Hands-on Pulmonary Curriculum: Interactive Learning Sessions on Oxygen Delivery, Spirometry, Positive Airway Pressure Devices, Tracheostomy, and Thoracostomy Tubes.

Introduction: Pulmonary equipment has become ubiquitous in clinical care. Basic device troubleshooting and mechanical manipulation skills are crucial to the practicing physician yet are frequently neglected in standard pulmonary curricula. Methods: We developed a hands-on pulmonary curriculum for medical residents and students, focusing on oxygen delivery, spirometry, positive airway pressure devices, thoracostomy, and tracheostomy knowledge. The curriculum, consisting of five 1-hour sessions, offers hands-on experience with basic pulmonary equipment relevant to the ICU and/or pulmonary clinic. Each session is led by a pulmonologist or critical care facilitator and designed for a learning audience of 10-15 internal medicine trainees and medical students. More than 11 sessions have been conducted since curriculum implementation. Results: Voluntary, immediate, pre- and postsession surveys assessed objective subject knowledge, perceived subject understanding, and perceived effectiveness of this hands-on format versus a conventional lecture style. A total of 52 learners returned surveys. Aggregate responses demonstrated that these sessions were typically the first formal training learners had received in these subject areas. Subject knowledge and perceived level of subject understanding both improved, and respondents reported the hands-on style of teaching was more effective than conventional lecture format. Discussion: Focused on practical knowledge, this pulmonary hands-on curriculum addresses a knowledge gap for medical trainees, has been enthusiastically received by trainees, and provides a useful resource for faculty wishing to teach about these devices.

Assay and inhibition of diacylglycerol lipase activity.

A series of N-formyl-α-amino acid esters of ß-lactone derivatives structurally related to tetrahydrolipstatin (THL) and O-3841 were synthesized that inhibit human and murine diacylglycerol lipase (DAGL) activities. New ether lipid reporter compounds were developed for an in vitro assay to efficiently screen inhibitors of 1,2-diacyl-sn-glycerol hydrolysis and related lipase activities using fluorescence resonance energy transfer (FRET). A standardized thin layer chromatography (TLC) radioassay of diacylglycerol lipase activity utilizing the labeled endogenous substrate [1″-(14)C]1-stearoyl-2-arachidonoyl-sn-glycerol with phosphorimaging detection was used to quantify inhibition by following formation of the initial product [1″-(14)C]2-arachidonoylglycerol and further hydrolysis under the assay conditions to [1-(14)C]arachidonic acid.

A methodology for radiolabeling of the endocannabinoid 2-arachidonoylglycerol (2-AG).

The metabolic intermediate and endocannabinoid signaling lipid 2-arachidonoylglycerol (2-AG) has not been readily labeled, primarily because of its instability toward rearrangement. We now detail a synthetic method that easily gives tritiated 2-AG from [5,6,8,9,11,12,14,15-(3)H(N)]arachidonic acid in two steps. We utilized a short chain 1,3-diacylglycerol and proceeded through the "structured lipid" [5'',6'',8'',9'',11'',12'',14'',15''-(3)H(N)]2-arachidonoyl-1,3-dibutyrylglycerol, a triacylglycerol that was conveniently deprotected in ethanol with acrylic beads containing Candida antarctica lipase B to give [5'',6'',8'',9'',11'',12'',14'',15''-(3)H(N)]2-arachidonoylglycerol ([(3)H]2-AG). The flash chromatographic separation necessary to isolate the labeled 2-acylglycerol [(3)H]2-AG resulted in only 4% of the rearrangement byproducts that have been a particular problem with previous methodologies. This reliable "kit" method to prepare the radiolabeled endocannabinoid as needed gave tritiated 2-arachidonoylglycerol [(3)H]2-AG with a specific activity of 200 Ci/mmol for enzyme assays, metabolic studies, and tissue imaging. It has been run on unlabeled materials on over 10 mg scales and should be generally applicable to other 2-acylglycerols.

The preparation of 2-O-[1'-C]arachidonoyl-1-O-stearoyl-sn-glycerol.

2-O-Arachidonoyl-1-O-stearoyl-sn-glycerol is the most abundant molecular species of the 1,2-diacyl-sn-glycerol signaling lipids in neural tissue. The facile preparation of 2-O-[1'-(14)C]arachidonoyl-1-O-stearoyl-sn-glycerol from 2-O-[1'-(14)C]arachidonoyl-1-O-stearoyl-sn-glycero-3-phosphocholine at a hexane and phosphate buffer interface with phospholipase C was demonstrated on a 20 µCi scale in 83% radiochemical yield. The specific activity of the product 2-O-[1'-(14)C]arachidonoyl-1-O-stearoyl-sn-glycerol was 57.0 mCi/mmol and the radiochemical purity was determined to be >99% by TLC. The hydrolysis of this lipid biosynthetic intermediate with lipoprotein lipase was shown to produce 2-O-[1'-(14)C]arachidonoylglycerol (2-AG). The (14)C-radiolabeled monoacylglycerol 2-AG is an endogenous cannabinoid receptor-signaling molecule (endocannabinoid).

Covalent inhibitors of human monoacylglycerol lipase: ligand-assisted characterization of the catalytic site by mass spectrometry and mutational analysis.

The active site of recombinant hexa-histidine-tagged human monoacylglycerol lipase (hMGL) is characterized by mass spectrometry using the inhibitors 5-((biphenyl-4-yl)methyl)-N,N-dimethyl-2H-tetrazole-2-carboxamide (AM6701), and N-arachidonylmaleimide (NAM) as probes. Carbamylation of Ser(129) by AM6701 in the putative hMGL catalytic triad demonstrates this residue's essential role in catalysis. Partial NAM alkylation of hMGL cysteine residues 215 and/or 249 was sufficient to achieve approximately 80% enzyme inhibition. Although Cys(215) and/or Cys(249) mutations to alanine(s) did not affect hMGL hydrolytic activity as compared with nonmutated hMGL, the C215A displayed heightened NAM sensitivity, whereas the C249A evidenced reduced NAM sensitivity. These data conclusively demonstrate a sulfhydryl-based mechanism for NAM inhibition of hMGL in which Cys(249) is of paramount importance. Identification of amino acids critical to the catalytic activity and pharmacological modulation of hMGL informs the design of selective MGL inhibitors as potential drugs.

Full mass spectrometric characterization of human monoacylglycerol lipase generated by large-scale expression and single-step purification.

The serine hydrolase monoacylglycerol lipase (MGL) modulates endocannabinoid signaling in vivo by inactivating 2-arachidonoylglycerol (2-AG), the main endogenous agonist for central CB1 and peripheral CB2 cannabinoid receptors. To characterize this key endocannabinoid enzyme by mass spectrometry-based proteomics, we first overexpressed recombinant hexa-histidine-tagged human MGL (hMGL) in Escherichia coli and purified it in a single chromatographic step with high yield (approximately 30 mg/L). With 2-AG as substrate, hMGL displayed an apparent V max of 25 micromol/(microg min) and K m of 19.7 microM, an affinity for 2-AG similar to that of native rat-brain MGL (rMGL) (Km=33.6 microM). hMGL also demonstrated a comparable affinity (Km approximately 8-9 microM) for the novel fluorogenic substrate, arachidonoyl, 7-hydroxy-6-methoxy-4-methylcoumarin ester (AHMMCE), in a sensitive, high-throughput fluorometric MGL assay. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) unequivocably demonstrated the mass (34,126 Da) and purity of this hMGL preparation. After in-solution tryptic digestion, hMGL full proteomic characterization was carried out, which showed (1) an absence of intramolecular disulfide bridges in the functional, recombinant enzyme and (2) the post-translational removal of the enzyme's N-terminal methionine. Availability of sufficient quantities of pure, well-characterized hMGL will enable further molecular and structural profiling of this key endocannabinoid-system enzyme.

The interpretation of "culture": diverging perspectives on medical provision in rural Montana.

Seeking to address evident disparities in health care delivery to minority populations, researchers have developed a framework generally referred to as "cultural competency." This framework suggests that increasing providers' knowledge about culturally specific beliefs and behaviors will both assist providers in caring for particular, traditionally underserved groups and enhance the quality of health care delivery for all patients. Meanwhile, a number of critics have challenged the presuppositions of the "culture" concept underlying cultural competency, arguing that such well-intended efforts may merely exacerbate received stereotypes. Despite such criticism, the influence of cultural competency, along with the related categories of cultural sensitivity, cultural humility, cultural proficiency, and cultural awareness, continues to grow in medical schools, governmental agencies, and health care organizations, particularly in the United States. To better assess the varying theoretical and policy claims of proponents and opponents of the cultural competency framework, we undertook a modest qualitative, interview-based investigation. We explored how "culture" is being presented and enacted by Mexican agricultural workers and US health care providers in one rural Montana clinic. While the Mexican agricultural workers in the study emphasized structural dimensions of labor migration as the most relevant factors in shaping patient-provider interactions, the US health care providers tended to focus on the "cultural characteristics" peculiar to their patients. The discrepancy in these assessments serves to extend and complement existing criticism of cultural competency. While our study was limited to one locale with a limited number of participants, its findings highlight the paucity of empirical research in this area and suggest the need to examine the efficacy of cultural competency in settings outside conventional "needs assessment" or "outcome studies" models.