Implications of Evidence-Based Anatomy

WHAT IS EVIDENCE-BASED ANATOMY?

For ages, anatomy has been the cornerstone of clinical practice. From morphology to microstructure to imaging studies, it has grown dramatically. As a research scientific design for interventional studies, it is still a cretin as the majority of anatomical research is conducted using observational study methods. The focus is on creating a functional and evolutionary database of individual differences in race, sex, age, and laterality.[¹]

Evidence-based anatomy refers to the transformation of anatomy from a research-driven field that reported case reports and case series to one that offered a platter of evidence in the form of critical appraisal. Evidence-based medicine serves as the ancestor of evidence-based anatomy.[²] The former was first told in 1992. The idea of evidence-based medicine entails a thorough review of the literature and critical analysis, either with or without estimating the pool effect measure. It is a concise analysis of a research subject that is dealt with in a structured and repeatable way. Figure 1 below shows a schematic illustration of the five tiers of evidence-based medicine.[²]

Figure 1: Schematic illustration of the five tiers of Evidence-Based Medicine

The most recent WHO recommendations on the use of prenatal corticosteroids and tocolysis for enhancing preterm birth outcomes serve as an example of the Evidence-Based Anatomy's (EBM's) magical power. The Cochrane systematic reviews served as the basis for these recommendations. Medicine is an art and most often decisions about treatment choices are made by choice. Systematic reviews and/or meta-analysis help in making those decisions transparent and reducing bias to a large extent. This suggests that systematic reviews may be able to offer the best estimate and available evidence for clinical practice.[³]

Many anatomists are now moving beyond the straightforward reporting of prevalence statistics to a critical evaluation of the study designs. The works of Andreas Vesalius, the founder of modern anatomy, contain the earliest records of subjective statistics of anatomical differences. Since then, reporting epidemiological/observational research study designs that include documenting frequencies, as well as descriptive and inferential statistics of variables of anatomical data, has emerged using evidence-based anatomy. Most anatomical studies provide accurate frequency estimates for anatomical information such as age, sex, side, sex-based, and side-based frequencies.[²] It is imperative to synthesize data from these various studies to produce potentially better evidence than that of individual studies. This can be done by systematic reviews and/or meta-analyses.[⁴]

How can we advance along the evidence-based anatomy path? Doing a systematic review with or without meta-analysis is a straightforward solution. The following actions must be taken to conduct a systematic review.[⁵]

Identify the review topic

The anatomical characteristics of a certain structure can be the review topic for anatomy. Once a study topic has been chosen, primary and secondary objectives must be formulated while considering the research topic's clinical applicability. The second step is to choose a title that emphasizes systematic review and meta-analysis.

Register the review in PROSPERO

It is a global repository for upcoming systematic reviews. To prevent reporting biases such as citation bias, language prejudice, geographical bias, time-lag bias, and multiple publication bias, registration is essential.

Determining inclusion and exclusion criteria

For the inclusion criteria, take into account, patient variables such as age, sex, race, and health condition as they may raise the risk of bias. Along with standard dissection and imaging modalities, inclusion criteria might be expanded to incorporate intraoperative electrophysiological modalities. In addition, because it could affect interviewer bias, examination of prospective or retrospective study designs is crucial. Case studies, case series, abstracts, and letters to the editor may be excluded.

Apply search strategy

A systematic review of anatomy is highlighted by a broad search technique using eponyms in keywords. There are three primary types of search strategies:

1. Electronic databases such as ScienceDirect, Web of Science, Embase, PubMed, etc. Explore more databases such as PsycLIT (http://www.wesleyan.edu/libr), the Current Index to Statistics, the Cochrane Methodology Register, and the Cochrane Central Register of Controlled Trials. The Cochrane Library, the Centre for Reviews and Dissemination, the Campbell Collaboration, the Scottish Intercollegiate Guidelines Network, and others are just a few websites of review centers. Cross-referencing including article search is equally important[^5,6]
2. Hand search in anatomy journals such as Annals of Anatomy, Surgical and Radiologic Anatomy, Anatomical Science International, Folia Morphologica, Clinical Anatomy, The Anatomical Record, The Journal of Anatomy, National Journal of Clinical Anatomy, etc.[⁵]
3. Evidence synthesis – focused online journals (e.g., systematic reviews, epidemiologic reviews, and research systemic techniques).[⁵]

Selection of study

As a first step in the screening process, start by screening the papers by title and abstract. The three main tenets for research selection are the critical evaluation of studies by two independent reviewers, consideration of translators where necessary, and the vigilance of study duplication. Duplication studies might take the form of many studies with various sample sizes or multiple publications of the data in various languages.[⁵]

Extraction of data

The most straightforward way to extract data is to tabulate it along with subgroup data (gender, age, and laterality) on a Microsoft Excel spreadsheet. Then, the actual proportion number for the extracted data is unavailable; the reviewers might ask the authors of the original study for the raw data. The statistical integrity of the data must be maintained while obtaining prevalence rates, especially when reporting rare abnormalities.[⁵]

Statistical analysis

Data must be shown clearly in tables that summarize the findings for the systematic review and meta-analysis. As an appropriate outcome of the statistical analysis of meta-analysis, the authors must use pooled effect measures rather than only compiling raw data. Typically, the effect sizes are shown graphically as forest plots and as 95% confidence intervals. Pooled prevalence estimate, a measure of the pooled effect for proportional data, can be calculated using MetaXL 2.0, a free Excel add-in. With the use of Biostat Inc.'s Comprehensive meta-analysis program, the summed mean of the anatomical data may be determined. The Chi-squared test is used to evaluate the heterogeneity between the studies, and a P = 0.10 or above is reported as statistically significant according to Cochrane's Q.[^5,6,7]

Writing the manuscript

The authors' manuscript must be written in accordance with the requirements listed in the journal where they plan to publish it. The majority of publications advise writers to adhere to the meta-analysis of observational studies in epidemiology or Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines.[⁸] The emphasis of the essay should be on the future directions and the practical consequences of the combined data.[^5,9] Figure 2 presents the key messages for the conduct of a systematic review.[¹⁰]

Figure 2: Key messages for the conduct of Systematic review

EVIDENCE-BASED ANATOMY AND EVIDENCE-BASED EDUCATION

There are two aspects to anatomy: teaching and research. Of course, evidence-based teaching must be addressed in addition to evidence-based research. Hence, how do we handle schooling that is based on evidence?

This can be accomplished using fragments of evidence to make sure that students are learning, selecting effective teaching-learning tactics, and assessing students' progress using formative and summative assessment methods. Interactive lectures, dissections, and demonstrations have continued to be the standard teaching methods for anatomy. The “flipped classroom,” blended learning, and self-directed learning have all gained popularity as extensions of large-group training. Dissection cannot be replaced, but Cloudatomy, SR 3D animator, and the 3D anatomy dissection tables have revolutionized how dissection is taught in a virtual environment. Competency-based medical education was introduced by National Medical Council to the undergraduates in the year 2019, which geared up the medical fraternity to this change. Revised basic medical education techniques and curriculum implementation support programs are the main faculty development programs that were helpful to sensitize and upgrade the teaching faculty to evidence-based education.[¹¹]

WHAT ARE THE CHALLENGES IN EVIDENCE-BASED ANATOMY?

Creating a successful search strategy in evidence-based anatomy is challenging. One needs to use an extensive search approach that includes eponyms. For observational research, preregistration and protocol registration are not mandatory, making it challenging to track down unpublished and partially published studies.[^1,9]

SEVERAL ISSUES OF EVIDENCE-BASED ANATOMY AND POTENTIAL SOLUTIONS

What are the benefits of evidence-based anatomy for an anatomist?

We can expand our expertise and stay current with developments in the medical industry. The most recent ideas can be presented to our students, and we can assist them in integrating anatomy with practical relevance. A systematic review that is conducted and published will seem impressive on an anatomist's resume.

Who are the stakeholders for evidence-based anatomy?

In addition to anatomists, the students, and clinicians are the main stakeholders for Evidence-Based Anatomy (EBA). To illustrate a few, prostheses of the upper limb and lower limb, vertebral column screws, designing hearing devices, to avoid complications of paranasal sinus surgery, location of bronchial arteries for their embolization for the control of massive hemoptysis, knowledge of variations of skull base canals for diagnosis of perineural metastasis, pelvimetry for assessing cephalopelvic disproportion, risk assessment for rectovaginal fistula, etc.,[¹]

How do we link anatomy and public health?

Collaboration with clinicians and epidemiologists can be the best possible way to combat this issue

CONCLUSION

Evidence-based anatomy refers to the critical appraisal of the research study designs in anatomy. It provides the best possible platter to the clinicians for decision-making. We also need to focus on evidence-based education as holistic grooming of an anatomist. The best method that can successfully guide anatomists down the route of epidemiological anatomy research is the systematic review and/or meta-analysis of prevalence data. In addition, working together with clinicians can help anatomy become a discipline that embraces its various branches, including gross anatomy, surgical, microscopic, and developmental anatomy as a research-led specialty. Evidence-based anatomy gives anatomists the foundation they need to create a network of transdisciplinary research.

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Conflicts of interest

There are no conflicts of interest.