Beruflich Dokumente
Kultur Dokumente
Advances in Physiology Education is dedicated to the improvement of teaching and learning physiology, both in specialized
courses and in the broader context of general biology education. It is published four times a year in March, June, September and
December by the American Physiological Society, 9650 Rockville Pike, Bethesda MD 20814-3991. Copyright 2014 by the
American Physiological Society. ISSN: 1043-4046, ESSN: 1522-1229. Visit our website at http://www.the-aps.org/.
Staying Current
mechanisms; cardiovascular conditions; textbooks; eMedicine; YouTube; basic sciences; pathogenesis; linking basic and clinical sciences; integration of knowledge
CARDIOVASCULAR MECHANISMS are integral components in understanding pathophysiological changes of diseases and in
linking basic and clinical sciences in a meaningful way (20).
They also enable learners to examine the etiology and
contributing factors of cardiovascular diseases as well as the
chain of changes caused by the disease processes at molecular, cellular, organ, and body system levels (7, 36). Cardiovascular mechanisms can also provide an explanation for
the patients presenting symptoms and elicited clinical
signs. Therefore, mechanisms represent a system of casualty
outlining processes caused by a disease at its different stages
and providing an explanation for the changes. Mechanisms
could also accommodate not just basic sciences but also
Staying Current
LEARNING RESOURCES AND MECHANISMS
Medical Textbooks
125
Staying Current
126
Statistical Analysis
Analysis was conducted using SPSS software (version 18.0 for
Microsoft Windows, SPSS, Chicago, IL), and results were reported as
means, SDs, percentages, and minimums and maximums. t-Tests and
ANOVA were conducted to determine significant differences (32, 40).
To assess the degree to which different raters agreed in their assessment decisions, Cohens for interrater reliability was used to assess
interrater reliability (21, 43).
RESULTS
Medical Textbooks
The search ended with the identification of seven textbooks on human physiology, four textbooks on pathology,
and six textbooks on internal medicine commonly used in
teaching in undergraduate medical courses (Table 1). The 17
textbooks met the search criteria and were obtained for
further assessment. The number of chapters on cardiovascular diseases/system and blood vessels in the 17 textbooks
was 65. The percentage of cardiovascular mechanism content in physiology textbooks ranged from 5.4% [4 of 74,
Preston and Wilson (31)] to 28% [14 of 50, Mulroney and
Myers (29)], in pathology textbooks from 7.6% [4.5 of 59,
Underwood and Cross (38)] to 24.0% [24.5 of 102, Rubin et
al. (34)], and in internal medicine from 0.9% [1.5 of 152,
McPhee et al. (28)] to 10.1% [29 of 285, Longo et al. (27);
Table 1]. The overall average for cardiovascular mechanisms was 16.1% (99.5 of 618) in the seven textbooks on
physiology, 17.5% (64 of 364) in the four textbooks on
pathology, and only 6.9% (79.7 of 1,150) in the six textbooks on internal medicine. The percentage of figures committed to explain cardiovascular mechanisms in the physiology textbooks ranged from 7.2% [7 of 97, Preston and
Wilson (31)] to 30% [9 of 30, Mulroney and Myers (29)]. In
the pathology textbooks, the percentage of figures committed to cardiovascular mechanisms ranged from 5.2% [3 of
57, Underwood and Cross (38)] to 24% [12 of 50, Rubin and
Reisner (33)]. In the internal medicine textbooks, the percentage of figures committed to cardiovascular mechanisms
ranged from 0.0% [0 of 3, McPhee et al. (28)] to 9.7% [17
of 179, Longo et al. (27)].
All internal medicine textbooks except Longo et al. (27)
contained little information about cardiovascular mechanisms. For example, the textbook by McPhee et al. (28)
focused mainly on clinical findings such as symptoms,
clinical signs, investigations, differential diagnosis, treatment, and prognosis. Although the etiology of diseases was
provided, no pathophysiology or mechanisms were given.
Furthermore, no flow diagrams outlining mechanisms or the
pathogenesis of diseases were given. The textbook by Andereoli et al. (3) is a good textbook for undergraduate
medical students, but mechanisms were limited to certain
diseases. No flow diagrams outlining mechanisms or the
pathogenesis of diseases were given. The textbook by Longo
et al. (27) scored highest (10.1%) in relation to the percentage of cardiovascular mechanisms. However, more attention
to pathophysiology and mechanisms should be considered in
future editions. The three textbooks by Colledge et al. (13),
Kumar and Clark (23), and Goldman and Ausiello (18)
provided cardiovascular mechanisms at relatively reasonable percentages: 8.3%, 7.1%, and 7.0, respectively. Apart
from the textbooks by Mulroney and Myers (29), Sherwood
(35), Rubin and Reisner (33), and Widmaier et al. (42), none
of the remaining textbooks used flow diagrams to outline
mechanisms and explain the pathogenesis/pathophysiology
of cardiovascular diseases. These textbooks also limited the
mechanisms at physiological or pathological aspects with no
links to clinical symptoms, signs, or investigation results.
Physiology
Physiology
Physiology
Physiology
Physiology
Physiology
Pathology
Pathology
Pathology
Pathology
29
15
31
10
33
34
38
24
Barrett et al.
Mulroney and
Myers
Costanzo
Preston and
Wilson
Born and
Boulpaep
Rubin and
Reisner
Rubin et al.
Underwood
and Cross
Kumar et al.
Widmaier et al.
35
42
Sherwood
Discipline
Physiology
Reference
Chapter
Cardiovascular
system (2
chapters)
Cardiovascular
system (5
chapters)
Cardiovascular
system
Cardiovascular
physiology
Cardiovascular
physiology (2
chapters)
Cardiovascular
physiology (2
chapters)
Cardiac physiology
Cardiovascular
physiology
59
81
18.5
102
122
181
74
51
50
95
86
81
4.5
24.5
16.5
21
10
14
8.5
23
19
22.8
7.6
24.0
13.5
11.6
5.4
19.6
28
8.9
26.7
23.4
10 figures and 2
tables
3 figures and 0
tables
20 figures and 4
tables
12 figures and 2
tables
12 figures and 4
tables
7 figures and 0
tables
4 figures and 2
tables
9 figures and 0
tables
14 figures and 0
tables
16 figures and 2
tables
21 figures and 0
tables
Figures and
Tables on
Mechanisms
19.0 and
33.3
7.2 and 0
10 and
11.7
24 and 20
19.8 and
23.5
5.2 and 0
14.4 and
18.1
21 figures and 6
tables
97 figures and 0
tables
57 figures and 8
tables
69 figures and
11 tables
50 figures and
10 tables
30 and 0
30 figures and 0
tables
15.0 and 0
93 figures and
27 tables
26.5 and 0
Percentage
of
Content
Mechanism Clarity Quality Adequacy
22.8 and
22.2
70 figures and9
tables
79 figures and
15 tables
Total Figures
and Tables
Comments
Continued
A well-illustrated resource
for learning pathology.
However, mechanisms
need to be strengthened.
A well-illustrated resource
on pathology. However,
mechanisms need to be
strengthened.
The focus is on clinicpathological features.
Pathogenesis and
mechanisms are briefly
discussed.
A well-illustrated and
comprehensive textbook.
The pathogenesis of
diseases is clearly
provided, but this varied
from disease to disease.
Flow diagrams are
needed.
Authors
Percentage
Pages on
Total
of
Mechanisms Pages Mechanisms
Staying Current
127
13
28
23
27
18
McPhee et al.
Colledge et al.
Longo et al.
Andreoli et al.
Goldman and
Ausiello
Reference
Kumar and
Clark
Authors
Medicine
Medicine
Medicine
Medicine
Medicine
Medicine
Discipline
Cardiovascular disease
Cardiovascular disease
(11 chapters)
Disorders of the
cardiovascular
system (27 chapters)
Cardiovascular disease
Chapter
21
29
10
1.5
9.25
297
166
285
120
152
130
7.0
5.4
10.1
8.3
0.9
7.1
Percentage
Pages on
Total
of
Mechanisms Pages Mechanisms
9 figures and 2
tables
2 figures and 1
table
17 figures and 3
tables
4 figures and 0
tables
0 figures and 0
tables
10 figures and 2
tables
Figures and
Tables on
Mechanisms
3.8 and 0
9.4 and
3.4
2.5 and
1.6
4.6 and
1.6
79 figures and
60 tables
0 and 0
3 figures and 27
tables
7.7 and
4.0
Percentage
of
Content
Mechanism Clarity Quality Adequacy
Total Figures
and Tables
Comments
128
Table 1.Continued
Staying Current
LEARNING RESOURCES AND MECHANISMS
Staying Current
LEARNING RESOURCES AND MECHANISMS
129
eMedicine Topics
A total of 48 topics from eMedicine (Medscape) on cardiovascular diseases were identified and evaluated for mechanisms (Table 2). The percentage of cardiovascular mechanism
content varied from 0% in several topics, such as alcoholic
cardiomyopathy, acute coronary syndrome, and hypertensive
heart disease, to 41.6% (2.5 of 6) for the topic on renovascular
hypertension. The overall average for the cardiovascular mechanisms in the 48 topics was 15.8% (46.2 of 292). Cardiovascular mechanisms were adequately outlined in 22.9% (11 of
48) topics, for example, atrioventricular dissociation, paroxysmal supraventricular tachycardia, premature ventricular contraction, cardiogenic pulmonary oedema, cardiogenic shock,
dilated cardiomyopathy, coronary artery atherosclerosis, heart
failure, long QT syndrome, pulmonary edema, and infective
endocarditis. In the majority of these diseases, no flow diagrams outlining the mechanisms at the body system, organ,
cellular, and molecular levels were provided. Table 2 summarizes examples of the limitations/deficiencies observed in some
of the mechanisms given.
YouTube Videos
DISCUSSION
Staying Current
130
Topic*
Total
Pages
Percentage
of
Mechanism
Number of Diagrams/
Tables Covering
Mechanisms
Content
Clarity
Quality
Adequacy
1
1
9
6
11.1
16.6
0
2 images and 1 ECG
tracing
2
2
2
2
2
2
Atrial tachycardia
Atrioventricular block
Atrioventricular dissociation
First-degree atrioventricular block
Long QT syndrome
Paroxysmal supraventricular tachycardia
1.5
0.5
0.5
0.5
2
3
7
5
2
4
7
8
24.2
10.0
25
12.5
28.5
0
0
0
0
3
2
3
2
3
2
3
2
3
2
3
3
2
2
3
2
3
3
0.5
0.5
0.5
1
1.5
0.5
0.5
1.5
2
2
6
2
5
4
7
10
8
11
25
8.3
25.0
20.0
37.5
7.1
5
18.7
18.1
3
2
2
2
2
2
2
2
3
3
2
2
2
2
2
2
2
3
3
2
2
2
2
2
2
2
3
16
0.0
Noncoronary atherosclerosis
14.2
Renovascular hypertension
2.5
41.6
3 images
0.0
1 flow diagram
0
0.5
0.5
1.5
5
5
2
10
0.0
10
25
15
0
0
0
0
2
2
2
2
2
2
Unstable angina
25
Alcoholic cardiomyopathy
0.0
1
2
1
1
3
9
8
7
33.3
22.2
12.5
14.2
0
0
0
0
3
3
2
3
3
3
2
3
3
3
2
3
Heart failure
11
27.2
Hypertrophic cardiomyopathy
0.5
10.0
Restrictive cardiomyopathy
Acute pericarditis
Constrictive pericarditis
Pericardial effusion
Peripheral vascular disease
Aortic regurgitation
1
1
1
0.5
1
1
4
9
4
6
7
4
25
11.1
25
8.3
14.2
25
0
0
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1 table
2 diagrams plus 11
ECG tracings
0
0
0
2 diagrams
0
0
0
0
1 diagram
1 diagram
0
0
0
Continued
Advances in Physiology Education doi:10.1152/advan.00149.2013 http://advan.physiology.org
Atrial fibrillation
Atrial flutter
Comments (Reference)
Staying Current
LEARNING RESOURCES AND MECHANISMS
131
Table 2.Continued
Total
Pages
Percentage
of
Mechanism
Number of Diagrams/
Tables Covering
Mechanisms
Content
Clarity
Quality
Adequacy
Aortic stenosis
Infective endocarditis
0.5
2.5
5
11
10
22.7
0
0
2
3
2
3
2
3
Mitral regurgitation
Mitral stenosis
0.5
0.5
4
2
12.5
25
0
0
1
2
1
1
1
1
0.25
8.3
25
Pulmonary regurgitation
0.1
10
10.5
25
0.4
Topic*
Pulmonary stenosis
Rheumatic fever
5.7
Comments (Reference)
The mechanism is well
explained, but a diagram is
needed to summarize the
mechanism.
The underlying mechanism for
pulmonary arteriolar
constriction is not explained,
nor is that hypoxic
pulmonary vasoconstriction
resides in pulmonary arterial
smooth muscle cells. The
pathogenesis of right-sided
heart failure as the diseases
progresses is not explained.
No mechanism was given. The
authors discussed the natural
history of mitral valve
prolapse and myxomatous
degeneration of collagen
fibrils, etc.
Incomplete. The mechanism
given should be updated in
light of current
publications/research.
No mechanism given. The
authors briefly discussed the
causes of pulmonary
regurgitation.
Incomplete. The mechanism
given should be updated in
light of current
publications/research.
The mechanism did not discuss
the pathogenic mechanisms
of cross-reactive
autoantibodies that target
cells, cardiac valves in
rheumatic heart disease, and
neural cells in Sydenham
chorea.
*Not all cardiovascular topics shown on eMedicine were included in this evaluation. Topics that were too specialized and not needed at undergraduate level
were not included. Because of variability in the number of pages allocated to references, the list of references and information about the authors were not counted
in the total number of pages.
cardiogenic pulmonary edema, cardiogenic shock, dilated cardiomyopathy, heart failure, long QT syndrome, and infective
endocarditis. However, several topics lacked or had poorly
provided mechanisms, such as hypertensive heart disease,
noncoronary atherosclerosis, risk factors for coronary artery
disease, hypertrophic cardiomyopathy, mitral regurgitation,
mitral stenosis, mitral valve prolapse, pulmonary regurgitation,
and rheumatic fever. More importantly, no flow diagrams or
videos explaining mechanisms were included, and the topics
were presented in a way similar to that of textbooks. As an
online resource, eMedicine should effectively use the technical
advantages available to online resource and include videos,
educational multimedia programs, or interactive electronic
tasks that can deepen the understanding of mechanisms at
the body system, organ, cellular, and molecular levels,
therefore adding new dimensions to the understanding of
mechanisms (16).
Pages on
Mechanisms/
Pathophysiology
Staying Current
132
Table 3. Details about YouTube videos discussing cardiovascular mechanisms identified in the study
Number
Title
3
4
5
6
7
8
9
10
11
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
Pathophysiology of Wolff-Parkinson
White Syndrome
Pathophysiology of Cardiac
Arrhythmias
Pathophysiology of Hypertensive
Nephropathy
Pathophysiology cardiovascular 1 of
5 Risk factors
Pathophysiology Cardiovascular 2
of 5 Peripheral artery disease
Pathophysiology cardiovascular 3 of
5 heart disease
Pathophysiology of Pulmonary
Arterial Hypertension (PAH)
Pathogenesis of the Atherosclerotic
Plaque and Acute Coronary Syn
Shotgun USMLE Renal Cardiac
Pathophysiology 1
Overview of Coronary Artery
Disease
Congestive Heart Failure Medical
Animation
Coronary Artery Disease: Cause of
Heart Attack - One Minute
Medic
Pathophysiology of CAD/MI Dr.
Milind Hanchate
Pathophysiology, Hypertension
Pathophysiology, Mitral Valve
Stenosis
Atherosclerosis (Understanding
Disease: Cardiovascular
Medicine)
How Hypertension Affects Cardiac
Risk
Pathophysiology, Myocardial
Infarction
Pathophysiology of heart failure
Pathophysiology, Heart Failure
Congestive Heart Failure
Pathophysiology, Valvular Heart
Disease
Pathophysiology of Heart Failure
Hypertension and the Mechanism of
Blood Pressure
Duration
Days on
Viewers YouTube
Viewership
per Day
Total score*
http://www.youtube.com/watch?vOwvrBVw_J4Y
21 min 18 s
38,594
465
82.9
http://youtu.be/t4e8ucPzRjQ
55 min 7 s
7,723
414
18.6
http://www.youtube.com/watch?vFfPUaoyARtk
30 min 50 s
57
302
0.2
http://www.youtube.com/watch?vpXluagz53kc
20 min 10 s
22,019
465
47.3
http://www.youtube.com/watch?vrktoF7BHRiQ&list
PL4C480876D0558842
http://www.youtube.com/watch?v_cYThiC-0uk
23 min 50 s
22,021
465
47.3
12 min 37 s
5,052
465
10.8
http://www.youtube.com/watch?v_50jV3DKryQ&list
PL4C480876D0558842
http://www.youtube.com/watch?vUTLCPpM2vZ8
20 min 48 s
15,000
464
32.3
16 min 41 s
6,421
448
14.3
http://www.youtube.com/watch?vXPzYkTjN4t4
46 min 22 s
44
60
0.7
http://www.youtube.com/watch?vl3Pcoc3rzR4
28 min 56 s
56
183
0.3
http://www.youtube.com/watch?vF35dTjjGy_Y
38 min 42 s
63
60
1.0
http://www.youtube.com/watch?v9a4untSzLzg
7 min 19 s
2,305
178
12.9
http://www.youtube.com/watch?vupb37rbS1dE
3 min 45 s
26,614
536
49.6
http://www.youtube.com/watch?v08QUa6_zRUs
8 min 57 s
155
690
http://youtu.be/NZ14XjOQoFY
2 min 58 s
22,242
840
26.4
http://www.youtube.com/watch?vJJAMYHAwCMs
2 min 23 s
41,231
887
46.4
http://www.youtube.com/watch?vLmzfiA1FA-E
1 min 33 s
1,439
155
9.2
http://www.youtube.com/watch?v_pOeefZN-Wc
24 min 22 s
26
107
0.24
http://www.youtube.com/watch?v9FuSdiFRK3Y
http://www.youtube.com/watch?vVVlJX-Fd_hI
5 min 4 s
4 min 18 s
106
43
19
49
5.5
08
http://www.youtube.com/watch?v7JihvMpEP4w
2 min 48 s
36,288
628
57.7
http://www.youtube.com/watch?vjSrtyeXM59w
2 min 47 s
102
271
0.37
http://www.youtube.com/watch?vAquIpZVNc7w
2 min 36 s
340
193
1.7
http://www.youtube.com/watch?vBmkARWsZJAk
http://www.youtube.com/watch?v_IPuJvxtwqo
http://www.youtube.com/watch?vb2q672lG3Nk
http://www.youtube.com/watch?v7r4LQtACr-s
3
7
6
1
158
27
20,073
411
43
28
1605
190
3.6
0.9
12.5
2.1
http://www.youtube.com/watch?vECpGxkinwXs
http://www.youtube.com/watch?vsJop3D4YSr4
11 min 22 s
1 min 33 s
4,028
1,439
213
155
18.9
9.2
min
min
min
min
14
12
12
45
s
s
s
s
0.22
Numbers 116 comprise educationally useful videos on cardiovascular mechanisms (n 16). Numbers 1729 comprise noneducationally useful videos on
cardiovascular mechanisms (n 13). *Total score [in means SD (minimummaximum)] was calculated from the scores given by the three evaluators to each
video. CHF, congestive heart failure; USMLE, United States Medical Licensing Examination; CAD, coronary artery disease; MI, myocardial infarction.
12
URL
Staying Current
LEARNING RESOURCES AND MECHANISMS
133
Staying Current
134
16. Cox JR. Enhancing student interactions with the instructor and content
using pen-based technology, YouTube videos, and virtual conferencing.
Biochem Mol Biol Educ 39: 4 9, 2011.
17. Flores RL, Demoss P, Klene C, Havlik RJ, Tholpady S. Digital
animation versus textbook in teaching plastic surgery techniques to novice
learners. Plast Reconstr Surg 132: 101e9e, 2013.
18. Goldman L, Schafer AI. Goldmans Cecil Medicine (24th ed.). New
York: Saunders, 2012.
19. Goodwin D. Search Engine Watch. YouTube Now Serving 4 Billion
Videos Daily. http://searchenginewatch.com/article/2141050/YouTubeNow-Serving-4-Billion-Videos-Daily [24 March 2014].
20. Guerrero AP. Mechanistic case diagramming: a tool for problem-based
learning. Acad Med 76: 385389, 2001.
21. Kim HY. Statistical notes for clinical researchers: evaluation of measurement error 2: Dahlbergs error, Bland-Altman method, and kappa coefficient. Restor Dent Endod 38: 182185, 2013.
22. Kingsley K, Galbraith GM, Herring M, Stowers E, Stewart T, Kingsley KV. Why not just Google it? An assessment of information literacy
skills in a biomedical science curriculum. BMC Med Educ 11: 17, 2011.
23. Kumar P, Clark M. Kumar & Clarks Clinical Medicine (8th ed.).
Edinburgh: Saunders, Elsevier, 2012.
24. Kumar V, Abbas AK, Aster J. Robbins Basic Pathology (9th ed.).
Edinburgh: Saunders, Elsevier, 2013.
25. Lewis SP, Heath NL, St Denis JM, Noble R. The scope of nonsuicidal
self-injury on YouTube. Pediatrics 127: e552e557182185, 2011.
26. Lewis SP, Heath NL, Sornberger MJ, Arbuthnott AE. Helpful or
harmful? An examination of viewers responses to nonsuicidal self-injury
videos on YouTube. J Adolesc Health 51: 380 385, 2012.
27. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo
J. Harrisons Principles of Internal Medicine (18th ed.). New York:
McGraw-Hill Medical, 2012.
28. McPhee SJ, Papadakis MA, Rabow MW. Current Medical Diagnosis &
Treatment (50th Anniversary ed.). New York: McGraw-Hill, Lange, 2011.
29. Mulroney SE, Myers AK. Netters Essential Physiology. New York:
Saunders, Elsevier, 2009.
30. OSullivan PB, Beales DJ. Diagnosis and classification of pelvic girdle
pain disorderspart 1: a mechanism based approach within a biopsychosocial framework. Man Ther 12: 86 97, 2007.