Antenatal visualization of the caudo-thalamic groove at expert fetal neurosonography.

OBJECTIVE: to describe the normal features of the caudo-thalamic groove at antenatal brain ultrasound in a group of structurally normal fetuses at third trimester and to report a small series of cases with abnormal appearance of the caudothalamic groove at antenatal brain ultrasound. METHODS: This was an observational study conducted at two referral Fetal Medicine units. A non-consecutive cohort of pregnant women with a singleton non anomalous pregnancy were prospectively recruited and underwent 3D ultrasound of the fetal brain at 28-32 weeks. At offline analysis the ultrasound volumes were adjusted in the multiplanar mode according to a standardized methodology, until the caudothalamic groove was visible on the parasagittal plane. To evaluate the inter-observer agreement, two operators were independently asked to indicate if the caudothalamic groove was visible unilaterally or bilaterally on each volume. The digital archives of the two Centres were also retrospectively searched to retrieve cases with abnormal findings at the level of the caudothalamic groove at antenatal brain ultrasound which were postnatally confirmed. RESULTS: 180 non-consecutive cases fulfilling the inclusion criteria were prospectively included. At offline analysis of the 3D US volumes the caudo-thalamic groove was identified on the parasagittal plane by both operators at least unilaterally in 176 cases (97.8%) and bilaterally in 174 cases (96.6%). The K-coefficient for the agreement between the two independent operators in recognizing the caudo-thalamic groove was 0.89 and 0.83 on one and both hemispheres respectively. At the retrospective search of our archives 5 cases with abnormal appearance of the groove at antenatal brain ultrasound (2 haemorrhage and 3 cyst) were found. CONCLUSION: Our study has demonstrated that the caudo-thalamic groove is consistently seen among normal fetuses at third trimester submitted to multiplanar neurosonography and that abnormal findings at this level may be antenatally detected. This article is protected by copyright. All rights reserved.

Normal and abnormal appearance of fetal ganglionic eminence on second-trimester three-dimensional ultrasound.

OBJECTIVES: To describe the appearance and size of the ganglionic eminence (GE) in normal fetuses on midtrimester three-dimensional (3D) neurosonography and to report on the association between GE alterations (cavitation or enlargement) and malformation of cortical development (MCD). METHODS: This was a prospective multicenter cohort study of normal fetuses and a retrospective analysis of pathological cases with MCD. From January 2022 to June 2022, patients attending our tertiary centers for an expert fetal brain scan were recruited for the purpose of the study. A 3D volume of the fetal head, starting from the sagittal plane, was acquired in apparently normal fetuses using a transabdominal or transvaginal approach. Stored volume datasets were then evaluated independently by two expert operators. Two measurements (longitudinal diameter and transverse diameter) of the GE in the coronal view were obtained twice by each operator. Intra- and interobserver measurement variation was calculated. Reference ranges for GE measurements were calculated in the normal population. A previously stored volume dataset of 60 cases with MCD was also analyzed independently by the two operators using the same method in order to assess if GE abnormalities (cavitation or enlargement) were present. Postnatal follow-up was obtained in all cases. RESULTS: In the study period, 160 normal fetuses between 19 and 22 weeks of gestation were included in the study. The GE was visible in the coronal plane on 3D neurosonography in 144 (90%) cases and was not clearly visible in the remaining 16 (10%) cases. The intra- and interobserver agreement was almost perfect for the longitudinal diameter, with an intraclass correlation coefficient (ICC) of 0.90 (95% CI, 0.83-0.93) and 0.90 (95% CI, 0.86-0.92), respectively, and substantial for the transverse diameter, with an ICC of 0.80 (95% CI, 0.70-0.87) and 0.64 (95% CI, 0.53-0.72), respectively. A retrospective analysis of 50 cases with MCD in the second trimester showed that GE enlargement was present in 12 cases and GE cavitation was present in four cases. CONCLUSIONS: Systematic assessment of the GE in fetuses at 19-22 weeks of gestation is feasible on 3D neurosonography, with good reproducibility in normal cases. Cavitation or enlargement of the GE can be demonstrated in fetuses with MCD. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Long-term outcome following upper extremity replantation after major traumatic amputation.

BACKGROUND: Amputations in general and amputations of upper extremities, in particular, have a major impact on patients' lives. There are only a few long-term follow-up reports of patients after macro-replantation. We present our findings in contrast with the existing literature. METHODS: Sixteen patients with traumatic macro-amputation of an upper extremity were eligible for inclusion in this study. Altogether, the patients underwent replantation in 3 institutions between 1983 and 2011. RESULTS: Twelve male and four female patients with an average age at injury of 40.6 years (range, 14-61 years) were included in this study. The mean follow-up period was 13.5 years (range, 4.4-32.6 years; SD, 5.7 years). The mean disabilities of the arm, shoulder and hand (DASH) outcome measure was 41 (range, 5.2-94.8; SD, 18.2), functional independence measurement (FIM) was 125 (range, 120-126; SD, 1.8). Chen I representing very good function was accounted in six, Chen II representing good function in eight, Chen III (fair) in one and Chen IV (bad function) in one patient. CONCLUSIONS: We found that while the majority of the included patients exhibited good or very good function of the extremity, none of the replanted appendages regained normal levels of functionality. In addition, all participants were very satisfied with their outcomes. Positive long-term results with high rates of subjective satisfaction are possible after replantation of upper extremities.

Ultrasound diagnosis of placental and umbilical cord anomalies in singleton pregnancies resulting from in-vitro fertilization.

INTRODUCTION: placental anomalies can affect fetal and maternal outcome due to severe maternal hemorrhage potentially resulting in hysterectomy and cord accident including abruption that can determine fetal damage or death. The aims of our study are to determine if the rate of placental and umbilical cord anomalies are more common in IVF singleton pregnancies compared to spontaneous pregnancies; to evaluate the role of ultrasound in screening for these anomalies and to investigate if oocyte donor fertilization is an additional risk factor for the development of these anomalies. METHODS: this was a prospective cohort study involving two tertiary centers. Patients with a singleton pregnancy conceived with IVF and patients presenting with a spontaneous conception were recruited between 1st May 2019 to 31st March 2021. A total of 634 pregnancies were enrolled in the study. All patients underwent similar antenatal care, which included ultrasound examinations at 11-14, 19-22 and 33-35 weeks. Ultrasound findings of placental and/or umbilical cord abnormalities were recorded using the same protocol for both groups and confirmed after birth. RESULTS: IVF pregnancies had a significantly higher risk of low-lying placenta, placenta previa, bilobed placenta and velamentous cord insertion (VCI) compared with spontaneous pregnancies. In the heterologous subgroup there was a significant increased incidence of placenta accreta spectrum (PAS) disorders than in spontaneous pregnancies. All these anomalies were identified prenatally on ultrasound imaging and confirmed at birth. DISCUSSION: IVF pregnancies in general and those resulting from donor oocyte in particular are at higher risk of placental and umbilical cord abnormalities compared to spontaneous pregnancies. These anomalies can be diagnosed accurately at the mid-trimester detailed fetal anomaly scan and our findings support the need for a targeted ultrasound screening of these anomalies in IVF pregnancies.

Immunodeficiency due to chylous dysplasia: diagnostic and therapeutic considerations.

Among primary immunodeficiencies, common variable immunodeficiency (CVID) is defined by an impaired production of immunoglobulins characterized by low levels of plasma immunoglobulins and an altered antibody response. The case reported here was initially interpreted as a CVID. A 20 year old male suffered from diarrhea, weight loss, and malnutrition. Accurate diagnostic assessment uncovered a protein-losing enteropathy. Conventional oil contrast lymphangiography accurately documented the underlying problem and established the appropriate therapeutic approach. The operation consisted of multiple antigravitational ligatures of dilated and incompetent chylous vessels and chylous vessel-mesenteric vein microanastomoses. Serum albumin and leukocyte counts normalized by 1 week after operation and remained stable with time. There were no more episodes of diarrhea, and the patient regained weight. Accurate diagnostic assessment and particularly lymphangiography may be necessary to properly define difficult cases of immunodeficiency due to intestinal protein loss and to plan a corrective therapeutic functional approach.

Replantation of a circumferentially degloved thumb in an occupational crush injury - A case report and review of the literature.

BACKGROUND: Degloving injuries of the fingers and especially the thumb are highly demanding problems in hand surgery and replantation often is not successful because of severe soft tissue contusion. Only few cases of successfull replantation for hand degloving injuries in thumbs are reported in literature. CASE PRESENTATION: We present the case of a young right hand dominant worker experiencing an occupational accident with a circumferential avulsion of his right thumbs' soft tissue at the level of the metacarpophalangeal (MCP) joint with complete skeletization of his thumb and a deep laceration of the nail bed as he got trapped in a machine.Bony structures and tendons remained intact corresponding Urbaniak class III/Kay class IV injury. Immediate defect coverage by replantation was performed.Additionally, a deep palmar soft tissue defect to his middle finger pulp and a laceration with disruption of his eighth finger nerve on his ring finger was adressed by revision, debridement, direct coaptation of the nerve and occlusive dressing to the middle finger.The patient regained full function and excellent cosmesis without nail deformity but only protective sensibility. He is back to his former sports and occupation. CONCLUSIONS: Though sensitive outcome is poor we recommend primary attempt for defect coverage with replantation following degloving to achieve pliable skin coverage and good cosmesis. Especially in Urbaniak III cases with complete soft tissue degloving lacking fractures or tendon lacerations good functional outcome is possible but we recommend to consent the patient in advance for other reconstructive options and give them realistic exspectations in case of failure.Contrary to popular belief replantation of completely degloved fingers is more than saving nonfunctional parts as motivated patients are able to get back to previous sports and occupation after successful replantation.

Facial reconstruction with a unique osteomyocutaneous DCIA perforator flap variant: a case report.

BACKGROUND: Anatomical variance of the deep circumflex iliac artery is of high clinical value in facial reconstruction using a deep circumflex iliac artery perforator (DCIAP) flap. METHODS: We present the case of a 76-year-old woman treated with an osteomyocutaneous DCIAP flap variant for facial reconstruction. We also review here the literature on DCIA perforator flaps and the different anatomical variances, which might bring clinical benefits. RESULTS: The observed anatomy in our patient offered the possibility to raise a free flap variant with high mobility of a large skin paddle and a long vascular pedicle combined with a variable osteomuscular portion. CONCLUSION: The characteristics of the flap thus raised help overcome the disadvantages of the conventional DCIAP flap and offer excellent options for facial reconstruction.

[Soft tissue reconstruction in the extremities and the head and neck area using the anterolateral thigh free flap]. / Die freie anterolaterale Oberschenkellappenplastik zur Weichteilrekonstruktion an den Extremitäten und im Kopf-Hals-Bereich.

OBJECTIVE: Stable soft tissue coverage of exposed bone, tendons, or hardware in the extremities or the head and neck area with a microsurgically grafted free flap. INDICATIONS: Soft tissue defects measuring up to 42 × 15 cm in the extremities and the head and neck region. CONTRAINDICATIONS: Previous surgery or trauma in the anterolateral thigh region. Insufficient personnel and/or technical resources. SURGICAL TECHNIQUE: A line is marked from the anterior superior iliac spine to the superolateral patella pole, approaching the intermuscular septum between the rectus femoris and vastus lateralis muscle. The flap is centred on this line and after medial incision the perforators of the descending branch of the lateral circumflex femoral artery are identified and dissected to their origin. Afterwards the lateral incision is carried out and flap dissection is completed. After flap transfer microsurgical anastomoses are performed and the flap is sutured to the recipient region. POSTOPERATIVE MANAGEMENT: Flap monitoring for 1 week. Strict elevation and immobilization after flap transfer to the extremities; bedrest for 1 week. Thrombosis prophylaxis. RESULTS: From 2008-2011, 41 free anterolateral thigh flaps in 5 women and 36 men with an average age of 53 years (38-70 years) were performed for microsurgical soft tissue reconstruction. Total flap loss rate was 2.4 % and reoperation due to complications, e.g., hematoma, problems with microsurgical anastomosis, and partial flap loss was necessary in 13.8 % of patients.

Recurrent cranial fibroblastic neoplasm in a male adolescent: case report and review of the literature.

Paediatric fibroblastic tumours are rare neoplasms, of which cranial fasciitis is the most common. We present a case of a male 7-year-old suffering from a cranial tumour preceded by a mild trauma. The tumour recurred despite radical resection within 8 months. Histologically, neither tumour could be classified as any published pathological entity. Both lesions were described as cellular fibroblastic neoplasms; in addition, the recurrent tumour featured a prominent myxoid matrix. In the 12 months following resection of the second tumour, no further disease recurrence has occurred.

Quantification of faults resulting from disregard of standardised facial photography.

Medical photography is an important part of documentary procedures in plastic surgery both for quality assurance and for protecting surgeons from possible medico-legal claims filed by patients. Photo documentary standards were established to make photos reliable and to enable comparisons between pre- and post-operative views of a patient, different operative procedures and between results achieved by different surgeons. Despite their obvious importance, especially in the documentation of subtle surgical procedures on the face such as rhinoplasty, photo documentary standards continue to be disregarded. In this article, we analyse and quantify faults caused by even small deviations from photo documentary standards. Photos of 10 healthy, young adults (n = 10) taken in accordance with established standards were compared to photos with the similar types of faults in positioning of the head (±10° deviation from the standard), camera angles (±10° deviation from standard) or mimic expression (slight smile). A computer-assisted facial analysis was performed and the effects of faulty photo documentation on the final result were calculated. The analysis showed, for instance, that a +10° fault in positioning of the head causes a mean shortening of the nasal dorsum by 32.34% (p<0.001) and of the front by 15.33% (p = 0.001), whereas the chin is elongated by 6.82% (p = 0.004). A -10° fault elongates the nasal dorsum by 11.93% (p<0.001) and shortens the upper lip by 22.50% (p = 0.007) and the chin by 13.67% (p = 0.001). Deviations from standardised camera angles lead to similar mistakes, but to a lesser extent. A mistake in mimic expression leads to a shortening of the upper lip by 23.20% (p = 0.006) and also to a clear cheek lift. We show that slight deviations from photo documentary standards result in dramatic faults in the final outcome.