[Gender-specific Aspects of Knowledge and Gender Sensitivity in Medical Education - An Inventory]. / Geschlechtsspezifisches Wissen und Gendersensibilität in der medizinischen Lehre - eine Bestandsaufnahme.

BACKGROUND: Gender competence is an essential prerequisite for individualized patient care. OBJECTIVES: The aim of this study is to survey the level of knowledge and attitudes towards gender-related aspects at 2 German medical schools. MATERIALS AND METHODS: An online questionnaire was used to collect data on gender competence in medicine including biological basics of sex differences, clinical aspects, socio-cultural factors as well as questions regarding gender role concepts. In total 1 671 students, 330 basic scientists, 413 physicians and 53 professors from the German Medical Schools Münster and Duisburg-Essen took part in the survey. RESULTS: The level of knowledge on gender-specific aspects in medicine is unsatisfactory at both medical schools. The average of correct answers on gender-related questions of all groups is less than 55%. Looking at gender sensitivity the existence and importance of gender disparities in medicine is agreed upon by the majority of participants. However, most of them regard only the patients' but not the physician's sex as relevant. CONCLUSIONS: The study reveals a lack of knowledge and the necessity for improvement: the integration of gender-specific aspects into medical routine is an important step towards a truly individualized medical care.

[Why medicine? Analyzing students' motives for studying medicine]. / Warum Medizin studieren?

BACKGROUND: Despite increasing numbers of physicians, shortage of doctors is a predominant problem in the German health care system. AIM: AIM of the present study is a detailed and gendered analysis of current motives to study medicine in order to deduce implications for securing medical care in the future. METHODS: Study motives of medical students from Duisburg-Essen and Muenster were assessed using an online questionnaire. 13 given motives had to be rated on a 5 point Likert-scale according to their relevance for the decision to study medicine. Descriptive analysis regarding age, gender, location and study period was performed and a dichotomization of data (agreement vs. disagreement) was undertaken for logistic regression analysis. RESULTS: 1545 medical students took part in the survey (64.5% female). "Many-faceted workspaces", "varied tasks", "helping patients", "scientific interest" and "good career prospects" - backward-sorted - were the most frequent study motives indicated by medical students. The aspect "helping patients" was more important to female than to male students, the latter rated career-associated motives e. g. income, reputation etc. as more relevant. Only for about 8% of the respondents - independently of gender - compatibility of job and family was a motive to study medicine. CONCLUSION: Perspectively, results of this study could help to shape medicine in a way that will appeal to the growing up generation of doctors: a sophisticated, demanding and fulfilling occupation compatible with family with options to carve out a career for those who want to - regardless of gender. Furthermore, coaching programs paralleling either medical studies or work as clinician should be considered to improve the matching of gender-specific study motives and careers.

[Sex- and gender-sensitive research in epidemiology and medicine: how can this be achieved? Aims and first results of the network "Sex-/Gender-Sensitive Research in Epidemiology, Neurosciences and Genetics/Cancer Research"]. / Geschlechtersensible Forschung in Epidemiologie und Medizin: Wie kann das erreicht werden? : Ziele und erste Ergebnisse des Verbundes "Geschlechtersensible Forschung in Epidemiologie, Neurowissenschaften und Genetik/Tumorforschung".

BACKGROUND: It is considered general knowledge among physicians and epidemiologists that biological and social aspects associated with being male or female have a strong influence on health and disease. Integrating these aspects into research is necessary to counteract the problems--including ethical problems--resulting from a different evidence basis for men and women. From January 2011 to June 2014 the Federal Ministry of Education and Research supported the network "Sex-/Gender-Sensitive Research in Epidemiology, Neuroscience and Genetics/Cancer Research" with three subprojects, which aimed to promote gender-sensitive research practices. The concepts and results are presented in this article. METHODS: The subproject gathered data (literature analyses, questionnaires) and offered programs for young scientists. Experiences and results were collected and generalized, for instance, in the form of definitions of terms. RESULTS: 50 young scientists have taken part in the training program, identifying associations and barriers in sex-/gender-sensitive research. Among others, a working definition for "sex-/gender-sensitive research" was developed, as well as definitions for the terms "sex-specific" (for biological characteristics that are specific to men or women) and "sex-/gender-dependent" or "sex-/gender-associated" (for biological and social factors, for which the extent of occurrence differs between the sexes). PRELIMINARY ASSESSMENT: The concepts realized by the network are well suited to stimulate further development and discussions. The definition of terms is an important base for a productive and high-yielding interdisciplinary collaboration.

Suppression of ethylnitrosourea-induced schwannoma development involves elimination of neu/erbB-2 mutant premalignant cells in the resistant BDIV rat strain.

Contrary to the response of rats of the highly sensitive inbred strain BDIX, BDIV rats are resistant to the induction of malignant schwannomas by exposure to the alkylating N-nitroso carcinogen N-ethyl-N-nitrosourea (EtNU). In BDIX rats, a point mutation at nucleotide 2012 in the transmembrane region of the neu/erbB-2 gene has proved to be a very early marker of initiated Schwann precursor cells with an elevated risk of malignant transformation, and is diagnostic of the resulting schwannomas. To gain insight into the cellular and molecular mechanisms responsible for the resistance of the BDIV strain, comparative quantitative neu mutation analyses combined with histomorphological studies were performed on the trigeminal nerves of EtNU-treated BDIV and BDIX rats as well as on their (BDIX x BDIV) F1 progeny. It was found that neu-mutant Schwann cells are initially present at comparable frequency in the trigeminal nerves of both resistant and sensitive animals. Contrasting with the progressive multiplication of mutant Schwann cells in BDIX trigeminal nerves, however, the numbers of mutant cells began to decrease during the intermediary phase of the carcinogenic process in BDIV animals, and premalignant neu-mutant cells were no longer detectable by the time BDIX rats developed full-blown trigeminal schwannomas. The resistance of BDIV rats thus involves the elimination of initiated neu-mutant Schwann cells during the postinitiation period of EtNU-induced schwannomagenesis via mechanisms that remain to be clarified.

Allele-specific losses of heterozygosity on chromosomes 1 and 17 revealed by whole genome scan of ethylnitrosourea-induced BDIX x BDIV hybrid rat gliomas.

The induction of neural tumors by N-ethyl-N-nitrosourea (EtNU) in inbred strains of rats has evolved as a valuable model system of developmental stage- and cell type-dependent oncogenesis. Tumor yield and latency times are strongly influenced by genetic background. Compared with BDIX rats, BDIV rats are relatively resistant to the induction of brain tumors by EtNU, with a lower tumor incidence and latency periods prolonged by a factor of 3. To characterize genetic abnormalities associated with impaired tumor suppressor gene function in neuro-oncogenesis, losses of heterozygosity (LOHs) and microsatellite instability (MI) were investigated in brain tumors induced by EtNU in (BDIV x BDIX) F(1) and F(2) rats. The polymerase chain reaction was used to amplify 55 polymorphic microsatellite markers spanning the entire rat genome. The tumors displayed different histologies and grades of malignancy, corresponding to part of the spectrum of human gliomas. MI was not observed in any of the tumors. LOH of rat chromosome 1q was predominantly detected in oligodendrogliomas and mixed gliomas, with a 30% incidence in informative cases. 11p15.5, the human genome region syntenic to the consensus region of LOHs observed on rat chromosome 1, has been shown to be involved in the formation of gliomas in humans. Furthermore, rat brain tumors of different histologies often showed allelic imbalances on chromosome 17p. In both cases of LOH, there was a clear bias in favor of the parental BDIV allele, suggesting the involvement of tumor suppressor genes functionally polymorphic between the two rat strains.

Comparative genomic in situ hybridization discloses recurrent gain of chromosome 4 in experimental gliomas of the rat.

The genetic characterization of experimental tumors is essential in order to evaluate their relevance as appropriate animal models for human neoplasms. We have used flow cytometry and a recently established Comparative Genomic in situ Hybridization (CGH) protocol for the rat (Kappler et al., 1998) to investigate chromosome copy number changes in five ethylnitrosourea induced gliomas of the rat. Flow cytometry showed aneuploid DNA indices in three of the tumors investigated. CGH analysis of primary tumors revealed whole chromosome and subchromosomal gains of rat chromosomes (RNO) 1, 2, 4, 6, 7, 10, 11, 12, and 13. Loss of RNO 5q23-->q35 was apparent in one tumor. High level copy number gains were not observed using CGH as well as semiquantitative PCR with Tgfa, Met and Hbb primers. Low copy number gain of RNO 4 represents the most common aberration, since it was detected in four of five tumors investigated. Three tumors showed gain of RNO 7, while two tumors showed gains of RNO 10q31-->qter and RNO 12q. Deletion of RNO 5q23-->q35 and gain of RNO 4 occurred mutually exclusively. Therefore, we conclude that these two alterations may represent different pathways in the pathogenesis of experimental gliomas in the rat. Findings are discussed in analogy to human gliomas.

Ethylnitrosourea-induced development of malignant schwannomas in the rat: two distinct loci on chromosome of 10 involved in tumor susceptibility and oncogenesis.

Inbred rodent strains with differing sensitivity to experimental tumor induction provide model systems for the detection of genes that either are responsible for cancer predisposition or modify the process of carcinogenesis. Rats of the inbred BD strains differ in their susceptibility to the induction of neural tumors by N-ethyl-N-nitrosourea (EtNU). Newborn BDIX rats that are exposed to EtNU (80 microg/g body weight; injected s.c.) develop malignant schwannomas predominantly of the trigeminal nerves with an incidence >85%, whereas BDIV rats are entirely resistant. A T:A-->A:T transversion mutation at nucleotide 2012 of the neu (erbB-2) gene on chromosome 10, presumably the initial event in EtNU-induced schwannoma development, is later followed by loss of the wild-type neu allele. Genetic crosses between BDIX and BDIV rats served: (a) to investigate the inheritance of susceptibility; (b) to obtain animals informative for the mapping of losses of heterozygosity (LOH) in tumors with polymorphic simple sequence length polymorphisms (SSLPs); and (c) to localize genes associated with schwannoma susceptibility by linkage analysis with SSLPs. Schwannoma development was strongly suppressed in F1 animals (20% incidence). All of the F1 schwannomas displayed LOH on chromosome 10, with a consensus region on the telomeric tip encompassing D10Rat3, D10Mgh16 and D10Rat2 but excluding neu. A strong bias toward losing the BDIV alleles suggests the involvement of a BDIV-specific tumor suppressor gene(s). Targeted linkage analysis with chromosome 10 SSLPs in F2 intercross and backcross animals localized schwannoma susceptibility to a region around D10Wox23, 30 cM centromeric to the tip. Ninety-four % of F1 tumors exhibited additional LOH at this region. Two distinct loci on chromosome 10 may thus be connected with susceptibility to the induction and development of schwannomas in rats exposed to EtNU.

Determinants of carcinogen-induced malignant conversion in rat brain: proliferative properties of neural precursor cell subpopulations analyzed by multi-parameter flow cytometry.

The induction of neuroectodermal tumors in BDIX rats by N-ethyl-N-nitrosourea (EtNU) is a model system for the analysis of transformation risk as a function of target cell properties. The yield of neural tumors induced by EtNU varies with the developmental window chosen for the carcinogen pulse; i.e. with the relative proportions of different neural precursor cells exposed to EtNU at distinct developmental stages. Different subsets of fetal brain cells have been characterized previously with respect to their relative risk of malignant transformation using monoclonal antibodies. As DNA replication of target cells is considered to be a prerequisite for malignant conversion, we analyzed the cell cycle distributions, using flow-cytometry, of 4 subsets of neural precursor cells considered to be at high or low risk, respectively, of malignant conversion by EtNU in vivo. Cell populations associated with an elevated risk of transformation exhibited higher proportions of cells in S-phase. One of the 2 putative low-risk populations exhibited a significantly lower fraction of S-phase cells, while the value of the second one exceeded those obtained for the 2 high-risk subpopulations. Therefore, a higher than average fraction of cells in S-phase appears to be positively correlated with the cellular risk of malignant transformation by EtNU, but does not represent a dominant risk determinant per se.

In vitro differentiation of neural progenitor cells from prenatal rat brain: common cell surface glycoprotein on three glial cell subsets.

Glial progenitor cell differentiation and cell lineage relationships during brain development are complex hierarchical processes depending on genetic programming, cell-cell interactions, and microenvironmental factors. The identification of precursor cell-specific antigens provides a tool for the study of both normal development and deviations from lineage-specific differentiation associated with malignant transformation. Monoclonal antibody (mAb) RB13-6 recognizes a 130-kDa cell surface glycoprotein (gp130RB13-6) expressed by a subset of 9OAcGD3-positive glial precursor cells scattered in the rat neuroepithelium on prenatal day (PRD) 13. During prenatal development the fraction of gp130RB13-6-positive fetal brain cells (FBC) decreased from about 18% (PRD 14) to about 1.5% (PRD 22), coinciding with increasing fractions of more mature cell types, as indicated by the elevated expression of p24RB21-15, another cell surface determinant specified by mAb RB21-15 (Kindler-Röhrborn et al.; Differentiation 30:53-60, 1985) and other neural cell type-specific markers. Accordingly, gp130RB13-6 positive precursor cells were localized in the ventricular zones throughout brain development. Concomitant with their formation and in the adult rat brain, ependymal layers lining the ventricular surface, choroid plexus, and the leptomeninges were intensely labeled by anti-gp130RB13-6 mAb. As visualized by confocal laser scanning microscopy of FBC cultures from PRD 13, gp130RB13-6 was coexpressed with the RC1 antigen by progenitor cells morphologically resembling radial glia cells. In addition, a very small subpopulation of astrocytes coexpressing gp130RB13-6 and glial fibrillary acidic protein (GFAP; < 5%) occurred 3 days after seeding. Primary FBC cultures from PRD 18 contained an increased subset of astrocytes coexpressing gp130RB13-6 and GFAP (approximately 25% of all gp130RB13-6 expressing cells), apparently generated from gp130RB13-6-positive precursors. Corresponding to in vivo conditions, ciliated ependymal cells but also microglial cells/macrophages and leptomeningeal cells showed strong expression of gp130RB13-6 in culture. We thus present a new glycoprotein on the cell surfaces of a glial progenitor cell subset for further studies of cell lineage relationships between radial glia cells, astrocytes, and ependymal cells.

Characterization of rat NCA/CD9 cell surface antigen and its expression by normal and malignant neural cells.

As part of investigations on ethylnitrosourea (EtNU)-induced neuro-oncogenesis in the rat, we have produced monoclonal antibodies (Mabs) specific for neural cell surface antigens (NCAs) by immunization with cells of the clonal tumorigenic neural rat cell line BT4Ca. Mabs designated as anti-NCA (alpha NCA1, alpha NCA2, alpha NCA3, alpha NCA4, and alpha NCA5) recognize proteins of 25 kDa and 23 kDa, as shown by immunoprecipitation and Western blot. The predominant 25-kDa protein was purified from BT4Ca cells by immunoaffinity chromatography with immobilized Mab alpha NCA1 and identified by N-terminal sequencing as the rat homologue of the CD9 antigen. Identification of proline as N-terminal amino acid of the purified protein suggests post-translational modification of CD9 in the rat central nervous system. The NCA/CD9 protein was localized in distinct regions of fetal and adult rat brain by immunofluorescence staining of frozen sections. Flow cytometric analyses of isolated fetal rat brain cells (FBC) showed that the proportion and number of NCA/CD9-expressing cells increased during prenatal development. Immunoreactivity of approximately 40% of brain cells isolated 13 days post conception (p.c.) indicated that NCA/CD9 is expressed by neuronal precursors at this stage of development. In primary cultures of rat FBC isolated 18 days p.c., the NCA/CD9 antigen was expressed by all premature and mature astrocytes, oligodendrocytes, ependymal cells, and microglial cells, but not by E-N-CAM-expressing neuronal progenitor cells and neurons. Furthermore, eight out of ten EtNU-induced malignant neural rat cell lines as well as EtNU-induced tumors of the central and peripheral nervous system exhibited intermediate or strong immunoreactivity with Mab alpha NCA1. Expression of the NCA/CD9 protein is, therefore, characteristic of both normal glial precursor cells and their malignant counterparts in the rat.

A constitutional BWS-related t(11;16) chromosome translocation occurring in the same region of chromosome 16 implicated in Wilms' tumors.

Beckwith-Wiedemann syndrome (BWS) is a congenital overgrowth disorder with a varying spectrum of clinical manifestations including macroglossia, omphalocele, hemihypertrophy, and a predisposition to a subset of embryonal tumors, most frequently Wilms' tumor (WT). A variety of cytogenetic, genetic linkage, and molecular mapping data implicate a gene or genes on chromosome band 11p15.5 in BWS and its related tumors. However, some families with BWS do not show linkage to 11p15, and other alterations have been found in Wilms' tumors as well. One such alteration is loss of heterozygosity (LOH) for chromosome arm 16q. Here we have analyzed a balanced t(11;16)(p15;q13) chromosomal translocation associated with the BWS phenotype and mapped the breakpoint positions for both chromosomes 11 and 16 by using somatic cell hybrids and polymorphic markers. The chromosome 11 breakpoint was found to lie distal to the D11S12 locus, but proximal to TH on 11p15.5, a region shown previously to contain other BWS-related chromosomal events. The chromosome 16 breakpoint was distal to D16S290 in 16q13, but proximal to loci D16S265, D16S267, and D16S164 in band 16q21. This area encompasses the region of LOH occurring through mitotic recombination in sporadic WT. This raises interesting possibilities for the genetic and epigenetic involvement of both chromosomal regions (11p15 and 16q13) in the pathogenesis of BWS and Wilms' tumor.

Surface antigens of cell subpopulations in prenatal rat brain are expressed in a characteristic non-random pattern on their ethylnitrosourea-induced malignant counterparts.

Selective induction of neural tumors in the rat by single-dose exposure of the immature nervous system to ethylnitrosourea (EtNU) is a model for the study of cell lineage-, differentiation stage-, and carcinogen-dependent mechanisms in neuro-oncogenesis. Overall yields and relative frequencies of different types of neural tumors vary with the developmental window chosen for the EtNU-pulse. Precursor cells belonging to different neural lineages and targeted by the carcinogen at distinct developmental stages may thus bear a differential risk of malignant conversion. To specify subpopulations of neural precursors in fetal (prenatal day 18) BDIX-rat brain, four monoclonal antibodies (mAbs) recognizing cell surface differentiation antigens were used: mAb RB13-2 directed against O-acetylated gangliosides and binding to approximately 36% of fetal brain cells (FBC); mAb RB13-6 recognizing a 130 kDa glycoprotein (expressed by approximately 8% of FBC); and mAbs RB21-7 and RB21-15 which bind, respectively, to embryonal neural cell adhesion molecules (N-CAM) and a 24 kDa protein (expressed by approximately 55% and 12% of FBC). Antigen expression profiles were compared with those of 14 primary brain tumors and 16 malignant neural cell lines, all of which had been induced by EtNU on prenatal day 18 in vivo. Monoclonal antibodies RB13-2 and RB21-7 did not bind to any of the tumors or cell lines. In contrast, mAbs RB13-6 and RB21-15 both reacted with 14/14 tumors, and with 16/16 and 10/16 cell lines, respectively. Expression of the latter antigens might thus specify lineage-specific stages of FBC development/differentiation particularly susceptible to EtNU-induced malignant transformation. Two-color fluorescence analyses revealed three subsets of FBC binding mAb RB13-6 (RB13-2+/RB13-6+/RB21-15-; RB13-2-/RB13-6+/RB21-15-; and RB13-2-/RB13-6+/RB21-15+), representing successive stages of differentiation.

In vitro differentiation of E-N-CAM expressing rat neural precursor cells isolated by FACS during prenatal development.

Most fetal rat brain cells expressing the embryonal, highly sialylated form of the cell adhesion molecule N-CAM (E-N-CAM) are precursor cells, as judged from the absence of marker molecules specific for mature neural cell types. However, the detection of E-N-CAM+ cells in frozen sections does not provide information on the lineage-specific differentiation of these cells during development. To investigate their differentiation behaviour in vitro, E-N-CAM+ cells were isolated at different times of brain development by fluorescence-activated cell sorting (FACS), using a monoclonal antibody (Mab RB21-7) which specifically recognizes polysialic acid (PSA) residues on E-N-CAM. Double-immunofluorescence analyses showed that the majority of E-N-CAM+ cells isolated on prenatal days 15 to 18 differentiated into neurons while a small subset of Mab RB21-7 binding cells proved to be astrocytic precursors and/or bipotential. The proportion of E-N-CAM+ astrocytic precursors increased during later development (prenatal day 22) concomitantly with the onset of gliogenesis. While conversion of E-N-CAM to mature forms of N-CAM was never observed in neurons during cultivation, E-N-CAM+ cells of the astrocyte lineage switched to N-CAM soon after the onset of GFAP expression. A lineage-specific transition of E-N-CAM to mature N-CAM expression is, therefore, suggested for these astrocytic progenitor cells during rat brain development.

A standardized protocol for flow cytometric analysis of cells isolated from cerebrospinal fluid.

Flow cytometry (FC) is an useful tool for the analysis of subpopulations in complex cell suspensions. When applying this method to the cerebrospinal fluid (CSF), some characteristic properties of this cell type must be taken into consideration: there are only few cells which decay rapidly in their native medium and during centrifugation. One aim of the immunostaining procedure preceding flow cytometric analysis must be to minimize cell loss in order to get an undistorted picture of 'true' CSF cell populations. Consequently, morphological flow cytometric plots of high resolution are an indispensable precondition for reliable determination of subpopulations defined by monoclonal antibody (Mab) binding. We describe a standardized protocol for the flow cytometric examination of CSF cells which minimizes undesired cell loss. By the use of a 'quality control' the extent of cell loss could be monitored. Examples of morphological flow cytometric plots are given. The subsequent determination of Mab binding subpopulations is critical when fluorescence intensities of antigen positive and negative cells are non-disjunct. A statistical test was developed for these cases often seen when cell surface determinants are expressed at low levels only.

Determination of immunoreactive fraction and kinetic parameters of a radiolabeled monoclonal antibody in the absence of antigen excess.

Monoclonal antibodies (Mabs) directed against cell surface determinants and conjugated to fluochromes, radionuclids or drugs are of increasing importance in cell and tumor biology as well as in clinical oncology. Many of the applications of Mab require precise and quantitative information regarding the molecular interactions of labeled antibody with the respective antigen expressed on the cell surface. These interactions are characterized by the association rate constant (ka), the dissociation rate constant (kd) and the antibody affinity constant (K). The immunoreactive fraction (IRF) of the labeled antibody molecules directly influences these parameters. IRF is usually reduced below 100% by antibody purification and labeling procedures and, in case of radiolabeled antibodies, by radiation damage during antibody storage. Besides the calculation of kinetic parameters, IRF should, therefore, be determined for the quality control of any antibody preparation before experimental or clinical application. Commonly used methods for measuring IRF are based on radioimmunoassays (RIA) on intact cells performed under antigen excess. However, especially with Mabs directed against cell surface antigens expressed in small numbers per cell and for displaying low affinity constants, these assays often give unsatisfactory results. We have, therefore, established a method which permits us to determine IRF, ka, kd and K for an 125I-labeled Mab with precision even in the absence of antigen excess.

Calibration of fluorescence intensities to quantify antibody binding surface determinants of cell subpopulations by flow cytometry.

Quantitative indirect immunofluorescence analysis by flow cytometry was used to determine the mean number of antibody binding sites per cell in a small subpopulation of rat brain cells expressing low levels of a cell surface differentiation antigen recognized by monoclonal antibody (Mab) RB13-6 (Kindler-Röhrborn et al.: Differentiation 30:53-60, 1985). For these non-disjunct distributions of fluorescence intensities, the cut-off border between antigen-positive and antigen-negative cells was defined by a statistical test. To eliminate the influence of accidental disturbances leading to incorrect statistical decisions, the curves for antigen-negative cells were fitted according to cell number and shape. The flow cytometer was calibrated with the use of a clonal cell line for which the average number of Mab RB13-6 binding sites per cell had previously been determined by radioimmunoassay and Scatchard-plot analysis. Using this analytical procedure, both the proportion of Mab binding brain cells and the mean number of Mab binding sites per Mab binding cell could be determined as a function of developmental stage.