Ultrasound guided anterior approach to intra-articular injection of the knee.

In this clinical practice article, we describe a novel, anterior, approach for therapeutic intra-articular injection of the knee under ultrasound guidance. The benefits of this approach are improved accuracy in knees that do not have an effusion, simplified sonoanatomy for learners, and easy localization in patients with enlarged body habitus or altered anatomy. This article describes the positioning, sonographic anatomy, risks, and technical considerations for this anterior approach.

The medical students' perspective of faculty and informal mentors: a questionnaire study.

BACKGROUND: Student mentoring is an important aspect of undergraduate medical education. While medical schools often assign faculty advisors to medical students as mentors to support their educational experience, it is possible for the students to pursue mentors informally. The possible role of these informal mentors and their interactions with the students in a faculty mentorship program has not been reported. This study builds upon previous work that suggested many students have informal mentors, and that there might be interplay between these two types of mentors. This study was conducted to report the experience of undergraduate medical students in a faculty mentorship program of their faculty mentors and if applicable, of their informal mentors. METHODS: One month before residency (post-graduate training for Canadians) ranking, the survey was administered to the graduating class of 2014 at the University of Calgary's Cumming School of Medicine. The survey was created from focus groups of the previous graduating class of 2013. The survey investigated meeting characteristics and the students' perceptions of faculty advisors and informal mentors, and the students' intended choice for residency. RESULTS: The study response rate was 86% (95 of 111); 58% (54 of 93) of the students reported having an informal mentor. There was no reported difference in satisfaction ratings of the Faculty mentorship program between students with only faculty mentors and those with also informal mentors. Students' reporting of their satisfaction with the Faculty mentorship program and the faculty mentors did not differ between the students with informal mentors and those with faculty mentors only. The students' meeting frequency, discussed topics, and perceived characteristics of faculty mentors were not associated with having an informal mentor. The students generally perceived their informal mentors more positively than their faculty mentors. The reported student career intention was associated with the discipline of informal mentors and not with the discipline of faculty mentors. CONCLUSIONS: Informal mentorship was common for medical students. The presence of an informal mentor was not associated with dissatisfaction with the Faculty advisor or with the mentorship program. It is likely students may pursue informal mentorship for career-related reasons.

Recruitment and retention of physicians in rural Alberta: the spousal perspective.

INTRODUCTION: The overall geographic distribution of physicians in Canada, including Alberta, is misaligned with the population distribution. Some strategies, such as debt repayment, are currently in practice to increase recruitment and retention of physicians in rural locations. Of the factors influencing choice of practice location, 'spousal influence' is considered to play a significant role in recruitment and retention of physicians in literature. Most studies have focused on the physicians' perspective of their spouses' influence on staying in a rural location. This study is unique as it approaches rural recruitment and retention from the perspective of the physician spouse. METHODS: The physician population for this study consisted of doctors practicing in rural southern Alberta. Participants were recruited via an email invitation and were invited to complete an online survey. The survey collected information regarding physician demographics and some relationship characteristics. The email invitation also contained a link to a second survey specific to the physician spouse or partner, asking a similar panel of questions. Physicians were asked to request their spouse or partner to complete this survey. Semi-structured interviews were conducted for those who consented to be contacted for interviews. RESULTS: Descriptive statistical analysis of the survey data was carried out. Thematic analysis of the qualitative interview data was conducted and was organized into three sections. The first and second sections present the personal experiences of rural recruitment and rural retention. The third section presents recommendations made by physicians and spouses to improve these processes. Specific interview quotes led the authors to derive themes under each section. CONCLUSIONS: The results of this study raise the voice and profile of the spouse in the process of rural recruitment and retention. In this study, the spouses of Canadian medical graduates were a positive influence in rural recruitment and retention, while the spouses of international medical graduates were generally less supportive of a rural lifestyle. Considerations to accommodate the educational, professional and cultural needs of the physician spouse must be incorporated into policy if large areas of underserved rural communities will continue to rely on international recruitment.

Specialty resident perceptions of the impact of a distributed education model on practice location intentions.

OBJECTIVES: There is an increased focus internationally on the social mandate of postgraduate training programs. This study explores specialty residents' perceptions of the impact of the University of Calgary's (UC) distributed education rotations on their self-perceived likelihood of practice location, and if this effect is influenced by resident specialty or stage of program. METHODS: Residents participating in the UC Distributed Royal College Initiative (DistRCI) between July 2010 and June 2013 completed an online survey following their rotation. Descriptive statistics and student's t-test were employed to analyze quantitative survey data, and a constant comparative approach was used to analyze free text qualitative responses. RESULTS: Residents indicated they were satisfied with the program (92%), and that the distributed rotations significantly increased their self-reported likelihood of practicing in smaller centers (p < 0.05). The findings suggest that the shift in attitude is independent of discipline, program year, and logistical experiences of living at the distributed sites, and is consistent across multiple cohorts over several academic years. CONCLUSION: The findings highlight the value of a distributed education program in contributing to future practice and career development, and its relevance in the social accountability of postgraduate programs.

Effectiveness of the standard and an alternative set of Streptococcus pneumoniae multi locus sequence typing primers.

BACKGROUND: Multi-locus sequence typing (MLST) is a portable, broadly applicable method for classifying bacterial isolates at an intra-species level. This methodology provides clinical and scientific investigators with a standardized means of monitoring evolution within bacterial populations. MLST uses the DNA sequences from a set of genes such that each unique combination of sequences defines an isolate's sequence type. In order to reliably determine the sequence of a typing gene, matching sequence reads for both strands of the gene must be obtained. This study assesses the ability of both the standard, and an alternative set of, Streptococcus pneumoniae MLST primers to completely sequence, in both directions, the required typing alleles. RESULTS: The results demonstrated that for five (aroE, recP, spi, xpt, ddl) of the seven S. pneumoniae typing alleles, the standard primers were unable to obtain the complete forward and reverse sequences. This is due to the standard primers annealing too closely to the target regions, and current sequencing technology failing to sequence the bases that are too close to the primer. The alternative primer set described here, which includes a combination of primers proposed by the CDC and several designed as part of this study, addresses this limitation by annealing to highly conserved segments further from the target region. This primer set was subsequently employed to sequence type 105 S. pneumoniae isolates collected by the Canadian Immunization Monitoring Program ACTive (IMPACT) over a period of 18 years. CONCLUSIONS: The inability of several of the standard S. pneumoniae MLST primers to fully sequence the required region was consistently observed and is the result of a shift in sequencing technology occurring after the original primers were designed. The results presented here introduce clear documentation describing this phenomenon into the literature, and provide additional guidance, through the introduction of a widely validated set of alternative primers, to research groups seeking to undertake S. pneumoniae MLST based studies.

The specificity of protection against cationic antimicrobial peptides by lactoferrin binding protein B.

A variety of Gram-negative pathogens possess host-specific lactoferrin (Lf) receptors that mediate the acquisition of iron from host Lf. The integral membrane protein component of the receptor, lactoferrin binding protein A specifically binds host Lf and is required for acquisition of iron from Lf. In contrast, the role of the bi-lobed surface lipoprotein, lactoferrin binding protein B (LbpB), in Lf binding and iron acquisition is uncertain. A common feature of LbpBs from most species is the presence of clusters of negatively charged amino acids in the protein's C-terminal lobe. Recently it has been shown that the negatively charged regions from the Neisseria meningitidis LbpB are responsible for protecting against an 11 amino acid cationic antimicrobial peptide (CAP), lactoferricin (Lfcin), derived from human Lf. In this study we investigated whether the LbpB confers resistance to other CAPs since N. meningitidis is likely to encounter other CAPs from the host. LbpB provided protection against the cathelicidin derived peptide, cathelicidin related antimicrobial peptide (mCRAMP), but did not confer protection against Tritrp 1 or LL37 under our experimental conditions. When tested against a range of rationally designed synthetic peptides, LbpB was shown to protect against IDR-1002 and IDR-0018 but not against HH-2 or HHC10.

Beyond bricks and mortar: a rural network approach to preclinical medical education.

BACKGROUND: Countries with expansive rural regions often experience an unequal distribution of physicians between rural and urban communities. A growing body of evidence suggests that the exposure to positive rural learning experiences has an influence on a physician's choice of practice location. Capitalizing on this observation, many medical schools have developed approaches that integrate rural exposure into their curricula during clerkship. It is postulated that a preclinical rural exposure may also be effective. However, to proceed further in development, accreditation requirements must be considered. In this investigation, academic equivalence between a preclinical rural community based teaching method and the established education model was assessed. METHOD: Two separate preclinical courses from the University of Calgary's three year Undergraduate Medical program were taught at two different rural sites in 2010 (11 students) and 2012 (12 students). The same academic content was delivered in the pilot sites as in the main teaching centre. To ensure consistency of teaching skills, faculty development was provided at each pilot site. Academic equivalence between the rural based learners and a matched cohort at the main University of Calgary site was determined using course examination scores, and the quality of the experience was evaluated through learner feedback. RESULTS: In both pilot courses there was no significant difference between examination scores of the rural distributed learners and the learners at the main University of Calgary site (p > 0.05). Feedback from the participating students demonstrated that the preceptors were very positively rated and, relative to the main site, the small group learning environment appeared to provide strengthened social support. CONCLUSION: These results suggest that community distributed education in pre-clerkship may offer academically equivalent training to existing traditional medical school curricula while also providing learners with positive rural social learning environments. The approach described may offer the potential to increase exposure to rural practice without the cost of constructing additional physical learning sites.

The role of lactoferrin binding protein B in mediating protection against human lactoferricin.

Bacteria that inhabit the mucosal surfaces of the respiratory and genitourinary tracts of mammals encounter an iron-deficient environment because of iron sequestration by the host iron-binding proteins transferrin and lactoferrin. Lactoferrin is also present in high concentrations at sites of inflammation where the cationic, antimicrobial peptide lactoferricin is produced by proteolysis of lactoferrin. Several Gram-negative pathogens express a lactoferrin receptor that enables the bacteria to use lactoferrin as an iron source. The receptor is composed of an integral membrane protein, lactoferrin binding protein A (LbpA), and a membrane-bound lipoprotein, lactoferrin binding protein B (LbpB). LbpA is essential for growth with lactoferrin as the sole iron source, whereas the role of LbpB in iron acquisition is not yet known. In this study, we demonstrate that LbpB from 2 different species is capable of providing protection against the killing activity of a human lactoferrin-derived peptide. We investigated the prevalence of lactoferrin receptors in bacteria and examined their sequence diversity. We propose that the protection against the cationic antimicrobial human lactoferrin-derived peptide is associated with clusters of negatively charged amino acids in the C-terminal lobe of LbpB that is a common feature of this protein.

Patterns of sequence variation within the Neisseria meningitidis lactoferrin binding proteins.

Lactoferrin binding proteins A and B (LbpA and LbpB) compose the lactoferrin receptor of the obligate human pathogen Neisseria meningitidis . This receptor is thought to be important for colonization and initiation of invasive disease because of its role in acquiring host iron and providing protection from the cationic peptide, lactoferricin. By virtue of its function, the receptor is accessible to the host immune system and displays substantial sequence variation. In this study, we analyzed a broad collection of LbpAs (62) and LbpBs (101) to determine the distribution of sequence variation within each protein and to search for patterns between sequence similarity and strain typing. The sequence variation in LbpA was predominantly observed in 3 surface loops and, surprisingly, in the N-terminal region immediately upstream of the predicted TonB box. The analysis of LbpB revealed that the variability was distributed throughout the protein, particularly in the highly variable negatively charged regions in the C-lobe, but otherwise was greater in the N-lobe than the C-lobe. There was no readily identifiable correlation between the sequence variation within LbpA, LbpB, multi-locus sequence type, or serogroup.

Patterns of structural and sequence variation within isotype lineages of the Neisseria meningitidis transferrin receptor system.

Neisseria meningitidis inhabits the human upper respiratory tract and is an important cause of sepsis and meningitis. A surface receptor comprised of transferrin-binding proteins A and B (TbpA and TbpB), is responsible for acquiring iron from host transferrin. Sequence and immunological diversity divides TbpBs into two distinct lineages; isotype I and isotype II. Two representative isotype I and II strains, B16B6 and M982, differ in their dependence on TbpB for in vitro growth on exogenous transferrin. The crystal structure of TbpB and a structural model for TbpA from the representative isotype I N. meningitidis strain B16B6 were obtained. The structures were integrated with a comprehensive analysis of the sequence diversity of these proteins to probe for potential functional differences. A distinct isotype I TbpA was identified that co-varied with TbpB and lacked sequence in the region for the loop 3 α-helix that is proposed to be involved in iron removal from transferrin. The tightly associated isotype I TbpBs had a distinct anchor peptide region, a distinct, smaller linker region between the lobes and lacked the large loops in the isotype II C-lobe. Sequences of the intact TbpB, the TbpB N-lobe, the TbpB C-lobe, and TbpA were subjected to phylogenetic analyses. The phylogenetic clustering of TbpA and the TbpB C-lobe were similar with two main branches comprising the isotype 1 and isotype 2 TbpBs, possibly suggesting an association between TbpA and the TbpB C-lobe. The intact TbpB and TbpB N-lobe had 4 main branches, one consisting of the isotype 1 TbpBs. One isotype 2 TbpB cluster appeared to consist of isotype 1 N-lobe sequences and isotype 2 C-lobe sequences, indicating the swapping of N-lobes and C-lobes. Our findings should inform future studies on the interaction between TbpB and TbpA and the process of iron acquisition.

Rural longitudinal integrated clerkships: changing interests and demographics of medical students.

INTRODUCTION: The University of Calgary Longitudinal Integrated Clerkship (UCLIC) is an integrated curriculum of at least 32 weeks' duration based in rural communities. Rural LICs have been proposed as a method to respond to the needs of underserved rural communities; therefore, assessing evolving learner interest and demographics over time is of importance to rural communities. METHODS: Three surveys were administered to first-year medical students at the University of Calgary from the classes of 2009, 2010 and 2015. The surveys assessed demographic information as well as interest in and attitudes toward pursuing a rural-based LIC. RESULTS: Overall, 42% of students (76% of decided students) reported that they would consider the rural UCLIC. Between 2009 and 2010, the proportion of students who would not consider the UCLIC decreased from 25% to 8%, and thereafter was maintained at that level. Over the same period, interest among students considering Royal College of Physicians and Surgeons of Canada (RCPSC) specialties significantly increased. Although student attitudes about the value of the LIC were consistently positive, students remained concerned about social considerations. CONCLUSION: There has been an increase in student willingness to consider a rural LIC, most significantly among students interested in RCPSC specialties. Career plans and demographics of students continue to influence their interest in and attitudes toward LICs.

INTRODUCTION: Le stage intégré longitudinal (SIL) de l'Université de Calgary (ou UCLIC pour University of Calgary Longitudinal Integrated Clerkship) est un programme intégré d'une durée minimale de 32 semaines en communauté rurale. Les SIL ruraux ont été proposés comme moyen de répondre aux besoins des communautés rurales moins bien desservies; il est donc important pour les communautés rurales de suivre l'évolution des intérêts et des caractéristiques démographiques des stagiaires au fil du temps. MÉTHODES: Trois sondages ont été administrés à des étudiants de première année de médecine à l'Université de Calgary des promotions de 2009, 2010 et 2015. Les sondages portaient sur leurs données démographiques de même que sur leur intérêt et leurs attitudes à l'endroit d'un SIL en milieu rural. RÉSULTATS: Dans l'ensemble, 42 % des étudiants (76 % des étudiants décidés) ont déclaré qu'ils envisageraient un SIL en milieu rural. Entre 2009 et 2010, la proportion d'étudiants qui n'envisageaient pas un tel stage a diminué de 25 %, à 8 %, et par la suite s'est maintenue à ce niveau. Au cours de la même période, l'intérêt à l'égard de ce stage chez les étudiants qui envisageaient une spécialisation du Collège royal des médecins et chirurgiens du Canada (CRMCC) a significativement augmenté. Même si leurs attitudes à propos de la valeur d'un SIL sont demeurées favorables, les étudiants ont dit se soucier des enjeux sociaux. CONCLUSION: On a constaté que les étudiants envisagent plus volontiers un SIL en milieu rural s'ils souhaitent faire une spécialisation du CRMCC. Les plans de carrière et les caractéristiques démographiques continuent d'influer sur leurs intérêts et leurs attitudes à l'endroit des SIL.

Sequence and structural diversity of transferrin receptors in Gram-negative porcine pathogens.

Actinobacillus pleuropneumoniae, Actinobacillus suis, and Haemophilus parasuis are bacterial pathogens from the upper respiratory tract that are responsible for a substantial burden of porcine disease. Although reduction of disease has been accomplished by intensive management practices, immunization remains an important strategy for disease prevention, particularly when intensive management practices are not feasible or suitable. An attractive target for vaccine development is the surface receptor involved in acquiring iron from host transferrin, since it is common to all three pathogenic species and has been shown to be essential for survival and disease causation. It has also recently been demonstrated that an engineered antigen derived from the lipoprotein component of the receptor, transferrin-binding protein B (TbpB), was more effective at preventing infection by H. parasuis than a commercial vaccine product. This study was initiated to explore the genetic and immunogenic diversity of the transferrin receptor system from these species. Nucleic acid sequences were obtained from a geographically and temporally diverse collection of isolates, consisting of 41 A. pleuropneumoniae strains, 30 H. parasuis strains, and 2 A. suis strains. Phylogenetic analyses demonstrated that the receptor protein sequences cluster independently of species, suggesting that there is genetic exchange between these species such that receptor-based vaccines should logically target all three species. To evaluate the cross-reactive response of TbpB-derived antigens, pigs were immunized with the intact TbpB, the TbpB N-lobe and the TbpB C-lobe from A. pleuropneumoniae strain H49 and the resulting sera were tested against a representative panel of TbpBs; demonstrating that the C-lobe induces a broadly cross-reactive response. Overall our results indicate that there is a common reservoir for transferrin receptor antigenic variation amongst these pathogens. While this could present a challenge to future vaccine development, our results suggest a rationally designed TbpB-based vaccine may provide protection against all three pathogens.

Bacterial receptors for host transferrin and lactoferrin: molecular mechanisms and role in host-microbe interactions.

Iron homeostasis in the mammalian host limits the availability of iron to invading pathogens and is thought to restrict iron availability for microbes inhabiting mucosal surfaces. The presence of surface receptors for the host iron-binding glycoproteins transferrin (Tf) and lactoferrin (Lf) in globally important Gram-negative bacterial pathogens of humans and food production animals suggests that Tf and Lf are important sources of iron in the upper respiratory or genitourinary tracts, where they exclusively reside. Lf receptors have the additional function of protecting against host cationic antimicrobial peptides, suggesting that the bacteria expressing these receptors reside in a niche where exposure is likely. In this review we compare Tf and Lf receptors with respect to their structural and functional features, their role in colonization and infection, and their distribution among pathogenic and commensal bacteria.