Beta-1 adrenergic receptor signalling during early and late hypertensive cardiac remodelling

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): BioTechMed Graz

Objective

Chronic activation of β1-adrenergic receptors (β1AR) in response to hypertension is consistently linked to maladaptive remodelling in the heart, however, the underlying mechanisms are not well understood. Here, our aim was to determine the subcellular profile and extent of β1AR expression at baseline and upon acute β-adrenergic stimulation in cardiac myocytes during early- and late-stage cardiac remodelling due to systemic hypertension.

Methods

Male Dahl salt-sensitive rats were fed a high-salt diet (HSD; 8% NaCl) for either five or ten weeks to induce early or late hypertensive cardiac remodelling, respectively. Age-, sex- and weight-matched Dahl salt-sensitive rats on a low-salt diet (LSD; 0.3% NaCl) served as controls. To test the effect of conventional anti-hypertensive treatment, a subset of HSD-fed animals received daily doses of the angiotensin-converting-enzyme-inhibitor Imidapril (ACE-I; 1mg/kg/day) starting two weeks after the feeding protocol was switched to HSD. Isolated ventricular myocytes were stimulated either under control conditions or in the presence of β-adrenergic agonist isoprenaline (ISO; 100nM; 1h). Confocal imaging of single cardiomyocytes allowed detailed quantification of β1AR in different cellular compartments. Finally, immunoblotting and microarray analyses were applied to quantify β1AR in the left ventricles of the corresponding groups of animals.

Results

In control rats, β1AR was found in a striated pattern throughout the cell typical for T-tubular network and in the perinuclear regions, while its expression significantly dropped upon ISO treatment. During early remodelling, basal β1AR expression was unchanged, but increased on the T-tubules and perinuclear regions upon acute stimulation with ISO. In contrast, late remodelling was marked by reduced β1AR expression at baseline, and significantly blunted increase in response to ISO compared to early time point. Interestingly, daily ACE-I treatment resulted in even more adverse phenotype as compared to untreated HSD-fed rats in early remodelling, but favourable control-like characteristics at late remodelling stage. Immunoblotting and microarrays from left ventricular tissue confirmed the data, where applicable.

Conclusion

Taken together, we showed that early hypertensive remodelling is marked by altered β1AR responsiveness upon β-adrenergic stimulation, whereas late remodelling also exhibits altered β1AR expression. ACE-I treatment seemed to interfere with early adaptive mechanisms, thereby worsening the phenotype as compared to untreated HSD-fed animals. However, upon prolonged application, it showed a clear protective effect from pathological molecular alterations at late remodelling. Further experiments involving downstream targets of β1AR signalling are required to fully understand the molecular sequence of events leading to early and late alterations in molecular composition of cardiomyocytes in the hypertensive heart.

Functional remodeling of perinuclear mitochondria alters nucleoplasmic Ca2+ signaling in heart failure

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): BioTechMed-Graz

Mitochondrial dysfunction in cardiomyocytes is a hallmark of heart failure (HF) development. Although initial studies recognized the importance of different mitochondrial subpopulations, there is a striking lack of direct comparison of intrafibrillar (IF) vs. perinuclear (PN) mitochondria during the development of HF.

Here, we use multiple approaches to examine the morphology and functional properties of IF vs. PN mitochondria in pressure overload-induced cardiac remodeling in mice, and in non-failing and failing human cardiomyocytes. We could demonstrate that PN mitochondria from failing cardiomyocytes are more susceptible to changes in mitochondrial membrane potential (ΔΨm), ROS generation and impairment in Ca2+ uptake compared to IF mitochondria at baseline and under physiological stress protocol. We also demonstrated, for the first time, that under normal conditions PN mitochondrial Ca2+ uptake shapes nucleoplasmic Ca2+ transients (CaTs) and prevents nucleoplasmic Ca2+ overload. Loss of PN mitochondria Ca2+ buffering capacity translates into increased nucleoplasmic CaTs and may explain disproportionate rise in nucleoplasmic [Ca2+] in failing cardiomyocytes at increased stimulation frequencies. Therefore, a previously unidentified benefit of restoring the mitochondrial Ca2+ uptake may be normalization of nuclear Ca2+ signaling and alleviation of altered excitation-transcription, which could be an important therapeutic approach to prevent adverse cardiac remodeling.

C60 12–LEAD POST–ROSC ELECTROCARDIOGRAM DISCRIMINATES SURVIVAL TO HOSPITAL DISCHARGE. A SUB–ANALYSIS OF THE PEACE STUDY

Background

Once the return of spontaneous circulation (ROSC) after an out–of–hospital cardiac arrest (OHCA) is achieved in patients with an ST–elevation myocardial infarction, the acquisition of a 12–lead electrocardiogram (ECG) is strongly recommended in order to determine candidates for urgent coronary angiography. However, little is known so far about the association of ECG features and survival to hospital discharge in OHCA patients.

Methods

We analysed all the post–ROSC ECGs collected from January 2015 to December 2018 in three European centres (Pavia, Lugano and Vienna). For every ECG, the main features were analysed and filed in the database together with the pre–hospital data collected for every patient according to the Utstein style.

Results

We collected 370 ECGs: 287 males (77.6%); median age 62 years old (IQR 53–70 years); 121 from Pavia (32.7%), 38 from Lugano (10.3%) and 211 from Vienna (57.0%). In Cox univariable regression, age older than 62 years [HR 1.7 (95% IC 1.1–2.4), p = 0.007], QRS wider than 120 msec [HR 1.87 (95% IC 1.3–2.7), p < 0.001], ST elevation in more than one segment [HR 1.7(95% IC 1.2–2.5),p=0.003], the presence of left bundle branch block (LBBB) [HR 1.7 (95% IC 1.1–2.9), p = 0.03] and a right bundle branch block [HR 1.8 (95% IC 1.1–2.8), p = 0.01] were all associated with death before hospital discharge. In multivariable Cox regression, adjusted for the ROSC–to–ECG time, age older than 62 years [HR 1.6 (95% IC 1.1–2.3), p = 0.01], QRS wider than 120 msec [HR 1.7 (95%IC 1.2–2.5), p = 0.004] and the presence of ST elevation in more than one segment [HR 1.7 (95%IC 1.2–2.5), p = 0.004] were independently associated with death before hospital discharge. By considering these latter three risk factors, the rate of survival to hospital discharge was significantly influenced by their number [no risk factor: 80.8%; 1 factor: 71.2%; 2 factors: 61.9%; 3 factors: 34.4%; p < 0.001, p for trend <0.001]. With a Cox regression model, considering the absence of risk factor as a reference, we confirmed that having 2 or 3 risk factors was significantly associated with death before hospital discharge [HR 1.9 (95%IC 1–3.5), p = 0.037 e HR 5.1(95%IC 2.6–10.1), p < 0.001 respectively].

Conclusions

Our study confirms the central role of ECG in STEMI patients resuscitated after an OHCA and proves that post–ROSC ECG features can be used for both the selection of patients who may benefit from urgent coronary angiography as well as for prognostic stratifications.

Evaluation of Novel Substituted Furopyridines as Inhibitors of Protein Kinases Related to Tau Pathology in Alzheimer´s Disease

BACKGROUND

Alzheimer´s disease (AD) is characterized by a progressive neuronal degeneration caused by two pathological hallmarks, hyperphosphorylated tau protein aggregated into tau filaments and amyloid precursor protein derived beta amyloid peptides aggregated into extracellular amyloid plaques. All attempts so far to find effective drugs failed in clinical trials. AD is a multifactorial disease, so that selective drugs to target one AD-relevant structure alone may not be sufficient.

OBJECTIVE

We built novel furopyridines with various substitution patterns to evaluate them as protein kinases inhibitors of enzymes related to tau pathology.

METHOD

Furopyridine derivatives were synthesized and purified using column chromatography. The protein kinase inhibitory properties were determined in ATP-competition assays with determined affinity constants for the most active compounds.

RESULTS

The compounds were prepared in simple two-component reactions of substituted 1,4- dihydropyridines and respective quinones to obtain various substitutions of the molecular furopyridine scaffold. The substituent effects on the determined kinase inhibitory properties of cdk1, cdk2, Fyn, JNK3 and gsk-3β are discussed.

CONCLUSION

Various 3-substitutions were found most sensitive for the protein kinase inhibition depending on the length, nature and a substituent positioning within. We identified compounds as inhibitors of several kinases as a tool to potentially combat the disease progress in a multitargeting approach.

Post-ROSC electrocardiogram timing in the management of out-of-hospital cardiac arrest: results of an international multicentric study (PEACE study)

Background

Electrocardiogram (ECG) is a key tool to triage out-of-hospital cardiac arrest (OHCA) patients after achieving a sustained return of spontaneous circulation (ROSC). According to current guidelines, an immediate coronary angiography is indicated only when the post-ROSC ECG discloses a ST-elevation myocardial Infarction (STEMI). Moreover, the 12-lead ECG should be recorded as soon as possible after ROSC, although it is reasonable that in the early post-ROSC stages ECG could reflect the ischemia secondary to cardiac arrest besides that of coronary origin possibly causing an overdiagnosis of STEMI (false positive).

Purpose

To assess whether the time from ROSC to ECG acquisition could affect the percentage of false positive ECG for STEMI.

Methods

We performed a retrospective, international, multicenter study (PEACE Study - NCT04096079). We included all patients over 18 years of age hospitalized after an OHCA due to medical cause at one of the three participating high-volume hospitals of three different European countries between 2015, 1st January and 2018, 31st December. We considered for the present study only patients who underwent coronary angiography and in whom a post-ROSC ECG was available. For the electrocardiographic diagnosis of STEMI the criteria established by the ESC 2017 guidelines were used, while the execution of a percutaneous coronary angioplasty (PTCA) was evaluated as an angiographic endpoint. We used logistic regression to evaluate the association of time to acquisition and the endpoint. We computed odds ratios and 95% confidence intervals (OR, 95% CI).

Results

Population consisted of 370 patients (77.6% male, mean age 61±13 years, median ROSC-ECG time 15 minutes). Post-ROSC ECG was positive for STEMI in 198 patients and in 39 of them (10.5%) a PTCA was not performed during urgent coronary angiography, representing the false positive (FP) ECG. Dividing the population in three tertiles according to the time from ROSC to ECG (≤7 mins; 8–33 mins; >33 mins), the percentage of FP-ECG in the first tertile (18.5%) was statistically significantly higher than in the second (7.2%, OR 2.9 (95% CI 1.1–7.5) p=0.025) and third (5.8%, OR 3.7 (95% CI 2.2–6.5) p<0.001) as also shown in the Figure. These differences remained significant when adjusting for sex, age, number of segments involved at ECG (anterior, lateral, posterior, inferior and right), QRS duration >120 msec, ECG heart rate >100 bpm and adrenaline administered >1 mg.

Conclusion

Our study offers the first demonstration that the acquisition of the 12-leads ECG too early after ROSC can misleadingly lead to the diagnosis of STEMI. Despite further validation are required, our data suggest that it may be reasonable to delay the acquisition of the ECG at least 8 minutes after ROSC or to repeat the acquisition if the first ECG, resulting diagnostic for STEMI, was performed very early.

Figure 1

Funding Acknowledgement

Type of funding source: None

Student characteristics, professional preferences, and admission to medical school

Objectives: A potential new avenue to address the shortage of country doctors is to change the rules for admission to medical school. We therefore study the link between high-school grade point average and prospective physicians' choice to work in rural areas. To further inform the discussion about rules for admission, we also study the effects of other predictors: a measure of students' attitudes towards risk; whether they waited for their place of study (Wartesemester); whether their parents worked as medical doctors; and whether they have some practical experience in the medical sector. Methods: We conducted two internet surveys in 2012 and 2014. In the first survey, the sample comprised 701 students and in the second, 474 students. In both surveys, we asked students for their regional preferences; in the 2014 survey, we additionally asked students for their first, second, and third preferences among a comprehensive set of specializations, including becoming a general practitioner. In both surveys, we asked students for basic demographic information (age and gender), their parents' occupation, a measure of subjective income expectations, a measure of risk attitudes, and their high-school grade point average (Abiturnote), and First National Boards Examination grade (Physikum). In 2014, we additionally asked for waiting periods (Wartesemester) as well as for prior professional experience in the health-care sector. Results: We find that three factors increase the probability of having a preference for working in a rural area significantly, holding constant all other influences: having a medical doctor among the parents, having worse grades in the high-school grade point average, and being more risk averse. Moreover, we find that those willing to work in the countryside have significantly more experience in the medical sector before admission to medical school. Discussion: Our results suggest that a change in the selection process for medical school may increase the supply of country doctors. Instead of focusing on the high-school grade point average, universities could even more intensely screen for study motivation through interviews or by taking into account students' background, extracurricular activities, or waiting periods.

Prognosis of Accidental Hypothermia in the Urban Setting

Our goal was to study the outcome and factors affecting outcome in patients with accidental hypothermia in the urban setting. A retrospective cohort study was done on patients admitted to the emergency department with accidental hypothermia (core temperature less than 35°C) from 1991 to 1998. Patients received general intensive care (fluid replacement, mechanical ventilation, cardiopulmonary resuscitation) and were rewarmed actively by intravenous application of warmed fluids, warmed air, pleural lavage, or cardiopulmonary bypass as indicated. Rewarming was successful in 76 of 80 patients (95%) and hospital mortality was 34%. Survivors differed significantly from nonsurvivors with respect to demographic data (indoor finding, homelessness, alcohol abuse, chronic psychiatric disorder, presumed acute alcohol or drug intoxication), findings on admission [severity of hypothermia, systolic blood pressure, heart rate, multiple organ failure (MOF) score, hypothermia outcome score (HOS), BUN, creatinine, CPK, bilirubin, AST, platelet count], but not with respect to therapeutic modalities (mechanical ventilation, volume replacement, pleural lavage, mechanical ventilation, vasopressors, cardiopulmonary bypass). Rewarming time in nonsurvivors, however, was significantly longer. In logistic regression analysis only indoor occurrence, BUN, and platelet count proved to be independent predictors of in-hospital mortality. Survival of patients found outdoors was significantly higher than that of patients found indoors (p < 0.0001). Our study demonstrates that although rewarming and resuscitation are highly effective, accidental urban hypothermia is a condition with a significant in-hospital mortality. There were only a few independent indicators of unfavorable outcome, of which indoor occurrence was by far the most important. Therefore indoor occurrence of hypothermia has to be acknowledged as a risk factor of poor outcome in accidental urban hypothermia.

Knowledge is not enough to solve the problems - The role of diagnostic knowledge in clinical reasoning activities

BACKGROUND

Clinical reasoning is a key competence in medicine. There is a lack of knowledge, how non-experts like medical students solve clinical problems. It is known that they have difficulties applying conceptual knowledge to clinical cases, that they lack metacognitive awareness and that higher level cognitive actions correlate with diagnostic accuracy. However, the role of conceptual, strategic, conditional, and metacognitive knowledge for clinical reasoning is unknown.

METHODS

Medical students (n = 21) were exposed to three different clinical cases and instructed to use the think-aloud method. The recorded sessions were transcribed and coded with regards to the four different categories of diagnostic knowledge (see above). The transcripts were coded using the frequencies and time-coding of the categories of knowledge. The relationship between the coded data and accuracy of diagnosis was investigated with inferential statistical methods.

RESULTS

The use of metacognitive knowledge is correlated with application of conceptual, but not with conditional and strategic knowledge. Furthermore, conceptual and strategic knowledge application is associated with longer time on task. However, in contrast to cognitive action levels the use of different categories of diagnostic knowledge was not associated with better diagnostic accuracy.

CONCLUSIONS

The longer case work and the more intense application of conceptual knowledge in individuals with high metacognitive activity may hint towards reduced premature closure as one of the major cognitive causes of errors in medicine. Additionally, for correct case solution the cognitive actions seem to be more important than the diagnostic knowledge categories.

Home Use of an Artificial Beta Cell in Type 1 Diabetes

BACKGROUND

The feasibility, safety, and efficacy of prolonged use of an artificial beta cell (closed-loop insulin-delivery system) in the home setting have not been established.

METHODS

In two multicenter, crossover, randomized, controlled studies conducted under free-living home conditions, we compared closed-loop insulin delivery with sensor-augmented pump therapy in 58 patients with type 1 diabetes. The closed-loop system was used day and night by 33 adults and overnight by 25 children and adolescents. Participants used the closed-loop system for a 12-week period and sensor-augmented pump therapy (control) for a similar period. The primary end point was the proportion of time that the glucose level was between 70 mg and 180 mg per deciliter for adults and between 70 mg and 145 mg per deciliter for children and adolescents.

RESULTS

Among adults, the proportion of time that the glucose level was in the target range was 11.0 percentage points (95% confidence interval [CI], 8.1 to 13.8) greater with the use of the closed-loop system day and night than with control therapy (P<0.001). The mean glucose level was lower during the closed-loop phase than during the control phase (difference, -11 mg per deciliter; 95% CI, -17 to -6; P<0.001), as were the area under the curve for the period when the glucose level was less than 63 mg per deciliter (39% lower; 95% CI, 24 to 51; P<0.001) and the mean glycated hemoglobin level (difference, -0.3%; 95% CI, -0.5 to -0.1; P=0.002). Among children and adolescents, the proportion of time with the nighttime glucose level in the target range was higher during the closed-loop phase than during the control phase (by 24.7 percentage points; 95% CI, 20.6 to 28.7; P<0.001), and the mean nighttime glucose level was lower (difference, -29 mg per deciliter; 95% CI, -39 to -20; P<0.001). The area under the curve for the period in which the day-and-night glucose levels were less than 63 mg per deciliter was lower by 42% (95% CI, 4 to 65; P=0.03). Three severe hypoglycemic episodes occurred during the closed-loop phase when the closed-loop system was not in use.

CONCLUSIONS

Among patients with type 1 diabetes, 12-week use of a closed-loop system, as compared with sensor-augmented pump therapy, improved glucose control, reduced hypoglycemia, and, in adults, resulted in a lower glycated hemoglobin level. (Funded by the JDRF and others; AP@home04 and APCam08 ClinicalTrials.gov numbers, NCT01961622 and NCT01778348.).

The neuronal extracellular matrix restricts distribution and internalization of aggregated Tau-protein

Alzheimer's disease (AD) is a chronic degenerative disorder characterized by fibrillary aggregates of Aß and Tau-protein. Formation and progression of these pathological hallmarks throughout the brain follow a specific spatio-temporal pattern which provides the basis for neuropathological staging. Previously, we could demonstrate that cortical and subcortical neurons are less frequently affected by neurofibrillary degeneration if they are enwrapped by a specialized form of the hyaluronan-based extracellular matrix (ECM), the so called 'perineuronal net' (PN). PNs are composed of large aggregating chondroitin sulfate proteoglycans connected to a hyaluronan backbone, stabilized by link proteins and cross-linked via tenascin-R. Recently, PN-associated neurons were shown to be better protected against iron-induced neurodegeneration compared to neurons without PN, indicating a neuroprotective function. Here, we investigated the role of PNs in distribution and internalization of exogenous Tau-protein by using organotypic slice cultures of wildtype mice as well as mice lacking the ECM-components aggrecan, HAPLN1 or tenascin-R. We could demonstrate that PNs restrict both distribution and internalization of Tau. Accordingly, PN-ensheathed neurons were less frequently affected by Tau-internalization, than neurons without PN. Finally, the PNs as well as their three investigated components were shown to modulate the processes of distribution as well as internalization of Tau.

Towards a measurement of internalization of collaboration scripts in the medical context - results of a pilot study

Background: Collaboration as a key qualification in medical education and everyday routine in clinical care can substantially contribute to improving patient safety. Internal collaboration scripts are conceptualized as organized - yet adaptive – knowledge that can be used in specific situations in professional everyday life. This study examines the level of internalization of collaboration scripts in medicine. Internalization is understood as fast retrieval of script information.

Goal: The goals of the current study were the assessment of collaborative information, which is part of collaboration scripts, and the development of a methodology for measuring the level of internalization of collaboration scripts in medicine.

Method: For the contrastive comparison of internal collaboration scripts, 20 collaborative novices (medical students in their final year) and 20 collaborative experts (physicians with specialist degrees in internal medicine or anesthesiology) were included in the study. Eight typical medical collaborative situations as shown on a photo or video were presented to the participants for five seconds each. Afterwards, the participants were asked to describe what they saw on the photo or video. Based on the answers, the amount of information belonging to a collaboration script (script-information) was determined and the time each participant needed for answering was measured. In order to measure the level of internalization, script-information per recall time was calculated.

Results: As expected, collaborative experts stated significantly more script-information than collaborative novices. As well, collaborative experts showed a significantly higher level of internalization.

Conclusions: Based on the findings of this research, we conclude that our instrument can discriminate between collaboration novices and experts. It therefore can be used to analyze measures to foster subject-specific competency in medical education.

Improvements in teaching behavior at two German medical schools resulting from a modified Flanders interaction analysis feedback intervention process

Abstract Background: Person-centered teachers who are more empathic and "indirect" (accept, encourage, praise and ask questions) tend to be more effective than those who are "direct" (lecture, give directions and criticize) (Amidon & Flanders 1991). The Flanders Interaction Analysis (FIA) is a tool for diagnosing these teaching aspects, though not yet used to improve lecturing in undergraduate medical education.

AIMS

Does structured expert feedback to volunteer lecturers lead to improvement in person-centered teaching behavior as measured by a Modified Flanders Interaction Analysis (MFIA) and student questionnaires?

METHODS

Twenty-one volunteer lecturers from two German medical faculties were stratified by past teaching experience and randomized into two groups. The intervention group received MFIA diagnoses of their lectures plus feedback by an expert observer after winter and summer semester lectures, respectively. The control group was only diagnosed with the MFIA. Teaching behavior changes for both groups were compared and teacher feedback about the intervention process was assessed.

RESULTS

Faculty in the intervention group improved significantly in their summer lectures regarding person-centered teaching behavior while controls did not.

CONCLUSIONS

A structured individual expert feedback intervention using a MFIA as a teaching diagnostic tool is a powerful, cost-effective faculty development process for improving teaching behavior of volunteer lecturers in undergraduate medical education.

[Successor establishment in familiy business as field of action in health promotion]

Successor establishment in familiy business may lead to interpersonal and intrapsychological conflicts and is mostly a transition to retirement. This may have a negative impact on the senior's health. The "Sozialversicherung für Landwirtschaft, Forsten und Gartenbau (SVLFG)" reacts with an intervention of several days duration. Evaluation aim is measuring participants changes in specific activities and confidence on successor establishment and retirement indicating mental health stabilisation. The method comprises a panel of intervention group (I, n=61) and comparison group (V, n=28) randomly selected, structurally similar and parallelised to point of transfer. Retirement activities significantly rise in I (p=0.001, Cohen's d=0.48) and are steady in V (p=0.54) after one year. Level of confidence is equal in both groups and steady but strongly indicating response shift in I. Intervention activates targeted activities and improves confidence at least qualitatively in a field that has hardly been researched.

Cognitive problem solving patterns of medical students correlate with success in diagnostic case solutions

Context

Problem-solving in terms of clinical reasoning is regarded as a key competence of medical doctors. Little is known about the general cognitive actions underlying the strategies of problem-solving among medical students. In this study, a theory-based model was used and adapted in order to investigate the cognitive actions in which medical students are engaged when dealing with a case and how patterns of these actions are related to the correct solution.

Methods

Twenty-three medical students worked on three cases on clinical nephrology using the think-aloud method. The transcribed recordings were coded using a theory-based model consisting of eight different cognitive actions. The coded data was analysed using time sequences in a graphical representation software. Furthermore the relationship between the coded data and accuracy of diagnosis was investigated with inferential statistical methods.

Results

The observation of all main actions in a case elaboration, including evaluation, representation and integration, was considered a complete model and was found in the majority of cases (56%). This pattern significantly related to the accuracy of the case solution (φ = 0.55; p<.001). Extent of prior knowledge was neither related to the complete model nor to the correct solution.

Conclusions

The proposed model is suitable to empirically verify the cognitive actions of problem-solving of medical students. The cognitive actions evaluation, representation and integration are crucial for the complete model and therefore for the accuracy of the solution. The educational implication which may be drawn from this study is to foster students reasoning by focusing on higher level reasoning.

Learning the facts in medical school is not enough: which factors predict successful application of procedural knowledge in a laboratory setting?

BACKGROUND

Medical knowledge encompasses both conceptual (facts or "what" information) and procedural knowledge ("how" and "why" information). Conceptual knowledge is known to be an essential prerequisite for clinical problem solving. Primarily, medical students learn from textbooks and often struggle with the process of applying their conceptual knowledge to clinical problems. Recent studies address the question of how to foster the acquisition of procedural knowledge and its application in medical education. However, little is known about the factors which predict performance in procedural knowledge tasks. Which additional factors of the learner predict performance in procedural knowledge?

METHODS

Domain specific conceptual knowledge (facts) in clinical nephrology was provided to 80 medical students (3rd to 5th year) using electronic flashcards in a laboratory setting. Learner characteristics were obtained by questionnaires. Procedural knowledge in clinical nephrology was assessed by key feature problems (KFP) and problem solving tasks (PST) reflecting strategic and conditional knowledge, respectively.

RESULTS

Results in procedural knowledge tests (KFP and PST) correlated significantly with each other. In univariate analysis, performance in procedural knowledge (sum of KFP+PST) was significantly correlated with the results in (1) the conceptual knowledge test (CKT), (2) the intended future career as hospital based doctor, (3) the duration of clinical clerkships, and (4) the results in the written German National Medical Examination Part I on preclinical subjects (NME-I). After multiple regression analysis only clinical clerkship experience and NME-I performance remained independent influencing factors.

CONCLUSIONS

Performance in procedural knowledge tests seems independent from the degree of domain specific conceptual knowledge above a certain level. Procedural knowledge may be fostered by clinical experience. More attention should be paid to the interplay of individual clinical clerkship experiences and structured teaching of procedural knowledge and its assessment in medical education curricula.

A survey on visual information search behavior and requirements of radiologists

OBJECTIVES

The main objective of this study is to learn more on the image use and search requirements of radiologists. These requirements will then be taken into account to develop a new search system for images and associated meta data search in the Khresmoi project.

METHODS

Observations of the radiology workflow, case discussions and a literature review were performed to construct a survey form that was given online and in paper form to radiologists. Eye tracking was performed on a radiology viewing station to analyze typical tasks and to complement the survey.

RESULTS

In total 34 radiologists answered the survey online or on paper. Image search was mentioned as a frequent and common task, particularly for finding cases of interest for differential diagnosis. Sources of information besides the Internet are books and discussions with colleagues. Search for images is unsuccessful in around 25% of the cases, stopping the search after around 10 minutes. The most common reason for failure is that target images are considered rare. Important additions for search requested in the survey are filtering by pathology and modality, as well as search for visually similar images and cases. Few radiologists are familiar with visual retrieval but they desire the option to upload images for searching similar ones.

CONCLUSIONS

Image search is common in radiology but few radiologists are fully aware of visual information retrieval. Taking into account the many unsuccessful searches and time spent for this, a good image search could improve the situation and help in clinical practice.

Realisation of the guidelines for faculty-internal exams at the Department of General Medicine at the University of Munich: Pushing medical exams one step ahead with IMSm

Graded exams are prerequisites for the admission to the medical state examination. Accordingly the exams must be of good quality in order to allow benchmarking with the faculty and between different universities. Criteria for good quality need to be considered - namely objectivity, validity and reliability. The guidelines for the processing of exams published by the GMA are supposed to help maintaining those criteria. In 2008 the Department of General Medicine at the University of Munich fulfils only 14 of 18 items. A review process, appropriate training of the staff and the introduction of the IMSm software were the main changes that helped to improve the ‘GMA-score’ to 30 fulfilled items. We see the introduction of the IMSm system as our biggest challenge ahead. IMSm helps to streamline the necessary workflow and improves their quality (e.g. by the detection of cueing, item analysis). Overall, we evaluate the steps to improve the exam process as very positive. We plan to engage co-workers outside the department to assist in the various review processes in the future. Furthermore we think it might be of value to get into contact with other departments and faculties to benefit from each other’s question pools.

Acute hemoptysis and pulmonary hemorrhage after judo as presentation of intralobar sequestration

Intralobar sequestration (ILS) is a rare anomaly that is usually diagnosed with symptoms of cough, expectoration, or recurrent pneumonia in children. We experienced a case of an 11-year-old boy with massive hemoptysis after judo sports. He was admitted to hospital and intubated due to respiratory failure. His chest computed tomography (CT) scan which was performed without contrast agent revealed a large intrapulmonary hematoma or tumor, mimicking traumatic hemothorax. Due to blood loss and circulatory instability, emergency thoracotomy was performed and a massive intralobar hemorrhage due to a ruptured ILS artery was found. After lobectomy including resection of the ILS, the patient was stabilized and extubated. Aspergillus was detected in the resected lobe and postoperatively acute respiratory distress syndrome (ARDS) and invasive aspergillosis occurred and was treated specifically. However, the young patient was discharged home 3 weeks later. In young patients with hemoptysis and intrapulmonary hemorrhage after trauma, the possibility of ruptured ILS should be kept in mind. This report shows that ILS can have a dramatic course of disease, and for this reason a nonurgent resection should be considered in all patients when this diagnosis is made.

Using electronic flashcards to promote learning in medical students: retesting versus restudying

CONTEXT

The superiority of retesting over restudying in terms of knowledge retention and skills acquisition has been proven in both laboratory and classroom settings, as well as in doctors' practice. However, it is still unclear how important retesting strategies are to the learning of relevant factual knowledge in undergraduate medical education.

METHODS

Eighty students in Years 3-5 of medical school in Munich participated in a prospective, randomised, double-blinded, controlled study in which they were exposed to 30 electronic flashcards designed to help them memorise key factual knowledge in the domain of clinical nephrology. The flashcards were presented in four successive learning cycles, each consisting of a study period and a subsequent test period. Half of all participants were randomised to repetitive studying (restudy group) and half were randomised to repetitive testing (retest group) of successfully memorised flashcards. Knowledge retention was assessed after 1 week and 6 months. Additionally, personal data, self-reflection on the efficacy of the learning strategies and judgements of learning were obtained by questionnaires.

RESULTS

Repetitive testing promoted better recall than repetitive studying after 1 week (p<0.001). However, after 6 months general recall was poor and no difference between the restudy and retest groups was observed. Time on task and number of trials, in addition to sex, age, performance and psycho-social background, did not vary between the groups. Self-predictions of student performance did not correlate with actual performance.

CONCLUSIONS

In the context of using electronic flashcards, repetitive testing is a more potent learning strategy than repetitive studying for short-term but not long-term knowledge retention in clinical medical students. Although students use testing as a learning strategy, they seem to be unaware of its superiority in supporting short-term knowledge retention.

Evaluation of effectiveness of instruction and study habits in two consecutive clinical semesters of the medical curriculum Munich (MeCuM) reveals the need for more time for self study and higher frequency of assessment

BACKGROUND

Seven years after implementing a new curriculum an evaluation was performed to explore possibilities for improvements.

PURPOSES

To analyze students' study habits in relation to exam frequency and to evaluate effectiveness of instruction.

METHODS

Time spent on self study (TSS) and the quantity of instruction (QI) was assessed during the internal medicine and the surgical semester. Students and faculty members were asked about study habits and their evaluation of the current curriculum.

RESULTS

The TSS/QI ratio as a measure of effectiveness of instruction ranges mainly below 1.0 and rises only prior to exams. Students and teachers prefer to have multiple smaller exams over the course of the semester. Furthermore, students wish to have more time for self-guided study.

CONCLUSIONS

The TSS/QI ratio is predominantly below the aspired value of 1.0. Furthermore, the TSS/QI ratio is positively related to test frequency. We therefore propose a reduction of compulsory lessons and an increase in test frequency.

Pick-N multiple choice-exams: a comparison of scoring algorithms

To compare different scoring algorithms for Pick-N multiple correct answer multiple-choice (MC) exams regarding test reliability, student performance, total item discrimination and item difficulty. Data from six 3rd year medical students' end of term exams in internal medicine from 2005 to 2008 at Munich University were analysed (1,255 students, 180 Pick-N items in total). Scoring Algorithms: Each question scored a maximum of one point. We compared: (a) Dichotomous scoring (DS): One point if all true and no wrong answers were chosen. (b) Partial credit algorithm 1 (PS(50)): One point for 100% true answers; 0.5 points for 50% or more true answers; zero points for less than 50% true answers. No point deduction for wrong choices. (c) Partial credit algorithm 2 (PS(1/m)): A fraction of one point depending on the total number of true answers was given for each correct answer identified. No point deduction for wrong choices. Application of partial crediting resulted in psychometric results superior to dichotomous scoring (DS). Algorithms examined resulted in similar psychometric data with PS(50) only slightly exceeding PS(1/m) in higher coefficients of reliability. The Pick-N MC format and its scoring using the PS(50) and PS(1/m) algorithms are suited for undergraduate medical examinations. Partial knowledge should be awarded in Pick-N MC exams.

[The motivation to become a medical doctor - doctoral students in a formal academic study program compared with those pursuing their doctorate independently]

BACKGROUND AND OBJECTIVE

Weight and quality of medical doctoral theses have been discussed in Germany for years. Doctoral study programs in various graduate schools offer opportunities to improve quality of medical doctoral theses. The purpose of this study was to demonstrate distinctions and differences concerning motivation, choice of subject and the dissertation process between doctoral candidates completing the doctoral seminar for doctoral students in the Ludwig-Maximilians-University (LMU) Munich and doctoral candidates doing their doctorate individually.

METHODS

All 4000 medical students of the LMU obtained an online-questionnaire which was completed by 767 students (19 % response rate). The theoretical framework of this study was based upon the Self-Determination-Theory by Deci and Ryan.

RESULTS

Doctoral candidates completing the doctoral study program were more intrinsically motivated than doctoral candidates doing their doctorate individually; no difference was found in their extrinsic motivation. In regard to choice of subject and dissertation process the doctoral students in the seminar were distinguished from the individual group by having chosen a more challenging project. They anticipated a demanding dissertation process including conference participation, publishing of papers, etc. Intrinsic motivation correlates positively with choosing a challenging project and a demanding dissertation process.

CONCLUSION

High intrinsic motivation seems to be very important for autonomous scholarly practice. Our results suggest that doctoral study programs have a positive impact on intrinsic motivation and interest in research.

Using the Progress Test Medizin (PTM) for evaluation of the Medical Curriculum Munich (MeCuM)

Aims: The Medical Curriculum Munich (MeCuM) has been implemented since 2004 and was completely established in 2007. In this study the clinical part of MeCuM was evaluated with respect to retention of the knowledge in internal medicine (learning objectives of the 6th/7th semester).

Methods: In summer of 2009 and winter of 2009/2010 1065 students participated in the Progress Test Medizin (PTM) from Charité Medical School Berlin. Additionally the students answered a questionnaire regarding the acceptance and rating of the progress test and basic demographic data.

Results: The knowledge of internal medicine continuously increases during the clinical part of the medical curriculum in Munich. However, significant differences between the sub-disciplines of internal medicine could be observed. The overall acceptance of the PTM was high and increased further with the study progress. Interestingly, practical experiences like clinical clerkships positively influenced the test score.

Conclusions: The PTM is a useful tool for the evaluation of knowledge retention in a specific curriculum.