Rare high branching pattern from the first part of the right axillary artery.

A 77-year-old female cadaver was observed to have a rare branching pattern of the right axillary artery (AA). The first part of the AA typically gives off only a superior thoracic artery (STA) but was observed to give off three branches in the case: a lateral thoracic artery (LTA), a thoracoacromial trunk, and a large common trunk (CT). The LTA travelled to provide a variant STA to the 1st and 2nd intercostal spaces. The CT provided an accessory LTA and accessory thoracodorsal artery before bifurcating into a subscapular artery (SA) and posterior humeral circumflex artery. As expected, the SA further divided into the circumflex scapular artery and thoracodorsal artery. A pectoral artery and the anterior humeral circumflex artery originated directly from the second and third parts of the AA, respectively. Knowledge of AA branching variations is of great clinical significance to anatomists, radiologists, and surgeons due to the high rate of injury to this artery.

Unique case of vascularization: superficial brachial artery and radial persistent median artery.

During a routine cadaveric dissection of a 93-year-old male donor, unique arterial variations were observed in the right upper extremity. This rare arterial branching pattern began at the third part of the axillary artery (AA), where it gave off a large superficial brachial artery (SBA) before bifurcating into the subscapular artery and a common stem. The common stem then gave off a division for the anterior and posterior circumflex humeral arteries, before continuing as a small brachial artery (BA). The BA terminated as a muscular branch to the brachialis muscle. The SBA bifurcated into a large radial artery (RA) and small ulnar artery (UA) in the cubital fossa. The UA branching pattern was atypical, giving off only muscular branches in the forearm and a deep UA before contributing to the superficial palmar arch (SPA). The RA provided the radial recurrent artery and a common trunk (CT) proximally before continuing its course to the hand. The CT from the RA gave off a branch that divided into anterior and posterior ulnar recurrent arteries, as well as muscular branches, before it bifurcated into the persistent median artery (PMA) and the common interosseous artery. The PMA anastomosed with the UA before entering the carpal tunnel and contributed to the SPA. This case presents a unique combination of arterial variations in the upper extremity and is clinically and pathologically relevant.

Exemplarist medical ethics.

The field of medical ethics, such as the discipline of ethics in general, has traditionally focused on moral dilemmas and quandaries at the expense of 'everyday' moral issues. The methodologies, norms and principles of the field reflect this. Although the principle of double effect works well in adjudicating the provision of life-shortening medications to relieve pain, it fails to guide the vast majority of mundane moral decisions that providers make daily.This article contends that exemplarist medical ethics provides action guidance on everyday medical ethical issues. Further, it offers an ethical methodology that is not tethered to a comprehensive doctrine of the good.The paper develops an account of, and draws on Zagzebski's exemplarist moral theory. It then describes how medical providers can morally deliberate by appealing to exemplars. I contend there are three modes of exemplarist action guidance: dialogue, emulation and substituted judgement. It demonstrates how each of these modes guides moral deliberation regarding quotidian medical ethical issues. The article then turns to a moral exemplar of medical practice, Dr. Jim O'Connell, who Tracy Kidder profiles in his 2023 book, Rough Sleepers: Dr. Jim O'Connell's Urgent Mission to Bring Healing to Homeless People. The advantages and challenges of this approach are delineated before a brief conclusion.

A Unique Presentation of an Upper Subscapular Nerve Variation Accompanied by an Accessory Subscapular Artery.

The presence of an upper subscapular nerve branching from the posterior division of the superior trunk, and it being accompanied by an accessory subscapular artery, is of both clinical and surgical significance. During routine dissection of the root of the neck in a 75-year-old male cadaver, an unusual branch from the third part of the right subclavian artery was observed lateral to the dorsal scapular artery. Continued dissection revealed that this artery traveled between the anterior divisions of the superior and middle trunks of the brachial plexus before traveling alongside a nerve from the posterior division of the superior trunk of the brachial plexus. This artery and nerve descended on the anterior aspect of the subscapularis muscle before piercing into its muscle belly. We believe this to be a previously unreported unique variation of the upper subscapular nerve that is accompanied by an accessory subscapular artery on its course to the subscapularis muscle. Knowledge of anatomical variations like this may lead to decreased complications in nerve blocks and surgical procedures related to the shoulder.

Differential impact of yeast cell wall products in recovery of porcine intestinal epithelial cell barrier function following Lipopolysaccharide challenge.

BACKGROUND: In swine intestinal barrier deterioration can be caused by exposure to harmful bacteria, toxins or contaminants that can lead to a leaky gut and post weaning diarrhoea. A leaky gut leads to increased infection, inflammation and poor nutrient absorption that can impair piglet growth and ultimately survival. Application of yeast cell wall (YCW) products may offer an opportunity to reduce the intestinal barrier damage caused by microbial challenge. A Mannan rich fraction (MRF) and three YCW products were compared by examining their impact on intestinal barrier function using a Jejunal model of intestine in response to a bacterial challenge using Salmonella LPS. RESULTS: Trans epithelial electrical resistance (TEER) readings showed MRF had a significantly higher barrier function (P ≤ 0.05) over the positive control while YCW products A, B and C demonstrated no significant improvement to the positive control. Transcriptome analysis of the IPEC-J2 cells showed that differentially expressed genes associated with the gene ontology (GO) term for Structural molecule activity was significantly upregulated in the MRF treated cells over the positive control cells with 56 genes upregulated compared to product B (50 genes), Product C, (25 genes) and the negative control's 60 genes. Product A had no functional grouping under the structural molecule activity term. Both qPCR and western blotting analysis of tight junction associated genes showed that MRF treated cells demonstrated significantly higher Claudin 3 junctional gene expression (P ≤ 0.05) over the positive control and treatments A, B and C. Occludin expression was significantly higher in MRF treated cells (P ≤ 0.05) over the positive control and product B. A nonsignificant rise in TJP-1 gene expression was observed in the MRF treated cells when compared to the positive control. Protein abundances of Claudin 3, Occludin and TJP-1 were significantly (P ≤ 0.05) higher following MRF application to LPS challenged IPEC-J2 cells over the positive control. CONCLUSIONS: The difference in each YCW products production and composition appeared to influence intestinal barrier integrity. The action of MRF demonstrates its potential ability to raise intestinal barrier integrity of IPEC-J2 intestinal cells on an in vitro level through significantly elevated intracellular connections.

Froude Efficiency and Velocity Fluctuation in Forearm-Amputee Front Crawl: Implications for Para Swimming Classification.

PURPOSE: The impact of physical impairment on Froude efficiency and intracyclic velocity fluctuation in Para swimmers is not well documented. Identification of differences in these variables between disabled and nondisabled swimmers could help develop a more objective system for assigning Para swimmers to classes for competition. This study quantifies Froude efficiency and intracyclic velocity fluctuation in unilateral forearm-amputee front crawl swimmers and evaluates associations between these variables and performance. METHODS: Ten unilateral forearm-amputee swimmers completed front crawl trials at 50- and 400-m pace; three-dimensional video analysis provided mass center, and wrist and stump velocities. Intracyclic velocity fluctuation was calculated as follows: 1) maximum-minimum mass center velocity, expressed as percent of mean velocity, and 2) coefficient of variation in mass center velocity. Froude efficiency was the ratio between mean swimming velocity and wrist plus stump velocity during each segment's respective 1) underwater phase and 2) propulsive underwater phase. RESULTS: Forearm amputees' intracyclic velocity fluctuation (400 m: 22% ± 7%, 50 m: 18% ± 5%) was similar to published values for nondisabled swimmers, whereas Froude efficiencies were lower. Froude efficiency was higher at 400-m (0.37 ± 0.04) than 50-m pace (0.35 ± 0.05; P < 0.05) and higher for the unaffected limb (400 m: 0.52 ± 0.03, 50 m: 0.54 ± 0.04) than the residual limb (400 m: 0.38 ± 0.03, 50 m 0.38 ± 0.02; P < 0.05). Neither intracyclic velocity fluctuation nor Froude efficiency was associated with swimming performance. CONCLUSIONS: Froude efficiency may be a valuable measure of activity limitation in swimmers with an upper limb deficiency and a useful metric for comparing swimmers with different types and severity of physical impairment.

Swimmers with Down Syndrome Are Healthier and Physically Fit than Their Untrained Peers.

While there are positive benefits from physical activity participation for individuals with Down syndrome, little is known about the effects of swimming training. The aim of this study was to compare the body composition and physical fitness profile of competitive swimmers and moderately active (untrained) individuals with Down syndrome. The Eurofit Special test was applied to a group of competitive swimmers (n = 18) and a group of untrained individuals (n = 19), all with Down syndrome. In addition, measurements were taken to determine body composition characteristics. The results showed differences between swimmers and untrained subjects in height, sum of the four skinfolds, body fat %, fat mass index and all items of the Eurofit Special test. Swimmers with Down syndrome exhibited physical fitness levels near to the Eurofit standards, although lower fitness levels were attained by these persons when compared to athletes with intellectual disability. It can be concluded that the practice of competitive swimming seems to counteract the tendency for obesity in persons with Down syndrome and also helps to increase strength, speed and balance.

Progress in the Treatment of Small Intestine Cancer.

OPINION STATEMENT: Small intestine cancer is rare, accounting for approximately 3% of all gastrointestinal malignancies. The most common histological subtypes include adenocarcinoma, neuroendocrine tumours (NETs) and gastrointestinal stromal tumours (GISTs). In localised disease, surgery remains the mainstay of treatment and the best approach to improve survival. Current treatment for small intestine adenocarcinoma (SIA) is extrapolated from small studies and data from colorectal cancer (CRC). There is limited evidence to guide therapy in the adjuvant setting. However, there are small phase II studies in the advanced setting providing evidence for the role of chemotherapy and immunotherapy. There is also limited evidence assessing the efficacy of targeted therapies. Small intestine NETs are rare, with evidence for somatostatin analogue therapy, particularly in the low to intermediate-grade well-differentiated tumours. Poorly differentiated NETs are generally managed with chemotherapy but have worse outcomes compared with well-differentiated NETs. The management of small intestine GISTs is largely targeting KIT mutations with imatinib. Recent trials have provided evidence for effective therapies in imatinib-resistant tumours and the potential role of immunotherapy. The aim of this article was to review the evidence for the current management and recent advances in the management of small intestine adenocarcinoma, NETs and GISTs.

A Unique Branching Pattern of the Brachial Artery: Coexisting Superficial Ulnar Artery and Persistent Median Artery.

The presence of both a superficial ulnar artery (SUA) and persistent median artery (PMA) of antebrachial type is of both clinical and surgical significance. In an 84-year-old female cadaver received through the Gift Body Program at Saint Louis University School of Medicine, the right brachial artery was seen divided into an SUA and radial artery (RA) slightly below the interepicondylar line of the humerus. At the level of the radial neck, the RA sent out the common interosseous artery that then gave off the radial recurrent artery before bifurcating into anterior interosseous artery (AIA) and posterior interosseous artery. The AIA continued to appear to branch into the anterior ulnar recurrent artery and posterior ulnar recurrent artery, as well as a PMA of the antebrachial type. In the hand, the SUA and RA contributed to the complete superficial palmar arch seemingly equally, and the RA was the dominant contribution to the deep palmar arch. Ninety-one other arms were assessed for this variation, and none were observed. Knowledge of an anatomical variation such as this may lead to decreased complications in the planning of surgical bypass grafting.

Principlist approach to multiple heart valve replacements for patients with intravenous drug use-induced endocarditis.

Medical professionals often deny patients who inject opioids a second or third heart valve replacement, even if such a surgery is medically indicated. However, such a position is not well defended. As this paper demonstrates, the ethical literature on the topic too often fails to develop and apply an ethical lens to analyse the issue of multiple valve replacements. This paper addresses this lacuna by analysing the case of Mr Walsh, a composite case which protects the identity of any one patient, through the principlist approach of Beauchamp and Childress. It argues that the hospital should offer Mr Walsh, a second valve replacement because the procedure is: medically indicated, autonomously requested, non-maleficent, beneficent and does not violate a formal account of justice. The paper concludes with clinical ethical guidelines for valve surgery for patients with opioid use disorder.

A Unique Variation of Quadratus Plantae in Relation to the Tendons of the Midfoot.

A novel combination of variations involving the quadratus plantae muscle (QP) and its relationship to the flexor hallucis longus (FHL) tendon was observed unilaterally in the right foot of an 88-year-old female cadaver during routine dissection. The medial head of QP was observed inserting onto the tendon of FHL rather than the tendon of flexor digitorum longus (FDL), while also contributing to an anomalous tendinous slip to the second digit in conjunction with the tendon of FHL. The tendon of FHL also gave off a slip to the third digit. Both tendinous slips attached distally to the digital tendons of FDL. Lastly, the lateral head of QP inserted onto the tendinous slip from FHL to the third digit. Ninety-five additional feet were assessed for these variations, but none were observed. This combination of variations expands upon the proposed actions of QP in the literature. Furthermore, connections between the tendons of the midfoot are of clinical significance for harvesting tendon grafts.

A Case of Multiple Posterior Intercostal Artery Common Trunks in Conjunction with Additional Arterial Variations.

Several thoracic vasculature variations were observed in an 81-year-old male cadaver during routine dissection. These included 5 common trunks of posterior intercostal arteries, a descending branch of the right vertebral artery, and atypical neurovascular relationships within intercostal spaces. On the right side, two common trunks of posterior intercostal arteries were observed supplying the 4th-7th intercostal spaces and 9th-11th intercostal spaces, respectively. There was also a small accessary branch supplying the 9th intercostal space. The first three posterior intercostal spaces on the right were supplied by a descending branch of the vertebral artery. On the left side, three common trunks of posterior intercostal arteries were encountered, supplying intercostal spaces 3-5, 6-7, and 11 plus the subcostal space. An atypical neurovascular relationship was observed in the right 6th intercostal space, as well as the left 2nd, 3rd, and 6th intercostal spaces. This is the first case report that presents 5 common trunks of posterior intercostal arteries, as well as common trunks in conjunction with other arterial variation in the posterior thoracic wall. These variations carry a high level of clinical significance and may be helpful in guiding decision-making related to surgical procedures related to the posterior thoracic cavity and spine.

How to perform transcystic stenting in the COVID-19 pandemic: an approach to biliary stenting without specialized endobiliary stenting equipment.

Management options for common bile duct stones found at laparoscopic cholecystectomy (LC) includes concurrent transcystic biliary stenting, effectively providing a conduit for common bile duct drainage and improving the success of subsequent endoscopic retrograde cholangiopancreatography. In the unprecedented COVID-19 pandemic however, potential disruptions to the medical supply chain have been far reaching, including the distribution of specialised biliary stent sets. To overcome this, we devised an innovative method at our centre to substitute traditional procedural stent sets by employing standard, universally accessible open-ended ureteral catheters, jagwires and pancreatic or biliary stents with similar procedural success.

A Unique Case of Incomplete Bifid Ureter and Associated Arterial Variations.

Introduction. Urogenital and vascular anomalies, including a left duplex kidney and a left aberrant renal artery that gave rise to the left ovarian artery, were observed in a 77-year-old female cadaver during a routine dissection. Description. A left aberrant renal artery, which gave rise to the left ovarian artery, was observed originating from the aorta 4 cm below the left renal artery. Two independent contributions to a bifid ureter were found originating from the hilum of the left kidney. These two contributions descended 12.4 cm and 10.6 cm, respectively, posterior to the left aberrant renal artery and lateral to the left ovarian artery before uniting anterior to the psoas major muscle to descend 12.7 cm to the bladder. Significance. While the duplex kidney is a relatively common congenital anomaly that can be asymptomatic, it can also potentially be associated with compression of renal vasculature or the ureter. Ureteral compression can then result in several pathologies including reflux, urinary tract infection (UTI), ureteropelvic junction obstruction, or hydronephrosis. Compression of renal and ovarian vasculature can result in altered blood flow to the kidney and ovary, potentially causing fibrosis, atrophy, or organ failure. Current imaging techniques alone are insufficient for correct diagnostics of such complications, and they must be supplemented with a thorough understanding of the respective anatomical variations.

Immediate Effects of Aquatic Therapy on Balance in Older Adults with Upper Limb Dysfunction: An Exploratory Study.

BACKGROUND: Aquatic physiotherapy has been shown to be effective in developing balance, strength, and functional reach over time. When dealing with immediate effects, the literature has concentrated more on the body's physiological response to the physical and mechanical properties of water during passive immersion. The purpose of this study was to evaluate the effects of a single 45-min active aquatic physiotherapy session on standing balance and strength, and its relationship with functional reach in persons 55 years and older with upper limb dysfunction. METHODS: The intervention group (n = 12) was assessed before and after a single aquatic physiotherapy session, while the control group (n = 10) was evaluated before and after 45 min of sitting rest. Functional assessment was made using the visual analogue pain scale (points), step test (repetitions), functional reach test (cm), and global balance-standing test on a force platform (% time). A two-way repeated-measures ANOVA was applied (p < 0.05). RESULTS: The intervention group showed non-significant improvements between measurement before and after the intervention: Pain: 6.2 ± 1.9 vs. 5.2 ± 2.3 cm, steps: 7.0 ± 2.0 vs. 7.4 ± 1.8 repetitions, reach: 9.1 ± 2.8 vs. 10.4 ± 3.8 cm, and balance: 61.7 ± 5.9 vs. 71.3 ± 18.2% time in balance on the platform. The control group showed fewer changes but had better baseline values. A comparison between groups with time showed no significant differences in these changes. CONCLUSIONS: No significant immediate effects were found for one session of aquatic physiotherapy applied to patients older than 55 years with upper limb dysfunction.