Diogo Pais

Prostatic arterial supply: demonstration by multirow detector angio CT and catheter angiography.

ObjectivesTo evaluate the prostatic arterial supply with multidetector Angio CT and Digital Subtraction Angiography (DSA).MethodsDSA was performed in 21 male patients (7 of these also underwent Pelvic Angio CT); a further 4 patients only underwent Angio CT. Prostatic arteries were classified according to their origin, direction, number of pedicles, termination and anastomoses with surrounding arteries in 50 pelvic sides.ResultsThe most frequent origin was the internal pudendal artery (n = 28; 56%) with the common gluteal-pudendal trunk the next commonest (n = 14; 28%). Less frequent origins were the obturator artery (n = 6; 12%) or the inferior gluteal artery (n = 2; 4%). Two separate vascular pedicles were found in 12 pelvic sides (24%). There were anastomoses with the termination of the internal pudendal artery in 24% of cases (n = 12), with the contra-lateral prostatic arteries in 6 cases (12%), and to the superior vesical artery in 4 cases (8%).ConclusionsDefining prostatic artery origin and direction is paramount to allow selective catheterisation. Angio CT is very useful as a pre-intervention tool. The number of independent vascular pedicles and the presence of anastomoses with surrounding arteries should be taken into account when planning prostatic arterial embolisation.

A core syllabus for the teaching of neuroanatomy to medical students

There is increasingly a call for clinical relevance in the teaching of biomedical sciences within all health care courses. However, this presupposes that there is a clear understanding of what can be considered core material within the curricula. To date, the anatomical sciences have been relatively poorly served by the development of core syllabuses, particularly for specialized core syllabuses such as neuroanatomy. One of the aims of the International Federation of Associations of Anatomists (IFAA) and of the European Federation for Experimental Morphology (EFEM) is to formulate, on an international scale, core syllabuses for all branches of the anatomical sciences using Delphi Panels consisting of anatomists, scientists, and clinicians to initially evaluate syllabus content. In this article, the findings of a Delphi Panel for neuroanatomy are provided. These findings will subsequently be published on the IFAA website to enable anatomical (and other cognate learned) societies and individual anatomists, clinicians, and students to freely comment upon, and elaborate and amend, the syllabuses. The aim is to set internationally recognized standards and thus to provide guidelines concerning neuroanatomical knowledge when engaged in course development. Clin. Anat. 28:706–716, 2015.

A rare variant of the ulnar artery with important clinical implications: a case report

BackgroundVariations in the major arteries of the upper limb are estimated to be present in up to one fifth of people, and may have significant clinical implications.Case presentationDuring routine cadaveric dissection of a 69-year-old fresh female cadaver, a superficial brachioulnar artery with an aberrant path was found bilaterally. The superficial brachioulnar artery originated at midarm level from the brachial artery, pierced the brachial fascia immediately proximal to the elbow, crossed superficial to the muscles that originated from the medial epicondyle, and ran over the pronator teres muscle in a doubling of the antebrachial fascia. It then dipped into the forearm fascia, in the gap between the flexor carpi radialis and the palmaris longus. Subsequently, it ran deep to the palmaris longus muscle belly, and superficially to the flexor digitorum superficialis muscle, reaching the gap between the latter and the flexor carpi ulnaris muscle, where it assumed is usual position lateral to the ulnar nerve.ConclusionAs far as the authors could determine, this variant of the superficial brachioulnar artery has only been described twice before in the literature. The existence of such a variant is of particular clinical significance, as these arteries are more susceptible to trauma, and can be easily confused with superficial veins during medical and surgical procedures, potentially leading to iatrogenic distal limb ischemia.

Systematic Review and Meta-analysis of Unconventional Perfusion Flaps in Clinical Practice

Background: Although unconventional perfusion flaps have been in clinical use since 1975, many surgeons are still deterred from using them, because of some reports of high necrosis rates. Methods: The authors performed a systematic review and meta-analysis of all articles written in English, French, German, Spanish, and Portuguese on the clinical use of unconventional perfusion flaps and indexed to PubMed from 1975 until July 15, 2015. Results: A total of 134 studies and 1445 patients were analyzed. The estimated survival rate of unconventional perfusion flaps was 89.5 percent (95 percent CI, 87.3 to 91.3 percent; p < 0.001). Ninety-two percent of unconventional perfusion flaps (95 percent CI, 89.9 to 93.7 percent; p < 0.001) presented complete or nearly complete survival. Most defects mandating unconventional perfusion flap reconstruction were caused by trauma (63.6 percent), especially of the hand and fingers (75.1 percent). The main complication of all types of flaps was a variable degree of necrosis (7.5 percent of all unconventional perfusion flaps presented marginal necrosis; 9.2 percent and 5.5 percent had significant and complete necrosis, respectively). There was a positive correlation between the rate of postoperative infection and the need for a new flap (Pearson coefficient, 0.405; p = 0.001). Flaps used to reconstruct the upper limb showed better survival than those transferred to the head and neck or to the lower limb (p < 0.001). Conclusion: Unconventional perfusion flaps show high survival rates and should probably be used more liberally, particularly in the realm of upper limb reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

How optional should regional anatomy be in a medical course? An opinion piece

The use of optional (elective) courses within the medical curriculum is increasingly being seen as a way of allowing students to pursue their studies according to their personal interests. For anatomy, particularly where the subject is being taught in an integrative curriculum and by means of a systemic approach, the development of elective regional anatomy courses is being employed to reintroduce regional anatomy and/or dissection by students. However, there is presently little evidence that objectively evaluates optional/elective courses. In this paper we critique the concept and practice of using elective courses and assess whether their deployment is ultimately in the interests of medical education, the medical profession, society in general and the layperson (potential patient) in particular. Clin. Anat. 29:702–710, 2016.

The attitudes of medical students in Europe toward the clinical importance of embryology.

Although there have been many studies reporting the attitudes of medical students to the clinical importance of gross anatomy, little is known about their opinions concerning the clinical importance of embryology. Using Thurstone and Chave methods to assess attitudes, nearly 1,600 medical students across Europe in the early stages of their training provided responses to a survey that tested the hypothesis that they do not regard embryology as highly clinically relevant. Indeed, we further proposed that student attitudes to gross anatomy are much more positive than those toward embryology. Our findings show that our hypotheses hold, regardless of the university and country surveyed and regardless of the teaching methods employed for embryology. Clearly, embryology has a significant part to play in medical education in terms of understanding prenatal life, of appreciating how the organization of the mature human body has developed, and of providing essential information for general medical practice, obstetrics and pediatrics, and teratology. However, while newly recruited medical students understand the importance of gross anatomy in the development of professional competence, understanding the importance of embryology requires teachers, medical educationalists, and devisors of medical curricula to pay special attention to informing students of the significant role played by embryology in attaining clinical competence and achieving the knowledge and understanding of the biomedical sciences that underpins becoming a learned member of a health care profession. Clin. Anat. 29:144–150, 2016.

A critique of utilitarian and instrumentalist concepts for the teaching of gross anatomy to medical and dental students: Provoking debate

Medical and dental curricula, together with anatomical sciences courses, are increasingly having to change, mainly because there is a drive to being what is termed, without adequate definition, “clinically relevant.” The concept of “clinical anatomy” has accordingly been invented and it is expected that, at all times, the teaching of anatomy is directly focused on clinical scenarios, meaning almost invariably the disease‐based model of medicine and dentistry. Furthermore, students are not expected to have a detailed knowledge of gross anatomy and the time devoted to teaching and learning the subject has decreased significantly. The notion being fostered is that knowledge is not required “just in case” but “just in time.” However, the absence of agreed core syllabuses that are internationally accepted complicates a discussion about what is relevant practically and what does not need to be taught. In this article, we critique such an utilitarian and instrumentalist approach to the teaching of gross anatomy within medical and dental curricula. We draw attention to the need to embrace the functionality‐based model of medicine and dentistry by returning to an understanding that the role of the medical or dental practitioner is to value health and to restore to functionality the ill person or the pathologically affected region/organ/system. A fuller knowledge of anatomy than is presently taught is regarded as a prerequisite for appreciating normality and health. A further problem with the instrumentalist approach to medical education is that, by concentrating on what is seen to be at the time “useful” or “clinically relevant,” there is the danger of undermining, or discouraging, future developments that rely on what contemporaneously seems “useless” and “irrelevant” knowledge. Finally, the reliance instrumentalism has on just what is pragmatic and regardless of scientific validity is contrary to the ethos and practice of a university education that values deep learning and the development of learnèd professions. Clin. Anat. 30:912–921, 2017.

Paresthesia and hypesthesia in the dorsum of the foot as the presenting complaints of a ganglion cyst of the foot

Although ganglion cysts of the foot represent a substantial amount of lumps in this region, they rarely cause peripheral nerve symptoms. We describe the clinical case of a 43‐year‐old female with complaints in the previous three months of hypesthesia and paresthesia in the anterior portion of the medial half of the dorsum of her left foot that extended into the first interdigital cleft. She associated the start of her neurological symptoms to the appearance of a lump in the dorsum of the foot. A presumptive diagnosis of compression of the medial branch of the deep fibular nerve and of the medial dorsal cutaneous nerve in the dorsum of the foot by a ganglion cyst was made. Ultrasonography confirmed the cystic nature of the lesion and surgery allowed complete excision of a mass arising from the joint between the medial and intermediate cuneiform bones that was compressing the deep fibular nerve and the medial dorsal cutaneous nerve. Pathological examination confirmed that the lesion was a cystic ganglion. As far as the authors know, the simultaneous compression of the medial branch of the deep fibular nerve and of the medial dorsal cutaneous nerve in the dorsum of the foot by a ganglion cyst has not been described before. Clin. Anat. 23:606–610, 2010.

Reconstruction of a 10-mm-long median nerve gap in an ischemic environment using autologous conduits with different patterns of blood supply: A comparative study in the rat

The aim of this study was to evaluate in the Wistar rat the efficacy of various autologous nerve conduits with various forms of blood supply in reconstructing a 10-mm-long gap in the median nerve (MN) under conditions of local ischemia. A 10-mm-long median nerve defect was created in the right arm. A loose silicone tube was placed around the nerve gap zone, in order to simulate a local ischemic environment. Rats were divided in the following experimental groups (each with 20 rats): the nerve Graft (NG) group, in which the excised MN segment was reattached; the conventional nerve flap (CNF) and the arterialized neurovenous flap (ANVF) groups in which the gap was bridged with homonymous median nerve flaps; the prefabricated nerve flap (PNF) group in which the gap was reconstructed with a fabricated flap created by leaving an arteriovenous fistula in contact with the sciatic nerve for 5 weeks; and the two control groups, Sham and Excision groups. In the latter group, the proximal stump of the MN nerve was ligated and no repair was performed. The rats were followed for 100 days. During this time, they did physiotherapy. Functional, electroneuromyographic and histological studies were performed. The CNF and ANVF groups presented better results than the NG group in the following assessments: grasping test, nociception, motor stimulation threshold, muscle weight, and histomorphometric evaluation. Radial deviation of the operated forepaw was more common in rats that presented worse results in the other outcome variables. Overall, CNFs and ANVFs produced a faster and more complete recovery than NGs in the reconstruction of a 10-mm-long median nerve gap in an ischemic environment in the Wistar rat. Although, results obtained with CNFs were in most cases were better than ANVFs, these differences were not statistically significant for most of the outcome variables.

Reconstruction of a long defect of the ulnar artery and nerve with an arterialized neurovenous free flap in a teenager: A case report and literature review

There is evidence that nerve flaps are superior to nerve grafts for bridging long nerve defects. Moreover, arterialized neurovenous flaps (ANVFs) have multiple potential advantages over traditional nerve flaps in this context. This paper describes a case of reconstruction of a long defect of the ulnar artery and nerve with an arterialized neurovenous free flap and presents a literature review on this subject. A 16‐year‐old boy sustained a stab wound injury to the medial aspect of the distal third of his right forearm. The patient was initially observed and treated at another institution where the patient was diagnosed with a flexor carpis ulnaris muscle and an ulnar artery section. The artery was ligated and the muscle was sutured. Four months later, the patient was referred to our institution with complaints of ulnar nerve damage, as well as hand pain and cold intolerance. Physical examination and ancillary tests supported the diagnosis of ulnar artery and nerve complete section. Surgery revealed an 8 cm hiatus of the ulnar artery and a 5 cm defect of the ulnar nerve. These gaps were bridged with a flow through ANVF containing the sural nerve and the lesser saphenous vein. The postoperative course was uneventful. Two years postoperatively, the patient had regained normal trophism and M5 strength in all previously paralyzed muscles according to the Medical Research Council Scale. Thermography revealed good perfusion in the right ulnar angiosome. The ANVF may be an expedite, safe and efficient option to reconstruct a long ulnar nerve and artery defect.