Matthew J. Zdilla

Metformin With Either Histamine H2-Receptor Antagonists or Proton Pump Inhibitors: A Polypharmacy Recipe for Neuropathy via Vitamin B12 Depletion

According to the most recent data from the Centers for Disease Control and Prevention, 25.8 million people in the United States (8.3% of the population) have diabetes (1). Type 2 diabetes accounts for 90–95% of diabetes diagnoses, and >85% of people with type 2 diabetes are overweight or obese (1). Increased BMI, which is common in the type 2 diabetes population, has a well-established association with symptoms of gastroesophageal reflux disease (GERD) (2,3). Central adiposity is an important risk factor in the development of reflux and, subsequently, erosive esophagitis, Barrett’s esophagus, esophageal adenocarcinoma, and gastric cardia adenocarcinoma (2,3). Increased BMI is not the only risk factor for the development of GERD, particularly among people with diabetes. Among those with type 2 diabetes, peripheral neuropathy is an independent risk factor for erosive esophagitis (4). In this population, there is a greater incidence of erosive esophagitis among individuals with neuropathy than among those without neuropathy, although those with and without neuropathy experience similar GERD symptoms (4). Approximately 60–70% of people with diabetes have mild to severe forms of nervous system damage, which may partly explain why low-grade esophageal dysplasia is twice as likely in individuals with than in those without diabetes (1,5). Additionally, both asymptomatic and symptomatic reflux is more prevalent in individuals with diabetes than in those without diabetes (6,7). Likewise, type 2 diabetes has been demonstrated to be a risk factor for symptomatic GERD (8). Among individuals with diabetes, 40.7% experience symptomatic GERD, and 70% of those use oral antidiabetic medications. Thus, it is likely that millions of individuals are managing blood glucose and GERD concomitantly with oral medications (1,7) Therefore, it is important to assess the drug interactions and clinical sequelae that may occur with this particular …

Circularity, Solidity, Axes of a Best Fit Ellipse, Aspect Ratio, and Roundness of the Foramen Ovale: A Morphometric Analysis With Neurosurgical Considerations.

AbstractThe structure of the foramen ovale of the sphenoid bone is clinically important, particularly with regard to surgical procedures that cannulate the foramen such as percutaneous trigeminal rhizotomy for the treatment of trigeminal neuralgia, percutaneous biopsy of parasellar lesions, and electroencephalographic analysis of the temporal lobe among patients undergoing selective amygdalohippocampectomy. Differences in the morphology of the foramen ovale (FO) have been reported to contribute to difficulties in the cannulation of the FO. Reports regarding the structure of the FO, however, use subjective and ambiguous descriptions of morphology, including “oval,” “truly oval,” “elongated oval,” “elongated,” “semicircular,” “almond,” “round,” “rounded,” “slit,” “irregular,” “D shape,” and “pear.” Therefore, it is necessary to describe the structure of the FO with reproducible objective morphometric data. This study analyzed 169 foramina to determine normative morphometric shape descriptions of the following: area, perimeter, circularity, solidity, axes of a best fit ellipse, aspect ratio, and roundness. The shape descriptors reported herein may aid in identification and description of structural variation in FO including bony projections encroaching upon the foramina and may improve surgical approaches to transovale cannulation.

Orientation of the Foramen Ovale: An Anatomic Study With Neurosurgical Considerations.

AbstractUnsuccessful cannulation of the foramen ovale (FO) continues to occur with both fluoroscopic technique and technique using computed tomography paired with navigational technology. Despite advances in stereotactic neurosurgical imaging and technique, anatomic variation of the FO occasionally prevents successful cannulation. Morphometric study of the FO has been limited to length, width, and area parameters; therefore, this report analyzed the orientation of the FO. A total of 139 crania (235 foramina ovalae) were photographed and assessed digitally by ImageJ software (NIH). Foramina were fit with a best fit ellipse. For orientation, the midsagittal plane was located by bisecting the basilar process of the occiput; the coronal plane was identified as perpendicular to the midsagittal plane. The angles between the major axis of the best fit ellipse of the FO and the midsagittal and coronal planes were measured. The angle formed between the major axis of the best fit ellipse of the FO and the coronal plane averaged 35.43° ± 9.74° (mean ± SD) on the left and 36.47° ± 7.60° on the right. The angle formed between the major axis of the best fit ellipse of the FO and the sagittal plane averaged 54.57° ± 9.74° on the left and 53.53° ± 7.60° on the right. No significant difference was found between FO orientation among the sexes. Understanding the orientation of the FO may aid in stereotactic neurosurgical planning and successful cannulation of the FO.

Bilateral Duplication of the Foramen Spinosum: A Case Report with Clinical and Developmental Implications

In humans, the foramen spinosum (FS) is located within the sphenoid bone and transmits the middle meningeal artery (MMA). In species that evolutionarily predate humans, the FS exists within the temporal bone, the sphenosquamosal suture, or is absent altogether. It is therefore thought that, during the course of human evolution, the ossification of the posterior aspect of the greater wing of the sphenoid progressively developed around the MMA. The report documents the occurrence of a bilateral duplication of the FS in a male human skull. The report also discusses the clinical and developmental/anthropological significance. Because the foramen spinosum is utilized as a landmark for various surgical procedures involving the middle cranial fossa, the bilateral duplication of the foramen may be disorienting to the surgeon. Similarly, the dynamics of blood flow may be altered due to the bilateral bifurcation of the MMA. Because of the developmental significance of the FS, the occurrence of a bilateral duplication also has important anthropological implications.

The size and shape of the foramen magnum in man

Background: The foramen magnum (FM) has garnered broad interest across the disciplines of anthropology, comparative anatomy, evolutionary biology, and clinical sciences. Most studies regarding the structure of the FM in humans have been intrapopulation morphometric studies rather than interpopulation morphologic studies. The few studies assessing the morphology of the foramen have utilized ambiguous and subjective descriptors to describe foraminal shape and are, consequently, difficult to reproduce. Therefore, detailed study of FM shape among craniofacially and geographically diverse populations through reproducible methods is warranted. Objectives: The aim of this study was to assess intersex and interpopulation differences in FM size and shape among diverse populations. Materials and Methods: The study analyzed 152 FMs of varied sex and race via traditional and geometric morphometric methods. Results and Conclusions: The study demonstrates that, within each distinct population, the size of the FM is significantly larger in males than in females; however, there are no significant differences in the shapes of the foramina between sexes. However, when comparing different populations to one another, there are significant differences with regard to both the size and shape of the FM. This study also presents a new model of FM ontogeny. Specifically, the growth occurring between the anterior and posterior foraminal boundaries before 5 years of age predicts the ultimate shape of the adult FM.

The Retaining Ligament of the Anterior Digastric Muscle

Abstract The anterior belly of the digastric muscle (ABDM) is important in numerous esthetic surgeries including rhytidectomy, alteration of the cervicomental angle via partial resection of the ABDM muscle belly, and suprahyoid muscular medialization and suspension. Recently, the connection between the ABDM and the mylohyoid muscle (MH) has been proposed as important for the mechanism of the digastric corset procedure. This report refers to the connection between the ABDM and the MH as a type of retaining ligament of the anterior digastric muscle (RLAD). This report is the first to directly demonstrate the existence of the RLAD, via photograph and video, and document variation in its attachment sites, its composition, and its behavior when traction forces are applied. In addition to the importance of the RLAD in plastic surgery, the RLAD may affect neurovascular structures between the ABDM and MH and serve as a physical barrier separating the submental fascial space from the submandibular fascial space and, therefore, influence the spread of infection.

Unilateral duplication of the anterior digastric muscle belly: a case report with implications for surgeries of the submental region

Anterior belly of the digastric muscle (ABDM) variations have been reported to occur in as few as 2.7% to as many as 69.6% of individuals. Therefore, it is important to understand the anatomical diversity of ABDM variants, particularly with regard to head and neck surgery. The report documents a unilateral duplication of the ABDM with an oblique belly which crosses the midline. Measurements of muscle length, width, orientation and inferior surface area are documented. ABDM variants may cause confusion during surgeries, including submental lipectomy, rhytidectomy, surgical alteration of the cervicomental angle via partial resection of the ABDM, muscle transfer for reanimation of the mouth and submental artery flap procedures. Therefore, knowledge of this particular variant may aid in surgical planning as well as prevent confusion and disorientation during operations in the submental region.

Bilateral Duplication of the Sphenoidal Emissary Foramen: A Case Report with Implications for Surgeries using Transovale Cannulation

The sphenoidal emissary foramen (SEF) is an inconsistent foramen located in the middle cranial fossa. The SEF may transmit a sphenoidal emissary vein (of Vesalius), dural venous sinus, nervolulus sphenoidalis lateralis, or an accessory middle meningeal artery. Prior reports have noted SEF to exist unilaterally and bilaterally. Duplication of the SEF has also been documented to occur unilaterally. The case reported herein documents a bilateral duplication of the SEF. Because the SEF are occasionally cannulated by mistake in procedures which attempt to access the middle cranial fossa via the foramen ovale, knowledge of the bilateral duplication of the SEF is important for neurosurgeons and radiologists.

Variation of the mylohyoid: implications for Ludwig angina, cervical contouring, and digastric muscle transfer

The mylohyoid (MH) musculature separates the sublingual and submandibular spaces and is, therefore, important with regard to the spread of infection and space occupying lesions. Moreover, the MH may be elevated and included in the myocutaneous submental island flap or sutured in conjunction with the platysmas and the anterior bellies of the digastric muscles (ABDMs) to add stability to submental muscular medialization procedures. Therefore, variation in the anatomy of the MH musculature must be considered in the management of the spread of infection and space occupying lesions as well as in surgical planning. This report reviews mylohyoid variations and documents a unique case in which several suprahyoid muscular variations occurred concurrently. The variations included isolated anterior bellies of the mylohyoid inserting into the geniohyoid thereby forming mylo-geniohyoid muscles as well as isolated posterior bellies of the mylohyoid inserting into the ABDM and the intermediate tendon of the digastric muscle thereby forming mylo-digastric muscles. Surgeons operating in the suprahyoid region should be aware of potential anatomical variation of the mylohyoid to develop contingency plans.

The submental arrowhead variation of the mylohyoid and anterior belly of the digastric muscles

PurposeSubmental anatomical variation is of clinical importance with regard to head and neck surgeries. One such anatomical variation is that of additional musculature joining the intermediate tendon of the digastric muscle to the midline of the mylohyoid musculature—a variation which this report refers to, accordingly, as an arrowhead variation. Though the arrowhead variation has been described in several case reports, it has not been subject to cross-sectional study. The purpose of this study is to determine the prevalence of the arrowhead variation.MethodsPrevalence of the arrowhead variation was assessed in 19 cadavers via gross dissection.ResultsTwo of the 19 cadavers (10.5%) were found to have arrowhead variations. The arrowhead variation was found in one male (1:11; 9.1%) and one female (1:8; 12.5%), respectively.ConclusionsThis report demonstrates that the submental arrowhead variation of the anterior digastric and mylohyoid musculature has been reported in isolated case reports since the nineteenth century. This report is the first cross-sectional study of the arrowhead variant, identifying it in approximately one in ten individuals and in both sexes. Therefore, the presence of an arrowhead variation should be regularly considered with regard to diagnosis of submental masses. Likewise, the arrowhead variation should be considered in the preoperative planning of the myriad operations performed in the submental region.