Nirusha Lachman

Anatomy teaching assistants: facilitating teaching skills for medical students through apprenticeship and mentoring.

Background: Significant increase in the literature regarding “residents as teachers” highlights the importance of providing opportunities and implementing guidelines for continuing medical education and professional growth. While most medical students are enthusiastic about their future role as resident-educators, both students and residents feel uncomfortable teaching their peers due to the lack of necessary skills. However, whilst limited and perhaps only available to select individuals, opportunities for developing good teaching practice do exist and may be identified in courses that offer basic sciences. The Department of Anatomy, College of Medicine, Mayo Clinic offers a teaching assistant (TA) elective experience to third- and fourth-year medical students through integrated apprenticeship and mentoring during the Human Structure didactic block. Aim: This article, aims to describe a curriculum for a TA elective within the framework of a basic science course through mentoring and apprenticeship. Results: Opportunities for medical students to become TAs, process of TAs’ recruitment, mentoring and facilitation of teaching and education research skills, a method for providing feedback and debriefing are described. Conclusion: Developing teaching practice based on apprenticeship and mentoring lends to more accountability to both TAs and course faculty by incorporating universal competencies to facilitate the TA experience.

Cutaneous depth of the supraorbital nerve: a cadaveric anatomic study with clinical applications to dermatology.

BACKGROUND Common dermatologic procedures performed on the forehead may injure the supraorbital nerve (SON) leading to adverse outcomes. OBJECTIVE To describe SON anatomic course and cutaneous depth. MATERIALS AND METHODS Sixteen cadaver specimens were dissected. RESULTS The supraorbital nerve originated 2.63 ± 0.27 (range, 2.1–3.5) cm from the midline and 0.25 ± 0.16 (range, 0–0.5) cm above the orbital rim. Supraorbital nerve emerged as 1 root dividing into superficial (SON-S) and deep (SON-D) branches. The supraorbital nerve deep branch remained deep to the aponeurosis of the corrugator supercilii and frontalis muscles and coursed laterally toward the scalp. Supraorbital nerve superficial branch emerged nearly perpendicular to the orbital rim and traveled under the corrugator supercilii with an average depth of 0.75 ± 0.16 (range, 0.5–1.1) cm. Supraorbital nerve superficial branches entered the subfrontalis plane at a mean distance of 1.29 ± 0.20 (range, 1.0–1.8) cm above the orbital rim with an average depth of 0.45 ± 0.13 (range, 0.3–0.8) cm. These branches entered the subcutaneous plane by piercing through the frontalis muscle at a mean distance of 2.60 ± 0.32 (range, 1.9–3.2) cm above the orbital rim with an average depth of 0.30 ± 0.10 (range, 0.2–0.6) cm. CONCLUSION The supraorbital nerve depth and course are relevant when performing procedures on the forehead. A thorough understanding of the anatomy and depth of SON-S is critical to help minimize nerve damage and optimize patient counseling.

Three-Dimensional Computed Tomographic Angiography Study of the Interperforator Flow of the Lower Leg.

Background: The area perfused by a single perforator depends on its perforasome and its unique interperforator flow pattern. The purpose of this study was to clarify the interperforator flow patterns of the peroneal and posterior tibial artery perforators using three-dimensional computed tomographic angiography. Methods: Thirteen whole-leg skin flaps were harvested in the subfascial plane from fresh cadavers. Peroneal, posterior tibial, anterior tibial, and sural artery perforators with a diameter greater than 0.5 mm were documented. Three-dimensional computed tomographic angiography with an injection of iodinated contrast medium into the peroneal or posterior tibial artery perforator was used to investigate the percentages of the area and the perforators that were perfused. Results: The mean percentage of the total area perfused was as follows: peroneal artery perforator, 42.0 percent; posterior tibial artery perforator, 38.0 percent (p = 0.084). The mean percentage of the total perforators perfused was as follows: peroneal artery perforator, 55.0 percent; posterior tibial artery perforator, 44.2 percent (p = 0.004). Although the mean percentages of same-source artery perforators perfused by a peroneal artery perforator (73.6 percent) and by a posterior tibial artery perforator (77.2 percent) did not differ (p = 0.513), the mean percentages of other-source artery perforators perfused by a peroneal artery perforator (49.9 percent) and by a posterior tibial artery perforator (32.3 percent) were significantly different (p < 0.001). Conclusions: This study demonstrated that a single peroneal or posterior tibial artery perforator perfused approximately 40 percent of the whole leg surface and that peroneal and posterior tibial artery perforators had different interperforator flow patterns. The results of this study may improve preoperative planning for pedicled perforator flap surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

“The team is more than the sum of its parts”: Implementation of charters to improve team dynamics in an anatomy course

In the current healthcare environment, team-based models in the teaching and practice of medicine have become more a norm than a preference. Renewed focus on team-based practice discloses the effect that poorly functioning teams may have on successful outcomes in team-based delivery of patient care. Team incompetence compromises learning and work performance for all members; an outcome often rooted in poor communication and understanding of role responsibilities within the team. Business schools have been innovative and proactive in recognizing this problem and have instituted team charters to align team expectations and norms through discussion and consensus. Team charters were introduced in Block 2 Microscopic Anatomy and Block 3 Human Structure courses at Mayo Medical School in the first year curriculum. Teams were oriented on the concept of the team-charter and given the opportunity to create individual team charters to suit each team’s work ethos. Teams were encouraged to revisit their charters midway through the course to maintain a dynamic contract. Students took time to reflect on and adapt their strategy in order to facilitate better team cohesiveness, communication, interaction and ultimate performance. Qualitative student feedback indicated that the exercise fostered better group dynamic and improved communication within the team. Students were empowered to take responsibility for their own learning, professional identity formation, performance, academic development and their impact on total performance of the team.

A Three-Dimensional Micro–Computed Tomographic Study of the Intraosseous Lunate Vasculature: Implications for Surgical Intervention and the Development of Avascular Necrosis

Background: The purpose of this study was to use micro–computed tomography to demonstrate the intraosseous vascularity of the lunate within a three-dimensional orientation to identify areas of greatest perfusion and define vascular “safe zones” for surgical intervention. Methods: Fourteen upper extremities were injected with a lead-based contrast agent. The lunates were harvested and scanned using a micro–computed tomography scanner. The intraosseous vascularity was incorporated into a three-dimensional image. Vessel number, diameter, distribution, and pattern were evaluated and analyzed. Vascularity of all specimens was projected onto one representative lunate to identity areas of higher and lower vascularity. Results: Twelve specimens had nutrient vessels entering the bone from volar and dorsal; two specimens had no dorsal vessels. The intraosseous vascularity could be classified according to the Y, I, and X patterns described by Gelberman et al. Average number and diameter of vessels were 2.3 and 118.1 &mgr;m, respectively, for volar; and 1.4 and 135.8 &mgr;m, respectively, for dorsal. The long axis of the lunate showed the highest vascularity on both axial and lateral views. Lower vascularity was observed in the dorsoradial and volar-ulnar quadrants on the axial view, and in the proximal part on the lateral view. Lunate shape was not associated with an increase or decrease in nutrient vessels or vascular pattern. Conclusions: Vascular safe zones were identified, allowing for potentially safer surgical interventions to the lunate. Volar approaches to the lunate may result in localized ischemia in a subset of patients with absent dorsal nutrient vessels. This study may help to better define patients at risk for Kienböck disease.

Abstract 111: An Alternative to the SGAP Flap in Autologous Breast Reconstruction: The Gluteal Upper Lateral Flap (GULF).

PurPose: Flap ischemia is a worrisome complication in reconstructive surgery and can lead to partial or total flap necrosis, tissue fibrosis and stiffness, infection, and a poor aesthetic result. Deferoxamine (DFX) is an FDA-approved iron chelating medication which has also been shown to increase the growth of new blood vessels through its ability to upregulate HIF-1a, a key transcription factor for several genes important for angiogenesis. DFX has been shown to augment bone vascularity, however its use in soft tissue has not been fully evaluated. We hypothesize that the application of DFX will result in improved vascularity and tissue elasticity in a rat TRAM flap model.

A century later and not much has changed in use of Anatomic Nomenclature: should surgeons and anatomists be speaking the same language?

Recently, the Journal of the American Medical Association published in the ‘‘JAMA Revisited’’ section a centennial article entitled ‘‘Anatomic Nomenclature’’ by anatomist Dr Albert Eycleshymer (1867 to 1925). Dr Eycleshymer’s advocacy for uniformity in the use of anatomic terminology where its impact is most strongly felt echo’s the sentiments of anatomists today who are vested in the education of future physicians. While the use of anatomical terminology is today governed by the international standard on human anatomic terminology the challenge of maintaining coherency between anatomical and clinical referencing persists. In fact, the dilemma of anatomy educators providing medical students with a foundation on which to build clinical understanding is buried in the acceptance that much of the terminology that is learned during the anatomy will have to be unlearned during clinical training. Professor Barker’s (Johns Hopkins) campaign to promote the use of ‘‘Basle Nomina Anatomica’’ in the early 1900s strengthened the concept of standard terminology banks which have evolved through many iterations of Nomina Anatomica to the present day Terminologia Anatomica (developed by the Federative Committee on Anatomical Terminology). Anatomy books and journals have been standardized and tend to dissociate from the use of eponymous terms in favor of more meaningful descriptors, eg, ‘‘inguinal’’ instead of ‘‘Poupart’s’’ ligament or ‘‘internal thoracic’’ in place of ‘‘mammary artery.’’ However, clinical texts have made little attempt to amalgamate Terminologia Anatomica; and perhaps for no particular reason other than for the sake of perpetuity entrenched within the apprenticeship model of clinical training. But should there be a call for change? Should clinicians of the 21st century be persuaded to adopt a unified set of terms so