 21 (range 3-36) months, one of the remaining patients developed a graft stenosis. Fifteen patients with minor vessel injuries were treated with arterial embolization. Vessels embolized were subclavian artery branches (four), external carotid artery and branches (seven) and vertebral arteries (four). Successful embolization was accomplished in ten of 15 patients., Conclusion: Endovascular therapy is a promising alternative to surgery for selected patients with cervicothoracic arteriovenous fistula., (Copyright 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

The tongue (L. lingua; G. glossa) functions as a digestive organ by facilitating the movement of food during mastication and assisting swallowing. Other important functions include speech and taste. The tongue consists of striated muscle and occupies the floor of the mouth. The dorsal mucosal surface consists of stratified squamous epithelium, with numerous papillae and taste buds. The tongue, a voluntary muscular structure, is attached by a fold, called the frenulum, to the floor of the mouth. Typically, between 8 and 12 circumvallate papillae are arranged in an inverted V-shape towards the base of the tongue. This anatomical review focuses on structure, function relationships and diseases affecting the tongue. From a primary oral health care perspective, this overview will facilitate the process of differential diagnosis in persons presenting with vesiculo-bullous, ulcerative, atrophic and cystic disorders of the tongue. Suspicious lesions should be biopsied to rule out carcinoma.

The auditory (Eustachian) tube connects the middle ear with the nasopharynx. This conduit permits equalisation of pressure between the middle ear and the throat. Balanced pressure allows the eardrum to vibrate freely as sound waves strike it. The auditory tube is also a potential anatomical route whereby opportunistic pathogens may migrate from the nose and throat to the middle ear. Eustachian tube (ET) function is disturbed in children with cleft palate, thereby rendering them susceptible to chronic otitis media with effusion (OME) and temporary conductive deafness. ET obstruction follows in these patients, and is thought to be related to the inability of the tensor veli palatini (TVP) to function properly. This anatomical overview reviews the clinical importance of the ET in the normal population and children with cleft palate.

Purpose: We undertook this study to determine factors that adversely affect outcome in patients with penetrating injury to the extracranial cerebral vasculature. Patients and methods Medical records were reviewed for all patients who had undergone surgical intervention to treat penetrating injury to the extracranial cerebral arteries between January 1989 and December 1999. Forensic autopsy findings were also reviewed for all patients who died as a result of their injury., Results: One hundred fifty-one patients with injury to the brachiocephalic artery (n = 21), common carotid artery (n = 98), or internal carotid artery (n = 32) were identified. Overall mortality was 21.2%, and stroke rate in surviving patients was 15.1%. Twenty-five of 32 deaths (78.1%) were stroke-related. Brachiocephalic artery injury was associated with the highest mortality (38.1%), and survivor stroke rate was highest in patients with internal carotid injuries (22.7%). Hemodynamic instability at presentation led to both higher mortality (30.7%) and stroke rate (19.2%). Preoperative angiography did not influence mortality or stroke rate in hemodynamically stable patients. Procedural mortality associated with arterial ligation was 45% (9 of 20 patients), and no surviving patient experienced a change in pre-ligation neurologic state. Nine patients remained neurologically intact after ligation, and 2 patients with preoperative localized neurologic deficit were unchanged postoperatively. In 131 patients, mortality after arterial repair was 17.6%, and in 5 surviving patients (5.4%) an ischemic neurologic deficit developed. Twelve of 15 surviving patients (80%) with preoperative neurologic deficit who underwent arterial repair had improved neurologic status. Cerebral infarcts were confirmed at autopsy in 23 patients; 18 infarcts were ischemic (10, repair; 8, ligation), and 5 infarcts were hemorrhagic (all, repair). No factor was identified that was predictive of ischemic versus hemorrhagic infarction in patients undergoing repair., Conclusions: The presence of hypovolemic shock, internal carotid artery injury, complete vessel transection, and arterial ligation are associated with unfavorable outcome. Penetrating injury to the brachiocephalic, common carotid, or internal carotid artery should be repaired rather than ligated when technically possible. Subsequent ischemic or hemorrhagic cerebral infarction is unpredictable, but overall outcome is superior to that with ligation of the injured artery.

N. lingualis supplies general sensory branches to the mucosa of the anterior two-thirds of the tongue, sublingual mucosa and the mandibular lingual gingiva. From an oral surgery point of view, the course of the lingual nerve is critical due to the intimate medial relationship to the roots of the mandibular third molar. "Hitch-hiking" special sensory taste fibres from the chorda tympani (cranial nerve seven) are distributed to the mucosa of most of the anterior two-thirds of the tongue, together with the general sensory branches derived from the mandibular division of the trigeminal nerve. The circumvallate papilLae anterior to the sulcus terminalis are supplied by special sensory fibres (taste) of the glossopharyngeal nerve, latrogenic lingual nerve injury, subsequent to mandibular wisdom teeth removal, can result in irreversible gustatory deficits and somatosensory dysfunction. Patients undergoing oral surgery for impacted mandibular molars should be informed of the anatomical relationship of the lingual nerve to the roots, and the implications of denervation.

Anatomically, the auriculo-temporal nerve (ATN), a peripheral branch of the trigeminal nerve is in close relation to the parotid gland, neck of the mandible, temporal vessels, and sphenomandibular ligament. Fine branches of the ATN are at risk of division during surgical intervention of the parotid gland or condyle of the mandible. "Frey's syndrome", or abnormal gustatory sweating, may be a consequence of injury to the branches of the auriculo-temporal nerve. This uncommon syndrome can also occur with fractures of the temporo-mandibular joint (TMJ), due to the anatomic proximity of the nerve to the bone.

Objectives: To evaluate the results of an evolving policy of primary repair of duodenal injuries, when considered feasible and safe, complemented by pyloric exclusion if any doubt as to the integrity of the repair existed., Patients and Methods: A prospective analysis of all patients with surgically identified duodenal injuries treated at a single institution over a 3-year period., Results: In 30 patients studied, there were four deaths (13%) and an overall complication rate of 47%. There were 68 associated intra-abdominal injuries in 29 patients. Primary duodenorraphy was employed in 18 patients (60%), pyloric exclusion in 11 (37%) and pancreatoduodenectomy in one patient (3%). No failures of duodenal repair were recorded., Conclusion: Adverse results in patients with duodenal trauma are largely a reflection of frequent associated injuries and their consequences. Selective, liberal employment of pyloric exclusion, based on individualized intra-operative assessment, can minimize duodenum-related morbidity.

Purpose: To describe the endovascular repair of 2 subclavian arteries occluded due to penetrating trauma., Case Reports: Two male patients were admitted with zone-I neck stab wounds. Both were hemodynamically stable and had absent pulses in the ipsilateral upper limb with decreased Doppler pressures. There were no signs of critical ischemia or active bleeding. On arteriography, complete occlusion of the second segment of the left subclavian arteries in both patients was demonstrated. Stent-graft repair and embolectomy under local anesthesia were successfully performed. No procedure-related complications occurred, and both patients were discharged after 2 days. At 1-year follow-up, stent-graft patency was demonstrated in both patients., Conclusions: Endovascular repair is a feasible and safe option in the management of occluded subclavian arteries due to penetrating trauma. This may represent another indication for stent-grafting in the expanding role of this technique.

Context: Ligation of the pancreatic duct, distally to its confluence into the bile duct has been shown to induce endocrine tissue regeneration. The surplus endocrine tissue formed is presumed to be able to replace pathologically and/or experimentally compromised tissue., Objective: This is a quantitative study on the histology of duct ligated pancreas employing immunocytochemistry and computerised morphometry., Interventions: Pancreatic duct ligation was performed on 25 groups of six normal Sprague-Dawley rats. Experimental animals were sacrificed at 12-hour intervals from day one to ten post-duct ligation and every 24 hours thereafter to day 14, the pancreas removed, fixed and processed. Six consecutive 3-6 micron serial sections were cut on a rotary hand microtome, floated onto 3-aminopropyl-trimethoxysilan coated slides and alternatively immunocytochemically stained for insulin, glucagon, pancreatic polypeptide and somatostatin., Results: Pancreas transformation between days 1/2 and 3 1/2 was characterised by acinar deletion and the appearance of immunoreactive cells for the primary endocrine hormones. Transdifferentiation of existing endocrine tissue saw islet insulin core cells replaced by pancreatic polypeptide- and somatostatin positive cells, glucagon deletion and random appearance of all endocrine cell types within the inter-islet interstitium by day 3 1/2. Days 4 to 14 were characterised by cellular migration and islet reconstruction., Conclusions: To date our laboratory has investigated transplantation of foetal tissue beneath the renal capsule in syngeneic, isogeneic and allogeneic normal and diabetic rats. As pancreatic duct ligation induces the development of surplus endocrine tissue our next step would be to investigate the use of ligated pancreas as a replacement for foetal tissue.