Multivariate Modeling of Student Performance on NBME Subject Exams.

Aim This study sought to determine whether it was possible to develop statistical models which could be used to accurately correlate student performance on clinical subject exams based on their National Board of Medical Examiner (NBME) self-assessment performance and other variables, described below, as such tools are not currently available.  Methods Students at a large public medical school were provided fee vouchers for NBME self-assessments before clinical subject exams. Multivariate regression models were then developed based on how self-assessment performance correlated to student success on the subsequent subject exam (Medicine, Surgery, Family Medicine, Obstetrics-Gynecology, Pediatrics, and Psychiatry) while controlling for the proximity of the self-assessment to the exam, USMLE Step 1 score, and the academic quarter. Results The variables analyzed satisfied the requirements of linear regression. The correlation strength of individual variables and overall models varied by discipline and outcome (equated percent correct or percentile, Model R2 Range: 0.1799-0.4915). All models showed statistical significance on the Omnibus F-test (p<0.001). Conclusion The correlation coefficients demonstrate that these models have weak to moderate predictive value, dependent on the clinical subject, in predicting student performance; however, this varies widely based on the subject exam in question. The next step is to utilize these models to identify struggling students to determine if their use reduces failure rates and to further improve model accuracy by controlling for additional variables.

HPV16 E6 29-38-specific T cells kill cervical carcinoma cells despite partial evasion of T-cell effector function.

Persistent human papillomavirus type 16 (HPV16) infection is associated with the development of more than 50% of cervical cancers. The HPV16 E6 and E7 oncoproteins are constitutively expressed in cervical carcinomas and are attractive targets for cytotoxic T lymphocyte (CTL)-based immunotherapy. However, cervical carcinomas may possess multiple evasion mechanisms for HPV16 E6/E7-specific CTL. In this study, we investigated whether HPV16(+) cervical carcinoma cell lines (CaCxCL) could evade all effector functions of HPV16 E6(29-38)-specific T cells. Such CD8(+) T cells were detected in the blood (4/10) or invaded lymph node (1/1) of cervical cancer patients using HLA-A*0201/HPV16 E6(29-38) tetramers after in vitro stimulation. T cells cultured from 3 different donors killed HPV16 E6(29-38) peptide-pulsed target cells but not HPV16(+) CaCxCL in (51)Cr release assays. The absence of killing correlated with limited T-cell degranulation against CaCxCL, but this was not due to antigen processing defects per se; CaCxCL could induce specific T-cell release of IFN-gamma and TNF-alpha, and CaCxCL could be killed in longer cytotoxicity assays (>20 hr). Interestingly, the 'slow' killing of CaCxCL could be partially inhibited by concanamycin A, a known perforin inhibitor. The results suggest that CaCxCL was only partially activating T cells, but this was still sufficient for slow killing. Overall, our results highlight the need to examine multiple T-cell effector functions in the context of endogenous antigen presentation by tumour cells. In this study, testing for cytotoxicity using short-term assays only would have ruled out a candidate epitope for immunotherapy.

Comparative evaluation of Etest and sensititre yeastone panels against the Clinical and Laboratory Standards Institute M27-A2 reference broth microdilution method for testing Candida susceptibility to seven antifungal agents.

To assess their utility for antifungal susceptibility testing in our clinical laboratory, the Etest and Sensititre methods were compared with the Clinical and Laboratory Standards Institute (CLSI) M27-A2 reference broth microdilution method. Fluconazole (FL), itraconazole (I), voriconazole (V), posaconazole (P), flucytosine (FC), caspofungin (C), and amphotericin B (A) were tested with 212 Candida isolates. Reference MICs were determined after 48 h of incubation, and Etest and Sensititre MICs were determined after 24 h and 48 h of incubation. Overall, excellent essential agreement (EA) between the reference and test methods was observed for Etest (95%) and Sensititre (91%). Etest showed an >or=92% EA for MICs for all drugs tested; Sensititre showed a >or=92% EA for MICs for I, FC, A, and C but 82% for FL and 85% for V. The overall categorical agreement (CA) was 90% for Etest and 88% for Sensititre; minor errors accounted for the majority of all categorical errors for both systems. Categorical agreement was lowest for Candida glabrata and Candida tropicalis with both test systems. Etest and Sensititre provided better CA at 24 h compared to 48 h for C. glabrata; however, CA for C. glabrata was <80% for FL with both test systems despite MIC determination at 24 h. Agreement between technologists for both methods was >or=98% for each agent against all organisms tested. Overall, Etest and Sensititre methods compared favorably with the CLSI reference method for determining the susceptibility of Candida. However, further evaluation of their performance for determining the MICs of azoles, particularly for C. glabrata, is warranted.

Appreciation of holistic nursing.

The author's appreciation for holistic nursing has stemmed from working as a nurse for several years and coming to the realization that although patients may have the same illness or symptoms, their plan of care must be as unique as the individual. During the process of obtaining her Holistic Nursing Certification, she learned the importance of assessing the integrated dimensions of a person. She is discovering there are many ways to care for and nurture an individual. And what works well for one person may not work for the next. Nurses who incorporate the holistic philosophy into their practice will most definitely improve the outcome of the patient's care as well as the care of themselves.

Cross-typic specificity and immunotherapeutic potential of a human HPV16 E7-specific CTL line.

Cervical cancer (CaCx) is strongly associated with human papillomavirus (HPV) infection, particularly HPV types 16 and 18. The constitutive expression of HPV E6 and E7 proteins in CaCx makes them attractive targets for CTL based immunotherapy. However cervical carcinomas may have features, e.g., antigen processing defects, that limit the effectiveness of HPV specific CTL. Furthermore most vaccine development has concentrated on HPV type 16, and it is not clear whether such vaccines could induce CTL able to cross-react on related oncogenic HPV types, e.g., HPV31 and 52. To investigate these potentially important parameters in vitro, we used a CTL (D4) specific for HPV16 E7(11-20). D4 was able to kill a variety of HPV16+ CaCx cell lines including those with suspected (CaSki) or known antigen processing defects (C33A), and with low HPV DNA copy number (SiHa). D4 was also able to cross react on a related peptide from HPV52 E7 but not HPV31 E7. Further analysis suggested that D4 cross reactivity against related peptides was influenced both by TCR contact residues and a certain threshold for peptide binding. The HPV cross-reactivity was confirmed at the whole protein level as D4 was also able to recognize the endogenously processed forms of HPV16 and 52 E7 but not 31 E7. These results suggest that HPV16 E7(11-20) would be a useful epitope for immunotherapy in both HPV 16 and 52 tumours. Despite this, it is difficult to generate these CTL in response to vaccination, emphasizing the need for definition of novel epitopes and more efficient vaccination strategies.

Epitope specificity and longevity of a vaccine-induced human T cell response against HPV18.

Persistent human papillomavirus (HPV) type 16 and 18 infection can lead to pre-malignant and malignant diseases of the lower genital tract. Several lines of evidence suggest that T cell responses can control HPV infection. However, relative to other human viruses, strong effector memory T cell responses against HPV have been difficult to detect. We used an in vitro stimulation step prior to enzyme-linked immunospot assays to identify IFN-gamma-secreting T cells specific for HPV16 and 18 E6/E7 peptides. This allowed the detection of HPV-specific CD4+ T cells that were not evident in direct ex vivo assays. T cell responses against HPV16 or 18 peptides were detected in healthy volunteers (7/9) and patients with lower genital tract neoplasia (10/20). Importantly, this assay allowed tracking of vaccine-induced T cell responses in nine patients, following inoculation with a live recombinant vaccinia virus (HPV16 and 18 E6/E7, TA-HPV). Novel vaccine-induced T cell responses were demonstrated in five patients, but no clinical responses (lesion regressions) were seen. For one vaccinated patient, the T cell response was mapped to a single dominant HPV18 E7 epitope and this response was sustained for >3 years. Our data suggest that systemic memory T cells against HPV16 and 18, induced naturally or by TA-HPV vaccination, are relatively rare. Nevertheless, the assay system developed allowed estimation of magnitude, epitope specificity, and longevity of vaccine-induced CD4+ T cell responses. This will be useful for vaccine design and measurement of immunological endpoints in clinical trials.