Discrimination, harassment and non-reporting in UK medical education.

CONTEXT: Discrimination and harassment create a hostile environment with deleterious effects on student well-being and education. In this study, we aimed to: (i) measure prevalences and types of discrimination and harassment in one UK medical school, and (ii) understand how and why students report them. METHODS: The study used a mixed-methods design. A medical school population survey of 1318 students was carried out in March 2014. Students were asked whether they had experienced, witnessed or reported discrimination or harassment and were given space for free-text comments. Two focus group sessions were conducted to elicit information on types of harassment and the factors that influenced reporting. Proportions were analysed using the Wilson score method and associations tested using chi-squared and regression analyses. Qualitative data were subjected to framework analysis. Degrees of convergence between data were analysed. RESULTS: A total of 259 (19.7%) students responded to the survey. Most participants had experienced (63.3%, 95% confidence interval [CI]: 57.3-69.0) or witnessed (56.4%, 95% CI: 50.3-62.3) at least one type of discrimination or harassment. Stereotyping was the form most commonly witnessed (43.2%, 95% CI: 37.4-49.3). In the qualitative data, reports of inappropriate joking and invasion of personal space were common. Black and minority ethnic students had witnessed and religious students had experienced a greater lack of provision (χ2  = 4.73, p = 0.03 and χ2  = 4.38, p = 0.04, respectively). Non-heterosexual students had experienced greater joking (χ2  = 3.99, p = 0.04). Students with disabilities had experienced more stereotyping (χ2  = 13.5, p < 0.01). Female students and students in clinical years had 2.6 (95% CI: 1.3-5.3) and 3.6 (95% CI: 1.9-7.0) greater odds, respectively, of experiencing or witnessing any type of discrimination or harassment. Seven of 140 survey respondents had reported incidents (5.0%, 95% CI: 2.4-10.0). Reporting was perceived as ineffective and as potentially victimising of the reporter. CONCLUSIONS: Harassment and discrimination are prevalent in this sample and associated with gender, ethnicity, sexuality, disability and year group. Reporting is rare and perceived as ineffective. These findings have informed local developments, future strategies and the development of a national prevention policy.

GAMSAT: A 10-year retrospective overview, with detailed analysis of candidates' performance in 2014.

BACKGROUND: The Graduate Australian Medical Schools Admission Test (GAMSAT) is undertaken annually in centres around Australia and a small number of overseas locations. Most Australian graduate entry medical schools also use Grade Point Average and interview score for selection. The aim of this study was to review the performance of the GAMSAT over the last 10 years; the study provides an analysis of the impact of candidates' gender, age, language background, level of academic qualification and background discipline on performance; and details on the performance of higher-scoring candidates. These analyses were undertaken on the 2014 data; and trends in the data over the 10-year period are noted. METHODS: In reviewing performance, the main variables considered were: - Overall GAMSAT score and scores for Section 1, Reasoning in Humanities and Social Sciences, Section 2, Written Communication, and Section 3, Reasoning in Biological and Physical Sciences. - Proportions of candidates achieving a Typical Entry Score. - Impact of gender, age, language background, level of academic qualification and undergraduate course (i.e. subject discipline) on test scores. Descriptive statistics and tests of significance were applied to determine the impact of demographic variables on performance. RESULTS: The number of candidates is increasing. Test reliability is consistently high. Higher scores overall are more likely for candidates who are male; are less than 24 years old; have an English-speaking background; have an Honours degree or a doctorate; and have completed a degree which is not health-related. CONCLUSIONS: Performance of the GAMSAT exam over the last 10 years has been stable with high reliability. There are significant variations in candidate performance related to age, gender, level and discipline of previous academic study and language background.

Barriers to access, transition and progression of Widening Participation students in UK Medical Schools: The students' perspective.

This article was migrated. The article was marked as recommended. Much attention is being given to the implementation of fair selection criteria for access to Medical Schools in the UK, in order to address an imbalance in social class representation in the medical professions. Largely overlooked however, are the disadvantages faced by potential applicants both before and after selection by the Medical Schools. Here, we explore the nature of the barriers - both real and perceived - to accessing, transitioning and progressing in the medical education system as experienced by 125 current students at three UK Medical Schools. An online survey was conducted and responses to open and closed questions were categorised on the basis of the number of Widening Participation (WP) flags (e.g. index of multiple-deprivation, parental education and school Higher Education participation rate). The results show that differences in economic, social and cultural capital that students acquire through their background impact on their chances of admission to medical schools, highlighting issues such as access to finance and privileged knowledge, with school support and work experience opportunities being less available to WP students. Equally, these students found the transition to Medical School harder, and highlighted a lack of peers from similar backgrounds, a perception of being less well prepared academically and generally finding it difficult to fit in. Money worries and having to work for extra income, exacerbated the feeling of not fitting in, by losing out on key extracurricular activities. The data presented stress the importance of early support of (potential) WP students in secondary schools, and of a strong support network throughout their medical education.

How can the perceptions and experiences of medical educator stakeholders inform selection into medicine? An interpretative phenomenological pilot study.

This article was migrated. The article was marked as recommended. Background Attempts to utilise the experiences of stakeholders to better inform selection into medicine are rare in the literature. Published scholarship to date reflects a myriad of competing goals for selecting and graduating 'good doctors' amidst increasingly complex health care environments. This includes debates around what is the 'good doctor', selection methods, health care decision-making, the doctor-patient relationship, patient-centredness, professionalism and stakeholder experiences with doctors. Within the complexity manifested by these multiple dimensions, decisions about the characteristics and capabilities on which selection should be based may have privileged some stakeholder groups over others, with patient experiences particularly de-emphasised. The aims of this pilot study were to focus on front-line medical educators as stakeholders whose experiences might be valuable for informing selection into medicine and to inform a larger-scale study of the topic from the perspectives of a more diverse group of stakeholders, including patients. Method Fourteen (14) medical educator participants were recruited for a semi-structured group interview at an international conference for health professional educators. The audio-recording was transcribed verbatim and the raw data were de-identified and organised with the aid of computer assisted data analysis software. Coding was initiated and Smith's interpretative phenomenological analytical (IPA) method employed ( Smith, Flowers, & Larkin, 2009). Results Initial analysis yielded four broad phenomenological themes: perceptions of 'good doctors', selection processes, selection-related challenges and possible solutions. The more deeply experiential data were captured in an analytical commentary of first-person accounts that may be useful for informing future selection strategies. Participant experiences mirrored the major debates in medical selection but their accounts revealed a negativity and cynicism about the topic that was concerning and warrants further investigation. Conclusion This study contributes to medical student selection research through offering an account of the 'lived experiences' of front-line medical educator stakeholders.

Stat1 and CD74 overexpression is co-dependent and linked to increased invasion and lymph node metastasis in triple-negative breast cancer.

Triple-negative breast cancer is difficult to treat because of the lack of rationale-based therapies. There are no established markers and targets that can be used for stratification of patients and targeted therapy. Here we report the identification of novel molecular features, which appear to augment metastasis of triple negative breast tumors. We found that triple-negative breast tumors can be segregated into 2 phenotypes based on their genome-wide protein abundance profiles. The first is characterized by high expression of Stat1, Mx1, and CD74. Seven out of 9 tumors from this group had invaded at least 2 lymph nodes while only 1 out of 10 tumors in group 2 was lymph node positive. In vitro experiments showed that the interferon-induced increase in Stat1 abundance correlates with increased migration and invasion in cultured cells. When CD74 was overexpressed, it increased cell adhesion on matrigel. This effect was accompanied with a marked increase in the membrane expression of beta-catenin, MUC18, plexins, integrins, and other proteins involved in cell adhesion and cancer metastasis. Taken together, our results show that Stat1/CD74 positive triple-negative tumors are more aggressive and suggest an approach for development of better diagnostics and more targeted therapies for triple negative breast cancer. This article is part of a Special Issue entitled: Proteomics: The clinical link.

Optimized Protocol for Protein Extraction from the Breast Tissue that is Compatible with Two-Dimensional Gel Electrophoresis.

Proteomics is a highly informative approach to analyze cancer-associated transformation in tissues. The main challenge to use a tissue for proteomics studies is the small sample size and difficulties to extract and preserve proteins. The choice of a buffer compatible with proteomics applications is also a challenge. Here we describe a protocol optimized for the most efficient extraction of proteins from the human breast tissue in a buffer compatible with two-dimensional gel electrophoresis (2D-GE). This protocol is based on mechanically assisted disintegration of tissues directly in the 2D-GE buffer. Our method is simple, robust and easy to apply in clinical practice. We demonstrate high quality of separation of proteins prepared according to the reported here protocol.

Meta-data analysis as a strategy to evaluate individual and common features of proteomic changes in breast cancer.

BACKGROUND: Individual differences among breast tumours in patients is a significant challenge for the treatment of breast cancer. This study reports a strategy to assess these individual differences and the common regulatory mechanisms that may underlie breast tumourigenesis. MATERIALS AND METHODS: The two-step strategy was based firstly on a full-scale proteomics analysis of individual cases, and secondly on the analysis of common features of the individual proteome-centred networks (meta-data). RESULTS: Proteomic profiling of human invasive ductal carcinoma tumours was performed and each case was analysed individually. Analysis of primary datasets for common cancer-related proteins identified keratins. Analysis of individual networks built with identified proteins predicted features and regulatory mechanisms involved in each individual case. Validation of these findings by immunohistochemistry confirmed the predicted deregulation of expression of CK2α, PDGFRα, PYK and p53 proteins. CONCLUSION: Meta-data analysis allowed efficient evaluation of both individual and common features of the breast cancer proteome.

A peptide-centric approach to breast cancer biomarker discovery utilizing label-free multiple reaction monitoring mass spectrometry.

We report an approach for multiplex analysis of cancer biomarkers based on the measurement of diagnostic peptides in whole tissue protein digests. Label-free quantitation with MS3 multiple reaction monitoring (MRM) was developed to afford accurate analysis of prospective marker peptides in a panel of breast tumors. This approach provides an economical and robust alternative to stable isotope-based methods. It is equally applicable to the analysis of samples derived from tissue biopsy, aspirate, or plasma and can be easily translated to clinic.

Decreased poly(ADP-ribosyl)ation of CTCF, a transcription factor, is associated with breast cancer phenotype and cell proliferation.

PURPOSE: There is compelling evidence of a relationship between poly(ADP-ribosyl)ation and tumorigenesis; however, much less is known about the role of specific targets of poly(ADP-ribosyl)ation in tumor development. Two forms of the multifunctional transcription factor, CTCF, were previously identified: a 130-kDa protein (CTCF-130), characteristic for cell lines, and a 180-kDa protein (CTCF-180), modified by poly(ADP-ribosyl)ation. This study was aimed to investigate differential poly(ADP-ribosyl)ation of CTCF in normal and tumor breast tissues. EXPERIMENTAL DESIGN: Western blot analysis, mass spectrometry, and immunohistochemical and immunofluorescent stainings were used to characterize CTCF-130 and CTCF-180 in breast cell lines, primary cultures, and normal and tumor breast tissues. The immunoreactivity score was used for CTCF-130 quantification in tissues. RESULTS: We discovered that only CTCF-180 is detected in the normal breast tissues, whereas both CTCF-130 and CTCF-180 are present in breast tumors. Using an antibody specific for CTCF-130, we observed that 87.7% of breast tumors were positive for CTCF-130. A negative correlation existed between the levels of CTCF-130, tumor stage, and tumor size. Significantly, a transition from CTCF-180 to CTCF-130 was discovered in primary cultures generated from normal breast tissues, indicating a link between CTCF-130 and proliferation. Conversely, the appearance of CTCF-180 was observed following growth arrest in breast cell lines. CONCLUSIONS: Collectively, our data suggest that the loss of CTCF poly(ADP-ribosyl)ation is associated with cell proliferation and breast tumor development. We propose the use of CTCF-130 as a marker for tumor breast cells and lower levels of CTCF-130 as an indicator of unfavorable prognosis.

Breast Cancer and Proteomics: The inaugural Mammary Gland Proteome Initiative (MGPI) workshop 12-13 July 2007, Cambridge, UK.

Breast cancer proteomics has progressed to a level where further development requires the coordination and cooperation of research strategies and resources. The Mammary Gland Proteome Initiative (MGPI) aims to provide a platform to promote such a coordination of comprehensive studies of mammary glands in health and disease. An inaugural MGPI workshop, Breast Cancer and Proteomics, was held in Cambridge, UK in July 2007. The workshop outlined the development of the MGPI, with emphasis on four specific programs: (i) breast cancer, (ii) standardisation, deposition and processing of data, (iii) technology and (iv) logistics.

Phosphoproteomics: A possible route to novel biomarkers of breast cancer.

Proteomics is rapidly transforming the way that cancer and other pathologies are investigated. The ability to identify hundreds of proteins and to compare their abundance in different clinical samples presents a unique opportunity for direct identification of novel disease markers. Furthermore, recent advances allow us to analyse and compare PTMs. This gives an additional dimension for defining a new class of protein biomarker based not only on abundance and expression but also on the occurrence of covalent modifications specific to a disease state or therapy response. Such modifications are often a consequence of the activation/inactivation of a particular disease related pathway. In this review we evaluate the available information on breast cancer related protein-phosphorylation events, illustrating the rationale for investigating this PTM as a target for breast cancer research with eventual clinical relevance. We present a critical survey of the published experimental strategies to study protein phosphorylation on a system wide scale and highlight recent specific advances in breast cancer phosphoproteomics. Finally we discuss the feasibility of establishing novel biomarkers for breast cancer based on the detection of patterns of specific protein phosphorylation events.

Proteome profiling of breast tumors by gel electrophoresis and nanoscale electrospray ionization mass spectrometry.

We have conducted proteome-wide analysis of fresh surgery specimens derived from breast cancer patients, using an approach that integrates size-based intact protein fractionation, nanoscale liquid separation of peptides, electrospray ion trap mass spectrometry, and bioinformatics. Through this approach, we have acquired a large amount of peptide fragmentation spectra from size-resolved fractions of the proteomes of several breast tumors, tissue peripheral to the tumor, and samples from patients undergoing noncancer surgery. Label-free quantitation was used to generate protein abundance maps for each proteome and perform comparative analyses. The mass spectrometry data revealed distinct qualitative and quantitative patterns distinguishing the tumors from healthy tissue as well as differences between metastatic and non-metastatic human breast cancers including many established and potential novel candidate protein biomarkers. Selected proteins were evaluated by Western blotting using tumors grouped according to histological grade, size, and receptor expression but differing in nodal status. Immunohistochemical analysis of a wide panel of breast tumors was conducted to assess expression in different types of breast cancers and the cellular distribution of the candidate proteins. These experiments provided further insights and an independent validation of the data obtained by mass spectrometry and revealed the potential of this approach for establishing multimodal markers for early metastasis, therapy outcomes, prognosis, and diagnosis in the future.

Differential modulatory effects of annexin 1 on nitric oxide synthase induction by lipopolysaccharide in macrophages.

Annexin-1 (ANXA1) is a glucocorticoid-regulated protein that modulates the effects of bacterial lipopolysaccharide (LPS) on macrophages. Exogenous administration of peptides derived from the N-terminus of ANXA1 reduces LPS-stimulated inducible nitric oxide synthase (iNOS) expression, but the effects of altering the endogenous expression of this protein are unclear. We transfected RAW264.7 murine macrophage-like cell lines to over-express constitutively ANXA1 and investigated whether this protein modulates the induction of iNOS, cyclooxygenase-2 (COX-2) and tumour necrosis factor-alpha (TNF-alpha) in response to LPS. In contrast to exogenous administration of N-terminal peptides, endogenous over-expression of ANXA1 results in up-regulation of LPS-induced iNOS protein expression and activity. However, levels of iNOS mRNA are unchanged. ANXA1 has no effect on COX-2 or TNF-alpha production in response to LPS. In experiments to investigate the mechanisms underlying these phenomena we observed that activation of signalling proteins classically associated with iNOS transcription was unaffected. Over-expression of ANXA1 constitutively activates extracellular signal regulated kinase (ERK)-1 and ERK-2, components of a signalling pathway not previously recognized as regulating LPS-induced iNOS expression. Inhibition of ERK activity, by the inhibitor U0126, reduced LPS-induced iNOS expression in our cell lines. Over-expression of ANXA1 also modified LPS-induced phosphorylation of the ERK-regulated translational regulation factor eukaryotic initiation factor 4E. Our data suggest that ANXA1 may modify iNOS levels by post-transcriptional mechanisms. Thus differential effects on iNOS expression in macrophages are seen when comparing acute administration of ANXA1 peptides versus the chronic endogenous over-expression of ANXA1.

Annexin 1 regulates cell proliferation by disruption of cell morphology and inhibition of cyclin D1 expression through sustained activation of the ERK1/2 MAPK signal.

Cellular proliferation is controlled by the integration and coordination of extracellular signals. This study explores the role of the protein annexin 1 (ANXA1) in the regulation of such events. We show that ANXA1 has a cell-type independent, anti-proliferative function through sustained activation of the ERK signaling cascade. Moreover, ANXA1 reduces proliferation by ERK-mediated disruption of the actin cytoskeleton and ablation of cyclin D1 protein expression and not by ERK-mediated induction of the cyclin-dependent kinase, CDK2, inhibitor p21(cip/waf). Finally, ANXA1 regulates the ERK pathway at a proximal location, by SH2 domain-independent association with the adapter protein Grb-2. In summary, overexpression of ANXA1 mediates the disruption of normal cell morphology and inhibits cyclin D1 expression, therefore reducing cell proliferation through proximal modulation of the ERK signal transduction pathway.

Stimulation of Toll-like receptor 4 by lipopolysaccharide during cellular invasion by live Salmonella typhimurium is a critical but not exclusive event leading to macrophage responses.

Invasion of macrophages by salmonellae induces cellular responses, with the bacterial inducers likely to include a number of pathogen-associated molecular patterns. LPS is one of the prime candidates, but its precise role in the process, especially when presented as a component of live infecting bacteria, is unclear. We thus investigated this question using the lipid A antagonist E5531, the macrophage-like cell line RAW 264.7, and primary macrophage cultures from C3H/HeJ and Toll-like receptor 4(-/-) (TLR-4(-/-)) mice. We show that LPS presented on live salmonellae provides an essential signal, via functional TLR-4, for macrophages to produce NO and TNF-alpha. Furthermore, the mitogen-activated protein kinase c-Jun N-terminal kinase and p38 are activated, and the transcription factor NF-kappa B is translocated to the nucleus when RAW 264.7 cells are presented with purified LPS or live salmonellae. Purified LPS stimulates rapid, transitory mitogen-activated protein kinase activation that is inhibited by E5531, whereas bacterial invasion stimulates delayed, prolonged activation, unaffected by E5531. Both purified LPS and bacterial invasion caused translocation of NF-kappa B, but whereas E5531 always inhibited activation by purified LPS, activation by bacterial invasion was only inhibited at later time points. In conclusion, we show for the first time that production of NO and TNF-alpha is critically dependent on activation of TLR-4 by LPS during invasion of macrophages by salmonellae, but that different patterns of activation of intracellular signaling pathways are induced by purified LPS vs live salmonellae.