Aims The bone marrow procedure (BMP) has been performed worldwide for years. Nonetheless, no generally accepted standards or guidelines for the performance of the BMP exist. Recent studies suggested that the lateral angulation technique (LAT), targeting the anterior superior iliac spine (ASIS) after penetration of the posterior superior iliac spine, yields longer biopsy cores and is safer for patients. We assessed the feasibility and safety of targeting the ASIS in the prone and lateral decubitus positions. Methods We first observed the BMP needle tracks on cadavers. Our cadaver study revealed that the LAT is feasible and safe but requires different operator techniques. Next, we studied 25 adult haematology patients undergoing elective BMP via the LAT approach. Patients returned 5 days after the BMP for a haemoglobin assessment, pain questionnaire and low-dose non-contract CT. Results 8% of patients reported persistent pain. No fall in haemoglobin and no pelvic haematomas or neurovascular injuries were detected. 88% of BMPs were successfully accomplished by targeting the ASIS. 12% required a back-up traditional angulation technique (TAT), directing the needle straight in, perpendicular to the coronal plane of the back. All three demonstrated inadvertent, but asymptomatic, penetration of the sacrum. Biopsy lengths were compared with a historical TAT control demonstrating that specimens obtained by LAT are significantly longer. Imaging studies showed that a seven-degree change in needle direction can convert a TAT to a LAT. Conclusion The LAT approach is feasible, safe and more productive than the TAT, and may be the preferred standard for training haematologists. Trial registration number NCT02524613.

Medical students are expected to perform common procedures such as suturing on patients during their third-year clerkships. However, these experiences are often viewed by medical students as stressors rather than opportunities for learning. The source of this stress is the lack of instruction on common procedures prior to being asked to observe or perform the procedure on a patient. First-time exposures to procedures in stressful environments may result in decreased confidence in medical students and decrease the frequency with which they perform these procedures in the future. The authors sought to change this paradigm by: (1) introducing a suturing module to first-year medical students in the context of the anatomy dissection laboratory and (2) measuring its effects on student attitudes and behavior over the course of their third-year clerkships when they encounter patients. The authors found that early and prolonged introduction to suturing was associated with increased student confidence relative to suturing a patient. Participation in the suturing module was associated with increased student confidence in identifying suturing instruments (P < 0.001) and suturing patients (P = 0.013). Further it positively affected their behavior as demonstrated by increased performance of suturing events from students exposed to the suturing module. (P < 0.001) This study demonstrates that early and prolonged opportunities to practice a procedural skill in a low-stress environment increases student confidence during patient interactions and alters student behavior.

Development of urogenital anatomy in the human fetus is the result of a complex interplay between multiple different tissues. The time course of development is well documented and the morphologic outcomes of insults at various time points during development are predictable. We present a cadaveric case of unilateral agenesis of the left kidney, ureter, bladder hemitrigone, ureteric opening, seminal vesicle, vas deferens, and epididymis. Failure of development of the mesonephric duct early during embryogenesis, likely between the third and fifth week, caused ipsilateral urogenital organ agenesis.

Address for Correspondence: Priti L. Mishall, MD, MBBS, Assistant Professor, Department of Anatomy and Structural Biology, 1300 Morris Park Ave, Forchheimer 620SA, Albert Einstein College of Medicine, Bronx, NY United States 10465. Telephone number: 718-430-3483 E-Mail: priti.mishall@einstein.yu.edu Having up-to-date knowledge of the variability in facial artery topography is an essential starting point in performing certain surgical and radiological procedures on the head and neck (e.g. oromucosal reconstruction flaps, transarterial embolization). We report a unique case with: (1) the left facial artery truncating as an atypical inferior labial artery, (2) the left anterolateral face being perfused by unusual arterial collaterals derived from the right superior labial, left infraorbital and left dorsal nasal arteries, (3) the transverse facial artery not being one of the perfusing collaterals, and (4) the right submental artery piercing the mylohyoid muscle and entering the oral cavity. The embryologic basis of this atypical vascular pattern is discussed. Discovery of a highly atypical facial artery highlights the importance of performing a thorough pre-operative vascular evaluation to prevent iatrogenic injuries and complications before any surgical or therapeutic procedure.

Bone marrow biopsy is generally a safe procedure. However, infrequently the procedure is associated with serious injuries that are attributed to inadvertent needle penetration of the iliac bone's inner cortex. An evidence-based approach to needle orientation during iliac crest biopsy does not exist. In our study, the posterior to anterior path of the bone marrow needle from the posterior superior iliac spine (PSIS) was studied in human cadavers in two orientations: (1) perpendicularly to the coronal plane (the perpendicular approach) and (2) laterally toward the ipsilateral anterior superior iliac spine (ASIS) (the lateral approach). The biopsy needle was deliberately advanced through the inner ilial cortex in both approaches. Dissections and imaging studies were done to identify the relationship of the penetrating needle to internal structures. Both approaches begin with a perpendicular puncture of the outer cortex at the PSIS. The perpendicular approach proceeds anteriorly whereas in the lateral approach the needle is reoriented toward the ipsilateral ASIS before advancing. The lateral approach caused less damage to neurovascular structures and avoided the sacroiliac joint compared to the perpendicular approach. This procedure is best done in the lateral decubitus position. Proper use of the lateral approach should obviate many of the complications reported in the literature.

OBJECTIVETo identify and categorize anatomical anomalies of the vertebral artery and determine the relationship of these unexpected variations to the site for cervical transforaminal epidural steroid injections (CTESI).DESIGNThe cervical region and course of the vertebral arteries was dissected in 10 cadavers. Anatomical anomalies of the vertebral arteries were identified and documented. Those that could increase the risk of intra-arterial injection during fluoroscopically guided procedures are detailed.RESULTSTwenty percent of vertebral arteries were found to have anatomical variations including accessory vessels and lateral loops. These variations placed arterial segments in a portion of the posterior neural foramen where they could be at risk for cannulation during CETSI. In addition, 20% of the vertebral arteries entered the transverse foraminal column at a level other than C6.DISCUSSIONCTESI have become a mainstay in the treatment algorithm for painful cervical radiculopathy. Described techniques take extreme care to avoid cannulation of the vertebral artery during this procedure. Unexpected deviation of the artery, or an arterial segment, into the posterior neural foramen, the target zone for CTESI, increases the risk of intraarterial cannulation during injection. Accordingly, the practitioner must be aware of variant anatomy of the vertebral artery and take all precautions to avoid potential complications that may arise as a consequence.

Abstract Introduction Bone marrow examination is an essential and commonly performed bedside procedure in diagnosis and staging of hematological malignancies and benign hematological disorders. Although when performed on the posterior superior iliac spine(PSIS), it is considered a safe procedure with minimal complications, cases of excessive bleeding , hematoma formation, injury to neurovascular structures, retroperitoneal and intraperitoneal hemorrhage, pseudo aneurysm formation and gluteal compartment syndrome have been reported. Cases of retroperitoneal hemorrhage are presumed to occur due to penetration of the needle through the iliac crest indicating that accurate placement and angulation of the biopsy needle is critical to avoid iatrogenic complications. Bone marrow biopsy has been described in various publications and text books. However, standardized technique for positioning the biopsy needle and its penetration orientation are lacking. Various authors have described the correct needle placement and orientation as perpendicular to the bone or pointing towards the anterior superior iliac spine (ASIS) but most of the studies do not specify angulation of the needle. These methods appear to be extrapolated from personal experience and, to date, an evidence based approach for needle angulation has not been described. We present a comparison of different described approaches to perform bone marrow biopsy relative to injury to critical structures should the needle penetrate the inner bone cortex. This study compares the two most commonly used PSIS biopsy approaches that advance the needle towards: 1. The Umbilicus (Medial Approach) 2. Ipsilateral ASIS (Lateral Approach). Methods The study was done on cadavers in the dissection laboratory at the Albert Einstein College of Medicine. The procedure was performed by Attendings and Fellows in Hematology Division who are experienced in performing bone marrow biopsy. Manual Jamshidi needles or powered bone marrow device were used. Anatomy professors helped identify the landmarks and performed dissections after biopsy procedures. The Radiology Department assisted with performing and reading the CT scans of the pelvises. The first phase of study involved placing two dissected cadavers with intact pelvises in prone and lateral positions. Bone marrow needle was placed perpendicular to the PSIS and, during penetration, the direction was changed toward the umbilicus for the Medial Approach and towards the ASIS during the Lateral Approach. A bone marrow biopsy was obtained. Subsequently, using the same needle track, the needle was deliberately pushed through the inner ilial cortex to assess the resultant potential for injury. Keeping the needles in situ, metal wire probes were inserted via the needle for better visualization. The cadavers were further dissected to identify injury to neurovascular bundles and adjacent structures. In the second phase, bone marrow biopsy was performed on two intact cadavers. The needles with inserted probes were left in situ to mark different angulations. The cadavers were then scanned and dissected to identify penetrated structures and closely related neurovascular bundles that were at risk had the orientation varied slightly. Results Dissections and CT scan imaging showed that Lateral Approach was less likely to cause injury to significant neurovascular structures and penetrate the sacroiliac joint in comparison to the Medial Approach. Using the Medial Approach, in the event of penetration of inner cortex, we documented injury to the sacro-iliac joint, femoral nerve, common iliac vessels and mesentery of the sigmoid colon. The needle was observed in close proximity to the iliolumbar vein and artery and the lumbosacral trunk. Using the Lateral Approach, the structures adjacent to the needle were limited to the iliacus muscle and the lateral cutaneous branch of femoral nerve. The lateral approach had the added benefit of more consistent orientation since the relationship of the ASIS to the PSIS is both consistent and palpable whereas the location of the umbilicus may vary. We suggest that the safest way to perform a bone marrow biopsy is to advance the needle in a perpendicular direction to reach the PSIS. Once the needle penetrates the outer cortex of the bone, the direction should be changed pointing towards the ipsilateral ASIS. We believe that this procedure will obviate complications reported in the literature. Disclosures: No relevant conflicts of interest to declare.

BACKGROUND:Transforaminal epidural steroid injection (TFESI) is a widely utilized interventional pain technique for radicular pain. Although the six o'clock position of the pedicle in the so-called "safe triangle" has been used as a target location, there have been a number of reported catastrophic complications of this procedure, including paraplegia. The mechanism of this has been attributed to the intravascular injection of steroids. The goal of this study was to examine the intraforaminal location of thoracolumbar medullary arteries which would help guide pain physicians in developing safer techniques and guidelines.METHODS:Twenty-four (24) embalmed cadavers were dissected and examined for the presence and distribution of thoracolumbar anterior medullary arteries. Access to the anterior surface of the spinal cord was made via anterior corpectomy from C2 to S5. Each medullary artery's course was determined by dissection from its origin, the anterior spinal artery, through the intervertebral foramen. The foramen was subsequently opened in the coronal plane, and the intraforaminal location of the artery, its diameter, and its relation to other foraminal structures were examined and measured.RESULTS:In the thoracolumbar foramina (T4-L2), 39 anterior medullary arteries were found, including 23 great medullary arteries (Adamkiewicz artery). One Adamkiewicz artery was found to be located in the left S2 foramen and was not included in the statistical analysis. Of the analyzed 39 anterior medullary arteries, 29 (74%) were located in the upper 1/3 of the foramen, 9 (23%) were located in the middle, and 1 (3%) artery was located in the lower 1/3. In relation to the dorsal root ganglion--ventral root complex, 21 (54%) arteries were located anterosuperiorly, 16 (41%) anteriorly, and 2 (5%) anteroinferiorly. The average intraforaminal artery diameter was 1.20 mm (0.84-1.91 mm). At thoracolumbar levels, the artery is almost always (92% ± 15%) located anterosuperior to the nerve. At typical thoracic levels, it is less often anterosuperior (38% ± 19%), but more often anterior to the nerve.CONCLUSIONS:At thoracolumbar levels, if needles were to encounter an artery, they are most likely to do so if placed anterosuperior to the nerve. Encountering an artery anterosuperior to the nerve is less likely at typical thoracic levels, but the likelihood is far from negligible. Pain physicians should be cognizant of this when considering optimal needle placement during transforaminal epidural steroid injections.

Ralph Ger (Fig. 1) was born in Cape Town, South Africa on February 20, 1921 and died peacefully at home in Great Neck, New York on April 9, 2012 forty-nine days past his 91st birthday. Ralph was a rare and special man to clinical anatomists around the world not only because he played the major role in the creation of the American Association of Clinical Anatomists (AACA) but also because he touched, inspired, and was a guide to everyone who met him professionally and came to know him personally during his life. Ralph Ger, July 17, 2009, 26th Annual Meeting of the American Association of Clinical Anatomists, Cleveland, Ohio. Photo by Samuel A. Scott. Starting from almost his first school days as a child, Ralph excelled in his studies with one fortuitous exception. Luckily, the one subject where he dawdled was Afrikaans. His resistance to learning this language was indeed fortunate for the world of clinical anatomy and his future patients because this deficiency would in later years be his undoing as he pursued his childhood ambition to become a veterinarian. There was only one veterinary school in South Africa, and it was located in Pretoria almost a 1,000 miles from Cape Town. However, more significant than its distance from Ralph's home was the fact that instruction, at that time, was entirely in Afrikaans and not in English as was the case at Cape Town's university. With some sadness, he took this reality to heart and refocused his career ambitions on going to medical school and caring for bipeds rather than quadrupeds. Ralph finished school and started university at the precociously ripe age of 15! As one of over one hundred and fifty-first year medical students at the University of Cape Town, he took zoology, botany, chemistry, and physics. He earned one of the highest scores in his exams and was among the select group, of about one hundred students, admitted to the second year of medical school in 1938. It was there that his ardor for anatomy blossomed in the dissection room. Based upon continued stellar exam performances, Ralph was honored at the beginning of his third year with the distinction of being appointed Demonstrator of Anatomy at the age of 17. Ralph joined the South African Medical Corps upon receipt of his M.B., Ch.B degree in 1943 and served in the Corps for the remainder of World War II. Following his 1946 discharge, he returned to Cape Town to pursue a career in surgery and resumed his anatomy training as a postgraduate student. In 1948, Ralph decided that he needed to travel to England for further training and to complete the fellowship exams at the Royal College of Surgeons. During his five-year journey to pass these exams, one of the two catalytic events that would catapult Ralph further down the path of clinical anatomy occurred. He met the consultant surgeon Alfred M. Abrahams, the father of our Honored Member Peter Abrahams, while working at Walton Hospital in Liverpool. The seeds for clinical anatomy, which Ralph had planted in Cape Town while learning anatomy and practicing medicine, were skillfully cultivated and stimulated by Mr. Abrahams. Ralph told of a hiking trip they took to the beautiful Lake District during which they pondered the surgical anatomical adventure of kidney transplantation over half a decade before the first such operation was performed in Boston in 1954. Clinicians would come to know Ralph as a surgeon whose anatomical creativeness in the service of his patients was equally matched by his technical skill and courage born from his knowledge of the body. Ralph pioneered the use of muscle flaps to promote wound closure (Ger, 1966) and performed the first human laparoscopic hernia repair (Ger, 2003). As such, Ralph joined the 20th century giants in innovative minimally invasive surgery who forever changed the practice of surgery and the character and philosophy of surgical education. He was also a prodigious inventor of surgical devices. He developed and patented one of the first laparoscopic staplers as well as a mechanical device—the Proxiderm™—to promote treatment of chronic wounds using traction (Ger, 1995, 2012). Ralph's first five years in England and Scotland were arduous. The pressing demands of clinical work and studying for the surgical fellowship exams weighed heavily on his time and energy but he would eventually complete these exams in London and Edinburgh in 1953 to qualify as FRCS and FRCS (Ed). He returned to South Africa in 1955 after working two more years in England, one of which was in Birkenhead in Merseyside where Alfred Abrahams had relocated his practice. Returning to South Africa, Ralph was appointed an Assistant Surgeon at the University of Witwatersrand's Baragwanath Hospital, which at the time was the largest hospital in the world with a huge volume of trauma patients who needed surgery. Taking this position in Johannesburg was also significant because, at Baragwanath Hospital, he met an occupational therapist, Dorrit Neumann. They married in 1958 and started a family which, eventually included Amanda (1959), Michael (1960), and Kevin (1964). Ralph's stay in the Johannesburg, while eventful, was brief as he was quickly recruited back to Cape Town. From 1957 through 1966, he practiced and taught at the University of Cape Town where he rose to the positions of Surgical Attending at the Groote Schuur Hospital and Lecturer (=Assistant Professor) in Anatomy at the medical school. In 1966, persecution by the racist apartheid government, which had identified him as a subversive, resulted in Ralph losing all of his hospital privileges. At this bleak time for the Ger family, there appeared the second catalytic individual who would play a very significant role in Ralph's surgical career, his passion for clinical anatomy, and ultimately in the creation of the AACA. This individual was Gershon “Effie” Efron. Effie was a Cape Town medical school graduate who had become a surgical resident and worked at the same hospital as Ralph. After finishing his residency, he too journeyed to England for additional training and to complete the Royal College of Surgeons fellowship exams. After three years of postgraduate surgical training and passing his exams, Effie had a chance encounter in London with a visiting professor of orthopedic surgery from New York's Albert Einstein College of Medicine who invited him to come to the United States to interview for a position at the relatively new medical college. Effie, who was then looking for a job, flew to New York and within the week was hired. Before moving to New York, Effie—who would subsequently become one of the Founding Members of the AACA—decided to make what he describes as a “possibly last visit” to Cape Town to visit family and friends. He arrived in South Africa shortly after the authorities had stripped Ralph of all his hospital privileges and appointments. Rejecting the advice of friends to stay away and not visit his former colleague and family who were being “watched,” Effie went to see Ralph and Dorrit to tell them about the job opportunities in the United States. Several months after Effie left Cape Town for New York, Ralph made his own trip to New York City where, not surprisingly, he too secured a surgery position at Einstein. Ralph returned to South Africa to collect the Ger family and emigrate to the United States. At Einstein, Ralph's abilities and potential were almost immediately appreciated and he was promoted to Chief of Surgery at Weiler Hospital located on the college's campus. With this relocation, Ralph gained, as he had in Cape Town, convenient access to a dissection laboratory where he could explore and teach anatomy with the goal of improving surgical outcomes and training. Ralph's surgical career at Einstein lasted until 1987 when he departed to become the Chair of the Department of Surgery at Winthrop University Hospital and to have a much shorter drive from his home on Long Island. Turning to Ralph's educational activities, Ralph and Effie emerged in 1968 as major figures charged with reshaping Einstein's anatomy course to emphasize the importance of anatomy in clinical practice and surgery. Two years later, Ralph was named the course director. Ralph and Effie continued to share many ideas about teaching applied or clinical anatomy. They were appalled at the increasingly woeful anatomical knowledge displayed by first year surgical residents, and motivated by what they saw as the need for more medically qualified faculty to teach anatomy. Under Ralph's direction these ideas were liberally incorporated into Einstein's anatomy course and eventually made their way into Ralph's textbook Essentials of Clinical Anatomy (Ger and Abrahams, 1986). The textbook was based upon Ralph's lecture notes and benefited significantly from the editing and input of his coauthor, the aforementioned, Peter Abrahams. Since Ralph's departure from Liverpool in 1955, Peter had grown up to become a practicing physician as well as a Senior Lecturer (Associate Professor) in Anatomy at The Middlesex Hospital Medical School in London. A second edition of Ralph's textbook was published in 1996 (Ger et al., 1996). Ralph's departure from Einstein's hospital in 1986 did not diminish his commitment to its anatomy course. When I arrived at Einstein in 1989 as the new course director, Ralph was a very active and omnipresent legend. He continued as the principle lecturer for the next 20 years and retired from teaching in 2009 when he gave his last lecture on the abdominal wall and herniae at the age of 88. Any one who attended even one of his lectures would remember his colorful chalkboard drawings (he only showed projection slides during the last 5–10 min of each lecture), his witty sayings and striking accent, and the way he made improving patient care the focus for each of his clinical anatomy lectures. Needless to say, Ralph received every teaching award offered by the medical college. Finally, what about Ralph's role in the creation of the AACA? After arriving in New York, Ralph regularly attended national and international surgical meetings. At these meetings, he found many likeminded surgeons who shared both his vision for teaching clinically oriented anatomy and his concerns about diminished anatomical training and its ultimate impact on the care of current and future surgical patients. Three such surgeons, frequently cited by Ralph, played central and critical roles in the events prior to his calling for the creation of the AACA in 1982. One was N. Alan Green from Norwich, England who would become a Founding Member of the AACA as well as one of our Honored Members. Alan was one of the founders and an early President of the British Association of Clinical Anatomists (BACA) that was established in 1977 to promote a stronger relationship between clinicians and anatomists (McDonald, 2003). Alan is currently writing a much more comprehensive account of Ralph for the Royal College of Surgeons (England) series: Plarr's Lives of the Fellows that can be accessed online by the public when it is published (Green, in prep., Online. URL: http://livesonline. rcseng.ac.uk/biogs/E002545b.htm [accessed September 2012]). The two other prominent surgeons who encouraged Ralph and lent their early and strong support were Oliver H. Beahrs (Ger, 2006) and Robert A. Chase who together with Ralph would serve as the first three Presidents of the AACA. Together, they also coauthored the only article, Gross Anatomy in Medical Education (Beahrs et al., 1986), cited by the late David Dawson in his omnibus history of AACA's first five years (Dawson, 1988). What is not covered in Dawson's excellent account of the AACA's origins, Ralph covers in his own words in an Editorial (Ger, 2004). While there were many individuals, listed in the official rooster of the 84 Founding Members (Dawson, 1988), who played seminal roles in founding the AACA in 1983, Ralph Ger stands apart as deserving our recognition as The Founding Father. Ralph, or “Sir Ralph” as he came to be known, would have generously spread a great deal of the initial credit upon other worthy individuals but history points to him as the key player. He was the person who, after several years of preparation and collaboration with many of the invitees, would call the inaugural organization meeting for February 18, 1983. According to Effie Efron, who was one of the 18 invitees present at this gathering, Ralph chaired and, with a creator's hand, orchestrated its proceedings. As a direct consequence of the formative decisions made at this meeting, the AACA was officially born on October 17 in Atlanta at the 1983 meeting of the American College of Surgeons. Oliver Beahrs was selected as the first president and Ralph the vice president. Several years later, Ralph was the driving force, along with several others, in the Association's decision to sever its relationship with The American Surgeon and to embark upon the creation of its own journal, Clinical Anatomy. Ralph was also a single and immutable clarion for Clinical Anatomy becoming a joint publication with the British association BACA. Influenced by his skillful guidance and enthusiasm, BACA decided to unite with us in this new venture. Ray Scothorne from Glasgow was named to join Ralph as Clinical Anatomy's first Editors (Ger and Scothorne, 1988). Ralph held this position through 1991 and the printing of the journal's fourth volume. Finally, Ralph's unique and special standing amongst the many who have contributed so much to creating and building the AACA and its journal is evidenced by the fact that he was the first member to receive both the Association's Honored Member in 1991 and the R. Benton Adkins Distinguished Service Awards in 2007. Only two other members, Keith Moore and Art Dalley, have been so honored in AACA's 30-year history. Art was one of the many who wrote to the Association upon learning of Ralph's death. I think his remarks speak—well beyond what I write here—for the many who shared their dismay and sadness at the news we would not see Ralph again. “Ralph Ger was a personal hero to me almost from the moment of our acquaintance. Ralph was as resolute in his stand for human rights in opposing apartheid as he was in his concern for the pain and suffering of patients. Ralph demonstrated great innovation in the surgical theater by applying anatomical principles to restore near normal function. Similarly, he demonstrated exceptional scholarship in his desire to see that his and his colleagues' experiences were shared with other clinicians and anatomists for their benefit, analysis, and criticism. Yet, his self-deprecating humor and stories would bring tears to my eyes as he painted himself as ideally-intentioned, yet as vulnerable to catastrophic situations as a Chevy Chase character.” Arthur F. Dalley, Ph.D. Nashville, TN Ralph taught me almost everything I know and appreciate about clinical anatomy. The most important of his lessons was that he cared for his patients by using his anatomical knowledge and creativity to solve problems that diminished his patients as fully functional human beings. Ralph did not treat patients. He cared for them. This is the soul of clinical anatomy as well as the man who was one of the founders and ardent promoters of this discipline. As consequential as Ralph's role in AACA may seem to us, the clinical ground upon which he walked is far loftier and now less traveled. Ralph was a true and unique pioneer, a revolutionary clinical innovator, encouraging mentor in the operating room, and a courageous surgeon. While most of us felt rewarded and stimulated from our acquaintance with him as a clinical anatomist, there are many more who knew him much more dearly and gratefully. They are the thousands of patients who appreciated him because, in so many instances, he surgically created for them a life and quality of existence that would not exist if Ralph Ger had not been their surgeon. The bottom line for Ralph was always that clinical anatomy is all about improving patient care! Ralph was a valued and influential mentor because he appreciated that the greatest teachers were those who continued to learn in spite of their vast experience. Front row center is where Ralph liked to sit during our meetings where he joined with us as a peer who was more eager to ask questions than to expound or pontificate. He definitely had his own strong opinions but he was always approachable with an inviting smile, sparkling blue eyes, and a charming greeting. Ralph cared about clinical anatomy and our association. Front row center in each of our hearts is where the man, we all came to know and love, will be remembered. Sir Ralph, gone but never to be forgotten.

The growing popularity of complementary and alternative medicine (CAM), of which estimated 38% of adults in the United States used in 2007, has engendered changes in medical school curricula to increase students' awareness of it. Exchange programs between conventional medical schools and CAM institutions are recognized as an effective method of interprofessional education. The exchange program between Albert Einstein College of Medicine (Einstein, Yeshiva University) and Pacific College of Oriental Medicine, New York campus (PCOM-NY) is in its fifth year and is part of a broader relationship between the schools encompassing research, clinical training, interinstitutional faculty and board appointments, and several educational activities. The Einstein/PCOM-NY student education exchange program is part of the Einstein Introduction to Clinical Medicine Program and involves students from Einstein learning about Chinese medicine through a lecture, the experience of having acupuncture, and a four-hour preceptorship at the PCOM outpatient clinic. The students from PCOM learn about allopathic medicine training through an orientation lecture, a two-and-a-half-hour dissection laboratory session along side Einstein student hosts, and a tour of the clinical skills center at the Einstein campus. In the 2011/2012 offering of the exchange program, the participating Einstein and PCOM students were surveyed to assess the educational outcomes. The data indicate that the exchange program was highly valued by all students and provided a unique learning experience. Survey responses from the Einstein students indicated the need for greater emphasis on referral information, which has been highlighted in the literature as an important medical curriculum integrative medicine competency.

Cone beam computed tomography (CBCT) has proved to be a useful tool in many aspects of oral and maxillofacial surgery and in implant dentistry. 1 Guerrero M. Jacobs R. Loubele M. et al. State-of-the-art on cone beam CT imaging for preoperative planning of implant placement. Clin Oral Investig. 2006; 10: 1 Crossref PubMed Scopus (256) Google Scholar , 2 Hatcher D.C. Dial C. Mayorga C. Cone beam CT for pre-surgical assessment of implant sites. J Calif Dent Assoc. 2003; 31: 825 PubMed Google Scholar , 3 Peck J.N. Conte G.J. Radiologic techniques using CBCT and 3-D treatment planning for implant placement. J Calif Dent Assoc. 2008; 36: 287 PubMed Google Scholar , 4 Nickenig H.J. Eitner S. Reliability of implant placement after virtual planning of implant positions using cone beam CT data and surgical (guide) templates. J Craniomaxillofac Surg. 2007; 35: 207 Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar In addition to implant dentistry, CBCT has been valuable in dentoalveolar surgery, temporomandibular joint evaluation, orthodontics, orthognathic surgery, clefts, trauma, and benign and malignant pathologic processes of the maxillofacial region. 5 Tantanapornkul W. Okouchi K. Fujiwara Y. et al. A comparative study of cone-beam computed tomography and conventional panoramic radiography in assessing the topographic relationship between the mandibular canal and impacted third molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 103: 253 Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar , 6 Terakado M. Hashimoto K. Arai Y. et al. Diagnostic imaging with newly developed ortho cubic super-high resolution computed tomography (ortho-CT). Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000; 89: 509 Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar , 7 Quereshy F. Savell T. Palomo J. Applications of cone beam computed tomography in the practice of oral and maxillofacial surgery. J Oral Maxillofac Surg. 2008; 66: 791 Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar , 8 Araki K. Maki K. Seki K. et al. Characteristics of a newly developed dentomaxillofacial X-ray cone beam CT scanner (CB MercuRay): System configuration and physical properties. Dentomaxillofac Radiol. 2004; 33: 51 Crossref PubMed Scopus (138) Google Scholar , 9 Kau C.H. Richmond S. Three-dimensional cone beam computerized tomography in orthodontics. J Orthod. 2005; 32: 282 Crossref PubMed Scopus (211) Google Scholar , 10 Cevidanes L. Bailey L. Tucker S. et al. Three-dimensional cone-beam computed tomography for assessment of mandibular changes after orthognathic surgery. Am J Orthod Dentofac Orthop. 2007; 131: 44 Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar , 11 Ghaeminia H. Meijer G.J. Soehardi A. et al. Position of the impacted third molar in relation to the mandibular canal Diagnostic accuracy of cone beam computed tomography compared with panoramic radiography. Int J Oral Maxillofac Surg. 2009; 38: 964 Abstract Full Text Full Text PDF PubMed Scopus (159) Google Scholar , 12 Lofthag-Hansen S. Huumonen S. Gröndahl K. et al. Limited cone-beam CT and intraoral radiography for the diagnosis of periapical pathology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 103: 114 Abstract Full Text Full Text PDF PubMed Scopus (319) Google Scholar , 13 Closmann J. Schmidt B. The use of cone beam computed tomography as an aid in evaluating and treatment planning for mandibular cancer. J Oral Maxillofac Surg. 2007; 65: 766 Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar , 14 Rigolone M. Pasqualini D. Bianchi L. et al. Vestibular surgical access to the palatine root of the superior first molar: “Low-dose cone-beam” CT analysis of the pathway and its anatomic variations. J Endod. 2003; 29: 773 Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar , 15 Schramm A. Rucker M. Sakkas N. et al. The use of cone beam CT in cranio-maxillofacial surgery. Int Congr Ser. 2005; 1281: 1200 Crossref Scopus (10) Google Scholar , 16 Ziegler C.M. Woertche R.Brief J. et al. Clinical indications for digital volume tomography in oral and maxillofacial surgery. Dentomaxillofac Radiol. 2002; 31: 126 Crossref PubMed Scopus (213) Google Scholar , 17 Tyndall D.A. Brooks S.L. Selection criteria for dental implant site imaging: A position paper of the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000; 89: 630 Abstract Full Text PDF PubMed Scopus (201) Google Scholar

To describe the clinical and MR imaging features of a unique strain at the iliac tubercle enthesis. While this strain appeared to correspond to the iliotibial band (IT band) enthesis, the literature regarding the IT band origin was discrepant. As such, our second goal was to prove that the IT band originated at the iliac tubercle, through cadaveric dissection.

Numerous medical schools in the United States and abroad have determined that anatomy taught through cadaver dissection is untenable. Concerns for cost effectiveness, educational efficacy, the shortage of trained anatomist teachers, the increasing demand for cadavers, and pressure to convert dissection rooms to research laboratories, all argue for minimizing or eliminating cadaver dissection. However, arguments against dissection tend to ignore the emotional growth students experience in the process. Cadaver dissection prepares them for one of the core dilemmas of patient care, namely, the need to be personally engaged yet clinically detached. This dilemma, traditionally encountered with the first incision in the dissection lab, will persist throughout professional life, and it must be addressed in order to provide humanistic care with scientific objectivity. What follows is one perspective on how to shape students' self-awareness in the first weeks of dissection. The premise is simply that examination of the cadaver provides the student a unique opportunity to examine the self.

Introduction and hypothesis The objective of this study was to identify nerve(s) vulnerable to entrapment during uterosacral ligament fixation (USLF), which could cause postoperative lower extremity pain previously described in the literature. Methods Preserved cadavers in a medical anatomy course were used. Before the students’ pelvic dissections, a 2-0 prolene suture was placed in the middle third of each left uterosacral ligament visualized. The sutures were re-evaluated at the end of the course. Results Nine sutures remained in place after the course, and one entrapped a nerve. It was part of the inferior hypogastric plexus, included fibers from S2 and S3, and radiated to the bladder and rectum. The posterior femoral cutaneous nerve was lateral and posterior to this nerve. Conclusions The inferior hypogastric plexus is vulnerable during USLF. Entrapment of S2 and S3 fibers could cause pain in their respective dermatomes and could be responsible for the postoperative pain previously described.

BACKGROUND: Virtual reality simulators provide an effective learning environment and are widely used. This study evaluated the Endoscopic Sinus Surgery Simulator (ES3; Lockheed Martin) as a tool for anatomic education.METHODS: Two medical student groups (experimental, n = 8; control, n = 7) studied paranasal sinus anatomy using either the simulator or textbooks. Their knowledge was then tested on the identification of anatomic structures on a view of the nasal cavities.RESULTS: The mean scores were 9.4 +/- 0.5 and 5.1 +/- 3.0 out of 10 for the simulator and textbook groups, respectively (P = .009). Moreover, the simulator group completed the test in a significantly shorter time, 5.9 +/- 1.1 versus 8.3 +/- 2.0 minutes (P = .021). A survey asking the students to rate their respective study modality did not materialize significant differences.CONCLUSION: The ES3 can be an effective tool in teaching sinonasal anatomy. This study may help shape the future of anatomic education and the development of modem educational tools. (c) 2608 Elsevier Inc. All rights reserved.

Anatomical Sciences EducationVolume 1, Issue 6 p. 269-269 Letter to the Editor Impact of cadaver dissection: Working toward solutions Charles E. Schwartz M.D., Corresponding Author Charles E. Schwartz M.D. [email protected] Physician Coordinator, Generalist Physician Anatomy, Faculty Program, Departments of Psychiatry, Medicine, and Family Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New YorkDepartment of Medicine, Albert Einstein College, Centennial 327, Montefiore Hospital, 111 East 210th Street, Bronx, New York 10467Search for more papers by this authorSherry A. Downie Ph.D., Sherry A. Downie Ph.D. Assistant Course Director, Clinical and Developmental Anatomy, Department of Anatomy and Structural Biology, Albert Einstein College of Medicine, Bronx, New YorkSearch for more papers by this authorAlice B. Fornari Ed.D., Alice B. Fornari Ed.D. Assistant Director of Medical Education, Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New YorkSearch for more papers by this authorTodd R. Olson Ph.D., Todd R. Olson Ph.D. Course Director, Clinical and Developmental Anatomy, Anatomist Coordinator, Generalist Physician Anatomy Faculty Program, Department of Anatomy and Structural Biology, Albert Einstein College of Medicine, Bronx, New YorkSearch for more papers by this author Charles E. Schwartz M.D., Corresponding Author Charles E. Schwartz M.D. [email protected] Physician Coordinator, Generalist Physician Anatomy, Faculty Program, Departments of Psychiatry, Medicine, and Family Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New YorkDepartment of Medicine, Albert Einstein College, Centennial 327, Montefiore Hospital, 111 East 210th Street, Bronx, New York 10467Search for more papers by this authorSherry A. Downie Ph.D., Sherry A. Downie Ph.D. Assistant Course Director, Clinical and Developmental Anatomy, Department of Anatomy and Structural Biology, Albert Einstein College of Medicine, Bronx, New YorkSearch for more papers by this authorAlice B. Fornari Ed.D., Alice B. Fornari Ed.D. Assistant Director of Medical Education, Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New YorkSearch for more papers by this authorTodd R. Olson Ph.D., Todd R. Olson Ph.D. Course Director, Clinical and Developmental Anatomy, Anatomist Coordinator, Generalist Physician Anatomy Faculty Program, Department of Anatomy and Structural Biology, Albert Einstein College of Medicine, Bronx, New YorkSearch for more papers by this author First published: 04 December 2008 https://doi.org/10.1002/ase.54Citations: 7AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume1, Issue6November/December 2008Pages 269-269 RelatedInformation

Our objective was to document variations in the topography of pelvic floor nerves (PFN) and describe a nerve-free zone adjacent to the sacrospinous ligament (SSL). Pelvic floor dissections were performed on 15 female cadavers. The course of the PFN was described in relation to the ischial spine (IS) and the SSL. The pudendal nerve (PN) passed medial to the IS and posterior to the SSL at a mean distance of 0.6 cm (SD = +/-0.4) in 80% of cadavers. In 40% of cadavers, an inferior rectal nerve (IRN) variant pierced the SSL at a distance of 1.9 cm (SD = +/-0.7) medial to the IS. The levator ani nerve (LAN), coursed over the superior surface of the SSL-coccygeus muscle complex at a mean distance of 2.5 cm (SD = +/-0.7) medial to the IS. Anatomic variations were found which challenge the classic description of PFN. A nerve-free zone is situated in the medial third of the SSL.

The topography of the adult gastrointestinal tract and viscera together with the remodeling of their original mesenteric connections create some of the most vexing spatial relationship problems encountered in mastering the clinical anatomy of the human body. The complex, tortuous and, on first inspection, haphazard arrangement of the digestive tract is neither easily explained in text nor clearly elucidated with illustrations. Thirty years of personal experience teaching human embryology has demonstrated that when students attempt to follow the developmental succession of 90° and 180° rotations around the body's three axes their understanding often becomes more knotted‐up than straightened out. While animations greatly facilitate understanding, cognitive deficits persist for students who have difficulty visualizing and spatially integrating the chronology and final disposition of structures into their own body schema or image. All anatomists who teach in a dissection lab have witnessed many a student holding and maneuvering the heart or a bone against his or her own body until it is in the correct orientation. I believe this sensory‐motor learning process helps to personalize the location, orientation and relationships of structures within the student's own body. Through this kinesthetic and proprioceptive process, students gain a deeper appreciation for their own body and, consequently, an enhanced ability to mentally map anatomical structures in other bodies. Building upon this learning process, I have developed a didactic routine using a 15″ party balloon and 4′ rubber garden hose that permits students to observe and perform directly the rotations of the stomach and midgut loop.

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We described the innervation of the levator ani muscles (LAM) in human female cadavers. Detailed pelvic dissections of the pubococcygeus (PCM), iliococcygeus (ICM), and puborectalis muscles (PRM) were performed on 17 formaldehyde-fixed cadavers. The pudendal nerve and the sacral nerves entering the pelvis were traced thoroughly, and nerve branches innervating the LAM were documented. Histological analysis of nerve branches entering the LAM confirmed myelinated nerve tissue. LAM were innervated by the pudendal nerve branches, perineal nerve, and inferior rectal nerve (IRN) in 15 (88.2%) and 6 (35.3%) cadavers, respectively, and by the direct sacral nerves S3 and/or S4 in 12 cadavers (70.6%). A variant IRN, independent of the pudendal nerve, was found to innervate the LAM in seven (41.2%) cadavers. The PCM and the PRM were both primarily innervated by the pudendal nerve branches in 13 cadavers (76.5%) each. The ICM was primarily innervated by the direct sacral nerves S3 and/or S4 in 11 cadavers (64.7%).