Knowledge Retention and Clinical Skills Acquisition in Sexual and Gender Minority Health Curricula: A Systematic Review.

PURPOSE: To identify exemplary medical education curricula, operationalized as curricula evaluating knowledge retention and/or clinical skills acquisition, for health care for sexual and gender minoritized (SGM) individuals and individuals born with a difference in sex development (DSD). METHOD: The authors conducted a systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were performed in PubMed/MEDLINE, The Cochrane Library, Web of Science, ERIC, Embase, PsycINFO, and the gray literature to identify studies that (1) pertained to undergraduate and/or graduate medical education, (2) addressed education on health care of SGM/DSD individuals, and (3) assessed knowledge retention and/or clinical skills acquisition in medical trainees. The final searches were run in March 2019 and rerun before final analyses in June and October 2020. RESULTS: Of 670 full-text articles reviewed, 7 met the inclusion criteria. Five of the 7 studies assessed trainee knowledge retention alone, 1 evaluated clinical skills acquisition alone, and 1 evaluated both outcomes. Studies covered education relevant to transgender health, endocrinology for patients born with DSDs, and HIV primary care. Only 1 study fully mapped to the Association of American Medical Colleges (AAMC) SGM/DSD competency recommendations. Six studies reported institutional funding and development support. No studies described teaching SGM/DSD health care for individuals with multiply minoritized identities or engaging the broader SGM/DSD community in medical education curriculum development and implementation. CONCLUSIONS: Curriculum development in SGM/DSD health care should target knowledge retention and clinical skills acquisition in line with AAMC competency recommendations. Knowledge and skill sets for responsible and equitable care are those that account for structures of power and oppression and cocreate curricula with people who are SGM and/or born with DSDs.

Influenza A virus infections in swine: pathogenesis and diagnosis.

Influenza has been recognized as a respiratory disease in swine since its first appearance concurrent with the 1918 "Spanish flu" human pandemic. All influenza viruses of significance in swine are type A, subtype H1N1, H1N2, or H3N2 viruses. Influenza viruses infect epithelial cells lining the surface of the respiratory tract, inducing prominent necrotizing bronchitis and bronchiolitis and variable interstitial pneumonia. Cell death is due to direct virus infection and to insult directed by leukocytes and cytokines of the innate immune system. The most virulent viruses consistently express the following characteristics of infection: (1) higher or more prolonged virus replication, (2) excessive cytokine induction, and (3) replication in the lower respiratory tract. Nearly all the viral proteins contribute to virulence. Pigs are susceptible to infection with both human and avian viruses, which often results in gene reassortment between these viruses and endemic swine viruses. The receptors on the epithelial cells lining the respiratory tract are major determinants of infection by influenza viruses from other hosts. The polymerases, especially PB2, also influence cross-species infection. Methods of diagnosis and characterization of influenza viruses that infect swine have improved over the years, driven both by the availability of new technologies and by the necessity of keeping up with changes in the virus. Testing of oral fluids from pigs for virus and antibody is a recent development that allows efficient sampling of large numbers of animals.

Clinicopathological features of Swine influenza.

In this chapter, the clinical presentations, the development of infection and the macroscopic and microscopic lesions of swine influenza virus (SIV) infection are described. Both natural and experimental infections are discussed.

Kinetics of lung lesion development and pro-inflammatory cytokine response in pigs with vaccine-associated enhanced respiratory disease induced by challenge with pandemic (2009) A/H1N1 influenza virus.

The objective of this report was to characterize the enhanced clinical disease and lung lesions observed in pigs vaccinated with inactivated H1N2 swine δ-cluster influenza A virus and challenged with pandemic 2009 A/H1N1 human influenza virus. Eighty-four, 6-week-old, cross-bred pigs were randomly allocated into 3 groups of 28 pigs to represent vaccinated/challenged (V/C), non-vaccinated/challenged (NV/C), and non-vaccinated/non-challenged (NV/NC) control groups. Pigs were intratracheally inoculated with pH1N1 and euthanized at 1, 2, 5, and 21 days post inoculation (dpi). Macroscopically, V/C pigs demonstrated greater percentages of pneumonia compared to NV/C pigs. Histologically, V/C pigs demonstrated severe bronchointerstitial pneumonia with necrotizing bronchiolitis accompanied by interlobular and alveolar edema and hemorrhage at 1 and 2 dpi. The magnitude of peribronchiolar lymphocytic cuffing was greater in V/C pigs by 5 dpi. Microscopic lung lesion scores were significantly higher in the V/C pigs at 2 and 5 dpi compared to NV/C and NV/NC pigs. Elevated TNF-α, IL-1ß, IL-6, and IL-8 were detected in bronchoalveolar lavage fluid at all time points in V/C pigs compared to NV/C pigs. These data suggest H1 inactivated vaccines followed by heterologous challenge resulted in potentiated clinical signs and enhanced pulmonary lesions and correlated with an elevated proinflammatory cytokine response in the lung. The lung alterations and host immune response are consistent with the vaccine-associated enhanced respiratory disease (VAERD) clinical outcome observed reproducibly in this swine model.

The role of swine in the generation of novel influenza viruses.

The ecology of influenza A viruses is very complicated involving multiple host species and viral genes. Avian species have variable susceptibility to influenza A viruses with wild aquatic birds being the reservoir for this group of pathogens. Occasionally, influenza A viruses are transmitted to mammals from avian species, which can lead to the development of human pandemic strains by direct or indirect transmission to man. Because swine are also susceptible to infection with avian and human influenza viruses, genetic reassortment between these viruses and/or swine influenza viruses can occur. The potential to generate novel influenza viruses has resulted in swine being labelled 'mixing vessels'. The mixing vessel theory is one mechanism by which unique viruses can be transmitted from an avian reservoir to man. Although swine can generate novel influenza viruses capable of infecting man, at present, it is difficult to predict which viruses, if any, will cause a human pandemic. Clearly, the ecology of influenza A viruses is dynamic and can impact human health, companion animals, as well as the health of livestock and poultry for production of valuable protein commodities. For these reasons, influenza is, and will continue to be, a serious threat to the wellbeing of mankind.

Genotype-phenotype correlation in a German family with a novel complex CRX mutation extending the open reading frame.

PURPOSE: To describe the genotype-phenotype correlation in a German family with a novel CRX mutation and to perform a comparative analysis of published cases. DESIGN: Retrospective observational case series, systematic review, and comparative analysis of the literature. PARTICIPANTS: Four related patients with progressive retinal degeneration. METHODS: Mutation screening by single-strand polymorphism analysis and direct sequencing. Clinical examination included kinetic visual fields (VFs), 2-color threshold perimetry (2CTP), full-field electroretinography, fundus photography, optical coherence tomography, and fundus autofluorescence (FA) recording. MAIN OUTCOME MEASURES: Visual fields, subjective and objective cone- and rod-specific function, fundus aspect, retinal stratification, and FA. RESULTS: A novel heterozygous complex mutation (c.816delCACinsAA) in CRX predicting the substitution of 27 C-terminal amino acids by 44 novel amino acids, thus abolishing the OTX tail, was identified in a 2-generation family finally diagnosed with cone-rod dystrophy (CRD), which was confirmed by 2CTP. Patients presented with variability in progression, nystagmus, and nyctalopia. Most of the patients were hyperopic. Electroretinography recordings showed residual rod and mixed cone-rod responses in 2 of the subjects. Age-dependent VF losses followed funduscopic changes of progressive atrophy of the retinal pigment epithelium and neuroretina in the macula and midperiphery marked by disturbed FA. Optical coherence tomography showed decreased central retinal thickness. Comparative analysis of the 131 published data sets revealed 2 groups: patients with early and late onset. CONCLUSIONS: We described a 2-generation family with a novel mutation in CRX. The resulting phenotype is that of CRD with variable age at onset and progression. The phenotype description of previously published cases is conclusive only for CRD.

Cardiovascular lesions in pigs naturally or experimentally infected with porcine circovirus type 2.

Abundant intracytoplasmic porcine circovirus type 2 (PCV2) was associated with myocardiocyte swelling or necrosis, or myocardial fibrosis (or both) in three naturally infected pigs aged 4-7 weeks from three different farms. One 6 week old pig from a fourth farm had severe diffuse segmental to circumferential lymphohistiocytic and plasmacytic periarteritis and endarteritis in several organs, PCV2 antigen was demonstrated in endothelial cells, and inflammatory cells in the arterial walls. In three pigs experimentally infected with PCV2, viral antigen was also associated with obliterated blood vessels in areas of granulomatous and necrotizing lymphadenitis. Together these findings suggest that the cardiovascular system in general and endothelial cells in particular play an important role in the pathogenesis of PCV2-associated diseases.

Characterization of the humoral immune response of experimentally infected and vaccinated pigs to swine influenza viral proteins.

The value of serologic tests for diagnosis of swine influenza virus (SIV) infection has been diminished by the emergence of new subtypes and by antigenic drift within subtype. The intensive use of vaccination also has complicated interpretation of serology results. Serologic assays are needed that can detect infection regardless of subtype or antigenic variation and that can differentiate antibody induced by infection from that induced by vaccination. In this study, the antibody responses to specific viral proteins in pigs infected by or vaccinated for SIV were characterized by Western immunoblot. Both IgM and IgG against hemagglutinin, nucleoprotein, NS1 and NS2 were detected in experimentally infected pigs by 7 days post inoculation (DPI). IgG against these proteins was still detectable at the end of the study (28 DPI). In contrast, IgG against neuraminidase and M1 was not detected until 14 DPI and no IgM against these proteins was detected. In vaccinated pigs, no antibody against NS1 was detected while antibody responses to other proteins were identical to those in exposed pigs. In conclusion, nucleoprotein may be a suitable antigen for use in a subtype-unrestricted serologic assay. NS1 protein may be suitable for a serologic assay that differentiates between infected and vaccinated pigs.

Exogenous porcine viruses.

Porcine organs, cells and tissues provide a viable source of transplants in humans, though there is some concern of public health risk from adaptation of swine infectious agents in humans. Limited information is available on the public health risk of many exogenous swine viruses, and reliable and rapid diagnostic tests are available for only a few of these. The ability of several porcine viruses to cause transplacental fetal infection (parvoviruses, circoviruses, and arteriviruses), emergence or recognition of several new porcine viruses during the last two decades (porcine circovirus, arterivirus, paramyxoviruses, herpesviruses, and porcine respiratory coronavirus) and the immunosuppressed state of the transplant recipients increases the xenozoonoses risk of humans to porcine viruses through transplantation. Much of this risk can be eliminated with vigilance and sustained monitoring along with a better understanding of pathogenesis and development of better diagnostic tests. In this review we present information on selected exogenous viruses, highlighting their characteristics, pathogenesis of viral infections in swine, methods for their detection, and the potential xenozoonoses risk they present. Emphasis has been given in this review to swine influenza virus, paramyxovirus (Nipah virus, Menagle virus, LaPiedad paramyxovirus, porcine paramyxovirus), arterivirus (porcine reproductive and respiratory syndrome virus) and circovirus as either they represent new swine viruses or present the greatest risk. We have also presented information on porcine parvovirus, Japanese encephalitis virus, encephalomyocarditis virus, herpesviruses (pseudorabies virus, porcine lymphotropic herpesvirus, porcine cytomegalovirus), coronaviruses (TGEV, PRCV, HEV, PEDV) and adenovirus. The potential of swine viruses to infect humans needs to be assessed in vitro and in vivo and rapid and more reliable diagnostic methods need to be developed to assure safe supply of porcine tissues and cells for xenotransplantation.

Porcine circovirus type 2 (PCV-2) coinfections in US field cases of postweaning multisystemic wasting syndrome (PMWS).

The prevalence of different pathogens detected in combination with porcine circovirus type 2 (PCV-2) was studied retrospectively in field cases of postweaning multisystemic wasting syndrome (PMWS) diagnosed at the Iowa State University Veterinary Diagnostic Laboratory, Ames, Iowa, between January 2000, and September 2001. The presence of PCV-2 antigen in lymphoid tissues and/or lung, demonstrated by immunohistochemistry, together with moderate to severe lymphoid depletion and/or granulomatous lymphadenitis, was used as the criteria for the diagnosis of PMWS. A total of 484 cases fulfilled these criteria. Most of the cases (294/369) of PMWS occurred in pigs between the ages of 8 and 18 weeks, with a peak at 10 weeks of age. Porcine reproductive and respiratory syndrome virus was detected in 51.9% of the cases, Mycoplasma hyopneumoniae in 35.5%, bacterial septicemia in 14.0%, bacterial pneumonia in 7.6%, swine influenza virus in 5.4%, and PCV-2 alone in 1.9%. In cases with bacterial septicemia the most frequently isolated pathogen was Streptococcus suis. In cases with bacterial pneumonia, Pasteurella multocida was the most prevalent.

Estudio retrospectivo de casos de intoxicación por cobre en ovejas / Retrospective study of chronic copper poisoning in sheep

En este trabajo se recopilan los valores de cobre en hígado y riñón de 112 casos de ovejas diagnosticadas con intoxicación crónica por cobre en el Veterinary Diagnostic Laboratory de Iowa State University durante un período de 6 años. Los animales que murieron con signos clínicos y lesiones de una crisis hemolítica tenían unas concentraciones medias (+DE) de cobre en hígado y riñón de 268.5 + 100.4 ppm y 49.9 + 36.2 ppm (peso húmedo), respectivamente. Los valores en riñón estaban aumentados con respecto a los valores normales del hígado, por lo que el riñón es el tejido de elección cuando el animal se sospecha haber muerto por intoxicación crónica de cobre. El análisis de 35 muestras de alimento procedentes de algunos de los casos diagnosticados revelaron relaciones de cobre: molibdeno superiores a 10:1. Se hace referencia a la patogénia y toxicocinética del cobre, así como al tratamiento recomendado (AU)

Paramyxovirus infection in pigs with interstitial pneumonia and encephalitis in the United States.

In the last few years, newly recognized paramyxoviruses have been associated with severe disease in several animal species, including swine, as well as in human beings. Recently, a paramyxovirus was isolated from a swine herd in the northcentral United States that experienced an epizootic of respiratory and central nervous system disease. Affected pigs had interstitial pneumonia with necrotizing bronchiolitis and encephalitis characterized by lymphocytic perivasculitis and diffuse gliosis. Germ-free pigs inoculated with this isolate developed mild clinical illness and similar but less severe histopathologic lesions in lungs and brain.

A three-dimensional study of calcaneonavicular tarsal coalitions.

The authors studied 37 presumed calcaneonavicular tarsal coalitions from the Hamann-Todd Osteological Collection at the Cleveland Museum of Natural History. The anatomy of the coalitions and the associated subtalar and transverse tarsal joints was quite variable. The coalitions in 8 specimens completely spared the anterior facet of the calcaneus and in 7 specimens it was partially replaced by the navicular portion of the coalition, whereas in 22 specimens the anterior calcaneal facet was completely replaced by the navicular portion of the coalition. The authors suggest that the pathoanatomy of calcaneonavicular coalitions is not uniform and may involve the subtalar and transverse tarsal joints. This may have clinical relevance and contribute to the unsatisfactory results in feet undergoing coalition resection and soft tissue interposition.

Interaction between Mycoplasma hyopneumoniae and swine influenza virus.

An experimental respiratory model was used to investigate the interaction between Mycoplasma hyopneumoniae and swine influenza virus (SIV) in the induction of pneumonia in susceptible swine. Previous studies demonstrated that M. hyopneumoniae, which produces a chronic bronchopneumonia in swine, potentiates a viral pneumonia induced by the porcine reproductive and respiratory syndrome virus (PRRSV). In this study, pigs were inoculated with M. hyopneumoniae 21 days prior to inoculation with SIV. Clinical disease as characterized by the severity of cough and fever was evaluated daily. Percentages of lung tissue with visual lesions and microscopic lesions were assessed upon necropsy at 3, 7, 14, and 21 days following SIV inoculation. Clinical observations revealed that pigs infected with both SIV and M. hyopneumoniae coughed significantly more than pigs inoculated with a single agent. Macroscopic pneumonia on necropsy at days 3 and 7 was greatest in both SIV-infected groups, with minimal levels of pneumonia in the M. hyopneumoniae-only-infected pigs. At 14 days post-SIV inoculation, pneumonia was significantly more severe in pigs infected with both pathogens. However, by 21 days postinoculation, the level of pneumonia in the dual-infected pigs was similar to that of the M. hyopneumoniae-only-infected group, and the pneumonia in the pigs inoculated with only SIV was nearly resolved. Microscopically, there was no apparent increase in the severity of pneumonia in pigs infected with both agents compared to that of single-agent-challenged pigs. The results of this study found that while pigs infected with both agents exhibited more severe clinical disease, the relationship between the two pathogens lacked the profound potentiation found with dual infection with M. hyopneumoniae and PRRSV. These findings demonstrate that the relationship between mycoplasmas and viruses varies with the individual agent.

A subtractive hybridisation analysis of genomic differences between the uropathogenic E. coli strain 536 and the E. coli K-12 strain MG1655.

Suppression subtractive hybridisation (SSH) was performed to identify genomic differences between the uropathogenic Escherichia coli strain 536 and the non-pathogenic E. coli K-12 strain MG1655. In total, 22 DNA fragments were isolated which were specific for strain 536. Five of these fragments showed homology to known virulence determinants and four fragments matched genes for lipopolysaccharide (LPS) or capsule biosynthesis and a siderophore receptor. Seven fragments did not show any homology to known genes. These fragments may represent parts of putative pathogenicity islands (PAIs). Whereas two fragments were highly specific for uropathogenic E. coli (UPEC), the other fragments could also be detected among the other tested wild-type strains.

A comparison of diagnostic assays for the detection of type A swine influenza virus from nasal swabs and lungs.

Nasal swabs and lung samples from pigs experimentally infected with H1N1 swine influenza virus (SIV) were examined for the presence of SIV by the indirect fluorescent antibody assay, immunohistochemistry, cell culture virus isolation, egg inoculation, and 2 human enzyme immunoassays (membrane enzyme immunoassay, microwell enzyme immunoassay). Egg inoculation was considered to be the gold standard for assay evaluation. The 2 human enzyme immunoassays (EIA) and egg inoculation agreed 100% for the prechallenge nasal swabs. Agreement on SIV identification in nasal swabs with egg inoculation following challenge was considered to be good to excellent for membrane EIA (kappa = 0.85) and microwell EIA (kappa = 0.86). Agreement on SIV identification in lung tissue with egg inoculation following challenge was good to excellent for membrane EIA (kappa = 0.75), fair for microwell EIA, fluorescent antibody, and cell culture virus isolation (kappa = 0.48, 0.64, 0.62, respectively), and poor for immunohistochemistry (kappa = 0.36). No assay was 100% accurate, including the "gold standard," egg inoculation. In light of this information, it is important to consider clinical signs of disease and a thorough herd history in conjunction with diagnostic results to make a diagnosis of SIV infection.

Toxin genes on pathogenicity islands: impact for microbial evolution.

Toxin-specific genes are often located on mobile genetic elements such as phages, plasmids and pathogenicity islands (PAIs). The uropathogenic E. coli strain 536 carries two alpha-hemolysin gene clusters, which are part of the pathogenicity islands I536 and II536, respectively. Using different genetic techniques, two additional PAIs were identified in the genome of the E. coli strain 536, and it is likely that further PAIs are located on the genome of this strain. Pathogenicity islands are often associated with tRNA genes. In the case of the E. coli strain 536, the PAI-associated tRNA gene leuX, which encodes a minor leucyl-tRNA, affects the expression of various virulence traits including alpha-hemolysin production. The exact mode of action of the tRNA5Leu-dependent gene expression has to be identified in the future.

Detection and isolation of coronavirus from feces of three herds of feedlot cattle during outbreaks of winter dysentery-like disease.

Clinical signs of a winter dysentery-like syndrome in 6- to 9-month-old cattle in 3 feedlots included acute onset of diarrhea with high morbidity and low mortality, respiratory tract problems that included dyspnea, coughing, and nasal discharge, and high rectal temperatures. Bovine coronavirus was detected by use of an ELISA and immune electron microscopy in fecal and nasal swab samples and by immunohistochemical analysis of intestinal sections collected from calves during necropsy. Bovine coronavirus should be considered in the differential diagnoses for diseases that cause acute onset of bloody diarrhea in feedlot cattle.