Bilateral fracture-dislocation of the shoulder following a seizure- A case report & review of literature.

Introduction: and Importance: Bilateral shoulder dislocations are uncommon and those are usually posterior dislocations. Bilateral anterior fracture-dislocations are rarest of their kind following seizure episodes. Case presentation: We present a case of bilateral fracture-dislocations of the shoulder following a seizure episode. Bilateral dislocations were relocated to the emergency unit and managed conservatively as he refused to undergo surgery. The patient was followed up at the Orthopaedic clinic and achieved a full range of movements of the bilateral shoulder the one-year post-intervention. Clinical discussion: A closed reduction is also an option on occasion like this patient. Conclusion: Careful radiological assessment and follow-up with physiotherapy will help to achieve a good outcome.

An artificial intelligence algorithm that identifies middle turbinate pneumatisation (concha bullosa) on sinus computed tomography scans.

OBJECTIVE: Convolutional neural networks are a subclass of deep learning or artificial intelligence that are predominantly used for image analysis and classification. This proof-of-concept study attempts to train a convolutional neural network algorithm that can reliably determine if the middle turbinate is pneumatised (concha bullosa) on coronal sinus computed tomography images. METHOD: Consecutive high-resolution computed tomography scans of the paranasal sinuses were retrospectively collected between January 2016 and December 2018 at a tertiary rhinology hospital in Australia. The classification layer of Inception-V3 was retrained in Python using a transfer learning method to interpret the computed tomography images. Segmentation analysis was also performed in an attempt to increase diagnostic accuracy. RESULTS: The trained convolutional neural network was found to have diagnostic accuracy of 81 per cent (95 per cent confidence interval: 73.0-89.0 per cent) with an area under the curve of 0.93. CONCLUSION: A trained convolutional neural network algorithm appears to successfully identify pneumatisation of the middle turbinate with high accuracy. Further studies can be pursued to test its ability in other clinically important anatomical variants in otolaryngology and rhinology.

An artificial intelligence algorithm that differentiates anterior ethmoidal artery location on sinus computed tomography scans.

OBJECTIVE: Deep learning using convolutional neural networks represents a form of artificial intelligence where computers recognise patterns and make predictions based upon provided datasets. This study aimed to determine if a convolutional neural network could be trained to differentiate the location of the anterior ethmoidal artery as either adhered to the skull base or within a bone 'mesentery' on sinus computed tomography scans. METHODS: Coronal sinus computed tomography scans were reviewed by two otolaryngology residents for anterior ethmoidal artery location and used as data for the Google Inception-V3 convolutional neural network base. The classification layer of Inception-V3 was retrained in Python (programming language software) using a transfer learning method to interpret the computed tomography images. RESULTS: A total of 675 images from 388 patients were used to train the convolutional neural network. A further 197 unique images were used to test the algorithm; this yielded a total accuracy of 82.7 per cent (95 per cent confidence interval = 77.7-87.8), kappa statistic of 0.62 and area under the curve of 0.86. CONCLUSION: Convolutional neural networks demonstrate promise in identifying clinically important structures in functional endoscopic sinus surgery, such as anterior ethmoidal artery location on pre-operative sinus computed tomography.

Blunt laryngeal trauma secondary to sporting injuries.

BACKGROUND: Laryngeal injury after blunt trauma is uncommon, but can cause catastrophic airway obstruction and significant morbidity in voice and airway function. This paper aims to discuss a case series of sports-related blunt laryngeal trauma patients and describe the results of a thorough literature review. METHOD: Retrospective case-based analysis of laryngeal trauma referrals over six years to a tertiary laryngology centre. RESULTS: Twenty-eight patients were identified; 13 (46 per cent) sustained sports-related trauma. Most were young males, presenting with dysphonia, some with airway compromise (62 per cent). Nine patients were diagnosed with a laryngeal fracture. Four patients were managed conservatively and nine underwent surgery. Post-treatment, the majority of patients achieved good voice outcomes (83 per cent) and all had normal airway function. CONCLUSION: Sports-related neck trauma can cause significant injury to the laryngeal framework and endolaryngeal soft tissues, and most cases require surgical intervention. Clinical presentation may be subtle; a systematic approach along with a high index of suspicion is essential, as early diagnosis and treatment have been reported to improve airway and voice outcome.

Audit: patient reported outcomes of extracorporeal septorhinoplasty.

BACKGROUND: Extracorporeal septorhinoplasty (ECS) presents an important option in the surgical correction of the markedly deformed and twisted nose. However, there is a paucity of literature on the qualitative outcomes of ECS. METHODOLOGY: Retrospective telephone and postal questionnaire study of operations performed over 2 years (2008-2009) under the care of a senior rhinologist at two linked hospitals in the United Kingdom. Questionnaires were designed (i) relating to the procedure and (ii) patient perceptions of surgical success, improvements in physical health, psychosocial functioning and social interactions. For succinctness a shortened version of the Glasgow Benefit Inventory was used. RESULTS: Forty-six cases were analysed eight of which were revision cases. Two cases required revision surgery and two minor complications occurred, managed conservatively. The patients had a minimum of two to three follow-ups from seven days to one year. Questionnaire scores suggested high satisfaction in response to surgical success, with notable improvements in physical health (sleep disturbance) and in general health and well-being. Regarding psychosocial functions patients reported feeling either moderately less self-conscious or not self-conscious at all post-surgery. Improvements in social interactions were less well-defined. CONCLUSION: In this audit of cases with significant deformities, ECS appears to confer high levels of satisfaction.

'Coughing up a tonsil' - oesophageal leiomyoma.

We report on a case of oesophageal leiomyoma presenting as a potential cause of sudden airway obstruction. The patient presented with a large mass in the oral cavity after an episode of forceful vomiting. The operative findings and histology of which confirmed this to be an oesophageal leiomyoma emanating from the upper oesophagus, a rare finding. The mass was excised and the patient's subsequent post-operative recovery and follow-up has been unremarkable. This diagnosis should be borne in mind when one is referred the odd-sounding case of a patient who appears to have 'coughed up their tonsil'.

Nonlinear ion modes in a dense plasma with strongly coupled ions and degenerate electron fluids.

The properties of solitary and shock structures associated with nonlinear ion modes in a dense plasma with strongly coupled nondegenerate ions and degenerate electron fluids are presented. For this purpose, we have used the viscoelastic fluid model for the ions, the inertialess electron momentum equation with weakly and ultrarelativistic pressure laws for the degenerate electron fluids, and Poisson's equation to derive the Burgers and Kortweg-de Vries equations. Possible stationary solutions of the latter are the shock and solitary structures, respectively. It is found that the speed, amplitude, and width of the shock and solitary waves critically depend on the strong coupling between ions and electron degeneracy effects. The relevance of our investigation to the role of localized excitations in dense astrophysical objects is briefly discussed.

An unusual case of prolonged tinnitus following low-dose amitriptyline.

We report on a case of unilateral tinnitus after a short course of low-dose amitriptyline for neuralgic foot pain. This has been described in the literature previously at much higher doses and is associated with prolonged administration; we present our case with a review of the current literature in-order to raise awareness of this possible complication of anti-depressant therapy. We also propose a novel hypothesis for the pharmacological basis of amitriptyline-induced tinnitus.

Case series: variations in the embryology of congenital midline cervical clefts.

Congenital midline cervical clefts (CMCC) is a clinical diagnosis and represents a spectrum of rare developmental anomalies. Fewer than 100 cases have been reported overall, the first being described by Bailey in 1924 (1). It is not a true cleft because it does not include a gap between adjacent skin flaps. It is thought to represent a failure of midline fusion of the branchial arches although this is controversial. It is a clinical diagnosis and presents at birth with a ventral midline defect of the skin of the neck. This consists of a skin tag (nipple-like projection), an atrophic mucosal surface and a caudal sinus. It may be associated with a subcutaneous fibrous cord, which can cause a vertical midline tethering restricting cervical extension. Associated defects may be a median cleft of the mandible, tongue and lower lip. There may be an associated delay in mandibular development and hypoplasia or absence of neck structures such as the hyoid bone. Associated thyroglossal and bronchogenic cysts may occur as well as defects in other parts of the body such as a sternal cleft (2). CMCC has been previously reported in the literature as being of a branchial origin, however a review of the histology of previous cases suggests a combined branchial and bronchogenic component (2-6). We report on two cases that presented with the clinical picture of a classical CMCC. Our first case appears to have a bronchogenic origin with possible branchial components and the second case appears to be solely branchial in origin. There is much debate as to the embryology of this clinical entity; we shall endeavour to address the main theories.

Buried umbilicus: an iatrogenic cause of a discharging umbilical wound.

We report on a patient who had a previous abdominoplasty with umbilical reconstruction. The patient presented one-year postoperatively with periumbilical cellulitis. This was felt to be due to a retained stitch, which when removed improved the patient's symptoms. However, a further recurrence prompted a surgical exploration, which demonstrated that the original umbilicus had been left in place and buried. This was corrected and the patient has had no further problems at subsequent follow-up. This case presents an iatrogenic cause of a discharging umbilicus; it is reported in context with the differential diagnoses, which should be considered for an infected umbilicus.

Subcutaneous leiomyosarcoma of the frenulum.

Leiomyosarcomas of the penis are rare, with only 29 reported cases to date. We record the case of a patient who presented with a 2-year history of a seemingly indolent penile skin lesion. On histopathology of the local resection, a diagnosis of subcutaneous leiomyosarcoma was made. Specifically, leiomyosarcoma of the penile frenulum has not been clearly reported previously. The patient underwent a further excision to ensure an adequate resection margin and has had no disease recurrence at subsequent follow-up. Our case was of a lesion that, although clinically benign, was malignant and this possibility should be borne in mind when assessing patients.

Joseph Towne (1806-1879), master modeller of wax.

Joseph Towne (1806-1879) was a pioneer in the art of wax modelling of anatomical and dermatological material. He began his career at the age of 17, at Guy's Hospital, London, where he spent the whole of his professional life. He was a secretive, self-taught individual, and the finer points of his technique died with him. His brilliant works are on view at the Gordon Museum at Guy's, and are still used for teaching.

Management of spontaneous pneumothorax: are British Thoracic Society guidelines being followed?

In 1993, the British Thoracic Society (BTS) issued guidelines for the management of spontaneous pneumothorax. The aim of this study was to determine the level of adherence to and awareness of these guidelines at a London teaching hospital. A retrospective case note audit of 59 episodes of acute spontaneous pneumothorax was performed. In patients undergoing intervention, the initial procedure was simple aspiration in 32 (73%) and chest tube insertion in 12 (27%) cases, contrasting with the BTS recommendation that aspiration should be attempted first in all such patients. Simple aspiration was successful on 34% of occasions. Successful aspiration was associated with a significantly shorter hospital stay (median 3, range 1-11 days) than either failed aspiration (7, 3-66 days; p=0.003) or chest tube insertion without aspiration (9, 3-16 days; p=0.005). Other areas where practice differed from the BTS guidelines were clamping of chest tubes and use of a pursestring suture for wound closure. A follow up questionnaire survey suggested a lack of familiarity with the guidelines. These findings indicate that current management of spontaneous pneumothorax deviates from the BTS guidelines in a number of potentially important respects. Attention should be directed to improving awareness of and access to clinical guidelines.

Cell biotinylation provides a sensitive and effective detection technique for cellular adhesion assays: comparison with existing methods.

A simple, sensitive, colorimetric labelling method was devised to quantify cell adhesion, based on labelling the cell plasma membrane with biotin. This method was applied in adhesion assays, which involved the adherence of biotin-labelled, PMA-stimulated, U937 cells. These cells resemble monocytes, and were bound onto fibronectin-coated wells and to an ECV304 cell monolayer. The adherent U937 cells were detected by the addition of a peroxidase-conjugated anti-biotin antibody and a soluble colorimetric substrate. This assay is convenient, fast and sensitive, and able to detect 320-1000 U937 cells under the conditions described. This study has used titration assays to compare the biotinylation method with the existing cell quantification approaches of 51Cr radiolabelling and antibody dependent ELISA. Chromium labelling was the most sensitive technique, but we found the biotinylation method to be more convenient than radioactive labelling and more sensitive than conventional ELISA. Biotinylated cells were also used very effectively in a Stamper-Woodruff adhesion assay with U937 cells binding to histological sections of atherosclerotic plaques. The selective detection of the bound cells permitted automated quantitation by image analysis. Whole cell biotinylation may have wider applications in biological research.

Regional and cellular distribution of CYP2D subfamily members in rat brain.

1. Human CYP2D6 is present in brain, metabolizes many drugs and has been implicated in Parkinson's and Alzheimer's diseases and some cancers. It is still unclear which of the six known rat CYP2D subfamily members is/are homologous to human CYP2D6. 2. In this study, RT-PCR, Southern and Western blotting and immunohistochemical techniques were used to study the distribution of CYP2D subfamily member mRNA and proteins across 10 rat brain regions. CYP2D subfamily mRNA and protein levels were correlated with brain dextromethorphan O-demethylation (DOD), a measure of human CYP2D6 and rat CYP2D1 activities. 3. The data showed a strong relationship between CYP2D1 and CYP2D1-18 with brain DOD activity. In addition, it was shown that CYP2D proteins are present in brain mitochondrial as well as microsomal membranes. CYP2D subfamily member mRNA and proteins varied across brain regions and were highly concentrated in specific cell types. 4. These data strongly suggest that CYP2D1 and not CYP2D5 mediates DOD activity in rat brain, and may be the rat homologue of human CYP2D6. The highly localized nature of CYP2D indicates that in specific neurones enzyme levels may approach hepatic levels and, hence, contribute to local alterations in brain drug metabolism.

The small leucine-rich repeat proteoglycan biglycan binds to alpha-dystroglycan and is upregulated in dystrophic muscle.

The dystrophin-associated protein complex (DAPC) is necessary for maintaining the integrity of the muscle cell plasma membrane and may also play a role in coordinating signaling events at the cell surface. The alpha-/beta-dystroglycan subcomplex of the DAPC forms a critical link between the cytoskeleton and the extracellular matrix. A ligand blot overlay assay was used to search for novel dystroglycan binding partners in postsynaptic membranes from Torpedo electric organ. An approximately 125-kD dystroglycan-binding polypeptide was purified and shown by peptide microsequencing to be the Torpedo ortholog of the small leucine-rich repeat chondroitin sulfate proteoglycan biglycan. Biglycan binding to alpha-dystroglycan was confirmed by coimmunoprecipitation with both native and recombinant alpha-dystroglycan. The biglycan binding site was mapped to the COOH-terminal third of alpha-dystroglycan. Glycosylation of alpha-dystroglycan is not necessary for this interaction, but binding is dependent upon the chondroitin sulfate side chains of biglycan. In muscle, biglycan is detected at both synaptic and nonsynaptic regions. Finally, biglycan expression is elevated in muscle from the dystrophic mdx mouse. These findings reveal a novel binding partner for alpha-dystroglycan and demonstrate a novel avenue for interaction of the DAPC and the extracellular matrix. These results also raise the possibility of a role for biglycan in the pathogenesis, and perhaps the treatment, of muscular dystrophy.

Induction of SC1 mRNA encoding a brain extracellular matrix glycoprotein related to SPARC following lesioning of the adult rat forebrain.

SC1 is an extracellular matrix (ECM) glycoprotein related to SPARC which exhibits anti-adhesive properties. ECM molecules are thought to play important roles in influencing cell shape, proliferation and migration during neurogenesis. Following localized injury to the adult rat forebrain, a biphasic induction of SC1 mRNA was apparent, namely a rapid, transient induction at 1 day post-lesion in cortical neurons which border the lesion site followed by a more prolonged induction in astrocytes which are proximal to the wound site. A similar SC1 induction pattern was observed in the hippocampus in response to the injury. SPARC mRNA exhibits a divergent pattern of induction because it is induced in mature blood vessels close to the lesion and in blood vessels which develop following the trauma. Thus mRNAs encoding the related ECM glycoproteins SC1 and SPARC are induced in different cell populations in the adult forebrain during the neural response to localized injury.

CPEB-mediated cytoplasmic polyadenylation and the regulation of experience-dependent translation of alpha-CaMKII mRNA at synapses.

Long-term changes in synaptic efficacy may require the regulated translation of dendritic mRNAs. While the basis of such regulation is unknown, it seemed possible that some features of translational control in development could be recapitulated in neurons. Polyadenylation-induced translation of oocyte mRNAs requires the cis-acting CPE sequence and the CPE-binding protein CPEB. CPEB is also present in the dendritic layers of the hippocampus, at synapses in cultured neurons, and in postsynaptic densities of adult brain. alpha-CaMKII mRNA, which is localized in dendrites and is necessary for synaptic plasticity and LTP, contains two CPEs. These CPEs are bound by CPEB and mediate polyadenylation-induced translation in injected Xenopus oocytes. In the intact brain, visual experience induces alpha-CaMKII mRNA polyadenylation and translation, suggesting that this process likely occurs at synapses.