Summer Meeting of the Anatomical Society

The proceedings contain 71 papers. The topics discussed include: experience of learning human anatomy and histology during COVID-19 pandemic in Kharkiv National Medical University;using musculoskeletal modelling to investigate the functional significance of craniofacial form variation within the genus homo;a morphometric analysis of the cranial fossae in patients with scaphocephaly;exploring the thalamus in young adolescents with psychotic experiences;to replace or not replace that is the question: addressing fate decisions during minipig tooth replacement;anatomy of termination of popliteal artery: a multidetector CT angiographic study;anatomical variation between populations of British red squirrels: the potential impact of supplementary feeding;revealing the biomechanics of the masticatory muscles in the eastern grey squirrel (Sciurus carolinensis) using multibody dynamics analysis;and myoepithelial and immune cell dynamics in the ovine mammary gland during postnatal development.

Paediatric Aps - Children Are Not Just Small Adults

Introduction/Background: Antiphospholipid syndrome (APS) is a rare autoimmune multisystem disease characterised by thrombosis and pregnancy morbidity in the presence of persistently elevated titres of: lupus anticoagulant, anticardiolipin and/or anti-glycoprotein 1. It may be primary (occurring alone) or secondary (in combination with another disease, most commonly systemic lupus erythematosus (SLE)). Recent publications highlighted clinical criteria limitations for children and raised awareness of the burden and prevalence of non-criteria manifestations in this population. This case report adds further weight to the need to raise multi-specialty awareness of non-criteria manifestations to aid recognition and treatment of this rare condition with potentially severe sequelae. Description/Method: 13-year-old female with SLE diagnosed aged 8 in India with bilateral optic neuritis occurring two months later. ANA positive at diagnosis with low complement and thrombocytopenia. Treated with prednisolone and hydroxychloroquine. Patient moved to the UK aged 9;initial abnormal bloods: mildly positive ANA (ENA negative), thrombocytopenia, strong lupus anticoagulant. As serology not strongly suggestive and optic neuritis rare in lupus diagnosis questioned. Ophthalmology review confirmed bilateral optic atrophy without evidence of previous vasculitis. There was debate whether the postretinal demyelination was due to antiphospholipid syndrome or a primary demyelinating condition. Hydroxychloroquine stopped and azathioprine started. Following normal neurology investigations (brain, spine MRI/MRV/MRA) concluded if patient developed new APSrelated symptoms or worsening visual evoked potentials anticoagulation would be discussed. Patient remained stable over four years with chronic thrombocytopenia and ESR persistently elevated. Azathioprine changed to Mycophenolate mofetil (MMF) due to side effects. Routine medication monitoring bloods in 2022 showed ESR 97, CRP 78, Platelets 61. Review identified vasculitic rash on soles of both feet with palpable nodules and normal pulses. Further investigation confirmed antiphospholipid antibody triple positivity. Aspirin commenced, hydroxychloroquine restarted, MMF dose increased and rituximab administered. Left foot rash settled but right progressed with toe discolouration and numbness. Skin biopsy considered but not performed due to skin integrity concerns. Foot pulses remained present and normal. Bilateral lower limb doppler reported as normal;increased symptoms resulted in CT angiogram which revealed bilateral non-occlusive popliteal thrombus and left pulmonary embolus. Subsequent echocardiogram was normal. Patient was anticoagulated with low molecular weight heparin followed by warfarin. Vascular surgical team advocated medical management and patient received seven infusions of Iloprost followed by Sildenafil. She achieved near total resolution of skin changes to toes with only minimal loss of skin over tip of right great toe. Patient will now require long-termanticoagulation. Discussion/Results: APS was considered in initial differential diagnosis but patient did not meet current clinical criteria as no past evidence of thrombosis. Lupus anticoagulant was consistently strongly positive and anticardiolipin repeatedly negative. As anti-B2 glycoprotein 1 antibody is not routinely tested and must be verbally requested, it was only checked once (negative) prior to discovery of triple positivity. ANA reported as strongly positive at time of SLE diagnosis but reviewing original notes from India titre was 1:100 and therefore not highly convincing. ENA negative and complement and white cell count normal on repeat testing since. Therefore, it is probable that this patient has primary APS as opposed to secondary APS in association with SLE. However, it is possible that this patient may develop more symptoms of SLE over time. When this patient presented with foot rash there were high numbers of children presenting with varying severity of painful, itchy toes coined 'covid toes' due to suspected lin to SARS-CoV-2 infection. Patient had exposure history, and COVID antibody serology was difficult to interpret due to recent vaccination. Dermatology found appearance to be consistent with 'covid toes' and advised supportive treatment. The triple APS antibody positivity result provided probable aetiology. Providing evidence of thrombus was problematic with false reassurance from apparently normal lower limb arterial doppler when actually popliteal arteries were not checked in view of the presence of normal flow proximally at the groin and distally in the feet. This case highlights the need to continue to search for thrombus in presence of high titres antiphospholipid antibodies and particularly in the case of triple positivity as although patient presented with colour change to toes, she was entirely asymptomatic from her PE and her left foot improved spontaneously despite a left popliteal thrombus also being present. Key learning points/Conclusion: Non-criteria manifestation of thrombocytopenia (occurs in 25% paediatric APS patients) was present throughout and patient had past history of haematuria (a recognised renal non-criteria manifestation). A paediatric specific APS criteria including these may have resulted in earlier detection of triple antiphospholipid antibody positivity and thus earlier treatment escalation and possible avoidance of thrombus. It has been reported that a high proportion of children with positive antiphospholipid antibodies don't develop a thrombus. However, it is interesting that our patient was entirely asymptomatic from her pulmonary embolus which was an incidental finding on her CT angiogram. This prompts a discussion about how much imaging should be performed in those with high levels of persistent positive antiphospholipid antibodies. Rituximab resulted in normalisation of platelet count and ESR for the first time since initial presentation. Anticardiolipin antibodies normalised, lupus anticoagulant decreased from strong to moderate and anti- B2 glycoprotein levels decreased but remained positive. Rituximab is a recognised treatment for catastrophic antiphospholipid syndrome (CAPS) but not routinely used in APS. The consistently raised ESR in an apparently clinically well patient is a reminder to continue to search for causes of inflammation. As the CRP was largely in normal range, this demonstrates the unique value of the ESR. In view of anti-B2 glycoprotein 1 antibody requiring to be verbally requested, discussions are ongoing with the laboratory department regarding the possibility of electronic request and a comment with recommendation to check other two antiphospholipid antibodies following one positive antibody result. As a result of this case, a plan will be put in place to ensure annual screening of antiphospholipid antibodies in all juvenile SLE patients in our care. It is hoped that this case report promotes discussion amongst the paediatric rheumatology community regarding further research required for development of paediatric specific APS criteria and management.

Symptomatic Popliteal Artery Aneurysms in Recently SARS-CoV-2-Infected Patients: The Microangiopathic Thrombosis That Undermines Treatment.

BACKGROUND: Arterial and venous thrombosis are complications in SARS-CoV-2-infected patients. The microangiopathic thrombosis in affected patients can compromise results in urgent limb revascularizations. Aim of our study is to report on the incidence of symptoms development in patients affected by popliteal artery aneurysm (PAA) and to analyze the effect of COVID-19 infection on outcomes. METHODS: Data on patients surgically treated for PAA from the massive widespread of COVID-19 vaccine (March 2021) to March 2022 were prospectively collected. Factors considered for analysis were: presence of symptoms, aneurysm diameter and length, time from symptom onset and hospital referral, ongoing or recently COVID-19 infection. Outcomes measures were: death, amputation, and neurological deficit. RESULTS: Between March 2021 and March 2022, 35 patients were surgically treated for PAA. Among them 15 referred to our hospital for symptomatic PAA and were urgently treated. Urgent treatments included both endovascular procedures and open surgeries. Nine out of 15 symptomatic patients had an ongoing or recently recovered COVID-19 infection. COVID-19 infection was strongly associated to symptoms development in patients affected by PAA and to surgical failure in those patients (OR 40, 95% CI 2.01-794.31, p = 0.005). CONCLUSION: In our series, presence of COVID-19 infection was strongly associated to ischemic symptoms onset and to complications after urgent treatment in symptomatic patients.

Critical leg ischemia related to COVID 19 in doubly vaccinated patients

Background: COVID and venous thromboembolism in unvaccinated population is now a well-established entity but this case is unique as the 1) patient had both COVID vaccines and then tested positive for COVID and 2) presented with vague symptoms and had minimum oxygen requirement 3) developed arterial thromboembolism and acute leg ischemia after 4 days of admission leading to limb amputation ultimately. Data on COVID and COVID vaccine's association with Arterial thromboembolismstill needs to be explored. In our case it was challenging to establish whether the thromboembolism was a complication of vaccine, COVID or was that the result of synergistic interaction of both. Case Presentation: 61 Years old gentleman presented to Emergency Department with vague history of lethargy ongoing for 3-4 weeks and no significant prior co-morbid except sickle cell trait. He had received both doses of COVID vaccine 2 months before presentation and denied any shortness of breath, cough, fever or pain. On presentation he was de-saturating to 77% on Room air and had bilateral crepitations in his chest with PO2 of 7.4 kPa on ABG and raised inflammatory markers on bloods. His CXR showed changes consistent with COVID and he was started on Dexamethasone. His COVID test came back as positive. Throughout his staymaximumamount of oxygen required by him was 36% day1 which improved to 28-32% later, he had not been tachypneic or tachycardiac. His d-dimer was raised at 3000 which was thought to be COVID related, and the decision was taken to perform CTPA to rule out Pulmonary embolism if oxygen requirement worsens. His oxygen requirement continued to remain static with a little improvement or worsening. His inflammatory markers also got better. On Day 4 Patient complained of Right Leg pain. On further enquiry he revealed pain has been ongoing for last 2-3 weeks. His legs were bilaterally ice cold to touch and had hair loss in bilateral legs, pulses in both legs down the femoral artery were not palpable bilaterally. His blood gas Lactate was 2.6 with worsening inflammatory markers but no fever spikes or worsening in oxygen requirement or any other symptoms apart from leg pain. He was immediately seen by vascular Surgery team and was started on therapeutic anticoagulation suspecting acute leg ischemia. CT Angio report showed: Occlusion of Right iliac system, common femoral artery part of the SFA and all the popliteal artery and tibial vessels and unstable thrombus in the left common iliac artery causing severe stenosis and occluded left TP trunk. He was continued on therapeutic anticoagulation and then underwent Right iliofemoral embolectomy, on table angiogram, left common iliac angioplasty via left groin approach and right above knee amputation. Postoperatively he remained well and was tested COVID negative later. He was then discharged to Rehab from hospital for further care. Discussion and conclusion: We suggest that COVID patients with significantly raised d-dimers should be investigated for hidden thromboembolic focus in same way in non COVID patients and not just in lungs but in other organ systems as well. There should be some guidelines regarding increased dose prophylaxis or a flowchart to investigate for these thromboembolic association in COVID.

Arterial Thrombosis as a Presentation of Systemic Lupus Erythematosusin a Young Child

Introduction: Systemic lupus erythematosus (SLE) is a rare diagnosis in children and can present with nonspecific symptoms. Similarly, arterial thromboses in children without risk factors is also rare. Together, they present a diagnostic challenge which may lead to a delay in proper management. Our objective is to emphasize the importance of having high suspicion for SLE in children, especially when presenting with arterial thrombosis. Case Description: Our patient is a 6-year-old female who presented with a 3-week history of severe right foot pain with a 1-week history of discoloration in the same foot. She sought care multiple times prior to presentation. She initially received the diagnosis of “COVID toes” despite a negative COVID PCR. Prior to presentation, she developed fevers, worsening foot pain, increasing discoloration, decreased oral intake, weight loss, and fatigue. Further lab work showed acute kidney injury, elevated inflammatory markers, and coagulopathy. She was also found to have elevated troponins and QTc prolongation. Additionally, a lower extremity Doppler demonstrated an acute partially occluding thrombus in her right popliteal artery. She was transferred to the pediatric intensive care unit (PICU) and started on a heparin infusion. An Echocardiogram with bubble study showed no interatrial shunting. Thrombolysis was considered but held due to concerns regarding thrombus chronicity. COVID-19 PCR and antibodies were negative, so Infectious Disease team determined this was unlikely related to an acute or remote COVID-19 infection or multisystem inflammatory syndrome in children (MIS-C). Her hemoglobin and platelets began to downtrend and Coombs was positive, raising concern for autoimmune hemolytic anemia. Autoimmune and coagulopathy work-up was significant for positive ANA titer, low complement levels and elevated anticardiolipin, anti-dsDNA, anti-Smith, anti-chromatin, and anti-RNP antibodies. She also had a chest X-ray that showed small non-infectious pleural and pericardial effusions suggestive of serositis. The constellation of these findings eventually led to the diagnosis of SLE. Discussion: There have been several cases of thrombotic or thromboembolic events reported in pediatric patients with SLE, with a majority being venous related events. Only two reports involving cerebral arteries have been published. For several of these patients, thrombosis was the presenting symptoms of their disease. In our literature review, we did not find any cases of arterial thrombosis outside the central nervous system related to SLE. Conclusion: Arterial thrombosis can be a presenting symptom for SLE in children. Despite being a rare presentation, rheumatologic diseases such as SLE should always be considered to prevent a delay in diagnosis and management. In our case, our patient experienced a notable delay in care due to a misdiagnosis related to the COVID-19 pandemic. While it is extremely important to consider sequelae of COVID-19, we would like to emphasize the importance of ensuring consideration of other diagnoses as well.

The Management of Popliteal Artery Aneurysms With Acute Limb Ischemia in the Vascular Quality Initiative

Objective: Endovascular popliteal artery aneurysm (PPA) repair has acceptable outcomes compared with open repair for elective therapy. However, endovascular repair for urgent PAA causing acute limb ischemia (ALI) has not been well studied. This project compares the outcomes of urgent endovascular and open repair of PAA presenting with ALI. Methods: The Vascular Quality Initiative database for peripheral vascular interventions and infrainguinal bypass was reviewed for popliteal artery aneurysms presenting with ALI. The characteristics and outcomes of patients undergoing urgent open and endovascular repair were compared. Results: Urgent PAA repair for ALI constituted 10.5% (N = 571) of all PAA repairs with no change in proportion during the study period. The majority (80.6%, n = 460) of urgent repairs were open. However, the proportion of endovascular repair significantly increased from 16.7% in 2010 to 85.7% in 2021 with a sharp increase after 2019 (Fig). Patients undergoing endovascular repair were more likely to be African American (3.6% vs 3.3%, P =.044) and older (71.2 ± 12.5 vs 68.0 ± 11.8) than patients undergoing open repair. They were also more likely to have coronary artery disease (32.4% vs 21.7%, P =.006) but less likely to have chronic kidney disease (66.1% vs 69.6%, P =.027) compared with patients undergoing open repair (Table). Open PAA repair was more likely to be associated with bleeding (20.8% vs 2.7%, P <.001), longer postoperative length of stay (8.1 ± 9.3 days vs 4.9 ± 5.6 days, P <.001), and less likelihood of discharge home (64.9% vs 70.3%, P =.051). The perioperative major amputation rate was 7.5% with no difference in major amputations between the two treatment strategies even at 1 year. However, patients receiving endovascular repair had significantly higher inpatient (1.1% vs 0%, P <.001), 30-day (6.3% vs 0.4%, P <.001), and 1-year (16.5% vs 8.4%, P =.02) mortality compared with open repair (Table). Multivariable regression analysis suggested that endovascular repair was independently associated with increased 30-day mortality, but not 1-year mortality compared with open repair. Conclusions: The utilization of endovascular PAA has exponentially increased during the coronavirus pandemic. Even though endovascular repair is associated with decreased complications and resource utilization, it should be offered selectively in the urgent setting for ALI because of concern with perioperative mortality. [Formula presented] [Formula presented]

Aortic thrombosis leading to acute limb ischemia in the setting of COVID-19 pneumonia versus recently resolved pancreatitis

Case Report Hypercoagulability in the setting of COVID 19 infection is well known, but data about arterial thrombosis in this context is limited. There have also been rare instances of aortic thrombosis in the setting of acute pancreatitis. We present the case of a 64-year-old female who was admitted for acute hypoxic respiratory failure due to COVID pneumonia. A few days earlier, the patient was admitted for a bout of acute pancreatitis that was medically managed but left the hospital against medical advice. During this admission, she was found to be covid positive but was asymptomatic. Chest imaging showed bilateral interstitial opacities. The patient was readmitted due to worsening hypoxia and received dexamethasone, antibiotics and prophylactic heparin on admission. The patient didn't receive remdesivir due to acute kidney injury. Oxygen requirements increased over the next 2 days. On hospital day 3 , the patient developed right lower limb pain not relieved with analgesics with symptoms suggestive for acute limb ischemia. CT angiography of the abdominal aorta and lower extremities revealed significant clot burden in infrarenal aorta and acute occlusion of bilateral popliteal arteries and right profunda femoral artery likely due to aortic clot emboli. Vascular surgery was consulted and proceeded with thrombectomy in the infrarenal aorta, bilateral common iliac arteries and bilateral lower extremity arteries with compartment fasciotomy of the lower extremities. Unfortunately, the patient developed severe septic shock and passed away a few hours after the surgery. Although rare, there have been a few other case reports where aortic thrombosis was caused by COVID 19 or acute pancreatitis. In our patient, both pancreatitis and COVID 19 likely have played a role in aortic thromboembolism leading to critical limb ischemia. Once diagnosed, arterial occlusion is a medical emergency and needs urgent attention and immediate intervention! Physicians should be aware of the possibility of arterial occlusion in the context of Covid 19, especially if acute pancreatitis preceded Covid 19 infection.