American Association for Anatomy recommendations for the management of legacy anatomical collections.

Collections of human remains in scientific and private institutions have a long tradition, though throughout history there has often been variable regard for the respect and dignity that these tissues demand. Recent public scandals around the use of human remains, coupled with an increasing community awareness around accountability in such instances, forces scholars to confront the ethical and moral concerns associated with these collections. This includes specific focus on the acquisition, storage, use, and disposition of these remains, which were often collected with no consent and with little knowledge, or concern, about the individual or their respective culture and practices surrounding death and postmortem treatment. As a response, the American Association for Anatomy convened a Legacy Anatomical Collections Task Force to consider these issues and to develop recommendations to assist those working with these tissues in education, research, and museum collections. This has culminated with the development of Recommendations for the Management of Legacy Anatomical Collections. The recommendations provide both an ethical foundation and practical considerations for the use, storage, and disposition of legacy collections of human tissues, and deliver guidance for establishing appropriate management and oversight, investigating provenance, and engaging with communities of care. While these Recommendations are considered a living document which will change over time as ethical principles concerning human tissue evolve, they currently represent 'best practice' recommendations that can guide researchers, teachers, and museum associates as they consider the future of legacy anatomical collections in their care.

Wilhelm Waldeyer as an object - Anatomists as body donors.

INTRODUCTION: Berlin anatomist Wilhelm von Waldeyer-Hartz (1836-1921) donated his skull, brain, and hands to his institute. Only the skull survives in the present-day collection. This study investigates the skull itself as much as the historical context of Waldeyer's donation. METHODS: Physical-anthropological investigation of the remains and historical research. RESULTS: Waldeyer's main motivation was the donation of his brain to science. While this was the first ever recorded body donation in Berlin, it was not unusual for scientists of his time to donate their brains and/or to investigate brains of fellow scientists to correlate brain morphology to individual traits. Nevertheless, Waldeyer's pupil Hans Virchow expressed reservations dissecting his former boss, reservations that were unknown to him when dissecting others. Waldeyer's brain was never investigated and not preserved, likely due to damage by stroke and poor anatomical fixation. Waldeyer's skull shows the common features of a male European of senile age with some notable anatomical variation including a "trigeminus bridge". DISCUSSION: Waldeyer's donation is embedded in a tradition of research looking, if in vain, for traceable signs of intelligence or geniality in brains of well-known individuals. Reservations of anatomists to dissect other anatomists and to donate their own bodies persist until today.

Strong and aversive cold processing and pain facilitation in fibromyalgia patients relates to augmented thermal grill illusion.

The thermal grill illusion (TGI) is assumed to result from crosstalk between the thermoreceptive and nociceptive pathways. To elucidate this further, we compared 40 female fibromyalgia patients to 20 healthy women in an exploratory cross-sectional study. Sensations (cold, warm/heat, unpleasantness, pain and burning) evoked by 20 °C, 40 °C and alternating 20 °C/40 °C (TGI) and somatosensory profiles according to standardized quantitative sensory testing (QST) were assessed on the palm of the dominant hand. Compared to healthy controls, fibromyalgia patients reported stronger thermal grill-evoked cold, warm, unpleasantness and pain as well as stronger and more aversive 20 °C- and 40 °C-evoked sensations. They showed a loss in warm, mechanical and vibration detection, a gain in thermal pain thresholds and higher temporal summation (TS). Among QST parameters higher TS in fibromyalgia patients was most consistently associated with an augmented TGI. Independently, an increased TGI was linked to cold (20 °C) but less to warm (40 °C) perception. In fibromyalgia patients all thermal grill-evoked sensations were positively related to a higher 20 °C-evoked cold sensation and/or 20 °C-evoked unpleasantness. In conclusion, the TGI appears to be driven mainly by the cold-input. Aversive cold processing and central pain facilitation in fibromyalgia patients seem to independently augment the activation of the pain pathway.

Das Schambein und die Scham.

SHAME ON THE PUBIC BONE: The German term "Schambein" (literally "shame bone") for the pubic bone, the anterior part of the pelvis, takes its name from its proximity to the sexual organs. At least the female external genitalia also carry German names built with the term "Scham" (shame). While the same is true for many Latin terms referring to the female genitalia like pudendum (pudor meaning shame), this is not true for the Os pubis which has a different Latin root that does not carry the negative connotation of shame.It has recently been suggested that the official Latin terms for the anatomy of the female genitalia should be replaced with less derogatory designations. This also applies to the German term "Schambein" - nobody needs to be ashamed of the pubic bone. We therefore suggest that it should be renamed as "Schoßbein" (literally "lap bone"), a term that is neutral and correctly describes its anatomical location.

Anatomist Hermann Stieve used Nazi victims for his research on the menstrual cycle, but did he also fabricate facts?

PURPOSE: Hermann Stieve (1886-1952), director of the Berlin Anatomical Institute from 1935, benefited from the rise of execution numbers during the "Third Reich". He used organs and tissues from executed women for his histological research on the reproductive organs and investigated the influence of "nervous agitation" on the cyclical changes of endometrium and ovary. It is still controversial how he was able to acquire intimate data on the executed women and it was therefore suggested that some of his data may have been "invented". METHODS: Newly emerged dissection protocols and histological drawings from Stieve's research, together with archived court records, enable a more detailed analysis of Stieve's published data. RESULTS: We extracted 304 case descriptions from Stieve's publications. Of these, 88 could be linked with 33 identifiable women and related historical records. Nearly all reported causes of death and/or verdicts of executed women were false. Reported clinical data, particularly the day of the menstrual cycle and uterine bleeding shortly before death, are more difficult to verify. We found non-standardised documentation and possible confusions of cases, which may in part be attributable to war effects. CONCLUSION: Stieve actively concealed the fate of the executed women, mostly by inventing imaginary stories. This followed a request by the German and Soviet authorities after 1945 not to publish results from cases of political victims, but only from "dangerous criminals". Scientifically relevant clinical data were not always reported correctly, but are not necessarily fraudulent as different interpretations of this finding can be suggested.

The "economy of truth" - New historical sources allow new insights into Hermann Stieve's use of bodies of execution victims for research.

INTRODUCTION: During the times of National Socialism, Berlin anatomist Hermann Stieve had access to many bodies of executed women for his histological research on reproductive organs. Newly emerged sources add to our knowledge of this research and allow a critical examination of some of Stieve's post-war claims. SOURCES: Descendants of Stieve have preserved more than 200 dissection protocols in Stieve's own hand, which are now held at the archive of Humboldt University in Berlin. In addition, a list of names of execution victims related to this research has been newly identified at the Federal Archive in Berlin. RESULTS: The 207 protocols mostly relate to women executed in Berlin Plötzensee from March 1942 onwards and include two women executed after the war in January 1947. Other sources show that bodies of executed men were delivered to the institute of anatomy until November 1950. The documents confirm that Stieve did not use only the bodies of "Schwerverbrecher [felons]" as he had asserted in 1952. They do verify some of Stieve's post war claims, like that he had access to court records of the victims and likely also to information from attending doctors and family members, if only in rare cases. DISCUSSION: The anatomists' access to bodies of the executed continued after 1945 as this practice was not seen as something Nazi-typical by the allied authorities. Hermann Stieve's post-war defence strategy can be characterised by an "economic" handling of the truth, avoiding outright lies by making true statements on rare cases which, however, were not representative of his general course of actions.

Traces of Nazi victims in Hermann Stieve's histological collection.

INTRODUCTION: Berlin anatomist Hermann Stieve (1886-1952) had access to many bodies of execution victims during the period of National Socialism and used tissues from these bodies to conduct histological research. Estate material of his eldest son, who died in 2012, included histological specimens related to this research, some of them carrying inscriptions with names. This historical investigation tried to identify the individuals behind these names and their fate. SOURCES AND METHODS: Information was sought in several archives, the data collection of the Gedenkstätte Deutscher Widerstand (German Resistance Memorial Center), Stieve's own publications, and in other estate material. FINDINGS: Thirty-six of the hundreds of histological slides from the estate carried a total of 20 personal names. Fifteen of these could be unequivocally related to individual historical persons, twelve women and three men, all of them executed at Berlin Plötzensee prison between 1937 and 1945. As detailed as the archival sources allowed, the fate of these individuals was reconstructed. They include men and women convicted of alleged political resistance activities, but also of just stealing cigarettes or speaking bad of Hitler. They were all victims of a murderous justice system, and their fate demonstrates the involvement of the anatomist in this system. CONCLUSIONS: The histological slides from Stieve's estate were buried on the Dorotheenstädtischer Friedhof in central Berlin on 13 May 2019. For most execution victims, this place now is the only known burial site of their mortal remains, as they were denied a grave at the time.

Pain is not the major determinant of quality of life in fibromyalgia: results from a retrospective "real world" data analysis of fibromyalgia patients.

OBJECTIVE: To identify correlates of quality of life (QoL) measured with the Quality of Life Scale (QOLS) in participants of a multidisciplinary day hospital treatment program for fibromyalgia (FM). METHODS: In this cross-sectional, observational study, "real world" data from 480 FM patients including socio-demographics, pain variables and questionnaires such as the SF-36, Beck Depression Inventory (BDI), Multiphasic Pain Inventory (MPI), SCL-90-R and others were categorized according to the components (body structure and function, activities and participation, personal factors, environmental factors) of the International Classification of Functioning (ICF). For every ICF component, a linear regression analysis with QOLS as the dependent variable was computed. A final comprehensive model was calculated on the basis of the results of the five independent analyses. RESULTS: The following variables could be identified as main correlates for QoL in FM, explaining 56% of the variance of the QOLS (subscale/questionnaire and standardized beta in parenthesis): depression (- 0.22), pain-related interference with everyday life (- 0.19), general activity (0.13), general health perception (0.11), punishing response from others (- 0.11), work status (- 0.10), vitality (- 0.11) and cognitive difficulties (- 0.12). Pain intensity or frequency was not an independent correlate. CONCLUSIONS: More than 50% of QoL variance could be explained by distinct self-reported variables with neither pain intensity nor pain frequency playing a major role. Therefore, FM treatment should not primarily concentrate on pain but should address multiple factors within multidisciplinary therapy.

The Importance of Daily Activity for Reducing Fibromyalgia Symptoms: A Retrospective "Real World" Data Comparison of two Multimodal Treatment Programs.

OBJECTIVES: This study aims to evaluate the effectiveness of two multidisciplinary fibromyalgia programs with different intensities. MATERIALS AND METHODS: In this retrospective real-world comparison of patient data, pre- and post-program datasets of Short Form 36 (SF36) and Fibromyalgia Impact Questionnaire (FIQ) were obtained from a total of 210 female patients in two fibromyalgia multidisciplinary day hospital programs including one intensive program with daily treatments summing up to 20 treatment days during four weeks (P20, n=70) versus a less intensive program with 12 treatment days during four weeks (P12, n=140). RESULTS: Multiple subscales of SF36 and FIQ were improved in the pre-post comparison in both groups. In the comparison between the two groups, a statistically significantly higher improvement was found in the P20 group compared to the P12 group for the FIQ subscales of stiffness (p=0.001) and the number of days during which the patient felt "good" (p=0.007). CONCLUSION: An intensive program of daily treatments and activity seems to be more effective in reducing fibromyalgia-associated stiffness and improving the number of days during which patients feel good than a less intensive program.

A teaching coordinator's nightmare?

This field report compares the planning and coordination effort of an anatomy teaching coordinator in a subject-oriented standard curriculum with a cross-subject, modularly organized reformed curriculum at a faculty with 600 medical students per year. The distribution of the anatomical teaching over several locations and modules in all semesters, as well as the rotation of these modules within the semester, results in an increased amount of coordination of teaching content and in particular a very complicated timetable. Appropriate and nevertheless non-overlapping allocation of anatomy teaching staff in this timetable is a special challenge. There is no question that interdisciplinary curricula, as called for in the "Master Plan for Medical Studies 2020", represent progress. However, an increased amount of work in the teaching coordination of the subjects must be taken into account in the realization of such curricula in large faculties, irrespective of the efforts required to convert to a new curriculum.

The Brandenburg reformed medical curriculum: study locally, work locally.

The Brandenburg Medical School "Theodor Fontane" (MHB) was founded in 2014 by municipal and non-profit institutions in Bernau, Brandenburg an der Havel and Neuruppin to train more physicians for the non-metropolitan region of Brandenburg. Since the 2015 summer term, 48 medical students have been enrolled each year, accepted through the university's own selection process in which the score on the German school-leaving exam (Abitur) and time spent on the waiting list play subordinate roles. Tuition fees can be partially financed through scholarship agreements with regional hospitals if the applicants commit themselves to medical specialist training (Facharztweiterbildung) at a particular hospital. The main places of study are Neuruppin and Brandenburg an der Havel; there is a decentralized study phase from the eighth to tenth semester of study. The Brandenburg Reformed Medical Curriculum (BMM) complies with the model clause contained in the German regulations governing the licensing of medical doctors (ÄAppO). The curriculum is based on problem-based learning (PBL) and focused on competencies and consists of integrated interdisciplinary modules that combine, from the very beginning, basic sciences with clinical and theoretical medical subjects. The focus on general practice is visible in the regularly held "Practical Days" (Praxistag) during which second-year students and above have the opportunity to observe at participating medical practices and familiarize themselves with primary care in Brandenburg. A special focus of BMM is on the acquisition and development of communication and interpersonal skills. These are imparted through a longitudinal curriculum referred to as "Teamwork, Reflection, Interaction, Communication" (TRIK). High value is placed on critical thinking and scientific scholarship and this is reflected in an eight-week academic placement in which the students independently write a research paper. Several different teaching formats ensure that, along with learning specific subjects, sustained personal development can also take place. BMM's decentralized study phase starting in the eighth semester represents a special part of the curriculum in which students complete their clinical training in small groups at selected cooperating hospitals in Brandenburg. This phase encompasses not only hospital placements and other local patient-centered courses, but also centralized instruction via video conferencing to assure that basic sciences and clinical theory continue to be covered. Knowledge- and performance-based semester assessments, in particular OSCEs, reinforce the practical aspects of the training. These replace the M1 state medical examination in the first study phase. The first medical students are now in their ninth semester as of April 2019, making it still too early for final evaluations. The curriculum, successfully implemented to date, already satisfies core requirements of the Master Plan 2020 for undergraduate medical education (Masterplan Medizinstudium 2020) with the curriculum's organization and structure, curricular content, assessment formats and student admission process. With its decentralized structure, BMM specifically addresses the social and health policy challenges facing rural regions of Brandenburg. This is the first curriculum that has taken on the improvement of healthcare in rural regions as its central aim.

[Undetected coccyx fracture in a woman with fibromyalgia]. / Unentdeckte Os-coccygis-Fraktur bei Patientin mit Fibromyalgiesyndrom.

This article presents the case of a 46-year-old woman with fibromyalgia with an undetected fracture of the coccyx. The heterogeneity of the symptoms of patients suffering from fibromyalgia including chronic widespread pain, vegetative and functional disorders, mental and physical exhaustion as well as sleep disorders can cause accidentally undetected comorbidities, especially if these are rare and predominantly present with pain as the main symptom. In the present case the reason for symptoms was detected only after 14 months of ineffective therapies and diagnostic procedures. The coccygeal pain was eliminated through a coccygectomy as ultima ratio. It should be nevertheless emphasized that patients with fibromyalgia suffer from a central pain-processing disorder. Indications for operative treatment must be very carefully considered. Surgery should only be considered in consultation with the patient and after failed conservative therapy.

BODIES R US: Ethical Views on the Commercialization of the Dead in Medical Education and Research.

With the ongoing and expanding use of willed bodies in medical education and research, there has been a concomitant rise in the need for willed bodies and an increase in the means of supplying these bodies. A relatively recent development to enlarge this supply has been the growth of for- profit willed body companies ("body brokers") in the United States. These companies advertise for donors, cover all cremation and other fees for the donor, distribute the bodies or body parts nationally and internationally, and charge their users for access to the body or body parts. In doing so, they generate substantial profits. This review examines the historical development of willed body programs, the legal and economic aspects of willed body programs, and then provides an ethical framework for the use of willed bodies. The ethical principles described include detailed informed consent from the donors, comprehensive and transparent information about the process from the body donation organizations, and societal input on the proper and legal handling of willed bodies. Based on the ethical principles outlined, it is recommended that there be no commercialization or commodification of willed bodies, and that programs that use willed bodies should not generate profit.

Recommendations of the working group of the Anatomische Gesellschaft on reduction of formaldehyde exposure in anatomical curricula and institutes.

The practice of human and veterinary medicine is based on the science of anatomy and dissection courses are still irreplaceable in the teaching of anatomy. Embalming is required to preserve body donors, for which process formaldehyde (FA) is the most frequently used and well characterized biocidal substance. Since January 2016, a new occupational exposure limit (OEL) for FA of 0.37mg/m3 issued by the European Committee on Hazardous Substances is obligatory since FA has been classified as a human 1B carcinogen. The anatomical institutes in the German-speaking region are called upon to consolidate efforts to reduce use of FA in anatomical curricula and body donations. As a result, the Anatomische Gesellschaft (AG) has formed a "Working Group for Reduction of Formaldehyde Exposure in Dissection Courses" tasked with discussion and recommendation of measures to reduce FA. Based on the assessment of the Working Group, the AG has issued an official opinion to the effect that, at this point in time, embalming of body donors without FA completely is not feasible. Therefore, a combination of approaches are to be used to reduce FA exposure, including technical and structural (architectural) adaptations, modification of protocols for fixation and preservation as well as organizational measures. One structural measure considered unavoidable is the integration of air supply and exhaust of individual dissecting tables into the ventilation system of the anatomy building. To embalm human body donors, intra-arterial perfusion fixation with up to 4% FA and a total fluid volume of 150mL/kg body weight will suffice. For animals where body weights and biology of bodies vary widely (i.e. special needs of fixation for ruminants, large animals as horses) perfusion fixation with up to 4% FA and a quantity of fixative solution of 10-15% of the body weight may be required. Preservation of body donors in storage (immersion) can be done with 40% ethanol or in a full bath preservation containing up to 2% FA. Corpse humidification in the dissecting room is possible with 2% phenoxyethanol, in each case without FA. In veterinary anatomy, microbiological burden is often higher and therefore might lead to a need of FA in long-time storage. Compliance with the current OEL in all institutes would appear to be feasible in combination with various organizational measures.

[Searching the Roots of Erb's Auscultation Point]. / Auf den Spuren des Erb'schen Auskultationspunkts: Rätsel gelöst.

"Erb's point" is the fifth point of auscultation for the heart exam, located in the third intercostal space close to the sternum. It has sometimes been attributed to famous German neurologist Wilhelm Heinrich Erb (1840 - 1921), but without historical evidence. Erb's focus on neurology suggested that the auscultation point may have been confused with other points in the neck named after Erb. As Erb was a specialist for neurological manifestations of syphilis, we speculated that the heart murmur of aortic incompetence produced by syphilitic aortitis, best heard at Erb's point, linked Erb's name to the auscultation point. However, we eventually found a publication by an American physician who visited Erb's lectures in Heidelberg and reported that Erb explicitly introduced this "fifth point" in his case presentations in the late 1890 s. After all, Erb was chair of general medicine, with the first German chair of neurology only being established in 1919.