Cambios curriculares basados en la enseñanza por problemas y entrenamiento en la comunidad: experiencia cubana en Suráfrica / Curricular changes based on problems-based learning and community-based education: the cuban experience in south Africa

Introducción: la escuela de Medicina de la Facultad de Ciencias de la Salud de la Universidad Walter Sisulu (antigua Universidad de Transkei), realizó tres grandes cambios del plan de estudios de la Carrera durante los últimos 15 años.Objetivo: hacer una valoración sobre el cambio de paradigma para la implementación exitosa del nuevo modelo de médico comunitario; Analizar las formas de enseñanza utilizadas (basada en problemas y en la comunidad) durante dicho periodo de estudio y comentar los hechos más relevantes. Material y métodos: se realizó un estudio longitudinal descriptivo de los cambios del plan de estudio de la Carrera de Medicina, y el total de estudiantes matriculados en el tercer año de la Carrera en particular (MB ChB 3), desde 1998 hasta 2011; en la Escuela de Medicina de la Facultad de Ciencias de la Salud de la Universidad Walter Sisulu. Se describieron los retos originados y la dinámica de los cambios en los planes de estudio; así como los ajustes paralelos utilizados para mantener los estándares cualitativos.Resultados: la Enseñanza Basada en Problemas {Problem Based Learning:PBL, siglas en inglés) y servicios basados en la comunidad (Community-Based Education:COBES, siglas en inglés) son la piedra angular de la enseñanza de las Ciencias de la Salud en la Universidad Walter Sisulu.Conclusiones: el trabajo en equipo y la integración de los miembros del colectivo de todas las disciplinas involucradas cada año es crucial para lograr resultados exitosos en la Carrera de Medicina en general y su tercer año en particular(AU)

Introduction: the school of medicine of the Faculty of Health Sciences at Walter Sisulu University (former University of Transkei) performed three major changes in the medical curriculum during the past 15 years. Objectives: to analyze the teaching and learning approaches (Problem-Based Learning and Community-Based Education) during the timeframe of the study and comment on the most remarkable aspects. Material and methods: a longitudinal, descriptive study of the curricular changes of the MB ChB programme, as well as the number of students enrolled in the MB ChB 3 programme per academic year since 1998 up to 2011 were performed. The challenges raised as well as the bases of the changes in the curriculum were describes, as well as the parallel adjustments used, in order to preserve the qualitative standard obtained already. Results: problem-Based Learning (PBL) and Community Oriented Based Education and Services (COBES) are the cornerstone of the teaching and learning health sciences at Walter Sisulu University. Conclusions: integration and working as team among the staff of all involved disciplines per academic year is crucial to reach successful results within the medical curriculum in general and MB ChB 3 in particular(AU)

Cambios curriculares basados en la enseñanza por problemas y entrenamiento en la comunidad: experiencia cubana en Suráfrica / Curricular changes based on problems-based learning and community-based education: the cuban experience in south Africa

Introducción: la escuela de Medicina de la Facultad de Ciencias de la Salud de la Universidad Walter Sisulu (antigua Universidad de Transkei), realizó tres grandes cambios del plan de estudios de la Carrera durante los últimos 15 años. Objetivo: hacer una valoración sobre el cambio de paradigma para la implementación exitosa del nuevo modelo de médico comunitario; Analizar las formas de enseñanza utilizadas (basada en problemas y en la comunidad) durante dicho periodo de estudio y comentar los hechos más relevantes. Material y métodos: se realizó un estudio longitudinal descriptivo de los cambios del plan de estudio de la Carrera de Medicina, y el total de estudiantes matriculados en el tercer año de la Carrera en particular (MB ChB 3), desde 1998 hasta 2011; en la Escuela de Medicina de la Facultad de Ciencias de la Salud de la Universidad Walter Sisulu. Se describieron los retos originados y la dinámica de los cambios en los planes de estudio; así como los ajustes paralelos utilizados para mantener los estándares cualitativos. Resultados: la Enseñanza Basada en Problemas {Problem Based Learning:PBL, siglas en inglés) y servicios basados en la comunidad (Community-Based Education:COBES, siglas en inglés) son la piedra angular de la enseñanza de las Ciencias de la Salud en la Universidad Walter Sisulu. Conclusiones: el trabajo en equipo y la integración de los miembros del colectivo de todas las disciplinas involucradas cada año es crucial para lograr resultados exitosos en la Carrera de Medicina en general y su tercer año en particular.

Introduction: the school of medicine of the Faculty of Health Sciences at Walter Sisulu University (former University of Transkei) performed three major changes in the medical curriculum during the past 15 years. Objectives: to analyze the teaching and learning approaches (Problem-Based Learning and Community-Based Education) during the timeframe of the study and comment on the most remarkable aspects. Material and methods: a longitudinal, descriptive study of the curricular changes of the MB ChB programme, as well as the number of students enrolled in the MB ChB 3 programme per academic year since 1998 up to 2011 were performed. The challenges raised as well as the bases of the changes in the curriculum were describes, as well as the parallel adjustments used, in order to preserve the qualitative standard obtained already. Results: problem-Based Learning (PBL) and Community Oriented Based Education and Services (COBES) are the cornerstone of the teaching and learning health sciences at Walter Sisulu University. Conclusions: integration and working as team among the staff of all involved disciplines per academic year is crucial to reach successful results within the medical curriculum in general and MB ChB 3 in particular.

Valores éticos en la educación médica. Consideraciones generales y comparación de dos escuelas médicas en países diferentes / Ethics values in medical education. General considerations and comparison of two different medical schools in different countries

La formación de los recursos humanos en la profesión médica, está basada en la expresión más completa de la Ética Médica, donde se incluye entre otros aspectos, la conciencia del médico, la confianza del enfermo y la observancia del método clínico, como partes importantes en la repercusión social que se presenta ante cada caso clínico ya sea agudo o crónico, y dentro de estos, las situaciones urgentes o emergentes, todas ellas con afectación de la esfera psicosocial. El objetivo principal de nuestro trabajo es el de valorar la aplicación de la enseñanza de la ética ante la actuación y atención con el paciente desde la etapa de formación del estudiante de Medicina, así como comparar las diferentes situaciones a las que se enfrentan los estudiantes y educadores médicos, modificadas e influenciadas por la cultura, la sociedad y la economía. En este trabajo, enfocamos los cuatro componentes fundamentales de la Ética Médica cubana y su proyección en la educación y formación de los recursos humanos del área de la salud. Se muestra nuestra experiencia en la enseñanza de la ética en el área clínica en dos programas de la carrera de Medicina; en Cuba y en Sudáfrica. El baluarte de nuestra Medicina cubana es educar según los principios que están acordes con los planteamientos del Juramento Hipocrático y la política de salud actual, reflejada tanto en nuestro país, como en otras universidades, a las cuales apoyamos en la formación de los futuros trabajadores de la salud. Las condiciones sociales modifican la actividad profesional y personal. Como consecuencia, la salud de los pacientes se ve igualmente afectada. El trabajo refleja, ademas, algunas consideraciones generales de profesores cubanos sobre la enseñanza de pregrado y los valores éticos en Sudáfrica.

The development of human resources in medical profession relies on the most complete expression of medical ethics. It includes medical awareness, patients' confidence and the observance of clinical method. All of them are important portions of the social repercussion in every clinical case, either acute or chronic; including medical emergencies among them. Psychosocial aspects are also involved in clinical cases. The main objective of this article, is to assess the teaching of ethics, applied to the attention and action with patients during the medical studies; as well as to compare different situations faced by students and lecturers; which are modified and influenced by culture, economy and society. This paper focuses on the four main components of Cuban medical ethics and how do they project the teaching and training of future health workers. We comment on our humble experience on teaching ethical issues in medical studies, comparing two medical programs of two countries: Cuba and South Africa. The strength of our Cuban medicine is to educate following the principles according to our policy of health and Hippocrates' oath. Both are reflected in our country, as well as overseas, in other universities, where we contribute with the preparedness of future health workers. Social conditions modify personal and professional activities. As a result, patients' health may modify as well. This article also reflects general opinions of Cuban professors on undergraduate learning and ethical values in South African medical students.

Valores éticos en la educación médica: consideraciones generales y comparación de dos escuelas médicas en países diferentes / Ethics values in medical education: general considerations and comparison of two different medical schools in different countries

La formación de los recursos humanos en la profesión médica, está basada en la expresión más completa de la Ética Médica, donde se incluye entre otros aspectos, la conciencia del médico, la confianza del enfermo y la observancia del método clínico, como partes importantes en la repercusión social que se presenta ante cada caso clínico ya sea agudo o crónico, y dentro de estos, las situaciones urgentes o emergentes, todas ellas con afectación de la esfera psicosocial. El objetivo principal de nuestro trabajo es el de valorar la aplicación de la enseñanza de la ética ante la actuación y atención con el paciente desde la etapa de formación del estudiante de Medicina, así como comparar las diferentes situaciones a las que se enfrentan los estudiantes y educadores médicos, modificadas e influenciadas por la cultura, la sociedad y la economía.En este trabajo, enfocamos los cuatro componentes fundamentales de la Ética Médica cubana y su proyección en la educación y formación de los recursos humanos del área de la salud. Se muestra nuestra experiencia en la enseñanza de la ética en el área clínica en dos programas de la carrera de Medicina; en Cuba y en Sudáfrica. El baluarte de nuestra Medicina cubana es educar según los principios que están acordes con los planteamientos del Juramento Hipocrático y la política de salud actual, reflejada tanto en nuestro país, como en otras universidades, a las cuales apoyamos en la formación de los futuros trabajadores de la salud. Las condiciones sociales modifican la actividad profesional y personal. Como consecuencia, la salud de los pacientes se ve igualmente afectada. El trabajo refleja, ademas, algunas consideraciones generales de profesores cubanos sobre la enseñanza de pregrado y los valores éticos en Sudáfrica(AU)

The development of human resources in medical profession relies on the most complete expression of medical ethics. It includes medical awareness, patients' confidence and the observance of clinical method. All of them are important portions of the social repercussion in every clinical case, either acute or chronic; including medical emergencies among them. Psychosocial aspects are also involved in clinical cases. The main objective of this article, is to assess the teaching of ethics, applied to the attention and action with patients during the medical studies; as well as to compare different situations faced by students and lecturers; which are modified and influenced by culture, economy and society.This paper focuses on the four main components of Cuban medical ethics and how do they project the teaching and training of future health workers. We comment on our humble experience on teaching ethical issues in medical studies, comparing two medical programs of two countries: Cuba and South Africa. The strength of our Cuban medicine is to educate following the principles according to our policy of health and Hippocrates' oath. Both are reflected in our country, as well as overseas, in other universities, where we contribute with the preparedness of future health workers. Social conditions modify personal and professional activities. As a result, patients' health may modify as well. This article also reflects general opinions of Cuban professors on undergraduate learning and ethical values in South African medical students(AU)

Familial hypophosphataemic rickets affecting a father and his two daughters: a case report.

BACKGROUND: Hypophosphataemic rickets (HR) is a rare cause of short stature associated with limb deformities. OBJECTIVE: To report the clinical and laboratory features of HR in two siblings and their father. METHODS: Following the diagnosis of HR in a 4-year-old girl, her siblings and parents were screened using clinical, laboratory, and radiological parameters. RESULTS: Short stature, lower limb deformities, frontal bossing and hypophosphataemia were present in all three patients. Serum alkaline phosphatase (ALP) was markedly elevated in both siblings who were aged two and 11 years but only minimally raised in their 43-year-old father. While spontaneous mutation is the presumed aetiology in the father, X linked dominant inheritance is the likely cause in both daughters. CONCLUSIONS: Hypophosphataemic rickets should be considered in the differential diagnosis of short stature associated with limb deformities regardless of a family history of HR. Serum ALP may not be remarkably elevated when the diagnosis is made in adulthood.

Postmortem findings in HIV/AIDS patients in a tertiary care hospital in rural South Africa.

South Africa has the largest number of people living with HIV/AIDS, and various associated infectious and noninfectious conditions contribute towards mortality. The objective of this study was to determine the important post-mortem findings in HIV-infected individuals in a high HIV burden rural area in South Africa. The patient population included HIV patients who died at the tertiary care hospital, from 2000-2008. Autopsies were performed according to standard protocols and diagnoses were made with additional laboratory investigations wherever required. A total of 86 patients were autopsied (30 males, 56 females). The major postmortem findings were related to infections, with 38% of the patients having had some form of tuberculosis, followed by pyogenic infections--pneumonias (21.5%), meningitis (10.1%) and septicemias (5.1%). Other important infections included opportunistic fungi like cryptococcosis (7.6%) and pneumocystis pneumonia (8.9%). Among the noninfectious conditions, the findings seen were predominantly related to liver (10.1%) and cardiac involvement (10.1%).

Hyperglycaemic crisis in the Eastern Cape province of South Africa: high mortality and association of hyperosmolar ketoacidosis with a new diagnosis of diabetes.

OBJECTIVES: To describe the frequencies, presenting characteristics (demographic, clinical and biochemical) and outcomes (duration of admission and mortality rates) for various types of hyperglycaemic crisis. METHODS: Retrospective review of medical records of patients with hyperglycaemic crisis admitted to Nelson Mandela Academic Hospital, Mthatha, E Cape, from 1 January 2008 to 31 December 2009. Outcome measures were duration of admission and mortality. RESULTS: Data were available for 269 admissions (response rate 81.0%), 169 females and 100 males. Admissions for hyperglycaemia (HG, N=119), and non-hyperosmolar diabetic ketoacidosis (NHDKA, N=97) were more frequent than those for hyperosmolar hyperglycaemic state (HHS, N=29) and hyperosmolar diabetic ketoacidosis (HDKA, N=24). Duration of admission was similar in all groups. Mortality was high in all groups, but was higher in patients with HDKA (37.5%, risk ratio (RR) 3.88, 95% confidence interval (CI) 1.41 - 10.67, p=0.009), HHS (31.0%, RR 2.91, 95% CI 1.09 - 7.75, p=0.033) and HG (19.5%, RR 1.56, 95% CI 0.75 - 3.21, p=0.236) than in those with NHDKA (13.4%). HDKA (62.5%) was associated with new-onset diabetes more often than NHDKA (27.8%), HHS (44.8%) or HG (17.6%) (p<0.0001). An altered level of consciousness was more frequent in HDKA than NHDKA admissions (RR 5.71, 95% CI 1.90 - 17.17, p=0.002). CONCLUSIONS: Duration of hospital stay was similar across groups. Mortality rates were high in all groups. New-onset diabetes, altered level of consciousness and mortality were more characteristically associated with HDKA than any of the other types of hyperglycaemic crisis. Optimal glycaemic control in known diabetic patients will reduce rates of hyperglycaemic crisis admissions.

Correlation between Different PBL Assessment Components and the Final Mark for MB ChB III at a Rural South African University

Problem-based learning (PBL) is now an accepted component of many medical school programmes worldwide. Our university also follows the PBL `SPICES' model for MB ChB III. The assessment modalities used are the modified essay questions (MEQ); objective structured practical examination (OSPE); individualised process assessment (IPA) and tutorial continuous assessment (TUT). This study was done to compare the students' performances in individual assessment components with the final mark to determine the correlation between these parameters. Materials and methods. The study was retrospective; descriptive and analytical; based on the integrated marks of all the MB ChB III students at Walter Sisulu University (WSU) in 2007. Assessment marks were stratified according to blocks and different types of assessment (MEQ; TUT; OSPE; IPA). Regression analysis was used to compute and scrutinise these vis-a-vis their correspondence with the final marks for each block.Results. Three hundred and seventy-nine block assessment marks of 96 students from 4 blocks of MB ChB III were analysed and the correlation between the assessment components and final mark were compared. Regression analysis showed good correlation when analysing the assessment modality versus the final mark for the MEQs (r=0.93; 0.93; 0.94; 0.96); followed by OSPEs (r=0.71; 0.70; 0.76; 0.77) and IPAs (r=0.62; 0.51; 0.68; 0.77). However; correlation was not significant with the TUT. Conclusion. There was good correlation between the students' performance in the majority of assessment modalities and the final mark in the different blocks of the MB ChB III examination. There may be a need to make tutorial assessment methods more objective; partly by additional tutor training

Self-induced vomiting -- risk for oesophageal cancer?

BACKGROUND: Chronic inflammation of the oesophagus is considered a precursor condition for the development of oesophageal cancer. Identification of the causes of chronic oesophageal irritation is therefore relevant in developing preventive measures. Self-induced vomiting is a cultural practice among the black population of South Africa, particularly those living in the Transkei, a region reported to have one of the highest incidences of oesophageal cancer worldwide. METHODS: We retrospectively examined the association between the practice of self-induced vomiting and the development of cytological features of inflammation in 478 self-selected subjects living in Transkei who underwent early screening for oesophageal cancer. Screening involved brush biopsy, cytological investigation and a questionnaire interview. RESULTS: The prevalence of self-induced vomiting was 80.5% and 79.1% in males and females, respectively, and this was stable across all ages. Furthermore, self-induced vomiting was found to be significantly and independently associated with oesophageal chronic inflammation (odds ratio 1.83, 95% confidence interval: 1.13 - 2.96, p = 0.013). CONCLUSION: While the association between the cultural practice of self-induced vomiting and oesophageal cancer has previously been hypothesised, this is the first study to report on an association between this practice and oesophageal chronic inflammation. Further studies that take into account the method used, frequency and duration of vomiting, age of commencement and fasting state of subjects practicing self-induced vomiting coupled with accurate indicators of inflammation are needed to elucidate the role of self-induced vomiting in oesophageal pathogenesis.

Prevalence of diabetes mellitus and impaired glucose tolerance in factory workers from Transkei, South Africa.

OBJECTIVE: To determine the prevalence of diabetes mellitus and impaired glucose tolerance (IGT) in a group of peri-urban black South Africans. DESIGN: Cross-sectional study in which an oral glucose tolerance test (OGTT) was performed on each subject. SETTING: Two of the largest factories in the surroundings of Umtata, the capital of the former homeland of Transkei, South Africa. SUBJECTS: A total of 374 Xhosa-speaking factory workers. MAIN OUTCOME MEASURES: Frequency of diabetes mellitus and IGT according to age group and gender using the current World Health Organisation (WHO) criteria for the diagnosis of abnormal glucose tolerance and its relationship to obesity. RESULTS: The crude prevalences for diabetes mellitus and IGT were 2.45% and 2.7% respectively. The age-adjusted prevalences using a standard world population were 4.5% (confidence interval (CI) 1.54-7.42) and 5.1% (CI 2.45-5.51) for diabetes and IGT respectively. The prevalence of diabetes was similar in male and female workers (P = 0.31), with the highest incidence observed in the age group from 40 to 59 years. No subject below the age of 40 years was found to be diabetic, and the prevalence of the disease was found to increase with age. Obesity was present in 22.2% of all subjects. Prevalence of obesity was similar in subjects with diabetes and in those with impaired and normal glucose tolerance (P = 0.71). However, overweight, identified in 26.8% of subjects, was more frequently observed in the IGT group than in the other two groups (P = 0.01). IGT was observed in 3.4% of male and 1.5% of female workers respectively (P = 0.13), with peak prevalences occurring between the ages of 30 and 49 years. CONCLUSION: In conclusion, this study found a prevalence of diabetes and IGT comparable to prevalence results reported in other black South African communities. The implications with regard to this community merit further study.

Importance of family history in type 2 black South African diabetic patients.

OBJECTIVE: To assess the family history of diabetes in type 2 black South African diabetics with emphasis on the parental phenotype. DESIGN: Prospective case-control study in which family histories were obtained from patients. SETTING: Diabetic clinic of a provincial teaching hospital in the Transkei region of South Africa. SUBJECTS: A total of 1111 type 2 diabetics attending the diabetic clinic and 687 controls. MAIN OUTCOME MEASURES: History of diabetes in parents, siblings, maternal and paternal grandparents, aunts, and uncles. RESULTS: Altogether 27.3% of diabetic subjects had a family history of diabetes compared with 8.4% in the control group (p<0.01). Among the group with positive family history 82.6% reported only one diabetic family member, while 17.4% reported at least two relatives; 6.6% had a diabetic relative from both maternal and paternal sides, and 87.8% had first degree relative with diabetes. Among them there was a significant maternal aggregation with 64.7% of patients having a diabetic mother compared with 27% who had a diabetic father (p<0.01). No maternal effect was observed among the second and third degree relatives. Patients with positive family history had an earlier onset of diabetes than those without family history (p<0.01). CONCLUSION: These data suggest that type 2 diabetes is heritable in black South African diabetics. It is also likely that maternal influences may play an important part.

Assessment of glycaemic control in stable type 2 black South African diabetics attending a peri-urban clinic.

Glycaemic control was assessed in type 2 black diabetics attending the diabetic clinic at a peri-urban hospital. Baseline glycosylated haemoglobin levels were measured and a subsequent estimation was carried out in those patients who attended a follow-up consultation to see whether current recommended targets for glycosylated haemoglobin levels were being attained. Out of 708 patients, mean age 56.3 years, 14.7% were insulin treated and 85.3% were non-insulin-treated. Target values of HbA1c < 7% were achieved in only 20.1% (142) of patients. Although mean glycosylated haemoglobin levels were significantly higher in females (p = 0.03), the proportion of poorly controlled diabetics was similar in the two sexes. Patients whose HbA1c levels fell within the target values had diabetes of significantly shorter duration than those exhibiting poor control (5.0 + 0.2 vs 7.03 + 0.5 years). Obesity was present in 562 patients (79.4%). Target values were only achieved in 16.4% of non-obese and 21% of obese diabetics, with mean glycosylated haemoglobin levels being significantly higher (p < 0.05) in the former group (10.3 + 0.4% vs 9.5 + 0.2%). Similar results were observed with respect to type of treatment, with only 14.4% of insulin-treated and 21% of non-insulin-treated diabetics achieving target values. The follow-up HbA1c estimation did not show any difference in the glycaemic control status of patients, with only 19.9% of them achieving the target values. Dietary advice (though minimal) seemed to have no impact on the metabolic control of our patients. These results suggest that glycaemic control was poor irrespective of sex, duration, BMI, educational status, dietary advice and type of treatment with recommended target values not being achieved in the majority of patients. Behavioural changes through health educational programmes need to be instituted with both patient and medical personnel being motivated to take this process forward.

Avulsion fractures of the posterior cruciate ligament of the knee. An experimental percutaneous rigid fixation technique under arthroscopic control.

A posterior cruciate ligament avulsion fracture (PCLAF) of the knee can be repaired through a large approach. A new technique based on internal fixation under arthroscopic control employed a posterolateral puncture. The fracture was reduced and the osseous fragment transfixed using a new forceps guide. The osseous fragment was stabilized through a tunnel drilled from the proximal anterior aspect of the tibial metaphysis by means of a cortical screw and an intraarticular nutwasher. The technique was made in eight undamaged normal fresh knees from distal ischemic amputated lower limbs. In six knees the technique was successful. In two knees the presence of hypertrophic synovium impeded a good visualization and the technique failed. In the hands of arthroscopic surgeons, this technique could be an effective alternative to arthrotomy in the treatment of PCLAF.