Indian Journal of Clinical Anatomy and Physiology

130-132

Authors: Jyothi SR, Dakshayani KR.

Objectives: An intimate knowledge of the anatomy of coronary ostia does a self-evident pre-requisite for complete understanding of coronary artery diseases and for more intelligent planning of surgery. The present study is undertaken 1. To measure the diameters of coronary ostia and the diameters of roots of coronary arteries. 2. To note for accessory ostia Materials and Method: 49 human hearts fixed with 10% formalin were collected from Department of Anatomy and Forensic Medicine, Mysore Medical College and Research Institute, Mysore. Ethical clearance has been taken for the above. Morphometric study of coronary ostia was performed using Vernier callipers. Data obtained was statistically analysed. Results: It was observed that the mean diameter of left coronary ostia was greater than right coronary ostia which were statistically significant. A statistically significant decrease in diameter from coronary ostia to the roots of coronary arteries was observed. Multiple coronary orifices were common in anterior aortic sinus. Conclusion: The knowledge of coronary ostia becomes important to cardiac surgeons for selective intubation.

136-143

Authors: Kasat PA, Shyamkishore K, Bhuiyan PS, Bhosale YJ.

Introduction: The clinicians need to be aware of various anatomical features in the mandible to avoid confusion in the variants of anatomical features with pathology. This would also help the clinicians to avoid difficulties and complications during their surgical work. Method: Hundred dry adult human mandibles were examined for the number of retromolar foramina and fossae, condylar defects, accessory mandibular foramen, deep mylohyoid grooves, torus mandibularis, wide and shallow mandibular notch and additional sockets for teeth. Results: Retromolar foramen was found in 12 right sides and 7 left sides. Retromolar fossae were found bilaterally in 5 mandibles. Condylar defects were observed in three mandibles. Accessory mandibular foramen was found in three right and two left sides. Deep mylohyoid groove was observed in three mandibles. Torus mandibularis was observed in one of them. The curved length of the mandibular notch ranged from 30–54mm with a mean of 39.0±4.57mm on the right side and on the left side ranged from 31–56mm with a mean of 39.6±4.12mm. The anteroposterior length of the mandibular ramus ranged from 25–50mm with a mean of 37.8±3.83mm on the right side and on the left side ranged from 28–48mm with a mean of 38.4±3.84mm. The mandibular notch was found to be wide and shallow in four mandibles. An additional socket of teeth was noted unilaterally in two mandibles. Conclusions: The morphologic variations of the dry adult mandible are clinically important for dental surgeons, head & neck oncosurgeons and anesthetists.

148-151

Authors: Debasis Bandopadhyay, Sushil Kumar.

Introduction: Chromosomal anomalies that change developmental gene expression are the most common cause of mental retardation. Roughly about 10% of all mental retardation cases suffer from chromosomal abnormalities. Sub-telomeric regions of chromosomes are gene-rich regions where rearrangements and deletions can cause mental retardation which accounts for nearly 2.5% of mental retardation cases, with or without dysmorphic features. Our study focuses on mental retardation likely to be due to chromosomal aneuploidies and large structural defects. These cases were detected using conventional cytogenetic technique by peripheral blood karyotype. A total of 30 cases of mental retardation as per exclusion/inclusion criteria were referred for genetic analysis to Cytogenetic lab, Dept of Anatomy, from May 2013 to Apr 2016. A peripheral blood karyotype was carried out in all patients. Materials and Method: 5ml of venous blood was cultured for leucocytes and subsequently karyotyped using standard protocol of Trypsin Giemsa banding. The slides were visualised for metaphase spread under oil immersion and 20 cells were captured in every case for analysis using Cytovision software. Results: Cytogenetic analysis of peripheral blood of 30 cases of mental retardation revealed 02 Down Syndrome pure cell line, 02 Down syndrome mosaic males, 01 Down syndrome female with 14/21 translocation, 01 Fragile X Syndrome male and 24 cases with normal karyotype. Discussion & Conclusion: In our study only 06 out of 30 cases of mental retardation showed chromosomal anomaly analysed by peripheral blood karyotype. Previous data has concluded that genetically determined mental retardation aetiology is found in less than half the number of cases. Chromosomal aberrations, single-gene disorders, and other genetic conditions account for 17 to 41% of genetic cases of MR, even with newer techniques of genetic analysis. Karyotype is gold standard investigation for aneuploidies and large structural defects however small deletions and alterations on chromosome are often missed in conventional cytogenetic procedures. Hence it is suggested that newer molecular cytogenetic techniques like Microarray and purely molecular techniques like Polymerase Chain Reaction (PCR) be used to diagnose submicroscopic aberrations which account for majority of aetiologically undiagnosed cases of mental retardation.

156-159

Authors: Haleemath Soudhabi KS, Bhima Bhat, Sayed Anees, Shobith Bangera.

Introduction: Children of orphanages are more prone to malnutrition compared to children staying at home with their parents. Four out of ten malnourished children in the world live in India. Malnutrition and anemia are the most widespread nutrition related public health problems in developing countries, yet only little data is available on its prevalence in children of orphanages. Objectives 1. To assess nutritional status among children of an orphanage by anthropometry 2. To diagnose signs of nutritional deficiency among the study group by clinical assessment. Materials and Method: This cross sectional study was conducted in an orphanage in Kasaragod. Data was collected from 100 students of the age group 5 to16 years. Weight and height was measured. BMI was calculated. Nutritional status was assessed and categorized using BMI chart. Nutritional deficiency assessment was done by clinical examination of hair, nail, oral cavity and skin. Results: The data was analyzed using appropriate method. It was found that 23% of students were in underweight category (<5th percentile). 95% of students had nutritional deficiency, among those 60% had pallor 34% had nail changes (platynychia and koilonychia) and 31% had angular stomatitis suggestive of iron deficiency anemia. Conclusion: In this study we observed that children residing in orphanage were having healthy weight but nutritional deficiency signs were present. The findings highlight the need for health education regarding balanced diet and more attention may be required from medical practitioners.

163-168

Authors: Satya N. Shukla, SB Ray.

Introduction: Protein synthesis in cells is regulated by transcriptional activator proteins like cAMP response element binding(CREB) protein, which binds to the DNA molecule near the start of the target gene sequence. This results in the activation of promoter region of DNA by RNA polymerase and the beginning of transcription. Phosphorylation of CREB(p-CREB) greatly increases the transcriptional process. In the present work, the expression of CREB and p-CREB were examined in the spinal cord after morphine tolerance. The underlying cellular basis of morphine tolerance is presently unknown. Presumably increased synthesis of CREB and its phosphorylation to p-CREB might be responsible for tolerance as these have been shown to mediate long lasting changes in brain function. Aims & Objective: 1. To study the alteration in the expression of c-AMP response element-binding (CREB) protein and its phosphorylated form (p-CREB) after chronic morphine administration 2. Immunohistochemical localization of cyclic-AMP response element-binding(CREB) protein expression and it phosphorylated form p-CREBin dorsal horn of thecervical segmentof rat spinal cord 3. Quantitation of expression of CREB and p-CREB with the help of Image Pro Plus 6 Analysis System. Materials and Method: Adult male Wistar rats were divided to in two groups (n=6/Group) and administered the following: Normal Saline (Group-I), & Morphine (Group-II), for 14 days. Development of Morphine tolerance was determined by the tail-flick test. Expression of CREB and p-CREB was observed by immunohistochemistry using specific antibodies to these proteins. Visualization was done by ABC method. The immuno histochemical staining was quantitatively expressed by measuring the Integrated optical density (IOD) of immunostaining with the help of Image Analysis System driven by Image Pro-plus 6.2 software. Result and Conclusion: Morphine administration showed increased expression of CREB and p-CREB in dorsal horn of spinal cord. The result of this study demonstrates that CREB and p-CREB may have an important role in the development of morphine tolerance.

173-176

Authors: Arshiya Zeba, Khwaja Nawazuddin Sarwari.

Learning is acquisition of information and memory is retention and storage of information. The process of learning is most essential to become academically more effective and memory status plays an important role. Thepresent study is aimed to establish that different memory improvement techniques can help to enhance and retain a particular object for longer time and also to see its influence on gender. Materials and Method: Two hundred young healthy medical males and females of age group 18-25 years were randomly selected for this study (100 males and 100 females). Short term status by visual tasks before and after application of memory improvement methods by using words and objects were analyzed. Student’s paired ‘t’ test was used to analyze the memory status before and application of memory improvement methods. ‘Z’ test was used to compare the memory status between the various tests. Results: There was statistically significant decrease in short term memory status in higher trials of test. Short term memory status for object test was significantly greater than word test. Statistically significant gender difference was observed in object test in which female showed better short term memory. There was statistically significant improvement in memory status after application of memory improvement methods in all subjects and more so in females. Interpretation and Conclusion: progressive decrease in memory status in higher trials of word test is due to increase in number of bits or items more than seven as an individual can hold 7+2 bits of information. Short term memory status for object test was significantly better than word test which may be due to good sight, one’s relation with the world around. Females showed a significantly better object memory due to better attention, involvement in task and concentration.

181-184

Authors: Pabbati Raji Reddy.

Introduction: Congenital abnormalities of the kidneys and urinary tract play a major role in the morbidity and mortality. Many of these renal anomalies predispose to obstruction which lay lead to renal failure. We had in our study observed the different malformations in human kidneys among the adults human cadavers. Materials and Method: 50 cadavers who died of renal failure and were scheduled for post mortem were included in the study. The position of the suprarenal gland and the upper poles of the kidneys, the size, shape and the kidneys, the arrangement of the attached structures such as the hilum, ureter, bladder abdominal aorta and the inferior vena cava were noted and recorded. Results: Out of the 50 cadavers that were included into the study, 5 of them had congenital renal anomaly accounting for 10% of the deaths due to renal failure in adults. All the patients were between 40–60 years of age. There were two cases of lobulated kidney, one horse – shoe shaped kidney, one case of congenital hypoplasia and one 7 shaped left kidney. Conclusion: Renal anomalies are one of the common congenital anomalies which may remain unnoticed till adulthood. Of them, renal agenesis, horseshoe kidneys, renal hypoplasia and lobulated kidneys are relatively predominant.

190-191

Authors: R. Niruba, KC Subha, A. Vijayalakshmi.

Introduction: Diabetes has become a worldwide epidemic and need to reduce the morbidity due to this disease has become the need of hour. India ranks first in diabetic population and diabetic retinopathy affects third of all diabetic patients and its prevalence increases with the duration of diabetes both in urban and rural areas.(1,2) So we aimed to correlate Critical flicker fusion frequency (CFF) and HbA1C among the type 2 diabetic subjects. Noninvasive simple method of assessing retinal function was applied. Study Design: Cross sectional observational study. Materials and Method: Subjects n= 50 males, Age group 40-50 years. All participants had a sedentary life style, Blood pressure and HbA1C were measured. Subjects with history of epilepsy, neurological diseases, peripheral vascular disease, alcoholics, smokers and any other illness or medications that affects CFF were excluded. CFF was measured using in house built LED based CFF M1model instrument. Results: Mean age = 46 ±82 years, Mean SBP = 117± 15mmHg, Mean CFF = 35 ± 3Hertzs, Mean HbA1C = 6.6 ±.3%. Pearson correlation was applied. CFF correlated negatively with HbA1C with r value of -0.499. Conclusion: We conclude that increased blood glucose affects the retinal functions and decreases the critical flicker fusion frequency indicating the failure of retina to differentiate the flicker in higher frequencies.

196-201

Authors: Satish S. Patil, Roopa S. Mathapathi.

Introduction: Students’ perception of their educational environment has shown to have an impact on their academics as well as on their behaviour. Also there is a need to evaluate the perceptions of the medical educational environment as part of any assessment of quality standards for education. The study was undertaken to assess the perceptions of medical education environment among first year medical students, so as to improve the quality of medical education. Materials and Method: Study conducted in the Department of Physiology, in a private medical college in Kalaburagi. First year students of MBBS 2015-2016 batch were included in the study. The Dundee Ready Education Environment Measure (DREEM) questionnaire was administered to the students after they were briefed about the purpose of the study and about the questionnaire in detail. DREEM questionnaire consists of 50 statements concerning a range of topics relevant to the educational environment. The students were asked to respond to each statement using a 5 point Likert scale. Results: The results obtained under various domains of DREEM subscale scores are as follows: Students Perception of Learning (SPoL): A more positive approach (mean score 29.91). Students Perception of Teachers (SPoT): Model teachers (mean score 27.07).Students Academic Self-Perception (SASP): Feeling more on positive side (mean score 21.12). Students Perception of Atmosphere (SPoA): A more positive environment (mean score 28.37). Students Social Self-Perception (SASP): Not too bad (mean score 17.12). Conclusion: The study showed that first-year MBBSstudents positively perceived their learning environment. This study also provides guidelines for further improvement of educational environment.

208-211

Authors: Sarita Kumari, Padamjeet Panchal, Bheem Prasad.

Introduction: The gestational age estimation is an essential part of the care and management of pregnant women. A number of methods have been used for fetal dating and ultrasonography have become as an integral part of Obstetrics. Objective of this study is to determine whether Ultrasonography (USG) based Expected date of delivery (EDD) is better or Last menstrual period (LMP) based EDD. Materials and Method: This study was done on randomly selected 50 pregnant women. Cases were selected from those attending antenatal clinic, labour room, Indoor and outdoor of the Department of Obstetrics and Gynaecology, at medical college and hospital Kolkata. The parameters like Crown-Rump Length (CRL), Bi-parietal Diameter (BPD), and Femur Length (FL) were used to determine Gestational Age (GA) during 1st, 2nd and 3rd trimester with help of USG. Result: The CRL was better parameter to determine GA in first trimester and BPD and FL was better parameters to determine GA in second and third trimester for gestational age estimation. The CRL, BPD and FL parameters together give the best assessment of GA in Uterus. Conclusion: USG is a better diagnostic tool for estimation of EDD than the LMP method.

222-224

Authors: Vinay G, Mangala Gowri SR.

Introduction: The nutrient artery which enters the nutrient canal obliquely would provide the vascular supply. The nutrient foramen can be seen as a well-marked groove, which shows raised edges at the starting of the canal. The knowledge about the nutrient foramen is enlightening to the orthopedician during the procedures like bone grafting and internal fixation. Aims and Objectives: To determine the topography, direction and number of the nutrient foramina in lower limb long bones and to check if the nutrient foramen follow the general rule, the foramen is directed away from the growing end of the bone. To determine the foramen index of lower limb long bones from South Indian population. Materials and Method: We studied the topography, direction and location of nutrient foramina in shafts of 260 lower limb adult dried long bones, which were collected from the osteology collection of the department of Anatomy, Mahatma Gandhi Medical College, Pondicherry and Sri Sathya Sai Medical College, Kancheepuram. Results: It was observed that the most of the bones exhibited solitary nutrient foramen. The topography of nutrient foramen was mainly observed over the posterior surface. The mean foramen index of femur was 46.49, tibia was 34.82 and fibula was 49.58. Conclusion: The present investigation provided the details about the data about morphology of nutrient foramen in lower limb long bones of South Indian population. It was observed that the double nutrient foramen were commonly seen in femur and were rare in the tibia and fibula bones. The morphological information about the nutrient foramen may assist in some operative procedures and bone grafting.

227-230

Authors: Umamaheswari Kannan, Anitha Achuthan.

Introduction: Obesity and anemia are considered as the double burden of malnutrition. Significant changes in life style, stressful working conditions, consumption of quick preserved foods, snacks and soft drinks of low nutritional value, has led to the increasing trend of obesity and nutritional disorders including anemia even among the literate affluent young adults. We aimed at finding the correlation of anemia and BMI among young adults. Materials and Method: 310 healthy medical students in the age group of 19-25 years volunteered to participate in the study. Height, weight, hip circumference, waist circumference were measured and hemoglobin estimation done according to standard protocol. BMI and Waist hip ratio were calculated. Results: A total of 310 students in the age group of 19-25 years were included in the study. 136 (44%) were males and 174 (56%) were females. 66 (21.29%) students were anemic. Of the anemic students 54 (81.8%) females and 12 (18.8%) males had anemia based on WHO criteria. Under nutrition was identified among 6 (3.5%) females, and 3 (2.2%) males. The number of Overweight/ Obese females were 49 (28.2%) and males 42(30.9%) respectively. Those with adequate nutritional status were 119 (68.4%) females and 91 (66.9%) males. There was a positive correlation in the group with BMI <18.5 kg/m2 in females and a negative correlation in the group which had BMI > 23 kg/m2 in both males and females with anemia. There was an inverse correlation between waist circumference and Hb concentration only in the underweight group with an r value of -0.92 (p<0.05). Conclusion: The findings of the present study revealed anemia and obesity, to be prevalent among medical students. Both overweight/obesity and increased waist circumference are inversely associated with anemia in this representative group of medical students from urban area. We recommend regular screening of adolescents for anemia and obesity to challenge this public health issue.

235-237

Authors: Vinod Prabhushetty T.

Introduction: Method of Assessment in medical education plays a major role in student’s performance specially in the practicals, mainly the psychomotor domain. The presently followed traditional method has many lacunaes & need for newer methods like OSPE. The study has been taken to compare the OSPE with traditional subjective assessment method & to evaluate OSPE as reliable and valid assessment method. Materials and Method: This comparative study was conducted at Physiology Department, M.R. Medical College, 300 out of 350 apparently healthy, first year students of MBBS, BDS and BHMS streams were included in the study. Practical demonstration on Study of Compound Microscope was conducted. After the demonstration they appeared for practical examination on handling of microscope as per the informed schedule. Students appearing for practical examination were divided into two groups. Group A consisting of 150 students were assessed by traditional subjective method like practical viva-voce. Group B consisting of 150 students were assessed by OSPE which had one observation station carrying 10 marks and 4 minutes was allotted. A check list was prepared based on the objectives and the same is used for assessment and consideration of marks. Chi-square and Z- test was used for statistical analysis and p value of < 0.05 considered as statistically significant. Results: On observation of mean and standard deviation values of marks scored Z = 2.63, P<0.05 was statistically significant and overall performance of two groups ᵡ2 = 48.07 P < 0.0001 highly significant, results indicate that OSPE is effective method of evaluation as shown by the better performance of students. Conclusion: Hence OSPE is a reliable and valid method of assessment and can be considered in the practical examinations.

241-246

Authors: Anant Dattatray Dhanwate, Dope Santoshkumar Ankushrao.

Introduction: Skull is the preferred bone for identification of sex of the deceased as it resists decomposition, mutilation and fire. Cranial Index, Nasal Index and Orbital Index are commonly used for sexual dimorphism of skull. Previous studies present large variations in these indices due to genetic and environmental factors, racial and ethnic differences, different measurement methods and sample size. To know the reliability of these indices for sexual dimorphism of the skull, the present study was conducted. Materials and Method: The study was performed on 98 adult Indian skulls consisting of 60 male and 38 female skulls of known age and sex. Parameters measured were Cranial Index (CI), Nasal Index (NI) and Orbital Index (OI) which were expressed in descriptive statistics i.e. mean, range and standard deviation. For all the three indices, ‘identification points’ and ‘demarking points’ were calculated and then percentage of skulls identified by these points were recorded. Results were compared with available literature. Results- In the present study, mean CI in male and female skulls was 74.68±4.21 and 77.12±4.92 respectively while their NI was 50.76±5.61 and 56.86±6.65 respectively. In male skulls the mean OI was 87.47±8.09, while it was 87.88±5.55 in female skulls. The identification points and demarking points were calculated for all these three indices. Using identification points of CI and NI, 5% to 33% skulls were identified correctly as male or female. However, no sex could be determined from demarking points of three indices. Conclusion: None of the three indices namely CI, NI or OI were promising individually in identifying sex as a very low percentage of skulls could be identified. The study concludes that the reliability of these three cranial indices is doubtful in sexual dimorphism of the skull.

250-253

Authors: Nagalakshmi Vijaykumar, Vivek P, Shobha C. Nallulwar.

Introduction: Exercise intolerance is typical characteristic of the subclinical hypothyroidism. Purpose: Evaluation of heart rate responses to sub maximal exercise in subclinical hypothyroidism. Materials and Method: Twenty three subclinical hypothyroids and thirty age, sex and BMI matched euthyroid controls were selected. Sub maximal exercise was performed using Bruce protocol using 75% target heart rate in treadmill. Heart rate recovery to sub maximal exercise was done using ECG lead II. Results: Compared to Euthyroid controls, Subclinical Hypothyroidism (SCH) show a significant increase in warm up period heart rate. (p=0.05). There is a significant increase in the heart rate during recovery period at both 1st and 2nd minute in SCH when compared to controls. (p=0.03, 0.01), negative correlation exist between TSH level and 1st minute heart rate recovery. Conclusion: We conclude that subjects with Subclinical hypothyroidism, shows a delayed heart rate recovery in response to a sub maximal exercise.

259-262

Authors: Karthikeyan G, Sankaran PK, Kumaresan M, Zareena Begum, Yuvaraj M.

Introduction: The trigeminal ganglion consists of pseudounipolar neurons surrounded by satellite glial cells and processes innervating craniofacial region. The gap junctions are transmembrane proteins formed between the cell membranes of adjacent cells and calcitonin gene related peptide are neuropeptides secreted by sensory neurons. Aim and Objective: In present study the immunohistochemical localization for connexin 43 gap junctions and CGRP was done in the trigeminal ganglion of male Wistar rats. Result: The result showed connexin 43 was present between the satellite glial cells, between satellite glial cell and neuron and in the Schwann cells. CGRP was localized densely in the cytoplasm of small neurons. Conclusion: The excited neuron can influence the surrounding satellite glial cells and neurons through gap junctions and by paracrine actions altering its environment leading to pathological role in inducing painful conditions like migraine.

266-269

Authors: Manisha Upadhyay, M.K. Gupta, Ganesh Kumar, Anand Bihari.

The present study was a hospital based study carried out in 50 patients in department of anatomy, otolaryngology and radiology of the government medical college and superfacility hospital Azamgarh U.P. The aim of this study to study the role of anatomical variations of osteomeatal complex in rhinosinusitis. Lateral nasal wall of each nasal cavity provides the final common pathway of drainage of mucociliary clearence of frontal, maxillary and anterior ethmoid air cells. Anatomical variants like concha bullosa, haller cells, aggernasi cells, enlarged bulla ethmoidalis may obstruct the drainage pathway and cause rhinosinusitis. In our study computed tomography(CT) was done for assessment of paranasal sinuses, nasal fossae and their anatomical variants. Computed tomography offer detailed study of anatomical variation and it is invaluable tool for managing clinical decision and planning surgical strategies. It has become imperative for radiologist and clinicians to improve understanding of osteomeatal complex.

273-275

Authors: D.N. Sinha.

Recent trend of encroachment of Medical Education by the corporate sector and to make this system more service provider, will be costly affair in the process of delivering of Medical services to the community at large. No doubt some changes in pattern of Medical Education may take place as per the demand of Corporate. In view of this, the medical education will become more costly & technological dependent. This will certainly cause erosion in the fundamental subjects of the medical sciences. Age old conventional pattern of the medical education may be lost in due course Fragmental approach in Medical education will be detrimental for the future development of this science. To retain its identity as more humanitarian for the purpose of service to ailing will be future challenge for the Medical Educationist.

279-280

Authors: Suba Ananthi K, Sandosh S, Aruna S.

Pre-ureteral vena cava is a rare congenital anomaly that results from altered vascular development. During routine dissection of the abdominal cavity of a 62year old male cadaver in the department of Anatomy, a congenital anomaly of right preureteric vena cava was observed. The right ureter coursed behind inferior vena cava but anterior to right psoas major muscle and then emerged between the inferior vena cava and abdominal aorta. Inferior vena cava was formed anterior to the common iliac arteries which is very rare. The left ureter crossed in front of inferior venacava and then right common iliac artery and entered pelvis. Pelvic part of ureter was normal. The course of left ureter was normal. There was no obvious dilatation of renal pelvis. Imaging studies such as helical CT scan and magnetic resonance imaging (MRI) can clearly demonstrate the entire course of ureter.

284-287

Authors: Rashmi Malhotra, Rajani Singh, Munish Wadhawan, Manu Malhotra.

Introduction: Upper limb arterial tree variations have being drawing attention of anatomists and surgeons since ages owing to the clinical significance attached to them. The main artery of the arm is the brachial artery which after giving branches to it terminates in the forearm. Aim: The present study aims at exploring the gross anatomy, embryological and applied aspects of the high termination of the brachial artery. Materials and Method: An unusually high termination of brachial artery into its terminal branches radial and ulnar arteries was noted during routine dissection in the upper part of the arm at AIIMS Rishikesh. The course, branches and relations of these arteries were studied and assessed in the light of available literature. Conclusion: High termination of the brachial artery implicates a huge applied importance for radiologists, physicians, orthopaedic surgeons. So, encountering such variations might be possible during diagnosis, surgical procedures or interpreting angiograms of the upper limb.