08Fall

H A P S I N S T I T U T E

Spring 10

Special Project for Course HAPS-009_A903 Cadaver-Anatomy of Abdomen and Thorax

WILTON REMIGIO

TITLE: REPORT YOUR SERENDIPITY

HAPS Institute

Course: HAPS-009_A903_Cadaver-Anatomy-of-Abdomen-and-Thorax

Instructor: Kevin Petti

Dates Februrary 24, 2010 , San Diego, California.

PART IProject name:

REPORT YOUR SERENDIPITY

Student: Wilton Remigio

Summary/Description:

This activity is intended for use near the beginning of a one-year cadaver dissection lab. It is primarily targeted to medical and allied health prospective students or medical students that have never encountered the subject of anatomical variation. This activity introduces students to the subject of anatomical variation in the dissection of the thorax and abdomen by using an example of variation in the circulatory system. It aims to bring awareness about anatomical variation in anatomy class, with a view that students can use it in the lab. The purpose of the activity is to help students spot and identify such variations during lab dissection and write about it. Students will prepare a mock case report describing an anatomical variation from pictures in class on the arterial kidney supply. Since variations can happen in hundreds of different anatomical structures, teachers may want to use this as a template to create other activities that introducing variations in nerve supply, in different bones, organs etc.

INTRODUCTION

Modern textbooks of Human anatomy are more or less devoid of information on anatomical variations that commonly show up in the dissecting lab. Though variations are a common occurrence, they are also a serendipitous finding to students performing cadaver dissection. Anatomical variation however, is typically treated as a mere ‘curiosity’ rather than something that is important enough to be documented or studied on their own merits. Moreover, during dissection, students will often ablate and cut off structures they find ‘odd’ in an attempt to conform to the expected textbook view. Variations in anatomy are not only normal (non pathological and not anatomical aberrations). Variation may or may not have important clinical implications for the aspiring clinician or surgeon. Textbook descriptions of anatomical structures are estimated to be accurate only in about 50-70-% of individuals (Bergman, 1988). Anatomical variation can be considered a perpetual frontier in anatomy education that will keep human anatomy an ever-fresh discipline. Observed differences in the structures of the body don’t need to be pathological to be considered variation nonetheless it is important for clinicians to establish to what degree they may affect one’s clinical perspective.

Objectives:

1. Students will develop a conceptual awareness regarding anatomical variation in the setting of cadaver dissection, through exposure to sample pictures.

2. Students will be able to recognize and identify an anatomical variation in a specific picture

3. Students will be able to write a mini mock case report based on a picture supplied by the teacher, showing an anatomical variation of the renal artery.

Lesson Theme: Anatomic variation of the renal arteries.

Materials: Slide projector, Elmo, or multimedia projector or colored photocopies.

Drawing pencil, red pens

Handouts

Disclaimer: All pictures are internet/public domain pictures obtained from journals or through Yahoo or Google image searches. The references are found in the end of Part II

Total Time for the activity: 45 minutes

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Total Point for this activity is 14. Thirteen points from the discover quiz, and 1 point from the ‘ Find the error in the picture’ activity. These point could comprise 10 or 15% of the total score for Anatomy Lab dissection.

PART II

Report your Serendipity

An introduction to anatomical variation in the cadaver dissection lab

Activity #1

A Renal Arterial Supply Picture Primer

Background: A review of blood supply of the kidney using a short lecture coupled with pictures as suggested below.

Teachers engage students in a brief expository lecture showing in textbook or on the screen normal arterial supply of the kidney and other related structures. Lecture should familiarize the student with arterial insertion and origin, and topological terminology.

Pictures:

Fig.1 Showing location of kidneys in abdominal Cavity

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Fig. 2. Anterior view of Posterior Abdominal Cavity showing Abdominal Aorta and Blood supply of left kidney. The renal artery courses adjacent to the renal vein immediately above it.

Activity #2

THE VARI-A-THON

Background:

This activity is intended primarily to engage the ‘imaginative mind’ of students. To introduce it, teachers can ask the students whether they would be surprised if they found that their right kidney had more than one renal artery. The purpose of this activity is to help students to consider different routes and arrangements the renal artery can take during development.

Grading system: No grading will be necessary for this activity.

Description:

The students will be divided into groups of 5 or 6. Each group will be given 5 copies of Fig 3 (see below). The instructor will ask them to think of 5 alternative ways a variation could conceivably occur in arterial supply to the kidney. Instructor can give hints if necessary, for instance: ‘you might see an artery coming from the back of the abdominal aorta? or an artery that inserts in a place other than the hilum?

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On the sheet provided, draw 5 possible scenarios of anatomical variations of the renal artery. Since most of the variations are in the number of arteries we emphasize that particular ‘type’ of variation . The scenarios should be different from one another in origin or form or insertion places; ( the words origin and insertion are used here for didactic purposes and may not reflect formal terminology used by anatomists).

It is important to consider that more than one renal artery can be found in one or both kidneys. Students will add arteries to Fig. 3 using a pen or pencil. At the end of this activity the group ‘scenarios’ will be collected and some pictures chosen to be displayed on a table projector such as the ‘elmo’. Papers will be handed back to students after this activity. Below is the template the students are expected to use.

Fig. 3 Schematic of the basic structures of the kidney that will serve as template for activity #2 and #3

Activity #3

Find the Error in the Picture and draw what you found

Background:

For many students cadaver dissection colored pictures is not novelty any longer since many textbooks are solely based on cadaver dissection. However, college and high school level textbooks depicting anatomical variation are rare or non-existent. This activity

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intends to train students in observing anatomical variation in a picture thus enabling them in recognizing variations in cadavers. Additionally, after this activity is complete, the instructor will have the chance to introduce students to several other pictures from the ‘imaging’ world such as CT, angiogram, MRI, ultrasonography images and arteriograms, and demonstrate how variation in anatomy show up in routinely prescribed exams. A discussion about the possible implications of these variants can be carried out.

Description:

Students will be shown Fig. 5 (below) without the labels and will be asked the following: #1. Identify the variation, and # 2. State In which kidney the variation is found. The pictures displayed should hide the labels displayed here. The label ARA (accessory renal artery)’ on the left kidney is the variant intended for students to identify and report on. The activity requires that students take one the sheets displaying Fig 3 and draw the variation observed with a red colored pen . The final correct result should look similar to Fig. 4. Groups will hand in their sheet with the picture. Students will receive ONE point for correctly identifying and drawing the variation identified. Students will be given basic information about the picture so they will be able to distinguish vein from artery prior to the activity. This particular figure is taken the article entitled: ‘Presence of accessory renal artery and kinking of aorta due to the abnormal origin of renal arteries’ (Nayak, 2008)

Time for the activity: 3 minutesType: Group activity

Grading: Students will receive ONE point if they correctly discover the variation.

(Left Renal Vein), LTA ( left Testicular Artery),

Fig 4. SMA – superior mesenteric artery, CA – celiac artery, K – kink in the aorta, RA – renal arteries, AA –abdominal aorta, IVC – inferior vena cava, LRV- left renal vein, RK – right kidney, LK – left kidney,LTA – left testicular artery, LU – left ureter, IMA – inferior mesenteric artery, ARA – accessory renal

artery.

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Fig 3 with the correct drawing of variation seen in Fig 4.

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Activity # 4

Which image shows renal artery variations?

Description:

This is a loosely added activity in which the teacher can ask for general consensus in class and show of hands. The idea is to expose students to renal artery variation or normal views using images taken from different diagnostic instruments such as arteriograms, CT-Scans and MRIs. Teachers can points out structures as they show them in the screen and analyze the images.

Fig. 6. Contrast arteriogram of renal artery (note the presence of a duplication of the left renal artery).

No additional artery

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Image 2

Fig. 7 Arteriogram of apparently normal artery supply

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Fig. 9. Magnetic Resonance image of kidney with no variation in the blood supply.F

Fig 8. CT Scan of right renal artery showing stenosis in renal artery but the view is inconclusive about the presence of a variation.

Activity #5

GUESS TEST

Background:

This quiz is not intended to test students on previous knowledge. It is simply an instrument to give students substrate to activity # 4 involving writing three small paragraphs following a certain order specified by the teacher.

Description:

Answer the quiz bellow to the best of your knowledge, consulting with the group. No computers, internet or open text is allowed. Data from the test is taken from : ‘A case report: Accessory Right Renal Artery’ (Patasi Beala, 2009)

Time: 15 minutes

Type: Individual activity if classroom clickers (Classroom response systems , CRS or audience response systems) are available. In settings where SRS are not available the test will be done. Teacher will collect the papers and go over them in class. This activity will not be graded.

Guess test: Chose the answer you believe to be the correct one.

Question 1

Variations of the Renal Artery are:

1) Uncommon

2) Common

3) Data is not available

4) Not well understood

Correct Answer # 2

Question 2

The Renal arteries arise more often than not

1) from the anterior aspect of the abdominal aorta

2) From the mesenteric artery

3) From the anteriolateral aspect of the abdominal aorta

4) Bellow the mesenteric artery

Correct Answer # 1

Question 3

The frequency of variation in the renal arteries is thought to be

1) 12%

2) 20%

3) 25%

4) 30%

Correct answer # 3

Question 4

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In a dissection lab report students were asked to describe a variation found. What is the best order to describe the finding of a variation of an arterial supply if they were intending to publish their finding on a journal?

1) State the size of the variation, the height of the point of origin of the variation, the approach taken to open the abdominal cavity, the variation topologies (origin and insertion), what organs or structures were removed to access kidneys, whether it was unilateral or bilateral,

2) Describe the variation found, describe the topology (origin and insertion), approaches taken to open the abdominal cavity and what organs or structures were removed to access the kidneys, The height of the point of origin.

3) Describe the approach to open the abdominal wall, describe what structures had to be removed, describe the variation found, the topology details (insertion and origin), and the height of the point of origin.

Correct Answer: #2

Answer TRUE or False

1. ( T ) Knowledge of the embryology of the renal vasculature and development of the kidney is essential in order to understand the possibilities of the multiple anomalies and variations of the renal arteries.

2. ( T ) Case reports of variations only need to have an introduction , the case being reported and a discussion session.

3. ( F ) In the discussion session of a simple case report it is not advisable to quote what others have found in terms of the variation you are describing.

4. ( F ) Nomenclature for variation of the different accessory or extra arteries is established and follows the same rules as regular nomenclature.

5. ( T ) Some studies show that the left and right renal arteries are at the same level in about 30% of cases.

6. ( F ) The right renal artery is shorter than the left renal and normally courses behind the inferior vena cava.

7. ( T ) There are reports showing that accessory or supernumerary renal arteries can vary in number from two to four and rarely five or six arranged either unilaterally or bilaterally.

Activity # 6

Background:

This activity is a tentative but real effort on the part of groups to write up a short paper describing the renal artery variation in the picture found on activity #4, “Find the error in the picture”.

Description:

Student groups will write a mini case report paper describing the variation seen in Activity 3. The paper should comprise 3 short paragraphs without any references, and no internet search is allowed. The paper will be divided in three sessions and the content can be 10% gleaned from their own knowledge on anatomy of the kidney arterial supply derived from the lecture (Activity # 1), the other 90% of the content will be gleaned from the quiz of activity # 5 after teacher goes over correct answers. The format will be as such:

1. Introduction: Comment on the kidney in general and its blood supply. It should introduce the topic of variation

2. Case Report: Describe how you found this variation, create a scenario involving the dissection lab, what approach for opening and getting to the structure you took.

3. Discussion: A brief exposition that should incorporate material presented in the quiz and any other interesting addition

Total points 13

Grading Rubric for Activity # 6

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COURSE TITLE:

ANCHOR ACTIVITY: Activities #1-5

PROFESSOR: TERM:

1. Student uses ALL of quiz material fully to substantiate mock paper.

The case report contains an important controlling idea, thesis or proposal that is fully developed with concrete and pertinent details.

The case report contains a main idea, thesis or proposal supported by appropriate detail.

The case report contains a main idea, thesis or proposal, but it is too general, vague, and confused; lacks sufficient support with specific detail.

The case report contains no discernible idea or thesis to control the random details that are included.

2. Student advances an argument/responds to the task in a clearly readable, logical and orderly manner.

The case report moves toward a clear conclusion with a sense of symmetry and emphasis; paragraphs contain related material that fits together well, and transitions between sentences and paragraphs assist the reader’s progress.

The case report contains the necessary steps toward a conclusion; paragraphs are structured appropriately to assist the reader.

The case report lacks a clear sense of order and direction; paragraphs are jumbled or underdeveloped; transitions are weak or unclear

The case report lacks discernable order or emphasis.

3. Student’s writing establishes a personal style and the ability to interest the reader in the information.

The case report uses sentences that are forceful, varied in length and structure; language is fresh and precise; the tone appropriate for the subject, defines the audience, and reveals the writer.

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The case report uses sentences that are varied and function well; language is clear, and the tone fits the subject, writer, and audience.

The case report uses sentences that lack order and are repetitious or immature; language is vague or inappropriate; tone is inappropriate or inconsistent.

The case report contains incoherent sentences, inappropriate or non-standard diction, and little discernable tone.

4. Student uses correct English and the traits of good writing to powerfully communicate a final product.

Student consistently employs standard, correct English, concise word choice, and sophisticated written expression to powerfully convey his/her message.

Student most often employs standard, correct English, appropriate word choice, and adequate written expression to accomplish successful communication.

Student’s work contains numerous usage problems of various kinds and many mistakes in grammar.

Student’s work has consistent problems with grammar and usage of many kinds. The written work is not acceptable for graduate level.

Adapted from RUBRIC FOR ASSESSMENT OF STUDENT WORK, courtesy, Dr Manuel Fuentes, Concordia University Southern California.

References

Bergman, R. A. (1988). Compendium of human anatomic variation : text, atlas, and world literature. Baltimore, Md.: Urban & Schwarzenberg.

Nayak, S. (2008). Presence of accessory renal artery and kinking of aorta due to the abnormal origin of renal arteries. The internet journal of biological anthropology, 2(1).

Patasi Beala, B. A. (2009). A case report: Accesory right renal artery. International Journal of Anatomical Variations 2, 118-121.

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