INTRODUCTION:Neuromuscular ultrasound has been increasingly used in the detection and diagnosis of amyotrophic lateral sclerosis (ALS), commonly characterized by peripheral nerve atrophy, degeneration, and muscle fasciculations. The aim of this study was to assess the ultrasound characteristics of ALS patients. METHODS:A total of 67 consecutive patients with sporadic ALS and 19 with ALS mimics (63.16% peripheral neuropathy) were recruited. Ultrasound and electrophysiological examinations were performed; the peripheral nerve cross-sectional area (CSA) and fasciculation grades were compared between the groups, and correlations between ultrasound and electrophysiological data in ALS patients were determined. RESULTS:ALS patients had smaller proximal median and ulnar nerve CSAs than those of ALS mimics, who exhibited asymmetric changes. Fasciculation differences in the trapezius, triceps brachii, extensor digitorum communis, thenar, and first dorsal interosseous muscles were observed. In ALS patients, the CSA and fasciculation relative scores were correlated with electrophysiological indicators. CONCLUSION:Ultrasound is a valuable tool for monitoring peripheral nerve CSA and muscle fasciculations, both of which correlate with electrophysiological indices, in ALS patients.

Objective To explore the establishment of a discussion and feedback mode of difficult consultation cases for the training of specialist physicians.Methods This paper selected 12 neurology specialists who participated in the work of chief resident from January to August 2021to participate in the study.The total number of difficult cases and the diagnosis distribution of difficult cases.This paper compared the number of knowledge points summarized by specialists and superiors on representative cases.The needs in seven aspects:improving consultation response ability,self-learning ability,clinical thinking level,knowledge reserve,communication skills,management ability and overall clinical work ability were analyzed.An open questionnaire survey was conducted.Results A total of 34 cases of difficult consultation involving 11clinical departments were presented.Systemic diseases with nervous system involvement were the most common.For five representative cases,the numbers of knowledge points summarized by specialists was significantly less than that of their superior doctors（P＜0.05）.The top three needs of specialists were to improve their clinical thinking ability,consultation response ability and overall clinical work ability.In view of the problems such as failure to summarize regularly and insufficient time for consultation preparation,it was recommended to increase inter-professional knowledge lectures,organize regular consultation case discussions,and continuously improve teaching resources.Conclusion This teaching model will help to improve the thinking ability of specialists,and it is of certain significance to improve the training and evaluation system of specialists.

目的:调查分析轮转神经内科的精神科住院医师的教学需求.方法:对2017年9月-2018年2月在北医三院神经内科轮转的35名精神科住院医师进行问卷调查.结果:与培训开始相比,培训过半时研究对象对神经系统体格检查、神经精神科共病及辅助检查的培训需求降低(分别为x2 =10.189,4.769,7.124;P=0.001,0.029,0.015),对神经系统常用药物使用和小讲课的需求增加(x2=4.786和7.467;P=0.029和0.006).最关注问题为考勤与请假、掌握和运用知识能力以及家庭对工作和学习的影响.结论:了解轮转精神科住院医师的教学需求变化有助于完善培训方法.

随着医疗卫生体制改革的深化,医疗集团模式是近年来大型公立医院发展的一种重要模式."慕课"式培训可以有助于解决医疗集团模式下神经内科培训目前存在的诸多问题."慕课"由具有专业特长和带教经验丰富的医师精心准备并录制培训课程,再上传至网络平台,由住院医师根据自身的时间和临床需求自行学习."慕课"式培训集中了师资力量,具有形式更灵活、内容更丰富的特点,是可供临床教学实践探索的方式.

目前国内以胜任力为导向的人才培养模式尚处起步阶段,存在一些困难,如针对各个专科统一的胜任力培养细则尚未完备、传统教育模式难以适应以胜任力为导向的教育模式、实际执行过程中落地难等.作为独立二级学科,阶梯式评估反馈模式可能为神经科教学提供落地实施的方法.建立以胜任力为导向的评价体系,为各年资住院医师设立要求指标,每年考核,不合格学员由带教老师有针对性地反复强化培训、补考,直至达到标准.以胜任力为导向的阶梯式评估反馈模式,是对神经科住院医师教学方法的一种初探,希望能够探索出一套临床可行的高效模式.

将思维导图结合以问题为基础教学法(problem-based learning,PBL)应用于急诊神经内科住院医师卒中培训的理论学习、急诊跟诊和全程诊治中,可以提高卒中诊疗的教学效果.思维导图结合PBL的教学法有利于激发住院医师学习的主动性,提高学习效率,提升教学效果,对综合性教学医院急诊卒中诊疗的培训工作有促进作用.

目的 了解神经内科病房轮转住院医师的医患沟通技能状况,为住院医师规范化培训(住培)提供参考.方法 选取2016年9月至2017年5月在北京大学第三医院神经内科病房轮转的住院医师及其主管患者各81名,采用SEGUE量表进行住院医师自评以及教师对住院医师医患沟通能力的量化评价及基线和接受培训后的评价结果.共有36位住院医师接受连续评价,并根据是否接受教师即时反馈分为即时反馈组(n=18)和未接受即时反馈组(n=18).同时患者也对住院医师进行评价.结果 两类量表有效回收率均为100％.基线住院医师自评SEGUE量表总分显著高于教师评分(P<0.001).培训后SEGUE量表评分显著高于培训前(P=0.001).教师评价和住院医师自评SEGUE量表五个维度均有项目存在明显差异.患者评价中住院医师得分最低的三项依次为"建议将社区资源作为额外的信息和支持"(43.2％)、"清楚解释以后如何预防疾病"(39.5％)和"在需要的时间向专家咨询"(35.8％).患者最希望住院医师做到的前三件事情依次为"普及健康知识和出院指导"(38.0％)、"解决治疗问题"(24.1％)以及"努力学习成为好医师"(20.7％).结论 SEGUE量表适用于评价培训和反馈效果.神经内科轮转住院医师自我评价医患沟通技能明显高于教师评价.培训和教师即时反馈有助于快速提升住院医师医患沟通技能.医患沟通培训应考虑到患者的实际需求.

采用问卷对八年制临床医学生实习情况的调查,评价在导师制和传统模式下进行实习的效果,并对问卷的信度和效度进行检测.结果 表明,与传统模式相比,导师制在师生联系的紧密程度和学生学习的主动性等方面得分更高,更有利于激发导师的教学积极性,增强学生的学习主动性,提升临床实践教学的效果.

The standardized neurology training base undertakes not only the training of neurologists, but also the training for physicians, psychiatrists, emergency department physicians and etc. Before making the standardized training management plan, it is necessary to know the department source and professional background of trainees, their training objective and duration of rotation in neurology department. A variety of teaching methods were used to implement the training plan, and cultivation of humanistic quality were also integrated into daily work. To achieve the goal of training competent doctors in neurology, the adjustments were made timely according to the arising problems and the feedback of the trainees.

With the establishment of hospital consortium and the promotion of the policy of hierarchical medical system, it has become very common for doctors from the tertiary hospitals in the hospital consortium to visit in community hospitals and guide doctors in community hospitals. When guiding the primary medical doctors in hospital consortium, it becomes an important problem to improve their medical professional level. Based on the characteristics and needs of primary medical staff, Beijing University Third Hospital put forward targeted training program and established a multimodal neurological training for primary medical staff. Through this mode of training, the primary medical doctors’capability of diagnosing and dealing with the common neurological diseases were improved greatly, and they had a much better and deeper understanding of rare and difficult neurological diseases.

To investigate the clinical significance of ultrasonic determination of tongue muscle fasciculations in patients with amyotrophic lateral sclerosis (ALS). A total of 108 ALS patients, enrolled from May to September 2017 in Peking University Third Hospital, with the diagnosis of possible to definite ALS according to revised El Escorial criteria were examined by ultrasound through the submental way. Fasciculation of the tongue muscle was evaluated using a 7.5 MHz linear array transducer while the patients remain seated. We compared the ultrasonic and clinical determination of fasciculations of tongue muscle. The relationship between the fasciculations of tongue muscle and the course of disease, ALSFRS-R score, BMI and the results of electrophysiological examination were determined. The percentage of tongue muscle fasciculations detected by ultrasound was significantly higher than that of clinical judgment (81.5% vs 43.5%, P < 0.05). In ALS patients of bulbar onset, with diffuse neurogenic changes on electromyography with bulbar involvement, and with the bulbar involvement of both upper and lower motor neurons, the percentages of fasciculations were higher than those of limb onset, without diffuse neurogenic changes on electromyography with bulbar involvement or both bulbar upper and lower neurons involvement (c2 = 6.190, 6.364 and 5.031, separately; P < 0.05). The ALSFRS-R bulbar score in patients with ultrasonic fasciculations was significantly lower than that in patients without fasciculations (10.4 ± 2.1 vs 11.4 ± 1.2, t = −3.03, P < 0.05). Our study indicates ultrasound is more sensitive than clinical examination in judgement of tongue fasciculations. Ultrasonography can provide valuable reference for the diagnosis and treatment of ALS.

神经病学临床见习是高等医学院校临床医学系开设的课程,与临床关系密切.教学目标是掌握神经系统常见疾病的解剖和理论基础,建立分析思路,对疾病诊疗提出自己的看法和见解. 八年制临床医学是医学院内的主流专业,以培养可进入临床从事医疗、教学和科研的专业人才为目的,因此临床见习结合大课讲授疾病临床表现、诊疗原则及进展,直接接触临床病患,重点培养学生自主学习、建立正确临床思维、分析和解决问题的能力.传统的教学实践是教师将知识细化传授,学生被动接受知识点的过程,缺陷是理解反馈和融会贯通过程缓慢.神经病学教研室引入基于问题的学习(problem based learning,PBL)和基于病例的教学(case-based teaching,CBT),现将2种教学方法的临床见习教学效果与传统教学比较,报告如下.

住院医师规范化培训是培养临床医学人才的重要途径,很多教学方法在医学生培养的不同阶段出现,包括以授课为基础的教学方法、以问题为导向的教学方法、以案例为主体的教学方法以及以团队合作为基础的教学方法.笔者采用以学生为主体的规培方式,结合了上述几种教学方法,对不同的知识点采用不同的方法,核心是以学生为主体,以教师为主导的小组课堂讨论式教学法,取得满意效果.

在八年制见习带教中引入了腰椎穿刺术,基于《北京大学医学部临床基本技能操作指南》及《北京市住院医师规范化培训腰穿考核标准》规范操作标准,理论授课与实际操作相结合,通过仿真模型进行实际操作,提高了学习积极性,并且锻炼操作能力.同时,强调无菌操作和自我保护的重要性,并在操作过程中注重人文关怀,促使学生以后给真正的患者进行腰穿操作时能够顺利完成腰穿操作,减少并发症的出现.

通过分析比较传统模式与导师制在八年制医学生临床实习中的异同,发现导师制较传统的实习模式具有多方面的优势,更有利于激发导师的教学积极性,增强学生的学习主动性,提升临床实践教学的效果.但有必要对导师制进行适当的完善和调整,健全监督管理机制,以使其更好地适应八年制医学人才的培养教育.

Objective To establish a method which could measure tongue muscle thickness and evaluate the fasciculation of the tongue muscle by submental way ultrasonic detection , and to obtain the reference values of tongue muscle thickness in healthy volunteers , exploring its clinical application in the patients with amyotrophic lateral sclerosis (ALS).Methods In two-hundred healthy volunteers who took physical examination at the Medical Examination Center of Peking University Third Hospital , the tongue thickness was determined by measuring the distance between the upper and lower surfaces of the lingual muscles in the center of the plane perpendicular to the Frankfurt horizontal plane of the frontal section with a 3.5 MHz convex array transducer .The fasciculation of tongue muscle was evaluated using a 7.5 MHz linear array transducer in the same position .This method was used to measure the thickness of tongue muscle and to evaluate tongue muscle fasciculation in 30 patients with ALS who visited neurological clinic with the diagnosis of possible or definite ALS according to revised El Escorial criteria during the same period .We compared the tongue muscle thickness between 30 ALS patients and the same number of age-and gender-matched healthy volunteers .Results The mean value of tongue muscle thickness of males was significantly higher than that of females ((4.09 ±0.52) cm vs (3.70 ±0.56) cm, t=5.108, P<0.01), but there was no significant difference in the tongue muscle thickness between the different age groups .The mean value of tongue muscle thickness was significantly correlated with the body mass index value in healthy subjects ( r=0.412, P<0.01).No tongue muscle fibrillation was detected in healthy volunteers .In ALS group, the tongue was significantly thinner than that in healthy subjects ((3.77 ±0.58) cm vs (4.05 ±0.49) cm, t=-0.253, P<0.05).Of the total 30 ALS patients, we recognized tongue muscle fasciculation in 12 (40%).Conclusion The method to measure tongue muscle thickness and evaluate tongue musclefibrillation is reliable , and has good clinical application value in related diseases such as ALS .

By conducting a questionnaire-based survey , we evaluated the teaching effect of tutorial system , which has been applied at clinical practice stage of eight-year medical program .The results showed that tutorial system could contribute to students'learning of specialized theories and training of their clinical thinking and skills .At the same time, it is necessary to improve and adjust tutorial system to better nurture students of eight-year medical program .

在八年制医学生神经内科实习中实施导师制,通过对实施情况的总结分析发现,导师制对八年制医学生专业理论的学习、临床思维的训练有较大帮助,提升了八年制医学教育培养的质量.同时,有必要对导师制进行适当的调整和完善,以使其更好地适应八年制医学人才的培养教育.

目的 探索教师标准化患者(TSP)+病例导引教学(CBL)模式解决短暂性脑缺血发作(TIA)课临床教学“老大难”问题的可行性.方法 分别对八年制临床医学系2012级(38人)和2011级(38人)的TIA课采用TSP+CBL教学法和单纯TSP教学法.学习结束时,比较分析两组教学课堂考核成绩和教学效果调查问卷自评分.用t检验评价2种方法的教学效果.结果 TSP+CBL组学生课堂考核平均分达(88.76±3.48)分,显著高于TSP组的(85.27±3.01)分(P＜0.05).TSP+CBL组尤在临床思维、与人合作和解决问题能力方面成绩明显高于TSP组(P＜0.01).TSP+CBL组对教学效果调查问卷的平均自评分为(92.29±1.56)分,显著高于TSP组的(85.27±3.01)分(P＜0.01).TSP+CBL组在“对教材内容理解掌握程度”、“对新教学法满意程度”、“有利理论与临床实践结合”3个方面显著高于TSP组(均P＜ 0.01).结论 以TSP+CBL的教学模式值得推广,对此类发作-间歇型疾病的临床教学具有普遍性意义.