Effectiveness of student tutors in problem-based learning of undergraduate medical education.

Problem-based learning (PBL) is a teaching and learning method designed to develop clinical reasoning skills. Tutor performance in PBL affects both the process and outcome of student learning. In this study, we investigated the factors that influence the evaluation by undergraduate students on the performance of tutors in medical education. From April 2009 to February 2010, 49 PBL sessions were conducted for 191 3rd- and 4th-year medical students at Saga Medical School in Japan. Twenty-nine 6th-year students and 205 faculty members tutored these sessions. After each session, students evaluated their tutor by a Likert scale. This evaluation score was dichotomized and used as the dependent variable. A multivariate logistic regression analysis was used to assess the contribution of student's gender and year level (3rd or 4th), the tutor's gender and background, and the quality of the case scenario to evaluation ratings. A total of 4,469 responses were analyzed. Male student and tutor background were associated with excellent tutor evaluation. Concerning the tutor background, compared with basic scientists, the 6th-year students and content-expert clinicians were positively associated with excellent tutor evaluations (ORs of 1.77 [95% CI: 1.15-2.72] and 1.47 [95% CI: 1.11-1.97]), while non-content-expert clinicians received negative evaluations (OR of 0.72 [95% CI: 0.55-0.95]). The quality of the case scenario was also associated with excellent tutor evaluation (odds ratio [OR] of 12.43 [95% CI: 10.28-15.03]). In conclusion, excellence of case scenarios, 6th-year student tutors, and content-expert clinicians show positive impact on tutor evaluation in a PBL curriculum.

Improvement in medical students' communication and interpersonal skills as evaluated by patient satisfaction questionnaire after curriculum reform.

Fifteen years of undergraduate medical education curriculum reform at Saga Medical School was evaluated by measuring medical students' communication and interpersonal skills with a patient satisfaction questionnaire developed by the American Board of Internal Medicine. A multiphase cross-sectional study was conducted at the General Medicine Clinic of Saga Medical School Hospital in phase I (1998-1999), phase II (2001-2002), and phase III (2009-2010). A total of 1,963 patient ratings for 437 medical students' performance was analyzed. The average scores of phases II and III were significantly higher than for phase I. The average score of female students showed a significant difference between phases I and II, but no difference between phases II and III. The average score of male students showed no difference between phases I and II, but significant difference between phases II and III. The phase II curriculum introduced basic clinical skills and examination and improved female students' performance. The phase III curriculum was effective for male students because it emphasized the clinical skill program more and introduced problem-based learning. Curriculum reform at Saga Medical School is considered to have made good progress in improving students' clinical competence and patient-centered attitudes.

The characteristics of a good clinical teacher as perceived by resident physicians in Japan: a qualitative study.

BACKGROUND: It is not known whether the characteristics of a good clinical teacher as perceived by resident physicians are the same in Western countries as in non-Western countries including Japan. The objective of this study was to identify the characteristics of a good clinical teacher as perceived by resident physicians in Japan, a non-Western country, and to compare the results with those obtained in Western countries. METHODS: Data for this qualitative research were collected using semi-structured focus group interviews. Focus group transcripts were independently analyzed and coded by three authors. Residents were recruited by maximum variation sampling until thematic saturation was achieved. RESULTS: Twenty-three residents participated in five focus group interviews regarding the perceived characteristics of a good clinical teacher in Japan. The 197 descriptions of characteristics that were identified were grouped into 30 themes. The most commonly identified theme was "provided sufficient support", followed by "presented residents with chances to think", "provided feedback", and "provided specific indications of areas needing improvement". Using Sutkin's main categories (teacher, physician, and human characteristics), 24 of the 30 themes were categorized as teacher characteristics, 6 as physician characteristics, and none as human characteristics. CONCLUSIONS: "Medical knowledge" of teachers was not identified as a concern of residents, and "clinical competence of teachers" was not emphasized, whereas these were the two most commonly recorded themes in Sutkin's study. Our results suggest that Japanese and Western resident physicians place emphasis on different characteristics of their teachers. We speculate that such perceptions are influenced by educational systems, educational settings, and culture. Globalization of medical education is important, but it is also important to consider differences in educational systems, local settings, and culture when evaluating clinical teachers.

Patient satisfaction questionnaire for medical students' performance in a hospital outpatient clinic: a cross-sectional study.

Medical education in Japan has undergone significant reforms. Patient perspective and outcome have been highly valued in curricular reforms. Therefore, we evaluated an undergraduate curriculum particularly on communication skills by comparing outpatient satisfaction before and after the reforms implemented at Saga Medical School. Cross-sectional study was conducted at the General Medicine Clinic of Saga University Hospital in 1999 and 2009. A total of 729 newcomer patients evaluated 159 students; namely, 287 patients evaluated sixth-year medical students (n = 82) in 1999, and in 2009, 442 patients evaluated fifth-year medical students (n = 77). Students interviewed newcomer patients prior to a faculty's clinical examination. After a student-patient encounter, the patient was asked to fill in six-item Patient Satisfaction Questionnaire (PSQ) developed by the American Board of Internal Medicine. Mixed model two-way analysis of variance (ANOVA) with covariant of students' gender was conducted. Effect sizes were calculated to evaluate the amplitude of influence. The average score in 2009 was significantly higher than that in 1999 (3.63 ± 0.62 versus 3.36 ± 0.66; p < 0.001). Since the "encouraging and answering questions" and "clear explanations" were lower than those of the other items (3.24 ± 0.98 and 3.46 ± 0.85), these two items showed the most significant improvements (Phi coefficient = 0.31 and 0.24, p < 0.001). Thus, students' performance has improved since 1999, which may represent the success of curricular reforms at Saga Medical School. We propose that "encouraging and answering questions" and "clear explanations" should be emphasized in interview training.

Impaired taste acuity in patients with diabetes mellitus on maintenance hemodialysis.

AIMS: It has been reported that taste acuity for the four primary tastes, sour, sweet, salty and bitter, is impaired in hemodialysis (HD) patients. However, there have been no studies reported on taste acuity of diabetic HD patients. The present study aimed to quantify and compare the taste acuity of diabetic and non-diabetic HD patients, and further to determine if there were correlations between diminished taste acuity and certain blood serum parameters typically askew in hemodialysis patients. METHODS: In a test group of 24 diabetic and 24 non-diabetic HD patients matched for age, body mass index and duration of HD, taste acuity for the four tastes was determined by asking patients to identify them at varying concentrations. RESULTS: Statistical analyses indicate that bitter and total taste acuity were significantly impaired in diabetic HD patients. In diabetic HD patients, correlation was found between sweet, salty or total taste acuity and blood urea nitrogen or normalized protein catabolic rate. CONCLUSIONS: We conclude that taste acuity is partially impaired in diabetic HD patients, and suggest this contributes to reduced appetite, leading to malnutrition and poor prognoses.

Acute myelogenous leukemia following treatment with cyclosporin A in a nephrotic patient.

We report here a very rare case of a nephrotic patient who developed acute myelogenous leukemia (AML, M2) 8 months after receiving cyclosporin A (CsA) therapy. A 30-year-old man with nephrotic syndrome had been taking diphenylhydantoin (DPH, 300 mg/day) for 6 years for treatment of convulsion and then received treatment of prednisolone and CsA (75 mg/day) for a nephrotic syndrome. Approximately 4 months after CsA therapy began, myeloblasts appeared in his peripheral blood at a ratio of 1%. Four months later, bone marrow aspiration and a biopsy confirmed a diagnosis of AML M2, showing hypercellular bone marrow with 60% leukemic cells. He received induction chemotherapy, which led to a complete remission.

[A case of systemic lupus erythematosus patient who died of rupture of abdominal aortic aneurysm].

Although many cardiovascular complications have been described in systemic lupus erythematosus (SLE), aortic involvement is rare. We report here a 51-year-old woman who suffered from SLE and died of a rupture of abdominal aortic aneurysm. She was diagnosed as having SLE in 1981, and administered prednisolone. She was admitted to our hospital for the treatment of nephrotic syndrome and hypocomplementaemia in December, 1996. Kidney biopsy revealed lupus nephritis(type IV of WHO classification). Methylprednisolone and cyclophosphamide pulse therapies were started, which resulted in an incomplete remission of nephrotic syndrome. After discharge, her clinical course was uneventful, and the dose of prednisolone was tapered. On April 22, 2001, she developed sudden abdominal pain and was admitted to a nearby hospital. Abdominal CT showed calcification of the aorta and an abdominal aortic aneurysm of 6.3 x 8 cm. She died of a rupture of abdominal aneurysm on the first hospital day. We think that prolonged prednisolone therapy might play a major role in accelerating atherosclerosis, which could result in aortic aneurysmal enlargement in this patient. Considerable attention should be paid to patients with SLE who are given prednisolone to detect and prevent vascular complications such as aneurysm.

Two cases of minor glomerular abnormalities with proteinuria disproportionate to the degree of hypoproteinemia.

We experienced two female cases of minor glomerular abnormalities with proteinuria disproportionate to the degree of hypoproteinemia. They did not have adequately large amounts of urine protein so as to cause nephrotic syndrome; however, we were unable to determine any cause of hypoproteinemia other than proteinuria. The renal pathology revealed foot process effacement, and hyaline droplet degeneration, suggesting urine protein hyper-reabsorption in the proximal convoluted tubule. Therefore, we thought these cases involved pathophysiological conditions, such as minimal change nephrotic syndrome. In both cases, the hypoproteinemia improved following the administration of oral prednisolone. As in past reports, it is thought that the principal causative factor of hypoalbuminemia in patients with nephrotic syndrome is a catabolic reaction after the serum albumin filtered at the glomerulus is reabsorbed in the proximal tubule. In the present two cases, it is supposed that a large amount of urine protein was filtered in the primitive urine; however, the amount of final urinary protein did not reach the nephrotic range because most of it was reabsorbed in the proximal tubule and reabsorbed in the blood after being disintegrated into amino acids by a catabolic reaction. Or we might simply observe the process before the case 1 got nephrotic syndrome and the healing process of nephrotic syndrome in the case 2.

An investigation of the basic education of Japanese nurses: comparison of competency with European nurses.

BACKGROUND: A few studies have compared nursing education systems of Japan and Europe, particularly focusing on competency. OBJECTIVE: We evaluated the competency of registered Japanese nurses by comparing it with that of European nurses; the implications of evaluation for the education of nurses are discussed. DESIGN AND PARTICIPANTS: Subjects were 468 European graduate nurses and 100 Japanese nurses. Study used data from the Graduates in Knowledge Society (REFLEX) survey in Europe and the Japanese language version of REFLEX (2006) used in a survey of Japanese nurses. METHODS: The questionnaire referred to the survey items of REFLEX modified for use in Japan. Items common to the Japanese and European surveys were (1) The importance placed on university course elements while at university (2) Nineteen items of competency: for the abilities acquired in the present job ('Acquired skills') and those considered necessary to perform the job ('Required abilities on the job') (3) Usefulness of subject matter taught at university to the current job RESULTS: (1) The important course elements in Europe were 'Internship, work placement' and 'Lecture' while those in Japan were 'Theories and paradigms' and 'Lecture'. (2) The mean values for 'Acquired skills' were 5.06 for Europe and 3.73 for Japan and those for 'Required abilities on the job' were 4.86 for Europe and 5.16 for Japan. In Europe, no significant gap was observed between the above two scores, but in Japan, a big gap was found, particularly in relation to 'Ability to assert your authority'. (3) In terms of the usefulness of university-learned nursing education, Japan scored significantly lower on all five items. CONCLUSIONS: The content of basic university education for nursing is directly linked to the workplace in Europe but not in Japan. A comparison of competencies shows that in Japan, self-evaluation scores are low and expectations are high.

Acute renal failure associated with acute non-fulminant hepatitis B.

A 38-year-old female presenting with a high fever of 39 °C developed severe liver dysfunction and acute renal failure (ARF). In tests for a hepatitis associated virus, an Immunoglobulin M-anti-hepatitis B virus core antibody was the only positive finding. Moreover, the progression of ARF coincided with the pole period of liver damage and all the other assumed causes for the ARF were unlikely. Therefore, this case was diagnosed as ARF caused by acute hepatitis B. ARF associated with non-fulminant hepatitis has been infrequently reported, usually in association with acute hepatitis A. This case is considered to be an extremely rare and interesting case.

A case of endocapillary glomerulonephritis associated with peripheral blood natural killer cell proliferation.

A 69-year-old male was admitted to our hospital due to rapidly progressive glomerulonephritis. A peripheral blood smear showed a marked increase in large granular lymphocytes. Flow cytometry analysis of the blood showed a marked increase in CD3-negative and CD56-positive natural killer (NK) cells. A renal biopsy showed a characteristic pathological pattern that involved endocapillary proliferation, a predominance of mononuclear cells and mesangiolysis. Prednisolone was administered, and the patient's renal function subsequently improved concomitant with the amelioration of NK cell proliferation. In our case, there was evidence of a strong association between NK cell proliferation and glomerulonephritis.

Partial blood recirculation: a new trial for prolonging filter life during continuous hemodiafiltration.

Although continuous hemodiafiltration (CHDF) has been widely accepted in the management of complicated acute renal failure, the requirement for prolonged continuous systemic anticoagulation appears to be a major drawback. We herein describe the case of a patient who developed postoperative multiple organ failure and received CHDF therapy with partial blood recirculation (PBR). PBR is a mode of extracorporeal circulation used as an anticoagulation modality. The technique accelerates the blood flow rate with the goal of extending filter life, and it was performed because the filter life had been significantly shortened (10.5 +/- 5.1 h) during the CHDF process in this case. Despite increasing the dose of the anticoagulant, changing the hemofilter and changing the mode from postdilution to predilution, we did not obtain amelioration of filter life. The filter life was significantly improved (41.5 +/- 1.4 h) when we performed PBR. It is difficult to minimize the bleeding risk and maintain filter life during CHDF. Our success in prolonging the filter life during this case therefore suggests that PBR might resolve one of the main problems related to CHDF, although more study is needed to clarify the advantages of this system.

A case report of nephrotic syndrome due to collapsing focal segmental glomerulosclerosis treated with low-density lipoprotein apheresis.

We herein report the case of a 73-year-old woman with steroid and cyclosporine resistant collapsing focal segmental glomerulosclerosis (FSGS) whose refractory proteinuria and hypoproteinemia were controlled with low-density lipoprotein apheresis (LDL-A). She was initially treated with steroid therapy, including methylprednisolone pulse and cyclosporine therapy. However, her hypoproteinemia, accompanied with renal insufficiency, persisted despite these therapies. We treated her using LDL-A and found improvement in her urine protein excretion, hyperlipidemia, hypoproteinemia, and renal function as a result of this treatment. This suggests that LDL-A may therefore be an effective therapy for nephrotic syndrome due to collapsing FSGS.

Effect of soy protein added to casein diet on the development of glomerular injury in spontaneous hypercholesterolemic male Imai rats.

BACKGROUND: We have already reported an attenuating effect of a semipurified alcohol extract of soy protein (mainly consisting of isoflavones) on glomerular injury. Therefore, in the present study, we investigated whether soy protein itself has an ability to attenuate glomerular injury when added to casein diet in male Imai rats of a spontaneous focal segmental glomerulosclerosis model. METHOD: Male Imai rats were used and allocated into five groups. Group A of control casein diet (Ca) was fed standard diets containing 24.5% casein as a protein source. Group B of control soy protein diet (SP) was fed soy protein diet containing 24.5% protein that substituted a soy protein isolate for casein. Groups C (Ca-SP10) and D (Ca-SP20) were fed a mixture diet of casein (24.5%) and SP (10%) or SP (20%). Group E (Ca-Ca) was fed high casein diet containing the same quantity in protein content (44.5% casein) as the Ca-SP20 diet. Body weight, urinary protein, serum constituents and systolic blood pressure were investigated every 4 weeks from 12 weeks through 24 weeks of age. At 24 weeks of age, rats were studied morphologically. RESULTS: Animals fed control SP diet showed a significantly greater body growth than animals fed the other 4 test diets. No significant differences were found in body growth among the other 4 groups except for group E, which showed a stunt at the end of the experiment. Control SP diet significantly decreased proteinuria and serum cholesterol and attenuated glomerular injury and glomerular hypertrophy as compared with control casein diet. Added SP failed to attenuate glomerular injury, but when compared with high casein diet (group E), added SP resulted in less proteinuria, less hyperlipidemia, less hypoalbuminemia, less glomerular hypertrophy and less renal histological damage despite the quantity being the same in protein content. CONCLUSION: The present study indicates that soy protein added to conventional casein diet did not have the ability to attenuate glomerular injury, but soy protein is not as harmful as casein as a protein source when added to casein diet in the development of glomerular injury in the rat model of spontaneous focal glomerular sclerosis.

Coculture of endothelial cells and mature adipocytes actively promotes immature preadipocyte development in vitro.

Adipose tissue consists of mature adipocytes and endothelial cells, which are all supported by the extracellular matrix. Adipose tissue development is closely associated with angiogenesis. However, the adipocyte-endothelial cell interaction is unclear. To address this issue, we examined the effects of endothelial cells on the growth, apoptosis, and differentiation of mature adipocytes in three-dimensional collagen gel culture of the adipocytes with or without rat lung endothelial (RLE) cells. Spindle-shaped preadipocytes, an immature type of adipocyte, developed more actively around the adhesion sites of RLE cells to mature adipocytes in the coculture (rate of preadipocytes: 18.9+/-4.3%) than in the culture of adipocytes alone (2.0+/-5.1%). With respect to growth, RLE cells induced about a three-fold increase in bromodeoxyuridine uptake of mature adipocytes alone, while RLE cells did not influence the uptake of preadipocytes. RLE cells also did not affect the apoptotic indices by immunohistochemistry for single-stranded DNA in mature adipocytes or preadipocytes. These phenomena were not reproduced by RLE cell-conditioned medium, or by certain endothelial cell-produced cytokines. Our in vitro study is the first demonstration that endothelial RLE cells promote the active development of preadipocytes together with increased growth of mature adipocytes. These results suggest that endothelial cells are involved in the enlargement mechanism of adipose tissue mass through their direct adhesion to mature adipocytes.

Nephrotic syndrome due to immunologically mediated hypocomplementic glomerulonephritis in a patient of Waldenström's macroglobulinemia.

A 72-year-old man was diagnosed as having nephritic syndrome complicated by Waldenström's macroglobulinemia (WM). A monoclonal IgM lambda protein and decreased serum complements were observed. The renal biopsy disclosed the capillary occluded by thrombi which was stained with IgG, IgA, IgM, C4, lambda light chain and slight kappa light chain in a granular pattern. Electron dense deposits were noted in the subendothelial spaces. An unusual case of WM who developed nephrotic syndrome due to immunologically mediated hypocomplementic glomerulonephritis is described.

Different effects of castration and estrogen administration on glomerular injury in spontaneously hyperglycemic Otsuka Long-Evans Tokushima Fatty (OLETF) rats.

AIM: Non-insulin-dependent diabetic mellitus model rats, Otsuka-Long-Evans-Tokushima-Fatty (OLETF), develop diabetic nephropathy presenting with mesangial expansion leading to glomerular sclerosis and thickening of the glomerular basement membrane (GBM), especially in elderly males. The effects of sex hormones and castration on the incidence of diabetes mellitus (DM) have been studied in this strain rat. However, there have been no detailed studies on the effects of castration and sex hormone in the development of diabetic nephropathy. METHODS: In this study we examine the effect of castration or estrogen on the development of glomerular injury in OLETF rats. Thirty male OLETF rats and 10 male long-Evans Tokushima Otsuka (LETO) rats as a normal control were used. OLETF rats were divided into three groups: group 1 received sham-operation, group 2 was castrated at 6 weeks, and group 3 was administered 0.1 mg estrogen subcutaneously once a month from 6 weeks to 58 weeks of age and LETO rats were assigned to group 4. Body weight, urinary protein and fasting blood glucose, serum albumin and other serum constituents were investigated every 12 weeks from 12 weeks to 60 weeks of age. In groups 1-3, glucose tolerance test was performed at 38 weeks. Each group was studied morphologically at the end of the experiment (60 weeks of age). RESULTS: Castration attenuated proteinuria and glomerular sclerosis accompanied by an amelioration of glucose tolerance, a decrease in mesangial expansion and an attenuation of the GBM thickening. In contrast, although estrogen equally ameliorated glucose tolerance and attenuated the mesangial expansion and the GBM thickening, estrogen failed to attenuate proteinuria and glomerulosclerosis. A significant increase in glomerular tuft volume, and serum levels of growth hormone, total cholesterol and triglycerides was observed in the estrogen-treated rats as compared with the castrated rats. CONCLUSION: Besides the mechanisms involved in the development of diabetic nephropathy, other mechanisms may be involved and contribute to the development of glomerulosclerosis in the estrogen-treated rats, leading to a difference in glomerular injury between the castrated and estrogen-treated OLETF rats.

Crescentic glomerulonephritis in a patient with heterozygous Fabry's disease.

A 58-year-old woman who suffered from a heterozygous Fabry's disease and immune complex crescentic glomerulonephritis (GN) is reviewed. The diagnosis was made on the basis of the pathologic findings and peripheral leukocyte alpha-galactosidase activity. Light microscopy revealed a vacuolization of epithelial cells and electron microscopy showed myelin figures in the cytoplasm of visceral epithelial cells typical of Fabry's disease at the first renal biopsy. During the following 4 months she developed progressive renal failure and a second renal biopsy disclosed the formation of cellular crescents in 7 of 11 glomeruli observed. A rare case of combined Fabry's disease and crescentic glomerulonephritis is discussed.