The effectiveness of three-dimensional printing in undergraduate and postgraduate anatomy education: A review of reviews.

PURPOSE: Several reviews and meta-analyses about the value of three-dimensional (3D) printing in anatomy education have been published in the last years, with variable-and sometimes confusing- outcomes. We performed a review of those reviews, in order to shed light on the results concerning the effectiveness of 3D printing in anatomy education, compared to specific traditional methods and other technologies. METHODS: The electronic databases PubMed, ERIC and Cochrane library were searched for reviews or meta-analyses with purpose to investigate the effectiveness of 3D printing in undergraduate and postgraduate anatomy education. RESULTS: Seven papers were included: four systematic reviews with meta-analysis, one narrative, one scoping and one systematic review. Overall, it has been shown that 3D printing is more effective than two-dimensional (2D) images for undergraduate health science students, but not for medical residents. Also, it seems to be more effective than 2D methods for teaching anatomy of some relatively complex structures, such as the nervous system. However, there is generally lack of evidence about the effectiveness of 3D printing in comparison with other 3D visualization methods. CONCLUSIONS: For students, the effectiveness of 3D printing in anatomy education is higher than 2D methods. There is need for studies to investigate the effectiveness of 3D printing in comparison with other 3D visualization methods, such as cadaveric dissection, prosection and virtual reality. There is also need for research to explore if 3D printing is effective as a supplementary tool in a blended anatomy learning approach.

Gestures-enhanced anatomy teaching: A literature review of an educational strategy with promising outcomes.

PURPOSE: The educational use of gestures has resulted in positive outcomes in several fields. We performed a literature review to investigate the outcomes of the use of gestures to enhance the existing anatomy education methods. METHODS: PubMed, SCOPUS, ERIC and Cochrane databases were searched for papers with purpose to investigate the outcomes of the use of gestures (either seeing or performing them or both) as adjuncts to existing anatomy education methods. RESULTS: Six articles were included. Three studies comprised both seeing and performing gestures by the students, while the remaining three studies only comprised either seeing or performing gestures by the students. Most studies evaluated the acquisition of anatomical knowledge after the educational intervention and demonstrated that the addition of gestures resulted in significant benefit compared to control groups, while positive students' perceptions were recorded. It was not clarified whether seeing or performing gestures by the students leads to better educational outcomes. CONCLUSION: Gestures-enhanced anatomy education seems to be a promising teaching strategy, given that it has led to significantly increased acquisition of anatomical knowledge compared to no gestures-enhanced modalities. The addition of gestures to existing anatomy education modalities seems able to increase their potential without increasing their cost. Further research is needed to determine if seeing or performing gestures by the students is more effective.

Do virtual dissection tables add benefit to cadaver-based anatomy education? An evaluation.

PURPOSE: The anatomy education literature suggests blended-learning approaches as more effective. We performed a literature review to answer the question if virtual dissection tables can play a significant role as supplements to traditional cadaver-based anatomy education methods. METHODS: PubMed, SCOPUS, ERIC and Cochrane databases were searched for articles with purpose to explore the outcomes of the use of virtual dissection tables in conjunction with cadaver-based anatomy education. RESULTS: Six articles were included. Three articles were comparative and comprised evaluation of participants' anatomy examinations results. Three articles were non-comparative and comprised only evaluation of participants' opinions about the educational intervention. In all studies, the participants expressed satisfaction about the educational value of this intervention, while the data about anatomy examinations' results suggest that virtual dissection tables may also enhance students' academic performance, when they are used in conjunction with cadavers. CONCLUSION: Virtual dissection tables seem to do have a role in modern blended-learning anatomy curricula and could essentially supplement the educational power of cadaver-based methods. Our findings may stimulate further implementation of virtual dissection tables as supplementary tools to cadaver-based anatomy education.

Incorporation of team-based learning in the cadaveric anatomy laboratory: An overview.

PURPOSE: Team-based learning is a strategy which has resulted in positive outcomes concerning health professions education. We aimed to shed light on the role of this strategy when it is incorporated in the cadaveric anatomy laboratory. METHODS: We explored PubMed, SCOPUS, ERIC and Cochrane databases for articles with purpose to investigate the educational outcomes of the integration of team-based learning in the cadaveric anatomy laboratory. RESULTS: Six articles were eligible for inclusion. One of them assessed only participants' opinions about the educational intervention and five papers evaluated students' knowledge. Overall, the research showed significant improvement in students' examinations performance and significant superiority to control groups, as well as positive perceptions. There are limited data regarding the factors which may contribute to this success, but it seems that particularly the degree of teacher's involvement and competency needs to be further investigated. CONCLUSION: Anatomy educators may consider further adopting team-based learning to facilitate the achievement of the learning objectives of the cadaveric anatomy laboratory and increase the teaching potential of cadavers.

Evaluation of the use of cadaveric computed tomography in anatomy education: An overview.

OBJECTIVE: We aimed to explore to what extent the literature supports that the use of cadaveric computed tomography can play an important role in anatomy education. MATERIALS AND METHODS: PubMed, SCOPUS, Education Resources Information Center and Cochrane Databases were searched for papers with purpose to explore the outcomes of the use of cadaveric computed tomography scans in anatomy education. The following data were obtained from each paper: authors, number of participants, type of study (comparative or not), level of outcome according to Kirkpatrick hierarchy, possible evaluation of statistical significance, acquisition of anatomical knowledge after the educational intervention and perceptions about the effectiveness of this intervention in anatomy learning. RESULTS: Seven articles were included. Four of them evaluated students' knowledge after the use of cadaveric computed tomography scans in anatomy education and three papers evaluated only students' perceptions. Generally, the outcomes, which mainly concerned students' perceptions, were positive, while it was showed that students' academic performance may also be improved. CONCLUSIONS: The outcomes of the use of cadaveric computed tomography scans in anatomy education encourage the implementation of this teaching modality in anatomy curricula. Further research, including comparative studies with evaluation of acquisition of students' knowledge, is needed to show if cadaveric computed tomography will be proved a remarkable supportive tool in anatomy educators' hands.

Is expansion of artificial dermis a reliable reconstructive option?

Reconstruction of full-thickness defects with the use of artificial dermis has been well established in the recent literature. The capacity of artificial dermis to expand over a period of years, months, or even days is described. Three such cases are reported. Two female patients, aged 21 and 30 years, with post-burn contractures of the chest with right breast hypoplasia and abdominal wall post-burn contractures respectively, and a 14-year-old male with a giant congenital naevus on the forearm, are presented. After excision of the contractures and the congenital naevus, the patients underwent staged reconstruction with the use of artificial dermal template and split-thickness skin autografts at monthly intervals. The 21-yr-old female also had a tissue expander placed submuscularly which six months later was replaced by a permanent silicone implant. Gradual expansion of artificial dermis within three weeks resulted in reconstruction of a breast of natural shape, size, and volume. In the second patient the artificial dermis was expanded over a period of months, until full-term pregnancy, while the third patient took years to achieve expansion naturally as he grew up. In conclusion, artificial dermis can be expanded over various periods of time (days to years), providing a reliable and safe alternative reconstructive method, particularly in areas where expansion is an absolute necessity for a good functional and aesthetic result.

E2F-1 overexpression correlates with decreased proliferation and better prognosis in adenocarcinomas of Barrett oesophagus.

BACKGROUND: E2F-1 expression is positively associated with tumour growth in oesophageal squamous-cell carcinomas (OSCC), while it exhibits oncosuppressive features in colonic adenocarcinomas (AC). To date there are no data regarding E2F-1 expression and its relationship with tumour kinetics (proliferation, apoptosis) in adenocarcinomas that develop on Barrett oesophagus. AIM: As oesophageal adenocarcinomas occur almost exclusively in the metaplastic Barrett epithelium and the opposing E2F-1 behaviour seems to be cell and tissue-type dependent, we examined the manner in which E2F-1 acts in ACs of Barrett oesophagus. METHODS: We estimated the immunohistochemical expression of E2F-1, Ki-67, caspase-3 and p53 immunohistochemical status in 35 Barrett oesophagus ACs. RESULTS: E2F-1 immunopositivity correlated inversely with Ki-67, by semi-serial section and statistical analysis (p = 0.023, Spearman correlation). Semi-serial section analysis revealed a direct association between E2F-1 and caspase-3 staining. No correlation was found with p53 status. Cases with higher E2F-1 immunoexpression exhibited longer survival (p = 0.047, Cox-regression). CONCLUSIONS: E2F-1 expression was negatively related to tumour proliferation in ACs of Barrett oesophagus. Additionally, E2F-1 immunohistochemical status correlated positively with patient survival. These findings are opposite from those seen in OSCCs, suggesting that the tumour-suppressing E2F-1 behaviour in oesophageal adenocarcinomas is possibly due to the intestinal-type nature of the metaplastic Barrett mucosa.

Evaluation of claspin as a proliferation marker in human cancer and normal tissues.

Claspin is a nuclear protein involved in DNA replication and the DNA damage response. Its structural and functional properties suggest that it may represent a potentially useful proliferation marker. To this end, a monoclonal antibody was generated and the expression of claspin was investigated in normal fibroblasts and various cancer cell lines, as well as in tumour and normal tissues from patients with primary epithelial carcinomas. Immunoblotting analysis confirmed the specificity of the antibody, while immunohistochemistry demonstrated its applicability in archival material. In normal cells and tissues, claspin expression was weak, whereas increased levels were observed in cancer cell lines and tumour specimens. Claspin staining correlated strongly with Ki67 staining in both normal (p < 0.001) and tumour tissues (p < 0.001). However, the labelling index (LI) of claspin was consistently lower than that of Ki67, suggesting that claspin expression may be limited to a narrower part of the cell cycle. Co-localization assays with cyclin A and cell synchronization experiments indicated that claspin expression coincides with the S phase. Interestingly, the relative increase of the claspin LI in tumour samples compared with normal tissues was significantly higher (14-fold) than that of the Ki67 LI (five-fold), suggesting that claspin may be a more sensitive marker of aberrant proliferation.

Hypoxia-inducible factors HIF-1alpha and HIF-2alpha expression in bladder cancer and their associations with other angiogenesis-related proteins.

Hypoxia-inducible factors (HIF-1alpha and HIF-2alpha) are closely related protein complexes that activate transcription of target genes in response to hypoxia. The immunohistochemical expression of these two proteins was investigated in 144 bladder cancer tissue samples and correlated with standard clinicopathological features, in order to elucidate their prognostic significance. We also evaluated their possible associations with other angiogenesis related markers such as microvessel density (MVD), vascular endothelial growth factor, thymidine phosphorylase, tenascin, fibronectin, p53 and bcl-2 to further clarify their implication in tumor stroma vascularization. Nuclear HIF-1alpha expression in tumor cells was detected in 57.1% of the cases. A trend of correlation of this expression with poorly differentiated tumors was observed. In addition, HIF-1alpha expression was positively correlated with stromal cells thymidine phosphorylase expression. Tumors that were progressed in muscle-infiltrating disease showed a higher HIF-1alpha expression. A higher HIF-1alpha expression was also observed in tumors with an in situ component. In tumor cells, low HIF-2alpha expression was observed in 6.3%, moderate in 31.9% and high in 61.8% of the cases. A trend of correlation of this expression with MVD was observed. In addition, HIF-2alpha expression was positively correlated with thymidine phosphorylase and fibronectin expression. A lower HIF-2alpha expression was detected in tumors that recurred earlier in univariate methods of analysis. HIF-2alpha was expressed in tumor stroma associated cells in 53.5% of specimens and was correlated with advance tumor stage, thymidine phosphorylase and tenascin expression. There was no statistically significant difference in the expression of both HIF-1alpha and HIF-2alpha between primary and recurrent tumors. In multivariate analysis including T stage, T grade, multifocality and T size, both HIF-1alpha and HIF-2alpha expression were not considered dependent in the prediction of recurrence or progression. In conclusion, the results of the present study indicate that HIF-1alpha and HIF-2alpha expression may help to predict recurrence or progression to muscle invasive disease but not as independent prognostic factors. In addition, the expression of HIF-1alpha and HIF-2alpha, appear to play a role in bladder cancer, vascularization possibly and in cooperation with other angiogenic factors.

Thrombospondin-1 expression in urothelial carcinoma: prognostic significance and association with p53 alterations, tumour angiogenesis and extracellular matrix components.

BACKGROUND: Thrombospondin-1 (TSP-1) is an extracellular matrix component glycoprotein, which is known to be a potent inhibitor of angiogenesis and may be important in cancer invasiveness. We examined the TSP-1 expression in correlation with conventional clinicopathological parameters to clarify its prognostic significance in bladder cancer. In addition, the possible correlation of TSP-1 expression with microvessel count, VEGF expression, p53 expression as well as with the expression of the extracellular matrix components was studied to explore its implication in vascularization and tumour stroma remodeling. METHODS: The immunohistochemical expression of TSP-1 in tumour cells and in the tumour stroma was studied in 148 formalin-fixed paraffin-embedded urothelial cell carcinoma tissue samples. RESULTS: TSP-1 was detected in perivascular tissue, at the epithelial-stromal junction, in the stroma and in tumour cells in the majority of the cases. In tumour cells, low TSP-1 expression was observed in 43% of the cases, moderate and high in 7%, while 50% showed absence of TSP expression. A higher TSP-1 immunoreactivity in well and moderately differentiated tumours compared to poorly differentiated was noted. PT1 tumours showed decreased TSP-1 expression in comparison to pTa and pT2-4 tumours. Increased tumour cell TSP-1 expression was related to increased microvessel density. In the tumour stroma, 37% of the cases showed small amount of TSP-1 expression, 7.5% moderate and high, while 55% of the cases showed absence of TSP-1 stromal immunoreactivity. Stromal TSP-1 expression was inversely correlated with tumour stage and tumour size. This expression was also positively correlated with microvessel density, VEGF expression and extracellular matrix components tenascin and fibronectin. Using univariate and multivariate analysis we didn't find any significant correlation of TSP-1 expression in superficial tumours in both tumour cells and tumour stroma in terns of the risk of recurrence and disease progression CONCLUSION: Our data suggest that both tumour and stromal TSP-1 expression may play a role in tumour aggressiveness and angiogenesis. In addition, the correlation of stromal TSP-1 expression with extracellular matrix components fibronectin and tenascin indicate its possible implication in tumour stroma remodeling.

Expression patterns of cyclins D1, E in laryngeal epithelial lesions: correlation with other cell cycle regulators (p53, pRb, Ki-67 and PCNA) and clinicopathological features.

The expression of cell-cycle progression molecules cyclin D1 and cyclin E were immunohistochemically examined in a series of 64 squamous cell invasive carcinomas of the larynx, 10 in situ carcinomas, 34 cases of dysplasia, 11 papillomas and 23 cases of keratosis. The results of their expression were compared with two cell-cycle implicated tumor suppressor proteins p53 and pRb as well as with two proliferation associated indices PCNA and Ki-67 in an attempt to elucidate their potential role in the pathogenesis and progression of these lesions. Nuclear staining for cyclin D1 and E (>5% positive cells) was observed in 19% and 39.7% of the laryngeal carcinomas, respectively. Significantly elevated levels of cyclin D1 and E in invasive laryngeal carcinomas compared with in situ carcinomas were revealed (p=0.045 and p=0.0003, respectively). High levels of cyclin D1 and E expression were correlated with increased Ki-67 score (p=0.037 and 0.017 respectively). A significant positive correlation between cyclin D1 and E was also detected in carcinomas (p=0.018). Decreased levels of cyclins D1 and E in the group of in situ carcinomas compared with those of dysplastic cases and papillomas were also observed. In the dysplastic lesions cyclin D1 expression was correlated with pRb expression (p=0.02). In the cases of keratosis cyclins D1 and E expression were correlated with pRb (p=0.002 and p=0.036, respectively), while cyclin D1 was associated with PCNA (p=0.008) and Ki-67 score (p=0.009). The prognostic significance of cyclins D1, E in determining the risk of recurrence and overall survival with both univariate (long-rang test) and multivariate (Cox regression) methods of analysis showed no statistically significant differences. We conclude that the expression of cyclins D1 and E in squamous cell carcinomas of the larynx does not seem to have a prognostic significance. In addition, their expression may be involved in the development of laryngeal lesions, implicated in cell proliferation, with other cell cycle related proteins, probably by different molecular pathways.

Expression patterns of cyclins D1, E and cyclin-dependent kinase inhibitors p21(Waf1/Cip1) and p27(Kip1) in urothelial carcinoma: correlation with other cell-cycle-related proteins (Rb, p53, Ki-67 and PCNA) and clinicopathological features.

INTRODUCTION: The expression pattern of cyclins D1 and E, as well as cyclin-dependent kinase inhibitors p21(Wa1/Cip1) and p27(Kip1) and their relationship to tumour behaviour and patients' prognosis was examined in 142 urothelial cell carcinomas. The expression of these proteins was also analyzed along with other cell-cycle-related proteins such as: p53, pRb and the proliferation-associated indices Ki-67 and proliferating cell nuclear antigen (PCNA). PATIENTS AND METHODS: These molecule markers were localized immunochemically using the monoclonal antibodies anti-cyclin D1 (DCS-6), anti-cyclin E (13A3), anti-p21 (4D10), and anti-p27 (1B4) in 142 patients with urothelial cell carcinoma. RESULTS: Focal positivity (<10% of tumour cells) or the absence of cyclin D1 immunostaining was observed in 105/142 (73.9%) of the tumours. Cyclin D1 expression was correlated with tumour grade and stage as well as with the existence of in situ component. In addition, cyclin D1 expression was positively correlated with p21(Waf1/Cip1) and p27(Kip1) and inversely with the Ki-67 score. Focal positivity (<20% of tumour cells) or the absence of cyclin E immunoreactivity was observed in 105/142 (73.9%) in all cases. Cyclin E expression was correlated with tumour stage. A positive relationship between cyclin E expression and the two associated proliferating indices Ki-67 and PCNA, as well as with p53 and p27(Kip1) proteins expression was noted. Absence or focal positivity (<5% of tumour cells) of p21(Waf1/Cip1) was detected in 88/142 (62%) of the carcinomas. p21(Waf1/Cip1) expression was correlated with tumour grade and stage. A positive relationship of its expression cyclin D1, cyclin E, p27 and pRb expression was observed. Absence or focal immunostaining (<20% of tumour cells) of p27 protein was detected in 55/141 (39%) in all cases. p27(Kip1) expression was correlated with tumour grade as well as with cyclins D1 and E. The prognostic significance of cyclins D1, E and cyclin-dependent kinase inhibitors p21(Waf1/Cip1), p27(Kip1) in determining the risk of recurrence and progression with both univariate (log rank test) and multivariate (Cox regression) methods of analysis showed no statistically significance differences. CONCLUSION: These findings suggest that the level of the cell cycle regulators studied does not seem to have a clinical value in terms of predicting the risk of early recurrence and progression. In addition the interrelationship probably means their contribution to the regulation of cell growth through different pathways in bladder carcinogenesis.

Immunohistochemical evaluation of cathepsin D in normal, hyperplastic and malignant endometrium: correlation with hormone receptor status c-erbB-2, p53, Rb proteins and proliferation associated indices.

The immunohistochemical expression of cathepsin D was performed in paraffin embedded tissue from 79 endometrial carcinomas, 35 cases of hyperplasia, and 32 normal endometrium using the streptavidin-biotin method to investigate the role of cathepsin D (CD) in these lesions and its possible relationship with other potential and established prognostic markers. The association between CD and the other markers was assessed by univariate analysis. Tumor cell CD expression was lower in the group of carcinomas compared to the normal proliferative (P = 0.022) and secretory endometrium (P = 0.0005). In addition, hyperplastic cell CD expression was lower compared with epithelial cell CD expression in the secretory phase of normal endometrium (P = 0.009). Malignant cell CD expression was inversely correlated with tumor stromal cells (P = 0.007). A positive relationship of stromal cell CD expression with pRb (P = 0.046) and PCNA score (P < 0.0001) was detected in the group of carcinomas. In the proliferative phase of normal endometrium, epithelial CD expression was positively correlated with estrogen status (P = 0.015). The data show that down-regulation of CD expression is an early event in endometrial carcinogenesis. In addition, stromal cell CD expression may be involved in cell growth process in endometrial carcinomas.

Immunohistochemical expression of heat shock protein 27, in normal hyperplastic and neoplastic endometrium: correlation with estrogen and progesterone receptor status, p53, pRb and proliferation associated indices (PCNA, MIB1).

Heat shock protein 27 (HSP27) is a relatively small protein produced in response to pathophysiological stress. In the current prospective study the presence and localization of HSP27 was associated with other potential prognostic factors such as: estrogen and progesterone receptors, p53 and proliferative associated indices (MIB1, PCNA). One hundred and twenty-two samples of endometrial tissues (65 endometrial carcinomas, 28 adenomatous hyperplasias, 31 normal endometrium) were studied. Patient records were examined for FIGO stage, grade, and depth of myometrial invasion, histology and lympho-vascular space invasion. HSPp27 expression was lower in the group of carcinomas when compared with the cases of adenomatous hyperplasias (p < 0.0001), normal proliferative (p < 0.0001) and secretory endometrium (p = 0.02). HSP27 expression was higher in carcinomas from premenopausal women in comparison with women in menopausal status and postmenopausal status. Multivariate tests showed no statistical significance of HSP27 expression according to tumor grade and stage. A positive relationship between the expression of HSP27 expression and estrogen receptors (p = 0.0018) as well as with progesterone receptor (p = 0.0012) was found with linear regression analysis of variance. Our data showed that the lower HSP27 expression in endometrial carcinomas in comparison with hyperplastic and normal endometrium may indicate a decreased endogenous protection mechanism against the various stressful stimuli. This expression could be under hormonal control and does not seem to be correlated with other conventional or possible prognostic parameters.

Estimation of artifacts induced by the Ilizarov device in quantitative computed tomographic analysis of tibiae.

This study concerns the estimation of the artifacts introduced by the metallic frame of an Ilizarov apparatus during quantitative computed tomography for the assessment of neoosteogenesis. Ten cadaver tibiae were tomographed before and after the mounting of an Ilizarov device. The increase in mean density and in the relative number of pixels were used as indicators of the artifacts induced by the apparatus. No significant influence by the device was recorded in regions corresponding to a corticotomy site. In regions close to the metallic rings of the Ilizarov apparatus, measurements are distorted significantly, but with no influence on the assessment of neoosteogenesis.