Re-conceptualizing medical education in the post-COVID era.

PURPOSE: The COVID-19 pandemic has forced changes in the delivery of medical education. We aimed to explore these changes and determine whether they will impact the future of medical education in any way. METHODS: We invited leaders in medical education from all accessible US-based medical schools to participate in an online individual semi-structured interview. RESULTS: Representatives of 16 medical schools participated. They commented on the adequacy of online education for knowledge transfer, and the logistical advantages it offered, but decried its negative influence on social learning, interpersonal relationships and professional development of students, and its ineffectiveness for clinical education. Most participants indicated that they would maintain online learning for didactic purposes in the context of flipped classrooms but that a return to in-person education was essential for most other educational goals. Novel content will be introduced, especially in telemedicine and social medicine, and the students' roles and responsibilities in patient care and in curricular development may evolve in the future. CONCLUSIONS: This study is the first to document the practical steps that will be adopted by US medical schools in delivering medical education, which were prompted and reinforced by their experience during the COVID-19 pandemic.

Identifying the core concepts of pharmacology education: A global initiative.

BACKGROUND AND PURPOSE: In recent decades, a focus on the most critical and fundamental concepts has proven highly advantageous to students and educators in many science disciplines. Pharmacology, unlike microbiology, biochemistry, or physiology, lacks a consensus list of such core concepts. EXPERIMENTAL APPROACH: We sought to develop a research-based, globally relevant list of core concepts that all students completing a foundational pharmacology course should master. This two-part project consisted of exploratory and refinement phases. The exploratory phase involved empirical data mining of the introductory sections of five key textbooks, in parallel with an online survey of over 200 pharmacology educators from 17 countries across six continents. The refinement phase involved three Delphi rounds involving 24 experts from 15 countries across six continents. KEY RESULTS: The exploratory phase resulted in a consolidated list of 74 candidate core concepts. In the refinement phase, the expert group produced a consensus list of 25 core concepts of pharmacology. CONCLUSION AND IMPLICATIONS: This list will allow pharmacology educators everywhere to focus their efforts on the conceptual knowledge perceived to matter most by experts within the discipline. Next steps for this project include defining and unpacking each core concept and developing resources to help pharmacology educators globally teach and assess these concepts within their educational contexts.

Do Medical Students' Learning Styles and Approaches Explain Their Views and Behavior Regarding Lecture Attendance?

INTRODUCTION: Medical students' attendance at lectures, particularly in the preclinical years, has been steadily declining over the years. One of the many explanations offered for this observation is that students have different learning styles and approaches, such that not all of them benefit from attending lectures; however, no studies have specifically examined this possibility. While there is evidence against learning styles as affecting objective measures of learning, they are associated with subjective measures of learning and may therefore influence student behavior. We hypothesized that students' learning styles and/or approaches influence their views about the value and purpose of lectures and their motivation to attend them, which, in turn will affect their behavior. MATERIALS AND METHODS: A LimeSurvey was distributed to all preclinical students at the American University of Beirut. The survey included questions about demographic data, self-reported attendance rates in Year 1 of medical school, two validated and standardized questionnaires assessing the students' learning styles (visual, auditory, kinesthetic, tactile, group, individual) and learning approaches (superficial, deep, strategic), and a series of questions exploring the students' views about the purpose and value of lectures and their motivation to attend lectures. RESULTS: No associations were found between learning styles or approaches and attendance rates, but this may have been confounded by the mandatory attendance policy at the time. There were, however, a few positive associations between some learning styles or approaches and the students' views about the value of attending lectures. In particular, students with high scores as auditory learners tended to see absolutely no value in attending lectures, and those with high scores as group, auditory or visual learners, tended to see less value in taking their own notes in lectures. Students with superficial approaches to learning felt that watching videos of a lecture provides equivalent education to attending a lecture. There were no statistically significant associations with either the perceived purpose of lectures or the motivation to attend lectures after correction for multiple testing. CONCLUSIONS: This study reveals that except for some interesting findings related to auditory learners, differences in learning styles or approaches among students cannot adequately explain differences in their attitudes, and likely, behavior, regarding lecture attendance. The idea that learning styles and approaches can influence educational preferences and outcomes, while attractive and intuitive, continues to require supporting evidence. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01362-3.

Pharmacological regulation of cytochrome P450 metabolites of arachidonic acid attenuates cardiac injury in diabetic rats.

Diabetic cardiomyopathy (DCM) is a well-established complication of type 1 and type 2 diabetes associated with a high rate of morbidity and mortality. DCM is diagnosed at advanced and irreversible stages. Therefore, it is of utmost need to identify novel mechanistic pathways involved at early stages to prevent or reverse the development of DCM. In vivo experiments were performed on type 1 diabetic rats (T1DM). Functional and structural studies of the heart were executed and correlated with mechanistic assessments exploring the role of cytochromes P450 metabolites, the 20-hydroxyeicosatetraenoic acids (20-HETEs) and epoxyeicosatrienoic acids (EETs), and their crosstalk with other homeostatic signaling molecules. Our data displays that hyperglycemia results in CYP4A upregulation and CYP2C11 downregulation in the left ventricles (LV) of T1DM rats, paralleled by a differential alteration in their metabolites 20-HETEs (increased) and EETs (decreased). These changes are concomitant with reductions in cardiac outputs, LV hypertrophy, fibrosis, and increased activation of cardiac fetal and hypertrophic genes. Besides, pro-fibrotic cytokine TGF-ß overexpression and NADPH (Nox4) dependent-ROS overproduction are also correlated with the observed cardiac functional and structural modifications. Of interest, these observations are attenuated when T1DM rats are treated with 12-(3-adamantan-1-yl-ureido) dodecanoic acid (AUDA), which blocks EETs metabolism, or N-hydroxy-N'-(4-butyl-2-methylphenol)Formamidine (HET0016), which inhibits 20-HETEs formation. Taken together, our findings confer pioneering evidence about a potential interplay between CYP450-derived metabolites and Nox4/TGF-ß axis leading to DCM. Pharmacologic interventions targeting the inhibition of 20-HETEs synthesis or the activation of EETs synthesis may offer novel therapeutic approaches to treat DCM.

Effect of Targeted Curricular Reform on the Learning Environment, Student Empathy, and Hidden Curriculum in a Medical School: A 7-Year Longitudinal Study.

OBJECTIVE: The American University of Beirut Faculty of Medicine follows the American model of medical education. In 2013-2014, a carefully designed new curriculum replaced the previous, largely traditional curriculum, and aimed to improve student wellbeing, upgrade the learning environment, enhance student empathy, and counter the negative influences of the hidden curriculum. This longitudinal study assessed the effectiveness of the new curriculum in those domains over a period of 7 years. METHODS: Three cohorts of medical students anonymously filled a paper-based survey at the end of years 1, 2, 3, and 4 of the 4-year curriculum. These included the Class of 2016, the last batch of students who followed the old curriculum, and 2 cohorts that followed the new curriculum (Class of 2017 and Class of 2019). The perceived learning environment was assessed by the Dundee Ready Education Environment Measurement survey; the student's empathy was assessed by the Jefferson Scale of Physician Empathy-Student version; and the hidden curriculum was examined using a locally developed survey. RESULTS: The scores on the learning environment survey were significantly higher among the cohorts following the new curriculum relative to those following the old curriculum. Similar significant results appeared when looking at each of the subscales for the learning environment. The students' empathy scores were also significantly higher in both cohorts of the new curriculum when compared with the old curriculum. Nevertheless, there was a significant decrease in empathy in both third and fourth years relative to second year. The new curriculum also improved aspects of the students' perceptions and responses to the hidden curriculum. CONCLUSION: In conclusion, a well-planned and well-researched curricular intervention, based on sound educational theories, practices, and standards can indeed transform the learning environment, as well as the attitudes, values, and experiences of medical students.

Factors That Determine the Perceived Effectiveness of Peer Feedback in Collaborative Learning: a Mixed Methods Design.

INTRODUCTION: Peer assessment has been promoted as a valuable approach to formative assessment to support learning and peer professionalism. This mixed methods study employed a conceptual framework to explore the factors that enhance the perceived effectiveness of formative peer assessment in the context of team-based learning as a form of collaborative learning. MATERIALS AND METHODS: The volume and quality of written peer comments of two medical school classes at three time points were analyzed. Focus groups were then conducted to clarify issues that appeared in the quantitative data and to explore other emerging dimensions. RESULTS: There was a notable deficiency in both the volume and quality of the comments provided, with no improvement over time. Several factors were identified, including some that are logistical and operational and can be corrected easily, such as the timing of the assignments. Others that stood out as major substantive issues and/or limitations related to the students' conceptions of the purpose of the peer assessment and to their interpersonal variables. DISCUSSION: There were social disincentives for students to provide constructive feedback to peers with whom a continuing working relationship is necessary. There was also an inconsistency between the quality of the peer feedback being typically shallow and lacking in substance, and students considering it beneficial. CONCLUSION: The findings identify factors that need to be addressed in order to ensure the quality and effectiveness of formative peer assessment among medical students.

Respecting patient choices: using the 'Go Wish' cards as a teaching tool.

BACKGROUND: Individuals have different values and priorities that can have an important impact on their medical management. Understanding this concept can help physicians provide medical care that is in line with the goals of their patients. Communicating this message effectively to students is challenging. OBJECTIVE: To report our experience with using Go Wish cards in the medical education setting. DESIGN: A thematic analysis of student reflection papers using grounded theory. SETTING/SUBJECTS: Second-year medical students participated in an activity using the Go Wish cards as part of a course module on palliative care. The activity aimed to encourage students to reflect on their own choices at the end of life and to highlight that different people have different priorities. RESULTS: Forty-two students (42%) mentioned the Go Wish activity in their reflections on the module. They reported that the activity demonstrated the different priorities at the end of life, it illustrated the importance of providing personalised care, it promoted self-discovery, it transformed their view of death and dying, and it increased their appreciation of the importance of palliative care. CONCLUSION: Go Wish cards can be used to help illustrate the variability in priorities of patients. They can be used as an effective to teach medical students about the importance of considering patient preferences when illness progresses.

Facilitation by the renin-angiotensin system of cyclosporine-evoked hypertension in rats: Role of arterial baroreflexes and vasoreactivity.

AIMS: Cyclosporine (CSA) elevates blood pressure (BP) and alters arterial baroreflex sensitivity (BRS) and vasoreactivity. In this study we determined whether the renin-angiotensin system (RAS) interplays with other vasopressor pathways in mediating the CSA actions. MATERIALS AND METHODS: Whole animal and isolated vascular preparations were employed to determine the effects of pharmacologic interruption of angiotensin II (Ang II), endothelin (ET), or thromboxane (TXA2) signaling on the adverse cardiovascular effects of CSA. KEY FINDINGS: CSA (25mg/kg/day i.p. for 7days) caused significant increases in BP that were paralleled with (i) reduced BRS measured by phenylephrine (BRSPE) or sodium nitroprusside (BRSSNP), (ii) enhanced aortic contractile responses to Ang II and U-46619 (thromboxane analogue), and (iii) reduced aortic eNOS expression and acetylcholine, but not SNP, vasorelaxations. Except for the reduced BRSSNP, the CSA effects disappeared upon concurrent administration of losartan (angiotensin AT1 receptor antagonist), captopril (angiotensin converting enzyme inhibitor), or their combination. Moreover, CSA augmentation of Ang II contractions was abolished after cyclooxygenase inhibition (indomethacin) or endothelin ETA/ETB receptor blockade (atrasentan/BQ788). By contrast, the blockade of thromboxane receptors (terutroban) failed to alter the CSA-evoked facilitation of Ang II responsiveness. SIGNIFICANCE: The facilitation of baroreflex control and inhibition of vascular responsiveness to Ang II and thromboxane contribute to the BP lowering effect of RAS inhibitors in CSA-treated rats. Further, endothelin receptors and vasoconstrictor prostanoids contribute to the CSA-evoked exaggeration of Ang II vascular responsiveness and hypertension.

mTORC2 Signaling Regulates Nox4-Induced Podocyte Depletion in Diabetes.

AIM: Podocyte apoptosis is a critical mechanism for excessive loss of urinary albumin that eventuates in kidney fibrosis. Oxidative stress plays a critical role in hyperglycemia-induced glomerular injury. We explored the hypothesis that mammalian target of rapamycin complex 2 (mTORC2) mediates podocyte injury in diabetes. RESULTS: High glucose (HG)-induced podocyte injury reflected by alterations in the slit diaphragm protein podocin and podocyte depletion/apoptosis. This was paralleled by activation of the Rictor/mTORC2/Akt pathway. HG also increased the levels of Nox4 and NADPH oxidase activity. Inhibition of mTORC2 using small interfering RNA (siRNA)-targeting Rictor in vitro decreased HG-induced Nox1 and Nox4, NADPH oxidase activity, restored podocin levels, and reduced podocyte depletion/apoptosis. Inhibition of mTORC2 had no effect on mammalian target of rapamycin complex 1 (mTORC1) activation, described by our group to be increased in diabetes, suggesting that the mTORC2 activation by HG could mediate podocyte injury independently of mTORC1. In isolated glomeruli of OVE26 mice, there was a similar activation of the Rictor/mTORC2/Akt signaling pathway with increase in Nox4 and NADPH oxidase activity. Inhibition of mTORC2 using antisense oligonucleotides targeting Rictor restored podocin levels, reduced podocyte depletion/apoptosis, and attenuated glomerular injury and albuminuria. INNOVATION: Our data provide evidence for a novel function of mTORC2 in NADPH oxidase-derived reactive oxygen species generation and podocyte apoptosis that contributes to urinary albumin excretion in type 1 diabetes. CONCLUSION: mTORC2 and/or NADPH oxidase inhibition may represent a therapeutic modality for diabetic kidney disease. Antioxid. Redox Signal. 25, 703-719.

The long-term impact of team-based learning on medical students' team performance scores and on their peer evaluation scores.

BACKGROUND: The Faculty of Medicine at the American University of Beirut implemented a new medical curriculum, which included 90 team-based learning (TBL) sessions in years 1 and 2 of medical school. METHODS: A validated team performance scale (TPS) and peer evaluation of communication skills, professionalism and personal development were collected at different time points during the two years. Grades on the individual and group readiness assurance tests and an evaluation form were collected after every TBL session. RESULTS: Students generally positively evaluated most TBL sessions as promoters of critical thinking and appreciated the self-learning experience, though they preferred and had better individual grades on those that entailed preparation of didactic lectures. There was a sustained and cumulative improvement in teamwork skills over time. Similar improvement was noted with peer evaluations of communication skills, professionalism, and personal development over time. CONCLUSIONS: This is the first report about such a longitudinal follow-up of medical students who were exposed to a large number of TBL sessions over two years. The results support the suggestion that TBL improves medical students' team dynamics and their perceived self-learning, problem solving and communication skills, as well as their professionalism and personal development.

Interactive and collaborative learning in the classroom at the medical school Automated response systems and team-based learning.

There has been a pedagogic shift in higher education from the traditional teacher centered to the student centered approach in teaching, necessitating a change in the role of the teacher from a supplier of information to passive receptive students into a more facilitative role. Active learning activities are based on various learning theories such as self-directed learning, cooperative learning and adult learning. There exist many instructional activities that enhance active and collaborative learning. The aim of this manuscript is to describe two methods of interactive and collaborative learning in the classroom, automated response systems (ARS) and team-based learning (TBL), and to list some of their applications and advantages. The success of these innovative teaching and learning methods at a large scale depends on few elements, probably the most important of which is the support of the higher administration and leadership in addition to the availability of "champions" who are committed to lead the change.

Temporal cardiac remodeling post-myocardial infarction: dynamics and prognostic implications in personalized medicine.

Despite dramatic improvements in short-term mortality rates following myocardial infarction (MI), long-term survival for MI patients who progress to heart failure remains poor. MI occurs when the left ventricle (LV) is deprived of oxygen for a sufficient period of time to induce irreversible necrosis of the myocardium. The LV response to MI involves significant tissue, cellular, and molecular level modifications, as well as substantial hemodynamic changes that feedback negatively to amplify the response. Inflammation to remove necrotic myocytes and fibroblast activation to form a scar are key wound healing responses that are highly variable across individuals. Few biomarkers of early remodeling stages are currently clinically adopted. The discovery of underlying pathophysiological mechanisms and associated novel biomarkers has the potential of improving prognostic capability and therapeutic monitoring. Combining these biomarkers with other prominent ones could constitute a powerful diagnostic and prognostic tool that directly reflects the pathophysiological remodeling of the LV. Understanding temporal remodeling at the tissue, cellular, and molecular level and its link to a well-defined set of biomarkers at early stages post-MI is a prerequisite for improving personalized care and devising more successful therapeutic interventions. Here we summarize the integral mechanisms that occur during early cardiac remodeling in the post-MI setting and highlight the most prominent biomarkers for assessing disease progression.

Mechanical stretch-induced vascular hypertrophy occurs through modulation of leptin synthesis-mediated ROS formation and GATA-4 nuclear translocation.

BACKGROUND: Obesity and hypertension are associated with increased leptin production contributing to cardiovascular remodeling. Mechanisms involving mechanical stretch-induced leptin production and the cross talk between signaling pathways leading to vascular remodeling have not been fully elucidated. METHODS AND RESULTS: Rat portal vein (RPV) organ culture was used to investigate the effect of mechanical stretch on leptin protein expression in vascular smooth muscle cells (VSMCs). Moreover, the involvement of reactive oxygen species (ROS), the RhoA/ROCK pathway, actin cytoskeleton dynamics and the transcriptional factor GATA-4 activation in mechanical stretch-induced vascular remodeling were investigated. Stretching the RPV for 1 or 24 h significantly increased leptin protein level and ROS formation in VSMCs, which was prevented by 1 h pretreatment with the ROCK inhibitor Y-27632 and the actin cytoskeleton depolymerization agent cytochalasin D. Moreover, Western blotting and immunohistochemistry revealed that mechanical stretch or treatment with 3.1 nmol/L leptin for 24 h significantly increased actin polymerization, as reflected by an increase in the F-actin to G-actin ratio. Increases in blood vessels' wet weight and [(3)H]-leucine incorporation following a 24 h treatment with conditioned media from cultured stretched RPVs indicated RPV hypertrophy. This effect was prevented by 1 h pretreatment with anti-leptin antibody, indicating leptin's crucial role in promoting VSMC hypertrophy. As an index of GATA-4 activation, GATA-4 nuclear translocation was assessed by immunohistochemistry method. Pretreating VSMC with leptin for 1 h significantly activated GATA-4 nuclear translocation, which was potently attenuated by the NADPH oxidase inhibitor apocynin, Y-27632, and cytochalasin D. CONCLUSION: Our results demonstrate that ROS formation, RhoA/ROCK pathway, and GATA-4 activation play a pivotal role in mechanical stretch-induced leptin synthesis leading to VSMC remodeling.

Blockade of endothelin ET(A), but not thromboxane, receptors offsets the cyclosporine-evoked hypertension and interrelated baroreflex and vascular dysfunctions.

The impairment of arterial baroreceptor and vasodilator functions are two major contributors to the hypertensive action of cyclosporine (CSA). In this study, in vivo and in vitro pharmacological studies were performed to investigate whether these effects of CSA are differentially modulated by endothelin and thromboxane signaling. The treatment of rats with CSA (25mg/kg/day i.p.) for 7 consecutive days caused significant increases in blood pressure (BP), attenuated reflex heart rate (HR) responses to vasopressor (phenylephrine, PE) and vasodepressor (sodium nitroprusside, SNP) agents, and reduced cumulative vasorelaxant responses elicited by acetylcholine (Ach, 1×10(-9)-1×10(-5)M) in PE-precontracted isolated aortas. These effects of CSA were blunted after concurrent i.p. administration of atrasentan (selective ETA blocker, 10mg/kg/day), but not terutroban (thromboxane receptor blocker, 10mg/kg/day). Moreover, atrasentan reversed the reductions in aortic protein expression of eNOS caused by CSA whereas terutroban was without effect. We also report that the favorable effect of atrasentan on CSA-evoked impairment in aortic Ach responsiveness disappeared in rats treated simultaneously with L-NAME (NOS inhibitor, 10mg/kg/day) but not BQ 788 (ETB receptor blocker, 0.1mg/kg/day) or indomethacin (cycloxygenase inhibitor, 5mg/kg/day). Together, the data implicate endothelin ETA receptors in baroreflex and vascular derangements which predispose to the hypertensive effect of CSA. Moreover, the facilitation of NOS, but not ETB receptors or cycloxygenase-derived prostanoids, signaling is pivotal for advantageous effect of atrasentan on the aortic CSA-Ach interaction.

Crowd-funded micro-grants for genomics and "big data": an actionable idea connecting small (artisan) science, infrastructure science, and citizen philanthropy.

Biomedical science in the 21(st) century is embedded in, and draws from, a digital commons and "Big Data" created by high-throughput Omics technologies such as genomics. Classic Edisonian metaphors of science and scientists (i.e., "the lone genius" or other narrow definitions of expertise) are ill equipped to harness the vast promises of the 21(st) century digital commons. Moreover, in medicine and life sciences, experts often under-appreciate the important contributions made by citizen scholars and lead users of innovations to design innovative products and co-create new knowledge. We believe there are a large number of users waiting to be mobilized so as to engage with Big Data as citizen scientists-only if some funding were available. Yet many of these scholars may not meet the meta-criteria used to judge expertise, such as a track record in obtaining large research grants or a traditional academic curriculum vitae. This innovation research article describes a novel idea and action framework: micro-grants, each worth $1000, for genomics and Big Data. Though a relatively small amount at first glance, this far exceeds the annual income of the "bottom one billion"-the 1.4 billion people living below the extreme poverty level defined by the World Bank ($1.25/day). We describe two types of micro-grants. Type 1 micro-grants can be awarded through established funding agencies and philanthropies that create micro-granting programs to fund a broad and highly diverse array of small artisan labs and citizen scholars to connect genomics and Big Data with new models of discovery such as open user innovation. Type 2 micro-grants can be funded by existing or new science observatories and citizen think tanks through crowd-funding mechanisms described herein. Type 2 micro-grants would also facilitate global health diplomacy by co-creating crowd-funded micro-granting programs across nation-states in regions facing political and financial instability, while sharing similar disease burdens, therapeutics, and diagnostic needs. We report the creation of ten Type 2 micro-grants for citizen science and artisan labs to be administered by the nonprofit Data-Enabled Life Sciences Alliance International (DELSA Global, Seattle). Our hope is that these micro-grants will spur novel forms of disruptive innovation and genomics translation by artisan scientists and citizen scholars alike. We conclude with a neglected voice from the global health frontlines, the American University of Iraq in Sulaimani, and suggest that many similar global regions are now poised for micro-grant enabled collective innovation to harness the 21(st) century digital commons.

Teaching clinical pharmacology using team-based learning: a comparison between third- and fourth-year medical students.

The purpose of this study was to formulate evidence-based recommendations on whether to deliver the team-based learning (TBL)-designed clinical pharmacology course at the American University of Beirut Faculty of Medicine (AUBFM) during the third year instead of the fourth and final year of the medical curriculum. Between June 2010 and May 2011, AUBFM offered the course to both classes simultaneously to compare their performance. The findings of this endeavor supported the introduction of the course during the third year, first because fourth-year students did not outperform third-year students despite having the advantage of an additional year of clinical experience, and second, third-year teams seemed more likely to develop into better functioning teams. The findings also suggested that simultaneous delivery of TBL sessions to both third- and fourth-year teams was less favorably recommended because of the varying learning pace of both student groups.

In-vivo evidence of a role for nitric oxide in regulating the activity of the norepinephrine transporter.

We examined the role of nitric oxide (NO) in the regulation of neuronal uptake of norepinephrine (uptake-1) in rats under anesthesia. The effect on systolic blood pressure of two pressor drugs that work by different mechanisms, norepinephrine and angiotensin II, was explored in anesthetized rats under control conditions and after prevention of NO synthesis with Nw-nitro-L-arginine (L-NNA). The results showed that whereas the pressor effects of increasing doses of norepinephrine were potentiated by L-NNA, those of angiotensin II were not affected, which implied that NO was selectively involved in modulating the pressor effect of norepinephrine. To explore the mechanisms involved in this potentiation, we examined the effect of L-NNA on the pressor effect of tyramine, a purely-indirectly-acting sympathomimetic amine which enters nerve terminals thorough uptake 1 and liberates norepinephrine from storage vesicles. Increasing doses of tyramine produced pressor effects which, in contrast to those of norepinephrine, were significantly attenuated by pre-treatment with L-NNA. Similarly, pretreatment with cocaine, the classical inhibitor of uptake 1, significantly decreased the pressor effect of tyramine; however, the response to tyramine was then restored when L-NNA was administered, thus reversing the effect of cocaine. We conclude that NO plays a major role in the adrenergic system by enhancing the activity of uptake 1 in sympathetic nerve terminals. Blockade of uptake 1 by cocaine is also partly dependent on NO. The stimulus for the mobilization of the NO synthase pathway in adrenergic neurons and the subsequent steps involved in modulating uptake 1 deserve further exploration.

Attitudes of health care professionals toward pharmacogenetic testing.

BACKGROUND: Pharmacogenetics has emerged as a new tool for the optimization of drug therapy. Although the pharmacogenetics concept was first recognized at least 50 years ago, clinical testing to determine pharmacogenetic traits is still relatively rare, and many hurdles are markedly slowing its development. There is a lot of literature and speculation about potential ethical challenges in genetic and pharmacogenetic testing, yet few researchers have actually examined the attitudes of health care professionals regarding the clinical application of these tests. OBJECTIVE: In this article, we aim to review the current literature on health care professionals' perceptions of the role of pharmacogenetic data and describe the attitudes of medical students when faced with a clinical pharmacogenetic testing scenario. METHODS: A group of 59 third-year medical students from the American University of Beirut Medical Center were asked to answer a questionnaire about pharmacogenetic testing after being exposed to a clinical scenario of a patient who was diagnosed with mild Alzheimer Disease (AD) and hence was a candidate for therapy with one of the acetylcholinesterase (AChE) inhibitors. RESULTS: The students indicated that they would respect patients' confidentiality and inform them about the test results and therapeutic plan, but they would not be as open about bad prognoses. They did not agree on the therapeutic plan that would follow a pharmacogenetic test result and were uncertain about potential patient discrimination in insurability. CONCLUSION: Our and others' findings demonstrate the existence and seriousness of several challenges pertaining to pharmacogenetic applications in the clinical setting. Further training and education are needed for health care professionals, since they are the ones who will most probably request these tests in the near future.

Pharmacogenetics and personalized medicine: the future for drug prescribing.

Pharmacogenetics, the study of interindividual variations in DNA sequence related to drug response, aims at the optimization of treatment regimens based on each patient's unique genetic makeup. Currently, there is a trend towards moving away from the concept of "one drug fits all" to a rather more individualized and personalized medicine. The goal is to define the appropriate drug dose that maximizes efficacy and minimizes toxicity in each individual patient. An example of genotyping for CYP2C9 genetic polymorphisms in patients receiving oral anticoagulants is provided. In spite of its inherent challenges, we hope that pharmacogenetic research and clinical applications expand to improve healthcare outcomes in Lebanon and worldwide.