Despite explicit expectations and accreditation requirements for integrated curriculum, there needs to be more clarity around an accepted common definition, best practices for implementation, and criteria for successful curriculum integration. To address the lack of consensus surrounding integration, we reviewed the literature and herein propose a definition for curriculum integration for the medical education audience. We further believe that medical education is ready to move beyond “horizontal” (1-dimensional) and “vertical” (2-dimensional) integration and propose a model of “6 degrees of curriculum integration” to expand the 2-dimensional concept for future designs of medical education programs and best prepare learners to meet the needs of patients. These 6 degrees include: interdisciplinary, timing and sequencing, instruction and assessment, incorporation of basic and clinical sciences, knowledge and skills-based competency progression, and graduated responsibilities in patient care. We encourage medical educators to look beyond 2-dimensional integration to this holistic and interconnected representation of curriculum integration.

Despite explicit expectations and accreditation requirements for integrated curriculum, there needs to be more clarity around an accepted common definition, best practices for implementation, and criteria for successful curriculum integration. To address the lack of consensus surrounding integration, we reviewed the literature and herein propose a definition for curriculum integration for the medical education audience. We further believe that medical education is ready to move beyond “horizontal” (1-dimensional) and “vertical” (2-dimensional) integration and propose a model of “6 degrees of curriculum integration” to expand the 2-dimensional concept for future designs of medical education programs and best prepare learners to meet the needs of patients. These 6 degrees include: interdisciplinary, timing and sequencing, instruction and assessment, incorporation of basic and clinical sciences, knowledge and skills-based competency progression, and graduated responsibilities in patient care. We encourage medical educators to look beyond 2-dimensional integration to this holistic and interconnected representation of curriculum integration.

Despite explicit expectations and accreditation requirements for integrated curriculum, there needs to be more clarity around an accepted common definition, best practices for implementation, and criteria for successful curriculum integration. To address the lack of consensus surrounding integration, we reviewed the literature and herein propose a definition for curriculum integration for the medical education audience. We further believe that medical education is ready to move beyond “horizontal” (1-dimensional) and “vertical” (2-dimensional) integration and propose a model of “6 degrees of curriculum integration” to expand the 2-dimensional concept for future designs of medical education programs and best prepare learners to meet the needs of patients. These 6 degrees include: interdisciplinary, timing and sequencing, instruction and assessment, incorporation of basic and clinical sciences, knowledge and skills-based competency progression, and graduated responsibilities in patient care. We encourage medical educators to look beyond 2-dimensional integration to this holistic and interconnected representation of curriculum integration.

Bladder cancer(BC)is one of the most frequently diagnosed types of urinary cancer.Despite advances in treatment methods,no specific biomarkers are currently in use.Targeted and untargeted profiling of metabolites and elements of human blood serum from 100 BC patients and the same number of normal controls(NCs),with external validation,was attempted using three analytical methods,i.e.,nuclear magnetic resonance,gold and silver-109 nanoparticle-based laser desorption/ionization mass spec-trometry(LDI-MS),and inductively coupled plasma optical emission spectrometry(ICP-OES).All results were subjected to multivariate statistical analysis.Four potential serum biomarkers of BC,namely,iso-butyrate,pyroglutamate,choline,and acetate,were quantified with proton nuclear magnetic resonance,which had excellent predictive ability as judged by the area under the curve(AUC)value of 0.999.Two elements,Li and Fe,were also found to distinguish between cancer and control samples,as judged from ICP-OES data and AUC of 0.807(in validation set).Twenty-five putatively identified compounds,mostly related to glycans and lipids,differentiated BC from NCs,as detected using LDI-MS.Five serum metab-olites were found to discriminate between tumor grades and nine metabolites between tumor stages.The results from three different analytical platforms demonstrate that the identified distinct serum metabolites and metal elements have potential to be used for noninvasive detection,staging,and grading of BC.

Hiccup is an intermittent, involuntary and erratic contraction of the diaphragm, immediately followed by a laryngeal closure. Persistent and intractable hiccups are rare but severe, keeping a person from doing daily activities; these can result in depression, fatigue, impaired sleep, dehydration, weight loss, malnutrition, and aspiration. Therefore, proper treatments are necessary. We present a case with intractable hiccup treated with an unusual treatment. A 61-year-old man presented with intractable hiccups, which started 6 years ago after subarachnoid and intraventricular hemorrhage. Conventional pharmacologic treatments including metoclopramide, gabapentin, and baclofen were unsuccessful. Cooperating with cardiothoracic surgeons, phrenic nerve clipping operation was done under intraoperative electrophysiologic monitoring. This method was successful that the symptoms were relieved. Reversible clipping done under intraoperative electrophysiologic monitoring can be a promising therapeutic method for persistent and intractable hiccups in patients with stroke.
Baclofen ; Dehydration ; Depression ; Diaphragm ; Electromyography ; Fatigue ; Hemorrhage ; Hiccup* ; Humans ; Malnutrition ; Methods ; Metoclopramide ; Middle Aged ; Phrenic Nerve* ; Stroke* ; Surgeons ; Weight Loss

OBJECTIVE: To determine the optimal stimulation and recording site for infrapatellar branch of saphenous nerve (IPBSN) conduction studies by a cadaveric study, and to confirm that obtained location is practically applicable to healthy adults. METHODS: Twelve lower limbs from six cadavers were studied. We defined the optimal stimulation site as the point IPBSN exits the sartorius muscle and the distance or ratio were measured on the X- and Y-axis based on the line connecting the medial and lateral poles of the patella. We defined the optimal recording site as the point where the terminal branch met the line connecting inferior pole of patella and tibial tuberosity, and measured the distance from the inferior pole. Also, nerve conduction studies were performed with obtained location in healthy adults. RESULTS: In optimal stimulation site, the mean value of X-coordinate was 55.50±6.10 mm, and the ratio of the Y-coordinate to the thigh length was 25.53%±5.40%. The optimal recording site was located 15.92±1.83 mm below the inferior pole of patella. In our sensory nerve conduction studies through this location, mean peak latency was 4.11±0.30 ms and mean amplitude was 4.16±1.49 µV. CONCLUSION: The optimal stimulation site was located 5.0–6.0 cm medial to medial pole of the patella and 25% of thigh length proximal to the X-axis. The optimal recording site was located 1.5–2.0 cm below inferior pole of patella. We have also confirmed that this location is clinically applicable.
Adult ; Cadaver* ; Clinical Study* ; Electromyography ; Humans ; Knee Injuries ; Lower Extremity ; Neural Conduction* ; Patella ; Reference Values* ; Thigh

BACKGROUND/AIMS: As the prevalence of diabetes mellitus and its complications increase rapidly, diabetic foot ulcers (DFUs), which are a major diabetic complication, are expected to increase. For prevention and effective treatment, it is important to understand the clinical course of DFUs. The aim of this study was to investigate the natural course and predictors of amputation in patients with DFUs who required hospitalization. METHODS: A total of 209 patients with type 2 diabetes, aged 30 to 85 years, who visited emergency department or needed hospitalization due to DFUs were consecutively enrolled from May 2012 to January 2016, by retrospective medical record review. The main outcome was lower extremity amputation (LEA). RESULTS: Among 192 patients who completed follow-up, 113 patients (58.9%) required LEAs. Compared to patients without amputation, baseline levels of white blood cell counts and C-reactive protein were higher in patients with amputation. In addition, bone and joint involvement was more frequently observed in patients with amputation. Multivariable regression analysis revealed that combined infection (odds ratio [OR], 11.39; 95% confidence interval [CI], 2.55 to 50.93; p = 0.001) and bone or joint involvement (OR, 3.74; 95% CI, 1.10 to 12.70; p = 0.035) were significantly associated with an increased risk of LEA. CONCLUSIONS: The depth of the wound and combined infection of DFU, rather than the extent of the wound, were significant prognostic factors of LEAs in patients with type 2 diabetes.
Amputation* ; C-Reactive Protein ; Diabetes Complications ; Diabetes Mellitus ; Diabetic Foot* ; Emergency Service, Hospital ; Follow-Up Studies ; Hospitalization ; Humans ; Joints ; Leukocyte Count ; Lower Extremity* ; Medical Records ; Prevalence ; Prognosis ; Retrospective Studies ; Ulcer* ; Wounds and Injuries

Spinal accessory nerve (SAN) injury mostly occurs during surgical procedures. SAN injury caused by manipulation therapy has been rarely reported. We present a rare case of SAN injury associated with manipulation therapy showing scapular winging and droopy shoulder. A 42-year-old woman visited our outpatient clinic complaining of pain and limited active range of motion (ROM) in right shoulder and scapular winging after manipulation therapy. Needle electromyography and nerve conduction study suggested SAN injury. Physical therapy (PT) three times a week for 2 weeks were prescribed. After a total of 6 sessions of PT and modality, the patient reported that the pain was gradually relieved during shoulder flexion and abduction with improved active ROM of shoulder. Over the course of 2 months follow-up, the patient reported almost recovered shoulder ROM and strength as before. She did not complain of shoulder pain any more.
Accessory Nerve Injuries* ; Accessory Nerve* ; Adult ; Ambulatory Care Facilities ; Electromyography ; Female ; Follow-Up Studies ; Humans ; Musculoskeletal Manipulations* ; Needles ; Neural Conduction ; Range of Motion, Articular ; Shoulder ; Shoulder Pain

An adrenal incidentaloma is an adrenal mass found in an imaging study performed for other reasons unrelated to adrenal disease and often accompanied by obesity, diabetes, or hypertension. The prevalence and incidence of adrenal incidentaloma increase with age and are also expected to rise due to the rapid development of imaging technology and frequent imaging studies. The Korean Endocrine Society is promoting an appropriate practice guideline to meet the rising incidence of adrenal incidentaloma, in cooperation with the Korean Adrenal Gland and Endocrine Hypertension Study Group. In this paper, we discuss important core issues in managing the patients with adrenal incidentaloma. After evaluating core proposition, we propose the most critical 20 recommendations from the initially organized 47 recommendations by Delphi technique.
Adrenal Glands ; Delphi Technique ; Humans ; Hypertension ; Incidence ; Obesity ; Prevalence

Serological diagnoses for infectious diseases such as those based on disease¬specific IgM antibody detection often confuse clinicians and therefore make treatment decisions difficult. This is due to the relatively long persistence of IgM in the blood circulation following exposure to the organism or nonspecific polyclonal activation of memory cells. We report a Lao patient diagnosed as having scrub typhus on admission based on detection of IgM to Orientia tsutsugamushi and initially treated with Doxycycline. The patient became afebrile but had severe pulmonary involvement. The blood culture was subsequently positive for Leptospira spp. which is the cause of leptospirosis. The admission blood sample of the patient was negative for Orientia tsutsugamushi, Rickettsia typhi, and Rickettsia spp. DNA targets, by PCR, suggesting that the patient did not have scrub typhus, murine typhus or Spotted Fever. After one week of IV ceftriaxone treatment, the patient improved and was discharged well. The positive IgM to scrub typhus detected on admission was probably due to previous exposure to O. tsutusgamushi, and scrub typhus was not the cause of her presenting illness. Fortunately, Doxycycline, given to the patient for scrub typhus treatment, is also effective for leptospirosis preventing death. However, the patient required intravenous ceftriaxone (which would not have been effective for scrub typhus) when she developed severe disease. This patient’s illness is a reminder that clinicians should be cautious about serological diagnosis. At present, laboratory diagnosis of leptospirosis remains a big challenge for the clinicians because the existing gold standard test such as Microscopic Agglutination Test (MAT) and culture are labour intensive, expensive and seldom available. Until the development of the simple, rapid, and more reliable tests, the empirical treatment of patients with suspected leptospirosis with doxycycline, penicillins or ceftriaxone are strategies to reduce severe complications and death although it should be born in mind that penicillins and ceftriaxone will not be effective against rickettsial organisms.