Anatomy of the lymphatic drainage of the upper limb and breast and its role in lymphedema prevention after breast cancer treatment / Anatomía del drenaje linfático del miembro superior y de la mama y su papel en la prevención del linfedema después del tratamiento del cáncer de mama

The surgical treatment of breast cancer has been enhanced throughout the years in order to offer oncologically safer and more effective results with lower esthetic impact and fewer sequelae. The lymphedema of the upper limb is still an iatrogenic result of great incidence and morbidity after this treatment. A possible existence of independent breast and upper limb lymphatic pathways has become the issue of many researchers willing to minimize its occurrence. This review aims to compare the lymphatic pathways in the axilla described by traditional anatomy books and recently published articles about Axillary Reverse Mapping (ARM). With this purpose, a comparative table was made with the descriptions found in books and articles, a statistic table of the data collected, a flowchart of anastomoses among nodes and an analytical drawing of the most statistically mentioned drained areas. It was observed that there is great variability in the descriptions of drainage and anastomoses among the lymph nodes in the references used, so there should be a consensus of a universal description which also assembles possible anatomical variations. Furthermore, the findings brought about by recent studies show possible anastomoses among pathways and lymph nodes, however they have not been taken into consideration when ARM was initially proposed. Therefore, the axillary resection with the preservation of the posterior and lateral axillary lymph nodes is theoretically possible to avoid lymphedema of the upper limb, but the development of an updated universal description that involves all possible anatomical variations will provide a safer and more effective treatment.

El tratamiento quirúrgico del cáncer de mama ha mejorado a lo largo de los años con el fin de ofrecer resultados oncológicamente más seguros y eficaces con menor impacto estético y menos secuelas. El linfedema del miembro superior es todavía un resultado iatrogénico de gran incidencia y morbilidad después de este tratamiento. La posible existencia de vías linfáticas de mama y de los miembros superiores independientes se ha convertido en un tema central de muchas investigaciones para lograr minimizar su ocurrencia. Esta revisión tiene como objetivo comparar las vías linfáticas en la axila descritas en los libros de anatomía tradicionales con artículos recientemente publicados sobre Mapeo Reverso Axilar (MRA). Con este fin, se realizó un cuadro comparativo con las descripciones y un diagrama de flujo de las anastomosis entre los nodos, además de un dibujo analítico de las áreas drenadas estadísticamente más mencionadas. Se observó que existe una gran variabilidad en las descripciones sobre el drenaje y las anastomosis entre los nodos linfáticos, por lo que la descripción universal no debería ser considerada un consenso debido a que también presenta posibles variaciones anatómicas. Por otra parte, los resultados producidos por los estudios recientes muestran posibles anastomosis entre las vías y los nodos linfáticos, sin embargo, no se han tomado en consideración cuando se propuso inicialmente el MRA. Por lo tanto, la resección axilar con la preservación de la parte posterior y los nodos linfáticos axilares laterales es teóricamente posible para evitar el linfedema del miembro superior, pero el desarrollo de una descripción universal actualizada, que incluya todas las posibles variaciones anatómicas, proporcionará un tratamiento más seguro y eficaz.

Unusual relationship between the piriform muscle and sciatic, inferior gluteal and posterior femoral cutaneous nerves / Relación inusual entre el músculo piriforme y los nervios isquiático, glúteo inferior y cutâneo femoral posterior

Piriformis muscle syndrome has been increasingly recognized as a cause of leg pain. Overuse, strain, or anatomical variations of the relationship between the nerve and the piriformis muscle are thought to be the underlying causes of the entrapment of the sciatic nerve. We report a variation not previously described which was found during a routine dissection. During routine dissection of the left gluteal region of an adult male cadaver we observed a high division of the sciatic nerve and the presence of an accessory piriformis muscle. The sciatic nerve divided beneath the piriformis muscle and the common fibular nerve passed over the accessory piriformis muscle, whereas the tibial nerve reflected anteriorly to pass between the accessory piriformis and the superior gemellus muscle. Additionally, both nerves communicated with a side branch under the inferior border of the accessory piriformis muscle and the inferior gluteal nerve originated from the fibular nerve. Anatomical variations in the relationship between the piriformis muscle and the sciatic nerve may be present in up to 17% of the population. Six different variations have been described and none of them is similar to our description. Though complete understanding of the physiopathology of the piriformis muscle syndrome remains to be elucidated, knowledge of the possible anatomical variations may be useful for its adequate diagnosis and treatment.

El síndrome del músculo piriforme se ha reconocido cada vez más como una causa de dolor en los miembros inferiores. Tensión excesiva o variaciones anatómicas del nervio y del músculo piriforme se cree son las causas subyacentes de pinzamiento del nervio isquiático. Se presenta una variación no descrita anteriormente. Durante una disección de rutina en un cadáver de sexo masculino, se observó una división más alta del nervio isquiático y la presencia de un músculo piriforme accesorio. El nervio isquiático se dividía bajo el músculo piriforme y el nervio fibular común pasaba sobre el músculo piriforme accesorio. Por otra parte, el nervio tibial cruzaba entre los músculos piriforme accesorio y gemelo superior. Además, ambos nervios se comunicaban con un ramo lateral bajo el margen inferior del músculo piriforme accesorio y el nervio glúteo inferior se originaba desde el nervio fibular. Variaciones anatómicas y relaciones entre el músculo piriforme y nervio isquiático pueden estar presentes hasta en el 17% de la población. Seis variaciones diferentes se han descrito en este artículo y ninguna es similar a nuestra descripción. A pesar del completo entendimiento de la fisiopatología del síndrome del músculo piriforme, aún queda por esclarecer y conocer las posibles variaciones anatómicas que pueden ser útiles tanto para su diagnóstico como para el tratamiento adecuado.

A rare pattern of brachial artery variation: case report / Un patrón de variación raro de la arteria braquial: reporte de caso

Unlike the venous system, variations in arterial anatomy are less frequent and most of them affect visceral arteries. In limbs, variations of the brachial artery are the most reported and at least six different patterns have been described so far. The commonest is the superficial brachial artery which lies superficially to the median nerve. Much less prevalent are the high origin of the radial artery (brachioradial artery) or the existence of a doubled brachial artery (accessory brachial artery). We present a previously undescribed pattern of brachial artery variation. During dissection of the right upper limb of a 60 year-old male embalmed cadaver, we found the bifurcation of the brachial artery in the proximal portion of the middle third of the arm. Its medial branch reaches the medial aspect of the arm, posterior to the median nerve. Afterwards, this medial branch redirects laterally and crosses again the median nerve, this time lying anterior to the nerve until it reaches the lateral aspect of the arm. At the elbow level, the medial branch originates the radial artery. The lateral branch of the brachial artery remains lateral to the median nerve and continues as ulnar artery and originates the interosseus artery.

A diferencia del sistema venoso, las variaciones en la anatomía arterial son menos frecuentes y la mayoría afecta a las arterias viscerales. En los miembros, las variaciones de la arteria braquial son las más informadas y por lo menos seis diferentes patrones han sido descritos. La variación más común es de la arteria braquial superficial que está superficialmente al nervio mediano. Mucho menos frecuente es el origen alto de la arteria braquial radial (la arteria braquiorradial) o la existencia de una arteria braquial doble (arteria braquial accesoria). Presentamos un patrón de variación no descrito de la arteria braquial observado durante la disección del miembro superior derecho de un cadáver en un hombre de 60 años de edad. Encontramos la bifurcación de la arteria braquial en la porción medial del brazo, pasando posterior al nervio mediano. Luego, esta rama medial se redirecciona lateralmente y cruza nuevamente al nervio mediano, esta vez, anterior a él, hasta alcanzar la región lateral del brazo. A nivel de la flexura del codo, la rama medial origina la arteria radial. La rama lateral de la arteria braquial se mantiene lateral al nervio mediano y continúa como arteria ulnar y origina la arteria interósea común.

Brachial artery variation: a rare pattern

Unlike venous system, variations in arterial anatomy are less frequent and most of them affect visceral arteries.In limbs, variations of the brachial artery are the most reported and at least six different patterns have beendescribed so far. The commonest is the superficial brachial artery, which lies superficially to the median nerve.Much less prevalent are the high origin of the radial artery (brachioradial artery) or the existence of a doubledbrachial artery (accessory brachial artery). We present a previously undescribed pattern of brachial arteryvariation. During dissection of the right upper limb of a 60-year-old male embalmed cadaver, we found thebifurcation of the brachial artery in the proximal portion of the middle third of the arm. Its medial branchreaches the medial aspect of the arm, posterior to the median nerve. Afterwards, this medial branch redirectslaterally and crosses again the median nerve, this time lying anterior to the nerve until it reaches the lateralaspect of the arm. At the elbow level, the medial branch originates the radial artery. The lateral branch of thebrachial artery remains lateral to the median nerve, continues as ulnar artery, and originates the interosseusartery.

Pharyngeal lymphatic ring: anatomical review

The tonsils form part of a circular band of adenoid tissue which guards the opening into the digestive andrespiratory tubes, known as Waldeyer’s ring. The anterior part of the ring is formed by the submucouslymphoid clusters (lingual tonsil) on the posterior part of the tongue; the lateral portions consist of thepalatine tonsils and the lymphoid tissue in the vicinity of the auditory tubes, while the ring is completedbehind by the pharyngeal tonsil on the posterior wall of the pharynx. In the intervals between these mainsmaller collections of lymphoid tissue are found. This paper intends to give to the clinician an anatomicalreview about the subject.

Evaluation of oral-motor movements and speech in patients with tetanus of a public service in Brazil.

The characterisation of oral-motor movements and speech of patients with tetanus were investigated to determine the existence of possible signs that are characteristic of this pathology. Thirteen patients clinically diagnosed with tetanus (10 with severe tetanus and three with very severe tetanus) and admitted to an intensive care unit underwent clinical evaluation of oral-motor movements and speech. Statistical analysis indicated significant between-group differences for speech motor functions, suggesting that individuals with very severe tetanus present rigidity as a characteristic interfering in articulatory precision (P = 0·035) and movement rate (P = 0·038). For lip closure, tongue movement, palatal elevation, gag reflex and voice quality, no between-group differences were identified for the specific abnormal characteristics. The observed abnormal results indicate that muscle strength and functional status of the oral-motor system presented by most of the participants of the study did not ensure the necessary integrity for satisfactory performance. The characterisation of the oral myofunctional aspects of patients with tetanus provides medical teams, patients and families with a wider and better description of the clinical situation, giving support to the diagnosis, prognostics and treatment.

Growth after ventricular septal defect repair: does defect size matter? A 10-year experience.

AIM: To evaluate whether the ventricular septal defect (VSD) size, along with the degree of preoperative growth impairment and age at repair, may influence postoperative growth, and if VSD size can be useful to identify children at risk for preoperative failure to thrive. METHODS: Sixty-eight children submitted to VSD repair in a Brazilian tertiary-care institution were evaluated. Weight and height measurements were converted to Z-scores. Ventricular septal defect size was normalized by dividing it by the aortic root diameter (VSD/Ao ratio). RESULTS: Twenty-six patients (38%) had significantly low weight-for-height, 10 patients (15%) had significantly low height-for-age and 13 patients (19%) had both conditions at repair. Catch-up growth occurred in 82% of patients for weight-for-age, in 75% of patients for height-for-age and in 89% of patients for weight-for-height. Weight-for-height Z-scores at surgery were significantly lower in patients who underwent repair before 9 months of age. The VSD/Ao ratio did not associate with any other data. On multivariate analysis, weight-for-age Z-scores and age at surgery were independent predictors of long-term weight and height respectively. CONCLUSION: The VSD/Ao ratio was not a good predictor of preoperative failure to thrive. Most patients had preoperative growth impairment and presented catch-up growth after repair. Preoperative growth status and age at surgery influenced long-term growth.

Comparison of serum hormone levels of captive and free-living maned wolves Chrysocyon brachyurus.

Serum hormone levels were compared between captive and free-living maned wolves and seasonal variations of sex hormones were studied. Blood samples were collected from 16 male and 26 female adult animals from Brazilian zoos, and from 30 male and 24 female free-living adults to determine serum progesterone and testosterone by radioimmunoassay. Serum testosterone concentrations varied (P < 0.05) across seasons for 16 captive males, being higher in autumn (2184.7 +/- 355.1 pg/mL) than in summer (1080.7 +/- 205.4 pg/mL), winter (1270.1 +/- 276.6 pg/mL) and spring (963.9 +/- 248.1 pg/mL), although they did not differ between summer, winter and spring. Testosterone concentration of 30 free-living males differed (P < 0.05) between autumn (824.1 +/- 512.2 pg/mL), winter (14.4 +/- 8.0 pg/mL) and spring (151.9 +/- 90.5 pg/mL). Comparison between captive and free-living animals showed no difference in autumn (P > 0.05). Sixteen captive males showed higher testosterone concentration during winter and spring compared with 30 free-living animals (P < 0.05). Progesterone concentration varied among seasons in 26 captive females (P < 0.05), being higher in autumn (15.3 +/- 3.1 ng/mL) than in summer (6.6 +/- 1.5 ng/mL), winter (5.3 +/- 3.1 ng/mL) and spring (4.3 +/- 0.7 ng/mL). Progesterone concentration of 24 free-living females varied between autumn (17.1 +/- 6.0 ng/mL) and winter (1.7 +/- 0.3 ng/mL) (P < 0.05), but we could not obtain data for spring or summer. No difference in progesterone levels was observed between captive and free-living females in autumn and winter.

Comparison of serum hormone levels of captive and free-living maned wolves Chrysocyon brachyurus

Serum hormone levels were compared between captive and free-living maned wolves and seasonal variations of sex hormones were studied. Blood samples were collected from 16 male and 26 female adult animals from Brazilian zoos, and from 30 male and 24 female free-living adults to determine serum progesterone and testosterone by radioimmunoassay. Serum testosterone concentrations varied (P < 0.05) across seasons for 16 captive males, being higher in autumn (2184.7 ± 355.1 pg/mL) than in summer (1080.7 ± 205.4 pg/mL), winter (1270.1 ± 276.6 pg/mL) and spring (963.9 ± 248.1 pg/mL), although they did not differ between summer, winter and spring. Testosterone concentration of 30 free-living males differed (P < 0.05) between autumn (824.1 ± 512.2 pg/mL), winter (14.4 ± 8.0 pg/mL) and spring (151.9 ± 90.5 pg/mL). Comparison between captive and free-living animals showed no difference in autumn (P > 0.05). Sixteen captive males showed higher testosterone concentration during winter and spring compared with 30 free-living animals (P < 0.05). Progesterone concentration varied among seasons in 26 captive females (P < 0.05), being higher in autumn (15.3 ± 3.1 ng/mL) than in summer (6.6 ± 1.5 ng/mL), winter (5.3 ± 3.1 ng/mL) and spring (4.3 ± 0.7 ng/mL). Progesterone concentration of 24 free-living females varied between autumn (17.1 ± 6.0 ng/mL) and winter (1.7 ± 0.3 ng/mL) (P < 0.05), but we could not obtain data for spring or summer. No difference in progesterone levels was observed between captive and free-living females in autumn and winter.

Transferability of short tandem repeat markers for two wild Canid species inhabiting the Brazilian Cerrado.

The maned wolf (Chrysocyon brachyurus) and the crab-eating fox (Cerdocyon thous) are two wild-canid species found in the Brazilian Cerrado. We tested cross-amplification and transferability of 29 short tandem repeat primers originally developed for cattle and domestic dogs and cats on 38 individuals of each of these two species, collected in the Emas National Park, which is the largest national park in the Cerrado region. Six of these primers were successfully transferred (CSSM-038, PEZ-05, PEZ-12, LOCO-13, LOCO-15, and PEZ-20); five of which were found to be polymorphic. Genetic parameter values (number of alleles per locus, observed and expected heterozygosities, and fixation indices) were within the expected range reported for canid populations worldwide.

Transferability of short tandem repeat markers for two wild Canid species inhabiting the Brazilian Cerrado

The maned wolf (Chrysocyon brachyurus) and the crab-eating fox (Cerdocyon thous) are two wild-canid species found in the Brazilian Cerrado. We tested cross-amplification and transferability of 29 short tandem repeat primers originally developed for cattle and domestic dogs and cats on 38 individuals of each of these two species, collected in the Emas National Park, which is the largest national park in the Cerrado region. Six of these primers were successfully transferred (CSSM-038, PEZ-05, PEZ-12, LOCO-13, LOCO-15, and PEZ-20); five of which were found to be polymorphic. Genetic parameter values (number of alleles per locus, observed and expected heterozygosities, and fixation indices) were within the expected range reported for canid populations worldwide.

Comparative analyses of semen and endocrine characteristics of free-living versus captive jaguars (Panthera onca).

Semen and blood samples were obtained from free-living (n = 6) and captive (n = 8) jaguars (Panthera onca) to compare reproductive characteristics between the two populations. Semen samples were analysed for volume (ml), percentage of motile spermatozoa, rate of forward progression (0-5), concentration (10(6) ml(-1)), total sperm count (10(6)) and sperm morphology. Serum testosterone concentration was determined by radioimmunoassay. Although ejaculate volume was greater in captive jaguars (n = 47 samples) than in free-living jaguars (n = 7 samples) (P < 0.05), the free-living jaguars produced more total spermatozoa (59.3 +/- 12.8 versus 152.0 +/- 88.0 x 10(6), respectively; not significant) with better viability and forward progression (2.8 +/- 0.1 versus 3.5 +/- 0.2, respectively; P < 0.05) and more spermatozoa with normal morphology (73.5 +/- 3.9 versus 5.0 +/- 1.1%, respectively; P < 0.05). Serum testosterone concentrations were similar for captive and free-living male jaguars (3.1 +/- 0.7 and 2.1 +/- 0.8 ng ml(-1), respectively). In summary, the data showed that semen may be collected successfully from free-living jaguars and evaluated under field conditions to establish normative reproductive values in this species. The results also indicate that jaguars maintained in zoos show inferior seminal characteristics compared with free-living animals.

Early diagnosis of septic arthritis of the hip in neonates.

Fourteen neonates with septic arthritis of the hip, which had been diagnosed late, were reviewed with the aim of establishing the difficulties of making an early diagnosis. The history, physical signs, blood tests and examination of the synovial fluid are the most important guidelines. Radiography was not helpful as less than 50% of cases show early signs, most often a joint effusion. Early diagnosis and surgical drainage are necessary to avoid permanent damage to the cartilaginous femoral head.

[Morphologic study of the inferior cavo-atrial transition in man. Morphofunctional considerations]. / Estudo morfológico da transição cavo-atrial inferior no homem. Considerações morfo-funcionais.

PURPOSE: Analysis the fibrous elements of the transition between the inferior vena cava and right atrium. METHODS: Twenty adult (20-40 ys) were used. Properly preserved samples were analysed macro and microscopically. Fragments were excised from the inferior cavo-atrial transition and analysed under stereomicroscopic. RESULTS: The inferior vena cava valve was disposed at the wall of the vein. Insertions of striated muscular cardiac fibers bundles are seen at the anterior wall of inferior vena cava. These muscular bundles are directed towards the intima of the vein. There were at the venous posterior wall insertions of the cardiac muscular bundles, originated from the crista terminalis and from the interatrial septum, these bundles show an orientation predominantly oblique, with tendency to become circular. At the transition level, the bundles of smooth muscular fibers of the inferior vena cava, presented an oblique disposition, becoming predominantly circular. CONCLUSION: As the disposition of muscular cardiac fibers presents a predominantly circular direction and, the bundles of smooth muscular fibers of the inferior vena cava present the same direction, we could postulate that, when the atrial systole occurs, these muscular bundles would obliterate the cavo-atrial transition, preventing, this way, the venous reflux.

[Morphofunctional study of the cava-hepatic venous transition in humans]. / Contribuição para o estudo morfofuncional da transição venosa cavo-hepática no homem.

Using mesoscopic techniques, the authors observed that fibrous muscular bundles were distributed in three layers, from the external to the intima, in the cava-hepatic venous transition zone; these bundles start with a helical course, and bend progressively towards their outlet. Regarding the collagen component, two kinds of fibre bundles were observed: 1) as longitudinal strips, two for each vein that join in an arched form close to the outlet; 2) bundles running in the same direction as muscular bundles. The elastic tissue appears as a component of the myoelastic tendons or as independent bundles. The latter follow the direction of the muscular fibres, but show a decreasing amount when they approach the transition zone. At this point, however, the myoelastic tendons grow thicker.

[Anatomical variations in the hypoglossal canal]. / Contribuição ao estudo das variações anatômicas do canal do hipoglosso.

In this paper, 492 human dried skulls grouped according to sex and race (White and no White) were examined and the presence of a double hypoglossal canal was observed in 97 skulls. The statistical analysis allowed us to conclude that no significative difference exists in race X canal type; sex X canal type; race X side and sex X side interations.

Heart rate in fetuses and neonates in normal conditions and with mild depression.

The continuous recording of fetal and neonatal heart rate gives reliable information on the condition of the fetus and neonate. In the present study the results obtained in vigorous and mildly depressed newborns, by the continuous recording of fetal heart rate during labor and of neonatal heart rate during 90 minutes after birth, are presented. Twenty three pregnant women were studied during labor, as well as their newborns. They fulfilled the following conditions: --Mothers without known complications and good prenatal care. --Term pregnancies with single fetuses in vertex presentation with birthweight normal for age. --All labors started, progressed and delivered spontanously withoug signs of fetal distress. No drugs were given to the mother during labor or to the neonate. The umbilical cord was clamped immediately after birth. Seventeen neonates were vigorous at 1 and 5 minutes (Apgar score 7 or higher). Six neonates were slightly depressed at the first minute but all of them recovered at 5 minutes. Both groups are studied separately. Figure 1 shows the average values of BFHR and NHR corresponding to 17 vigorous newborns (Apgar scores 7-10 at the first and fifth minutes of life). No major variations were found in the average values of BFHR in the time period studied. No statistically significant differences were found in the BFHR of the same fetus at 60, 30 and 8 minutes before delivery (Fig. 2). A decrease in BFHR occurred during the 6 minutes preceding birth (fig. 1). After birth the average values of NHR were higher than the fetal ones (Fig. 1). This post-natal increase in heart rate (32 beats/min) is statistically significant when BFHR values 30 minutes before delivery are compared with NHR values recorded 10 minutes after birth (Fig. 3). After this initial increase, NHR starts a gradual fall, lasting about 50 minutes and then becomes stable at a level similar to that of fetal heart rate (Fig. 1). Figure 1 shows that puncture of the heel causes an increase in NHR. The difference between NHR before and after the puncture is significant (Fig. 6). The heart rate of 6 newborns which were slightly depressed at the first minute of life (Apgar score 4-6) but vigorous at the fifth minute, are not significantly different from those of the vigorous group of 17 neonates (Fig.7). The cases chosen for this study have been carefully selected with the aim of establishing the "normal" pattern of fetal and neonatal heart rate. We concluded that in normal term labors BFHR remains stable from 90 until 10 minutes before delivery; there is a tendency to fall during the last 6 minutes preceeding birth. Immediately after birth, neonatal heart rate rises significantly, then falls gradually and becomes stabilized 50 minutes after delivery, at levels similar to those of BFHR.