Dynamic Opportunities for Medical Students to Assume the Roles of "Medical Teacher".

The traditional undergraduate medical education curriculum focuses on bolstering knowledge for practice and building clinical skills. However, as future clinicians, medical students will be tasked with teaching throughout their careers, first as residents and then as attendings. Here, we describe teaching opportunities for students that foster their development as future teachers and potential clinician educators. These offerings are diverse in their focus and duration and are offered across various levels of the curriculum - including course-based learning, longitudinal electives, and extra-curricular opportunities for medical students who have a passion for teaching.

The Effect of Histology Examination Format on Medical Student Preparation and Performance: Stand-Alone Versus Integrated Examinations.

Most medical schools have transitioned from discipline-based to integrated curricula. Although the adoption of integrated examinations usually accompanies this change, stand-alone practical examinations are often retained for disciplines such as gross anatomy and histology. Due to a variety of internal and external factors, faculty at the University of Cincinnati College of Medicine recently began to phase out stand-alone histology practical examinations in favor of an integrated approach to testing. The purpose of this study was to evaluate this change by (1) comparing examination performance on histology questions administered as part of stand-alone versus integrated examinations and (2) ascertaining whether students alter their approach to learning histology content based on the examination format. Data from two courses over a period ranging from 2018 to 2022 were used to evaluate these questions. Results indicated histology question performance initially dropped after being included on integrated examinations. Stratification of students by class rank revealed this change had a greater impact on lower-performing students. Longitudinal data showed that performance 2 years after the change yielded scores similar to previous standards. Despite the initial performance drop, survey results indicate students overwhelmingly prefer when histology is included on integrated examinations. Additionally, students described alterations in study approaches that align with what is known to promote better long-term retention. The results presented in this study have important implications for those at other institutions who are considering making similar changes in assessment strategies.

A Guide to Competencies, Educational Goals, and Learning Objectives for Teaching Medical Histology in an Undergraduate Medical Education Setting.

Horizontal and vertical integration within medical school curricula, truncated contact hours available to teach basic biomedical sciences, and diverse assessment methods have left histology educators searching for an answer to a fundamental question-what ensures competency for medical students in histology upon completion of medical school? The Liaison Committee for Medical Education (LCME) and the Commission on Osteopathic College Accreditation (COCA) advocate faculty to provide medical students with a list of learning objectives prior to any educational activities, regardless of pedagogy. It is encouraged that the learning objectives are constructed using higher-order and measurable action verbs to ensure student-centered learning and assessment. A survey of the literature indicates that there is paucity of knowledge about competencies, goals, and learning objectives appropriate for histology education in preclinical years. To address this challenge, an interactive online taskforce, comprising faculty from across the United States, was assembled. The outcome of this project was a desired set of competencies for medical students in histology with educational goals and learning objectives to achieve them.

Involvement of methylated HBHA expressed from Mycobacterium smegmatis in an IFN-γ release assay to aid discrimination between latent infection and active tuberculosis in BCG-vaccinated populations.

IFN-γ release assays (IGRAs) based on region of difference 1 (RD1) antigens have improved diagnosis of Mycobacterium tuberculosis (M. tb) infection. However, IGRAs with these antigens cannot discriminate between active tuberculosis (ATB) and latent tuberculosis infection (LTBI). M. tb heparin-binding-hemagglutinin (HBHA) induces relatively high IFN-γ responses in LTBI individuals and low responses in ATB patients, but purification of the native methylated HBHA from cultures of M. tb for immunological tests is complex and time-consuming. To overcome these cumbersome procedures, we constructed a recombinant Mycobacterium smegmatis strain that over-expressed HBHA under control of a strong furA promoter. The methylated activity of purified protein was verified by hybridization with anti-methylated Lys antibody, and the methylated HBHA (mHBHA) was further evaluated for antigen-specific IFN-γ responses in BCG-vaccinated Chinese population. A total of 138 individuals including 86 active TB (ATB) patients, 15 latent TB infection (LTBI) cases, and 37 healthy controls (HC) were tested by using an IFN-γ enzyme-linked immunospot (ELISPOT) assay. The results showed that T-cell responses against mHBHA were always lower in ATB patients than in LTBI individuals, regardless of the site of infection or the results of bacteriological tests. This allowed for a good discrimination between these two groups of M. tb-infected individuals, even in the BCG-vaccinated and high TB-incidence setting that is China. Additionally, combination of mHBHA and RD1 antigens in an IFN-γ release assay enhanced diagnostic efficacy for active TB cases. Taken together, inclusion of the immune response to mHBHA can discriminate healthy LTBI cases from ATB patients.

Etiology and clinical features of 229 cases of bloodstream infection among Chinese HIV/AIDS patients: a retrospective cross-sectional study.

Bloodstream infections (BSIs) are prevalent among people living with HIV/AIDS. The etiology varies in different regions and different periods. We aimed to survey the etiological and clinical features of BSIs in HIV patients in mainland China. We assessed all HIV patients with a positive blood culture in a Chinese teaching hospital from September 2009 through December 2014. We excluded those with specimens likely to have been contaminated. We used Pearson's chi-squared test to measure the differences in characteristics among subgroups of different pathogens. Among 2442 Chinese HIV-seropositive inpatients, 229 (9.38 %) experienced BSIs. The most common pathogens detected included Cryptococcus neoformans (22.7 %), Penicillium marneffei (18.8 %), Mycobacterium tuberculosis (15.3 %), and non-tuberculous mycobacterium (14.8 %). 30/229 (13.1 %) HIV patients with BSIs had a poor prognosis. BSIs are prevalent in hospitalized patients with HIV/AIDS in China. Fungi and mycobacteria are the predominant pathogens.

Virtual laboratory manual for microscopic anatomy.

Using digital technology, we have assembled a virtual laboratory manual (VLM) that is a Web-based copy of our traditional laboratory manual. The VLM is used to enhance traditional laboratory instruction in histology. For each reference in the VLM to either a histological slide or an electron micrograph (EM), hyperlinks are included that download digital images derived from the students' glass slide sets or scanned EMs. The VLM serves as an atlas of digital images for concurrent study of similar sections by light microscopy during laboratory sessions. In addition, students can review the images from the VLM at remote locations. We have encouraged continued use of light microscopes in laboratories by basing the majority of practical examination identifications on analysis of marked histological slides that require students to use their own microscopes. The VLM provides the convenience of a Web-based resource with high-quality images, yet allows retention of the many excellent traditional aspects of our course. An example of a VLM laboratory on epithelium is available online (http://users.von.uc.edu/michaeje/VLM-Epithelium/exLab4.pdf).

DNA injection in combination with electroporation: a novel method for vaccination of farmed ruminants.

Injection of plasmid DNA encoding antigens into rodents followed by electroporation improved the immune response when compared with injection without electroporation (Widera et al. J Immunol 2000;164:4635-40; Zucchelli et al. J Virol 2000;74:11598-607; Kadowaki et al. Vaccine 2000;18:2779-88). The present study describes the extension of this technology to farm animals, by injecting plasmid DNA encoding mycobacterial antigens (MPB70, Ag85B and Hsp65) into the muscles of goats and cattle using two different types of electrodes, both allowing DNA delivery at the site of electroporation. The animals were vaccinated under local anaesthesia without any observed immediate or long-term distress or discomfort, or any behavioural signs of muscle damage or pathological changes after the electroporation. DNA-injected and electroporated goats showed increased humoral response after the primary vaccination when compared with nonelectroporated animals. Improved T-cell responses following electroporation were observed in hsp65 DNA-vaccinated cattle. DNA injection with or without electroporation did not compromise the specificity of the tuberculin skin test. In conclusion, a protocol applying in vivo electroporation free of side effects to farmed ruminants was established. In addition, we show that DNA vaccination in combination with electroporation can improve the primary immune responses to the encoded antigens.

Sulfate disinfection, stabilisation and heavy metal removal from sewage sludge--process description and preliminary results.

A new, closed loop process for the disinfection, stabilisation and removal of heavy metal from sewage sludge (consisting of a sludge/sulfuric acid reactor, hybrid H2S generator and H2S bioscrubber) is described. Preliminary results for total solids (TS), volatile suspended solids (VSS), chemical oxygen demand (COD), acetate and propionate destruction in the hybrid H2S generator have shown that digestion efficiency is not compromised in a hybrid reactor generating H2S compared to a methanogenic reactor. 70% of the electron flow in the hybrid H2S generator was diverted to methane at a COD:SO4 ratio of 5.45:1. Enough H2SO4 could be generated from the H2S emitted at this ratio to effect sufficient metal solubilisation and pathogen removal from primary sludge.

Survey of gross anatomy, microscopic anatomy, neuroscience, and embryology courses in medical school curricula in the United States.

Directors of courses in the basic anatomical sciences in allopathic and osteopathic medical schools in the United States were surveyed regarding the present composition of their courses. Results indicate the majority of gross anatomy courses are in the range of 126 to 200 total course hours, and that laboratory dissection is a key component of these courses. The majority of microscopic anatomy courses are in the range of 61 to 100 total course hours, generally divided equally between lecture and laboratory components. Additionally, despite the availability of computer technology, microscopes are still used in the vast majority of microscopic anatomy courses. The majority of neuroscience courses are in the range of 71 to 90 total course hours, with most of these hours devoted to lectures. Embryology is usually taught in conjunction with gross anatomy, although some schools present it with the microscopic anatomy course or as a separate course. Most embryology courses are in the range of 6 to 20 total course hours, with only a few having a laboratory component.

Laser scanning of patient outlines for three-dimensional radiotherapy treatment planning.

In the planning of radiation treatments it is important to have a knowledge of the patient outline in order to correctly calculate the dose distribution that can be expected within the patient. This information is routinely obtained using x-ray computed tomography (CT). Although the CT data set is the ultimate data set, it can be impractical for economic and physical reasons. These impracticalities have been overcome using a commercial three dimensional (3D) laser scanning system. The system scans a laser line across the surface of the patient while a CCD camera views the patient from an offset angle. From a knowledge of the spatial orientation of the camera and the laser source, the system is able to detect the patient's surface and generate an equivalent 3D point cloud. Manipulation of 3D data sets allows the appropriate outlines of the patient to be obtained, that can then be used with the radiotherapy planning system. This has enabled the evaluation of 3D dose distributions for patients, and hence will allow the development of techniques for improving the uniformity of dose in breast treatments. The technique has no radiation overhead associated with it, is quick and is relatively cheap.

Immune responses in tuberculosis: antibodies and CD4-CD8 lymphocytes with vascular adhesion molecules and cytokines (chemokines) cause a rapid antigen-specific cell infiltration at sites of bacillus Calmette-Guérin reinfection.

Rabbit primary dermal bacillus Calmette-Guérin (BCG) lesions were compared with reinfection BCG lesions in order to gain insight into how immune responses protect against clinical tuberculosis. As early as 3 hr, a marked infiltration of macrophages and lymphocytes occurred in the reinfection group, while very little cell infiltration occurred in the primary group. It seems that only an antigen-antibody reaction could produce such an immediate pronounced antigen-specific chemotactic effect, because very few lymphocytes are normally present in the skin. Therefore, antibodies hasten the accumulation of an expanded antigen-specific T-lymphocyte population (memory cells) at sites of bacillary lodgement. By 1-2 days, the primary and reinfection BCG lesions differed 400- to 500-fold in size. By 4-5 days, the size of the reinfection lesions had declined, while the size of the primary lesions had increased, so that, grossly, both types of lesion were similar. At 8 days in reinfection lesions and at 12 days in primary lesions, small secondary peaks in size occurred, which were probably caused by cell-mediated immune responses. In rabbits with primary BCG lesions, skin tests with Old Tuberculin were positive at 9 days, accompanied by a rise in the levels of antibodies to the secreted antigen, phosphate-specific transport protein 1, but the levels of antibodies to the constitutive antigens, purified protein derivative and heat-shock protein 65, did not increase appreciably until some time after 23 days. In tissue sections of reinfection BCG lesions, the percentage of mononuclear cells labelled, by in situ hybridization techniques, for the mRNA of monocyte chemoattractant protein 1 (MCP-1), a chemokine, peaked at 3 hr and then was down-regulated, whereas in primary lesions, this percentage was down-regulated only after 2 days. [The percentage in the tissue sections for the mRNAs of interleukins 1beta and 8, as well as the proteins of MCP-1 and tumor necrosis factor alpha (TNF-alpha), followed a somewhat similar time-course to that of MCP-1 mRNA.] A high percentage of mononuclear cells containing the MCP-1 mRNA 'factory' would favour enlargement of the lesions and a low percentage would favour their regression. At 5 days, the percentage of CD4 and CD8 lymphocytes, stained by immunohistochemical techniques, and the amount of microvasculature stained similarly for vascular cell adhesion molecule 1 were higher in the reinfection group, indicating that prior immunization caused a more rapid (antigen-dependent) up-regulation of these factors. Tuberculin reactions resembled early reinfection BCG lesions in almost every factor evaluated herein. In brief, the production of chemokines began soon after BCG reinfection, peaked within a few hours and was markedly down-regulated by 24 hr, a time at which the lesions of reinfection were of maximal size. Therefore, the amount of cell infiltration was tightly controlled, probably by the variety of mechanisms listed herein.

A DNA vaccine encoding MPB83 from Mycobacterium bovis reduces M. bovis dissemination to the kidneys of mice and is expressed in primary cell cultures of the European badger (Meles meles).

Nucleic acid (DNA) vaccination against tuberculosis in the European badger (Meles meles) is one approach to addressing the escalating problem of bovine tuberculosis in Great Britain. The aim of vaccination is to reduce the burden of tuberculosis within the badger population and the shedding of Mycobacterium bovis to levels that would break the transmission of infection to cattle. To this end, the vaccine would be required to limit the amount of disseminated tuberculosis in the badger, especially dissemination to the kidney from where M. bovis can be shed in the urine. A promising candidate DNA vaccine encoding a 26 kDa major antigen (MPB83) of M. bovis was evaluated in a mouse model of disseminated M. bovis infection. Using the DNA vaccine, protection against infection of the kidney was found to be greater than that achieved with the current live vaccine, Bacille Calmette-Guerin (BCG). Kidney tissue and skeletal muscle from the badger was used to derive primary cell cultures in which to examine the expression of MPB83 following transfection with the DNA vaccine. Kidney cortex gave rise to a monotypic culture of epithelial cells whilst the muscle gave rise to a mixed culture of fibroblasts and myoblasts. During culture the myoblasts differentiated into multinucleated myotubes, verified by immunofluorescent detection of mammalian desmin. Successful expression of MPB83 by transfected epithelial and myotube cells was confirmed by immunofluorescence using a monoclonal antibody specific to the protein. These observations fulfil the early requirements for the development of a DNA vaccine for badger tuberculosis.

Interaction between two isoforms of the NF2 tumor suppressor protein, merlin, and between merlin and ezrin, suggests modulation of ERM proteins by merlin.

The product of the neurofibromatosis type II (NF2) tumor suppressor gene, merlin, is closely related to the ezrin-radixin-moesin (ERM) family, a group of proteins believed to link the cytoskeleton to the plasma membrane. Mutation in the NF2 locus is associated with Schwann cell tumors (schwannomas). The two predominant merlin isoforms, I and II, differ only in the carboxy-terminal 16 residues and only isoform I is anti-proliferative. Merlin lacks an actin-binding domain conserved among ezrin, radixin and moesin. Because merlin, ezrin and moesin are co-expressed in Schwann cells, and all homodimerize, we have examined whether merlin and ezrin dimerize with one another. We found by immunoprecipitation and yeast two-hybrid assays that both merlin isoforms interact with ezrin. The interaction occurs in a head-to-tail orientation, with the amino-terminal half of one protein interacting with the carboxy-terminal half of the other. The two merlin isoforms behave differently in their interaction with ezrin. Isoform I binds only ezrin whose carboxy-terminus is exposed, whereas isoform II binds ezrin regardless of whether ezrin is in the open or closed conformation. The heterodimerization of merlin is a much stronger interaction than the interaction between either merlin isoform and ezrin, and can inhibit merlin-ezrin binding. This suggests that, in vivo, merlin dimerization could regulate merlin-ERM protein interaction, and could thus indirectly regulate other interactions involving ERM proteins.

Vaccination of mice and cattle with plasmid DNA encoding the Mycobacterium bovis antigen MPB83.

A scientific review of bovine tuberculosis in Great Britain has concluded that the development of a cattle vaccine holds the best prospect for long-term disease control. Recent reports of successful DNA vaccination against Mycobacterium tuberculosis in small animal models have raised the possibility of using a similar strategy to produce vaccines against Mycobacterium bovis infection in cattle. To test this possibility, BALB/c mice were immunized with DNA encoding the M. bovis antigen MPB83. The mice responded to vaccination with a mixed IgG1/IgG2a response to the antigen and were protected from intravenous challenge with virulent M. bovis to a similar extent as those vaccinated with bacille Calmette-Guérin. The immunogenicity of the DNA vaccine in cattle was tested, after having established that DNA encoding MPB83 was immunogenic and elicited protective immunity in mice. In these studies, vaccinated animals had strong proliferative responses to MPB83.

Identification and characterization of murine cytotoxic T cells that kill Mycobacterium tuberculosis.

As we seek to develop and evaluate new vaccines against tuberculosis, it is desirable that we understand the mechanisms of protective immunity in our models. Adoptive transfer of protection with hsp65-specific T-cell clones from infected or vaccinated mice into naïve mice had indicated that cytotoxic T cells can make a major contribution to protection. We characterized 28 CD4(+) CD8(-) and 28 CD4(-) CD8(+) hsp65-specific T-cell clones derived from infected or vaccinated mice. Half of the CD4(+) CD8(-) and 64% of the CD4(-) CD8(+) clones were cytotoxic. Cytotoxicity was associated with high expression of CD44 and gamma interferon production. Most (86%) of the cytotoxic CD4(+) CD8(-) clones lysed target cells via the Fas-FasL pathway, and most (83%) of the cytotoxic CD4(-) CD8(+) clones lysed target cells via cytotoxic granules. Only the clones using the granule-mediated pathway caused substantial loss of viability of virulent Mycobacterium tuberculosis during lysis of infected macrophages, and the degree of killing closely correlated with the availability of granule marker enzyme activity. Granule-mediated cytotoxicity thus may have a key role in protection against tuberculosis by delivering mycobactericidal granule contents.

Enhancement of immunocompetence in tuberculosis by DNA vaccination.

Our studies in mice show that DNA vaccines, initially designed to prevent infection, can have a dramatic therapeutic action too. In heavily infected mice, simply by giving DNA vaccination, the immune response can be caused to switch from one that is relatively inefficient and gives bacterial stasis to one that kills the bacteria, and persistent bacteria can be eliminated. Adoptive transfer of protection with T cell clones and in vitro tests of clone function indicate that the effects are probably mainly mediated by antigen specific CD8+/CD4-/CD44hi T cells that both produce gamma-interferon and kill the bacteria during granule-dependent lysis of infected macrophages. We can speculate that application of such immunotherapy in conjunction with conventional chemotherapeutic antibacterial drugs might result in faster or more certain cure of the disease in man. Furthermore, similar vaccines used prophylactically and therapeutically might be able to both prevent establishment of this persistent state and eliminate it if it is already established.

Immunostimulatory bacterial DNA sequences activate dendritic cells and promote priming and differentiation of CD8+ T cells.

CD8+ T lymphocytes producing high levels of interferon-gamma (IFN-gamma) and expressing antigen specific cytotoxic activity are effectively induced after plasmid DNA vaccination and mediate protection against several intracellular micro-organisms. Recent evidence suggests that the priming of CD8+ T-cell responses following DNA injection involves antigen presentation mediated by dendritic cells. Here, we show that bacterial DNA and synthetic oligonucleotides containing dinucleotide (CpG) motifs activate cytokine expression in dendritic cells and modulate in vivo CD8+ T-cell priming and differentiation.

Properties of the nonhelical end domains of vimentin suggest a role in maintaining intermediate filament network structure.

To investigate the functional role of the nonhelical domains of the intermediate filament (IF) protein vimentin, we carried out transient transfection of constructs encoding fusion proteins of these domains with enhanced green fluorescent protein (EGFP). Expression of these fusion proteins did not have any effect on the endogenous IF networks of transfected cells. However, the head domain-EGFP fusion protein localized almost exclusively to the nucleus. This localization could be disrupted in a reversible fashion by chilling cells. Furthermore, the head domain was capable of targeting to the nucleus a strictly cytoplasmic protein, pyruvate kinase. Thus, the vimentin head domain contains information that specifically directs proteins into the nucleus. In contrast, the nonhelical tail domain of vimentin, when expressed as a fusion protein with EGFP, was retained in the cytoplasm. Cytoplasmic retention of tail domain-containing fusion proteins appeared to be dependent on the integrity of the microtubule network. Our results are consistent with a proposal that the nonhelical end domains of vimentin are involved in maintaining an extended IF network by exerting oppositely directed forces along the filaments. The head domains exert a nuclear-directed force while the tail domains extend the IF network toward the cell periphery via a microtubule-dependent mechanism.