Towards outcome-based programme evaluation: using student comparative self-assessments to determine teaching effectiveness.

BACKGROUND: Programme evaluation of medical education should be multi-dimensional. While structural and organisational aspects of teaching are frequently assessed, programme evaluation tools are rarely matched to specific learning objectives. AIMS: This study used one medical school's catalogue of specific learning objectives to implement and critically appraise a novel programme evaluation tool based on comparative student self-assessments. METHOD: Medical students enrolled in the clinical phase of the undergraduate curriculum in Göttingen were invited to self-rate their knowledge, skills and attitudes before and after each course. A newly developed formula controlling for student performance levels when entering a course was used to compute a percentage gain in knowledge, skills and attitudes. Data derived from a prospective, longitudinal intervention study on the development of electrocardiogram interpretation skills including 636 students from four consecutive cohorts were used to provide validity evidence of the new approach. RESULTS: The novel tool appeared superior to plain mean differences and effect sizes in detecting outstanding teaching as well as shortcomings of the curriculum. In addition, it adequately reflected objectively measured performance levels and was responsive to curriculum change. CONCLUSIONS: Comparative student self-assessment is a valid tool to appraise undergraduate medical curricula at the level of specific learning objectives.

Significant increase in factual knowledge with web-assisted problem-based learning as part of an undergraduate cardio-respiratory curriculum.

In recent years, increasing attention has been paid to web-based learning although the advantages of computer-aided instruction over traditional teaching formats still need to be confirmed. This study examined whether participation in an online module on the differential diagnosis of dyspnoea impacts on student performance in a multiple choice examination of factual knowledge in cardiology and pneumology. A virtual problem-based learning environment for medical students supervised by postgraduate teachers was created. Seventy-four out of 183 fourth-year medical students volunteered to use the online module while attending a 6-week cardio-respiratory curriculum in summer 2007. Of these, 40 were randomly selected to be included (intervention group); the remaining 34 served as an internal control group. Analysis of all written exams taken during the preceding term showed that both groups were comparable (86.4 ± 1.1 vs. 85.9 ± 1.1%; p = 0.751). Students in the intervention group scored significantly higher in the final course assessment than students allocated to the control group (84.8 ± 1.3 vs. 79.5 ± 1.4%; p = 0.006; effect size 0.67). Thus, additional problem-based learning with an online module as part of an undergraduate cardio-respiratory curriculum lead to higher students' scores in an exam testing factual knowledge. Whether using this teaching format increases overall student motivation to engage in the learning process needs to be further investigated.

[Elements of managed care in Germany and in Switzerland]. / Regelleistungsvolumina orientieren sich an der Morbidität der Patienten. Welche Erfahrungen gibt es mit dem neuen Honorarsystem?

With the introduction of the GVK (health insurance) modernization statute (GMG), health policy in Germany will focus on a more highly differentiated form of remuneration of the physician's services that is based on the degree of morbidity of the patient. Simultaneously with the introduction of morbidity-oriented risk structure adjustment in the year 2007, the level of payment to the doctor will be determined by the standard services volume based on risk categories and relative weightings as well as the case-based flat rates. A glance across the border to our Swiss neighbors provides information on their experience with diagnosis-related forms of remuneration.

[Patient classification and analysis of risk profiles for type 2 diabetics as the main focus point in practice. Results of the TEMPO study]. / Patientenklassifikation und Risikoprofilanalysen bei Typ-2-Diabetikern in der Schwerpunktpraxis. Ergebnisse der TEMPO-Studie.

BACKGROUND AND OBJECTIVE: Disease management programs (DMP) e. g. for diabetes mellitus, should be the clinical and economic basis for a structured treatment. This article shows results of specialized outpatient treatment using a risk factor depending patient classification. PATIENTS AND METHODS: Diabetes associated co-morbidities, micro- and macrovascular complications, the results and findings of blood pressure and metabolism of glucose and lipids, as well as all treatment-associated costs of 5245 type 2 diabetics were collected for a period of 12 months, accompanied by different measures of quality control. For documentation in the centres, all available original data were used as local data sources. RESULTS: The patient classification system, on which diabetic risk profiles are based, covered 74.3 % of all type 2 diabetic patients. Daily direct costs for all treatment measures ranged between EUR 4.79 (primary prevention) and EUR 8.96 for patients suffering from advanced diabetic foot syndrome. Most of the treatment costs arose from prescriptions of pharmaceuticals, other remedies and aids. Specific strategies of therapy were both related to the severity of co-morbidities and the time since manifestation of diabetes (r = 0.486; p < 0.01, two-sided). The share of patients receiving diet and exercise only decreased from 22.8 % (primary prevention) to below 10 % of patients suffering from microvascular complications. Simultaneously, the share of patients receiving insulin increased up to 81.8 % of patients suffering from advanced diabetic retinopathy. CONCLUSION: The risk profile specific variation in the results clearly shows the need of a risk factor depending classification system for type 2 diabetes, which could be useful to reform and focus the system of compensating payments between health insurance companies more and more on morbidity, or on risk profiles.

Morphological-cytochemical and molecular genetic analyses of mitochondria in isolated human oocytes in the reproductive age.

Molecular genetic, cytochemical and morphometric analyses have been performed on isolated oocytes from 41 women (27-39 years of age) in order to detect mutations of mitochondrial DNA (mtDNA), defects of the respiratory chain (ubiquinone-cytochrome-c-oxidoreductase = complex III; cytochrome-c-oxidase = complex IV) and alterations of mitochondrial volume during cellular ageing. Morphometric analyses showed an increase in mitochondrial numerical density with age from the mean values of 7.36 per micron2 and 6.97 per micron3 up to 30 years to 10.74 per micron2 and 11.66 per micron3 in the age group 31-40 years (P < 0.001). Similarly, an increase in the mitochondrial profile area from 0.074 per micron2 in the age group < 30 years to 0.101 per micron2 was noted in the fourth decade. The mitochondrial volume fraction was also significantly increased in the elder age group. Neither point mutations of mtDNA (nucleotide pairs 3243, 8344) nor the common deletion (4977 bp, nucleotide pairs 8482-13460) could be detected. In parallel, ultra- and immunocytochemical studies of the complexes III-IV failed to reveal functional defects. In conclusion there is an age-related increase in the volume fraction of the mitochondria which might reflect subtle changes in the oxidative phosphorylation capacity, but is not linked to mutations of mtDNA or functional defects of the respiratory chain enzymes in mature human oocytes from women of reproductive age.

Defects of the respiratory chain in oxyphil and chief cells of the normal parathyroid and in hyperfunction.

Immunohistochemical detection of complex HIII (ubiquinone- cytochrome-c-oxidoreductase) and complex IV (cytochrome-c-oxidase) of the respiratory chain was performed in parathyroids of 164 humans with normal renal function (group I) and in 55 patients with chronic renal insufficiency (group II) obtained at autopsy. In group I, 33 of the 164 cases showed defects of the respiratory chain (20%). Eighty-five percent of the defects occurred in advanced age (> 50 years). In group II, 39 of 55 cases (70%) had defects, and about 70% of the defects occurred after age 50. In both groups, more than 80% of the defects were localized in oxyphil cell nodules. However, not every oxyphil nodule was involved. In group I, selective defects of complex IV predominated and were found in 47 of 86 defects (55%). Combined defects of complexes III and IV were present in 25 of 86 defects (29%). In contrast, in group II combined defects predominated and were found in 45% (107 of 240 defects), whereas single defects of complex IV existed in 38% (93 of 240 defects). The frequency of selective defects of complex III was about 16% to 17% in both groups. In situ hybridization and PCR studies for the detection of the common deletion (4.977 base pairs) and of various point mutations of mitochondrial of (m)DNA revealed no consistent molecular genetic abnormalities. A point mutation in the tRNALeu(UUR) at nucleotide (nt) 3.260 was found in only one probe. The results show that defects of the respiratory chain occur already in normal parathyroids, most probably during cell aging, especially in oxyphil cells and at a higher rate in hyperfunction. The high predominance of respiratory chain defects in oxyphil cells and their random distribution favors mutations of mtDNA as a possible cause of oxyphilic cell transformation and of the respiratory chain defects. However, the mutations of mtDNA in the parathyroids are apparently different from those in other ageing tissues.

Human aging is associated with stochastic somatic mutations of mitochondrial DNA.

Deletions and point mutations of mitochondrial DNA (mtDNA), which are characteristic of various human mitochondrial diseases, have been identified mainly in postmitotic tissues like brain, heart and skeletal muscle of healthy humans of advanced age but not in young people. An exponential increase with age was described for deletions of mtDNA. This paper reviews the molecular basis and experimental results on mutations of mtDNA in patients with mitochondrial diseases and in aged individuals. In addition new data on the exponential increase of point mutations of mtDNA, characteristic for MERRF and MELAS disease, in extraocular muscle from elderly humans are shown. Finally the 'mitochondrial hypothesis on aging' based on stochastic somatic mutations of mtDNA is presented.

Human aging is associated with various point mutations in tRNA genes of mitochondrial DNA.

In extraocular muscle tissue of elderly humans small amounts of point mutations in tRNA genes of mitochondrial DNA (mtDNA) were identified by point mutation-specific PCR. These mutations were not found in navel-string samples from newborns. While the mutations in tRNA(Leu(UUR)) (np 3243) and tRNA(Gly) (np 10006), previously identified in patients with MELAS and CIPO, respectively, were found in most elderly people, the mutations in tRNA(Ser(GCU)O (np 12246) and tRNA(Asn) (np 5692), identified in patients with CIPO and CPEO, respectively, were found only in two of 15 tissue samples from different individuals. The data suggest that some nucleotides of mtDNA represent "hot spots" for somatic mutations, which contribute to human aging.

The point mutation of mitochondrial DNA characteristic for MERRF disease is found also in healthy people of different ages.

The A-to-G transition mutation in the tRNA(Lys) gene of mitochondrial DNA (mtDNA), characteristic for the maternally inherited MERRF syndrome (myoclonic epilepsy with ragged red fibers), has been identified by point mutation-specific polymerase chain reaction in extraocular muscle from 11 of 16 healthy people of different ages. No mutation was found in navel-string samples from 5 newborns, in HeLa cells, and in 2 individuals younger than 20 years. On the other hand, the mutation is present in all 5 tested 74-89-year-old individuals and in 6 of 9 20-70-year-old individuals. The amount of mutated from total mtDNA was estimated by 'mispairing PCR' in extraocular muscle of 2 individuals of 74 and 89 years to 2.0 and 2.4%, respectively. In most tissue samples the MERRF mutation occurs together with the 'common deletion' of mtDNA, which was previously shown to accumulate in healthy individuals with increasing age. It is proposed that during aging, deletions and point mutations of mtDNA accumulate, which could impair mitochondrial energetics.