Creating a Diverse Physician Workforce Through Training in Diversity, Bias, and Selection: An Innovative Approach to Preparing Medical Students as Future Academic Leaders.

Medical students are the future of academic medicine. They will serve as admissions committee members, deans, and program directors with responsibility for selecting future physicians. At the same time, schools and programs are working to diversify the physician workforce to care for diverse patient populations. At UAB Heersink School of Medicine, we developed an elective course, Holistic Review: Creating a Mission-Driven Physician Workforce, to train learners in bias, diversity, and data-informed decision-making. Students applied lessons to the admissions process by participating in application screening and multiple-mini interview rating. Student reflections demonstrated course applicability for careers in medicine and beyond.

Competency-based education in transitioning nurse practitioner students from education into practice.

Competency-based education (CBE) provides a framework for nursing programs including those educating nurse practitioners (NPs). The basic assumption of CBE is that the student will demonstrate acquisition of the identified essential knowledge, skills, and attitudes expected for the designated educational process before leaving the learning environment. The work done to date in developing competencies and progression indicators provides the critical basis to move toward a common language and clear expectations for the continuum of linear progression of proficiency. Entrustable professional activities (EPAs) are built on competencies and stated as measurable activities that providers can be expected to do, at varying levels of competence or trust or supervision, and allow the faculty member, preceptor, or supervisor to make decisions as to what teaching methods and level of supervision are needed. Numerous methods are used to measure competency in clinical skill knowledge, performance, and practice readiness including clinical preceptor feedback, objective structured clinical examination, and simulation, just to name a few. NP programs continue to struggle with the education practice gap between theory and the actual provision of care. The discussion about novel and reliable methods for measurement of competencies must address the strategic importance of a consensus about when, where, and how students can obtain the appropriate amount and type of experience and supervision required in the transition to independent practice. There is also a significant need for processes and standardized guidelines that can contribute to EPA development.

Neutrophils contain prolyl endopeptidase and generate the chemotactic peptide, PGP, from collagen.

Prolyl endopeptidase (PE), a protease that cleaves after proline residues in oligopeptides, is highly active in brain and degrades neuropeptides in vitro. We have recently demonstrated that PE, in concert with MMP's, can generate PGP (proline-glycine-proline), a novel, neutrophil chemoattractant, from collagen. In this study, we demonstrate that human peripheral blood neutrophils contain PE, which is constitutively active, and can generate PGP de novo from collagen after activation with LPS. This novel, pro-inflammatory role for PE raises the possibility of a self-sustaining pathway of neutrophilic inflammation and may provide biomarkers and therapeutic targets for diseases caused by chronic, neutrophilic inflammation.

The presence of a matrix-derived neutrophil chemoattractant in bronchiolitis obliterans syndrome after lung transplantation.

Lung transplantation is a therapeutic modality frequently used in end-stage lung disease. Unfortunately, lung transplant recipients have poor clinical outcomes, often due to the development of bronchiolitis obliterans syndrome (BOS). This process is often characterized by the pathologic findings of obliterative bronchiolitis: neutrophil influx and extracellular matrix remodeling leading to luminal obstruction and airway inflammation. The molecular mechanisms underlying BOS are poorly understood and disease-specific biomarkers are lacking. We report that in addition to increased levels of IL-8, the level of the neutrophil chemoattractant proline-glycine-proline (PGP) is elevated in BOS patient bronchoalveolar lavage (BAL) fluid. The enzymes responsible for generating PGP, matrix metalloproteases 8 and -9 and prolyl endopeptidase, are also elevated in these samples. Together, IL-8 and PGP account for most of the neutrophil chemoattractant capacity seen in BOS BAL fluid. Using specific neutralizing Abs to both IL-8 and PGP, we demonstrate that PGP is a prominent neutrophil chemoattractant found in BAL fluid from individuals at the time of diagnosis of BOS. These findings highlight the influence of a matrix-derived neutrophil chemoattractant in posttransplantation BOS and provide opportunities for the development of unique diagnostics and therapeutics to potentially improve disease outcomes.

Possible therapeutic vaccines for canine myasthenia gravis: implications for the human disease and associated fatigue.

Myasthenia gravis (MG) is caused by T cell-dependent antibodies reactive with acetylcholine receptors. These autoreactive antibodies cause muscle weakness by interfering with neuromuscular transmission via removal of acetylcholine receptors from the neuromuscular junction as well as changing the architecture of the junction itself. Consequently, muscle fatigue is a debilitating aspect of MG often leading to more general feelings of tiredness not directly due to muscle weakness. We have previously described two peptides that are mimetics of antigen receptors on certain autoreactive T and B cells that are involved in MG. When used as vaccines in the rat model of MG, these peptides prevented and ameliorated disease and muscle fatigue by blunting acetylcholine receptor antibody responses. Such disease protection resulted from vaccine-induced anergizing antibodies against acetylcholine receptor-specific T and B cell antigen receptors. The present study prospectively evaluated the efficacy of these two vaccines in spontaneous acquired MG in pet dogs. When compared to historical controls that were prospectively studied, the vaccines increased the proportion of remitted dogs from 17 to 75%. In comparison to retrospectively studied historical controls that spontaneously remitted from MG, the vaccines accelerated the rate of decline in acetylcholine receptor antibody titers which resulted in a 3-fold decrease in the mean time to remission. These results are suggestive of a new type of targeted therapy that can drive autoimmune responses into long-term remission and possibly afford a means of determining whether correction of a physical cause of muscle weakness also corrects the perception of chronic, generalized fatigue.

A novel peptide CXCR ligand derived from extracellular matrix degradation during airway inflammation.

We describe the tripeptide neutrophil chemoattractant N-acetyl Pro-Gly-Pro (PGP), derived from the breakdown of extracellular matrix (ECM), which shares sequence and structural homology with an important domain on alpha chemokines. PGP caused chemotaxis and production of superoxide through CXC receptors, and administration of peptide caused recruitment of neutrophils (PMNs) into lungs of control, but not CXCR2-deficient mice. PGP was generated in mouse lung after exposure to lipopolysaccharide, and in vivo and in vitro blockade of PGP with monoclonal antibody suppressed PMN responses as much as chemokine-specific monoclonal antibody. Extended PGP treatment caused alveolar enlargement and right ventricular hypertrophy in mice. PGP was detectable in substantial concentrations in a majority of bronchoalveolar lavage samples from individuals with chronic obstructive pulmonary disease, but not control individuals. Thus, PGP's activity links degradation of ECM with neutrophil recruitment in airway inflammation, and PGP may be a biomarker and therapeutic target for neutrophilic inflammatory diseases.