A novel assay for discovery and characterization of pro-apoptotic drugs and for monitoring apoptosis in patient sera.

We have developed an apoptosis assay based on measurement of a neoepitope of cytokeratin-18 (CK18-Asp396) exposed after caspase-cleavage and detected by the monoclonal antibody M30. The total amount of caspase-cleaved CK18 which has accumulated in cells and tissue culture media during apoptosis is measured by ELISA. The sensitivity is sufficient for use in the 96-well format to allow high-through-put screening of drug libraries. We here describe strategies allowing classification of pro-apoptotic compounds according to their profiles of induction of apoptosis in the presence of pharmacological inhibitors. The time course of induction of CK18 cleavage can furthermore be used to distinguish structurally similar compounds. We propose that compounds that induce rapid CK18 cleavage have mechanisms of actions distinct from conventional genotoxic and microtubuli-targeting agents, and we present one example of an agent that induces almost immediate mitochondrial depolarization and cytochrome c release. Finally, CK18-Asp396 cleavage products are released from cells in tissue culture, and presumably from tumor cells in vivo. These products can be measured in sera from cancer patients. We present evidence suggesting that it will be possible to use the M30-ELISA assay for measuring chemotherapy-induced apoptosis in patient sera, opening possibilities for monitoring therapy.

Caloric restriction alters the feeding response of key metabolic enzyme genes.

Differential 'fuel usage' has been proposed as a mechanism for life-span extension by caloric restriction (CR). Here, we report the effects of CR, initiated after weaning, on metabolic enzyme gene expression 0, 1.5, 5, and 12 h after feeding of 24-month-old mice. Plasma glucose and insulin were reduced by approximately 20 and 80%. Therefore, apparent insulin sensitivity, as judged by the glucose to insulin ratio, increased 3.3-fold in CR mice. Phosphoenolpyruvate carboxykinase mRNA and activity were transiently reduced 1.5 h after feeding, but were 20-100% higher in CR mice at other times. Glucose-6-phosphatase mRNA was induced in CR mice and repressed in control mice before, and for 5 h following feeding. Feeding transiently induced glucokinase mRNA fourfold in control mice, but only slightly in CR mice. Pyruvate kinase and pyruvate dehydrogenase activities were reduced approximately 50% in CR mice at most times. Feeding induced glutaminase mRNA, and carbamyl phosphate synthetase I and glutamine synthase activity (and mRNA). They were each approximately twofold or higher in CR mice. These results indicate that in mice, CR maintains higher rates of gluconeogenesis and protein catabolism, even in the hours after feeding. The data are consistent with the idea that CR continuously promotes the turnover and replacement of extrahepatic proteins.

Professionalism and professional values in orthopaedics.

During a consensus conference in Fall, 1998, the Academic Orthopaedic Society identified the values and qualities of professionalism as defined by its members. One hundred eighty-six respondents rated 20 characteristics and values describing professionalism, based on the extent to which they believed each item was appropriate. The five items receiving highest average ratings were: integrity, trustworthiness, responsibility, reliability, and accountability. Principal components analysis yielded five factors that captured 62% of the total variability. These factors were labeled respect and relationships, altruism, accountability and reliability, integrity, and excellence. The authors anticipate that the Academic Orthopaedic Society will find these data useful, and incorporate this information into their decisions concerning evaluation of current residents and applicants to their programs. An additional challenge will be to develop a values curriculum (formal curriculum) and a learning environment (informal curriculum) that will encourage residents and faculty to aspire to the highest in professional values and professional conduct.

Can professional values be taught? A look at residency training.

Although medicine has long valued and reinforced certain behaviors, collectively labeled "professionalism," among its members, it is not clear if or how these behaviors might be conveyed to physicians in training. Despite this, teachers are required to assess and at times to act on their perceptions of their charges' professionalism. Surgery residents at a large metropolitan hospital were tracked during a 50-month period. They were evaluated on objective criteria, such as clinical abilities and performance, and more subjective qualities, including ethical standards and interpersonal skills (professionalism). Analysis of the data indicated that residents who scored above the mean on professionalism also scored significantly higher than their classmates on every dimension of skills and knowledge performance evaluated. This convergence suggests that those qualities comprising professionalism are important elements in resident's training, and tend to produce better overall clinical performance. This finding, and previous research in this area, should encourage investigators to explore the relationship between professionalism and clinical competence.

A randomized controlled study of brief interventions to teach residents about domestic violence.

PURPOSE: To test an educational intervention regarding domestic violence. METHOD: Residents beginning their training in 1995 or 1996 were randomly assigned to attend, at their hospital orientation, either a 20-minute session emphasizing the importance of screening for domestic violence or a session on an unrelated topic. RESULTS: Seventy-one percent of the residents in the experimental group diagnosed domestic violence; 52% in the control did so (RR, 1.35; 95% CI, 0.96-1.90; p = .07) in the nine to 12 months following the intervention. Rates of diagnosis differed by specialty (p < .01): 100% family practice, 90% emergency medicine, 80% obstetrics-gynecology, 63% pediatrics, 47% internal medicine, 0% surgery. Change in knowledge was assessed in 1996; significant improvement was noted (p = .002). CONCLUSION: An intervention about domestic violence conducted at orientation for residents improved the rate of diagnosis of domestic violence. While the improvement was not statistically significant in this case, the intervention was brief and harmless. Other institutions should consider this kind of brief intervention.

Unethical and unprofessional conduct observed by residents during their first year of training.

PURPOSE: To present residents' personal observations of unethical and unprofessional conduct in medicine during their first year of training. METHOD: Eight hundred and fifty-seven second-year residents who had previously participated in a study of perceived mistreatment as senior medical students were resurveyed by a three-tiered mail process concerning their experiences during their first postgraduate year, including their personal observations of four types of unethical and unprofessional conduct. RESULTS: Surveys were returned by 571 residents, for a response rate of 67%. Personal observations of falsification of patient records by others on at least one occasion were reported by 44.5% of the responding residents, while 73.8% reported direct observations of mistreatment of patients. Nearly half of the residents (46.7%) reported that others had taken credit for their work, and 72.8% said they had observed colleagues working in an impaired condition at least once during their first year of training. Over one fourth of the residents (28.6%) stated that they had been required to do something during the year that they believed was immoral, unethical, or personally unacceptable. There was an inverse relationship between the residents' observations of unethical and unprofessional conduct and their overall satisfaction with their first year of training (p < .001). CONCLUSIONS: The residents reported observing several types of unethical and unprofessional conduct among their colleagues and superiors. These findings confirm similar reports among medical students and residents and raise questions about the possible effect of such observations on the ethical principles and behavior of physicians-in-training.

Learning, satisfaction, and mistreatment during medical internship: a national survey of working conditions.

CONTEXT: Concerns about the working and learning environment of residency training continue to surface. Previous surveys of residents have focused on work hours and income, but have shed little light on how residents view their training experience. OBJECTIVE: To provide a description of the internship year as seen by a large cross section of second-year residents. DESIGN: Mail survey conducted in 1991. SETTING: Residency programs in the United States. PARTICIPANTS: Random 10% sample (N=1773) of all second-year residents listed in the American Medical Association's medical research and information database. MAIN OUTCOME MEASURES: What and who contributes most to residents' learning during internships, degree of satisfaction with the internship experience, on-call and sleep schedules, incidents of perceived mistreatment or abuse, observations of unethical behavior, and experiences of harassment or discrimination. RESULTS: A total of 1277 surveys (72%) of 1773 mailed were returned. Overall, respondents reported a moderate level of satisfaction with their first year of residency. On a scale of 0 to 3, residents rated other residents as contributing most (score of 2.3) to their learning, with special patients ranked second (2.1). During a typical work week, residents reported that they spent an average of 56.9 hours on call in the hospital. A total of 1185 (93%) residents reported experiencing at least 1 incident of perceived mistreatment, with 53% reporting being belittled or humiliated by more senior residents. Among women residents, 63% reported having experienced at least 1 episode of sexual harassment or discrimination. A total of 45% of residents reported having observed another individual falsifying medical records, and 70% saw a colleague working in an impaired condition, most often lack of sleep. Regression analyses suggest that satisfaction with the residency experience was associated with the presence of factors that enhanced learning, and fewer experiences of perceived mistreatment. CONCLUSIONS: Residents report significant problems during their internship experience. Satisfaction with internship is enhanced by positive learning experiences and lack of mistreatment.

Educating the rehabilitation engineer as a service provider.

This paper reviews a 12-month masters-level rehabilitation engineering training program to prepare engineers to be rehabilitation service providers. The extent of the rehabilitation engineering shortage is discussed. The curriculum is then provided with descriptions of 16 courses, the program's internship, and a comparison with other training programs. A listing of the intended customers of the program graduates is given along with a description of the advisory committee to help interface with these customers. Four educational goals consisting of disability and technology, major rehabilitation systems, applied skills, and life-long learning are discussed. The results of six years' experience with this program, including a survey of graduates, are presented.

Disruption of epithelial gamma delta T cell repertoires by mutation of the Syk tyrosine kinase.

Chimeric mice in which lymphocytes are deficient in the Syk tyrosine kinase have been created. Compared with Syk-positive controls, mice with Syk -/- lymphocytes display substantial depletion of intraepithelial gamma delta T cells in the skin and gut, with developmental arrest occurring after antigen receptor gene rearrangement. In this dependence on Syk, subsets of intraepithelial gamma delta T cells are similar to B cells, but distinct from splenic gamma delta T cells that develop and expand in Syk-deficient mice. The characteristic associations of certain T-cell receptor V gamma/V delta gene rearrangements with specific epithelia are also disrupted by Syk deficiency.

Cheating in medical school: a survey of second-year students at 31 schools.

BACKGROUND: Although there have been a number of studies of cheating in universities, surprisingly little has appeared recently in the literature regarding academic dishonesty among medical students. METHOD: To assess the prevalence of cheating in medical schools across the country, class officers at 31 of 40 schools contacted distributed a survey in the spring of 1991 to their second-year classmates. The survey consisted of questions about the students' attitudes toward cheating, their observations of cheating among their classmates, and whether they had themselves cheated. The results were analyzed using contingency tables, t-tests, Pearson correlations, and one-way analysis of variance. RESULTS: Of the 3,975 students attending the 31 schools, 2,459 (62%) responded. Thirty-nine percent of the respondents reported witnessing some type of cheating among classmates during the first two years of medical education, while 66.5% reported having heard about such cheating. When reporting about themselves, 31.4% admitted cheating in junior high school, 40.5% in high school, 16.5% in college, and only 4.7% in medical school. Reports of cheating varied across medical schools, but no relationship was found between rates of cheating and medical school characteristics. Men were more likely to report having cheated than were women. The best predictor of whether someone was likely to cheat in medical school was whether they had cheated before, although the data strongly support the role of environmental factors. Medical school honor codes exercised some effect on cheating behavior, but the effect was not large. CONCLUSION: About 5% of the medical students surveyed reported cheating during the first two years of medical school. The students appeared resigned to the fact that cheating is impossible to eliminate, but they lacked any clear consensus about how to proceed when they became aware of cheating by others. The guidance students appear to need concerns not so much their own ethical behaviors as how and when to intervene to address the ethical conduct of their peers.

Withdrawal and extended leave during residency training: results of a national survey.

BACKGROUND: Although national figures for medical student withdrawal and extended leave have long been reported, similar data have not been available for residents in training. METHOD: Data for this study came from the American Medical Association survey of the 1991-92 residency year, in which program directors were asked for information about residents who had taken extended leave or had withdrawn or been dismissed from their programs prior to completion. Data are reported for 89,368 residents enrolled in 6,302 programs (89.2% of all surveyed programs). RESULTS: During the 1991-92 year, 2,449 residents (2.7%) withdrew or were dismissed from their programs and 887 (1.0%) took extended leave. Specialty and program changes accounted for 56% of the withdrawals, while performance difficulties were implicated in 12.9%. Maternity or paternity leave was involved in 32.2% of extended leaves, followed by research sabbaticals (11.4%) and physical problems (10.5%). Women had higher rates of both withdrawal and extended leave than men. Withdrawal for performance difficulties was lowest among graduates of U.S. and Canadian allopathic schools as compared with graduates of osteopathic or foreign medical schools, and lowest among Caucasians as compared with those of other racial-ethnic identities. CONCLUSION: Although overall figures and percentages are low, there are small but persistent losses of residents annually that vary by specialty, gender, race-ethnicity, and education.

Syk tyrosine kinase required for mouse viability and B-cell development.

The Syk cytoplasmic protein-tyrosine kinase has two amino-terminal SH2 domains and a carboxy-terminal catalytic domain. Syk, and its close relative ZAP-70, are apparently pivotal in coupling antigen- and Fc-receptors to downstream signalling events. Syk associates with activated Fc receptors, the T cell receptor complex and the B-cell antigen-receptor complex (BCR) in immature and mature B lymphocytes. On receptor activation, the tandem SH2 domains of Syk bind dual phosphotyrosine sites in the conserved ITAM motifs of receptor signalling chains, such as the immunoglobulin alpha and beta-chains of the BCR, leading to Syk activation. Here we have investigated Syk function in vivo by generating a mouse strain with a targeted mutation in the syk gene. Homozygous syk mutants suffered severe haemorrhaging as embryos and died perinatally, indicating that Syk has a critical role in maintaining vascular integrity or in wound healing during embryogenesis. Analysis of syk-/- lymphoid cells showed that the syk mutation impaired the differentiation of B-lineage cells, apparently by disrupting signalling from the pre-BCR complex and thereby preventing the clonal expansion, and further maturation, of pre-B cells.

Evaluation of an enzyme-linked immunosorbent assay for diagnosis of paratuberculosis in goats.

A commercial rapid-absorbed ELISA developed to detect antibodies to Mycobacterium paratuberculosis in bovine serum was modified for use with goat serum. Diagnostic sensitivity was evaluated, using a group of 163 goats from a herd with endemic paratuberculosis. Blood and fecal samples were obtained simultaneously, and prevalence of shedding of M paratuberculosis in the feces was estimated by detection of DNA of the mycobacterial insertion sequence, IS900, using a commercial test kit. Diagnostic specificity was evaluated, using blood samples from a total of 123 goats in 10 herds that were considered clinically free of paratuberculosis. The IS900 DNA was detected in 35 of the 163 goats (21%) from the infected herd. Serum antibody to M paratuberculosis was detected in 19 of the 35 IS900 DNA-positive goats, for apparent sensitivity of 54%. Serum antibody was detected in 18 of the 128 IS900 DNA-negative goats from the infected herd. Negative results for serum antibody to M paratuberculosis were obtained for all 123 goats from the herds that were considered clinically free of paratuberculosis.

Selected characteristics of graduate medical education in the United States.

For the second year, the Department of Data Systems in the Medical Education Group of the American Medical Association gathered information on graduate medical education primarily by means of an electronic data collection system. Eighty-eight percent of 6622 programs surveyed responded, with 83% reporting detailed information on residents. Analysis of graduate medical education data shows that the number of residents increased by 34.9% from the academic years 1980-1981 to 1990-1991, while the number of graduate year 1 residents decreased by 2%. In the same decade, the proportion of women residents increased by 7.1%. The number of minorities in graduate medical education has grown, but their proportions within the total resident population have remained largely unchanged. The number of graduates from schools of osteopathic medicine has increased by 265% over the same 10-year period. Between 1989 and 1990, a 31.6% increase was recorded in the number of international medical graduates in graduate year 1 residency positions; most of this increase (63.4%) occurred among noncitizens of the United States.

The computerized pupil.

An IBM-compatible computer graphics software program has been developed which simulates pupillary function. A light pen, electronically interfaced with the computer, simulates a pen light and, when it is placed on the computer image of the pupil, causes pupillary constriction; when it is withdrawn, the pupils redilate. A variety of abnormal pupillary responses are depicted. Anatomical diagrams and questions concerning various simulated pupillary conditions further enhances the educational experience. Medical students, residents in ophthalmology and the neurosciences, optometrists, nurses, ophthalmic assistants, and other health care professionals can utilize this program to learn a wide range of pupillary abnormalities in an interactive environment.

Graduate medical education in the United States.

The annual surveys of residency programs on which this report is based have had a higher than 90% response rate for the 5 years previous to 1989. Because of a change to the new electronic data collection system in 1989, the response rate decreased to 78.3%. To adjust for the lower response rate, a regression model computed from data from previous years was developed that permitted projected estimates for 1989 data. These numbers are included in several key tables. The number of GY-1 positions seems to have decreased for 1990, although this may be an artifact of the response rate. Reported unfilled positions, including GY-1 unfilled positions, have increased each year since 1985. The number of new-entry residents (GY-1) seems to be leveling out after decreasing since 1985. Because of the lower response rate, it is difficult to determine the trend in the total number of residents on duty. While the observed number of residents is lower than in 1988, statistical projections indicate an increase of 5% over the 1988 count. Thirty-nine percent of residents were training in family practice, internal medicine, or pediatrics. The number and percent of women in residency programs has remained relatively stable despite a steady increase in the number of women graduating from US medical schools. The percentage of FMG residents has continued to decrease. The percentage of black non-Hispanic residents remains steady. The number of graduates of osteopathic medical schools in ACGME programs has increased 17% since 1987. The number of institutions involved in graduate medical education has not changed significantly during the past 3 years.

Alternative models for the delivery of rural health care: a case study of a western frontier state.

This is a case study illustrating the wide variety of models for rural health care delivery found in a western "frontier" state. In response to a legislative mandate, the University of Nevada School of Medicine created the Office of Rural Health in 1977. Utilizing a cooperative, community development approach, this office served as a resource, as well as a catalyst, in the development and expansion of a variety of alternative practice models for health care delivery to small, underserved rural communities. These models included small, single, and multispecialty group practices; self-supporting and subsidized solo practices; contract physicians; midlevel practitioners; and National Health Service Corps personnel. The rural health care system that was created featured regional and consortial arrangements, urban and medical school outreach programs, and a "flying doctor" service.

Murine pregnancy decidua produces a unique immunosuppressive molecule related to transforming growth factor beta-2.

Non-T small lymphocytic suppressor cells in murine allopregnancy release a potent immunosuppressive factor in vitro that is neutralized by rabbit anti-transforming growth factor (TGF)-beta. Previous studies have suggested that the decidual suppressor factor (DSF) is smaller than TGF-beta 1, and in this paper, we show that DSF on HPLC-sieving columns also elutes later than TGF-beta 2. Nevertheless, DSF has the ability to promote anchorage-independent growth of NRK fibroblasts similar to TGF-beta s. Using turkey antibodies specific for TGF-beta 1 or beta 2, we show that DSF is related to TGF-beta 2 rather than TGF-beta 1, and this relationship was confirmed by using a panel of murine mAb to TGF-subtypes. PAGE and Western blotting showed that the TGF-beta 2-reactive molecules in HPLC-purified DSF was slightly smaller than TGF-beta 2 and approximately 20 to 23 kDa. The DSF molecule is therefore closely related to TGF-beta 2 but as released from decidua, differs in size. The TGF-beta 2-related decidual suppressor factor was also obtained from the decidua of synpregnant C.B.-17 severe combined immune deficiency (SCID) and pregnant SCID-BG (C57BL/6 background) mice, confirming the lack of T or B cell dependence of DSF production and the generality of production of a TGF-beta-related suppressor factor by decidua associated with successful pregnancy in mice.