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Medical Terminology Daily (MTD) is a blog sponsored by Clinical Anatomy Associates, Inc. as a service to the medical community, medical students, and the medical industry. We will post a workweek daily medical or surgical term, its meaning and usage, as well as biographical notes on anatomists, surgeons, and researchers through the ages. Be warned that some of the images used depict human anatomical specimens.

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A Moment in History

Giovanni Batista Morgagni
Original image courtesy of National Institutes of Health

Giovanni Battista Morgagni

(1682 - 1771)

Italian anatomist, physician, and pathologist, Morgagni was born in the city of Forli. He started his medical studies at the University of Bologna, graduating in 1701 with a degree in Medicine and Philosophy. In 1712 he became a professor of anatomy at the University of Padua, Italy, 175 years after Andreas Vesalius. Morgagni was offered and accepted the Chair of Anatomy in 1715 at the University of Padua. Although Morgagni held a position at the anatomy department of the University of Padua, his name is associated mostly with his pathological studies.

Morgagni was interested in the works of Theophile Boneti (1620 - 1689), who started analyzing the correlation between post-mortem anatomical findings and diseases. He tried to establish a relation between the disease and the cause of death. In 1761 Morgagni published his most influential work "De Sedibus et Causis Morburum Per Anatomen Indagatis"  (On the Sites and Causes of Diseases, Investigated by Dissection). His work was essential for pathological anatomy to be recognized as a science in itself.

Morgagni was elected to become a member of several Academies of Science and Surgery: The Royal Society of London, The Academy of Science in Paris, The Berlin Academy of Science, and the Imperial Academy of Saint Petersburg in Russia. He is remembered today by several eponyms in anatomy and pathology:

• Morgagni's caruncle or lobe, referring to the miidle lobe of the prostate
• Morgagni's columns: the anal (or anorectal) colums
• Morgagni's concha, referring to the superior nasal concha
• Morgagni's foramina: two hiatuses in the respiratory diaphragm allowing for passage of the superior epigastric vessels
 Morgagni's hernia: an hiatal hernia through Morgagni's foramen, in the respiratory diaphragm
• Morgagni's ventricle: an internal pouch or dilation between the true and false vocal cords in the larynx
• Morgagni's nodules: the nodules at the point of coaptation of the leaflets (cusps) of the pulmonary valve. Erroneously called the "nodules of Arantius", which are only found in the aortic valve

Sources:
1. "A Note From History:The First Printed Case Reports of Cancer" Hadju, S.I. Cancer 2010;116:2493–8
2. "Giovanni Battista Morgagni" Klotz, O. Can Med Assoc J 1932 27:3 298-303
3. "Morgagni (1682 -1771)" JAMA 1964 187:12 948-950

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Esophageal hiatus

UPDATED: The esophageal hiatus is one of the seven hiatuses found in the respiratory diaphragm allowing passage of structures between the thorax and abdomen. As it name implies, the esophageal hiatus is the passageway for the esophagus. It also allows passage of the anterior and posterior vagus nerves, (CN X).

The hiatus is bound by two muscular crura, both of which arise from the right tendinous aortic crus. Since the intraabdominal pressure is higher than the intrathoracic pressure, there is a series of structures at the phrenoesophagogastric junction to close the esophageal hiatus.

The infradiaphragmatic parietal peritoneum reflects off the diaphragm towards the stomach to form its serosa layer (visceral peritoneum). At the same time the infradiaphragmatic fascia, also known as the  endoabdominopelvic fascia, splits into two components or limbs. These are the superior and inferior phrenoesophageal ligaments or phrenoesophageal membranes. (the root [-phren-] means "diaphragm"). These phrenoesophageal ligaments create a disc-like plug between the abdomen and the thorax. This "plug" is reinforced by a circular infradiaphragmatic fat pad. The phrenoesophageal ligaments are reinforced on their thoracic aspect by the endothoracic fascia.

Esophageal hiatus

Images property of: CAA.Inc. Artist: Dr. E. Miranda

The lower esophagus has a dilation (evident in the image) called the "esophageal ampulla", in relation to this dilation the circular muscle layer of the esophagus slightly thickens creating the so-called "lower esophageal sphincter". This area is not a true anatomical sphincter, but rather is a functional sphincter. 

The esophagogastric mucosal junction shows a marked transition in the shape of a wavy line. This is called the Z-line or the ora serrata. Extensions of the gastric mucosa and submucosa inferior to the ora serrata create a valve-like flap called the "gastroesophageal flap valve". When viewing this mucosal flap through and endoscope, it looks corrugated and flower-like, hence it is also called the "rosette". 

The congenital or pathological dilation of the esophageal hiatus can predispose to esophageal hiatus hernia.


Acetabulum

The word acetabulum is formed by the combination of the Latin root [acetum], meaning "vinegar", and the Latin suffix [-abulum] a diminutive of [abrum], meaning a "cup", "holder", or "receptacle". Thus formed, the word acetabulum means "a small vinegar cup".

Roman soldiers liked to drink their water mixed with a small quantity of vinegar, so as to reduce the sensation of thirst. This mix was called "Posca". An acetabulum was used to add specific quantities of vinegar to the water, so over time the acetabula (plural form of acetabulum) were considered measuring devices. It is said that they measured one cup, or 2 1/2 oz. of wine.

The anatomical acetabula are bilateral cup-like depressions in the os coxae which serve as a component of the coxofemoral joint (hip joint). They are found at the intersection of the three bony components of the os coxae, the ilium, ischium, and pubic bone and look anteroinferiorly.

Acetabulum
Image property of: CAA.Inc. 
Photographer:
David M. Klein
The acetabulum has several components:

• Acetabular margin: An incomplete circular bony edge or border that marks the edge of the acetabulum

• Acetabular notch: The area where the acetabular margin is incomplete

• Acetabular labrum: Labrum (Lat. :lip). The acetabular labrum is a complete circular ring of fibrocartilage found on the acetabular margin that helps maintain the head of the femur in place. It is not shown in the accompanying image

• Lunate surface: A smooth, half-moon shaped area on the floor of the acetabulum. It is covered with hyaline cartilage and allows for articulation with the head of the femur

• Acetabular fossa: The non-articular region of the floor of the acetabulum. It contains fat, vessels, and the ligament of the head of the femur

Interesting fact:  You may find that in older English anatomy books the acetabulum is referred to as the cotyloid cavity. The word cotyloid arises from the Greek [κοτυλοειδές] and means "similar to a cup". This separation in terms still exists when studying anatomy in other languages. For example, in Spanish the acetabulum is called "cavidad cotiloídea" or "cotilo", and in French it is called "cavité cotyloïde" or "cotyle". I guess the Greek soldiers did not drink vinegar with their water...


Sternal angle (of Louis)

UPDATED:The sternal angle is the term used to denote the angulation at the  joint between the manubrium and the body of the sternum. This transverse joint is called the "manubriosternal joint" and is a secondary cartilaginous joint of a type known as a symphysis. The angle varies between 160 and 169 degrees.

It is know eponymously as the "angle of Louis" named after Antoine Louis1 (1723-1792), a French physician. The importance of the sternal angle is that of an anatomical superficial landmark, which forms a horizontal plane which indicates a series of anatomical occurrences, as follows:

• Location of the cartilages of the second rib
• Beginning and end of the aortic arch
• Boundary between the inferior and superior mediastinum
• Location of the bifurcation of the trachea
• Posteriorly, the plane of the sternal angle passes trough the T4-T5 intervertebral disc
• Highest point of the pericardial sac, etc.

Sternal angle - Angle of Luis

Click on the image for a larger version.

Thoracic anatomy, pathology and surgery, are some of the many lecture topics developed and presented by Clinical Anatomy Associates, Inc.

1. Some authors contest the eponym, adjudicating it to Pierre Charles Alexander Louis (1787-1872), another French physician.
Image property of: CAA.Inc.. Artist: David M. Klein

In Search of Andreas Vesalius The Quest for the Grave, Lost and not yet found

My partner in crime and fellow traveler, Theo Dirix, has just published a new account of our common quest for the lost grave of Andreas Vesalius. Until the scientific results of our latest mission in Zakynthos in September 2017, will become public, this collection of articles published since 2014 represents a detailed and complete status quaestionis of a search that will never be the same anymore.


I'm proud and grateful to be part of a team he describes a most tenacious.

Following is a remarkable quote from the book: "The beast you have in your hands may appear as aged and stubborn: indeed, the texts collected here are not new and they regularly echo each other. The beast barks and growls: these words do not intend to examine or research but were meant to sell a project to potential sponsors. I feel the taste of the creature’s spit in my face, but pleading not guilty to any accusation of self-glorification, I do hope I managed to teach it a few tricks you will enjoy. While continuing to write about Vesalius’s death and his grave, black dogs may still be scratching at my hermitage. When I will finally throw open the doors to the beauty beyond, here’s hoping the encounter with the female spider will taste as fresh as a first kiss and be the beginning of something else."

No surprise some have described the book as: "a truly captivating story (a Live Adventure!) written in a fascinating, passionate and inspiring way. Theo Dirix, with his unique style is describing facts from his adventure to locate the grave of Vesalius and he is mentioning with great respect all his collaborators, the friends of Vesalius and those who share the same passion for Anatomy and Art." (Vasia Hatzi on Med in Art).

Cover of the book by Theo Dirix
Cover of the book by Theo Dirix.
Click on the image for a larger depiction

The book can be ordered here: https://www.shopmybooks.com/US/en/book/theo-dirix-32/in-search-of-andreas-vesalius. (English version of the website). More information about the author on his website www.theodirix.com. or here.


Personal note: Thanks to Pascale Pollier, a contributor to this website, for allowing us to publish this article, originally published on Vesalius Continuum.

I received a personalized copy from the author, Theo Dirix; Thank you very much for the recognition and the use of this website as reference in some of your comments. It is a great read for anyone even mildly interested in the life and specially the death and disappearance of the grave of Andreas Vesalius. There are several passages in the book that I will have to research and transform in articles for this blog.

For those who collaborated in the GoFundMe campaign because or our article entitled Do you want your name in a book? The Quest for the Lost Grave.... this is the book and the name of all the contributors are listed in it! 

The quest continues... Dr. Miranda


Coumadin ridge

The [Coumadin ridge], also known as the [Warfarin ridge], or a [left atrial pseudotumor]. is an excessive elevation or protrusion of a normal ridge found between the left superior pulmonary vein and the internal ostium of the left atrial appendage. Usually this ridge will extend inferiorly towards and anterior to the ostium of the left inferior pulmonary vein. The Coumadin ridge is considered an anatomical variation of the otherwise small ridge, which is nameless.

Because of its location and morphology, some cardiologists and radiologists have mistaken this elevation or fold of the internal anatomy of the left atrium for a thrombus and prescribed anticoagulant therapy (Coumadin or Warfarin) when none was needed, hence its name.

Pes anserinus. Image courtesy of Primal Pictures
Click on the image for a larger version
To understand the generation of the Coumadin ridge we must understand the embryology of this area of the heart. The left atrial appendage is the original left atrium in the embryo, which is displaced anteriorly and superolaterally when the veins that enter the atrium start to dilate at their distal end creating the left sinus venarum. After the left atrium proper has formed, the left atrial appendage is left as nothing more than an embryological remnant that can cause problems if the patient has atrial fibrillation (AFib). The ridge forms at the point where the left atrial appendage and the sinus venarum meet.

The Coumadin ridge can vary in morphology, from presenting as an elevated ridge, to a bulbous, pedunculated mass that seems to float within the left atrial appendage and undulate, following the cardiac motion, forcing the cardiologist into believing they are in the presence of a thrombus or a tumor within the heart.

This fold of tissue may contain the ligament of Marshall, autonomic nerves, and a small artery. In rare cases there may be an actual tumor arising from the location of the Coumadin ridge, but this is just a coincidence.

Now that the Coumadin ridge is a better known anatomical variation, cardiologist sometimes refer to their finding as a pseudotumor, a description that may scare the patient, but is only but a fold of tissue inside the heart.

Finding a Coumadin ridge in a patient with atrial fibrillation can be an interesting situation requiring differential diagnosis, as a patient with AFib can present with thrombi in the left atrial appendage. What to do? Is it or is it not a thrombus? Also, a differential diagnosis is needed in the case where the image is actually that of a left atrial tumor or an atrial myxoma.

The accompanying image an own work based on Sra (2004) and McKay (2008), and is a graphite on paper sketch. The image shown an internal view of the left atrium showing the left superior and inferior pulmonary vein, the ostium of the left atrial appendage and a segment of the area of the mitral valve.

We would like to thank Dr. Randall K Wolf, a contributor to Medical Terminology Daily for suggesting this article.

Sources:
1. “Coumadin ridge: An incidental finding of a left atrial pseudotumor on transthoracic echocardiography” Lohdi,AM, et al. World J Clin Cases. 2015 Sep 16; 3(9): 831–834
2. “Coumadin ridge” Tasco, V. https://radiopaedia.org/articles/coumadin-ridge
3. “Papillary fibroelastoma arising from the coumadin ridge” Malik, M, Shilo, K, Kilic,A. J Cardiovasc Thorac Res. 2017;9(2):118-120.
4. “‘Coumadin ridge’ in the left atrium demonstrated on three dimensional transthoracic echocardiography” McKay,T., Thomas, L. Europ J Echocard (2008) 9, 298–300
5. “Endocardial imaging of the left atrium in patients with atrial fibrillation” Sra J; Krum D; Okerlund D; Thompson H. J Cardiovasc Electrophysiol 2004 Feb; Vol. 15 (2), pp. 247


HOUSTON AFib PATIENT EXPERIENCE SEMINAR


If you arrived to this article looking for information on Atrial Fibrillation, you will find some in this article. If you need to contact Dr. Wolf, please click here.


HOUSTON AFib PATIENT EXPERIENCE SEMINAR

Saturday, April 21st, 2018 9am – 4pm
Westin at Memorial City, 945 Gesner Rd.
Houston, TX 77024
877-900-AFIB (2342)

This seminar is free and open to the public. To attend, please call the telephone number to register.

WELCOME MESSAGE FROM DR. RANDALL WOLF

In my experience over the last 18 years as a physician who specializes in the treatment of Atrial fibrillation (AFib), I have learned AFib sufferers want two things: Hope and a chance to feel better.

The first step to hope and to feeling better is to self educate. Learn about the latest medications, techniques and devices to treat AFib. Ask questions. Get a second opinion. Take charge of your health.

The purpose of the Houston AFib Patient Experience Seminar is to help AFib sufferers like you take charge of your health.

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About 30 million people worldwide carry an AFib diagnosis. Today seems everyone either has AFib or knows someone that has AFib. When I first held an Afib seminar in Beijing, China, over 1200 people with AFib signed up for the seminar. It was standing room only!

Despite the common occurrence of AFib around the world, a recent study found that in patients who were diagnosed with AFib, 40-50% of patients with an elevated risk of stroke were not treated with the best therapy, and the rate of stroke over the next five years was 10%.

Here in Houston, we can do better! Learn more about AFib right here today, and I guarantee you will have hope and be more likely to reach your goal of feeling better.

Towards an AFib free healthy life,

Randall K. Wolf, MD.


SEMINAR AGENDA

9:00 am     Introductions -  Randall Wolf, MD, FACS, FACC, Professor at McGovern Medical School, Cardiothoracic Surgery, Course Director for the AFib Patient Experience Seminar

9:15 am      The cost of AFib

9:30 am     Mechanisms

9:45 am     Blood Thinners – W. Ross Brown, MD, FACC, Comprehensive Heart Care, PA

10:15 am   Medications – Sunil Reddy, MD, Assistant Professor at McGovern Medical School, Cardiovascular Medicine

10:30 am   BREAK

10:45 am   Diet – Baxter Montgomery, MD, FACC, Clinical Assistant Professor of Medicine, McGovern Medical School, Department of Cardiology

11:00 am   Sleep Apnea – Murtuza Ahmed, MD, FAASM, Razzack and Associates, Houston

11:15 am   AF Monitoring – Sunil Reddy, MD, Assistant Professor at McGovern Medical School, Cardiovascular Medicine

11:30 am   Questions with panel

12 noon      LUNCH

Testimonials: Donna Roth, Houston, TX Gary Wight, Houston, TX Mac Peirson, Houston, TX Ross Wroblewski, Lompac, CA Michaela Senk-Eustace, Hartford, CT

1:00 pm     Catheter Ablation – Siddharth S. Mukerji, MD, Assistant Professor at McGovern Medical School, Cardiovascular Medicine

1:30 pm     Surgery – Randall Wolf, MD, FACS, FACC

2:00 pm     Stop AFib.org – Mellanie True Hills, President

2:30 pm     Panel Discussion

2:45 pm     Stroke – Ritvij Bowry, MD, Assistant Professor at McGovern Medical School, Vivian L. Smith Department of Neurosurgery

3:00 pm     LAA Closure – Siddharth S. Mukerji, MD, Assistant Professor at McGovern Medical School, Cardiovascular Medicine & Randall Wolf, MD, FACS, FACC

3:30 pm     Panel Discussion

4:00 pm     Adjourn – Meet with Faculty


ABOUT THE HOUSTON AFIB PATIENT EXPERIENCE SEMINAR

The University of Texas McGovern Medical School, Cardiothoracic and Vascular Surgery Department in Houston, is proud to host the inaugural Houston AFIB Patient Experience Seminar. The purpose is to educate the public in an interactive format allowing the audience to engage in conversation in a question/answer format with leading medical professionals. Our list of panel members and guest presentations include surgeons, cardiologists, neurologists, pulmonologists as well as testimonials from AFib patients. We are honored to be able to bring awareness to the resources and options available to patients suffering from AFIB.

NOTE: If you cannot attend the seminar, there is more information on Atrial Fibrillation at this website; click here.