Erle Ch Lim

Demystifying neurology: preventing 'neurophobia' among medical students.

Medical students tend to perceive neurology as one of the most difficult medical specialties, and practicing doctors often feel ill-prepared to handle disorders of the nervous system. Lim and Seet believe that the key to solving this problem is to simplify the subject at medical school. In this Training Matters article, they outline neurology teaching approaches that have been adopted at the National University of Singapore.

Products of 5-lipoxygenase and myeloperoxidase activities are increased in young male cigarette smokers

Abstract The significance of 5-lipoxygenase and myeloperoxidase activities has not been extensively studied among young male smokers. Leukotriene B4, 20-hydroxy-leukotriene B4, 20-carboxy-leukotriene B4 and 3-chlorotyrosine were measured in plasma and urinary samples of young male smokers at 8 hours following cigarette abstinence and an hour after cigarette smoking. Leukotriene B4 and 3-chlorotyrosine were determined in neutrophils isolated from these individuals. The levels of these markers were compared with those of age-matched controls. In vitro studies were performed to evaluate the production of leukotriene B4 and 3-chlorotyrosine from human neutrophils following exposure to nicotine and cotinine. Thirty male smokers (mean age, 27.4 years) and 28 male non-smokers (mean age, 28.7 years) were studied. Plasma levels of leukotriene B4, 20-carboxy-leukotriene B4 and 3-chlorotyrosine were higher in smokers than in non-smokers; leukotriene B4 and 20-carboxy-leukotriene B4 levels increased further an hour after cigarette smoking. Peripheral neutrophils isolated from smokers showed greater expressions of myeloperoxidase and 5-lipoxygenase activities compared with non-smokers, while plasma leukotriene B4 and 3-chlorotyrosine were correlated significantly with high-sensitivity C-reactive protein and plasma nicotine concentrations. Exposure of human neutrophils to nicotine and cotinine resulted in a higher production of leukotriene B4 and 3-chlorotyrosine. To conclude, leukotriene B4 and 3-chlorotyrosine levels are increased in young male cigarette smokers. These results suggest that cigarette smoking aggravates neutrophil-mediated inflammation by modulating the activities of myeloperoxidase and 5-lipoxygenase pathways.

In-House Medical Education: Redefining Tele-Education

Background: Hip and tech-savvy medical students and junior doctors are likely to find lecture-based professionalism and ethics modules boring. Medical-based television dramas and films, on the other hand, are exciting and topical, and often feature real-life situations, albeit presented with artistic license. Current “hot” television series, such as House, ER, and Greys Anatomy, feature scenarios which are thought-provoking, not only for the fascinating cases featured, but also for the ethical dilemmas and professionalism issues which present themselves. Summary: We discuss the educational merits of the genre of the medical drama and propose to develop an “In-House” Medical Education Initiative, in which an episode of House is shown, and participants encouraged, at the end of the screening, to discuss the following: ethics, professionalism (communications skills, confidentiality, sensitivity, and empathy), history taking and clinical examination, diagnostic steps and mis-steps, and finally learning points (or take-home messages). Conclusion: Television programs, purported to “rot the mind,” can actually be put to good use in the teaching of “soft skills” in medicine.

Augmentation of 5-lipoxygenase activity and expression during dengue serotype-2 infection

BackgroundLeukotriene B4, a 5-lipoxygenase product of arachidonic acid with potent chemotactic effects on neutrophils, has not been assessed in dengue patients. In this study, plasma leukotriene B4 and serum high-sensitivity C-reactive protein levels were determined in adult patients during the febrile, convalescent and defervescent stages of dengue serotype-2 (DENV-2) infection, and compared with those of age--matched healthy and non-dengue febrile subjects. In vitro studies were performed to examine the effects of live and heat-inactivated DENV-2 on the activities and expression of 5-lipoxygenase in human neutrophils.ResultsPlasma leukotriene B4 was elevated during the febrile stages of dengue infection compared to levels during convalescence and in study controls. Plasma leukotriene B4 also correlated with serum high-sensitivity C-reactive protein in dengue patients (febrile, ru2009=u20090.91, pu2009<u20090.001; defervescence, ru2009=u20090.87, pu2009<u20090.001; convalescence, ru2009=u20090.87, pu2009<u20090.001). Exposure of human neutrophils to DENV-2 resulted in a significant rise in leukotriene B4; the extent of increase, however, did not differ between exposure to live and heat-inactivated DENV-2. Pre-incubation of either live or heat-inactivated DENV-2 resulted in reduced leukotriene B4 release by neutrophils, indicating that contact with dengue antigens (and not replication) triggers the neutrophil response. Production of leukotriene B4 was associated with an increase in 5-lipoxygenase expression in human neutrophils; addition of MK886 (a 5-lipoxygenase activating protein inhibitor) attenuated further increase in leukotriene B4 production.ConclusionThese findings provide important clinical and mechanistic data on the involvement of 5-lipoxygenase and its metabolites in dengue infection. Further studies are needed to elucidate the therapeutic implications of these findings.

Using an online neurological localisation game

Context and setting Our medical school has conducted an online modified essay question (eMEQ) examination since 2003, using an in-house integrated virtual learning environment (IVLE) which enables academic staff to distribute course materials, schedule and administer lessons and assessments, and interact with students online. We present the eNLG, an online neurological localisation game, designed to teach the principles of neurological localisation to students using the eMEQ format. Evaluation data for a period of 6 months are presented to document the participants’ assessment of its efficacy. Why the idea was necessary Neurophobia (i.e. fear of the neurosciences and neurology) has worldwide prevalence. Earlier efforts to link the neuroscience and clinical neurology modules and simplify clinical neurology by means of dedicated lectures and small-group tutorials were appreciated by our students. However, student feedback indicated that they had not received adequate grounding in the neurosciences, deemed clinical neurology to be difficult and lacked the confidence to localise the lesion in a neurological case. What was done We designed eMEQs featuring simulated patients with neurological problems, taking the student-gamers through history taking, physical examination (with appropriate video vignettes and digital photographs), relevant investigations (including digitised neuroimages) and the management steps of a consultation. In the game, once students have submitted their answers to short-answer and multiple-choice questions online, the eNLG concludes at a webpage that presents the submitted answers alongside recommended answers, with commentaries explaining the rationale for the correct choices. (A trial version of the game may be attempted at ANONYMISED FOR REVIEW, by logging in as ‘gstjournal’, using the password ‘9zd491’ in the ‘guest’ domain and clicking on the ‘NeuroGame’ icon; https://ivle.nus.edu.sg). Evaluation of results and impact A total of 76 students (43 male, 33 female) participated in the online trial and provided evaluation data. Of these, 71 (93.4%) felt that the eNLG helped them to better understand neurological localisation principles, 69 (90.7%) believed that the eMEQ provided a suitable format for the learning of the principles, 73 (96.1%) applauded our use of videotaped vignettes to demonstrate the signs and 75 (98.6%) requested more eNLG scenarios in the future. A total of 32 (42.1%) students felt that the eNLG could replace regular bedside teaching. The eNLG, which incorporates the use of videotaped vignettes, digitised photographs and neuroimages, can be used to facilitate the teaching of clinical neurology. Various levels of difficulty can be set for the eNLG, allowing medical students, doctors and advanced trainees in neurology to learn at their own pace.

Neurological localisation course for postgraduate candidates.

Context and setting The five and a half year MBBS programme in India prepares a ‘basic’ doctor. The internship period occurs during the final year of this programme, and is intended to develop the skills required. The 3-month internship rotation in community medicine is the time when the intern works in a primary care setting to acquire the skills required for primary care. Why the idea was necessary Regulatory bodies have recommended monitoring of the acquisition of competencies by interns. However, there is no structured programme for interns to develop essential competencies in primary care settings or assessment of skills acquired at the end of the community posting. Moreover, because there is a shortage of faculty in primary care settings, the curriculum innovation evaluated peer feedback as a tool for improving competencies among interns. What was done Diarrhoea case management (DCM) and family planning counselling (FPC) were prioritised based on health-centre and faculty data. The faculty and primary health-centre staff were orientated about the need, the role of feedback and correct usage of the checklists. Each patient encounter was observed by peers or faculty using a standardised checklist [DCM, using the World Health Organization/United Nation’s Children’s Fund integrated management of sick child guidelines and FPC using the GATHER (Greet, Ask, Tell, Help, Explain, Return) technique] and interns were provided with feedback at the end of the encounter. A total of 22 interns posted for 3 months in 7 health centres underwent 145 patient encounters (74 for DCM and 71 for FPC). Most of the interns underwent at least 3 and 4 feedback encounters, respectively, for diarrhoea and family planning. A retrospective pre–post survey was performed to assess the impact the programme had had on the intern’s knowledge, attitude and skill, as well as to gain input on the process for its improvement. Evaluation of the results and impact Analysis of the scoring pattern on the feedback checklist showed improvement in the interns’ competency, as revealed by an increasing proportion scoring ‘completely done’ with every subsequent session. Similarly, submodule analysis using repeated-measures ANOVA with Greenhouse–Geisser correction revealed that interns improved significantly in skill from their first case to their third or fourth case in mean marks for most submodules for diarrhoea case management (F-value 22Æ56, P < 0Æ005). Although there was also an increase in competency in the family planning counselling submodules, it was inconclusive (F-value 3Æ42, P 1⁄4 0Æ054). Analysis of the impact of the programme on the interns using a retrospective pre–post survey tool revealed a statistically significant change in their knowledge, skill and attitude, with most interns reporting that the structured checklist and feedback programme helped them to improve their competencies and acquire the art of self-directed life-long learning. The proportion of peer:faculty feedback was 60:40 and 65:35, respectively, for the DCM and FPC cases; thus, any improvement in clinical competency is likely to be due to peer feedback. Peer feedback using structured checklists appears to be a useful, feasible and effective method of enhancing competencies of interns in primary care settings in resource-poor countries.

Putting ethics on the spot in neurology.

What is the duty of care owed by neurologists to the man on the street? Does the ethical imperative to treat exist only in a medical emergency or after the establishment of a formal doctor–patient relationship? In this Viewpoint, Lim et al. draw on their personal experiences to explore these important questions.