Evaluation of architectural distortion with contrast-enhanced mammography.

Architectural distortion (AD) is the third most common abnormality detected on mammograms. In the absence of an accurate non-invasive tool to evaluate ADs, clinical management often requires surgical excision for histological diagnosis. This problem is expected to worsen with the growing use of digital breast tomosynthesis (DBT) and the resultant increasing detection of ADs. There is therefore a great clinical need for a diagnostic imaging tool to complement non-enhanced mammography for the evaluation of AD. Contrast-enhanced mammography (CEM) is an emerging breast imaging method that uses contrast media and the principle of dual-energy subtraction to evaluate vascularity of suspicious breast lesions. CEM, a cost-effective alternative to breast magnetic resonance imaging (MRI), can be used to evaluate AD by juxtaposing CEM images with non-enhanced mammograms for comparison. In this review, the authors aim to provide readers with an overview of the interpretation of AD on CEM using imaging examples. Relevant imaging features of CEM and their respective significance will be matched with information from a literature review. Finally, the authors would like to highlight the added value of CEM in relevant clinical applications in the assessment of AD.

Cerebral palsy and its medicolegal implications in low- resource settings - the need to establish causality and revise criteria to implicate intrapartum hypoxia: A narrative review.

The objective of this study was to establish scientific causality and to devise criteria to implicate intrapartum hypoxia in cerebral palsy (CP) in low-resource settings, where there is potential for an increase in damaging medicolegal claims against obstetric caregivers, as is currently the situation in South Africa. For the purposes of this narrative review, an extensive literature search was performed, including any research articles, randomised controlled trials, observational studies, case reports or expert or consensus statements pertaining to CP in low-resource settings, medicolegal implications, causality, and criteria implicating intrapartum hypoxia. In terms of causation, there are differences between high-income countries (HICs) and low-resource settings. While intrapartum hypoxia accounts for 10 - 14% of CP in HICs, the figure is higher in low-resource settings (20 - 46%), indicating a need for improved intrapartum care. Criteria implicating intrapartum hypoxia presented for HICs may not apply to low-resource settings, as cord blood pH testing, neonatal brain magnetic resonance imaging (MRI) and placental histology are frequently not available, compounded by incomplete clinical notes and missing cardiotocography tracings. Revised criteria in an algorithm for low-resource settings to implicate intrapartum hypoxia in neonatal encephalopathy (NE)/ CP are presented. The algorithm relies first on specialist neurological assessment of the child, determination of the occurrence of neonatal encephalopathy (by documented or verbal accounts) and findings on childhood MRI, and second on evidence of antepartum and intrapartum contributors to the apparent hypoxia-related CP. The review explores differences between low-resource settings and HICs in trying to establish causation in NE/CP and presents a revised scientific approach to causality in the context of low-resource settings for reaching appropriate legal judgments.

Clinical practice.

Basal ganglia and thalamus (BGT) hypoxic-ischaemic brain injury is currently the most contentious issue in cerebral palsy (CP) litigation in South Africa (SA), and merits a consensus response based on the current available international literature. BGT pattern injury is strongly associated with a preceding perinatal sentinel event (PSE), which has a sudden onset and is typically unforeseen and unpreventable. Antepartum pathologies may result in fetal priming, leading to vulnerability to BGT injury by relatively mild hypoxic insults. BGT injury may uncommonly follow a gradual-onset fetal heart rate deterioration pattern, of duration ≥1 hour. To prevent BGT injury in a clinical setting, the interval from onset of PSE to delivery must be short, as little as 10 - 20 minutes. This is difficult to achieve in any circumstances in SA. Each case needs holistic, multidisciplinary, unbiased review of all available antepartum, intrapartum and postpartum and childhood information, aiming at fair resolution without waste of time and resources.

Right of Reply.

To the Editor: The article by Bhorat et al. [1] in the SAMJ, entitled 'Cerebral palsy and criteria implicating intrapartum hypoxia in neonatal encephalopathy - an obstetric perspective for the South African setting', starts off by raising concerns about 'steep rises in insurance premiums, placing service delivery under serious threat'. It does not acknowledge any service delivery issues that already exist in the public sector obstetric services in South Africa (SA). According to Whittaker,[2] in 2019, there were 303 obstetricians and gynaecologists employed in the SA public sector and 579 in the private sector, and of those employed in the public sector, 190 were performing private sector work. That a large number of the children with cerebral palsy (CP) were delivered in the public sector service was not noted by Bhorat et al.,[1] nor was the fact that the overwhelming majority of court cases are against the state (not against individual doctors) in provinces and hospitals with significant medical staffing and resource issues. For example, the liabilities for Eastern Cape Province in the 2019/20 period were ZAR36 751 207 v. only ZAR33 155 in Western Cape Province for the same period.[2].

Decreased severity of disease during the first global omicron variant covid-19 outbreak in a large hospital in tshwane, south africa.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) first reported in Wuhan, China in December 2019 is a global pandemic that is threatening the health and wellbeing of people worldwide. To date there have been more than 274 million reported cases and 5.3 million deaths. The Omicron variant first documented in the City of Tshwane, Gauteng Province, South Africa on 9 November 2021 led to exponential increases in cases and a sharp rise in hospital admissions. The clinical profile of patients admitted at a large hospital in Tshwane is compared with previous waves. METHODS: 466 hospital COVID-19 admissions since 14 November 2021 were compared to 3962 admissions since 4 May 2020, prior to the Omicron outbreak. Ninety-eight patient records at peak bed occupancy during the outbreak were reviewed for primary indication for admission, clinical severity, oxygen supplementation level, vaccination and prior COVID-19 infection. Provincial and city-wide daily cases and reported deaths, hospital admissions and excess deaths data were sourced from the National Institute for Communicable Diseases, the National Department of Health and the South African Medical Research Council. RESULTS: For the Omicron and previous waves, deaths and ICU admissions were 4.5% vs 21.3% (p<0.00001), and 1% vs 4.3% (p<0.00001) respectively; length of stay was 4.0 days vs 8.8 days; and mean age was 39 years vs 49,8 years. Admissions in the Omicron wave peaked and declined rapidly with peak bed occupancy at 51% of the highest previous peak during the Delta wave. Sixty two (63%) patients in COVID-19 wards had incidental COVID-19 following a positive SARS-CoV-2 PCR test . Only one third (36) had COVID-19 pneumonia, of which 72% had mild to moderate disease. The remaining 28% required high care or ICU admission. Fewer than half (45%) of patients in COVID-19 wards required oxygen supplementation compared to 99.5% in the first wave. The death rate in the face of an exponential increase in cases during the Omicron wave at the city and provincial levels shows a decoupling of cases and deaths compared to previous waves, corroborating the clinical findings of decreased severity of disease seen in patients admitted to the Steve Biko Academic Hospital. CONCLUSION: There was decreased severity of COVID-19 disease in the Omicron-driven fourth wave in the City of Tshwane, its first global epicentre.

The ulnar nerve in the cubital tunnel: a foetal study.

BACKGROUND: The ulnar nerve (UN), a terminal branch of the medial cord of the brachial plexus, is located posteromedial to brachial artery coursing along medially in the arm from the anterior to the posterior compartment through the arcade of Struthers. It passes posterior to medial epicondyle of humerus and enters the cubital tunnel. Then, it exits through the distal part of the cubital fossa to enter the medial side of the forearm between the two heads of the flexor carpi ulnaris muscle underneath Osborne's ligament to enter the anterior compartment of the forearm. Entrapment of the UN at the cubital tunnel results in a pain and a tingling sensation on the medial side of the forearm and fourth and fifth digits. MATERIALS AND METHODS: This foetal study documented the course of the UN within the cubital tunnel and its anatomical relations utilising bilateral microscopic dissection of 25 foetuses (gestational age: 19-36 weeks). RESULTS: The UN followed the standard anatomical course in 96% (48/50) of the specimens, however it was found to lie deep to the muscles of the cubital tunnel in 6% (3/50). The radial artery joined the UN distal to the cubital tunnel in 8% (4/50), while the superior ulnar collateral artery was posteriorly related to the UN in 32% (16/50) of specimens. The Osborne's ligament (crossed between the two heads of the flexor carpi ulnaris muscle, posterior to the medial epicondyle of the humerus) was present in all specimens 100% (50/50). It had a mean length of 6.32 ± 0.97 mm and 6.30 ± 1.10 mm on the left and right sides, respectively. The current study observed that the flexor pronator aponeurosis was present in 2% (1/50) of specimens. CONCLUSIONS: Knowledge of the normal and variable anatomical course of the UN in the cubital tunnel in this study may assist in the diagnosis and treatment of compressive neuropathy of the UN in the cubital tunnel.

Cerebral Palsy and Criteria Implicating Intrapartum Hypoxia in Neonatal Encephalopathy - An Obstetric Perspective for the South African Setting.

The science surrounding cerebral palsy indicates  that it is a complex medical condition with multiple contributing variables and factors, and causal pathways are often extremely difficult to delineate. The pathophysiological processes are often juxtaposed on antenatal factors, genetics, toxins, fetal priming, failure of neuroscientific autoregulatory mechanisms, abnormal biochemistry and abnormal metabolic pathways. Placing this primed compromised compensated brain through the stresses of an intrapartum process could be the final straw in the pathway  to brain injury and later CP.  It is thus simplistic to base causation of cerebral palsy on only an intrapartum perspective with radiological 'confirmation', as is often the practice in medicolegal cases in South African courts. The present modalities (MRI and CTG when available) that retrospectively attempt to determine causation in courts are inadequate when used in isolation. Unless a holistic scientific review of the case including all contributing clinical factors (antepartum, intrapartum and neonatal), fetal heart rate monitoring, neonatal MRI if possible (and preferred) or late MRI, and histology (placental histology if performed) are taken into account, success for plaintiff or defendant currently in a court of law will depend on eloquent legal argument rather than true scientific causality. The 10 criteria set out in this document to implicate acute intrapartum hypoxia in hypoxic ischaemic encephalopathy/neonatal encephalopathy serve as a guideline in the medicolegal setting.

Metabolic syndrome at 6 weeks after delivery in a cohort of pre-eclamptic and normotensive women.

BACKGROUND: The association between pre-eclampsia and the subsequent development of metabolic syndrome has not been well documented in low- and middle-income countries. OBJECTIVES: To compare the prevalence of metabolic syndrome at 6 weeks after delivery among women with pregnancies complicated by pre-eclampsia with that in a normotensive, low-risk control group in an urban South African (SA) setting. METHODS: This was a prospective cohort study at two tertiary-level hospitals and one district-level hospital in Pretoria, SA. Women were recruited after delivery and were followed up 6 weeks later to confirm or exclude the diagnosis of metabolic syndrome. RESULTS: Metabolic syndrome was diagnosed in 48/150 women with pregnancies complicated by pre-eclampsia (32.0%), compared with 33/150 (22.0%) of the control group (p=0.05). CONCLUSIONS: Women who developed pre-eclampsia during pregnancy had an increased chance of metabolic syndrome being diagnosed 6 weeks after delivery. Guidelines should be developed to identify women with cardiometabolic risk, so that interventions may be implemented to modify this risk before and after pregnancy.

Classification of the patterns of the emerging branches of the superficial cervical plexus / Clasificación de los patrones de las ramas emergentes del plexo cervical superficial

SUMMARY: The cutaneous branches of the superficial cervical plexus (SCP) emerge at variable points, from beneath the posterior margin of the sternocleidomastoid muscle and from this point radiate like "spokes of a wheel" antero-inferiorly and postero-superiorly. This study aimed to classify the emerging points of the branches of the superficial cervical plexus in relation to their location on the sternocleidomastoid muscle. In order to classify the emerging points of the superficial cervical plexus, the sternocleidomastoid muscle was first measured from mastoid process to clavicle; subsequently each branch of the superficial cervical plexus was measured from the mastoid process to their exit points. The emerging points of the superficial cervical plexus branches were classified according to Kim et al. (2002) seven categories: Type I (32 %); Type II (13 %); Type III (35 %); Type IV (13 %); Type V, VI, VII (2 %). The order in which the superficial cervical plexus branches emerged from the posterior margin of the sternocleidomastoid muscle remained constant, i.e. lesser occipital, great auricular, transverse cervical and supraclavicular nerves. Knowledge of emerging points may assist in the effective anaesthesia to all branches of the superficial cervical plexus during surgical procedures of the neck, viz. carotid endarterectomy and thyroid surgery.

RESUMEN: Las ramas cutáneas del plexo cervical superficial (SCP) emergen en puntos variables, desde el margen pos- terior del músculo esternocleidomastoideo y desde este punto inferior irradian como "radios de rueda" anteroinferior y postero-superior. Este estudio tuvo como objetivo clasificar los puntos emergentes de las ramas del plexo cervical superficial en relación a su ubicación en el músculo esternocleidomastoideo. Para clasificar los puntos emergentes del plexo cervical superficial, primero se midió el músculo esternocleidomastoideo desde el proceso mastoides hasta la clavícula; posteriormente se midió cada rama del plexo cervical superficial desde el proceso mastoideo hasta sus puntos de salida. Los puntos emergentes de las ramas del plexo cervical superficial se clasificaron según Kim et al. (2002) en siete categorías: Tipo I (32 %); Tipo II (13 %); Tipo III (35 %); Tipo IV (13 %); Tipo V, VI, VII (2 %). El orden en el que las ramas del plexo cervical superficial emergían del margen posterior del músculo esternocleidomastoideo se mantuvo constante, es decir, los nervios occipital menor, auricular magno, cervical transverso y supraclavicular. El conocimiento de los puntos emergentes puede ayudar a la anestesia eficaz de todas las ramas del plexo cervical superficial durante los procedimientos quirúrgicos del cuello, a saber, endarterectomía carotídea y cirugía de tiroides.

Classification of the musculocutaneous nerve fetuses / Clasificación del nervio musculocutáneo en fetos

SUMMARY: The musculocutaneous nerve is a terminating branch of lateral cord of the brachial plexus and is formed from spinal roots of C5, C6 and C7. The anatomical variations of the musculocutaneous nerve (MCN) are not common, literary reports have described the different course of the MCN in the arm, however very few fetal studies have been conducted on the variations of the MCN. Therefore, the aim of this study was to describe the course of the MCN in fetuses and document variations, if any. In this study, a sample size of twenty-five fetuses were bilaterally dissected (n=50) using a stereomicroscope. The anatomy of the MCN was described using a classification system generated based on the findings of this study. Ethical clearance was obtained from Biomedical Research Ethics Committte (BE385/17). Type I (normal anatomy) of the MCN was found in 42/50 (84 %) of specimens in this study. This study found a few variations, viz. 1/50 (2 %) case of Type II (absent), 1/50 (2 %) Type III (communication between the MCN and MN, from the MN to the MCN), 4/50 (8 %) cases of Type IV (communication from the MCN to the MN) and 2/50 (4 %) cases of Type V (communication from the MCN to the MN, where the MCN does not pierce the coracobrachialis muscle). Therefore, this study provides evidence of variations of the MCN in fetuses that may help surgeons in the interpretation of abnormal innervation patterns in the arm.

RESUMEN: El nervio musculocutáneo es un ram terminal del fascículo lateral del plexo braquial y está formado por las raíces espinales de C5, C6 y C7. Las variaciones anatómicas del nervio musculocutáneo (NMC) no son comunes, los informes literarios han descrito el curso diferente del NMC en el brazo, sin embargo, se han realizado muy pocos estudios fetales sobre las variaciones de este nervio. Por lo tanto, el objetivo del estudio fue describir el curso del NMC en fetos y documentar las variaciones. En este estudio, una muestra de veinticinco fetos fue disecada bilateralmente (n = 50) usando un estereomicroscopio. La anatomía del NMC se describió mediante un sistema de clasificación en base a los hallazgos. La aprobación ética se obtuvo del Comité de Ética en Investigación Biomédica (BE385 / 17). El tipo I (anatomía normal) del NMC se encontró en 42/50 (84 %) de las muestras. Se observaron algunas variaciones, por ejemplo: 1/50 (2 %) caso de Tipo II (ausente), 1/50 (2 %) de Tipo III (comunicación entre NMC y nervio mediano (NM), de NM a NMC), 4/50 (8 %) casos de Tipo IV (comunicación del NMC al NM) y 2/50 (4 %) casos de Tipo V (comunicación del NMC al NM, donde el NMC no perfora el músculo coracobraquial). Este estudio proporciona evidencia de variaciones del NMC en fetos que puede ayudar a los cirujanos a interpretar patrones de inervación anormales en el brazo.

Morphology and morphometry of the hyoid bone in a black South African population / Morfología y morfometría del hueso hioides en una población sudafricana negra

SUMMARY: The hyoid is a unique, 'U' shaped bone, located on the anterior aspect of the neck, between the mandible and thyroid cartilage. This bone displays morphological and morphometric characteristics that can assist in determination of age, sex and race of an individual.Therefore, the present study aimed to investigate the morphology and morphometric parameters of the hyoid bone in a Black South African population of KwaZulu-Natal. The morphological and morphometric parameters of the 40 hyoid bones obtained from the Department of Clinical Anatomy, University of KwaZulu-Natal were classified in accordance with Deepak et al. (2013). In this s. tudy, 35 % of hyoid bones were 'U'- shaped and 65 % were 'V'- shaped in males, whereas in the female specimens, 70 % of hyoid bones were 'U'- shaped and 30 % 'V'- shaped. Furthermore, this study recorded a statistically significant relationship between the shape of the hyoid bone and sex. With regard to the morphometry, the width of the hyoid bone was greater in males than females however; the length of the hyoid bone was greater in females than males. In addition, this study concludes that these results may contribute to the existing knowledge on the morphology and morphometry of the hyoid bone and may assist forensic procedures.

RESUMEN: El hioides es un hueso singular en forma de "U", ubicado en la region del cuello anterior, entre la mandíbula y el cartílago tiroides, que presenta características morfológicas y morfométricas que pueden ayudar a determinar la edad, el sexo y la raza de un individuo. El objetivo de este estudio fue investigar la morfología y los parámetros morfométricos del hueso hioides en una población sudafricana negra de KwaZulu-Natal. Los parámetros morfológicos y morfométricos de los 40 huesos hioides obtenidos del Departamento de Anatomía Clínica de la Universidad de KwaZulu-Natal se clasificaron de acuerdo con Deepak et al. En este análisis, en los hombres el 35 % (7/20) de los huesos hioides tenían forma de 'U' y el 65 % (13/20) tenían forma de 'V', mientras que en las mujeres, el 70 % (14/20) de los los huesos hioides tenían forma de 'U' y un 30 % (6/20) de 'V'. Además, se registró una relación estadísticamente significativa entre la forma del hueso hioides y el sexo. En cuanto a la morfometría, el ancho del hueso hioides fue mayor en los hombres que en las mujeres; la longitud del hueso hioides fue mayor en mujeres que en hombres. Además, el estudio concluye que estos resultados pueden contribuir al conocimiento existente sobre la morfología y morfometría del hueso hioides y pueden ayudar a los procedimientos forenses.

Detection of Schistosoma DNA in genital specimens and urine: A comparison between five female African study populations originating from S. haematobium and/or S. mansoni endemic areas.

Female Genital Schistosomiasis (FGS) is a neglected disease affecting millions, however challenging to diagnose. This explorative descriptive study compares Schistosoma real-time PCR analysis of cervico-vaginal lavages (CVL) with corresponding urine and stool samples of 933 women from five different previously described study populations. Sampling included 310 women from an S. mansoni endemic region in Mwanza, Tanzania and 112 women from a nearby S. haematobium endemic region. Findings were compared with samples collected from S. haematobium endemic regions in South Africa from 394 women and from 117 women from Madagascar of which 79 were urine pre-selected microscopy positive cases from highly-endemic communities and 38 were urine microscopy negatives from a low-endemic community. As anticipated, urine and stool microscopy and gynecological investigations varied substantially between study populations; however, the same Schistosoma real-time PCR was performed in one reference laboratory. Schistosoma DNA was detected in 13% (120/933) of the CVL, ranging from 3% in the S. mansoni Tanzanian endemic region to 61% in the pre-selected Malagasy urine microscopy positive cases. Detectable Schistosoma DNA in CVL was associated with Schistosoma DNA in urine but not with microscopic detection of eggs in urine or by cytological examination. This study confirmed real-time PCR for the detection of Schistosoma DNA in gynecological samples to be a valuable diagnostic tool to study the distribution of FGS within schistosomiasis endemic areas.

Hypertensive disorders in pregnancy: 2019 National guideline.

BACKGROUND: Hypertensive disorders of pregnancy (HDP), including pre-eclampsia/eclampsia, account for significant maternal and fetal mortality globally and especially in South Africa. Objective. To formulate clinical guidelines for the management of HDP in order to substantially reduce the number of maternal deaths from HDP. Methods. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was used to formulate the guidelines and included six domains: scope and purpose; stakeholder involvement; rigour and development; clarity of presentation; applicability; and editorial independence. Recommendations. The guideline stipulates management strategies for all levels of care where women with hypertensive disorders in pregnancy are seen. It also has a detailed implementation plan. Conclusion. A clinical guideline that is of practical value has been formulated by a wide group of stakeholders. It is hoped that its dissemination and implementation by all doctors and nurses will reduce mortality and morbidity associated with HDP.

Morphometry and morphology of the acetabulum within the black African population of South Africa / Morfometría y morfología del acetábulo dentro de la población africana negra de Sudáfrica

The acetabulum is the large cup-shaped cavity on the lateral surface of the hip bone, which articulates with the head of the femur to form the hip joint. The morphometry and morphology of the acetabulum is important in the diagnosis and treatment of hip joint injuries and disease. Population specific differences exist regarding the acetabulum, therefore, this study aimed to document the morphometry and morphology of the acetabulum within a Black African population in Kwa-Zulu Natal, South Africa. A total of 100 dry hip bones (R= 44; L= 56) from the University of KwaZulu-Natal (Westville and NRMSOM campuses) were examined for this study. The hip bones, with documented sex, were all from the Black African population. A sliding digital caliper was used to measure the acetabular diameter, depth and acetabular notch width. The morphology of the acetabular margin was document in accordance with Govsa et al. (2005). Statistical analysis was conducted using SPSS version 24 software. A p-value of less than 0.05 was considered statistically significant. The means and standard deviations of the morphometric measurements for the entire population were as follows: (a) acetabular diameter of 54.84 ± 4.18 mm, (b) acetabular depth of 31.30 ± 3.18 mm and (c) acetabular notch width of 21.72 ± 2.98 mm. The observed shapes of the acetabular margin that were angular (41 %), curved (22 %), irregular (23 %) and straight (14 %). Knowledge of the anatomy of the acetabulum is useful to surgeons, prosthetists, anthropologists and forensic anthropology experts. The morphometry and morphology of the Black African population group of KwaZulu-Natal presented with differences when compared to other population groups studied in literature.

El acetábulo es una cavidad grande, en forma de copa, ubicada en la superficie lateral del hueso coxal, que se articula con la cabeza del fémur para formar la articulación coxofemoral. La morfometría y morfología del acetábulo son importantes en el diagnóstico y tratamiento de las lesiones y enfermedades de las articulaciones de la cadera. Existen diferencias específicas de la población con respecto al acetábulo, por lo tanto, este estudio tuvo como objetivo documentar la morfometría y la morfología del acetábulo en una población Africana negra, perteneciente a Kwa-Zulu Natal, Sudáfrica. Para este estudio se examinaron un total de 100 huesos coxales secos (Right = 44; Left = 56) de la Universidad de KwaZulu-Natal (campus de Westville y NRMSOM). Los huesos coxales, con sexo documentado, eran todos de población africana negra. Se utilizó un calibrador digital deslizante para medir el diámetro acetabular, la profundidad y el ancho de la incisura acetabular. La morfología del margen acetabular anterior se documentó de acuerdo con Govsa et al. (2005). El análisis estadístico se realizó utilizando el software SPSS versión 24. Un valor de p inferior a 0,05 se consideró estadísticamente significativo. Las medias y desviaciones estándar de las medidas morfométricas para toda la población fueron las siguientes: (a) diámetro acetabular de 54,84 ± 4.18 mm, (b) profundidad acetabular de 31,30 ± 3,18 mm y (c) ancho de la incisura acetabular de 21,72 ± 2,98 mm. Las formas observadas del margen acetabular fueron angulares (41 %), curvas (22 %), irregulares (23 %) y rectas (14 %). El conocimiento de la anatomía del acetábulo es útil para cirujanos, antropólogos y expertos en antropología forense. La morfometría y morfología del grupo poblacional de África negra de KwaZulu-Natal presentaron diferencias cuando se compararon con otros grupos poblacionales estudiados en la literatura.

Anatomical investigation of the vascular supply of the suprarenal glands in fetuses / Investigación anatómica del suministro vascular de las glándulas suprarrenales en los fetos

The suprarenal glands are bilaterally supplied by three suprarenal arteries and drained by a single suprarenal vein. Variable vascular origins of the fetal suprarenal gland have been documented in different population groups viz. Indian, Polish and Argentinian. However, there is lack of a detailed description regarding the course, relations, number of branches and vertebral levels of the origins of the vasculature of the suprarenal glands in fetuses. This study aimed to identify and document the vascular supply of the suprarenal glands in fetuses in a South African setting. Fifty fetal specimens (26 males; 24 females) with a gestational age ranging between 12 and 20 weeks, were bilaterally micro-dissected (n=100) using a Zeiss Stemi DV4 microscope. Data was recorded and the frequencies of the origin, course, relations, number of branches and vertebral levels of the suprarenal vascular supply were determined. Arterial supply: Origin: (i) The superior suprarenal artery (SSA) bilaterally arose from the inferior phrenic arteries in 98 % of the fetuses; (ii) the middle suprarenal artery (MSA) frequently arose from the renal artery (RA) on the right side (46 %) and the abdominal aorta on the left side (34 %); while (iii) the inferior suprarenal artery (ISA) predominantly arose from the RA in 91 % of the specimens, bilaterally. Course and relations: The suprarenal arteries followed a superior, inferior, lateral, supero-lateral and infero-lateral course to the gland. These arteries were closely related to the crura of the diaphragm, the inferior vena cava, the left inferior phrenic vein and the pancreas. Number of branches: The branches ranged from one to seven for the SSA, one to four for the MSA and one to three for the ISA. Vertebral levels: The SSA predominantly arose from the first lumbar (L1) vertebral body (32 %), the MSA arose from the middle third of the intervertebral disc between the L1 and the second lumbar (L2) vertebrae (19 %) and the ISA arose from the L2 vertebral body (28 %). Venous drainage: In 1 % of the specimens, an additional right suprarenal vein (ARSV) was observed. This ARSV followed a superomedial course into the inferior vena cava, just below the entrance of the main right suprarenal vein. The arteries supplying the suprarenal gland presented varying origins and number of branches, corroborating with the reviewed literature and standard anatomical textbooks. The findings of this study may aid pediatric surgeons in understanding the vascular morphology (and the variations thereof) of the suprarenal gland, when performing adrenelectomy surgery in neonates.

Las glándulas suprarrenales son irrigadas bilateralmente por tres arterias suprarrenales y drenadas por una sola vena suprarrenal. Los orígenes vasculares variables de la glándula suprarrenal fetal se han documentado en diferentes grupos de población: indios, polacos y argentinos. Sin embargo, no existe una descripción detallada del curso, las relaciones, el número de ramas y los niveles vertebrales de los orígenes de la vasculatura de las glándulas suprarrenales en los fetos. Este estudio tuvo como objetivo identificar y documentar el suministro vascular de las glándulas suprarrenales en fetos en una población sudafricana. Cincuenta especímenes fetales (26 hombres; 24 mujeres) con una edad gestacional que oscila entre las 12 y las 20 semanas, fueron micro-diseccionados bilateralmente (n = 100) utilizando un microscopio Zeiss Stemi DV4. Se registraron los datos y se determinaron las frecuencias de origen, curso, relaciones, número de ramas y niveles vertebrales del suministro vascular suprarrenal. Suministro arterial: Origen: (i) La arteria suprarrenal superior (SSA) surgió bilateralmente de las arterias frénicas inferiores en el 98 % de los fetos; (ii) la arteria suprarrenal media (MSA) surgió frecuentemente de la arteria renal (AR) en el lado derecho (46 %) y en la parte abdominal de la aorta en el lado izquierdo (34 %); mientras que (iii) la arteria suprarrenal inferior (AIS) surgió predominantemente de la AR en el 91 % de los especímenes, bilateralmente. Curso y relaciones: las arterias suprarrenales seguían un curso superior, inferior, lateral, superolateral e inferolateral hacia la glándula. Estas arterias estaban estrechamente relacionadas con la crura del diafragma, la vena cava inferior, la vena frénica inferior izquierda y el páncreas. Número de ramas: Las ramas variaron de una a siete para la SSA, de una a cuatro para la MSA y de una a tres para la ISA. Niveles vertebrales: la SSA surgió predominantemente del primer cuerpo vertebral lumbar (L1) (32 %), la MSA surgió del tercio medio del disco intervertebral entre la L1 y la segunda vértebra lumbar (L2) (19 %) y la ISA surgió del cuerpo vertebral L2 (28 %). Drenaje venoso: en el 1 % de las muestras, se observó una vena suprarrenal derecha (ARSV) adicional. Este ARSV siguió un curso superomedial hacia la vena cava inferior, justo debajo de la entrada de la vena suprarrenal derecha principal. Las arterias que irrigaban la glándula suprarrenal presentaban diversos orígenes y número de ramas, lo que corrobora la literatura revisada y los libros de texto anatómicos estándar. Los hallazgos de este estudio pueden ayudar a los cirujanos pediátricos a comprender la morfología vascular (y sus variaciones) de la glándula suprarrenal, al realizar una cirugía de adrenelectomía en neonatos.

Osteometric and radiological study of the mandibular notch / Estudio osteométrico y radiológico de la incisura mandibular

The mandibular notch is located on the superior margin, between two prominent processes of the mandibular ramus, the coronoid and condylar processes. The mandibular notch permits the entry of the masseteric artery, vein and nerve to the deep surface the masseteric muscle. Literary reports documented variations in both, the shape and size of the mandibular notch. Therefore, this study aimed to document the morphology and morphometry of the mandibular notch in the South African Black and Indian population groups and to determine their relationship to sex, age and race (if any). The morphometric and morphological parameters of the mandibular notch were measured and assessed in 149 digital panoramic radiographs and 51 dry mandible specimens (n=400) belonging to the South African Black African and Indian population groups. A combination of classification schemes by Mohammad et al. (2012) and Shakya et al. (2013) were adopted to assess the morphology of the mandibular notch. The morphometric parameter was measured using the Dicom x-ray viewer and a digital vernier caliper. Each of the morphometric and morphological parameters were statistically analyzed using SPSS, to determine if a relationship existed between the afore-mentioned parameters and sex, age and race. This study recorded the round shaped mandibular notch to be the most prevalent type in both sexes with a combined incidence of 44.2 %. The length of the mandibular notch was reported to be greater in males than females and concurred with previous studies. However, the selected South African group displayed a smaller mandibular notch than the Japanese and Chinese population groups. Furthermore, this study documented population differences among the South African population group, as the Black African population group showed a wider mandibular notch than the Indian population group. This suggests that population-specific differences may exist for both the morphological and morphometric parameters of the mandibular notch. However, only a statistically significant relationship between the length of the mandibular notch with age and race was documented. The mandibular notch may be of clinical significance to maxillofacial surgeons for surgical and reconstructive procedures, in addition it may also aid forensic anthropologists in the identification of unknown remains.

La incisura mandibular se encuentra en el margen superior, entre dos procesos importantes de la rama mandibular, el proceso coronoides y el proceso condilar. La incisura mandibular permite la entrada de la arteria, la vena y el nervio masetérico en la superficie profunda del músculo masetero. En la literatura se han documentado variaciones tanto en la forma como en el tamaño de la incisura mandibular. Este estudio tuvo como objetivo documentar la morfología y la morfometría de la incisura mandibular en los grupos de población de negros e indios sudafricanos y determinar su relación con el sexo, la edad y la raza. Los parámetros morfométricos y morfológicos de la incisura mandibular se midieron y evaluaron en 149 radiografías panorámicas digitales y 51 especímenes de mandíbula seca (n = 400) pertenecientes a los grupos de población sudafricana negra e india. Una combinación de esquemas de clasificación de Mohammad et al. (2012) y Shakya et al. (2013) fueron adoptados para evaluar la morfología de la incisura mandibular. El parámetro morfométrico se midió utilizando el visor de rayos X Dicom y un calibrador Vernier digital. Cada uno de los parámetros morfométricos y morfológicos se analizaron estadísticamente utilizando el software SPSS, para determinar si existía una relación entre los parámetros mencionados anteriormente y el sexo, la edad y la raza. Este estudio registró la incisura mandibular de forma redonda como el tipo más prevalente en ambos sexos, con una incidencia de un 44,2 %. Se informó que la longitud de la incisura mandibular es mayor en hombres que en mujeres y coincidió con estudios anteriores. Sin embargo, el grupo sudafricano seleccionado mostró una incisura mandibular más pequeña que los grupos de población japoneses y chinos. Además, se documentó las diferencias de población entre el grupo de Sudáfrica, ya que el grupo de población negra de África mostró una incisura mandibular más amplia que el grupo de la población India. Esto sugiere que pueden existir diferencias específicas de la población para los parámetros morfológicos y morfométricos de la incisura mandibular. Sin embargo, solo se documentó una relación estadísticamente significativa entre la longitud de la incisura mandibular con la edad y la raza. La incisura mandibular puede ser de importancia clínica para los cirujanos maxilofaciales en procedimientos quirúrgicos y reconstructivos; además, también puede ayudar a los antropólogos forenses en la identificación de restos desconocidos.

Starvation ketoacidosis in pregnancy presenting as euglycaemic, high anion gap metabolic acidosis: A case report highlighting the significance of early recognition and prompt intervention.

Starvation ketoacidosis (SKA) constitutes an important consideration in the pregnant patient who presents with profound metabolic acidosis. Pregnancy-related changes predispose the patient to develop SKA following relatively short periods (12 - 14 hours) of 'starvation'. Patients also typically look clinically well in relation to the significant metabolic derangements that accompany the condition. Prompt recognition and early institution of appropriate therapy is therefore extremely important in terms of optimising maternal and fetal outcome. We describe a pregnant patient with SKA who presented with profound euglycaemic ketoacidosis that resolved rapidly following the early initiation of appropriate therapy. Furthermore, appropriate therapy resulted in our patient avoiding the need for an emergency caesarean section, which is often reported in this scenario. The ensuing discussion addresses SKA in pregnancy, the unique features of our patient, and management considerations from a maternal and fetal perspective. We also discuss the various causes of ketoacidosis such as diabetic ketoacidosis (DKA), euglycaemic DKA, alcohol-induced euglycaemic ketoacidosis and SKA in pregnant patients.