Undergraduate Medical Student Perceptions and Learning Outcomes Related to Anatomy Training Using Thiel- and Ethanol-Glycerin-Embalmed Tissues
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| Title: | Undergraduate Medical Student Perceptions and Learning Outcomes Related to Anatomy Training Using Thiel- and Ethanol-Glycerin-Embalmed Tissues |
|---|---|
| Language: | English |
| Authors: | Antipova, Veronica (ORCID |
| Source: | Anatomical Sciences Education. 2023 16(6):1144-1157. |
| Availability: | Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us |
| Peer Reviewed: | Y |
| Page Count: | 14 |
| Publication Date: | 2023 |
| Document Type: | Journal Articles Reports - Research |
| Education Level: | Higher Education Postsecondary Education |
| Descriptors: | Undergraduate Students, Premedical Students, Student Attitudes, Outcomes of Education, Anatomy, Laboratory Procedures |
| DOI: | 10.1002/ase.2306 |
| ISSN: | 1935-9772 1935-9780 |
| Abstract: | Anatomical dissection is known to serve as an integral tool in teaching gross anatomy, including postgraduate training. A variety of embalming techniques exist, resulting in different haptic and optical tissue properties. This study aimed to objectify learning outcomes and medical student perceptions related to the use of two widely used embalming techniques, namely Thiel and ethanol-glycerin embalming. Between 2020 and 2022, first- and second-year medical students enrolled in the course on topographic anatomy participated in this study. Objective structured practical examinations were carried out for the head, neck, thorax, abdomen, pelvis, and extremity regions following regional dissection just before the oral examinations began. Six to ten numbered tags were marked in prosections of each region in Thiel- and ethanol-glycerin-embalmed specimens. Following the examinations, the students were surveyed regarding the suitability of the two embalming techniques with respect to preservation, colorfastness, tissue pliability, and the suitability in preparing for their anatomy examinations. Consistently higher scores were achieved for the thoracic and abdominal regions in ethanol-glycerin-embalmed specimens when compared to Thiel. No benefit was found for Thiel-embalmed upper or lower extremities. Tissues embalmed with ethanol-glycerin were rated higher for preservation and suitability to achieve the learning objectives, tissue pliability was rated higher for Thiel-embalmed tissues. Ethanol-glycerin embalming appears to offer certain advantages for undergraduate students in recognizing visceral structures, which may align with students' ideas on tissue suitability for their learning. Consequently, the benefits reported for Thiel embalming for postgraduate study unlikely reflect its suitability for novices. |
| Abstractor: | As Provided |
| Entry Date: | 2023 |
| Accession Number: | EJ1398218 |
| Database: | ERIC |
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| FullText | Links: – Type: pdflink Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwGw70Ot6mTt84hrj6z76FGeAAAA4jCB3wYJKoZIhvcNAQcGoIHRMIHOAgEAMIHIBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDAsVB5UQrBysZoHTPAIBEICBmpEnuvLHMoxsQyLVAMBgk0i5fGZ9S0dyQCB3mbny_wkoDAzcq-nwePvYkA02SRmetEZmeFtE0FBIjOfmOSSSyAKdVqtcrOLR1i6w_g2PjyRpr32XFsyFuCnEYU52k8dIwgtqDrdoUjqsLAFQl7efk0H2HoKewRWinT7zR71Z5eI9MxLmh6Ax4_1ngZXPySNzAzv_nv6Gvv4en3M= Text: Availability: 1 Value: <anid>AN0173339726;[8z8k]01nov.23;2023Nov02.05:42;v2.2.500</anid> <title id="AN0173339726-1">Undergraduate medical student perceptions and learning outcomes related to anatomy training using Thiel‐ and ethanol‐glycerin‐embalmed tissues </title> <p>Anatomical dissection is known to serve as an integral tool in teaching gross anatomy, including postgraduate training. A variety of embalming techniques exist, resulting in different haptic and optical tissue properties. This study aimed to objectify learning outcomes and medical student perceptions related to the use of two widely used embalming techniques, namely Thiel and ethanol‐glycerin embalming. Between 2020 and 2022, first‐ and second‐year medical students enrolled in the course on topographic anatomy participated in this study. Objective structured practical examinations were carried out for the head, neck, thorax, abdomen, pelvis, and extremity regions following regional dissection just before the oral examinations began. Six to ten numbered tags were marked in prosections of each region in Thiel‐ and ethanol‐glycerin‐embalmed specimens. Following the examinations, the students were surveyed regarding the suitability of the two embalming techniques with respect to preservation, colorfastness, tissue pliability, and the suitability in preparing for their anatomy examinations. Consistently higher scores were achieved for the thoracic and abdominal regions in ethanol‐glycerin‐embalmed specimens when compared to Thiel. No benefit was found for Thiel‐embalmed upper or lower extremities. Tissues embalmed with ethanol‐glycerin were rated higher for preservation and suitability to achieve the learning objectives, tissue pliability was rated higher for Thiel‐embalmed tissues. Ethanol‐glycerin embalming appears to offer certain advantages for undergraduate students in recognizing visceral structures, which may align with students' ideas on tissue suitability for their learning. Consequently, the benefits reported for Thiel embalming for postgraduate study unlikely reflect its suitability for novices.</p> <p>Keywords: dissection; embalming method; ethanol‐glycerin fixation; OSPE; Thiel; topographic anatomy course; undergraduate education</p> <hd id="AN0173339726-2">INTRODUCTION</hd> <p>Anatomy forms one of the pillars of undergraduate medical education (Turney, [<reflink idref="bib110" id="ref1">110</reflink>]; Ghazanfar et al., [<reflink idref="bib40" id="ref2">40</reflink>]; Song &amp; Jo, [<reflink idref="bib105" id="ref3">105</reflink>]). A wide range of contemporary anatomy teaching methods has become available in recent years (Macpherson &amp; Lisk, [<reflink idref="bib74" id="ref4">74</reflink>]; Santos et al., [<reflink idref="bib102" id="ref5">102</reflink>]; Cullinane &amp; Barry, [<reflink idref="bib30" id="ref6">30</reflink>]; Khan et al., [<reflink idref="bib60" id="ref7">60</reflink>]). In spite of these developments, gross anatomy dissection courses continue to be considered an integral part of human and dental medical training (Dangerfield et al., [<reflink idref="bib31" id="ref8">31</reflink>]; Magee, [<reflink idref="bib75" id="ref9">75</reflink>]; Korf et al., [<reflink idref="bib63" id="ref10">63</reflink>]; Williams et al., [<reflink idref="bib115" id="ref11">115</reflink>]; Ghosh, [<reflink idref="bib41" id="ref12">41</reflink>]; Rafai et al., [<reflink idref="bib95" id="ref13">95</reflink>]) and present the mainstream of delivering an anatomical curriculum in most medical schools worldwide (Eisma et al., [<reflink idref="bib36" id="ref14">36</reflink>]; Dissabandara et al., [<reflink idref="bib33" id="ref15">33</reflink>]). They help students to understand spatial‐topographical relationships and in recognizing anatomical variations (Lempp, [<reflink idref="bib66" id="ref16">66</reflink>]; Azer &amp; Eizenberg, [<reflink idref="bib7" id="ref17">7</reflink>]; Winkelmann, [<reflink idref="bib116" id="ref18">116</reflink>]; Mwachaka et al., [<reflink idref="bib84" id="ref19">84</reflink>]).</p> <p>Chemically embalmed human tissue have formed the basis of undergraduate gross anatomy training for more than 100 years (Weiglein, [<reflink idref="bib114" id="ref20">114</reflink>]; Drake et al., [<reflink idref="bib35" id="ref21">35</reflink>]; Hammer et al., [<reflink idref="bib46" id="ref22">46</reflink>]; Brenner, [<reflink idref="bib18" id="ref23">18</reflink>]; Balta, Cronin, et al., [<reflink idref="bib8" id="ref24">8</reflink>]; Balta, Lamb, &amp; Soames, [<reflink idref="bib9" id="ref25">9</reflink>]; Kennel et al., [<reflink idref="bib59" id="ref26">59</reflink>]; Rakuša &amp; Kocbek Šaherl, [<reflink idref="bib96" id="ref27">96</reflink>]) but also postgraduate training, workshops and answering anatomical and biomechanical research questions (Löffler et al., [<reflink idref="bib72" id="ref28">72</reflink>]; Eisma et al., [<reflink idref="bib37" id="ref29">37</reflink>]; Jaung et al., [<reflink idref="bib55" id="ref30">55</reflink>]; Prasad Rai et al., [<reflink idref="bib93" id="ref31">93</reflink>]; Eisma et al., [<reflink idref="bib36" id="ref32">36</reflink>]; Löffler et al., [<reflink idref="bib71" id="ref33">71</reflink>]; Hammer et al., [<reflink idref="bib45" id="ref34">45</reflink>]; Choi et al., [<reflink idref="bib24" id="ref35">24</reflink>]). Post‐mortem tissues are commonly embalmed with formaldehyde owing its ease of use, broad availability, and low cost (Blum, [<reflink idref="bib16" id="ref36">16</reflink>], [<reflink idref="bib17" id="ref37">17</reflink>]; Benkhadra, Bouchot, et al., [<reflink idref="bib11" id="ref38">11</reflink>]; Eisma et al., [<reflink idref="bib36" id="ref39">36</reflink>]). In contrast, formaldehyde forms a health hazard, as an airway, skin, and eye irritant (Muzi et al., [<reflink idref="bib83" id="ref40">83</reflink>]; Viegas et al., [<reflink idref="bib112" id="ref41">112</reflink>]), and being carcinogenic to humans (Albert et al., [<reflink idref="bib3" id="ref42">3</reflink>]; Swenberg et al., [<reflink idref="bib106" id="ref43">106</reflink>]; Kang et al., [<reflink idref="bib58" id="ref44">58</reflink>]; Lam et al., [<reflink idref="bib64" id="ref45">64</reflink>]). The use of formaldehyde therefore puts at risk prosectors, students and teaching staff likewise (Hauptmann et al., [<reflink idref="bib48" id="ref46">48</reflink>]; Hauptmann et al., [<reflink idref="bib49" id="ref47">49</reflink>]; Goldstein, [<reflink idref="bib42" id="ref48">42</reflink>]). Other fixatives have been proposed to reduce the use of formaldehyde, including ethanol‐glycerin, isopropanol, methanol, phenoxyethanol, or commercially available fixatives (Frølich et al., [<reflink idref="bib38" id="ref49">38</reflink>]; Messmer et al., [<reflink idref="bib80" id="ref50">80</reflink>]; Hammer et al., [<reflink idref="bib46" id="ref51">46</reflink>]; Jaung et al., [<reflink idref="bib55" id="ref52">55</reflink>]; Hammer et al., [<reflink idref="bib47" id="ref53">47</reflink>]; Zanini et al., [<reflink idref="bib122" id="ref54">122</reflink>]). Embalming fluids should help ensure long‐term structural preservation without overly hardening the tissues, retain color, and result in long‐term tissue durability for both undergraduate and postgraduate purposes (Coleman &amp; Kogan, [<reflink idref="bib26" id="ref55">26</reflink>]). Thiel and ethanol‐glycerin embalming are two commonly used alternatives to formaldehyde fixation commonly employed in undergraduate and postgraduate training, respectively (Hammer et al., [<reflink idref="bib46" id="ref56">46</reflink>]; Hammer et al., [<reflink idref="bib47" id="ref57">47</reflink>]; Balta, Lamb, &amp; Soames, [<reflink idref="bib9" id="ref58">9</reflink>]; Hammer et al., [<reflink idref="bib45" id="ref59">45</reflink>]; Kennel et al., [<reflink idref="bib59" id="ref60">59</reflink>]; Crosado et al., [<reflink idref="bib29" id="ref61">29</reflink>]; Ackermann et al., [<reflink idref="bib1" id="ref62">1</reflink>]; Hammer, [<reflink idref="bib44" id="ref63">44</reflink>]; Rakuša &amp; Kocbek Šaherl, [<reflink idref="bib96" id="ref64">96</reflink>]). Reportedly, Thiel embalming provides more realistic visual and haptic properties than most other fixatives, making it very suitable for postgraduate purposes (Balta, Lamb, &amp; Soames, [<reflink idref="bib9" id="ref65">9</reflink>]; Hammer et al., [<reflink idref="bib45" id="ref66">45</reflink>]; Ottone et al., [<reflink idref="bib86" id="ref67">86</reflink>]; Lone et al., [<reflink idref="bib73" id="ref68">73</reflink>]; Hammer, [<reflink idref="bib44" id="ref69">44</reflink>]; Rakuša &amp; Kocbek Šaherl, [<reflink idref="bib96" id="ref70">96</reflink>]). However, Thiel embalming is expensive (Benkhadra, Bouchot, et al., [<reflink idref="bib11" id="ref71">11</reflink>]; Brenner, [<reflink idref="bib18" id="ref72">18</reflink>]; Hayashi et al., [<reflink idref="bib50" id="ref73">50</reflink>]), time‐consuming and difficult to perform (Wolff et al., [<reflink idref="bib117" id="ref74">117</reflink>]; Hammer et al., [<reflink idref="bib47" id="ref75">47</reflink>]). Its scope is limited to macroscopic examinations. Ethanol‐glycerin fixation has become mainstream in anatomical embalming in European and Australasian countries (Hammer et al., [<reflink idref="bib47" id="ref76">47</reflink>]; Hammer et al., [<reflink idref="bib45" id="ref77">45</reflink>]), with the tissues being suitable predominantly for student dissection courses, but also for histological examination and providing tissue prosections. A consequent comparison on the utility of both Thiel and ethanol‐glycerin embalming for undergraduate training, however, remained to be quantified.</p> <p>This given study aimed to substantiate the learning gain and the related ability to identify anatomical structures in Thiel‐ and ethanol‐glycerin‐embalmed tissues. A second aim was to assess student perceptions related to the use of both techniques for their own anatomy learning. For this purpose, objective structured practical examinations (OSPE, "tag examinations") and structured surveys were used.</p> <p>Based on the authors experience and data on the applicability of different embalming chemicals, and their strengths and weaknesses provided in the literature, it was hypothesized that both techniques provide similar (positive) benefits, resulting in better OSPE scores for certain anatomical regions: ethanol‐glycerin embalming in recognizing viscera structures (head, neck, thorax, abdomen), and Thiel embalming in recognizing musculoskeletal tissues (pelvis, upper extremity, lower extremity). It was further hypothesized that OSPE scores and student perceptions on tissue features to achieve the anatomy learning objectives correlated positively.</p> <hd id="AN0173339726-3">MATERIALS AND METHODS</hd> <p></p> <hd id="AN0173339726-4">Course details on anatomy in the medical curriculum at the Johannes Keppler University Linz a...</hd> <p>Gross anatomy is a first‐ and second‐year subject taught to undergraduate medical students at both the Medical Faculty of the Johannes Kepler University Linz (JKU) and the Medical University of Graz (MUG) in Austria. This practice is based on a memorandum of understanding and supporting agreement between the MUG and the JKU. Undergraduate medical students from the JKU participate, as part of their mandatory curriculum, in the course on regional anatomy at the MUG. These dissection courses on regional anatomy are taught hands‐on using human bodies bequeathed to the Division of Macroscopic and Clinical Anatomy of the Medical University of Graz exclusively. The cadavers used for the gross anatomy course were embalmed using ethanol‐glycerin (Hammer et al., [<reflink idref="bib47" id="ref78">47</reflink>]) or Thiel fixation (Thiel, [<reflink idref="bib108" id="ref79">108</reflink>]), with both types of embalming made available to the students throughout the course. The total number of participants was 74, 125, and 132 students for the 2020, 2021, and 2022 JKU course, respectively, and 484 for the 2021 Graz course. The dissection courses are comprised of 60 academic units versus 56 academic units, respectively. During dissection classes, 12 to 18 students were allocated per cadaver, divided in two different groups, and each student was allocated one or two anatomical regions for a guided dissection supervised by experienced anatomists and supported by student demonstrators. The dissection was accompanied by topographical anatomy lectures. More insights about the course on anatomy in the medical curriculum at the MUG are presented in Figure 1.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/8Z8K/01nov23/ase2306-fig-0001.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="ase2306-fig-0001.jpg" title="1 Undergraduate curriculum at the Medical University of Graz, Austria. Anatomy is taught in the first three semesters as part of different modules and tracks. In the first semester, 20 h of lectures are spent on gross anatomy focusing on the basics of general anatomy of the skeletal system and osseous structures. Students are examined orally for the completion of each of these modules and tracks. In the second semester two modules (systematic anatomy on the musculoskeletal system and nervous system) are taught, comprising integrated gross anatomy, histology, physiology, and biophysics, with 46 and 41 h of lectures and 36 and 20 h of anatomical dissection, respectively. Course manuals make distinct description of the aims, objectives, and procedures for the practical courses. In the third semester, a self‐standing course on regional anatomy comprised of 86 h of theoretical lectures, 60 h of hands‐on dissection class and 18 h of self‐study is held. For this course, 12 medical students are allocated per body and every region is dissected. Throughout the course, the students dissect under supervision four to five anatomical regions. A detailed dissection guide and image materials are provided mainly online for the students allowing them to prepare for each session. Successful course completion was achieved if students were actively present and had passed all oral examinations held during the course." /> </p> <p></p> <hd id="AN0173339726-6">Participants</hd> <p>Between 2020 and 2022, first‐ and second‐year medical students of the JKU and the MUG who were actively enrolled in the course on topographic anatomy were admitted to the given study (Figure 2). All participants gave their written and informed consent prior to their voluntary participation. The outcomes of the OSPE examinations were not made prerequisites for a successful completion of the anatomy course. Ethical approval was obtained from the ethical committee of the Medical University of Graz, Austria (33‐500 ex 20/21).</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/8Z8K/01nov23/ase2306-fig-0002.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="ase2306-fig-0002.jpg" title="2 Undergraduate medical students of Johannes Kepler University Linz, performing the objective structured practical examinations at an ethanol‐glycerin‐embalmed human specimen." /> </p> <p></p> <hd id="AN0173339726-8">Demographic information</hd> <p>A total of 477 undergraduate medical students completed the OSPE (244 females, 212 males, 21 not given); 74, 268 and 135 in the dissection courses conducted in 2020, 2021 and 2022, respectively. OSPE examinations on the neck, thorax, and abdomen regions were conducted in all courses. The remaining topographical regions (head, pelvis, extremities) were assessed in one or two of the courses, respectively. For the JKU courses, the head region was assessed in 2020 and 2021, pelvis was assessed in 2021, and extremities were assessed in 2021.</p> <p>The quality and suitability of the tissues embalmed with ethanol‐glycerin or Thiel was assessed by 241 students (130 females, 106 males, five not given). 16 students rated on ethanol‐glycerin only, 50 on Thiel only, and 175 on both embalming types.</p> <hd id="AN0173339726-9">Embalming procedure</hd> <p>The embalming of the bodies was conducted according to published protocols available elsewhere. In the case of ethanol‐glycerin embalming, the method by Hammer et al., ([<reflink idref="bib47" id="ref80">47</reflink>]) was used, comprised of ethanol, glycerin, and (if needed) formaldehyde for the fixation step. No ethanol submersion step was included as explosion proof tanks lacked at the time of the study in Graz. The conservation step comprised of thymol diluted in ethanol and water. For Thiel embalming, the protocol published by Thiel ([<reflink idref="bib108" id="ref81">108</reflink>]) was used.</p> <hd id="AN0173339726-10">Data acquisition</hd> <p>OSPE examinations were conducted following the dissection of the respective topographical regions prior to the respective oral examinations of the students.</p> <p>The OSPE is a traditional tool for the objective evaluation of learning achievements and practical examinations in the preclinical stage of a medical curriculum (Rowland et al., [<reflink idref="bib98" id="ref82">98</reflink>]; Malhotra et al., [<reflink idref="bib76" id="ref83">76</reflink>]; Yaqinuddin et al., [<reflink idref="bib120" id="ref84">120</reflink>]; Vishwakarma et al., [<reflink idref="bib113" id="ref85">113</reflink>]; Dissabandara et al., [<reflink idref="bib32" id="ref86">32</reflink>]).</p> <p>For the OSPE, one ethanol‐glycerin‐ and one Thiel‐embalmed donor was prepared and used. Six to ten numbered tags were marked in the prosections of each of the regions and placed prominently to clearly identify specific anatomical structures. The same structures were tagged in ethanol‐glycerin‐ and Thiel‐embalmed prosections in the same way (Figures 3 and 4; Figure S1). Care was taken to allow the visualisation of the structures of interest in a standardized manner. One multiple‐choice question was asked per tag, requiring the participants to select only the most suitable out of five possible answers (Supplementary materials). Students were allotted one minute per question, while neither manipulation of the numbered tags nor touching of the structures was allowed to keep the test setting standardized. Based on the absolute numbers of correct responses, a percentage was calculated for each region. Only questions on topics that were specified in examinations in the gross anatomy dissection course were included. The study design and the choice of questions for the OSPE was carried out by experienced anatomists and psychologists.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/8Z8K/01nov23/ase2306-fig-0003.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="ase2306-fig-0003.jpg" title="3 On the left Thiel‐embalmed (A), on the right ethanol‐glycerin‐embalmed (B) human specimens used in the objective structured practical examinations. In both front views of the abdomen tags indicate: 01, hepatoduodenal ligament; 02, superior mesenteric artery; 03, umbilical artery; 04, right colic artery; 05, gall bladder. Scale bar = 20 mm." /> </p> <p></p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/8Z8K/01nov23/ase2306-fig-0004.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="ase2306-fig-0004.jpg" title="4 On the left Thiel‐embalmed (A) and ethanol‐glycerin‐embalmed (B) hearts used in the objective structured practical examinations. In both preparations, tags indicate: 01, left coronary artery, 02, anterior papillary muscle. On the left Thiel‐embalmed (C) and ethanol‐glycerin‐embalmed (D) lungs used in the objective structured practical examinations. In both preparations, tags indicate: 04, oblique fissure. Scale bar = 20 mm." /> </p> <p></p> <p>Following the last OSPE, the students were surveyed on their opinion regarding the suitability of ethanol‐glycerin and Thiel embalming concerning tissue preservation, colorfastness, tissue pliability, and perceptions on tissue suitability to achieve the anatomy learning objectives (Supplementary materials). The selection of the items for both survey questionnaires was conducted by experienced anatomists and one psychologist. In addition, the validity of the questions was confirmed by students' performance during the dissection course in topographic anatomy. For this purpose, a 5‐point Likert scale was adopted (1 = most suitable/strongly agree, 5 = most unsuitable/strongly disagree) (Likert, [<reflink idref="bib69" id="ref87">69</reflink>]). This survey was conducted without the students knowing the results of the OSPE.</p> <p>All OSPE examinations were conducted based on the same anatomical prosections for each embalming method used throughout. One set of prosections was prepared based on ethanol‐glycerin and another based on Thiel embalming for each anatomical region. In the same manner, OSPE examinations were held by the same examiner and at the same time interval following the dissection of the respective topographical regions prior to the respective oral examinations of the students. To avoid any falsification or influencing the students' results, the examiner at no stage expressed their opinion on both ethanol‐glycerin and Thiel fixations during the OSPE. Accordingly, the examiner hid their assessment when the students were surveyed on their opinion regarding the suitability of ethanol‐glycerin and Thiel embalming concerning tissue preservation, colorfastness, tissue pliability and perceptions on tissue suitability to achieve the anatomy learning objectives.</p> <hd id="AN0173339726-13">Statistical evaluation</hd> <p>The data analysis was conducted using Prism version 9 (GraphPad Software Inc., La Jolla, CA, USA) and Microsoft Excel version 16.49 (Microsoft Corp., Armonk, NY, USA). A D'Agostino and Pearson test was used to assess normal distribution of the sample. A Kruskal–Wallis test with post hoc correction (Dunn's test) was deployed for between‐group comparisons of the anatomical regions of interest and tissue assessment. OSPE results were compared between embalming types. Correlations between test scores and tissue quality assessment were computed using Spearman correlations. <emph>p</emph>‐Values ≤0.05 were considered statistically significant.</p> <hd id="AN0173339726-14">RESULTS</hd> <p></p> <hd id="AN0173339726-15">OSPE scores were higher for the thorax and abdomen regions in ethanol‐glycerin‐embalmed tissu...</hd> <p>OSPE scores were found to be non‐significantly different between ethanol‐glycerin and Thiel embalming for the head (55% ± 28% vs. 46% ± 30%; <emph>n</emph> = 133) and neck (43% ± 22% vs. 38% ± 22%; <emph>n</emph> = 417) regions (<emph>p</emph> ≥ 0.126; Figure 5). Significantly higher scores in OSPE were observed for the thorax (60% ± 20% vs. 55% ± 19%; <emph>n</emph> = 436) and abdomen (55% ± 19% vs. 48 ± 22%; <emph>n</emph> = 436) regions in ethanol‐glycerin‐embalmed tissues (<emph>p</emph> ≤ 0.035; Figure 5). The mean test scores were consistently higher for ethanol‐glycerin for each of these regions.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/8Z8K/01nov23/ase2306-fig-0005.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="ase2306-fig-0005.jpg" title="5 Box plots comparing the scores of the objective structured practical examinations separated for ethanol‐glycerin (Ethanol) and Thiel embalming. The boxes indicate the 25th percentile, median and 75th percentile, whiskers the minima and maxima. Crosses depict the mean values. Significantly higher scores were found for ethanol‐glycerin‐embalmed tissues in the thorax and abdomen regions." /> </p> <p></p> <hd id="AN0173339726-17">Thiel‐embalmed musculoskeletal tissues yielded no difference in OSPE scores when compared to...</hd> <p>Comparison of the OSPE scores achieved in ethanol‐glycerin‐ and Thiel‐embalmed tissues yielded similar and non‐significantly different results for the upper (31% ± 19% vs. 36% ± 16%; <emph>n</emph> = 96) and lower (58% ± 17% vs. 50% ± 21%; <emph>n</emph> = 64) extremity and pelvis (71% ± 20% vs. 69% ± 17%; <emph>n</emph> = 64) regions (<emph>p</emph> ≥ 0.408; Figure 5).</p> <hd id="AN0173339726-18">Tissue preservation and suitability was rated better in ethanol‐glycerin‐embalmed tissues, ti...</hd> <p>Further comparison of student assessment on ethanol‐glycerin‐ to Thiel‐embalmed tissues yielded that ethanol‐glycerin was deemed better preserved (1.9 ± 0.7 vs. 2.5 ± 1.1; <emph>p</emph> &lt; 0.0001; Figure 6). No significant difference was seen when comparing tissue colorfastness (2.7 ± 1.0 vs. 2.9 ± 1.3; <emph>p</emph> = 0.542; Figure 6). Tissue pliability was evaluated better in Thiel‐embalmed tissues (2.7 ± 1.2 vs. 2.0 ± 1.2; <emph>p</emph> &lt; 0.0001; Figure 6). When surveyed on the suitability for examination preparation, ethanol‐glycerin embalming was rated superior (1.5 ± 0.8 vs. 2.8 ± 1.3; <emph>p</emph> &lt; 0.0001; Figure 6).</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/8Z8K/01nov23/ase2306-fig-0006.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="ase2306-fig-0006.jpg" title="6 Box plots on the assessment of ethanol‐glycerin (Ethanol) and Thiel embalming based on Likert ratings. The boxes indicate the 25th percentile, median and 75th percentile, whiskers the minima and maxima. Crosses depict the mean value. Tissue preservation and suitability to achieve the anatomy learning objectives in were rated higher for ethanol‐glycerin embalming, tissue pliability for Thiel." /> </p> <p></p> <hd id="AN0173339726-20">Exclusively abdomen OSPE scores were related to tissue quality assessment</hd> <p>The observations were such that only exclusively abdomen OSPE scores were related to tissue quality assessment. The OSPE scores of the abdominal region correlated positively (weak) with the assessment of colorfastness in ethanol‐glycerin‐embalmed tissues (<emph>r</emph> = 0.34; <emph>p</emph> = 0.046), that is, lower colorfastness was related to better OSPE scores (Figure S2). A weak negative correlation was found for colorfastness and the scores on the abdomen region in Thiel tissues (<emph>r</emph> = −0.31; <emph>p</emph> = 0.030), that is, better colorfastness was related to better OSPE scores (Figure S2).</p> <p>Consistently positive correlations were observed for tissue preservation, colorfastness, and tissue pliability related to student perceptions that tissues are suitable to achieve the anatomy learning objectives in ethanol‐glycerin (<emph>r</emph> ≥ 0.31; <emph>p</emph> ≤ 0.004) and Thiel (<emph>r</emph> ≥ 0.46; <emph>p</emph> ≤ 0.001) embalming (Figure S2).</p> <hd id="AN0173339726-21">DISCUSSION</hd> <p>The use of Thiel embalming for undergraduate training purposes is uncommon. In fact, only two sites deploy Thiel‐embalmed tissues in a regular manner for medical, dental, and forensic teaching: Graz (Austria) and Dundee (UK) (Eisma et al., [<reflink idref="bib36" id="ref88">36</reflink>]; Balta, Lamb, &amp; Soames, [<reflink idref="bib9" id="ref89">9</reflink>]; Kennel et al., [<reflink idref="bib59" id="ref90">59</reflink>]; Hammer, [<reflink idref="bib44" id="ref91">44</reflink>]).</p> <p>No study so far compares the suitability of Thiel embalming for undergraduate medical students to other embalming types such as ethanol‐glycerin. As a part of quality assurance measures in Graz for continuous improvement in medical teaching, alternatives to Thiel embalming have been assessed. Therefore, both OSPE examination outcomes and student perceptions on the suitability of Thiel embalming compared with another well‐established method using ethanol and glycerin as the main components of the embalming were analyzed.</p> <p>The here given study utilized the OSPE to assess topographical knowledge on head, neck, thorax, abdomen regions, pelvis, upper, and lower extremities regional anatomy in two student groups separated for both embalming techniques. Alongside the standardized modes of assessment of student performance, the participants were surveyed on their perception regarding the suitability of ethanol‐glycerin and Thiel concerning tissue preservation, colorfastness, tissue pliability, and the suitability to prepare for their examinations.</p> <p>It was hypothesized that both embalming types provide certain advantages in learning, reflected by higher OSPE scores: Ethanol‐glycerin‐embalmed tissues were thought to be more suitable for visceral anatomy (neck, thorax, and abdomen), whereas Thiel‐embalmed tissues were thought to be more suitable for recognizing musculoskeletal tissues (pelvis, upper, and lower extremities). All specimens used for the given study bequested to the Division of Macroscopic and Clinical Anatomy, Medical University of Graz, Austria as part of an ongoing body donation program and in accordance with the Austrian legislation concerning body donations. While alive, all body donors had given their informed consent for the donation of their post‐mortem tissues for research and teaching purposes (https://anatomie.medunigraz.at/en/body‐donation).</p> <hd id="AN0173339726-22">Ethanol‐glycerin embalming appears to offer certain advantages for undergraduate students in...</hd> <p>The present study found no difference in the OSPE scores achieved for the head and neck regions using ethanol‐glycerin‐ or Thiel‐fixed anatomical specimens. Both ethanol‐glycerin and Thiel embalming appeared equally suitable for undergraduate teaching and for the aptitude of the students to identify anatomical structures in these regions. The utility of both these embalming methods can also be seen in anatomical studies concerning head and neck regions conducted on tissues previously used in the classroom. Both ethanol‐glycerin‐ (Hammer et al., [<reflink idref="bib46" id="ref92">46</reflink>]; Shin et al., [<reflink idref="bib103" id="ref93">103</reflink>]; Cotofana et al., [<reflink idref="bib27" id="ref94">27</reflink>]; Planitzer et al., [<reflink idref="bib92" id="ref95">92</reflink>]; Lee et al., [<reflink idref="bib65" id="ref96">65</reflink>]; Ruiz et al., [<reflink idref="bib99" id="ref97">99</reflink>]; Çırak et al., [<reflink idref="bib25" id="ref98">25</reflink>]; Siwetz et al., [<reflink idref="bib104" id="ref99">104</reflink>]; Jung et al., [<reflink idref="bib56" id="ref100">56</reflink>]) and Thiel‐ (Benkhadra et al., [<reflink idref="bib14" id="ref101">14</reflink>]; Pilsl &amp; Anderhuber, [<reflink idref="bib88" id="ref102">88</reflink>]; Hölzle et al., [<reflink idref="bib52" id="ref103">52</reflink>]; Pilsl et al., [<reflink idref="bib90" id="ref104">90</reflink>]; Pilsl et al., [<reflink idref="bib91" id="ref105">91</reflink>]; Ottone et al., [<reflink idref="bib86" id="ref106">86</reflink>]; Pilsl et al., [<reflink idref="bib89" id="ref107">89</reflink>]; Bruneder et al., [<reflink idref="bib20" id="ref108">20</reflink>]; Bruneder et al., [<reflink idref="bib19" id="ref109">19</reflink>]) embalmed specimens were used successfully in macroscopic anatomy studies related to the peripheral nervous system, maxillofacial surgery, and other dental surgical interventions.</p> <p>In contrast, higher OSPE scores were observed for student assessments of the thorax and abdomen regions embalmed with ethanol‐glycerin as compared to Thiel. In these regions, the requirements of optical and haptic features may vastly differ between undergraduate study and clinical workshops or surgical training (Rack, [<reflink idref="bib94" id="ref110">94</reflink>]; Drake, [<reflink idref="bib34" id="ref111">34</reflink>]; Messmer et al., [<reflink idref="bib80" id="ref112">80</reflink>]; Hammer et al., [<reflink idref="bib46" id="ref113">46</reflink>]; Hammer et al., [<reflink idref="bib47" id="ref114">47</reflink>]; Ackermann et al., [<reflink idref="bib1" id="ref115">1</reflink>]). As opposed to postgraduate study where the primary objective is to provide most lifelike tissues, a certain bleaching and curing of the tissues is intended for undergraduate study to facilitate identifying certain anatomical structures that surgeons ideally do not even wish to observe as part of their intervention (Hammer et al., [<reflink idref="bib45" id="ref116">45</reflink>]). This finding comes with the limitation that the students interviewed were at an early stage of their medical curriculum (second year) and also that the students were asked to complete objectives in regional anatomy. The approach to delivering such knowledge to students through anatomical dissection makes it necessary to help them distinguish the structures of interest for their examinations as well as possible. The viscera of Thiel‐embalmed bodies are comparably softer than those embalmed with ethanol‐glycerin, making them collapse and therefore more difficult for undergraduate students to distinguish the anatomical structures. In detail, the collapse of Thiel‐embalmed hollow organs and the effects of decellularization deform tissues (Hammer et al., [<reflink idref="bib45" id="ref117">45</reflink>]; McDougall et al., [<reflink idref="bib77" id="ref118">77</reflink>]) to the end that their appearance is more difficult to recognize than in specimens which underwent a certain extent of curing and discoloration. These findings have partly been summarized visually in Figures 3 and 4; Figure S1. Moreover, the "lifelike" visual features diminish soon after the tissues are exposed to air, they turn brown and have the appearance of Bakelite. Over time, the visual advantages of Thiel embalming deteriorate affecting the students' ability to identify structures in later dissection or training stages. These findings for undergraduate students have partly been confirmed by Hayashi et al., ([<reflink idref="bib50" id="ref119">50</reflink>]) describing that surgically active medical doctors found Thiel embalming to be too soft for their practice of surgical interventions. Ethanol‐glycerin‐embalmed viscera such as the liver, spleen, and kidneys as well as neuromuscular tissues and vessels bleached and indurated (Hammer et al., [<reflink idref="bib45" id="ref120">45</reflink>]). The fading related to ethanol‐glycerin presumably makes it easier for medical students to identify relevant structures. The same authors showed that this slight hardening caused by the ethanol‐glycerin fixative facilitates skin separation from the subcutaneous tissue, muscles from their surrounding fascia or intestines from the mesentery (Hammer et al., [<reflink idref="bib46" id="ref121">46</reflink>]; Hammer et al., [<reflink idref="bib47" id="ref122">47</reflink>]; Hammer et al., [<reflink idref="bib45" id="ref123">45</reflink>]). Thus, ethanol‐glycerin appears to be a more suitable method of fixation for the thorax and abdomen for the undergraduate teaching dissection courses when compared to Thiel. In consequence, the hypothesis that ethanol‐glycerin‐embalmed tissues are better suited for undergraduate medical teaching of viscera can partly be confirmed — for the thorax and abdomen regions.</p> <p>No benefit was found in Thiel‐embalmed musculoskeletal tissues; nor for the upper and lower extremities and the pelvis between the ethanol‐glycerin‐ and Thiel‐embalmed specimens. According to previously published studies, Thiel‐embalmed specimens yield superior joint flexibility and muscle elasticity (Bertone et al., [<reflink idref="bib15" id="ref124">15</reflink>]; Jaung et al., [<reflink idref="bib55" id="ref125">55</reflink>]; Hayashi et al., [<reflink idref="bib50" id="ref126">50</reflink>]; Hammer et al., [<reflink idref="bib45" id="ref127">45</reflink>]; Liao et al., [<reflink idref="bib68" id="ref128">68</reflink>]; Crosado et al., [<reflink idref="bib29" id="ref129">29</reflink>]), similar to non‐embalmed tissues and suitable for most realistic representations of the passive movement and kinematics of the musculoskeletal system (Jaung et al., [<reflink idref="bib55" id="ref130">55</reflink>]; Balta, Lamb, &amp; Soames, [<reflink idref="bib9" id="ref131">9</reflink>]; Alamneh, [<reflink idref="bib2" id="ref132">2</reflink>]; Kalthur et al., [<reflink idref="bib57" id="ref133">57</reflink>]). This large range of joint motion allows orthopedic and trauma surgeons to perform simulation interventions in the most realistic conditions (Hammer et al., [<reflink idref="bib45" id="ref134">45</reflink>]; Klima et al., [<reflink idref="bib62" id="ref135">62</reflink>]; Klima et al., [<reflink idref="bib61" id="ref136">61</reflink>]; Rakuša &amp; Kocbek Šaherl, [<reflink idref="bib96" id="ref137">96</reflink>]). Moreover, musculoskeletal surgery, anesthesia, and intensive care are the disciplines that use Thiel‐embalmed tissues for research (Benkhadra et al., [<reflink idref="bib12" id="ref138">12</reflink>]; Munirama et al., [<reflink idref="bib82" id="ref139">82</reflink>]; Hammer, [<reflink idref="bib44" id="ref140">44</reflink>]; McLeod et al., [<reflink idref="bib79" id="ref141">79</reflink>]). Thus, these specimens are seemingly more suited for postgraduate students and clinical workshops than for undergraduate dissection courses (Hammer et al., [<reflink idref="bib45" id="ref142">45</reflink>]; Hammer, [<reflink idref="bib44" id="ref143">44</reflink>]).</p> <p>Ethanol‐glycerin fixation at first sight seems to have less advantageous haptic and optical qualities. The stiffening, though less extensive when compared to formaldehyde embalming, may make the tissues more prone to damage or preparation artifacts than in Thiel embalming (Hammer et al., [<reflink idref="bib47" id="ref144">47</reflink>]). Hammer et al. ([<reflink idref="bib45" id="ref145">45</reflink>]) compared the modified method of Thiel embalming (Thiel, [<reflink idref="bib108" id="ref146">108</reflink>]) to ethanol‐glycerin fixation and found that muscles, nerves and vessels were overstained and softened with the Thiel fixative but were bleached and indurated in ethanol‐glycerin‐embalmed musculoskeletal tissues (Hammer et al., [<reflink idref="bib45" id="ref147">45</reflink>]). These processes appear to limit joint movement. All of these aforementioned observations, however, seemed not to negatively influence the suitability of ethanol‐glycerin‐embalmed tissues for undergraduate training when compared to Thiel embalming.</p> <hd id="AN0173339726-23">Ethanol‐glycerin‐embalmed tissues appear to be better preserved and more suitable for undergr...</hd> <p>The student questionnaire regarding tissue properties and of ethanol‐glycerin‐ and Thiel‐embalmed tissues and their suitability to prepare for anatomy examinations yielded interesting results. Tissue preservation was rated better for ethanol‐glycerin. No difference was seen by the students with respect to tissue colorfastness. These findings from an undergraduate setting somehow contrast perceptions on postgraduate trainees and researchers including Walter Thiel himself who described above all the color of Thiel‐embalmed tissues to be "lifelike" (Thiel, [<reflink idref="bib107" id="ref148">107</reflink>]; Hammer et al., [<reflink idref="bib45" id="ref149">45</reflink>]; Ottone et al., [<reflink idref="bib86" id="ref150">86</reflink>]).</p> <p>Tissue pliability was evaluated higher in Thiel‐embalmed specimens by the students, which was well in line with previous descriptions (Wolff et al., [<reflink idref="bib117" id="ref151">117</reflink>]; Bertone et al., [<reflink idref="bib15" id="ref152">15</reflink>]; Hölzle et al., [<reflink idref="bib52" id="ref153">52</reflink>]; Hayashi et al., [<reflink idref="bib50" id="ref154">50</reflink>]; Hunter et al., [<reflink idref="bib54" id="ref155">54</reflink>]; Ottone et al., [<reflink idref="bib86" id="ref156">86</reflink>]; Miyake et al., [<reflink idref="bib81" id="ref157">81</reflink>]).</p> <p>When surveyed on the suitability for their examination preparation, undergraduate students rated ethanol‐glycerin‐embalmed tissues superior to Thiel‐embalmed tissues. These results agree with the results of Balta and colleagues, who compared formaldehyde with Thiel embalming in an undergraduate and postgraduate teaching environment (Balta, Lamb, &amp; Soames, [<reflink idref="bib9" id="ref158">9</reflink>]). Undergraduate students working with formaldehyde‐embalmed tissues were given the opportunity to study Thiel‐embalmed tissues which postgraduate students were working on and vice versa. The undergraduate students found it easier to identify thoracic, abdominal, and pelvic structures in formaldehyde‐embalmed tissues, which speaks in line with the student assessments on tissue suitability for their study from the here given trial and the OSPE outcome. The same undergraduate group by Balta found that Thiel‐embalmed tissues were more advantageous for the identification of limb structures (Balta, Lamb, &amp; Soames, [<reflink idref="bib9" id="ref159">9</reflink>]). The latter cannot be substantiated in the here given study and cohorts, which showed the ethanol embalming not to be inferior for musculoskeletal anatomy teaching.</p> <hd id="AN0173339726-24">Different embalming techniques may potentially trigger student stress response differently</hd> <p>For most medical students, the exposure to post‐mortem human bodies in an anatomy setting is their first encounter with the transience of life and, ultimately, death (Attardi et al., [<reflink idref="bib6" id="ref160">6</reflink>]; Chaudhuri, [<reflink idref="bib22" id="ref161">22</reflink>]; Yakura et al., [<reflink idref="bib119" id="ref162">119</reflink>]; Zhang et al., [<reflink idref="bib123" id="ref163">123</reflink>]; Wu et al., [<reflink idref="bib118" id="ref164">118</reflink>]). The procedure of dissecting human tissues and incising an intact corpse can result in a broad variety of discomfort or stressful experiences for students in health science (Arráez‐Aybar et al., [<reflink idref="bib5" id="ref165">5</reflink>]; Cahill &amp; Ettarh, [<reflink idref="bib21" id="ref166">21</reflink>]; Lindsey et al., [<reflink idref="bib70" id="ref167">70</reflink>]; Bati et al., [<reflink idref="bib10" id="ref168">10</reflink>]; Getachew, [<reflink idref="bib39" id="ref169">39</reflink>]; Sándor et al., [<reflink idref="bib101" id="ref170">101</reflink>]; Tseng &amp; Lin, [<reflink idref="bib109" id="ref171">109</reflink>]; Criado‐Álvarez et al., [<reflink idref="bib28" id="ref172">28</reflink>]; Chia et al., [<reflink idref="bib23" id="ref173">23</reflink>]; Zibis et al., [<reflink idref="bib124" id="ref174">124</reflink>]).</p> <p>Jaung and coworkers reported that formaldehyde‐embalmed bodies showed more extensive discoloration when compared to fresh or Thiel‐embalmed specimens (Jaung et al., [<reflink idref="bib55" id="ref175">55</reflink>]). Remarkably, further comparison of Thiel‐ and formaldehyde‐embalmed anatomical specimens yielded that one third of undergraduate students expressed that Thiel‐embalmed tissues made them feel more uncomfortable when compared to formaldehyde‐embalmed tissues owing to their appearance (Balta, Lamb, &amp; Soames, [<reflink idref="bib9" id="ref176">9</reflink>]; Miyake et al., [<reflink idref="bib81" id="ref177">81</reflink>]). It may therefore be hypothesized that the dissection of Thiel‐embalmed tissues may trigger a more extensive stress response of undergraduate students when compared to ethanol‐glycerin‐embalmed human bodies, yielding discoloration and bleaching likewise (Hammer et al., [<reflink idref="bib47" id="ref178">47</reflink>]; Niedermair et al., [<reflink idref="bib85" id="ref179">85</reflink>]). Such stress experience tends to have a negative impact on student learning (Tyng et al., [<reflink idref="bib111" id="ref180">111</reflink>]; Rowe &amp; Fitness, [<reflink idref="bib97" id="ref181">97</reflink>]). Also, Balta and colleagues showed that students' first impressions and feelings influence their dissection experience, which in turn could impact their learning and preservation of anatomical knowledge (Balta, Lamb, &amp; Soames, [<reflink idref="bib9" id="ref182">9</reflink>]). While this explanation remains largely hypothetical and warrants further study, the general response of experienced anatomists in the German‐speaking community when surveyed if they would use Thiel embalming in an undergraduate setting is largely dismissive.</p> <hd id="AN0173339726-25">There is preliminary evidence for the abdomen to be a decisive region for student rating on t...</hd> <p>Correlations between OSPE scores and student assessment were only found for the abdominal region. Here, a weak negative correlation was found for student assessment on colorfastness in ethanol‐glycerin‐embalmed tissues, but a positive correlation was found for Thiel embalming. It seems in consequence that embalming‐dependent, opposing features may promote student learning. Seemingly, a better visibility of anatomical structures promotes the learning success of undergraduate students. The hypothesis presented in the introduction can therefore only be accepted for Thiel but must be rejected for ethanol‐glycerin embalming.</p> <hd id="AN0173339726-26">There is substantial evidence that undergraduate medical students prefer ethanol‐glycerin ove...</hd> <p>Contemporary research suggests that Thiel embalming preserves the body in natural color, and, at the same time, helps minimize formaldehyde use as a known health hazard (Hayashi et al., [<reflink idref="bib50" id="ref183">50</reflink>]; Ottone et al., [<reflink idref="bib86" id="ref184">86</reflink>]; Liao &amp; Wang, [<reflink idref="bib67" id="ref185">67</reflink>]; Rakuša &amp; Kocbek Šaherl, [<reflink idref="bib96" id="ref186">96</reflink>]). However, no research to date substantiated the utility of Thiel embalming to other types of anatomical fixation in an undergraduate student environment based on the same cohort. The Thiel method has a number of advantages that seemingly makes it the first choice for use in postgraduate education, surgical training, and partly in research (Hammer et al., [<reflink idref="bib45" id="ref187">45</reflink>]; Yiasemidou et al., [<reflink idref="bib121" id="ref188">121</reflink>]; Crosado et al., [<reflink idref="bib29" id="ref189">29</reflink>]; Hammer, [<reflink idref="bib44" id="ref190">44</reflink>]; Humbert et al., [<reflink idref="bib53" id="ref191">53</reflink>]; Rakuša &amp; Kocbek Šaherl, [<reflink idref="bib96" id="ref192">96</reflink>]; Sanchez‐Ferrer et al., [<reflink idref="bib100" id="ref193">100</reflink>]). Anatomy in medical education attempts to teach students how to extrapolate their knowledge on human morphology to living individuals (McLachlan, [<reflink idref="bib78" id="ref194">78</reflink>]). The approach to delivering such knowledge to students through anatomical dissection makes it apparent that the embalming method should ideally retain the most natural characteristics as seen in living humans. However, tissue bleaching, and induration may make it easier for novices in medicine to distance themselves emotionally from the initial confrontation and stressful experience of incising a human body. Moreover, the induration of the tissues facilitates dissecting fine anatomical structures such as nerves, vessels, or tissue planes. Such aspects may not form the focus for most postgraduate activities, where nerves or vessels are commonly considered risk structures and therefore often not exposed so to lower the risk of iatrogenic injury. Ethanol‐ or formaldehyde‐based techniques may consequently be better suited to enter anatomical education. The advantages Thiel embalming brings have to be outbalanced with the costs of the chemicals and infrastructure (Benkhadra, Gérard, et al., [<reflink idref="bib13" id="ref195">13</reflink>]; Hammer et al., [<reflink idref="bib45" id="ref196">45</reflink>]; Yiasemidou et al., [<reflink idref="bib121" id="ref197">121</reflink>]), the complexity of the method (Eisma et al., [<reflink idref="bib36" id="ref198">36</reflink>]; Hammer et al., [<reflink idref="bib45" id="ref199">45</reflink>]; Healy et al., [<reflink idref="bib51" id="ref200">51</reflink>]) and the limited usability of tissues. Hammer and colleagues (Hammer et al., [<reflink idref="bib45" id="ref201">45</reflink>]) demonstrated that Thiel‐embalmed body donors appear ideally suited for clinical workshops but have limitations for student dissection classes in facilities with limited storage space, airflow, or technical staff. Conversely, ethanol‐glycerin‐fixed body donors are well suited for student dissection courses in such an environment but are limited in their use for clinical workshops. Thiel embalming therefore ideally complements the ethanol‐glycerin fixation to provide tailor‐made solutions for clinical workshops and student dissection courses in a wide range of applications.</p> <p>In line with these objectifiable findings, it was decided to change the type of anatomical embalming used for first‐ and second‐year medical teaching from the formerly used Thiel method, to ethanol‐glycerin‐based embalming only so to enhance student learning gain in our undergraduate courses. Though this shift towards an evidence‐based embalming strategy in Graz led to the change away from the "Graz method" for undergraduate students, Thiel clearly remains a mainstay of professional education especially for musculoskeletal, ear, nose, and throat, dental, and maxillo‐facial surgeons (Thiel, [<reflink idref="bib107" id="ref202">107</reflink>], [<reflink idref="bib108" id="ref203">108</reflink>]).</p> <p>This is likely to the fact that at different stages of training the requirements and demands on the fixatives change from learning the human anatomy in the best possible (visual) way to representing more lifelike (haptic) behavior to simulate operations and interventions. Thiel‐embalmed bodies provide the visual and haptic properties which are required for clinical workshops (Alberty et al., [<reflink idref="bib4" id="ref204">4</reflink>]; Löffler et al., [<reflink idref="bib72" id="ref205">72</reflink>]; Pattanshetti &amp; Pattanshetti, [<reflink idref="bib87" id="ref206">87</reflink>]; Eisma et al., [<reflink idref="bib36" id="ref207">36</reflink>]). Therefore, clinical research and other disciplines use Thiel more often and therefore is more commonly used for postgraduate students especially in neck, head, and extremity surgery training. However, this often is not science‐driven as a result rather than empirical and the result of subjective surveys (Alberty et al., [<reflink idref="bib4" id="ref208">4</reflink>]; Wolff et al., [<reflink idref="bib117" id="ref209">117</reflink>]; Eisma et al., [<reflink idref="bib37" id="ref210">37</reflink>]; Guo et al., [<reflink idref="bib43" id="ref211">43</reflink>]; Hammer et al., [<reflink idref="bib45" id="ref212">45</reflink>]; Hammer, [<reflink idref="bib44" id="ref213">44</reflink>]).</p> <hd id="AN0173339726-27">Future directions</hd> <p>It was found that undergraduate medical students prefer ethanol‐glycerin embalming over Thiel embalming to fulfill their learning objectives. As a next step, it would be of scientific and practical interest to evaluate and compare the respective parameters studied in Thiel‐ and ethanol‐glycerin‐embalmed tissues with those of formalin‐embalmed specimens, as formalin embalmment is still widely used for undergraduate dissection courses worldwide. This would enable the assessment, in the same way, the students' perception of their anatomy learning in relation to these three embalming techniques. It would also be desirable to retrieve the same aspects evaluated in corresponding dissections of postgraduate students having special demands on embalmed tissues.</p> <hd id="AN0173339726-28">Limitations of the study</hd> <p>A number of limitations apply for the given study. First, we were only able to assess a limited number of undergraduate medical students as part of the quality‐assurance approach in teaching. Secondly, the OSPE have certain limitations as a means of assessment on student performance which are beyond the scope of this article. Though all students enrolled in this study had the chance to work on both embalming methods, it was impossible for the students to assess the texture of the anatomical structures as part of their (examination) decision making. Third, our findings are strongly limited to undergraduate (medical) teaching and may likely only be applicable in the ecosystem of the Austrian medical curriculum.</p> <hd id="AN0173339726-29">CONCLUSIONS</hd> <p>Tissues embalmed with ethanol‐glycerin appear to provide certain benefits to undergraduate medical students, through the recognition of visceral structures which likewise match student perceptions on tissue suitability to achieve the anatomy learning objectives. Consequently, the benefits reported for Thiel embalming for postgraduate study unlikely reflect best practice for novices in medical training. The results of this study changed the anatomical setup for dissection course in both JKU and MUG.</p> <hd id="AN0173339726-30">ACKNOWLEDGMENTS</hd> <p>The authors would like to express their sincere thanks to the body donors for donating their bodies for research after passing. Equally, we wish to thank their relatives for supporting this valuable decision. We thank Professor Maren Engelhardt who provided support with the OSPE examinations. The images of Figures 2–4 and Figure S1 were taken by Christine Hammer. All authors hereby declare that there is no potential conflict of interest in any form concerning them.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/8Z8K/01nov23/ase2306-sup-0001-FigureS1.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="ase2306-sup-0001-FigureS1.jpg" title="Figure S1." /> </p> <p></p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/8Z8K/01nov23/ase2306-sup-0002-FigureS2.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="ase2306-sup-0002-FigureS2.jpg" title="Figure S2." /> </p> <p></p> <p>GRAPH: Data S1.</p> <ref id="AN0173339726-33"> <title> REFERENCES </title> <blist> <bibl id="bib1" idref="ref62" type="bt">1</bibl> <bibtext> Ackermann J, Wedel T, Hagedorn H, Maass N, Mettler L, Heinze T, et al. Establishment and evaluation of a training course in advanced laparoscopic surgery based on human body donors embalmed by ethanol‐glycerol‐lysoformin fixation. 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Pretterklieber; Andreas Wree and Niels Hammer</p> <p>Reported by Author; Author; Author; Author; Author; Author; Author; Author; Author; Author; Author; Author</p> <p></p> <p>Veronica Antipova is a Senior lecturer at the Department of Clinical and Macroscopic Anatomy at the Medical University of Graz, Austria and teaches anatomy to medical, dentistry and to graduate students. Her research focused on neuroanatomy, neurodegenerative disease, clinical anatomy, cranio‐facial system, and teaching in clinical anatomy.</p> <p>Julian F. Niedermair is a trainee doctor at the Kepler University Hospital Linz, Austria. He is interested in pursuing residency in Radiology at the Kepler University Hospital, Linz.</p> <p>Martin Siwetz is a sixth‐year medical student at the Medical University of Graz, Austria and student assistant at the Department of Macroscopic and Clinical Anatomy. His research interest is in macroscopic anatomy of the human body combined with clinical questioning. He is interested in pursuing residency in trauma surgery and orthopedics.</p> <p>Franz A. Fellner is a Full Professor and Chair of the Central Radiology Institute of Johannes Kepler University, Linz, Austria. He teaches anatomy and radiology to students and his research focuses on magnetic resonance imaging especially in neuroradiology, virtual anatomy education, and cinematic rendering.</p> <p>Sabine Löffler is a lecturer of dental students at the Institute of Anatomy at the University of Leipzig, Faculty of Medicine, Leipzig, Germany. She teaches anatomy and histology to first‐ and second‐year dental and medical students and offers demonstrations for medical schools.</p> <p>Simone Manhal is a psychologist and chairs the office of the Vice‐Rector for Studies and Teaching at the Medical University of Graz, Austria. Her research interest is in medical education, learning outcome, student‐centered learning and student selection.</p> <p>Benjamin Ondruschka is a Full Professor and Chair of the Institute of Legal Medicine, University Medical Center Hamburg‐Eppendorf, Hamburg, Germany. He teaches forensic medicine to medical and forensic students and to graduate students.</p> <p>Sandra M. Pietras is a fourth‐year medical student at the Medical University of Graz, Austria and working as a technical assistant at the Department of Macroscopic and Clinical Anatomy. Her research interest is in macroscopic anatomy. She is interested in pursuing residency in surgery.</p> <p>Amélie J. Poilliot is an anatomist, researcher and demonstrator at the Anatomical Institute at University of Basel, Switzerland. She takes part in the undergraduate anatomy dissection courses of first‐, second‐ and third‐year medical students. Her research focuses on the biomechanics of the healthy and dysfunctional sacroiliac joint and trabecular architecture of the spine.</p> <p>Michael L. Pretterklieber is a Professor of the Anatomy Division at the Medical University of Graz, Austria. He teaches gross and clinical anatomy to undergraduate and to graduate students and clinicians. His research focuses on macroscopic and clinical anatomy and teaching in clinical anatomy.</p> <p>Andreas Wree is a Senior Professor and the former Chair of the Institute of Anatomy, Rostock University Medical Center, Rostock, Germany. He teaches gross and clinical anatomy and histology to undergraduate and graduate students and surgeons. His research focuses on neuroanatomy, neurodegenerative diseases, clinical anatomy, and teaching in clinical anatomy.</p> <p>Niels Hammer is a Full Professor and the Chair of the Anatomy Division at the Medical University of Graz, Austria. He teaches gross, clinical and neuroanatomy to undergraduate and postgraduate students and to surgeons. His research focuses on teaching in clinical anatomy, surgical anatomy, and biomechanics.</p> </aug> <nolink nlid="nl1" bibid="bib110" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib40" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib105" firstref="ref3"></nolink> <nolink nlid="nl4" bibid="bib74" firstref="ref4"></nolink> <nolink nlid="nl5" bibid="bib102" firstref="ref5"></nolink> <nolink nlid="nl6" bibid="bib30" firstref="ref6"></nolink> <nolink nlid="nl7" bibid="bib60" firstref="ref7"></nolink> <nolink nlid="nl8" bibid="bib31" firstref="ref8"></nolink> <nolink nlid="nl9" bibid="bib75" firstref="ref9"></nolink> <nolink nlid="nl10" bibid="bib63" firstref="ref10"></nolink> <nolink nlid="nl11" bibid="bib115" firstref="ref11"></nolink> <nolink nlid="nl12" bibid="bib41" firstref="ref12"></nolink> <nolink nlid="nl13" bibid="bib95" firstref="ref13"></nolink> <nolink nlid="nl14" bibid="bib36" firstref="ref14"></nolink> <nolink nlid="nl15" bibid="bib33" 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| Items | – Name: Title Label: Title Group: Ti Data: Undergraduate Medical Student Perceptions and Learning Outcomes Related to Anatomy Training Using Thiel- and Ethanol-Glycerin-Embalmed Tissues – Name: Language Label: Language Group: Lang Data: English – Name: Author Label: Authors Group: Au Data: <searchLink fieldCode="AR" term="%22Antipova%2C+Veronica%22">Antipova, Veronica</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-7631-9080">0000-0002-7631-9080</externalLink>)<br /><searchLink fieldCode="AR" term="%22Niedermair%2C+Julian+F%2E%22">Niedermair, Julian F.</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-2321-7996">0000-0002-2321-7996</externalLink>)<br /><searchLink fieldCode="AR" term="%22Siwetz%2C+Martin%22">Siwetz, Martin</searchLink><br /><searchLink fieldCode="AR" term="%22Fellner%2C+Franz+A%2E%22">Fellner, Franz A.</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-3009-4944">0000-0003-3009-4944</externalLink>)<br /><searchLink fieldCode="AR" term="%22Löffler%2C+Sabine%22">Löffler, Sabine</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-3071-6125">0000-0003-3071-6125</externalLink>)<br /><searchLink fieldCode="AR" term="%22Manhal%2C+Simone%22">Manhal, Simone</searchLink><br /><searchLink fieldCode="AR" term="%22Ondruschka%2C+Benjamin%22">Ondruschka, Benjamin</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-8277-6616">0000-0002-8277-6616</externalLink>)<br /><searchLink fieldCode="AR" term="%22Pietras%2C+Sandra+M%2E%22">Pietras, Sandra M.</searchLink><br /><searchLink fieldCode="AR" term="%22Poilliot%2C+Amélie+J%2E%22">Poilliot, Amélie J.</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-1835-4344">0000-0003-1835-4344</externalLink>)<br /><searchLink fieldCode="AR" term="%22Pretterklieber%2C+Michael+L%2E%22">Pretterklieber, Michael L.</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-2570-2730">0000-0003-2570-2730</externalLink>)<br /><searchLink fieldCode="AR" term="%22Wree%2C+Andreas%22">Wree, Andreas</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-6446-0095">0000-0002-6446-0095</externalLink>)<br /><searchLink fieldCode="AR" term="%22Hammer%2C+Niels%22">Hammer, Niels</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-8230-9383">0000-0001-8230-9383</externalLink>) – Name: TitleSource Label: Source Group: Src Data: <searchLink fieldCode="SO" term="%22Anatomical+Sciences+Education%22"><i>Anatomical Sciences Education</i></searchLink>. 2023 16(6):1144-1157. – Name: Avail Label: Availability Group: Avail Data: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us – Name: PeerReviewed Label: Peer Reviewed Group: SrcInfo Data: Y – Name: Pages Label: Page Count Group: Src Data: 14 – Name: DatePubCY Label: Publication Date Group: Date Data: 2023 – Name: TypeDocument Label: Document Type Group: TypDoc Data: Journal Articles<br />Reports - Research – Name: Audience Label: Education Level Group: Audnce Data: <searchLink fieldCode="EL" term="%22Higher+Education%22">Higher Education</searchLink><br /><searchLink fieldCode="EL" term="%22Postsecondary+Education%22">Postsecondary Education</searchLink> – Name: Subject Label: Descriptors Group: Su Data: <searchLink fieldCode="DE" term="%22Undergraduate+Students%22">Undergraduate Students</searchLink><br /><searchLink fieldCode="DE" term="%22Premedical+Students%22">Premedical Students</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Attitudes%22">Student Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Outcomes+of+Education%22">Outcomes of Education</searchLink><br /><searchLink fieldCode="DE" term="%22Anatomy%22">Anatomy</searchLink><br /><searchLink fieldCode="DE" term="%22Laboratory+Procedures%22">Laboratory Procedures</searchLink> – Name: DOI Label: DOI Group: ID Data: 10.1002/ase.2306 – Name: ISSN Label: ISSN Group: ISSN Data: 1935-9772<br />1935-9780 – Name: Abstract Label: Abstract Group: Ab Data: Anatomical dissection is known to serve as an integral tool in teaching gross anatomy, including postgraduate training. A variety of embalming techniques exist, resulting in different haptic and optical tissue properties. This study aimed to objectify learning outcomes and medical student perceptions related to the use of two widely used embalming techniques, namely Thiel and ethanol-glycerin embalming. Between 2020 and 2022, first- and second-year medical students enrolled in the course on topographic anatomy participated in this study. Objective structured practical examinations were carried out for the head, neck, thorax, abdomen, pelvis, and extremity regions following regional dissection just before the oral examinations began. Six to ten numbered tags were marked in prosections of each region in Thiel- and ethanol-glycerin-embalmed specimens. Following the examinations, the students were surveyed regarding the suitability of the two embalming techniques with respect to preservation, colorfastness, tissue pliability, and the suitability in preparing for their anatomy examinations. Consistently higher scores were achieved for the thoracic and abdominal regions in ethanol-glycerin-embalmed specimens when compared to Thiel. No benefit was found for Thiel-embalmed upper or lower extremities. Tissues embalmed with ethanol-glycerin were rated higher for preservation and suitability to achieve the learning objectives, tissue pliability was rated higher for Thiel-embalmed tissues. Ethanol-glycerin embalming appears to offer certain advantages for undergraduate students in recognizing visceral structures, which may align with students' ideas on tissue suitability for their learning. Consequently, the benefits reported for Thiel embalming for postgraduate study unlikely reflect its suitability for novices. – Name: AbstractInfo Label: Abstractor Group: Ab Data: As Provided – Name: DateEntry Label: Entry Date Group: Date Data: 2023 – Name: AN Label: Accession Number Group: ID Data: EJ1398218 |
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| RecordInfo | BibRecord: BibEntity: Identifiers: – Type: doi Value: 10.1002/ase.2306 Languages: – Text: English PhysicalDescription: Pagination: PageCount: 14 StartPage: 1144 Subjects: – SubjectFull: Undergraduate Students Type: general – SubjectFull: Premedical Students Type: general – SubjectFull: Student Attitudes Type: general – SubjectFull: Outcomes of Education Type: general – SubjectFull: Anatomy Type: general – SubjectFull: Laboratory Procedures Type: general Titles: – TitleFull: Undergraduate Medical Student Perceptions and Learning Outcomes Related to Anatomy Training Using Thiel- and Ethanol-Glycerin-Embalmed Tissues Type: main BibRelationships: HasContributorRelationships: – PersonEntity: Name: NameFull: Antipova, Veronica – PersonEntity: Name: NameFull: Niedermair, Julian F. – PersonEntity: Name: NameFull: Siwetz, Martin – PersonEntity: Name: NameFull: Fellner, Franz A. – PersonEntity: Name: NameFull: Löffler, Sabine – PersonEntity: Name: NameFull: Manhal, Simone – PersonEntity: Name: NameFull: Ondruschka, Benjamin – PersonEntity: Name: NameFull: Pietras, Sandra M. – PersonEntity: Name: NameFull: Poilliot, Amélie J. – PersonEntity: Name: NameFull: Pretterklieber, Michael L. – PersonEntity: Name: NameFull: Wree, Andreas – PersonEntity: Name: NameFull: Hammer, Niels IsPartOfRelationships: – BibEntity: Dates: – D: 01 M: 01 Type: published Y: 2023 Identifiers: – Type: issn-print Value: 1935-9772 – Type: issn-electronic Value: 1935-9780 Numbering: – Type: volume Value: 16 – Type: issue Value: 6 Titles: – TitleFull: Anatomical Sciences Education Type: main |
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