Opportunities for pedagogical change in Turkish medical education revealed in the wake of the COVID-19 pandemic.

Phenomenon: As the first stage of a large-scale educational design research (EDR) study focused on the complex problem of providing authentic experiential "hands-on, minds-in" learning opportunities online during a pandemic or other exigency, we conducted a literature review and we interviewed Turkish academic staff and students about their experiences during the first year of the COVID-19 Pandemic. ApproachWe interviewed faculty members, faculty members of medical education departments, and medical students from both public and private medical schools in Türkiye between October 1 and December 31, 2020. Working in pairs, we analyzed the transcripts of 49 interviews using open qualitative coding methods with satisfactory levels of coefficients of agreement. FindingsWe defined six major themes from the qualitative analysis: 1) Fear and concern were the most common reactions when first encountering the pandemic; 2) Teaching methods during the pandemic were primarily unidirectional from faculty to students. This largely one way transmission of information occurred both synchronously and asynchronously; 3) Technological support during the pandemic shutdowns was found to be challenging for both faculties and students; 4) Evaluation of learning during the pandemic was opportunistic and had questionable rigor; 5) Healthy communication was valued by both faculty and students using an array of different tools including social media; and 6) The pandemic had both negative and positive impacts on the educational processes experienced by students and provided by faculty and resulted in recommendations for new approaches to teaching and learning in the future. Medical students were primarily concerned about the susceptibility to COVID-19 of themselves and others, and how the pandemic would affect their progress toward completing their studies. Faculty were primarily concerned about the capacity of online learning to provide clinical learning opportunities and the difficulties of assessing student clinical skills using online modalities. Medical education specialists were primarily concerned about the quality of educational opportunities offered online. InsightsOur findings were similar to other studies conducted in the USA, China, United Kingdom, and other countries. However, the interviews revealed interest among faculty and medical education specialists for further investigation of experiential or active learning models that could be applied in medical education regardless of whether the delivery mode is face-to-face, online, or most likely, blended. In the next stage of our larger scale EDR study, we will design and construct prototype learning environments that incorporate experiential, active, and authentic learning design principles.

Serum NADPH oxidase concentrations and the associations with iron metabolism in relapsing remitting multiple sclerosis.

BACKGROUND: Overproduction of reactive oxygen species (ROS) and impaired iron metabolism are considered to be possible factors in the pathogenesis of Multiple sclerosis (MS). Nicotinamide adenine dinucleotide phosphate (NADPH) oxidases are the primary sources of regulated ROS production. The NADPH oxidase (NOX) family consists of seven catalytic homologues, NOX1-5 and two dual oxidases. NOX1 and NOX5 are associated with endothelial dysfunction and inflammation but NOX4 has a protective effect on vascular function. The aims of this study were to investigate the status of NOX1, NOX4 and NOX5 and its relationship with serum iron metabolism biomarkers in relapsing-remitting MS patients. METHODS: The study included 53 RRMS patients and 45 control subjects. Serum NOX1,4,5, ferritin, iron, unbound-iron binding capacity, C-reactive protein (CRP), white blood count (WBC) and erythrocyte sedimentation rate (ESR) levels were measured in all the study subjects. RESULTS: Higher serum NOX5 (p < 0.0001), CRP (p = 0.014), ferritin (p = 0.040) and lower serum NOX4 (p < 0.0001) and iron (p = 0.013) concentrations were found in the patients than in controls. No correlation was found between NOXs, CRP, WBC, ESR and iron metabolism biomarkers in patients. CONCLUSION: Our data suggest that increased NOX5 expression and decreased levels of NOX4 might be related with oxidative stress related vascular changes in MS patients. These findings provide future opportunities to combat MS with separately target individual NOX isoforms.

Monocyte/high-density lipoprotein ratio predicts the mortality in ischemic stroke patients.

OBJECTIVE: The inflammatory process is a very important stage in the development and prognosis of acute ischemic stroke (AIS). The monocyte to high-density lipoprotein (HDL) ratio (MHR) is accepted as a novel marker for demonstrating inflammation. However, the role of MHR as a predictor of mortality in patients with AIS remains unclear. METHODS: We retrospectively enrolled 466 patients who were referred to our clinic within the first 24hours of symptom presentation and who were diagnosed with AIS between January 2008 and June 2016. Four hundred and eight controls of similar age and gender were also included. The patient group was classified into two groups according to 30-day mortality. The groups were compared in terms of monocyte counts, HDL, and MHR values. RESULTS: The patient group had significantly higher monocyte counts and lower HDL levels; therefore, this group had higher values of MHR compared to controls. Additionally, the monocyte count and MHR value were higher, and the HDL level was lower in non-surviving patients (p<0.001). The MHR value was also observed as a significant independent variable of 30-day mortality in patients with AIS (p<0.001). The optimum cut-off value of MHR in predicting the 30-day mortality for patients with AIS was 17.52 (95% CI 0.95-0.98). CONCLUSION: Our study demonstrated that a high MHR value is an independent predictor of 30-day mortality in patients with AIS.

A DWI study of the contralateral hemisphere in cerebral hemiatrophy.

BACKGROUND AND AIM: Cerebral hemiatrophy (CHA) is a congenital or acquired loss of volume in one hemisphere of the brain. The MR findings of the affected hemisphere have been a subject of many studies, however, the contralateral hemisphere has not been investigated. There is, in fact, an integrity between two hemispheres of the brain through transverse connection fibers. The aim of this study is to investigate the changes in the contralateral hemisphere in CHA. MATERIALS AND METHODS: Apparent diffusion coefficient (ADC) values were measured in deep gray and white matter areas in the normal-appearing contralateral hemisphere in 23 patients with CHA, in order to get in vivo information about a possible Wallerian degeneration or microstructural changes. Results were compared with the control group. RESULTS: Normal ADC values were encountered in the contralateral hemisphere in all (100%) CHA patients. The difference between the ADC values of gray and white matter in CHA patients and the control group was not statistically significant. CONCLUSION: Normal ADC values in the contralateral hemisphere in CHA patients suggests a compensatory mechanism restricting Wallerian degeneration or diffusion alteration.

Serum 25-hydroxyvitamin D levels in restless legs syndrome patients.

OBJECTIVE: Restless legs syndrome is characterised by discomfort during rest and an urge to move the limbs that is accompanied by abnormal sensations. Studies on disease pathophysiology have focused on dopaminergic dysfunction. Vitamin D may play an important role in dopamine function, but the role of vitamin D in restless legs syndrome has not been examined. We compared the serum vitamin D levels of RLS patients and matched controls and explored the correlation of plasma vitamin D levels with disease severity. PATIENTS/METHODS: We measured serum 25-hydroxyvitamin D levels in 36 patients with restless legs syndrome and compared them to 38 healthy control subjects. RESULTS: The mean serum 25-hydroxyvitamin D levels were 7.31±4.63 ng/mL in female patients with restless legs syndrome and 12.31±5.27 ng/mL in female control subjects (p=0.001). We found a significant inverse correlation between vitamin D levels and disease severity in females (p=0.01, r=-0.47). CONCLUSION: The mean serum vitamin D levels were lower in female patients with restless legs syndrome. Low vitamin D levels may cause dopaminergic dysfunction in restless legs syndrome patients. Further studies are required to confirm these results.

Consciousness disturbance and poikilothermia revealing brain involvement in neuromyelitis optica.

A 21-year-old woman was admitted due to altered mental status and hypothermia. The patient had a diagnosis of neuromyelitis optica (NMO) for 12 years and she was positive for serum anti-aquaporin 4 antibody. On admission, physical examination revealed coma with decerebration rigidity and poikilothermia. Magnetic resonance images of the brain revealed widespread, gadolinium enhancing lesions in the periventricular areas and the diencephalic structures. Laboratory investigations revealed hyponatremia and hypothyroidism. The patient was treated with high dose steroids. Both symptomatic and asymptomatic brain lesions may develop in patients with NMO. However, poikilothermia has not been reported in patients with NMO before.

The role of event-related potentials in subclinical cognitive dysfunction in essential tremor.

Several studies have reported that patients with essential tremor (ET) may also have mild cognitive impairment. Event-related potentials (ERPs) involve cognitive processes in the brain. No detailed investigation has been conducted into auditory ERPs (AERPs) to detect the subclinical cognitive dysfunction in patients with ET. Therefore, this study aimed to clarify the usefulness of AERPs in ET-related cognitive impairment. The AERPs were obtained by using an oddball paradigm in 27 patients with ET and 27 age-matched control subjects. The mean latency and amplitude of the ERPs were compared between the two groups. The correlation between disease duration and the mean values of all components of the potentials was assessed. The association between tremor severity and potentials was also evaluated. The patients with ET showed significant prolongation of all components of the ERP latencies at each electrode site. The N200 and P300 amplitudes were reduced in the ET group. Interestingly, the significant prolongation of N100 and N200 latencies correlated with disease duration, and N200 latencies appeared significantly longer in patients with severe tremor. Significant differences were found between the components of the AERPs and tremor severity and disease duration. This finding implies that ERPs may be useful in evaluating the cognitive functions in ET and that those AERP abnormalities may appear before clinical presentation.

Cerebral venous sinus thrombosis presenting as transient ischemic attacks in a case with homozygous mutations of MTHFR A1298C and CG677T.

We report a case with recurrent, transient attacks of slurred speech, weakness, and numbness of the right half of the face and the right arm without seizure activity, accompanied by headache and double vision. Neurologic examination revealed bilateral papilledema and right abducens palsy. Brain magnetic resonance imaging revealed thrombosis of the dural venous sinuses and the cortical veins, with no evidence of parenchymal lesion. Homozygous mutations were found for methylenetetrahydrofolate reductase (MTHFR) A1298C and MTHFR CG677T. Anticoagulation with heparin and warfarin resulted in prompt cessation of the transient attacks, as well as the signs and symptoms of increased intracranial pressure. This report documents that, although rare, transient ischemic attacks can result from cerebral venous thrombosis.

Previous antiplatelet use is associated with hematoma expansion in patients with spontaneous intracerebral hemorrhage.

BACKGROUND: Patients with intracerebral hemorrhage (ICH) often report the use of antiplatelet medications, even more commonly than the use of anticoagulants. The effect of antiplatelet drugs on the course of ICH is controversial. In this study, our aim was to determine the effects of previous antiplatelet therapy on admission hematoma volume and hematoma expansion in patients with spontaneous ICH. METHODS: A consecutive series of patients with a diagnosis of ICH who underwent brain computed tomographic (CT) scans within 12 hours of symptom onset and a follow-up CT scan within 72 hours were included in the study. Hematoma volume was calculated by using the ABC/2 method on admission and follow-up images. Univariate and multivariate analyses were performed to determine the independent role of antiplatelet use on baseline hematoma volume and hematoma expansion (defined as an increase in hematoma volume >12.5 mL or 33% of the baseline ICH volume). RESULTS: A total of 153 patients were included in the study. Fifty-two (34%) patients were using antiplatelet drugs at the time of symptom onset. Antiplatelet users tend to have a larger baseline hematoma volume; however, this difference failed to reach statistical significance (P = .17). Antiplatelet therapy was found to be a significant determinant of substantial hematoma expansion, both in univariate and multivariate analyses (P < .01). CONCLUSIONS: Previous antiplatelet use significantly contributes to hematoma expansion in patients with ICH.

Anti-GQ1b-Negative Miller Fisher Syndrome with Acute Areflexic Mydriasis and Cholinergic Supersensitivity.

Miller Fisher syndrome is a rare variant of Guillain-Barré syndrome and it is characterised by ophthalmoplegia, ataxia, and areflexia. Pupillomotor involvement occurs in approximately half of the patients with the disorder. The authors report a patient with acute areflexic mydriasis, external ophthalmoplegia, areflexia, and ataxia. Although the pupils were unreactive to light and near stimuli, administration of 0.1% pilocarpine resulted in marked miosis, suggesting cholinergic supersensitivity. Antibodies against GM1, GD1b, and GQ1b were negative. This is the first report of acute areflexic mydriasis with cholinergic supersensitivity in anti-GQ1b-negative Miller Fisher syndrome.

Isolated cortical vein thrombosis after epidural anesthesia: report of three cases.

Cerebral venous thrombosis rarely develops after lumbar puncture and spinal anesthesia with accidental dural puncture, however, occurrence of isolated cortical vein thrombosis after epidural anesthesia is extremely rare. We report three cases who developed postural headache and isolated cortical vein thrombosis after epidural anesthesia. We postulate that intracranial hypotension is the cause of compensatory venous dilatation and resultant thrombosis.

Sydenham chorea and Hashimoto thyroiditis: an unusual association.

Sydenham chorea is an immune-mediated neuropsychiatric disorder associated with group A beta-hemolytic streptococci infection. The authors present a 12-year-old female patient with Sydenham chorea and Hashimoto thyroiditis. Although Hashimoto thyroiditis has been associated with other autoimmune disorders, the association of Sydenham chorea and Hashimoto thyroiditis has not been previously reported. Immunological processes are suggested to be implicated in the pathogenesis of this association; however, the exact mechanism remains unclear.