Toshio J. Sato

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.

Morphometrical study of the arterial perforators of the deep inferior epigastric perforator flap

Abstract: Although abdominal perforator flaps based on a cutaneous branch of the deep inferior epigastric artery (DIEP flaps) have many advantages, preparing these flaps is technically difficult and requires great skill, especially as the portion of the artery running under the anterior rectus abdominis sheath must be operated upon “blind”. To allow easier preparation and elevation of a DIEP flap pedicle, we propose that the arterial perforator should: 1) be more than 1.0 mm large; 2) run a straight intramuscular course, parallel to the rectus abdominis m. fibers, with no large muscular branches; and 3) have only a short portion running immediately under the anterior rectus abdominis sheath. We examined 329 perforators (more than 0.5 mm in diameter at the anterior sheath) in 66 rectus abdominis mm. from 33 cadavers among them: 1) 52 “large” perforators were over 1.0 mm in diameter; 2) 107 “suitable” perforators ran parallel to the muscle fibers without giving off large muscular branches; and 3) 35 “ideal” perforators combined these characteristics. The ideal perforators were usually located in the mid-abdominal region, 10-30 mm lateral to the umbilicus. The suitable perforators were usually present, often in combination with the ideal perforator(s), in a restricted area 20 mm cranial and 40-50 mm lateral to the umbilicus. We classified the course and ramification pattern of the deep inferior epigastric a. into six patterns, depending on whether the anastomosis was sited in the medial or lateral branch and the level at which the branches originated.

Spread of injectate during C6 stellate ganglion block and fascial arrangement in the prevertebral region: an experimental study using donated cadavers.

Background and Objectives The precise fascial space through which the injectate spreads during stellate ganglion block (SGB) remains unclear. Recent studies using magnetic resonance imaging or computed tomography have suggested that the injectate is deposited around and/or within the longus colli muscle during SGB. However, a fascial space, close to the longus colli, is the most likely route of spread. We identified the prevertebral interlaminal space (PVILS), situated between the anterior and posterior laminae of the prevertebral layer of the fascia, as an important route for the spread of the injectate and as a potential pathway to the ganglion. The danger of downward spread of deep infections through this space has previously been recognized. Methods and Results Using the 6th cervical vertebra paratracheal approach technique, we performed experimental SGB with 10 mL latex on donated cadavers. Spreading of latex into the PVILS was observed in 45 of 52 (86.5%) cadavers that had been fixed with formaldehyde after death, and 5 of 8 (62.5%) fresh cadavers. In these experiments, the latex usually reached the ganglion via the PVILS (39 of 45 and 5 of 5, respectively). Moreover, after direct injection into the PVILS, latex reached the ganglion in 13 of a further 19 (68.4%) postmortem-fixed donated cadavers. Conclusion These results suggest that the PVILS plays a critical role in the spread of injectate as well as being a potential pathway to the stellate ganglion during SGB.

Investigation of the Localization of Nerves in the Uterosacral Ligament: Determination of the Optimal Site for Uterosacral Nerve Ablation

We select surgical treatment for cases for which severe dysmenorrhea persists following medical treatment. Many reports have described the use of neurectomies by cutting off pain conducting nerve pathways using laparoscopic surgery. Laparoscopic uterosacral nerve ablation (LUNA) has been associated with a high success rate for pain control, but there are few reports of anatomical studies in the uterosacral ligament. Using an immunohistochemical method, we examined the number and types of nerve fiber bundles in the uterosacral ligaments and its surrounding tissue in cadavers. The greatest number of nerve fiber bundles was found at a distance of 16.5–33 mm and at a depth of 3–15 mm distal to the site of attachment of the uterosacral ligament to the uterine cervix. Furthermore, there were many more sympathetic and parasympathetic nerve fiber bundles than sensory ones in the uterosacral ligament and its surrounding tissue. These results show the appropriate site of transection of uterosacral ligaments when performing LUNA.

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.

Morphometric study of the sphincter of Oddi (hepatopancreatic) and configuration of the submucosal portion of the sphincteric muscle mass

The sphincter of Oddi (SO) hepatopancreatic sphincter from 114 Japanese adults, especially the sphincteric muscle mass lying in the duodenal mucosal layer (the submucosal portion of the SO: SMSO), was measured macroscopically under a binocular microscope. The SMSO was classified into two types according to shape. The horizontal type (95/114) usually displayed a rod‐like shape (6.0 mm at average diameter at the root) directed toward the anus and was situated on the duodenal muscle wall with the papillary orifice at or near the tip (anal side) of the SMSO. The horizontal type SMSO followed the underlying muscle wall widely ranging from 5.0 mm to 17.9 mm length (9.8 mm at average) and was attached to the wall by the loose connective tissue along the entire length. In the horizontal type, the extramural portion (the portion penetrating and outside of duodenal muscle of the SO) of the SO was very small. The vertical type (19/114) erected on the muscle wall vertically into the lumen of the duodenum. The average length and average maximum diameter of the vertical type were 6.0 mm and 6.2 mm, respectively. The extramural portion of the SO was thicker and tighter in the vertical type, which suggested that endoscopic sphincterotomy might preserve the length of the SO longer than endoscopic papillary balloon dilation (EPBD). Of the individuals in our study, 18% (19/114) had SO diameters <5 mm, a finding that may have implications for selection of balloon size in EPBD. Clin. Anat. 13:159–167, 2000.

Morphometric study of the medial aspect of the human maxillary sinus with special reference to the nasal fontanelle.

OBJECTIVE The purpose of this study was to clarify configurations of the nasal fontanelle (NF) from the morphometrical point of view, especially variations of its four margins (anterior, posterior, superior, and inferior), for clinical application. METHODS We used 136 sides of hemi-sectioned heads that were obtained from 119 donated Japanese cadavers (66 men and 53 women with an average age of 77.6+/-12.0). After mucosal examination, the specimens were boiled with a small amount of powdered soap and treated with protease. The residual mucous membrane was then gently removed. These specimens were originally made for our previous study describing variations of the uncinate process (Isobe M, Murakami G, Kataura A. Variations of the uncinate process of the lateral nasal wall with clinical implications, Clin. Anat. 1998;11:295-303). Different series of measurements were conducted based on surgical approaches and angles of observation. RESULTS The superior margin of the NF is difficult to identify because the ethmoidal infundibulum, which leads the anterior end of the margin upward, often interrupts the superior margin. Because the inferior and posterior margins are modified by thin paper-like bony structures and because the anterior margin is disturbed by variations of the lacrimal bone and/or the inferior turbinate, they are also difficult to identify. Knowing these variables, we evaluated the NF morphometrically. The NF was located 12.6+/-4.3 mm posterior to the anterior nasal spine and 6.6+/-2.2 mm anterior to the sphenopalatine foramen. The size of the NF was 17.9+/-3.2 mm (anteroposterior axis) x 11.5+/-3.0 mm (inferosuperior axis). The lowest orbital floor was located 10 mm below the superior margin of the anterior NF (-10 mm), and the distance was therefore measured as -3.7+/-2.4 mm on average. Viewed from the maxillary sinus, the location of the NF varied along the anteroposterior axis, whereas it was located consistently at the most superior portion of the medial aspect of the sinus wall. CONCLUSION During endoscopic sinus surgery for tumor resection in the maxillary sinus, a large and primary window should be prepared in the posterior NF, including partial removal of the uncinate process. Preparation of an additional window in the inferior meatus is preferable to enlargement of the primary window. Approaching the anterior NF should be avoided, if possible, due to its complicated configuration as well as its proximity to the orbital floor.

Encouraging Appreciation of Community Health Care by Consistent Medical Undergraduate Education

Hokkaido Prefecture of Japan covers a vast geographical area. The uneven distribution of medical personnel in Hokkaido is accountable for the scarcity of medical services in certain areas. As a result, the anxiety of the population living in those underserved areas increases, thereby posing a serious social concern. The interprofessional education (IPE) program was proposed as a response to a concern about community health care. This program was meant to systematize various practical experience training programs and restructure them into one joint curriculum for community health care, in addition to expanding the residential community internship program. This enables the entire university to undertake consistent education on community health. The residential community and team-based training programs aim at producing professionals who will serve in the community. These programs encourage students to have an interest in community health as professionals through practice training during their initial school years. Furthermore, the residential joint curriculum (team-based residential community health care internship) provides students with an opportunity to interact not only with medical professionals but also patients and their families and health care staff. This leads to opening their eyes to disease prevention specifically and more widely to community issues. Through IPE, students are expected to: (1) strengthen their interest in community health care, which they have had even upon entry to the university; (2) deepen their understanding of the community, particularly community health care; (3) obtain an appreciation toward and a sense of empowerment within community health care; and (4) develop a sense of mission and deep commitment to community health care.