Association between waist circumference change after smoking cessation and incidence of hypertension in Korean adults

OBJECTIVES

This study investigates the association between smoking cessation and hypertension incidence, as well as the association between waist circumference change after smoking cessation and hypertension incidence.

STUDY DESIGN

This was a nationwide population-based cohort study.

METHODS

We used the Korean Health Screening Cohort data and included 158,505 participants who had undergone two or more health examinations between 2008 and 2011, with follow-ups throughout 2019. Smoking cessation and waist changes were captured based on difference between first and follow-up screening dates. Hazard ratio (HR) and 95% confidence interval (CI) for hypertension risk were estimated using multivariable Cox proportional hazard regression models.

RESULTS

There were 31,270 cases of hypertension during a median follow-up of 8.50 years. After adjusting for potential confounding factors, HR for hypertension were 1.01 (95% CI: 0.97-1.05), 0.91 (95% CI: 0.87-0.95), and 0.88 (95% CI: 0.85-0.91) for recent quitters, long-term quitters, and non-smokers, respectively, compared with current smokers. HR for hypertension, compared with current smokers, were 0.89 (95% CI: 0.84-0.94), 0.91 (95% CI: 0.85-0.97), and 0.99 (95% CI: 0.91-1.08) for long-term quitters with no waist gain, long-term quitters with waist gain of 0.1-5.0 cm, and long-term quitters with waist gain of ≥5.0 cm, respectively.

CONCLUSIONS

Long-term smoking cessation was significantly associated with decreased risk of hypertension, and long-term smoking cessation with no waist gain or less than 5.0 cm of waist gain was significantly associated with decreased risk of hypertension. However, more than 5.0 cm of waist gain can attenuate the effect of long-term smoking cessation on lowering the risk of hypertension.

Sihler's staining technique: How to and guidance for botulinum neurotoxin injection in human muscles

The Sihler's stain is a whole-mount nerve staining technique that allows visualization of the nerve distribution and permits mapping of the entire nerve supply patterns of the organs, skeletal muscles, mucosa, skin, and other structures that contain myelinated nerve fibers. Unlike conventional approaches, this technique does not require extensive dissection or slide preparation. To date, the Sihler's stain is the best tool for demonstrating the precise intramuscular branching and distribution patterns of skeletal muscles. The intramuscular neural distribution is used as a guidance tool for the application of botulinum neurotoxin injections. In this review, we have identified and summarized the ideal botulinum neurotoxin injection points for several human tissues.

Novel Clinical Anatomical Consideration of the Superficial and Deep Layers of the Deep Temporal Fascia

BACKGROUND

The deep temporal fascia provides anchoring during thread lifting, which is a minimally invasive face-lifting procedure. However, anatomical studies involving the deep temporal fascia in addition to effective and safe thread-lifting procedures are scarce. The authors clarified the anatomy of the superficial layer of the deep temporal fascia and its surrounding structure using ultrasonography, histologic sections, and cadaveric dissection to propose an effective thread-lifting procedure guideline.

METHODS

The authors included 20 healthy young participants from the Republic of Korea. Real-time, two-dimensional, B-mode ultrasonography was performed. Longitudinal scanning was performed along three vertical lines: the line passing through the jugale, the anterior margin of the condylar process of the mandible, and the midpoint between the jugale and anterior margin of the condylar process. Histologic samples from three fresh adult cadavers were harvested from 2.5 cm above and below the zygomatic arch. Eighteen fresh adult hemifaces of cadavers from the Republic of Korea (six men and three women, aged 67.3 ± 7.2 years) were used to confirm the morphology of the deep temporal fascia.

RESULTS

The superficial layer of the deep temporal fascia crossed the zygomatic arch and was connected to the origin of the zygomaticus major muscle at the line passing through the jugale. The superficial layer continued inferiorly to the parotidomasseteric fascia at the line passing through the midpoint and condylar process of the mandible.

CONCLUSION

This study yielded the novel anatomy of the superficial layer of the deep temporal fascia, and this anatomical structure may be used for an ideal thread-lifting procedure.

A practical guide to botulinum neurotoxin treatment of teres major muscle in shoulder spasticity: Intramuscular neural distribution of teres major muscle in cadaver model

BACKGROUND

Botulinum neurotoxin treatment typically focuses on the teres major muscle as a primary target for addressing shoulder spasticity. The muscle is located deep within a large muscle group and optimal injection locations have not been identified.

OBJECTIVE

To identify the preferred location for administering botulinum toxin injections in the teres major muscle.

METHODS

Teres major specimens were removed from 18 cadaveric models and stained with Sihler's method to reveal the neural distribution within the muscle. The muscles were systematically divided into equal lengths from origin to insertion. The neural density in each section was evaluated to determine the location that would be likely to increase effectiveness of the injection.

RESULTS

The greatest density of intramuscular nerve endings was located in the middle 20% of the muscle. The tendinous portion was observed at the ends of the muscle.

CONCLUSIONS

The results suggest that botulinum neurotoxin should be delivered in the middle 20% of the teres major muscle.

Intramuscular Neural Distribution of the Gluteus Maximus Muscle: Diagnostic Electromyography and Injective Treatments

INTRODUCTION

The purpose of this study was to investigate neural patterns within the gluteus maximus (Gmax) muscle to identify optimal EMG placement and injection sites for botulinum toxin and other injectable agents.

METHODS

This study used 10 fixed and 1 non-fixed adult Korean cadavers. Intramuscular arborization patterns were confirmed in the cranial, middle, and caudal segments of 20 Gmax muscles using Sihler staining. Ultrasound images were obtained from one cadaver, and blue dye was injected using ultrasound guidance to confirm the results.

RESULTS

The intramuscular innervation pattern of the Gmax was mostly in the middle part of this muscle. The nerve endings of the Gmax are mainly located in the 40-70% range in the cranial segment, the 30-60% range in the middle segment, and the 40-70% range in the caudal segment.

DISCUSSION

Addressing the spasticity of the gluteus maximus requires precise, site-specific botulinum toxin injections. The use of EMG and other injection therapies should be guided by the findings of this study. We propose that these specific sites, which correspond to areas with the densest nerve branches, are the safest and most efficient locations for both botulinum toxin injections and EMG procedures.

Does injecting small amounts of fillers prevent the development of secondary blindness?

INTRODUCTION

Inadvertent entry of filler products into the supratrochlear, supraorbital, or dorsal nasal arteries, among other branches of the ophthalmic artery, might result in an immediate and devastating loss of vision. We wanted to examine how much filler could block the ophthalmic artery.

MATERIALS AND METHODS

Twenty-nine fresh cadavers were examined. We exposed the arterial supply to the opthalmic artery by dissecting the orbital area. Thereafter, 17 filler injections were introduced into the supratrochlear, supraorbital, and dorsal nasal arteries each. The amount of filler injection that completely blocked the ophthalmic artery was measured. Additionally, one of the head specimens was processed using phosphotungstic acid-based contrast enhancement micro-computed tomography to analyze each arteries to obstruct its whole ophthalmic artery.

RESULTS

The supratrochlear, supraorbital, and dorsal nasal arteries had mean volumes in milliliter (mean ± standard deviation) of 0.0397 ± 0.010 mL, 0.0409 ± 0.00932 mL, and 0.0368 ± 0.00732 mL, respectively. However, the arteries did not differ significantly.

CONCLUSION

Even a modest amount of filler injection can completely block the ophthalmic artery, resulting in visual loss.

A standardized protocol for needle placement in the infraspinatus muscle: an anatomical perspective

PURPOSE

This study aimed to evaluate the morphology of the three parts of the infraspinatus muscle based on surface landmarks for precise and effective access, and to propose the most effective fine-wire electrode insertion technique and sites.

METHODS

Fifteen Asian fresh cadavers were used. We investigated the probability of the presence of the superior, middle, and inferior parts in each infraspinatus muscle based on surface landmarks. Based on the positional characteristics of the muscle, we determined the needle insertion method and confirmed its effectiveness by dissection.

RESULTS

The superior part was mostly observed near the spine of the scapula. The middle part was broadly observed within the infraspinous fossa. The inferior part showed variable location within the infraspinous fossa. The injection accuracy of the superior, middle, and inferior parts in the infraspinatus muscle was 95.8%, 100%, and 91.7%, respectively. Targeting the superior and middle parts for injection of the infraspinatus muscle is relatively more straightforward than targeting the inferior part. Targeting the inferior part of the infraspinatus muscle in this study was more challenging than targeting the superior and middle parts.

CONCLUSION

Needling for electromyography should be performed with special care to avoid unintended muscle parts, which could lead to inaccurate data acquisition and affect the conclusions about muscle function.

Sonoanatomy of the platysmal bands: What causes the platysmal band?

BACKGROUND

The platysmal band is created by the platysma muscle, a thin superficial muscle that covers the entire neck and the lower part of the face. The platysmal band appears at the anterior and posterior borders of the muscle. To date, no definite pathophysiology has been established. Here, we observed a lack of knowledge of the anatomy of the platysma muscle using ultrasonography in this study.

METHODS

We conducted a descriptive, prospective study observing the platysmal band in resting and contraction states to reveal muscle changes. Twenty-four participants (aged 23-57 years) with anterior and posterior neck bands underwent ultrasonography in resting and contracted states. Ten cadavers were studied aged 67-85 years to measure the thickness of the platysma muscle at 12 points: horizontally (medial, middle, lateral) and vertically (inferior mandibular margin, hyoid bone, cricoid cartilage, superior margin of clavicle).

RESULTS

The anterior and posterior borders of the platysma muscle were thicker than the middle of the platysma muscle when in a contracted state, and the muscle also had a convex shape when contracted. The thickness of the platysma muscle was not significantly different over 12 points in the resting state. During contraction, the platysma muscles contracted in the medial and lateral margins of the muscle, which was more significant in the posterior bands.

CONCLUSION

The anterior and posterior platysmal bands are related to muscle thickness during contraction. These observations support the change in platysmal band treatment only at the anterior and posterior border of the muscle.

Ideal Injection Points for Botulinum Neurotoxin for Pectoralis Minor Syndrome: A Cadaveric Study

Pectoralis Minor Syndrome (PMS) causes significant discomfort due to the compression of the neurovascular bundle within the retropectoralis minor space. Botulinum neurotoxin (BoNT) injections have emerged as a potential treatment method; however, their effectiveness depends on accurately locating the injection site. In this study, we aimed to identify optimal BoNT injection sites for PMS treatment. We used twenty-nine embalmed and eight non-embalmed human cadavers to determine the origin and intramuscular arborization of the pectoralis minor muscle (Pm) via manual dissection and Sihler's nerve staining techniques. Our findings showed the Pm's origin near an oblique line through the suprasternal notch, with most neural arborization within the proximal three-fourths of the Pm. Blind dye injections validated these results, effectively targeting the primary neural arborized area of the Pm at the oblique line's intersection with the second and third ribs. We propose BoNT injections at the arborized region within the Pm's proximal three-fourths, or the C region, for PMS treatment. These findings guide clinicians towards safer, more effective BoNT injections.

A three-dimensional analysis of the tibialis anterior tendon: emphasizing tendon insertion patterns for effective repair and understanding hallux valgus development

PURPOSE

The present study aimed to evaluate the insertion site of the tibialis anterior tendon three-dimensionally.

METHODS

Seventy lower limbs were dissected. The tibialis anterior tendon was dissected to verify the insertion site to the medial cuneiform and the base of the first metatarsal bone. The three-dimensional (3D) territory of the tibialis anterior tendon insertion on the medial cuneiform and the first metatarsal bones was measured on a reconstructed 3D model.

RESULTS

The insertion pattern of the tibialis anterior tendon was classified into three types, the most common being Type I: a single tibialis anterior tendon dividing into two equal-sized bands to the medial cuneiform and base of the first metatarsal bone (57.1%, 40/70 of cases). The 3D territory of the tibialis anterior tendon was larger in the plantar aspect than in the medial side of both the medial cuneiform and the base of the first metatarsal bone. The width of the tendon inserted into the medial cuneiform was wider than that inserted into the first metatarsal bone.

CONCLUSION

The tibialis anterior tendon was more commonly attached to the plantar part than the medial part in both the medial cuneiform and the base of the first metatarsal bone. This anatomical information will help surgeons perform anatomical reconstruction of the tibialis anterior tendon, reduce further tendon damage in the first metatarsocuneiform joint area and also provide valuable knowledge to improve understanding of hallux valgus pathogenesis.

Distribution of the intramuscular innervation of the triceps brachii: Clinical importance in the treatment of spasticity with botulinum neurotoxin

This study aimed to identify ideal sites for botulinum toxin injection by analyzing the intramuscular nerve patterns of the triceps brachii muscles. A modified Sihler's method was applied to the triceps brachii muscle (15 specimens), with long, medial, and lateral heads. The intramuscular arborization areas of the long, medial, and lateral heads of the triceps brachii muscle were measured as a percentage of the total distance from the midpoint of the olecranon (0%) to the anteroinferior point of the acromion (100%), by dividing the medial and lateral parts based on the line connecting the midpoint of the olecranon and the anteroinferior point of the acromion. Intramuscular arborization patterns were observed at the long head at two medial regions, proximally 30%-50% and distally 60%-70%; medial head of 30%-40%; and lateral head of 30%-60%. These results suggest that the treatment of spasticity of the triceps brachii muscles involves botulinum toxin injections in specific areas. The areas corresponding to the areas of maximum arborization are recommended as the most effective and safe points for botulinum toxin injection.

Intramuscular neural distribution of the obturator internus muscle regarding injective treatment

INTRODUCTION

The obturator internus muscle is frequently targeted for injective treatments such as botulinum toxin injections in the management of pain syndromes. However, there are controversies over injective method delivering injection to the muscle.

METHOD

A method called modified Sihler's method was used to stain the OI muscle in 16 specimens to reveal the intramuscular neural distribution of the muscle.

RESULT

The greatest intramuscular neural distribution was located on the 2/10-4/10 of the muscle in the medial edge of the obturator foramen (0/0) to the greater trochanter of the femur (10/10).

CONCLUSION

The result suggests that botulinum neurotoxin should be delivered in the intrapelvic portion of the obturator internus muscle. As most of the extrapelvic portion of the obturator muscle is composed of a tendinous portion, it should be considered unsuitable as an injection site by medical professionals.

Unusual insertion of the levator scapulae muscle: a case report

The current case report describes an uncommon insertion of the levator scapulae (LS), which broadly attaches to multiple structures, including the serratus posterior superior, ligamentum nuchae, and the 6th and 7th spinous processes of the cervical vertebrae. The most superior portion of this aponeurosis merged with the ligamentum nuchae at the C7 level. The middle and inferior portions of the head were inserted (or fused) into the tendon of the rhomboid minor as well as the fibers of the serratus posterior superior muscle. Consequently, recognizing this anatomical variation, characterized by an additional slip of the LS attaching to the 7th vertebra and other muscular structures, is crucial not only for anatomists but also for surgeons performing procedures on the posterior neck related to cervical or shoulder pain and cervical dystonia.

Intramuscular neural distribution of the teres minor muscle using Sihler's stain: application to botulinum neurotoxin injection

The aim of this study was to elucidate the intramuscular arborization of the teres minor muslce for effective botulinum neurotoxin injection. Twelve specimens from 6 adult Korean cadavers (3 males and 3 females, age ranging from 66 to 78 years) were used in the study. The reference line between the 2/3 point of the axillary border of the scapula (0/5), where the muscle originates ant the insertion point of the greater tubercle of the humerus (5/5). The most intramuscular neural distribution was located on 1/5-3/5 of the muscle. The tendinous portion was observed in the 3/5-5/5. The result suggests the botulinum neurotoxin should be delivered in the 1/5-3/5 area of the teres minor muscle.

Observation of Anatomical Structures in the Human Larynx Using Micro-Computed Tomography with Lugol's Solution Enhancement

Histological and naked-eye dissections are frequently used to investigate human anatomy. However, limitations of conventional methods include tissue damage and difficulty in observing structures, rendering findings limited. Micro-computed tomography (micro-CT) allows for a three-dimensional observation with whole-mount staining for contrast enhancement. A precise anatomical understanding of the larynx is essential for both the medical and surgical fields; however, the larynx is difficult to dissect because of its minuscule and complex structures. Therefore, we aimed to clarify the detailed anatomy of the larynx using micro-CT. The study was conducted on twelve specimens of cadavers using Lugol-based-contrast micro-CT. Using Lugol-micro-CT, relevant information on human structures was obtained. Consequently, we successfully employed the Lugol-micro-CT technique in the analysis of specific human soft tissue structures that are challenging to analyze using conventional methods.

Trans-anal small bowel evisceration in a patient with a perforated rectal prolapse

SUMMARY

An 85-year-old lady with a history of chronic constipation presented with gangrenous small bowel protruding from the anus through a hole in a prolapsed rectum. At surgery, a resection of 125 cm of gangrenous small bowel was performed in the perineum prior to laparotomy, where rectal repair was followed by the creation of a sigmoid loop colostomy and double-barrel ileostomy. This avoided an intrabdominal anastomosis which was felt likely to complicate due to the lady's intraoperative haemodynamic instability requiring inotropic support. This tailored management of a trans-anal small bowel evisceration through a rectal prolapse resulted in recovery and a patient who was content with her stomas and preferred to live with them rather than have continuity restored.

Anatomical analysis of the motor endplate zones of the suprascapular nerve to the infraspinatus muscle and its clinical significance in managing pain disorder

Myofascial pain syndrome caused by myofascial trigger points is a musculoskeletal disorder commonly encountered in clinical practice. The infraspinatus muscle is the region most frequently involved in the myofascial pain syndrome in the scapular region. The characteristics of the myofascial trigger points are that they can be found constantly in the motor endplate zone. However, localizing myofascial trigger points within the motor endplate zone and establishing an accurate injection site of the infraspinatus muscle has been challenging because the anatomical position of the motor endplate zone of the infraspinatus muscle is yet to be described. Therefore, this cadaveric study aimed to scrutinize the motor endplate zone of the infraspinatus muscle, propose potential myofascial trigger points within the muscle, and recommend therapeutic injection sites. Twenty specimens of the infraspinatus muscle for nerve staining and 10 fresh frozen cadavers for evaluation of the injection were used in this study. The number of nerve branches penetrating the infraspinatus muscle and their entry locations were analyzed and photographed. Modified Sihler's staining was performed to examine the motor endplate regions of the infraspinatus muscle. The nerve entry points were mostly observed in the center of the muscle belly. The motor endplate was distributed equally throughout the infraspinatus muscle, but the motor endplate zone was primarily identified in the B area, which is approximately 20-40% proximal to the infraspinatus muscle. The second-most common occurrence of the motor endplate zone was observed in the center of the muscle. These detailed anatomical data would be very helpful in predicting potential pain sites and establishing safe and effective injection treatment using botulinum neurotoxin, steroids, or lidocaine to alleviate the pain disorder of the infraspinatus muscle.

Intramuscular Neural Distribution of Adductor Pollicis Muscle Spasticity in Cadaver Model Regarding Botulinum Neurotoxin Treatment

PURPOSE

The adductor pollicis muscle is frequently targeted for botulinum neurotoxin injective treatment for spasticity. However, there are no injective guidelines for delivering injection to the muscle.

MATERIALS AND METHODS

A method known as the modified Sihler's method was used to stain the adductor pollicis muscle in 16 specimens to reveal intramuscular neural distribution of the muscle.

RESULTS

The most intramuscular neural distribution was located on 1/5 to 3/5 of the muscle regarding midline of 3rd metacarpal bone (0) to the base of the 1st proximal phalanx (5/5). The nerve entry point was mostly located on 0 to 1/5 of the muscle.

CONCLUSION

The result suggests that botulinum neurotoxin should be delivered at the middle of second metacarpal bone via deep injection.

Phase II study of a trastuzumab biosimilar in combination with paclitaxel for HER2-positive recurrent or metastatic urothelial carcinoma: KCSG GU18-18

BACKGROUND

Human epidermal growth factor receptor 2 (HER2) is a widely explored therapeutic target in solid tumors. We evaluated the efficacy and safety of trastuzumab-pkrb, a biosimilar of trastuzumab, in combination with paclitaxel, in HER2-positive recurrent or metastatic urothelial carcinoma (UC).

PATIENTS AND METHODS

We enrolled 27 patients; they were administered a loading dose of 8 mg/kg trastuzumab-pkrb on day 1, followed by 6 mg/kg and 175 mg/m2 paclitaxel on day 1 every 3 weeks, intravenously. All patients received six cycles of the combination treatment and continued to receive trastuzumab-pkrb maintenance until disease progression, unacceptable toxicity, or for up to 2 years. HER2 positivity (based on immunohistochemistry analysis) was determined according to the 2013 American Society of Clinical Oncology /College of American Pathologists HER2 testing guidelines. The primary endpoint was objective response rate (ORR); the secondary endpoints were overall survival (OS), progression-free survival (PFS), and safety.

RESULTS

Twenty-six patients were evaluated via primary endpoint analysis. The ORR was 48.1% (1 complete and 12 partial responses) and the duration of response was 6.9 months [95% confidence interval (CI) 4.4-9.3 months]. With a median follow-up of 10.5 months, the median PFS and OS were 8.4 months (95% CI 6.2-8.8 months) and 13.5 months (95% CI 9.8 months-not reached), respectively. The most common treatment-related adverse event (TRAE) of any grade was peripheral neuropathy (88.9%). The most common grade 3/4 TRAEs were neutropenia (25.9%), thrombocytopenia (7.4%), and anemia (7.4%).

CONCLUSIONS

Trastuzumab-pkrb plus paclitaxel demonstrates promising efficacy with manageable toxicity profiles in patients with HER2-positive recurrent or metastatic UC.

Intramuscular Neural Distribution of the Gastrocnemius for Botulinum Neurotoxin Injection: Application to Cosmetic Calf Shaping

PURPOSE

Anatomical landmarks can provide vital information on the distribution of nerves in the gastrocnemius muscle. We aimed to provide an anatomical perspective on appropriate locations for botulinum neurotoxin (BoNT) injections in the medial and lateral parts of the gastrocnemius for calf shaping.

MATERIALS AND METHODS

A modified Sihler's method was applied to both the medial and lateral parts of the gastrocnemius muscles (16 specimens). Intramuscular neural distributions were revealed by dissecting along a transverse line crossing the fibular head and superior margin of the calcaneal tuberosity.

RESULTS

The intramuscular neural distribution for the medial and lateral parts of the gastrocnemius had the greatest arborized patterns in the 7/10-8/10 section of the medial head and 7.5/10-8.5/10 section of the lateral part of the gastrocnemius.

CONCLUSION

We propose that BoNT injections should be directed to the 7/10-8/10 section of the medial head and the 7.5/10-8.5/10 section of the lateral part of the gastrocnemius. Following our guidelines, clinicians can ensure satisfactory results with the use of minimal doses to limit adverse effects, such as gait disturbance, antibody production, and bruising, due to multiple injections. The results can also be altered and applied to electromyography.

Botulinum neurotoxin injection for treating plunged nose and post-rhinoplasty: anatomical perspectives of depressor septi nasi, nasalis, leveator labii superioris alaeque nasi muscle

Botulinum neurotoxin (BoNT) injection for the treating plunged nose, post-rhinopasty and hyaluronic filler migration is common procedures in clinical settings. However, the lack of thorough anatomical understanding makes it difficult to locate the nose region muscles. The anatomical considerations concerned with BoNT injection into the nasalis, levator labii superioris alaeque, and depressor septi nasi muscles were reviewed in this study. The injection spots have been presented for the nasalis, levator labii superioris alaeque, and depressor septi nasi muscles, with the recommended injection technique for each muscle. We have suggested the ideal injection sites in association with outer anatomical landmarks of the nose region. Moreover, these proposals would support a more accurate procedure of BoNT injection in relieving plunged nose, preventing post-rhinoplasty deviation, and migration of the hyaluronic acid filler.

Ultrasound-guided Injection of the Levator Scapulae Muscle in a Cadaver Model

BACKGROUND

Despite the advantages of ultrasound and previous anatomical data on neuromuscular junction locations, to the best of our knowledge, the feasibility and accuracy of precise ultrasound-guided injection techniques into the proposed injection site of botulinum neurotoxin for the levator scapulae muscle have not been assessed in any publication.

OBJECTIVE

In the present cadaver-based study, the ultrasound-guided injection technique in the middle and distal portions of the levator scapulae muscle was evaluated to determine whether this method distributes injections properly to the target muscle in fresh cadavers.

STUDY DESIGN

Cadaveric study.

SETTING

A cadaver laboratory.

METHODS

Twenty fresh cadavers were used. Real-time B-mode ultrasound scanning was performed interfaced with a linear array transducer. A mixture of 0.5 mL of dye and yellow filler was injected transverse in-plane with a 6 cm 21-G. needle. Each specimen was dissected to determine whether the dye was correctly targeted to the middle and distal portions of the levator scapulae muscle and to evaluate the accuracy of the injections and any complications.

RESULTS

All 40 injections were successfully injected within the middle and distal portions of the levator scapulae muscle. When dissecting the cadavers, the dye spread was evenly distributed along the muscle fiber.

LIMITATION

Despite successful injection into the middle and distal portions of the levator scapulae muscle, the usefulness of this technique was not verified in clinical practice.

CONCLUSIONS

The ultrasound-guided injection technique presented in this study might facilitate precise visualization and localization of the levator scapulae muscle, thereby enhancing the effectiveness and safety of botulinum neurotoxin treatment in cervical dystonia.

Delayed immune-mediated hepatitis after three cycles of pembrolizumab for the treatment of sinonasal melanoma

Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that induce the anti-tumor effects of T cells by targeting co-inhibitory immune checkpoints. The development of ICIs has revolutionized the clinical practice of oncology, leading to significant improvements in outcomes; therefore, ICIs are now standard care for various types of solid cancers. Immune-related adverse events, the unique toxicity profiles of ICIs, usually develop 4-12 weeks after initiation of ICI treatment; however, some cases can occur >3 months after cessation of ICI treatment. To date, there have been limited reports about delayed immune-mediated hepatitis (IMH) and histopathologic findings. Herein, we present a case of delayed IMH that occurred 3 months after the last dose of pembrolizumab, including histopathologic findings of the liver. This case suggests that ongoing surveillance for immune-related adverse events is required, even after cessation of ICI treatment.

Guidance in botulinum neurotoxin injection for lower extremity spasticity: Sihler's staining technique

Spasticity is a motor disease characterized by a velocity-dependent acceleration in muscle tone or tonic stretch reflexes linked to hypertonia. Lower limb spasticity has been successfully treated with botulinum neurotoxin; however, the injection sites have not been generalized. Sihler's stain has been used to visualize intramuscular nerve distribution to guide botulinum neurotoxin injection. Sihler staining is a whole-mount nerve staining technique that allows visualization of nerve distribution and mapping of entire nerve supply patterns in skeletal muscle with hematoxylin-stained myelinated nerve fibers. This study reviewed and summarized previous lower extremity spasticity studies to determine the ideal injection site for botulinum neurotoxin.

Botulinum neurotoxin injection in the deltoid muscle: application to cosmetic shoulder contouring

BACKGROUND AND OBJECTIVES

This study describes the intramuscular nerve branching of the deltoid muscle in relation to shoulder surface anatomy, with the aim of providing essential information regarding the most appropriate sites for botulinum neurotoxin injection during shoulder line contouring.

METHODS

The modified Sihler's method was used to stain the deltoid muscles (16 specimens). The intramuscular arborization areas of the specimens were demarcated using the marginal line of the muscle origin and the line connecting the anterior and posterior upper edges of the axillary region.

RESULTS

The intramuscular neural distribution of the deltoid muscle had the greatest arborization patterns in the area between the horizontal 1/3 and 2/3 lines of the anterior and posterior deltoid bellies, and 2/3 to axillary line in middle deltoid bellies. The greatest part of the posterior circumflex artery and axillary nerve ran below the areas with the highest aborizations.

CONCLUSION

We propose that botulinum neurotoxin injections should be administered in the area between the 1/3 and 2/3 lines of the anterior and posterior deltoid bellies, and 2/3 to axillary line on middle deltoid bellies. Accordingly, clinicians will ensure minimal dose injections and fewer adverse effects of the botulinum neurotoxin injection. Deltoid intramuscular injections, such as vaccines and trigger point injections, should ideally be adapted according to our results.

Anatomical analysis of the intramuscular distribution patterns of the levator scapulae and the clinical implications for pain management

PURPOSE

The present study aimed to demonstrate the intramuscular nerve distribution of the levator scapulae muscle that is responsible for pain and to use this anatomic data to propose possible injection sites.

METHODS

Twenty levator scapulae muscles were dissected from 16 Korean embalmed cadavers. The intramuscular nerve distribution of the levator scapulae muscle was identified by whole-mount nerve staining to preserve and stain the nerve fibers without damage.

RESULTS

The posterior ramus of spinal nerves C3, C4, and C5 innervated the levator scapulae muscles. When the origin and insertion of the muscle were set to 0% and 100%, respectively, most of the intramuscular nerve terminals were located between 30 and 70%. This area may correspond to the cricoid cartilage of the sixth cervical vertebra.

CONCLUSION

Most intramuscular nerve terminals can be found in the middle and distal portions of the levator scapulae muscle. Our findings improve our understanding of the intramuscular nerve distribution of the levator scapulae muscle and will aid in pain management in clinical practice.

Sonoanatomy and an ultrasound scanning protocol of the intramuscular innervation pattern of the infraspinatus muscle

INTRODUCTION

Botulinum neurotoxin injection is a valuable treatment method for patients with myofascial pain syndrome in the infraspinatus muscle. However, there is no botulinum neurotoxin injection guideline, and the most appropriate injection site based on topographical anatomic information for this injection to effectively treat myofascial pain syndrome in the infraspinatus muscle is unclear. The purpose of this study was to evaluate the intramuscular nerve terminal of the infraspinatus muscle and to suggest the most efficient botulinum neurotoxin injection sites.

METHODS

This study used 5 formalin-embalmed and 10 fresh frozen cadavers with a mean age of 78.9 years. Sihler's staining was applied to evaluate the intramuscular nerve terminal of the infraspinatus muscle. The ultrasound scanning of the infraspinatus muscle was performed based on the surface landmarks and internal structures near the scapular region.

RESULTS

The intramuscular nerve terminal was mostly observed in the medial third area of the infraspinatus muscle. The deltoid tubercle, inferior angle, and acromion of the scapula are useful as surface landmarks to scan the infraspinatus muscle.

DISCUSSION

The proposed injection sites based on the intramuscular nerve terminal and surface landmarks can be regarded as accurate locations to reach the cluster area of the intramuscular nerve terminal and each compartment of the infraspinatus muscle to manage the myofascial pain syndrome in the infraspinatus muscle.

Novel anatomical proposal for botulinum neurotoxin injection targeting depressor anguli oris for treating drooping mouth corner

The depressor anguli oris (DAO) muscle is a thin, superficial muscle located below the corner of the mouth. It is the target for botulinum neurotoxin (BoNT) injection therapy, aimed at treating drooping mouth corners. Hyperactivity of the DAO muscle can lead to a sad, tired, or angry appearance in some patients. However, it is difficult to inject BoNT into the DAO muscle because its medial border overlaps with the depressor labii inferioris and its lateral border is adjacent to the risorius, zygomaticus major, and platysma muscles. Moreover, a lack of knowledge of the anatomy of the DAO muscle and the properties of BoNT can lead to side effects, such as asymmetrical smiles. Anatomical-based injection sites were provided for the DAO muscle, and the proper injection technique was reviewed. We proposed optimal injection sites based on the external anatomical landmarks of the face. The aim of these guidelines is to standardize the procedure and maximize the effects of BoNT injections while minimizing adverse events, all by reducing the dose unit and injection points.

Evaluating intramuscular neural distribution in the cricopharyngeus muscle for injecting botulinum toxin

OBJECTIVES

The objective of this study was to determine the area in the cricopharyngeus muscle (CPM) where botulinum neurotoxin (BoNT) can be injected safely and effectively by evaluating neural distribution in the CPM.

METHODS

Eleven specimens of the CPM were gathered from human cadavers. The anatomical relationship between the posterior cricoarytenoid muscle (PCAM) and the CPM was evaluated. Myelinated nerve fibers in the CPM were stained using modified Sihler's method. The CPM was classified into five zones according to the area accessible within the CPM via transcutaneous and transluminal approaches for BoNT injection as follows: i) lateral area including upper area (zone 1) and lower area (zone 2); ii) posterolateral area including upper area (zone 3) and lower area (zone 4); and iii) posterior area (zone 5). Neural distribution originating from the pharyngeal plexus and the extralaryngeal branches of recurrent laryngeal nerve (EBRLN) within each classified zone in stained specimens was determined.

RESULTS

Six specimens (12 lateral areas, 12 posterolateral areas, and 6 posterior areas) were suitable for evaluating neural distribution within the CPM. Zone 1 was adjacent to the PCAM the most in all specimens. Nerve endings originating from the EBRLN were observed on four sides of zone 2 (33.3%, 4/12 sides) in three specimens (3/6, 50%). Neural distribution originating from the pharyngeal plexus was found on ten sides (83.3%, 10/12 sides) of zone 3 in five specimens (83.3%, 5/6 specimens) and on nine sides (75.0%, 9/12 sides) of zone 4 in five specimens (83.3%, 5/6 specimens).

CONCLUSION

The posterolateral area (zone 3 and zone 4) is thought to be the most suitable area for alleviating the spasticity of CPM with a minimum dose of BoNT.

Anatomical Proposal for Botulinum Neurotoxin Injection Targeting the Platysma Muscle for Treating Platysmal Band and Jawline Lifting: A Review

The platysma muscle is a thin superficial muscle that covers the entire neck and lower part of the face. The platysma muscle is the primary target muscle for botulinum neurotoxin injection therapy aimed at treating platysmal band and lower facial lifting. In the procedure of botulinum neurotoxin injection therapy, a lack of knowledge of the anatomy of the platysma muscle and the properties of botulinum neurotoxin can lead to side effects such as dysphagia, dysphonia, and weakness of the neck muscles. Anatomically safe injection sites have been proposed for the platysma muscle, and the appropriate injection technique has been reviewed. We proposed optimal injection sites based on the external anatomical features of the mandible. The aim of these proposal was to standardize the procedure for the effective use of botulinum neurotoxin injections by minimizing the dose unit and injection points and thereby preventing adverse events.

Stachydrine alleviates lipid-induced skeletal muscle insulin resistance via AMPK/HO-1-mediated suppression of inflammation and endoplasmic reticulum stress

OBJECTIVE

Insulin resistance develops due to skeletal muscle inflammation and endoplasmic reticulum (ER) stress. Stachydrine (STA), extracted from Leonurus heterophyllus, has been shown to suppress proliferation and induce apoptosis in breast cancer cells and exert anti-inflammatory properties in the brain, heart, and liver. However, the roles of STA in insulin signaling in skeletal muscle remain unclear. Herein, we examined the impacts of STA on insulin signaling in skeletal muscle under hyperlipidemic conditions and its related molecular mechanisms.

METHODS

Various protein expression levels were determined by Western blotting. Levels of mouse serum cytokines were measured by ELISA.

RESULTS

We found that STA-ameliorated inflammation and ER stress, leading to attenuation of insulin resistance in palmitate-treated C2C12 myocytes. STA dose-dependently enhanced AMPK phosphorylation and HO-1 expression. Administration of STA attenuated not only insulin resistance but also inflammation and ER stress in the skeletal muscle of high-fat diet (HFD)-fed mice. Additionally, STA-ameliorated glucose tolerance and insulin sensitivity, as well as serum TNFα and MCP-1, in mice fed a HFD. Small interfering (si) RNA-associated suppression of AMPK or HO-1 expression abolished the effects of STA in C2C12 myocytes.

CONCLUSIONS

These results suggest that STA activates AMPK/HO-1 signaling, resulting in reduced inflammation and ER stress, thereby improving skeletal muscle insulin resistance. Using STA as a natural ingredient, this research successfully treated insulin resistance and type 2 diabetes.

Systemic proinflammatory-profibrotic response in aortic stenosis patients with diabetes and its relationship with myocardial remodeling and clinical outcome

Background

It is unclear whether and how diabetes mellitus may aggravate myocardial fibrosis and remodeling in the pressure-overloaded heart. We investigated the impact of diabetes on the prognosis of aortic stenosis (AS) patients and its underlying mechanisms using comprehensive noninvasive imaging studies and plasma proteomics.

Methods

Severe AS patients undergoing both echocardiography and cardiovascular magnetic resonance (CMR) (n=253 of which 66 had diabetes) comprised the imaging cohort. The degree of replacement and diffuse interstitial fibrosis by late gadolinium enhancement (LGE) and extracellular volume fraction (ECV) was quantified using CMR. Plasma samples were analyzed with the multiplex proximity extension assay for 92 proteomic biomarkers in a separate biomarker cohort of severe AS patients (n=100 of which 27 had diabetes).

Results

In the imaging cohort, diabetic patients were older (70.4±6.8 vs. 66.7±10.1 years) and had a higher prevalence of ischemic heart disease (28.8% vs. 9.1%), with more advanced ventricular diastolic dysfunction. On CMR, diabetic patients had increased replacement and diffuse interstitial fibrosis (LGE% 0.3 [0.0–1.6] versus 0.0 [0.0–0.5], p=0.009; ECV% 27.9 [25.7–30.1] versus 26.7 [24.9–28.5], p=0.025) (Figure 1).

Plasma proteomics analysis of the biomarker cohort revealed that 9 proteins (E-selectin, interleukin-1 receptor type 1, interleukin-1 receptor type 2, galectin-4, intercellular adhesion molecule 2, integrin beta-2, galectin-3, growth differentiation factor 15, and cathepsin D) are significantly elevated in diabetic AS patients (Figure 2). Pathway over-representation analyses of the plasma proteomics with Gene Ontology terms indicated that pathways related to inflammatory response and extracellular matrix components were enriched, suggesting that diabetes is associated with systemic effects that evoke proinflammatory and profibrotic response to the pressure-overloaded myocardium.

During follow-up (median 6.3 years [IQR 5.2–7.2]) of the imaging cohort, 232 patients received aortic valve replacement (AVR) with 53 unexpected heart failure admissions or death. Diabetes was a significant predictor of heart failure and death, independent of clinical covariates and AVR (hazard ratio 1.88, 95% confidence interval 1.06–3.31, p=0.030).

Conclusion

Plasma proteomic analyses indicate that diabetes potentiates the systemic proinflammatory and profibrotic milieu in AS patients. These systemic biological changes underlie the increase of myocardial fibrosis, diastolic dysfunction, and worse clinical outcomes in severe AS patients with concomitant diabetes.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): National Research Foundation of Korea

Augmented risk of ischemic stroke in hypertrophic cardiomyopathy patients without documented atrial fibrillation

Background

Ischemic stroke is a common complication in patients with hypertrophic cardiomyopathy (HCM) (1). Although atrial fibrillation (AF) is a well-established risk factor for ischemic stroke in HCM, the risk of ischemic stroke in patients with HCM without documented AF is less recognized (1, 2). This study aimed to determine the risk of ischemic stroke and identify its risk factors in patients with HCM without documented AF.

Methods

This nationwide population-based cohort study used the Korean National Health Insurance database. After excluding patients with a prior history of AF, thromboembolic events, cancer, or the use of anticoagulants, we identified 8,328 HCM patients without documented AF and 1:2 propensity score-matched 16,656 non-HCM controls. The clinical outcome was an incident ischemic stroke.

Results

During a mean follow-up of approximately 6 years, ischemic stroke occurred in 328/8,328 (3.9%) patients with HCM and 443/16,656 (2.7%) controls. Among individuals who developed ischemic stroke, the proportion of AF concomitantly detected accounted for 26.5% (87/328) and 5.8% (26/443) in the HCM and control groups, respectively. The overall incidence of ischemic stroke was 0.716/100 person-years in the HCM group, which was significantly higher than that in the control group (0.44/100 person-years) (HR 1.643; 95% CI, 1.424–1.895; P<0.001, Figure 1). The subgroup analysis according to age, sex, and comorbidities (chronic heart failure, hypertension, dyslipidemia, and vascular disease) consistently demonstrated a higher risk of ischemic stroke in the HCM group (P for interaction >0.05). In the HCM group, age ≥65 years (adjusted hazard ratio [HR] 2.741; 95% confidence interval [CI], 2.156–3.486; P<0.001) and chronic heart failure (adjusted HR 1.748; 95% CI, 1.101–2.745; P=0.018) were independent risk factors for ischemic stroke. Overall incidence was 1.360/100 in patients with HCM aged ≥65 and 2.315/100 person-years years in those with chronic heart failure, respectively. Also, compared to controls aged <65 years and without CHF, adjusted HR for ischemic stroke was 4.756 (95% CI 3.807–5.867) in patients with HCM aged ≥65 years and 2.539 (95% CI 1.638–3.936) in those with CHF, respectively (Figure 2).

Conclusions

Patients with HCM without documented AF are at a higher risk of ischemic stroke than the propensity score-matched general population. Age ≥65 years and chronic heart failure are two strong independent risk factors for ischemic stroke in this population.

Funding Acknowledgement

Type of funding sources: None.

Atomistic deformation mechanism of silicon under laser-driven shock compression

Silicon (Si) is one of the most abundant elements on Earth, and it is the most widely used semiconductor. Despite extensive study, some properties of Si, such as its behaviour under dynamic compression, remain elusive. A detailed understanding of Si deformation is crucial for various fields, ranging from planetary science to materials design. Simulations suggest that in Si the shear stress generated during shock compression is released via a high-pressure phase transition, challenging the classical picture of relaxation via defect-mediated plasticity. However, direct evidence supporting either deformation mechanism remains elusive. Here, we use sub-picosecond, highly-monochromatic x-ray diffraction to study (100)-oriented single-crystal Si under laser-driven shock compression. We provide the first unambiguous, time-resolved picture of Si deformation at ultra-high strain rates, demonstrating the predicted shear release via phase transition. Our results resolve the longstanding controversy on silicon deformation and provide direct proof of strain rate-dependent deformation mechanisms in a non-metallic system.

Understanding the how silicon deforms under pressure is important for several fields, including planetary science and materials design. Laser-driven shock compression experiments now confirm that shear stress generated during compression is released via a high-pressure phase transition.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with prostate cancer

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of prostate cancer was published in 2020. It was therefore decided, by both the ESMO and the Singapore Society of Oncology (SSO), to convene a special, virtual guidelines meeting in November 2021 to adapt the ESMO 2020 guidelines to take into account the differences associated with the treatment of prostate cancer in Asia. These guidelines represent the consensus opinions reached by experts in the treatment of patients with prostate cancer representing the oncological societies of China (CSCO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence and was independent of the current treatment practices and drug access restrictions in the different Asian countries. The latter were discussed when appropriate. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with prostate cancer across the different regions of Asia.

Intramuscular Innervation of the Supraspinatus Muscle Assessed Using Sihler’s Staining: Potential Application in Myofascial Pain Syndrome

Despite the positive effects of botulinum neurotoxin (BoNT) injection into the neural arborized area, there is no anatomical evidence in the literature regarding the neural arborization of the supraspinatus muscle. The present study aimed to define the intramuscular neural arborized pattern of the supraspinatus muscle using the modified Sihler’s staining method to facilitate the establishment of safe and effective injection sites in patients with myofascial pain in the supraspinatus muscle. Seventeen supraspinatus muscles from 15 embalmed cadavers were dissected. Precise suprascapular nerve entry locations were also observed. Intramuscular neural arborization was visualized by Sihler’s staining. The supraspinatus muscle was divided into four portions named A, B, C, and D. The nerve entry points were observed in 88.2% (15 of 17 cases) of section B and 76.5% (13 of 17 cases) of section C of the supraspinatus muscle, respectively. The concentration of intramuscular neural arborization was highest in section B of the supraspinatus muscle, which was the center of the supraspinatus muscle. When the clinician performs a trigger point and a BoNT injection into the supraspinatus muscle, injection within the medial 25–75% of the supraspinatus muscle will lead to optimal results when using small amounts of BoNT and prevent undesirable paralysis.

Intramuscular Neural Arborization of the Latissimus Dorsi Muscle: Application of Botulinum Neurotoxin Injection in Flap Reconstruction

Postoperative pain after breast reconstruction surgery with the latissimus dorsi flap is a common occurrence. Botulinum neurotoxin (BoNT) injection during surgery is effective in reducing postoperative pain. This study aimed to determine the most appropriate locations for BoNT injection. A modified Sihler’s method was performed on the latissimus dorsi muscles in 16 specimens. Intramuscular nerve arborization was noted under the landmark of the medial side surgical neck of the humerus to the line crossing the spinous process of T5 and the middle of the iliac crest. The latissimus dorsi muscles were divided into medial, middle, and lateral segments with 10 transverse divisions to give 10 sections (each 10%). Intramuscular nerve arborization of the latissimus dorsi muscle was the largest from the medial and lateral part of the muscle ranging from 40 to 60%, middle part from 30 to 60% and medial, middle and lateral part from 70 to 90%. The nerve entry points were at the medial and lateral part with 20–40% regarding the medial side of surgical neck of the humerus to the line crossing spinous process of T5 to the middle of iliac crest. These outcomes propose that an injection of BoNT into the latissimus dorsi muscles should be administered into specific zones.

Dynamic compression of water to conditions in ice giant interiors

Recent discoveries of water-rich Neptune-like exoplanets require a more detailed understanding of the phase diagram of H₂O at pressure–temperature conditions relevant to their planetary interiors. The unusual non-dipolar magnetic fields of ice giant planets, produced by convecting liquid ionic water, are influenced by exotic high-pressure states of H₂O—yet the structure of ice in this state is challenging to determine experimentally. Here we present X-ray diffraction evidence of a body-centered cubic (BCC) structured H₂O ice at 200 GPa and ~ 5000 K, deemed ice XIX, using the X-ray Free Electron Laser of the Linac Coherent Light Source to probe the structure of the oxygen sub-lattice during dynamic compression. Although several cubic or orthorhombic structures have been predicted to be the stable structure at these conditions, we show this BCC ice phase is stable to multi-Mbar pressures and temperatures near the melt boundary. This suggests variable and increased electrical conductivity to greater depths in ice giant planets that may promote the generation of multipolar magnetic fields.

Efflux pump gene expression study using RNA-seq in multidrug-resistant TB

BACKGROUND: The mechanism underlying kanamycin (KM) resistance in Mycobacterium tuberculosis is not well understood, although efflux pump proteins are thought to play a role. This study used RNA-seq data to investigate changes in the expression levels of efflux pump genes following exposure to KM.METHODS: RNA expression of efflux pump and regulatory genes following exposure to different concentrations of KM (minimum inhibitory concentration MIC 25 and MIC50) in rrs wild-type strain and rrs A1401G mutated strain were compared with the control group.RESULTS: The selected strains had differential RNA expression patterns. Among the 71 putative efflux pump and regulatory genes, 46 had significant fold changes, and 12 genes (Rv0842, Rv1146, Rv1258c, Rv1473, Rv1686c, Rv1687c, Rv1877, Rv2038c, Rv3065, Rv3197a, Rv3728 and Rv3789) that were overexpressed following exposure to KM were thought to contribute to drug resistance. Rv3197A (whiB7) showed a distinct fold change based on the concentration of KM.CONCLUSION: The significant changes in the expression of the efflux pump and regulatory genes following exposure to KM may provide insights into the identification of a new resistance mechanism.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with renal cell carcinoma

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of renal cell carcinoma was published in 2019 with an update planned for 2021. It was therefore decided by both the ESMO and the Singapore Society of Oncology (SSO) to convene a special, virtual guidelines meeting in May 2021 to adapt the ESMO 2019 guidelines to take into account the ethnic differences associated with the treatment of renal cell carcinomas in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with renal cell carcinoma representing the oncological societies of China (CSCO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence and was independent of the current treatment practices and drug access restrictions in the different Asian countries. The latter were discussed when appropriate.

Efficacy and safety of epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) monotherapy for advanced EGFR-mutated non-small cell lung cancer: systematic review and meta-analysis

OBJECTIVE

It is controversial whether there is efficacy or safety benefit of epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) in advanced EGFR-mutated non-small cell lung cancer (NSCLC) compared to standard chemotherapy. We aim to assess the efficacy and safety of EGFR-TKIs compared to other chemotherapeutics in EGFR-mutated NSCLC.

MATERIALS AND METHODS

Up to April 27th, 2020, PubMed, Embase, Medline, Scopus, Cochrane library, and ClinicalTrials.gov were searched for articles or trials meeting the inclusion criteria. After filtering, 230 eligible studies were initially identified. Data extraction followed PRISMA and included outcomes were progression-free survival (PFS), overall survival (OS), and severe adverse events (SAEs). Direct and indirect meta-analyses were generated in the context of log-linear mixed-effects models, with fixed effects for each relative comparison and random effects for each study.

RESULTS

The results showed that EGFR-TKI therapy had improved PFS with a hazard ratio (HR) of 0.40 (95% CI: 0.36-0.44, p<0.001) compared to standard chemotherapy. Nevertheless, the EGFR-TKIs showed no benefit on OS (HR: 0.96, 95% CI: 0.83-1.10, p=0.556). In the analysis of adverse events, EGFR-TKIs had fewer SAEs than standard chemotherapy (HR: 0.29, 95% CI: 0.26-0.33, p<0.001).

CONCLUSIONS

Our systemic review indicates that EGFR-TKI therapy has improved PFS, and reduced SAEs compared to standard chemotherapy in advanced EGFR-mutated NSCLC.

Risk of dementia according to smoking cessation after newly diagnosed atrial fibrillation: a nationwide cohort study

Background

Incident atrial fibrillation (AF) is associated with an increased risk of dementia. There are limited data about the impact of smoking cessation after AF diagnosis on the risk of incident dementia.

Purpose

To evaluate the association between changes in smoking status after newly diagnosed AF and the risk of dementia.

Methods

Among patients with new-onset AF between 2010 and 2016, those who received a national health checkup exam within 2 years before and after the AF diagnosis were included. Patients who had prevalent dementia were excluded. Subjects were categorized into 4 groups according to the status of smoking before and after AF diagnosis: (1) never smoker; (2) ex-smoker; (3) quit-smoker after AF diagnosis; and (4) current smoker. The primary outcome was incident dementia during follow-up.

Results

A total of 126,252 patients were included (mean age 63, SD 12.0; men 62%; mean CHA2DS2-VASc 2.7). During a median 3 years of follow-up, dementia occurred in 5,925 patients (1.11 per 1000 person-years [1000PY]) (Alzheimer's dementia 1.5 per 1000 PY and vascular dementia 0.24 per 1000 PY, respectively). Never smokers, ex-smokers, quit-smokers, and current smokers were 52%, 27%, 7%, and 14% of the total study population, respectively. After multivariable adjustment, quit-smokers showed a higher risk of dementia than never smokers (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.03–1.32), but the risk was significantly decreased when compared to current smokers (HR 0.83, 95% CI 0.72–0.95). Alzheimer's dementia and vascular dementia showed consistent results as main (Figure).

Conclusion

All types of smoking were associated with a significantly higher risk of dementia in patients with new-onset AF. Smoking cessation after AF diagnosis showed a lower risk of dementia compared to patients smoking persistently. These findings may support the promotion of smoking cessation to lower the risk of dementia in patients with new-onset AF.

Funding Acknowledgement

Type of funding sources: None.

Measuring the structure and equation of state of polyethylene terephthalate at megabar pressures

We present structure and equation of state (EOS) measurements of biaxially orientated polyethylene terephthalate (PET, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$({\hbox {C}}_{10} {\hbox {H}}_8 {\hbox {O}}_4)_n$$\end{document}(C10H8O4)n, also called mylar) shock-compressed to (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$155 \pm 20$$\end{document}155±20) GPa and (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$6000 \pm 1000$$\end{document}6000±1000) K using in situ X-ray diffraction, Doppler velocimetry, and optical pyrometry. Comparing to density functional theory molecular dynamics (DFT-MD) simulations, we find a highly correlated liquid at conditions differing from predictions by some equations of state tables, which underlines the influence of complex chemical interactions in this regime. EOS calculations from ab initio DFT-MD simulations and shock Hugoniot measurements of density, pressure and temperature confirm the discrepancy to these tables and present an experimentally benchmarked correction to the description of PET as an exemplary material to represent the mixture of light elements at planetary interior conditions.

Three-Dimensional Evaluation of the Depressor Anguli Oris and Depressor Labii Inferioris for Botulinum Toxin Injections

BACKGROUND

Botulinum toxin type A (BoNT-A) injection administered at an inappropriate site or depth can produce an unwanted change in facial animation because the depressor anguli oris (DAO) and depressor labii inferioris (DLI) muscles are partially overlapped. Therefore, simple BoNT-A injection guidelines, based on 3-dimensional (3D) facial anatomic references and landmarks, would be very useful.

OBJECTIVES

The aim of this study was to establish novel BoNT-A injection guidelines that include the soft tissue thickness at the lower perioral region. Data were acquired with a 3D scanning system combined with dissections in order to obtain accurate injection sites and depths for the DAO and DLI.

METHODS

3D scans of the facial skin, superficial fat, and facial muscle surface were performed in 45 embalmed cadavers. The thicknesses of the skin and subcutaneous layer were calculated automatically from superimposed images at each of 5 reference points (P) in the perioral region.

RESULTS

In every case (100%), P3 and P5 were located in the DLI and DAO areas, respectively (45/45). Therefore, we defined P3 as the "DLI point" and P5 as the "DAO point." The soft tissue thicknesses at the DLI and DAO points were 6.4 [1.7] mm and 6.7 [1.8] mm, respectively.

CONCLUSIONS

The P3 and P5 described in this study are effective guidelines that only target the DLI and DAO. Clinicians, specifically, can easily use facial landmarks, such as the cheilion and pupil, to assign the DLI and DAO points without any measurement or palpation of the modiolus.

Clinical anatomy considerations on the muscular and vascular components of the midface by ultrasonographic imaging

The first signs of face aging appear in the midface, so procedures such as botulinum toxin and filler injections are performed there. However, no guidelines based on clinical anatomy describing the muscular and vascular components in vivo have been published. The aim of this research was to describe the depths of the midface muscles and the locations of vessels using ultrasonographic (US) imaging. US was applied at 12 landmarks on the midface in 88 volunteers (49 males and 39 females; 19-36 years) to detect sex differences in the depths of muscles and the locations of the vessels. The depths of the orbicularis oculi (OOc), levator labii superioris alaeque nasi (LLSAN), and zygomaticus minor (Zmi) differed significantly with sex at P7 (p = 0.001) and P8 (p = 0.017), P1 (p = 0.028), and P4 (p = 0.035), respectively. The facial artery, facial vein, angular artery, angular vein, and perforator vessels were found at P9, P2 and P10, P1, P1 and P5, and P8, P11 and P12, respectively. The findings indicate that the depths of the OOc, LLSAN, and Zmi muscles differ between the sexes and that the vessels appear at specific landmarks. This information could help in developing anatomical guidelines for several procedures.

Application of Botulinum Neurotoxin Injections in TRAM Flap for Breast Reconstruction: Intramuscular Neural Arborization of the Rectus Abdominis Muscle

Breast reconstruction after mastectomy is commonly performed using transverse rectus abdominis myocutaneous (TRAM) flap. Previous studies have demonstrated that botulinum neurotoxin injections in TRAM flap surgeries lower the risk of necrosis and allow further expansion of arterial cross-sectional diameters. The study was designed to determine the ideal injection points for botulinum neurotoxin injection by exploring the arborization patterns of the intramuscular nerves of the rectus abdominis muscle. A modified Sihler's method was performed on 16 rectus abdominis muscle specimens. Arborization of the intramuscular nerves was determined based on the most prominent point of the xyphoid process to the pubic crest. All 16 rectus abdominis muscle specimens were divided into four muscle bellies by the tendinous portion. The arborized portions of the muscles were located on the 5-15%, 25-35%, 45-55%, and 70-80% sections of the 1st, 2nd, 3rd, and 4th muscle bellies, respectively. The tendinous portion was located at the 15-20%, 35-40%, 55-60%, and 90-100% sections. These results suggest that botulinum neurotoxin injections into the rectus abdominis muscles should be performed in specific sections.

Correlation analysis between lower limb muscle architectures and cycling power via ultrasonography

The primary purpose was to examine the relationship between the muscle architectural characteristics of short and long-distance cyclist—including muscle thickness, fascicle angle, and fascicle length—of the anterior thigh and posterior leg and its impact in 20-s cycling power. The secondary purpose was to clarify the muscle variables that predict the cycling power by using ultrasonography to measure the muscle architectural characteristics. Twenty-four varsity cyclists participated in this study, of whom 12 were short-distance cyclists and 12 were long-distance cyclists. B-mode ultrasonography was used to measure muscle architecture parameters. A cycle ergometer was used to measure the cycling power. The rectus femoris, vastus medialis, and medial head of gastrocnemius were significantly thicker in short-distance cyclists than in long-distance cyclists at every site (p < 0.05). Our analysis revealed that the rectus femoris fascicle length at the 30% level of the thigh was a significant independent predictor of the 20-s cycling power in short-distance cyclists, while the rectus femoris fascicle angle at the 50% level was that of the 20-s cycling power in long-distance cyclists. These findings highlight the significance of rectus femoris muscle architecture to cycling power.

Ultrasonographic Considerations for Safe and Efficient Botulinum Neurotoxin Injection in Masseteric Hypertrophy

There are still concerns about masseteric bulging due to a lack of knowledge about the internal architecture of the masseter muscle. Further investigations are therefore required of the most-effective botulinum neurotoxin (BoNT) injection points and strategies for managing masseteric bulging. The purpose of this study was to identify safer and more effective botulinum neurotoxin injection points and strategies by using ultrasonography to determine the structural patterns of the deep inferior tendon. We also measured the precise depths and locations of the deep inferior tendon of the masseter muscle. Thirty-two healthy volunteers participated in this study, and ultrasonography was used to scan the masseter muscle both longitudinally and transversely. Three structural patterns of the deep inferior tendon were identified: in type A, the deep inferior tendon covered the anterior two-thirds of the masseter muscle (21.8%); in type B, the deep inferior tendon covered the posterior two-thirds of the masseter muscle (9.4%); and in type C, the deep inferior tendon covered most of the inferior part of the masseter muscle (68.8%). Depending on the ultrasonography scanning site, the depth from the skin surface to the mandible in the masseteric region ranged from 15 to 25 mm. The deep inferior tendon was typically located 2 to 5 mm deep from the mandible. Ultrasonography can be used to observe the internal structure of the masseter muscle including the deep inferior tendon in individual patients. This will help to reduce the side effects of masseteric bulging when applying retrograde or dual-plane injection methods depending on the structural pattern of the deep inferior tendon.

2D monochromatic x-ray imaging for beam monitoring of an x-ray free electron laser and a high-power femtosecond laser

In pump-probe experiments with an X-ray Free Electron Laser (XFEL) and a high-power optical laser, spatial overlap of the two beams must be ensured to probe a pumped area with the x-ray beam. A beam monitoring diagnostic is particularly important in short-pulse laser experiments where a tightly focused beam is required to achieve a relativistic laser intensity for generation of energetic particles. Here, we report the demonstration of on-shot beam pointing measurements of an XFEL and a terawatt class femtosecond laser using 2D monochromatic Kα imaging at the Matter in Extreme Conditions end-station of the Linac Coherent Light Source. A thin solid titanium foil was irradiated by a 25-TW laser for fast electron isochoric heating, while a 7.0 keV XFEL beam was used to probe the laser-heated region. Using a spherical crystal imager (SCI), the beam overlap was examined by measuring 4.51 keV Kα x rays produced by laser-accelerated fast electrons and the x-ray beam. Measurements were made for XFEL-only at various focus lens positions, laser-only, and two-beam shots. Successful beam overlapping was observed on ∼58% of all two-beam shots for 10 μm thick samples. It is found that large spatial offsets of laser-induced Kα spots are attributed to imprecise target positioning rather than shot-to-shot laser pointing variations. By applying the Kα measurements to x-ray Thomson scattering measurements, we found an optimum x-ray beam spot size that maximizes scattering signals. Monochromatic x-ray imaging with the SCI could be used as an on-shot beam pointing monitor for XFEL-laser or multiple short-pulse laser experiments.