A three-headed piriformis muscle: an anatomical case study and narrative review of literature.

The piriformis muscle (PM) is found in the gluteal region, exiting the pelvis through the greater sciatic foramen and dividing it into the suprapiriform and infrapiriform foramina. The piriformis works as part of the hip external rotator muscle group, and is responsible for rotation of the femur upon hip extension and abduction of the femur during flexion of the hip joint. The aim of the present report is to describe a very rare case of the primary three-headed PM. To the best knowledge of the authors, the said variant has not yet been described in the existing literature. The 71-year-old male formalin-fixed cadaver was subjected to routine dissection. After careful removal of the connecting tissue, three separate, primary heads of the PM were identified. The lower head of the PM arose from the middle part of the sacral bone; 87.56 mm long and 9.73 mm wide. The medial head was attached to the internal part of the posterior inferior iliac spine; 121.6 mm long and 20.97 mm wide. The upper head was attached to the external part of the posterior inferior iliac spine; 78.89 mm long and 23.94 mm wide. All heads converged into a common tendon which inserted onto the greater trochanter. The clinical importance of this work comes down to the fact that the aberrant PM may be the reason behind the piriformis syndrome and its associated symptoms. Moreover, knowledge regarding the variant anatomy of the PM is of immense importance to, e.g. anaesthesiologists performing computed tomography- or ultrasound-guided sciatic nerve injection for local anaesthesia, radiologists interpreting imaging studies, and surgeons, especially during posterior approaches to the hip and pelvis.

Extensive pneumatisation of the sphenoid bone: anatomical investigation of the recesses of the sphenoid sinuses and their clinical importance.

BACKGROUND: There is a great variance between the extents of pneumatisation of the sphenoid sinuses that can reach beyond the body of the sphenoid bone. The purpose of this study was to find the prevalence of the recesses of the sphenoid sinuses in Polish adult population. MATERIALS AND METHODS: Two hundred ninety-six computed tomography (CT) scans of patients who did not present any pathology in the sphenoid sinuses were evaluated in this retrospective analysis. Spiral CT scanner (Siemens Somatom Sensation 16) was used to glean the medical images. Standard scan procedure was applied, with Siemens CARE Dose 4D option enabled. No contrast medium was administered. RESULTS: In the majority of the patients (93.92%), the pneumatisation of the sphenoid sinuses expanded beyond the body of the sphenoid bone; hence, there were recesses of the sinuses present. The most common variant was the presence of two recesses - 12.84% of cases. The prevalence of all the 17 recesses was only 0.34%. Amongst the uneven recesses present, the sphenoidal rostrum's recess (61.15% of the patients) and the inferior clinoid recess (56.42%) were the most common. Amongst the even recesses present, the lateral recess was prevalent in the majority (65.88%), whereas the posterior clinoid process' recess was the least common (9.8%). CONCLUSIONS: Presence of the recesses might facilitate access to the cranial fossae; hence, comprehensive evaluation of the sphenoid sinuses is of immense importance in order to avoid unnecessary drills through the hard bone, which could potentially damage the nearby neurovascular structures.

Utility of Botulinum Injections in Stiff-Person Syndrome.

Stiff-person syndrome (SPS) is an uncommon neurological disorder characterized by significant rigidity and muscle spasms primarily affecting the truncal and proximal musculature. Furthermore, a wide-based gait with functional impairment is generally seen. High-dose benzodiazepines or baclofen are widely considered the optimal initial therapy; however, major adverse effects often preclude adequate dosing. Refractory cases may be treated with intravenous immunoglobulins (IVIG), plasma exchange, or B-cell depletion with rituximab, although these are also associated with major, sometimes fatal, adverse reactions. Several reports have validated the safety and utility of botulinum injections in this setting, yet botulinum remains markedly underutilized in this cohort. Below, a case report and review of the literature show botulinum can decrease pain and stiffness, improve gait and balance, and decrease dependence on powerful systemic treatments in this group.

Correlation between integration of high-risk HPV genome into human DNA detected by molecular combing and the severity of cervical lesions: first results of the EXPL-HPV-002 study.

OBJECTIVES: The aim of the EXPL-HPV-002 study is to evaluate the integration of 14 high-risk HPV as a biomarker of the severity and the progression of cervical lesions. Such a „triage biomarker“ would help to reduce the number of unnecessary colposcopies, to avoid over-treatment of lesions that spontaneously regress and to better target the lesions requiring treatment. DESIGN: EXPL-HPV-002 is a prospective, open-label, single arm, GCP study conducted at 2 clinical sites in the Czech Republic. SETTINGS: Investigations centers: Private Gynecology Center, Brno; Gynecological and Obstetrical Clinic, Brno; Genotyping central lab: NRL for Papillomaviruses and polyomaviruses, IHBT, Prague; Histology Central reading: Aeskulab Pathology, Prague; Molecular combing HPV test: Genomic Vision, Bagneux. METHODS: From June 2016 to May 2018, 688 patients aged 25-65, referred to colposcopy after an abnormal Pap-smear, were enrolled in the study. Among them 60% were found HPV high-risk. The study is divided in two phases: 1. a cross-sectional phase using data collected at first visit (colposcopy images ± histology, pap-smear for HPV genotyping and molecular combing) to study the association between HPV integration status versus colposcopy and histology grades; 2. a longitudinal phase using data collected in follow-up visits: cytology at 6, 18 and 30 months and colposcopy ± histology at 12, 24 and 36 months. A pap-smear collected at 12, 24 and 36 months allows to perform genotyping and molecular combing. HPV integration status is analyzed in comparison with the evolution of lesions, viral clearance and HPV genotype. HPV genotyping and molecular combing were performed on pap-smear samples in central laboratories. Histology data were reviewed by central reading. RESULTS: The transversal phase of the study is achieved and shows that the HPV integration into the human DNA, monitored by molecular combing, can significantly differentiate normal subjects from women with cervical lesions or cancer. CONCLUSION: HPV integration into the host genome, monitored by Genomic Visions technology, is a reliable diagnostic biomarker that will greatly help clinicians to improve their medical decision tree.

Cerebral Venous Sinus Thrombosis in a Patient with Ulcerative Colitis Flare.

Inflammatory bowel disease is characterized by a chronic inflammatory state and is therefore associated with abnormalities in coagulation and a hypercoagulable state. Cerebral venous sinus thrombosis is a rare complication of inflammatory bowel disease yet contributes significant morbidity and mortality to those affected. Early diagnosis is critical, as a delay in diagnosis portends a worse prognosis. This paper seeks to highlight the increased risk of venous sinus thrombosis in patients with inflammatory bowel disease. We start by discussing the case of a seventeen-year-old female who presented with ulcerative colitis flare and developed new-onset seizures, found to be caused by a large venous sinus thrombosis.

Electrochemically controlled winding and unwinding of substrate-supported carbon nanoscrolls.

Carbon nanoscrolls (CNSs) formed spontaneously on the basal plane of highly ordered pyrolytic graphite (HOPG) show winding and unwinding movements when potential steps from 0 V to -0.5 V, -0.6 V and -0.9 V are applied on HOPG immersed in an aqueous electrolyte solution (0.1 M H2SO4). Reversible changes in CNS radial dimensions exceeding 10 nm in the axial direction and 50 nm in the lateral direction are ascribed to variations in the surface tension and electric double-layer structure under applied potentials. Radial motion is observed exclusively on scrolled tube-shaped nanostructures, while other parts of the HOPG surface including planar areas, simple bended and lifted step edges, and kinks remain intact. The mechanism explaining the observed phenomenon is proposed and its significance for prospective applications in electrochemically controlled nanomechanical actuators is outlined.

[Doctors specialty training in obstetrics and gynecology at university medical schools: 2012-2013]. / Specializacní vzdelávání v gynekologii a porodnictví na lékarských fakultách: 2012-2013.

OBJECTIVE: The paper addresses transfer of doctors specialty training from the national Institute of postgraduate medical education (IPVZ) to University Medical Schools (UMS) with the special focus to Obstetrics and Gynecology (OG). METHODS: The National Specialty Board (NSB) has been established. NSB tasks include definition of inclusion criteria and process of specialty choice at UMS. In OG specialty there are defined mid-term and final postgraduate training courses and other requirements for final specialty exam (FSE) - in particular trainees scientific work and surgery done with the supervision of NTB member. The system of FSE, its content, application, reimbursement and mechanisms are described in details. RESULTS: In the whole country in 2012 there have been done 864 FSE in all basic medical specialties, which took place at seven UMS. Autumn semester terms has been utilized significantly more than spring terms (57% vs. 43%). There have been differences in the numbers of specialties and also numbers of candidates in each specialty among different UMS. In total 94% of applicants succeed in the FSE. In 2012 within OG specialty training there has been held 56 FSE - 24 exams on five UMS in spring term and 32 (57%) exams only on two UMS in autumn term. In the spring 2013 FSE were organized on 1st LF UK in Prague with 23 applicants, from which 22 successfully passed. During autumn 2013 the FSE in OG will be held on LF UP in Olomouc with 44 applicants for final postgraduate training course and 39 candidates for FSE. CONCLUSION: Within OG specialty the transfer of doctors specialty training from IPVZ to UMS has been successfully managed. The NSB in OG specialty closely cooperates with past IPVZ and the Accreditation Commission of the Czech Ministry of Health. Thus continuity, quality and continuous enhancement of specialty training program in OG in Czech Republic is assured.

[Treatment strategies of the colorectal anastomosis stricture]. / Strategie lécby striktury kolorektální anastomózy.

INTRODUCTION: The treatment of the stenoses of colorectal anastomoses represents a difficult area of colonic surgery. This is partly connected to the introduction of staplers and an increasing amount of sphincter-preserving surgeries. At our clinic, we solve the stenoses of colorectal anastomoses using a surgical rectoscope with a good effect. MATERIAL AND METHODS: We analysed retrospectively a group of 27 patients with benign stenosis of colorectal anastomosis of the medial and upper rectum who underwent surgery at our clinic in the period between January 2004 and December 2011. From the total amount of 27 patients, in 23 patients the stenosis was caused by the dehiscence of anastomosis, and in 4 patients the stenosis had a different etiology. RESULTS: In the group of 27 patients, in 14 patients the stenosis of colorectal anatomosis was solved radiologically using a high pressure balloon. Total of 13 patients underwent surgery, in 10 of them we used the surgical rectoscope and 3 patients underwent an open abdominal procedure. CONCLUSION: The first method of choice in treatment of the stenoses of the colorectal anastomoses is a balloon dilatation. If this is not successful we can use the surgical rectoscope as a minimally invasive though effective and safe method.

Nanobubble assisted nanopatterning utilized for ex situ identification of surface nanobubbles.

Nanobubble assisted nanopatterning of polystyrene (PS) film allows visualization of nanobubble positions and identification of their appearance on the surface ex post by atomic force microscopy (AFM) imaging ex situ. Due to the PS nanograin size, ∼10(1) nm, nanobubbles of diameter less than 50 nm can be resolved, as well as microbubbles and micropancakes. The time scale of the nanopattern formation was found to be in the seconds range. This relatively short exposure time thus provides the possibility of also resolving some aspects of microbubble and nanobubble dynamics. In this work we demonstrate that ex post, ex situ AFM imaging of a PS surface after its exposure to deionized water allows us to examine nanobubble and microbubble formation, distribution and arrangement without any influence of the AFM scanning tip and under experimental conditions where in situ AFM imaging is not feasible, e.g. in liquid flow.

[Myxoma and myxoid chondrosarcoma of the nasal septum: two case reports]. / Myxomatöse Neoplasien des Nasenseptums: 2 Fallberichte.

Myxoid neoplasms are histopathologically divided into true myxomas and other tumors of myxomatous character. In the region of the nasal septum, this tumor entity is extremely rare. In the following two case reports, the unusual findings of a myxoma and a myxoid chondrosarcoma of the nasal septum are presented and discussed. At first visit, both patients reported a slowly progressing, bilateral nasal obstruction. In nasal endoscopy, both showed a smoothly surfaced, spheroid, soft tissue mass in the dorsal nasal septum. On CT-scans, a displacing growth was described for the first patient; in the second patient, a bony arrosion of the floor of the sphenoid sinus was suspected. Both lesions were surgically completely removed. The histopathological diagnosis was myxoma in the first and myxoid chondrosarcoma in the second patient. An early, locally recurrent tumor in the second patient could also be surgically removed. Both patients have been in full remission for more than a year. In spite of the similar symptoms and clinical findings, histopathologically different myxoid neoplasms of the nasal septum show marked variations in growth and recurrence.

[Adenocarcinoma in the tear sack after endonasal dacryocystorhinostomy]. / Adenokarzinom des Tränensackes nach endonasaler Dakryozystorhinostomie.

Primary adenocarcinoma of the nasolacrimal drainage system is a highly uncommon diagnosis, which is presumably derived from malignantly transformed glandular cells that are interspersed amongst the epithelium of the nasolacrimal duct. The patients usually present with unspecific orbital or sinus-nasal symptoms. An appropriate therapeutic regime consists of a preferably early, radical resection and local postoperative radiation therapy. This brief contribution deals with an especially uncommon case of a carcinoma of the nasolacrimal drainage system. On his first presentation, the 62-year old patient complained about right sided epiphora which had been present over the last few weeks. Eight years prior to presentation, he had been treated for a nasolacrimal duct stenosis by endoscopic dacryocystorhinostomy on this side. Diagnostic imaging revealed a soft tissue mass in the right nasolacrimal duct which was removed by a combined extra-endonasal approach. The final histopathological evaluation was adenocarcinoma. Following postoperative radiotherapy, the patient has been free of disease for 42 months. The occurrence of adenocarcinoma of the nasolacrimal drainage system in the setting of previous surgery may provide a new insight into the clinical spectrum of the natural history of this disease.

[Fluorescence staining of oral and laryngeal cancer after application of 5-aminolevulinic acid]. / Fluoreszenzdiagnostik von Karzinomen im Mund-Rachen-Kehlkopf-Bereich nach Applikation von 5-Aminolävulinsäure.

BACKGROUND: Cancer of the oral cavity, oropharynx and larynx are the most common malignancies in the head and neck region. The prognosis for the patients concerned is highly dependent on an early detection and fast surgical treatment. Fluorescence guided examinations may serve as a possible diagnostic tool for better demarcation and delimitation of head and neck cancer. Therefore, the presented study was aimed at the detection of a selective Protoporphyrin IX (PPIX) accumulation in malignant oral, oropharyngeal and laryngeal lesions following topical and systemic application of 5-aminolevulinic acid (5-ALA). PATIENTS: We investigated 193 patients with suspected lesions in the oral cavity and oropharynx (n = 126) as well as in the larynx (n = 67). The patients received a varying dose (rinsing 200 mg, inhalation 30 mg, 2,5 - 25 mg/kg BW by mouth) of 5-ALA in aqueous solution. Both fluorescence pictures and macroscopic findings under white light were recorded using a target integrating, color CCD camera. Fluorescence contrasts between tumor and normal tissue were registered by an optical multichannel analyser. RESULTS: Our results have shown that after topical and systemic application of 5-ALA, PPIX fluorescence could be identified within the mucosa of the oral cavity, oropharynx and the larynx of all patients with a duration of up to 48 hours after systemic application. Malignant lesions usually showed higher intensities of PPIX-fluorescence than surrounding innocuous mucosa. A maximum fluorescence contrast between normal tissue and neoplastic lesions was observed at 1.5 hours after topical application and 3 hours after systemic application. CONCLUSIONS: It will be the aim of further investigations to verify the optimal time of incubation and dosing of systemical 5-ALA application to enhance fluorescence contrasts and set the basis for fluorescence guided resections.

[Ho:YAG and diode laser treatment of hyperplastic inferior nasal turbinates]. / Die Laserkonchotomie mit Ho:YAG- und Dioden-Laser zur Behandlung von hyperplastischen Nasenmuscheln.

BACKGROUND: Since the early 80's, chronic nasal obstruction due to hyperplastic turbinates is treated by laser light. Comparative clinical studies were performed to assess the clinical outcome of laser assisted endonasal turbinate surgery in longterm. METHODS: By means of a pulsed Ho:YAG laser emitting light at lambda = 2100 nm (0.8 - 1.2 J/pulse, 4 - 8 Hz), 69 patients suffering from nasal obstruction due to allergic rhinitis (46 %) and vasomotor rhinitis (54 %) were treated under local anesthesia. Furthermore, 50 patients (52 % with allergic rhinitis and 48 % with vasomotor rhinitis) were treated by means of a GaAlAs-diode laser (c. w., lambda = 940 nm, 8 - 10 W). The treatment time took 3 - 10 min/turbinate and nasal packing was not necessary after the laser procedure. The study was conducted by a standardized questionnaire, photo documentation, allergy test, mucociliar function test, rhinomanometry, and acoustic rhinometry. RESULTS: Within 4 weeks after laser treatment, an improvement of nasal airflow correlating to the extent of the ablated turbinate tissue could be determined in more than 80 % of the patients. Rhinomanometry revealed a significant improvement of the nasal airflow 6 months and 1 year after the laser treatment compared to the preoperative data. Side effects like nasal dryness and pain were rare (< 5 %). Diode laser treatment revealed more effective results than Ho:YAG laser treatment, however there was no significant difference between the two investigated groups. Patients suffering from vasomotor rhinitis showed far better results in long term in comparison to allergic rhinitis patients. CONCLUSIONS: Ho:YAG and diode laser treatment can be performed as an outpatient procedure under local anesthesia in a short treatment time with promising results. It could become a time and cost effective treatment modality in endonasal laser surgery.

Laser treatment of hyperplastic inferior nasal turbinates: a review.

BACKGROUND AND OBJECTIVE: Since the early 80s various types of lasers have been used for the reduction of hyperplastic inferior nasal turbinates. Up to now many studies have revealed a variety of important information. To summarize these findings and to determine the value of laser treatment of hyperplastic inferior nasal turbinates, a comparative review of the literature was performed. STUDY DESIGN/MATERIALS AND METHODS: The study of the literature revealed that hyperplastic inferior turbinates of more than 2,000 patients have been treated and followed up. Treatment was performed with the CO2 (10,600 nm), diode (805/810/940 nm), Argon-ion (488/514 nm), KTP (532 nm), Nd:YAG (1,064 nm), and Ho:YAG (2,080 nm) laser in more than 20 studies so far. Generally, the authors of the trials used different laser parameters (power, energy) and application modalities (contact, non-contact, interstitial, superficial). To determine the long-term results objective (active anterior rhinomanometry, acoustic rhinometry, mucociliary function tests, allergy tests) as well as subjective parameters (questionnaire) were recorded and evaluated. In some cases morphological changes of the turbinate tissue were studied by light and scanning electron microscopy (SEM). RESULTS: Laser surgery of inferior turbinates can be performed as an outpatient procedure under local anesthesia. Due to a minimally invasive and controllable coagulation and ablation of soft tissue, almost no complications or bleedings were observed during the operation or postoperatively. Depending on the chosen parameters (power, energy) and the application modalities (contact, non-contact, superficial, interstitial) laser treatment of hyperplastic inferior nasal turbinates achieved comparable or better results than most of the conventional techniques for turbinate surgery like conchotomy, electrocautery, cryotherapy, chemical cauterization, and vidian neurectomy. More invasive (radical) operative methods, such as inferior turbinoplasty, submucous turbinectomy, lateral outfracture, partial and total turbinectomy, seemed to be more effective than laser surgery in the long-term. CONCLUSIONS: Laser treatment of hyperplastic inferior nasal turbinates can be considered as a useful, cost-effective, and time-saving procedure for the reduction of hyperplastic inferior nasal turbinates. Short operation time, good results, and minor side effects compared to other surgical methods provide an excellent clinical response of the patients.

Diode laser treatment of hyperplastic inferior nasal turbinates.

UNLABELLED: Background and Objective Different laser types have been used for the treatment of hyperplastic inferior nasal turbinates. The clinical experiences of its treatment by means of a diode laser are presented. Study Design/Materials and Methods A total of 76 patients suffering from nasal obstruction due to hyperplastic inferior nasal turbinates were treated with a continuous diode laser (wavelength of lambda = 940 nm, laser parameter 10 W/energy/turbinate 5 kJ) in "noncontact" mode and under local anesthesia. All patients were refractory to conservative medical treatment. Fifty patients (26 of 50 [52%] with allergic rhinitis and 24 of 50 [48%] with vasomotor rhinitis) were included into this clinical trial with a follow-up of 1 year. The study was conducted by a questionnaire, photo documentation, allergy test, mucociliary clearance test, rhinomanometry, acoustic rhinometry, conventional radiology of the paranasal sinuses, and histology. RESULTS: The mean operation time took 6 min/turbinate, no nasal packing was necessary and no immediate complications (e.g., major bleeding) were observed. During the first 2-4 weeks, nasal obstruction was correlated to the extent of postoperative edema and nasal crusting. Statistical analysis revealed significant improvement of the nasal airflow (rhinomanometry) and nasal cavity volume (acoustic rhinometry) 6 months and 1 year after laser surgery, respectively. A total of 86% of the patients described a subjective improvement of nasal airflow 6 months and 76% of the patients 1 year after laser treatment. The mucociliary function test showed no significant variation in comparison to the preoperative measurements 1 year after laser treatment. CONCLUSION: Diode laser treatment of hyperplastic inferior nasal turbinates is a useful procedure, which can be performed as an outpatient surgery under local anesthesia, resulting in a controlled coagulation and ablation of the soft tissue. The short operation time and the good results provide an excellent patient acceptance.