Variations of the obturator nerve and implications in obturator nerve entrapment treatment: an anatomical study.

INTRODUCTION: Obturator nerve entrapment or idiopathic obturator neuralgia is an unfamiliar pathology for many physicians which can lead to diagnostic errancy. This study aims to identify the potential compression areas of the obturator nerve to improve therapeutic management. MATERIAL AND METHODS: 18 anatomical dissections of lower limbs from 9 anatomical cadavers were performed. Endopelvic and exopelvic surgical approaches were utilized to study the anatomical variations of the nerve and to identify areas of entrapment. RESULTS: On 7 limbs, the posterior branch of the obturator nerve passed through the external obturator muscle. A fascia between the adductor brevis and longus muscles was present in 9 of the 18 limbs. The anterior branch of the obturator nerve was highly adherent to the fascia in 6 cases. In 3 limbs, the medial femoral circumflex artery was in close connection with the posterior branch of the nerve. CONCLUSION: Idiopathic obturator neuropathy remains a difficult diagnosis. Our cadaveric study did not allow us to formally identify one or more potential anatomical entrapment zones. However, it allowed the identification of zones at risk. A clinical study with staged analgesic blocks would be necessary to identify an anatomical area of compression and would allow targeted surgical neurolysis.

Saphenous nerve injury after anterior cruciate ligament reconstruction: Reduced numbness area after ligamentoplasty using quadriceps tendon compared with hamstring tendon.

PURPOSE: Injury to the infra-patellar branches of the saphenous nerve (IPBSN) is the main neurological complication of anterior cruciate ligament (ACL) reconstruction procedures. Surgical technique using quadriceps tendon (QT) autograft allows a less invasive tibial approach potentially protecting the IPBSN. The aim of this study was to compare the numbness surface of the cutaneous area supplied by the IPBSN after ACL reconstruction using either hamstring tendon (HT) or QT autografts. METHODS: This was a retrospective comparative cohort study including 51 patients who underwent ACL reconstruction (27 QT and 24 HT) between January 2017 and April 2018. A sensory clinical evaluation was performed on each patient: length of the tibial scar, eventual numbness surface area and the type of sensory disorder were reported. To be considered as an IPBSN lesion, the numbness area had to spread at least one-centimeter away from the scar. RESULTS: The average follow-up was 15 months. In the HT group, the numbness area surface measured 21.2 ± 19 cm2 (0-77) and the scar length was on average 31.3 ± 5.6 mm. In the QT group, the numbness area was reduced to 5 ± 10 cm2 (P = .0007) as well as the scar length (13.3 ± 2.8 mm, P < .0001). We counted five (17.8%) and 19 (76%) real IPBSN lesions in the QT and HT groups, respectively (P = .0002). Hypoesthesia was the main sensory disorder observed (87.5%). CONCLUSION: Numbness area of the cutaneous surface supplied by the IPBSN after ACL reconstruction is reduced using QT autograft compared with HT autograft.

T1 Vertebra Pedicular Osteoid Osteoma: Minimally Invasive Surgical Resection Aided by New Integrated Navigation to 3D Imaging Device.

We hereby describe a minimally invasive resection of a T1 pedicular osteoid osteoma next to the vertebral canal. The patient had an 18-month report of painful radiculopathy. We performed the surgery under 3D imaging guidance using navigation with an all-in-one device. Full procedure irradiation was 1.17 mSv for a 181-picture acquisition. Complete operative time incision to closure was 58 minutes. Despite sparing the vertebral stability without any fixation, the tumor resection was well-margined, thanks to the focused guidance. After surgery, the patient had complete relief of his symptoms at the 6-month follow-up. 3D imaging system coupled to navigation made the procedure safe without consuming time. The single Surgivisio® device allows comfortable 3D minimally invasive spine navigation surgery with the ergonomics of a C-arm.

Feedback on the usefulness of an illustrated guidebook in an anatomical dissection course.

PURPOSE: Dissection provides direct experience in anatomy, which constitutes an essential discipline for medical students. For this purpose, we created a dissection guide for students in the 2nd-year of medical studies at the Grenoble University School of Medicine. The objective was to evaluate this tool of reverse pedagogy in terms of student satisfaction and educational interest. METHODS: Every 2nd-year student takes four sessions of limb dissection. To assist this dissection course, we developed a photographic guide launched in 2013. It includes an introduction presenting a methodology for dissection, followed by detailed protocols for each dissection area. Each step is illustrated with captioned photographs associated with a concise explanatory text. A questionnaire was then sent to 242 students to assess the impact of this tool and their overall satisfaction. RESULTS: Overall student satisfaction with this guidebook was rated 8.1 out of 10 with a 93.2% with significant improvement (p = 0.0137) and 78.7% of them declaring they had a better understanding of anatomy and mastery of the dissection techniques, respectively. In addition, students assessed the usefulness of the dissection guide at 3.6 out of 4 with the relevance of the content and presentation judged at 3.4 out of 4. Finally, the exam scores increased significantly with use of the guidebook (p < 0.0001). CONCLUSIONS: Students deemed the organization of this anatomy tutorial as highly satisfactory, and using the guidebook as a reference in dissection sessions allowed students to prepare for the dissection and improve their knowledge of anatomy, as demonstrated by improved exam scores.

The round ligament of the uterus: Questioning its distal insertion.

PURPOSE: Classically, the round ligament of the uterus (RLU) attaches distally in the ipsilateral labia majora. This attachment has rarely been described in adults. That is why we have performed an anatomical study focused on this distal ending. PATIENTS: We performed in 2015 the cadaveric dissection of 19 RLU. METHODS: In all cases, the RLU was individualized on its entire length from its uterine origin to the inguinal canal. Then this canal was open from its internal orifice to its external orifice. We described the distal attachment of the RLU according four areas: before the internal inguinal ring, after the external inguinal ring, under the pubic bone and in labia majora. RESULTS: We found 3 types of distal attachments with first an attachment after the external inguinal ring in more than half of cases (52.6%). Then, before the internal inguinal ring (26.3%) and under the pubic bone (22.1%). No RLU was found inlabia majora. However, the proximal attachment seems constant at the antero-superior face of uterus, near the tubo-uterine junction like its pelvic path under the broad ligament. CONCLUSION: In adult, the RLU is a structure, which begins at the cranio-ventral part of the uterine bottom near the tubo-uterine junction. Then it passes under the broad ligament and reaches the inguinal canal, that it crosses in more half of cases. However, 3 distal attachment areas have been identified but never in the labia majora. Indeed, some anatomical information available in anatomical treaties seems not correct and should be amended.

Anatomy and histology of the scrotal ligament in adults: inconsistency and variability of the gubernaculum testis.

PURPOSE: The anatomy of gubernaculum testis (GT) is often discussed; however, the postnatal anatomy of the GT or scrotal ligament (SL) is rarely described. Hence, we performed an anatomical and histological study to analyze histologically the structures between testis and scrotum. METHODS: We performed anatomical dissections on 25 human fresh cadavers' testes. Each testis was removed with its envelopes and macroscopically analyzed. Then samples were included for histological study. Finally, they were analyzed under microscope, looking for attachments between testis, epididymis and scrotal envelopes. RESULTS: The absence of proximal and distal attachment was found in 56.0% of cases. Looking at the proximal attachment of the SL, the main one found is the epididymal attachment (28.0%), whereas no cases of testis attachment was found. Distally, there are more variations with scrotal attachment (12%) and cremaster attachment (12.0%). We found a significant prevalence of multiple adherences in 16.0% of cases too. Finally, in 15 cases (57.7%) an attachment is present between testis and epididymis, as it is commonly described. CONCLUSIONS: In the majority of cases there is no attachment of the lower pole of the testis and epididymis and these structures remain free. So it seems that the SL disappears with aging. Moreover, there is not only one kind of ligamentous attachment, but a high variability of attachments at the lower pole of the testiculo-epididymal structure. When it exists, this structure is never a real ligament and it seems more appropriate to use the term "attachments".

Relationship between the ansa cervicalis and the omohyoid muscle: clinical consequences in parathyroid surgery.

PURPOSE: To determine the position of the lower loop of the ansa cervicalis (AC) compared to the inferior edge of the omohyoid muscle to guide minimally invasive surgery for the lateral oblique approach of parathyroid glands. METHODS: Authors performed 36 anatomical dissections in the laboratory of anatomy (Laboratoire d'Anatomie Des Alpes Françaises) of the Grenoble medical school in 2012 on human cadavers. They independently measured the distance between the caudal extremity of the AC and the lower edge of the superior belly of the omohyoid muscle. Then, they controlled this measure on pictures. RESULTS: The study shows a majority of long AC (under the omohyoid muscle) in 66.7 % of cases. In addition, the AC was located on an average value of 0.1 cm below the lower edge of the omohyoid muscle (median -0.5 cm). Thus, two-thirds of AC are between 0 and -2 cm under the omohyoid muscle. Furthermore, the AC is generally non-symmetrical: there is a mean difference of 1.3 cm between the left and right AC. In this series, there are as many long AC on the right side as on the left side. CONCLUSIONS: These results are in contradiction with literature data. To preserve the ansa cervicalis and its phonatory functions, it is necessary for the surgeon to perform a systematic per operative identification of the AC because the position of the AC is mainly under the omohyoid muscle and because of an asymmetry. Per operative neurostimulation and/or magnified lenses might be helpful during the surgical approach.

The antiprogestin RU486 in advanced breast cancer: preliminary clinical trial.

Twenty-two oophorectomized or postmenopausal women with metastatic breast cancer resistant to several medical therapies (tamoxifen, or other endocrine therapy, and chemotherapy) were treated in a first trial with 200 mg per day of RU486 for 1 to 3 months. The long-term tolerance was good but there was a moderate decrease in plasma potassium. Plasma cortisol was increased 2-fold without clinical hypo- or hypercorticism. Twelve patients had a partial response or a stabilization of secondary deposits for 6 weeks but the response rate at 3 months was 18%. When available, estrogen and progesterone receptor levels were positive in these patients. This preliminary trial shows for the first time that the antiprogestin RU486 is well tolerated for medium term treatment. It suggests that it might be active on advanced breast cancer becoming resistant to tamoxifen.

Ribulose-1,5-bisphosphate carboxylase/oxygenase expression in melon plants infected with Colletotrichum lagenarium : Activity, content and rate of synthesis.

Ribulose-1,5-bisphosphate carboxylase/oxygelase (RuBPCase) was studied in melon leaves infected by Colletotrichum lagenarium, a fungal pathogen of melons. Electrophoretic analysis of melon leaf proteins indicated a strong effect of infection on RuBPCase, the subunits of which gradually disappeared during the different stages of infection. Enzyme activity also declined 4 d after inoculation and its content, measured by immunoelectrophoresis, decreased to a similar extent. Synthesis of the large and small subunits of RuBPCase was followed by in-vivo pulse-labeling experiments. A drastic decrease in the rate of RuBPCase-subunit synthesis occurred 3 d after inoculation and preceded the appearance of disease symptoms. There was an apparent coordination of the synthesis of the two subunits under these conditions.

Distribution of the Mr 52,000 estrogen-regulated protein in benign breast diseases and other tissues by immunohistochemistry.

A secreted glycoprotein with a molecular weight of 52,000 is induced by estrogen in breast cancer cells and has been purified to prepare monoclonal antibodies. The protein has been detected in some breast cancers but not in normal breast and uterus. In order to study its potential value as a marker, we have tested by immunohistochemistry frozen sections of several normal and malignant tissues and of benign mastopathies. Among different tissues tested, the Mr 52,000 protein was detected only in liver, sweat glands, and some sebaceous glands, and in malignant melanomas and some breast tumors. Other estrogen-responsive tissues (ovary, placenta, endometrium, etc.) gave negative results. Immunoradiometric assay of the Mr 52,000 protein in biological fluid revealed an elevated concentration in cyst fluid (0.5 to 7.4 micrograms/ml), pleural effusions of certain metastatic breast cancer, and sweat. By immunohistochemistry, the Mr 52,000 antigen was also detected in 42% of 129 benign mastopathies. Gynecomastia, fibrous disease, fibroadenoma, and adenosis were mainly negative, whereas ductal hyperplasia and cysts were positive. The Mr 52,000 protein was found mostly in proliferative ducts and in cysts but not in lobular hyperplasia and nonproliferative lesions without cyst. More Mr 52,000 protein was found in postmenopausal patients than in premenopausal patients. We conclude that the Mr 52,000 protein is a marker associated with mammary cysts and proliferative ducts. On the basis of the increased risk of breast cancer in proliferative mastopathies, we suggest that the Mr 52,000 protein is useful for predicting high-risk mastopathies acting as a marker associated with the proliferation of ductal tissue.

[Comparison of biosynthetic human insulin and purified pork insulin. Studies in insulin-resistant obese patients using the insulin suppression test]. / Comparaison de l'insuline humaine bio-synthétique et de l'insuline porcine purifiée. Etude chez les obèses insulino-résistants par le test de suppression insulinique.

An insulin suppression test performed in random order with either biosynthetic human insulin or purified pork insulin was used to compare biological activity of these two insulins in obese patients suffering from varying degrees of glucose intolerance. Blood glucose curve, steady-state blood glucose levels, insulin sensitivity indices and steady-state plasma insulin levels were identical during the two sets of tests. Furthermore endogenous insulin and glucagon secretion were similarly suppressed. The insulin suppression test is a simple and rapid procedure to compare the biological activity of fast-acting insulins. Our results confirm the insulin-resistance in obesity and clearly show that biosynthetic human and porcine insulins have similar biological potency.

[Urinary excretion of 3-methylhistidine. Value and application to the study of protein catabolism]. / L'excrétion urinaire de 3-méthylhistidine. Intérêt et application dans l'étude du catabolisme protidique.

The urinary excretion of 3-methylhistidine (3 MH) is considered an easy and reliable method to quantify muscle protein catabolism in man. The 3 MH/creatinine (Cr) ratio is thought to be a good index of fractional degradation of muscle fibre protein. In the present article, the stress is placed on the limitations of 3 MH assays an- on their clinical applications. In thyroid diseases and in malnutrition (anorexia nervosa), the 3 MH/Cr ratio differentiates clearly marasmic malnutrition without increase in protein catabolism from hypercatabolic states, such as hyperthyroidism, with excessive protein degradation. 3 MH measurements therefore appear to be useful to determine the contribution of protein catabolism to lean mass reduction.

Human (recombinant DNA) and porcine NPH insulins are unequally effective in diabetic patients. A comparative study using continuous blood glucose monitoring.

The hypoglycemic activities of NPH biosynthetic human and pork insulins were compared in eight insulin-dependent diabetic patients using continuous blood glucose monitoring. After an overnight normalization of blood glucose levels, either human or pork NPH were injected subcutaneously in random order. Blood glucose was continuously recorded during 9.5 h while patients were consuming their usual diet. After NPH biosynthetic human insulin, blood glucose levels from the 2nd to the 9th h post-injection were lower as well as the glycemic nadir. The area under the curve was smaller after human than after pork insulin. But, in the last half-hour of the experiment, blood glucose was falling after pork insulin, while it was rising after human insulin. Under the conditions of this study, our results demonstrate that NPH biosynthetic human insulin may be more effective than NPH pork insulin, due to more rapid subcutaneous absorption but its duration is shorter than after porcine NPH insulin. These data may be of importance in the treatment of insulin-dependent diabetes mellitus.

Thyroid status and muscle protein breakdown as assessed by urinary 3-methylhistidine excretion: study in thyrotoxic patients before and after treatment.

Urinary 3-methylhistidine (3MH) excretion was studied in nine thyrotoxic patients before and after treatment. Urinary creatinine (Cr) output was also measured and was low in the thyrotoxic subjects before treatment. Thus, although urinary output of 3MH was not greater than among the control population when expressed per subject, it was significantly elevated when expressed as the ratio of 3MH to Cr; this ratio fell significantly, reaching normal control values after a euthyroid state was obtained. In one patient who became hypothyroid, the 3MH/Cr ratio fell under the control value. There was a significant linear correlation between the 3MH/Cr ratio and the hormonal variables (T3, T4, FT4l); moreover, variations in the 3MH/Cr ratio and variations in the T3 level were closely correlated. 3-Methylhistidine appears to be a reliable index of muscular breakdown in thyrotoxicosis. From our results, it can be concluded, first of all, that hyperthyroidism is accompanied by an increased muscular catabolism, and, second, that the return to a euthyroid state results in an immediate normalization of muscular breakdown.

[Value of continuous registration of blood D-beta-hydroxybutyrate and glucose. Application in a case of acromegaly]. / Intérêt de l'enregistrement continu du D-beta-hydroxybutyrate et du glucose sanguins. Application à un cas d'acromégalie.

We describe the use of an autoanalyzer II for continuous whole blood D-beta-hydroxybutyrate and glucose monitoring. The former is analyzed by an enzymatic-fluorimetric determination. This method is simple, reliable and sensitive at low cost. It permits to record dynamic patterns of the two major energetic substrates in response to various stimuli, as shown in an acromegalic patient following a glucose load.

Purification and properties of ribulose 1,5-bisphosphate carboxylase from sunflower leaves.

Extracts from sunflower leaves possess a high ribulose-1,5-bisphosphate (RuBP) carboxylase capacity but this enzyme activity is not stable. A purification procedure, developed with preservation of carboxylase activity by MgSO4, yielded purified RuBP carboxylase with high specific activity (40 nkat mg(-1) protein). Measurement of kinetic parameters showed high Km values (RuBP, HCO 3 (-) ) and high Vmax of the reaction catalyzed by this sunflower enzyme; the results are compared with those obtained for soybean carboxylase. Enzyme characteristics are discussed in relation to stabilization and activation procedures and to the high photosynthesis rates of this C3 species.

Photosynthetic characteristics of mesophyll eells isolated from sunflower (helianthus annuus L.) leaves.

Mesophyll cells were isolated from sunflower leaves by an enzymic procedure. The cell suspensions possessed high photosynthesis rates. The products of cell photosynthesis were similar to the products of leaf disc photosynthesis. The relatively high radioactivity incorporated into malate after (14)CO2 feeding suggests that PEP carboxylase might participate in CO2 fixation. Sunflower leaf extracts possessed a PEP carboxylase activity slightly higher than that of other C3 species. Inhibition of PEP carboxylase by maleate decreased cell photosynthesis by only 15% and the first products of cell photosynthesis were phosphorylated compounds. It is concluded that the high photosynthesis rates displayed by sunflower are not due to a parallel C4 pathway of photosynthesis but are rather dependent, at least in part, on the activity, or the amount, of RuBP carboxylase.