RESUMEN
Inclusion of population medicine in a medical school curriculum has received growing attention. Recently, the Association of American Medical Colleges has highlighted this issue through support of the Regional Medicine and Public Health Education Centers initiative. The Case Western Reserve University School of Medicine joined this consortium while implementing a new curriculum in which population medicine would be an underlying theme woven with the classic science elements of disease. The organization for the first two years of the new curriculum, which was implemented in 2006, is a six-block structure during which the basic sciences are learned with key concepts of population medicine woven throughout. The focus for this article is Block One, in which population medicine is the major emphasis of the introduction to medicine. The first week, students learn social determinants, impact on communities, and social aspects of diabetes mellitus, even before addressing a patient's clinical presentation. Emphasis on student-centered learning is undertaken as part of the new curriculum, using a series of weekly, case-based, small-group sessions. This type of group learning is used throughout Block One as students encounter key components of population medicine. A thesis requirement was also introduced as a mechanism to emphasize research with opportunities for research in population medicine as well as other medical sciences. A variety of mechanisms are described to measure the outcomes of Block One.
Asunto(s)
Curriculum , Educación de Pregrado en Medicina/métodos , Salud Pública/educación , Facultades de Medicina , Curriculum/tendencias , Evaluación Educacional , Humanos , Aprendizaje , Ohio , Medicina Preventiva/educación , Desarrollo de Programa , Facultades de Medicina/tendencias , Estudiantes de Medicina , EnseñanzaRESUMEN
Tracheomalacia (TM) is abnormal flaccidity of the trachea caused by inadequate cartilaginous support by the C-shaped tracheal rings. This defect generally results in various degrees of dynamic narrowing of the airway lumen. TM usually presents with expiratory stridor, wheeze, and respiratory obstruction. TM is usually associated with tracheoesophageal fistula and esophageal atresia or with other thoracic lesions of vascular rings and tumors. We report a well-documented case of a 20-month-old boy who presented to our institution with a severe history of obstructive sleep apnea and adenotonsillar hypertrophy. On direct laryngoscopy/bronchoscopy, severe TM was noted. Tonsillectomy and adenoidectomy was performed, and by the 37th postoperative day, the TM had completely resolved. We review the literature, discuss the differential diagnosis and clinical evaluation, and propose a new pathophysiological mechanism by which obstructive sleep apnea causes TM.
Asunto(s)
Apnea Obstructiva del Sueño/complicaciones , Estenosis Traqueal/etiología , Adenoidectomía , Humanos , Lactante , Masculino , Apnea Obstructiva del Sueño/fisiopatología , Apnea Obstructiva del Sueño/cirugía , Tonsilectomía , Estenosis Traqueal/diagnósticoRESUMEN
BACKGROUND: The Lung Health Study (LHS), a 5-year, randomized, prospective clinical trial, studied the effects of smoking intervention and therapy with inhaled anticholinergic bronchodilators on FEV(1) in participants who were 35 to 60 years of age and had mild COPD. Participants were randomized into the following three groups: usual care; smoking cessation plus inhaled ipratropium bromide; and smoking cessation plus placebo inhaler. This report evaluates the effects of these interventions, demographic characteristics, smoking status, and FEV(1) changes on airway responsiveness (AR). METHODS AND RESULTS: Of 5,887 participants, 4,201 underwent methacholine challenge testing both at study entry and study completion. All groups increased AR during the 5-year period. The increase in AR was greatest in continuing smokers and was associated with a greater FEV(1) decline. An intent-to-treat analysis indicated no significant differences in AR changes among the three groups. CONCLUSIONS: Changes in AR over a 5-year period in the LHS were primarily related to changes in the FEV(1). The greater the decline in FEV(1), the greater the increase in AR. Smoking cessation had a small additional benefit in AR beyond its favorable effects on FEV(1) changes.
Asunto(s)
Bronquios/efectos de los fármacos , Broncodilatadores/uso terapéutico , Ipratropio/uso terapéutico , Enfermedad Pulmonar Obstructiva Crónica , Cese del Hábito de Fumar , Fumar/efectos adversos , Adulto , Femenino , Volumen Espiratorio Forzado/efectos de los fármacos , Humanos , Masculino , Persona de Mediana Edad , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Enfermedad Pulmonar Obstructiva Crónica/fisiopatología , Enfermedad Pulmonar Obstructiva Crónica/terapiaRESUMEN
Chronic obstructive pulmonary disease (COPD) is a major health problem across the world and its medical, societal and economic impacts continue to grow. There are several hypotheses regarding the pathogenesis of COPD and important new information on airway inflammation, oxidative stress and proteolysis in the lungs that are important for the development of effective treatments. The differences in susceptibility to COPD among cigarette smokers and the common familial risk of developing disease point to important genetic influences. The identification of candidate gene loci and various gene polymorphisms have improved our understanding of the mechanisms by which genetic factors predispose for COPD. The beneficial effects of smoking cessation in slowing the decline in lung function and the progression of disease have been clearly established. Whether other factors such as mucus hypersecretion, respiratory infections and airway hyperreactivity contribute to disease progression independent of cigarette smoking is still being debated. There is new interest in dietary strategies to prevent or control COPD and preliminary information suggesting the usefulness of diets favoring antioxidant-rich foods. On the other hand several large, long-term, randomized, controlled clinical trials have failed to show a beneficial effect of either anticholinergics or corticosteroids in slowing the rate of decline in lung function in COPD. Corticosteroid treatment, however, appears to reduce the frequency of COPD exacerbations and there is some suggestion that it may also reduce the risk of death in patients with severe COPD.
Asunto(s)
Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Corticoesteroides/uso terapéutico , Broncodilatadores/uso terapéutico , Inhibidores de la Colinesterasa/uso terapéutico , Ensayos Clínicos como Asunto , Terapia Combinada , Dietoterapia , Humanos , Pulmón/fisiopatología , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Enfermedad Pulmonar Obstructiva Crónica/fisiopatología , Infecciones del Sistema Respiratorio/fisiopatología , Cese del Hábito de Fumar , Teofilina/uso terapéuticoRESUMEN
OBJECTIVES: To compare the effect of respiratory muscle stretch gymnastics (RMSG), proposed as a possible additional form of rehabilitation for patients with chronic obstructive pulmonary disease (COPD), with that of inspiratory muscle training (IMT). PATIENTS: Twelve naive outpatients with COPD at a university hospital. METHOD: The patients performed IMT (2 sessions of 10 minutes of training at 30% of PImax, daily) for 4 weeks and RMSG (3 sessions of 5 RMSG patterns 4 times each, daily) for 4 weeks, in randomized order, with a 4-week washout period between the two interventions. MEASUREMENTS AND RESULTS: PImax increased with IMT (mean 66.1 to 79.1 cmH2O), but not with RMSG (mean 66.0 to 69.4 cmH2O). RMSG and IMT similarly increased maximum chest wall expansion. FRC was significantly decreased by 158 ml with RMSG, but not with IMT. There were no significant changes in VC, FEV1, or PEF nor in arterial blood gases with either form of rehabilitation. Six-minute walking distance was more significantly increased with RMSG (mean 383 to 430 m), than with IMT (mean 386 to 412 m). CONCLUSIONS: RMSG may have clinically significant benefits, which may be somewhat different from the benefits of IMT, in patients with COPD.