Best teaching practices in anatomy education: A critical review

Next Generation Case Report: Supraorbital Craniotomy for Anterior Communicating Artery Aneurysm Clipping in Annotated Virtual Reality Environment

BACKGROUND AND IMPORTANCE

Recent years have seen significant advancements in virtual reality. Implementation of this technology in combination with traditional learning methods is a powerful tool for medical teaching.

CLINICAL PRESENTATION

This is a 60-yr-old woman who presented with a history of headaches and was found to have an unruptured 4-mm anterior communicating artery aneurysm. After discussion, the patient elected to have the aneurysm treated by surgical clipping. The aneurysm was completely occluded through a supraorbital craniotomy with a single clip. The patient was discharged home in good condition on postoperative day 2. This case was imported into a virtual reality environment with annotated slides and operative video for resident teaching.

CONCLUSION

As virtual reality technology continues to grow, library of interactive case reports could revolutionize neurosurgical education.

Heart Anatomy of Rhincodon typus: Three-Dimensional X-Ray Computed Tomography of Plastinated Specimens

In this study, we examined the structure of the heart of the whale shark, Rhincodon typus, using a plastination technique and three-dimensional X-ray computer tomography (3DCT). Inspection of the atrium revealed a symmetric distribution of the pectinate muscles attached to the commissures of the sino-atrial valve, suggesting some functional advantages. The majority of the ventricular wall comprised spongiosa, and compacta accounted for only ~3% of the entire thickness. There were three major fiber orientations in the spongiosa: the fibers on the endocardial side formed trabeculae that were aligned with the blood flow tract, whereas those on the epicardial side formed a circular pattern around the flow tract. Transmural myofibers connected the inner and outer layers in the spongiosa, which may serve as an intraventricular conduction pathway. Plastination and 3DCT is a powerful combination that allowed for multifaceted visualization of the internal structure of rare heart specimens in a nondestructive manner. Anat Rec, 301:1801-1808, 2018. © 2018 Wiley Periodicals, Inc.

Analysis of immediate student outcomes following a change in gross anatomy laboratory teaching methodology

OBJECTIVE:

To compare student performance following a change in laboratory teaching methodology from cadavers to models to virtual dissection table in a musculoskeletal gross anatomy course in a doctor of chiropractic program.

METHODS:

Three marking periods of laboratory and lecture examination scores from 3 consecutive academic calendar years were evaluated and compared using simple analysis as well as analysis of variance and post hoc t tests. The 1st cohort of students ( n = 352) utilized cadavers. The 2nd cohort of students ( n = 350) had anatomical models as their primary gross laboratory modality. The 3rd cohort of students ( n = 393) utilized virtual dissection tables.

RESULTS:

The midterm and final laboratory examination scores were evaluated and showed successive increase in aggregate averages between cohort 1 (mean = 76.1%), cohort 2 (mean = 81.4%), and cohort 3 (mean = 85.1%). Lecture examination scores remained consistent between the cohorts at 61.2%, 62.4%, and 61.1%, respectively. Significant improvements were seen in lab exam scores between cohorts ( F [2, 2113] = 58.6, p < .001), and no significant differences were seen in lecture exam scores.

CONCLUSION:

Students utilizing virtual dissection tables scored higher on laboratory examinations than students having models or cadavers. However, they displayed a similar testing competency in lecture examinations, suggesting a possible change in laboratory examination difficulty between the cohorts but a similar knowledge base. Further studies are warranted to evaluate the long-term retention of student knowledge.

Augmented reality in dentistry: a current perspective

Augmentation reality technology offers virtual information in addition to that of the real environment and thus opens new possibilities in various fields. The medical applications of augmentation reality are generally concentrated on surgery types, including neurosurgery, laparoscopic surgery and plastic surgery. Augmentation reality technology is also widely used in medical education and training. In dentistry, oral and maxillofacial surgery is the primary area of use, where dental implant placement and orthognathic surgery are the most frequent applications. Recent technological advancements are enabling new applications of restorative dentistry, orthodontics and endodontics. This review briefly summarizes the history, definitions, features, and components of augmented reality technology and discusses its applications and future perspectives in dentistry.

A shortage of cadavers: The predicament of regional anatomy education in mainland China

Both in mainland China and around the world, regional anatomy stands as one of the most important basic science courses in medical school curricula. As such, dissection of human cadavers and use of prosected specimens remains the most essential teaching method in anatomy education. However, medical educators have raised increasing concerns about an ongoing shortage of cadavers for medical use in mainland China, a problem which may seriously limit the future development of human anatomy education. Based on a survey on cadaver usage in anatomy education in mainland China, this study found that the cadaver resources of most given medical schools in mainland China are associated with their geographic location, academic ranking, and local support for body donation policies. Effective measures to alleviate this shortage of cadavers may include future efforts to promote national-level body donation legislation, broader acceptance of body donation among Chinese citizens, and an efficient and humane protocol for body donation. Anat Sci Educ 11: 397-402. © 2018 American Association of Anatomists.

What do medical students learn from dissection?

Dissection has long been the accepted method for teaching anatomy to medical students. More recently, some educators have suggested that easier, cheaper, alternative methods are just as effective. But what do the students think? This paper aimed to identify what undergraduate medical students learn, how they cope, and what effects participating in dissection has on them as individuals. A cohort of 267 second year medical students at Otago Medical School were invited to complete three online surveys; before their first dissection laboratory class, after their first musculoskeletal system dissection and following the last semester of studying anatomy. Open-ended questions showcasing the attitudes, beliefs, and opinions on what dissection had taught the medical students over years two and three were analyzed. A general inductive approach was used and common emergent themes were identified. In total, 194 students completed the second, and 108 students completed the third questionnaire. Students commonly conveyed dissection as an appropriate and valuable educational tool, useful for teaching and learning anatomical knowledge and relationships, appreciating the body in three-dimension, teamwork, and how to cope with death/dead bodies. The noted effects of personal growth while participating in dissection were highly varied, but in general, impacted positively on the majority of students. This study shows that at Otago Medical School the students also believe that dissection is not only a useful tool to learn anatomy but also that it fosters teamwork, assists professional development and helps them come to terms with death and dying. Anat Sci Educ 11: 325-335. © 2017 American Association of Anatomists.

A New Approach to Body Donation for Medical Education: The Silent Mentor Programme

Cadaveric dissection is an integral component of medical education. There had been concerns about negative impact on medical students exposed to deceased donors before their clinical years, but most studies reported overall positive outcome following this form of teaching. Due to reducing number of body donations in most parts of the world, many institutions are adopting alternative models especially for the teaching of gross anatomy. A new body donation programme that incorporate humanistic values in the procurement process was initiated by Tsu Chi University of Taiwan in 1996. Early observations following teaching with the so-called “silent mentors” noted less negative emotional impact on the students. With increasing number of body donation following the initiation of the silent mentor programme as reported in some regions, we will be able to continue the time-honoured cadaveric dissection for anatomy teaching, at the same time promoting humanistic values on junior doctors.

3D-Printed specimens as a valuable tool in anatomy education: A pilot study

Three-dimensional (3D) printing is a modern technique of creating 3D-printed models that allows reproduction of human structures from MRI and CT scans via fusion of multiple layers of resin materials. To assess feasibility of this innovative resource as anatomy educational tool, we conducted a preliminary study on Curtin University undergraduate students to investigate the use of 3D models for anatomy learning as a main goal, to assess the effectiveness of different specimen types during the sessions and personally preferred anatomy learning tools among students as secondary aim. The study consisted of a pre-test, exposure to test (anatomical test) and post-test survey. During pre-test, all participants (both without prior experience and experienced groups) were given a brief introduction on laboratory safety and study procedure thus participants were exposed to 3D, wet and plastinated specimens of the heart, shoulder and thigh to identify the pinned structures (anatomical test). Then, participants were provided a post-test survey containing five questions. In total, 23 participants completed the anatomical test and post-test survey. A larger number of participants (85%) achieved right answers for 3D models compared to wet and plastinated materials, 74% of population selected 3D models as the most usable tool for identification of pinned structures and 45% chose 3D models as their preferred method of anatomy learning. This preliminary small-size study affirms the feasibility of 3D-printed models as a valuable asset in anatomy learning and shows their capability to be used adjacent to cadaveric materials and other widely used tools in anatomy education.

The Various Applications of 3D Printing in Cardiovascular Diseases

PURPOSE OF REVIEW

To highlight the various applications of 3D printing in cardiovascular disease and discuss its limitations and future direction.

RECENT FINDINGS

Use of handheld 3D printed models of cardiovascular structures has emerged as a facile modality in procedural and surgical planning as well as education and communication. Three-dimensional (3D) printing is a novel imaging modality which involves creating patient-specific models of cardiovascular structures. As percutaneous and surgical therapies evolve, spatial recognition of complex cardiovascular anatomic relationships by cardiologists and cardiovascular surgeons is imperative. Handheld 3D printed models of cardiovascular structures provide a facile and intuitive road map for procedural and surgical planning, complementing conventional imaging modalities. Moreover, 3D printed models are efficacious educational and communication tools. This review highlights the various applications of 3D printing in cardiovascular diseases and discusses its limitations and future directions.

Cadaveric Dissection a Thing of the Past? The Insight of Consultants, Fellows, and Residents

Objective

The objective of our study was to determine whether cadaveric dissection is a necessity in medical education. Another purpose of our study was to assess the attitude and perception of consultants, residents, and fellows about cadaveric dissection and whether it helped them in their medical practices.

Method

We performed an analytical cross-sectional study among consultants, fellows, and residents of different specialty areas practicing in Punjab. A self-constructed questionnaire compromising of 41 items was used to assess the perception of doctors about cadaveric dissection and other alternative anatomy teaching methods. Consultants, fellows, and residents who were in clinical practice for more than six months were included in the study.

Results

Out of the total sample size of 842, 44.7% were female medical doctors and 55.3 % were male medical doctors. Cadaveric dissection was thought to be the most effective method for teaching anatomy by 27.9% of the doctors. Mean cadaveric dissection, prosection and didactic teaching components were scored significantly higher by doctors in surgery and allied fields (p<0.001). Doctors in the surgical and allied field were 0.55 times less likely to think that cadaveric dissection was unethical as compared to doctors working in medicine and allied fields (p<0.001).

Conclusion

Dissection is still considered by several doctors as a valuable source of learning anatomy. However, the future of teaching anatomy does not depend on any single method. It is, in fact, the right combination of all available resources and using them in an interactive way that maximizes outcomes.

Drawing method can improve musculoskeletal anatomy comprehension in medical faculty student

The Chinese philosophy of Confucianism said “What I heard I forgot, what I see, I remember, what I do, I understand.” During this time, most of the teaching and learning process relies on viewing and listening modalities only. As a result, much information does not last long in memory as well as the material understanding achieves became less deep. In studying anatomy science, drawing is one of effective important methods because it is an integration of ideas and knowledge of vision thereby increasing comprehension and learning motivation of college students. The purpose of this research is to know the musculoskeletal anatomy comprehension by drawing learning method in Medical Faculty student. This research uses observational analytic design with the cross-sectional design. Total sampling was done to the entire student of Physiotherapy Study Program in 2012, 2013, and 2014, Medical Faculty of Udayana University. The average value of musculoskeletal anatomy of the student in 2012, 2013, and 2014 sequentially are 31.67, 33.57, and 45.00, respectively. Normality test with Shapiro-Wilk and homogeneity with Levene's test showed normal results and homogeneous. One-way ANOVA test between groups showed a significant result that is 11.00 (P<0.05). It is concluded that the drawing method can improve the musculoskeletal anatomy comprehension in Medical Faculty student.

Development of "Core Syllabus" for Facial Anatomy Teaching to Aesthetic Physicians: A Delphi Consensus

Background:

A detailed understanding of facial anatomy, specifically the vascular framework, is crucial for delivering safe nonsurgical aesthetic procedures. To date, there is no core document based on consensus for the teaching of facial anatomy to aesthetic physicians exists. The aim of this study was to ascertain the most critical anatomical structures for avoiding disastrous complications during nonsurgical aesthetic procedures.

Methods:

After a detailed literature review, Delphi questionnaire was developed listing 154 anatomical structures of the face and neck for consensus review. Thirty-five international experts in surgical and nonsurgical facial aesthetics were invited to complete an online survey designed to rank the relevance of each anatomical element on a Likert scale from 1 (not at all important) to 4 (very important) or 5 (no opinion). Consensus for items included in the core syllabus was predefined as achieving a Cronbach’s α ≥ 0.90 and an agreement score of ≥ 80%.

Results:

Thirty-four international experts (97.14%) completed the iterative online Delphi survey. The consensus among the specialists polled was achieved after 1 round of the survey (Cronbach’s α = 0.94). The expert panel reached an agreement score of ≥ 80% on 137 of the 154 anatomical structures listed.

Conclusion:

The outcome of this Delphi study represents an essential first step in systematizing an evidence-based facial anatomy “Core Syllabus” for the teaching of aesthetic physicians and practitioners. This “Core Syllabus” will act as a blueprint for the educators while crafting a program.

Medical students' perspective on training in anatomy

Gaining sufficient knowledge of anatomy is an important part of medical education. Factors that influence how well students learn anatomical structures include available sources, learning time and study assistance. This study explores the attitude of medical students with regard to studying anatomy and evaluates possibilities for improvement of training in anatomy. Twenty medical students participated in a focus group meeting. Based on this focus group, an online survey consisting of 27 questions was developed and distributed amongst medical students of Maastricht University, the Netherlands. A total of 495 medical students (both Bachelor and Master level) participated in this survey. Master students found studying anatomy less attractive than Bachelor students (36.8% of the Master students vs. 47.9% of the Bachelor students (p=.024)). Although most students responded that they thought it is important to study anatomy, 48% of all students studied anatomy less than 10h per study block of 8 weeks. Only 47.9% of the students rated their knowledge of anatomy as adequate. Students suggested that three-dimensional techniques would help improve their knowledge of anatomy. Therefore investing in three-dimensional tools could prove beneficial in the future.

An exploration of anatomists' views toward the use of body painting in anatomical and medical education: An international study

Previous research has explored the experiences of medical students using body painting as a learning tool. However, to date, faculty experiences and views have not been explored. This international qualitative study utilized a grounded theory approach with data collection through interviews with academics and clinicians who utilized body painting as part of their anatomical teaching. Twenty-six anatomists participated in the study from 14 centers worldwide. Three themes emerged from the data: (1) the efficacy of body painting, (2) the promotion of knowledge retention and recall, (3) considerations and practicalities regarding the use of body painting as a teaching tool. Subthemes show that body painting is used as an adjunct to the curriculum for teaching surface anatomy and peer examination. Benefits included diffusing the formal curricula, high student engagement and learning for future clinical practice. Body painting was advocated for promoting knowledge retention and recall, particularly learning through the process of cognitive load due to combining the use of color and kinesthetic learning with anatomical theory. Critical discussions surfaced on the topic of undressing in the classroom due to cultural and personal considerations possibly leading to unequal involvement and different learning experiences. Overall results support previous research showing that anatomists appreciate body painting as an effective, enjoyable, engaging and cost efficient adjunct to the multimodal anatomy curriculum. The role of cognitive load theory in learning anatomy through body painting emerged from the data as a possible theoretical framework supporting learning benefits from body painting and is suggested for further investigation. Anat Sci Educ 11: 146-154. © 2017 American Association of Anatomists.

3D Models of Female Pelvis Structures Reconstructed and Represented in Combination with Anatomical and Radiological Sections

We present a computer program designed to visualize and interact with three-dimensional models of the main anatomical structures of the female pelvis. They are reconstructed from serial sections of corpse, from the Visible Human project of the Medical Library of the United States and from serial sections of high-resolution magnetic resonance. It is possible to represent these three-dimensional structures in any spatial orientation, together with sectional images of corpse and magnetic resonance imaging, in the three planes of space (axial, coronal and sagittal) that facilitates the anatomical understanding and the identification of the set of visceral structures of this body region. Actually, there are few studies that analysze in detail the radiological anatomy of the female pelvis using three-dimensional models together with sectional images, making use of open applications for the representation of virtual scenes on low cost Windows® platforms. Our technological development allows the observation of the main female pelvis viscera in three dimensions with a very intuitive graphic interface. This computer application represents an important training tool for both medical students and specialists in gynecology and as a preliminary step in the planning of pelvic floor surgery.

Use and perceptions of plastination among medical anatomy educators in the United States

Traditionally, medical schools have maintained collections of tissues/organs to engage students in anatomy. Such collections are often stored in volatile and toxic preservatives. Plastination is an alternative tissue preservation technique in which polymers replace water and lipids resulting in benign, dry, and anatomically authentic specimens. Plastination is used in medical education internationally; however, its use within U.S. medical schools is not widely discussed in the anatomical literature. This study aimed to determine the knowledge, use, and perceptions of plastination as a teaching tool among U.S. anatomy medical educators. A total of 98 medical anatomy educators who fit inclusion criteria and teach allopathic (MD) students and/or osteopathic (DO) students in the United States completed a national survey, representing 77 medical schools across 37 states. Of these, 100% had heard of plastination, 57% correctly defined plastination, but only 39% currently utilize plastinates for anatomy education. The most frequent explanation for nonuse of plastinates was a preference for the dissection experience, followed by lack of resources and negative past experiences related to durability and quality. A majority (75%) of U.S. medical anatomy educators perceived plastination as a good supplement to, but not a replacement for, cadaveric dissection, 19% indicated no curiosity to use plastination or considered it not useful, and 14% expressed ethical concerns. These findings suggest plastinates are more widely used in the United States than reflected by the literature; however, perceptions regarding their utility indicate a dominant theme for their use to supplement, not replace, cadaveric dissection. Clin. Anat, 2017. © 2017 Wiley Periodicals, Inc.

The effectiveness of virtual and augmented reality in health sciences and medical anatomy

Although cadavers constitute the gold standard for teaching anatomy to medical and health science students, there are substantial financial, ethical, and supervisory constraints on their use. In addition, although anatomy remains one of the fundamental areas of medical education, universities have decreased the hours allocated to teaching gross anatomy in favor of applied clinical work. The release of virtual (VR) and augmented reality (AR) devices allows learning to occur through hands-on immersive experiences. The aim of this research was to assess whether learning structural anatomy utilizing VR or AR is as effective as tablet-based (TB) applications, and whether these modes allowed enhanced student learning, engagement and performance. Participants (n = 59) were randomly allocated to one of the three learning modes: VR, AR, or TB and completed a lesson on skull anatomy, after which they completed an anatomical knowledge assessment. Student perceptions of each learning mode and any adverse effects experienced were recorded. No significant differences were found between mean assessment scores in VR, AR, or TB. During the lessons however, VR participants were more likely to exhibit adverse effects such as headaches (25% in VR P < 0.05), dizziness (40% in VR, P < 0.001), or blurred vision (35% in VR, P < 0.01). Both VR and AR are as valuable for teaching anatomy as tablet devices, but also promote intrinsic benefits such as increased learner immersion and engagement. These outcomes show great promise for the effective use of virtual and augmented reality as means to supplement lesson content in anatomical education. Anat Sci Educ 10: 549-559. © 2017 American Association of Anatomists.

Hand-held Ultrasound Scanners in Medical Education: A Systematic Review

Background

Ultrasound imaging devices are becoming popular in clinical and teaching settings, but there is no systematic information on their use in medical education. We conducted a systematic review of hand-held ultrasound (HHU) devices in undergraduate medical education to delineate their role, significance, and limitations.

Methods

We searched Cochrane, PubMed, Embase, and Medline using the strategy: [(Hand-held OR Portable OR Pocket OR "Point of Care Systems") AND Ultrasound] AND (Education OR Training OR Undergraduate OR "Medical Students" OR "Medical School"). We retained 12 articles focusing on undergraduate medical education. We summarised the patterns of HHU use, pooled and estimated sensitivity, and specificity of HHU for detection of left ventricular dysfunction.

Results

Features reported were heterogeneous: training time (1-25 hours), number of students involved (1-an entire cohort), number of subjects scanned (27-211), and type of learning (self-directed vs. traditional lectures + hands-on sessions). Most studies reported cardiac HHU examinations, but other anatomical areas were examined, e.g. abdomen and thyroid. Pooled sensitivity 0.88 [95% confidence interval (CI) 0.83-0.92] and specificity 0.86 (95% CI 0.81-0.90) were high for the detection of left ventricular systolic dysfunction by students.

Conclusion

Data on HHU devices in medical education are scarce and incomplete, but following training students can achieve high diagnostic accuracy, albeit in a limited number of (mainly cardiac) pathologies. There is no consensus on protocols best-suited to the educational needs of medical students, nor data on long-term impact, decay in proficiency or on the financial implications of deploying HHU in this setting.

From ancient to avant-garde: a review of traditional and modern multimodal approaches to surgical anatomy education

The landscape of surgical anatomy education is progressively changing. Traditional methods, such as cadaveric dissection and didacticism are being increasingly phased out in undergraduate courses for multimodal approaches incorporating problem-based learning, radiology and computer-based simulations. Although effective at clinically contextualizing and integrating anatomical information, these approaches may be a poor substitute for fostering a grasp of foundational 'pure' anatomy. Dissection is ideal for this purpose and hence remains the cornerstone of anatomical education. However, novel methods and technological advancements continually give way to adjuncts such as cadaveric surgery, three-dimensional printing, virtual simulation and live surgical streaming, which have demonstrated significant efficacy alone or alongside dissection. Therefore, although divergent paradigms of 'new versus old' approaches have engulfed and divided the community, educators should seek to integrate the ancient and avant-garde to comprehensively satisfy all of the modern anatomy learner's educational needs.

Anatomy education environment measurement inventory: A valid tool to measure the anatomy learning environment

Students' perceptions of the education environment influence their learning. Ever since the major medical curriculum reform, anatomy education has undergone several changes in terms of its curriculum, teaching modalities, learning resources, and assessment methods. By measuring students' perceptions concerning anatomy education environment, valuable information can be obtained to facilitate improvements in teaching and learning. Hence, it is important to use a valid inventory that specifically measures attributes of the anatomy education environment. In this study, a new 11-factor, 132-items Anatomy Education Environment Measurement Inventory (AEEMI) was developed using Delphi technique and was validated in a Malaysian public medical school. The inventory was found to have satisfactory content evidence (scale-level content validity index [total] = 0.646); good response process evidence (scale-level face validity index [total] = 0.867); and acceptable to high internal consistency, with the Raykov composite reliability estimates of the six factors are in the range of 0.604-0.876. The best fit model of the AEEMI is achieved with six domains and 25 items (X²  = 415.67, P < 0.001, ChiSq/df = 1.63, RMSEA = 0.045, GFI = 0.905, CFI = 0.937, NFI = 0.854, TLI = 0.926). Hence, AEEMI was proven to have good psychometric properties, and thus could be used to measure the anatomy education environment in Malaysia. A concerted collaboration should be initiated toward developing a valid universal tool that, using the methods outlined in this study, measures the anatomy education environment across different institutions and countries. Anat Sci Educ 10: 423-432. © 2017 American Association of Anatomists.

Similarities and differences of a selection of key accreditation standards between chiropractic councils on education: a systematic review

BACKGROUND

Councils of Chiropractic Education (CCE) indirectly influence patient care and safety through their role of ensuring the standards of training delivered by chiropractic educational institutions. This is achieved by a process of accreditation where CCEs define and assess graduate competencies and educational standards. A previous study comparing CCE graduate competencies found variations between the CCE jurisdictions. It was proffered that variations in standards may potentially compromise patient care and safety and also inter-jurisdictional mutual recognition. This study continues the examination of CCEs by looking for similarities and differences in CCE accreditation standards. There were two purposes of this review. The first was to compare the accreditation standards, domains of accreditation standards, and components of the domains of accreditation standards as represented by the domains of "Mission, goals, vision, objectives", "Resources", "Faculty/Academic staff", "Educational program/curriculum". In addition, we compared the accreditation standards between CCEs and those of the widely accepted medical accreditation standards of the World Federation of Medical Education (WFME), in order to search for deficiencies and opportunities for improvements in these standards. The second purpose was to make recommendations, if significant deficiencies or variations were found.

METHOD

We undertook a systematic review of the similarities and differences between five CCEs' definitions of an accreditation standard and the descriptive lists of accreditation standards they have adopted. CCE selection criteria and data selection method were undertaken in a systematic manner. This information was tabulated for a comparative analysis and took place in April 2016.

RESULTS

Only two CCEs had a definition of the term "accreditation / educational standard". At the domain level there was considerably more similarities than differences. The differences became more apparent when the comparisons were made at the component level. These included intended purposes of the mission statement, standards for faculty staff, requirements for clinical training by students, program budgetary autonomy and transparency, the inclusion of chiropractic philosophy and history, and which subjects should be taught in basic, behavioural and clinical sciences.

CONCLUSIONS

A series of recommendations were made. These included the need for an increased clarity of the required basic and clinical science subjects, teaching clinic student requirements, and faculty staff qualifications. These are proposed with the intention of creating uniform and high quality international accreditation standards for chiropractic education. Future research should compare the levels of CCEs inspection standards and processes to see if similarities and differences exist also there.

TRIAL REGISTRATION

Not applicable.

Augmented and virtual reality in surgery-the digital surgical environment: applications, limitations and legal pitfalls

The continuing enhancement of the surgical environment in the digital age has led to a number of innovations being highlighted as potential disruptive technologies in the surgical workplace. Augmented reality (AR) and virtual reality (VR) are rapidly becoming increasingly available, accessible and importantly affordable, hence their application into healthcare to enhance the medical use of data is certain. Whether it relates to anatomy, intraoperative surgery, or post-operative rehabilitation, applications are already being investigated for their role in the surgeons armamentarium. Here we provide an introduction to the technology and the potential areas of development in the surgical arena.