Vascular dysfunction in juvenile idiopathic arthritis: a systematic review and meta-analysis.

We performed a systematic review and meta-analysis of studies evaluating vascular function in patients with JIA. Relevant literature published from 1st January 1965 to 1st March 2022 was searched systematically utilizing PubMed, Web of Science, and Embase databases. Observational studies were included-patients with JIA (classified according to the International League of Associations for Rheumatology criteria) were included as cases (study population) and age/sex-matched healthy participants as controls (comparator group). Outcome measures were differences in non-invasive parameters of vascular function. Online Population, Intervention, Comparison, Outcomes Portal was used for deduplication of studies and data extraction. Review Manager, Comprehensive Meta-analysis, and Meta-Essential softwares were used for data synthesis/analysis (encompassing data pooling and evaluation of heterogeneity and publication bias). Newcastle-Ottawa Scale and GRADEpro GDT software were utilized to assess study quality and certainty of evidence, respectively. Of 338 citations, 17 observational studies with 1423 participants (cases = 757, controls = 666) were included. Carotid intima-media thickness (CIMT) was higher [mean difference (MD) 0.02 mm {95% confidence interval (CI) 0.01-0.04}, p = 0.0006, I2 = 69%] in patients with JIA. Besides, decreased flow-mediated dilatation (FMD) [MD - 2.18% {95%CI - 3.69- - 0.68}, p = 0.004, I2 = 73%] was also observed. Results of studies assessing pulse wave velocity or arterial stiffness could not be pooled due to significant methodological variations. A 'very low' certainty of evidence suggests the presence of vascular dysfunction in JIA. Future longitudinal studies are required to determine whether altered CIMT and FMD in patients with JIA translate to an enhanced risk of (adverse) clinical cardiovascular events. PROSPERO (CRD42022323752).

Identification of valid anatomical landmarks to locate and protect recurrent laryngeal nerve during thyroid surgery: a cadaveric study.

PURPOSE: Recurrent laryngeal nerve (RLN) is the most critical structure in terms of intricacy. Anatomic variations of the nerve may further make thyroid surgery cumbersome. The present study was undertaken to provide comprehensive knowledge about the soundness of commonly used anatomical landmarks such as Berry's ligament (BL), tracheo-esophageal groove (TEG), inferior thyroid artery (ITA), and the midpoint of the posterior border of the thyroid gland in the identification of the nerve intraoperatively. METHODS: Thirty adult cadavers were dissected to identify the RLN in the neck and to locate it in relation to the aforementioned anatomical landmarks. RESULTS: The RLN/BL relationship: RLN was most often located superficial to the BL (88.3%), followed by deep to the BL in 8.4%, and piercing the BL in 3.3% of cases, respectively. The RLN/TEG relationship: the RLN was located inside the TEG in most cases (71.7%), followed by RLN lying outside the TEG in 28.3%. Outside the groove, it was most commonly found lateral to the TEG (64.7%). RLN/ITA relationship: the nerve was passing deep to the artery in most of the cases (65%), followed by superficial (30%) and rarely (5%) in-between the branches. RLN/ midpoint posterior border of thyroid relationship: In 57 (95%) cases, RLN was coursing in the area posterior to the midpoint of the posterior border of the gland with an average distance of 4.95 ± 2.23 mm ranging between 2.21 and 12.1 mm. CONCLUSIONS: Both the BL and TEG are potentially crucial for safeguarding RLN. Although in results, BL turns out to be more consistent than TEG, we propose the utilization of both these anatomical landmarks together for complication-free neck surgeries. Furthermore, the midpoint of the posterior border of the thyroid turns out to be the single most consistent landmark for identifying RLN during partial thyroidectomy.

Moynihan's hump of the right hepatic artery in Calot's triangle: a systematic review and meta-analysis of its incidence and surgical importance.

INTRODUCTION: A rare variation known as "Moynihan's or caterpillar hump" of the right hepatic artery raises the danger of vascular and biliary injuries during hepatobiliary surgery. This research intends to carefully record every case (i.e., patients undergoing laparoscopic cholecystectomy or cadaver dissections) where the right hepatic artery received a caterpillar hump. METHODS: The literature search was conducted with the medical subject headings (MeSH) and EMTREE (subject headings unique to Embase) keywords. The keywords with Boolean operators (OR, AND, and NOT) were used to create search strings in all possible combinations to retrieve bibliographic data. Two authors independently performed a risk of bias assessment and data extraction. The random effects model was used to conduct a meta-analysis. RESULTS: Thirty studies with a total of 8418 subjects reported that Moynihan's hump was present in 3.81% of them, with a predictive interval of 0.88-16.45%. The incidence of the hump was 3.1% in surgical studies (7496 subjects) and 7.22% (95% CI 4.7-10.93%) in cadaveric data (625 cadavers). Only ten studies addressed the relationship between the caterpillar hump and the common bile duct. CONCLUSION: A patient with an unusually "small cystic artery" or "large right hepatic artery" is likely to have a "caterpillar hump". The caterpillar's hump of the right hepatic artery is subject to rare anatomical variations in its course that increase the risk of incorrect vessel ligation or injury during laparoscopic cholecystectomy.

Bifid median nerve as an anatomical risk factor for carpal tunnel syndrome: A meta-analysis.

As the median nerve enters the carpal tunnel, it is a single nerve that soon bifurcates into lateral and medial branches into the hand. If the bifurcation is proximal to the carpel tunnel, a bifid median nerve (BMN) results. Carpal tunnel syndrome is often associated with a BMN with or without a persistent median artery. Individual keywords and MeSH phrases were searched in the Google Scholar, SCOPUS, and PubMed databases. Full texts were then collected and assessed for suitability. The prevalence of BMN at the wrist joint in normal and carpal tunnel syndrome wrists (precanal part) and the mean difference between groups were recorded. Only human data were used to test the findings. The pooled odds ratio (with minimal heterogeneity) was 1.50 [1.17-1.93, 95% CI]. The BMN cross-sectional area (CSA) was significantly greater than that of a solitary median nerve in normal wrists. The mean difference in CSA between the two was 1.50 mm2 [0.56-2.45 mm2 , 95% CI] without heterogeneity (i2  = 0). Sex and laterality distributions scarcely differed between the two types of wrists. Owing to the insufficiency of data, the relationships with mean height and weight were not examined. There was a 50% greater incidence of bifid median nerves in carpal tunnel syndrome patients than in normal subjects. A bifid median nerve increases the mean CSA at the wrist joint by 1.5 mm2 . These findings indicate that the bifid median nerve is an anatomical risk factor for carpal tunnel syndrome.

The potential scope of a humanoid robot in anatomy education: a review of a unique proposal.

INTRODUCTION: Applications based on artificial intelligence and machine learning are becoming more popular in teaching learning. Advanced technologies have facilitated robots to carry out various human-like functions, which have navigated the interest of educators to discover the role of robots as potential teachers, instructors, or teaching assistants in education. METHODS: An extensive search for articles for humanoid robots and education either in the title or keywords was done utilizing PubMed, Google Scholar and Web of Science data sets. The tracking terms were artificial intelligence, education, medical education, anatomy, robots, humanoid robots, teaching, teaching assistant and tutor. RESULTS: The usage of artificial intelligence in the form of humanoid robots is quite common. However, literature citing its usage in medical education is rare. Humanoid robots as a teacher or teaching assistants are predominantly used in learning foreign languages. Primarily, a humanoid robot can discharge five functions as a potential teacher. CONCLUSION: Humanoid robots can effectively fulfil numerous educational goals in medicine since they can replicate human responses, work relentlessly regardless of students' repeated mistakes, be loaded with innovative teaching methodologies, and be upgraded with more current information. As a subject of medicine, anatomy is highly visual; therefore, constant endeavors have been initiated to develop technology-enhanced learning over the decades. Although artificial intelligence in humanoid robots has been successfully used in primary education and in learning a foreign language, its scope as an anatomy teacher or teaching assistant is a new and unique idea that needs exploration.

Integration of innovative educational technologies in anatomy teaching: new normal in anatomy education.

COVID-19 pandemic has created a lot of turmoil in medical teaching, the magnitude of impact is many folds in the subject of anatomy, as it is practical based. A major challenge for anatomy teachers is to replicate the experience of practical exposures. These exposures range from cadaveric dissection to demonstration of bones, museum specimens, and histology slides, where they will have interactive communication with students, and thus help in the enhancement of communication and clinical skills among them. In recent days, anatomy teachers throughout the globe started using various advanced technology to make the teaching-learning session more interesting. In pre-pandemic era, usage of such advancements in information and communication technology was a 'choice'. But pandemic has changed the situation drastically, what was a 'choice' earlier is now an 'obligation.' Presently although infection rate is low, vaccination rate is high, most of the medical schools re-opened for usual offline teaching, still body donation is all time low making the situation 'back to square one'. Keeping such unprecedented situations in mind, we need to incorporate various innovative educational technologies in day-to-day teaching-learning methodologies.

Artificial intelligence, nano-technology and genomic medicine: The future of anaesthesia.

Nanotechnology with artificial intelligence (AI) can metamorphose medicine to an extent that has never been achieved before. AI could be used in anesthesia to develop advanced clinical decision support tools based on machine learning, increasing efficiency, and accuracy. It is also potentially highly troublesome by creating insecurity among clinicians and allowing the transfer of expert domain knowledge to machines. Anesthesia is a complex medical specialty, and assuming AI can easily replace the expert as a clinically sound anesthetist is a very unrealistic expectation. This paper focuses on the association and opportunities for AI developments and deep learning with anesthesia. It reviews the current advances in AI tools and hardware technologies and outlines how these can be used in the field of anesthesia.

Estimation of the relationship between the sacral hiatus and other dorsal sacral parameters using principle component analysis.

PURPOSE: Correct localization of the sacral hiatus is essential for administering a successful caudal epidural block. The purpose of this study is to create a statistical model of sacral hiatus from dorsal sacral parameters to improve the location of the hiatus and thus, reduce the failure rate. The aim of this investigation was to examine the relationship of sacral hiatus morphology and dimension with sacral curvature. This study further examines the dorsal sacral parameters that could affect the sacral hiatus dimension. METHODS: Adult, human, dry sacra and three-dimensionally reconstructed sacra from computed tomography imaging of normal subjects were included in the study and measured using digital Vernier calipers of 0.01 mm accuracy and Geomagic freeform plus software, respectively. RESULT: The most frequent shape of the sacral hiatus was an inverted V (48%) followed by inverted U shape (32%), an irregular shape (12.3%), an M shape (4.7) and an A shape (2.8%). The data were represented by mean and standard deviation. Sacra with M-shaped hiatus had the lowest hiatal length (14.21 ± 5.44 mm), whereas sacra with an inverted V-shaped hiatus had the highest length (25.41 ± 11.3 mm). The anteroposterior diameter of the sacral hiatus at the base in males and females was found to be 3.46 ± 1.48 mm and 2.79 ± 0.83 mm, respectively (P < 0.001). The distance between the caudal end of the median sacral crest and the apex of the sacral hiatus (7.90 ± 6.74 mm, 4.4 ± 5.86 mm) also revealed sexual dimorphism (P < 0.001). CONCLUSION: The correlations between most of the dorsal sacral parameters and length of the sacral hiatus are significant. The intercornual distance is also moderately correlated with the distance between right and left lateral sacral crest S1 level. Dorsal sacral parameters predicts variance of the sacral hiatus dimension from 40 to 73% and this could be utilized for statistical model of the sacral hiatus.

Prevalence of anomalous or ectopic insertion of pectoralis minor: a systematic review and meta-analysis of 4146 shoulders.

INTRODUCTION: The proximal insertion beyond coracoid process of pectoralis minor is considered as hidden culprit of rotator cuff disorders. The ectopic insertion is also associated with thoracic outlet syndrome. The current review was conducted to provide a comprehensive evidence-based assessment of the anatomical characteristics of ectopic insertion of pectoralis minor. MATERIALS AND METHODS: A through systematic search was conducted on the major electronic database, PubMed, EMBASE, Google Scholar and Journals of Anatomy, orthopedics, plastic surgery, sports medicine. The primary outcome was to measure the prevalence of ectopic insertion of pectoralis minor tendons. The data extraction was conducted for pooled estimation and metanalysis. RESULTS: A total of 25 studies were included for systematic review. The overall pooled estimate of ectopic insertion of Pectoralis Minor was 19.27% (95% CI 15-24%). The prevalence rate in dissected specimen was 21% (CI 15-28%) and in arthroscopic evaluation was 22% (95% CI 5-59%) which was marginally higher with wide confidence interval due small sample size. The prevalence rate in MRI and USG were 15 and 12%, because MRI and USG have almost similar sensitivity in the detection of anomalous insertion of Pectoralis Minor. The distribution of subtypes of anomalous or ectopic insertion based on Le Double classification was 34% for type I, 42 and 9% for Type III. The incidence of ectopic insertion of pectoralis minor was highest in Japanese population. The female and left side have slightly higher incidence at insignificant level. CONCLUSION: The preoperative MRI or at least USG evaluation of shoulder joint must be conducted for appropriate surgical planning, because the prevalence of ectopic insertion is around 20%. The preoperative detection of anomalous insertion of pectoralis minor can be crucial in minimizing the incidences of iatrogenic injuries of tendon or post-operative complications.

Prolonged Use of Supraglottic Airway Device for Mechanical Ventilation in the Intensive Care Unit.

How to cite this article: Naaz S, Sahay N, Kumar R, Kumar A, Asghar A. Prolonged Use of Supraglottic Airway Device for Mechanical Ventilation in the Intensive Care Unit. Indian J Crit Care Med 2020;24(10):1001-1002.

An Anatomic Morphological Study of Occipital Spurs in Human Skulls.

Occipital spurs are quite common; however, they are also the source of frequent discomfort to the patients. Their role has been implicated in causation of pain at the base of skull, which may extend to shoulder limiting the movement of the shoulder and neck. The present was carried out to find out the prevalence of occipital spur in human skull and to find out the anatomic morphological characteristics of occipital spur. A total of 30 cadaveric skulls were examined in the Department of Anatomy, Uttar Pradesh University of Medical Sciences, for the presence of occipital spur. These skulls were the part of boneset obtained as a part of undergraduate training in the department. All the measurements were taken using a digital Vernier Caliper after taking all necessary precaution to avoid any damage to these spurs. The prevalence of occipital spur in the present study was 10%. The mean width recorded in the present study was 13.40 mm (±6.7) and the mean length recorded was 13.45 mm (±1.05). Similarly, mean thickness noted was 2.43 mm (±0.43). Thus, the present study concludes that occipital spurs are the frequent source of discomfort to patients. The knowledge of this tubercle is of paramount importance to neurosurgeons, sports physicians, and radiologists for the diagnosis of such discomfort.

Blending Conventional Learning Approach with Contemporary Visualization Technologies: Prerequisite Toward Evidence-Based Surface Anatomy.

Proficiency in surface anatomy knowledge plays a pivotal role in fostering complication-free and efficacious clinical practice across a wide spectrum of healthcare specialties. This comprehensive understanding and adept utilization of surface anatomy principles serve as the linchpin for deciphering normal anatomical structures within medical imaging and the aptitude to articulate the topographical attributes, visual characteristics, and interrelations of palpable anatomical entities. Despite the advent of advanced direct visualization techniques, such as ultrasound guidance, which assist in interventional procedures, clinicians have not relinquished the indispensable requirement for pertinent surface anatomy knowledge to ensure the successful and secure execution of procedures. Regrettably, evidence-based surface anatomy remains an underemphasized facet in the pedagogy of anatomical sciences. The current narrative review underscores the various methodologies employed in imparting surface anatomy education to students. However, it is noteworthy that no singular, unequivocal best practice has emerged for the teaching and acquisition of surface anatomy knowledge. Therefore, as custodians of anatomical education, there is a pressing need to innovate and amalgamate contemporary pedagogical approaches with state-of-the-art technologies to furnish students with evidence-based surface anatomy insights, thereby enhancing comprehension, retention, and the lasting utility of this essential domain of medical knowledge.

Morphometric analysis of sacral corridor in the upper three sacral segments to prevent neurovascular injury.

Although studies of the sacral corridor dimension have been reported in the European population, little attention has been paid to this issue in the Asian population. The purpose of the study is to estimate the safe dimension of the corridor to avoid neurovascular damage during the fixation of the sacral fracture. The study aimed to examine the cephalocaudal (vertical) and the anteroposterior diameter of the bony passage in the upper three sacral segments. The study further examines the effect of age and sex on corridor dimensions at different sacral levels. Three-dimensionally reconstructed sacra from computed tomography of normal subjects were included in the study. Cephalocaudal and anteroposterior diameters were measured in coronal and axial sections using Geomagic Freeform Plus software. Anteroposterior diameter of the sacral corridor at the first, second, and third sacral segments are significantly higher in males (P=0.013, 0.0011, and <0.0001, respectively). The length of the sacrum also revealed sexual dimorphism (P<0.00016). The anteroposterior diameter of the second sacral segment (ap-S2c) correlated moderately with the first sacral anteroposterior diameter (ap-S1c) (R=0.519, P<0.001). The ap-S2c exhibited a moderate correlation to the third sacral segment (ap-S3c) (R=0.677, P<0.001). The sacral corridor at the level of S1 has the largest cephalocaudal (18.25 mm) and anteroposterior diameter (17.11 mm). Placement of the screw in the first sacral corridor may avoid damage to the neurovascular bundle during the fixation of the sacral fracture.

Exploring the variations of the pancreatic ductal system: a systematic review and meta-analysis of observational studies.

The exocrine part of the pancreas has a duct system called the pancreatic ductal system (PDS). Its mechanism of development is complex, and any reorganization during early embryogenesis can give rise to anatomical variants. The aim of this study is to collect, classify, and analyze published evidence on the importance of anatomical variants of the PDS, addressing gaps in our understanding of such variations. The MEDLINE, Web of Science, Embase, and Google Scholar databases were searched to identify publications relevant to this review. R studio with meta-package was used for data extraction, risk of bias estimation, and statistical analysis. A total of 64 studies out of 1,778 proved suitable for this review and metanalysis. The meta-analysis computed the prevalence of normal variants of the PDS (92% of 10,514 subjects). Type 3 variants and "descending" subtypes of the main pancreatic duct (MPD) predominated in the pooled samples. The mean lengths of the MPD and accessory pancreatic duct (APD) were 16.53 cm and 3.36 cm, respectively. The mean diameters of the MPD at the head and the APD were 3.43 mm and 1.69 mm, respectively. The APD was present in only 41% of samples, and the long type predominated. The pancreatic ductal anatomy is highly variable, and the incorrect identification of variants may be challenging for surgeons during ductal anastomosis with gut, failure to which may often cause ductal obstruction or pseudocysts formation.

Reappraisal of the morphological and morphometric study of the psoas minor muscle with clinical and developmental insights: cadaveric study.

BACKGROUND: The Psoas Minor (PMi) is the most unstable muscle of the psoas group of the posterior abdominal muscle. This muscle has a fusiform shape and consists of a short fusiform belly continuing distally as a long tendon inserted on the pecten pubis and the iliopectineal arch. The present study was conducted to obtain more detailed information about the muscle and to expand knowledge about its morphology and morphometry. MATERIALS AND METHODS: The posterior abdominal wall of 30 adult cadavers was dissected. Anatomical variabilities in origin, insertion, length, width, and muscle-to-cone ratio were measured when PMi was found. The data collected was interpreted descriptively. RESULTS: PMi was found in 12 cases, ten bilateral and two unilateral. The origin was constant in all cases and, except for three cases, extended into the iliac fascia and the iliopubic eminence. Morphometric analysis revealed that the average length of the proximal muscle belly and distal tendons was 4.52 ± 1.35 cm and 13.05 ± 0.90 cm, respectively. The mean width of the muscle belly was 1.71 ± 0.17 cm, and that of the tendon was 0.47 ± 0.10 cm. On average, the muscle belly occupied the proximal 33.71 ± 6.15% of the total musculotendinous unit. CONCLUSIONS: Findings confirm the inconsistency of PMi in the study population. Morphological variations became more evident as the tendon approached the insertion level. The muscle's distal attachment to the iliac fascia may partially control the position, mechanical stability of the underlying iliopsoas and this circumstantial function may be clinically related to iliopsoas inflammation and pathology. However, further studies recommended to determine biomechanical validity and clinical applicability of this vestigial muscle in human.

Anatomical correlates for the newly discovered meningeal layer in the existing literature: A systematic review.

The existence of a previously unrecognized subarachnoid lymphatic-like membrane (SLYM) was reported in a recent study. SLYM is described as an intermediate leptomeningeal layer between the arachnoid and pia mater in mouse and human brains, which divides the subarachnoid space (SAS) into two functional compartments. Being a macroscopic structure, having missed detection in previous studies is surprising. We systematically reviewed the published reports in animals and humans to explore whether prior descriptions of this meningeal layer were reported in some way. A comprehensive search was conducted in PubMed/Medline, EMBASE, Google Scholar, Science Direct, and Web of Science databases using combinations of MeSH terms and keywords with Boolean operators from inception until 31 December 2023. We found at least eight studies that provided structural evidence of an intermediate leptomeningeal layer in the brain or spinal cord. However, unequivocal descriptions for this layer all along the central nervous system were scarce. Obscure names like the epipial, intermediate meningeal, outer pial layers, or intermediate lamella were used to describe it. Its microscopic/ultrastructural details closely resemble the recently reported SLYM. We further examined the counterarguments in current literature that are skeptical of the existence of this layer. The potential physiological and clinical implications of this new meningeal layer are significant, underscoring the urgent need for further exploration of its structural and functional details.

Teacher or Researcher: Who Comes First in Medical Academia?

The field of medical academia presents a unique challenge in the professional development of individuals, as it requires balancing two distinct roles: that of a teacher and that of a researcher. This dilemma arises from the inherent tension between the educational responsibilities of imparting knowledge and the scholarly pursuits of generating new knowledge. In this commentary, we seek to explore the question of whether teachers or researchers should take precedence in the medical academic setting.

The Reliability of Kaplan's Cardinal Line as a Potential Surface Marker for the Superficial Palmar Arch During Carpal Tunnel Release: An Anatomical Study With Surgical Perspective.

Purpose Kaplan's cardinal line (KCL) provides a more accurate reference point to the superficial palmar arch (SPA). The aim was to determine the KCL-SPA distances and their relationship with the other defined superficial landmarks, such as distal wrist crease (DWC) or distal portion of the transverse carpal ligament (TCL) or DWC-TCL distance. The objective was to determine the distal limit of the incision made during carpal tunnel release (CTR). Methods Sixty hands were dissected after KCL was drawn on each hand using standard methods. The distance from KCL to the SPA was measured along the radial and ulnar borders of the ring finger and recorded as radial and ulnar KCL-SPA distance, respectively. The distance between the DWC and the distal portion of the TCL was also measured (DWC-TCL). Correlation analysis was done between the DWC-TCL and KCL-SPA distance. The ratios between the radial and ulnar KCL-SPA distance and DWC-TCL distance were calculated and mentioned as radial and ulnar Kaplan cardinal index, respectively. Results KCL-SPA distance was 6.8±3.7 mm along the radial border and 6.6±3.6 mm along the ulnar border of the ring finger. The DWC-TCL distance was 29.4±1.2 mm. The means of radial and ulnar Kaplan cardinal indices were 0.23 and 0.22, respectively. A significant correlation was found between the DWC-TCL distance and the KCL-SPA distances. Conclusion Clinically, KCL can be appraised as a predictable surface landmark in limiting the distal-most extent of the incision during CTR and protecting SPA from transection. The SPA was found to lie at a variable distance from the KCL, and the minimum distance was found to be 3.3 mm. This should be considered as the maximum permissible extension of CTR incision beyond KCL.

An evaluation of mandibular canal variations: a systematic review and meta-analysis.

The inferior alveolar nerve and vessels are carried via the mandibular canal, which extends bilaterally from the inferior alveolar foramen to the mental foramen. Bifid and trifid mandibular canals result from abnormal fusions of nerve canals. The purpose of this study was to provide an up-to-date and comprehensive analysis of the prevalence of mandibular canal variations among healthy adults, and to identify any potential ethnic, sex, or laterality predilections. The prevalence of the bifid mandibular canal was 18.87% and that of the trifid canal 1.3%. Unilateral variants were three times commoner than bilateral. Each mandibular half had four canals emanating from separate openings on the lingual surface of the mandibular ramus. Retromolar and forward canals were the predominant subtypes, followed by dental; buccolingual were the least frequent. The mean length and diameter of the bifid mandibular canal were 13.62 mm and 1.63 mm, respectively. The possibility of a bifid mandibular canal is a crucial consideration in dental medicine. Because anatomical variations of the mandibular canal are fairly common, awareness of them is essential for anatomy teachers and for surgeons who operate in the oromaxillofacial region.