Training medical students in health promotion: twenty years of experience at the Faculty of Medicine of the University of Geneva.

Background: In most cases, the work of medical doctors, be they general practitioners or specialists, involves some dimension of health promotion (HP). There is thus ample justification for increasing the awareness of medical students vis-à-vis HP and its relevance for their future practice. Methods: In the context of a major curriculum reform (problem-based learning [PBL]) at the Faculty of Medicine of the University of Geneva in the mid-1990s, several steps were taken to strengthen HP throughout the curriculum and include HP in its key domains as defined by the Ottawa Charter (OC). Results: First, the political dimension of HP was developed in a series of first- and fifth-year lectures and third-year workshops; second, community action was strengthened through a third-year one-month community immersion program; third, the development of personal skills was integrated into second- and third-year PBL cases and into fourth-and fifth-year learning activities in clinical settings as well as second- and third-year HP electives; in terms of reorienting health services, the chosen approach included the development of a HP-specific track in the context of a Certificate of Advanced Studies (CAS) in Community Health and a Master of Advanced Studies(MAS) in Public Health. Furthermore, a supportive intra-university environment was created through a collaborative convention with Health Promotion Switzerland, which is in charge of coordinating HP in Switzerland. Conclusion: In our view, HP teaching for medical students seems all the more relevant given that future medical doctors will have to take care of an increasing number of patients likely to develop chronic non-communicable diseases.

Distinct roles of NFATc1 and NFATc4 in human primary myoblast differentiation and in the maintenance of reserve cells.

Ca2+ signaling plays a key role during human myoblast differentiation. Among Ca2+-sensitive pathways, calcineurin is essential for myoblast differentiation and muscle regeneration. Nuclear factor of activated T-cell (NFAT) transcription factors are the major calcineurin targets. We investigated the expression and the role of each NFAT gene during human primary myoblast differentiation. We found that three NFAT isoforms are present, NFATc1, NFATc3 and NFATc4. Importantly, while their mRNA expression increases during differentiation, NFATc1 is more highly expressed in myotubes, whilst NFATc4 is specifically maintained in reserve cells. NFATc3 is present in both cell types, although no specific role during myoblast differentiation was observed. Knockdown of either NFATc1 or NFATc4 affects the differentiation process similarly, by decreasing the expression of late differentiation markers, but impairs myotube formation differently. Whereas NFATc1 knockdown strongly reduced the number and the surface area of myotubes, NFATc4 knockdown increased the surface area of myotubes and reduced the pool of reserve cells. We conclude that NFAT genes have specific roles in myotube formation and in the maintenance of the reserve cell pool during human postnatal myogenesis.

TRPC1 and TRPC4 channels functionally interact with STIM1L to promote myogenesis and maintain fast repetitive Ca2+ release in human myotubes.

STIM1 and Orai1 are essential players of store-operated Ca2+ entry (SOCE) in human skeletal muscle cells and are required for adult muscle differentiation. Besides these two proteins, TRPC (transient receptor potential canonical) channels and STIM1L (a longer STIM1 isoform) are also present on muscle cells. In the present study, we assessed the role of TRPC1, TRPC4 and STIM1L in SOCE, in the maintenance of repetitive Ca2+ transients and in muscle differentiation. Knockdown of TRPC1 and TRPC4 reduced SOCE by about 50% and significantly delayed the onset of Ca2+ entry, both effects similar to STIM1L invalidation. Upon store depletion, TRPC1 and TRPC4 appeared to interact preferentially with STIM1L compared to STIM1. STIM1L invalidation affected myoblast differentiation, with the formation of smaller myotubes, an effect similar to what we reported for TRPC1 and TRPC4 knockdown. On the contrary, the overexpression of STIM1L leads to the formation of larger myotubes. All together, these data strongly suggest that STIM1L and TRPC1/4 are working together in myotubes to ensure efficient store refilling and a proper differentiation program.

[International Health Electives in developing countries for medical and nursing students: four experiences from French-speaking Switzerland]. / Stages dans des pays en développement au cours des etudes de médecine. Eléments de littérature et réflexions basées sur quatre expériences en Suisse romande.

International Health Electives performed in developing countries by students of medical and nursing schools from industrialized nations have recently become a highly valued element in curricula of medical and nursing schools. We report here four examples of such electives developed over the years at the Faculties of medicine of Geneva and Lausanne, one involving both medical and nursing school students. These electives foster enthusiasm and commitment among students and host institutions abroad. A selective review of the literature highlights the many positive aspects of such electives for the professional and personal development of students. It also emphasizes what the host institutions can gain from these electives provided the latter are organized in a balanced partnership and that the students receive a careful preparation to avoid possible pitfalls.

STIM1L traps and gates Orai1 channels without remodeling the cortical ER.

STIM proteins populate and expand cortical endoplasmic reticulum (ER) sheets to mediate store-operated Ca(2+) entry (SOCE) by trapping and gating Orai channels in ER-plasma membrane clusters. A longer splice variant, STIM1L, forms permanent ER-plasma membrane clusters and mediates rapid Ca(2+) influx in muscle. Here, we used electron microscopy, total internal reflection fluorescence (TIRF) microscopy and Ca(2+) imaging to establish the trafficking and signaling properties of the two STIM1 isoforms in Stim1(-/-)/Stim2(-/-) fibroblasts. Unlike STIM1, STIM1L was poorly recruited into ER-plasma membrane clusters and did not mediate store-dependent expansion of cortical ER cisternae. Removal of the STIM1 lysine-rich tail prevented store-dependent cluster enlargement, whereas inhibition of cytosolic Ca(2+) elevations or removal of the STIM1L actin-binding domain had no impact on cluster expansion. Finally, STIM1L restored robust but not accelerated SOCE and clustered with Orai1 channels more slowly than STIM1 following store depletion. These results indicate that STIM1L does not mediate rapid SOCE but can trap and gate Orai1 channels efficiently without remodeling cortical ER cisternae. The ability of STIM proteins to induce cortical ER formation is dispensable for SOCE and requires the lysine-rich tail of STIM1 involved in binding to phosphoinositides.

Inositol 1,4,5 trisphosphate receptor 1 is a key player of human myoblast differentiation.

Cytosolic Ca(2+) signals are fundamental for the early and late steps of myoblast differentiation and are, as in many cells, generated by Ca(2+) release from internal stores as well as by plasma membrane Ca(2+) entry. Our recent studies identified the store-operated Ca(2+) channels, Orai1 and TRPC1&C4, as crucial for the early steps of human myogenesis and for the late fusion events. In the present work, we assessed the role of the inositol-1,4,5 tris-phosphate receptor (IP3R) type 1 during human myoblast differentiation. We demonstrated, using siRNA strategy that IP3R1 is required for the expression of muscle-specific transcription factors such as myogenin and MEF2 (myocyte enhancer factor 2), and for the formation of myotubes. The knockdown of IP3R1 strongly reduced endogenous spontaneous Ca(2+) transients, and attenuated store-operated Ca(2+) entry. As well, two Ca(2+)-dependent key enzymes of muscle differentiation, NFAT and CamKII are down-regulated upon siIP3R1 treatment. On the contrary, the overexpression of IP3R1 accelerated myoblasts differentiation. These findings identify Ca(2+) release mediated by IP3R1 as an essential mechanism during the early steps of myoblast differentiation.

The predictive validity of the aptitude test for the performance of students starting a medical curriculum.

INTRODUCTION: Selection of medical students varies between German- and French-speaking Swiss faculties. Geneva introduced an aptitude test in 2010, aimed at helping decision making among students. The test was compulsory: it had to be taken by those who intended to register for medical studies. But it was not selective: there was no performance threshold under which registration would have been denied. METHODS: We followed 353 students who took the test in 2010, checked whether they confirmed their registration for medical studies and studied their performance during year 1 (selective year). RESULTS: The correlation between the aptitude test result and the academic performance during year 1 was 0.47 (n = 191), and weakened to 0.38 (n = 214) when including repetition of year 1. The failure to pass in year 2 or success were associated with the aptitude test results (p <0.001). Overall, 20% of the students succeeded after one year, 26% after a repeated year 1, and 53% failed and could not follow further medical studies. CONCLUSION: Though there was a clear association between the aptitude test and academic performance, students did not appear to take into account when making their career decisions the ability of the test (as implemented in Geneva, that is, compulsory but not selective) to predict their future performance in the medical programme. The test was withdrawn after the 2012 session, but a number of issues regarding the medical selection procedure remain to be addressed.

Epidermal growth factor receptor down-regulation triggers human myoblast differentiation.

Initiation of human myoblast differentiation requires a negative shift (hyperpolarization) of the resting potential of myoblasts that depends on the activation of Kir2.1 potassium channels. These channels are regulated by a tyrosine phosphorylation. Using human primary myoblast culture, we investigated a possible role of various receptor tyrosine kinases in the induction of the differentiation process. We found that Epidermal Growth Factor Receptor (EGFR) is a key regulator of myoblast differentiation. EGFR activity is down-regulated during early human myoblast differentiation, and this event is required for normal differentiation to take place. Furthermore, EGFR silencing in proliferation conditions was able to trigger the differentiation program. This occurs through an increase of Kir2.1 channel activity that, via a rise of store-operated Ca(2+) entry, leads to the expression of myogenic transcription factors and muscle specific proteins (Myogenin, Myocyte Enhancer Factor 2 (MEF2), Myosin Heavy Chain (MyHC)). Finally, blocking myoblast cell cycle in proliferation conditions using a cdk4 inhibitor greatly decreased myoblast proliferation but was not able, on its own, to promote myoblast differentiation. Taken together, these results show that EGFR down-regulation is an early event that is required for the induction of myoblast differentiation.

During post-natal human myogenesis, normal myotube size requires TRPC1- and TRPC4-mediated Ca²âº entry.

Myogenesis involves expression of muscle-specific transcription factors such as myogenin and myocyte enhancer factor 2 (MEF2), and is essentially regulated by fluctuations of cytosolic Ca(2+) concentration. Recently we demonstrated that molecular players of store-operated Ca(2+) entry (SOCE), stromal interacting molecule (STIM) and Orai, were fundamental in the differentiation process of post-natal human myoblasts. Besides STIM and Orai proteins, the family of transient receptor potential canonical (TRPC) channels was shown to be part of SOCE in several cellular systems. In the present study, we investigated the role of TRPC channels in the human myogenesis process. We demonstrate, using an siRNA strategy or dominant negative TRPC overexpression, that TRPC1 and TRPC4 participate in SOCE, are necessary for MEF2 expression, and allow the fusion process to generate myotubes of normal size. Conversely, the overexpression of STIM1 with TRPC4 or TRPC1 increased SOCE, accelerated myoblast fusion, and produced hypertrophic myotubes. Interestingly, in cells depleted of TRPC1 or TRPC4, the normalization of SOCE by increasing the extracellular calcium concentration or by overexpressing STIM1 or Orai1 was not sufficient to restore normal fusion process. A normal differentiation occurred only when TRPC channel was re-expressed. These findings indicate that Ca(2+) entry mediated specifically by TRPC1 and TRPC4 allow the formation of normal-sized myotubes.

[Community immersion program at Geneva medical school: a fifteen-year experience]. / Immersion en communauté au cours des etudes de médecine a Genève: un bilan a quinze ans.

Over the past decades there have been many new developments in medical education due to new public health challenges and to new learning theories. Medical schools throughout the world have adapted to these challenges in adopting community-based learning activities, an approach that the World Health Organization has promoted. The aim of the present article is to describe the characteristics, as well as the evolution, of such a community-based training program which has been implemented over 15 years at the Faculty of medicine of the University of Geneva and to present some evaluation data addressing students' perception, achievement of learning objectives as well as interactions between students and the community.

Design, implementation and evaluation of a community health training program in an integrated problem-based medical curriculum: a fifteen-year experience at the University of Geneva Faculty of Medicine.

BACKGROUND: In the literature the need for relevance in medical education and training has been stressed. In the last 40 years medical schools have been challenged to train doctors competent to respond to community health needs. In the mid-90s the University of Geneva Faculty of Medicine introduced an integrated medical curriculum. In this initiative a particular emphasis was put in introducing a 6-year longitudinal and multidisciplinary Community Health Program (CHP). OBJECTIVES: The aims of the present article are to describe the conception, elaboration and implementation of the CHP as well as its evolution over 15 years and the evaluation of its outcomes. METHODS: The CHP was at its origin elaborated by a small group of highly motivated teachers and later on developed by a multi-disciplinary group of primary care physicians, epidemiologists, public health and bio-ethics specialists, occupational health professionals, lawyers and historians. Evaluation of the program outcomes included educational innovations, new developments of the curriculum and interactions between students and the community. RESULTS: The CHP learning objectives and teaching modalities were defined by the multi-disciplinary group in consensus meetings which triggered a collaborative spirit among teachers and facilitated further developments. The evaluation procedures allowed the monitoring of students' satisfaction which remained high over the years, students' active participation which decreased over time and success at certifying exams which was globally as good as in basic life sciences. The evaluation also assessed outcomes such as educational innovations, new developments of the curriculum and interactions between students and the community. CONCLUSION: As suggested in the literature, our experience shows that the students' direct exposure and practice in the community health environment is an effective training approach to broaden students' education by offering them a community perspective of health and disease.

STIM1L is a new actin-binding splice variant involved in fast repetitive Ca2+ release.

Cytosolic Ca(2+) signals encoded by repetitive Ca(2+) releases rely on two processes to refill Ca(2+) stores: Ca(2+) reuptake from the cytosol and activation of a Ca(2+) influx via store-operated Ca(2+) entry (SOCE). However, SOCE activation is a slow process. It is delayed by >30 s after store depletion because stromal interaction molecule 1 (STIM1), the Ca(2+) sensor of the intracellular stores, must form clusters and migrate to the membrane before being able to open Orai1, the plasma membrane Ca(2+) channel. In this paper, we identify a new protein, STIM1L, that colocalizes with Orai1 Ca(2+) channels and interacts with actin to form permanent clusters. This property allowed the immediate activation of SOCE, a characteristic required for generating repetitive Ca(2+) signals with frequencies within seconds such as those frequently observed in excitable cells. STIM1L was expressed in several mammalian tissues, suggesting that many cell types rely on this Ca(2+) sensor for their Ca(2+) homeostasis and intracellular signaling.

Sleep-deprivation regulates α-2 adrenergic responses of rat hypocretin/orexin neurons.

We recently demonstrated, in rat brain slices, that the usual excitation by noradrenaline (NA) of hypocretin/orexin (hcrt/orx) neurons was changed to an inhibition following sleep deprivation (SD). Here we describe that in control condition (CC), i.e. following 2 hours of natural sleep in the morning, the α(2)-adrenergic receptor (α(2)-AR) agonist, clonidine, had no effect on hcrt/orx neurons, whereas following 2 hours of SD (SDC), it hyperpolarized the neurons by activating G-protein-gated inwardly rectifying potassium (GIRK) channels. Since concentrations of clonidine up to a thousand times (100 µM) higher than those effective in SDC (100 nM), were completely ineffective in CC, a change in the availability of G-proteins is unlikely to explain the difference between the two conditions. To test whether the absence of effect of clonidine in CC could be due to a down-regulation of GIRK channels, we applied baclofen, a GABA(B) agonist known to also activate GIRK channels, and found that it hyperpolarized hcrt/orx neurons in that condition. Moreover, baclofen occluded the response to clonidine in SDC, indicating that absence of effect of clonidine in CC could not be attributed to down-regulation of GIRK channels. We finally tested whether α(2)-ARs were still available at the membrane in CC and found that clonidine could reduce calcium currents, indicating that α(2)-ARs associated with calcium channels remain available in that condition. Taken together, these results suggest that a pool of α(2)-ARs associated with GIRK channels is normally down-regulated (or desensitized) in hcrt/orx neurons to only become available for their inhibition following sleep deprivation.

Human muscle economy myoblast differentiation and excitation-contraction coupling use the same molecular partners, STIM1 and STIM2.

Our recent work identified store-operated Ca(2+) entry (SOCE) as the critical Ca(2+) source required for the induction of human myoblast differentiation (Darbellay, B., Arnaudeau, S., König, S., Jousset, H., Bader, C., Demaurex, N., and Bernheim, L. (2009) J. Biol. Chem. 284, 5370-5380). The present work indicates that STIM2 silencing, similar to STIM1 silencing, reduces myoblast SOCE amplitude and differentiation. Because myoblasts in culture can be induced to differentiate into myotubes, which spontaneously contract in culture, we used the same molecular tools to explore whether the Ca(2+) mechanism of excitation-contraction coupling also relies on STIM1 and STIM2. Live cell imaging of early differentiating myoblasts revealed a characteristic clustering of activated STIM1 and STIM2 during the first few hours of differentiation. Thapsigargin-induced depletion of endoplasmic reticulum Ca(2+) content caused STIM1 and STIM2 redistribution into clusters, and co-localization of both STIM proteins. Interaction of STIM1 and STIM2 was revealed by a rapid increase in fluorescence resonance energy transfer between CFP-STIM1 and YFP-STIM2 after SOCE activation and confirmed by co-immunoprecipitation of endogenous STIM1 and STIM2. Although both STIM proteins clearly contribute to SOCE and are required during the differentiation process, STIM1 and STIM2 are functionally largely redundant as overexpression of either STIM1 or STIM2 corrected most of the impact of STIM2 or STIM1 silencing on SOCE and differentiation. With respect to excitation-contraction, we observed that human myotubes rely also on STIM1 and STIM2 to refill their endoplasmic reticulum Ca(2+)-content during repeated KCl-induced Ca(2+) releases. This indicates that STIM2 is a necessary partner of STIM1 for excitation-contraction coupling. Thus, both STIM proteins are required and interact to control SOCE during human myoblast differentiation and human myotube excitation-contraction coupling.

STIM1- and Orai1-dependent store-operated calcium entry regulates human myoblast differentiation.

Our previous work on human myoblasts suggested that a hyperpolarization followed by a rise in [Ca(2+)](in) involving store-operated Ca(2+) entry (SOCE) channels induced myoblast differentiation. Advances in the understanding of the SOCE pathway led us to examine more precisely its role in post-natal human myoblast differentiation. We found that SOCE orchestrated by STIM1, the endoplasmic reticulum Ca(2+) sensor activating Orai Ca(2+) channels, is crucial. Silencing STIM1, Orai1, or Orai3 reduced SOCE amplitude and myoblast differentiation, whereas Orai2 knockdown had no effect. Conversely, overexpression of STIM1 with Orai1 increased SOCE and accelerated myoblast differentiation. STIM1 or Orai1 silencing decreased resting [Ca(2+)](in) and intracellular Ca(2+) store content, but correction of these parameters did not rescue myoblast differentiation. Remarkably, SOCE amplitude correlated linearly with the expression of two early markers of myoblast differentiation, MEF2 and myogenin, regardless of the STIM or Orai isoform that was silenced. Unexpectedly, we found that the hyperpolarization also depends on SOCE, placing SOCE upstream of K(+) channel activation in the signaling cascade that controls myoblast differentiation. These findings indicate that STIM1 and Orai1 are key molecules for the induction of human myoblast differentiation.

Initiation of human myoblast differentiation via dephosphorylation of Kir2.1 K+ channels at tyrosine 242.

Myoblast differentiation is essential to skeletal muscle formation and repair. The earliest detectable event leading to human myoblast differentiation is an upregulation of Kir2.1 channel activity, which causes a negative shift (hyperpolarization) of the resting potential of myoblasts. After exploring various mechanisms, we found that this upregulation of Kir2.1 was due to dephosphorylation of the channel itself. Application of genistein, a tyrosine kinase inhibitor, increased Kir2.1 activity and triggered the differentiation process, whereas application of bpV(Phen), a tyrosine phosphatase inhibitor, had the opposite effects. We could show that increased Kir2.1 activity requires dephosphorylation of tyrosine 242; replacing this tyrosine in Kir2.1 by a phenylalanine abolished inhibition by bpV(Phen). Finally, we found that the level of tyrosine phosphorylation in endogenous Kir2.1 channels is considerably reduced during differentiation when compared with proliferation. We propose that Kir2.1 channels are already present at the membrane of proliferating, undifferentiated human myoblasts but in a silent state, and that Kir2.1 tyrosine 242 dephosphorylation triggers differentiation.

Myogenic precursor cell transplantation in pigs: a step towards a clinical use for muscle regeneration?

It is most probable that, in a near future, myogenic precursor cell transplants will have clinical applications in domains as different as orthopaedics, endocrinology, management of heart infarct, and therapies of muscle diseases. We have proposed to introduce the use of myogenic precursor cell transplantation in patients, after preliminary tests in a large animal model, the pig. Our initial effort was centred on the domain of orthopaedics. Muscle damages are frequent complications of traumas and sport accidents with serious consequences both in terms of disabilities and health economics. Often these lesions heal very poorly. A number of growth factors seemed successful as healing agents but they are difficult to deliver clinically. The goal was to use ex vivo somatic gene therapy with myogenic precursor cells modified to secrete growth factors with the aim of improving muscle healing in patients and of demonstrating the potential of this technology. To do so, we used a suitable large animal model, the pig, for exploring myogenic precursor cell transplantation strategies that could be used in patients.

The calcineurin pathway links hyperpolarization (Kir2.1)-induced Ca2+ signals to human myoblast differentiation and fusion.

In human myoblasts triggered to differentiate, a hyperpolarization, resulting from K+ channel (Kir2.1) activation, allows the generation of an intracellular Ca2+ signal. This signal induces an increase in expression/activity of two key transcription factors of the differentiation process, myogenin and MEF2. Blocking hyperpolarization inhibits myoblast differentiation. The link between hyperpolarization-induced Ca2+ signals and the four main regulatory pathways involved in myoblast differentiation was the object of this study. Of the calcineurin, p38-MAPK, PI3K and CaMK pathways, only the calcineurin pathway was inhibited when Kir2.1-linked hyperpolarization was blocked. The CaMK pathway, although Ca2+ dependent, is unaffected by changes in membrane potential or block of Kir2.1 channels. Concerning the p38-MAPK and PI3K pathways, their activity is present already in proliferating myoblasts and they are unaffected by hyperpolarization or Kir2.1 channel block. We conclude that the Kir2.1-induced hyperpolarization triggers human myoblast differentiation via the activation of the calcineurin pathway, which, in turn, induces expression/activity of myogenin and MEF2.

Calcium sources used by post-natal human myoblasts during initial differentiation.

Increases in cytoplasmic Ca(2+) are crucial for inducing the initial steps of myoblast differentiation that ultimately lead to fusion; yet the mechanisms that produce this elevated Ca(2+) have not been fully resolved. For example, it is still unclear whether the increase comes exclusively from membrane Ca(2+) influx or also from Ca(2+) release from internal stores. To address this, we investigated early differentiation of myoblast clones each derived from single post-natal human satellite cells. Initial differentiation was assayed by immunostaining myonuclei for the transcription factor MEF2. When Ca(2+) influx was eliminated by using low external Ca(2+) media, we found that approximately half the clones could still differentiate. Of the clones that required influx of external Ca(2+), most clones used T-type Ca(2+) channels, but others used store-operated channels as influx-generating mechanisms. On the other hand, clones that differentiated in low external Ca(2+) relied on Ca(2+) release from internal stores through IP(3) receptors. Interestingly, by following clones over time, we observed that some switched their preferred Ca(2+) source: clones that initially used calcium release from internal stores to differentiate later required Ca(2+) influx and inversely. In conclusion, we show that human myoblasts can use three alternative mechanisms to increase cytoplasmic Ca(2+) at the onset of the differentiation process: influx through T-types Ca(2+) channels, influx through store operated channels and release from internal stores through IP(3) receptors. In addition, we suggest that, probably because Ca(2+) elevation is essential during initial differentiation, myoblasts may be able to select between these alternate Ca(2+) pathways.