The Anatomical Society core regional anatomy syllabus for undergraduate medicine.

The Anatomical Society's core syllabus for anatomy (2003 and later refined in 2007) set out a series of learning outcomes that an individual medical student should achieve on graduation. The core syllabus, with 182 learning outcomes grouped in body regions, referenced in the General Medical Council's Teaching Tomorrow's Doctors, was open to criticism on the grounds that the learning outcomes were generated by a relatively small group of anatomists, albeit some of whom were clinically qualified. We have therefore used a modified Delphi technique to seek a wider consensus. A Delphi panel was constructed involving 'experts' (n = 39). The revised core syllabus of 156 learning outcomes presented here is applicable to all medical programmes and may be used by curriculum planners, teachers and students alike in addressing the perennial question: 'What do I need to know ?'

Undergraduate radiology teaching in a UK medical school: a systematic evaluation of current practice.

AIM: To use the Royal College of Radiologists' Undergraduate Radiology Curriculum (RCR URC) as an innovative tool to review undergraduate radiology teaching and ensure it is comprehensive and balanced. MATERIALS AND METHODS: Quantitative and qualitative methods were used to audit and review radiology teaching for students in years 1-3. All radiological teaching on the course was mapped against the RCR URC learning outcomes. An online survey of students in year 3 (n=138) was conducted using Likert (1-5), multiple choice, and free-text questions. RESULTS: There were 954 instances of radiology teaching, with 70% occurring during lectures. Radiology teaching was mapped to 81 of the 96 RCR URC learning outcomes (84.4%). Forty-seven of 138 students responded to the survey. They expressed confidence in understanding what basic imaging entails (x=4.23) and the risks associated with various imaging techniques (x=4.34). They were also confident in chest radiograph interpretation (x=3.62), but were less confident understanding abdominal radiographs (x=2.87). In free-text comments, students requested more tutorial-type teaching and ultrasound instruction. CONCLUSION: The RCR URC is an effective tool for auditing undergraduate radiology teaching, and other medical schools may, therefore, benefit from using this method. This evaluation process incorporating audit and feedback has identified areas for curriculum development. These include incorporating ultrasound into teaching sessions, delivering more small-group teaching, and introducing clinical placements in radiology departments.

Guidelines for chest drain insertion may not prevent damage to abdominal viscera.

OBJECTIVES: Guidelines to improve the ease and safety of chest drain insertion recommend using the fifth intercostal space, around the midaxillary line (MAL). This study aimed to assess whether compliance with published guidelines reliably ensured such placement and avoided the potentially serious complications of subdiaphragmatic insertion and peripheral nerve injury. METHODS: Three international guidelines were assessed by identifying the intercostal space for chest drain insertion using 16 cadavers (32 sides) at a point 1 cm anterior to MAL. The European Trauma Course method was compared with the British Thoracic Society's 'safe triangle' and the ATLS course technique. RESULTS: The level most commonly found was the sixth intercostal space (43%; 41 of 96 sides). Overall the sixth space or below was found in 83% of insertions (80 of 96 sides). In the fifth intercostal space, the long thoracic nerve ran posterior to the marker placed in all cases and the lateral cutaneous branches of intercostal nerves arose anteriorly to the marker in all but one case. CONCLUSIONS: The results suggest these guidelines may result in insertion of chest drains below the fifth intercostal space, potentially risking injury to subdiaphragmatic structures. Peripheral nerves of the lateral thoracic wall appear safe from incisions 1 cm anterior to MAL.

Finding the fifth intercostal space for chest drain insertion: guidelines and ultrasound.

OBJECTIVES: International guidelines exist for chest drain insertion and recommend identifying the fifth intercostal space or above, around the midaxillary line. In a recent study, applying these guidelines in cadavers risked insertion in the 6th intercostal space or below in 80% of cases. However, there are limitations of cadaveric studies and this investigation uses ultrasound to determine the intercostal space identified when applying these guidelines in healthy adult volunteers. METHODS: On each side of the chest wall in 31 volunteers, the position for drain insertion was identified using the European Trauma Course method, Advanced Trauma Life Support (ATLS) method, British Thoracic Society's 'safe triangle' and the 'traditional' method of palpation. Ultrasound imaging was used to determine the relationship of the skin marks with the underlying intercostal spaces. RESULTS: Five methods were assessed on 60 sides. In contrast to the cadaveric study, 94% of skin marks lay over a safe intercostal space. However, the range of intercostal spaces found spanned the second to the seventh space. In 44% of women, the inferior boundary of the 'safe triangle' and the ATLS guidelines located the sixth intercostal space or below. CONCLUSIONS: Current guidelines often identify a safe site for chest drain insertion, although the same site is not reproducibly found. In addition, women appear to be at risk of subdiaphragmatic drain insertion when the nipple is used to identify the fifth intercostal space. Real-time ultrasonography can be used to confirm the intercostal space during this procedure, although a safe guideline is still needed for circumstances in which ultrasound is not possible.

Facial appearance is a cue to oestrogen levels in women.

Although many accounts of facial attractiveness propose that femininity in women's faces indicates high levels of oestrogen, there is little empirical evidence in support of this assumption. Here, we used assays for urinary metabolites of oestrogen (oestrone-3-glucuronide, E1G) and progesterone (pregnanediol-3-glucuronide, P3G) to investigate the relationship between circulating gonadal hormones and ratings of the femininity, attractiveness and apparent health of women's faces. Positive correlations were observed between late follicular oestrogen and ratings of femininity, attractiveness and health. Positive correlations of luteal progesterone and health and attractiveness ratings were marginally significant. Ratings of facial attributions did not relate to hormone levels for women wearing make-up when photographed. There was no effect of sex of rater on the relationships between oestrogen and ratings of facial appearance. These findings demonstrate that female facial appearance holds detectable cues to reproductive health that are considered attractive by other people.

Menstrual cycle, pregnancy and oral contraceptive use alter attraction to apparent health in faces.

Previous studies demonstrating changes in women's face preferences have emphasized increased attraction to cues to possible indirect benefits (e.g. heritable immunity to infection) that coincides with periods of high fertility (e.g. the late follicular phase of the menstrual cycle). By contrast, here we show that when choosing between composite faces with raised or lowered apparent health, women's preferences for faces that are perceived as healthy are (i) stronger during the luteal phase of the menstrual cycle than during the late follicular, fertile phase, (ii) stronger in pregnant women than in non-pregnant women and (iii) stronger in women using oral contraceptives than in women with natural menstrual cycles. Change in preference for male faces was greater for short- than long-term relationships. These findings indicate raised progesterone level is associated with increased attraction to facial cues associated with possible direct benefits (e.g. low risk of infection) and suggest that women's face preferences are influenced by adaptations that compensate for weakened immune system responses during pregnancy and reduce the risk of infection disrupting foetal development.

The conjoint junction of the triceps surae: implications for gastrocnemius tendon lengthening.

Forty embalmed cadaver lower limbs were dissected to identify the morphology of the conjoint junction of the tendons of gastrocnemius and soleus and the location of the gastrocnemius tendon relative to bony landmarks. Five patterns of conjoint junction morphology were found: transverse (25%), oblique passing distally and medially (45%), oblique passing distally and laterally (5%) and arcuate as an inverted U (17.5%) and a U-shape (7.5%). Left-right asymmetry of the junction was observed in 31.6% of 19 paired cadaver legs. On the medial side of the calf the gastrocnemius tendon could be located between 38 and 46% of the proportion of the distance between the upper border of the calcaneus and the fibular head. Corresponding values for the midline and lateral side of the calf were 45-58% and 48-51%. The location of the gastrocnemius tendon relative to bony landmarks may help to guide incision planning for open or endoscopic division of the tendon.

Marks, scores and grades: scaling and aggregating student assessment outcomes.

The term marks conflates the concepts of scores (raw test performance) and grades (level of performance). Neither scores nor grades represent interval scales, and therefore properly speaking arithmetic means should not be calculated during aggregation. The distributions of scores from a variety of kinds of assessment are considered, and ways of converting scores to grades are discussed. Methods of aggregation are also considered, and several strategies for implementing these via spreadsheets are made available. It is recommended that: 1 Scores should always be converted to grades before aggregation. The process of converting scores to grades requires both subject-specific skills, and familiarity with educational principles. 2 Whatever grade scale is used, it should be readily distinguishable from scores. 3 The median should be calculated as the measure of overall performance, not the arithmetic mean. 4 The interquartile range should be calculated as the measure of dispersion. 5 Students should be informed of both their score and grade for each assessment. 6 Where possible, assessment should report performance by individual assessment, not by a single aggregated mark. 7 When aggregation takes place, it should be possible to aggregate student performance by type of assessment as well as by academic subject. 8 Students who perform inconsistently should receive particular scrutiny during assessment.

The study of early human embryos using interactive 3-dimensional computer reconstructions.

Tracings of serial histological sections from 4 human embryos at different Carnegie stages were used to create 3-dimensional (3D) computer models of the developing heart. The models were constructed using commercially available software developed for graphic design and the production of computer generated virtual reality environments. They are available as interactive objects which can be downloaded via the World Wide Web. This simple method of 3D reconstruction offers significant advantages for understanding important events in morphological sciences.

Computer-aided interactive three-dimensional reconstruction of the embryonic human heart.

Despite the fact that development of the human embryo heart is of considerable clinical importance, there is still disagreement over the process and the timing of events. It is likely that some of the conflicting accounts may have arisen from difficulties in describing and visualising 3-dimensional structures from 2-dimensional sections. To help overcome this problem and to improve our understanding of the development of the heart, we have devised techniques for the production of interactive 3D models reconstructed from serial histological sections of human embryos. Our method uses commercial software designed for the creation of 3D models and virtual reality environments. The ability to construct interactive visual images which both illustrate and communicate complex 3D information contributes to our understanding of the complex developmental changes occurring in embryogenesis.

Assessing the emotional impact of cadaver dissection on medical students.

AIM: The study's first aim was to assess the emotional impact of cadaver dissection on first year medical students using the newly developed Appraisal of Life Events Scale (ALE). Its secondary aim was to evaluate the validity of the ALE by comparing it with the Impact of Events Scale (IOE). SETTING: Division of Biomedical Sciences, School of Biology, University of St. Andrews. SUBJECTS AND METHOD: Appraisal of Life Events and Impact of Events data were obtained from 114 UK medical students 4 weeks after their first cadaver dissecting class. Main outcome measures referred to the ALE and IOE scales. RESULTS: The students rated the experience as largely positive, registering significantly higher scores on the ALE challenge factor than on ALE threat or ALE loss. Significant correlations between ALE threat and loss scores and IOE intrusions and avoidance scores were noted. CONCLUSION: The results indicate that medical students do not report their first exposure to cadaver dissection as an aversive experience. Instead, as the ALE results confirm, they found it to be a positive and challenging life event. The ALE appears to be a useful instrument in assessing positive and negative emotional reactions to significant life events.

The anatomical and neurophysiological basis of the sensate free TRAM and DIEP flaps.

Recent developments in autogenous breast reconstruction using the rectus abdominis myocutaneous free flap include attempts to reinnervate the flap tissue. We have carried out anatomical studies to determine the nature of abdominal-wall cutaneous innervation, with particular emphasis on the harvesting of sensate flaps. Dissections were performed on four embalmed and 12 fresh human cadavers (32 sides). The lowest five intercostal nerve trunks were identified and traced to the lateral border of the rectus sheath. A detailed dissection of the intramuscular course of the nerves and associated vasculature was performed. The relationship of the nerves to the vascular perforators used for rectus abdominis myocutaneous flaps was determined visually, and confirmed histologically. In contrast to previous studies, we show that nerves supplying cutaneous sensation can travel with both medial and lateral vascular perforators. In order to confirm clinically useful innervation, the abdominal flap skin of five patients undergoing TRAM flap reconstruction was stimulated electrically, and sensory recordings were made directly from the related intercostal nerve just prior to flap harvest. These studies represent, to our knowledge, the first clinical application of neurophysiological techniques to outline the perforator neurosomes of flaps based on the deep inferior epigastric vascular axis. We provide the first comprehensive study of abdominal-wall innervation with regard to sensate free-flap harvest. Our dissections show complex patterns of abdominal skin innervation that have not been previously described. The implications for sensate free TRAM and DIEP flap reconstructions, as well as the potential for more accurate inclusion of innervated flap skin, are discussed.

Cartilaginous development of the human craniovertebral junction as visualised by a new three-dimensional computer reconstruction technique.

Serial transverse histological sections of the human craniovertebral junction (CVJ) of 4 normal human embryos (aged 45 to 58 d) and of a fetus (77 d) were used to create 3-dimensional computer models of the CVJ. The main components modelled included the chondrified basioccipital, atlas and axis, notochord, the vertebrobasilar complex and the spinal cord. Chondrification of the component parts of CVJ had already begun at 45 d (Stage 18). The odontoid process appeared to develop from a short eminence of the axis forming a third occipital condyle with the caudal end of the basioccipital. The cartilaginous anterior arch of C1 appeared at 50-53 d (Stages 20-21). Neural arches of C1 and C2 showed gradual closure, but there was still a wide posterior spina bifida in the oldest reconstructed specimen (77 d fetus). The position of the notochord was constant throughout. The normal course of the vertebral arteries was already established and the chondrified vertebral foramina showed progressive closure. The findings confirm that the odontoid process is not derived solely from the centrum of C1 and that there is a 'natural basilar invagination' of C2 during normal embryonic development. On the basis of the observed shape and developmental pattern of structures of the cartilaginous human CVJ, we suggest that certain pathologies are likely to originate during the chondrification phase of development.