Anatomy: a must for teaching the next generation.

Teaching anatomy to both undergraduate medical students and medical graduates is in the midst of a downward spiral. The traditional anatomy education based on topographical structural anatomy taught by didactic lectures and complete dissection of the body with personal tuition, has been replaced by a multiple range of special study modules, problem-based workshops, computers, plastic models and many other teaching tools. In some centres, dissected cadaver-based anatomy is no longer taught. Changing the undergraduate medical curriculum in the UK has taken place without any research into the key aspects of knowledge necessary or comparing methods of teaching. There is no agreement on a common national core curriculum and as a result, numerous new curricula have been introduced. No external audit or validation is carried out, so medical schools have been free to teach and assess their own work themselves. There is a great divergence in medical schools across the UK and Ireland in teaching medicine in general and anatomy in particular. Published data on the impact of these changes is scant. The reduction in undergraduate teaching and knowledge of anatomy has caused great concern, not only for undergraduates but also to postgraduate students, especially in surgery. This, together with a change in basic surgical training, a marked reduction in demonstrator posts and a change in examination standards, has set up a system that is allowing young men and women with a poor knowledge of anatomy to become surgeons. There should be a full public debate at every level; the Royal Colleges, specialist associations, the Universities, Government, both health and education. This debate should highlight areas of concern, explore in depth and define a minimal core curriculum for anatomy. Teaching must be enhanced with a critical look at both teachers and methods. The dominance of research must be reassessed to establish an equitable cohabitation with teaching. The place of basic science, especially anatomy in basic surgical teaching, must be examined. A thorough knowledge of anatomy should be required in the new MRCS-UK. This should be mandatory as a preliminary to higher surgical training. The teaching of anatomy in surgical specialities must be improved. Does the dissecting room still have a place in educating our under- and postgraduate students? Yes--a sound knowledge of anatomy is essential if the medical practitioner is going to accurately define and successfully treat the problem presented by the patient. The dissected cadaver remains the most powerful means of presenting and learning anatomy as a dynamic basis for solving problems. The cadaver must not be dismissed as obsolete. Dissection has survived the most rigorous test of pedagological fitness--the test of time. The student--cadaver--patient encounter is paramount in medical education.

Cutaneous benign mixed tumor (chondroid syringoma) of the eyelid: clinical presentation and management.

PURPOSE: To describe the clinical presentation of cutaneous benign mixed tumor of the eyelid and its management options. METHODS: Periocular cases of cutaneous benign mixed tumor were gathered from members of an oculoplastics specialty Internet discussion group. A total of 9 patients are described in this retrospective, interventional case series. The clinical presentation, histopathology, and management of these lesions is reviewed. RESULTS: Patients were typically asymptomatic, presenting with a slowly enlarging, nontender nodule of 2 to 8 years' duration. The lesions ranged from 4 mm to 17 mm in greatest dimension. Four of the lesions were on the eyelid margin, three in the sub-brow area of the upper eyelid, and two in the central lids. All six cases not involving the brow were fixed to the tarsus; one brow lesion was believed to be adherent to the skin. None of the lesions was associated with significant changes of the overlying epidermis, although one lesion showed overlying pigmentation. All patients underwent excisional biopsy for diagnostic or cosmetic reasons. On histopathologic examination, the tumors were biphasic, with an epithelial component exhibiting apocrine or hair follicle differentiation and a myxoid, adipocytic, chondroid, and/or fibrous stroma. The pathologic diagnoses were all consistent with cutaneous benign mixed tumor (chondroid syringoma, pleomorphic adenoma). Follow-up ranged from 2 weeks to 12 months, although several patients failed to keep scheduled follow-up appointments. No clinical recurrences were identified. CONCLUSIONS: Cutaneous benign mixed tumor may occur in the eyelid, and, although uncommon, should be included in the differential diagnosis of firm, nodular eyelid tumors. The histopathologic features are similar to those seen in this tumor type arising in other areas of the body. Preoperative consideration of this diagnostic possibility may allow the surgeon to plan for complete excision, thereby reducing the possibility of recurrence or malignant transformation.

Secretory villous adenomas that cause depletion syndrome.

Secretory villous adenomas of the colon have been known to cause a depleting syndrome characterized by dehydration, prerenal azotemia, hyponatremia, hypokalemia, metabolic acidosis, obtundation, and, in severe cases, death. We describe 1 case of classic depleting syndrome and review the literature on possible mechanisms. Both cyclic adenosine monophosphate and prostaglandin E2 have been implicated as possible secretagogue compounds in the pathogenesis of this syndrome unique to the secretory variant form of villous adenomas. Indomethacin as a prostaglandin inhibitor has been used with apparent benefit in controlling the volume of rectal effluent in patients with secretory villous adenomas.

Pyomyositis.

In the past, most cases of pyomyositis occurred among persons living in tropical climates, with the most common pathogen being Staphylococcus aureus. Increased numbers of cases have been reported more recently in North America, particularly in immunocompromised persons, such as those infected with the human immunodeficiency virus (HIV) and those with diabetes mellitus. These patients present with a wider variety of pathogens, including gram-negative bacteria, Streptococcus groups B, C and G, and Mycobacterium avium. Therefore, it seems prudent to consider pyomyositis in the differential diagnosis of persons with HIV infection, diabetes mellitus or other immunocompromising conditions, who present with persistent or worsening muscle aches and pains. Antibiotic treatment with a pencillinase-resistant penicillin is recommended for up to six weeks.

Ptosis repair and blepharoplasty in the adult.

When contemplating upper lid ptosis and blepharoplasty surgery, preoperative evaluation is essential so that the patient and the surgeon have similar expectations as to the final result of the surgery. Blepharoplasty and ptosis repair can be performed as a combined procedure in the adult. The procedure involves excising excess skin and underlying orbicularis muscle, and in some cases, orbital fat. The levator aponeurosis is advanced onto the tarsus and the excess levator excised. An eyelid crease is formed during closure by passing a suture through the advanced aponeurosis.

Upper lid blepharoplasty and ptosis repair using a transcutaneous approach.

Ptosis repair can be combined with a transcutaneous upper eyelid approach. The procedure includes removal of the excess skin, underlying orbicularis, and, possibly, orbital fat combined with levator aponeurosis advancement. Excellent results have been achieved for patients with dermatochalasis and ptosis causing significant visual field abnormalities, as well as for patients with no visual field abnormalities who desire improved cosmesis.

Testing drugs on human osteoarthritic articular cartilage.

New drugs are generally developed against animal models of the human disease. Before they are subjected to clinical trials it might be helpful to be able to test whether they are as effective against the disease in human tissue as they were in animals. It is proposed that this can be achieved by the use of organ maintenance culture of the human diseased tissue, the relevant biochemical parameters being measured by quantitative cytochemistry. In the present studies differences between the effect of indomethacin and of the 'chondroprotective' drug diclofenac sodium, on human osteoarthritic cartilage, have been measured.

Canaliculorhinostomy following dacryocystectomy for removal of a benign fibrous histiocytoma of the lacrimal sac.

A 41-year-old woman had epiphora and a right lacrimal sac mass. A solid mass filling the entire lacrimal sac was found at surgery. After a month of testing and evaluation at the Armed Forces Institute of Pathology, the final diagnosis was benign fibrous histiocytoma. A dacryocystectomy was performed, and the entire tumor was removed. The area of the common canaliculus was then attached to a nasal mucosal flap, and the system was intubated with silicone tubing for 1 year. Two years after the tubing was removed, the epiphora had resolved and there was no recurrence of the tumor.

Abnormalities of DNA in human osteoarthritic articular cartilage.

The normal amount of DNA in human diploid nuclei was determined by the use of the Feulgen reaction measured by microdensitometry. The DNA-content of nuclei in normal human articular cartilage was determined in nuclei of zones 3 and 4 of cartilage of the femoral head removed from osteoporotic fractured necks of femur. Analysis of the results indicated that a degree of synthesis of DNA occurred even in these zones of very elderly persons. Results on these zones in the articular cartilage of osteoarthritic joints indicated that different populations occurred. In some there was DNA-synthesis related to tetraploidy; in others, the DNA was very stable to acid hydrolysis with no sign of biosynthetic activity; in the last group, which contained erosions of the superficial zones, the DNA was unstable to hydrolysis.

Surgical treatment of eyelid retraction associated with thyroid eye disease.

Fifteen patients (22 eyelids) were treated for upper eyelid retraction related to thyroid eye disease by recessing the levator aponeurosis and Müller's muscle through a lid crease incision. Neither spacers nor traction sutures were used, and the recessed muscles were not sutured to any of the surrounding tissues. The patients were not sedated and thus were able to sit up during the procedure; final lid heights also were determined with the patients in the sitting position. There were no overcorrections or undercorrections during follow up of at least 3 months.

Advances in oculoplastic surgery.

Ophthalmic plastic surgery, a sub-specialty within ophthalmology, encompasses diagnosis and treatment of diseases and abnormalities of the eyelids, orbit, and lacrimal systems. Eyelid carcinoma is a more common entity as well as blepharoptosis seen in children and adults. It can usually be corrected by surgery involving the levator palpebrae superioris or a tarsofrontalis suspension using synthetic material or human tissue. Retraction of the upper eyelid, the opposite of blepharoptosis, may be seen in patients with thyroid eye (Graves') disease. Treatment by recession of the levator aponeurosis and Muller's sympathetic muscle yields excellent results. Blepharoplasty and other procedures frequently performed by the ophthalmic plastic surgeon can be done for cosmetic or functional (correction of vision) reasons and often in conjunction with other eyelid surgery such as ptosis repair.

A controlled trial of sip-feed supplements in elderly orthopaedic patients.

The potential nutritional and clinical benefits of sip-feed supplements were investigated by means of a controlled trial in elderly female patients admitted for orthopaedic surgery. A nutritional risk assessment procedure (Nutritional Risk Questionnaire, NRQ) was used to identify patients who might benefit from supplementation. Patients identified as high risk who did not receive supplements showed significant losses in triceps skinfold thickness (TSF) and mid-upper arm muscle circumference (MUAMC) measurements during hospitalization. Such changes were not observed in high-risk supplemented patients, but significant losses of MUAMC were also recorded in a group of patients who failed to comply with the supplement. No differences in biochemical parameters, muscle function, or clinical outcome were observed between supplemented and unsupplemented and non-compliant patients. The problems of poor compliance to sip-feed supplements and failure to observe clinical benefit in supplemented patients are discussed.

The first four years' experience of day case orthopaedic surgery in a district general hospital.

Clinical data were obtained for 2838 consecutive patients admitted to a new day case unit in a district general hospital by four consultant surgeons between 1 October 1981 and 30 September 1985. Surgical procedures under general anaesthesia: on 2581 patients were analysed in detail. Intra-articular arthroscopic surgery was performed on 60% of knees. A fifth of patients had manipulation and intra-articular infection of a joint. Surgical operations involving the hands and forearm were required by 17%. Toe surgery was performed on 11% of patients of whom 21% had a distal metatarsal osteotomy. Overnight admission was necessary for 6% of patients because of postanaesthetic difficulties, the operation occurring too late in the day or proving more extensive. The use of day case facilities was an economic saving, pleased 98% of patients and reduced waiting list time significantly, except for patients with serious chronic joint disorders. The waiting list for total hip and knee replacements increased in the four year period.

Cytological assessment of knee effusions.

Effusion fluid from 80 knee joints was obtained from patients prior to arthroscopy and arthroscopic surgery and submitted to independent physicochemical analysis and cytological examination. The majority of the effusions were secondary to osteoarthrosis and traumatic mechanical derangement. These two conditions gave nonspecific findings on physicochemical analysis and cytology, and the cytologist diagnosed on 13% of these correctly. Cytological examination of fluid from rheumatoid knees revealed ragocytes in just over half the cases, and on this basis, the cytologist was able to correctly diagnose rheumatoid arthritis. Contrary to other reports, we conclude that physicochemical analysis and cytological examination of joint fluid is of little value in the assessment of knees presenting to the orthopaedic surgeon.

Bilateral lymphocytic infiltrates causing dacryostenosis after bilateral successful dacryocystorhinostomies.

A 73-year-old woman with a history of chronic lymphocytic leukemia had bilateral dacryocystorhinostomies for bilateral chronic dacryocystitis. The procedures were performed 7 months apart. Twenty-four months after the first dacryocystorhinostomy on the left side, the patient developed a mass in the area of the left lacrimal sac causing epiphora. A repeat dacryocystorhinostomy revealed a lymphocytic infiltrate causing the left dacryostenosis. Thirty-three months after the right dacryocystorhinostomy, the patient developed a right dacryostenosis with epiphora and no mass. Pathology specimens obtained during a repeat dacryocystorhinostomy on the right side revealed a similar lymphocytic infiltrate. This case is an unusual presentation of solid lymphoma in a traumatized area in a patient with chronic lymphocytic leukemia.