Battle of the sections: Student outcomes and course feedback support combined prosection and dissection laboratory formats to maximize student success.

Gross anatomy laboratories frequently utilize dissection or prosection formats within medical curricula. Practical examination scores are consistent across the formats, yet these examinations assessed larger anatomical structures. In contrast, a single report noted improved scores when prosection was used in the hand and foot regions, areas that are more difficult to dissect. The incorporation of prosected donors within "Head and Neck" laboratories provided an opportunity to further characterize the impact of prosection in a structurally complex area. Retrospective analysis of 21 Head and Neck practical examination questions was completed to compare scores among cohorts that utilized dissection exclusively or incorporated prosection. Mean scores of practical examination questions were significantly higher in the prosection cohort (84.27% ± 12.69) as compared with the dissection cohort (75.59% ± 12.27) (p < 0.001). Of the 12 questions that performed better in the prosection cohort (88.42% ± 8.21), 10 items mapped to deeper anatomical regions. By comparison, eight of nine questions in the dissection cohort outperformed (88.44% ± 3.34) the prosection cohort (71.74% ± 18.11), and mapped to anatomically superficial regions. Despite the mean score increase with positional location of the questions, this effect was not statically significant across cohorts (p = 1.000), suggesting that structure accessibility in anatomically complex regions impacts performance. Student feedback cited structure preservation (71.5%) and time savings (55.8%) as advantages to prosection; however, dissection was the perceived superior and preferred laboratory format (88.6%). These data support combined prosection and dissection formats for improving student recognition of deeply positioned structures and maximizing student success.

Communicating Branches of the Facial Nerve: Descriptions and Clinical Considerations.

BACKGROUND: Major branching patterns of the facial nerve have been extensively studied because damage to branches of the nerve is associated with complications ranging from weakness to paralysis. However, communicating branches of the facial nerve have received far less attention despite being hypothesized as a means of motor recovery following facial nerve injury. OBJECTIVES: The aim of this study was to characterize the frequency of communicating branches of the facial nerve to provide clarity on their anatomy and clinical correlations. METHODS: Bilateral facial dissections were completed on cadaveric donors (n = 20) to characterize the frequency and location of communicating branches across terminal branches of the facial nerve. Statistical analyses were employed to analyze differences between the location of communications by side and whether the communicating branches were more likely to occur on the left or right side (P < 0.05). RESULTS: Communicating branches were identified among all terminal branches of the facial nerve and their frequencies reported. The highest frequencies of communicating branches were identified between the buccal-to-marginal mandibular and zygomatic-to-buccal branches, at 67.5% (27 comm/40 hemifaces). The second highest frequency was identified between the temporal-to-zygomatic branches in 62.5% (25/40) of donors. The marginal mandibular-to-cervical branches had communicating branches at a frequency of 55% (22/40). Location or sidedness of communicating branches did not significantly differ. CONCLUSIONS: Our characterization more accurately defines generalizable areas in which communicating branches are located. These locations of branches, described in relation to nearby landmarks, are fundamental for clinical and surgical settings to improve procedural awareness.

Osteopathic Manipulative Treatment as an Intervention to Reduce Stress, Anxiety, and Depression in First Responders: A Pilot Study.

In this pilot study, we examined the efficacy of Osteopathic Manipulative Treatment (OMT) for improving symptoms of stress, anxiety, and depression (SAD) to determine a correlation between overall improvement in health and quality of life for first responders. Participants received weekly OMT or sham OMT targeting autonomic imbalance. Indicators of SAD were examined pre- and post-study. Overall, this pilot study suggests improvement in both the social-psychological (mental) self-assessments, and alterations in SAD-associated biomarkers from OMT.

Anatomy of the sural nerve complex: Unaccounted anatomic variations and morphometric data.

BACKGROUND: The sural nerve (SN) is a cutaneous sensory nerve innervating the posterolateral leg. The SN is formed from a highly variable set of contributing nerves called the sural nerve complex (SNC). The SNC is made up of the lateral sural cutaneous nerve, medial sural cutaneous nerve, sural communicating branch, and SN. The SN is frequently cited as the most common donor nerve graft and is commonly injured in procedures of the lower extremity. Recent meta-analysis standardized six morphologies of the SNC and established a required reporting criterion for the group of nerves forming the SN. Due to the inconsistencies in previous literature, this study will group observed SNC's by one of these six SNC morphologies to assess and validate the meta-analysis grouping criteria. This study will also collect the same morphometric data previously outlined in order to grow the number of samples that are reported in a standardized fashion. METHODS: 100 formalin and 4 Theil preserved cadavers (n = 208) lower limbs were bilaterally dissected at Kansas City University and Creighton University School of Dentistry to observe the SNC in its entirety on the posterolateral leg. Anatomic data was captured utilizing the standardized morphologies types 1-6 with two sub-typing. Nerves that were found to be outside of this categorization were placed in an unassigned grouping. RESULTS: The most prevalent SNCs were type 1 at 41.35% (n = 86) and type 3 nerves at 34.62% (n = 72). Type 2 was found 8.65% (n = 18), type 4 and 5 were found each at 0.48% (n = 1). Type 6 was not observed. When comparing the present studies frequency of nerve types 1-6 to the meta-analysis a sub-grouping of "North American" cadaveric studies a X2 = .903 p = .030 was found. Two distinct and previously unassigned formations of the SNC were 10.58% (n = 20) and 3.85% (n = 8) of data. These two SNC are termed type 7 & 8, these represent two formations of SN that are outside of what was previously reported. 15.87% (n = 33) did not match visual descriptions based on nerve origin of a type 1 SNC but met written definitions. These were termed type 1A1 and type 1A2. The SNC was asymmetrical in 57.69% (n = 120). The pooled mean length of the SN was 32.97 ± 14.12 cm (31.05-34.88), mean diameter was 2.31 ± 0.83 mm (2.20-2.42, and the distance of the posterior border of the lateral malleolus to the SN was found to be 1.72 ± 0.70 cm (1.63-1.80). CONCLUSION: Anatomic variation in the SNC is highly variable, yet is consistent with previously observed literature. This study demonstrates two unaccounted formations of the SNC as well as two additional subcategories of SNC that were not included in the previous meta-analysis. These four variants warrant inclusion as standard formations of the SNC due to the high prevalence observed in this study as well as historical consistency observed in previous literature and case reports. These two SNC formations increase the risk of iatrogenic injury during surgical interventions of the lower extremity. Morphometric data describing the spatial relationship of this nerve complex on the posterolateral leg is consistent with previously reported data and aids in generating a large data set for future studies to characterize spatial properties of this nerve complex.

Gender differences in acute stone admissions - should we have a lower threshold for treatment in female patients?

OBJECTIVES: To examine the gender-related differences in the presentation, management and outcomes of patients admitted with acute renal colic at our institution. PATIENTS AND METHODS: A retrospective analysis of 231 consecutive patients requiring inpatient admission for acute renal colic between October 2015 and March 2018. For each admission, data on demographics, admission blood results, stone characteristics, management and outcomes were collected. Differences between genders were compared using the chi-squared and Student's t-test. RESULTS: Gender distribution was 35% female: 65% male. There was no significant difference in age, American Society of Anesthesiologists Physical Status Classification grade or history of diabetes. Women had a higher admission C-reactive protein level (89.3 vs 32.9 mg/L, P < 0.001) and neutrophil count (10.0 vs 8.8 × 109 /L, P = 0.04) than men. They also had more positive cultures (34.1% vs 6.0%, P < 0.001) and were more likely to require percutaneous nephrostomy insertion (9.8% vs 0.7%, P = 0.005). Women had more intensive therapy unit (ITU) admissions (12.2% vs 0.6%, P < 0.001) and longer lengths of stay (4.4 vs 1.8 days, P < 0.001) than men. There was no mortality in our series. CONCLUSION: In the present study, women admitted with acute renal colic were more likely to have an associated infection than men and require rapid decompression. Although there was no difference in mortality, women experienced greater morbidity as evidenced by the higher rate of ITU admissions and longer length of stay. These differences are important to consider when assessing the suitability of conservative management for female patients.

Key Anatomical Clarifications for the Marginal Mandibular Branch of the Facial Nerve: Clinical Significance for the Plastic Surgeon.

BACKGROUND: The marginal mandibular branch (MMBr) of the facial nerve is the least likely to recover from injury due to infrequent anastomosis with other branches. The MMBr has been described as coursing superior to the inferior border of the mandible. However, studies have reported variations in its location in embalmed and fresh specimens. It has been postulated that the embalming process may effect its anatomic position. OBJECTIVES: The aim of this study was to re-evalulate the location of the MMBr relative to the inferior border of the mandible in both fresh and embalmed cadavers, and investigate variation in its position with sex, side of the face, and age. METHODS: Superficial fascial planes were dissected to reveal the MMBr and its anatomic relations. Distance between the most inferior branch of the MMBr and the antegonial notch were measured bilaterally. The most inferior position of the MMBr between the antegonial notch and gonion was measured. Fresh heads were used as a comparison, with an additional measurement taken of the distance between the MMBr and the gonial angle. RESULTS: The MMBr was located inferior to the border of the mandible (90.3%) more often than above (9.6%). No significant differences were found between fresh and embalmed cadavers, sex, side of body, or age (P > 0.05). No significant difference was found between intact cadavers and fresh heads (P > 0.05). CONCLUSIONS: This study confirms and describes reliable landmarks for safety zones for the MMBr during plastic and reconstructive surgery of the lower face and upper neck. These data add reliability to studies that have investigated nerve locations in embalmed cadavers.

Ketamine cystitis: practical considerations in management.

OBJECTIVE: The aim of this study was to investigate and report the clinical spectrum and practical problems in the management of a cohort of patients presenting with lower urinary tract symptoms (LUTS) related to abuse of ketamine. MATERIAL AND METHODS: The clinical presentation, cystoscopic findings, radiological features and outcomes of patients presenting with LUTS related to ketamine abuse between January 2008 and April 2013 were retrospectively reviewed and analysed. RESULTS: In total, 34 patients were seen during this period. All patients had LUTS, haematuria and abdominal pain to varying degrees. Two patients (7%) had a concomitant urinary tract infection. Upper tract imaging was carried out in 18 out of 34 patients and bilateral hydronephrosis was found in two cases (6%). Cystoscopy showed a small inflamed bladder (capacity 60-350 ml) in 14 out of the 16 cases where this was performed. Bladder biopsies showed denudation of urothelium and infiltration of submucosa with lymphocytes and eosinophils with no increase in mast cells. Fifty-nine per cent of patients did not attend their clinic, imaging and/or cystoscopy appointments. One patient underwent a subtotal cystectomy and bladder reconstruction. CONCLUSIONS: Ketamine cystitis is a complex problem whose exact pathological mechanism and natural history remain unknown. The only known effective treatment is to abstain from the drug. Urologists need to recognize the condition early and work together with the local substance misuse service, focusing on drug cessation therapy to reduce complications.

Percutaneous nephrostomy for ureteric obstruction due to advanced pelvic malignancy: have we got the balance right?

PURPOSE: The optimal management of patients with ureteric obstruction in advanced pelvic malignancy is unclear. Effective judgment is required to decide which patients would benefit most from decompression of the urinary tract. The objective of our study was to assess survival and complication rates post-percutaneous nephrostomy (PCN) in patients with ureteric obstruction due to advanced pelvic malignancy. METHODS: A detailed retrospective case review of all patients who underwent PCN for ureteric obstruction due to pelvic malignancy in one calendar year was conducted to assess indication, survival time, length of stay post-procedure and complications. RESULTS: Thirty-six nephrostomies were performed on 22 patients with prostate cancer being the commonest primary (55 %). Renal failure was the commonest mode of presentation (56 %). Eight patients (36 %) presented without a prior diagnosis of cancer. All PCNs except one were initially technically successful, and 56 % of renal units were able to be antegradely stented and rendered free of nephrostomy. Median survival post-nephrostomy was 78 days (range 4-1,137), with the subset of bladder cancer patients having the poorest survival. Dislodgement of the nephrostomy tube was the most common troublesome complication which led to the greatest morbidity, sometimes requiring repeat nephrostomy insertion. Patients stayed for a median of 23 (range 3-89) days in hospital, which amounted to 29 % of their remaining lifetime spent in hospital. CONCLUSIONS: Although effective in improving renal function, PCN is a procedure not without associated morbidity and does not always prolong survival. Therefore, the decision to decompress an obstructed kidney with advanced pelvic malignancy should not be taken lightly. We recommend that such cases be discussed in a multidisciplinary setting, and a decision is taken only after a full informed discussion involving patients and their relatives.

A rare and unusual presentation of urological infection on a patient on steroids.

We report the rare case of adult lobar nephronia in a 49-year-old female, on long-term steroids with no prior urological or transplant history. More frequently reported in paediatric literature, adult lobar nephronia (focal pyelonephritis) is an unusual radiological finding sometimes preceding the development of renal abscess. We advocate that treatment should be a prolonged course of antibiotics and close follow-up.

Ultrasonography of simple intratesticular cysts: a 13 year experience in a single centre.

OBJECTIVES: Simple intratesticular cysts are being reported more commonly due to the wider use of scrotal ultrasonography however, their management remains unclear. Treatment has included enucleation, radical orchidectomy (over fear of an associated malignancy) and a more conservative approach with serial ultrasonography (if a neoplastic cyst is clearly ruled out). In view of the benign nature of such cysts, even serial ultrasonography may be unnecessary. We evaluate the presentation, diagnosis and management of ultrasound-detected simple intratesticular cysts over a 13-year period. METHODS: Between May 1994 and August 2007, 24 men were found to have simple intratesticular cysts on scrotal ultrasonography. Records were analysed retrospectively to identify the clinicoradiologic findings and the management. RESULTS: Median follow up was 29.5 months (range 4 - 108 months). Only one patient became symptomatic with a cyst which increased in size by 13 mm over 15 months. Orchidectomy performed at the patient's request confirmed a benign simple cyst. CONCLUSIONS: In our series, a significant change in size of the cyst with accompanying symptoms was observed in one case only. Asymptomatic patients with simple intratesticular cysts without associated features of bias towards malignancy can be discharged without need for further follow-up.

Pulsed radiofrequency for chronic testicular pain-a preliminary report.

OBJECTIVE: To evaluate the effectiveness of pulsed radiofrequency (PRF) of spermatic cord in the treatment of chronic testicular pain. DESIGN: Ten patients with chronic testicular pain were treated with PRF stimulation of the spermatic cord. A radiofrequency probe placed percutaneously into the spermatic cord was used to deliver four 120-second cycles of 20-millisecond pulses at 2 Hz. Test stimulation was first used to confirm the precise placement of the probe. The short-form McGill Pain Questionnaire was used to assess pain before treatment and at 3 months. Patients who had experienced improvement were followed up by telephone, to determine whether pain relief was sustained. RESULTS: Ten patients were entered into the study but one was lost to follow-up. Of the nine patients evaluated, four had complete resolution of pain, while one had partial pain relief. Three patients experienced no change and one reported that his pain was worse. All patients who experienced complete and partial pain relief continued to do so at a mean long-term follow-up of 9.6 months (range 3-14 months). There were no complications observed immediately or during the follow-up period. CONCLUSION: In this pilot study, pain scores improved in five out of nine patients. PRF of spermatic cord appears to be a safe minimally invasive outpatient procedure that should be investigated further with placebo-controlled trials.

An unusual presentation of ureteric colic.

A patient presented with acute pain in the right iliac fossa and was found to have a small stone in the lower ureter of a crossed ectopic right kidney. This unique presentation highlights the potential pitfalls that may occur when assessing an acute pain in the right iliac fossa and reminds the invaluable role of IVP.