The beginning doctor: a problem-based course for first year medical and dental students*

A problem-based course designated as ‘Beginning Doctor’ was given to 136 first year medical and dental students. The students were divided into small groups and under guidance of a tutor studied largely unfamiliar clinical problems presented to them as written résumés. They determined what further information they required, obtained the information on their own and described it to the others in plenary sessions. The tutors acted as facilitators of student learning rather than as sources of information. Contrary to the widely held assumption that students in these parts of the world are passive learners, incapable of taking direct responsibility for their own learning, the staff was pleasantly surprised to see the enthusiasm and the competence with which the students tackled the problems and easily adopted the self-learning mode.     

A New Classification Algorithm for Discrimination of Ventricular from Supraventricular Tachycardia in a Dual Chamher Implantable Cardioverter Defibrillator

New Atrioventricular Classification Algorithm. Introduction : The high incidence of inappropriate therapies due to supraventricular tachycardia remains a major unsolved problem of implantable cardioverter defibrillators. We report a new detection formula for discrimination of ventricular tachycardia from supraventricular tachycardia in a patient with a dual chamber implantable cardioverter defibritlator and a new atrioventricular classification algorithm.
Methods and Results : The enhanced detection algorithm performs a stepwise arrhythmia analysis. The rhythm is first classified on the basis of cycle length. Each episode is then classified as supraventricular or ventricular on the basis of atrioventricular association, stability of circle length, and origin of acceleration, Sophisticated diagnostic information is provided by atrioventricular markers and electrogram recordings. Successful discrimination of two spontaneous episodes of ventricular tachycardia and supraventricular tachycardia is demonstrated.
Conclusion : This new dual chamber detection algorithm may significantly improve the specificity of tachyarrhythmia detection without sacrificing sensitivity, thereby reducing the number of spurious shocks in patients with recurrent supraventricular tachycardias. Further studies are needed to assess the sensitivity and specificity of this detection atgorithm.     

Impact of teacher training: a shift toward problem-solving orientation

This study explores the effect of World Health Organization (WHO) sponsored teacher-training activities conducted by the medical education department located at Pahlavi University School of Medicine in Shiraz, Iran.
The first study was conducted in 1974, before the influence of organized teacher-training activities at Pahlavi University. From that study it was concluded that class standing, based upon examinations given in 1968–1973, was dependent upon ability to recall information.
The present study, conducted in 1976 after the influence of organized teacher training, revealed that the basis for the determination of class standing, based upon examinations given in 1971–1976, was shifting from ability to recall information to problem-solving competencies.
The tangible changes identified by this study were assumed to be related to several variables such as the heightened awareness and skill among the medical teachers, students' demand for relevancy and their familiarity with the new testing method, particularly the PMP, and perhaps some other variables. However, no attempt was made to draw causality between teacher-training activities had the position in class. Due to the fact that teacher-training has been the most prominent activity since 1972, it was assumed that the significant changes in this study could be related to such efforts.     

Pain management and the effect of guidelines in neonatal units in Austria, Germany and Switzerland

BACKGROUND: Painful invasive procedures are frequently performed on preterm infants admitted to a neonatal intensive care unit (NICU). The aim of the present study was to investigate current pain management in Austrian, German and Swiss NICU and to identify factors associated with improved pain management in preterm infants. METHODS: A questionnaire was sent to all Austrian, German and Swiss pediatric hospitals with an NICU (n = 370). Pain assessment and documentation, use of analgesics for 13 painful procedures, presence of written guidelines for pain management and the use of 12 analgesics and sedatives were examined. RESULTS: A total of 225 units responded (61%). Pain assessment and documentation and frequent analgesic therapy for painful procedures were performed more often in units using written guidelines for pain management and in those treating >50 preterm infants at <32 weeks of gestation per year. This was also the case for the use of opioid analgesics and sucrose solution. Non-opioid analgesics were used more often in smaller units and in units with written guidelines. There was a broad variation in dosage of analgesics and sedatives within all groups. CONCLUSION: Pain assessment, documentation of pain and analgesic therapy are more frequently performed in NICU with written guidelines for pain management and in larger units with more than 50 preterm infants at <32 weeks of gestation per year.     

Incidence and Characteristics of Appropriate and Inappropriate Therapies in Recipients of ICD Implanted for Primary Prevention of Sudden Cardiac Death

Background: We evaluated the number of appropriate and inappropriate therapies for ventricular tachyarrhythmias and trigger mechanisms in 55 MADIT II (MII)-like (group 1) and 86 SCD-HeFT-like (group 2) patients.
Methods and Results: We analyzed 399 appropriate episodes in 31 patients with implantable cardioverter defibrillators (ICD) implanted according to the MII trial indications, and 502 appropriate episodes in 47 patients matching the SCD-HeFT trial criteria (mean follow-up in both groups = 33 ± 19 months). In group 1, 39 treated episodes were inappropriate (9% of all episodes), while in group 2, 76 episodes were treated inappropriately (15% of all episodes). At least one episode of inappropriate ICD therapy was recorded in 18% of patients in group 1 (n = 10) and in 22% of patients in group 2 (n = 19).
Conclusions: Our study supports the implantation of ICD as primary prevention in patients who are at risk of sudden cardiac death, although the proportion of inappropriate ICD interventions remains high.     

An Unusual Case of Pacemaker Failure: Complete Disconnection of Connector Block and Battery of a Subpectorally Implanted Dual Chamber Pacemaker

MELLERT, F., et al. : An Unusual Case of Pacemaker Failure: Complete Disconnection of Connector Block and Battery of a Subpectorally Implanted Dual Chamber Pacemaker. Local trauma to patients with implanted pacemaker devices may result in lead fracture or breakage of the lead socket with leakage of fluid into the connector system. This report describes an unusual case of complete entrance and exit block in a subpectorally implanted dual chamber pacemaker due to total disconnection and dislodgement of header block and battery part. Damage may be caused by an interaction of machine fatigue/manufacturing defective and fixation of the header with unusual movability of the battery, leading to breakage with intermittent malfunction and consecutive bradycardia and syncope.