Undergraduate research in medical education: a descriptive study of students' views

Background: Medical students engage in curricular and extracurricular activities, including undergraduate research (UR). The advantages, difficulties and motivations for medical students pursuing research activities during their studies have rarely been addressed. In Brazil, some medical schools have included undergraduate research into their curriculum. The present study aimed to understand the reality of scientific practice among medical students at a well-established Brazilian medical school, analyzing this context from the students' viewpoint.Methods: A cross-sectional survey based on a questionnaire applied to students from years one to six enrolled in an established Brazilian medical school that currently has no curricular UR program.Results: The questionnaire was answered by 415 students, 47.2% of whom were involved in research activities, with greater participation in UR in the second half of the course. Independent of student involvement in research activities, time constraints were cited as the main obstacle to participation. Among students not involved in UR, 91.1% said they favored its inclusion in the curriculum, since this would facilitate the development of such activity. This approach could signify an approximation between the axes of teaching and research. Among students who had completed at least one UR project, 87.7% said they would recommend the activity to students entering the course.Conclusion: Even without an undergraduate research program, students of this medical school report strong involvement in research activities, but discussion of the difficulties inherent in its practice is important to future developments.

Optional course "Homeopathically potentised substances: placebos or effective?" for medical students at the University of Bern, Switzerland

Background Apart from compulsory lectures on classical homeopathy (CH), traditional Chinese medicine/acupuncture, neural therapy and anthroposophically extended medicine (AEM), our institute at the University of Bern offers several optional practical courses for medical students. The aim of this course during autumn 2011 and spring 2012 was to discuss basic research, observational and clinical studies in the fields of CH and AEM, so that students i) learned how to read and appraise scientific publications, ii) learned how complementary medicine can be investigated with scientific methods, and iii) were able to form their own opinion about the possible specific effects and effectiveness of homeopathically potentised substances. Methods Introductory lectures on AEM, CH and study design were given to 12 second year medical students. The students appraised 12 research articles and presented the results in class, followed by discussions with experts in the fields of basic and clinical research from our institute. A company producing homeopathic remedies was visited and students could practise potentization procedures and trituration. At the end of the course, students compiled posters with arguments in favour of and against specific effects and effectiveness as well as their own conclusions. The course was evaluated using a written questionnaire with closed and open questions. Results Previous knowledge about CH and AEM was scarce among the students. It slightly increased during the course, and the course itself fostered their interest on the topic. This course was chosen by most students, because they were genuinely interested in the topic (and not because other courses they had wanted to visit were fully booked). The students especially valued the discussions, the various perspectives presented to them, and experiencing a potentization process. Conclusion Medical students were interested to learn more about homeopathically potentised substances. The contradictory study results made it difficult for them to form their own opinion. Apart from appraising articles, the students would have liked to meet and talk to patients.

Motivating Young Students to Start a Career in Nuclear: The Basic Course of Science and Nuclear Technology, An Educational Activity of Spanish Young Generation in Nuclear (JÓVENES NUCLEARES)

The main objective of this course, conducted by Jóvenes Nucleares (Spanish Young Generation in Nuclear, JJNN), a non-profit organization that depends on the Spanish Nuclear Society (SNE) is to pass on basic knowledge about Science and Nuclear Technology to the general public, mostly students and introduce them to its most relevant points. The purposes of this course are to provide general information, to answer the most common questions about Nuclear Energy and to motivate the young students to start a career in nuclear. Therefore, it is directed mainly to high school and university students, but also to general people that wants to learn about the key issues of such an important matter in our society. Anybody could attend the course, as no specific scientific education is required. The course is done at least once a year, during the Annual Meeting of the Spanish Nuclear Society, which takes place in a different Spanish city each time. The course is done also to whichever university or institution that asks for it to JJNN, with the only limit of the presenter´s availability. The course is divided into the following chapters: Physical nuclear and radiation principles, Nuclear power plants, Nuclear safety, Nuclear fuel, Radioactive waste, Decommission of nuclear facilities, Future nuclear power plants, Other uses of nuclear technology, Nuclear energy, climate change and sustainable development. The course is divided into 15 minutes lessons on the above topics, imparted by young professionals, experts in the field that belongs either to the Spanish Young Generation in Nuclear, either to companies and institutions related with nuclear energy. At the end of the course, a 200 pages book with the contents of the course is handed to every member of the audience. This book is also distributed in other course editions at high schools and universities in order to promote the scientific dissemination of the Nuclear Technology. As an extra motivation, JJNN delivers a course certificate to the assistants. At the end of the last edition course, in Santiago de Compostela, the assistants were asked to provide a feedback about it. Some really interesting lessons were learned, that will be very useful to improve next editions of the course. As a general conclusion of the courses it can be said that many of the students that have assisted to the course have increased their motivation in the nuclear field, and hopefully it will help the young talents to choose the nuclear field to develop their careers

Evaluation of online tools as didactic resource in the university education

Recently, many efforts have been made in the academic world to adapt the new degrees to the new European Higher Education Area (EHEA). New technologies have been the most important factor to carry out this adaptation. In particular, the tools 2.0 have been spreading quickly, not just the Web 2.0, but even in all the educational levels. Nevertheless, it is now necessary to evaluate whether all these efforts and all the changes, carried out in order to obtain improved academic performance among students, have provided good results. Therefore, the aim of this paper is focused on studying the impact of the implementation of information and communication technologies (ICTs) in a subject belonging to a Master from the University of Alicante in the academic year (2010-2011). In special, it is an elective course called "Advanced Visual Ergonomics" from the Master of Clinical Optometry and Vision. The methodology used to teach this course differs from the traditional one in many respects. For example, one of the resources used for the development of this course is a blog developed specifically to coordinate a series of virtual works, whose purpose is that the student goes into specific aspects of the current topic. Next, the student participates in an active role by writing a personal assessment on the blog. However, in the course planning, there is an attendance to lessons, where the teacher presents certain issues in a more traditional way, that is, with a lecture supported with audiovisual materials, such as materials generated in powerpoint. To evaluate the quality of the results achieved with this methodology, in this work the personal assessment of the students, who have completed this course during this academic year, are collected. In particular, we want to know their opinion about the used resources, as well as the followed methodology. The tool used to collect this information was a questionnaire. This questionnaire evaluates different aspects of the course: a general opinion, quality of the received information, satisfaction about the followed methodology and the student´s critical awareness. The design of this questionnaire is very important to get conclusive information about the methodology followed in the course. The questionnaire has to have an adequate number of questions; whether it has many questions, it might be boring for the student who would pay no enough attention. The questions should be well-written, with a clear structure and message, to avoid confusion and an ambiguity. The questions should be objectives, without any suggestion for a desired answer. In addition, the questionnaire should be interesting to encourage the student´ s interest. In conclusion, this questionnaire developed for this subject provided good information to evaluate whether the methodology was a useful tool to teach "Advanced Visual Ergonomics". Furthermore, the student´s opinion collected by this questionnaire might be very helpful to improve this didactic resource.

The poetical works of Hemans, Heber and Pollok.

The poetical works of Reginald Heber.--The course of time, a poem, in ten books, by Robert Pollok.--The poetical works of Mrs. Felicia Hemans.

The relationship between faculty perceptions and implementation of elements of transactional distance theory and online web-based course completion rates

The purpose of this study was to explore the relationship between faculty perceptions, selected demographics, implementation of elements of transactional distance theory and online web-based course completion rates. This theory posits that the high transactional distance of online courses makes it difficult for students to complete these courses successfully; too often this is associated with low completion rates. Faculty members play an indispensable role in course design, whether online or face-to-face. They also influence course delivery format from design through implementation and ultimately to how students will experience the course. This study used transactional distance theory as the conceptual framework to examine the relationship between teaching and learning strategies used by faculty members to help students complete online courses. Faculty members' sex, number of years teaching online at the college, and their online course completion rates were considered. A researcher-developed survey was used to collect data from 348 faculty members who teach online at two prominent colleges in the southeastern part of United States. An exploratory factor analysis resulted in six factors related to transactional distance theory. The factors accounted for slightly over 65% of the variance of transactional distance scores as measured by the survey instrument. Results provided support for Moore's (1993) theory of transactional distance. Female faculty members scored higher in all the factors of transactional distance theory when compared to men. Faculty number of years teaching online at the college level correlated significantly with all the elements of transactional distance theory. Regression analysis was used to determine that two of the factors, instructor interface and instructor-learner interaction, accounted for 12% of the variance in student online course completion rates. In conclusion, of the six factors found, the two with the highest percentage scores were instructor interface and instructor-learner interaction. This finding, while in alignment with the literature concerning the dialogue element of transactional distance theory, brings a special interest to the importance of instructor interface as a factor. Surprisingly, based on the reviewed literature on transactional distance theory, faculty perceptions concerning learner-learner interaction was not an important factor and there was no learner-content interaction factor.

The Relationship between Faculty Perceptions and Implementation of Elements of Transactional Distance Theory and Online Web-Based Course Completion Rates

The purpose of this study was to explore the relationship between faculty perceptions, selected demographics, implementation of elements of transactional distance theory and online web-based course completion rates. This theory posits that the high transactional distance of online courses makes it difficult for students to complete these courses successfully; too often this is associated with low completion rates. Faculty members play an indispensable role in course design, whether online or face-to-face. They also influence course delivery format from design through implementation and ultimately to how students will experience the course. This study used transactional distance theory as the conceptual framework to examine the relationship between teaching and learning strategies used by faculty members to help students complete online courses. Faculty members’ sex, number of years teaching online at the college, and their online course completion rates were considered. A researcher-developed survey was used to collect data from 348 faculty members who teach online at two prominent colleges in the southeastern part of United States. An exploratory factor analysis resulted in six factors related to transactional distance theory. The factors accounted for slightly over 65% of the variance of transactional distance scores as measured by the survey instrument. Results provided support for Moore’s (1993) theory of transactional distance. Female faculty members scored higher in all the factors of transactional distance theory when compared to men. Faculty number of years teaching online at the college level correlated significantly with all the elements of transactional distance theory. Regression analysis was used to determine that two of the factors, instructor interface and instructor-learner interaction, accounted for 12% of the variance in student online course completion rates. In conclusion, of the six factors found, the two with the highest percentage scores were instructor interface and instructor-learner interaction. This finding, while in alignment with the literature concerning the dialogue element of transactional distance theory, brings a special interest to the importance of instructor interface as a factor. Surprisingly, based on the reviewed literature on transactional distance theory, faculty perceptions concerning learner-learner interaction was not an important factor and there was no learner-content interaction factor.

The role of inflammation in vascular function and pregnancy outcome in the pregnant stroke prone spontaneously hypertensive rat

During pregnancy, the maternal cardiovascular system undergoes major adaptation. One of these changes is a 40-50 % increase in circulating blood volume which requires a systemic remodelling of the vasculature in order to regulate maternal blood pressure and maximise blood supply to the developing placenta and fetus. These changes are broadly conserved between humans and rats making them an appropriate pre-clinical model in which to study the underlying mechanisms of pregnancy-dependent cardiovascular remodelling. Whilst women are normally protected against cardiovascular disease; pregnancy marks a period of time where women are susceptible to cardiovascular complications. Cardiovascular disease is the leading cause of maternal mortality in the United Kingdom; in particular hypertensive conditions are among the most common complications of pregnancy. One of the main underlying pathologies of these pregnancy complications is thought to be a failure of the maternal cardiovascular system to adapt. The remodelling of the uterine arteries, which directly supply the maternal-fetal interface, is paramount to a healthy pregnancy. Failure of the uterine arteries to remodel sufficiently can result in a number of obstetric complications such as preeclampsia, fetal growth restriction and spontaneous pregnancy loss. At present, it is poorly understood whether this deficient vascular response is due to a predisposition from existing maternal cardiovascular risk factors, the physiological changes that occur during pregnancy or a combination of both. Previous work in our group employed the stroke prone spontaneously hypertensive rat (SHRSP) as a model to investigate pregnancy-dependent remodelling of the uterine arteries. The SHRSP develops hypertension from 6 weeks of age and can be contrasted with the control strain, the Wistar Kyoto (WKY) rat. The phenotype of the SHRSP is therefore reflective of the clinical situation of maternal chronic hypertension during pregnancy. We showed that the SHRSP exhibited a deficient uterine artery remodelling response with respect to both structure and function accompanied by a reduction in litter size relative to the WKY at gestational day (GD) 18. A previous intervention study using nifedipine in the SHRSP achieved successful blood pressure reduction from 6 weeks of age and throughout pregnancy; however uterine artery remodelling and litter size at GD18 was not improved. We concluded that the abnormal uterine artery remodelling present in the SHRSP was independent of chronic hypertension. From these findings, we hypothesised that the SHRSP could be a novel model of spontaneously deficient uterine artery remodelling in response to pregnancy which was underpinned by other as yet unidentified cardiovascular risk factors. In Chapter 1 of this thesis, I have characterised the maternal, placental and fetal phenotype in pregnant (GD18) SHRSP and WKY. The pregnant SHRSP exhibit features of left ventricular hypertrophy in response to pregnancy and altered expression of maternal plasma biomarkers which have been previously associated with hypertension in human pregnancy. I developed a protocol for accurate dissection of the rat uteroplacental unit using qPCR probes specific for each layer. This allowed me to make an accurate and specific statement about gene expression in the SHRSP GD18 placenta; where oxidative stress related gene markers were increased in the vascular compartments. The majority of SHRSP placenta presented at GD18 with a blackened ring which encircled the tissue. Further investigation of the placenta using western blot for caspase 3 cleavage determined that this was likely due to increased cell death in the SHRSP placenta. The SHRSP also presented with a loss of one particular placental cell type at GD18: the glycogen cells. These cells could have been the target of cell death in the SHRSP placenta or were utilised early in pregnancy as a source of energy due to the deficient uterine artery blood supply. Blastocyst implantation was not altered but resorption rate was increased between SHRSP and WKY; indicating that the reduction in litter size in the SHRSP was primarily due to late (>GD14) pregnancy loss. Fetal growth was not restricted in SHRSP which led to the conclusion that SHRSP sacrifice part of their litter to deliver a smaller number of healthier pups. Activation of the immune system is a common pathway that has been implicated in the development of both hypertension and adverse pregnancy outcome. In Chapter 2, I proposed that this may be a mechanism of interest in SHRSP pregnancy and measured the pro-inflammatory cytokine, TNFα, as a marker of inflammation in pregnant SHRSP and WKY and in the placentas from these animals. TNFα was up-regulated in maternal plasma and urine from the GD18 SHRSP. In addition, TNFα release was increased from the GD18 SHRSP placenta as was the expression of the pro-inflammatory TNFα receptor 1 (Tnfr1). In order to investigate whether this excess TNFα was detrimental to SHRSP pregnancy, a vehicle-controlled intervention study using etanercept (a monoclonal antibody which works as a TNFα antagonist) was carried out. Etanercept treatment at GD0, 6, 12 and 18 resulted in an improvement in pregnancy outcome in the SHRSP with an increased litter size and reduced resorption rate. Furthermore, there was an improved uterine artery function in GD18 SHRSP treated with etanercept which was associated with an improved uterine artery blood flow over the course of gestation. In Chapter 3, I sought to identify the source of this detrimental excess of TNFα by designing a panel for maternal leukocytes in the blood and placenta at GD18. A population of CD3- CD161+ cells, which are defined as rat natural killer (NK) cells, were increased in number in the SHRSP. Intracellular flow cytometry also identified this cell type as a source of excess TNFα in blood and placenta from pregnant SHRSP. I then went on to evaluate the effects of etanercept treatment on these CD3- CD161+ cells and showed that etanercept reduced the expression of CD161 and the cytotoxic molecule, granzyme B, in the NK cells. Thus, etanercept limits the cytotoxicity and potential damaging effect of these NK cells in the SHRSP placenta. Analysing the urinary peptidome has clinical potential to identify novel pathways involved with disease and/or to develop biomarker panels to aid and stratify diagnosis. In Chapter 4, I utilised the SHRSP as a pre-clinical model to identify novel urinary peptides associated with hypertensive pregnancy. Firstly, a characterisation study was carried out in the kidney of the WKY and SHRSP. Urine samples from WKY and SHRSP taken at pre-pregnancy, mid-pregnancy (GD12) and late pregnancy (GD18) were used in the peptidomic screen. In order to capture peptides which were markers of hypertensive pregnancy from the urinary peptidomic data, I focussed on those that were only changed in a strain dependent manner at GD12 and 18 and not pre-pregnancy. Peptide fragments from the uromodulin protein were identified from this analysis to be increased in pregnant SHRSP relative to pregnant WKY. This increase in uromodulin was validated at the SHRSP kidney level using qPCR. Uromodulin has previously been identified to be a candidate molecule involved in systemic arterial hypertension but not in hypertensive pregnancy thus is a promising target for further study. In summary, we have characterised the SHRSP as the first model of maternal chronic hypertension during pregnancy and identified that inflammation mediated by TNFα and NK cells plays a key role in the pathology. The evidence presented in this thesis establishes the SHRSP as a pre-clinical model for pregnancy research and can be continued into clinical studies in pregnant women with chronic hypertension which remains an area of unmet research need.

Increased Endothelial Cell-Leukocyte Interaction in Murine Schistosomiasis: Possible Priming of Endothelial Cells by the Disease

Background and Aims: Schistosomiasis is an intravascular parasitic disease associated with inflammation. Endothelial cells control leukocyte transmigration and vascular permeability being modulated by pro-inflammatory mediators. Recent data have shown that endothelial cells primed in vivo in the course of a disease keep the information in culture. Herein, we evaluated the impact of schistosomiasis on endothelial cell-regulated events in vivo and in vitro. Methodology and Principal Findings: The experimental groups consisted of Schistosoma mansoni-infected and age-matched control mice. In vivo infection caused a marked influx of leukocytes and an increased protein leakage in the peritoneal cavity, characterizing an inflamed vascular and cellular profile. In vitro leukocyte-mesenteric endothelial cell adhesion was higher in cultured cells from infected mice as compared to controls, either in the basal condition or after treatment with the pro-inflammatory cytokine tumor necrosis factor (TNF). Nitric oxide (NO) donation reduced leukocyte adhesion to endothelial cells from control and infected groups; however, in the later group the effect was more pronounced, probably due to a reduced NO production. Inhibition of control endothelial NO synthase (eNOS) increased leukocyte adhesion to a level similar to the one observed in the infected group. Besides, the adhesion of control leukocytes to endothelial cells from infected animals is similar to the result of infected animals, confirming that schistosomiasis alters endothelial cells function. Furthermore, NO production as well as the expression of eNOS were reduced in cultured endothelial cells from infected animals. On the other hand, the expression of its repressor protein, namely caveolin-1, was similar in both control and infected groups. Conclusion/Significance: Schistosomiasis increases vascular permeability and endothelial cell-leukocyte interaction in vivo and in vitro. These effects are partially explained by a reduced eNOS expression. In addition, our data show that the disease primes endothelial cells in vivo, which keep the acquired phenotype in culture.

E-Learning Used in a Training Course on Atraumatic Restorative Treatment (ART) for Brazilian Dentists

The purpose of this study was to assess the benefits of using e-learning resources in a dental training course on Atraumatic Restorative Treatment (ART). This e-course was given in a DVD format, which presented the ART technique and philosophy. The participants were twenty-four dentists from the Brazilian public health system. Prior to receiving the DVD, the dentists answered a questionnaire regarding their personal data, previous knowledge about ART, and general interest in training courses. The dentists also participated in an assessment process consisting of a test applied before and after the course. A single researcher corrected the tests, and intraexaminer reproducibility was calculated (kappa=0.89). Paired t-tests were carried out to compare the means between the assessments, showing a significant improvement in the performance of the subjects on the test taken after the course (p<0.05). A linear regression model was used with the difference between the means as the outcome. A greater improvement on the test results was observed among female dentists (p=0.034), dentists working for a shorter period of time in the public health system (p=0.042), and dentists who used the ART technique only for urgent and/or temporary treatment (p=0.010). In conclusion, e-learning has the potential of improving the knowledge that dentists working in the public health system have about ART, especially those with less clinical experience and less knowledge about the subject.

Rest energy expenditure is decreased during the acute as compared to the recovery phase of sepsis in newborns

Background: Little is known with respect to the metabolic response and the requirements of infected newborns. Moreover, the nutritional needs and particularly the energy metabolism of newborns with sepsis are controversial matter. In this investigation we aimed to evaluate the rest energy expenditure (REE) of newborns with bacterial sepsis during the acute and the recovery phases. Methods: We studied nineteen neonates (27.3 +/- 17.2 days old) with bacterial sepsis during the acute phase and recovery of their illness. REE was determined by indirect calorimetry and VO(2) and VCO(2) measured by gas chromatography. Results: REE significantly increased from 49.4 +/- 13.1 kcal/kg/day during the acute to 68.3 +/- 10.9 kcal/kg/day during recovery phase of sepsis (P < 0.01). Similarly, VO(2) (7.4 +/- 1.9 vs 10 +/- 1.5 ml/kg/min) and VCO(2) (5.1 +/- 1.7 vs 7.4 +/- 1.5 ml/kg/min) were also increased during the course of the disease (P < 0.01). Conclusion: REE was increased during recovery compared to the sepsis phase. REE of septic newborns should be calculated on individualized basis, bearing in mind their metabolic capabilities.

Historic Bridge Photographs: The Lahey Collection

Romeo Watkins Lahey (1887-1968) was a distinguished Queensland engineer. He graduated in engineering from the University of Sydney in 1914 and served in World War I from 1915 to 1918 with The Royal Australian Engineers. Following the war, he accepted an offer to remain for a period in England and studied town planning at the University of London. He visited Europe and collected a remarkable set of historic bridge photographs. In the course of this visit, he met Paul Sejourne, a distinguished French bridge engineer, the designer of at Ieast one of the bridges (at Fontpedrouse, pages 25-27) included in this set. When Lahey died, his wife Sybil and daughter Ann took steps to give this remarkable set of 58 historic bridge photographs to The University of Queensland. More recently, Lahey's daughters Ann Neale and Alison Drake have given a set of lantern plates collected by their father, many of which also have photographs of bridges. This volume is divided into three parts: (a) a biography of Romeo Watkins Lahey, written by his daughter, Ann Neale; (b) copies of the original set of 58 bridge photographs, and (c) copies taken from 32 lantern plates. To these have been added captions. Many of the original photographs carried titles; where these are available they have been printed in italics. Further work has been done to identify bridges and where possible the captions include the completion date, major dimensions, locations, and references to published works. Plates 8.1-10 are copies of drawings used as Figures in a book. These drawings have not been copied and the source has not been identified. Two lists of photographs and plates are included - the first in the order of the original collections and a second with bridges listed in the order of material, structural form and date. The collection is of remarkable value to any bridge historian, and is recommended for study by students.

Protection against Paracoccidioides brasiliensis infection conferred by the prophylactic administration of native and recombinant ArtinM

We determined the prophylactic effect of both the d-mannose-binding lectin ArtinM extracted from the seeds of Artocarpus integrifolia (jackfruit) and its recombinant counterpart during the course of experimental paracoccidioidomycosis induced in BALB/c mice. Four experimental protocols of prophylaxis were employed to evaluate the most protective regimen of ArtinM administration. It was demonstrated that the best effect was obtained by administration of two ArtinM doses on days 10 and 3 before the challenge with Paracoccidioides brasiliensis. By following this protocol, the lungs of mice that received native or recombinant ArtinM exhibited reduced fungal burden and granuloma incidence. In addition, the protocol augmented contents of IL-12, IFN-gamma, TNF-alpha and NO. On the other hand, the control group consisting of untreated infected mice had higher pulmonary levels of IL-4 and IL-10. In conclusion, prophylaxis with ArtinM significantly reproduces the effect of its therapeutic administration, i.e, it confers resistance to P. brasiliensis infection in mouse models by promoting IL-12 production and favours Th1-immunity.

Chronic Recurrent Multifocal Osteomyelitis Primarily Affecting the Spine Treated With Anti-TNF Therapy

Study Design. A case report describing chronic recurrent multifocal osteomyelitis (CRMO) with initial presentation limited to spine, successfully treated by anti-TNF-alpha therapy after failure of conventional treatment methods. Objective. To describe an unusual manifestation and treatment of a rare disease. Summary of Background Data. CRMO is a rare inflammatory bone disease that should be differentiated from bacterial osteomyelitis. Rarely, it can affect the spine and in this case the most important differential diagnosis is infectious spondylodiscitis. The disease has an unpredictable course with exacerbations and spontaneous remissions. Although the majority of cases remit spontaneously (or after the use of nonsteroidal anti-inflammatory drugs [NSAIDs]), some progressive and resistant cases have been reported. Methods. We describe a case of CRMO with an unusual clinical presentation emphasizing the importance of this finding as a differential diagnosis of spondylodiscitis and comment on the available treatment alternatives. Results. A 17-year-old man presented with debilitating dorsal spine pain. Magnetic resonance imaging of the spine revealed bone lesions at multiple vertebral levels. After failure of antibiotic treatment, the diagnosis of CRMO was suggested. An initial good response to NSAIDs was followed by a recurrent course and involvement of peripheral joints besides the use of corticosteroids and other drugs. The introduction of infliximab was followed by complete remission of the disease. Conclusion. Our observation highlights the need of awareness for the differential diagnosis in suspected cases of osteomyelitis not responding to antibiotics. Anti-TNF-alpha agents should be considered in CRMO refractory cases.

A university extension course in leprosy: telemedicine in the Amazon for primary healthcare

There is a high prevalence of leprosy in the Amazon region of Brazil. We have developed a distance education course in leprosy for training staff of the Family Health Teams (FHTs). The course was made available through a web portal. Tele-educational resources were mediated by professors and coordinators, and included the use of theoretical content available through the web, discussion lists, Internet chat, activity diaries, 3-D video animations (Virtual Human on Leprosy), classes in video streaming and case simulation. Sixty-five FHT staff members were enrolled. All of them completed the course and 47 participants received a certificate at the end of the course. At the end of the course, 48 course-evaluation questionnaires were answered. A total of 47 participants (98%) considered the course as excellent. The results demonstrate the feasibility of an interactive, tele-education model as an educational resource for staff in isolated regions. Improvements in diagnostic skills should increase diagnostic suspicion of leprosy and may contribute to early detection.