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Background: Financial incentives are effective in moderating physician and patient behaviour, but they have not been studied in the context of medical education., Aim: This study assessed whether financial incentives can motivate students to acquire electrocardiogram (ECG) interpretation skills., Methods: Students enrolled for a cardio-respiratory teaching module (n = 121) were randomised to an intervention (financial incentive) or a control (book voucher raffle) condition. All students took three validated exams of ECG interpretation skills (at module entry, module exit and seven weeks later). Only the exit exam was financially incentivised in the intervention group. The primary outcome was the proportion of students who correctly identified ≥60% of clinically important diagnoses in the exit exam., Results: Financial incentives more than doubled the odds of correctly identifying ≥60% of diagnoses in the exit exam (adjusted odds ratio 2.44, 95% confidence interval 1.05-5.67) and significantly increased student learning time. However, there was no significant effect on performance levels in the retention exam., Conclusions: Financial incentives increase reported learning time and examination results in the short-term. The lack of a sustained effect on performance suggests that financial incentives may foster a superficial or strategic rather than a deep approach to learning.

Aims: In Germany, the final year of undergraduate medical education ('practice year') consists of three 16-week clinical attachments, two of which are internal medicine and surgery. Students can choose a specific specialty for their third 16-week attachment. Practice year students do not receive specific teaching to prepare them for the National Licensing Examination. It is unknown whether knowledge levels increase during this year. This study aimed at assessing knowledge at the beginning and the end of the final year of medical school., Methods: Three hundred pre-selected United States Medical Licensing Examination type items from ten medical disciplines were reviewed by ten recent medical graduates from the Netherlands and Germany. The resulting test included 150 items and was taken by 77 and 79 final year medical students from Göttingen and Hamburg at the beginning and the end of their practice year, respectively., Results: Cronbach's α of the pre- and post-test was 0.75 and 0.68, respectively. Mean percent scores in the pre- and post-test were 63.9±6.9 and 69.4±5.7, respectively (p<0.001; effect size calculated as Cohen's d: 0.87). In individual students, post-test scores were particularly high for items related to their specific chosen specialty., Conclusion: The knowledge test used in this study provides a suitable external tool to assess progress of undergraduate medical students in their knowledge during the practice year. The pre-test may be used to guide individual learning behaviour during this final year of undergraduate education.

Background: Little is known about the knowledge and attitudes towards tobacco use among medical students in Canada. Our objectives were to estimate the prevalence of tobacco use among medical students, assess their perceived level of education about tobacco addiction management and their preparedness to address tobacco use with their future patients., Methods: A cross-sectional online survey was administered to University of Alberta undergraduate medical school trainees. The 32-question survey addressed student demographics, tobacco use, knowledge and attitudes around tobacco and waterpipe smoking, tobacco education received in medical school, as well as knowledge and competency regarding tobacco cessation interventions., Results: Of 681 polled students, 301 completed the survey. Current (defined as "use within the last 30 days") cigarette, cigar/cigarillo and waterpipe smoking prevalence was 3.3%, 6% and 6%, respectively. One third of the respondents had ever smoked a cigarette, but 41% had tried cigars/cigarillos and 40% had smoked a waterpipe at some time in the past. Students reported moderate levels of education on a variety of tobacco-related subjects but were well-informed on the role of tobacco in disease causation. The majority of students in their final two years of training felt competent to provide tobacco cessation interventions, but only 10% definitively agreed that they had received enough training in this area., Conclusions: Waterpipe exposure/current use was surprisingly high among this sample of medical students, a population well educated about the role of tobacco in disease causation. The majority of respondents appeared to be adequately prepared to manage tobacco addiction but education could be improved, particularly training in behavioral modification techniques used in tobacco use cessation.

Background: Electrocardiogram (ECG) interpretation is a core clinical skill that needs to be acquired during undergraduate medical education. Intensive teaching is generally assumed to produce more favorable learning outcomes, but recent research suggests that examinations are more powerful drivers of student learning than instructional format. This study assessed the differential contribution of teaching format and examination consequences to learning outcome regarding ECG interpretation skills in undergraduate medical students., Methods: A total of 534 fourth-year medical students participated in a six-group (two sets of three), partially randomized trial. Students received three levels of teaching intensity: self-directed learning (two groups), lectures (two groups) or small-group peer teaching facilitated by more advanced students (two groups). One of the two groups on each level of teaching intensity was assessed in a formative, the other in a summative written ECG examination, which provided a maximum of 1% credit points of the total curriculum. The formative examination provided individual feedback without credit points. Main outcome was the correct identification of ≥3 out of 5 diagnoses in original ECG tracings. Secondary outcome measures were time spent on independent study and use of additional study material., Results: Compared with formative assessments, summative assessments increased the odds of correctly identifying at least three out of five ECG diagnoses (OR 5.14; 95% CI 3.26 to 8.09), of spending at least 2 h/week extra on ECG self-study (OR 4.02; 95% CI 2.65 to 6.12) and of using additional learning material (OR 2.86; 95% CI 1.92 to 4.24). Lectures and peer teaching were associated with increased learning effort only, but did not augment examination performance., Conclusions: Medical educators need to be aware of the paramount role of summative assessments in promoting student learning. Consequently, examinations within medical schools need to be closely matched to the desired learning outcomes. Shifting resources from implementing innovative and costly teaching formats to designing more high-quality summative examinations warrants further investigation.

Purpose: Learning outcome is an important measure for overall teaching quality and should be addressed by comprehensive evaluation tools. The authors evaluated the validity of a novel evaluation tool based on student self-assessments, which may help identify specific strengths and weaknesses of a particular course., Method: In 2011, the authors asked 145 fourth-year students at Göttingen Medical School to self-assess their knowledge on 33 specific learning objectives in a pretest and posttest as part of a cardiorespiratory module. The authors compared performance gain calculated from self-assessments with performance gain derived from formative examinations that were closely matched to these 33 learning objectives., Results: Eighty-three students (57.2%) completed the assessment. There was good agreement between performance gain derived from subjective data and performance gain derived from objective examinations (Pearson r=0.78; P<.0001) on the group level. The association between the two measures was much weaker when data were analyzed on the individual level. Further analysis determined a quality cutoff for performance gain derived from aggregated student self-assessments. When using this cutoff, the evaluation tool was highly sensitive in identifying specific learning objectives with favorable or suboptimal objective performance gains., Conclusions: The tool is easy to implement, takes initial performance levels into account, and does not require extensive pre-post testing. By providing valid estimates of actual performance gain obtained during a teaching module, it may assist medical teachers in identifying strengths and weaknesses of a particular course on the level of specific learning objectives.

In forensic medicine, there is an undefined data background for the phenomenon of re-establishment of rigor mortis after mechanical loosening, a method used in establishing time since death in forensic casework that is thought to occur up to 8 h post-mortem. Nevertheless, the method is widely described in textbooks on forensic medicine. We examined 314 joints (elbow and knee) of 79 deceased at defined time points up to 21 h post-mortem (hpm). Data were analysed using a random intercept model. Here, we show that re-establishment occurred in 38.5% of joints at 7.5 to 19 hpm. Therefore, the maximum time span for the re-establishment of rigor mortis appears to be 2.5-fold longer than thought so far. These findings have major impact on the estimation of time since death in forensic casework.

Background and Objective: Smoking and alcohol use disorders (AUD) are associated with significant morbidity and mortality in Germany. However, it has recently been shown that German medical students in years 1 to 5 do not feel competent to treat patients who are addicted to tobacco or alcohol. This study examined whether these deficits are also prevalent in students in the final (sixth) year of training., Methods: Students enrolled in the final year at University Medical Centre Hamburg-Eppendorf were invited to complete a questionnaire assessing smoking status and self-reported knowledge of health consequences of and treatment options for AUD and smoking as well as arterial hypertension and diabetes mellitus. Students were also asked to provide effectiveness estimates for different methods to treat AUD and smoking., Results: A total of 228 out of 345 students participated in the survey (response rate 66 %). Smoking prevalence was 24 %. Approximately 90 % of students believed they knew how to treat arterial hypertension and diabetes mellitus, but less than a third thought they knew how to treat smokers and patients with AUD. Effectiveness ratings of treatments for the two addictive disorders revealed severe misconceptions., Conclusion: The deficits in undergraduate medical education regarding the treatment of addictive disorders reported for students from years 1 to 5 extend to students in the sixth year. Just before graduation, students still have severe knowledge gaps. In order to prevent tobacco- and alcohol-related deaths, medical school curricula need to be urgently improved., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background/aims: A minority of German medical students believe they know how to support smokers willing to quit. This paper examined whether the same would be true for treating alcohol use disorder (AUD), and individual factors associated with incorrect beliefs about the effectiveness of methods to treat AUD., Methods: In this cross-sectional study, 19,526 undergraduate students from 27 German medical schools completed a survey addressing beliefs about the effectiveness of different methods of overcoming AUD. Beliefs about AUD treatment effectiveness were compared across the 5 years of undergraduate education and predictors identified by means of multiple linear regression., Results: Even in the fifth year, 28.1% (95% CI: 26.5-29.7) of students believed that willpower alone was more effective for overcoming AUD than a comprehensive treatment program. The only significant predictor of this belief was a similar belief for stopping smoking., Conclusion: Our results indicate that a considerable proportion of German medical students overestimate the effectiveness of willpower to treat smoking and AUD. The addictive nature of these disorders needs to be stressed during undergraduate medical education to ensure that future physicians will be able and motivated to support patients in their quit attempts., (Copyright © 2013 S. Karger AG, Basel.)

Aim: To assess the extent of undergraduate medical training on alcohol use disorders (AUD) and smoking, and medical students' perceived knowledge regarding consequences of, and treatment options for, these disorders compared with other chronic conditions., Design: Cross-sectional survey assessing teaching and perceived knowledge of health consequences and treatment options for AUD and smoking compared with diabetes and hypertension., Setting: Medical schools in Germany., Participants: Twenty-five of 36 medical school offices (response rate 69.4%) and 19 526 of 39 358 students from 27 medical schools (response rate 49.6%)., Measurement: Medical schools were asked to provide information on curricular coverage of the four conditions. Students reported their year of study and perceived knowledge about the consequences of all four disorders and perceived knowledge of treatment options., Findings: Courses time-tabled approximately half as many teaching hours on AUD and tobacco as on diabetes or hypertension. Final-year students reported high levels of knowledge of consequences of all four conditions and how to treat diabetes and hypertension, but only 20% believed they knew how to treat alcohol use disorders or smoking., Conclusions: Curriculum coverage in German medical schools of alcohol use disorders and smoking is half that of diabetes and hypertension, and in the final year of their undergraduate training most students reported inadequate knowledge of how to intervene to address them., (© 2012 The Authors. Addiction © 2012 Society for the Study of Addiction.)

Purpose of Review: Tobacco smoking is the leading cause of avoidable deaths worldwide, and half of these deaths are due to cardiovascular disease (CVD). Physicians specialized in the management of CVD play a key role in ensuring that all smokers with cardiovascular disorders are offered best evidence support to help them quit smoking. This review summarizes recent findings on smoking as a risk factor for CVD, effects of smoking cessation on the prognosis of CVD patients, interactions between drug treatment for CVD and smoking, effective interventions to promote quitting in CVD patients and policy issues regarding tobacco control., Recent Findings: Smoking cessation following an acute cardiovascular event yields a substantial reduction in morbidity and mortality. Recent declines in CVD mortality were mainly a result of risk factor modification rather than improvement of medical treatments for CVD. The latter are also less effective in smokers than in nonsmokers, and smokers are at high risk of medication nonadherence. Effective interventions to support quit attempts in smokers with CVD are available. Cardiovascular specialists should encourage policy-makers to take appropriate tobacco control action., Summary: Cardiovascular specialists are in a unique position to promote cardiovascular health at the individual as well as at a population level.

Background: Evaluation is an integral part of medical education. Despite a wide use of various evaluation tools, little is known about student perceptions regarding the purpose and desired consequences of evaluation. Such knowledge is important to facilitate interpretation of evaluation results. The aims of this study were to elicit student views on the purpose of evaluation, indicators of teaching quality, evaluation tools and possible consequences drawn from evaluation data., Methods: This qualitative study involved 17 undergraduate medical students in Years 3 and 4 participating in 3 focus group interviews. Content analysis was conducted by two different researchers., Results: Evaluation was viewed as a means to facilitate improvements within medical education. Teaching quality was believed to be dependent on content, process, teacher and student characteristics as well as learning outcome, with an emphasis on the latter. Students preferred online evaluations over paper-and-pencil forms and suggested circulating results among all faculty and students. Students strongly favoured the allocation of rewards and incentives for good teaching to individual teachers., Conclusions: In addition to assessing structural aspects of teaching, evaluation tools need to adequately address learning outcome. The use of reliable and valid evaluation methods is a prerequisite for resource allocation to individual teachers based on evaluation results.

The mechanically stimulated idiomuscular contraction of skeletal muscles is part of the widely used compound method for death time estimation and therefore represents an item of high relevance and practicability in forensic case work. However, data on the topic are scarce and inconsistent and the currently reported maximum time span for the occurrence of the phenomenon until 13 h post-mortem (hpm) is based on a single case report from the beginning of the twentieth century. Therefore, idiomuscular contraction following mechanical stimulation has been investigated in skeletal muscles of 270 cases with assured time of death at defined post-mortem time points between 7 and 15 hpm. Of all investigated cases, 45 (16.7%) showed a positive reaction with a preponderance of cases of sudden death. Our investigations confirmed the upper time limit of 13 hpm up until idiomuscular contraction could be stimulated. With every hour of the post-mortem interval, a 0.61-fold decrease of the phenomenon's occurrence was observed (95%CI, 0.52-0.72; p < 0.001). Furthermore, several parameters showed significant correlations with the likelihood of the phenomenon's occurrence, namely stimulation of upper arm as opposed to the thigh (p < 0.001), gender (p = 0.017), and BMI (p < 0.001). These findings for the first time give reliable evidence of a post-mortem time limit of mechanically stimulated idiomuscular contraction and therefore contribute to the future application of the method in forensic case work.

Eighteen per cent of all deaths in adults aged 35 or over in England are still attributable to smoking. Almost all these premature deaths could be avoided if smokers stopped before their mid-thirties but only a quarter of people who have ever smoked regularly manage to quit by this age. Advice from the patient's GP is one of the most important triggers to a smoker making an attempt to quit. All patients attending a surgery for any reason who have smoked within the past three years should be offered advice on stopping smoking. Smokers without smoking-related diseases are just as likely to respond to advice as those with them. It is also important to re-assess the status of former smokers who were recorded as having stopped within the past three years. Half of those who stopped six months ago will relapse at some point as will 40% of those who stopped a year ago. Offer help with stopping to all smokers. The National Centre for Smoking Cessation and Training has launched a new online training module on how GPs can best deliver smoking cessation support to their patients. Optimum treatment involves behavioural support plus one of the smoking cessation medications. Behavioural support includes a number of specific behaviour change techniques that enhance the smoker's chances of remaining abstinent. These include: measurement of carbon monoxide in expired air; advice on best use of medication and helping smokers to put in place a clear 'not a puff' rule.

Mediastinal lymphangioma is a rare benign tumor that can be a cause of dyspnea. In our case, endobronchial ultrasound-transbronchial needle aspiration in addition to computed tomography imaging was a useful diagnostic tool in narrowing down the differential diagnosis of this mediastinal mass and to find a suitable therapeutic intervention.

Tobacco smoking causes cardiovascular, respiratory and malignant disease, and stopping smoking is among the key medical interventions to lower the worldwide burden of these disorders. However, the addictive properties of cigarette smoking, including nicotine inhalation, render most quit attempts unsuccessful. Recommended therapies, including combinations of counselling and medication, produce long-term continuous abstinence rates of no more than 30%. Thus, more effective treatment options are needed. An intriguing novel therapeutic concept is vaccination against nicotine. The basic principle of this approach is that, after entering the systemic circulation, a substantial proportion of nicotine can be bound by antibodies. Once bound to antibodies, nicotine is no longer able to cross the blood-brain barrier. As a consequence, the rewarding effects of nicotine are diminished, and relapse to smoking is less likely to occur. Animal studies indicate that antibodies profoundly change the pharmacokinetics of the drug and can interfere with nicotine self-administration and impact on the severity of withdrawal symptoms. To date, five phase I/II clinical trials using vaccines against nicotine have been published. Results have been disappointing in that an increase in quit rates was only observed in small groups of smokers displaying particularly high antibody titres. The failure of encouraging preclinical data to completely translate to clinical studies may be partially explained by shortcomings of animal models of addiction and an incomplete understanding of the complex physiological and behavioural processes contributing to tobacco addiction. This review summarizes the current status of research and suggests some directions for the future development of vaccines against nicotine. Ideally, these vaccines could one day become part of a multifaceted approach to treating tobacco addiction that includes counselling and pharmacotherapy.

Aims: Different approaches to performance-oriented allocation of resources according to teaching quality are currently being discussed within German medical schools. The implementation of these programmes is impeded by a lack of valid criteria to measure teaching quality. An assessment of teaching quality should include structural and procedural aspects but focus on learning outcome itself. The aim of this study was to implement a novel, outcome-based evaluation tool within the clinical phase of a medical curriculum and address differences between the novel tool and traditional evaluation methods., Methods: Student self-assessments before and after completion of a teaching module were used to compute performance gains for specific learning objectives. Mean performance gains in each module were compared to student expectations before the module and data derived from a traditional evaluation tool using overall course ratings at the end of the module., Results: A ranking of the 21 modules according to computed performance gains yielded entirely different results than module rankings based on overall course ratings. There was no significant correlation between performance gain and overall ratings. However, the latter were significantly correlated to student expectations before entering the module as well as structural and procedural parameters (Pearson's r 0.7-0.9)., Conclusion: Performance gain computed from comparative self-assessments adds an important new dimension to course evaluation in medical education. In contrast to overall course ratings, the novel tool is less heavily confounded by construct-irrelevant factors. Thus, it appears to be more appropriate than overall course ratings in determining teaching quality and developing algorithms to guide performance-oriented resource allocation in medical education.

In undergraduate medical education, the training of post-mortem external examination on dead bodies might evoke strong emotional reactions in medical students that could counteract the intended learning goals. We evaluated student perception of a forensic medicine course, their perceived learning outcome (via self-assessment) and possible tutor-dependent influences on the overall evaluation of the course by a questionnaire-based survey among 150 medical students in Hamburg, Germany. The majority of students identified post-mortem external examination as an important learning objective in undergraduate medical education and did not feel that the dignity of the deceased was offended by the course procedures. After the course, more than 70% of the students felt able to perform an external examination and to fill in a death certificate. Respectful behavior of course tutors towards the deceased entailed better overall course ratings by students (p<0.001). Our findings highlight the importance of factors such as clearly defined learning goals and course standardization (formal curriculum) as well as tutor behavior (informal curriculum) in undergraduate education in forensic medicine. Furthermore, we suggest embedding teaching in forensic medicine in longitudinal curricula on death and dying and on the health consequences of interpersonal violence., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: Hospitalization is an opportune time for smoking cessation support; cessation interventions delivered by hospital physicians are effective. While general practitioners' and outpatients' knowledge and attitudes towards smoking cessation have been studied in great detail, in-patient cessation programmes have received less attention., Design: Questionnaire-based survey of a convenience sample of hospital physicians and in-patients at Göttingen University Hospital, Germany., Methods: All 159 physicians directly involved in bedside care on medical and surgical wards received a three-page questionnaire examining smoking status, knowledge of smoking-attributable morbidity and mortality, and their understanding of the effectiveness of methods to achieve long-term smoking cessation. Perceived barriers to the delivery of counselling and cessation services to smoking patients were identified. One thousand randomly selected patients on medical (N = 400) and surgical (N = 600) wards were invited to complete a similar questionnaire., Results: Seventy-seven physicians (response rate 48.4%) and 675 patients (67.5%) completed the questionnaire. Patients and physicians alike underestimated the smoking-attributable risk of developing smoking-related cancers and chronic obstructive lung disease. In addition, severe misperceptions regarding the effectiveness of cessation methods were noted in both populations with 'willpower' being thought to be most effective in achieving abstinence. Only one-third of smoking patients recalled having been counselled to quit. Physicians identified lack of time as a central barrier to counselling smoking patients., Conclusions: These findings suggest that hospitalized smokers in a large German university hospital might not be treated according to international guidelines.

Objectives: COPD with emphysema causes marked neurohumoral activation. Angiotensin II receptors are highly expressed within the lung and interfere with mechanisms involved in the progression of emphysema. This study examined the effects of an angiotensin II receptor blocker (ARB) on pulmonary and systemic manifestations of emphysema in a mouse model., Methods: Female NMRI mice received five intratracheal instillations of porcine pancreatic elastase (emphysema; n = 11) or phosphate-buffered saline (PBS; n = 4). Emphysema severity was quantified histologically by mean linear intercept, exercise tolerance by treadmill running distance, and lung biomechanics by compliance. Following emphysema induction, 6 mice were treated with the ARB irbesartan for 8 weeks, while 5 mice receiving standard food served as controls., Results: Following emphysema induction, mean linear intercept was higher in elastase-treated than in PBS-treated lungs (103.0 ± 6.2 μm vs. 35.0 ± 0.6 μm; p = 0.043) while running distance was shorter in emphysema mice (418.6 ± 83.5 m vs. 906.6 ± 244.6 m, p = 0.028). Irbesartan-treated emphysema mice showed a lower mean linear intercept (90.8 ± 3.8 μm vs. 121.5 ± 8.1 μm; p = 0.005), improved compliance (163.6 ± 55.9 μl/cmH(2)O vs. 354.4 ± 72.5 μl/cmH(2)O; p = 0.063) and greater running distance (p ANOVA = 0.015) compared to emphysema mice receiving standard food., Conclusions: The ARB irbesartan elicits encouraging beneficial effects on emphysema severity, lung biomechanics and exercise capacity in an emphysema mouse model. These findings might help to understand the corresponding positive effects of angiotensin II receptor blockade noticed in patients with COPD., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Successful smoking cessation is associated with a survival benefit for patients with lung cancer. However, smokers newly diagnosed with non-small cell lung cancer and scheduled for curative resection are frequently discouraged from stopping smoking in the immediate preoperative period. This recommendation is based on the results of one single prospective cohort study published in 1998 which reported an increased risk of perioperative pulmonary complications in patients undergoing non-thoracic surgery who had reduced their tobacco consumption within the two months leading up to the operation. During the past 12 years, numerous observational studies have investigated the impact of preoperative smoking cessation on perioperative risk for thoracic and non-thoracic surgery. However, no more than six studies included patients with pulmonary neoplasms. Owing to methodological limitations and considerable heterogeneity of the included patient groups, the existing data are insufficient to support or refuse any recommendation regarding cessation advice for patients during the immediate preoperative phase. In view of the post-cessation recovery time-course of pathophysiological alterations relevant to the occurrence of perioperative complications, a smoke-free preoperative interval of 2 - 6 weeks appears most favourable. However, this is difficult to achieve as a curative resection should not be postponed. Since there is no scientific evidence demonstrating a negative impact of preoperative smoking cessation on prognosis, patients newly diagnosed with lung cancer should be encouraged to make an attempt to quit while waiting for thoracic surgery.

In recent years, increasing attention has been paid to web-based learning although the advantages of computer-aided instruction over traditional teaching formats still need to be confirmed. This study examined whether participation in an online module on the differential diagnosis of dyspnoea impacts on student performance in a multiple choice examination of factual knowledge in cardiology and pneumology. A virtual problem-based learning environment for medical students supervised by postgraduate teachers was created. Seventy-four out of 183 fourth-year medical students volunteered to use the online module while attending a 6-week cardio-respiratory curriculum in summer 2007. Of these, 40 were randomly selected to be included (intervention group); the remaining 34 served as an internal control group. Analysis of all written exams taken during the preceding term showed that both groups were comparable (86.4 ± 1.1 vs. 85.9 ± 1.1%; p = 0.751). Students in the intervention group scored significantly higher in the final course assessment than students allocated to the control group (84.8 ± 1.3 vs. 79.5 ± 1.4%; p = 0.006; effect size 0.67). Thus, additional problem-based learning with an online module as part of an undergraduate cardio-respiratory curriculum lead to higher students' scores in an exam testing factual knowledge. Whether using this teaching format increases overall student motivation to engage in the learning process needs to be further investigated.

Objectives: Interpretation of the electrocardiogram (ECG) is a core clinical skill that should be developed in undergraduate medical education. This study assessed whether small-group peer teaching is more effective than lectures in enhancing medical students' ECG interpretation skills. In addition, the impact of assessment format on study outcome was analysed., Methods: Two consecutive cohorts of Year 4 medical students (n=335) were randomised to receive either traditional ECG lectures or the same amount of small-group, near-peer teaching during a 6-week cardiorespiratory course. Before and after the course, written assessments of ECG interpretation skills were undertaken. Whereas this final assessment yielded a considerable amount of credit points for students in the first cohort, it was merely formative in nature for the second cohort. An unannounced retention test was applied 8 weeks after the end of the cardiovascular course., Results: A significant advantage of near-peer teaching over lectures (effect size 0.33) was noted only in the second cohort, whereas, in the setting of a summative assessment, both teaching formats appeared to be equally effective. A summative instead of a formative assessment doubled the performance increase (Cohen's d 4.9 versus 2.4), mitigating any difference between teaching formats. Within the second cohort, the significant difference between the two teaching formats was maintained in the retention test (p=0.017). However, in both cohorts, a significant decrease in student performance was detected during the 8 weeks following the cardiovascular course., Conclusions: Assessment format appeared to be more powerful than choice of instructional method in enhancing student learning. The effect observed in the second cohort was masked by an overriding incentive generated by the summative assessment in the first cohort. This masking effect should be considered in studies assessing the effectiveness of different teaching methods.

Background: Diseases associated with smoking are a foremost cause of premature death in the world, both in developed and developing countries. Eliminating smoking can do more to improve health and prolong life than any other measure in the field of preventive medicine. Today's medical students will play a prominent role in future efforts to prevent and control tobacco use., Methods: A cross-sectional, self-administered, anonymous survey of fifth-year medical students in Berlin, Germany was conducted in November 2007. The study explored the prevalence of smoking among medical students. We assessed their current knowledge regarding tobacco dependence and the effectiveness of smoking cessation methods. Students' perceived competence to counsel smokers and promote smoking cessation treatments was also explored. Analyses were based on responses from 258 students (86.6% response rate)., Results: One quarter of the medical students surveyed were current smokers. The smoking rate was 22.1% among women, 32.4% among men. Students underestimated smoking-related mortality and the negative effect of smoking on longevity. A considerable number of subjects erroneously assumed that nicotine causes coronary artery disease. Students' overall knowledge of the effectiveness of smoking cessation methods was inadequate. Only one third of the students indicated that they felt qualified to counsel patients about tobacco dependence., Conclusions: This study reveals serious deficiencies in knowledge and counseling skills among medical students in our sample. The curriculum of every medical school should include a tobacco module. Thus, by providing comprehensive training in nicotine dependence interventions to medical students, smokers will have access to the professional expertise they need to quit smoking.

This historical cohort study conducted in a University Hospital between 2004 and 2006 included 322 smokers willing to quit and assessed whether adding a teaching session on nicotine addiction to a smoking cessation program could increase the proportion of participants using pharmacotherapy. The control cohort received the standard course while two short talks were added to the course for a consecutive intervention cohort. These talks used the metaphor of a pizza delivery service to explain neural mechanisms underlying nicotine addiction. Medication use was significantly more common in the intervention than control cohort (82.1% vs. 51.2%; adjusted odds ratio 4.0; 2.34-6.83).

Objectives: Neurohumoral activation has been shown to be present in patients with chronic obstructive pulmonary disease (COPD). The increase in respiratory muscle work might be responsible for the observed elevation of sympathetic tone via a respiratory muscle ergoreflex in these patients. The aim of this study is to investigate whether moderately increasing inspiratory resistive loading will impact on sympathetic activity in healthy subjects and COPD patients., Methods: Efferent muscle sympathetic nerve activity, blood pressure, heart rate and respiratory movements were continuously measured in 15 patients and 15 healthy control subjects. In order to increase work of breathing as evaluated by the tension-time index, inspiratory resistive loading was performed while patients were breathing through a spirometer., Results: At baseline, sympathetic nerve activity was significantly elevated in patients. Resistive loading increased work of breathing (tension-time index) by roughly 110% (COPD) and 130% (controls) but did not significantly alter blood gases or sympathetic activity in either group., Conclusions: Doubling the work of breathing does not affect sympathetic activation in COPD patients or healthy control subjects. Thus in COPD the respiratory muscle ergoreflex does not seem to play a major role in sympathoexcitation., (Copyright 2009 Elsevier Ltd. All rights reserved.)

Background: In addition to patient care and research activity, physicians working in medical school hospitals serve as teachers in undergraduate medical education. However, teaching qualifications of German university hospital physicians have not been studied in great detail., Methods: In January 2009, medical students as well as physicians involved in medical teaching at Göttingen Medical School, Germany, were invited to complete an online survey addressing their views on clinical teachers' educational skills. In addition, physicians' motivation to engage in pedagogical training was assessed., Results: During a 12-day period, 359 students and 126 physicians involved in undergraduate medical education completed the survey. The latter did not feel well prepared for their teaching activities. At the same time, they expressed the willingness to improve their teaching skills. Students felt that, across all instructional methods, teachers would benefit from teacher training programs., Conclusion: In order to improve undergraduate education for future physicians, politicians and local representatives alike must set the scene for the implementation of faculty development measures in German medical schools.

Aims: The combined therapeutic impact of atrial overdrive pacing (AOP) and cardiac resynchronization therapy (CRT) on central sleep apnoea (CSA) in chronic heart failure (CHF) so far has not been investigated. We aimed to evaluate the effect of CRT alone and CRT + AOP on CSA in CHF patients and to compare the influence of CRT on CHF between CSA positive and CSA negative patients., Methods and Results: Thirty patients with CRT indication underwent full night polysomnography, echocardiography, exercise testing, and neurohumoral evaluation before and 3 months after CRT implantation. In CSA positive patients (60%), two additional sleep studies were conducted after 3 months of CRT, with CRT alone or CRT + AOP, in random order. Cardiac resynchronization therapy resulted in significant improvements of NYHA class, left ventricular ejection fraction, N-terminal pro-brain natriuretic peptide, VO(2)max, and quality of life irrespective of the presence of CSA. Cardiac resynchronization therapy also reduced the central apnoea-hypopnoea index (AHI) (33.6 +/- 14.3 vs. 23.8 +/- 16.9 h(-1); P < 0.01) and central apnoea index (17.3 +/- 14.1 vs. 10.9 +/- 13.9 h(-1); P < 0.01) without altering sleep stages. Cardiac resynchronization therapy with atrial overdrive pacing resulted in a small but significant additional decrease of the central AHI (23.8 +/- 16.9 vs. 21.5 +/- 16.9 h(-1); P < 0.01)., Conclusion: In this study, CRT significantly improved CSA without altering sleep stages. Cardiac resynchronization therapy with atrial overdrive pacing resulted in a significant but minor additional improvement of CSA. Positive effects of CRT were irrespective of the presence of CSA.

Background: Systemic effects of chronic obstructive pulmonary disease (COPD) significantly contribute to severity and mortality of the disease. We aimed to develop a COPD/emphysema model exhibiting systemic manifestations of the disease., Methods: Female NMRI mice were treated 5 times intratracheally with porcine pancreatic elastase (emphysema) or phosphate-buffered saline (control). Emphysema severity was quantified histologically by mean linear intercept, exercise tolerance by treadmill running distance, diaphragm dysfunction using isolated muscle strips, pulmonary hypertension by measuring right ventricular pressure, and neurohumoral activation by determining urinary norepinephrine concentration., Results: Mean linear intercept was higher in emphysema (260.7 +/- 26.8 microm) than in control lungs (24.7 +/- 1.7 microm). Emphysema mice lost body weight, controls gained weight. Running distance was shorter in emphysema than in controls. Diaphragm muscle length was shorter in controls compared to emphysema. Fatigue tests of muscle strips revealed impaired relaxation in emphysema diaphragms. Maximum right ventricular pressure and norepinephrine were elevated in emphysema compared to controls. Linear correlations were observed between running distance changes and intercept, right ventricular weight, norepinephrine, and diaphragm length., Conclusion: The elastase mouse model exhibited severe emphysema with consecutive exercise limitation, and neurohumoral activation. The model may deepen our understanding of systemic aspects of COPD.

Introduction: Prevention of smoking-related disease is a major challenge to medicine. Although interventions delivered by clinicians can reduce smoking rates, the teaching of smoking cessation methods is not a top priority in most medical curricula., Methods: Medical students from Göttingen, Germany (n = 1,435), and London (n = 656) were asked to complete a questionnaire on smoking-related mortality and the effectiveness of different approaches to smoking cessation. In addition, students' perceived competence to counsel smokers was assessed., Results: Smoking-related mortality was underestimated by students from both study sites. The data suggest that smoking medical students greatly overestimated the chances of reaching old age as a smoker. A substantial number of students falsely assumed that nicotine causes coronary artery disease. Overall knowledge of the long-term effectiveness of smoking cessation methods was poor. For example, medical students from Göttingen considered "willpower alone" more effective than comprehensive group cessation programs. Less than a third of medical students from both study sites felt competent to counsel smoking patients. This finding was constant across different stages of medical education., Discussion: Students in both countries lacked relevant information about smoking and health and the effectiveness of cessation methods. Given the importance of smoking in practically all aspects of medicine and the role of clinicians in advising patients on and aiding cessation, this problem urgently needs to be addressed.

Objective: This study assessed a newly set-up, hospital-based smoking cessation clinic with regard to continuous abstinence rates and the effectiveness of concomittant nicotine replacement therapy., Methods: Smoking status of 369 participants of this 8-week cognitive-behavioural smoking cessation group programme was obtained using exhaled carbon monoxide at the end of the course as well as self-report 6 months after the course. In addition to demographic data, FTND score, SDS score, and usage of nicotine replacement products were recorded., Results: Overall, 29.8% of all participants reported to have been continuously abstinent for 6 months after the course. Success rates increased significantly during the first year after initiation of the programme (from 15 to 35%, p<0.001), indicating a learning process of the staff running the course. Nicotine replacement therapy was used by 51.3% of participants, but 58% of these discontinued its use within 5 weeks. Nicotine substitution for more than 5 weeks was associated with a 50% success rate after 6 months., Conclusions: Our data indicate a learning effect of smoking cessation course staff and a possible minimum duration required for nicotine replacement to be effective., Practice Implications: The observed learning effect in smoking cessation programmes should be considered when evaluating newly established interventions of this kind. Patients tend to stop nicotine replacement therapy too early, thereby decreasing their chances of middle-term abstinence.

Passive smoking is the third leading but preventable cause of death worldwide. It is associated with an elevated risk of developing acute respiratory diseases, obstructive lung disorders, lung cancer, and cardiovascular disease. Whereas the dose-response relationship between second-hand smoke exposure and respiratory diseases is likely to be linear, a non-linear dose-response curve has been observed with respect to acute cardiovascular events. This explains the disproportionately high risk of myocardial infarction among passive smokers as compared to unexposed individuals. Over the last ten years, exposure to second-hand smoke has declined in Germany, but it is still substantial. With passive smoking in the home being a difficult target for preventive measures, public smoking bans have recently been shown to greatly reduce second-hand smoke-related morbidity and mortality. In addition, such measures are usually well tolerated and highly relevant regarding legal aspects related to workplace issues. This article summarises the current evidence on the health consequences of passive smoking and on the favourable effects of public smoking bans.

Smoking is the main risk factor for chronic obstructive pulmonary disease (COPD) and lung cancer. Being a chronic disease, COPD severely impairs the quality of life. Lung cancer is the leading cause of death among German males and the third most important cause of death among German females. This review gives data on the primary prevention of both diseases and the beneficial effects of smoking cessation following disease manifestation. Smoking-induced oxidative stress triggers a chronic inflammation which is central to the pathogenesis of COPD. Smoking causes lung cancer by oncogenic mutations as well as inhibition of tumour-supressor genes. Women have an increased risk to develop COPD and lung cancer as compared to men when exposed to the same amounts of tobacco smoke. Smoking cessation is the only treatment capable of reducing exacerbations and mortality as well as sustainedly improving lung function. The high level of nicotine dependence in COPD patients mandates an intensive smoking cessation treatment including pharmacotherapy and psychosocial intervention. In patients with lung cancer, smoking cessation has confirmed favourable effects on body weight, performance status, postoperative complications and mortality. Thus, smoking cessation should be an integral part of lung cancer treatment. Further research is needed to better delineate the effects of smoking cessation in relation to other treatment modalities.

Background and Objective: Smoking is a major risk factor for coronary heart disease and lung cancer. While nicotine causes addiction, heart and lung diseases are caused by other substances contained in tobacco smoke. This study assessed whether these facts are adequately portrayed in German medical textbooks., Methods: The sections on cardiovascular and lung cancer risk factors in 28 German textbooks of internal medicine, available in two bookstores as well as the library of Göttingen University (Germany), were scanned for the words "smoking" and "nicotine" as risk factors for coronary artery disease and lung cancer., Results: In 12 of the 25 textbooks covering cardiovascular disease, smoking was mentioned as a risk factor for coronary artery disease; another 12 textbooks listed nicotine or nicotine addiction. In one textbook both terms were used. While smoking was referred to in all 21 textbooks that also discussed risk factors for lung cancer, nicotine was not mentioned in this context., Conclusion: Many German textbooks of internal medicine contain misleading terms for the health effects of smoking, which may influence the thoughts and possibly also the behaviour of their readers. The use of the words "smoking" and "nicotine" as synonymous within the context of cardiovascular risk factors, suggesting a causal relationship between nicotine and coronary heart disease, is incorrect and should be removed from the specialist medical literature.

More than 30 % of the German population are regular smokers, over half of whom will eventually die of smoking-related diseases. Life expectancy is abridged by 10 years in smokers compared to non-smokers. Smoking tobacco is the main risk factor for lung cancer and chronic obstructive pulmonary disease (COPD) and predisposes to a number of other lung diseases. A smoking cessation programme including pharmacological as well as psychosocial support is highly effective in COPD Patients. Smoking cessation improves lung function, symptoms and mortality. In conclusion, smoking cessation services are among the most effective medical interventions. Thus, a sufficient supply of smoking cessation services on a population level must be ensured.

Background and Objective: In Germany over 30% of the population are smokers. Only very few smokers succeed in giving up smoking, because of the addictive nature of nicotine use. The objective of the present study was to evaluate a smoking cessation program which was recently established at a tertiary care clinic., Patients and Methods: The median age of the 275 participants was 45.5 years; 60.4% of participants were female. Participants had tobacco dependence of 5.1 (Fagerstrom scale). The cognitive-behavioral smoking cessation program implemented in this clinic consisted of 8 sessions. Pharmacological support was recommended. A standardized evaluation was carried out after 6 and 12 months., Results: All 275 smokers took part in the program over a period of 21 months. At the end of the course, 72% of participants had become non-smokers, after 6 months 37.6% and after 12 months 27.1% had stopped smoking. Those who have not yet been evaluated 12 months after the end of the program demonstrated a point prevalence of 45.7% after 6 months. The cigarette consumption of participants who were smoking at the end of the course was reduced to less than half. 6 months later they smoked an average of 18.0 cigarettes /day; 12 months after ending the course, 19.0 /day were consumed (p<0,001). Costs of about 250 Euro per gained life year were approximated., Conclusion: It is possible to establish a smoking cessation program at a large clinic. The results correspond to international published experiences and confirm that such a program is efficacious and cost-effective.

The evidence that active smoking is a risk factor for cardiovascular disease (CVD) and the leading cause of preventable death is overwhelming. However, numerous epidemiological findings indicate that even passive exposure to cigarette smoke may exert detrimental effects on vascular homoeostasis. Recent experimental data provide a deeper insight into the pathophysiological mechanisms linking secondhand smoke (SHS) to CVD. Importantly, most of these effects appear to be characterized by a rapid onset. For example, the relatively low doses of toxins inhaled by passive smoking are sufficient to elicit acute endothelial dysfunction, and these effects may be related, at least in part, to the inactivation of nitric oxide. Moreover, passive smoking may directly impair the viability of endothelial cells and reduce the number and functional activity of circulating endothelial progenitor cells. In addition, platelets of non-smokers appear to be susceptible to pro-aggregatory changes with every passive smoke exposure. Overall, SHS induces oxidative stress and promotes vascular inflammation. Apart from vasoconstriction and thrombus formation, however, the myocardial oxygen balance is further impaired by SHS-induced adrenergic stimulation and autonomic dysfunction. These data strongly suggest that passive smoking is capable of precipitating acute manifestations of CVD (atherothrombosis) and may also have a negative impact on the outcome of patients who suffer acute coronary syndromes.

We present a 71-year-old female patient suffering from a sore throat with unilateral neck swelling, pain on swallowing, subfebrile temperatures and general fatigue persisting for several weeks without any clinical signs of hyperthyroidism, although laboratory findings show high concentrations of T(3) and T(4) and a low TSH. A massive ESR elevation is found as well. Ultrasound reveals an inhomogeneous pattern of the thyroid gland with low echogenicity. (99m)Tc pertechnetate uptake is suppressed. The diagnosis of acute/subacute thyroiditis de Quervain is concluded. Therapeutic application of prednisone leads to a swift improvement, yet two weeks later asymptomatic hypothyroidism is diagnosed, requiring substitution of thyroxine. We discuss de Quervain's thyroiditis and the differential diagnosis of inflammatory disorders of the thyroid gland.

Intracellular pH (pH(i)) is an important factor for understanding cellular processes associated with the response of central neurons to metabolic disturbances such as anoxia or ischemia. In the present study, pH(i) was fluorometrically measured in 2'7'-bis(carboxyethyl)-5(6)-carboxyfluorescin (BCECF)-filled, voltage-clamped dorsal vagal neurons (DVN) of brainstem slices from rats during metabolic disturbances activating ATP-sensitive K(+) (K(ATP)) channels. Chemical anoxia induced by cyanide, rotenone or p-trifluoromethoxy-phenylhydrazone (FCCP) decreased pH(i) by >0.4 pH units. Untreated neurons with normal pH(i) baseline (7.2) responded to glucose-free superfusate after a delay of 7-16 min with a progressive fall of pH(i). In contrast, pH(i) increased by >0.2 pH units after approximately 10 min in cells that had a mean pH(i) of 6.8 due to incomplete recovery from a CN(-)induced acid load prior to glucose depletion. Metabolic arrest, induced by cyanide in glucose-free solution after 30 min preincubation in glucose-free saline, caused a progressive glutamate-mediated inward current with no change of pH(i). Upon metabolic arrest, depolarization-evoked pH(i) decreases ( approximately 0.2 pH units) were abolished, whereas glucose-free superfusate slightly delayed their recovery without major effects on amplitude. The glucose-dependent pH(i) fall coincided with activation of the K(ATP) channel-mediated outward current, while K(ATP) currents due to anoxia or metabolic arrest could reach their maximum in the absence of a major pH(i) change. The results indicate that the anoxic pH(i) decrease is due to enhanced glycolysis and lactate formation with often no obvious effect on K(ATP) channel activity. The origin of glucose-dependent acidosis and its relation to K(ATP) channel activity remain to be determined.