Anatomy has historically been a cornerstone in medical education regardless of nation or specialty. Until recently, dissection and didactic lectures were its sole pedagogy. Teaching methodology has been revolutionized with more reliance on models, imaging, simulation, and the Internet to further consolidate and enhance the learning experience. Moreover, modern medical curricula are giving less importance to anatomy education and to the acknowledged value of dissection. Universities have even abandoned dissection completely in favor of user-friendly multimedia, alternative teaching approaches, and newly defined priorities in clinical practice. Anatomy curriculum is undergoing international reformation but the current framework lacks uniformity among institutions. Optimal learning content can be categorized into the following modalities: (1) dissection/prosection, (2) interactive multimedia, (3) procedural anatomy, (4) surface and clinical anatomy, and (5) imaging. The importance of multimodal teaching, with examples suggested in this article, has been widely recognized and assessed. Nevertheless, there are still ongoing limitations in anatomy teaching. Substantial problems consist of diminished allotted dissection time and the number of qualified anatomy instructors, which will eventually deteriorate the quality of education. Alternative resources and strategies are discussed in an attempt to tackle these genuine concerns. The challenges are to reinstate more effective teaching and learning tools while maintaining the beneficial values of orthodox dissection. The UK has a reputable medical education but its quality could be improved by observing international frameworks. The heavy penalty of not concentrating on sufficient anatomy education will inevitably lead to incompetent anatomists and healthcare professionals, leaving patients to face dire repercussions. Anat Sci Educ 3: 83–93, 2010. © 2010 American Association of Anatomists.

The anatomy of anatomy: A review for its modernization

In 2014, CDC published updated guidelines for the prevention and treatment of anthrax (Hendricks KA, Wright ME, Shadomy SV, et al. Centers for Disease Control and Prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis 2014;20[2]. Available at http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article.htm). These guidelines provided recommended best practices for the diagnosis and treatment of persons with naturally occurring or bioterrorism-related anthrax in conventional medical settings. An aerosolized release of Bacillus anthracis spores over densely populated areas could become a mass-casualty incident. To prepare for this possibility, the U.S. government has stockpiled equipment and therapeutics (known as medical countermeasures [MCMs]) for anthrax prevention and treatment. However, previously developed, publicly available clinical recommendations have not addressed the use of MCMs or clinical management during an anthrax mass-casualty incident, when the number of patients is likely to exceed the ability of the health care infrastructure to provide conventional standards of care and supplies of MCMs might be inadequate to meet the demand required. To address this gap, in 2013, CDC conducted a series of systematic reviews of the scientific literature on anthrax to identify evidence that could help clinicians and public health authorities set guidelines for intravenous antimicrobial and antitoxin use, diagnosis of anthrax meningitis, and management of common anthrax-specific complications in the setting of a mass-casualty incident. Evidence from these reviews was presented to professionals with expertise in anthrax, critical care, and disaster medicine during a series of workgroup meetings that were held from August 2013 through March 2014. In March 2014, a meeting was held at which 102 subject matter experts discussed the evidence and adapted the existing best practices guidance to a clinical use framework for the judicious, efficient, and rational use of stockpiled MCMs for the treatment of anthrax during a mass-casualty incident, which is described in this report. This report addresses elements of hospital-based acute care, specifically antitoxins and intravenous antimicrobial use, and the diagnosis and management of common anthrax-specific complications during a mass-casualty incident. The recommendations in this report should be implemented only after predefined triggers have been met for shifting from conventional to contingency or crisis standards of care, such as when the magnitude of cases might lead to impending shortages of intravenous antimicrobials, antitoxins, critical care resources (e.g., chest tubes and chest drainage systems), or diagnostic capability. This guidance does not address primary triage decisions, anthrax postexposure prophylaxis, hospital bed or workforce surge capacity, or the logistics of dispensing MCMs. Clinicians, hospital administrators, state and local health officials, and planners can use these recommendations to assist in the development of crisis protocols that will ensure national preparedness for an anthrax mass-casualty incident.

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Clinical Framework and Medical Countermeasure Use During an Anthrax Mass-Casualty Incident.

The teaching of anatomy has consistently been the subject of societal controversy, especially in the context of employing cadaveric materials in professional medical and allied health professional training. The reduction in dissection-based teaching in medical and allied health professional training programs has been in part due to the financial considerations involved in maintaining bequest programs, accessing human cadavers and concerns with health and safety considerations for students and staff exposed to formalin-containing embalming fluids. This report details how additive manufacturing or three-dimensional (3D) printing allows the creation of reproductions of prosected human cadaver and other anatomical specimens that obviates many of the above issues. These 3D prints are high resolution, accurate color reproductions of prosections based on data acquired by surface scanning or CT imaging. The application of 3D printing to produce models of negative spaces, contrast CT radiographic data using segmentation software is illustrated. The accuracy of printed specimens is compared with original specimens. This alternative approach to producing anatomically accurate reproductions offers many advantages over plastination as it allows rapid production of multiple copies of any dissected specimen, at any size scale and should be suitable for any teaching facility in any country, thereby avoiding some of the cultural and ethical issues associated with cadaver specimens either in an embalmed or plastinated form. Anat Sci Educ 7: 479–486. © 2014 American Association of Anatomists.

The production of anatomical teaching resources using three-dimensional (3D) printing technology

In this report we review the range of teaching resources and strategies used in anatomy education with the aim of coming up with suggestions about the best teaching practices in this area. There is much debate about suitable methods of delivering anatomical knowledge. Competent clinicians, particularly surgeons, need a deep understanding of anatomy for safe clinical procedures. However, because students have had very limited exposure to anatomy during clinical training, there is a concern that medical students are ill-prepared in anatomy when entering clerkships and residency programs. Therefore, developing effective modalities for teaching anatomy is essential to safe medical practice. Cadaver-based instruction has survived as the main instructional tool for hundreds of years, however, there are differing views on whether full cadaver dissection is still appropriate for a modern undergraduate training. The limitations on curricular time, trained anatomy faculty and resources for gross anatomy courses in integrated or/and system-based curricula, have led many medical schools to abandon costly and time-consuming dissection-based instruction in favour of alternative methods of instruction including prosection, medical imaging, living anatomy and multimedia resources. To date, no single teaching tool has been found to meet curriculum requirements. The best way to teach modern anatomy is by combining multiple pedagogical resources to complement one another, students appear to learn more effectively when multimodal and system-based approaches are integrated. Our review suggests that certain professions would have more benefit from certain educational methods or strategies than others. Full body dissection would be best reserved for medical students, especially those with surgical career intentions, while teaching based on prosections and plastination is more suitable for dental, pharmacy and allied health science students. There is a need to direct future research towards evaluation of the suitability of the new teaching methodologies in new curricula and student perceptions of integrated and multimodal teaching paradigms, and the ability of these to satisfy learning outcomes.

Best teaching practices in anatomy education: A critical review

Background The transversus abdominis plane (TAP) block is usually performed by landmark-based methods. This prospective, randomized, and double-blinded study was designed to describe a method of ultrasound-guided TAP block and to evaluate the intra- and postoperative analgesic efficacy in patients undergoing laparoscopic cholecystectomy under general anaesthesia with or without TAP block. Methods Forty-two patients undergoing laparoscopic cholecystectomy were randomized to receive standard general anaesthetic either with (Group A, n=21) or without TAP block (Group B, n=21). Ultrasound-guided bilateral TAP block was performed with a high frequent linear ultrasound probe and an in-plane needle guidance technique with 15 ml bupivacaine 5 mg ml−1 on each side. Intraoperative use of sufentanil and postoperative demand of morphine using a patient-controlled analgesia device were recorded. Results Ultrasonographic visualization of the relevant anatomy, detection of the shaft and tip of the needle, and the spread of local anaesthetic were possible in all cases where a TAP block was performed. Patients in Group A received significantly more intraoperative sufentanil and postoperative morphine compared with those in Group B [mean (sd) 8.6 (3.5) vs 23.0 (4.8) μg, P Conclusions Ultrasonographic guidance enables exact placement of the local anaesthetic for TAP blocks. In patients undergoing laparoscopic cholecystectomy under standard general anaesthetic, ultrasound-guided TAP block substantially reduced the perioperative opioid consumption.

Ultrasound-guided transversus abdominis plane block: description of a new technique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy

The safe and successful performance of a lumbar puncture demands a working and specific knowledge of anatomy. Misunderstanding of anatomy may result in failure or complications. This review attempts to aid understanding of the anatomical framework, pitfalls, and complications of lumbar puncture. It includes special reference to 3D relationships, functional and imaging anatomy, and normal variation. Lumbar puncture is carried out for diagnostic and therapeutic purposes. Epidural and spinal anesthesia, for example, are common in obstetric practice and involve the same technique as diagnostic lumbar puncture except that the needle tip is placed in the epidural space in the former. The procedure is by no means innocuous and anatomical pitfalls include inability to find the correct entry site and lack of awareness of structures in relation to the advancing needle. Headache is the most common complication and it is important to avoid traumatic and dry taps, herniation syndromes, and injury to the conus medullaris. With a thorough knowledge of the contraindications, regional anatomy and rationale of the technique, and adequate prior skills practice, a lumbar puncture can be carried out safely and successfully. Clin. Anat. 17:544–553, 2004. © 2004 Wiley-Liss, Inc.

Lumbar puncture: Anatomical review of a clinical skill

Background : The ilioinguinal/iliohypogastric nerve block is safe, effective and easy to perform in order to provide analgesia for a variety of inguinal surgical procedures in pediatric patients. A relatively high failure rate of 10–25% has been reported, even in experienced hands. The aim of this study was to determine the exact anatomical position of the ilioinguinal and iliohypogastric nerves in relation to an easily identifiable constant bony landmark, the anterior superior iliac spine (ASIS) in neonates and infants. The current ilioinguinal/iliohypogastric nerve block techniques were also evaluated from an anatomical perspective.

Method : Dissections were performed on a sample of 25 infant and neonatal cadavers (mean weight = 2.2 kg; mean height = 45.6 cm). The distance from the ASIS to both the ilioinguinal and iliohypogastric nerves, on a line connecting the ASIS to the umbilicus was carefully measured using a digital caliper. Three techniques, commonly used in clinical practice, were simulated on the anatomical specimens.

Result : The left and right ilioinguinal nerves were closer to the ASIS than previously described, i.e. 1.9 ± 0.9 mm (mean ± sd) and 2.0 ± 0.7 mm, respectively. The mean distance from the left and right iliohypogastric nerves to the ASIS are 3.3 ± 0.8 mm and 3.9 ± 1.0 mm, respectively.

Conclusions : We suggest that the high failure rate of the ilioinguinal/iliohypogastric nerve block in this age group could be due to lack of specific spatial knowledge of the anatomy of these nerves in infants and neonates. This cadaver-based study suggests an insertion point closer to the ASIS, approximately 2.5 mm (range: 1.0–4.9) from the ASIS on a line drawn between the ipsilateral ASIS and the umbilicus.

Anatomical considerations of the pediatric ilioinguinal/iliohypogastric nerve block

Over the past decade, the role of anatomical teaching in the undergraduate medical curriculum has changed considerably. At some medical schools, active dissection of cadaveric specimens is gradually being replaced by prosection-based methods and other resources such as e-learning. Warwick Medical School has recently obtained a large collection of plastinated prosections, which replace wet cadaveric specimens in undergraduate anatomy teaching. The aim of this study was to examine students' views on the use of plastinated prosections for their anatomical learning. A mixed method approach was employed using a questionnaire and focus group for data collection. The questionnaire was completed by 125 first-year medical students (response rate 68%). The majority of students (94%) rated plastinated prosections as a valuable resource for their anatomical learning. Various features of the specimens were highlighted, such as the detailed view of relevant anatomy, appreciation of relations between structures, and visualization of anatomy in real life. However, learning on plastinated prosections was perceived to be compromised because of limitations in terms of tactile and emotional experience. We conclude that plastinated prosections are an adequate resource for the early stages of undergraduate training, but that the learning experience may be further enhanced by providing opportunity for the study of wet cadaveric material.

The use of plastinated prosections for teaching anatomy—The view of medical students on the value of this learning resource

The safe and successful performance of a cricothyroidotomy demands a working and yet specific knowledge of anatomy. An ignorance or misunderstanding of anatomy may result in failure or complications. The Educational Affairs Committee of the American Association of Clinical Anatomists has highlighted the importance of clinical anatomy for several invasive procedures. This review is building on their work and contribute further to the understanding of the anatomical framework, particularly the pitfalls and complications related to performing a cricothyroidotomy. Clin. Anat. 17:478–486, 2004. © 2004 Wiley-Liss, Inc.

Peter H. Abrahams

Papers

The anatomy of anatomy: A review for its modernization

Lumbar puncture: Anatomical review of a clinical skill

Anatomical considerations of the pediatric ilioinguinal/iliohypogastric nerve block

The use of plastinated prosections for teaching anatomy—The view of medical students on the value of this learning resource

Cricothyroidotomy: a clinical anatomy review.