Competence-based teaching and learning in the outpatient clinic: development of a clinical elective in ambulatory medicine.

Aim: Although physicians have the most contact with patients in the outpatient setting, topics relating to ambulatory medicine have been less present in medical education. To teach professional skills, practical learning opportunities must be created in which students can practice medical skills under authentic working conditions in the outpatient setting. The clinical elective in ambulatory medicine has been developed, evaluated and revised at the Mannheim Medical School as a practical, competency-based learning experience in outpatient clinics (liver clinic, psychiatric outpatient clinic, uro-oncological consultations, etc.). Methods: The elective was designed using the plan-do-check-act (PDCA) cycle in the form of a longitudinal practical course during the fourth year of study. By selecting one of four concentrations in ambulatory care, students have the opportunity to focus on and pursue an individual interest. Students are given assignments during three separate sessions at an outpatient clinic and complete a log book which contains the learning objectives, assignments and grading criteria. Once the elective had been completed, the students (n=165) and mentors (n=7) had the option to participate in a survey to evaluate knowledge gain and satisfaction with the elective. Results: The students rated their personal growth in knowledge about common diseases and patient-centered communication positively, while rating their knowledge gain in ambulatory patient management somewhat lower. The first offering of the elective was evaluated as satisfactory by students and mentors. In 85.8% of the cases, students reported that they would recommend the selected outpatient clinic for this course. Suggestions for improvement, such as those concerning the log book and scheduling system, were considered during the first revision. Conclusion: This elective provides an opportunity to become familiar with ambulatory medicine in a practical and competency-based manner during medical studies. Skills in ambulatory medicine are already taught and applied in the fourth year of study in a practical setting and also deepened further through interconnections with other courses and chosen concentrations. Moreover, this elective format may be used by other medical schools depending on which aspects of ambulatory medicine are focused on.

Biologic activity of cyclic and caged phosphates: a review.

The recognition in the early 1960s by Morifusa Eto that tri-o-cresyl phosphate (TOCP) is hydroxylated by the cytochrome P450 system to an intermediate that spontaneously cyclizes to a neurotoxic phosphate (saligenin phosphate ester) ignited the interest in this group of compounds. Only the ortho isomer can cyclize and clinically cause Organo Phosphate Induced Delayed Neurotoxicity (OPIDN); the meta and para isomers of tri-cresyl phosphate are not neuropathic because they are unable to form stable cyclic saligenin phosphate esters. This review identifies the diverse biological effects associated with various cyclic and caged phosphates and phosphonates and their possible use. Cyclic compounds that inhibit acetylcholine esterase (AChE), such as salithion, can be employed as pesticides. Others are neurotoxic, most probably because of inhibition of neuropathy target esterase (NTE). Cyclic phosphates that inhibit lipases, the cyclipostins, possibly represent promising therapeutic avenues for the treatment of type 2 diabetes mellitus and/or microbial infections; those compounds inhibiting ß-lactamase may prevent bacterial resistance against ß-lactam antibiotics. Naturally occurring cyclic phosphates, such as cyclic AMP, cyclic phosphatidic acid and the ryanodine receptor modulator cyclic adenosine diphosphate ribose, play an important physiological role in signal transduction. Moreover, some cyclic phosphates are GABA-antagonists, while others are an essential component of Molybdenum-containing enzymes. Some cyclic phosphates (cyclophosphamide, ifosfamide) are clinically used in tumor therapy, while the coupling of therapeutic agents with other cyclic phosphates (HepDirect® Technology) allows drugs to be targeted to specific organs. Possible clinical applications of these compounds are considered. Copyright © 2016 John Wiley & Sons, Ltd.

Alpha-2-delta ligands for singultus (hiccup) treatment: three case reports.

Chronic idiopathic singultus (hiccup) is a debilitating condition affecting mostly elderly males. While in the past, pharmacologic singultus treatment was mostly "trial and error," more recently, treatment has become both more evidence based and pathophysiology guided. A combination of an acidity-reducing drug (H(2)-receptor blocker or proton pump inhibitor) with baclofen (gamma-amino-butyric-acid receptor type B agonist) has become the most widely used regimen. Some clinicians replace or supplement baclofen with gabapentin. We present three cases of chronic idiopathic hiccup managed with gabapentin or another alpha-2-delta ligand, pregabalin. This is the first reported use of pregabalin for this indication.