人体解剖教学与临床结合初探

为配合解剖教学改革,解剖学系在教学中提出了人体解剖教学与临床全方位结合的教学体系,通过转变教学理念、调整教学安排、实行多样化教学方式和与国外一流医学院校交流等措施,并开展了“面向临床的解剖学讲座”,不仅巩固了解剖学教学内容,还强调了所学知识在临床中的应用,初步取得了良好的效果.     

人体解剖学workshop教学实践

为了激发学习兴趣、提高教学质量,人体解剖学引入workshop教学模式。根据课程教学计划有系统的阶段性安排workshop教学,每次由1个解剖小组与临床带教老师合作,在标本上完成1个常见的临床模拟手术操作,以加深对局部解剖结构的理解。经过几年时间的探索和试验,workshop教学实践现在已经正式成为人体解剖学教学的一部分,成为一种新的教学模式,受到学生们的普遍欢迎。     

An innovative approach to remedial continuing medical education, 1992-2002.

The authors describe the process of remedial retraining programs organized and planned for Quebec physicians by the College des medecins du Quebec (CMQ) and report the outcomes of these efforts from April 1992 to March 2002. The CMQ (the Quebec medical licensing authority) developed a process to identify physicians who had shortcomings in their clinical performance, determine their educational needs, propose, in collaboration with the four medical schools in the province, personalized retraining programs (clinical training programs, tutorials, focused readings, workshops, and refresher courses), and subsequently evaluate the impact of these retraining programs. During the ten-year period reported, 305 physicians (216 family physicians and 89 specialists) were referred to the Practice Enhancement Division of the CMQ for personalized remedial retraining. The vast majority of these physicians were men (81%). The following difficulties were identified: therapeutic knowledge (37%), diagnostic knowledge (32%), record-keeping (14%), technical skills (10%), clinical judgment (5%), and communication skills (2%). A total of 329 personalized retraining programs were completed: 273 clinical training programs, 41 tutorials, and 15 focused readings. A reevaluation of all these physicians showed that 70% of the retraining programs had succeeded, 15% were partially successful and only 13% had failed. The remaining 2% involved missing data or withdrawal of physicians. The authors conclude that the collaborative CME process described has important and effective original features.     

Weaving basic and social sciences into a case-based, clinically oriented medical curriculum: one school's approach.

Southern Illinois University School of Medicine recently completed its fourth year of a resource-session-enhanced, case-based, tutor-group-oriented curriculum. As an example of a curricular unit, the authors describe the implementation of the basic and clinical sciences in one of the four units in year one, and detail that unit's organization, logistics, content, rationale, and other characteristics. The Sensorimotor Systems and Behavior (SSB) unit is preceded by a cardio-respiratory-renal unit and is followed by an endocrine-reproductive-gastrointestinal unit. A Doctoring unit temporally spans each of these three units. The SSB unit is allotted an 11.5-week period that includes an aggregate of 2.5 weeks of available clinical time, 1.5 weeks for examinations and exam study time, and approximately 8.5 weeks for tutor-group sessions, mandatory laboratory sessions, and self-directed learning. Optional resource sessions are offered during a two- to four-hour block on a single morning each week. Clinical training in the SSB unit augments self-directed, laboratory, and tutor-group learning of neuroscience, gross anatomy, cell biology, physiology, biochemistry, behavioral and social science, embryology, limited pharmacology and genetics, and basic clinical neurology for first-year students. Although it is fast-paced and places heavy responsibility for independent learning on the students, the SSB unit culminates in significant achievement in the basic and clinical sciences. The unit provides substantial clinical training and practical experience in physical and neurological examinations that directly integrate with basic science knowledge. The unit reduces lecture-based instruction, demands self-determination, and promotes experience in team effort, professionalism, peer interaction, empathy in clinical medicine, and practical use of basic science knowledge.     

The Clinical Education Partnership Initiative: an innovative approach to global health education

Background

Despite evidence that international clinical electives can be educationally and professionally beneficial to both visiting and in-country trainees, these opportunities remain challenging for American residents to participate in abroad. Additionally, even when logistically possible, they are often poorly structured. The Universities of Washington (UW) and Nairobi (UoN) have enjoyed a long-standing research collaboration, which recently expanded into the UoN Medical Education Partnership Initiative (MEPI). Based on MEPI in Kenya, the Clinical Education Partnership Initiative (CEPI) is a new educational exchange program between UoN and UW. CEPI allows UW residents to partner with Kenyan trainees in clinical care and teaching activities at Naivasha District Hospital (NDH), one of UoN’s MEPI training sites in Kenya.

Methods

UW and UoN faculty collaborated to create a curriculum and structure for the program. A Chief Resident from the UW Department of Medicine coordinated the program at NDH. From August 2012 through April 2014, 32 UW participants from 5 medical specialties spent between 4 and 12 weeks working in NDH. In addition to clinical duties, all took part in formal and informal educational activities. Before and after their rotations, UW residents completed surveys evaluating clinical competencies and cross-cultural educational and research skills. Kenyan trainees also completed surveys after working with UW residents for three months.

Results

UW trainees reported a significant increase in exposure to various tropical and other diseases, an increased sense of self-reliance, particularly in a resource-limited setting, and an improved understanding of how social and cultural factors can affect health. Kenyan trainees reported both an increase in clinical skills and confidence, and an appreciation for learning a different approach to patient care and professionalism.

Conclusions

After participating in CEPI, both Kenyan and US trainees noted improvement in their clinical knowledge and skills and a broader understanding of what it means to be clinicians. Through structured partnerships between institutions, educational exchange that benefits both parties is possible.

     

A new and clinically symptomatic variant of thyroid cartilage anatomy

We present a previously undescribed variation in the anatomy of the superior cornu of the thyroid cartilage. In the five cases described, the tip of the cornu turned medially and caused an indentation into the pharynx. These indentations were symptomatic and caused pain and globus sensation. Resection of them led to resolution of the symptoms. A survey of the incidence of this variation of the thyroid cartilage in a clinic population is presented.     

Cleveland Clinic Lerner College of Medicine: an innovative approach to medical education and the training of physician investigators.

Cleveland Clinic Lerner College of Medicine (CCLCM) is an innovative, five-year medical education track within Case Western Reserve University School of Medicine (Case) with a focused mission to attract and educate a limited number of highly qualified persons who seek to become physician investigators. CCLCM curriculum governance, faculty appointments and promotions, and admissions committees are integrated with respective Case committees. The CCLCM curriculum is based on faculty-defined professional attributes that graduates are expected to develop. These attributes were used to create curricular and assessment principles that guided the development of an integrated basic science, clinical science, and research curriculum, conducted in an active learning environment. An organ-system approach is used to solidify an understanding of basic science discipline threads in the context of relevant clinical problems presented in PBL and case-based discussion formats. Clinical skills are introduced in the first year as part of the two-year longitudinal experience with a family practice or internal medicine physician. The research program provides all students with opportunities to learn and experience basic and translational research and clinical research before selecting a research topic for their 12- to 15-month master-level thesis project. All Case students participate in required and elective clinical curriculum after the second year, but CCLCM students return to the Cleveland Clinic on selected Friday afternoons for program-specific research and professionalism-learning activities. A unique portfolio-based assessment system is used to assess student achievements in nine competency areas, seven of which reflect the Accreditation Council for Graduate Medical Education competencies.     

An innovative approach to supplement the teaching of the spatial gross anatomy relationships of muscles to undergraduates in health sciences

Satisfactory assessment of the musculoskeletal disorders in patients by health professionals, followed by diagnosis, treatment, and referral require a good understanding of spatial and three-dimensional (S&3D) anatomy of musculature. Meanwhile, the importance and impact of S&3D learning has been underscored. A novel method to promote S&3D skills in the learning of the musculature of the upper and lower limb was developed, and subsequently evaluated among 120 first-year Physiotherapy and Occupational Therapy undergraduate students at the University of Cape Town. Outlines of human muscles were mapped onto A4 papers, digitalized into a 22-page electronic document, labeled with anatomical details, and printed out. Each student was given a copy to cut out the diagrams and paste them correctly onto adult skeletons using Prestik, in what was called the muscle cut-out exercise (MCOE), just prior to each dissection practical. A questionnaire evaluating the MCOE was developed and 56 students responded. The students "strongly agreed" that the MCOE was useful in teaching them the spatial perspective of the human musculature. Forty-nine percent of the students felt that the size of the diagrams did not always match the skeletons due to variable sizes of the skeletons and 27% suggested the use of color as a means of enhancing the diagrams. The MCOE is a low-cost, enjoyable, time-efficient, easily reproducible, and hands-on practical learning experience.     

Dropping out of substance abuse treatment: A clinically oriented review

Early attrition from substance abuse treatment is very high, although rates do not differ dramatically from those found in medical and psychiatric treatments. The consequences of substance abuse treatment dropout are severe, however, with early dropouts having the same outcome as untreated clients. Evidence is considered regarding the impact of demographic and social variables on continuation in treatment. The effects of client motivation, substance use, criminality and legal pressure, prior treatment history, and psychopathology are also examined. An analysis of treatment factors and procedures used to enhance retention indicates that more conveniently located, smaller, decentralized clinics, with higher clinical staff ratios and more per capita expenditures, have lower attrition rates. Clients are also likely to continue in treatment longer when they receive rapid initial response and individual attention, and when they are seen in smaller groups in friendly, comfortable environments. Inexpensive techniques such as reminder phone calls and personal letters can be employed in the absence of resources needed to mount more extensive attrition prevention interventions.     

A new clinically relevant approach to expand myelin specific T cells

Human self-reactive T cells are potentially involved in many autoimmune diseases. Although ex vivo detection of self-reactive T cells is possible, exhaustive functional characterization of these cells is impeded by their low frequency. In vitro expansion of antigen (Ag) specific T cells is typically achieved by using autologous (fresh or frozen) irradiated peripheral blood mononuclear cells (PBMCs), EBV-immortalized B cells or dendritic cells in the presence of Ag. These approaches require a large blood volume. We explored a method successfully applied for tumor specific T cells using in vitro expanded autologous B cells. PBMCs were stimulated with irradiated CD40L-expressing fibroblasts and IL-4, resulting in an enriched population of B cell that expressed high levels of MHC and co-stimulatory molecules, essential hallmarks of antigen presenting cells (APCs). Expanded B cells were loaded with Ag, irradiated and then used as APCs to stimulate T cells. The specificity of T cell lines was assessed by comparing their proliferation and IFN-γ secretion when cultured with antigen-loaded B cells vs. unloaded B cells. T cell lines exhibiting antigen-specific proliferation and/or IFN-γ secretion were expanded. Using this method, MBP and MOG specific CD4⁺ and CD8⁺ T cell lines were obtained from multiple donors in comparable numbers to those obtained using the traditional approach (i.e. fresh PBMCs as APCs) and were kept in culture for many weeks. We have shown that myelin specific CD4⁺ and CD8⁺ T cells can be expanded from a relatively small volume of blood (50–100 ml) from multiple donors using expanded B cells as APCs.     

A unique therapeutic approach to emesis and itch with a proanthocyanidin-rich genonutrient

Background

We examined the therapeutic potential of a proprietary Croton palanostigma extract (Zangrado^®) in the management of emesis and itch.

Methods

Emesis was induced in ferrets with morphine-6-glucuronide (0.05 mg/kg sc) in the presence of Zangrado (3 mg/kg, ip) and the cannabinoid receptor 1 antagonist, AM 251 (5 mg/kg, ip). Topical Zangrado (1%) was assessed for anti-pruretic actions in the 5-HT-induced scratching model in rats and evaluated in capsaicin-induced gastric hyperemia as measured by laser doppler flow. In the Apc ^Min mouse model of precancerous adenomatosis polyposis, mice received Zangrado (100 μg/ml in drinking water) from the age of 6 – 16 weeks for effects on polyp number. In RAW 264.7 cells Zangrado was examined for effects on lipopolysaccharide-induced nitrite production.

Results

Zangrado was a highly effective anti-emetic, reducing morphine-induced vomiting and retching by 77%. These benefits were not associated with sedation or hypothermia and were not reversed by cannabinoid receptor antagonism. Itch responses were blocked in both the morphine and 5-HT models. Zangrado did not exacerbate the Apc ^Min condition rather health was improved. Capsaicin-induced hyperemia was blocked by Zangrado, which also attenuated the production of nitric oxide by activated macrophages.

Conclusion

Zangrado is an effective anti-emetic and anti-itch therapy that is devoid of common side-effects, cannabinoid-independent and broadly suppresses sensory afferent nerve activation. This complementary medicine represents a promising new approach to the management of nausea, itch and irritable bowel syndrome.

     

Functionally oriented and clinically feasible quantitative gait analysis method

A protocol for clinical gait analysis is described, and data from 30 normal adult female subjects are presented. Extensive application to pathologic subjects has proven to be feasible and sufficiently accurate. The method is based on a particular location and attachment of retro-reflective markers on the body and on a particular arrangement of four TV cameras. A motion analyser measures the 3D coordinates of each marker. A modelling approach, based on individual anthropometric measurements, and a functional approach, based on kinematical considerations, are used to estimate the location of hip, knee, and ankle joint centers and the orientation of the flexion-extension axis of the knee. 3D relative and absolute movements of pelvis and lower limbs are obtained and shown to be consistent with functional anatomy.     

An ecologically oriented approach to youth deviance

In recent years the social problems of youth have been described in terms of delinquency and alienation. Social intervention programs with youth, however, have tended to focus only on the overt disruptive behavior of delinquency. These programs have been disappointingly unsuccessful, perhaps because of their overly narrow conceptual orientation. This paper reviews some of the major theories of delinquency from an ecological perspective, and relates them to an ecological view of alienation. The result is a preliminary sketch of an ecological theory of social satisfaction. It is proposed that common mechanisms underlie alienation and delinquency as negative socialization outcomes as well as penetration, integration, and achieved success as positive socialization outcomes. Some implications of this idea for understanding the behavior of youth are discussed.     

Clinical academies: innovative school-health services partnerships to deliver clinical education.

During the past five years (2001-2006), the University of Bristol Medical School has developed and implemented a new model for delivering clinical education: the clinical academy. The principal features of the model are (1) having both in-Bristol and out-of-Bristol campuses for clinical education, (2) innovative partnerships with local health care providers, (3) local leadership of educational delivery, and (4) the recruitment and training of new cadres of clinical teachers.The seven clinical academies consist of two academies based in traditional acute-care teaching hospitals in the city of Bristol and five academies in the surrounding counties. The same Bristol curriculum is delivered in every clinical academy by locally recruited hospital specialists and family physicians. Each academy is led by an academy medical dean, who has local responsibility for program delivery, quality assurance, academic and personal support for students, and finances on behalf of the university.Medical students rotate between clinical academies every half academic year, alternately based in and outside of Bristol. They learn clinical medicine and develop clinical competence as apprentice members of a local multiprofessional learning community. The medical school now has enough high-quality clinical placements to accommodate increasing numbers of medical students whilst keeping a "human-scale" educational environment.Clinical academies are thus the key components of a decentralized system of curriculum delivery; they differ in concept and purpose from the new academies of medical educators in the United States that offer a centralized focus for the educational mission.