Promoting psychological health in women with SCI: Development of an online self-esteem intervention.

BACKGROUND: There are no known interventions addressing self-esteem in women following spinal cord injury (SCI). OBJECTIVES: To test the feasibility of an online self-esteem intervention for women with disabilities, as modified for women with SCI. METHOD: We conducted a randomized, controlled feasibility test of a self-esteem intervention (N = 21). Participants were randomly assigned to the intervention or control group that received intervention materials at the end of the study. Intervention participants met as avatars for 7 weekly real-time group sessions in Second Life (SL), a free online virtual world. Feasibility indicators were study engagement, acceptability of SL and the intervention, and improvements on measures of psychological health promoting behaviors, social support, self-efficacy, self-esteem, and depression. RESULTS: Intervention participants (n = 10) were highly engaged, and most described the SL program as more enjoyable and more convenient than in-person programs. All rated the intervention as "good" (n = 4) or "very good" (n = 6), and all 10 rated themselves has having made positive life changes as a result of the program. Intervention participants experienced significantly greater change than controls on two measures of health-promoting behavior (Health Promoting Lifestyle Profile-II Spiritual Growth/Self-actualization; Interpersonal Relations). Examining change in the intervention group using regression analyses, we found medium-to-large effects of the intervention on these behaviors and measures of depression (CESD-10, PHQ-9). The intervention had small effects on remaining measures. CONCLUSION: We found preliminary support for the feasibility of this modified self-esteem intervention offered in SL. Such programming may help circumvent barriers to community-based psychological services and may improve psychological health.

A pilot test of the GoWoman weight management intervention for women with mobility impairments in the online virtual world of Second Life®.

Objective: Pilot test GoWoman, a small-group weight management intervention for mobility impaired women that was a disability- and gender-responsive adaptation of the Diabetes Prevention Program delivered in the online virtual world of Second Life®. Objectives were to (1) examine pre-/post-intervention differences in weight, waist circumference, diet, physical activity, self-efficacy for diet and physical activity, nutrition knowledge and social support for weight management, (2) determine intervention feasibility (fidelity, attrition, engagement, acceptability). Design: Single-group modified interrupted time series quasi-experimental design whereby participants served as their own controls. Results: Thirteen women attended ≥8 of 16 GoWoman weekly sessions and lost an average of 5.97 pounds (2.71 kg) (3.31%) body weight (Cohen's d = 0.74) and 1.44 inches (3.66 cm) (3.58%) waist circumference (Cohen's d = 0.83). There were significant improvements in physical activity, diet and self-efficacy for diet and physical activity. All benchmarks for feasibility were met. Ratings of intervention content, group interactions and support and virtual world experiences were highly positive. Conclusion: Findings suggest that a disability- and gender-responsive weight management intervention with peer group support delivered in an online virtual world is feasible, meaningful and may assist with weight management for mobility impaired women. Implications for Rehabilitation This study addresses a gap in the general and rehabilitation research literature by addressing the disproportionately high rates of obesity among women with mobility impairments, who are generally excluded from tests of weight management interventions if they have limited ability to engage in vigorous physical activity. The GoWoman program is an adaptation of the Diabetes Prevention Program Lifestyle Change curriculum that is tailored to meet the unique weight management needs of women with mobility impairments, and was created to become a publicly available, disability- and gender-responsive intervention that can be used in community and rehabilitation settings. More rehabilitation and health promotion program should be offered in the free, online, virtual world of Second Life® since participants in this pilot study offered many favorable comments about the new learning and social opportunities available to them there and they did not have to deal with the disability-related environmental and health challenges that often prevent them from participating in face-to-face workshops. Preliminary indications of improvements in body weight, waist circumference, diet and physical activity after attending the GoWoman weight management intervention offered in Second Life® tell us that these strategies are feasible for helping women with mobility impairments manage their weight and should undergo further testing.

An Internet-based virtual reality intervention for enhancing self-esteem in women with disabilities: Results of a feasibility study.

PURPOSE: To examine the feasibility of an online self-esteem enhancement group program for women with disabilities. METHOD: A sample of 19 racially and ethnically diverse, community-living women with physical disabilities, 22 to 61 years old, participated in a 7-session interactive group intervention (extending Hughes et al., 2004) in the 3-D, immersive, virtual environment of SecondLife.com, using avatars with voice and text communication. Baseline and postintervention questionnaires were administered online. Criteria for determining feasibility were (a) enrollment, (b) engagement, (c) acceptability, and (d) improvement on measures of self-esteem, depression, self-efficacy, and social support. RESULTS: We attained our enrollment goal and engagement exceeded expectations. Acceptability was positive; participants gave "helpful" and "enjoyable" ratings of 3.21 and 3.27, respectively, (mean on a 1 to 4 Likert scale, where 4 = high) to 5 intervention components-session materials, group sharing and discussion, relaxation exercises, action planning, and group excursions. Significant increases from baseline to postintervention were found on the Rosenberg Self-Esteem Scale (p = .02; Cohen's d = .60) and the Center for Epidemiologic Studies Depression Scale-10 (p = .005; Cohen's d = .74), with a trend toward significance on the Generalized Self-Efficacy Scale (p = .08; Cohen's d = .42). The intervention did not significantly affect the measure of social support. IMPLICATIONS: An intervention to enhance self-esteem may have a corollary benefit on depressive symptomatology. Offering psycho-educational, small group interventions using online virtual worlds shows promise for circumventing disability-related and environmental barriers to accessing mental health services experienced by women with mobility limitations, and should undergo further development and testing. (PsycINFO Database Record

Muscle Fatigue from the Perspective of a Single Crossbridge.

The repeated intense stimulation of skeletal muscle rapidly decreases its force- and motion-generating capacity. This type of fatigue can be temporally correlated with the accumulation of metabolic by-products, including phosphate (Pi) and protons (H). Experiments on skinned single muscle fibers demonstrate that elevated concentrations of these ions can reduce maximal isometric force, unloaded shortening velocity, and peak power, providing strong evidence for a causative role in the fatigue process. This seems to be due, in part, to their direct effect on muscle's molecular motor, myosin, because in assays using isolated proteins, these ions directly inhibit myosin's ability to move actin. Indeed, recent work using a single molecule laser trap assay has revealed the specific steps in the crossbridge cycle affected by these ions. In addition to their direct effects, these ions also indirectly affect myosin by decreasing the sensitivity of the myofilaments to calcium, primarily by altering the ability of the muscle regulatory proteins, troponin and tropomyosin, to govern myosin binding to actin. This effect seems to be partially due to fatigue-dependent alterations in the structure and function of specific subunits of troponin. Parallel efforts to understand the molecular basis of muscle contraction are providing new technological approaches that will allow us to gain unprecedented molecular detail of the fatigue process. This will be crucial to fully understand this ubiquitous phenomenon and develop appropriately targeted therapies to attenuate the debilitating effects of fatigue in clinical populations.

Hyperthermia: from diagnostic and treatments to new discoveries.

Hyperthermia is an important approach for the treatment of several diseases. Hyperthermia is also thought to induce hypertrophy of skeletal muscles in vitro and in vivo, and has been used as a therapeutic tool for millennia. In the first part of our work, we revise several relevant patents related to the utilization of hyperthermia for the treatment and diagnostic of human diseases. In the second part, we present exciting new data on the effects of forced and natural overexpression of HSP72, using murine in vitro (muscle cells) and ex vivo (primary skeletal muscles) models. These studies help to demonstrate that hyperthermia effects are orchestrated by tight coupling between gene expression, protein function, and intracellular Ca2+ signaling pathways with a key role for calcium-induced calcium release. We hope that the review of current patents along with previous unknown information on molecular signaling pathways that underlie the hypertrophy response to hyperthermia in skeletal muscles may trigger the curiosity of scientists worldwide to explore new inventions that fully utilize hyperthermia for the treatment of muscle diseases.

Kruppel-like factor 15 regulates skeletal muscle lipid flux and exercise adaptation.

The ability of skeletal muscle to enhance lipid utilization during exercise is a form of metabolic plasticity essential for survival. Conversely, metabolic inflexibility in muscle can cause organ dysfunction and disease. Although the transcription factor Kruppel-like factor 15 (KLF15) is an important regulator of glucose and amino acid metabolism, its endogenous role in lipid homeostasis and muscle physiology is unknown. Here we demonstrate that KLF15 is essential for skeletal muscle lipid utilization and physiologic performance. KLF15 directly regulates a broad transcriptional program spanning all major segments of the lipid-flux pathway in muscle. Consequently, Klf15-deficient mice have abnormal lipid and energy flux, excessive reliance on carbohydrate fuels, exaggerated muscle fatigue, and impaired endurance exercise capacity. Elucidation of this heretofore unrecognized role for KLF15 now implicates this factor as a central component of the transcriptional circuitry that coordinates physiologic flux of all three basic cellular nutrients: glucose, amino acids, and lipids.

Store-operated Ca(2+) entry (SOCE) contributes to normal skeletal muscle contractility in young but not in aged skeletal muscle.

Muscle atrophy alone is insufficient to explain the significant decline in contractile force of skeletal muscle during normal aging. One contributing factor to decreased contractile force in aging skeletal muscle could be compromised excitation-contraction (E-C) coupling, without sufficient available Ca(2+) to allow for repetitive muscle contractility, skeletal muscles naturally become weaker. Using biophysical approaches, we previously showed that store-operated Ca(2+) entry (SOCE) is compromised in aged skeletal muscle but not in young ones. While important, a missing component from previous studies is whether or not SOCE function correlates with contractile function during aging. Here we test the contribution of extracellular Ca(2+) to contractile function of skeletal muscle during aging. First, we demonstrate graded coupling between SR Ca(2+) release channel-mediated Ca(2+) release and activation of SOCE. Inhibition of SOCE produced significant reduction of contractile force in young skeletal muscle, particularly at high frequency stimulation, and such effects were completely absent in aged skeletal muscle. Our data indicate that SOCE contributes to the normal physiological contractile response of young healthy skeletal muscle and that defective extracellular Ca(2+) entry through SOCE contributes to the reduced contractile force characteristic of aged skeletal muscle.

Muscle-specific inositide phosphatase (MIP/MTMR14) is reduced with age and its loss accelerates skeletal muscle aging process by altering calcium homeostasis.

We have recently reported that a novel muscle-specific inositide phosphatase (MIP/MTMR14) plays a critical role in [Ca2+]i homeostasis through dephosphorylation of sn-1-stearoyl-2-arachidonoyl phosphatidylinositol (3,5) bisphosphate (PI(3,5)P2). Loss of function mutations in MIP have been identified in human centronuclear myopathy. We developed a MIP knockout (MIPKO) animal model and found that MIPKO mice were more susceptible to exercise-induced muscle damage, a trademark of muscle functional changes in older subjects. We used wild-type (Wt) mice and MIPKO mice to elucidate the roles of MIP in muscle function during aging. We found MIP mRNA expression, MIP protein levels, and MIP phosphatase activity significantly decreased in old Wt mice. The mature MIPKO mice displayed phenotypes that closely resembled those seen in old Wt mice: i) decreased walking speed, ii) decreased treadmill activity, iii) decreased contractile force, and iv) decreased power generation, classical features of sarcopenia in rodents and humans. Defective Ca2+ homeostasis is also present in mature MIPKO and old Wt mice, suggesting a putative role of MIP in the decline of muscle function during aging. Our studies offer a new avenue for the investigation of MIP roles in skeletal muscle function and as a potential therapeutic target to treat aging sarcopenia.

Temporal adaptive changes in contractility and fatigability of diaphragm muscles from streptozotocin-diabetic rats.

Diabetes is characterized by ventilatory depression due to decreased diaphragm (DPH) function. This study investigated the changes in contractile properties of rat DPH muscles over a time interval encompassing from 4 days to 14 weeks after the onset of streptozotocin-induced diabetes, with and without insulin treatment for 2 weeks. Maximum tetanic force in intact DPH muscle strips and recovery from fatiguing stimulation were measured. An early (4-day) depression in contractile function in diabetic DPH was followed by gradual improvement in muscle function and fatigue recovery (8 weeks). DPH contractile function deteriorated again at 14 weeks, a process that was completely reversed by insulin treatment. Maximal contractile force and calcium sensitivity assessed in Triton-skinned DPH fibers showed a similar bimodal pattern and the same beneficial effect of insulin treatment. While an extensive analysis of the isoforms of the contractile and regulatory proteins was not conducted, Western blot analysis of tropomyosin suggests that the changes in diabetic DPH response depended, at least in part, on a switch in fiber type.

Deficiency of MIP/MTMR14 phosphatase induces a muscle disorder by disrupting Ca(2+) homeostasis.

The intracellular Ca(2+) concentration ([Ca(2+)](i)) in skeletal muscles must be rapidly regulated during the excitation-contraction-relaxation process. However, the signalling components involved in such rapid Ca(2+) movement are not fully understood. Here we report that mice deficient in the newly identified PtdInsP (phosphatidylinositol phosphate) phosphatase MIP/MTMR14 (muscle-specific inositol phosphatase) show muscle weakness and fatigue. Muscles isolated from MIP/MTMR14(-/-) mice produced less contractile force, had markedly prolonged relaxation and showed exacerbated fatigue relative to normal muscles. Further analyses revealed that MIP/MTMR14 deficiency resulted in spontaneous Ca(2+) leakage from the internal store - the sarcoplasmic reticulum. This was attributed to decreased metabolism (dephosphorylation) and the subsequent accumulation of MIP/MTMR14 substrates, especially PtdIns(3,5)P(2) and PtdIns (3,4)P(2). Furthermore, we found that PtdIns(3,5)P(2) and PtdIns(3,4)P(2) bound to, and directly activated, the Ca(2+) release channel (ryanodine receptor 1, RyR1) of the sarcoplasmic reticulum. These studies provide the first evidence that finely controlled PtdInsP levels in muscle cells are essential for maintaining Ca(2+) homeostasis and muscle performance.

A serious gaming/immersion environment to teach clinical cancer genetics.

We are creating an interactive, simulated "Cancer Genetics Tower" for the self-paced learning of Clinical Cancer Genetics by medical students (go to: http://casemed.case.edu/cancergenetics). The environment uses gaming theory to engage the students into achieving specific learning objectives. The first few levels contain virtual laboratories where students achieve the basic underpinnings of Cancer Genetics. The next levels apply these principles to clinical practice. A virtual attending physician and four virtual patients, available for questioning through virtual video conferencing, enrich each floor. The pinnacle clinical simulation challenges the learner to integrate all information and demonstrate mastery, thus "winning" the game. A pilot test of the program by 17 medical students yielded very favorable feedback; the students found the Tower a "great way to teach", it held their attention, and it made learning fun. A majority of the students preferred the Tower over other resources to learn Cancer Genetics.

Troponin T core structure and the regulatory NH2-terminal variable region.

The conserved central and COOH-terminal regions of troponin T (TnT) interact with troponin C, troponin I, and tropomyosin to regulate striated muscle contraction. Phylogenic data show that the NH2-terminal region has evolved as an addition to the conserved core structure of TnT. This NH2-terminal region does not bind other thin filament proteins, and its sequence is hypervariable between fiber type and developmental isoforms. Previous studies have demonstrated that NH2-terminal modifications alter the COOH-terminal conformation of TnT and thin filament Ca2+-activation, yet the functional core structure of TnT and the mechanism of NH2-terminal modulation are not well understood. To define the TnT core structure and investigate the regulatory role of the NH2-terminal variable region, we investigated two classes of model TnT molecules: (1) NH2-terminal truncated cardiac TnT and (2) chimera proteins consisting of an acidic or basic skeletal muscle TnT NH2-terminus spliced to the cardiac TnT core. Deletion of the TnT hypervariable NH2-terminus preserved binding to troponin I and tropomyosin and sustained cardiac muscle contraction in the heart of transgenic mice. Further deletion of the conserved central region diminished binding to tropomyosin. The reintroduction of differently charged NH2-terminal domains in the chimeric molecules produced long-range conformational changes in the central and COOH-terminal regions to alter troponin I and tropomyosin binding. Similar NH2-terminal charge effects are demonstrated in naturally occurring cardiac TnT isoforms, indicating a physiological significance. These results suggest that the hypervariable NH2-terminal region modulates the conformation and function of the TnT core structure to fine-tune muscle contractility.

Muscle aging is associated with compromised Ca2+ spark signaling and segregated intracellular Ca2+ release.

Reduced homeostatic capacity for intracellular Ca2+ ([Ca2+]i) movement may underlie the progression of sarcopenia and contractile dysfunction during muscle aging. We report two alterations to Ca2+ homeostasis in skeletal muscle that are associated with aging. Ca2+ sparks, which are the elemental units of Ca2+ release from sarcoplasmic reticulum, are silent under resting conditions in young muscle, yet activate in a dynamic manner upon deformation of membrane structures. The dynamic nature of Ca2+ sparks appears to be lost in aged skeletal muscle. Using repetitive voltage stimulation on isolated muscle preparations, we identify a segregated [Ca2+]i reserve that uncouples from the normal excitation-contraction process in aged skeletal muscle. Similar phenotypes are observed in adolescent muscle null for a synaptophysin-family protein named mitsugumin-29 (MG29) that is involved in maintenance of muscle membrane ultrastructure and Ca2+ signaling. This finding, coupled with decreased expression of MG29 in aged skeletal muscle, suggests that MG29 expression is important in maintaining skeletal muscle Ca2+ homeostasis during aging.

Coupled expression of troponin T and troponin I isoforms in single skeletal muscle fibers correlates with contractility.

Striated muscle contraction is powered by actin-activated myosin ATPase. This process is regulated by Ca(2+) via the troponin complex. Slow- and fast-twitch fibers of vertebrate skeletal muscle express type I and type II myosin, respectively, and these myosin isoenzymes confer different ATPase activities, contractile velocities, and force. Skeletal muscle troponin has also diverged into fast and slow isoforms, but their functional significance is not fully understood. To investigate the expression of troponin isoforms in mammalian skeletal muscle and their functional relationship to that of the myosin isoforms, we concomitantly studied myosin, troponin T (TnT), and troponin I (TnI) isoform contents and isometric contractile properties in single fibers of rat skeletal muscle. We characterized a large number of Triton X-100-skinned single fibers from soleus, diaphragm, gastrocnemius, and extensor digitorum longus muscles and selected fibers with combinations of a single myosin isoform and a single class (slow or fast) of the TnT and TnI isoforms to investigate their role in determining contractility. Types IIa, IIx, and IIb myosin fibers produced higher isometric force than that of type I fibers. Despite the polyploidy of adult skeletal muscle fibers, the expression of fast or slow isoforms of TnT and TnI is tightly coupled. Fibers containing slow troponin had higher Ca(2+) sensitivity than that of the fast troponin fibers, whereas fibers containing fast troponin showed a higher cooperativity of Ca(2+) activation than that of the slow troponin fibers. These results demonstrate distinct but coordinated regulation of troponin and myosin isoform expression in skeletal muscle and their contribution to the contractile properties of muscle.

Enhanced resistance to fatigue and altered calcium handling properties of sarcalumenin knockout mice.

Sarcalumenin is a Ca2+-binding protein located in the sarcoplasmic reticulum of striated muscle cells, the physiological function of which has not been fully determined yet. Using sarcalumenin knockout (sar(-/-)) mice, we showed that sar ablation altered store-operated Ca2+ entry (SOCE) and enhanced muscle fatigue resistance. Sar(-/-) mice fatigued less with treadmill exercise, and intact isolated soleus and extensor digitorum longus muscles from sar(-/-) mice were more resistant to intermittent fatiguing stimulation than those from wild-type mice. Enhanced SOCE was observed in the sar(-/-) muscles. Biochemical analysis revealed that sar(-/-) muscles contained significantly elevated expression of mitsugumin 29 (MG29), a synaptophysin-related membrane protein located in the triad junction of skeletal muscle. Because the ablation of mg29 has been shown to cause increased fatigability and dysfunction of SOCE, the enhanced SOCE activity seen in sar(-/-) muscle may be correlated with the increased expression of MG29. Our data suggest that systemic ablation of sarcalumenin caused enhanced resistance to muscle fatigue by compensatory changes in Ca2+ regulatory proteins that effect SOCE.

Functional and biochemical modifications in skeletal muscles from malarial mice.

Although it is well established that patients suffering from malaria experience skeletal muscle problems (contracture, aches, fatigue, weakness), detailed studies have not been performed to investigate changes in the contractile function and biochemical properties of intact and skinned skeletal muscles of mammals infected with malaria. To this end, we investigated such features in the extensor digitorium longus (EDL, fast-twitch, glyocolytic) and in the soleus (SOL, slow-twitch, oxidative) muscles from mice infected with Plasmodium berghei. We first studied maximal tetanic force (T(max)) produced by intact control and malaria-infected muscles before, during and after fatigue. Triton-skinned muscle fibres were isolated from these muscles and used to determine isometric contractile features as well as a basic biochemical profile as analysed by silver-enhanced SDS-PAGE. We found that the T(max) of intact muscles and the maximal Ca2+-activated force (F(max)) of Triton-skinned muscle fibres were reduced by approximately 50% in malarial muscles. In addition, the contractile proteins of Triton-skinned muscle fibres from malarial muscles were significantly less sensitive to Ca2+. Biochemical analysis revealed that there was a significant loss of essential contractile proteins (e.g. troponins and myosin) in Triton-skinned muscle fibres from malarial muscles as compared to controls. The biochemical alterations (i.e., reduction of essential contractile proteins) seem to explain well the functional modifications resolved in both intact muscles and Triton-skinned muscle fibres and may provide a suitable paradigm for the aetiology of muscle symptoms associated with malaria.

Defective maintenance of intracellular Ca2+ homeostasis is linked to increased muscle fatigability in the MG29 null mice.

Mitsugumin 29 (MG29) is a transmembrane protein that is normally found in the triad junction of skeletal muscle. Our previous studies have shown that targeted deletion of mg29 from the skeletal muscle resulted in abnormality of the triad junction structure, and also increased susceptibility to muscle fatigue. To elucidate the basis of these effects, we investigated the properties of Ca2+-uptake and -release in toxin-skinned Extensor Digitorium Longus (EDL) muscle fibers from control and mg29 knockout mice. Compared with the control muscle, submaximal Ca2+-uptake into the sarcoplasmic reticulum (SR) was slower and the storage of Ca2+ inside the SR was less in the mutant muscle, due to increased leakage process of Ca2+ movement across the SR. The leakage pathway is associated with the increased sensitivity of Ca2+/caffeine -induced Ca2+ release to myoplasmic Ca2+. Therefore, the increased fatigability of mutant EDL muscles can result from a combination of a slowing of Ca2+ uptake, modification of Ca2+-induced Ca2+ release (CICR), and a reduction in total SR Ca2+ content.

Troponin T isoforms alter the tolerance of transgenic mouse cardiac muscle to acidosis.

Troponin T (TnT) is an essential protein in the Ca2+ regulatory system of striated of muscle. Three fiber type-specific TnT genes have evolved in higher vertebrates to encode cardiac, slow and fast skeletal muscle TnT isoforms. To understand the functional significance of TnT isoforms, we studied the effects of acidosis on the contractility of transgenic mouse cardiac muscle that expresses fast skeletal muscle TnT. Contractility analysis of intact cardiac muscle strips showed that while no differences were detected at physiological pH, the transgenic cardiac muscle had significantly greater decreases in +dF/dtmax at acidic pH than that of the wild-type control. Contractility of skinned cardiac muscles demonstrated that the presence of fast TnT resulted in significantly larger decreases in force and Ca2+ sensitivity at acidic pH than that of the wild-type control. The effect of TnT isoforms on the tolerance of muscle to acidosis may explain the higher tolerance of embryonic versus adult cardiac muscles. The results are consistent with the hypothesis that charge differences in TnT isoforms contribute to the contractility of muscle. The data further support a hypothesis that slow TnT is similar to the cardiac, but not fast, and TnT may contribute to the higher tolerance of slow muscles to stress conditions. Therefore, TnT isoform diversity may contribute to the compatibility of muscle thin filaments to cellular environments in different fiber types, during development and functional adaptation.

Disease prevention and health promotion in medical education: reflections from an academic health center.

PURPOSE: It is unclear whether academic health centers are successfully addressing societal needs and expectations by preparing students with knowledge and skills in disease prevention and health promotion. The authors assessed whether students were exposed to key content in these areas and whether they felt this exposure was adequate. METHOD: All components of the first three years of the Case Western Reserve University (Case) curriculum were examined in 2001 to create a curricular map, using competencies in disease prevention and health promotion identified by the Association of Teachers of Preventive Medicine (ATPM) as a template to assess the scope of instruction. Case students' United States Medical Licensing Examination (USMLE) Step 2 subscores in preventive medicine and health maintenance from 1994 to 2000 and graduating seniors' assessment of the adequacy of their training were compared to national data from the Association of American Medical Colleges' 2000 Graduation Questionnaire (GQ). RESULTS: Most content areas identified by ATPM were present in the Case curriculum and were offered frequently in a variety of educational venues over the first three years. USMLE scores increased nationally and at Case from 1994 to 2000 and Case students' perception of training adequacy in preventive medicine and health promotion was comparable to national ratings from the 2000 GQ. CONCLUSIONS: Broad and frequent exposure to disease prevention and health promotion core competencies has value, but may not sufficiently prepare students to deliver health-promoting services confidently. Creative curricula highlighting prevention's relevance throughout clinical practice and incorporating formal opportunities to apply knowledge and build experience may result in greater success.

Truncation by Glu180 nonsense mutation results in complete loss of slow skeletal muscle troponin T in a lethal nemaline myopathy.

A lethal form of nemaline myopathy, named "Amish Nemaline Myopathy" (ANM), is linked to a nonsense mutation at codon Glu180 in the slow skeletal muscle troponin T (TnT) gene. We found that neither the intact nor the truncated slow TnT protein was present in the muscle of patients with ANM. The complete loss of slow TnT is consistent with the observed recessive pattern of inheritance of the disease and indicates a critical role of the COOH-terminal T2 domain in the integration of TnT into myofibrils. Expression of slow and fast isoforms of TnT is fiber-type specific. The lack of slow TnT results in selective atrophy of type 1 fibers. Slow TnT confers a higher Ca2+ sensitivity than does fast TnT in single fiber contractility assays. Despite the lack of slow TnT, individuals with ANM have normal muscle power at birth. The postnatal onset and infantile progression of ANM correspond to a down-regulation of cardiac and embryonic splice variants of fast TnT in normal developing human skeletal muscle, suggesting that the fetal TnT isoforms complement slow TnT. These results lay the foundation for understanding the molecular pathophysiology and the potential targeted therapy of ANM.