Satona Murakami

Relationship between screw trajectory of C1 lateral mass screw and internal carotid artery.

Study Design. Evaluation of diagnostic imaging. Objective. To comprehend anatomic relationships between the internal carotid artery (ICA) and bicortical purchase of C1 lateral mass screws from the perspective of avoiding ICA injury. Summary of Background Data. No studies have evaluated safety trajectory of atlantal lateral mass screw that would avoid the ICA injury in relation to its location, although previous studies have indicated concern about ICA injury by the screw tip at the anterior surface of the lateral mass of the atlas. Methods. From 149 of 177 human 3-dimensional computed tomography reconstruction images, 6 distance and 2 angle parameters related to both atlas and ICA were measured on the plane 15° cephalad to the transverse plane. In addition, angle of error during screw insertion from intended trajectory was checked. Results. The ICA was located in front of the C1 lateral mass in 64.4% of cases and faced the lateral one third of the C1 lateral mass in 54.6% of cases. None were located in front of the medial one third of the C1 lateral mass. The maximum inward screw trajectory that would violate the ICA was 8.6°. Mean angle of preoperative C1/2 rotation and angle of error from intended trajectory was about 5°, respectively. Conclusion. The possibility of ICA injury can be excluded by correct insertion of the screw 10° inward. Although bicortical purchase with adequately medially angulated trajectory might be safe enough, we must remember the possibility to violate the ICA in bicortical purchase, because the intended screw trajectory never be assured.

Anatomical basis of distally based anterolateral thigh flap.

Abstract Soft tissue coverage around the knee has persisted as a challenge for plastic and reconstructive surgeons. The distally-based anterolateral thigh flap is often used for coverage. Nevertheless, few anatomical studies have investigated the retrograde vascular pedicle. This report clarifies the anatomy of the connection between the descending branch of the lateral circumflex femoral artery and the lateral superior genicular artery. This study examined 38 lower limbs from cadavers and recorded the numbers and locations of perforating vessels. Proximal and distal pivot points were also recorded. The proximal pivot point was 1.0–12.1 cm (average = 6.0 cm) from the inguinal ligament. The distal pivot point, found under the vastus lateralis muscle in all 38 specimens, was 4.0–13.6 cm (average = 9.8 cm) from the lateral superior edge of the patella. The most distal perforator was 8.2–28.0 cm (average = 18.9 cm) from the proximal pivot point. The most proximal perforator was 3.0–19.5 cm (average = 8.7 cm) from the distal pivot point. Details of the anastomosis of the descending branch and the superior lateral genicular artery were clarified. The distally-based anterolateral thigh flap presents one option for reconstruction around the knee.

Possible gastrointestinal symptoms in a subset of children with autism

There is a continuing debate as to whether or not gastrointestional (GI) problems may exist in a subset of children with autism. If GI disorders are common in some children with developmental disorders, why could they not also exist in children with autism? It is known that constipation and fecal impaction are common in children with mental retardation [1], Rett syndrome [2], Prader–Willi syndrome, Hunter disease and autism [3,4]. It is also an established fact that a certain percentage of children with autism have varying degrees of mental retardation, thus is it not possible that these children may experience the increased risk of GI symptoms associated with mental retardation? A recent review by Buie et al. in Pediatrics reported that the prevalence of GI symptoms (constipation, diarrhea, bloating, belching, abdominal pain, reflux, vomiting and flatulence) in children with autism spectrum disorders (ASD) range widely from nine to 91% based on 11 studies that average 44% [5]. It is interesting to note that D’Eufemia et al. observed that 43% (nine out of 21) of children with ASD had altered intestinal permeability (leaky gut) compared with 0% of controls (zero out of 40) [6]. Other GI problems common in genetically related mental disorders include: possible functional megacolon in Rett syndrome, where 76% of these patients experience GI symptoms [7]; gallbladder dysfunction (gallstones and cholecystectomy) in Rett syndrome [8]; and gastroparesis in Prader– Willi syndrome [9]. Levy even stated that “Down syndrome is recognized as one of the most common predisposing conditions for a group of serious GI anomalies – tracheo–esophageal fistula, duodenal obstruction with or without pyloric stenosis, annular pancreas, imperforate anus and Hirschsprung’s disease” [10]. He added that “intestinal anomalies can be found in many other genetic disorders, with recent evidence suggesting the presence of GI develop mental regulatory genes on chromosome 13q.” In terms of celiac disease, The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition recognizes in their clinical guidelines that at least three developmentally delayed conditions have higher risk rates than the normal population [11]. They reported that strong evidence exists for an association between Down syndrome and celiac disease, with a prevalence rate of 5–12%. Approximately one third of Down syndrome patients with celiac disease exhibit no GI symptoms. Hilhorst et al. reported a 43-times higher celiac rate in patients with Down syndrome [12]. According to the 1999 Health Care Guidelines of the Down Syndrome Medical Interest Group, an initial screening for celiac disease is recommended at the age of 2 years [13]. Approximately 4–8% of children with Turner syndrome have celiac disease [14–18], and one study revealed an 8% rate in children with Williams syndrome [19]. The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition also recognized increased rates of celiac disease in children with Type 1 diabetes mellitus. The 2009 American Diabetes Association Standards of Medical Care in Diabetes listed the increased rates of celiac disease to be 1–16% versus 0.3–1% in the general population, and recommended celiac disease screening in these patients [20]. Children with cerebral palsy are also at risk as 43% have high serological celiac markers [21]. Amy Brown, PhD