How Medical Students Apply Their Biomedical Science Knowledge to Patient Care in the Family Medicine Clerkship.

Medical students enter clerkships with the requisite biomedical science knowledge to engage in supervised patient care. While poised to apply this knowledge, students face the cognitive challenge of transfer: applying knowledge learned in one context (i.e., preclinical classroom) to solve problems in a different context (i.e., patients in the clinic). To help students navigate this challenge, a structured reflection exercise was developed using Kolb's experiential learning cycle as an organizing framework. Students selected a patient encounter (concrete experience), wrote and addressed biomedical science learning objectives related to the care of the patient (reflective observation), reflected on how addressing the learning objectives influenced patient care (abstract conceptualization), and described their attending engaging in a similar process (active experimentation). A directed content analysis of students' written reflections revealed that most students wrote clinical science learning objectives in addition to biomedical science learning objectives. When viewed through the lenses of knowledge encapsulation theory and illness script theory, some students recognized knowledge encapsulation as a process beginning to occur in their own approach and their attendings' approach to clinical reasoning. Students readily applied their biomedical science knowledge to explain the pathophysiologic basis of disease (fault illness script domain) and signs and symptoms (consequence illness script domain), with fewer addressing predisposing conditions (enabling conditions illness script domain). Instances in which students observed their attending applying biomedical science knowledge were rare. Implications for using structured reflective writing as a tool to facilitate student application of their biomedical science knowledge in clerkships are discussed. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01697-5.

Medical Student Attitudes and Perceptions on the Relevance of Neuroscience to Psychiatry: a Mixed Methods Study.

OBJECTIVE: Many psychiatry residency programs are actively incorporating neuroscience training into their curricula; however, relatively little scholarship exploring neuroscience and psychiatry integration in undergraduate medical education has been conducted. This study investigated second-year, pre-clerkship medical students' perceptions on the relationship between neuroscience and psychiatry following foundational neuroscience and behavior instruction to identify their views before they enter clerkships. METHODS: A mixed methods design combined qualitative analysis of medical students' essays in response to the prompt: "What is the relationship between neuroscience and psychiatry?" with quantitative analysis of survey responses on a 7-point scale. RESULTS: Ninety-three percent of the class participated in the study (n = 77). Learners rated neuroscience as important for understanding and treating psychiatric disorders, albeit less important for psychiatric compared to neurological disorders. Using applied thematic analysis, the authors identified qualitative themes. Specifically, participants recognized neuroscience as a foundational science for psychiatry, but some emphasized that factors other than neuroscience are needed to explain psychiatric disorders. Some students perceived neuroscience and psychiatry as complementary approaches to understanding the brain and behavior. Others identified a role for neuroscience in reducing the stigma of psychiatric disorders and thereby improving access to psychiatric care. CONCLUSIONS: The quantitative and qualitative findings reinforced each other and provided novel insight to pre-clerkship medical students' views on the relevance of neuroscience for psychiatry. Educating all medical students, not just psychiatry residents, on the neuroscience of psychiatric disorders may better equip the next generation of physicians, regardless of specialty, to care for their patients with psychiatric conditions.

A Case-Based Neuroanatomy Laboratory on the Neurobiology of Psychiatric Conditions for Second-Year Medical Students.

A case-based laboratory event integrating neuroanatomy, neuroscience, and psychiatry was implemented into a pre-clerkship psychiatry-based course for second-year medical students. Learners rotating through lab stations to work on different cases to make interdisciplinary connections among these fields is an innovative way for them to integrate foundational neurology, neuroanatomy, and psychiatry concepts. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-020-01171-0.

Correction to: "It is this very knowledge that makes us doctors": an applied thematic analysis of how medical students perceive the relevance of biomedical science knowledge to clinical medicine.

An amendment to this paper has been published and can be accessed via the original article.

Lessons learned while creating an effective emergency remote learning environment for students during the COVID-19 pandemic.

The COVID-19 pandemic is forcing many institutions to consider remote, virtual instruction for the safety of employees and students. Based upon the authors' experiences in transforming preclerkship medical science courses to virtual platforms, this paper shares tips for faculty rapidly establishing remote medical science instruction. With planning and support, faculty can create engaging, high-quality educational experiences for learners.

"It is this very knowledge that makes us doctors": an applied thematic analysis of how medical students perceive the relevance of biomedical science knowledge to clinical medicine.

BACKGROUND: Intensive study of the biomedical sciences remains a core component of undergraduate medical education with medical students often completing up to 2 years of biomedical science training prior to entering clerkships. While it is generally accepted that biomedical science knowledge is essential for clinical practice because it forms the basis of clinical reasoning and decision-making, whether medical students perceive an expanded role for their biomedical science knowledge remains to be examined. METHODS: We conducted a qualitative research study to explore how medical students in the first clerkship year perceived the relevance of biomedical science knowledge to clinical medicine during this pivotal time as they begin their transition from students to physicians. To identify previously unidentified perspectives and insights, we asked students to write brief essays in response to the prompt: How is biomedical science knowledge relevant to clinical medicine? Ten codes and four themes were interpreted through an applied thematic analysis of students' essays. RESULTS: Analysis of students' essays revealed novel perspectives previously unidentified by survey studies and focus groups. Specifically, students perceived their biomedical science knowledge as contributory to the development of adaptive expertise and professional identity formation, both viewed as essential developmental milestones for medical students. CONCLUSIONS: The results of this study have important implications for ongoing curricular reform efforts to improve the structure, content, delivery, and assessment of the undergraduate medical curriculum. Identifying the explicit and tacit elements of the formal, informal, and hidden curriculum that enable biomedical science knowledge to contribute to the development of adaptive expertise and professional identity formation will enable the purposeful design of innovations to support the acquisition of these critical educational outcomes.

Transgenic Mice Expressing Human α-Synuclein in Noradrenergic Neurons Develop Locus Ceruleus Pathology and Nonmotor Features of Parkinson's Disease.

Degeneration of locus ceruleus (LC) neurons and dysregulation of noradrenergic signaling are ubiquitous features of Parkinson's disease (PD). The LC is among the first brain regions affected by α-synuclein (asyn) pathology, yet how asyn affects these neurons remains unclear. LC-derived norepinephrine (NE) can stimulate neuroprotective mechanisms and modulate immune cells, while dysregulation of NE neurotransmission may exacerbate disease progression, particularly nonmotor symptoms, and contribute to the chronic neuroinflammation associated with PD pathology. Although transgenic mice overexpressing asyn have previously been developed, transgene expression is usually driven by pan-neuronal promoters and thus has not been selectively targeted to LC neurons. Here we report a novel transgenic mouse expressing human wild-type asyn under control of the noradrenergic-specific dopamine ß-hydroxylase promoter (DBH-hSNCA). These mice developed oligomeric and conformation-specific asyn in LC neurons, alterations in hippocampal and LC microglial abundance, upregulated GFAP expression, degeneration of LC fibers, decreased striatal DA metabolism, and age-dependent behaviors reminiscent of nonmotor symptoms of PD that were rescued by adrenergic receptor antagonists. These mice provide novel insights into how asyn pathology affects LC neurons and how central noradrenergic dysfunction may contribute to early PD pathophysiology.SIGNIFICANCE STATEMENT ɑ-Synuclein (asyn) pathology and loss of neurons in the locus ceruleus (LC) are two of the most ubiquitous neuropathologic features of Parkinson's disease (PD). Dysregulated norepinephrine (NE) neurotransmission is associated with the nonmotor symptoms of PD, including sleep disturbances, emotional changes such as anxiety and depression, and cognitive decline. Importantly, the loss of central NE may contribute to the chronic inflammation in, and progression of, PD. We have generated a novel transgenic mouse expressing human asyn in LC neurons to investigate how increased asyn expression affects the function of the central noradrenergic transmission and associated behaviors. We report cytotoxic effects of oligomeric and conformation-specific asyn, astrogliosis, LC fiber degeneration, disruptions in striatal dopamine metabolism, and age-dependent alterations in nonmotor behaviors without inclusions.

Loss of ß-arrestin2 in D2 cells alters neuronal excitability in the nucleus accumbens and behavioral responses to psychostimulants and opioids.

Psychostimulants and opioids increase dopamine (DA) neurotransmission, activating D1 and D2 G protein-coupled receptors. ß-arrestin2 (ßarr2) desensitizes and internalizes these receptors and initiates G protein-independent signaling. Previous work revealed that mice with a global or cell-specific knockout of ßarr2 have altered responses to certain drugs; however, the effects of ßarr2 on the excitability of medium spiny neurons (MSNs), and its role in mediating the rewarding effects of drugs of abuse are unknown. D1-Cre and D2-Cre transgenic mice were crossed with floxed ßarr2 mice to eliminate ßarr2 specifically in cells containing either D1 (D1ßarr2-KO ) or D2 (D2ßarr2-KO ) receptors. We used slice electrophysiology to characterize the role of ßarr2 in modulating D1 and D2 nucleus accumbens MSN intrinsic excitability in response to DA and tested the locomotor-activating and rewarding effects of cocaine and morphine in these mice. Eliminating ßarr2 attenuated the ability of DA to inhibit D2-MSNs and altered the DA-induced maximum firing rate in D1-MSNs. While D1ßarr2-KO mice had mostly normal drug responses, D2ßarr2-KO mice showed dose-dependent reductions in acute locomotor responses to cocaine and morphine, attenuated locomotor sensitization to cocaine, and blunted cocaine reward measured with conditioned place preference. Both D2ßarr2-KO and D1ßarr2-KO mice displayed an enhanced conditioned place preference for the highest dose of morphine. These results indicate that D1- and D2-derived ßarr2 functionally contribute to DA-induced changes in MSN intrinsic excitability and behavioral responses to psychostimulants and opioids dose-dependently.

Selective D2 and D3 receptor antagonists oppositely modulate cocaine responses in mice via distinct postsynaptic mechanisms in nucleus accumbens.

The dopamine D3 receptor (D3R) has emerged as a promising pharmacotherapeutic target for the treatment of several diseases including schizophrenia, Parkinson's disease, and substance use disorders. However, studies investigating the D3R's precise role in dopamine neurotransmission or how it may be exploited to modulate responses to drugs of abuse have produced contrasting results, in part because most D3R-targeted compounds often also interact with D2 receptors (D2R). To resolve this issue, we set out to systematically characterize and compare the consequences of selective D2R or D3R antagonists on the behavioral-stimulant properties of cocaine in mice, and to identify putative neurobiological mechanisms underlying their behavior-modifying effects. Pretreatment with the selective D2R antagonist L-741,626 attenuated, while pretreatment with the selective D3R antagonist PG01037 enhanced, the locomotor-activating effects of both acute cocaine administration as well as sensitization following repeated cocaine dosing. While both antagonists potentiated cocaine-induced increases in presynaptic dopamine release, we report for the first time that D3R blockade uniquely facilitated dopamine-mediated excitation of D1-expressing medium spiny neurons in the nucleus accumbens. Collectively, our results demonstrate that selective D3R antagonism potentiates the behavioral-stimulant effects of cocaine in mice, an effect that is in direct opposition to that produced by selective D2R antagonism or nonselective D2-like receptor antagonists, and is likely mediated by facilitating D1-mediated excitation in the nucleus accumbens. These findings provide novel insights into the neuropharmacological actions of D3R antagonists on mesolimbic dopamine neurotransmission and their potential utility as pharmacotherapeutics.

Noradrenergic Transmission at Alpha1-Adrenergic Receptors in the Ventral Periaqueductal Gray Modulates Arousal.

BACKGROUND: Dysregulation of arousal is symptomatic of numerous psychiatric disorders. Previous research has shown that the activity of dopamine (DA) neurons in the ventral periaqueductal gray (vPAG) tracks with arousal state, and lesions of vPAGDA cells increase sleep. However, the circuitry controlling these wake-promoting DA neurons is unknown. METHODS: This study combined designer receptors exclusively activated by designer drugs (DREADDs), behavioral pharmacology, electrophysiology, and immunoelectron microscopy in male and female mice to elucidate mechanisms in the vPAG that promote arousal. RESULTS: Activation of locus coeruleus projections to the vPAG or vPAGDA neurons induced by DREADDs promoted arousal. Similarly, agonist stimulation of vPAG alpha1-adrenergic receptors (α1ARs) increased latency to fall asleep, whereas α1AR blockade had the opposite effect. α1AR stimulation drove vPAGDA activity in a glutamate-dependent, action potential-independent manner. Compared with other dopaminergic brain regions, α1ARs were enriched on astrocytes in the vPAG, and mimicking α1AR transmission specifically in vPAG astrocytes via Gq-DREADDS was sufficient to increase arousal. In general, the wake-promoting effects observed were not accompanied by hyperactivity. CONCLUSIONS: These experiments revealed that vPAG α1ARs increase arousal, promote glutamatergic input onto vPAGDA neurons, and are abundantly expressed on astrocytes. Activation of locus coeruleus inputs, vPAG astrocytes, or vPAGDA neurons increase sleep latency but do not produce hyperactivity. Together, these results support an arousal circuit whereby noradrenergic transmission at astrocytic α1ARs activates wake-promoting vPAGDA neurons via glutamate transmission.

In vivo detection of optically-evoked opioid peptide release.

Though the last decade has seen accelerated advances in techniques and technologies to perturb neuronal circuitry in the brain, we are still poorly equipped to adequately dissect endogenous peptide release in vivo. To this end we developed a system that combines in vivo optogenetics with microdialysis and a highly sensitive mass spectrometry-based assay to measure opioid peptide release in freely moving rodents.

LSD1 protects against hippocampal and cortical neurodegeneration.

To investigate the mechanisms that maintain differentiated cells, here we inducibly delete the histone demethylase LSD1/KDM1A in adult mice. Loss of LSD1 leads to paralysis, along with widespread hippocampus and cortex neurodegeneration, and learning and memory defects. We focus on the hippocampus neuronal cell death, as well as the potential link between LSD1 and human neurodegenerative disease and find that loss of LSD1 induces transcription changes in common neurodegeneration pathways, along with the re-activation of stem cell genes, in the degenerating hippocampus. These data implicate LSD1 in the prevention of neurodegeneration via the inhibition of inappropriate transcription. Surprisingly, we also find that transcriptional changes in the hippocampus are similar to Alzheimer's disease (AD) and frontotemporal dementia (FTD) cases, and LSD1 is specifically mislocalized to pathological protein aggregates in these cases. These data raise the possibility that pathological aggregation could compromise the function of LSD1 in AD and FTD."LSD1 is a histone demethylase that plays many roles during development. Here, the authors provide evidence that loss of LSD1 in adult mice leads to paralysis and neurodegeneration in the hippocampus and cortex and suggest a potential link between LSD1 and human neurodegenerative disease.

Arresting the Development of Addiction: The Role of ß-Arrestin 2 in Drug Abuse.

The protein ß-arrestin (ßarr) 2 directly interacts with receptors and signaling pathways that mediate the behavioral effects of drugs of abuse, making it a prime candidate for therapeutic interventions. ßarr2 drives desensitization and internalization of G protein-coupled receptors, including dopamine, opioid, and cannabinoid receptors, and it can also trigger G protein-independent intracellular signaling. ßarr2 mediates several drug-induced behaviors, but the relationship is complex and dependent on the type of behavior (e.g., psychomotor versus reward), the class of drug (e.g., psychostimulant versus opioid), and the circuit being interrogated (e.g., brain region, cell type, and specific receptor ligand). Here we discuss the current state of research concerning the contribution of ßarr2 to the psychomotor and rewarding effects of addictive drugs. Next we identify key knowledge gaps and suggest new tools and approaches needed to further elucidate the neuroanatomical substrates and neurobiological mechanisms to explain how ßarr2 modulates behavioral responses to drugs of abuse, as well as its potential as a therapeutic target.

Individual differences in orexin-I receptor modulation of motivation for the opioid remifentanil.

Orexin-1 receptors (Ox1Rs) have been implicated in the motivation for drugs of abuse. Here, we utilized a within-session behavioral-economics threshold procedure to screen for individual differences in economic demand for the ultra-short-acting opioid remifentanil and to test whether antagonism of Ox1Rs reduces remifentanil demand. The behavioral-economics procedure revealed robust individual differences in free consumption of remifentanil (Q0 parameter; hedonic set point). Rats with low baseline Q0 (low takers) displayed high demand elasticity (α parameter; reduced responding as drug price increased indicating low motivation for drug), whereas subjects with a higher Q0 (high takers) exhibit low demand elasticity (low α) by continuing to self-administer remifentanil despite increased cost (reflecting higher motivation for drug). In a punished responding paradigm utilizing footshock, subjects that were classified as high takers at baseline withstood twice as much shock as low takers to continue self-administering remifentanil. Interestingly, Ox1R antagonism with SB-334867 reduced Q0 and increased α in low takers but not in high takers. Similarly, the Ox1R antagonist attenuated cue-induced, but not drug-induced, reinstatement of remifentanil seeking in low takers but had no significant effect on reinstatement of drug seeking in high takers. Together, these data reveal a novel role of orexins in demand for remifentanil: Ox1Rs modulate demand in low takers but not in individuals that exhibit addictive-like behaviors (high takers). Finally, the behavioral assays in this study can serve as a novel laboratory model for studying individual differences in opioid use disorders.

Dopamine and opioid systems interact within the nucleus accumbens to maintain monogamous pair bonds.

Prairie vole breeder pairs form monogamous pair bonds, which are maintained through the expression of selective aggression toward novel conspecifics. Here, we utilize behavioral and anatomical techniques to extend the current understanding of neural mechanisms that mediate pair bond maintenance. For both sexes, we show that pair bonding up-regulates mRNA expression for genes encoding D1-like dopamine (DA) receptors and dynorphin as well as enhances stimulated DA release within the nucleus accumbens (NAc). We next show that D1-like receptor regulation of selective aggression is mediated through downstream activation of kappa-opioid receptors (KORs) and that activation of these receptors mediates social avoidance. Finally, we also identified sex-specific alterations in KOR binding density within the NAc shell of paired males and demonstrate that this alteration contributes to the neuroprotective effect of pair bonding against drug reward. Together, these findings suggest motivational and valence processing systems interact to mediate the maintenance of social bonds.

Rapid dopamine transmission within the nucleus accumbens: dramatic difference between morphine and oxycodone delivery.

While most drugs of abuse increase dopamine neurotransmission, rapid neurochemical measurements show that different drugs evoke distinct dopamine release patterns within the nucleus accumbens. Rapid changes in dopamine concentration following psychostimulant administration have been well studied; however, such changes have never been examined following opioid delivery. Here, we provide novel measures of rapid dopamine release following intravenous infusion of two opioids, morphine and oxycodone, in drug-naïve rats using fast-scan cyclic voltammetry and rapid (1 min) microdialysis coupled with high-performance liquid chromatography - tandem mass spectrometry (HPLC-MS). In addition to measuring rapid dopamine transmission, microdialysis HPLC-MS measures changes in GABA, glutamate, monoamines, monoamine metabolites and several other neurotransmitters. Although both opioids increased dopamine release in the nucleus accumbens, their patterns of drug-evoked dopamine transmission differed dramatically. Oxycodone evoked a robust and stable increase in dopamine concentration and a robust increase in the frequency and amplitude of phasic dopamine release events. Conversely, morphine evoked a brief (~ 1 min) increase in dopamine that was coincident with a surge in GABA concentration and then both transmitters returned to baseline levels. Thus, by providing rapid measures of neurotransmission, this study reveals previously unknown differences in opioid-induced neurotransmitter signaling. Investigating these differences may be essential for understanding how these two drugs of abuse could differentially usurp motivational circuitry and powerfully influence behavior.

Development of behavioral preferences for the optimal choice following unexpected reward omission is mediated by a reduction of D2-like receptor tone in the nucleus accumbens.

To survive in a dynamic environment, animals must identify changes in resource availability and rapidly apply adaptive strategies to obtain resources that promote survival. We have utilised a behavioral paradigm to assess differences in foraging strategy when resource (reward) availability unexpectedly changes. When reward magnitude was reduced by 50% (receive one reward pellet instead of two), male and female rats developed a preference for the optimal choice by the second session. However, when an expected reward was omitted (receive no reward pellets instead of one), subjects displayed a robust preference for the optimal choice during the very first session. Previous research shows that, when an expected reward is omitted, dopamine neurons phasically decrease their firing rate, which is hypothesised to decrease dopamine release preferentially affecting D2-like receptors. As robust changes in behavioral preference were specific to reward omission, we tested this hypothesis and the functional role of D1- and D2-like receptors in the nucleus accumbens in mediating the rapid development of a behavioral preference for the rewarded option during reward omission in male rats. Blockade of both receptor types had no effect on this behavior; however, holding D2-like, but not D1-like, receptor tone via infusion of dopamine receptor agonists prevented the development of the preference for the rewarded option during reward omission. These results demonstrate that avoiding an outcome that has been tagged with aversive motivational properties is facilitated through decreased dopamine transmission and subsequent functional disruption of D2-like, but not D1-like, receptor tone in the nucleus accumbens.

Chemical gradients within brain extracellular space measured using low flow push-pull perfusion sampling in vivo.

Although populations of neurons are known to vary on the micrometer scale, little is known about whether basal concentrations of neurotransmitters also vary on this scale. We used low-flow push-pull perfusion to test if such chemical gradients exist between several small brain nuclei. A miniaturized polyimide-encased push-pull probe was developed and used to measure basal neurotransmitter spatial gradients within brain of live animals with 0.004 mm(3) resolution. We simultaneously measured dopamine (DA), norepinephrine, serotonin (5-HT), glutamate, γ-aminobutyric acid (GABA), aspartate (Asp), glycine (Gly), acetylcholine (ACh), and several neurotransmitter metabolites. Significant differences in basal concentrations between midbrain regions as little as 200 µm apart were observed. For example, dopamine in the ventral tegmental area (VTA) was 4.8 ± 1.5 nM but in the red nucleus was 0.5 ± 0.2 nM. Regions of high glutamate concentration and variability were found within the VTA of some individuals, suggesting hot spots of glutamatergic activity. Measurements were also made within the nucleus accumbens core and shell. Differences were not observed in dopamine and 5-HT in the core and shell; but their metabolites homovanillic acid (460 ± 60 nM and 130 ± 60 nM respectively) and 5-hydroxyindoleacetic acid (720 ± 200 nM and 220 ± 50 nM respectively) did differ significantly, suggesting differences in dopamine and 5-HT activity in these brain regions. Maintenance of these gradients depends upon a variety of mechanisms. Such gradients likely underlie highly localized effects of drugs and control of behavior that have been found using other techniques.

Cocaine must enter the brain to evoke unconditioned dopamine release within the nucleus accumbens shell.

In addition to blocking dopamine (DA) uptake, cocaine also causes an unconditioned increase in DA release. In drug naive rats, this effect is most robust within the nucleus accumbens (NAc) shell. Recent studies have shown that, in rats trained to self-administer cocaine, cocaine may act in the periphery to enhance mesolimbic DA release. Further, these studies have suggested that peripheral cocaine action may also enhance unconditioned DA release. Here, we test if it is necessary for cocaine to enter the brain to evoke unconditioned increases in DA release within the NAc shell. Administration of a cocaine analogue that crosses the blood brain barrier (cocaine HCl) enhances electrically evoked DA release and the number of cocaine-evoked phasic DA release events (i.e., DA transients) within the NAc shell. However, administration of a cocaine analogue that does not cross the blood brain barrier (cocaine MI) does not alter either measure. We therefore conclude that cocaine must act within the central nervous system to evoke unconditioned DA release within the NAc shell.