Ethics education in pediatrics: Implementation and evaluation of an interactive online course for medical students.

Introduction: The COVID-19 pandemic has catalyzed the development of online learning formats in virtually all areas of medical education. In pediatric ethics, online learning may not only substitute but also offer specific advantages over traditional classroom teaching. Many pediatricians rate their ethics education as poor and medical ethics education lacks evaluation, especially regarding the students' needs. The aim of this project was to implement and evaluate a novel interactive distance learning approach to engage medical students in pediatric ethics education. Methods: An online ethics course was designed and delivered between May and June 2020. Core item of this course was a moderated, written forum discussion spanning several days. Evaluation was mixed methods. We evaluated the effectiveness of the course in terms of quality of the learning environment with a particular focus on relevance to students as well as interactive learning and reflective thinking. The Constructivist On-Line Learning Environment Survey (COLLES) was used to evaluate six different domains of the course. Data are presented as mean (standard deviation [SD]). The respective score range is 1-5, whereby a score of 4 or 5 means that the participants indicated the corresponding item as frequently or almost always present. Results: Responses were available from 104 (78.3%) of the 133 participating students. "Relevance" yielded a score of 4.17 (0.83), "reflective thinking" a score of 4.22 (0.83). "Interactivity" was scored 3.76 (0.99) and "tutor support" 4.72 (0.53). "Peer support" and "interpretation" scored 3.87 (0.98) and 4.49 (0.60), respectively. In qualitative analysis, students particularly valued the structure of the course, the relevance for their professional practice, their active participation and the incentive to reflective thinking. Students also indicated that this was an innovative and exciting format, which fills a current educational gap and should hence be continued beyond the pandemic. Conclusion: In conclusion, students actively engaged in online learning and perceived this ethics course as highly relevant for their professional practice.

Teaching Practical Skills in Anesthesia, Intensive Care, Emergency and Pain Medicine-What Is Really Relevant for Medical Students? Results of a German National Survey of Nearly 3000 Anesthesiologists.

As a part of a major reform of the medical curriculum in Germany, the national catalogue of learning objectives is being revised with the focus shifting from theory-based learning to teaching practical skills. Therefore, we conducted an online survey to answer the question, which practical skills are essential in anesthesia. Participants were asked to rate the relevance of several skills, that medical students should be able to perform at the time of graduation. A total of 2898 questionnaires could be evaluated. The highest ratings were made for "bringing a patient into lateral recumbent position" and "diagnosing a cardiac arrest". All learning objectives regarding regional anesthesia were rated as irrelevant. Furthermore, learning objectives like "performing a bronchoscopy" or "performing a rapid sequence induction" had low ratings. In the subgroup analysis, physicians with advanced training and those who were working at university hospitals rated most skills with higher relevance compared to others. Our survey provides a good prioritization of practical skills for the development of new curricula and assessment frameworks. The results can also help to establish our discipline as a cross-sectional subject in competency-based medical education, thus further increasing the attractiveness for medical students.

Quantification of Aortic Valve Regurgitation by Pulsed Doppler Examination of the Left Subclavian Artery Velocity Contour: A Validation Study with Cardiovascular Magnetic Resonance Imaging.

BACKGROUND: Reflux of the aortic regurgitation (AR) causes an increased diastolic reverse flow in the aorta and its branching vessels. We aimed to evaluate the feasibility and accuracy of Doppler measurements in the left subclavian artery (LSA) for quantification of AR in a cardiovascular magnetic resonance imaging (CMR) validation study. METHODS: Systolic and diastolic flow profiles of the LSA (subclavicular approach) were evaluated prospectively by use of pulsed wave Doppler in 59 patients (55.5 ± 15 years; 44 men), 47 with a wide spectrum of AR and 12 as control group. Using CMR phase-contrast sequences (performed 1 cm above the aortic valve), the AR was divided into three groups: mild, regurgitant fraction (RF) < 20% (n = 17); moderate, RF 20%-40% (n = 10); and severe, RF > 40% (n = 20). The LSA Doppler-derived RF was calculated as the ratio between diastolic and systolic velocity-time integrals (VTI). RESULTS: Quality LSA Doppler signal could be obtained in all cases. Patients with CMR severe AR had higher values of LSA Doppler-derived RF (51% ± 9% vs 36% ± 11% vs 16% ± 8%; P < .0001). LSA Doppler showed a good correlation with CMR, with a sensitivity of 95%, specificity of 89%, and diagnostic accuracy for severe AR of 91.5%. Finally, Bland-Altman plots showed agreement in the group with moderate to severe AR (mean bias = -2.2% ± 8%, 95% CI, -17.7 to 13.3; P = .145) but differed in mild AR. CONCLUSIONS: Measurements of the RF for quantification of AR using LSA Doppler are comparable to those of CMR, highlighting the potential role of LSA Doppler as an adjunctive technique to assess the severity of AR.

Sirtuin-1 (SIRT1) is required for promoting chondrogenic differentiation of mesenchymal stem cells.

Sirtuin-1 (SIRT1), NAD(+)-dependent deacetylase, has been linked to anabolic effects in cartilage, although the mechanisms of SIRT1 signaling during differentiation of mesenchymal stem cells (MSCs) to chondrocytes are poorly understood. Therefore, we investigated the role of SIRT1-mediated signaling during chondrogenic differentiation of MSCs in vitro. High density and alginate cultures of MSCs were treated with chondrogenic induction medium with/without the SIRT1 inhibitor nicotinamide, antisense oligonucleotides against SIRT1 (SIRT1-ASO), IL-1ß, and/or resveratrol. Transient transfection of MSCs with SIRT1-antisense oligonucleotides, nicotinamide, and IL-1ß inhibited chondrogenesis-induced down-regulation of cartilage-specific proteins, cartilage-specific transcription factor Sox9, and enhanced NF-κB-regulated gene products involved in the inflammatory and degradative processes in cartilage (MMP-9, COX-2, and caspase-3), and NF-κB phosphorylation, acetylation, and activation of IκBα kinase. In contrast, the SIRT1 activator resveratrol or BMS-345541 (inhibitor of IKK) inhibited IL-1ß- and NAM-induced suppression of cartilage-specific proteins, Sox9, and up-regulation of NF-κB-regulated gene products. Moreover, SIRT1 was found to interact directly with NF-κB and resveratrol-suppressed IL-1ß and NAM but not SIRT1-ASO-induced NF-κB phosphorylation, acetylation, and activation of IκBα kinase. Knockdown of SIRT1 by mRNA abolished the inhibitory effects of resveratrol on inflammatory and apoptotic signaling and Sox9 expression, suggesting the essential role of this enzyme. Finally, the modulatory effects of resveratrol were found to be mediated at least in part by the association between SIRT1 and Sox9. These results indicate for the first time that SIRT1 supports chondrogenic development of MSCs at least in part through inhibition/deacetylation of NF-κB and activation of Sox9.

Curcumin enhances the effect of chemotherapy against colorectal cancer cells by inhibition of NF-κB and Src protein kinase signaling pathways.

OBJECTIVE: Development of treatment resistance and adverse toxicity associated with classical chemotherapeutic agents highlights the need for safer and effective therapeutic approaches. Herein, we examined the effectiveness of a combination treatment regimen of 5-fluorouracil (5-FU) and curcumin in colorectal cancer (CRC) cells. METHODS: Wild type HCT116 cells and HCT116+ch3 cells (complemented with chromosome 3) were treated with curcumin and 5-FU in a time- and dose-dependent manner and evaluated by cell proliferation assays, DAPI staining, transmission electron microscopy, cell cycle analysis and immunoblotting for key signaling proteins. RESULTS: The individual IC50 of curcumin and 5-FU were approximately 20 µM and 5 µM in HCT116 cells and 5 µM and 1 µM in HCT116+ch3 cells, respectively (p<0.05). Pretreatment with curcumin significantly reduced survival in both cells; HCT116+ch3 cells were considerably more sensitive to treatment with curcumin and/or 5-FU than wild-type HCT116 cells. The IC50 values for combination treatment were approximately 5 µM and 1 µM in HCT116 and 5 µM and 0.1 µM in HCT116+ch3, respectively (p<0.05). Curcumin induced apoptosis in both cells by inducing mitochondrial degeneration and cytochrome c release. Cell cycle analysis revealed that the anti-proliferative effect of curcumin and/or 5-FU was preceded by accumulation of CRC cells in the S cell cycle phase and induction of apoptosis. Curcumin potentiated 5-FU-induced expression or cleavage of pro-apoptotic proteins (caspase-8, -9, -3, PARP and Bax), and down-regulated anti-apoptotic (Bcl-xL) and proliferative (cyclin D1) proteins. Although 5-FU activated NF-κB/PI-3K/Src pathway in CRC cells, this was down-regulated by curcumin treatment through inhibition of IκBα kinase activation and IκBα phosphorylation. CONCLUSIONS: Combining curcumin with conventional chemotherapeutic agents such as 5-FU could provide more effective treatment strategies against chemoresistant colon cancer cells. The mechanisms involved may be mediated via NF-κB/PI-3K/Src pathways and NF-κB regulated gene products.

Resveratrol modulates interleukin-1ß-induced phosphatidylinositol 3-kinase and nuclear factor κB signaling pathways in human tenocytes.

Resveratrol, an activator of histone deacetylase Sirt-1, has been proposed to have beneficial health effects due to its antioxidant and anti-inflammatory properties. However, the mechanisms underlying the anti-inflammatory effects of resveratrol and the intracellular signaling pathways involved are poorly understood. An in vitro model of human tenocytes was used to examine the mechanism of resveratrol action on IL-1ß-mediated inflammatory signaling. Resveratrol suppressed IL-1ß-induced activation of NF-κB and PI3K in a dose- and time-dependent manner. Treatment with resveratrol enhanced the production of matrix components collagen types I and III, tenomodulin, and tenogenic transcription factor scleraxis, whereas it inhibited gene products involved in inflammation and apoptosis. IL-1ß-induced NF-κB and PI3K activation was inhibited by resveratrol or the inhibitors of PI3K (wortmannin), c-Src (PP1), and Akt (SH-5) through inhibition of IκB kinase, IκBα phosphorylation, and inhibition of nuclear translocation of NF-κB, suggesting that PI3K signaling pathway may be one of the signaling pathways inhibited by resveratrol to abrogate NF-κB activation. Inhibition of PI3K by wortmannin attenuated IL-1ß-induced Akt and p65 acetylation, suggesting that p65 is a downstream component of PI3K/Akt in these responses. The modulatory effects of resveratrol on IL-1ß-induced activation of NF-κB and PI3K were found to be mediated at least in part by the association between Sirt-1 and scleraxis and deacetylation of NF-κB and PI3K. Overall, these results demonstrate that activated Sirt-1 plays an essential role in the anti-inflammatory effects of resveratrol and this may be mediated at least in part through inhibition/deacetylation of PI3K and NF-κB.

Sirt-1 is required for the inhibition of apoptosis and inflammatory responses in human tenocytes.

Tendon overuse injuries and tendinitis are accompanied by catabolic processes and apoptosis of tenocytes. However, the precise molecular mechanisms of the destructive processes in tendon are not fully understood. Sirt-1, a nicotinamide adenine dinucleotide (NAD(+))-dependent deacetylase, has been linked to transcriptional silencing and appears to play a key role in inflammation. The purpose of this study was to examine whether down-regulation of Sirt-1 using antisense oligonucleotides (ASO) affects inflammatory and apoptotic signaling in tenocytes. Transient transfection of tenocytes with ASO against Sirt-1 induced expression of Bax and other proteins involved in apoptosis (cleaved caspase-3 and poly(ADP-ribose)polymerase), acetylation of tumor suppressor p53, and mitochondrial degradation. Interestingly, Sirt-1 was found to interact directly with p53. In contrast, Sirt-1 activator resveratrol inhibited interleukin-1ß (IL-1ß)- and nicotinamide-induced NF-κB activation and p65 acetylation and suppressed the activation of IκB-α kinase. Resveratrol also reversed the IL-1ß- or nicotinamide-induced up-regulation of various gene products that mediate inflammation (cyclooxygenase-2) and matrix degradation (matrix metalloproteinase-9) that are known to be regulated by NF-κB. Knockdown of Sirt-1 by using ASO abolished the inhibitory effects of resveratrol on inflammatory and apoptotic signaling including Akt activation and SCAX suppression. Down-regulation of histone deacetylase Sirt-1 by mRNA interference abrogated the effect of resveratrol on NF-κB suppression, thus highlighting the crucial homeostatic role of this enzyme. Overall, these results suggest for the first time that Sirt-1 can regulate p53 and NF-κB signaling via deacetylation, demonstrating a novel role for resveratrol in the treatment of tendinitis/tendinopathy.

Resveratrol mediated modulation of Sirt-1/Runx2 promotes osteogenic differentiation of mesenchymal stem cells: potential role of Runx2 deacetylation.

OBJECTIVE: Osteogenic repair in response to bone injury is characterized by activation and differentiation of mesenchymal stem cells (MSCs) to osteoblasts. This study determined whether activation of Sirt-1 (a NAD(+)-dependent histone deacetylase) by the phytoestrogen resveratrol affects osteogenic differentiation. METHODS: Monolayer and high-density cultures of MSCs and pre-osteoblastic cells were treated with an osteogenic induction medium with/without the Sirt-1 inhibitor nicotinamide or/and resveratrol in a concentration dependent manner. RESULTS: MSCs and pre-osteoblastic cells differentiated to osteoblasts when exposed to osteogenic-induction medium. The osteogenic response was blocked by nicotinamide, resulting in adipogenic differentiation and expression of the adipose transcription regulator PPAR-γ (peroxisome proliferator-activated receptor). However, in nicotinamide-treated cultures, pre-treatment with resveratrol significantly enhanced osteogenesis by increasing expression of Runx2 (bone specific transcription factor) and decreasing expression of PPAR-γ. Activation of Sirt-1 by resveratrol in MSCs increased its binding to PPAR-γ and repressed PPAR-γ activity by involving its cofactor NCoR (nuclear receptor co-repressor). The modulatory effects of resveratrol on nicotinamide-induced expression of PPAR-γ and its cofactor NCoR were found to be mediated, at least in part, by Sirt-1/Runx2 association and deacetylation of Runx2. Finally, knockdown of Sirt-1 by using antisense oligonucleotides downregulated the expression of Sirt-1 protein and abolished the inhibitory effects of resveratrol, namely nicotinamide-induced Sirt-1 suppression and Runx2 acetylation, suggesting that the acetylated content of Runx2 is related to downregulated Sirt-1 expression. CONCLUSION: These data support a critical role for Runx2 acetylation/deacetylation during osteogenic differentiation in MSCs in vitro. (242 words in abstract).

IGF-1 and PDGF-bb suppress IL-1ß-induced cartilage degradation through down-regulation of NF-κB signaling: involvement of Src/PI-3K/AKT pathway.

OBJECTIVE: Interleukin-1ß (IL-1ß) is a pro-inflammatory cytokine that plays a key role in the pathogenesis of osteoarthritis (OA). Growth factors (GFs) capable of antagonizing the catabolic actions of cytokines may have therapeutic potential in the treatment of OA. Herein, we investigated the potential synergistic effects of insulin-like growth factor (IGF-1) and platelet-derived growth factor (PDGF-bb) on different mechanisms participating in IL-1ß-induced activation of nuclear transcription factor-κB (NF-κB) and apoptosis in chondrocytes. METHODS: Primary chondrocytes were treated with IL-1ß to induce dedifferentiation and co-treated with either IGF-1 or/and PDGF-bb and evaluated by immunoblotting and electron microscopy. RESULTS: Pretreatment of chondrocytes with IGF-1 or/and PDGF-bb suppressed IL-1ß-induced NF-κB activation via inhibition of IκB-α kinase. Inhibition of IκB-α kinase by GFs led to the suppression of IκB-α phosphorylation and degradation, p65 nuclear translocation and NF-κB-regulated gene products involved in inflammation and cartilage degradation (COX-2, MMPs) and apoptosis (caspase-3). GFs or BMS-345541 (specific inhibitor of the IKK) reversed the IL-1ß-induced down-regulation of collagen type II, cartilage specific proteoglycans, ß1-integrin, Shc, activated MAPKinase, Sox-9 and up-regulation of active caspase-3. Furthermore, the inhibitory effects of IGF-1 or/and PDGF-bb on IL-1ß-induced NF-κB activation were sensitive to inhibitors of Src (PP1), PI-3K (wortmannin) and Akt (SH-5), suggesting that the pathway consisting of non-receptor tyrosine kinase (Src), phosphatidylinositol 3-kinase and protein kinase B must be involved in IL-1ß signaling. CONCLUSION: The results presented suggest that IGF-1 and PDGF-bb are potent inhibitors of IL-1ß-mediated activation of NF-κB and apoptosis in chondrocytes, may be mediated in part through suppression of Src/PI-3K/AKT pathway, which may contribute to their anti-inflammatory effects.

Curcumin modulates nuclear factor kappaB (NF-kappaB)-mediated inflammation in human tenocytes in vitro: role of the phosphatidylinositol 3-kinase/Akt pathway.

Inflammatory processes play essential roles in the pathogenesis of tendinitis and tendinopathy. These events are accompanied by catabolic processes initiated by pro-inflammatory cytokines such as interleukin-1ß (IL-1ß) and tumor necrosis factor-α (TNF-α). Pharmacological treatments for tendinitis are restricted to the use of non-steroidal anti-inflammatory drugs. Recent studies in various cell models have demonstrated that curcumin targets the NF-κB signaling pathway. However, its potential for the treatment of tendinitis has not been explored. Herein, we used an in vitro model of human tenocytes to study the mechanism of curcumin action on IL-1ß-mediated inflammatory signaling. Curcumin at concentrations of 5-20 µm inhibited IL-1ß-induced inflammation and apoptosis in cultures of human tenocytes. The anti-inflammatory effects of curcumin included down-regulation of gene products that mediate matrix degradation (matrix metalloproteinase-1, -9, and -13), prostanoid production (cyclooxygenase-2), apoptosis (Bax and activated caspase-3), and stimulation of cell survival (Bcl-2), all known to be regulated by NF-κB. Furthermore, curcumin suppressed IL-1ß-induced NF-κB activation via inhibition of phosphorylation and degradation of inhibitor of κBα, inhibition of inhibitor of κB-kinase activity, and inhibition of nuclear translocation of NF-κB. Furthermore, the effects of IL-1ß were abrogated by wortmannin, suggesting a role for the phosphatidylinositol 3-kinase (PI-3K) pathway in IL-1ß signaling. Curcumin suppressed IL-1ß-induced PI-3K p85/Akt activation and its association with IKK. These results demonstrate, for the first time, a potential role for curcumin in treating tendon inflammation through modulation of NF-κB signaling, which involves PI-3K/Akt and the tendon-specific transcription factor scleraxis in tenocytes.

Nocturnal gastric acid breakthrough is not associated with night-time gastroesophageal reflux in GERD patients.

BACKGROUND: Nocturnal acid breakthrough (NAB) is defined as gastric pH below 4 over 60 consecutive minutes at night-time in subjects who take proton pump inhibitors twice daily. The link between NAB and gastroesophageal reflux (GER) episodes has not been investigated using combined multichannel intraluminal impedance and pH-metry (MII-pH). AIMS AND METHODS: The aim was to investigate the relationship between NAB and GER by means of MII and gastroesophageal pH-metry. We reanalyzed MII-pH recordings obtained in patients on twice-daily proton pump inhibitors. RESULTS: Overall 15 eligible recordings were reanalyzed in detail (7 males, 8 females; age 59 +/- 10 years, range 36-68 years). NAB was detected in 7/15 (46%) recordings with one NAB in 4 subjects and two 2 NABs in 3 subjects. In 6 of the cases with NAB, reflux symptoms were reported at night, but in no case did these occur in association with NAB. Patients with NAB reported significantly more typical than atypical symptoms (77 times vs. 47 times), whereas patients without NAB reported fewer typical than atypical symptoms (48 times vs. 60; p = 0.011). Over the total 24-hour period, acid reflux was more frequent (9 +/- 11 times) in patients with NAB than in patients without NAB (1 +/- 0.5 times; p = 0.04). Weakly acid reflux also occurred more frequently (15 +/- 9 times) in subjects with NAB than in subjects without NAB (6 +/- 4 times; p = 0.02). Weakly alkaline reflux occurred in equal frequencies in subjects with and without NAB (2 +/- 4, 0 +/- 0.4, respectively). Esophageal acid exposure in the upright position was not different between subjects with NAB and subjects without NAB, but subjects with NAB presented a higher recumbent esophageal acid exposure than subjects without NAB (2.0 +/- 2.4 vs. 0%, respectively). CONCLUSION: Esophageal acid exposure is not increased during NAB episodes. However, over a period of 24 h, patients with NAB presented with increased gastroesophageal reflux. Although NAB and GER are not strongly associated, symptoms of patients with and without NAB are different.