Anatomy of the vesicovaginal fascia and its relation to branches of the inferior hypogastric plexus.

The inferior hypogastric plexus (IHP) lies in the extraperitoneal pelvis, and supplies branches to pelvic and perineal viscera. In men, the rectoprostatic fascia (Denonvillier's fascia) forms a distinct double fascial layer between the seminal glands and the rectum. The hypogastric nerve projections to the prostate and seminal glands run anterior to this. An analagous fascial layer in women between the vagina and cervix posteriorly and the urinary bladder anteriorly has recently been described. The purpose of this study was to examine the anatomy of the vesicovaginal fascia (VVF) and to determine its relationship to the anterior branches of the IHP. This dissection study examined the fascial layers between the posterior urinary bladder and anterior vagina/cervix (VVF) in 15 female embalmed cadavers and three fresh specimens. Anterior branches of the IHP were identified and followed distally. The relationship between these nerve projections and the VVF was examined. In 16 dissection, the VVF was identified as a complete fascial plane extending beneath the vesicouterine pouch to the neck of the bladder inferiorly and to the endopelvic fascia laterally. Anterior projections from the hypogastric nerves and IHP maintained an extraperitoneal course passing anteriorly to the VVF towards the urinary bladder The VVF is a distinct fascial structure and projections of the hypogastric nerves pass anterior to this. This may have implications for nerve sparing hysterectomy.

Increasing Perfusion Pressure Does Not Distend Perforators or Anastomoses but Reveals Arteriovenous Shuntings.

BACKGROUND: It has been proposed that hyperperfusion of perforators and distension of anastomotic vessels may be a mechanism by which large perforator flaps are perfused. This study investigates whether increasing perfusion pressure of radiographic contrast in cadaveric studies altered the radiographic appearance of vessels, particularly by distending their anastomotic connections. METHODS: From 10 fresh cadavers, bilateral upper limbs above the elbow were removed. Three cadavers were excluded. Seven pairs of limbs were injected with lead oxide solutions via the brachial artery while distally monitoring intravascular pressure in the radial artery using a pressure transducer. One limb was injected slowly (0.5 mL/s) and the other rapidly (1.5 mL/s) to produce low and high perfusion pressures, respectively. Skin and subcutaneous tissue were then removed and radiographed. RESULTS: The filling of perforators and their larger caliber branches appeared unchanged between low- and high-pressure injections, with no significant increase in true anastomoses (P = 0.32) and no association between maximum perfusion pressure and number (P = 0.94) or caliber (P = 0.10). However, high-pressure injections revealed arteriovenous shunting with filling of the tributaries of the major veins. CONCLUSIONS: This study demonstrated that increased perfusion pressure of the cutaneous arteries (1) did not change the caliber of vessels; (2) did not convert choke to true anastomoses; and (3) revealed arteriovenous shunting between major vessels with retrograde filling of venous tributaries as pressure increased. This suggests that it is not possible to distend anastomotic connections between vascular territories by increasing perfusion alone.

Early Life Conditions and Immune Defense in Nestling Swainson's Hawks.

The quality of perinatal conditions directly influences the physical and immunological development of nestlings, yet it is inherently variable across space and time. Long-term breeding data for a population of Swainson's hawks (Buteo swainsoni) in northern California show a continuum of territory occupancy and productivity values of individual territories and nests. Here we explore effects of variation among territories on immune system development. We hypothesize that nestlings benefitting from favorable conditions will invest in stronger immune systems, a trait with long-term benefits. We used two immunological assays, a bactericidal assay and a hemolytic-complement activity assay, with leukocyte differentials (heterophil∶lymphocyte ratio) to evaluate the constitutive innate immune system. We examined whether early brood-rearing conditions (i.e., number of siblings, hatch date, endoparasite prevalence) were associated with immunological development. Linear mixed-effects models indicated a positive relationship between extended territory occupancy history-an index of habitat quality-and nestling immune function during years with poorer reproduction. There was no association during an exceptionally good reproductive year. Hence, at least under some circumstances, nestling environments or territory characteristics may affect immune function of nestlings. Our study contributes to the growing body of evidence highlighting the importance of facultative allocation to immune traits using long-term demographic data of a top avian predator.

Motivations & Experiences of Postgraduate Anatomy Training.

This article was migrated. The article was marked as recommended. Background: Anatomy teaching at medical schools has undergone significant changes in philosophy, and reduction in content, in recent years. Senior clinicians and speciality training Colleges have raised concerns regarding these changes and questioned their impact on 'anatomical competence' and adequacy of training for safe clinical practice. The literature on the perceptions of medical school anatomy teaching among those preparing to enter post-graduate training (i.e. towards a specialist qualification) is sparse. Aim: To assess the motivations for study, and experiences of training, in junior doctors undertaking an intensive post-graduate anatomy training program. Methods: A sample of candidates (13/119, 10%) undertaking the University of Melbourne Graduate Diploma in Surgical Anatomy were recruited for interview. These interviews were recorded, transcribed and then analysed using a combination of thematic and contextual approaches. Key themes were identified and explored. Results: Participant responses fell into two broad categories - motivations for enrolling into the course and their actual experiences of the course. The primary motivation for enrolling into the course was the perceived career requirement to do so, with participants asserting that attending such courses was perceived as mandatory for success in specialty training. Once enrolled, participants valued the teaching and learning and enjoyed the academic pursuit of high-level anatomy study. These benefits, however, were offset by a range of undesirable outcomes associated with undertaking the course. Participants identified the financial cost of the course, the unwillingness of employers to provide rostered study leave and the negative impact on work-life balance as the most significant challenges. Conclusions: Understanding the concerns and expectations of junior doctors preparing for a speciality training program by increasing their anatomy knowledge has implications for both Colleges and medical educators. The participants in this study recognised the limitations in their anatomy knowledge and actively sought additional training at significant financial and personal cost to themselves. This was counterbalanced by the perceived benefits to their career, and an opportunity to enter a specialist training program, by completing additional study.

Prediction of ischial ramal angle for transfemoral ischial containment sockets.

BACKGROUND:: A well-fitting and comfortable ischial containment socket relies on accurately replicating the transverse plane angle of the ischium and ischial ramus angle, inside the medial socket brim. Prediction of the ischial ramus angle, may provide a way to determine the ischial ramus angle without in vivo measurement. OBJECTIVES:: To determine the accuracy with which the ischial ramus angle could be predicted and identify which variables contributed significantly to the prediction. STUDY DESIGN:: Cross-sectional study. METHODS:: Computed tomography scans were randomly sampled from a cadaveric database (n = 200). Standard multiple regression models were developed to predict the ischial ramus angle based on pelvic measures. RESULTS:: The regression model explained 10.5% of the variance in ischial ramus angle (p = 0.018). The standard error of the estimate was 11.32°. While regression models by sex explained a larger proportion of the variance, the resulting accuracy was not improved. CONCLUSION:: The regression models explained a small proportion of variance in ischial ramus angle. The average error associated with the prediction was too large to accurately predict the ischial ramus angle for use in clinical practice. Contrary to commonly held beliefs, there was no statistically significant difference in ischial ramus angle between sexes. CLINICAL RELEVANCE: Prediction of ischial ramus angle does not have sufficient accuracy to be clinically useful, but descriptive data may help clinicians identify casting errors and correct these in a plaster positive, knowing that the average ischial ramus angle was 32.65°±5.59° (relative to mid-sagittal plane) and does not vary between sexes.

The Relationship of Superficial Cutaneous Nerves and Interperforator Connections in the Leg: A Cadaveric Anatomical Study.

BACKGROUND: The lower limb is a source of many flaps both for closure of local defects and for free transfer. Fasciocutaneous flap techniques have been progressively refined, although the vascular basis for their success needs clarification. METHODS: Archival studies of 48 lower limbs were reviewed and combined with 20 studies of lower limbs from fresh cadavers, making a total of 68 investigations. Lower limbs were injected with a dilute lead oxide solution; the integument was removed and radiographed; and the cutaneous nerves were dissected, tagged with wire, radiographed again, and their paths traced on the original images. RESULTS: The major cutaneous nerves in the leg are paralleled by a longitudinal vascular axis often comprising long branches with large-caliber true anastomotic connections between perforators. The most highly developed vascular axes followed the medial sural cutaneous and saphenous nerves, together with their accompanying veins, immediately superficial to the deep fascia. The intervening areas were characterized by shorter branches usually connected by small-caliber choke anastomotic connections. CONCLUSIONS: These findings provide the anatomical basis for the observed reliability of longitudinal flaps in the leg. The superficial cutaneous nerves of the leg, especially the saphenous and medial sural cutaneous nerves, are paralleled by a vascular axis on or beside the nerve comprising long perforator branches connected usually but not always by large-caliber true anastomotic connections. This emphasizes the importance of understanding the characteristics of interperforator anastomoses when designing and raising flaps.

Predicting the location of the hip joint centres, impact of age group and sex.

Clinical gait analysis incorporating three-dimensional motion analysis plays a key role in planning surgical treatments in people with gait disability. The position of the Hip Joint Centre (HJC) within the pelvis is thus critical to ensure accurate data interpretation. The position of the HJC is determined from regression equations based on anthropometric measurements derived from relatively small datasets. Current equations do not take sex or age into account, even though pelvis shape is known to differ between sex, and gait analysis is performed in populations with wide range of age. Three dimensional images of 157 deceased individuals (37 children, 120 skeletally matured) were collected with computed tomography. The location of the HJC within the pelvis was determined and regression equations to locate the HJC were developed using various anthropometrics predictors. We determined if accuracy improved when age and sex were introduced as variables. Statistical analysis did not support differentiating the equations according to sex. We found that age only modestly improved accuracy. We propose a range of new regression equations, derived from the largest dataset collected for this purpose to date.

Prediction of Skeletal Medial-Lateral for transfemoral ischial containment sockets.

Accurate measurement of the pelvis is critical for well-fitting and comfortable ischial containment sockets. The "Skeletal Medial-Lateral (ML)" is intrusive and unreliable to measure in vivo. This study aimed to determine how accurately the Skeletal ML could be predicted and to identify which measurements were significant predictors. Computed tomography scans were randomly sampled from a cadaveric database (n = 200). Inclusion criteria were age > 20 yr; lower-limb alignment that replicated the anatomical position; and no evidence of osteological trauma, implants, or bony growths. Multivariate linear regression models were developed to predict the Skeletal ML based on a suite of independent variables, including sex, body mass, and distance between pelvic landmarks. The regression model explained 76% of the variance in the Skeletal ML (p < 0.001). Variables that contributed significantly to the prediction of the Skeletal ML (p < 0.05) included body mass, sex, inter-greater trochanter distance, pelvic depth, and age. Significant predictors of the Skeletal ML dimension characterize variation in subcutaneous adipose tissue thickness and pelvic morphology. The Skeletal ML could be predicted with relatively small errors (standard error of the estimate = 7 mm) that could be easily and reliably adjusted during socket fitting. Further research is needed to test the predictive tool in a real-world setting.

A review of factors predicting perioperative death and early outcome in hepatopancreaticobiliary cancer surgery.

OBJECTIVES: In the context of comparisons of surgical outcomes, risk adjustment is the retrospective adjustment of a provider's or a surgeon's results for case mix and/or hospital volume. It allows accurate, meaningful inter-provider comparison. It is therefore an essential component of any audit and quality improvement process. The aim of this study was to review the literature to identify those factors known to affect prognosis in hepatobiliary and pancreatic cancer surgery. METHODS: PubMed was used to identify studies assessing risk in patients undergoing resection surgery, rather than bypass surgery, for hepatobiliary and pancreatic cancer. RESULTS: In total, 63 and 68 papers, pertaining to 24 609 and 63 654 patients who underwent hepatic or pancreatic resection for malignancy, respectively, were identified. Overall, 22 generic preoperative factors predicting outcome on multivariate analysis, including demographics, blood results, preoperative biliary drainage and co-morbidities, were identified, with tumour characteristics proving disease-specific factors. Operative duration, transfusion, operative extent, vascular resection and additional intra-abdominal procedures were also found to be predictive of early outcome. CONCLUSIONS: The development of a risk adjustment model will allow for the identification of those factors with most influence on early outcome and will thus identify potential targets for preoperative optimization and allow for the development of a multicentre risk prediction model.

Ultrasound-guided midthigh sciatic nerve block-a clinical and anatomical study.

BACKGROUND AND OBJECTIVES: Ultrasound-guided sciatic nerve block is a relatively new regional anesthesia technique with few descriptions in the literature. The objective of this study was to assess the ease with which the sciatic nerve could be imaged in the midthigh region using ultrasound and to describe the anatomy surrounding the sciatic nerve at this location. METHODS: In this prospective observational study, 40 patients scheduled for surgery where sciatic nerve block was indicated were scanned between the gluteal and the popliteal regions using an ultrasound machine (Vivid-i, GE Healthcare, Chalfont St. Giles, Bucks, UK). Patients then received real time ultrasound-guided sciatic nerve block. Validation of the ultrasound image of the sciatic nerve was achieved using nerve stimulation. Description and confirmation of the anatomy surrounding the sciatic nerve was based on a review of anatomical texts and an anatomical study on 5 unembalmed cadavers. RESULTS: The sciatic nerve was identified with ultrasound and its image validated using nerve stimulation in 38 of 40 patients (95%). In 15 patients (37.5%) nerve stimulation was required to confirm identification of the sciatic nerve. Surrounding muscles (biceps femoris, vastus lateralis, and adductor magnus) and fascial planes (lateral intermuscular septum) were identified as sonographic landmarks and were confirmed in the anatomical study. CONCLUSIONS: Ultrasonic identification of the sciatic nerve at the midthigh level can be achieved; however, in this study, 37.5% of patients required nerve stimulation to confirm its sonographic appearance. Target nerve localization and the subsequent performance of the sciatic nerve block may be enhanced by recognition of surrounding muscular and fascial structures which were also identified using ultrasound.

Guidelines for the effective conduct of mass burials following mass disasters: post-Asian tsunami disaster experience in retrospect.

The frequency of mass disasters is increasing, demanding actions that deal with these promptly and effectively to secure human interests. An undeniable and inevitable reality of any mass disaster is the massive number of fatalities, which will give rise to a further chain of events ranging from the recovery of the deceased, to their transport, storage, identification and, finally, disposal. Past experience has shown that traditional human disposal methods should be redesigned according to the requisites of mass fatality scenarios, and it has been proven that a proper mass burial is by far the most appropriate and standard method for disposal of the dead due to mass disasters as it takes all its practical issues into consideration. A mass burial can be defined as burying more than one deceased of a single or related incident in a single grave or multiple graves simultaneously or separately within a restricted time period in a single or multiple burial sites located within an identified geographical area. In the present context, it is an utmost necessity that we develop uniform detailed guidelines for the proper conduct of mass burials that provide the deceased with all due respect to human dignity, as this will enable these guidelines to be incorporated into future national mass disaster management schemes as an integral component.

Anatomical study of the obturator foramen and dorsal nerve of the clitoris and their relationship to minimally invasive slings.

OBJECTIVES: The objective of the study is to clarify potential risks to the dorsal nerve of the clitoris (DNC) and obturator canal using different minimally invasive slings. STUDY DESIGN: Ten embalmed hemipelves were dissected to demonstrate the course of the DNC and the obturator canal. On each cadaver, tension-free vaginal tape (TVT), transobturator in-out (TVT-O) and transobturator out-in (Monarc) procedures were performed. Distances between the DNC and the obturator canal to the different devices were measured. RESULTS: The DNC passes beneath the pubic bone at a distance of 14.3 +/- 4.7 mm of the midline. The distances of the different devices to the DNC were similar. The distance to the obturator canal was significantly different, with TVT being the furthest (40.1 +/- 3.7 mm) and TVT-O the closest (19.3 +/- 3.1 mm; p < 0.0001). CONCLUSION: Given the course of the DNC along the medial aspect of the ischiopubic ramus, the out-in technique may be safer. The in-out technique is the closest to the obturator canal.

Neonatal paratesticular abscess mimicking perinatal torsion.

Management of perinatal torsion varies between centers from urgent surgical exploration and contralateral fixation to conservative nonoperative management. We present a case of paratesticular abscess in a neonate mimicking a perinatal torsion which may influence management of this condition in some cases.