Impact of Quantitative Feedback via High-Fidelity Airway Management Training on Success Rate in Endotracheal Intubation in Undergraduate Medical Students-A Prospective Single-Center Study.

Endotracheal intubation is still the gold standard in airway management. For medical students and young professionals, it is often difficult to train personal skills. We tested a high-fidelity simulator with an additional quantitative feedback integration to elucidate if competence acquisition for airway management is increased by using this feedback method. In the prospective trial, all participants (n = 299; 4th-year medical students) were randomized into two groups-One had been trained on the simulator with additional quantitative feedback (n = 149) and one without (n = 150). Three simulator measurements were considered as quality criteria-The pressure on the upper front row of teeth, the correct pressure point of the laryngoscope spatula and the correct depth for the fixation of the tube. There were a total of three measurement time points-One after initial training (with additional capture of cognitive load), one during the exam, and a final during the follow-up, approximately 20 weeks after the initial training. Regarding the three quality criteria, there was only one significant difference, with an advantage for the control group with respect to the correct pressure point of the laryngoscope spatula at the time of the follow-up (p = 0.011). After the training session, the cognitive load was significantly higher in the intervention group (p = 0.008) and increased in both groups over time. The additional quantitative feedback of the airway management trainer brings no measurable advantage in training for endotracheal intubation. Due to the increased cognitive load during the training, simple airway management task training may be more efficient for the primary acquisition of essential procedural steps.

Medical Education for "Generation Z": Everything online?! - An analysis of Internet-based media use by teachers in medicine.

Aim: The aims of this study were to gain an overview of the web-based media used during the clinical phase of medical study at German medical schools and to identify the resources needed for web-based media use. Also examined were the influences on web-based media use, for instance, the assessment of their suitability for use in teaching. Method: An online survey of 264 teacher coordinators in internal medicine, surgery, anesthesiology, gynecology, pediatrics and psychiatry was conducted in March and April, 2016. This survey was carried out in the German-speaking countries using a 181-item questionnaire developed by us. Analysis took place in the form of descriptive and exploratory data analysis. Results: The response rate was 34.8% with 92 responses. Individual web-based media were actively used in the classroom by a maximum of 28% of participants. Reasons cited against using web-based media in teaching included the amount of time required and lack of support staff. The assessment of suitability revealed that interactive patient cases, podcasts and subject-specific apps for teaching medicine were predominantly viewed as constructive teaching tools. Social media such as Facebook and Twitter were considered unsuitable. When using web-based media and assessing their suitability for teaching, no correlations with the personal profiles of the teachers were found in the exploratory analysis, except regarding the use of different sources of information. Conclusion: Despite the Internet's rapid development in the past 15 years, web-based media continue to play only a minor role in teaching medicine. Above all, teacher motivation and sufficient staff resources are necessary for more effective use of Internet-based media in the future.

Students benefit from developing their own emergency medicine OSCE stations: a comparative study using the matched-pair method.

BACKGROUND: Students can improve the learning process by developing their own multiple choice questions. If a similar effect occurred when creating OSCE (objective structured clinical examination) stations by themselves it could be beneficial to involve them in the development of OSCE stations. This study investigates the effect of students developing emergency medicine OSCE stations on their test performance. METHOD: In the 2011/12 winter semester, an emergency medicine OSCE was held for the first time at the Faculty of Medicine at the University of Leipzig. When preparing for the OSCE, 13 students (the intervention group) developed and tested emergency medicine examination stations as a learning experience. Their subsequent OSCE performance was compared to that of 13 other students (the control group), who were parallelized in terms of age, gender, semester and level of previous knowledge using the matched-pair method. In addition, both groups were compared to 20 students who tested the OSCE prior to regular emergency medicine training (test OSCE group). RESULTS: There were no differences between the three groups regarding age (24.3 ± 2.6; 24.2 ± 3.4 and 24 ± 2.3 years) or previous knowledge (29.3 ± 3.4; 29.3 ± 3.2 and 28.9 ± 4.7 points in the multiple choice [MC] exam in emergency medicine). Merely the gender distribution differed (8 female and 5 male students in the intervention and control group vs. 3 males and 17 females in the test OSCE group).In the exam OSCE, participants in the intervention group scored 233.4 ± 6.3 points (mean ± SD) compared to 223.8 ± 9.2 points (p < 0.01) in the control group. Cohen's effect size was d = 1.24. The students of the test OSCE group scored 223.2 ± 13.4 points. CONCLUSIONS: Students who actively develop OSCE stations when preparing for an emergency medicine OSCE achieve better exam results.

Study of medicine 2.0 due to Web 2.0?! -- risks and opportunities for the curriculum in Leipzig.

Web 2.0 is changing the study of medicine by opening up totally new ways of learning and teaching in an ongoing process. Global social networking services like Facebook, YouTube, Flickr, Google Drive and Xing already play an important part in communication both among students and between students and teaching staff. Moreover, local portals (such as the platform [http://www.leipzig-medizin.de] established in 2003) have also caught on and in some cases eclipsed the use of the well-known location-independent social media. The many possibilities and rapid changes brought about by social networks need to be publicized within medical faculties. Therefore, an E-learning and New Media Working Group was set up at the Faculty of Medicine of Universität Leipzig in order to harness the opportunities of Web 2.0, analyse the resulting processes of change in the study of medicine, and curb the risks of the Internet. With Web 2.0 and the social web already influencing the study of medicine, the opportunities of the Internet now need to be utilized to improve the teaching of medicine.

Effects of Music Listening on Cortisol Levels and Propofol Consumption during Spinal Anesthesia.

BACKGROUND: This study explores effects of instrumental music on the hormonal system (as indicated by serum cortisol and adrenocorticotropic hormone), the immune system (as indicated by immunoglobulin A) and sedative drug requirements during surgery (elective total hip joint replacement under spinal anesthesia with light sedation). This is the first study investigating this issue with a double-blind design using instrumental music. METHODOLOGY/PRINCIPAL FINDINGS: Patients (n = 40) were randomly assigned either to a music group (listening to instrumental music), or to a control group (listening to a non-musical placebo stimulus). Both groups listened to the auditory stimulus about 2 h before, and during the entire intra-operative period (during the intra-operative light sedation, subjects were able to respond lethargically to verbal commands). Results indicate that, during surgery, patients of the music group had a lower propofol consumption, and lower cortisol levels, compared to the control group. CONCLUSION/SIGNIFICANCE: Our data show that listening to music during surgery under regional anesthesia has effects on cortisol levels (reflecting stress-reducing effects) and reduces sedative requirements to reach light sedation.

The serotonin transporter availability in untreated early-onset and late-onset patients with obsessive-compulsive disorder.

The pathogenetic role of central serotonin transporters (SERT) in obsessive-compulsive disorder (OCD) has been investigated in vivo by positron emission tomography (PET) or single-photon emission computed tomography (SPECT) studies with inconsistent results. This might reflect methodological differences but possibly also the pathophysiological heterogeneity of the disorder, i.e. the age at onset of OCD. The aim of our study was to compare SERT availability in patients with OCD to healthy controls (HC) taking into account the onset type, other factors and covariates (e.g. SERT genotype, age, depression level, gender). We studied 19 drug-naive OCD patients (36±13 yr, eight females) with early onset (EO-OCD, n=6) or with late onset (LO-OCD, n=13), and 21 HC (38±8 yr, nine females) with PET and the SERT-selective radiotracer [11C]DASB. Statistical models indicated that a variety of covariates and their interaction influenced SERT availability measured by distribution volume ratios (DVR). These models revealed significant effects of onset type on DVR with lower values in LO-OCD (starting at age 18 yr) compared to EO-OCD and HC in limbic (e.g. the amygdala), paralimbic brain areas (the anterior cingulate cortex), the nucleus accumbens and striatal regions, as well as borderline significance in the thalamus and the hypothalamus. The putamen, nucleus accumbens and hypothalamus were found with significant interaction between two SERT gene polymorphisms (SERT-LPR and VNTR). These findings suggest that late but not early onset of OCD is associated with abnormally low SERT availability. In part, functional polymorphisms of the SERT gene might determine the differences.

Whole-brain mapping of venous vessel size in humans using the hypercapnia-induced BOLD effect.

Measuring the morphology of the cerebral microvasculature by vessel-size imaging (VSI) is a promising approach for clinical applications, such as the characterization of tumor angiogenesis and stroke. Despite the great potential of VSI, this method has not yet found widespread use in practice due to the lack of experience in testing it on healthy humans. Since this limitation derives mainly from the need for an invasive injection of a contrast agent, this work explores the possibility to employ instead the easily accessible blood oxygenation level dependent (BOLD) effect for VSI of the venous microstructure. It is demonstrated that BOLD-VSI in humans can be realized by a hypercapnic challenge using a fast gradient-echo (GE) and spin-echo (SE) sequence at 7T. Reproducible maps of the mean venous vessel radius, based on the BOLD-induced changes in GE and SE relaxation rates, could be obtained within a scan time of 10min. Moreover, the method yields maps of venous blood volume and vessel density. Owing to its non-invasive character, BOLD-VSI provides a low-risk method to analyze the venous microstructure, which will not only be useful in clinical applications, but also provide a better understanding of BOLD effect.

Dual echo EPI--the method of choice for fMRI in the presence of magnetic field inhomogeneities?

FMRI studies of the orbitofrontal cortex or the inferior temporal lobes are often compromised by susceptibility artefacts, which may result in signal reduction or loss in gradient echo (GE) EPI. Spin echo (SE) EPI is considerably more robust against susceptibility-related signal loss, but its intrinsic sensitivity to changes in the blood oxygenation level dependent (BOLD) contrast is generally lower. In this study, we performed a direct comparison of GE and SE fMRI using a single-shot dual echo EPI acquisition scheme. Transient hypercapnia, induced by breathing Carbogen (5% CO(2), 95% O(2)), was used as a global physiological stimulus to alter the BOLD contrast. In regions affected by magnetic field inhomogeneities, SE EPI provided significantly higher BOLD sensitivity than GE EPI. Such regions included the orbitofrontal cortex, temporal pole, anterior inferior temporal cortex, as well as parts of the lateral inferior temporal cortex and the lateral cerebellum. Dual echo fMRI benefits from the robustness of SE EPI in these critical regions while utilising the generally higher sensitivity of GE EPI in normal regions. It therefore provides an attractive solution for fMRI studies that require optimum sensitivity in both normal and critical brain regions. Furthermore, a general method is proposed to combine the GE and SE data into a single hybrid data set that provides optimum sensitivity in the whole brain. This method can be applied to any experimental design that can be expressed in terms of a generalised linear model. The feasibility of this approach is demonstrated both theoretically and experimentally.

Hypercapnia-induced effects on image contrast based on intermolecular double-quantum coherences.

Intermolecular double-quantum coherences (iDQCs) are well known to be sensitive to magnetic-field perturbations inside tissues. However, the exact relation between iDQC contrast in magnetic resonance imaging (MRI) and the underlying physiology is less well understood. To investigate parameters that influence iDQC signal changes observed during neuronal activation, carbogen-inhalation experiments were performed to produce a pure hemodynamic response without affecting oxidative metabolism. Eight human volunteers were studied at 2.9 T using gradient-recalled echo (GRE) and spin-echo (SE) variants of a single-shot sequence selecting iDQCs. Results were compared with conventional recordings of the blood oxygen level-dependent (BOLD) effect. Maps of voxels responding to the carbogen challenge showed similar distributions for iDQC and conventional MRI after adjustment for different sensitivities. Strong diffusion weighting of iDQC sequences and transverse relaxation effects suggested quantitative suppression of intravascular signal contributions. A particular susceptibility to local gradients during the evolution period (in which iDQCs evolve at twice the Larmor frequency) plus a strong relaxation weighting during the detection period due to the use of a long echo time (for refocusing of the dipolar signal) produced iDQC signal changes up to 21.7% +/- 2.5%. These results agreed quantitatively with computations based on the balloon model of BOLD-weighted MRI without requiring further assumptions.

Auditory processing during deep propofol sedation and recovery from unconsciousness.

OBJECTIVE: Using evoked potentials, this study investigated effects of deep propofol sedation, and effects of recovery from unconsciousness, on the processing of auditory information with stimuli suited to elicit a physical MMN, and a (music-syntactic) ERAN. METHODS: Levels of sedation were assessed using the Bispectral Index (BIS) and the Modified Observer's Assessment of Alertness and Sedation Scale (MOAAS). EEG-measurements were performed during wakefulness, deep propofol sedation (MOAAS 2-3, mean BIS=68), and a recovery period. Between deep sedation and recovery period, the infusion rate of propofol was increased to achieve unconsciousness (MOAAS 0-1, mean BIS=35); EEG measurements of recovery period were performed after subjects regained consciousness. RESULTS: During deep sedation, the physical MMN was markedly reduced, but still significant. No ERAN was observed in this level. A clear P3a was elicited during deep sedation by those deviants, which were task-relevant during the awake state. As soon as subjects regained consciousness during the recovery period, a normal MMN was elicited. By contrast, the P3a was absent in the recovery period, and the P3b was markedly reduced. CONCLUSIONS: Results indicate that the auditory sensory memory (as indexed by the physical MMN) is still active, although strongly reduced, during deep sedation (MOAAS 2-3). The presence of the P3a indicates that attention-related processes are still operating during this level. Processes of syntactic analysis appear to be abolished during deep sedation. After propofol-induced anesthesia, the auditory sensory memory appears to operate normal as soon as subjects regain consciousness, whereas the attention-related processes indexed by P3a and P3b are markedly impaired. SIGNIFICANCE: Results inform about effects of sedative drugs on auditory and attention-related mechanisms. The findings are important because these mechanisms are prerequisites for auditory awareness, auditory learning and memory, as well as language perception during anesthesia.

The effects of anesthetics on brain activity and cognitive function.

PURPOSE OF THIS REVIEW: This review presents an overview of recent findings related to changes in brain activity with increasing anesthesia mainly obtained with brain imaging and electrophysiological techniques in humans. RECENT FINDINGS: Recent studies have revealed that the brain as a whole is not affected to the same degree by anesthetics, but that specific brain regions (and particular cognitive processes mediated by these regions) are more sensitive to anesthesia and sedation than others. Inhibition of activity in multimodal association cortices (such as parietal and prefrontal association cortices) by sedative concentrations of anesthetics produces amnesia and attention deficits, whereas activity in unimodal cortices and in the thalamus remains largely unaffected by low doses of anesthetics. Activity in the midbrain reticular formation, thalamus, and unimodal cortices appears to be suppressed only by anesthetic concentrations causing unconsciousness. Besides those regional suppressive effects, anesthetics impair functional connections between neurons in distributed cortical and thalamocortical networks, which also contributes to the state of anesthesia. SUMMARY: Anesthetics produce changes in the patient's behavioral state by interacting with brain activity via at least two mechanisms: the dose-dependent global and regionally specific suppression of neuronal activity and the disruption of functional interactivity within distributed neural networks.

The effect of esmolol on cerebral blood flow, cerebral vasoreactivity, and cognitive performance: a functional magnetic resonance imaging study.

BACKGROUND: Esmolol is often applied perioperatively to maintain stable hemodynamic conditions in neurosurgical patients. Little is known, however, about its effects on cerebral circulation. The authors employed functional magnetic resonance imaging based on blood oxygenation level-dependent contrast to explore the effect of esmolol on the human brain. The purpose of the study was to investigate the effect of esmolol on cerebral blood flow, cerebral vasoreactivity, and cognitive performance. METHODS: Ten healthy volunteers were investigated in two separate experimental sessions using functional magnetic resonance imaging. During the first experimental session, a hyperventilation task and a cognitive task, subjects had to perform both tasks twice, once after administration of an esmolol bolus of 1 mg/kg followed by a continuous infusion of 150 microg.kg.min and once without beta-blockade, in a random order. During the second experimental session subjects were scanned at resting state after administration of esmolol. Furthermore, the effect of the esmolol dose on hemodynamic changes caused by beta-adrenergic stimulation with orciprenaline was investigated. RESULTS: Esmolol decreased heart rate and blood pressure during the various experimental conditions and blunted the increase in heart rate and blood pressure caused by orciprenaline. Infusion of esmolol affects neither the blood oxygenation level-dependent contrast during the functional challenges nor the reaction times during the cognitive task. However, the esmolol bolus caused a brief blood oxygenation level-dependent contrast increase. CONCLUSION: The results indicate that effective beta-blockade with esmolol does not affect cerebral blood flow, cerebrovascular reactivity, or cognitive performance.

Sequential effects of increasing propofol sedation on frontal and temporal cortices as indexed by auditory event-related potentials.

BACKGROUND: It is an open question whether cognitive processes of auditory perception that are mediated by functionally different cortices exhibit the same sensitivity to sedation. The auditory event-related potentials P1, mismatch negativity (MMN), and early right anterior negativity (ERAN) originate from different cortical areas and reflect different stages of auditory processing. The P1 originates mainly from the primary auditory cortex. The MMN is generated in or in the close vicinity of the primary auditory cortex but is also dependent on frontal sources. The ERAN mainly originates from frontal generators. The purpose of the study was to investigate the effects of increasing propofol sedation on different stages of auditory processing as reflected in P1, MMN, and ERAN. METHODS: The P1, the MMN, and the ERAN were recorded preoperatively in 18 patients during four levels of anesthesia adjusted with target-controlled infusion: awake state (target concentration of propofol 0.0 microg/ml), light sedation (0.5 microg/ml), deep sedation (1.5 microg/ml), and unconsciousness (2.5-3.0 microg/ml). Simultaneously, propofol anesthesia was assessed using the Bispectral Index. RESULTS: Propofol sedation resulted in a progressive decrease in amplitudes and an increase of latencies with a similar pattern for MMN and ERAN. MMN and ERAN were elicited during sedation but were abolished during unconsciousness. In contrast, the amplitude of the P1 was unchanged by sedation but markedly decreased during unconsciousness. CONCLUSION: The results indicate differential effects of propofol sedation on cognitive functions that involve mainly the auditory cortices and cognitive functions that involve the frontal cortices.