Transition from Longitudinal to Block Structure of Preclinical Courses: Outcomes and Experiences

Aim

To evaluate the transition from a longitudinal to block/modular structure of preclinical courses in a medical school adapting to the process of higher education harmonization in Europe.

Methods

Average grades and the exam pass rates were compared for 11 preclinical courses before and after the transition from the longitudinal (academic years 1999/2000 to 2001/2002) to block/modular curriculum (academic years 2002/2003 to 2004/2005) at Zagreb University School of Medicine, Croatia. Attitudes of teachers toward the 2 curriculum structures were assessed by a semantic differential scale, and the experiences during the transition were explored in focus groups of students and teachers.

Results

With the introduction of the block/modular curriculum, average grades mostly increased, except in 3 major courses: Anatomy, Physiology, and Pathology. The proportion of students who passed the exams at first attempt decreased in most courses, but the proportion of students who successfully passed the exam by the end of the summer exam period increased. Teachers generally had more positive attitudes toward the longitudinal (median [C]±intequartile range [Q], 24 ± 16) than block/modular curriculum (C±Q, 38 ± 26) (P = 0.001, Wilcoxon signed rank test). The qualitative inquiry indicated that the dissatisfaction of students and teachers with the block/modular preclinical curriculum was caused by perceived hasty introduction of the reform under pressure and without much adaptation of the teaching program and materials, which reflected negatively on the learning processes and outcomes.

Conclusion

Any significant alteration in the temporal structure of preclinical courses should be paralleled by a change in the content and teaching methodology, and carefully planned and executed in order to achieve better academic outcomes.The adoption of the Bologna Declaration on the European Higher Education Area in 1999 (1) initiated a wave of curriculum reforms at universities across Europe (2). The process of modernization of higher education supported by the European Commission has begun in countries surrounding the European Union even earlier, in the beginning of 1990s, and has since expanded to a total of 27 countries, including some in Central Asia, North Africa, and Middle East (3). Medical schools joined the process at a slower pace (4), taking into account their specifics, such as costliness of medical education and the long, one-tier structure of medical curricula (5). Changes in the curriculum design mostly related to the integration of preclinical and clinical courses and the introduction of problem-based learning (PBL) (6).While an increasing number of European medical schools accepted a combination of subject-based and integrated problem-based approaches (6), medical schools in the Southeast Europe mostly retained the traditional curricula with Anatomy, Physiology, and Pathology as dominant courses in the first 3 years of medical study (7). The School of Medicine at the University of Zagreb, Croatia, was the only school in the region delivering some case-based modules with a degree of integration, but only in the last (clinical) year of the study (7). Despite the expected reluctance of the teaching staff to accept reforms of the curriculum (8), the leadership of the Zagreb University School of Medicine decided in 2001 to change the structure of preclinical courses in the first 3 years of study from the longitudinal, spread-out form to block/modular form. Clinical courses in the last 3 years of study had already been taught in blocks. The change in the structure of preclinical courses was intended to be the first step in a broader process of the curriculum reform initiated and conducted in cooperation with the Harvard Medical International and the Ludwig Maximilian University from Munich, Germany (9) and a part of the general modernization of medical curricula in Croatia (10).Many reports have dealt with the curricular reforms in medical schools, mostly describing the introduction of PBL (11,12) and integration of preclinical and clinical courses (13). Previous studies have compared PBL and traditional curriculum (14,15), PBL and a hybrid form of curriculum (16,17), or PBL and some other type of interactive learning (18). No study has yet explored the effects of the transition from the longitudinal to block/modular structure of preclinical courses, without any other substantial change in the curriculum design or content. The case of University of Zagreb School of Medicine is representative of adjusting traditional curriculum to the requirements of the Bologna Process doing the least changes possible. As this phenomenon may occur in other medical schools, especially in the Southeast Europe, it is important to explore its effects and the related experiences of all involved educational actors.The first aim of our study was to compare the outcomes of 2 curriculum structures (the longitudinal vs block/modular) in the preclinical years of medical study and to identify their advantages and drawbacks. The second aim was to assess the attitudes of the teaching staff toward the longitudinal and block/modular form of teaching.     

Osteolytic lesions marker in multiple myeloma

The degradation product of collagen type I carboxy terminal telopeptide (ICTP) represents a new biochemical parameter that reflects the changes in the resorption properties of skeletal system. Affection of the skeleton is one of the most important characteristics of multiple myeloma (MM). We estimated significance of ICTP as osteolysis predictor and overall survival in comparison with standard prognostic parameters β₂-microglobulin and C-reactive protein (CRP), in patients with MM. With our results, we have shown significant difference in serum level of ICTP (P = 0.009) between patients with and without osteolysis on conventional radiography. It was proved that ICTP is the most significant predictor of osteolysis (P = 0.09), while CRP is the most significant risk factor for overall survival (P < 0.01). Being highly significant predictor of osteolysis, ICTP can be used for identification of patients with MM who had increased risk for developing osteolytic lesions.     

Divergent Squamous Differentiation in Upper Urothelial Carcinoma—Comparative Clinicopathological and Molecular Study

Upper urothelial carcinoma (UUC) has a plasticity to demonstrate divergent differentiation with squamous metaplastic elements. There was no previous study exploring profiling of molecular markers in metaplastic squamous upper urothelial carcinoma (SUUC) and conventional upper urothelial carcinoma (CUUC). The aims of this study was to compare expression of the phenotypic characteristics of tumors and molecular markers (p53, p16, cyclin D1, E-cadherin, HER-2, Ki-67, Bcl-2, Bax) in SUUC and CUUC. SUUC was detected in 20% of 44 patients. There was significant difference between SUUC and CUUC in the pathological stage, grade, growth and presence of lymphovasular invasion (p < 0.05; 0.05; 0.05; 0.01 respectively). The mean Ki-67 and p53 labeling index was significantly higher in SUUC than in CUUC (p < 0.05; 0.05). There was no significant difference in the expression of p16, cyclin D1, E-cadherin, HER-2, Bcl-2 and Bax between SUUC and CUUC. Univariant model showed that SUUC was significantly associated with lymphovascular invasion (p = 0.007), Ki-67 activity (p = 0.016) and growth (p = 0.026). Exploration of UUC with squamous divergent differentiation showed changes in phenotypic characteristics and Ki-67, as well as similar molecular profile with CUUC.     

Isolation and structure determination of oxidative degradation products of atorvastatin

Methods were developed for the preparation and isolation of four oxidative degradation products of atorvastatin. ATV-FX1 was prepared in the alkaline acetonitrile solution of atorvastatin with the addition of hydrogen peroxide. The exposition of aqueous acetonitrile solution of atorvastatin to sunlight for several hours followed by the alkalization of the solution with potassium hydroxide to pH 8–9 gave ATV-FXA. By the acidification of the solution with phosphoric acid to pH 3 ATV-FXA1 and FXA2 were prepared. The isolation of oxidative degradation products was carried out on a reversed-phase chromatographic column Luna prep C18(2) 10 μm applying several separation steps. The liquid chromatography coupled with a mass spectrometer (LC-MS), high resolution MS (HR-MS), 1D and 2D NMR spectroscopy methods were applied for the structure elucidation. All degradants are due to the oxidation of the pyrrole ring. The most probable reaction mechanism is intermediate endoperoxide formation with subsequent rearrangement and nucleophilic attack by the 5-hydroxy group of the heptanoic fragment. ATV-FX1 is 4-[1b-(4-Fluoro-phenyl)-6-hydroxy-6-isopropyl-1a-phenyl-6a-phenylcarbamoyl-hexahydro-1,2-dioxa-5a-aza-cyclopropa[a]inden-3-yl]-3-(R)-hydroxy-butyric acid and has a molecular mass increased by two oxygen atoms with regard to atorvastatin. ATV-FXA is the regioisomeric compound, 4-[6-(4-Fluoro-phenyl)-6-hydroxy-1b-isopropyl-6a-phenyl-1a-phenylcarbamoyl-hexahydro-1,2-dioxa-5a-aza-cyclopropa[a]inden-3-yl]-3-(R)-hydroxy-butyric acid. Its descendants ATV-FXA1 and FXA2 appeared without the atorvastatin heptanoic fragment and are 3-(4-Fluoro-benzoyl)-2-isobutyryl-3-phenyl-oxirane-2-carboxylic acid phenylamide and 4-(4-Fluoro-phenyl)-2,4-dihydroxy-2-isopropyl-5-phenyl-3,6-dioxa-bicyclo[3.1.0]hexane-1-carboxylic acid phenylamide, respectively. Quantitative NMR spectroscopy was employed for the assay determination of isolated oxidative degradation products. The results obtained were used for the determination of the UV response factors relative to atorvastatin.     

Effects of ghrelin on the feeding behavior of Lymantria dispar L. (Lymantriidae) caterpillars

Ghrelin is a 28-amino acid peptide which has significant effects on animal appetite, thus influencing body mass. The aim of our study was to examine the effects of ghrelin on the feeding behavior and physiology 4th instar caterpillars of the pest insect, Lymantria dispar L. Treatment of 4th instar caterpillars with four subpicomolar amounts of ghrelin had a positive influence on daily food intake, frass elimination, body mass. Also, locomotor activity increased, while stadium duration decreased in treated caterpillars. The similarity between the effects of ghrelin on caterpillar physiology and those in mammals suggests that using this model system for further studies of neuroendocrinological processes underlying feeding could lead to essential information about more complex organisms.     

Removal of tracheobronchial foreign bodies in adults using flexible bronchoscopy: experience 1995–2006

Background  Tracheobronchial foreign body (TFB) removal in adult patients using the combined technique of flexible bronchoscopy (FBSC) through the endotracheal tube as well as using the simple FBSC has not often been described. This study reports our experience with FBSC for removal of TFBs and describes diagnosis, techniques of removal, and types of TFBs. Methods  We retrospectively examined bronchoscopic records of adult patients performed between 1995 and 2006 and collection of foreign bodies in Clinical Department for Respiratory Diseases, University Hospital Split, Croatia. Results  TFBs were found in 86 (0.33%) out of 26,124 patients who were submitted to bronchoscopy. The majority of the patients (90%) had some risk factor for aspiration, among which stroke (30%) was the most frequent. Patients with different neurologic and neuromuscular diseases together accounted for 58% of all patients with TFB aspiration. Medical history was suggestive of foreign body aspiration in 38.4% of the patients, while chest X-ray was indicative in 7% of the patients. TFBs were most often found in the right bronchial tree (75.6%). The most common TFBs were animal and fish bones (39.5%). In 90.7% of the patients they were successfully removed under FBSC, whereas in 8.1% of the patients a TFB was extracted with flexible bronchoscope through endotracheal tube. Surgery was needed in only one case. Conclusions  Although foreign bodies in the tracheobronchial tree are rare in adults, the clinician must be aware of their likelihood. Foreign body aspiration should be considered especially in the etiology of recurrent lung diseases and in the presence of risk factors for aspiration, in particular with different neurologic and neuromuscular diseases. They can be successfully and safely removed in the majority of patients under local anesthesia by using FBSC. In cases when repeated procedure is needed, endotracheal tube is recommended.     

Spiritual well-being, intrinsic religiosity, and suicidal behavior in predominantly Catholic Croatian war veterans with chronic posttraumatic stress disorder: a case control study

We investigated relationships between spiritual well-being (SWB), intrinsic religiosity (IR), and suicidal behavior in 45 Croatian war veterans with chronic posttraumatic stress disorder and 32 healthy volunteers. Compared with the volunteers, the veterans had significantly lower SWB scores (p = 0.000) and existential well-being (EWB) scores (p = 0.000). Scores on the religious well-being (RWB) subscale (p = 0.108) and the IR scale did not differ significantly between the groups (p = 0.803). Veterans' suicidality inversely correlated with SWB (p = 0.000), EWB (p = 0.000), RWB (p = 0.026), and IR (p = 0.041), with the association being stronger for the EWB subscale than for the RWB subscale. Veterans who had attempted suicide at least once in their lifetime had significantly higher Suicidal Assessment Scale scores and lower EWB scores than veterans who never attempted suicide. Low EWB scores may imply an increased risk of suicidality. Some religious activities were more frequent among the veterans than among the healthy volunteers, possibly reflecting the veterans' increased help-seeking behavior due to poor EWB.     

Standard citrate versus sequential citrate/anticoagulant-free anticoagulation during hemodialysis: a randomized trial

Abstract:  In a randomized study, sequential anticoagulation for hemodialysis (citrate for the first 3.5 h, switching to 30-min anticoagulation-free hemodialysis) was compared to standard citrate anticoagulation. Fifty-two hemodialysis procedures were randomized either to sequential ( n  = 27) or standard citrate group ( n  = 25). The antithrombotic effect in the circuit was visually assessed after hemodialysis using a score from 1 (total clotting) to 5 (no clotting). The antithrombotic score for sequential versus standard group was as follows: dialyzer, 4.0 ± 1.1 versus 4.8 ± 0.4 ( P  < 0.01); arterial bubble trap, 4.0 ± 1.2 versus 4.7 ± 0.6 ( P  = 0.013); venous bubble trap, 4.0 ± 1.3 versus 4.8 ± 0.6 ( P  < 0.01). Serum citrate levels during sequential versus standard citrate anticoagulation (µmol/L) were as follows: at the beginning, 143 ± 65 versus 148 ± 77 (not significant [NS]); after 2 h, 317 ± 157 versus 354 ± 111 (NS); at the end, 125 ± 81 versus 405 ± 133 ( P  < 0.01). Sequential anticoagulation reduces the final serum citrate concentration to predialysis level. It can be a good anticoagulation strategy for patients in whom the reduction of citrate load is desired.