Recent Publications by CFE Educators

Increasing numbers of family practice residents and medical students require training in obstetrics and gynecology. The effect of these residents on medical student learning in a basic obstetrics and gynecology clerkship at the University of Washington was examined. Results of a questionnaire completed by 314 medical students revealed that family practice residents had a positive although highly variable impact on student learning. Individual differences in residents and students seem to account for much of the variability. Suggestions are made for enhancing the learning experience in obstetrics and gynecology for both medical students and family practice residents.

The impact of two methods of pelvic examination instruction on student performance and anxiety was examined. Forty second-year medical students were randomly assigned either to an experimental group which received initial pelvic examination instruction from professional patients or to a control group which received this instruction from a gynecologist with a clinic patient. Results revealed no significant difference between experimental and control subjects in subsequent performance of the pelvic examination, on heart rate, or on perceived anxiety using one anxiety inventory. However, significant differences were found using a second anxiety instrument. The cost per student examination was twice as much for the clinic-patient group as for the professional-patient group. These findings are discussed in relation to prior research and instructional practices.

Severe acute, diffuse lung inflammation was induced in rabbits immunized to bovine serum albumin (BSA) and subsequently challenged with BSA intrapleurally. Evidence suggesting involvement of circulating immune complexes in the pathogenesis of lung injury in these rabbits include 1) positive lung immunofluorescence, 2) a fall in serum hemolytic complement, 3) diffuse bilateral involvement despite unilateral antigen challenge, and 4) absence of these findings in control rabbits. Further investigation with this model may provide insight into the processes involved in the deposition of immune complexes in the lung and the mechanisms of lung injury provoked by immune complex deposition.

Nerve processes and cell bodies containing leucine enkephalin were demonstrated in the sacral autonomic nucleus of the cat by immunocytochemical methods. Enkephalinergic preganglionic perikarya were seen only when axonal transport was blocked either by colchicine or by ventral root ligation. Ligation of the sacral ventral roots also produced damming of enkephalin immunoreactivity proximal to the S2 ligature. These data indicate that parasympathetic preganglionic neurons synthesize and transport enkephalin or enkephalin-like immunoreactive compounds to the periphery.

Opiate suppression of spinal withdrawal reflexes was tested in rats with lesions of several spinal funiculi to determine the relative contribution of supraspinal descending systems. The latency of tail-flick to noxious heat was used to assess "analgesia". The effect of lesions of dorsolateral funiculus (DLF), dorsal columns (DC) and ventral quadrant (VQ) were compared to that of sham operations. None of the lesions produced a change in baseline latency. Each animal was tested with varying doses of morphine sulfate over several weeks. Only DLF lesions consistently antagonized tail-flick suppression by morphine across the dose range studied (5-15 mg/kg i.p.), although VQ lesions were somewhat effective. The reduction of morphine's action was proportionally greater for lower doses. The results indicate that both spinal and supraspinal sites contribute significantly to the analgesia produced by systemic administration of opiates.

A method for examining the equivalency of student performance in multi-site clinical clerkships is presented. Six student performance variables within the clerkship are explored: pretest, posttest, oral examination, presentation of a subject review, general clinical performance, and patient write-ups. Student achievement on two external examinations (a University of Washington School of Medicine third-year comprehensive examination and the Part II examination of the National Board of Medical Examiners) is reviewed and compared. This method applied to an obstetrics and gynecology clerkship at the University of Washington reveals no significant differences in student performance among sites on the pretest, oral examination, and both external examinations, but there were differences on four internal measures (posttest, presentations, write-ups, and clinical ratings). The use of this information for clerkship improvement and faculty development is described.

There is considerable evidence that the dorsolateral funiculus (DLF) of the spinal cord contains descending pathways critical for both opiate and brainstem stimulation-produced analgesia. To obtain a comprehensive map of brainstem neurons projecting to the spinal cord via the DLF, large injections of horseradish peroxidase (HRP) were made into the lumbosacral spinal cord of cat and rat. These injections were made caudal to midthoracic lesions which spared only a single DLF or ventral quadrant (VQ); thus only those neurons whose axons descended in the spared funiculus would be labelled. Cells with descending axons in the VQ were concentrated in the medullary nucleus raphe pallidus and obscurus, nucleus retroambiguus and in various subregions of the reticular formation including the nucleus reticularis ventralis, gigantocellularis, magnocellularis, pontis caudalis and pontis oralis. Significant numbers of neurons were also found in medial and lateral vestibular nuclei and in several presumed catecholamine-containing neurons of the dorsolateral pons. In the rat, but not in the cat, considerable numbers of cells are present in the mesencephalic reticular formation just lateral to the periaqueductal gray. In both species, some cells were found in the paraventricular nucleus of the hypothalamus. Brainstem cells projecting in the DLF were concentrated in the nucleus raphe magnus and in the adjacent nucleus reticularis magnocellularis, ipsilateral to the spared funiculus. Significant numbers of cells were found in the dorsolateral pons, differing somewhat in their distribution from those projecting in the VQ. DLF-projecting cells were also present in the ipsilateral Edinger-Westphal nucleus and periaqueductal grey contralateral red nucleus of the midbrain and in the ipsilateral hypothalamus. Smaller projections from other sites are described. These results are discussed in terms of the differential contribution of several brainstem neuronal groups, including the serotonergic nucleus, raphe magnus, the ventromedial reticular formation of the medulla, and various catecholamine-containing neurons of the dorsolateral pontine tegmentum to the analgesia produced by opiates and electrical brain stimulation.

We analyzed serum from six patients with pulmonary eosinophilic granuloma for the presence of circulating immune complexes. These levels were correlated with the pulmonary histopathology and immunofluorescence findings. Levels of circulating immune complexes were elevated in five subjects. All of the subjects had an active cellular histology. Immunofluorescent studies showed granular deposits of IgG and complement (C3) in alveolar walls and blood vessels in all five patients. One subject had no detectable circulating immune complexes and showed a predominantly fibrotic pattern by light microscopy. In addition, immunofluorescence in this patient also showed no immunoglobulin or complement deposition within the lung tissue. These findings show that circulating immune complexlike activity is present in patients with cellular disease and suggest that their formation or deposition, or both, may contribute to the pathogenesis of pulmonary eosinophilic granuloma.

In our horseradish peroxidase (HRP) study of the afferents to the medullary raphe nuclei in the cat, HRP uptake by damaged axons en route to the inferior olive (IO) was thought to be responsible for retrograde labelling of specific midbrain nuclei. To control for such indirect labelling, HRP was injected iontophoretically into the inferior olive. The location of retrogradely labelled neurons was related to the specific locus of HRP injection within the IO. Injection of HRP into the caudal dorsal accessory olive resulted in dense neuronal labelling in the ipsilateral caudal pole of the posterior pretectal nucleus (PPN). There was no labelling of the nucleus of Darkschevitch (Dk), interstitial nucleus of Cajal (ICA) or Edinger-Westphal nucleus (EW). In contrast, an injection focussed more rostrally, into the rostral, dorsal accessory, the medial accessory and the principal olive, produced dense labelling of Dk, ICA and EW; there was much less PPN labelling. It is concluded that labelling of Dk and PPN after HRP injections rostral to the IO, is due, at least in part, to uptake of HRP by damaged medial longitudinal fasciculus axons en route to the inferior olive. The direct PPN-inferior olivary projection provides a potential disynaptic retino-cerebellar connection, which may be involved in rapidly timed eye-body coordinate movements.

The development of a comprehensive evaluation system for an obstetrics and gynecology clerkship at the Unviersity of Utah is described and the results of two years experience using it are presented. Seven different measurement procedures were developed and used with 111 junior medical students including pre- and post-tests, oral examination, clinical performance ratings by residents, and ratings by faculty on oral and written presentations and participation in tutorial sessions. Learning gains as measured by pre-post test scores were significant at the 0.001 level. Only six of 37 correlations among the evaluation measures were significantly related at the 0.01 level; furthermore, little relationship could be found between measures of student achievement in cognitive as compared to clinical skill areas. The need for multiple sources of information on student performance in clerkships is discussed.