Morphometric evaluation of Anterior Cerebral Artery (on Digital Subtraction Angiography)-Potential implications.

PURPOSE: The aim of the present study was to perform a morphometric analysis of ACA and to establish significant differences, if any, with sex and age via Digital Subtraction Angiography (DSA). METHODS: This cross-sectional study was conducted on 70 patients (>20 years) for the evaluation of ACA by Digital Subtraction Angiography done on a Philips biplane system clarity (Allura FD20/20). Length and diameter of ACA were taken manually on the DSA console using auto-calibration. Statistical analysis was done. RESULT: Mean diameter and length of ACA was found to be greater in female. The f-ratio value for diameter and length of the same was 1.43 and 0.92 respectively. The length of ACA was found to be statistically significant for different age groups. The mean length of ACA followed a decreasing trend with age, whereas mean diameter of ACA was nearly the same in all the age groups. CONCLUSION: The results of our study show that the length of ACA was found to be statistically significant for different age groups.

Morphometry and variations of the human suprascapular notch.

AIM: The present study proposes a simple method to study variations in shape and dimensions of suprascapular notch, to classify different types and subtypes of notch and to measure the thickness of superior transverse scapular bar (ossified superior transverse ligament of scapula). MATERIAL AND METHODS: Seven hundred and twenty-eight dried scapulae were observed, examined and studied in detail. Scapulae with suprascapular notch, with suprascapular foramen having varying degree of ossification in the form of transverse scapular bar were included in the present study. Measurements of suprascapular notch and superior transverse scapular bar were taken with the help of digital vernier calliper and recorded in millimetres. The superior transverse diameter, inferior transverse diameter, depth, maximum thickness of suprascapular notch and thickness at lateral and medial end of transverse scapular bar, mean thickness of superior transverse scapular bar were recorded. The data was analyzed statistically. OBSERVATIONS AND RESULTS: We observed five types of notch in scapulae, type I: without a discrete notch (ill defined), 25 (3.43%); type II: a "V" shaped notch, 192 (26.37%); type III: "U" shaped notch, 383 (52.60%); type IV: inverted "V" shaped notch, 28 (3.84%); type V with absent suprascapular notch: 6 (0.82%). Type II and type III were again subclassified into subtypes (a, b, c and d) on the basis of depth of notch. Scapulae with superior transverse scapular bar (n=94, 12.91%) were classified according to variation in mean thickness of transverse scapular bar (MTSB). CONCLUSION: This study will help clinicians to correlate suprascapular nerve entrapment with a specific type of suprascapular notch and notch with ossified transverse scapular ligament.

Morphometric analysis and anatomical variations of infraorbital foramen: a study in adult North Indian population.

PURPOSE: Various studies have been conducted on morphometric variations of infraorbital foramen to provide data to surgeons for nerve block in infraorbital region. This study aims to analyse the anatomical variations by comparing various morphometric measurements of infraorbital foramen in dry skulls of adult North Indian population. This study becomes relevant in the present study group as very scant data is available about the variations and morphometric measurements in Indian population. The data thus collected can be standardized and become useful for the surgeons working in this area of face. MATERIALS AND METHODS: The study was conducted on 75 dry adult human skulls, which were a part of Department of Anatomy, used for teaching purposes in medical colleges. Straight distance of the Infraorbital foramen from the infraorbital rim, supraorbital foramen and sagittal plane was measured. The position of the infraorbital foramen was determined in relation to maxillary teeth and supraorbital foramen. The data thus obtained was analysed. RESULTS: The distance of infraorbital foramen from infraorbital rim, supraorbital foramen, sagittal plane in the present study was found to be 6.71 ± 1.11 mm, 42.02 ± 4.31 mm and 31.94 ± 4.88 mm respectively. The position of infraorbital foramen was lateral in relation to supraorbital foramen (in 88% of cases). Infraorbital foramen was above the 1st premolar tooth in most of the cases. Accessory infraorbital foramen was found in 11.2% cases (double foramen). CONCLUSION: The data thus obtained will perhaps be helpful to the surgeons in identifying the extent of the operative field thereby reducing procedural risks.

Morphometry of Posterior Cruciate Ligament in Knee joint - A Cadaveric Study.

Objectives: Surgical repair of severely injured posterior cruciate ligament is mandatory. Therefore, the anatomical features of the PCL and its two bundles description help to define the appropriate size of the allograft for excellent results in reconstruction surgeries. Material and methods: Fifty knees were dissected from twenty-five fresh human cadavers (15 male and 10 female) of donors used for teaching purpose. The length and footprint area of PCL and patellar tendon length were measured, and determined the range of normality according to sex and height. Results: The average lengths of the PCL's Antero-medial (AM) and posterolateral (PL) bundle were 35. 52 ± 0.66 mm and 32.76 ± 0.64mm, respectively in male and 35.37 ± 0.07 & 32.58 ± 0.61mm in female. The femoral footprint of PCL was 133.10 ± 0.7 mm2 in male and 133.05 ± 0.7 mm2 in female observed, while the tibial footprint 132.21± 1.02 mm2 in male and 132.42 ± 0.8 mm2 in female was observed. Conclusion: The AM and PL bundle lengths were higher in males than females. There was a strong correlation between height and length of ligaments but no correlation with age.

Morphometry of depth of interhemispheric fissure on Indian cadaveric brain specimens.

Background: During neurosurgeries like resection of interhemispheric lipoma or cyst, surgeon needs to remain within the limits of interhemispheric fissure (IHF). Despite a massive literature search, data regarding the morphometry of IHF is meagre. Therefore, the present study was done to calculate the depth of IHF. Materials and Methods: Twenty-five (fourteen male and eleven female) fresh human cadaveric brain specimens were used. The depth of IHF was measured from frontal pole; three points, anterior to coronal suture (A, B and C); four points, posterior to coronal suture (D, E, F and G) and from two points (via parieto-occipital sulcus and calcarine sulcus) on occipital pole. The measurements were taken from these points up to the floor of IHF. IHF is a midline groove and hence the measurements were taken from each point against both the left and the right cerebral hemispheres. At the end, not much bilateral asymmetry was found, hence the average of the reading for the same point against left and the right cerebral hemisphere was considered for calculation. Result: Maximum depth was found to be 59.60 mm and minimum depth was found to be 19.66 mm among all the points which were considered for evaluation. No statistical difference was found in the depth of IHF among the male and the female groups as well as in the various age groups. Conclusion: This data and knowledge about the depth of interhemispheric fissure will aid the neurosurgeons in order to perform the interhemispheric transcallosal approach as well as surgeries of interhemispheric fissure such as excision of lipoma, cyst, tumor of interhemispheric fissure through the shortest and the safest possible route.

Tibio-femoral Angle Assessment and Its Radiological Co-relation in Healthy Rajasthani Population.

Existence of variations in morphological proportions in human beings has led to the development of different values of tibio femoral angle (TFA) in different populations which is undoubtedly useful in clinical orthopaedic surgery. Meagre literature is available among Indian population. The cross-sectional study was creating baseline data of TFA among Rajasthani population of India with reasonable accuracy and also to correlate these data to radiological findings during July 2014-June 2016. The TFA (in degrees) of 500 healthy subjects from various regions of Rajasthan were measured in standing and supine positions. In addition, the TFA of 134 persons (randomly selected) from study group were also measured on roentgenogram. Subsequently both of these data were compared. The normal range of TFA angle in Rajasthani population was in between 160°-174°. TFA in standing position on right side was 170.96° (with 95% Confidence Interval (CI) = 170.24 to 171.68) and on left side was 170.14° (with 95% CI = 169.21 to 171.06). Mean TFA in supine position on right side in age group from 21 to 30 years was 167.12±6.73° and in age group from 31-40 years was 167.668±6.7°. No significant difference was observed in posture change and according to age. Statistically significant difference was observed in between radiological and gross measurement which was more in radiological than to clinical measurement of TFA (mean difference = +5.78° units) with 95% CI for the difference is (4.03°-7.53°). Higher values of tibio-femoral angle (TFA) were observed in males as compared to females and in radiological measurements.

Morphometry of Anterior Cruciate Ligament in Knee joint. A Cadaveric Study.

Objectives: The journey of Anterior Cruciate Ligament (ACL) reconstruction surgery has long way from open surgery to arthroscopy. Therefore, the anatomical features of the ACL and its two bundles description rewarded as good outcome of procedure. Material and methods: Fifty fresh knees were dissected. The insertion position, length and diameter of ACL and patellar tendon length were measured and determines the range of normality according to sex and side. Results: The average lengths of Antero- medial (AM) and postero- lateral (PL) bundle of the ACL were 35.35 mm and 26.11mm in male on right side, respectively while 34.21mm and 25.53 mm in female. Patellar tendon length was 45.24 mm in right side of male and 43.38 mm in female obtained. The average lengths of AM and PL bundle of the ACL were 35.47 mm and 26.04 mm in male on left side, respectively while 34.23 mm and 25.38 mm in female. Conclusion: The length of ligaments was higher in male than female. There was strong correlation between height and length of ligaments but no correlation with age.

Anatomical Variations of Corona Mortis in the Anterior Intrapelvic Approach: A Cadaveric Study.

Corona mortis (CMOR) is an anastomotic channel either arterial, venous or both connecting the obturator and external iliac systems excluding aberrant channels in the retropubic space. The goal of this study is to illustrate the type of CMOR via the Anterior Intrapelvic approach (AIP) which has not been studied in tandem. This descriptive observational study was performed in the Department of Anatomy, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India from January 2018 to December 2020. It is a potential culprit for significant haemorrhage in scenarios of pelvic trauma or when sectioned accidentally, augmenting difficult haemostasis behind the superior pubic ramus. Previously reported to be exclusively arterial, the venous variant has now emerged as the more frequent anastomosis. AIP was performed on 31 adult human cadavers of 62 hemipelvises to record variations and statistical analysis of retropubic anastomosis with respect to gender, weight groups and side distribution was done. Corona Mortis was observed in 50(80.6%) hemipelvises. To ramify, venous CMOR and arterial CMOR were exclusively encountered in 25(40.3%) and 10(16.10%) hemipelvises respectively. Males recorded a higher prevalence of CMOR. Despite being a frequent anastomotic variant, it is a rare entity in textbooks. CMOR can potentially alter patient outcome and have serious implications in pelvic surgeries via AIP owing to its easier accessibility. Besides, venous CMOR being more common, a venous bleed is inherently more arduous to manage in the pelvis. A larger calibre, less frequent aberrant channel could also prove to be lethal in its injury. Hence, cadaveric simulation of the technique is paramount to master the technique and to mitigate catastrophic vascular events.

Sex Determination in Western Indian Population by Limb Measurements.

For individual identification, the principal biological element is sex determination from disfigured and amputated limbs or body fragments in forensic investigation. Diverse dimensions and proportions affect the anthropometric assessment of sex in different populations. A cross-sectional study was conducted during July 2014 to June 2016 on five hundred and four healthy individuals of age-group 22-40 years of Western India to see the degree of sexual dimorphism in limb measurements. The forearm length, whole upper limb length, tibial length and whole lower limb length of both sides were measured by the universal anthropometric criteria. Demarking points, sexual dimorphism indices and discriminant functions were developed for each measurement. The sexual dimorphism was observed in all variables and males have a higher value than females (p<0.001). The tibial length showed the highest accuracy in sex determination and the highest sexual dimorphism, followed by whole lower limb length. The range of Cross-validated sex classification precision was between 58-90% for the individual variables, 91.7% for the stepwise method and 95.4% for all measurements taken together. The established prototypes delivered effective and consistent sex estimates with high precision rates and low prediction errors.

Carrying Angle in Population of Western India: Normative Values.

Carrying angle is one of the secondary sexual characteristics which is important for keeping the hand away from body to improve functionality. A cross-sectional survey was conducted in Western Indian population (rural and urban population in and around Jodhpur district) during July 2014-June 2016 with the purpose of evaluating the carrying angle in apparently healthy adult and determines the range of normality according to age, sex, height, waist circumference and special reference to handedness. The carrying angle (elbow) was measured in 504 adults aged between 20-40 years (by simple random sampling) by a digital Goniometer. The subjects were in anatomical position (stand up straight, roll his/her shoulders back and the elbow was fully extended and the forearm fully supinated) while the carrying angle were taken. Carrying angle of the right side in male's 11.54°±1.29° and in female's 13.41°±1.26°, whereas these value in left side 10.21°±1.34° and 12.19°±1.44° respectively. All measurements in females are significantly higher in comparison to males (p<0.001). The significant difference was observed in carrying angle according to handedness; dominant hand had higher value of carrying angle in comparison to non-dominant hand in both gender (p<0.001). The height of individuals is positively correlated with the angle whereas there was no correlation was found in between age, waist circumference. The present study showed that the females have greater carrying angle than males.

Estimation of Stature from Measurements of Superior Extremity in Western India.

As India has diverse environmental conditions in her regions, the different environmental condition must affect the growth and development of an individual may also affect the height achieved at adulthood. Total 504 volunteers of Western India were recruited in the study. Stature estimation equations were developed by single and multiple predictor models. Stature calculated in the present study was compared with earlier researchers. Evaluated with Pearson's correlation analysis all the eight measurements (Length of superior extremity, forearm and hand and breadth of hand on both sides) were positively correlated with stature. The strongest correlations were observed between superior extremity length and stature for all groups (combined r=0.886; males r=0.871; females r=0.950). Left superior extremity length had the lowest Standard error of estimation (SEE) for all groups (combined ±3.63cm; males ±2.736cm; females ±1.045cm) and coefficient of determination (R²) for the combined, males and female groups (78.6%, 76.1%, and 90.4% respectively) in single predictor linear regression model equation. In multiple regression model the highest accuracy (R²=0.908, SEE=1.381) was observed in the female when hand length and superior extremity length of the left side were used. Coefficients of determination (R²) obtained in this study were more than 70% in all the estimates except where hand breadth was involved. Predicted stature could be more accurate among females as compared to male. By single prediction model using superior extremity length was able to give the most accurate height, whereas, the accuracy improved as the number of predictors increased.

Stature Estimation from Measurements of Inferior Extremity in Different Stature Groups of Western Indian Population.

Growth and stature of individuals depend upon various factors like environment, race, and inheritance etc. India has different ethnic groups, which are unique in their genetic and socio economic status. Therefore, present study is formulated to estimate the stature by four anthropometric measurements of the inferior extremity in the Western Indian population (rural and urban population in and around Jodhpur district) during July 2014-June 2016 and to compare with other regions of India with respect to body proportion used for stature estimation equations. Measurements of lower limb length and tibial length on both side, and in both genders of 504 individuals were done. Stature estimation equations were developed by single and multiple predictor models and compared with previous researches. Four subgroups were also made according to the stature to see the hypothesis that body proportions will vary in short, medium and tall individuals. A positive correlation (Pearson's) was observed between stature and all the four measurements of inferior extremity. The strongest correlations observed were between lower limb length and stature for all groups (combined r=0.991; males r=0.971; females r=0.967). The highest estimation accuracy (R²=0.992, SEE=0.718) was observed in male during height estimation done by measurements of left side as suggested by low SEE value. Strong correlation in between stature and other body proportions was observed in taller group of individuals either male or female. Significant difference in all the regions was observed, when compared with previous research and suggests that western Indians are peculiar in their body proportions. It was also detected that body proportion may vary according to the stature.

Reflux rising! An essay on witnessing a disease in evolution.

BACKGROUND AND AIM: The prevalence of gastro-oesophageal reflux disease is thought to be rising but supporting evidence is sparse. We assessed trends from data prospectively collected over 25 years at our centre which serves Rotherham's 250000 population. PATIENTS AND METHODS: Detailed computerised records have been kept of all patients investigated for upper gastrointestinal symptoms. DEFINITION: Erosive oesophagitis=endoscopy-verified erosive changes. Non-erosive reflux=heartburn+/-regurgitation but normal endoscopy. Gastro-oesophageal reflux disease=erosive oesophagitis+non-erosive reflux, i.e. total. RESULTS: The data, presented in 5-year time periods spanning 1977-2001, showed four major changing trends. (1) The numbers with newly diagnosed gastro-oesophageal reflux disease rose markedly, affecting both erosive oesophagitis and non-erosive reflux. Gastro-oesophageal reflux disease: n=714; 1587; 2381; 3812; 3880. (2) The proportion of women affected rose from 0.36 to 0.82. (3) Gastro-oesophageal reflux disease patients were older than the general population; the mean age at presentation rose from 48.0 to 53.5 years. (4) Presentation with haemorrhage (percentage of erosive oesophagitis) rose from 5.2% to 10.9% but, as with stricture (around 4%), remained uncommon. Throughout, few (4.4%) changed from non-erosive reflux to erosive oesophagitis. CONCLUSION: The marked increase in gastro-oesophageal reflux disease cannot be accounted for by greater awareness alone for the demographic profile has changed, or by misclassification as erosive oesophagitis was diagnosed on endoscopic appearances. The dramatic five-fold increase in gastro-oesophageal reflux disease is a new phenomenon, perhaps an example of a disease in evolution.

The outcome of bleeding duodenal ulcer in the era of H2 receptor antagonist therapy.

We studied 2119 patients presenting with duodenal ulcer as sole lesion, in the period 1976-1993, the era of H2 receptor antagonist (H2RA) therapy, prior to the introduction of Helicobacter pylori eradication. We used clinical assessment and serial check endoscopy to investigate the incidence of bleeding at presentation (group I, n = 286, 13.5%), the long-term outcome in this group and in that presenting with pain alone (group II, n = 1833, 87%) with respect to ulcer recurrence and bleeding, and the effect of H2RA maintenance therapy. Most patients were treated with H2RA, principally cimetidine. In group I, seven patients died early on; 38 had urgent surgery, of whom six died post-operatively. The remainder were treated; five immediately re-bled, of whom three were operated on. On follow-up, 98/227 group I patients relapsed, 21 (21%) of whom rebled. Relapse in group II was 1017/1668, with only 42 (4%) bleeding (p < 0.001). In patients without maintenance treatment, relapse was markedly higher (50/78 group I, 529/742 group II), but group II still bled significantly less (20% group I vs. 3% group II). Relapse on maintenance was: 48/149 with five (10%) rebleeding in group I, and 488/926 with five (1%) bleeding in group II (p < 0.001). Despite the introduction of H2RA therapy, patients presenting with haemorrhage still have a risk of bleeding at ulcer relapse about 7-fold higher than that for those presenting with pain alone.

History in our lifetime: the changing nature of refractory duodenal ulcer in the era of histamine H2 receptor antagonists.

BACKGROUND AND AIM: This prospective cohort observational study, set in a district hospital, presents our experience (1976-1993) of duodenal ulcer refractory to histamine H2 receptor antagonists (defined as not healed after 3 months' treatment) and comments on onset, outcome and spontaneous decline. METHODS: Patients were treated mainly with cimetidine, the dose being titrated (up to 3.2 g daily) according to response, and followed by serial check endoscopy and clinical assessment. RESULTS: A total of 782 of the 4032 duodenal ulcer patients seen (19%) were refractory; the incidence declined over time: 1976-1978: 124/379 (33%); 1979-1983: 390/1240 (31%); 1984-1988: 190/1295 (15%); 1989-1993: 78/1118 (7%). A total of 344 were refractory for the first time on their first healing course and 174 on their second. Healing was achieved in two-thirds after a mean of 7 months' treatment with cimetidine 1 g; treatment for 12-18 months with higher doses was needed in the remainder. Relapse occurred in up to three-quarters of patients despite maintenance cimetidine up to 3 g daily. Eventually 47 patients were operated upon but good results (i.e., no ulcer, no symptoms) were achieved in only 11. CONCLUSION: Refractoriness was common until recently. Its incidence has declined dramatically, the fall preceding the newer more powerful treatment with proton pump inhibitors and with Helicobacter pylori eradication. We suggest this phenomenon is a modern example of a spontaneous change in the natural history of the disease.

Oesophageal acid-peptic strictures in the histamine H2 receptor antagonist and proton pump inhibitor era.

BACKGROUND AND AIM: We present a survey on the incidence, demography and natural history (re-dilatation rates) of patients with oesophageal acid-peptic stricture seen between 1977 and 1995. PATIENTS AND METHODS: Prospective, cohort observational study. Stricture severity was graded mild, moderate or severe (needing forcible dilatation with bougies). Most were treated with histamine H2 receptor antagonists or proton pump inhibitors, and were followed up by serial check endoscopy. RESULTS: A total of 156 of 7429 (2%) reflux patients had stricture: mild, n=56; moderate, n=25; severe, n=75. The prevalence of reflux disease is rising, paralleled by an increase in the number of patients with stricture; hence the incidence of stricture is unchanged: 1977-1982, 1.8% (18/986); 1983-1989, 2.4% (61/2595); 1990-1995, 2% (77/3848). Demography: mean age 68 years; mean length of reflux history 6.4 years; 15% on non-steroidal anti-inflammatory drugs/aspirin; 18% with Barrett's metaplasia. Mean follow-up: 5.6 years. OUTCOME: of the 75 with severe stricture, 36 (48%) needed forcible dilatation only once, and 39 more often (13 twice, nine three times), most within 2 years. Only six of these patients need > or = 6 re-dilatations. CONCLUSION: The incidence of stricture is low and remains unchanged, despite the increased prevalence of reflux disease. Most patients have a good prognosis, only half needing further forcible dilatation, mainly within the first 2 years.

Sensory nerve conduction velocities amongst healthy soldiers.

Sensory nerve conduction velocities (SNCV) have been studied amongst 50 healthy soldiers between age group 21-40 years on 4 mixed peripheral nerves and one purely sensory nerve. Motor nerve conduction velocities and sensory latency rates were studied under similar standardized conditions and at the same sitting. Sensory nerve conduction velocities are faster when compared to motor nerve conduction velocities. Median nerve shows the highest values and sural nerve the slowest values of SNCV. Latency rates are fastest in median nerve and slowest in sural nerve.

Diagnosing different stages of hepatitis B infection using a competitive polymerase chain reaction assay.

PURPOSE: Different stages of hepatitis B virus (HBV) infection can be defined by serum HBV DNA levels. This study attempts to (1) investigate serum HBV DNA levels in inactive carriers and patients with chronic HBV (CHB) infection and (2) define cut-off value between inactive carriers and HBeAg (precore antigen of HBV) negative CHB patients in Indian population. METHODS: One hundred and forty samples encompassing 42 inactive HBsAg carriers and 98 CHB patients (53 HBeAg-positive and 45 HBeAg-negative) were analysed. Serum HBV DNA levels were determined employing an in-house competitive polymerase chain reaction (cPCR) assay. RESULTS: The HBeAg-positive patients were found to have the maximum median HBV DNA load, which was significantly higher than the HBeAg-negative ones (median; 1.25 x 10(8) vs. 2.30 x 10(5) copies/mL ; P<0.05). Interestingly, the latter group has significantly higher HBV DNA levels than the inactive carriers (median; 2.30 x 10(5) vs. 4.28 x 10(3) copies/mL; P<0.05). The 2.5 x 10(4) copies/ml HBV DNA levels were optimal for discriminating CHB patients (HBeAg-negative) from inactive carriers with 75.6 and 78.6% sensitivity and specificity, respectively. CONCLUSIONS: Despite the extensive overlapping of HBV DNA levels in inactive carriers and HBeAg negative CHB patients, 2.5 x 10(4) copies/mL is the most favourable cut-off value to classify these individuals and would be imperative in the better management of this dreadful disease.

Pseudomembranous esophagitis.

BACKGROUND: Little is known of pseudomembranous esophagitis, a condition of striking endoscopic appearance. Presented here is a description of its nature and outcome. METHOD: Information on all patients with upper GI disease seen in our unit are held in a computerized database that includes presentation, diagnosis (including pseudomembranous esophagitis), treatment, and outcome. RESULTS: Forty-eight patients (mean age 70 years) with pseudomembranous esophagitis were seen over 15 years; 42 were in-patients with various illnesses. At endoscopy, a thin, concentric membrane and/or thick slough covered the distal half and occasionally the entire esophagus. This layer, yellow or blackened, could be peeled away to reveal underlying friable esophageal submucosa. The membrane was composed of fibrinous exudate and inflammatory cells; there was no basement membrane, hence the term pseudomembrane. Patients were treated with histamine H2 receptor antagonists or proton pump inhibitors for about 3 months and followed by endoscopy or clinical observation. All became asymptomatic; the pseudomembrane had disappeared in 32 who underwent follow-up endoscopy. It recurred in 3 of 38 being followed (mean 3.2 years), again associated with another illness requiring hospitalization. The long-term outcome was poor, determined by age and general condition and independent of pseudomembranous esophagitis. Seven patients died within 3 months and 17 during follow-up (mean 42 months, range 5-140 months). CONCLUSION: Pseudomembranous esophagitis is an unusual condition of unknown cause, probably under-reported and associated with systemic illness. It heals rapidly and recurrence is uncommon.