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Effective management of the upper nasal vault is based on a thorough preoperative analysis and detailed understanding of the requisite principles and techniques utilized to modify the anatomic structures in this region. The surgeon must equally consider form and function when performing manipulation of the upper nasal vault. Special considerations apply when managing this anatomic region via an endonasal or closed approach. A review of this topic is presented with a focus on techniques as they apply to the endonasal rhinoplasty patient.

To evaluate the feasibility of adding pathology to recent radiologist error characterization schemes of modality and anatomic region and the potential of this data to more specifically inform peer review and peer learning. Quality assurance data originating from 349 radiologists in a national teleradiology practice were collected for 2019. Interpretive errors were simply categorized as major or minor. Reporting or communication errors were classified as administrative errors. Interpretive errors were then divided by modality, anatomic region and placed into one of 64 pathologic categories. Out of 1,628,464 studies, the discrepancy rate was 0.5% (8181/1,634,201). The 8181 total errors consisted of 2992 major errors (0.18%) and 5189 minor errors (0.32%). Precisely, 3.1% (257/8181) of total errors were administrative. Of major interpretive errors, 75.5% occurred on CT, with CT abdomen and pelvis accounting for 40.4%. The most common pathologic discrepancy for all exams was in the category of mass, nodule, or adenopathy (1583/8181), the majority of which were minor (1315/1583). The most common pathologic discrepancy for the 2937 major interpretive errors was fracture or dislocation (27%; 793/2937), followed by bleed (10.7%; 315/2937). The addition of error-related pathology to peer review is both feasible and practical and provides a more detailed guide to targeted individual and practice-wide peer learning quality improvement efforts. Future research is needed to determine if there are measurable improvements in detection or interpretation of specific pathologies following error feedback and educational interventions.

Mask wearing is now ubiquitous because of the COVID-19 pandemic and has given rise to medical device-related pressure injuries in persons at risk of skin breakdown. The ear has unique anatomy that is particularly susceptible to injury from pressure. In this time of mandatory personal protective equipment requirements in healthcare facilities, protection and assessment of skin in the vulnerable postauricular area are needed. This article presents a case report of a pressure injury on the ear, reviews the anatomy of the ear, and provides strategies for assessment and treatment of pressure injuries in this often overlooked anatomic region.

OBJECTIVE. This article reviews the embryologic development, relevant anatomy, and imaging features, on CT, of pathologic processes involving the lesser sac and foramen of Winslow. CONCLUSION. The lesser peritoneal sac is an intricate anatomic region involved in many disease processes. It is a significant conduit for the spread of disease within the peritoneal cavity. The spectrum of pathologic processes pertaining to the lesser sac can be classified on the basis of the type of involvement, such as a fluid collection (e.g., transudate, exudate, bile, and blood), a mass (e.g., neoplastic or nonneoplastic conditions and lymphadenopathy), or an internal hernia into the lesser sac.

The mediastinum is a complex anatomic region that can pose many diagnostic challenges on fine-needle aspiration (FNA) and core needle biopsy (CNB). With the recent technological advancements in EBUS-TBNA and EUS-guided procedures, FNA/CNB is being increasingly utilized to obtain the initial and, in many cases, the only diagnosis. As a result, it is imperative to have an understanding of the pearls and pitfalls associated with both the more common and rarer malignancies that occur at this site. Although the vast majority of mediastinal malignancies encountered in routine clinical practice are metastatic carcinomas to mediastinal lymph nodes, primary tumors and tumors that directly extend into the mediastinum are also encountered. As always, a multimodal approach with clinical and radiographic correlation, a targeted IHC panel, and molecular testing when indicated are indisposable and necessary tools in the diagnostic workup of mediastinal malignancies. This review focuses on the salient diagnostic features of malignancies of epithelial and mesenchymal origin, excluding tumors of neurogenic, thymic, hematolymphoid, and germ cell origins, which are discussed in separate articles of this issue.

Objectives The groin is a complex anatomic region that has traditionally been ignored by radiologists because most lesions can be diagnosed from clinical data and physical examination. Nevertheless, ultrasound examinations of the groin are increasingly being requested to confirm injury or to resolve diagnostic uncertainty. On the other hand, some conditions involving the groin are found only in paediatric patients. This article describes the key imaging findings in paediatric groin injuries, placing special emphasis on the ultrasound appearance. Conclusions Knowledge about conditions that can affect the groin in paediatric patients and the key imaging findings associated with them helps improve the diagnostic performance of ultrasound.

Minimally invasive surgery for diseases of the chest offsets the morbidity of painful thoracic incisions while allowing for meticulous dissection of major anatomic structures. This benefit translates to improved outcomes and recovery following the surgical management of benign and malignant esophageal pathologic condition, mediastinal tumors, and lung resections. This anatomic region is particularly amenable to a robotic approach given the fixed space and need for complex intracorporeal dissection. As robotic platforms continue to evolve, more complex thoracic surgical interventions will be facilitated, translating to improved outcomes for our patients.

Background: Orthopaedic injuries in Major League Baseball (MLB) players can have a tremendous impact on player health, longevity, salaries, and time lost from play. Purpose: To summarize all data published between January 1980 and August 2019 on truncal and lower extremity orthopaedic injuries sustained by MLB players. Methods: A literature review of studies examining injuries in MLB was performed using the PubMed and Embase databases. Included studies focused on truncal and lower extremity injuries in professional baseball players. Studies pertaining to nonorthopaedic injuries, and case reports, were excluded. Results: A total of 41 articles met the inclusion criteria and were selected for the final analysis. Articles were divided based on anatomic region of injury: hip and pelvis (16%), thigh (15%), truncal (14%), knee (13%), and ankle (11%). Most studies (83.7%) were level 3 evidence. Most studies obtained data using publicly available internet resources (29.8%) compared with the MLB Health and Injury Tracking System (22.1%). Conclusion: This review provides physicians with a single source of the most current literature regarding truncal and lower extremity orthopaedic injuries in MLB players. Most research was published on hip and pelvic, truncal, and thigh injuries and consisted of level III evidence.

Inflammatory myofibroblastic tumor is an uncommon mesenchymal neoplasm, which can be seen in any anatomic region from the central nervous system to the gastrointestinal tract. Herein, we report the 68Ga-FAPI PET/CT findings in a 49-year-old man with mesenteric inflammatory myofibroblastic tumor.

Computer-assisted spine surgery based on preoperative CT imaging may be hampered by sagittal alignment shifts due to an intraoperative switch from supine to prone. In the present study, we systematically analyzed the occurrence and pattern of sagittal spinal alignment shift between corresponding preoperative (supine) and intraoperative (prone) CT imaging in patients that underwent navigated posterior instrumentation between 2014 and 2017. Sagittal alignment across the levels of instrumentation was determined according to the C2 fracture gap (C2-F) and C2 translation (C2-T) in odontoid type 2 fractures, next to the modified Cobb angle (CA), plumbline (PL), and translation (T) in subaxial pathologies. One-hundred and twenty-one patients (C1/C2: n = 17; C3-S1: n = 104) with degenerative (39/121; 32%), oncologic (35/121; 29%), traumatic (34/121; 28%), or infectious (13/121; 11%) pathologies were identified. In the subaxial spine, significant shift occurred in 104/104 (100%) cases (CA: *p = .044; T: *p = .021) compared to only 10/17 (59%) cases that exhibited shift at the C1/C2 level (C2-F: **p = .002; C2-T: *p 5 segments (“∆PL > 5 segments”: 4.5 ± 1.8 mm; “∆PL ≤ 5 segments”: 2 ± 0.6 mm; *p = .013) or in revision surgery with pre-existing instrumentation (“∆PL presence”: 5 ± 2.6 mm; “∆PL absence”: 2.4 ± 0.7 mm; **p = .007). Interestingly, typical morphological instability risk factors did not influence the degree of shift. In conclusion, intraoperative spinal alignment shift due to a change in patient position should be considered as a cause for inaccuracy during computer-assisted spine surgery and when correcting spinal alignment according to parameters that were planned in other patient positions.

Stridor, a common presenting sign of respiratory distress in a newborn, has many systemic causes. It may arise from the larynx or the tracheobronchial airway. This article presents the most common pathologic conditions in this anatomic region, with highlights on management.

Anatomical Neck Triangles are imaginary to some extent. Their significance to many surgical specialties is invaluable. Among all basic Medical sciences subjects, Anatomy is most prone to be forgotten. None of the other subjects has the amount of mnemonics described or invented compared to it. Junior years students of Medical schools need to memorize anatomy with no or very little knowledge of its clinical relevance. Relatively speaking, that can be quite cumbersome for them compared to those who are already involved in surgical residency training program, when anatomy knowledge is concerned. Surgeons who specialize or exclusively work in a selected anatomic region, they become experts and famous in their field and in that particular operation, mostly because they subconsciously become oriented to that region’s anatomy. However, those who work on various anatomical areas, frequently need to refresh their anatomy knowledge. Mnemonics, therefore are helpful for various level medical professionals. The Neck represents a relatively limited transition zone or passage of various tissue structures besides great vessels and nerves between Head, Chest and Upper extremities, very much like a three-way connector. Unless the concept of Neck triangles was there, it would have been very difficult to discuss or communicate about neck related interventional or surgical procedures. The theory of simulating Neck triangles to a Bird like creature was long thought and utilized by the author. Here we are describing this imaginary mnemonic to help in the ability of recalling and drawing those triangles. An analogy of a flying Bat is used.

Objectives Why is there a major gap between the promises of AI and its applications in the domain of diagnostic radiology? To answer this question, we systematically review and critically analyze the AI applications in the radiology domain. Methods We systematically analyzed these applications based on their focal modality and anatomic region as well as their stage of development, technical infrastructure, and approval. Results We identified 269 AI applications in the diagnostic radiology domain, offered by 99 companies. We show that AI applications are primarily narrow in terms of tasks, modality, and anatomic region. A majority of the available AI functionalities focus on supporting the “perception” and “reasoning” in the radiology workflow. Conclusions Thereby, we contribute by (1) offering a systematic framework for analyzing and mapping the technological developments in the diagnostic radiology domain, (2) providing empirical evidence regarding the landscape of AI applications, and (3) offering insights into the current state of AI applications. Accordingly, we discuss the potential impacts of AI applications on the radiology work and we highlight future possibilities for developing these applications. Key Points • Many AI applications are introduced to the radiology domain and their number and diversity grow very fast. • Most of the AI applications are narrow in terms of modality, body part, and pathology. • A lot of applications focus on supporting “perception” and “reasoning” tasks.

IntroductionAs the focus of the Royal Air Force (RAF) shifts from sustained to contingency operations and the number of personnel is reduced, the burden of retained, medically downgraded personnel may affect operational readiness. The main aims were: to define the prevalence of morbidity leading to permanent medical downgrading; to determine at risk populations and identify areas for improvement.MethodDatabase of personnel referred to the RAF Medical Board was analysed from January 2012 to October 2013 and January 2017 to December 2019. Patients were excluded if they did not require a formal medical board; incomplete and duplicate entries were also excluded. The primary reason for medical downgrade was categorised with an ICD-10 code. Further subanalysis compared musculoskeletal disease with age, individual trade groups and anatomic region.Results2% of RAF service personnel were permanently downgraded annually. Musculoskeletal disease was the leading cause for permanent downgrade across both periods: 58% and 49%. Female personnel were at a greater risk of musculoskeletal downgrade compared with males. Spinal and knee pathology were the leading cause for downgrading among ‘high risk’ personnel. Personnel downgraded due to musculoskeletal pathology were often retained in a limited role with 10% and 5% retained as medically fully deployable. 14% and 12% of personnel downgraded due to musculoskeletal pathology were medically discharged.ConclusionMusculoskeletal disease was the leading cause for permanent medical downgrades in the RAF. A greater proportion of downgraded personnel with musculoskeletal conditions were retained in service with medical limitations rather than medically discharged.

OBJECTIVE When the integrated vascular surgery training pathway was introduced, training was comprised of nearly equal amounts of core general surgery and vascular surgery experience. However, specific requirements for case numbers or types were not defined. Over time, the time spent on core general surgery requirements has been reduced, most recently in 2018, from 24 to 18 months. We sought to determine trends in general surgery case volume and type over the past 10 years for vascular surgery residents. METHODS We conducted a retrospective review of the Accreditation Council for Graduate Medical Education case log data for integrated vascular surgery graduates from 2012-2018. We evaluated trends in mean numbers of cases, categorized as general surgery open (GS-open), general surgery laparoscopic (GS-laparoscopic), vascular surgery open (VS-open), and vascular surgery endovascular (VS-endo). Cases were also categorized by anatomic region as head/neck, thoracic, or abdominal. RESULTS The mean number of total head/neck, thoracic, or abdominal cases logged by graduating integrated vascular surgery trainees was 263.5. This total, as well as the proportion of general surgery cases (35%-38%, p = 0.99) has remained constant over time. The type of general surgery cases has changed significantly, with an upward trend in the mean number of GS-open cases and downward trend in mean GS-laparoscopic cases (GS-open p = 0.006, GS-laparoscopic p = 0.048). Among head/neck and thoracic subgroups, no significant changes were observed, while in the abdominal subgroup, there has been a significant increase in GS-open over time (p = 0.005). Additionally, the number of open vascular abdominal aortic cases has remained stable, with an average of 36.82 per graduating trainee per year. CONCLUSIONS In the 10 years since the introduction of integrated vascular surgery programs, total case volume and proportion of general surgery cases have remained remarkably stable. The type of general surgery cases has shifted though, with a decrease in GS-laparoscopic cases, replaced primarily by open abdominal cases. These changes likely reflect integrated vascular residents actively seeking out these opportunities during their core rotations and a willingness by general surgery partners to provide these opportunities. At the program level, these data may help guide program directors’ choices about the specific core rotations they incorporate into their curriculum. At the national level, this information may contribute to future discussions regarding the optimal number of core general surgery rotation requirements.

Objetivos: Avaliar a influência da geometria dos implantes e região anatómica na estabilidade implantar. Métodos: Foi realizado um ensaio clínico controlado aleatorizado em 45 pacientes, onde foram colocados 79 implantes: 40 implantes MIS C1 e 39 implantes MIS Seven. O coeficiente de estabilidade do implante foi medido através da análise de frequência de ressonância (RFA) imediatamente após a colocação do implante e 8 semanas depois, com Osstell Mentor. Resultados: Foram analisados 76 implantes. O coeficiente de estabilidade do implante registado para estabilidade secundária foi significativamente maior que o verificado para a estabilidade primária (68,7±8,6 e 65,2±10,3, p=0,023). Considerando a estabilidade primária, não foi encontrada diferença estatisticamente significativa entre os comprimentos de 8,0 mm, 10,0 mm, 11,0 mm e 11,5 mm (67,9±7,6, 63,9±10, 57,2±11,1 e 66,4±11,3, p=0,312). O mesmo foi verificado para a estabilidade secundária (68,4±9,4, 67,9±9,3, 74,7±1,5 e 69,2±7,9, p=0,504). Não se observou diferença estatisticamente significativa entre os diâmetros dos implantes de 3,75 e 4,20 mm e estabilidade primária (64,3±8,7 e 66,1±11,7, p=0,445) ou estabilidade secundária (68,8±8,2 e 68,7±9,1, p=0,930). Foi encontrada diferença estatisticamente significativa para a estabilidade secundária, favorecendo o implante MIS Seven (p=0,048). A localização intraoral foi estatisticamente significativa para a estabilidade primária e secundária, sendo maior na maxila anterior em relação à maxila e mandíbula posteriores (p

New next-generation low-field magnetic resonance imaging systems (operating in the range of 0.5 T) hold great potential for increasing access to clinical diagnosis and needed health care both in developed countries and worldwide. The relevant history concerning the choice of field strength, which resulted in 1.5 T still dominating today the number of installed systems, is considered, together with design advances possible because of interval developments, since low field was considered for clinical use in the 1980s, and current research. The potential impact of low-cost, advanced-generation low-field magnetic resonance imaging systems, properly designed, is high in terms of further dissemination of health care-across the gamut from industrial to developing countries-regardless of disease entity and anatomic region of involvement, with major niche applications likely as well.

BACKGROUND The petrous apex is a complex anatomic region for which each surgical approach each has distinct limitations. The authors describe the use of frontal sinus instrumentation for the endonasal endoscopic approach to petrous apex lesions OBJECTIVE:: To demonstrate that the angled design of frontal sinus instrumentation has pronounced clinical utility for the transsphenoidal transclival approach to the petrous apex. METHODS The authors present cases of expansile petrous apex lesions approached endoscopically via transsphenoid and transclival corridors, and highlight the technique of using curved frontal sinus instruments and angled endoscopes for posterolateral reach in the petrous apex dissection. RESULTS As demonstrated in the accompanying video, dissection with frontal sinus instrumentation allows the surgeon to navigate around the internal carotid artery. CONCLUSIONS Significant technical and technological advances have been made in the field of expanded endoscopic endonasal skull base surgery in the past 3 decades. Increasing efforts are made to push the boundaries and access more laterally located lesions, such as those in the petrous apex. Surgical trajectory or vector is paramount to safely navigate around the internal carotid artery.

The incorporation of perspective into art and science revolutionized the study of the brain. Beginning in about 1504, Leonardo da Vinci began to model the ventricles of the brain in three dimensions. A few years later, Andreus Vesalius illustrated radically novel brain dissections. Thomas Willis' work, Cerebri Anatome (1664), illustrated by Christopher Wren, remarkably showed the brain undersurface. Later, in the early 1800s, Charles Bell's accurate images of neural structures changed surgery. In the 1960s, Albert L. Rhoton Jr. (1932–2016) began to earn his place among the preeminent neuroanatomists by focusing his lens on microanatomy to harness a knowledge of microneurosurgery, master microneurologic anatomy, and use it to improve the care of his patients. Although his biography and works are well known, no analysis has been conducted to identify the progression, impact, and trends in the totality of his publications, and no study has assessed his work in a historical context compared with the contributions of other celebrated anatomists. We analyzed 414 of 508 works authored by Rhoton; these studies were analyzed according to subjects discussed, including anatomic region, surgical approaches, subjects covered, anatomic methods used, forms of multimedia, and subspecialty. Rhoton taught detailed neuroanatomy from a surgical perspective using meticulous techniques that evolved as the technical demands of neurosurgery advanced, inspiring students and contemporaries. His work aligns him with renowned figures in neuroanatomy, arguably establishing him historically as the most influential anatomist of the neurosurgical era.

The right atrial appendage (RAA) vestibule is an area located in the right atrium between the RAA orifice and the right atrioventricular valve annulus and may be a target for invasive transcatheter procedures.We examined 200 autopsied human hearts. Three isthmuses (an inferior, a middle, and a superior isthmus) were detected. The average length of the vestibule was 67.4 ± 10.1 mm. Crevices and diverticula were observed within the vestibule in 15.3% of specimens. The isthmuses had varying heights: superior: 14.0 ± 3.4 mm, middle: 11.2 ± 3.1 mm, and inferior: 10.1 ± 2.7 mm (p .001). The superior isthmus had the thickest atrial wall (at midlevel: 16.7 ± 5.6 mm), the middle isthmus had the second thickest wall (13.5 ± 4.2 mm), and the inferior isthmus had the thinnest wall (9.3 ± 3.0 mm; p .001). This same pattern was observed when analyzing the thickness of the adipose layer (superior isthmus had a thickness of 15.4 ± 5.6 mm, middle: 11.7 ± 4.1 mm and inferior: 7.1 ± 3.1 mm; p .001). The average myocardial thickness did not vary between isthmuses (superior isthmus: 1.3 ± 0.5 mm, middle isthmus: 1.8 ± 0.8 mm, inferior isthmus: 1.6 ± 0.5 mm; p .05). Within each isthmus, there were variations in the thickness of the entire atrial wall and of the adipose layer. These were thickest near the valve annulus and thinnest near the RAA orifice (p .001). The thickness of the myocardial layer followed an inverse trend (p .001).This study was the first to describe the detailed topographical anatomy of the RAA vestibule and that of its adjoining isthmuses. The substantial variability in the structure and dimensions of the RAA isthmuses may play a role in planning interventions within this anatomic region.

Reconstruction of soft tissue craniofacial trauma represents a challenging and common problem. The soft tissue structures of the head and neck contain complex 3-dimensional geometry spanning across multiple subunits and structures. Each anatomic region requires careful attention in its repair to meet exacting aesthetic and functional demands. No other region of the body is as scrutinized during social interaction as the face, where even minute deformity is readily detectable at conversational distance. This chapter outlines the proper evaluation and treatment of soft tissue injury across the several subunits of the head and neck. Multiple cases are presented to demonstrate the variety of reconstructive options from simple closure to microsurgical techniques.

Biopsy samples are removed by inserting an endoscopic accessory. The current passive biopsy forceps have limited controllable bending movement. There is a need for actively bendable forceps for biopsy, with a more excellent range of motion to navigate small corners with spatial constraints within the narrow anatomic region. EndoGoose, a flexible biopsy forceps, is conceptualized in conjunction with existing endoscopes to perform actively steerable biopsies. The flexible biopsy tool system for an endoscope comprises a bendable gooseneck section, forceps, and control box. The gooseneck is used to maintain the position of the forceps after the desired position is attained from active steering. It provides the rigidity when it is being pushed out of the endoscopes. It can withstand forces of gravity acting on the distal end, long enough for the biopsy sample to be grasped, without the need to continue applying a force from the proximal end to retain the position of the forceps. The standards and requirements are in regard to the operator’s needs. Metrics benchmarking and functional specifications highlight the capabilities and how the operator can interact with it. The acceptance criteria ensure the prototype is safe and effective for use.

One patient with bladder leiomyosarcoma and urothelial carcinoma is very rare. Only 10 cases have been reported in the literature. A 70-year-old patient was admitted due to bladder tumor. Two TURBTs were performed confirming the patient was free of tumor, and pathology reported low-grade urothelial carcinoma. Three years later, a tumor was also found on the right anterolateral wall of urinary bladder and was diagnosed as leiomyosarcoma by pathological examination. Radical cystectomy was performed. With 45 months follow-up, the patient has no recurrence. Two malignancies in the same anatomic region at different time has never been reported to date.

PurposeThis study aimed to determine the volumes and types of magnetic resonance imaging exams being performed across Canada, common indications for the exams, and exam appropriateness using multiple evaluation tools.MethodsThirteen academic medical institutions across Canada participated. Data were obtained relating to a single common day, October 1, 2014. Patient demographics, type by anatomic region and indication for imaging were analysed. Each exam was assessed for appropriateness via the Canadian Association of Radiologists Referral Guidelines and the American College of Radiology Appropriateness Criteria. The Alberta and Saskatchewan spine screening forms and the Alberta knee screening form were also used where applicable. The proportion of exams that were unscorable, appropriate, and inappropriate was determined. Exam-level results were compared between the 2 main evaluation tools.ResultsData were obtained for 1087 relevant exams. There were 591 women and 460 men. 36 requisitions did not indicate the patient's sex. Brain exams were the most common, comprising 32.5% of the sample. Cancer was the most common indication. Overall, 87.0%–87.4% of the MR exams performed were appropriate; 6.6%–12.6% were inappropriate, based on the 2 main evaluation tools. Results differed by anatomic region; spine exams had the highest proportion, with nearly one-third of exams deemed inappropriate.ConclusionVariations by anatomic region indicate that focused exam request evaluation or screening methods could substantially reduce inappropriate imaging.

Objective The purpose of this study was to compare the relative efficacy of immobilization systems in limiting thoracic-lumbar movements. Methods A dynamic simulation system was used to reproduce transport-related shocks and vibration, and involuntary movements of the thoracic-lumbar region were measured using 3 immobilization configurations. Results The vacuum mattress and the long spine board were generally more effective than the cot alone in reducing thoracic-lumbar rotation and flexion/extension. However, the vacuum mattress reduced these thoracic-lumbar movements to a greater extent than the long spine board. In addition, the vacuum mattress significantly decreased thoracic-lumbar lateral movement relative to the cot alone under all simulated transport conditions. In contrast, the long spine board allowed greater lateral movement than the cot alone in a number of the simulated transport rides. Conclusion Under the study conditions, the vacuum mattress was more effective for limiting involuntary movements of the thoracic-lumbar region than the long spine board. Moreover, the increased lateral bend observed with the long spine board under some conditions suggests it may be inadequate for immobilizing this anatomic region as presently designed. Should emergency medical service providers choose to immobilize patients with suspected injuries of the thoracic-lumbar spine, study results support the use of the vacuum mattress.

Background and aim: A wide variety of foreign bodies have been found in the urinary bladder, most often due to self-introduction and autoerotism, or iatrogenically introduced during surgery in the anatomic region. We report the first case of a gastric banding clip found in the urinary bladder. Case presentation: We describe the case of a 33-year-old Chinese female who had previously undergone gastric banding and subsequent removal of the band. She presented with lower urinary tract symptoms which followed a diurnal pattern, and investigations revealed a portion of a gastric banding clip in the urinary bladder. There was no sign of perforation or erosion of the bladder. The clip was surgically removed and the patient recovered without complications. Discussion and conclusion: This is the first reported case of an intraperitoneal gastric banding clip migrating extraperitoneally into the urinary bladder. The use of the urinary bladder to expel foreign bodies has been documented in other vertebrates, and the mechanism by which this occurs without perforation or erosion of the urinary bladder warrants further investigation.

The blood–brain barrier (BBB) is a barrier that separates the blood from the brain tissue and possesses unique characteristics that make the delivery of drugs to the brain a great challenge. To achieve this purpose, it is necessary to design strategies to allow BBB passage, in order to reach the brain and target the desired anatomic region. The use of nanomedicine has great potential to overcome this problem, since one can modify nanoparticles with strategic molecules that can interact with the BBB and induce uptake through the brain endothelial cells and consequently reach the brain tissue. This review addresses the potential of nanomedicines to treat neurological diseases by using nanoparticles specially developed to cross the BBB.

Healthy cattle readily use grooming brushes but this behavior subsides when animals become ill. Tracking use of a brush may provide an opportunity for health monitoring, especially if the process could be automated. We assessed how healthy heifers groom themselves on a brush and hypothesized that radiofrequency identification (RFID) could be used to accurately and automatically record this behavior. Angus and Hereford heifers (n = 16) were fitted with 2 ultra-high-frequency RFID ear tags and monitored in groups of 8 while housed in a pen with an electronic brush, video cameras, and 4 RFID antennas. Each heifer was observed for a 6-h period using continuous video recordings, and brush contact was characterized in terms of anatomic region involved (head/neck, trunk, or posterior) and when not touching the brush but within 1 body length of it. The RFID data were collected for the same period and then processed such that intervals of up to 16 s with no detections but contained between 2 recordings were also considered positive (animal in brush proximity). Brush proximity (RFID) was regressed against brush contact duration (video) and the sensitivity and specificity for each individual heifer calculated. Across heifers, the majority of brush use involved the head/neck, although a few heifers demonstrated relatively large amounts of posterior contact, which contributed to false-negative readings when antennas failed to read the ear tags. Furthermore, for the majority of time that animals were near the brush, they were not in contact with it but rather standing or lying nearby, resulting in false-positive readings. It follows that the ability of the RFID system to accurately detect brush contact varied widely across individual heifers (sensitivity 0.54-1.0; specificity 0.59-0.98), with RFID generally overestimating the duration of brush proximity relative to actual time spent in brush contact. The implication is that RFID-based ear tag recording of brush proximity relative to continuous video observations of contact does not yield accurate results in certain heifers and therefore, as currently configured, is not a reliable representation of this type of grooming behavior.

The treatment of burn-related wounds requires consideration of several factors, including defect size, available donor sites, exposure of critical structures, and the ultimate functional and aesthetic result of reconstruction. Although skin grafts and locoregional flaps are workhorses in burn reconstruction, they have inherent limitations that can directly impact reconstructive outcomes. Microsurgical free tissue transfer represents a viable option for the reconstruction of burn-related wounds in certain patients. Each anatomic region of the body has unique challenges that must be addressed to achieve a successful reconstruction. Therefore, the choice of free flap must be individualized to the wound and patients.

Botulinum toxin is a potentially deadly anaerobic bacterial toxin that acts by inhibiting release of acetylcholine at the neuromuscular junction, thereby inhibiting contraction of the exposed striated muscle. There are currently 4 botulinum toxin preparations approved by the US Food and Drug Administration (FDA): onabotulinumtoxin, abobotulinumtoxin, incobotulinumtoxin and rimabotulinumtoxin. While significant overlap exists, each product has unique properties and specifications, including dosing, diffusion, and storage. Extensive physician knowledge of facial anatomy, coupled with key differences of the various neurotoxin types, is essential for safe and successful treatments. The first article in this continuing medical education series reviews key characteristics of each neurotoxin, including new and upcoming agents, and provides an anatomic overview of the most commonly injected cosmetic sites.

Introduction The aim of this study was to establish institutional diagnostic reference levels (DRLs) by summarising doses collected across the five computed tomography (CT) system in our institution. Methods CT dose data of 15940 patients were collected retrospectively from May 2015 to October 2015 in five institutional scanners. The mean, 75th percentile and 90th percentile of the dose spread were calculated according to anatomic region. The common CT examinations such as head, chest, combined abdomen/pelvis (A/P), and combined chest/abdomen/pelvis (C/A/P) were reviewed. Distribution of CT dose index (CTDIvol), dose‐length product (DLP) and effective dose (ED) were extracted from the data for single‐phasic and multiphasic examinations. Results The institutional DRL for our CT units were established as mean (50th percentile) of CTDIvol (mGy), DLP (mGy.cm) and ED (mSv) for single and multiphasic studies using the dose‐tracking software. In single phasic examination, Head: (49.0 mGy), (978.0 mGy.cm), (2.4 mSv) respectively; Chest: (6.0 mGy), (254.0 mGy.cm), (4.9 mSv) respectively; CT A/P (10.0 mGy), (514.0 mGy.cm), (8.9 mSv) respectively; CT C/A/P (10.0 mGy), (674.0 mGy.cm), (11.8 mSv) respectively. In multiphasic studies: Head (45.0 mGy), (1822.0 mGy.cm), (5.0 mSv) respectively; Chest (8.0 mGy), (577.0 mGy.cm), (10.0 mSv) respectively; CT A/P: (10.0 mGy), (1153.0 mGy.cm), (20.2 mSv) respectively; CT C/A/P: (11.0 mGy), (1090.0 mGy.cm), (19.2 mSv) respectively. Conclusions The reported metrics offer a variety of information that institutions can use for quality improvement activities. The variations in dose between scanners suggest a large potential for optimisation of radiation dose.

Pediatric spinal trauma is a broad topic with nuances specific to each anatomic region of the spinal column. The purpose of this report is to provide a brief review highlighting the most important and common clinical issues regarding the diagnosis and management of pediatric spine trauma. Detailed descriptions of imaging findings along with specific operative and nonoperative management of each fracture and dislocation type are beyond the scope of this review.

Rhinology refers to the study of the nose, paranasal sinuses, and nasopharynx. The field today involves an understanding of basic science principles including physiology as it relates to the mucociliary blanket, molecular biology with respect to the inflammatory process, and microbiology as it concerns the ever-changing spectrum of organisms that may infect the sinus passages. Equally important are the newer surgical procedures that deal with the disease in this anatomic region. The transition from open techniques to an endoscopic approach has enabled the modern physician to access vital structures in a more anatomic and functional manner. During the second half of the nineteenth century, major progress was made in learning the anatomy and physiology of the nose and sinuses. With the beginning of the twentieth century, an outburst of technology aroused that provided notable advances in the kind and quantity of surgeries carried out. Today’s knowledge of the anatomy to a great deal goes back to the basic work of Emil Zuckerkandl of Austria who, starting from the 1870s, described in subtle studies the anatomical and developmental details of the nose and sinuses, opening an entire new era regarding the clinical and surgical approach to the area. The several years around the turn of the century stand out with research on sectional and surgical anatomy, generating the specialty of rhinology and creating today’s principles of diagnosis and therapy of disorders of the nose and sinuses. Names such as Grunwald, Onodi, Hajek, and many more are closely associated with this particular productive interval. Historical progress of rhinology is also interesting. In this chapter, history of rhinology is presented in detail.

We report the first evidence of primary endometrioid adenocarcinoma arising in the vulva, expanding the morphological spectrum of the glandular neoplasms in this anatomic region.

Special site nevi or nevi with site-related atypia are terms used to describe melanocytic nevi located in some anatomic regions that, although benign, show unusual or atypical microscopic findings that may lead to diagnostic confusion with melanoma. A number of special sites have been proposed, including the ear, acral skin, genital region, the breast, and scalp. One may also include nevi of flexural sites and umbilical melanocytic nevi in this group. While anatomic site likely factors as a parameter for altered growth patterns of melanocytes when the cutaneous microanatomy is different, and/or the site more subject to repetitive trauma, as in the case of acral nevi, the proposed influence of anatomic region to the architecture of a melanocytic nevus is largely speculative and the designation “special site nevus” may be overused by pathologists, as there is significant overlap in the appearance of what nevi can look like at almost any site.

The medical tasks in ImageCLEF have been run every year from 2004–2018 and many different tasks and data sets have been used over these years. The created resources are being used by many researchers well beyond the actual evaluation campaigns and are allowing to compare the performance of many techniques on the same grounds and in a reproducible way. Many of the larger data sets are from the medical literature, as such images are easier to obtain and to share than clinical data, which was used in a few smaller ImageCLEF challenges that are specifically marked with the disease type and anatomic region. This chapter describes the main results of the various tasks over the years, including data, participants, types of tasks evaluated and also the lessons learned in organizing such tasks for the scientific community.

Sternoclavicular (SC) joint pathology is relatively uncommon; however, persistent pain and instability of the SC joint may result despite appropriate initial management and may require surgical treatment with resection arthroplasty and possible ligamentous reconstruction. For the correctly indicated patient, surgical treatment of the SC joint is an appropriate procedure when performed by surgeons with experience operating in this anatomic region.

The pelvic floor represents a complex anatomic region, which is prone to laxity, herniation and prolapse. Often, treatment will require a multidisciplinary approach with input from colorectal surgeons, urogynecologists and urologists. A thorough understanding of the anatomic deficit combined with its functional significance is imperative when contemplating invasive interventions. Excellent functional results are incumbent on the surgeon correlating the patients’ symptoms with the anatomic findings. Numerous approaches are available to correct pelvic floor deficits and should be tailored to the individual patient taking into account the need for a team approach and also their comorbidities.

Peripheral arterial occlusive disease constitutes a substantial portion of clinical practice in vascular surgery and, as such, trainees must graduate with proficiency in endovascular and open procedures to become capable vascular surgeons. Case volume for 0+5 integrated vascular surgery residents in the chief and junior years was compared with their 5+2 fellowship counterparts for the treatment of peripheral arterial occlusive disease.In this retrospective review, operative volume for peripheral arterial occlusive disease cases in both vascular training paradigms was evaluated. "Surgeon chief" cases in the final year of residency training, and "surgeon junior" cases for postgraduate year 4 and below were gathered for the integrated vascular surgery residents group. Annual fellow's case volume was collected using cases logged as "surgeon fellow." Procedures were divided by the following anatomic region and compared: aortoiliac, femoropopliteal, and infrapopliteal. Student's t tests were used to assess these differences.An aggregate of 887 residents and fellows from 137 programs were identified. Vascular surgery fellows consistently performed 1.7-fold (P.001) and 1.6-fold (P.001) more total peripheral cases than their integrated vascular surgery residents chief and junior counterparts, respectively. They also performed 1.8-fold (P = .002) and 1.5-fold (P = .004) more peripheral endovascular cases than their 0+5 chief and junior counterparts respectively. With respect to endovascular treatment of peripheral arterial occlusive disease by subgroup, we found the overall volume of aortoiliac and femoropopliteal increased, whereas infrapopliteal case volume decreased. Vascular surgery fellows were performing many more of these cases per year than the integrated vascular surgery residents chiefs and junior residents. When looking at 3 index open procedures, aortobifemoral bypass, femoropopliteal bypass with vein, and infrapopliteal bypass with vein in the academic year 2017-2018, the vascular surgery fellow trainees performed more cases than the integrated vascular surgery residents chief and junior residents.Earlier studies have compared the operative volume of vascular surgery fellows and integrated vascular surgery residents in their entire tenure of training. Our study specifically evaluated the years of training that confer the greatest level of autonomy. Vascular surgery fellows are performing more endovascular and open cases than their 0+5 counterparts for peripheral arterial occlusive disease during the final phase of training. These findings suggest that current suspected equipoise of vascular surgery training paradigms may not reflect what is occurring in practice and therefore warrants further investigation.

Primary cutaneous large B-cell lymphoma, leg-type is the most aggressive form of primary cutaneous B-cell lymphoma. It is characterized by progressive nodules and tumors initially localized to 1 anatomic region, most commonly the legs. A 48-year-old woman with melanoderma attended the service of oral and maxillofacial surgery reporting weight loss, fever, and swelling in the lower third of the face 3 months ago, followed by episodes of improvement and aggravation. Clinical extraoral examination revealed an increase in volume in the lower third of the face, reddish, diffuse plaque, and elevated and irregular surface in the chin and submental regions, associated with bilateral superficial cervical lymphadenomegaly. The incisional biopsy of the lesion was submitted to histopathological and immunohistochemical analysis, which revealed the diagnosis of diffuse cutaneous large B-cell lymphoma leg-type. The patient is in post-chemotherapy follow-up of 2 years and 4 months without evidence of relapse of the disease.

Objectives The aim of this study was to evaluate and compare cases of multicystic (MA) and unicystic ameloblastomas (UA). Methods The classification was based on the radiographic aspects. In addition, characteristics such as symptomatology, age, sex, and anatomic region were also compared. Fisher exact test was performed, with significance level of .05. Results The radiographic analyses were performed and the posterior region was the most prevalent one (77.6%), 15.3% cases were located in the anterior region, and 7.1% were observed in both regions. Moreover, 55 cases were classified as MA and 43 as UA. The cortical expansion was observed in 90 cases; from this amount, 54 cases of ameloblastoma were MA (98.2%) and 36 cases of UA (80%) (P = .01). The predominant histologic patterns in MA were the plexiform pattern (36%) and the follicular type (29%) and for UA were cystic (51%) and plexiform pattern (31%). Conclusions Radiographs and histopathologic exams are essential for the diagnosis of ameloblastoma. Unicystic ameloblastomas cannot be considered a less aggressive entity compared with the multicistic ameloblastoma in the studied cases. Institutional grant from Sao Leopoldo Mandic Dental School (PIC 021/2017).

Laparoscopic inguinal hernia repair is among the most common procedures performed today by general surgeons. There is increasing data that laparoscopic surgery has the advantage of decreased postoperative pain and quicker return to normal daily activities, and it may even afford better visualization of a challenging anatomic region. However, there is considerable variety among general surgeons regarding the operative technique for laparoscopic inguinal hernia repair.

Knowledge of surgical anatomy and skill in surgical dissection are seamlessly combined into the art of the competent surgeon. This chapter presents a discussion of the rationale for and techniques of tissue handling and hands-on surgical dissection that all competent surgeons have mastered. These techniques are the hallmark of a safe and efficient surgeon. Tissue handling skills are somewhat more important to master than the necessary knowledge of surgical anatomy. This is because the surgeon knows only approximately where the vital anatomy should be situated in the dissection field. These anatomic structures course in variable locations in individual patients, are hidden from view by peritoneum and visceral fatty areolar tissues, and are further distorted by the pathology involved. It is only by expert dissection techniques that these vital anatomic structures, such as the ureter and major blood vessels, are safely revealed in a bloodless field. These techniques are successfully applied in any surgical specialty and in any type of surgery—laparotomic, laparoscopic, robotic, or vaginal—and in any anatomic region or space.

Posterior arthrodesis for pediatric cervical spine problems may be done for deformity or instability that is related to a wide variety of pathologic processes, from trauma to congenital anomalies to connective tissue disorders. Arthrodesis technique has evolved from fusion in situ without instrumentation, to the use of wiring technique, to modern screw-rod constructs. Disorders of the cervical spine in children and adolescents are commonly subdivided based on etiology and anatomic region, into atlanto-occipital disorders and those disorders affecting the subaxial cervical spine. This chapter reviews surgical options available for surgeons treating occipital-cervical and subaxial cervical spine disorders in children and adolescents. Detailed descriptions of the most contemporary surgical techniques are discussed, with practical instructions provided to improve results and avoid complications. Published treatment results are discussed, providing surgeons with the best available evidence used in clinical decision-making.