The Tensegrity Curriculum: A Comprehensive Curricular Structure Supporting Cultural Humility in Undergraduate Medical Education.

Due to growing health disparities in underserved communities, a comprehensive approach is needed to train physicians to work effectively with patients who have cultures and belief systems different from their own. To address these complex healthcare inequities, Rowan-Virtua SOM implemented a new curriculum, The Tensegrity Curriculum, designed to expand beyond just teaching skills of cultural competence to include trainees' exploration of cultural humility. The hypothesis is that this component of the curriculum will mitigate health inequity by training physicians to recognize and interrupt the bias within themselves and within systems. Early outcomes of this curricular renewal process reveal increased student satisfaction as measured by course evaluations. Ongoing course assessments examine deeper understanding of the concepts of implicit bias, social determinants of health, systemic discrimination and oppression as measured by performance on graded course content, and greater commitment to continual self-evaluation and critique throughout their careers as measured by course feedback. Structured research is needed to understand the relationship between this longitudinal and integrated curricular design, and retainment or enhancement of empathy during medical training, along with its impact on health disparities and community-based outcomes.

Caterpillar Salivary Glucose Oxidase Decreases Green Leaf Volatile Emission and Increases Terpene Emission from Maize.

Caterpillar salivary glucose oxidase (GOX) can function as both an elicitor or as an effector of plant defense responses depending upon the system. Treatment with GOX reduces the stomatal aperture of tomato and soybean leaves, thereby reducing the emission of volatile organic compounds (VOCs), that are important indirect defense responses of plants by attracting natural enemies of the caterpillars. Here we examined the effect of fungal GOX (fungal glucose oxidases have been used to determine specificity in defense response elicitation) on stomatal closure of maize leaves and on the volatile emission pattern whole maize plants. We also used salivary gland homogenate from wild-type and CRISPR-Cas9 Helicoverpa zea mutants deficient in GOX activity to determine the effect caterpillar saliva with and without GOX had on maize volatile emission. Collecting volatiles at 2-hour intervals allowed us to examine the changes in emission over time. Fungal GOX reduced the stomatal aperture in maize leaves, which may have influenced the observed significant reduction in total green leaf volatile (GLV) emission. Furthermore, fungal GOX significantly increased the emission of several key terpenes: linalool, DMNT, and Z-ß-farnesene from maize, while salivary gland homogenate from wild type (WT; GOX+) H. zea increased the emission of α-pinene, ß-pinene, and ocimene compared to H. zea unable to synthesize GOX. This study addressed a significant knowledge gap about the effect of GOX on maize volatiles and provides a baseline for further research on the effect of GOX on the regulation of terpene synthase genes and their relation to terpene volatile emission.

Integrating Behavioral Health and Primary Care: Turning a Duet Into a Trio.

Family physicians are at the front lines of mental health concerns and distress, yet often feel stymied in their attempts to fully support patients' biopsychosocial needs within the barriers of a fragmented health care system. This article describes a practice transformation designed to facilitate more empowered care experiences. We reflect on our interdisciplinary work as a family physician and a behavioral health consultant working closely together in a Primary Care Behavioral Health model within a university setting. We describe our collaborative approach to a composite character from clinical practice: a college student with symptoms of psychomotor depression who screened negative for mood and anxiety concerns. Akin to a musical ensemble, wherein the inclusion of each voice turns a solo into a symphony, we describe key details of interdisciplinary collaboration which promotes holistic care for patients and fulfilling biopsychosocial practice for us as colleagues.

Pandemic Response Officers: Integration Between Medical, Public Health, and Higher Education Systems to Expedite Prevention and Response.

CONTEXT: Research and policy studies alike have enumerated population and community health benefits of system integration between medical, public health, and social entities. The emergence of the COVID-19 pandemic revealed the necessity of a well-trained and adequately staffed public health and medical workforce in order to process SARS-CoV-2 cases and prevent subsequent transmission. Higher education systems, in particular, represented defined populations of exposure and transmission. Opportunities existed for collaboration and task sharing between institutions of higher education and local public health departments to limit spread and impacts. PROGRAM: This article describes the Pandemic Response Officer (PRO) program at Cornell University, a team of staff and students created during the intensity of the pandemic to benefit the Tompkins County and Cornell University communities. IMPLEMENTATION: The PRO program was formed in January 2021, with an original team of 8 individuals, working iteratively to investigate and support employee cases and exposures. Implementation was motivated by Cornell University's dual responsibility as a large employer that also possessed SARS-CoV-2 test results of employees. PROs loaded case information into a shared HIPPA-compliant electronic record that collected information for case notification, case investigation, isolation support, contact tracing, contact notification, and quarantine support. Over time, the PROs grew to a team of 25, gaining responsibilities as university and public health systems shared roles to maximize resources. EVALUATION: From January 1 to December 31, 2021, PROs managed 773 employee and 2943 student cases. During the Omicron surge (November 28-December 31, 2021), PROs saved the public health department an estimated 2797 hours of effort, equating to more than 10 professionals working full-time, evenings and weekends, to process cases and contacts during this interval. DISCUSSION: By integrating efforts between a university and public health agency, this intervention minimized SARS-CoV-2 transmission via expedient case support and alleviated strain on public health systems by expanding the public health workforce.

Integrated Surveillance System for Controlling COVID-19 on a University Campus, 2020‒2021.

To minimize the impacts of COVID-19 and to keep campus open, Cornell University's Ithaca, NY, campus implemented a comprehensive process to monitor COVID-19 spread, support prevention practices, and assess early warning indicators linked to knowledge, behaviors, and attitudes of campus community members. The integrated surveillance approach informed leadership and allowed for prompt adjustments to university policies and practices through evidence-based decisions. This approach enhanced healthy behaviors and promoted the well-being and safety of all community members. (Am J Public Health. 2022;112(7):980-984. https://doi.org/10.2105/AJPH.2022.306838).

The dual function of elicitors and effectors from insects: reviewing the 'arms race' against plant defenses.

KEY MESSAGE: This review provides an overview, analysis, and reflection on insect elicitors and effectors (particularly from oral secretions) in the context of the 'arms race' with host plants. Following injury by an insect herbivore, plants rapidly activate induced defenses that may directly or indirectly affect the insect. Such defense pathways are influenced by a multitude of factors; however, cues from the insect's oral secretions are perhaps the most well studied mediators of such plant responses. The relationship between plants and their insect herbivores is often termed an 'evolutionary arms race' of strategies for each organism to either overcome defenses or to avoid attack. However, these compounds that can elicit a plant defense response that is detrimental to the insect may also benefit the physiology or metabolism of an insect species. Indeed, several insect elicitors of plant defenses (such as the fatty acid-amino acid conjugate, volicitin) are known to enhance an insect's ability to obtain nutritionally important compounds from plant tissue. Here we re-examine the well-known elicitors and effectors from chewing insects to demonstrate not only our incomplete understanding of the specific biochemical and molecular cascades involved in these interactions but also to consider the role of these compounds for the insect species itself. Finally, this overview discusses opportunities for research in the field of plant-insect interactions by utilizing tools such as genomics and proteomics to integrate the future study of these interactions through ecological, physiological, and evolutionary disciplines.

Herbivorous Caterpillars and the Green Leaf Volatile (GLV) Quandary.

Several herbivorous caterpillars contain effectors in their oral secretions that alter the emission of green leaf volatiles (GLVs) produced by the plants upon which the caterpillars are feeding. These effectors include an isomerase, a fatty acid dehydratase (FHD), and a heat-stable hexenal trapping (HALT) molecule. GLVs serve as signaling compounds in plant-insect interactions and inter-and intra-plant communication. However, it is not known whether these GLV-altering effectors are common among herbivorous caterpillars, or the evolutionary context of these effectors in relation to GLV emission by host plants in response to feeding damage. Here, we examined the distribution and activity of the isomerase, FHD, and HALT effectors across 10 species spanning 7 lepidopteran families. Six of the 10 species possessed all three effectors in their oral secretions. Activity from the HALT and FHD effectors was observed in all examined caterpillar species, while activity from the isomerase effector varied in some species and was absent in others. There was no discernable pattern in effector activity based on evolutionary divergence, since individual species within a family did not possess similar mechanisms to alter GLV emission. These data, demonstrating the GLV-altering effectors acting at different steps in the GLV biosynthetic pathway and present in the examined caterpillar species at different combinations with different activities, highlight the importance of these effectors in changing the emission of these compounds during caterpillar herbivory. Understanding the prevalence and roles of GLV-altering effectors and GLV emission itself will open new research areas in the dynamics of plant-insect interactions.

Herbivorous Caterpillars Can Utilize Three Mechanisms to Alter Green Leaf Volatile Emission.

Green plants emit green leaf volatiles (GLVs) as a general damage response. These compounds act as signals for the emitter plant, neighboring plants, and even for insects in the ecosystem. However, when oral secretions from certain caterpillars are applied to wounded leaves, GLV emissions are significantly decreased or modified. We examined four caterpillar species representing two lepidopteran families for their capacity to decrease GLV emissions from Zea mays leaf tissue. We also investigated the source of the GLV modifying components in the alimentary tract of the various caterpillars. In Spodoptera exigua (Hübner) (Lepidoptera: Noctuidae), Spodoptera frugiperda (Smith) (Lepidoptera: Noctuidae), Trichoplusia ni (Hübner) (Lepidoptera: Noctuidae), and Manduca sexta (Linnaeus) (Lepidoptera: Sphingidae), we found three distinct mechanisms to modify GLV emission: a heat-stable compound in the gut, a heat-labile enzyme in salivary gland homogenate (previously described in Bombyx mori (Linnaeus) (Lepidoptera: Bombycidae), and an isomerase in the salivary gland homogenate, which catalyzes the conversion of (Z)-3-hexenal to (E)-2-hexenal (previously described in M. sexta). These mechanisms employed by caterpillars to suppress or modify GLV emission suggest a counteraction against the induced indirect volatile defenses of a plant and provides further insights into the ecological functions of GLVs.

Straddling care and education: Developing interprofessional collaboration through a hotspotting service learning project.

Interprofessional (IP) team work has been shown to decrease burnout and improve care and decrease costs. However, institutional barriers have challenged adoption in practice and education. Faculty and students are turning to IP service-learning projects to help students gain experience and provide needed services. This paper highlights a "hotspotting" program where students from different health professions work collaboratively to improve high utilizing patients' health. Benefits, challenges and preliminary results including cost savings and student efficacy are shared. Institutions should surmount barriers that make hotspotting service-learning challenging as IP team-based experiences prepare students for the workplace and can help mitigate burnout.

Clinical and Educational Outcomes of an Integrated Inpatient Quality Improvement Curriculum for Internal Medicine Residents.

BACKGROUND: Integrating teaching and hands-on experience in quality improvement (QI) may increase the learning and the impact of resident QI work. OBJECTIVE: We sought to determine the clinical and educational impact of an integrated QI curriculum. METHODS: This clustered, randomized trial with early and late intervention groups used mixed methods evaluation. For almost 2 years, internal medicine residents from Dartmouth-Hitchcock Medical Center on the inpatient teams at the White River Junction VA participated in the QI curriculum. QI project effectiveness was assessed using statistical process control. Learning outcomes were assessed with the Quality Improvement Knowledge Application Tool-Revised (QIKAT-R) and through self-efficacy, interprofessional care attitudes, and satisfaction of learners. Free text responses by residents and a focus group of nurses who worked with the residents provided information about the acceptability of the intervention. RESULTS: The QI projects improved many clinical processes and outcomes, but not all led to improvements. Educational outcome response rates were 65% (68 of 105) at baseline, 50% (18 of 36) for the early intervention group at midpoint, 67% (24 of 36) for the control group at midpoint, and 53% (42 of 80) for the late intervention group. Composite QIKAT-R scores (range, 0-27) increased from 13.3 at baseline to 15.3 at end point (P < .01), as did the self-efficacy composite score (P < .05). Satisfaction with the curriculum was rated highly by all participants. CONCLUSIONS: Learning and participating in hands-on QI can be integrated into the usual inpatient work of resident physicians.

Fitness and physiology of Adelges tsugae (Hemiptera: Adelgidae) in relation to the health of the eastern hemlock.

The hemlock woolly adelgid, Adelges tsugae Annand is an invasive insect that frequently causes hemlock (Tsuga spp.) mortality in the eastern United States. Studies have shown that once healthy hemlocks become infested by the adelgid, nutrients are depleted from the tree, leading to both tree decline and a reduction of the adelgid population. Since A. tsugae is dependent on hemlock for nutrients, feeding on trees in poor health may affect the ability of the insect to obtain necessary nutrients and may consequently affect their physiological and population health. Trees were categorized as lightly or moderately impacted by A. tsugae based on quantitative and qualitative tree health measurements. Population health of A. tsugae on each tree was determined by measuring insect density and peak mean fecundity; A. tsugae physiological health was determined by measuring insect biomass, total carbon, carbohydrate, total nitrogen, and amino nitrogen levels. Adelges tsugae from moderately impacted trees exhibited significantly greater fecundity than from lightly impacted trees. However, A. tsugae from lightly impacted hemlocks contained significantly greater levels of carbohydrates, total nitrogen, and amino nitrogen. While the results of the physiological analysis generally support our hypothesis that A. tsugae on lightly impacted trees are healthier than those on moderately impacted trees, this was not reflected in the population health measurements. Adelges tsugae egg health in response to tree health should be verified. This study provides the first examination of A. tsugae physiological health in relation to standard A. tsugae population health measures on hemlocks of different health levels.

Republished: Key characteristics of successful quality improvement curricula in physician education: a realist review.

PURPOSE: Quality improvement (QI) is a common competency that must be taught in all physician training programmes, yet, there is no clear best approach to teach this content in clinical settings. We conducted a realist systematic review of the existing literature in QI curricula within the clinical setting, highlighting examples of trainees learning QI by doing QI. METHOD: Candidate theories describing successful QI curricula were articulated a priori. We searched MEDLINE (1 January 2000 to 12 March 2013), the Cochrane Library (2013) and Web of Science (15 March 2013) and reviewed references of prior systematic reviews. Inclusion criteria included study design, setting, population, interventions, clinical and educational outcomes. The data abstraction tool included categories for setting, population, intervention, outcomes and qualitative comments. Themes were iteratively developed and synthesised using realist review methodology. A methodological quality tool assessed the biases, confounders, secular trends, reporting and study quality. RESULTS: Among 39 studies, most were before-after design with resident physicians as the primary population. Twenty-one described clinical interventions and 18 described educational interventions with a mean intervention length of 6.58 (SD=9.16) months. Twenty-eight reported successful clinical improvements; no studies reported clinical outcomes that worsened. Characteristics of successful clinical QI curricula include attention to the interface of educational and clinical systems, careful choice of QI work for the trainees and appropriately trained local faculty. CONCLUSIONS: This realist review identified success characteristics to guide training programmes, medical schools, faculty, trainees, accrediting organisations and funders to further develop educational and improvement resources in QI educational programmes.

Key characteristics of successful quality improvement curricula in physician education: a realist review.

PURPOSE: Quality improvement (QI) is a common competency that must be taught in all physician training programmes, yet, there is no clear best approach to teach this content in clinical settings. We conducted a realist systematic review of the existing literature in QI curricula within the clinical setting, highlighting examples of trainees learning QI by doing QI. METHOD: Candidate theories describing successful QI curricula were articulated a priori. We searched MEDLINE (1 January 2000 to 12 March 2013), the Cochrane Library (2013) and Web of Science (15 March 2013) and reviewed references of prior systematic reviews. Inclusion criteria included study design, setting, population, interventions, clinical and educational outcomes. The data abstraction tool included categories for setting, population, intervention, outcomes and qualitative comments. Themes were iteratively developed and synthesised using realist review methodology. A methodological quality tool assessed the biases, confounders, secular trends, reporting and study quality. RESULTS: Among 39 studies, most were before-after design with resident physicians as the primary population. Twenty-one described clinical interventions and 18 described educational interventions with a mean intervention length of 6.58 (SD=9.16) months. Twenty-eight reported successful clinical improvements; no studies reported clinical outcomes that worsened. Characteristics of successful clinical QI curricula include attention to the interface of educational and clinical systems, careful choice of QI work for the trainees and appropriately trained local faculty. CONCLUSIONS: This realist review identified success characteristics to guide training programmes, medical schools, faculty, trainees, accrediting organisations and funders to further develop educational and improvement resources in QI educational programmes.

Educational system factors that engage resident physicians in an integrated quality improvement curriculum at a VA hospital: a realist evaluation.

PURPOSE: Learning about quality improvement (QI) in resident physician training is often relegated to elective or noncore clinical activities. The authors integrated teaching, learning, and doing QI into the routine clinical work of inpatient internal medicine teams at a Veterans Affairs (VA) hospital. This study describes the design factors that facilitated and inhibited the integration of a QI curriculum-including real QI work-into the routine work of inpatient internal medicine teams. METHOD: A realist evaluation framework used three data sources: field notes from QI faculty; semistructured interviews with resident physicians; and a group interview with QI faculty and staff. From April 2011 to July 2012, resident physician teams at the White River Junction VA Medical Center used the Model for Improvement for their QI work and analyzed data using statistical process control charts. RESULTS: Three domains affected the delivery of the QI curriculum and engagement of residents in QI work: setting, learner, and teacher. The constant presence of the QI material on a public space in the team workroom was a facilitating mechanism in the setting. Explicit sign-out of QI work to the next resident team formalized the handoff in the learner domain. QI teachers who were respected clinical leaders with QI expertise provided role modeling and local system knowledge. CONCLUSIONS: Integrating QI teaching into the routine clinical and educational systems of an inpatient service is challenging. Identifiable, concrete strategies in the setting, learner, and teacher domains helped integrate QI into the clinical and educational systems.

Characterization of physical and chemical defenses in the hemlock woolly adelgid.

The invasive hemlock woolly adelgid (Adelges tsugae Annand, Hemiptera: Sternorrhyncha: Adelgidae) causes significant mortality to eastern and Carolina hemlock (Tsuga canadensis Carrière and T. caroliniana Engelmann, respectively) throughout the eastern United States. Adelges tsugae produces vast quantities of a wax covering that surrounds most of the instars as well as the adult and eggs. Using direct probe EI mass spectrometry, this wax covering was characterized as a diketoester wax, 17-oxohexatriacontanyl 11-oxotriacontanoate, and accounted for ≈ 42 % of A. tsugae total biomass. The presence of the anthraquinone, chrysophanol, and its precursor anthrone, chrysarobin, in A. tsugae has only been briefly described. Further study confirmed these compounds in all A. tsugae life stages. Additionally, several predatory beetles in use or under consideration as biological control agents for this species appear to ingest and excrete these compounds when feeding on A. tsugae. The production of both a physical and a chemical defense may represent a significant energy investment by A. tsugae.

Potential feeding deterrents found in hemlock woolly adelgid, Adelges tsugae.

The nonnative hemlock woolly adelgid (Adelges tsugae Annand, Hemiptera: Sternorrhyncha: Adelgidae) has been a significant mortality agent of eastern hemlock (Tsuga canadensis Carriere) throughout a large portion of its geographic range. During a study investigating adelgid vigor in relation to host health, it was noted that adelgid extracts ranged from a yellow to a deep red color. Analysis by GC-MS identified the presence of the anthraquinone, chrysophanol and its anthrone precursor, chrysarobin in the extract. These compounds are predator deterrents in several other insects, including chrysomelid beetles. It is hypothesized that these compounds serve a similar purpose in the hemlock woolly adelgid.

Platelet-derived growth factor-BB stimulated cell migration mediated through p38 signal transduction pathway in periodontal cells.

BACKGROUND: Intracellular signaling pathways mediate specific responses to growth factors. The manipulation of these pathways ultimately may be used to control the clinical outcomes of periodontal regenerative therapy. The purpose of this study was to examine the role of the p38 signal transduction pathway in the responses of periodontal cells to platelet-derived growth factor-BB (PDGF). METHODS: Primary cultures of human periodontal ligament cells (PDLs) and gingival fibroblasts (GFs) were used for all experiments. Cell numbers, 3H-thymidine incorporation, and Boyden chamber assays were used to characterize the effects of SB 203580 (SB), a specific inhibitor of the p38 signaling pathway, on cell proliferation and migration. An in vitro wound model also was used to assess the effects of SB. For the in vitro wound assay, triplicate wells were incubated for 1, 3, 5, and 7 days using 0.1% fetal bovine serum (FBS), 10% FBS +/- 10 microM SB, or 20 ng/ml PDGF +/- 10 microM SB. Digital histomorphometric analysis assessed cellular fill within the wound area. RESULTS: SB specifically inhibited PDGF-induced migration in the Boyden chamber assays without affecting cell proliferation. The wound model data showed similar levels of wound fill for PDLs and GFs in 10% FBS. Relative to 10% FBS, PDLs stimulated with PDGF showed significantly (P < 0.01, analysis of variance) greater wound fill (74%) than GFs (12%). SB inhibited the PDGF-induced wound fill of PDLs and GFs by 64% and 57%, respectively. This inhibition was significant (P < 0.01, ANOVA) only for PDLs. The addition of SB to 10% FBS did not significantly affect the wound fill response of either cell type compared to 10% FBS alone. CONCLUSIONS: These results demonstrate that periodontal cells possess distinct responses to PDGF that may be altered at the signal transduction level. The manipulation of these responses through the use of inhibitors to specific signaling pathways may enhance our control of periodontal regeneration in the future.