Impact of the Las Vegas Mass Shooting Event on the Graduate Medical Education Mission: Can There Be Growth from Tragedy?

INTRODUCTION: Our aim was to determine the psychological and educational impact of the 2017 Las Vegas mass shooting on the graduate medical education (GME) mission within two cohorts of resident physicians and attending faculty at two nearby academic trauma centers. METHODS: A cross-sectional survey assessed 55 resident physicians and attending faculty involved in the acute care of the patients from the mass shooting. We measured the psychological impact of the event, post-traumatic growth, team cohesion, social support, and known risk factors for post-traumatic stress disorder (PTSD). Additionally, we assessed the impact of the event on GME-specific tasks. RESULTS: Attending faculty and physicians in training in GME residencies evaluated over 300 penetrating trauma patients in less than 24 hours, and approximately 1 in 3 physicians had a patient die under their care. Despite this potential for psychological trauma, the majority of clinicians reported minimal distress and minimal impact on GME activities. However, 1 in 10 physicians screened positive for possible PTSD. Paradoxically, the minority of physicians who sought psychological counseling after the event (20%) were not those who reported the highest levels of distress. Residents generally assessed the event as having an overall negative impact on their educational goals, while attendings reported a positive impact. Psychological impact correlated inversely with social support and the amount of prior education relating to mass casualty incidents (MCI) but correlated directly with the degree of stress prior to the event. CONCLUSION: Despite the substantial level of exposure, most resident physicians did not report significant psychological trauma or an impact on their GME mission. Some reported post-traumatic growth. However, a minority reported a significant negative impact; institutions should consider broad screening efforts to detect and assist these individuals after a MCI. Social support, stress reduction, and education on MCIs may buffer the effects of future psychologically traumatic events on physicians in training.

Multifunctional TH1 cells define a correlate of vaccine-mediated protection against Leishmania major.

CD4+ T cells have a crucial role in mediating protection against a variety of pathogens through production of specific cytokines. However, substantial heterogeneity in CD4+ T-cell cytokine responses has limited the ability to define an immune correlate of protection after vaccination. Here, using multiparameter flow cytometry to assess the immune responses after immunization, we show that the degree of protection against Leishmania major infection in mice is predicted by the frequency of CD4+ T cells simultaneously producing interferon-gamma, interleukin-2 and tumor necrosis factor. Notably, multifunctional effector cells generated by all vaccines tested are unique in their capacity to produce high amounts of interferon-gamma. These data show that the quality of a CD4+ T-cell cytokine response can be a crucial determinant in whether a vaccine is protective, and may provide a new and useful prospective immune correlate of protection for vaccines based on T-helper type 1 (TH1) cells.

Distinct lineages of T(H)1 cells have differential capacities for memory cell generation in vivo.

We studied here the long-term maintenance of distinct populations of T helper type 1 (T(H)1)-lineage cells in vivo and found that effector T(H)1 cells, defined by their secretion of interferon-gamma (IFN-gamma), are short-lived and do not efficiently develop into long-term memory T(H)1 cells. In contrast, a population of activated T(H)1-lineage cells that did not secrete IFN-gamma after primary antigenic stimulation persisted for several months in vivo and developed the capacity to secrete IFN-gamma upon subsequent stimulation. These data suggest that a linear differentiation pathway, as defined by the transition from IFN-gamma-producing to resting memory cells, is relatively limited in vivo and support a revised model for T(H)1 memory differentiation.

Vaccination with heat-killed leishmania antigen or recombinant leishmanial protein and CpG oligodeoxynucleotides induces long-term memory CD4+ and CD8+ T cell responses and protection against leishmania major infection.

CpG oligodeoxynucleotides (ODN) have potent effects on innate and adaptive cellular immune responses. In this report, the ability of CpG ODN to confer long-term immunity and protection when used as a vaccine adjuvant with a clinical grade of leishmanial antigen, autoclaved Leishmania major (ALM), or a recombinant leishmanial protein was studied. In two different mouse models of L. major infection, vaccination with ALM plus CpG ODN was able to control infection and markedly reduce lesion development in susceptible BALB/c and resistant C57BL/6 (B6) mice, respectively, up to 12 wk after immunization. Moreover, B6 mice immunized with ALM plus CpG ODNs were still protected against infectious challenge even 6 mo after vaccination. In terms of immune correlates of protection, ALM plus CpG ODN-vaccinated mice displayed L. major-specific T helper cell 1 and CD8+ responses. In addition, complete protection was markedly abrogated in mice depleted of CD8+ T cells at the time of vaccination. Similarly, mice vaccinated with a recombinant leishmanial protein plus CpG ODN also had long-term protection that was dependent on CD8+ T cells in vivo. Together, these data demonstrate that CpG ODN, when used as a vaccine adjuvant with either a recombinant protein or heat-killed leishmanial antigen, can induce long-term protection against an intracellular infection in a CD8-dependent manner.