RE-AIMing COVID-19 online learning for medical students: a massive open online course evaluation.

BACKGROUND: Clinical training during the COVID-19 pandemic is high risk for medical students. Medical schools in low- and middle-income countries (LMIC) have limited capacity to develop resources in the face of rapidly developing health emergencies. Here, a free Massive Open Online Course (MOOC) was developed as a COVID-19 resource for medical students working in these settings, and its effectiveness was evaluated. METHODS: The RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework was utilized to evaluate the effectiveness of MOOC in teaching medical students about COVID-19. The data sources included the student registration forms, metrics quantifying their interactions within the modules, students' course feedback, and free-text responses. The data were collected from the Moodle learning management system and Google analytics from May 9 to September 15, 2020. The research team analyzed the quantitative data descriptively and the qualitative data thematically. RESULTS: Among the 16,237 unique visitors who accessed the course, only 6031 medical students from 71 medical schools registered, and about 4993 (83% of registrants) completed the course, indicating high levels of satisfaction (M = 8.17, SD = 1.49) on a 10-point scale. The mean scores of each assessment modules were > 90%. The free-text responses from 987 unique students revealed a total of 17 themes (e.g., knowing the general information on COVID-19, process management of the pandemic in public health, online platform use, and instructional design) across the elements of the RE-AIM framework. Mainly, the students characterized the MOOC as well-organized and effective. CONCLUSIONS: Medical students learned about COVID-19 using a self-paced and unmonitored MOOC. MOOCs could play a vital role in the dissemination of accurate information to medical students in LMIC in future public health emergencies. The students were interested in using similar MOOCs in the future.

Social accountability: A national framework for Turkish medical schools.

PURPOSE: To define recommendations to the medical schools in Turkey about social accountability which meets the local needs. METHODOLOGY OF THE STUDY: The Association of Evaluation and Accreditation of Medical Education Programs (TEPDAD-Turkey) Social Accountability working group planned a study to determine national recommendations for social accountability of medical schools in two-stages. Delphi technique was used to develop the recommendations and finalize the recommendations in the first stage in which 61 members from 30 different institutions participated. Qualitative analysis was used for open questions in the first round and quantitative analysis for the data which is collected with a rating scale in the second and third rounds of the Delphi study. In the second stage, the recommendations were reviewed and finalized in a consensus workshop in which 68 members from 39 different institutions participated. RESULTS: In the Delphi study 63 recommendations were classified under five themes: the health needs of the society, health service delivery, institutional structure and management, educational program and implementation and development and evaluation of social accountability. In the consensus workshop, the 63 recommendations were evaluated and of which 54 of 63 recommendations were agreed upon. CONCLUSION: A national framework has been developed by including a wide range of experts from different institutions for the social accountability of medical schools in Turkey. Developing recommendations in a local context will enhance the conceptualization of the recommendations of social accountability in the medical schools. As an accreditation body embedding the principles in the national standards will have a further impact on this process.

Core Professionalism Education in Surgery: A Systematic Review.

BACKGROUND: Professionalism education is one of the major elements of surgical residency education. AIMS: To evaluate the studies on core professionalism education programs in surgical professionalism education. STUDY DESIGN: Systematic review. METHODS: This systematic literature review was performed to analyze core professionalism programs for surgical residency education published in English with at least three of the following features: program developmental model/instructional design method, aims and competencies, methods of teaching, methods of assessment, and program evaluation model or method. A total of 27083 articles were retrieved using EBSCOHOST, PubMed, Science Direct, Web of Science, and manual search. RESULTS: Eight articles met the selection criteria. The instructional design method was presented in only one article, which described the Analysis, Design, Development, Implementation, and Evaluation model. Six articles were based on the Accreditation Council for Graduate Medical Education criterion, although there was significant variability in content. The most common teaching method was role modeling with scenario- and case-based learning. A wide range of assessment methods for evaluating professionalism education were reported. The Kirkpatrick model was reported in one article as a method for program evaluation. CONCLUSION: It is suggested that for a core surgical professionalism education program, developmental/instructional design model, aims and competencies, content, teaching methods, assessment methods, and program evaluation methods/models should be well defined, and the content should be comparable.

Development and evaluation of the evidence-based medicine program in surgery: a spiral approach.

BACKGROUND: Evidence-based medicine (EBM) aims to provide skills that help physicians answer clinically important questions, determine new evidence, and incorporate the acquired knowledge in practice. EBM skills are necessary for the practice of modern medicine, since physicians should use up-to-date knowledge and information to justify their medical decisions. PURPOSE: We aimed to evaluate the EBM program implemented at Hacettepe University School of Medicine. METHODS: In 2004, a spiral program for the teaching and practice of EBM was developed for the first 3 years of medical school. Following this program, a practice of EBM was included in the fourth year during the surgery clerkship, after an introductory lecture. The students worked within collaborative teams of 3-5 and practiced EBM with actual cases seen in the surgical service in which they were involved. Each student was asked to complete a questionnaire that evaluated the more theoretical program from the first 3 years and the practical application in the fourth year. RESULTS: Nearly half of the students stated that the preclinical years of the EBM program were 'adequate', but only 30% of the students indicated that the program was practical. They stated that 'more practical approaches were used in the fourth year, whereas more theory-based approaches were used during the preclinical years'. More than 75% of the students declared that the practice of EBM in the fourth year was useful and appropriate for team-based learning. CONCLUSIONS: The EBM program was evaluated as 'adequate'. EBM courses should be included in the entire curriculum in an integrated manner. The students understand the main philosophy of EBM in the clinical year when involved in its practical application with actual patients.

Dexamethasone effects on vascular flow and organ injury in septic mice.

BACKGROUND: To demonstrate the effects of low-dose dexamethasone treatment on mesenteric artery blood flow, oxidative injury, vascular reactivity, and survival in Swiss albino mice with intra-abdominal polymicrobial sepsis accomplished by cecal ligation and puncture (CLP). METHODS: Mice were allocated to CLP + saline, CLP + dexamethasone, sham + saline, and sham + dexamethasone subgroups to evaluate blood flow, organ injury, and vascular response to consecutive phenylephrine administrations at 24, 48, and 72 h. Survival rates were also evaluated in a different group of mice. Dexamethasone (1 mg/kg/d) and saline (4 mL/kg/d) were administered intraperitoneally to mice 2 h after CLP or sham procedure, whichever appropriate, and repeated once a day until evaluation time at 48 and 72 h. Relaparotomy was performed at the concerned time and mesenteric blood flow was measured, and liver, lung, and peritoneum samples were obtained. Alteration in mesenteric blood flow response to intravenous phenylephrine injections was recorded at the related time intervals in different mice groups. Survival group was followed up by 7-d administration of dexamethasone or saline for 18 d. RESULTS: The significant fall in mesenteric blood flow after CLP ameliorated with dexamethasone treatment at 48 and 72 h. Dexamethasone also diminished the malonyl dialdehyde level, which is an indicator of organ injury raised after CLP, at 24 h in liver, lung, and peritoneum samples. Dexamethasone therapy has significantly enhanced the vascular response to phenylephrine injections at all doses; however, no change was observed in survival rates. CONCLUSIONS: Low-dose dexamethasone has beneficial effects on mesenteric blood flow and organ injury in experimental sepsis models.

The effect of problem-based learning with cooperative-learning strategies in surgery clerkships.

BACKGROUND: Cooperative learning is used often as part of the problem-based learning (PBL) process. But PBL does not demand that students work together until all individuals master the material or share the rewards for their work together. OBJECTIVE: A cooperative learning and assessment structure was introduced in a PBL course in 10-week surgery clerkship, and the difference was evaluated between this method and conventional PBL in an acute abdominal pain module. METHODS: An experimental design was used. RESULTS: No significant differences in achievement were found between the study and control group. Both the study and control group students who scored low on the pretest made the greatest gains at the end of the education. Students in the cooperative learning group felt that cooperation helped them learn, it was fun to study and expressed satisfaction, but they complained about the amount of time the groups had to work together, difficulties of group work, and noise during the sessions. CONCLUSIONS: This study evaluated the impact of a cooperative learning technique (student team learning [STL]) in PBL and found no differences. The study confirms that a relationship exists between allocated study time and achievement, and student's satisfaction about using this technique.

Effects of dexamethasone on ischemia reperfusion injury following pringle maneuver.

BACKGROUND/AIMS: Hepatic ischemia reperfusion injury induced by Pringle maneuver leads to bacterial translocation, endotoxemia and apoptosis. Our aim was to compare the effects of low and high dose dexamethasone pretreatment on antioxidant enzyme activities, bacterial translocation, endotoxemia and apoptosis, following Pringle maneuver. METHODOLOGY: Thirty-two rats were randomized into four groups; sham, control and two treatment groups; low dose dexamethasone (0.1 mg/kg) and high dose dexamethasone (1 mg/kg). In the treatment groups dexamethasone was administered intraperitoneally one hour before Pringle maneuver. Twenty-four hours after closing rats' abdomen, re-laparotomy was performed and tissue samples were taken from the mesenteric lymph nodes, liver, ileum and spleen and 1 mL of blood was drawn from the aorta. Bacterial translocation, endotoxemia, apoptosis and enzyme activities of G6PD, 6-PGD, GR, GST, GPx and CAT were evaluated. RESULTS: Low dose dexamethasone significantly decreased bacterial translocation to mesenteric lymph nodes, and reduced liver and enterocyte apoptosis, whereas high dose dexamethasone caused only a significant reduction in enterocyte apoptosis (p<0.05). Dexamethasone both in low and high doses significantly reduced the decrease in antioxidant enzyme levels (p<0.05). CONCLUSIONS: Low dose dexamethasone pretreatment caused constructive therapeutic effects after Pringle maneuver, whereas these effects were seen partially with a high dose.

Trace elements status in multinodular goiter.

Importance of iodine and selenium in thyroid metabolism is well known, but the roles of other essential trace elements including copper, zinc, manganese and iron on thyroid hormone homeostasis remain unclear. The aim of this study was to investigate the status of those trace elements in benign thyroid diseases and evaluate possible links between trace element concentrations and thyroid hormones. The study group was composed of 25 patients with multinodular goiter. Concentrations of thyroid hormones (plasma-free thyroxine, FT(4); free triiodothyronine, FT(3); and thyrotropin, TSH), selenium, copper, zinc, manganese and iron in plasma, and urinary iodine were determined. The results were compared with those of a healthy control group (n=20) with no thyroid disorder. A mild iodine deficiency was observed in the patients with multinodular goiter whereas urinary iodine levels were in the range of "normal" values in healthy controls. All patients were euthyroid, and their thyroid hormone concentrations were not significantly different from the control group. Plasma selenium, zinc and iron concentrations did not differ from controls, while copper and manganese levels were found to be significantly higher in the patients with multinodular goiter indicating links between these trace elements and thyroid function and possibly in development of goiter. Besides iodine, there was a significant correlation between plasma copper concentration and FT(3)/FT(4) ratio.

A novel fuzzy-logic inference system for predicting trauma-related mortality: emphasis on the impact of response to resuscitation.

INTRODUCTION: Trauma scoring aims for quantification and uniform reporting of trauma-related outcomes. Despite significant advances in trauma scoring, the exact time period at which relevant calculations should be made is not clear. Considering the importance of response to resuscitation, calculation of trauma scores after a period of resuscitation can allow better discrimination of patients who will survive. METHODS: A fuzzy-logic inference system, which is completely based on expert opinion and uses Glasgow Coma Scale (GCS) and systolic blood pressure at arrival to emergency room (ER) and their response to resuscitation as inputs, was developed. Records of the last 150 trauma patients admitted to our surgical intensive care unit (ICU) were used for calculations related to Injury Severity Score (ISS), Revised Trauma Score (RTS), Trauma and Injury Severity Score, and A Severity Characterization of Trauma (ASCOT) systems. Calculation of trauma severity and predicted mortality was performed at different time intervals during resuscitation [at arrival to emergency room (ER), after 1 h of resuscitation, and at ICU admission]. The performance of conventional systems and fuzzy-logic system was compared. RESULTS: Mean ISS was 32.31 ± 14.01. All systems included showed acceptable discriminative power. Among the conventional systems calculated at emergency room admission, ISS was the best performing [receiver operating characteristics (ROC), 0.9033] and RTS was the worst (ROC, 0.8106). Their performances were improved by up to 13% by use of post-resuscitation physiologic variables. Fuzzy-logic inference system performed slightly better (ROC, 0.9247) then the conventional systems calculated at arrival to ER. CONCLUSIONS: Response to resuscitation has significant impact on trauma mortality and must be considered in trauma scoring and mortality prediction. Fuzzy logic provides important opportunities for design of better predictive systems.

Metacognitive awareness and self-regulated learning skills of medical students in different medical curricula.

AIM: The aim of this study was to investigate the acquisition of metacognitive awareness and self-regulated learning skills in medical schools using different curricular models. METHODS: The study was carried out in four medical schools implementing different curricular models. Eight hundred and sixty two medical students took part in the study and two scales (self-regulated learning perception scale--SRLPS and metacognitive awareness inventory--MAI) were used. Cronbach's alpha was 0.93 for the MAI, and 0.88, 0.91, 0.83, and 0.76 for the four dimensions of the SRLPS. RESULTS: There were no statistically significant differences in MAI scores according to gender, curricular language, or previous exposure or not to a learner-centered method during secondary school, but the differences in scores according to the phase and curricular model were found to be significant. With regard to SRLPS total scores, no difference was found according to gender, but significant differences were found according to phase, curricular language, and curricular model. MAI and SRLPS scores of students from the medical school using a learner-centered curriculum were higher than the other schools' students. CONCLUSION: This study suggests that students who experience a learner-centered curriculum, such as PBL during their medical education demonstrate improved metacognitive awareness and self-regulated learning skills.

[Effects of autologous and homologous blood transfusion on TNF-alpha levels and survival in an intraabdominal infection model]. / Otolog ve homolog kan transfüzyonunun karin içi enfeksiyon modelinde TNF-alfa düzeyleri ve sagkalima etkisi.

BACKGROUND: Autologous blood transfusion is one of the approaches used for prevention of the undesirable immunomodulatory effects of homologous blood transfusion that can cause an increase in cancer recurrence and surgical site infections. On the other hand, the benefits of autologous blood transfusion in that respect are not yet clearly identified. In this experimental study, we investigated the differences in effects of autologous and homologous blood transfusion on tumor necrosis factor (TNF)-alpha levels and survival in an intraabdominal infection model in rats. METHODS: A total of 92 Sprague-Dawley rats were used in the study. Forty-four of those rats were divided into autologous and homologous transfusion groups, and intraabdominal infection was instituted by cecal ligation puncture method on the 7th day after blood transfusion. Blood samples were taken at the 90th minute and at 6-hour intervals after cecal ligation puncture and were used for measurement of TNF-alpha levels by ELISA method. In the remaining 48 rats, survival was investigated within the first week of cecal ligation puncture. RESULTS: Our results revealed significantly depressed TNF-alpha levels in the homologous blood transfusion group, but with respect to survival, no difference was detected between the groups. CONCLUSION: Based on these findings, we concluded that autologous blood transfusion decreases transfusion-related immunomodulation but does not cause a decrease in mortality due to intraabdominal infection.

Determinants of postoperative infection after laparoscopic cholecystectomy.

BACKGROUND/AIMS: The aim of this study was to evaluate the effect of antibiotic prophylaxis on the development of infectious complications in laparoscopic cholecystectomy. METHODOLOGY: A total of 208 patients undergoing elective laparoscopic cholecystectomy were randomized, double-blinded into one of two treatment arms: 1) cefazolin 1 g intravenously after induction of anesthesia and 2) no prophylactic antibiotics. The patients were followed-up for infectious complications for 30 days at the out-patient clinic. The data collected included age, sex, body mass index, ultrasonography findings, accompanying diseases, perforation during surgery, stone spillage, operation time, port of gallbladder delivery, suture material used for skin closure, preoperative and length of postoperative hospitalization, bile culture, pathology of the gallbladder, serum biochemical findings including alanine aminotransferase, aspartate aminotransferase, gammaglutamyl transpeptidase, bilirubin, alkaline phosphatase and glucose. RESULTS: Overall rate of infection was 3.36%. Four out of 105 patients who received antibiotics and 3 out of 103 patients who did not receive antibiotics developed infection. The difference was not statistically significant. Obesity and closing the skin with nylon sutures were found to be associated with increased rate of infectious complications. CONCLUSIONS: Cefazolin prophylaxis in low risk patients has no effect on postoperative infection rate in laparoscopic cholecystectomy.

Thyroid surgery: what has changed from (1970 to 2004): a Turkish perspective.

BACKGROUND: Turkey is an endemic region for goiter. The aim of this study was to evaluate the changing factors concerning thyroid disease and thyroid surgery in a referral center in Turkey. METHODS: This study was a retrospective evaluation of reports of patients who underwent surgery for thyroid disease at Hacettepe University Medical School between the years 1970 and 1974, 1980 and 1984, 1990 and 1994, and 2000 and 2004. RESULTS: A total of 1,270 patients were included in the study. There were 140, 141, 402, and 587 patients in the 1970-1974, 1980-1984, 1990-1994, and 2000-2004 groups, respectively. In the past decade, the use of ultrasonography has increased significantly; more thyroid cancer cases have been diagnosed and more extensive surgical procedures have been applied. CONCLUSIONS: During the past 40 years, significant changes have occurred in the treatment of thyroid disease, particularly diagnostic tools, pathologies, and surgical procedures.

The impact of clinical visits on communication skills training.

OBJECTIVE: The aim of the study is to evaluate a communication skills training program, and to investigate the relationship between communication skills and clinical visits. METHODS: This descriptive study was conducted at Hacettepe University Faculty of Medicine. 216 of the students (48.4%) took part in the study. They are evaluated at three steps of the program. Additionally, qualitative data were collected by interviewing with students and standardized patients. RESULTS: A paired t-test showed a significant difference between students' mean pretest scores (8.58+/-1.69) and posttest scores (11.26+/-1.74) (p<0.01). There was a significant difference between the progress test scores according to the site of visitation (p<0.01), but not between the posttest scores. The mean progress test scores of the students who visited the outpatient clinics (10.61+/-1.41 for group 2, 10.80+/-1.34 for group 4) were higher than those visiting the health centers (9.68+/-1.56 for group 1, 10.12+/-1.38 for group 3). CONCLUSIONS: Our study showed that the program was effective in achieving communication skills. Students can be better trained for communication skills while practicing in both skills laboratories and real settings. PRACTICAL IMPLICATIONS: The possible variations in the educational environments and the staff should be taken into account when planning the program.

Intestinal obstructions: what has changed so far?

The aim of this study is to evaluate the changing factors related to surgery in intestinal obstruction. The surgical records of patients who were operated for intestinal obstruction at Hacettepe University Medical School during the years 1980-1985 and 2000-2005 were evaluated retrospectively. There were 92 patients in group I and 185 patients in group II. The cause of intestinal obstruction was adhesions in 41.30% of the patients in group I and tumors in 45.95% of the patients in group II (P = 0.0001). Patients with peritoneal carcinomatosis constituted 3.26% of the patients in group I and 27.03% of the patients in group II (P = 0.0001). Abdominal computed tomography was not used in the first group and was used in 60.54% of those in the second group (P = 0.0001). Complications were seen in 40.54% of patients in the second group and in 26.08% of patients in the first group (P = 0.01). During the past 20 years, changes have occurred that were related to causes, diagnostic tools, and nutritional support for patients undergoing surgery for intestinal obstruction. Despite these changes, no changes in length of hospital stay or mortality have been reported. Intestinal obstruction due to peritoneal carcinomatosis seems to be a growing problem.

The effects of scolicidal agent propolis on liver and biliary tree.

BACKGROUND: This study was designed to examine the effects of propolis on the liver and biliary system when used as a scolicidal agent. MATERIALS AND METHODS: Thirty Wistar-Albino rats were divided into two groups. Propolis and 0.9% saline (NaCl) were injected into the biliary tract of the rats. Three rats from control group and four rats from propolis group died within 5 days after the procedure. Blood samples of remaining 23 rats were obtained 1 week after and at the end of the experimental study for liver function tests. Six months after the procedure, retrograde and magnetic resonance cholangiography were performed and liver, common bile duct, and duodenum were excised en bloc for histopathological examination. RESULTS: Liver function tests were slightly elevated 1 week after the procedure and were found to be normal at the end of the sixth month in both groups. No stricture in the biliary tree was found on the retrograde and magnetic resonance cholangiograms. The tissue samples of the propolis group showed no histomorphological difference from the control group. CONCLUSIONS: Propolis may be used as a scolicidal agent even in the case of cystobiliary communication with no side effects on liver and biliary tree.

Effects of honey as a scolicidal agent on the hepatobiliary system.

AIM: To examine the effects of 10% diluted honey, which has been shown to be scolicidal, on the liver and biliary system and determine whether it could be used as a scolicidal agent in the presence of biliary-cystic communication. METHODS: Thirty Wistar-Albino rats were divided into two groups. Honey with 10% dilution in the study group and 0.9% saline (NaCl) in the control group were injected into the common bile ducts of rats through a 3-mm duodenotomy. The animals were sacrificed 6 mo after the procedure. Histopathological, biochemical, and radiological examinations were performed for evaluation of side effects. RESULTS: At the end of the sixth month, liver function tests were found to be normal in both groups. The tissue samples of liver and ductus choledochus of the honey group showed no histomorphologic difference from the control group. No stricture on the biliary tree was detected on the retrograde cholangiograms. CONCLUSION: According to these results, we concluded that 10% diluted honey could be used as scolicidal agent safely in the presence of biliary-cystic communication.

Effect of peritoneal lavage on TNF-alpha, IL-1beta, and IL-6 levels and mortality in intraabdominal infections.

The mortality rate of intra-abdominal infections is high, and new prognostic factors are being investigated. Tumor necrosis factor alpha (TNF-alpha), interleukin (IL)-1beta, and IL-6 are among these factors. Intraoperative peritoneal lavage is part of surgical treatment for intra-abdominal infection. The aim of this study is to investigate the effect of peritoneal lavage on TNF-alpha, IL-1beta, and IL-6 levels and mortality when the source control has or has not been established. Eighty-five rats were divided into control, cecal ligation and puncture, and cecal ligation and puncture with excision groups. The effect of peritoneal lavage on TNF-alpha, IL-1beta, and IL-6 levels and mortality could not be shown in this study.