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PubMed2003

Workshop in clinical anatomy for residents in gynecology and obstetrics.

A workshop in the clinical anatomy of the female pelvic viscera has been part of the training program for the first year residents in Gynecology and Obstetrics at the University of Padova since the 1999-2000 academic year. The purpose of the workshop is to offer a direct experience of practical anatomy despite a shortage of cadavers. It is designed for six residents who work in three teams on three specimens. The anatomical specimens are unembalmed, unfixed, female pelvic visceral blocs that are harvested from the cadavers 24 hr after death. They are stored at -12 degrees C and removed from the freezer 12 hr before the workshop. The workshop is 3 hr in length and has two parts: one on theory and one practical. In the theoretical section (30 min), the teacher presents the topographical anatomy of the specimens and the residents analyze a clinically oriented worksheet. In the practical section (2 hr), the residents identify viscera, vessels, and nerves through inspection and palpation, and then a step-by-step dissection is carried out. In the last section (30 min), the workshop includes presentations on the three specimens that illustrate anatomical variability and assess knowledge of topographical anatomy. For many residents, this is the first practical experience of the anatomy of the female pelvic viscera because the anatomical courses for medical students do not include direct dissection by students. The unfixed viscera preserves the natural characteristics of the different tissues that exhibit the aspects of living organs, such as color, softness, and pliability, enhancing the knowledge of anatomy. The worksheet is structured as a guide to the anatomical basis of physical examination through inspection and palpation of the viscera. It also introduces the residents to the surgical anatomy of the female pelvis through a brief and selective dissection focused on the relationship between the different regional systems.

Anatomy↗
PubMedDate not supplied

Experience with a modified fine-needle aspiration biopsy technique in 533 breast cases.

Aspiration cytology depends on skillful preparation of smears, which normally requires a trained cytotechnologist. Collection of aspirates into Saccomanno fixative permits preparation of high-quality smears by trained technologists no matter who does the aspiration. Aspiration by a surgeon was used with palpation and mammography to examine 533 patients in an office-based regional breast health program. Lesions sampled ranged from diffuse thickening to frank tumors. Lesions suspicious to any one of the three examinations were biopsed. Cytologically diagnosable material was obtained in 349 instances: 120 were malignant, 22 suspicious, 12 atypical, and 195 benign. Of the 184 yielding insufficient cells, 116 were benign on palpation and mammography, and 68 were suspicious. Biopsy proved 57 of these benign and 11 malignant. There were no cytologic false positives in the study. There was a 2% false-negative rate on productive aspirates. Nonproductive aspiration occurred in 4.8% of malignant cases.

Adult↗
PubMed2004

Neural substrates of tactile object recognition: an fMRI study.

A functional magnetic resonance imaging (fMRI) study was conducted during which seven subjects carried out naturalistic tactile object recognition (TOR) of real objects. Activation maps, conjunctions across subjects, were compared between tasks involving TOR of common real objects, palpation of "nonsense" objects, and rest. The tactile tasks involved similar motor and sensory stimulation, allowing higher tactile recognition processes to be isolated. Compared to nonsense object palpation, the most prominent activation evoked by TOR was in secondary somatosensory areas in the parietal operculum (SII) and insula, confirming a modality-specific path for TOR. Prominent activation was also present in medial and lateral secondary motor cortices, but not in primary motor areas, supporting the high level of sensory and motor integration characteristic of object recognition in the tactile modality. Activation in a lateral occipitotemporal area associated previously with visual object recognition may support cross-modal collateral activation. Finally, activation in medial temporal and prefrontal areas may reflect a common final pathway of modality-independent object recognition. This study suggests that TOR involves a complex network including parietal and insular somatosensory association cortices, as well as occipitotemporal visual areas, prefrontal, and medial temporal supramodal areas, and medial and lateral secondary motor cortices. It confirms the involvement of somatosensory association areas in the recognition component of TOR, and the existence of a ventrolateral somatosensory pathway for TOR in intact subjects. It challenges the results of previous studies that emphasize the role of visual cortex rather than somatosensory association cortices in higher-level somatosensory cognition.

Adult↗
PubMed2002

Real-time computerized in situ guidance system for ACL graft placement.

A recent consensus within an international society for sports traumatology revealed that approximately 40% of ACL grafts are being surgically misplaced in current clinical practice. To help solve this problem, a computer-assisted system has been developed at the M.E. Müller Institute for Biomechanics to perform intraoperative planning and guidance of ACL replacement. Dynamic reference bases are fixed on the femur and tibia to track the knee's movement. No intraoperative imaging is required, and potential ligament attachment sites can be directly digitized using a computerized palpation hook in a minimally invasive fashion when used in conjunction with standard endoscopic tools. The palpation hook can be used by the surgeon to interactively define various anatomical structures and reference landmarks that are important for proper ligament positioning. The system can input a standard diagnostic X-ray (sagittal view of the femur) and allows intraoperative registration of this image with the patient to provide valuable X-ray landmarks for intraoperative guidance. The computer helps in situ planning of ligament placement by providing the surgeon with a 3D overview of the relevant anatomical landmarks and information on graft impingement and elongation for various simulated surgical insertions and graft sizes. After planning, the computer helps guide placement of the chosen insertion tunnels. This approach provides an augmented 3D view of knee anatomy and ligament function prior to drilling that is not possible with current procedures. The flexibility of the system in permitting surgeon-defined landmarks and free interpretation of functional factors allows it to support a variety of surgical workflows and techniques.

Anterior Cruciate Ligament↗
PubMed1988

Clinicopathologic study of esophageal cancer associated with simultaneous metastatic lesions in the stomach.

Between 1965 and 1985, 89 Japanese patients with esophageal squamous cell carcinoma underwent esophagectomy. In five of them (5.6%), a simultaneous metastatic lesion from the esophageal cancer was detected within the stomach in the resected specimens. Preoperative diagnosis of the gastric lesions had been made in none of the five patients because of an obstruction that was due to esophageal cancer. All gastric lesions were located at the gastric cardia, close to the esophagocardial junction, with a mean distance of 6.9 +/- 2.0 cm from the primary esophageal lesions. Provision of a gastric tube that contains metastatic lesions, for reconstruction of a new alimentary tract after esophagectomy, must be avoided. In cases of inadequate preoperative gastric examination, gastric lesions should be searched for intraoperatively, not only by serosal inspection and palpation, but also by mucosal inspection and palpation after partial proximal gastrectomy.

Carcinoma, Squamous Cell↗
PubMed1989

Intraoperative pancreatic biopsy--a diagnostic dilemma.

The intraoperative diagnostic dilemma of pancreatic cancer vs. chronic pancreatitis often remains unresolved. In the literature, diagnosis based on intraoperative pancreatic biopsy is a matter of controversy. Our study comprised 70 patients with a suspected space occupying pancreatic process who were operated on with the primary goal of arriving at a speedy and precise diagnosis, according to which the appropriate surgery for the specific patient would be performed. Frozen section showed that 44 patients had malignancy of the pancreas; in three patients, there was a false-negative result. In four patients, the histological picture was consistent with chronic pancreatitis. In the remaining 19 patients, biopsy was not performed and the diagnosis was made on the basis of intraoperative inspection and palpation of pancreas. On reviewing the patients, we found that the surgical risk involved in biopsy is quite low and that a high price was paid for diagnosis by inspection and palpation alone. The risk vs. benefit aspect of intraoperative pancreatic biopsy is discussed.

Adenocarcinoma↗
PubMed1992

Accurate specimen preparation and examination is mandatory to detect lymph nodes and avoid understaging in colorectal cancer.

Lymph node involvement in colorectal cancer, one of the most important prognostic factors, can be sometimes underestimated. In this study the authors report the results of two different techniques of specimen preparation and examination. In 240 patients (Group I), histologic examination was performed using a conventional procedure. In Group II (60 cases) the resected bowel and its mesentery were separately stretched, pinned on to a cork board, and fixed. The mesentery was divided according to node location (intermediate and principal) and evaluated by sight and palpation to identify lymph nodes. The bowel segment was divided from 5 cm proximally to 5 cm distally to the tumor every 10 mm in serial 3 mm slices. Three and 10 mm slices were then carefully examined by sight and palpation. Isolated lymph nodes embedded in groups (10-12 per paraffin block) were stained and investigated for neoplastic involvement. The specimen examination procedure used in Group II resulted in identification of a higher number of lymph nodes (mean = 41.1) and nodal metastases (mean = 10) compared to the standard technique used in Group I (mean = 11.3 and 2.4, respectively--P < .05). The percentage of N+ cases also was increased in Group II (48.3%) when compared to that in Group I (30.4%; P < .05). The new technique is simple, inexpensive, and efficacious for the detection of lymphatic metastases in colorectal cancer.

Colorectal Neoplasms↗
PubMed1993

Diagnosis and surgical treatment of small papillary carcinomas of the thyroid gland.

The preoperative and pathological findings of 38 cases of small papillary carcinoma of the thyroid gland measuring < or = 10 mm in diameter and 74 cases of large papillary carcinoma measuring more than 10 mm were compared. In the small carcinoma cases, the sensitivity of palpation, ultrasonography, and fine-needle aspiration biopsy (FNAB) was higher than that of computed tomography and soft tissue roentgenography of the neck. Therefore, palpation, US, and FNAB should be instituted as reliable diagnostic methods, but other examinations seem unsuitable as methods for preoperative qualitative diagnosis. No definite correlation was found between the intraglandular dissemination and the size of the carcinoma, and the frequency of metastasis was relatively high even in the small carcinoma cases. If the patient elects to undergo surgery, subtotal thyroidectomy with lymph node dissection should be performed for small thyroid carcinomas as well as large carcinomas.

Adult↗
PubMed1993

Clinical phenotypes and Wilms tumor.

Wilms tumor can occur in association with a number of recognizable patterns of malformation, as first described by Miller et al. in 1964. This paper represents a synthesis of the current state of knowledge regarding recognizable phenotypes associated with Wilms tumor. Specific disorders discussed include the Beckwith-Wiedemann syndrome, which has been localized to 11p15.5; isolated hemihypertrophy; sporadic aniridia, which is almost always associated with del(11p13); genital anomalies, particularly male pseudohermaphroditism and the Denys-Drash syndrome; and more weakly associated or uncommon conditions, such as neurofibromatosis and Perlman syndrome, respectively. Wilms tumor (WT) surveillance for specific high risk phenotypes should include a rational schedule of abdominal ultrasound examinations, taking into account the epidemiology of WT associated with specific disorders. Physical examination, with emphasis on abdominal palpation, and urinalysis should also be performed on a rational schedule. The schedule of examinations needs to be arrived at with input from clinical geneticists, oncologists, epidemiologists and pathologists with WT expertise. Lastly, care-takers of high risk individuals should be taught abdominal palpation, to be performed daily at home.

Aniridia↗
PubMed2000

Pressure pain thresholds of upper limb peripheral nerve trunks in asymptomatic subjects.

BACKGROUND AND PURPOSE: Palpation of peripheral nerve trunks has been advocated as a method of assessing the presence of hyperalgesic nerve tissue as a contributing factor to pain syndromes in musculoskeletal disorders of the upper quadrant. This study investigated, in the first instance, the pressure pain thresholds of the median, radial and ulnar nerve trunks of the upper limb in healthy, asymptomatic subjects. METHOD: Forty-five male and 50 female healthy volunteer subjects participated in this study which involved measurement of pressure pain thresholds by use of pressure algometry bilaterally over the three peripheral nerve trunks in the upper limbs. RESULTS: Pressure pain thresholds were shown to be lowest in the median nerve (p = 0.001) and lower in female subjects (p = 0.001). Laterality (p = 0.077) or the age of the subject (p = 0.254) did not significantly influence results. CONCLUSIONS: The study demonstrated differences in pressure pain thresholds in the three nerve trunks of the upper limb. These findings should be taken into account when interpreting the findings of nerve palpation in musculoskeletal upper quadrant disorders.

Adolescent↗
PubMed1989

Diagnostic assessment of benign prostatic hyperplasia.

Clinical evaluations of benign prostatic hyperplasia (BPH) are based upon careful history taking, uroflowmetry, palpation of the prostate, and diagnosis of urinary infection or possible damage to the kidneys caused by outflow obstruction. Symptom assessment includes scoring by the patient of the four obstructive and five irritative symptoms of prostatic obstruction: a simple questionnaire is used. The scoring system should be reviewed with the urinary flow measurements as part of the workup. The various forms of ultrasound used for diagnosis, although invaluable, may not be assessed out of context, and the combination of digital palpation and endoscopy generally provide most information leading to a decision for operation. When available, perrectal ultrasound scanning should be used to investigate palpable abnormalities and to identify unexpected prostatic cancer.

Humans↗
PubMed1988

Morphology and embryological interpretation of a congenital occipito-atlanto-axial malformation in a dog.

A clinical, radiological, and morphological study of a congenital occipito-atlanto-axial malformation in a 13-week-old male Saint Bernard dog that became suddenly tetraplegic at 8 weeks is described. The dog was recumbent, had generalized muscle atrophy, but was alert and responsive. Pain was elicited when the head-neck junction and the cervical vertebrae were palpated, and a bony abnormality was palpated at the occiput and atlas. Clinical signs of upper motor neuron and general proprioceptive deficits in all four limbs were compatible with a focal lesion in the cervical spinal cord. Plain radiographs of the head and neck revealed malformation of the occipital bones, atlas, and axis, unilateral atlanto-occipital fusion, and atlanto-axial subluxation. At necropsy the right half of the atlantal neural arch was fused to the right exoccipital bone. On the axis, the dens was small, malformed, and deviated to the left; the transverse processes were enlarged; and the spinous process was small with a cleft caudally. The spinal cord was severely compressed at the level of the atlanto-axial articulation, and histological examination revealed extensive loss of neuronal cell bodies, axons, myelin, and the central canal. Reactive astrogliosis was also extensive. After a discussion of normal and abnormal development of the vertebral column and its joints, it was concluded that a failure of normal joint development at about 30 days of gestation in the dog could lead to congenital occipito-atlanto-axial malformation.

Animals↗
PubMed1994

Hemispheric differences in image generation and use in the haptic modality.

Forty adults and 40 children, all right-handed, were presented with either of two series of six nonsense shapes to palpate: Those who were divided into sections by grid lines and thus provided categorical information or those who provided a whole shape and coordinate information that could be processed globally. Subjects were given an Input condition where they formed a mental representation of the shape while palpating the unseen tactual stimulus with either hand, followed by an Evaluation condition in which they attempted to solve the task by generating and using the previously stored image. Evaluation response times showed that the left hemisphere was significantly faster at generating images from categorically stored information. Neither hemisphere had an advantage when generating an image from globally stored information.

Adolescent↗
PubMed2001

Is there a place for a less extensive radical surgery in locally advanced cervical cancer patients?

OBJECTIVE: The aim of this study was to assess the association among the pathological status of different lymph node groups and parametrium in a single institutional population of 103 locally advanced cervical cancer (LACC) cases who underwent surgery after a neoadjuvant approach. A series of 29 early cervical cancer patients was also included in the analysis. METHODS: Eighty-two LACC patients with documented clinical response to neoadjuvant treatment and 29 early stage cases underwent radical surgery. The operative technique consisted of a type II-V radical hysterectomy and systematic pelvic lymphadenectomy (median number of lymph nodes removed 46; range 5-140). Sixty-four cases were submitted to para-aortic lymphadenectomy up to the level of the inferior mesenteric artery (median number of lymph nodes removed 13; range 1-37). RESULTS: Two subgroups of lymph nodes were defined: lower pelvic lymph nodes (LPN), including obturator and external iliac nodes, and upper pelvic nodes (UPN) including common iliac, presacral, and internal iliac nodes. Metastatic UPN involvement showed a strict association with LPN involvement: in LACC cases, 6 of 7 (86%) positive UPN cases had tumor disease at the LPN level. The single positive UPN case with negative LPN was intraoperatively identified by palpation and frozen section. Similarly, in early cervical cancer patients, 100% of positive UPN cases showed metastatic involvement at the LPN level. Sixty-three of 70 (90%) LACC patients with negative histological parametrium had negative LPN. Among 12 cases with metastatic involvement of parametrium, 5 cases (41.7%) had positive LPN. In early stage cervical cancer, 23 of 27 (85%) cases with negative parametrium showed no lymph nodal involvement. Intraoperative palpation of the parametrium could identify all cases with parametrial involvement not predicted by LPN status. CONCLUSIONS: These data offer the basis for tailoring the extent of radical surgery in LACC patients, through the selection of those lymph node stations likely to provide reliable information on the pathological status of UPN and parametrium.

Adult↗
PubMed1989

Unit activity in monkey parietal cortex related to haptic perception and temporary memory.

The neural responses of 456 single units were recorded in parietal cortex of behaving monkeys during a haptic delayed matching-to-sample task. (1) In areas 2 and 5 together, 22% of the neurons were activated by the auditory cue that signalled the beginning of a trial. Virtually all of these cells were also activated during the arm movements required by the task. These neurons, showing both auditory-related and movement-related responses, may function in sensorimotor integration. (2) Responses related to arm projection frequently began before movement onset, sometimes as much as 320 ms before. Such "premovement" responses were approximately equally common, and showed the same latency distribution, in areas 2, 5a, and 5b. (3) There was a topographic rostral-to-caudal gradient of decreasing neural responsiveness to the animal's manipulation of the cue (sample) objects. Eleven percent of manipulation-activated cells responded preferentially to one of the sample objects. (4) Many cells showed sustained (greater than 3 s) activation during the delay period (the time between handling of the sample object and palpation of the choice objects), even though at that time the monkey was sitting quietly and without stimulation. (5) Cells with sustained activation throughout most or all of the 18-s delay period were rare in all areas tested except area 5a. These cells, especially those that were preferentially activated depending on which sample object was palpated, may function in the temporary retention of haptic attributes. (6) The population of cells activated during sample manipulation was largely distinct from the population of cells showing sustained activation during the delay period. These two cell populations may represent different but complementary aspects of haptic perception. (7) The most common response during the delay period was sustained inhibition. This may be an expression of a nonspecific mechanism for decreasing background noise and enhancing neural responses to an anticipated perceptual event. (8) Relatively little evidence was found to support a functional distinction between the neural response properties of areas 2 and 5a. This suggests that area 2 may be at a higher level in the somatosensory hierarchy of the posterior parietal cortex than usually considered.

Acoustic Stimulation↗
PubMedDate not supplied

Fate of untreated benign thyroid nodules: results of long-term follow-up.

The fate of benign thyroid nodules has been unknown because there has been no study in this regard. We re-examined 134 patients with thyroid nodules who had had benign aspiration biopsy cytology 9 to 11 years ago. The thyroid gland was palpated by the same two thyroidologists throughout the study. Ultrasonography, fine-needle aspiration biopsy (FNAB), and ultrasound-guided FNAB were employed to examine the nature of nodules of 9 to 11 years' duration. Patients (n = 61) who had nodules difficult to palpate (small nodules), multiple nodules, or cystic nodules with papillomatous proliferation underwent ultrasound-guided FNAB; patients (n = 55) having a distinctly palpable single nodule underwent usual FNAB. None of the patients received any medical or surgical treatment. There were 86 single nodules, 14 multiple nodules, and 34 cystic nodules on the first examination. These benign nodules were reexamined for changes in size and cytology 9 to 11 years later. The most striking finding was a decrease in size or disappearance of the nodule in 42% to 79% of benign nodules. About 92% of nodules remained benign without changing cytologic classification. Only one case (0.9%) previously regarded as benign turned out to be malignant; this nodule grew in size compared with the previous examination. Among single and multiple nodules, 21% to 23% of the nodules increased in size; however, most patients with enlarged nodules (86%) showed the same class 2 cytology as before. Our present study indicates that biopsy-proved benign thyroid nodules remain benign over a prolonged period. Thus no medical or surgical treatment is required so long as the nodules do not grow.

Adult↗
PubMed1989

[Intraoperative sonography for the detection of occult liver metastases in colorectal cancer].

In a prospective study of 85 patients with operation of colorectal cancer intraoperative ultrasonography of the liver was performed for the detection of liver metastases. The findings were compared with the results of preoperative ultrasonography and CT-scan as well as the findings of intraoperative inspection and palpation of the liver. Seventeen (24.3%) of a total of 70 metastases of this series could only be detected by intraoperative ultrasonography. This was related to 12 (14.1%) of the examined patients. Four (5.7%) of these lesions were solitary and concerned 4.7% of the cases. Due to the intraoperative sonographic findings the tactics of operation was changed in 15.3% of the patients. Intraoperative ultrasonography has a significantly higher sensitivity for the detection of liver metastases from colorectal cancer than preoperative ultrasonography and computed tomography or intraoperative inspection and palpation. Intraoperative ultrasonography of the liver should be applied in all patients without preoperative evidence of liver metastases and in patients with a planned resection of metastases.

Colorectal Neoplasms↗
PubMedDate not supplied

Is preoperative radiographic localization of islet cell tumors in patients with insulinoma necessary?

Preoperative localization tests [sonography, computed tomography, angiography, percutaneous transhepatic portal venous sampling for insulin radioimmunoassay (PTP)] have a sensitivity of 60% to 90% in cases of organic hyperinsulinism. In all publications, however, the sensitivity of intraoperative localization, 75% to 100%, is distinctly higher. With the exception of PTP, all tumors that can be identified by preoperative localization can also be detected using palpation or intraoperative sonography. Preoperative localization diagnosis is therefore not absolutely necessary prior to primary operation in the case of organic hyperinsulinism. It is requested by many surgeons because: (1) only a few clinics have extensive experience with patients with an organic hyperinsulinism; (2) only a few clinics have extensive experience with intraoperative sonography; (3) the accuracy of palpation is improved following appropriate preoperative localization; and (4) in rare cases, the results of a PTP influence the operative procedure.

Humans↗