大槻 眞嗣

OBJECTIVE: This study aimed to clarify the relationship between interprofessional self-evaluation and peer evaluation during interprofessional education (IPE) using team-based learning (TBL). We also aimed to clarify differences in interprofessional cooperation between students with high and low peer evaluation scores. METHODS: In total, 483 students (grades 3-5) from nine faculties at three universities participated in a TBL-based IPE program. The students completed five interprofessional self-evaluation domains (the modified Tsukuba IPE model) before and after IPE. Students also completed peer evaluation after IPE. Students were divided into three groups by peer evaluation scores (low, middle, high), and the post-class self-evaluation scores of these groups were compared using a Kruskal-Wallis test. Multiple regression analysis was also performed. Peer evaluation comments were analyzed using a qualitative inductive method. RESULTS: Students in the low peer evaluation group had significantly lower scores in the "Regarding participation in group work" domain than students in the high group (P<0.05). Students in the high group received positive comments, such as [good communication] and [working cooperatively], whereas students in the low group were required to improve in two areas: [speaking up more] and [need more communication]. CONCLUSIONS: There was a significant relationship between peer evaluation by team members and self-evaluation for "Regarding participation in group work." Students with high peer evaluation scores participated with active attitudes, whereas students with low scores were considered passive. This study suggested that using peer evaluation may enhance students' professional cooperation by improving their communication and attitudes toward active participation.

Objectives: The current study sought to understand the learning outcomes experienced by students and to explain their learning process in detail using interpretive data analysis. Methods: A qualitative study examined students who participated in a multidisciplinary course in a ward. This study investigated latent meanings rather than factual information, using an interpretive paradigm. Data were collected via focus groups and analyzed using Steps for Coding and Theorization (SCAT). Results: Students in the Assembly IV trial (interprofessional education in actual medical settings) experienced a process of transition from a competing (exclusive) mode to a mutual-understanding mode when communicating with people in other professions, and they acquired the perspective of an interactive (dialectic) link between involved communication (communication that attempts to connect directly with patients) and uninvolved communication (communication with patients indirectly through data and other methods) for patient communication. This enabled students to move beyond superficial communication while deepening their connections with people in other professions, complementing each other's strengths, and learning about the possibilities inherent in the provision of collaborative medical practice. Conclusions: Students participating in interprofessional education within medical settings learned about the potential to achieve a circular realization of collaborative medical practice. A circular realization of collaborative medical practice involves incorporating diverse approaches into one's own professional work via exposure to the viewpoints of other occupations and avoiding decision-making based on assumptions that are only valid within one's own profession. This process enables the discovery of better methods and perspectives and the achievement of effective medical practice by moving beyond superficial communication.

<p>Objectives: The aim of this study was to investigate changes in health university students' attitudes toward community service before and after a community-oriented education program using team-based learning (TBL). </p><p>Methods: A community-oriented educational program using TBL was carried out with a total of 529 3rd- and 4th-year students in seven faculties of two departments at Fujita Health University, and a questionnaire survey was conducted before and after the program. There were eight questions on students' attitude toward community service.</p><p>Results: Responses with no missing information from 431 students were used in the analysis. There were significant increases in the number of positive responses to three questions after TBL. The item "I think there are things that university students can do as members of the community" increased from 81.9% before TBL to 86.5% after, "I can form specific images of activities that benefit the community" increased from 46.0% before to 70.3% after, and "In the future I want to participate in activities that benefit the community" increased from 74.7% before to 80.3% after.</p><p>Conclusion: The results suggest that this community-oriented educational program using TBL raised the motivation of university students in medical and health science programs to practice community health care.</p>

<p>Objective: This study aimed to examine the effects of interprofessional education (IPE) using team-based learning (TBL).</p><p>Methods: We analyzed the results of a scale to measure IPE among 449 fourth-year students from seven faculties of a health university in Japan. The students took the Assembly Special Lesson as part of IPE using TBL. Before and after the lesson, the participants completed a questionnaire, which consisted of the IPE Tsukuba Model, to which we added two items. The scale was divided into five domains. We compared the scores using the Wilcoxon signed-rank test.</p><p>Results: The overall scores of four of the five domains of the IPE evaluation were significantly higher after the lesson than before (P<0.05): "Understanding the role of each profession's specialization" ; "Regarding participation in group work" ; "Thoughts regarding the team in healthcare and welfare" ; and "Feelings about cooperation among different professions." </p><p>Conclusions: It was evident that the lesson enhanced the students' understanding of the role of other professionals, enabled them to participate in group work, and allowed them to understand the responsibilities of each profession within a team, thereby leading to greater cooperation and better health care. This TBL for IPE was found to be effective by producing valuable changes in perceptions and attitudes toward professional cooperation among students.</p>

<p>背景 : 臨床や研究と比較し, 医学部教員の教育における貢献や業績を適切に評価する尺度がない. 今回, 日本医学教育学会業績評価委員会の医学教育業績評価シートを用いて, 教員の教育業績を調査し, 職位や専門領域による差異を検討した.</p><p>方法 : 全国医学部の教員が評価シートの20項目について5段階で自己評価したものを集計, 解析した.</p><p>結果と考察 : 教育ユニット以外の部署に所属する教員は講義や実習といった現場教育に比較して, 試験や教育制度の運用管理には, あまり貢献していない傾向が見られた. また, 職位が高いほど, 教育への貢献が大きい傾向が見られた.</p><p>結語 : 本評価シートは医学教育業績を評価する標準的尺度として活用できる.</p>

&lt;p&gt;背景 : 臨床や研究と比較し, 医学部教員の教育における貢献や業績を適切に評価する尺度がない. 今回, 日本医学教育学会業績評価委員会の医学教育業績評価シートを用いて, 教員の教育業績を調査し, 職位や専門領域による差異を検討した.&lt;/p&gt;&lt;p&gt;方法 : 全国医学部の教員が評価シートの20項目について5段階で自己評価したものを集計, 解析した.&lt;/p&gt;&lt;p&gt;結果と考察 : 教育ユニット以外の部署に所属する教員は講義や実習といった現場教育に比較して, 試験や教育制度の運用管理には, あまり貢献していない傾向が見られた. また, 職位が高いほど, 教育への貢献が大きい傾向が見られた.&lt;/p&gt;&lt;p&gt;結語 : 本評価シートは医学教育業績を評価する標準的尺度として活用できる.&lt;/p&gt;

<p> 臨床実習を終了した国内9医学部の6年生903名を対象として, 臨床能力に関する自己評価と教育方略を調査した. 医学教育モデル・コア・カリキュラムに準じた27項目のうち約4割が病院実習とシミュレーションの両方, もしくは, シミュレーションのみで学習されていた. また, いずれの方略でも, 学習経験のない項目が少なくないことが判明した. シミュレーション教育の高利用大学4校が低利用大学5校よりも, 多くの学習領域で有意に医学生の臨床能力自己評価が高かった.</p>

1）新研修医が研修開始直後に必要となる手技を習得できることを目標としたスキルスラボを利用したトレーニングをオリエンテーション期間内に導入した．<br>2）新2年目研修医がトレーニングの内容を計画し，新研修医を指導し，3年目以上の上級医は，新2年目研修医の指導を支援する「屋根瓦方式」の指導体制の構築を目指した．<br>3）本トレーニングを開催したことにより研修医間の関係が良好なものとなり，新研修医に安心感を与えるといった波及効果がみられた．

平成15年から9年間に臨床研修センターが医学教育企画室と協力し，新医師臨床研修制度の基本理念の達成を目標に，卒後臨床研修の改善と充実・屋根瓦方式による指導体制の確立に向けて様々な取り組みを行った．藤田保健衛生大学病院での臨床研修において次のことが達成できた．<br>1）研修医2年目が研修医1年目に知識・技能を教える屋根瓦方式が確立され，研修医の自主性が育まれた．<br>2）救急に対する初期治療の教育システムが確立され，統一した救急処置が可能になった．<br>3）臨床研修に対する病院全体の共通意識が一応できた．<br>  しかし，研修医の到達度にはかなり差があり，各科の関り・指導法については，さらに改善が望まれた．

藤田保健衛生大学医学部入試では, 全入学者の約30%を推薦入試により選抜している.推薦入試入学者の入学後の成績が適正であるかどうかを検証するために, 入学直後に実施した基礎学力を測定するプレースメントテストの成績と, 入学後の1, 2年次の欠席状況と成績との関連性を比較検討した.&lt;BR&gt;1) 平成14年から17年までの入学生398名を, 推薦入試入学者 (126名), および, 一般入試の成績の上位1/2入学者 (137名) と下位1/2入学者 (135名) の3群に分類して解析した.&lt;BR&gt;2) 入学時のプレースメントテストの成績 (基礎学力) は, 一般上位&gt;一般下位&gt;推薦の順であったが, 入学後の成績は1, 2年次共に, 一般上位&gt;推薦&gt;一般下位となった.&lt;BR&gt;3) 推薦入試入学者の1, 2年次欠席コマ数は, 一般入試上位・下位入学者よりも少ない傾向にあった.&lt;BR&gt;4) 2年次の成績は1年次の成績とよく相関し, また, 2年次の欠席コマ数は1年次の欠席コマ数とも強く相関した.&lt;BR&gt;5) 入学時の基礎学力だけでなく, 1年次での勉強の取り組み方が, その後の成績に影響する重要な要因であることが示唆された.

The lipid-lowering and anti-atherosclerotic effects of atorvastatin (10 mg/day) were investigated by measuring changes in the levels of oxidized low-density lipoprotein (LDL), serum lipids (total cholesterol [TC], LDL-cholesterol [LDL-C] and triglycerides [TG]), and in the protein adiponectin. This was undertaken in 22 patients with ischaemic heart disease and serum LDL-C levels &gt; 100 mg/dl. After 3 months of therapy, atorvastatin significantly decreased serum lipids, oxidized LDL was reduced from 457.0 ± 148.6 to 286.9 ± 88.5 nmol/l, and adiponectin increased from 9.7 ± 7.4 to 13.9 ± 9.98 μg/ml. No significant correlation was observed between adiponectin and LDL-C, TG and high-density lipoprotein cholesterol. Atorvastatin therapy was not associated with side-effects, such as myalgia and gastrointestinal disorders, and did not give abnormal laboratory test results. It is concluded that atorvastatin decreases serum lipid and oxidized LDL levels, and increases adiponectin levels in patients with ischaemic heart disease.

Most patients with acute myocarditis manifest particular clinical signs and symptoms, including marked cardiac failure and/or a high degree of atrioventricular block on admission. However, a 78-year-old man did not have symptoms and was hospitalized as a result of abnormalities observed on an incidentally obtained electrocardiogram (ECG). Several days later, he developed cardiogenic shock and fulminant myocarditis, which required percutaneous cardiopulmonary support; however, the cardiac failure persisted and he died approximately 4 months later. The ECG showed findings similar to those of acute inferior myocardial infarction, and on left ventriculography, diffuse hypokinesis was observed most prominently in the inferoposterior wall. During autopsy, interstitial fibrosis was marked in the inferoposterior wall, with small, round, cell infiltration prominent at the same site. Clustering of these cells is a characteristic feature of chronic myocarditis.

Tenascin-C (TN-C) is an extracellular matrix protein that is expressed transiently in close association with tissue remodelling in various body sites. In the heart, TN-C is only present during early stages of development, is not expressed in the normal adult, but reappears in pathological states. The purpose of this study was to analyse the expression of TN-C in myocardial tissue from myocarditis patients, and to evaluate the diagnostic value of immunostaining for TN-C in the assessment of inflammatory activity in biopsy specimens. A total of 113 biopsy specimens obtained from 32 patients with a clinical diagnosis of acute myocarditis were examined by immunohistochemistry and in situ hybridization for TN-C. The immunostaining was semi-quantified and compared with histological diagnosis according to the Dallas criteria. Furthermore, serial biopsies from 22 patients were taken during convalescence, and sequential changes in TN-C levels were analysed. Expression of TN-C was specifically detected in endomyocardial biopsy specimens from patients with active-stage inflammation, and disappeared in healed stages. The degree of expression of TN-C correlated with the severity of histological lesions. These data suggest that TN-C reflects disease activity in cases of human myocarditis. Immunostaining for TN-C could enhance the sensitivity and accuracy of diagnosis using biopsy specimens.

Tetrahydrobiopterin (BH4) acts as an essential cofactor for the enzymatic activity of nitric oxide (NO) synthases. Biosynthesis of the cofactor BH4 starts from GTP and requires 3 enzymatic steps, which include GTP cyclohydrolase I (GCH I) catalysis of the first and rate-limiting step. In this study we examined the effects of cGMP on GCH I activity in human umbilical vein endothelial cells under inflammatory conditions. Exogenous application of the cGMP analogue 8-bromo-cGMP markedly inhibited GCH I activity in the short term, whereas an cAMP analogue had no effect on GCH I activity under the same condition. NO donors, NOR3 and sodium nitroprusside, elevated the intracellular cGMP level and reduced GCH I activity in the short term. This inhibition of GCH I activity was obliterated in the presence of an NO trapper carboxy-PTIO. NO donors had no effect on GCH I mRNA expression in the short term. Moreover, cycloheximide did not alter the inhibition by NO donors of GCH I activity. These findings suggest that stimulation of the cGMP signaling cascade down-regulates GCH I activity through post translational modification of the GCH I enzyme.

In many cases, the diagnosis of eosinophilic myocarditis is suggested by an elevated peripheral blood eosinophil count. However, no detailed studies have been performed on the sequential changes in the initial peripheral blood eosinophil count over the course of the disease. We measured the peripheral blood eosinophil count at the time of presentation in eight patients with eosinophilic myocarditis proven by endomyocardial biopsy and intermittently thereafter. The eosinophil count at the time of onset was <500/mm(3) in four patients, >500/mm(3) but <1,000/mm(3) in three patients, and > or =1,000/mm(3) in one patient. In three of the four patients with an initial eosinophil count of <500/mm(3), an increase to > or =500/mm(3) occurred 7-12 days after the onset. The remaining patient did not develop peripheral eosinophilia. In conclusion, in the early stage of eosinophilic myocarditis, peripheral hypereosinophilia is not present initially in some patients, and may not develop during the course of the illness in a subset of these patients.

急性心筋炎では,心原性ショックにおちいる症例が存在する.しかし,一体いかなる時期にいかなる症例が,心原性ショックにおちいるのかという点については明らかにされていない.今回,前述の問題点を明らかにしえたので報告する.<BR>心筋生検により,組織学的に診断された急性リンパ球性心筋炎47例中,入院時にすでに心原性ショックにおちいっていた8例を除く39例を対象とした.39例を,入院後にショックにおちいり第2～6病日に大動脈内バルーンパンピングあるいは経皮的心肺補助の補助循環を必要とした劇症群12例(30.8%)と,補助循環を必要としなかった非劇症群27例(69.2%)に分け,両群間における入院直後の臨床検査所見を比較検討した.また,劇症群12例において,ショックの発生時期とその増悪因子についてもあわせて検討した.<BR>劇症群は非劇症群に比較して年齢が高く(57.8±11.6,40.7±17.3歳,p<0.01),脈拍(110.9±29.0,86.5±26.9歳,p<0.05),C反応性蛋白(7.0±7.0,2.3±2.2mg/dl,p<0.01)およびクレアチンキナーゼ(1,147.1±876.2,594.6±568.7IU/l,p<0.05)も高値を示した.心電図では,劇症群において心室内伝導障害の合併(9/12,7/27例,p<0.01)が高頻度で,心エコー図では劇症群の左室駆出率(40.7±13.9,50.1±10.6%,p<0.05)が低下していた.また,ショックの発生時期は入院後1.8±1.2日であった.劇症群12例中7例(58.3%)では,心室頻拍あるいは完全房室ブロックなどの不整脈が誘因となってショックにおちいったことが明らかとなった.<BR>急性リンパ球性心筋炎では,入院後に心原性ショックにおちいる症例が約30%存在する.入院時に頻脈あるいはC反応性蛋白,クレアチンキナーゼの高値,心室内伝導障害合併,左室駆出率低下を示す症例が劇症化しやすいことが明らかとなった.また,その発症時期は入院後平均1.8日であり,増悪因子の一つとして不整脈の関与が示された.

副腎皮質ステロイド剤による重大な副作用のために, メトトレキサート療法への変更を行った心臓サルコイドーシスの4例について, 本剤の有用性を検討した. メトトレキサートによる副作用で再生不良性貧血が1例, 肝機能障害が2例で生じた. 再生不良性貧血については, 本剤を中止し顆粒球コロニー形成刺激因子 (G-CSF; granulocyte-colony stimulating factor) filgrastimを用いたところ, 速やかに改善した. 肝障害の2例については本剤を減量せざるを得なかった. 残り1例については, 明らかな副作用は生じなかったものの, 本剤への変更によりサルコイドーシスの活動性が再燃し, 再び副腎皮質ステロイド剤に変更せざるを得なかった. 心サルコイドーシスにおけるメトトレキサート療法の経験の蓄積が待たれるところであるが, 少なくとも, 今回経験した4例のうち3例に関して, 本治療は有用とは言えなかった.