Edgardo Enrico Edoardo Picardi

Medical professional values and education: A survey on Italian students of the medical doctor school in medicine and surgery

Background: The values such as participation/empathy, communication/sharing, self-awareness, moral integrity, sensitivity/trustfulness, commitment to ongoing professional development, and sense of duty linked to the practice of the medical professionalism were defined by various professional oaths. Aims: The aim of this study was to evaluate how these values are considered by the students of the degree course of medicine. Materials and Methods: Four hundred twenty three students (254 females, 169 males) taking part of the first, fourth, and fifth years of the degree course in medicine were asked to answer seven questions. Pearsons Chi-square, Wilcoxon rank sum test, and Kruskal–Wallis test were used for the statistical analysis. Results: The survey showed a high level of knowledge and self-awareness about the values and skills of medical profession. In particular, the respect, accountability, and the professional skills of competence were considered fundamental in clinical practice. However, the students considered that these values not sufficiently present in their educational experience. Conclusions: Teaching methods should be harmonized with the contents and with the educational needs to ensure a more complex patient-based approach and the classical lectures of teachers should be more integrated with learning through experience methods.

Clinical anatomy of the caudal pancreatic arteries and their relevance in the surgery of the splenic trauma

Splenectomy is the treatment of splenic trauma but is not exempt from intra-operative and post-operative complications. Conservative approach is preferred for paediatric population and for minor trauma. The aim of the present study was to evaluate the vascularisation of the tail of the pancreas, with particular reference to the presence of anastomosis between the pancreatic and splenic vessels, through an anatomoradiologic study performed on 9 unembalmed cadavers (age range 44-77 years). To obtain vascular corrosion casts, the splenic, the gastroduodenal and the superior mesenteric arteries were injected with acrylic and radioopaque resins and computed tomography (CT) of the specimens were acquired. The caudal pancreatic arteries (mean number ± standard deviation: 3.2 ± 2.4) were observable in all the casts, originating from the splenic artery at its distal third (70%) and from its inferior branch (30%). At CT scans analysis the mean calibre of caudal pancreatic arteries was 2.1 ± 1.1 mm. Anastomosis were found with great pancreatic artery in 20%, and with hilar splenic artery in 80%. The pattern of anastomosis between the pancreas tail and the spleen could allow the surgeon to close the splenic artery at the origin and also the short gastric and the left gastroepiploic arteries, in cases of splenic trauma, favouring the hemostasis and allowing splenic preservation at a same time.

Anatomical topography of the inferior lumbar triangle for transversus abdominis block: comment on the article by Chatzioglou et al.

in all the ILT, an arterial vessel was present, in particular, the second lumbar branch in 9%, third in 67%, or fourth in 8% [3]. Furthermore, we have documented on the oblique coronal images the presence of a ‘lumbar canal’, which can be useful clinically as a route to the deep planes. It shows an oblique course, with a postero-anterior direction, from deep layer corresponding to the superior lumbar triangle (deep lumbar ring), to the superficial layer corresponding to ILT (superficial lumbar ring). The walls of the tunnel would be formed by the latissimus dorsi superficially and the thoracolumbar fascia deeply [2]. There is analogy between the inguinal canal and the lumbar canal: the two canals are both located at the level of the inferior part of the abdominal wall, being one anterior and the other posterior. Both canals do not have own walls and they develop for moving away of the two rings due to the passage of anatomical structures (for the inguinal canal, the deferens duct/round ligament, for the lumbar canal intercostals, ileoinguinal, ileoipogastric nerves, and vessels). During the development of the abdominal wall, the morphogenesis of the muscles shows fixed bone attachments such as 12th rib, the lumbar column, iliac bone: the external oblique muscle is attached to 12th rib and iliac bone, whereas the internal oblique and the transverse muscles are attached to the lumbar column, constituting a posterior fixed point, with subsequent different spatial arrangements of the muscular fibers. The consequence is the moving away of the deep ring, corresponding to the entrance of the vasculo-nervous structures and their exit at the level of the superficial ring. Testut [5] stated that the inguinal canal models in analogy of the vessels and nerves that create their space between the muscular structures to reach their own territories. To the Editor

Friar Leopold Mandic (1866–1942): the computed tomography of the body of a saint

PurposeIn forensic clinical anatomy computed tomography (CT) is used in post-mortem radiological investigation as an objective nondestructive documentation of the body surface and of the interior of the body. This technique is applied also in paleopathology, in particular in mummy studies, with the aim of providing a permanent record of the mummy’s features, investigating the embalming procedure employed and analyzing the extent of the preservation in detail.MethodsFor the Extraordinary Jubilee of Mercy, the mortal remains of Saint Leopold Mandic and Saint Pio da Pietralcina, as examples of Mercy known by everyone, have been brought to Rome in February 2016. During the survey that preceded the preparation for transport to Rome, a whole-body CT was performed on the mummified corpse of Leopold Mandic, Capuchin Saint of Padova, Italy.ResultsThe CT examination demonstrated the presence of osteoarthritis at the level of the vertebral column, of the left knee and of the left hand. Moreover, CT showed the preservation of skeleton and partial preservation of the some viscera, such as remnants of the brain, heart, oesophagus, urinary bladder, plexuses and spinal nerves, ear ossicles, major arterial vessels (aorta and carotid arteries). It is to emphasize the fact that Saint Leopold was not subjected before the CT to any conservative treatment.ConclusionsComputed tomography demonstrated to be a non-destructive method to investigate Saint Leopold, in order to maintain the integrity of the body and to acquire data on his pathologies and on his preservation. CT allows not only the acquisition of sectional images but also, thanks to dedicated software, the post-processing and reconstruction of three-dimensional models, that can be used also for public displays.

Letter to Editor “Pancreaticoduodenal Arterial Arcades: Their Dominance and Variations-Their Potential Clinical Relevance”: Letter to Editor “Pancreaticoduodenal Arterial Arcades: Their Dominance and Variations-Their Potential Clinical Relevance”

Szuák et al. (2018) are to be congratulated for their recent article regarding the frequency of variants of pancreaticoduodenal (PD) arterial arcades, documenting through the analysis of casts and their computed tomography that the origin of the PD arcades are highly variable as well their number (three, four, and five arcades in 30%, 2%, and 4%, respectively). We would like to share our anatomical experience on the arterial vascularization of the pancreas based not only on dissection but also on radiological study of living patients (Macchi et al., 2017). In fact, the arterial vascolarization of the pancreas can be detected in patients that underwent to computed tomography (CT) angiography for atherosclerotic pathologies of the abdominal aorta, analyzing not only the 2D axial, coronal, and sagittal sections, but also the maximum intensity projection (Fig. 1), volume rendering technique, and multiplanar reconstruction (MPR) (Macchi et al., 2017). With reference to the head of the pancreas, it is supplied by branches of the gastroduodenal artery coming from the hepatic artery and by the inferior pancreaticoduodenal artery (PD), coming from the superior mesenteric artery, through the presence of the anterior and posterior pancreaticoduodenal arcades. Szuák et al. (2018) found that the origin of the superior PD artery only in 10%was from the gastroduodenal (GD) artery, whereas the inferior PF artery was found in 80% of cases, data that are comparable to those reported in our study on living patients (7.8% and 71.4%, respectively) (Macchi et al., 2017). Also the presence of variant of number of PD arcade is quite frequent, since Szuák et al. (2018) found multiple arcade in 36% versus nearly 23.7% in Macchi et al. (2017), that considered also the so-called Kirk’s arcade, that if constituted by the anastomosis between a branch of the dorsal pancreatic artery and the superior PD. The analysis of the average diameters of the arcades (anterior 1.47 mm and posterior 1.38 mm) performed on casts by Szuák et al. (2018) integrates the data of the diameters at the origin of the vessels (superior posterior PD 2.3mm, superior anterior PD 2.0 mm, and inferior PD 2.7 mm) reported in vivo by Macchi et al. (2017). This difference could be ascribed to the different point of measurements (arcade vs. origin) but also to the different parameters (internal lumen vs. outer vessel diameter). In the complex, these studies together with those of many other authors (i.e., Bertelli, 2004) demonstrate the great variability of the arterial vasculature of the pancreas, that should be carefully considered also from the forensic clinical point of view. In fact, individual anatomy may acquire specific significance in the application of the various steps of analysis in cases of Medical Responsibility and/or Liability (Porzionato et al., 2017). Thus the analysis of the presence of arterial variations on a CT angiography would be useful not only for local

INTEGRATION OF ANATOMICAL AND RADIOLOGICAL ANALYSIS SUGGESTS MORE SEGMENTS IN THE HUMAN KIDNEY: Anatomo-radiological study of the renal segments

An increasing number of observations have called the general scheme of five renal segments into question: anatomists, radiologists, and surgeons have reported discrepancies between Gravess scheme and morphological observations. The aims of the present study are: (1) to assess the correspondence between a virtual and a real vascular cast of the kidney; (2) to analyze the arterial anatomy with reference to the renal segments. Fifteen kidneys were injected with acrylic resins to obtain vascular casts, which were also analyzed by computed tomography. A mean of 6.3 (range 4–8) avascular fissures was found, indicating a mean of 7.3 segments (range 5–9). In the superior and middle territories there was a single segment in 4 (26.7%) and 8 (53.3%) cases, respectively, and there were two segments in 11 (73.3%) and in 7 (46.7%) cases, respectively. In the inferior territory there was a single segment in two cases (13.3%), two segments in nine (60%), and three segments in four (26.7%). A mean segmental volume of 550.5 mm3 was calculated; the posterior (1,030.1 mm3, 28.9%) and inferior (450.3 mm3, 24.2%) segments were the largest. More third order branches were identified in the inferior segments than in the other segments (three branches of the inferior segmental artery in 26.6%). According to these data the inferior segment occupies the inferior pole, extending both anteriorly and posteriorly. In conclusion, the high correspondence between a virtual and a real vascular cast permits more segments to be identified than those described by Graves, and the volume of each segment can be calculated. Clin. Anat., 2018.

Biomechanical behavior of Hoffa’s fat pad in healthy and osteoarthritic conditions: histological and mechanical investigations

The Infrapatellar Fat Pad (IFP) lies between patella, femur, meniscus and tibia and properly fills the space between these structures. This fatty structure facilitates distribution of synovial fluid and may act to absorb impulsive actions generated through the joint. In case of Osteoarthritis (OA), IFP is found to be affected by inflammation, hypertrophy and fibrosis. The aim of the present study is to analyze the correlation between microscopic characteristics and mechanical properties of the IFP in healthy and OA conditions. The microscopic anatomy of the IFP was analyzed through histological methods, whose results showed that the IFP affected by OA maintains similar lobules configuration but thicker interlobular septa. Geometrical data together with the morphological analysis of lobules and septa represented the basic data to provide numerical micro-models of the IFP. Numerical analyses were developed to evaluate the mechanical behavior considering the characteristic loading conditions as compressive, torsion and shear actions. The results were applied to identify the parameters of a homogenized hyperelastic constitutive formulation that interprets the IFP mechanics. The constitutive formulation was implemented within a finite element model of the knee, which was applied to evaluate the overall mechanical functionality of the knee structures. The results pointed out the actual mechanical relevance of IFP and the loss of proper stress–strain behavior of the OA IFP under mechanical loads.

ANATOMIC AND RADIOLOGIC STUDY OF RENAL AVASCULAR PLANE (BRODEL’S LINE) AND ITS POTENTIAL RELEVANCE ON PERCUTANEOUS AND SURGICAL APPROACHES TO THE KIDNEY

OBJECTIVE The aim of the present anatomic and radiologic study was to evaluate the location, extension, and characteristics of the Brödels plane and eventually define its different patterns. MATERIALS AND METHODS We evaluated 15 human normal kidneys sampled from unembalmed cadavers without clinical history or anatomical evidence of renal diseases. Kidneys with the surrounding perirenal fat tissue were removed en bloc with the abdominal segment of the aorta. The renal artery was injected with acrylic and radiopaque resins. A CT examination of the injected kidneys was performed. After the imaging acquisition, the specimens were treated with sodium hydroxide for removal of the parenchyma to obtain the vascular casts. All the CT images were elaborated using dedicated three-dimensional (3D) software with the aim to improve the possibility to identify the Brödels plane. The avascular plane was identified directly on the vascular casts and confirmed on the corresponding 3D images. RESULTS The avascular plane was located in all cases medially to the lateral convex border of the kidneys. The recorded mean distance was 2.04 cm (range 1.8-2.4 cm). Three patterns of distribution of the Brödels line were identified. In five (33.3%) cases the avascular plane was extended from the apical to the inferior segment of the kidneys (type 1); in six (40%) from the superior to the inferior segment (type 2); and in four (26.7%) from the apical to the middle segment (type 3). Fourth and fifth order vessels crossing the Brödels line were detected in all the analyzed cases. CONCLUSIONS The renal avascular plane showed a different extension allowing us to cluster three different patterns. Preoperative identification of the Brödels line patterns could help surgeons to minimize hemorrhagic complications during percutaneous and surgical procedures requiring an incision of the renal parenchyma such as traditional or robot-assisted nephrolithotomy or partial nephrectomy for endophytic renal tumors. Radiologic studies validated that the described patterns in the clinical practice are strongly needed.

An anatomo-radiological study of the renal segments

An increasing number of observations call the general scheme of five renal segments into question, with anatomists, radiologists and surgeons that have reported discrepancies between Graves’s scheme and morphological observations. The aims of the present study was to analyse the arterial vascular anatomy with reference to the renal segments. 15 kidneys were injected with acrylic resins to obtain vascular corrosions casts that were analyzed also with computed tomography. A mean number of 6,1 (range 4-8) avascular fissures were found, determining the presence of a mean number of 7,1 segments (range 5-9). The apical and posterior segments were in all the cases single. In the superior and middle territory there was a single segment in 6 cases (40%) and two segments in 9 cases (60%). In the inferior territory there was a single segment in 1 case (6,7%), two segments in 12 cases (80%), and three segments in 2 cases (13,3%). The renal arterial vasculature cannot be schematized according to the classical Graves classification because the majority of the evaluated cases showed a different number of segments. The presence of the fissures in the virtual vascular casts is a useful tool to identify the boundary between the vascular territories.

Anatomo-radiological patterns of pancreatic Vascularization, with surgical implications: Clinical and anatomical study

The pancreas receives multiple arterial sources that should be considered in patients undergoing pancreatic surgery. The aim of this study is to describe pancreatic vascularization and to explore the anatomical basis of postoperative complications. Ten specimens from unembalmed cadavers, including the retroperitoneal vessels and organs and spleen, were injected with acrylic resins to obtain vascular casts. Thirty computed tomography angiographies (CTA) of subjects with no pancreatic pathology (mean age 70.9 years) were also analyzed. A paucivascular area at the neck of the pancreas was apparent in all vascular casts. At CTA: (1) the transverse pancreatic artery, the only artery running from the cervicocephalic to the somatocaudal segment, was visible in 76.9% of cases; (2) the splenic artery was suprapancreatic in 66.7% and intrapancreatic with a tortuous course in 33.3%; (3) the posterior superior pancreaticoduodenal artery was visible in 100% of cases, the anterior superior pancreatico‐duodenal artery in 92.6%, the anterior inferior pancreaticoduodenal artery in 73.1%, the posterior inferior pancreaticoduodenal artery in 86.4%, the dorsal pancreatic artery in 65.4%, the great pancreatic artery in 73.1%, and the pancreatic arteries to the body and caudal pancreatic arteries in 96.2%. Our study demonstrated great individual variability of the pancreatic vasculature, which can be explored by CTA and could be relevant to surgical procedures. Clin. Anat. 30:614–624, 2017.