Integrating ultrasound into modern medical curricula.

Ultrasonography is widely practiced in many disciplines. It is becoming increasingly important to design well-structured curricula to introduce imaging to students during medical school. This review aims to analyze the literature for evidence of how ultrasonography has been incorporated into anatomy education in medical school curricula worldwide. A literature search was conducted using multiple databases with the keywords: "Ultrasound OR Ultrasonographic examination*" and "Medical student* OR Undergraduate teaching* OR Medical education*" and "Anatomy* OR Living anatomy* OR Real-time anatomy.*" This review found that ultrasound curricula vary in stage of implementation, course length, number of sessions offered to students as well as staffing and additional course components. Most courses consisted of didactic lectures supplemented with demonstration sessions and/or hands-on ultrasound scanning sessions. The stage of course implementation tended to depend on the aim of the course; introductory courses were offered earlier in a student's career. Most courses improved student confidence and exam performance, and more junior students tended to benefit more from learning anatomy with ultrasound guidance rather than learning clinical examination skills. Students tended to prefer smaller groups when learning ultrasound to get more access to using the machines themselves. Ultrasonography is an important skill, which should be taught to medical students early in their careers as it facilitates anatomical education and is clinically relevant, though further objective research required to support the use of ultrasound education as a tool to improve clinical examination skills in medical students. Clin. Anat. 30:452-460, 2017. © 2017 Wiley Periodicals, Inc.

Thyroid gland visualization with 3D/4D ultrasound: integrated hands-on imaging in anatomical dissection laboratory.

PURPOSE: In teaching anatomy, clinical imaging has been utilized to supplement the traditional dissection laboratory promoting education through visualization of spatial relationships of anatomical structures. Viewing the thyroid gland using 3D/4D ultrasound can be valuable to physicians as well as students learning anatomy. The objective of this study was to investigate the perceptions of first-year medical students regarding the integration of 3D/4D ultrasound visualization of spatial anatomy during anatomical education. METHODS: 108 first-year medical students were introduced to 3D/4D ultrasound imaging of the thyroid gland through a detailed 20-min tutorial taught in small group format. Students then practiced 3D/4D ultrasound imaging on volunteers and donor cadavers before assessment through acquisition and identification of thyroid gland on at least three instructor-verified images. A post-training survey was administered assessing student impression. RESULTS: All students visualized the thyroid gland using 3D/4D ultrasound. Students revealed 88.0% strongly agreed or agreed 3D/4D ultrasound is useful revealing the thyroid gland and surrounding structures and 87.0% rated the experience "Very Easy" or "Easy", demonstrating benefits and ease of use including 3D/4D ultrasound in anatomy courses. When asked, students felt 3D/4D ultrasound is useful in teaching the structure and surrounding anatomy of the thyroid gland, they overwhelmingly responded "Strongly Agree" or "Agree" (90.2%). CONCLUSION: This study revealed that 3D/4D ultrasound was successfully used and preferred over 2D ultrasound by medical students during anatomy dissection courses to accurately identify the thyroid gland. In addition, 3D/4D ultrasound may nurture and further reinforce stereostructural spatial relationships of the thyroid gland taught during anatomy dissection.

The Importance of the Saphenous Nerve in Ankle Surgery.

BACKGROUND: Recent evidence suggests that the saphenous nerve may be involved in the innervation of deeper structures at the medial ankle. In this study, we sought to determine the consistency and variability of the saphenous nerve innervation at the distal tibia and medial ankle joint capsule. METHODS: One hundred three lower extremities from 52 embalmed cadavers were dissected to identify the deep branches of saphenous nerve along its distal course. RESULTS: In all specimens, the saphenous nerve had branches, emerging between 3.9 and 8.2 cm above the medial malleolus, to the periosteum of the distal tibia and the medial capsule of the ankle joint. CONCLUSIONS: Deep branches of the saphenous nerve innervate the periosteum of the distal tibia and talocrural capsule.

Meckel's diverticulum complicated by axial torsion and gangrene.

Meckel's diverticulum is a remnant of the omphalomesenteric duct and is the most common congenital anomalies of the gastrointestinal tract. It has been known to mimic different disease states making its diagnosis difficult. Common complications consist of bleeding, intestinal obstruction and inflammation. The patient discussed in this case study was a 29-year-old Hispanic female who presented with right lower quadrant abdominal pain. A CT scan showed a normal appendix, thickened terminal ileum and a high-grade distal small bowel obstruction with a possible closed-loop obstruction. Laparoscopy revealed Meckel's diverticulum with the rare complication of torsion. The mechanism of torsion has been postulated but with little evidence. The purpose of this case report is to discuss the apparent mechanism of axial torsion secondary to the presence of a mesodiverticular band, provide visual evidence at surgery and recommend all Meckel's diverticulum associated with a mesodiverticular band be resected to prevent further complications.

Google Glass, ultrasound and palpation: the anatomy teacher of the future?

Traditional palpation techniques are used less often in today's modern medical arena. Technological advances in imaging, for example, often supplant the need for such types of tactility. Herein, we discuss our recent experience using Google Glass in the teaching of anatomy to medical students, a method that melds traditional medical palpation with cutting edge technology. Based on our study, teachers of the new millennium might use Google Glass coupled with ultrasound and palpation in the teaching of human anatomy to medical students. Such a technology combines palpation, diagnosis, visualization, and learning of anatomy. Glass has provided a platform to position a live ultrasound image for us to view while examining the patient. This technology will allow the physicians of the future to embrace placing ones hand on the body while receiving both palpation and visual stimulation.

Using ATP-driven bioluminescence assay to monitor microbial safety in a contemporary human cadaver laboratory.

INTRODUCTION: The objective of this study was to utilize a cost-effective method for assessing the levels of bacterial, yeast, and mold activity during a human dissection laboratory course. Nowadays, compliance with safety regulations is policed by institutions at higher standards than ever before. Fear of acquiring an unknown infection is one of the top concerns of professional healthcare students, and it provokes anti-laboratory anxiety. Human cadavers are not routinely tested for bacteria and viruses prior to embalming. Human anatomy dissecting rooms that house embalmed cadavers are normally cleaned after the dissected cadavers have been removed. There is no evidence that investigators have ever assessed bacterial and fungal activities using adenosine triphosphate (ATP)-driven bioluminescence assays. METHODS: A literature search was conducted on texts, journals, and websites regarding bacterial, yeast, and mold activities in an active cadaver laboratory. Midway into a clinical anatomy course, ATP bioluminescence assays were used to swab various sites within the dissection room, including entrance and exiting door handles, water taps, cadaver tables, counter tops, imaging material, X-ray box switches, and the cadaver surfaces. RESULTS: The results demonstrated very low activities on cadaver tables, washing up areas, and exiting door handles. There was low activity on counter tops and X-ray boxes. There was medium activity on the entrance door handles. CONCLUSION: These findings suggest an inexpensive and accurate method for monitoring safety compliance and microbial activity. Students can feel confident and safe in the environment in which they work.

Classic versus millennial medical lab anatomy.

This study investigated the integration, implementation, and use of cadaver dissection, hospital radiology modalities, surgical tools, and AV technology during a 12-week contemporary anatomy course suggesting a millennial laboratory. The teaching of anatomy has undergone the greatest fluctuation of any of the basic sciences during the past 100 years in order to make room for the meteoric rise in molecular sciences. Classically, anatomy consisted of a 2-year methodical, horizontal, anatomy course; anatomy has now morphed into a 12-week accelerated course in a vertical curriculum, at most institutions. Surface and radiological anatomy is the language for all clinicians regardless of specialty. The objective of this study was to investigate whether integration of full-body dissection anatomy and modern hospital technology, during the anatomy laboratory, could be accomplished in a 12-week anatomy course. Literature search was conducted on anatomy text, journals, and websites regarding contemporary hospital technology integrating multiple image mediums of 37 embalmed cadavers, surgical suite tools and technology, and audio/visual technology. Surgical and radiology professionals were contracted to teach during the anatomy laboratory. Literature search revealed no contemporary studies integrating full-body dissection with hospital technology and behavior. About 37 cadavers were successfully imaged with roentograms, CT, and MRI scans. Students were in favor of the dynamic laboratory consisting of multiple activity sessions occurring simultaneously. Objectively, examination scores proved to be a positive outcome and, subjectively, feedback from students was overwhelmingly positive. Despite the surging molecular based sciences consuming much of the curricula, full-body dissection anatomy is irreplaceable regarding both surface and architectural, radiological anatomy. Radiology should not be a small adjunct to understand full-body dissection, but rather, full-body dissection aids the understanding of radiology mediums. The millennial anatomy dissection laboratory should consist of, at least, 50% radiology integration during full-body dissection. This pilot study is an example of the most comprehensive integration of full-body dissection, radiology, and hospital technology.

Novel femoral artery terminology: integrating anatomy and clinical procedures leading to standardized intuitive nomenclature.

The objective of this study is to investigate the terminology of the femoral artery and recommended alternative terminology that satisfies both anatomy and clinical arenas.The femoral artery (FA) is often defined as the continuation of the external iliac artery. Specifically, when the external iliac artery reaches directly beneath the inguinal ligament, it becomes the FA. Currently, Terminologia Anatomica (TA) records the profunda femoris or deep femoral as a terminal branch. Clinicians often use superficial femoral artery (SFA) rather than FA and profunda or deep FA. SFA is actually very deep and well protected for most of its journey. On observation, the terminology in current use is not intuitive. The objective of this study was to investigate the terminology associated with the anatomical and clinical anatomical interpretations of the FA and its terminal branches and to suggest a more appropriate terminology that addresses the points of view of the macro anatomist, as well as that of the clinician. Literature search was conducted regarding the nomenclature of the FA and its terminal branches. Dissection of 89 embalmed cadavers (49F, 40M, ages 47-89) was conducted to analyze the morphology of the FA and its branches. Perusal of the literature revealed a difference in terminology between anatomical and clinical textbooks/atlases/journals regarding the FA and its terminal branch. Our dissections suggested that the FA may be better defined vis-à-vis its relationship to the anterior and posterior compartments of the thigh. A difference in terminology exists between the anatomical and clinical arenas. A need for a standardized terminology is necessary because clinicians and their publishers have not adopted TA. This study suggests that the current FA be considered the common FA and the continuation of the FA, the SFA be renamed the anterior FA and the current profunda (the deep FA) be renamed the posterior FA, respectively. The proposed terminology mirrors the lower limb anterior/posterior tibial artery terminology.

The nerve of McKenzie: anatomic study with application to intradural rhizotomy for spasmodic torticollis.

INTRODUCTION: Medically recalcitrant spasmodic torticollis may necessitate surgical intervention. One procedure used for this pathologic entity is intradural rhizotomy. However, some patients are symptomatic, perhaps due to an overlooked or underappreciated nerve of McKenzie. The authors' goal was to further elucidate the anatomy of this nerve of the craniocervical junction. MATERIALS AND METHODS: Fifteen adult cadavers (30 sides) underwent microsurgical dissection and observations of the nerve of McKenzie. Morphometrics were performed and anatomic relationships were documented under surgical magnification. RESULTS: The nerve of McKenzie was found on 70% of sides and was always a single branch. Average length was 5.2 mm for left sides and 6 mm for right sides. Average diameter was 0.9 mm (0.5-1.2 mm). In two specimens, the nerve was found bilaterally. It pierced the first denticulate ligament on 11 sides (52.4%) and travelled through its two prongs on three sides (14.3%) to connect to the anteriorly placed C1 ventral root. On five sides, it was in intimate contact with the adventitia of the vertebral artery. It was more common on right sides and in males, and this was statistically significant. CONCLUSIONS: The authors identified the nerve of McKenzie in most specimens. This nerve, if overlooked during surgical treatment of spasmodic torticollis, may result in continued symptoms. The nerve of McKenzie was often concealed within the denticulate ligament or adventitia of the vertebral artery. The authors hope the data presented here will aid neurosurgeons and decrease complications in patients who undergo neurotomy for spasmodic torticollis.

The development of a core syllabus for the teaching of head and neck anatomy to medical students.

The study of human anatomy has traditionally served as a fundamental component in the basic science education of medical students, yet there exists a remarkable lack of firm guidance on essential features that must be included in a gross anatomy course, which would constitute a "Core Syllabus" of absolutely mandatory structures and related clinical pathologies. While universal agreement on the details of a core syllabus is elusive, there is a general consensus that a core syllabus aims to identify the minimum level of knowledge expected of recently qualified medical graduates in order to carry out clinical procedures safely and effectively, while avoiding overloading students with unnecessary facts that have less immediate application to their future careers as clinicians. This paper aims to identify consensus standards of essential features of Head and Neck anatomy via a Delphi Panel consisting of anatomists and clinicians who evaluated syllabus content structures (greater than 1,000) as "essential", "important", "acceptable", or "not required." The goal is to provide guidance for program/course directors who intend to provide the optimal balance between establishing a comprehensive list of clinically relevant essential structures and an overwhelming litany, which would otherwise overburden trainees in their initial years of medical school with superficial rote learning, which potentially dilutes the key and enduring fundamental lessons that prepare students for training in any medical field.

Anastomoses between lower cranial and upper cervical nerves: a comprehensive review with potential significance during skull base and neck operations, part I: trigeminal, facial, and vestibulocochlear nerves.

Descriptions of the anatomy of the neural communications among the cranial nerves and their branches is lacking in the literature. Knowledge of the possible neural interconnections found among these nerves may prove useful to surgeons who operate in these regions to avoid inadvertent traction or transection. We review the literature regarding the anatomy, function, and clinical implications of the complex neural networks formed by interconnections among the lower cranial and upper cervical nerves. A review of germane anatomic and clinical literature was performed. The review is organized in two parts. Part I concerns the anastomoses between the trigeminal, facial, and vestibulocochlear nerves or their branches with any other nerve trunk or branch in the vicinity. Part II concerns the anastomoses among the glossopharyngeal, vagus, accessory and hypoglossal nerves and their branches or among these nerves and the first four cervical spinal nerves; the contribution of the autonomic nervous system to these neural plexuses is also briefly reviewed. Part I is presented in this article. An extensive anastomotic network exists among the lower cranial nerves. Knowledge of such neural intercommunications is important in diagnosing and treating patients with pathology of the skull base.

Cranial roots of the accessory nerve exist in the majority of adult humans.

The inclusion of a cranial root as a component of the accessory nerve is controversial with at least one recent study claiming that intracranial rootlets do not exist in humans. In response to this debate, the present study aimed to clarify this anatomy in a large cadaveric sample. In this study, 43 adult cadavers (86 sides) were dissected via a posterior approach to the craniocervical junction. Observations were made for the presence or absence of cranial roots of the accessory nerve, and when present, their lengths and diameters were measured. Relationships of these rootlets were documented. A cranial root of the accessory nerve was identified in 76% of sides. When identified, 1-6 cranial rootlets (mean 4.5) of the accessory nerve were observed. They ranged in diameter from 0.1 to 1.1 mm (mean 0.7 mm). The length of these nerves ranged from 8 to 24 mm with a mean of 17 mm. In general, the more superior rootlets were shorter and the more inferior rootlets were longer. Although there was a slight tendency for the cranial roots to be more numerous and larger on right sides and in males, this did not reach statistical significance. We believe this to be the largest study to date documenting the presence of a cranial root of the accessory nerve. Based on our findings, a cranial root exists in the majority of specimens. Neurosurgical procedures or high quality imaging of this area should enable the physician to see these structures.

Distal semimembranosus muscle-tendon-unit review: morphology, accurate terminology, and clinical relevance.

BACKGROUND: Our knowledge of the stability of the posteromedial knee is evolving. The distal semimembranosus is an important posteromedial stabilizer of the knee. Current anatomical texts and atlases do not accurately detail the distal insertion. Journal literature commonly mentions multiple distal insertions, one of which contributes to the oblique popliteal ligament. The purpose of this study was to review the literature, current morphology, terminology and clinical relevance of the distal semimembranosus muscle-tendon-unit (SMTU), and suggest alternative nomenclature. : METHODS: Literature search was conducted on anatomical and clinical texts, atlases, journals and websites to analyze the distal morphology of the semimembranosus muscle. Deep dissections were performed on 31 embalmed cadavers, 56 knees in total (27Rt and 29L), identifying the distal semimembranosus tendon morphology. : : RESULTS: Literature search revealed significantly inconsistent morphology of the distal semimembranosus muscle-tendon-unit. Cadaver dissection revealed a consistent trifurcation with three dominant expansions. Cadaver dissection also revealed an oblique popliteal tendon/expansion, indigenous to SMTU, not a ligament. : CONCLUSION: This study provides evidence of a consistent morphology and suggests a more precise nomenclature of the distal SMTU, which includes renaming the oblique popliteal ligament as the oblique popliteal tendon/expansion.

Splenomesenteric vein: formally recognising a clinically relevant section of the portal venous drainage system.

BACKGROUND AND AIMS: The objective of this study was to identify and examine a common vein in the portal system that is not consistently named, and when named, to assess whether fundamental concepts were applied in the process of naming. Essentially, the portal venous system drains 3 regions of the gastrointestinal system into 3 major veins (superior mesenteric - SMV, splenic - SV, and inferior mesenteric - IMV) ultimately forming the portal vein (PV). The SMV is formed from midgut veins generally representing the right side of the abdomen. The IMV is formed from hindgut veins generally representing the left side of the lower abdomen and pelvis, classically draining into the SV. The SV is formed from the foregut veins and generally accepts the IMV. The SV then joins the superior mesenteric vein to become the PV. MATERIALS AND METHODS: Sixty cadavers were dissected to observe the frequency of this morphology. Current anatomy and atlas texts were reviewed to identify the morphology and nomenclature. RESULTS: Observations from this study identified a vein being formed from the convergence of the SV and IMV the author named "splenomesenteric vein", which joins the superior mesenteric to form the PV. CONCLUSIONS: These findings suggest re-evaluating the morphology and nomenclature of this structure because of the pathology and clinical relevance of this area.

Anatomical factors causing oedema of the lower limb during pregnancy.

BACKGROUND: The objective of this study was to investigate the morphology of the common iliac artery and vein (CIA&V) comparing right and left sides in females versus males. Pregnant women favour lying on one side at rest and during sleep. The reason for this may be due to the morphology and orientation between the CIA&V. Virtually all women during their pregnancy suffer from lower limb swelling. This study provides an anatomical explanation for the propensity to lie consistently on one side, for lower limb swelling, and offers prevention measures. MATERIALS AND METHODS: A literature search was conducted on anatomical texts, atlases, journals, and websites regarding the morphology and orientation of the right and left CIA&V, lower limb oedema, and sleeping positions during pregnancy. Measurements from 15 dissected cadavers were conducted on the right and left CIA&V. RESULTS: The literature search revealed very limited studies on the morphology and orientation of the right and left CIA&V with no studies relating this orientation to lower limb oedema or sleeping positions during pregnancy. Cadaver dissection revealed a relatively direct anterior to posterior orientation left CIA&V and an oblique lateral to medial right CIA&V. CONCLUSIONS: This study suggests an explanation of why women lie on their left side when resting and sleeping during the third trimester due to the clinically relevant anatomy between the CIA&V.

Formally acknowledging donor-cadaver-patients in the basic and clinical science research arena.

Historically, in the healthcare profession, cadaveric tissue has been predominantly used for teaching the architecture of the human body. It is respectful practice in scientific writing to acknowledge colleagues who have helped to collect/analyze data and prepare manuscripts; however, it appears that we have omitted to thank those that have donated themselves for any of these projects to occur. The objective of this study was to investigate the formal acknowledgment thanking those who have given the amazing gift of themselves to science. A literature search was conducted on printed and electronic anatomical and clinical journals. Anatomical and clinical conferences were attended between 2008 and 2012; posters utilizing cadaveric tissue were examined for acknowledgment. University/private institutions were contacted to ascertain if memorial services were held. Literature revealed only one journal that required acknowledgment when donor-cadaver's (DC's) were used. Poster examination revealed very few acknowledgments of DC tissue at clinical conferences. While all university programs (n = 20) held memorial services, only 6 of 20 private procurement organizations had any such event. Our surgical anatomist forefathers faced awkward conditions because cadaveric tissue was not readily available. Contemporarily, anatomists and researchers have ready access to DC's. Socially, these donations are recognized as unparalleled educational tools and gifts, yet often they are not given the appropriate recognition and are overlooked in the publishing and scientific research arena. This research suggests editors, researchers, IRB committees, nonprofit body willed programs, and for-profit procurement organizations formally recognize and/or require recognition of those who donate their bodies for research.

Teaching a sonographically guided invasive procedure to first-year medical students using a novel finger transducer.

OBJECTIVES: The exposure to ultrasound technology in medicine is increasing at multiple training levels. Ultrasound transducers have evolved to provide higher-resolution imaging for more accurate structural identification, with few improvements in ease of use. This study investigated a novel finger ultrasound transducer used by first-year medical students conducting structural identification and practicing an invasive procedure. METHODS: A literature search was conducted on texts, specialty journals, and websites regarding the anatomy of internal jugular and subclavian vein central line placement with sonographic guidance and the use of a finger transducer. First-year medical students performed timed sonographically guided cannulation on the internal jugular and subclavian veins on a phantom torso and identified the internal jugular and subclavian veins on a healthy volunteer using the finger transducer and a conventional transducer. After exposure to both transducers, a survey was taken regarding transducer preference. RESULTS: The literature search revealed no studies comparing finger and classic transducers or sonographically guided central line techniques being conducted by first-year medical students. The students identified and cannulated the internal jugular and subclavian veins using both transducers. Survey results revealed that 70% of the students preferred the finger transducer. CONCLUSIONS: This study showed that first-year medical students could interpret sonographic anatomy while conducting a clinical procedure. The finger transducer proved successful in structure identification and was preferred to the classic transducer because of its combined tactile presence. This pilot study of a novel finger transducer showed the benefits of combining palpatory skills with ultrasound technology in teaching first-year medical students to perform invasive procedures.

Are distal femoral traction pins intra-articular? A cadaveric study.

OBJECTIVES: To examine the frequency of intra-articular placement of distal femoral traction pins and their proximity to the superficial femoral artery (SFA). METHODS: Wires were placed in the distal femurs of 28 cadaveric knees at the adductor tubercle (ADT), the superior pole of the patella (SPP), and 2 cm proximal to SPP (SPP+2). A lateral fluoroscopic image was obtained after injection of radiopaque contrast to assess for joint penetration. Dissection was performed to confirm or refute fluoroscopic findings. The distance from each wire to the SFA was measured. RESULTS: The percentage of intra-articular placement was higher (29%) at the ADT than the SPP+2 (0%) level. The mean (SD) distances from the ADT, SPP, and SPP+2 to the SFA were 7.4 (±1.8) cm, 5.7 (±1.7) cm, and 3.8 (±1.7) cm, respectively (P < 0.0001). None of the wires penetrated the femoral artery. The proportion of wires judged to be intra-articular was not statistically different whether judged by fluoroscopy or anatomic dissection (exact P = 1.0). CONCLUSIONS: Wires placed at the level of the ADT are at risk for capsular penetration. Risk of major vascular injury with transmedullary placement at all levels seems to be minimal. The optimum position for distal femoral pins remains unknown, but aiming >0.7 cm proximal to the ADT may lower the risk of intra-articular placement. No difference was detected between fluoroscopic arthrography and gross dissection.

A historical perspective: infection from cadaveric dissection from the 18th to 20th centuries.

Today, the study of human anatomy utilizing the ultimate study guide, the cadaver, is relatively safe. In the past, however, human dissection was dangerous. Prior to the germ theory, antibiotics, and the use of gloves, cadavers were often life threatening to dissectors including both the teacher and the student. Medical students who graduated in the United States before 1880 were unlikely to practice antisepsis in the dissecting room. In the present article, we review human cadaveric dissection in Europe and the United States primarily from the 1700s to the early 1900s in regard to its potential for transmission of infection to the dissector. A brief account of the infectious hazards of human cadavers in general and those of cadavers used for dissection in particular is given.