Implementation of team-based learning (TBL) in a second year medical school course: does prior experience with TBL improve the impact of this pedagogy?

BACKGROUND: We have shown that use of Team-based learning (TBL) in a first-year Infectious Diseases (ID) course improved final examination and course performance. Therefore, we implemented TBL in the second-year Women's Health (WH) course to improve acquisition of course content. We hypothesized that prior experience with TBL in the first-year of medical school would lead to a strong correlation between TBL performance in the first and second years. METHODS: Our study is a retrospective review of student TBL and final examination performance in the ID and WH courses. The ID course has weekly TBL exercises that cover all course material, while the WH course has one TBL that covers a small portion of the course material. Final examination and TBL individual readiness assurance test (iRAT) scores in the ID and WH courses from three classes (n = 226) were obtained with institutional review board approval. Statistical analyses were performed including comparisons of means and correlation studies. RESULTS: Average WH iRAT scores were significantly higher than ID iRAT scores (9.19 vs. 7.40,p < 0.01), and iRAT scores in both courses were highly correlated (r = 0.35,p < 0.01). When stratifying students based on WH course performance, in struggling students, iRAT but not final examination scores were higher in the WH course than the ID course (8.73 vs. 7.00,p < 0.01 and 82.45 vs. 80.51,p > 0.05, respectively). CONCLUSIONS: Our results suggest that prior experience with TBL improves TBL iRAT scores, especially in struggling students. Prior TBL experience is also associated with consistent iRAT performance between first- and second-year courses in high performing students.

Weekly team-based learning scores and participation are better predictors of successful course performance than case-based learning performance: role of assessment incentive structure.

BACKGROUND: Incentives for preparation and participation in case-based (CBL) and team-based learning (TBL) differ by virtue of differences in assessment, allowing us to evaluate the role these incentives play in preparation and participation in these activities as well as overall course performance. METHODS: Weekly TBL and CBL participation and performance as well as performance on the course final examination were recorded. Student participation was quantified and correlated with: (1) CBL preparation, participation, teamwork and completion of learning objectives scores, and (2) TBL individual readiness assurance test (iRAT) scores. RESULTS: Student final examination scores (n = 95) were more strongly correlated with TBL than CBL performance. No significant correlation was found between iRAT and CBL scores. Student participation was measured in 3 CBL groups (8 students/group) and 4 TBL teams (6 students/team). TBL participation was more strongly correlated with final examination scores than CBL participation. TBL participation was also correlated with iRAT scores. CBL scores for preparation, participation, teamwork and completion of learning objectives did not significantly correlate with iRAT scores or TBL participation. CONCLUSION: These results suggest that the assessment incentives and methods used in TBL result in student performance that better predicts performance on summative examinations.

Effectiveness of a Team-Based Learning exercise in the learning outcomes of a medical pharmacology course: insight from struggling students.

We have previously reported that multiple Team-Based Learning (TBL™) exercises in a 4-week pre-clinical medical school course improved final exam performance and significantly reduced the number of course failures. Here, we conducted a long-term study, with eight cohorts of first-year medical students, to determine whether the implementation of a single TBL individual readiness assessment test (iRAT) exercise in a 4-week medical school pharmacology course produces similar effects in overall course performance. We implemented a single TBL iRAT exercise that covered the subjects addressed during one week of the medical pharmacology course, with the four most recent cohorts of students matriculating at Cooper Medical School of Rowan University (n = 403). The first four cohorts matriculating at CMSRU did not participate in the TBL exercises (n = 266). Correlation of individual student TBL iRAT and final examination scores in the medical pharmacology course was compared to a second, unrelated first-year course (physiology) to control for variation in student performance between cohorts. We found that there was a significant moderate correlation between final examination and TBL iRAT scores (r = 0.49, p < 0.01, n = 403). Interestingly this moderate correlation was seen in students performing in the lower 25th percentile on the course final examination (r = 0.41, p < 0.01, n = 101) and negligible in students performing in the upper 25th percentile (r = 0.11, n = 101, p > 0.05). Implementation of the single TBL exercise also significantly reduced variance or range of student final examination performance compared to the group of the first four cohorts. These results suggest that implementation of a single TBL exercise, which covers only one week of content delivered in a 1-month medical pharmacology course, benefits first-year medical students by reducing the disparity in knowledge acquisition among them and providing a means to identify students who may struggle with course content.

Assessment of Pathology Learning Modules With Virtual Microscopy in a Preclinical Medical School Curriculum.

OBJECTIVES: To evaluate the ability of pathology modules to promote learning of pathology-related course content in a preclinical medical education curriculum. METHODS: Pathology modules were created for the "Hematology/Oncology" and "Women's Health" (WH) courses. Students were recruited over 2 consecutive academic years; cohorts 1 and 2 refer to 2 separate groups of students in years 1 and 2, respectively, of the study. Course performance data were collected. RESULTS: Use of pathology modules resulted in a statistically significant higher correlation between performance on the final examination and pathology-related questions in the Hematology/Oncology course and written examination and pathology-related questions in cohort 1 in the WH course. There was statistically significant improvement (P = .026) on pathology-related laboratory practical examination questions in the WH course for cohort 1, and no other statistically significant improvement for the other cohorts and examinations. The percentage of students completing all or part of the modules was highest in the WH course for cohort 1 (60%) compared with WH course cohort 2 (33%) and Hematology/Oncology cohort 1 (30%) and cohort 2 (39%). CONCLUSIONS: Pathology modules may improve acquisition and retention of pathology-related course content when used appropriately.

First year medical student performance on weekly team-based learning exercises in an infectious diseases course: insights from top performers and struggling students.

BACKGROUND: In Team-Based Learning (TBL) preparation of relevant coursework during self-directed learning time is evaluated by the individual readiness assurance test (iRAT). We recently reported that student performance on iRATs is strongly correlated with final examination scores in an infectious diseases (ID) course. We now investigated how student preparation for each individual iRAT exercise relates to course performance. METHODS: Two-hundred and sixty medical students were enrolled in this three-year study. Student TBL iRAT scores were collected and correlated with final examination scores using Kruskal-Wallis One-Way ANOVA and Newman-Keul's statistical methods. RESULTS: Students performing in the upper and middle 33rd percentile on the final examination showed highly significant (p < 0.01) weekly improvements in their iRAT scores. However, students performing in the lower 33rd percentile did not show improvement in their iRAT scores until the last week of the course. Although there was a highly significant correlation between final examination and iRAT scores amongst all students participating in the study, this correlation was stronger in students performing in the lower 33rd percentile. CONCLUSIONS: Our data suggest that students who do not consistently prepare for TBL, as evidenced by low iRAT scores, exhibit poorer performance on the final examination. This lack of preparation likely interferes with the efficacy of this learning method. iRAT scores can also be used for early identification of struggling students in need of additional supports. Additionally, changes in TBL incentive structure may provide more tangible rewards for pre-class preparation in particular for struggling students.

A Novel Tool for Problem-Based Learning Case Review.

The success of problem-based learning (PBL) depends on case quality and facilitator preparation. We developed a literature-based tool, the R2ICE form, to improve faculty case review. Its implementation and survey of end users showed the tool was expedient and advantageous. Literature-based tools can guide PBL construction and improve case development.

Implementation of Team-Based Learning: a Tale of Two New Medical Schools.

Team-based learning (TBL) is gaining popularity at medical schools transitioning from lecture-based to active learning curricula. Here, we review challenges and opportunities faced in implementing TBL at 2 new medical schools. We discuss the importance of using meaningful TBL grades as well as the role TBL plays in developing critical reasoning skills and in early identification of struggling students. We also discuss how the concurrent use of learning strategies with different incentive structures such as problem- and case-based learning could foster the development of well-rounded physicians. We hope this monograph helps and even inspires educators implementing TBL at their schools.

Cost per Case Mix Index-Adjusted Hospital Day as a Measure of Effective Laboratory Utilization Efforts in a Growing Academic Medical Center.

OBJECTIVES: Traditional laboratory utilization measures are unable to detect the results of small-scale utilization improvement efforts in a background of rising patient volumes and acuity. However, accurate assessment is necessary to document effectiveness of these efforts. METHODS: Test menu changes, physician education, and laboratory utilization feedback were used to address costs and overused tests. Effectiveness was evaluated using cost/case mix index (CMI)-adjusted hospital day and inpatient tests/CMI-adjusted discharge. These metrics were compared with the more traditional measures of cost/test and inpatient tests/discharge. RESULTS: Cost/CMI-adjusted hospital day and inpatient tests/CMI-adjusted discharge better demonstrated the impact of utilization improvement efforts compared with more traditional measures because they account for changes in patient volume and acuity. CONCLUSIONS: Cost/CMI-adjusted hospital day and tests/CMI-adjusted discharge show the effectiveness of laboratory utilization efforts despite increasing patient volume and acuity.

A Novel Grading Strategy for Team-Based Learning Exercises in a Hands-on Course in Molecular Biology for Senior Undergraduate Underrepresented Students in Medicine Resulted in Stronger Student Performance.

We developed a hands-on course in molecular biology for undergraduate underrepresented in medicine (URM) students. To incentivize student preparation for team-based learning (TBL) activities, we implemented a novel grading schema that requires a minimum individual readiness assurance test (iRAT) score to share the team group readiness assurance test (gRAT) score. Fifty-one students participated in this 2-year study and were divided in teams of five or six students that worked throughout the course on a unique, hands-on project and also participated in TBL exercises. In the laboratory sessions, students isolated RNA from cultured neuronal cells, synthesized complementary DNA (cDNA), and used gene sequencing to identify a gene relevant in human health and disease. Student participation in TBL was quantified and correlated with performance on individual iRATs and the course final examination. We found that implementation of the novel incentive structure lowered the variance of TBL scores (iRAT and gRAT) and strengthened the correlation between final examination scores and either iRAT scores or percentage participation in TBL. Subgroup analysis showed that with the new grading schema, stronger students benefited more from the gRAT exercises, while more poorly performing students were better helped by individual preparation prior to the iRAT exercise. A combination of two active learning strategies, TBL and hands-on sessions, may strengthen student acquisition of course content and promote teamwork skills. The new incentive structure seems to reduce the disparity in knowledge amongst our students as demonstrated by the reduced iRAT and gRAT score variances. © 2018 International Union of Biochemistry and Molecular Biology, 47(2): 115-123, 2019.

Acceleration of diabetic wound healing with adipose-derived stem cells, endothelial-differentiated stem cells, and topical conditioned medium therapy in a swine model.

OBJECTIVE: The purpose of our study was to investigate the effect of adipose-derived stem cells (ASCs), endothelial-differentiated ASCs (EC/ASCs), and various conditioned media (CM) on wound healing in a diabetic swine model. We hypothesized that ASC-based therapies would accelerate wound healing. METHODS: Diabetes was induced in four Yorkshire swine through intravenous injection of streptozotocin. ASCs were harvested from flank fat and cultured in either M199 or EGM-2 medium. A duplicate series of seven full-thickness dorsal wounds were surgically created on each swine. The wounds in the cellular treatment group underwent injection of low-dose or high-dose ASCs or EC/ASCs on day 0, with a repeat injection of one half of the initial dose on day 15. Wounds assigned to the topical CM therapy were covered with 2 mL of either serum-free M199 primed by ASCs or human umbilical vein endothelial cells every 3 days. Wounds were assessed at day 0, 10, 15, 20, and 28. The swine were sacrificed on day 28. ImageJ software was used to evaluate the percentage of wound healing. The wounded skin underwent histologic, reverse transcription polymerase chain reaction, and enzyme-linked immunosorbent assay examinations to evaluate markers of angiogenesis and inflammation. RESULTS: We found an increase in the percentage of wound closure rates in cell-based treatments and topical therapies at various points compared with the untreated control wounds (P < .05). The results from the histologic, messenger RNA, and protein analyses suggested the treated wounds displayed increased angiogenesis and a diminished inflammatory response. CONCLUSIONS: Cellular therapy with ASCs, EC/ASCs, and topical CM accelerated diabetic wound healing in the swine model. Enhanced angiogenesis and immunomodulation might be key contributors to this process.

Evaluation of the role of incentive structure on student participation and performance in active learning strategies: A comparison of case-based and team-based learning.

BACKGROUND: Student participation is important for the success of active learning strategies, but participation is often linked to the level of preparation. At our institution, we use two types of active learning activities, a modified case-based learning exercise called active learning groups (ALG) and team-based learning (TBL). These strategies have different assessment and incentive structures for participation. Non-cognitive skills are assessed in ALG using a subjective five-point Likert scale. In TBL, assessment of individual student preparation is based on a multiple choice quiz conducted at the beginning of each session. METHODS: We studied first-year medical student participation and performance in ALG and TBL as well as performance on course final examinations. RESULTS: Student performance in TBL, but not in ALG, was strongly correlated with final examination scores. Additionally, in students who performed in the upper 33rd percentile on the final examination, there was a positive correlation between final examination performance and participation in TBL and ALG. This correlation was not seen in students who performed in the lower 33rd percentile on the final examinations. CONCLUSIONS: Our results suggest that assessments of medical knowledge during active learning exercises could supplement non-cognitive assessments and could be good predictors of performance on summative examinations.

Fatal Gastrointestinal Hemorrhage in a Patient with Brunner's Gland Hyperplasia.

Brunner's gland hyperplasia is a rare cause of duodenal mass and gastrointestinal hemorrhage. Imaging and esophagoduodenoscopic evaluation of this condition are frequently consistent with a duodenal malignancy often resulting in surgical resection. However, the malignant potential of these lesions is still unknown, and most are benign. We report the case of a 74-year-old man who presented with fatal gastrointestinal bleeding and esophagoduodenoscopy findings consistent with a duodenal mass and mucosal ulceration. At autopsy, histologic examination of the mass revealed Brunner's gland hyperplasia with associated ulcer formation. In this report, we review the findings associated with this case as well the literature regarding presentation, clinical associations, and treatment of Brunner's gland hyperplasia.

Success of referral to genetic counseling after positive lynch syndrome screening test.

PURPOSE: Lynch syndrome (LS) is a hereditary condition that increases one's risk of developing colorectal, endometrial, and other extracolonic cancers. MD Anderson Cancer Center at Cooper implemented a reflex screening protocol for DNA mismatch repair (dMMR) deficiency. Those with findings suspicious for LS were referred for genetic counseling (GC). Our goal was to assess compliance with GC and factors associated with successful follow-up. METHODS: Immunohistochemistry (IHC) for the MMR proteins MSH2, MLH1, MSH6, and PMS2 was performed on all colorectal tumor resections from patients ≤70 years old and all stage II cancers. Tumors with loss of MLH1/PMS2 were subsequently tested for BRAF mutation or MLH1 promoter methylation to identify tumors with likely epigenetic inactivation of MLH1. Patients with loss of MLH1/PMS2 without BRAF mutations or with absence of MLH1 promoter methylation and those with loss of MSH2/MSH6 were referred to GC. Compliance with GC was assessed. RESULTS: Between March 2014 and August 2016, 203 tumors were tested by IHC. Fifteen (7.4%) patients had abnormal MMR protein expression patterns in the absence of BRAF mutation or MLH1 promoter methylation suggestive of possible LS. GC compliance was 35.7% overall and 85.7% in those with family history of LS-associated cancers. CONCLUSIONS: Overall, GC compliance was relatively low in our study. Interestingly, patients with a strong family history of LS-associated neoplasms were more likely to pursue GC. In the future, assessing and addressing barriers to seeking GC will provide opportunities to improve patient care through increased identification of patients with cancer predisposition syndromes.

Does team-based learning improve performance in an infectious diseases course in a preclinical curriculum?

OBJECTIVES: To examine whether introduction of Team-based Learning (TBL) improves student learning resulting in improved performance on final examination questions and decreased failures in an infectious diseases course. METHODS: To improve mastery of course content, we designed an intervention, which provided weekly TBL exercises in study years 2 and 3 to review concepts presented during didactic lectures and laboratory exercises.  The remaining course structure and content was essentially unchanged. All students taking the course (n=50 in year 1, n=64 in year 2, and n=72 in year 3) participated in this study. Student final examination performance and performance on individual final examination questions were collected and analyzed for changes in response to the study intervention. RESULTS: Addition of weekly TBL exercises improved student performance on the course final examination as demonstrated by a statistically significant increase in the distribution of correct answer percentages for questions in common between the final examinations in years 1 and 2 and between years 1 and 3 (t(99) = 3.1454, p<0.05 and t(99) = 4.1268, p<0.01, respectively; Student-Newman-Keuls).  There was no statistical difference (t(97) = 0.9814, p> 0.05; Student-Newman-Keuls) in the distribution of correct answer percentages between years two and three. There was also a decrease in final examination failures in years two and three. CONCLUSIONS: The results suggest that TBL could be used to improve mastery and retention of course content in a preclinical infectious diseases course. Weekly exercises allow students to identify and ameliorate weaknesses in understanding and make adjustments early in the course.

Impact of weekly feedback on test ordering patterns.

OBJECTIVES: We examined the impact of weekly feedback reports on the test-ordering behavior of internal medicine residents. STUDY DESIGN: Retrospective analysis of a performance improvement effort. METHODS: In a large, urban, academic medical center, we extracted raw data on every inpatient laboratory test ordered by all internal medicine residents during two 26-week time periods. The pre-intervention phase established baseline ordering volume as each resident rotated through the various clinical services. The intervention consisted of a 1-hour educational seminar detailing the potential harm and costs of laboratory overutilization followed by the post intervention phase, which consisted of weekly feedback reports graphically illustrating individual versus group ordering patterns, where the identity of individual residents was protected. The total numbers of tests ordered during the 2 phases were compared using an independent t test. RESULTS: During the post intervention phase, we observed a net reduction of 21% in tests ordered-an average of 941 tests per week-with the greatest reduction in the chemistry section of the laboratory, followed by hematology, coagulation, and all others combined. This reduction in test volume corresponded to a $1.3 million reduction in charges. CONCLUSIONS: Providing physicians-in-training with a weekly feedback report detailing their test ordering volume in comparison with those of their peers is an effective method for reducing laboratory overutilization. Benefits to our approach include maintaining physician autonomy without alteration of existing infrastructure or disclosure of test fees.

Increased SIAH expression predicts ductal carcinoma in situ (DCIS) progression to invasive carcinoma.

Hyperactivated HER2/Neu/EGFR/RAS signaling is a major growth-promoting pathway known to drive cellular transformation and oncogenesis in breast cancers. HER2 amplification is detected in ~20% of all human breast cancer and is quite prevalent (up to 49%) in ductal carcinoma in situ (DCIS). The E3 ubiquitin ligase SIAH is considered a key downstream "gatekeeper" required for proper HER2/EGFR/RAS signal transduction. Formalin-fixed, paraffin-embedded resection specimens from 65 patients with DCIS treated with wide excision only were stained with an anti-SIAH antibody, and the percentage of tumor and normal adjacent tissue cells positive for SIAH nuclear staining were recorded. Statistical analysis was performed comparing SIAH staining in tumor cells to disease recurrence, histologic type, necrosis, hormone receptor status, and Her2/neu status, as well as nuclear grade. Correlation of SIAH expression in tumor cells with SIAH expression in normal adjacent tissue and age was also examined. Expression levels of SIAH in tumor cells was significantly higher in specimens from patients with recurrence (median = 19%) as compared to patients without recurrence (7%) (P < 0.001). There was also significantly increased SIAH expression in tumors with more aggressive features including comedo morphology (13.5% in comedo vs. 7% in other histologic types, P = 0.014). No significant association was observed between SIAH expression and estrogen receptor, progesterone receptor, and Her2/neu status. There was a significant correlation between SIAH expression in tumors and normal adjacent tissue (Spearman correlation = 0.58, P < 0.001) as well as between SIAH expression in normal adjacent tissue and patient age (Spearman correlation = -0.59, P < 0.001). No significant correlation was identified between patient age and SIAH expression in tumors (Spearman correlation = -0.23, P = 0.067). In conclusion, SIAH may represent a useful prognostic biomarker that predicts DCIS progression to invasive breast cancer.

Graft-versus-Host Disease-Like Pattern in Mycophenolate Mofetil Related Colon Mucosal Injury: Role of FISH in Establishing the Diagnosis.

Mycophenolate mofetil (CellCept®), a commonly used immunosuppressive drug in solid organ transplantation, has recently been shown to cause graft-versus-host disease (GVHD)-like changes in the gastrointestinal tract. On rare occasions, true GVHD has also been documented in the gastrointestinal tract of solid organ transplant patients. Because the treatment for these two entities is different, i.e. removal of the offending agent versus the administration of steroids, proper identification of the cause is imperative. We present a case of mycophenolate mofetil colitis mimicking grade I GVHD of the gut. In our study, we used fluorescence in situ hybridization for the Y chromosome to document the lack of male donor lymphocytes in the female recipient colon biopsy. We suggest that molecular techniques including fluorescence in situ hybridization could be used to discriminate between MMF-related colitis and true GVHD in order to help guide therapy.

Abundant anti-apoptotic BCL-2 is a molecular target in leukaemias with t(4;11) translocation.

Chemotherapy resistance from imbalanced apoptosis regulation may contribute to poor outcome in leukaemias with t(4;11). Anti-apoptotic BCL-2 expression and target modulation were characterized in cell lines with t(4;11) and BCL-2 expression was examined in MLL and non-MLL infant/paediatric leukaemia cases by Western blot analysis and/or real-time polymerase chain reaction. Cytotoxicity of Genasensetrade mark (Oblimersen Sodium, G3139) alone or combined with cytotoxic drugs was assessed by MTT [(3-4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide] assays of the cell lines, applying pharmacostatistical response surface modelling of drug interactions. Apoptosis and cell cycle were evaluated by flow cytometry in RS4:11 cells. Primary leukaemias and cell lines with t(4;11) expressed abundant BCL2 mRNA and protein. Variable, sometimes substantial BCL2 mRNA was detected in other leukaemia subtypes. G3139 reduced BCL2 mRNA and protein in RS4:11 cells. The most sensitive cell line to single-agent G3139 was RS4:11. Low G3139 concentrations sensitized RS4:11 and MV4-11 cells to select anti-leukaemia cytotoxic drugs. In RS4:11 cells, combining G3139 with doxorubicin (ADR) increased active caspase 3 and TUNEL staining compared to ADR alone, indicating greater apoptosis, and G3139 increased S-phase progression. The abundant BCL-2 affords a molecular target in leukaemias with t(4;11). G3139 exhibits preclinical activity and synergy with select cytotoxic agents in RS4:11 and MV4-11 cells, and these effects occur through apoptosis.

Inhibition of retinal neovascularization by intraocular viral-mediated delivery of anti-angiogenic agents.

Neovascularization characterizes diabetic retinopathy and choroidal neovascularization associated with age-related macular degeneration, the most common causes of severe visual loss in the developed world. Gene transfer to the eye using adeno-associated viral (AAV) vectors is a promising new treatment for inherited and acquired ocular diseases. We used an AAV vector with rapid onset and high levels of gene expression in the retina to deliver three anti-angiogenic factors (pigment epithelium-derived factor, tissue inhibitor of metalloproteinase-3, and endostatin) to the eyes of mice in a mouse model of retinopathy of prematurity. All three vectors inhibited ischemia-induced neovascularization.