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An example of a practical biochemistry examination for health professional students
200 assured participation of all members of the class, the opportunity for drill, and the development of each student's speaking ability. The dialogue emphasizes debate, resourcefulness and adequate mastery of the material to field questions of peers. In this latter mode, more akin to clinical rounds, the facilitator serves as catalyst and referee and sees to it that the discussion proceeds in an orderly and constructive manner. He must ascertain that all participate and all understand. He is responsible for providing encouragement and re-enforcement to each speaker during the session and, where needed, one-on-one guidance to individual students after the session. One of the most important elements of every case study is the careful resum6: the facilitator must review the proceedings step-by-step to assure that all students clearly see the reasoning process and comprehend the conclusions and their bases.
An Example of a Practical Biochemistry Examination for Health Professional Students ALLEN OTSUKA* and BARNEY KADISt
* Department of Biomedical Sciences School of Dental Medicine Southern Illinois University Edwardsville, Illinois 62026, USA, and t Department of Basic Sciences School of Medichte Mercer University Macon, Georgia 31207, USA Introduction In presenting a biochemistry course to dental students, we have had noteworthy success using practical, caseoriented examinations. By making the tests relevant to their future endeavors, we believe that the students not only more readily accept taking such a course, but also view the information presented as being beneficial in understanding certain aspects of their chosen profession. For examination purposes, we have used clinical cases taken from the medical or dental literature, cases of patients who presented to the clinic, or formulated cases to suit particular goals. A case is usually given to the students at least a week prior to an examination so that they have ample time to research various aspects and to familiarize themselves with it. We have used a format of essay questions, multiple choice questions or a combination of both in our examinations. Our approach has been to formulate questions which (a) are derived from the data presented in the case rather than some esoteric or theoretical concepts; or (b) attempt to present broad principles rather than specific details. For a final examination, we also include questions related peripherally to the case that test the biochemical knowledge of the students. BIOCHEMICAL EDUCATION 16(4) 1988
The following clinical case, modified to suit our purposes, was used in one of our final examinations. We have excluded the patient's case history in this article but have included fifteen of the seventy multiple-choice questions that were used on the examination. No essay questions were utilized for this particular final examination.
Examination Case Study Mr PB, a 51-year-old while male, was administered an unidentified local anesthesia for multiple extractions at a dental clinic. During the next 24 hours he hemorrhaged profusely from the extraction sites and was referred to the dental service in a nearby hospital. The patient was a well-developed, well-nourished man who was slightly confused and disoriented but responded to verbal commands. There was ecchymotic swelling of the soft tissues in the submandibular area, icterus of the sclera, protrusion of the abdomen, and enlargement of the liver. The patient was taken immediately to the oral surgery operating room where an infusion of 5% dextrose in Ringer's lactate solution was started and 5 mg of a tranquilizer (Valium) was administered. Following local anesthesia (6 ml of 2% lidocaine containing epinephrine 1:100 000) the extraction sites were packed with oxidized cellulose and sutured. Except for a slight ooze, the bleeding subsided. The patient was taken to the dental ward in the hospital for observation. Admission laboratory test results were: Prothrombin time 19 s (Normal control: 11.5 s) SGOT 120 U/I (Normal: 7-27 U/l) Bilirubin (total) 5.4 mg/100 ml (Normal: Up to 1.0 rag/100 ml) Blood Ammonia 97 Ixmol/1 (Normal: 12-55 ~xmol/1) Twenty-four hours after admission, the patient became semicomatose and disoriented as to time and place. He did not respond to verbal commands. He remained in a semicomatose state for 72 hours and did not become completely oriented until the seventh day in the hospital. Treatment consisted of a protein-free diet of 1800 calories/day, 500 mg neomycin sulfate orally four times a day for seven days, 600 000 units procaine penicillin intramuscularly two times a day for seven days, 5 mg folic acid each day, 200 mg ferrous sulfate three times a day, 50 mg Aquamephyton (water solubilized Vitamin K-I) injection intramuscularly twice a day for three days, and an oral vitamin B complex supplement.
Sample Questions 1. Which of the following led to the patient's comatose condition? (a) ammonia toxicity. (b) hepatic cirrhosis. (c) amino acid metabolism. (d) all of the above choices. (e) none of the above choices.
201 2. The patient was placed on a protein-free diet because he needed (a) less calories in his diet. (b) to meet his metabolic requirements only with carbohydrates. (c) to reduce ammonia production in the liver. (d) to prevent the liver from synthesizing bile acids. (e) to reduce protein synthesis. 3. All of the following are normal functions of the liver EXCEPT (a) insulin biosynthesis. (b) gluconeogenesis. (c) urea synthesis. (d) lipoprotein biosynthesis. (e) carbohydrate interconversions. 4. The body possesses metabolic pathways for interconversion of the various foodstuffs ingested. One pathway, however, which does not operate is (a) carbohydrates to amino acids. (b) amino acids to carbohydrates. (c) amino acids to fatty acids. (d) fatty acids to carbohydrates. (e) carbohydrates to fatty acids. 5. During the hospital stay of the patient, treatment was geared towards resetting the patient's (a) liver towards gluconeogenesis. (b) kidney towards gluconeogenesis. (c) body homeostasis. (d) abnormal prothrombin time towards normal. (e) liver towards protein synthesis. 6. The increase in prothrombin time of the patient indicates (a) increased serum prothrombin levels. (b) decreased serum prothrombin levels. (c) increased serum fibrinogen levels. (d) increased calcium levels. (e) increased serum thrombin levels. 7. Blood clotting is an example of a cascade system. The value of cascades to the individual is that they (a) increase the body's steady state homeostasis. (b) can occur in any part of the body. (c) utilize a small amount of stimulus to obtain a large amount of product in a short period of time. (d) are used primarily as a rapid method of obtaining metabolic precursors for energy production. (e) are regulated by simple feedback inhibition. 8. The local anesthetic (lidocaine) was utilized to deaden the pain of suturing. Lidocaine's effect on pain is to (a) increase nerve transmission by the inward movement of K + into neurons. (b) increase nerve transmission through the release of substance P. (c) decrease nerve transmission through the release of neuronal Ca ++ . (d) decrease nerve transmission by blocking entry of Na + into neurons. (e) decrease nerve transmission by the outward movement of K + from the neurons.
BIOCHEMICAL EDUCATION 16(4) 1988
9. Two different antibiotics were administered in order to fight infection. Penicillin differs from neomycin in that penicillin affects (a) cell wall biosynthesis. (b) protein biosynthesis. (c) RNA transcription. (d) DNA replication. (e) polyribosome biosynthesis. 10. Vitamin K was administered because it is essential for the biosynthesis of (a) heparin. (b) hemoglobin. (c) collagen. (d) prothrombin. (e) thrombin. 11. Careful choice of an antibiotic depends on the realization that (a) only microbes are killed. (b) only unicellular organisms can absorb the antibiotic. (c) microbial as well as mammalian systems may be affected. (d) DNA biosynthesis will be affected. (e) R N A biosynthesis will be affected. 12. Infusion of a dextrose solution is performed because 1. dextrose is more readily metabolized than any other disaccharide. 2. glucose serves as the primary energy source. 3. carbohydrate is necessary for wound healing. 4. of the constant need of the brain for glucose. 5. dextrose can be converted into glucose and thus used as an energy source. (a) 1 , 2 a n d 3 (b) 1 , 3 a n d 5 (c) 2 , 3 a n d 4 (d) 2 , 4 a n d 5 (e) 1, 2, 3, 4 and 5 13. The high blood level of SGOT indicates (a) leakage from damaged tissue. (b) increased biosynthetic processes due to hepatic enlargement. (c) increased interconversion between amino sugars and ketone bodies. (d) deamination of neurotransmitter amines. (e) increased urea synthesis. 14. Ferrous sulfate was administered because iron is a component of essential biomolecules. All of the following substances contain iron E X C E P T (a) hemoglobin. (b) cytochrome c. (c) transferrin. (d) vitamin B12. (e) hemosiderin. 15. Above certain concentrations of ammonia, the blood (1) system would not be able to maintain the proper (2). 1 2 (a) enzyme; glucose concentration (b) enzyme; H + concentration
202 (c) enzyme; (d) buffer; (e) buffer;
osmotic pressure glucose concentration H + concentration
Answers to Sample Questions 1. 2. 3. 4. 5.
d c a d c
6. 7. 8. 9. 10.
b c d a d
ll.c 12. 13. 14. 15.
c a d e
Biochemical Education and Research in King Faisai University Medical College, Saudi Arabia A I ALAYASH Duke University Marine Biomedical Center Beaufort, NC 28516, USA
Introduction King Faisal University (KFU), the second largest university in the Eastern Province of Saudi Arabia, was founded in 1975/76 to include four colleges. The Dammam coastal campus comprises of the College of Medicine and Medical Sciences, and the College of Architecture and Planning. The other campus of the university is in the oasis of A1 Hassa, where the College of Veterinary Medicine and College of Agriculture are located. The author was an assistant professor at the department of biochemistry, College of Medicine and Medical Sciences, from 1980-87. A new College of Education has recently been opened in AI Hassa. The Department The department is responsible for teaching biochemistry to third-year medical students and also for contributing to the College of Medicine residency programs. The department was staffed throughout this period by 5-6 faculty members, mostly expatriates. However, more Saudi nationals working towards their higher degrees in biochemistry, are expected to return from Europe and the US in the next few years. The department is well equipped and teaching and research laboratories are housed in a modern building with fairly good facilities and equipment. The student population fluctuates from one semester to another, with generally 40-60 students in both male and female sections, taking each of the two biochemistry courses. Instruction is in English and KFU follows the semester credit hour system. Biochemistry Courses There are two biochemistry courses, 4 credit hours each as part of the third pre-clinical year. Prerequisites for Biochemistry I include advanced courses in physics, chemistry, and biology. Biochemistry I is a prerequisite for Biochemistry II. Medical students at this level are introduced to Biochemistry I beginning with the chemistry BIOCHEMICAL EDUCATION 16(4) 1988
of carbohydrates, lipids, and proteins with some emphasis on the structural-functional aspects of some important macromolecules, in both health and disease. The other part of the course deals with enzymes and the utilization of these proteins as a diagnostic tool. The chemistry and functions of fat- and water-soluble vitamins are dealt with in detail, as well as the state of deficiency of some of these vitamins. The structure and function of nucleic acids is taught under the heading of genetic information. Some emphasis is placed on recent advances in DNA technology. The course winds up with a short introduction to metabolism. Biochemical principles and concepts have become increasingly important for the understanding of diseases. Biochemistry II which deals primarily with the metabolism of carbohydrates, lipids, proteins, nucleotides, and biological oxidations, provides the opportunity to discuss with students extensively the biochemical basis of the metabolic processes in both health and disease, thus demonstrating to students of medicine that biochemical pathways should not be divorced from the analysis of human disease. The remainder of the course deals with short and specialized topics in biochemistry such as heme metabolism, minerals, tissue biochemistry and finally general characteristics of hormones. The re-structuring of the medical college curricula has recently been approved by the University Council, in which Biochemistry I and II will be taught as part of the second and third year, re-named 'level I' and 'level II', respectively. This has raised some legitimate concern in the basic science departments, and in particular the biochemistry department, as it was felt that students may not be sufficiently prepared for biochemistry courses. Practical sessions are an important part of biochemical education for medical students. Laboratory programs are structured largely, and whenever possible, to reflect the material presented in the theory. Experiments dealing with basic biochemistry do not generate much excitement - - in contrast to experiments with clinical relevance. A comprehensive and updated biochemistry experimental manual, designed for the students of medicine, has been compiled to replace the seemingly never ending process of xeroxing old experiment hand-outs, prior to the start of the laboratory. Tutorials are part of the biochemistry syllabus. They have recently, however, become more oriented towards overcoming the hurdles of examinations, rather than an exercise in maximising the full benefits of student-faculty interaction. Students are required to pass one mid-term and final examination which include one comprehensive oral examination, for students taking Biochemistry II. Students and faculty receive free copies of two textbooks, these are; 'Harper's Review of Biochemistry' and 'Textbook of Biochemistry with Clinical Correlations', by Devlin. In addition a few supplementary books are also available, such as 'Biochemistry - - A Caseoriented Approach', by Montgomery et al and 'Human Biochemistry' by Morten and Neuhaus. Several educational and research workshops were
An Example of a Practical Biochemistry Examination for Health Professional Students ALLEN OTSUKA* and BARNEY KADISt
* Department of Biomedical Sciences School of Dental Medicine Southern Illinois University Edwardsville, Illinois 62026, USA, and t Department of Basic Sciences School of Medichte Mercer University Macon, Georgia 31207, USA Introduction In presenting a biochemistry course to dental students, we have had noteworthy success using practical, caseoriented examinations. By making the tests relevant to their future endeavors, we believe that the students not only more readily accept taking such a course, but also view the information presented as being beneficial in understanding certain aspects of their chosen profession. For examination purposes, we have used clinical cases taken from the medical or dental literature, cases of patients who presented to the clinic, or formulated cases to suit particular goals. A case is usually given to the students at least a week prior to an examination so that they have ample time to research various aspects and to familiarize themselves with it. We have used a format of essay questions, multiple choice questions or a combination of both in our examinations. Our approach has been to formulate questions which (a) are derived from the data presented in the case rather than some esoteric or theoretical concepts; or (b) attempt to present broad principles rather than specific details. For a final examination, we also include questions related peripherally to the case that test the biochemical knowledge of the students. BIOCHEMICAL EDUCATION 16(4) 1988
The following clinical case, modified to suit our purposes, was used in one of our final examinations. We have excluded the patient's case history in this article but have included fifteen of the seventy multiple-choice questions that were used on the examination. No essay questions were utilized for this particular final examination.
Examination Case Study Mr PB, a 51-year-old while male, was administered an unidentified local anesthesia for multiple extractions at a dental clinic. During the next 24 hours he hemorrhaged profusely from the extraction sites and was referred to the dental service in a nearby hospital. The patient was a well-developed, well-nourished man who was slightly confused and disoriented but responded to verbal commands. There was ecchymotic swelling of the soft tissues in the submandibular area, icterus of the sclera, protrusion of the abdomen, and enlargement of the liver. The patient was taken immediately to the oral surgery operating room where an infusion of 5% dextrose in Ringer's lactate solution was started and 5 mg of a tranquilizer (Valium) was administered. Following local anesthesia (6 ml of 2% lidocaine containing epinephrine 1:100 000) the extraction sites were packed with oxidized cellulose and sutured. Except for a slight ooze, the bleeding subsided. The patient was taken to the dental ward in the hospital for observation. Admission laboratory test results were: Prothrombin time 19 s (Normal control: 11.5 s) SGOT 120 U/I (Normal: 7-27 U/l) Bilirubin (total) 5.4 mg/100 ml (Normal: Up to 1.0 rag/100 ml) Blood Ammonia 97 Ixmol/1 (Normal: 12-55 ~xmol/1) Twenty-four hours after admission, the patient became semicomatose and disoriented as to time and place. He did not respond to verbal commands. He remained in a semicomatose state for 72 hours and did not become completely oriented until the seventh day in the hospital. Treatment consisted of a protein-free diet of 1800 calories/day, 500 mg neomycin sulfate orally four times a day for seven days, 600 000 units procaine penicillin intramuscularly two times a day for seven days, 5 mg folic acid each day, 200 mg ferrous sulfate three times a day, 50 mg Aquamephyton (water solubilized Vitamin K-I) injection intramuscularly twice a day for three days, and an oral vitamin B complex supplement.
Sample Questions 1. Which of the following led to the patient's comatose condition? (a) ammonia toxicity. (b) hepatic cirrhosis. (c) amino acid metabolism. (d) all of the above choices. (e) none of the above choices.
201 2. The patient was placed on a protein-free diet because he needed (a) less calories in his diet. (b) to meet his metabolic requirements only with carbohydrates. (c) to reduce ammonia production in the liver. (d) to prevent the liver from synthesizing bile acids. (e) to reduce protein synthesis. 3. All of the following are normal functions of the liver EXCEPT (a) insulin biosynthesis. (b) gluconeogenesis. (c) urea synthesis. (d) lipoprotein biosynthesis. (e) carbohydrate interconversions. 4. The body possesses metabolic pathways for interconversion of the various foodstuffs ingested. One pathway, however, which does not operate is (a) carbohydrates to amino acids. (b) amino acids to carbohydrates. (c) amino acids to fatty acids. (d) fatty acids to carbohydrates. (e) carbohydrates to fatty acids. 5. During the hospital stay of the patient, treatment was geared towards resetting the patient's (a) liver towards gluconeogenesis. (b) kidney towards gluconeogenesis. (c) body homeostasis. (d) abnormal prothrombin time towards normal. (e) liver towards protein synthesis. 6. The increase in prothrombin time of the patient indicates (a) increased serum prothrombin levels. (b) decreased serum prothrombin levels. (c) increased serum fibrinogen levels. (d) increased calcium levels. (e) increased serum thrombin levels. 7. Blood clotting is an example of a cascade system. The value of cascades to the individual is that they (a) increase the body's steady state homeostasis. (b) can occur in any part of the body. (c) utilize a small amount of stimulus to obtain a large amount of product in a short period of time. (d) are used primarily as a rapid method of obtaining metabolic precursors for energy production. (e) are regulated by simple feedback inhibition. 8. The local anesthetic (lidocaine) was utilized to deaden the pain of suturing. Lidocaine's effect on pain is to (a) increase nerve transmission by the inward movement of K + into neurons. (b) increase nerve transmission through the release of substance P. (c) decrease nerve transmission through the release of neuronal Ca ++ . (d) decrease nerve transmission by blocking entry of Na + into neurons. (e) decrease nerve transmission by the outward movement of K + from the neurons.
BIOCHEMICAL EDUCATION 16(4) 1988
9. Two different antibiotics were administered in order to fight infection. Penicillin differs from neomycin in that penicillin affects (a) cell wall biosynthesis. (b) protein biosynthesis. (c) RNA transcription. (d) DNA replication. (e) polyribosome biosynthesis. 10. Vitamin K was administered because it is essential for the biosynthesis of (a) heparin. (b) hemoglobin. (c) collagen. (d) prothrombin. (e) thrombin. 11. Careful choice of an antibiotic depends on the realization that (a) only microbes are killed. (b) only unicellular organisms can absorb the antibiotic. (c) microbial as well as mammalian systems may be affected. (d) DNA biosynthesis will be affected. (e) R N A biosynthesis will be affected. 12. Infusion of a dextrose solution is performed because 1. dextrose is more readily metabolized than any other disaccharide. 2. glucose serves as the primary energy source. 3. carbohydrate is necessary for wound healing. 4. of the constant need of the brain for glucose. 5. dextrose can be converted into glucose and thus used as an energy source. (a) 1 , 2 a n d 3 (b) 1 , 3 a n d 5 (c) 2 , 3 a n d 4 (d) 2 , 4 a n d 5 (e) 1, 2, 3, 4 and 5 13. The high blood level of SGOT indicates (a) leakage from damaged tissue. (b) increased biosynthetic processes due to hepatic enlargement. (c) increased interconversion between amino sugars and ketone bodies. (d) deamination of neurotransmitter amines. (e) increased urea synthesis. 14. Ferrous sulfate was administered because iron is a component of essential biomolecules. All of the following substances contain iron E X C E P T (a) hemoglobin. (b) cytochrome c. (c) transferrin. (d) vitamin B12. (e) hemosiderin. 15. Above certain concentrations of ammonia, the blood (1) system would not be able to maintain the proper (2). 1 2 (a) enzyme; glucose concentration (b) enzyme; H + concentration
202 (c) enzyme; (d) buffer; (e) buffer;
osmotic pressure glucose concentration H + concentration
Answers to Sample Questions 1. 2. 3. 4. 5.
d c a d c
6. 7. 8. 9. 10.
b c d a d
ll.c 12. 13. 14. 15.
c a d e
Biochemical Education and Research in King Faisai University Medical College, Saudi Arabia A I ALAYASH Duke University Marine Biomedical Center Beaufort, NC 28516, USA
Introduction King Faisal University (KFU), the second largest university in the Eastern Province of Saudi Arabia, was founded in 1975/76 to include four colleges. The Dammam coastal campus comprises of the College of Medicine and Medical Sciences, and the College of Architecture and Planning. The other campus of the university is in the oasis of A1 Hassa, where the College of Veterinary Medicine and College of Agriculture are located. The author was an assistant professor at the department of biochemistry, College of Medicine and Medical Sciences, from 1980-87. A new College of Education has recently been opened in AI Hassa. The Department The department is responsible for teaching biochemistry to third-year medical students and also for contributing to the College of Medicine residency programs. The department was staffed throughout this period by 5-6 faculty members, mostly expatriates. However, more Saudi nationals working towards their higher degrees in biochemistry, are expected to return from Europe and the US in the next few years. The department is well equipped and teaching and research laboratories are housed in a modern building with fairly good facilities and equipment. The student population fluctuates from one semester to another, with generally 40-60 students in both male and female sections, taking each of the two biochemistry courses. Instruction is in English and KFU follows the semester credit hour system. Biochemistry Courses There are two biochemistry courses, 4 credit hours each as part of the third pre-clinical year. Prerequisites for Biochemistry I include advanced courses in physics, chemistry, and biology. Biochemistry I is a prerequisite for Biochemistry II. Medical students at this level are introduced to Biochemistry I beginning with the chemistry BIOCHEMICAL EDUCATION 16(4) 1988
of carbohydrates, lipids, and proteins with some emphasis on the structural-functional aspects of some important macromolecules, in both health and disease. The other part of the course deals with enzymes and the utilization of these proteins as a diagnostic tool. The chemistry and functions of fat- and water-soluble vitamins are dealt with in detail, as well as the state of deficiency of some of these vitamins. The structure and function of nucleic acids is taught under the heading of genetic information. Some emphasis is placed on recent advances in DNA technology. The course winds up with a short introduction to metabolism. Biochemical principles and concepts have become increasingly important for the understanding of diseases. Biochemistry II which deals primarily with the metabolism of carbohydrates, lipids, proteins, nucleotides, and biological oxidations, provides the opportunity to discuss with students extensively the biochemical basis of the metabolic processes in both health and disease, thus demonstrating to students of medicine that biochemical pathways should not be divorced from the analysis of human disease. The remainder of the course deals with short and specialized topics in biochemistry such as heme metabolism, minerals, tissue biochemistry and finally general characteristics of hormones. The re-structuring of the medical college curricula has recently been approved by the University Council, in which Biochemistry I and II will be taught as part of the second and third year, re-named 'level I' and 'level II', respectively. This has raised some legitimate concern in the basic science departments, and in particular the biochemistry department, as it was felt that students may not be sufficiently prepared for biochemistry courses. Practical sessions are an important part of biochemical education for medical students. Laboratory programs are structured largely, and whenever possible, to reflect the material presented in the theory. Experiments dealing with basic biochemistry do not generate much excitement - - in contrast to experiments with clinical relevance. A comprehensive and updated biochemistry experimental manual, designed for the students of medicine, has been compiled to replace the seemingly never ending process of xeroxing old experiment hand-outs, prior to the start of the laboratory. Tutorials are part of the biochemistry syllabus. They have recently, however, become more oriented towards overcoming the hurdles of examinations, rather than an exercise in maximising the full benefits of student-faculty interaction. Students are required to pass one mid-term and final examination which include one comprehensive oral examination, for students taking Biochemistry II. Students and faculty receive free copies of two textbooks, these are; 'Harper's Review of Biochemistry' and 'Textbook of Biochemistry with Clinical Correlations', by Devlin. In addition a few supplementary books are also available, such as 'Biochemistry - - A Caseoriented Approach', by Montgomery et al and 'Human Biochemistry' by Morten and Neuhaus. Several educational and research workshops were