Do virtual patients prepare medical students for the real world? Development and application of a framework to compare a virtual patient collection with population data.

BACKGROUND: An important aspect of virtual patients (VPs), which are interactive computer-based patient scenarios, is authenticity. This includes design aspects, but also how a VP collection represents a patient population and how a patient is presented in a VP scenario. Therefore, our aim was to analyze VP scenarios integrated into the combined internal medicine and surgery curriculum at the University of Munich (LMU) and compare the results with data from the population in Germany. METHOD: We developed a coding framework with four main categories: patient data, patient representation, diagnoses, and setting. Based on the framework we analyzed 66 VP and compared the results with data from the German healthcare system. RESULTS: Especially in the categories of patient data and patient representation, the VPs presented an unrealistic image of the real world; topics such as unemployment, disability, or migration background were almost non-existent. The diagnoses of the VPs and the onset of diseases were comparable with the healthcare data. CONCLUSIONS: An explanation for the lack of representativeness of the patient data and representation might be a trend to create VPs based on fictional patient stories with VP authors trying to minimize complexity and cognitive load for the students. We suggest raising awareness among VP authors concerning personalized representations of patients without overwhelming their students. Our framework can support educators to assess the authenticity and diversity of a VP collection.

Aminated ß-1,3-D-glucan has a dose-dependent effect on wound healing in diabetic db/db mice.

Inflammatory responses are common in diabetes and are operative in angiopathy, neuropathy, and wound healing. There are indications of incomplete macrophage activation in diabetes and reduced expression of growth factors. We have previously found that up to 15 topical applications of the macrophage-stimulant, aminated ß-1,3-D-glucan (AG), improved wound healing in db/db mice. The present open-label study was undertaken to examine dose-dependent effects of AG over 40 days in db/db mice. AG was given as a single dose (group 1), one dose every 10th day (group 2), five initial doses on consecutive days (group 3), and ≥15 doses (group 4). Controls were db/db mice receiving platelet-derived growth factor + insulin-like growth factor-1 (group 5), topical placebo (NaCl 9 mg/mL) and insulin (group 6), placebo (group 7), and a nondiabetic group receiving placebo (group 8). Seven to 14 animals were allocated to each group. Percentage wound closure 17 days after surgery in groups 1 and 2 were (mean ± standard error of the mean) 25.5 ± 5.3 and 32.2 ± 6.3, respectively. Corresponding closure in groups 3, 4, and 5 was 55.7 ± 5.0, 57.3 ± 5.0, and 55.6 ± 4.8, respectively (p < 0.05 vs. groups 1 and 2). Groups 6, 7, and 8 closed 32.0 ± 4.5, 38.2 ± 5.3, and 98.5 ± 0.4%, respectively. Significant association between the number of AG-dosages and wound closure indicates dose-related effects in db/db mice.

The role of TFPI in regulation of TF-induced thrombogenicity on the surface of human monocytes.

INTRODUCTION: Although the procoagulant reactivity of monocytes largely depends on expression and cell surface presentation of tissue factor (TF), little is known about the impact of tissue factor pathway inhibitor (TFPI) on regulation of TF function on the monocyte surface. MATERIALS AND METHODS: Peripheral blood mononuclear cells (PBMCs) were isolated from blood of healthy subjects and cryopreserved. We investigated TF and TFPI mRNA expression by reverse transcription-quantitative real-time PCR (RT-qPCR), surface presentation by flow cytometry and confocal microscopy, and TFPI-mediated regulation of TF functional activity on the surface of resting and LPS-stimulated PBMCs by TF activity assay and Calibrated Automated Thrombogram (CAT) assay. RESULTS: Unstimulated PBMCs contained nearly no TF, but detectable TFPI protein levels. TFPI mRNA levels were 2-fold higher than TF, and the TFPIα mRNA isoform expression was higher than TFPIß. LPS stimulation caused a parallel and sustained upregulation of both TFPI isoforms, concomitant with increased surface presentation of TFPI antigen. Stronger, but transient upregulation of TF mRNA and surface antigen was observed at 6hrs of LPS stimulation. After LPS stimulation TF and TFPI were co-localized in the same areas of the monocyte membrane. Pre-incubation of PBMCs with anti-TFPI IgG significantly enhanced TF activity, shortened Lag-time, and increased thrombin generation. TFPI-dependent inhibition of TF was more prominent in resting than in LPS-stimulated cells. CONCLUSIONS: Our results support the concept that surface TFPI is an important regulator of procoagulant reactivity of human monocytes.

Web-based collaborative training of clinical reasoning: a randomized trial.

BACKGROUND: Clinical reasoning skills are essential for medical practice. Problem-based collaborative learning via the internet might prove useful in imparting these skills. AIM: This randomized study assessed whether web-based learning (WBL) is superior to face-to-face problem-based learning (PBL) in the setting of a 6-week cardio-respiratory course. METHODS: During winter term 2007/08, all 148 fourth-year medical students enrolled in the 6-week course consented to be randomized in small groups to diagnose a patient complaining of dyspnoea either using a virtual collaborative online module or a traditional PBL session. Clinical reasoning skills were assessed by means of a key feature examination at the end of the course. RESULTS: No significant difference between the mean scores of both study groups was detected (p = 0.843). In virtual learning groups, costs for diagnostic tests were significantly correlated to the number of contributions to online group discussions (r = 0.881; p = 0.002). Evaluation data favored traditional PBL sessions over virtual collaborative learning. CONCLUSION: While virtual collaborative learning was as effective as traditional PBL regarding the acquisition of clinical reasoning skills, it was less well accepted than traditional PBL. Future research needs to determine the ideal format and time-point for computer-assisted learning in medical education.

Aminated beta-1,3-D-glucan improves wound healing in diabetic db/db mice.

Delayed wound healing in diabetes is caused by neuropathy, vascular changes, and impaired cellular response to the injury. Macrophages are crucial in normal wound healing, and impaired functions of these cells have been shown in diabetes. beta-1,3-D-glucans stimulate macrophage function. This open-label study was performed to see if aminated beta-1,3-D-glucan (AG) stimulates wound healing in diabetes. Four groups (1-4) of diabetic db/db mice and one nondiabetic control group, db/+(5) were studied: group 1 (n=11): topical AG; group 2 (n=10): topical AG and subcutaneous insulin; group 3 (n=14): topical placebo and subcutaneous insulin; group 4 (n=10): diabetic control (placebo); group 5 (n=12): normal control (placebo). At the end of the experiments fasting blood glucose and A1C were (mean +/- SE) as follows: Group 1: 30.5 +/- 1.9 mmol/L and 11.3 +/- 0.6%; group 2: 12.0 +/- 1.7 mmol/L and 8.0 +/- 0.6%; group 3: 15.4 +/- 2.4 mmol/L and 7.4 +/- 0.3%; group 4: 32.6 +/- 2.6 mmol/L and 12.3 +/- 0.6%; group 5: 7.2 +/- 0.4 mmol/L and 3.9 +/- 0.04%, respectively. The closed wound area was the same in group 1 (AG alone) and group 2 (AG plus insulin) after 17 days, 57.3 +/- 4.7 vs. 50.1 +/- 4.9% (p=0.7). The results of these two groups were superior to group 3 (insulin treatment alone, 32.0 +/- 4.3%, p<0.001) and diabetic controls (38.2 +/- 5.1%, p=0.001). The macrophage-stimulant AG improves wound healing in db/db mice.

European dissemination of a web- and case-based learning system for occupational medicine: NetWoRM Europe.

OBJECTIVE: Occupation has a large impact on health in Europe. In order to prevent and recognize occupational diseases, medical students and physicians should know about the potentially causal relationship between profession and diseases as well as the basic legal aspects of occupational medicine (OM). However, the opportunity of bedside teaching, the students' most favoured way of teaching, is limited. METHODS: One possibility to complete and improve traditional training in OM is computer-oriented case-based learning. Using the authoring system "CASUS" (INSTRUCT AG) cases can be created and handled without knowledge in computer sciences. RESULTS: So far, 19 cases have been created and evaluated by students of German universities. Due to the great efforts arising from the creation of such multimedia cases it is desirable and cost-effective to use the existing cases at several medical universities. Therefore, the Net-based Training in Work-Related Medicine (NetWoRM) project shares cases on an international base. In February and April 2005, 13 case-authors from 12 centres were trained in the basics of case creation during a 3 week programme in Munich. The overall evaluation of the participants indicated that this way of teaching case creation is very efficient. Up to now, nine cases were translated into English and five into Spanish. First implementation of the cases in Spain and Finland showed a good acceptance by the students but more evaluation has still to be done. CONCLUSION: Based on these results we conclude that exchange of case-based e-learning in OM is feasible and rewarding on an international base.