[Teaching emergency medicine at the University Medical Center Freiburg: establishment of an integrative concept]. / Lehrveranstaltung Notfallmedizin am Universitätsklinikum Freiburg : Etablierung eines integrativen Gesamtkonzeptes.

Efforts to improve the quality of undergraduate medical education are commonly hampered by limited human and financial resources. This deficiency may be offset by the development of well structured and innovative teaching concepts, which optimize available assets. The newly conceived modular course "Emergency Medicine" at the University Medical Center Freiburg was conducted for the first time in the winter semester 2006/2007. The core of the course is a 3-day practical training period. It provides the possibility to teach a maximum number of medical students with only four lecturers using patient simulators, interactive case scenarios (simulation software MicroSim), and case scenarios with standardized patients. Evaluation of the course revealed standardized patients to be the best of all teaching methods with an overall average grade of 1.1 (patient simulators 1.2, computer simulation 1.4). Of the students, 88% stated that the practical training encouraged their interest in the speciality emergency medicine. The excellent student evaluation results show that the new course "Emergency Medicine" for medical students constitutes a successful balance between the constraint of resource limitation and the goal of excellent medical education.

[Changes of selected immunological parameters after cardiopulmonary bypass in postop period]. / Wplyw krazenia pozaustrojowego na wybrane parametry odpowiedzi immunologicznej z uwzglednieniem przebiegu okresu pooperacyjnego.

The aim of the study was to evaluate the influence of changes of chosen immunological parameters on postoperative course patients after cardiopulmonary bypass operation. Complement components C3, C4 and immunoglobulins IgA, IgG, IgM were taken into account. The group consisted of 70 patients, 51 men at mean age 52.6 +/- 10.8 years and 19 women at mean age 50.7 +/- 11.0 years. All patients were operated in moderate hypothermia 26-32 degrees C with use of crystalloid cardioplegia. We used membrane oxygenators: Safe II (Polystan), Monolyth (Sorin), Maxima (Medtronic) and Bentley (Baxter). In 36 patients with multivessel coronary artery disease the internal thoracic artery and saphena vein grafts were performed. 27 patients underwent the valve prosthesis implantation procedure and 7 correction of the congenital heart dis-ease. The mean extracorporeal perfusion time was 127.5 +/- 51.0 min. The mean aortic cross-clamping time was 65.6 +/- 26.9 min. 6 blood samples were taken in the time periods called from 0 to 5: 0--before the operation, 1--right after the operation, 2--1 day after the operation, 3--3 days after the operation, 4--7 days after the operation, 5--14 days after the operation. All the immunological parameters were measured at the Technicon RA-1000 System device using plasma antibody serum of Behring Company. We compared two groups: 1) 21 patients extubated at operation day with 42 patients extubated at 1-th postoperative day, 2) 38 patients with postoperative organ failure with 32 patients without organ complications. The intubation time was shorter in patients with higher levels of C3 (to 7-th day) and C4 (at 1-th postoperative day). The postoperative organ failure were more frequently in patients with lower postoperative C3 (to 3-th day) and with lower C4 at 1-th postoperative day. The postoperative changes of immunoglobulins IgA, IgG, IgM were similar in patients with complicated and uncomplicated postoperative course.

[Echocardiographic assessment of pathologic geometry in the left left ventricle with aneurysm before and after endoventricular plasty]. / Echokardiograficzna ocena zaburzen geometrii lewej komory z tetniakiem przed i po operacji metoda plastyki wewnatrzkomorowej.

UNLABELLED: Large LV aneurysm (LVA) leads to progressive distortion of ventricular geometry. Endoventricular plasty (EVP) maintains LV original shape and size and may restrain this process. AIMS: Echocardiographic estimation of LVA size. Assessment of the results of EVP regarding operative technique. Assessment if the initial parameters of LV function and LVA size could predict the choice of surgical technique. MATERIAL AND METHOD: 33 patients with LVA underwent EVP: 18 with patch (group A), 15 without patch (group B). Echocardiography was performed before and after surgical procedure. LVA-area, LVA-volume, its proportion to LV area and volume (LVA-area/LV-EDA, LVA-volume/LV-EDV) were determined apart from routine parameters of LV function. RESULTS: Mean LVA-area was 15 cm2, LVA-volume was 50 mL. Mean LVA-areal LV-EDA was 0.38 LVA-volume/LV-EDV was 0.35. LVA exceeding 0.4 of LV area/volume was considered as a large. After surgery LV-EDV diminished +/- 40 mL, LVLd decreased +/- 1.5 cm. EF improved from 44% to 54%. Patients in group A had larger LVA-volume (60 vs 39 ml, p = 0.02) as well as LV-EDV (160 vs 120 ml, p = 0.03), and lower EF (41% vs 51% p = 0.002). Only 2 patients with LVA-volume greater than 56 ml were operated on without patch. After surgery echocardiographic parameters did not differ between the groups: in group A operation was much more extensive. SUMMARY: 1.) Echocardiographic parameters concerning size (LVA-area, LVA-area/LV-EDA) and volume (LVA-volume, LVA-volume/LV-EDV) of LVA provides information about disturbances in LV geometry, are valuable in planning operative method. 2.) EVP with or without patch provides significant improvement of LV geometry and function in echocardiographic investigation.

[Difficulties in distinguishing left ventricular aneurysm from pseudoaneurysm. Case report]. / Trudnosci w róznicowaniu rzekomego i prawdziwego tetniaka sciany dolnej serca. Opis przypadku.

A case of 51-year old female with large inferior left ventricular aneurysm developed 3 months after myocardial infarction is presented. The patient demonstrated advanced congestive heart failure and angina. Coronarography revealed amputation of the distal part of 3 coronary vessels without possibility of revascularisation. In ventriculography large inferior wall aneurysm was found. Echocardiography strongly suggest the presence of pseudoaneurysm. During the operation very large real aneurysm arising from inferior wall and apex was found. Postoperative period was complicated by many cardiac and non cardiac events. Authors discuss the problems of proper diagnostic and its influence on decision about surgical management.

Factors influencing students' borrowing that may affect their specialty choices and other after-graduation behaviors.

PURPOSE: To assess the factors that influence medical students' borrowing and how these factors may affect access to the profession, specialty choice, and medical graduates' repayment behaviors. METHOD: The borrowing patterns of the 3,495 indebted students enrolled at Jefferson Medical College of Thomas Jefferson University between 1989-90 and 1994-95 were analyzed. (Debt included both subsidized and unsubsidized debt.) These borrowing patterns were assessed in relation to changes in the cost of education, family (i.e., parents') income, availability of grant funding, legislative changes to loan-eligibility criteria (specifically, the Higher Education Amendments of 1992), and average interest rates on federal unsubsidized loans. RESULTS: The annual changes in average debt levels suggest that while cost of education, family resources, and availability of grant funding may be significant factors, changes in loan eligibility and prevailing interest rates on unsubsidized loan source also influence medical students' borrowing. A comparison of the borrowing patterns for three income groups (low, middle, high) further demonstrated that while overall fluctuations for low-income group mirrored changes in the cost and resource variables, annual borrowing fluctuations for the middle- and high-income groups were more reflective of the expansion of loan eligibility and reduced interest rates on unsubsidized loans. From 1989-90 to 1994-95 the average cost of education increased by $2,368. Average unsubsidized debt increased by $1,544 for the low-income group, $3,960 for the middle-income group, and $4,439 for the high-income group. The percentage of unsubsidized funding included in the borrowers' financing packages increased by just under 6% for the low-income group but almost 10% and 11% for the middle- and high-income groups, respectively. CONCLUSION: The results suggest that medical students borrow for a variety of reasons, ranging from financial need to personal financing or lifestyle choices. These reasons should be considered in relation to institutional and governmental financial aid policies and future research on the relationship between debt and speciality choice.

Reaching consensus on the National Dental Hygiene Research Agenda: a Delphi study. American Dental Hygienists Association Council on Research.

PURPOSE: The purpose of this study was to achieve consensus on specific research topics under the national dental hygiene research agenda categories developed by the ADHA Council on Research. METHODS: A Delphi technique was used to survey a group of 48 dental hygiene experts to gain consensus about the appropriateness of topics for dental hygiene research. The study was carried out in three phases: a development and pilot-testing phase and two rounds of mailed surveys. Responses were analyzed using descriptive statistics. Instrument reliability was analyzed using the Pearson Product-Moment Correlation Coefficient and Cronbach's Alpha for internal consistency. RESULTS: Sixty-six topics reflective of the research agenda categories were identified through the first phase. Return rates of 100% and 94% were achieved for the two survey rounds. Instrument reliability was established at .91 and internal consistency at .94. After two rounds, consensus was reached on 37 of the 66 topics. CONCLUSIONS: Each of the categories comprising the ADHA national dental hygiene research agenda was well represented by the 37 topics. This finding provided evidence that there was consensus on the national agenda. However, reaching consensus is just the first step in the development of a long-range plan to guide research efforts and to promote depth in the development of a body of knowledge based on scientific inquiry.

Mentorship experiences in a group of occupational therapy leaders.

OBJECTIVES: The development of occupational therapy leaders is a long-held goal of many members of the American Occupational Therapy Association and of state associations. The initiation of mentor programs is a common means to accomplish this goal. These programs take time and effort, and, although occupational therapists have described how mentorship programs work in the literature, there are few articles that describe the actual mentorship experiences of occupational therapy leaders. METHOD: To study the experiences of elected occupational therapy leaders, a 30-item questionnaire was distributed at the annual meeting of the Committee of State Association Presidents and completed by 53 respondents. Results were analyzed, and cross tabulations were run between selected items. RESULTS: Respondents were frequently exposed to role models, were assisted by sponsors, were mentored by other occupational therapists, and served as mentors themselves. There was little evidence that the respondents were mentored by high-powered individuals who helped launch their careers. CONCLUSION: More than half of the respondents were mentored by other occupational therapists, and only 29% of the respondents reported that they surpassed the status and position of their mentors. Plans to initiate mentorship programs should include activities that promote powerful leaders who move beyond the status and position of their mentors, so that occupational therapists can represent the interests of the profession to others.

[A case of perforation of the pericardial sac by Seldinger's catheter guide]. / Przypadek przebicia do worka osierdziowego prowadnikiem cewnika Seldingera.

This is a case report of perforation by Seldinger's catheter leader into pericardial sack. The leader was inserted contrary-wise++ to the subclavian vein with the sharp end in front. The leader moved forward toward the venous system and perforated into the pericardial sack. The preceding steroid therapy which the patient had undergone due to asthmatic status resulted in mediastinitis after the primary surgery. Right technique of reoperation and intensive postoperative care led to patient recovery.

Understanding and predicting the yield in medical school admissions.

Graduate and professional schools in general, and medical schools in particular, have traditionally not paid a great deal of attention to applicant "yield"--the proportion of accepted applicants who eventually confirm their intention to matriculate. This study examined data for all students who were accepted for the years 1985-1987 at an urban, private medical school in the Northeast. The author attempted both to estimate the probability of an accepted applicant's matriculating at the institution and to demonstrate the relative effects of selected variables on the applicant's final decision. Through the use of the maximum-likelihood estimation technique, the resulting model indicated that probability ranges for matriculation may be derived using data available from computerized student records. The model was able accurately to classify more than 70% of the students into either the "matriculant" or the "non-matriculant" category.

Success in NCLEX-RN: identifying predictors and optimal timing for intervention.

This ex post facto study was designed to identify predictors of success in the NCLEX-RN and determine the optimal point in time for identifying students at risk. The convenience sample consisted of 407 graduates of an integrated, upper division, baccalaureate nursing program, 1984-1987. Prematriculation (total lower division GPA, science GPA, type of lower division College, age, and sex), junior year (three Nursing theory course grades) and pre graduation variables (three senior year nursing theory course grades and Mosby ASSESSTEST) were analyzed for predictive value. Nursing theory courses at the junior and senior year and the Mosby ASSESSTEST strongly correlated (p less than .0001) with NCLEX performance. Discriminant analysis enabled successful classification of 62% of the sample at prematriculation, 81% at the end of the junior year, and 86% at the end of the senior year. The study indicates that students at high risk can be identified at the end of the junior year so that enrichment and support programs can be introduced at that time.

Progressive enzyme changes within anatomically defined segments of rabbit nephron: demonstration with a new technique.

The kidney is an extremely heterogeneous organ, with morphological, physiological, and metabolic changes occurring from segment to segment along each nephron. To determine the heterogeneity that might exist within discrete anatomical segments of rabbit nephron, we developed a technique for making quantitative enzyme assays in serial samples, about 100 micron long, along identified segments of the nephron. Results for three enzymes in proximal convoluted and straight tubules show that adenylate kinase, an enzyme of high-energy phosphate metabolism, gradually decreases along the S1 and S2 segments of the proximal tubule, with no abrupt changes. Fructose bisphosphatase, a gluconeogenic enzyme, is high along the major portion of the proximal tubule but plummets along the final millimeter of S3. Conversely, phosphofructokinase, a glycolytic enzyme, is very low along the proximal tubule but increases sharply within the final millimeter. These data underscore the biochemical heterogeneity of the nephron, illustrating the enzyme levels may change markedly even within anatomically defined regions. They also suggest the importance of further studies of this type and demonstrate a practical means for such studies.

Isolation of 1-monomethylphosphoinositol 4,5-bisphosphate [a product of methanolysis of inositol 1,2-(cyclic)-4,5-trisphosphate] from Swiss mouse 3T3 cells.

We have noted two previously undescribed inositol polyphosphates in neutral methanol extracts from Swiss mouse 3T3 cells that were grown in [3H]inositol and stimulated with platelet-derived growth factor. They have been identified as 1-monomethylphosphoinositol 4,5-bisphosphate and 1-monomethylphosphoinositol 4-phosphate by comparison to a synthesized standard using HPLC chromatography, paper electrophoresis, and enzymatic dephosphorylation with inositol polyphosphate 5-phosphomonoesterase and intestinal alkaline phosphatase [orthophosphoric-monoester phosphohydrolase (alkaline optimum), EC 3.1.3.1]. We propose that these compounds are formed by methanolysis of inositol 1,2-(cyclic)-4,5-trisphosphate and inositol 1,2-(cyclic)-4-bisphosphate present in the cells. Inositol cyclic phosphates did not react with neutral methanol in the absence of the cells, which are required for the methanolysis reaction. These findings suggest a role for inositol cyclic phosphates as reactive compounds that are added to as yet unidentified cellular acceptors.

The metabolism of tris- and tetraphosphates of inositol by 5-phosphomonoesterase and 3-kinase enzymes.

Phospholipase C cleaves phosphatidylinositol 4,5-bisphosphate to form both inositol 1,4,5-trisphosphate (Ins(1,4,5)P3) and inositol 1,2-cyclic 4,5-trisphosphate (cInsP3). The further metabolism of these inositol trisphosphates is determined by two enzymes: a 3-kinase and a 5-phosphomonoesterase. The first enzyme converts Ins(1,4,5)P3 to inositol 1,3,4,5-tetrakisphosphate (InsP4), while the latter forms inositol 1,4-bisphosphate and inositol 1,2-cyclic 4-bisphosphate from Ins(1,4,5)P3 and cInsP3, respectively. The current studies show that the 3-kinase is unable to phosphorylate cInsP3. Also, the 5-phosphomonoesterase hydrolyzes InsP4 with an apparent Km of 0.5-1.0 microM to form inositol 1,3,4-trisphosphate at a maximal velocity approximately 1/30 that for Ins(1,4,5)P3. The apparent affinity of the enzyme for the three substrates is InsP4 greater than Ins(1,4,5)P3 greater than cInsP3; however, the rate at which the phosphatase hydrolyzes these substrates is Ins(1,4,5)P3 greater than cInsP3 greater than InsP4. The 5-phosphomonoesterase and 3-kinase enzymes may control the levels of inositol trisphosphates in stimulated cells. The 3-kinase has a low apparent Km for Ins(1,4,5)P3 as does the 5-phosphomonoesterase for InsP4, implying that the formation and breakdown of InsP4 may proceed when both it and its precursor are present at low levels. Ins(1,4,5)P3 is utilized by both the 3-kinase and 5-phosphomonoesterase, while cInsP3 is utilized relatively poorly only by the 5-phosphomonoesterase. These findings imply that inositol cyclic trisphosphate may be metabolized slowly after its formation in stimulated cells.

The metabolism of phosphoinositide-derived messenger molecules.

The phosphoinositides are minor phospholipids present in all eukaryotic cells. They are storage forms for messenger molecules that transmit signals across the cell membrane and evoke responses to extracellular agonists. The phosphoinositides break down to liberate messenger molecules or precursors of messenger molecules. Many different compounds are formed, although the functions of only a few are understood. Recent studies elaborating the pathways for formation of products from phosphoinositides and the factors controlling their metabolism are summarized here.

Inositol cyclic triphosphate [inositol 1,2-(cyclic)-4,5-triphosphate] is formed upon thrombin stimulation of human platelets.

Cleavage of polyphosphoinositides in vitro by phospholipase C results in formation of both cyclic and noncyclic inositol phosphates. We have now isolated the cyclic product of phosphatidylinositol 4,5-bisphosphate cleavage, inositol 1,2(cyclic)-4,5-triphosphate [cIns(1:2,4,5)P3], from thrombin-treated platelets. We found 0.2-0.4 nmol of cIns-(1:2,4,5)P3 per 10(9) platelets at 10 sec after thrombin; none was found in unstimulated platelets or in platelets 10 min after thrombin addition. We conclude that cIns(1:2,4,5)P3 is a major product of polyphosphoinositide metabolism in thrombin-stimulated platelets.

Understanding factors involved in college choice: implications for baccalaureate programs in nursing and allied health.

Students entering their senior year ("rising" high school seniors) interested in baccalaureate programs in nursing and allied health were surveyed to determine which factors were most important in their college choice decision. Based on mean ratings, the five highest ranked factors were employment opportunities, quality of academic programs, educational opportunities after graduation, teaching reputation, and cost. However, when students were asked to list the most important factors in the final decision, financial aid, quality of academic programs, cost, and employment opportunities were mentioned most often. Analysis of variance (ANOVA) indicated that while the factors influencing college choice often differed among selected disciplines, those factors receiving the highest mean rating rarely did. More research of this kind is suggested to better understand student needs so that institutional resources may be appropriately allocated.

Isolation and characterization of the inositol cyclic phosphate products of phosphoinositide cleavage by phospholipase C. Metabolism in cell-free extracts.

The phosphoinositides are metabolized by phospholipase C in response to hormone or agonist stimulation in many cell types to produce diglyceride and water-soluble inositol phosphates. We have recently shown that the phospholipase C reaction products include cyclic phosphate esters of inositol. One of these, inositol 1, 2-cyclic 4,5-trisphosphate, is active in promoting Ca2+ mobilization in platelets and in inducing changes in conductance in Limulus photoreceptors similar to those produced by light (Wilson, D. B., Connolly, T. M., Bross, T. E., Majerus, P. W., Sherman, W. R., Tyler, A., Rubin, L. J., and Brown, J. E. (1985) J. Biol. Chem. 260, 13496-13501. In the current study, we have examined the metabolism of the inositol phosphates. We find that both cyclic and non-cyclic inositol trisphosphates are metabolized by inositol 1,4,5-trisphosphate 5-phosphomonoesterase, to inositol 1,2-cyclic bisphosphate and inositol 1,4-bisphosphate, respectively. However, the apparent Km of the enzyme for the cyclic substrate is approximately 10-fold higher than for the non-cyclic substrate. These inositol bisphosphates are more slowly degraded to inositol 1,2-cyclic phosphate and inositol 1-phosphate, respectively. Inositol 1,2-cyclic phosphate is then hydrolyzed to inositol 1-phosphate, which in turn is degraded to inositol and inorganic phosphate by inositol 1-phosphate phosphatase. The human platelet inositol 1,2-cyclic phosphate hydrolase enzyme and a similar rat kidney hydrolase do not utilize the cyclic polyphosphate esters of inositol as substrates. These results suggest that the inositol cyclic phosphates and the non-cyclic inositol phosphates are metabolized separately by phosphatases to cyclic and non-cyclic inositol monophosphates. The cyclic monophosphate is then converted to inositol 1-phosphate by a cyclic hydrolase. We suggest that the enzymes that metabolize the inositol phosphates may serve to regulate cellular responses to these compounds.