Nicotinamide mononucleotide adenylyltransferase promotes hypoxic survival by activating the mitochondrial unfolded protein response.

Gain-of-function mutations in the mouse nicotinamide mononucleotide adenylyltransferase type 1 (Nmnat1) produce two remarkable phenotypes: protection against traumatic axonal degeneration and reduced hypoxic brain injury. Despite intensive efforts, the mechanism of Nmnat1 cytoprotection remains elusive. To develop a new model to define this mechanism, we heterologously expressed a mouse Nmnat1 non-nuclear-localized gain-of-function mutant gene (m-nonN-Nmnat1) in the nematode Caenorhabditis elegans and show that it provides protection from both hypoxia-induced animal death and taxol-induced axonal pathology. Additionally, we find that m-nonN-Nmnat1 significantly lengthens C. elegans lifespan. Using the hypoxia-protective phenotype in C. elegans, we performed a candidate screen for genetic suppressors of m-nonN-Nmnat1 cytoprotection. Loss of function in two genes, haf-1 and dve-1, encoding mitochondrial unfolded protein response (mitoUPR) factors were identified as suppressors. M-nonN-Nmnat1 induced a transcriptional reporter of the mitoUPR gene hsp-6 and provided protection from the mitochondrial proteostasis toxin ethidium bromide. M-nonN-Nmnat1 was also protective against axonal degeneration in C. elegans induced by the chemotherapy drug taxol. Taxol markedly reduced basal expression of a mitoUPR reporter; the expression was restored by m-nonN-Nmnat1. Taken together, these data implicate the mitoUPR as a mechanism whereby Nmnat1 protects from hypoxic and axonal injury.

Faculty attitudes towards medical communication and their perceptions of students' communication skills training at Dalhousie University.

SETTING: Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. OBJECTIVES: (1) To assess the attitudes of full-time clinical faculty members towards medical communication using the newly developed Attitudes Towards Medical Communication Scale; (2) to determine faculty members' perceptions of communications training for students and residents. METHODS: An anonymous self-completion survey was sent to 233 full-time clinical faculty members. The questionnaire asked about faculty attitudes towards medical communication, and assessed faculty members' views of student and resident training in communication. RESULTS: Faculty scored highly in the Attitudes Towards Medical Communication Scale, with a mean score of 51.5 (SD 4.1) out of a possible 60. In univariate analysis, rating of personal enjoyment of teaching, rating of the importance of teaching, and having attended at least one faculty communications workshop in the previous 5 years were significantly associated with higher scale scores. When these factors were assessed using linear regression, only having attended a workshop and higher rating of the importance of teaching remained significant. Faculty assessed student training in communications skills poorly overall. When assessing seven specific communications areas, more than 20% rated this training as poor for six of the areas for third- and fourth-year students and for five of the areas for residents. CONCLUSIONS: Clinical faculty at Dalhousie have very positive attitudes towards medical communication, and more highly positive attitudes are found in those who have attended a communications workshop. Despite this evidence that faculty appreciate the importance of medical communication skills, many assessed students' training in this curriculum area as poor.

Differences in medical students' attitudes and self-efficacy regarding patient-doctor communication.

To examine students' attitudes and self-efficacy regarding patient-doctor communication across levels of training, a questionnaire was administered to three classes (n = 203 students). Students' year of study, prior experience, and sex influenced their attitudes and self-efficacy regarding patient-doctor communication.

Achieving cardiovascular health through continuing interprofessional development.

In order to achieve cardiovascular health for all Canadians, the ACHIC (Achieving Cardiovascular Health in Canada) partnership advocates that health promotion for healthy lifestyles be incorporated into practice, and that the consistent messages and professional skills required to motivate patients and the public be acquired through interprofessional education and development. Professional education specialists are essential members of health care promotion teams with expertise to develop educational interventions that impact behaviours of health professionals and subsequent patient outcomes. Continuing medical education (CME) is in evolution to continuing professional development (CPD), and then to continuing inter-professional development (CID). Providers of health promotion, public health, and health care can work with health educators to complete the cascade of learning, change in practice, and improvement in patient outcomes. The Canadian health care system can empower Canadians to achieve cardiovascular health, the most important health challenge in the 21st century.

A comparison of standard-setting procedures for an OSCE in undergraduate medical education.

PURPOSE: To compare four standard-setting procedures for an objective structure clinical examination (OSCE). METHODS: A 12-station OSCE was administered to 84 students in each of the final (fourth-) year medical classes of 1996 and 1997 at Dalhousie University Faculty of Medicine. Four standard-setting procedures (Angoff, borderline, relative, and holistic) were applied to the data to establish a cutoff score for a pass/fail decision. RESULTS: The procedures yielded highly inconsistent results. The Angoff and borderline procedures gave similar results; however, the relative and holistic methods gave widely divergent results. The Angoff procedure yielded results reliable enough to use in decision making for a high-stakes examination, but would have required more judges or more stations. CONCLUSIONS: The Angoff and borderline procedures provide reasonable and defensible approaches to standard setting and are practical to apply by non-psychometricians in medical schools. Further investigation of the other procedures is needed.

Self-reported effects of computer workshops on physicians' computer use.

BACKGROUND: The need for physicians to be proficient in the use of computers is undeniable. As computers have become easier to use and more widespread, their use in medicine is expanding. Several organizations have produced continuing medical education programs to teach physicians about the use of computers in medicine but little has been reported on the effects of such programs. METHOD: We present the self-reported effects of a series of workshops that taught physicians about basic computer skills: information retrieval, the Internet, CD-ROMs, electronic mail, and computer-aided learning. RESULTS: A questionnaire mailed to 65 workshop participants yielded a response rate of 46% (n = 30). Of the 30 respondents, 27% (n = 8) had bought new hardware or software because of attending the workshops, with the most common purchase being a new computer. Fifty-seven percent (n = 17) had increased their use of computers, with the most common applications being use of the Internet for information retrieval and electronic mail.

Carotid endarterectomy: improved clinical outcome and reduced length of hospitalization.

AUDIENCE: This exercise is intended for vascular surgeons, neurologists, cardiologists, and primary care physicians caring for persons who are at risk for or who have suffered a stroke. GOAL: To present data from a single institution on the incidence and costs associated with carotid endarterectomy compared with other techniques to diagnose and prevent stroke. OBJECTIVES: 1. Outline the prevalence of stroke in the United States and the role of carotid endarterectomy (CEA) in its treatment. 2. Discuss the various preoperative tests that help determine a patient's suitability for CEA. 3. Discuss the cost implications of stroke prevention.

Using problem-based learning in neurosciences education for medical students.

BACKGROUND: A Curriculum Task Force proposed problem-based learning as one important educational strategy and recommended changes to a traditional medical curriculum. METHODS: This paper describes how a problem-based learning course in neurosciences was developed and has evolved since its inception in the Dalhousie University Faculty of Medicine. The curriculum planning and design phases are outlined, followed by a description of how the course has been implemented and evaluated. RESULTS: Program evaluation results are presented, describing student performance on examinations and their feedback about the course. CONCLUSION: The authors summarize lessons learned and identify future issues to continue the ongoing development of the course.

Comparing achievement on the Medical Council of Canada Qualifying Examination Part I of students in conventional and problem-based learning curricula.

PURPOSE: To compare the levels of achievement on the Medical Council of Canada (MCC) Qualifying Examination Part I of students in conventional and problem-based learning (PBL) curricula. METHOD: Students in three classes (1995, 1996, and 1997) took the MCC Qualifying Examination Part I upon completing their MD degrees. This examination tests core knowledge in the major disciplines and clinical reasoning skills. Candidates' scores were masked to protect confidentiality. Total scores, individual discipline scores, and pass/fail proportions were compared among the classes. RESULTS: The PBL classes of 1996 and 1997 performed better on the psychiatry component than did the 1995 conventional class (p = .001); the 1997 class also exceeded the 1995 and 1996 classes in preventive medicine and community health scores (p = .001). No difference emerged in other disciplines, clinical reasoning scores, total multiple-choice question scores, or the proportions of successful candidates. CONCLUSION: PBL and conventional curriculum graduates performed similarly, except in psychiatry and preventive medicine and community health, where PBL graduates scored higher.

The relationship of tutors' content expertise to interventions and perceptions in a PBL medical curriculum.

This study addressed three questions: (1) Do content-expert tutors differ from non-expert tutors in the extent to which they present/explain case content? (2) Do tutors who present/explain case content differ from those who almost never do in their ratings of various outcomes of a PBL curriculum? (3) Are tutors who present/explain case content rated differently by students from tutors who almost never do? Data were gathered from 88 tutors and 168 students in the first 2 years of a PBL medical curriculum. Students assessed their tutor after each unit, and tutors completed a questionnaire near the end of the academic year. In this study, 'content expertise' was defined operationally as tutors' self-ratings on the question 'To what extent could you teach (at the Med I level) the material covered in the cases?' Less than half of the tutors reported that they almost never presented/explained case content. As tutors' content expertise increased, they tended to present/explain case content more frequently. Tutors who almost never presented/explained case content rated PBL more highly than traditional methods. No differences were found in student ratings of tutors who almost never presented/explained case content, compared to tutors who did. The results suggest that tutors who are content experts find it difficult to maintain the 'facilitator' role, but that those who maintain this role are more satisfied with PBL. It appears that other tutor behaviours may have a greater influence on students' ratings of their tutors.

Comparison of problem-based learning and lecture format in continuing medical education on headache diagnosis and management.

The purpose of the study was to compare the impact of continuing medical education for primary care physicians in Halifax, Nova Scotia, Canada, delivered through a problem-based learning (PBL) format with that of a lecture-based format, in the clinical area of headache diagnosis and management. From January to June 1995, 38 physicians participated in three problem-based learning sessions, and 49 in a lecture-based session in the clinical area of headache. Pre- and posttest assessments of knowledge were made of each group before and immediately after the educational sessions. A second evaluation using Key Features Problems (KFP) to measure clinical reasoning was administered to both groups 3 months later. Analysis of covariance between groups on the post-test, using the pre-test result as covariate, showed significantly greater knowledge in the PBL group. Mean post-test KFP scores also were significantly higher for the PBL group. The PBL group's satisfaction with several programme dimensions was significantly higher than that of the lecture group. These results must be viewed in the context of differing amounts of exposure for the two groups. Problem-based learning in continuing medical education in the area of headache management was associated with greater knowledge acquisition and with greater improvement in clinical reasoning skills than in a lecture-based approach. Problem-based learning also was preferred by family physicians. However, the cost-benefit of this approach was questioned, since the PBL group had more exposure. Several factors limit the generalizability of this study, e.g. the impossibility of randomly composing the two experimental groups. Further research is required to determine if the results are generalizable and whether a PBL approach results in change in practice behaviour.