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1.
INTRODUCTION Congestive heart failure is the end stage of manycardiovascular diseases. Myocardial infarction (MI)is a life-threatening event that may cause suddencardiac death and heart failure. Despite considerableadvances in diagnosis and treatment of heart disease,cardiac dysfunction after MI is still the majorworldwide cardiovascular disorder. Damaged myo-cardium after acute MI is gradually replaced by fi-brotic noncontractile cells to form scar tissue. Thedeveloping ventricul…  相似文献   

2.

Objective

To investigate stretch-induced electrophysiological changes in chronically infarcted hearts and the effect of streptomycin (SM) on these changes in vivo.

Methods

Sixty Wistar rats were divided randomly into four groups: a control group (n=15), an SM group (n=15), a myocardial infarction (MI) group (n=15), and an MI+SM group (n=15). Chronic MI was obtained by ligating the left anterior descending branch (LAD) of rat hearts for eight weeks. The in vivo blockade of stretch-activated ion channels (SACs) was achieved by intramuscular injection of SM (180 mg/(kg·d)) for seven days after operation. The hearts were stretched for 5 s by occlusion of the aortic arch. Suction electrodes were placed on the anterior wall of left ventricle to record the monophasic action potential (MAP). The effect of stretching was examined by assessing the 90% monophasic action potential duration (MAPD90), premature ventricular beats (PVBs), and ventricular tachycardia (VT).

Results

The MAPD90 decreased during stretching in both the control (from (50.27±5.61) ms to (46.27±4.51) ms, P<0.05) and MI groups (from (65.47±6.38) ms to (57.47±5.76 ms), P<0.01). SM inhibited the decrease in MAPD90 during inflation ((46.27±4.51) ms vs. (49.53±3.52) ms, P<0.05 in normal hearts; (57.47±5.76) ms vs. (61.87±5.33) ms, P<0.05 in MI hearts). The occurrence of PVBs and VT in the MI group increased compared with that in the control group (PVB: 7.93±1.66 vs. 1.80±0.86, P<0.01; VT: 7 vs. 1, P<0.05). SM decreased the occurrence of PVBs in both normal and MI hearts (0.93±0.59 vs. 1.80±0.86 in normal hearts, P<0.05; 5.40±1.18 vs. 7.93±1.66 in MI hearts, P<0.01).

Conclusions

Stretch-induced MAPD90 changes and arrhythmias were observed in chronically infarcted myocardium. The use of SM in vivo decreased the incidence of PVBs but not of VT. This suggests that SACs may be involved in mechanoelectric feedback (MEF), but that there might be other mechanisms involved in causing VT in chronic MI.  相似文献   

3.
Background:Bone marrow mesenehymal stem cell(MSC)transplantation is a promising strategy in the treatment of myocardial infarction(MI).However,the time for transplanting cells remains controversial.The aim of this study was to find an optimal time point for cell transplantation.Methods:MSCs were isolated and cultured from Sprague-Dawley(SD) rats.MI model was set up in SD rats by permanent ligation of left anterior descending coronary artery.MSCs were directly injected into the infarct berder zone at 1 h,1 week and 2 weeks after MI,respectively.Sham-operated and MI centrel groups received equal volume of phosphate buffered saline(PBS).At 4 weeks after MI,cardiac function Was assessed by echocardiography;vessel density Was analyzed on hematoxylin-eosin stained slides by light microscopy;the apoptosis of cardiomyocytes Was evaluated by terminal deoxynucleotidy1 transferase-mediated dUTP nick end-labeling(TUNEL) assay;the expressions of proteins were analyzed by Western blot.Results:MSC transplantation improved cardiac function.reduced the apoptosis of cardiomyocytes and increased vessel density.These benefits were more obvious in l-week group than in 1-h and 2-week groups.There are more obvious increases in the ratio of bc1-2/bax and the expression of vascular endothelial growth factor(VEGF)and more obvious decreases in the expression of cleaved-caspase-3 in 1-week group than those in other two groups.Conclusion:MSC transplantation was beneficial for the recovery of cardiac function.MSC transplantation at l week post-MI exerted the best effects on increases of cardiac function,anti-apoptosis and angiogenesis.  相似文献   

4.
Goat ovaries were collected from the slaughterhouse and categorized as right, left, corpus luteum （CL）-present and -absent group and evaluated on the basis of weight （g）, length （cm）, width （cm）, number of follicles, follicles aspirated and number and state ofcumulus-oocyte-complexes （COCs）. Comparatively higher weight [（0.66±0.02） vs （0.64±0.02） g], length [（1.17±0.02） vs （1.1 ±0.02） cm] and width [（0.77±0.02） vs （0.74±0.02） cm] were found in right ovaries than those of left. On the other hand significantly （P〈0.05） higher weight [（0.71±0.03） vs （0.64±0.01） g] and width [（0.76±0.03） vs （0.75±0.01） cm] were found in CL-present group than those of CL-absent group of ovaries. The left ovaries contained comparatively higher number of normal COCs [（1.06±0.09） per ovary] than fight ovaries [（1.03±0.10） per ovary] and the similar trend was found in total number of follicles [（4.51±0.25） vs （4.30±0.23） per ovary] and follicles aspirated [（2.55±0.14） vs （2.52±0.12） per ovary]. But the total COCs per ovary was almost similar in both ovaries [right and left： （1.85±0.12） and （1.85±0.11） per ovary, respectively]. Higher number of total COCs [（1.87±0.09） vs （1.76±0.16） per ovary], total number of follicles [（4.45±0.19） vs （4.16±0.37） per ovary], follicles aspirated [（2.55±0.10） vs （2.48±0.21） per ovary] and normal COCs [（1.12±0.07） vs （0.76±0.14） per ovary] were found in CL-absent group than those of CL-present group of ovaries.  相似文献   

5.
This report describes in vitro micropropagation of Boscia senegalensis, so-called famine foods, that helped the people in Darfur and Kordofan, Sudan survive during the 1984–1985 famine. Four types of explants prepared from green mature zygotic embryos were cultured on Murashige and Skoog (MS) medium augmented with 1–5 mg/L 6-benzyladenine (BA). The highest number of shoots per explant (14.3±0.9) was achieved on MS medium supplemented with 3 mg/L BA, while the highest shoot length [(3.5±0.4) cm] was obtained with 1 mg/L BA. The shoot cluster, when subcultured to its same medium, significantly increased the rate of shoot multiplication by the end of the third subculture. The maximum mean number of shoots per explant (86.5±3.6) was produced after three multiplication cycles on 3 mg/L BA-supplemented medium. In vitro induced shoots were excised and rooted on half strength MS medium fortified with 0.25 mg/L indole-3-butyric acid (IBA) to obtain complete plantlets. B. senegalensis-regenerated plantlets obtained in vitro for the first time, were hardened and 95% survived under greenhouse conditions.  相似文献   

6.
This study evaluated effect of mental rotation (MR) training on learning outcomes and explored effectiveness of teaching via three-dimensional (3D) software among medical students with diverse spatial intelligence. Data from n = 67 student volunteers were included. A preliminary test was conducted to obtain baseline level of MR competency and was utilized to assign participants to two experimental conditions, i.e., trained group (n = 25) and untrained group (n = 42). Data on the effectiveness of training were collected to measure participants’ speed and accuracy in performing various MR activities. Six weeks later, a large class format (LCF) session was conducted for all students using 3D software. The usefulness of technology-assisted learning at the LCF was evaluated via a pre- and post-test. Students’ feedback regarding MR training and use of 3D software was acquired through questionnaires. MR scores of the trainees improved from 25.9±4.6 points to 28.1±4.4 (P = 0.011) while time taken to complete the tasks reduced from 20.9±3.9 to 12.2±4.4 minutes. Males scored higher than females in all components (P = 0.016). Further, higher pre- and post-test scores were observed in trained (9.0±1.9 and 12.3±1.6) versus untrained group (7.8±1.8; 10.8±1.8). Although mixed-design analysis of variance suggested significant difference in their test scores (P < 0.001), both groups reported similar trend in improvement by means of 3D software (P = 0.54). Ninety-seven percent of students reported technology-assisted learning as an effective means of instruction and found use of 3D software superior to plastic models. Software based on 3D technologies could be adopted as an effective teaching pedagogy to support learning across students with diverse levels of mental rotation abilities.  相似文献   

7.
INTRODUCTION Matrine, a monomer of traditional Chinese medi-cine, comes from leguminosae plants such as Kusheng, is quinoilizidine with four-loop and molecular formula of C15H24N20. Matrine has been proved to have anti-arrhythmia (Xu et al., 2004), anti-hypoxia and decreasing heart rate effects (Zhang et al., 1990a; 1990b) in many animal experiments, and has the role of inducing calmness (Luo et al., 2001) and lowering body temperature (Tao and Wan, 1992). Traditional Chinese medicin…  相似文献   

8.
Objective: To observe the difference of androgen and inflammatory cytokines level in atherosclerosis and analyse their relations. Method: Both carotid arteries and arteries of lower extremity were subjected to ultrasonic examination by Doppler's method. Those with much atheromatous plaque formation were ranged into case group, and those with normal result formed control group. Total, free testosterone and estradiol were assayed by radioimmunoassay. C reactive protein (CRP) was assayed by nepheloturbidity. Tumor necrosis factor-α (TNF-α), Interleukin-6 (IL-6), Interleukin-8 (IL-8), Interleukin-10 (IL-10), Interleukin-18 (IL-18), soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular cell adhesion molecule-1 (sVCAM-1) were assayed by ELISA. The mean difference between two groups and the correlation between free testosterone and cytokines were analysed. Results: Free testosterone was (6.337±3.371) pg/L in case group and (11.375±4.733) pg/L in control group,P<0.01. No differences were found in total testosterone and estradiol. CRP was (27.294±10.238) mg/L in case group and (12.843±6.318) mg/L in control group,P<0.01. IL-6 was (41.700±31.385) pg/L in case group and (25.396±20.772) pg/L in control group,P<0.05. IL-8 was (89.249±58.357) pg/L in case group and (67.873±31.227) pg/L in control group,P<0.05. sICAM-1 was (470.491±134.078) pg/L in case group and (368.487±97.183) pg/L in control group,P<0.01.sVCAM-1 was (537.808±213.172) pg/L in case group and (457.275±157.273) pg/L in control group,P<0.05. There were no differences in TNF-α, IL-10 and IL-18. Correlation analysis showed that FT (free testosterone) had negative correlation with CRP, IL-6 and sICAM-1. Among them FT had well correlation with CRP, correlation index was −0.678. Conclusion: Free testosterone was in negative correlation with atherosclerosis in old-age male. Free testosterone may have the role of anti-atherosclerosis, and this effect was not achieved by its transformation to estradiol. Low free testosterone level was followed by increased level of inflammatory cytokines. Low free testosterones coexist with inflammation and they both affect the process of atherosclerosis in old-age male. Project (No. 2003B045) supported by the Health Bureau of Zhejiang Province, China  相似文献   

9.
The time, material, and staff‐consuming nature of anatomy's traditional pen‐and‐paper assessment system, the increase in the number of students enrolling in medical schools and the ever‐escalating workload of academic staff have made the use of computer‐based assessment (CBA) an attractive proposition. To understand the impact of such shift in the assessment method, an experimental study evaluating its effect on students’ performance was designed. Additionally, students’ opinions toward CBA were gathered. Second‐year medical students attending a Clinical Anatomy course were randomized by clusters in two groups. The pen‐and‐paper group attended two sessions, each consisting of a traditional sectional anatomy steeplechase followed by a theoretical examination, while the computer group was involved in two similar sessions conducted in a computerized environment. At the end of each of the computer sessions, students in this group filled an anonymous questionnaire. In the first session, pen‐and‐paper group students scored significantly better than computer‐group students in both the steeplechase (mean ± standard deviation: 66.00 ± 14.15% vs. 43.50 ± 19.10%; P < 0.001) and the theoretical examination (52.50 ± 12.70% vs. 39.00 ± 21.10%; P < 0.001). In the second session, no statistically significant differences were found for both the steeplechase (59.50 ± 17.30% vs. 54.50 ± 17.00%; P = 0.085) and the theoretical examination (57.50 ± 13.70% vs. 54.00 ± 14.30%; P = 0.161). Besides, an intersession improvement in students’ perceptions toward CBA was registered. These results suggest that, after a familiarization period, CBA might be a performance equivalent and student accepted alternative to clinical anatomy pen‐and‐paper theoretical and practical examinations. Anat Sci Educ 11: 124–136. © 2017 American Association of Anatomists.  相似文献   

10.
Objective: In addition to pH regulation, Na+/H+ exchange (NHE) has been shown to facilitate cell growth and proliferation. However, the effects of long-term inhibition of Na+/H+ exchange on cardiac structural and functional remodeling post myocardial infarction (MI) are still controversial. The present study was therefore carried out to further investigate the effects of long-term treatment with cariporide, a specific inhibitor of NHE-1, on cardiac remodeling after MI in rats; Methods: Male Wistar rats that underwent coronary ligation were randomly selected for cariporide treatment starting 6 h after induction of MI or no treatment. Treatment was continued up to 6 weeks post MI, after which, the arterial, venous and left ventricular catheters were chronically implanted. Twenty-four h later, after hemodynamic signals were recorded in conscious rats, they were sacrificed and hearts were taken out for morphological examinations; Results: Cariporide treatment decreased the heart weight and heart weight to body weight ratio (bothP<0.05), decreased left ventricular end-diastolic pressure (P<0.001), improved myocardial contractility (dP/dt max) (P<0.05) and tended to increase the survival of treated rats compared to that of untreated infarct rats; Conclusion: The results of the present study indicate that the long-term inhibition of NHE with cariporide can attenuate cardiac structural remodeling and improve left ventricular dysfunction in infarcted rats, and suggest that Na+/H+ exchange inhibition could be an effective therapeutic strategy for myocardial infarction-induced heart failure.  相似文献   

11.
The presentation of pre-sliced specimens is a frequently used method in the laboratory teaching of cross-sectional anatomy. In the present study, a new teaching method based on a hands-on slicing activity was introduced into the teaching of brain, heart, and liver cross-sectional anatomy. A randomized, controlled trial was performed. A total of 182 third-year medical students were randomized into a control group taught with the prosection mode (pre-sliced organ viewing) and an experimental group taught with the dissection mode (hands-on organ slicing). These teaching methods were assessed by testing the students' knowledge of cross-sectional specimens and cross-sectional radiological images, and analyzing students' feedback. Using a specimen test on three organs (brain, heart, and liver), significant differences were observed in the mean scores of the control and experimental groups: for brain 59.6% (±14.2) vs. 70.1% (±15.5), (P < 0.001, Cohen's d = 0.17); for heart: 57.6% (±12.5) vs. 75.6% (±15.3), (P < 0.001, d = 0.30); and for liver: 60.4% (±14.5) vs. 81.7% (±14.2), (P < 0.001, d = 0.46). In a cross-sectional radiological image test, better performance was also found in the experimental group (P < 0.001). The mean scores of the control vs. experimental groups were as follows: for brain imaging 63.9% (±15.1) vs. 71.1% (±16.1); for heart imaging 64.7% (±14.5) vs. 75.2% (±15.5); and for liver imaging 61.1% (±15.5) vs. 81.2% (±14.6), respectively. The effect sizes (Cohen's d) were 0.05, 0.23, and 0.52, respectively. Students in the lower tertile benefited the most from the slicing experiences. Students' feedback was generally positive. Hands-on slicing activity can increase the effectiveness of anatomy teaching and increase students' ability to interpret radiological images.  相似文献   

12.
Development of new methods for anatomy teaching is increasingly important as we look to modernize and supplement traditional teaching methods. In this study, a life-sized equine model, “Geoff,” was painted with surface and deep anatomical structures with the aim of improving students’ ability to convert theoretical knowledge into improved topographical anatomy knowledge on the live horse. Third and fourth year veterinary medicine students (n = 45) were randomly allocated into experimental (used “Geoff”) and control (used textbook) groups. The efficacy of the model was evaluated through a structured oral exam using a live horse. Questionnaires gathered information on student confidence and enjoyment of the task. There was no significant difference in the performance of experimental and control groups either immediately (44±20% vs. 40±21%; P = 0.504) or 9 weeks after the learning intervention (55±17% vs. 55±20%; P = 0.980). There were however specific questions on which the experimental group performed better than controls, and for which gender effects were apparent. The students using “Geoff” showed a transient gain in confidence following the session (Likert scale 2.7 to 3.6) however the initial increase was no longer present at the second test. There was a significant influence of gender on confidence with greater confidence gains in females in the Experimental group. The students found the model to be extremely useful and both groups found the sessions enjoyable. The model will be of benefit as a complementary learning tool for students.  相似文献   

13.
[目的]观察复方甘草甜素(美能)对慢性乙型肝炎的治疗作用.[方法]将病人随机分为为两组,治疗组10例,用美能40 m l/d.iv.3周后改为口服美能片75 mg,每日3次.对照组1 0例,使用甘利欣150 mg/d,VD.3周后改为口服甘利欣100 mg,每日3次.[结果]治疗组治疗后症状缓解率75%;血清ALT水平由306.70±229.33 u/L降为105.00±86.11 u/L;血清AST水平由137.90±71.44 u/L降为64.30±34.93 u/L;血清SB水平由31.80±28.90 umol/L降为16.20±3.43 umol/L.对照组治疗后症状缓解率为66.7%;血清ALT水平由208.20±160.13 u/L降为77.20±65.92 u/L;血清AST水平由92.60±61.19 u/L降为51.20±31.38 u/L;血清SB水平由20.60±5.08 umol/L降为11.70±2.06 umol/L.[结论]复方甘草甜素(美能)的临床疗效与国内同类产品(甘利欣)相仿,具有较好的保肝、降酶作用,有一定的优势.  相似文献   

14.
Eighty-two patients with supraventricular tachycardia undergoing radiofrequency catheter ablation (RFCA) were studied to observe the inhibition effect of aspirin and ticlopidine on platelet aggregability (PAG) and thromboxane B2 (TXB2) of the blood samples. Patients were divided into aspirin group A, ticlopidine group B, aspirin + ticlopidine group C and control group D. PAG and TXB2 were increased clearly after RFCA in all groups (P<0.001). Treatment with aspirin or ticopidine before operation could reduce the platelet aggregability caused by RFCA and the joint effect of two drugs (change rate of group A: 52.51±12.51%; group B: 54.78±11.27%; group C: 30.51±10.59%; group D: 91.75±21.43%;P<0.05) was studied. The much decreased platelet aggregability after antiplatelet therapy was evidence of the potential benefit of the treatment in preventing thromboembolism after ablation. Pretreatment with aspirin and ticlopidine together is a good way to decrease palatelet aggregability after RFCA.  相似文献   

15.
Therapeutically delivered mesenchymal stem cells (MSCs) improve ventricular remodeling. However,the mechanism underlying MSC cardiac remodeling has not been clearly determined. Congestive heart failure (CHF) was induced in rats by cauterization of the left ventricular free wall. MSCs were cultured from autologous bone marrow and injected into the border zone and the remote myocardium 5 d after injury. Ten weeks later,when compared with sham operation,CHF significantly increased nucleus mitotic index,capilla...  相似文献   

16.
Mercer University School of Medicine utilizes a problem-based learning (PBL) curriculum for educating medical students in the basic clinical sciences. In 2014, an adjustment was piloted that enabled PBL cases to align with their corresponding cadaver dissection that reviewed the content of anatomy contained in the PBL cases. Faculty had the option of giving PBL cases in sequence with the cadaveric dissection schedule (sequential group) or maintaining PBL cases out of sequence with dissections (traditional group). During this adjustment, students’ academic performances were compared. Students’ perception of their own preparedness for cadaveric dissection, their perceived utility of the cadaver dissections, and free-response comments were solicited via an online survey. There were no statistically significant differences when comparing student mean examination score values between the sequential and traditional groups on both multidisciplinary examinations (79.39 ± 7.63 vs. 79.88 ± 7.31, P = 0.738) and gross anatomy questions alone (78.15 ± 10.31 vs. 79.98 ± 9.31, P = 0.314). A statistically significant difference was found between the sequential group's and traditional group's (63% vs. 29%; P = 0.005) self-perceived preparedness for cadaveric dissections in the 2017 class. Analysis of free-response comments found that students in the traditional group believed their performance in PBL group, participation in PBL group and examination performance was adversely affected when compared to students with the sequential schedule. This study provides evidence that cadaveric dissections scheduled in sequence with PBL cases can lead to increased student self-confidence with learning anatomy but may not lead to improved examination scores.  相似文献   

17.
Aquilaria agallocha can produce fragrant agarwood used for incense, traditional medicine and other products. An efficient plant regeneration system was established via organogenesis from shoots developed from seedlings ofAquilaria agallocha. Shoots generated many buds on MS medium supplemented with 1.3 μmol/L BA (6-benzylaminopurine) in the first 7 weeks, and the buds elongated on MS medium with 1.3 μmol/L BA+0.5 μmol/L NAA (naphthaleneacetic acid) in another 7 weeks, 2.3 shoots 2 cm in length per explant were obtained within 14 weeks. Plantlets were rooted on 1/2 MS medium after being immersed in 5 μmol/L NAA for 48 h, 96.7% of the roots grew up two weeks later. All plantlets that survived acclimatization grew well in the pots. Project supported by the National Natural Science Foundation of China (No. 30070066) and the Science and Technology Project of Guangzhou City (No. 2003J1-C0241), China  相似文献   

18.
ＩＮＴＲＯＤＵＣＴＩＯＮＴｈｅＮａ /Ｈ ｅｘｃｈａｎｇｅｒ (ＮＨＥ)ｉｓａｐＨ ｒｅｇｕｌａｔｏｒｙｐｒｏｔｅｉｎｐｒｅｓｅｎｔｉｎｔｈｅｐｌａｓｍａｍｅｍ ｂｒａｎｃｅｏｆｃａｒｄｉｏｍｙｏｃｙｔｅｓａｎｄｏｔｈｅｒｃｅｌｌｔｙｐｅｓ.ＡｌｔｈｏｕｇｈｓｅｖｅｒａｌｉｓｏｆｏｒｍｓｏｆＮＨＥｈａｖｅｂｅｅｎｄｅ ｃｒｉｂｅｄ,ｔｈｅｐｒｅｄｏｍｉｎａｎｔｉｓｏｆｏｒｍｉｎｔｈｅｈｅａｒｔｉｓｔｈｅｕｂｉｑｕｉｔｏｕｓＮＨＥ 1 ,ｗｈｉｃｈｕｎｄｅｒｃｅｎｔａｉｎｐｈｙｓｉｏｌｏｇｉｃａｌｃｏｎｄｉｔｉ…  相似文献   

19.
[目的]了解甘草酸苷对慢性乙肝患者血糖的影响.[方法]把95例确诊为慢性乙型肝炎的患者随机分为A、B、C三组,分别给予复方甘草酸苷80 m l、复方甘草酸单铵120 m l、甘草酸二铵40 m l静脉点滴,用药前、用药2周及4周观察三组患者的空腹血糖、肝功能、HBVM、HBV-DNA定量.[结果]治疗前三组患者空腹血糖的均数分别为5.28±1.75、5.32±1.66及5.65±1.82 mmol/L,在用药2周时,三组患者空腹血糖的均数即已有所下降,至用药4周其空腹血糖的均数分别为4.5 1±1.6 5、4.6 8±1.3 7及4.9 8±1.87 mmol/L,与治疗前相比三组患者空腹血糖的均数都有不同程度下降,但治疗前后的差异无显著性(P>0.05),各组之间下降的差异亦无显著性(P>0.05).[结论]甘草酸苷对慢性乙肝患者的血糖没有升高作用,反而在一定剂量下有降低的作用.  相似文献   

20.
Competitive game-based learning within Second Life enables effective teaching of basic radiological anatomy and radiological signs to medical students, with good acceptance and results when students participate voluntarily, but unknown in a compulsory context. The objectives of this study were to reproduce a competitive online game based on self-guided presentations and multiple-choice tests in a mandatory format, to evaluate its development and student perceptions compared to a voluntary edition in 2015 (N = 90). In 2016 and 2017, respectively, 191 and 182 third-year medical students participated in the game as a mandatory course activity. The mean (±SD) score of the game was 74.7% (±19.5%) in 2015, 71.2% (±21.5%) in 2016, and 67.5% (±21.5%) in 2017 (P < 0.01). Participants valued positively the organization and educational contents but found the virtual world less attractive and the game less interesting than in the voluntary edition. The experience globally was rated with 8.2 (±1.5), 7.8 (±1.5), and 7.1 (±1.7) mean points (±SD) in a ten-point scale, in the 2015, 2016, and 2017 editions, respectively (P < 0.05). Competitive learning games within virtual worlds like Second Life have great learning potential in radiology, but the mean score in the game decreased, acceptance of virtual world technology was lower, and opinion about the game was worse with a compulsory participation, and even worse when dropouts were not allowed. Under the conditions in which this study was conducted, learning games in three-dimensional virtual environments should be voluntary to maintain adequate motivation and engagement of medical students.  相似文献   

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