Medical students' attitudes towards peer physical examination: findings from an international cross-sectional and longitudinal study.

Although studies have begun to shed light on medical students' attitudes towards peer physical examination (PPE), they have been conducted at single sites, and have generally not examined changes in medical students' attitudes over time. Employing both cross-sectional and longitudinal designs, the current study examines medical students' attitudes towards PPE at schools from different geographical and cultural regions and assess changes in their attitudes over their first year of medical study. Students at six schools (Peninsula, UK; Durham, UK; Auckland, New Zealand; Flinders, Australia; Sapporo, Japan and Li Ka Shing, Hong Kong) completed the Examining Fellow Students (EFS) questionnaire near the start of their academic year (T1), and students at four schools (Peninsula, Durham, Auckland and Flinders) completed the EFS for a second time, around the end of their academic year (T2). Univariate and multivariate analyses revealed a high level of acceptance for PPE of non-intimate body regions amongst medical students from all schools (greater than 83%, hips, at T1 and 94.5%, hips and upper body, at T2). At T1 and T2, students' willingness to engage in PPE was associated with their gender, ethnicity, religiosity and school. Typically, students least comfortable with PPE at T1 and T2 were female, non-white, religious and studying at Auckland. Although students' attitudes towards PPE were reasonably stable over their first year of study, and after exposure to PPE, we did find some statistically significant differences in attitudes between T1 and T2. Interestingly, attitude changes were consistently predicted by gender, even when controlling for school. While male students' attitudes towards PPE were relatively stable over time, females' attitudes were changeable. In this paper, we discuss our findings in light of existing research and theory, and discuss their implications for educational practice and further research.

Potential foramen to allow communication between the pleural cavity and retroperitoneal space during laparoscopic surgery: a cadaver study of Bochdalek's triangle.

The indications for laparoscopic retroperitoneal surgery have recently been greatly extended and the technique has become popular, but concomitant pleural injury or pneumothorax has been reported from numerous hospitals in Japan. Which anatomical information is useful to avoid surgical injury of the suggested weak portion of the diaphragm? We identified a diaphragm-free triangular area or Bochdalek's triangle in 90.1% of elderly Japanese cadavers (100/111 cadavers), comprising about 622.8 mm(2) in area (height 47.9 mm, base 25.0 mm). In most cases (80.1%; 129/161), the entire triangle was restricted to the superior side of the 12th rib in addition to the medial side of the distal end of the rib. A "potential foramen" (PF) was defined as the diaphragm-free triangle >100 mm(2) in area on the parietal pleura. Most triangles (77.6%, 125/161) met this criterion. The PF was often covered by the kidney (93.3%), and had a mean area of 318.9 mm(2). The PF was located 42.3 mm from the distal end of the 12th rib, while the inferior pleural margin was 27.8 mm superior to the rib end. When the triangle was large, the PF was also large, with the PF often occupying >50% of the triangle area (62/125; 49.6%). To avoid the distal end of the 12th rib, in laparoscopic retroperitoneal surgery, we recommend making a transverse skin incision at the midpoint between the end of the 12th rib and the iliac crest.

Which morphology of dry bone articular surfaces suggests so-called fibrous ankylosis in the elderly human sacroiliac joint?

Usually, joint degeneration with aging results in articular cartilage defects, which results in bony ankylosis. However, the sacroiliac articular cartilage is maintained even in the elderly and the fibrous tissues make so-called 'fibrous ankylosis'. Macroscopically and histologically, we observed two sacroiliac joints obtained from one young cadaver as well as 23 sacroiliac joints from 23 elderly cadavers. Each joint was divided into two pieces along the long axis: one half was processed for routine histology after decalcification, whereas the other half was macerated to provide a dry bone specimen. The articular cartilage consistently contained abundant fibers and some of the fibers connected to tight intra-articular fiber bands. Fiber insertion into the thin subchondral bone displayed a tidemark in a spotty manner. Thus, the calcified fibrocartilage seemed to be present and seemed to provide fine granularity on the dry bone specimen. The joint cavity was sometimes closed with fibrocartilage-like tissues: we termed this complete fibrous ankylosis. The dry bone specimen corresponding to complete fibrous ankylosis exhibited significant microporosity and granularity because of fragmented subchondral bone. Moreover, bony ankylosis along the sacroiliac joint margin also contained fibrocartilage-like tissues. Therefore, complete fibrous ankylosis is also likely to be the preliminary step to bony ankylosis in the entire joint area. Consequently, microporosity with granularity seemed to be the most critical anthropological characteristic for estimation of sacroiliac joint movability.

Anatomic evaluation of postural bronchial drainage of the lung with special reference to patients with tracheal intubation: which combination of postures provides the best simplification?

BACKGROUND: Although several sequences of specific postures, each corresponding to a particular lung segment, have been recommended for therapeutic bronchial drainage, these are based on little or no anatomic evidence. Moreover, because these sequences are too complex, especially for intubated patients, they require simplification. MATERIALS AND METHODS: The courses of the segmental bronchi B(1), B(2), B(1 + 2), B(3), and B(6) and their subsegmental bronchi are extremely variable. This can result in a small branching angle at the subsegmental bronchial origin. Using 106 lungs, we measured the branching angles of the subsegmental bronchi and examined their running directions in each posture of the sequences recommended for bronchial drainage. RESULTS: A small branching angle (< 120 degrees ) at the subsegmental bronchial origin was sometimes evident, and this made postural drainage difficult. Drainage of B(3) and B(6) was often difficult because they formed angles of < 45 degrees from the horizontal in certain postures (supine for B(3) and prone for B(6)). Further, we found a 45 degrees rotative prone position effective for draining B(1)a and B(6). CONCLUSION: Our anatomic findings predicted increased effectiveness in a sequence of postures: supine, 45 degrees rotative prone with left side up, 45 degrees rotative prone with right side up, and return to supine for simple, safe, and effective bronchial drainage, especially for patients with tracheal intubation. The 10 degrees right-side-up supine and 45 degrees rotative prone with head raised 45 degrees positions seemed helpful if added to the basic sequence.

Cantlie's plane in major variations of the primary portal vein ramification at the porta hepatis: cutting experiment using cadaveric livers.

Major variations of the primary portal vein ramifications at the porta hepatis, such as trifurcation or an anterior sectorial trunk originating from the left portal vein (L+A pattern), seem to be relatively common morphologic features, with an incidence of 10% to 30%. However, it has not been clearly demonstrated whether the usual landmarks of Cantlie's line and the middle hepatic vein (MHV) are reliable indicators of the border between the right and left liver when these variations are present. We searched for any discrepancies between the actual left/right territorial border of the intrahepatic portal vein and the usual position of Cantlie's line or the MHV course using 30 fixed cadaveric livers with major variations including hilar trifurcation and the L+A pattern. In most livers (63.3%) the usual transection plane for left/right hepatectomy was occupied by Couinaud's segment VIII (S8), and the territory of the right portal vein extended to the left of Cantlie's plane. The MHV course did not correspond with the actual border between the right and left liver. Significant rightward shift of the MHV occurred in 76.9% of livers. The severity of the discrepancy seemed to depend on the distance between the origins of the anterior and posterior sectorial trunks along the main portal vein. In conclusion, variations of the primary portal ramifications alter the segmental configurations of the liver. Our results evoke doubt over the reliability of Cantlie's line and the MHV course as landmarks for major hepatectomy when such variations are present.

Configurations of the segmental and subsegmental bronchi and arteries in the right upper lobe of the human lung with special reference to their concomitant relations and double subsegmental arterial supply.

The basic, concomitant topographical relation between the segmental bronchus and artery shows derived figures in the dorsolateral part of the cranial portion of the mammalian lung, especially in humans. However, the pulmonary arterial supply has not been investigated well in the subsegmental level, even in humans. One or two subsegments of S2 received a double arterial supply from both the superior and inferior pulmonary trunks in 39.8% of the right upper lobes of 194 human lung dissections, whereas 20.6% did so in S3, although the latter cases were limited to one of the two subsegments. Moreover, we found several arterial patterns that were significantly frequently observed in a specific group of the bronchial tree in S2 and/or S3. Invasion of an additional artery of inferior trunk origin seemed to happen at the same time in both segments even without complementary territorial relations with the essential segmental artery of the superior trunk origin. S2 and S3 in the human right lung seemed to be the best fields for reconsideration of the basic rules in the lung segment system in mammals as a result of their having the largest sets of variations. We speculate that the discrepancy between the bronchial and arterial ramification patterns, which was frequently found in S2 and S3, is a result of a hypothetical secondary increase of the comparative volume of this area in evolution and/or development of the lung.

Individual variations in aging of the male urethral rhabdosphincter in Japanese.

Although the degenerative changes with aging of the male urethral rhabdosphincter (URS) have been investigated, its individual morphological variations are still unclear. To provide an anatomical basis for clinical evaluation of the individual URS function in the aged, we investigated the structural differences in the URS of 25 elderly Japanese men using semiserial sections stained immunohistochemically and by hematoxylin-eosin. Before removal of the histological specimens, we dissected the ischioanal fossa and labeled several structures by carbon particles to allow proper orientation during the histological observations. In addition, macroscopic slices (10 mm thickness) made from five other male pelves were examined and, when necessary, followed by routine histological procedure to confirm the gross observations. An extended circular URS (over (1/2) circumferential configuration) was found in 15/25 cadavers, but showed very limited height (proximal-distal length) and thickness. A more restricted URS, including even a thin, arc-like pattern, was observed in the remaining cadavers. The attachment of the URS to the smooth muscle layer was loose and usually clearly separated. Continuation between the URS and deep transverse perineal muscle was sometimes observed. The thick fascia of the levetor ani, with high content of smooth muscles, usually provided the lateral or dorsal insertions of the URS. Our results in elderly Japanese subjects suggest that the sphincteric action is weak or incomplete. We suggest that the elderly URS maintains continence by retracting the urethra backward and upward with the aid of the levator sling, rather than the real sphincteric action expected in younger men.

An anatomical study of short hepatic veins, with special reference to delineation of the caudate lobe for hanging maneuver of the liver without the usual mobilization.

BACKGROUND/PURPOSE: The present study was designed to anatomically assess a very recently reported hanging maneuver of the liver without mobilization, in which forceps are inserted blindly between the inferior vena cava (IVC) and liver parenchyma. METHODS: We dissected 56 formalin-fixed livers (1) to determine whether preservation of the caudate vein (the largest vein draining Spiegel's lobe) and inferior right hepatic vein (IRHV) was possible and (2) to identify the territories drained by other, non-preserved short hepatic veins. RESULTS: A potential space for insertion of the forceps was found between the openings of the caudate vein and IRHV; however, if preservation of both veins is absolutely necessary, we recommended protecting the IRHV, such as by taping and retracting it. We classified the other short hepatic veins into two categories, i.e., those draining the left portal vein territory and those draining the right territory. The distributions of the openings of the veins in these territories overlapped. CONCLUSIONS: Clear delineation of the left caudate lobe according to the drainage veins appeared to be difficult when the liver was divided along a straight line in front of the IVC.