Integration of clinical anatomical sciences in medical education: Design, development and implementation strategies.

For the last 20 years, undergraduate medical education has seen a major curricular reform movement toward integration of basic and clinical sciences. The rationale for integrated medical school curricula focuses on the application of knowledge in a clinical context and the early ability to practice key skills such as critical thinking and clinical problem-solving. The method and extent of discipline integration can vary widely from single sessions to entire programs. A challenge for integrated curricula is the design of appropriate assessments. The goal of this review is to provide a framework for clinical anatomy educators with definitions of integration, examples of existing integration models, strategies, and instructional methods that promote integration of basic and clinical sciences.

Novel mechanisms and signaling pathways of esophageal ulcer healing: the role of prostaglandin EP2 receptors, cAMP, and pCREB.

Clinical studies indicate that prostaglandins of E class (PGEs) may promote healing of tissue injury e.g., gastroduodenal and dermal ulcers. However, the precise roles of PGEs, their E-prostanoid (EP) receptors, signaling pathways including cAMP and cAMP response element-binding protein (CREB), and their relation to VEGF and angiogenesis in the tissue injury healing process remain unknown, forming the rationale for this study. Using an esophageal ulcer model in rats, we demonstrated that esophageal mucosa expresses predominantly EP2 receptors and that esophageal ulceration triggers an increase in expression of the EP2 receptor, activation of CREB (the downstream target of the cAMP signaling), and enhanced VEGF gene expression. Treatment of rats with misoprostol, a PGE1 analog capable of activating EP receptors, enhanced phosphorylation of CREB, stimulated VEGF expression and angiogenesis, and accelerated esophageal ulcer healing. In cultured human esophageal epithelial (HET-1A) cells, misoprostol increased intracellular cAMP levels (by 163-fold), induced phosphorylation of CREB, and stimulated VEGF expression. A cAMP analog (Sp-cAMP) mimicked, whereas an inhibitor of cAMP-dependent protein kinase A (Rp-cAMP) blocked, these effects of misoprostol. These results indicate that the EP2/cAMP/protein kinase A pathway mediates the stimulatory effect of PGEs on angiogenesis essential for tissue injury healing via the induction of CREB activity and VEGF expression.

Improving Integration of Basic Science into Clinical Medicine: Vertical Integration into Clinical Education (VICE) Activity.

The integration of basic science into clinical clerkships continues to be a challenge in medical curricula. We developed an integrated session for 3rd year medical students enrolled in OB-Gyn/Pediatric Block. The session focused on transplacental and perinatal infections, and consisted of a student-driven pedagogy activity in which students were required to explain the basic science principles behind the pathophysiology of the clinical presentations, the work-up, and the treatment of the infections. This approach helps students understand how basic science knowledge informs clinical practice and potential increase clerkship-level students' confidence as it makes them serve as leaders of active learning modules. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01485-7.

Dexamethasone augments CXCR4-mediated signaling in resting human T cells via the activation of the Src kinase Lck.

Dexamethasone (DM) is a synthetic member of the glucocorticoid (GC) class of hormones that possesses anti-inflammatory and immunosuppressant activity and is commonly used to treat chronic inflammatory disorders, severe allergies, and other disease states. Although GCs are known to mediate well-defined transcriptional effects via GC receptors (GCR), there is increasing evidence that GCs also initiate rapid nongenomic signaling events in a variety of cell types. Here, we report that DM induces the phosphorylation of Lck and the activation of other downstream mediators, including p59Fyn, Zap70, Rac1, and Vav in resting but not activated human T cells. DM treatment also augments CXCL12-mediated signaling in resting T cells through its cell surface receptor, CXCR4 resulting in the enhanced actin polymerization, Rac activation, and cell migration on ligand exposure. Lck was found to be a critical intermediate in these DM-induced signaling activities. Moreover, DM-mediated Lck phosphorylation in T cells was dependent on the presence of both the GCR and the CD45 molecule. Overall, these results elucidate additional nongenomic effects of DM and the GCR on resting human T cells, inducing Lck and downstream kinase activation and augmenting chemokine signaling and function.

Prostaglandin E2 transactivates EGF receptor: a novel mechanism for promoting colon cancer growth and gastrointestinal hypertrophy.

Prostaglandins (PGs), bioactive lipid molecules produced by cyclooxygenase enzymes (COX-1 and COX-2), have diverse biological activities, including growth-promoting actions on gastrointestinal mucosa. They are also implicated in the growth of colonic polyps and cancers. However, the precise mechanisms of these trophic actions of PGs remain unclear. As activation of the epidermal growth factor receptor (EGFR) triggers mitogenic signaling in gastrointestinal mucosa, and its expression is also upregulated in colonic cancers and most neoplasms, we investigated whether PGs transactivate EGFR. Here we provide evidence that prostaglandin E2 (PGE2) rapidly phosphorylates EGFR and triggers the extracellular signal-regulated kinase 2 (ERK2)--mitogenic signaling pathway in normal gastric epithelial (RGM1) and colon cancer (Caco-2, LoVo and HT-29) cell lines. Inactivation of EGFR kinase with selective inhibitors significantly reduces PGE2-induced ERK2 activation, c-fos mRNA expression and cell proliferation. Inhibition of matrix metalloproteinases (MMPs), transforming growth factor-alpha (TGF-alpha) or c-Src blocked PGE2-mediated EGFR transactivation and downstream signaling indicating that PGE2-induced EGFR transactivation involves signaling transduced via TGF-alpha, an EGFR ligand, likely released by c-Src-activated MMP(s). Our findings that PGE2 transactivates EGFR reveal a previously unknown mechanism by which PGE2 mediates trophic actions resulting in gastric and intestinal hypertrophy as well as growth of colonic polyps and cancers.

Sperm-derived SPANX-B is a clinically relevant tumor antigen that is expressed in human tumors and readily recognized by human CD4+ and CD8+ T cells.

PURPOSE: The sperm-derived SPANX family proteins can be found expressed in human tumors. Here, we aimed to perform a comprehensive study to evaluate immunotherapeutic relevance of one of its members, SPANX-B. We wanted to test its expression pattern in human tumors and to evaluate CD4(+) and CD8(+) T-cell responses in healthy humans after in vitro immunizations. EXPERIMENTAL DESIGN: Expression of SPANX-B in human malignancies, including a multitumor tissue array of 145 primary tumors, was assessed using reverse transcription-PCR, Western blotting, and immunohistochemical analysis. T-cell immunogenicity and immunodominant epitopes of SPANX-B were studied using in vitro immunizations of healthy human donor-derived leukocytes. RESULTS: SPANX-B was abundantly expressed in melanoma and carcinomas of lung, ovary, colon, and breast. In melanoma, tissue array data indicated that it was expressed in advanced and metastatic disease. Unlike most tumor-associated antigens, SPANX-B was an immunogenic antigen that was recognized by circulating T-cell precursors in healthy humans. Importantly, these T cells were readily expanded to generate SPANX-B-specific helper CD4(+) and cytolytic CD8(+) T cells that recognized unique immunodominant epitopes: at least one HLA-DR-restricted Pep-9 epitope (SPANX-B(12-23)) and two HLA-A2-restricted Pep-2 and Pep-4 epitopes (SPANX-B(23-31) and SPANX-B(57-65), respectively). CD8(+) T cells were fully functional to recognize and lyse HLA-A2-expressing tumors, including primary human melanomas. CONCLUSIONS: SPANX-B is an immunogenic sperm-derived antigen that is expressed in several human tumors. SPANX-B is also efficiently recognized by the human T-cell immune arm, indicating its significant value for the development of protective and therapeutic cancer vaccines.

Tregs utilize beta-galactoside-binding protein to transiently inhibit PI3K/p21ras activity of human CD8+ T cells to block their TCR-mediated ERK activity and proliferation.

Regulatory T cells (Tregs) and beta-galactoside-binding protein (betaGBP), a regulatory protein often found expressed at sites of immunological privilege, have similar functions. Their presence affects the outcome of harmful autoimmunity and cancers, including experimental autoimmune encephalomyelitis and malignant gliomas. Here we report a novel pathway by which Tregs express and utilize betaGBP to control CD8(+) T cell responses partially activating TCR signaling but blocking PI3K activity. As a result, this leads to a loss of p21(ras), ERK and Akt activities despite activation of TCR proximal signals, such as phosphorylation of CD3zeta, Zap70, Lat and PKCtheta. Although non-processive TCR signaling often leads to cell anergy, Tregs/betaGBP did not affect cell viability. Instead, betaGBP/Tregs transiently prevented activation of CD8(+) T cells with self-antigens, while keeping their responses to xenogeneic antigens unaffected.

Innate and Adaptive Immune Response to a Virus: An Integrated Learning Module.

Introduction: Medical schools must expand their teaching strategies to address a new generation of medical students and ensure their growth into lifelong, self-directed learners. Integration across basic science disciplines packaged together with clinical medicine produces learning materials that better enable medical students to achieve these goals. Methods: We created a narrated audiovisual learning module illustrating the foundational sciences and clinical presentation surrounding immune responses to viral infections. We integrated immunology, microbiology, histology, pathology, and clinical medicine and included a self-assessment quiz and clinical vignette with questions to test students' understanding of the material. We published the module on our school's learning management system and tracked student usage, which was followed by an in-class survey to assess student perceptions of the usefulness of the module. Results: Sixty-four (59%) of the first-year medical students used the module. Thirty-seven students completed the in-class survey assessing their perceptions of the module. Over 95% of responders reported that the module helped them learn the new material, identify areas of weakness, understand the big picture for this immune response, and apply the material in a clinical context. Discussion: This module illustrates an approach to integrating basic science disciplines in order to facilitate students' understanding of the mechanisms underlying patients' clinical presentations. Survey results indicated that students valued the module as a self-directed learning component that integrated essential clinical concepts. The module was a helpful tool for students to evaluate their comprehension of immunology in a clinical context and can be used as required or optional material.

Immune Response in Allergic Contact Dermatitis: An Integrated Learning Module.

Introduction: Medical students are introduced to skin rashes during their preclinical years and often express difficulty in differentiating the underlying mechanisms. The preclinical lessons regarding immunologically mediated skin rashes are largely forgotten by the time the students begin diagnosing and treating skin rashes during clinical rotations. This module aims to enhance student understanding of immunologic concepts by integrating material across disciplines, contextualizing within a clinical scenario, and providing opportunity for self-testing. Methods: A diagram illustrating immune responses in allergic contact dermatitis was used in the Texas Tech University Paul L. Foster School of Medicine preclinical curriculum. This diagram was updated as an audiovisual learning module that traced the immune mechanisms and pathogenesis of contact dermatitis from allergen exposure to skin-rash development. A self-assessment quiz and a clinical vignette with questions were included in the module. Student usage was monitored, and an in-class survey evaluating student perception was administered. Results: Sixty-four (58%) first-year medical students used this module. Twenty-eight students completed the in-class survey. Over 95% of respondents felt that the module helped them learn the new material, identify areas of weakness, and both understand the underlying pathology and big picture for this immune response. Discussion: Student survey results indicate the module is clinically relevant and enhances learning. The module may be used as a component of self-directed learning in any immunology curriculum or may be used in any basic immunology course to exemplify the role of the immune system in disease.

Immune Response to Bacteria: An Integrated Learning Module to Enhance Preclinical Students' Competency in Immunology.

INTRODUCTION: Medical students express frustration that they cannot assemble a comprehensive big picture of how the immune system responds to a microbe and that integration of basic science knowledge, especially across disciplines, with clinical knowledge is difficult. Yet medical student competency requires application of knowledge of immune mechanisms to inform diagnosis and treatment. METHODS: A diagram for immune response to extracellular microbes was previously published by MedEdPORTAL in 2011. This diagram has been updated here as a narrated audiovisual module with integrated histopathology. It contains a self-assessment quiz that tests students' understanding of the module followed by a clinical vignette that tests students' ability to apply the concepts in a clinical context. The module was published and usage was tracked via our learning management system. An in-class survey was conducted to gauge students' perceptions of the module. RESULTS: Eighty-two out of 102 (76%) first-year medical students used the module. Over 85% of survey participants felt that the module was a useful resource for learning and reviewing. More than 90% felt that the module helped them to understand the big picture and identify areas for further study. DISCUSSION: This module assembles a big picture of the immunologic mechanisms involved in a bacterial infection. It was created in response to requests and suggestions by preclinical medical students and used for first-year students during the first few weeks of their training in the basic sciences. This approach integrates multiple disciplines and facilitates students' learning and application of difficult concepts in immunology and pathology.

Local expression of platelet-activating factor-acetylhydrolase reduces accumulation of oxidized lipoproteins and inhibits inflammation, shear stress-induced thrombosis, and neointima formation in balloon-injured carotid arteries in nonhyperlipidemic rabbits.

BACKGROUND: Platelet-activating factor (PAF) and PAF-like phospholipids are inactivated by PAF-acetylhydrolase (PAF-AH). Using nonhyperlipidemic animals, we tested whether local expression of PAF-AH into injured arteries might induce antithrombotic and antiinflammatory effects.Method and Results- Balloon-injured rabbit carotid arteries were infected at the time of injury with an adenovirus expressing either human plasma PAF-AH (AdPAF-AH) or bacterial beta-galactosidase (AdLacZ) or infused with saline. Seven days later, shear stress-induced thrombosis was observed in all AdLacZ-infected and saline-infused arteries (controls) but eliminated in AdPAF-AH-treated contralateral arteries, even in the presence of epinephrine or an inhibitor of NO production. Injury-induced expression of tissue factor was also significantly suppressed. In AdPAF-AH-treated arteries compared with controls, the expressions of intercellular adhesion molecule-1 and vascular cell adhesion molecule-1 and macrophage infiltration were decreased by 66%, 66%, and 71%, respectively (P<0.01), and intimal area and intima/media ratio were decreased on day 21 by 43% and 52%, respectively (P<0.05). Within 1 week after injury, oxidized lipoproteins (OxLDL) had readily accumulated in the arterial wall. However, this was markedly reduced in the AdPAF-AH-treated arteries. No differences in the titers of autoantibodies to OxLDL or total cholesterol in blood were found between controls and AdPAF-AH-treated rabbits. CONCLUSIONS: Our results show for the first time that OxLDL accumulates in arteries in nonhyperlipidemic animals within 1 week after injury and that local expression of PAF-AH reduces this accumulation and exerts antiinflammatory, antithrombotic, and antiproliferative effects without changing the plasma levels of PAF-AH activity or titers of autoantibodies to OxLDL.

The effects of ghrelin on inflammation and the immune system.

A number of hormones and metabolic mediators signal the brain of changes in the body's energy status and when an imbalance occurs; the brain coordinates the appropriate changes in energy intake and utilization via the control of appetite and food consumption. Under conditions of chronic inflammation and immune activation, there is often a significant loss of body mass and appetite suggesting the presence of shared ligands and signaling pathways mediating "crosstalk" between the immune and neuroendocrine systems. Ghrelin, the endogenous ligand for growth hormone secretagogue receptor (GHS-R), is produced primarily by cells in the stomach and serves as a potent circulating orexigenic hormone controlling food intake, energy expenditure, adiposity and GH secretion. The functional roles of ghrelin and other growth hormone secretagogues (GHS) within the immune system and under states of inflammatory stress and injury are only now coming to light. A number of reports over the past decade have described ghrelin to be a potent anti-inflammatory mediator both in vitro and in vivo and a promising therapeutic agent in the treatment of inflammatory diseases and injury. Moreover, ghrelin has also been shown to promote lymphocyte development in the primary lymphoid organs (bone marrow and thymus) and to ablate age-associated thymic involution. In the current report, we review the literature supporting a role for ghrelin as an anti-inflammatory agent and immunoregulatory hormone/cytokine and its potential use in the treatment of inflammatory diseases and injury.

Breast cancer lung metastasis requires expression of chemokine receptor CCR4 and regulatory T cells.

Cancer metastasis is a leading cause of cancer morbidity and mortality. More needs to be learned about mechanisms that control this process. In particular, the role of chemokine receptors in metastasis remains controversial. Here, using a highly metastatic breast cancer (4T1) model, we show that lung metastasis is a feature of only a proportion of the tumor cells that express CCR4. Moreover, the primary tumor growing in mammary pads activates remotely the expression of TARC/CCL17 and MDC/CCL22 in the lungs. These chemokines acting through CCR4 attract both tumor and immune cells. However, CCR4-mediated chemotaxis was not sufficient to produce metastasis, as tumor cells in the lung were efficiently eliminated by natural killer (NK) cells. Lung metastasis required CCR4(+) regulatory T cells (Treg), which directly killed NK cells using beta-galactoside-binding protein. Thus, strategies that abrogate any part of this process should improve the outcome through activation of effector cells and prevention of tumor cell migration. We confirm this prediction by killing CCR4(+) cells through delivery of TARC-fused toxins or depleting Tregs and preventing lung metastasis.

CCR4-expressing T cell tumors can be specifically controlled via delivery of toxins to chemokine receptors.

Expression of chemokine receptors by tumors, specifically CCR4 on cutaneous T cell lymphomas, is often associated with a poor disease outcome. To test the hypothesis that chemokine receptor-expressing tumors can be successfully controlled by delivering toxins through their chemokine receptors, we have generated fusion proteins designated chemotoxins: chemokines fused with toxic moieties that are nontoxic unless delivered into the cell cytosol. We demonstrate that chemokines fused with human RNase eosinophil-derived neurotoxin or with a truncated fragment of Pseudomonas exotoxin 38 are able to specifically kill tumors in vitro upon internalization through their respective chemokine receptors. Moreover, treatment with the thymus and activation-regulated chemokine (CCL17)-expressing chemotoxin efficiently eradicated CCR4-expressing cutaneous T cell lymphoma/leukemia established in NOD-SCID mice. Taken together, this work represents a novel concept that may allow control of growth and dissemination of tumors that use chemokine receptors to metastasize and circumvent immunosurveillance.

Human peripheral blood T regulatory cells (Tregs), functionally primed CCR4+ Tregs and unprimed CCR4- Tregs, regulate effector T cells using FasL.

Regulatory CD25(+)CD4(+) T cells (Tregs) play an important role in the control of peripheral tolerance. In this study we demonstrate that human peripheral blood Tregs can be divided into two distinct populations based on the expression of CCR4. The majority ( approximately 75%) of freshly isolated Tregs express CCR4 and presumably represent memory-type Tregs. Interestingly, CCR4(-) Tregs require anti-CD3 Ab-mediated activation to acquire a regulatory activity, while CCR4(+) Tregs appear to be already primed to suppress the proliferation of CD8(+) T cells. CCR4 is also expressed on CD25(low)CD4(+) T cells (CCR4(+) non-Tregs) that mostly suppress Th1-type polarization without affecting T cell proliferation, presumably via the production of immunomodulatory cytokines like IL-10. In contrast, CCR4(+) Tregs express FasL to primarily regulate T cell proliferation via a contact-mediated process involving FasL/Fas signaling, a major regulatory pathway of T cell homeostasis. Finally, we also demonstrate that the depletion of CCR4(+) T cells leads to Th1-type polarization of CD4(+) T cells and augmentation of CD8(+) T cell responses to tumor Ags.

Tumor-associated embryonic antigen-expressing vaccines that target CCR6 elicit potent CD8+ T cell-mediated protective and therapeutic antitumor immunity.

Despite its potency, the wider use of immunotherapy for B cell malignancies is hampered by the lack of well-defined tumor-specific Ags. In this study, we demonstrate that an evolutionarily conserved 37-kDa immature laminin receptor protein (OFA-iLRP), a nonimmunogenic embryonic Ag expressed by a variety of tumors, is rendered immunogenic if targeted to the APCs using the CCR6 ligands MIP3alpha/CCL20 and mDF2beta. The CCR6 targeting facilitated efficient Ag cross-presentation and induction of tumor-neutralizing CTLs. Although the Ag targeting alone, without activation of dendritic cells (DCs), is proposed to induce tolerance, and MIP3alpha does not directly activate DCs, the MIP3alpha-based vaccine efficiently induced protective and therapeutic antitumor responses. The responses were as strong as those elicited by the OFA-iLRP fusions with moieties that activated DCs and Th1-type cytokine responses, mDF2beta, or mycobacterial Hsp70 Ag. Although the same cDNA encodes the dimerized high-affinity mature 67-kDa mLRP that is expressed in normal tissues to stabilize the binding of laminin to cell surface integrins, the vaccines expressing OFA-iLRP elicited long-term protective CD8(+) T cell-mediated memory responses against syngeneic B cell lymphoma, indicating the potential application of these simple vaccines as preventive and therapeutic formulations for human use.

Chemokine receptor targeting efficiently directs antigens to MHC class I pathways and elicits antigen-specific CD8+ T-cell responses.

Chemokines are key controllers of cell trafficking and are involved in numerous pathologic and inflammatory conditions. However, the fate of a chemokine ligand, once it is endocytosed with its receptor, remains obscure. Here, using chemokine-tumor antigen fusion constructs, we demonstrate for the first time that chemokines are internalized to early/late endosomal and lysosomal compartments through a clathrin-dependent process and subsequently delivered to the cytosol for proteasomal processing, facilitating efficient cross-presentation to the TAP-1-dependent MHC class I processing pathway. These data not only elucidate the intracellular fate of chemokine ligands upon receptor uptake, but also demonstrate the superior carrier potency of chemokines for delivering self-antigens to both class I and II processing pathways to induce CD8(+) and CD4(+) T-cell responses.

Serum response factor promotes re-epithelialization and muscular structure restoration during gastric ulcer healing.

BACKGROUND & AIMS: Serum response factor (SRF) regulates transcription of immediate early genes and muscle genes. In this study, we examined the role of SRF in gastric ulcer healing and the mechanisms involved. METHODS: Gastric ulcers were induced in rats by serosal application of acetic acid. Gastric specimens were obtained sequentially after ulcer induction for analyses of SRF messenger RNA (mRNA), protein expression, and for immunohistochemistry. We examined the role of SRF in ulcer healing by local injection of an SRF expression plasmid into ulcers (gene therapy). To elucidate the cellular mechanisms of the action of SRF, we examined the effect of SRF overexpression on actin dynamics, cell migration, and proliferation in rat gastric epithelial cell (RGM1) and smooth muscle cell (A7R5). To determine the clinical relevance, we examined SRF expression in human gastric ulcer specimens. RESULTS: Gastric ulceration activated SRF expression in epithelial cells lining regenerating glands and in myofibroblasts and smooth muscle cells of granulation tissue. SRF up-regulation in human gastric ulcers was similar to that found in rat gastric ulcers. Gene therapy with SRF significantly accelerated experimental gastric ulcer healing and promoted re-epithelialization and muscle restoration. Overexpression of SRF in RGM1 and A7R5 cells accelerates migration and proliferation of these cells by promoting actin polymerization and activation of immediately early genes. CONCLUSIONS: Activation of SRF is an important component of ulcer healing. SRF promotes migration and proliferation of gastric epithelial and smooth muscle cells, which are essential for re-epithelialization and restoration of muscular structures.

Dual actions of nitric oxide on angiogenesis: possible roles of PKC, ERK, and AP-1.

Regulation of angiogenesis by nitric oxide (NO) is controversial since NO has been shown to have both pro- and anti-angiogenic effects. In this study, we examined the effect of the NO donor, S-nitro-N-acetyl-penicillamine (SNAP), on in vitro angiogenesis, and the mechanisms involved: PKC activity, ERK and c-Jun phosphorylation, and AP-1 DNA binding activity, in microvascular endothelial cells. SNAP, at 0.5-4 mM, significantly and dose-dependently inhibited angiogenesis, PKC activity, and ERK and c-Jun phosphorylation up to 80%, 83%, and 63% and 73%, respectively. SNAP at concentrations > 2mM also abolished AP-1 binding activity. Lower concentrations of SNAP (0.1-0.3 mM) significantly increased angiogenesis, PKC activity, and ERK and c-Jun phosphorylation up to 46%, 60%, and 61% and 180%, respectively. These findings indicate that the dual pro- and anti-angiogenic actions of NO are dose-dependent and suggest that they are mediated by PKC and ERK acting on AP-1.

Esophageal ulceration activates keratinocyte growth factor and its receptor in rats: implications for ulcer healing.

BACKGROUND & AIMS: Cellular and molecular mechanisms of esophageal ulcer healing remain unexplored. We studied the sequential cellular events and the expression of keratinocyte growth factor (KGF) and its receptor (KGF-R) during the healing of experimental esophageal ulcers. METHODS: Esophageal ulcers were produced in rats by local application of acetic acid. Studies included (1) ulcer size, (2) quantitative histology, and (3) KGF and KGF-R messenger RNA and protein expression by reverse-transcription polymerase chain reaction, Western blotting, and immunostaining. In separate groups, ulcer size and esophageal epithelial proliferation were evaluated after a single injection of recombinant human KGF (1 mg/kg) around the ulcer. RESULTS: Ulcers were fully developed 3 days after induction, and 58% of ulcers were re-epithelialized by 9 days. At 3 days, in esophageal tissue bordering the ulcers, KGF messenger RNA and protein were increased by 191% and 151%, respectively, and KGF-R messenger RNA and protein were increased by 357% and 237%, respectively. KGF was expressed in stromal cells, whereas KGF-R was expressed in epithelial cells. At 6 days, epithelial proliferation at the ulcer margin was increased by 216%, and treatment with KGF further enhanced cell proliferation and accelerated ulcer healing. CONCLUSIONS: KGF is a likely mediator of esophageal epithelial proliferation and ulcer healing.