Patients as teachers: a within-subjects randomized pilot experiment of patient-led online learning modules for health professionals

PURPOSE

Many health professions education programs involve people with lived experience as expert speakers. Such presentations may help learners better understand the realities of living with chronic illness or experiencing an acute health problem. However, lectures from only one or a small number of people may not adequately illustrate the perspectives and experiences of a diverse patient cohort. Additionally, logistical constraints such as public health restrictions or travel barriers may impede in-person presentations, particularly among people who have more restrictions on their time. Health professions education programs may benefit from understanding the potential effects of online patient-led presentations with a diverse set of speakers. We aimed to explore whether patient-led online learning modules about diabetes care would influence learners' responses to clinical scenarios and to collect learners' feedback about the modules.

METHOD

This within-subjects randomized experiment involved 26 third-year medical students at Université Laval in Quebec, Canada. Participation in the experiment was an optional component within a required course. Prior to the intervention, participating learners responded to three clinical scenarios randomly selected from a set of six such scenarios. Each participant responded to the other three scenarios after the intervention. The intervention consisted of patient-led online learning modules incorporating segments of narratives from 21 patient partners (11 racialized or Indigenous) describing why and how clinicians could provide patient-centered care. Working with clinical teachers and psychometric experts, we developed a scoring grid based on the biopsychosocial model and set 0.6 as a passing score. Independent evaluators, blinded to whether each response was collected before or after the intervention, then scored learners' responses to scenarios using the grid. We used Fisher's Exact test to compare proportions of passing scores before and after the intervention.

RESULTS

Learners' overall percentage of passing scores prior to the intervention was 66%. Following the intervention, the percentage of passing scores was 76% (p = 0.002). Overall, learners expressed appreciation and other positive feedback regarding the patient-led online learning modules.

DISCUSSION

Findings from this experiment suggest that learners can learn to provide better patient-centered care by watching patient-led online learning modules created in collaboration with a diversity of patient partners.

A Non-Canonical Role for the Glycosyltransferase Enzyme UGT2B17 as a Novel Constituent of the B Cell Receptor Signalosome

In chronic lymphocytic leukemia (CLL), an elevated glycosyltransferase UGT2B17 expression (UGT2B17^HI) identifies a subgroup of patients with shorter survival and poor drug response. We uncovered a mechanism, possibly independent of its enzymatic function, characterized by an enhanced expression and signaling of the proximal effectors of the pro-survival B cell receptor (BCR) pathway and elevated Bruton tyrosine kinase (BTK) phosphorylation in B-CLL cells from UGT2B17^HI patients. A prominent feature of B-CLL cells is the strong correlation of UGT2B17 expression with the adverse marker ZAP70 encoding a tyrosine kinase that promotes B-CLL cell survival. Their combined high expression levels in the treatment of naïve patients further defined a prognostic group with the highest risk of poor survival. In leukemic cells, UGT2B17 knockout and repression of ZAP70 reduced proliferation, suggesting that the function of UGT2B17 might involve ZAP70. Mechanistically, UGT2B17 interacted with several kinases of the BCR pathway, including ZAP70, SYK, and BTK, revealing a potential therapeutic vulnerability. The dual SYK and JAK/STAT6 inhibitor cerdulatinib most effectively compromised the proliferative advantage conferred by UGT2B17 compared to the selective BTK inhibitor ibrutinib. Findings point to an oncogenic role for UGT2B17 as a novel constituent of BCR signalosome also connected with microenvironmental signaling.

COVID-19 restrictions and recreational fisheries in Ontario, Canada: Preliminary insights from an online angler survey

The COVID-19 pandemic and corresponding public health mitigation strategies have altered many facets of human life. And yet, little is known about how public health measures have impacted complex socio-ecological systems such as recreational fisheries. Using an online snowball survey, we targeted resident anglers in Ontario, Canada, to obtain preliminary insights on how the pandemic has impacted recreational fishing and related activity. We also explored angler perspectives on pandemic-related restrictions and other aspects of fisheries management. Our results point to the value of recreational fisheries for the mental and physical well-being of participants, as well as the value and popularity of outdoor recreation during a pandemic. Although angling effort and fish consumption appeared to decline during the early phases of the pandemic, approximately 21 % of the anglers who responded to our survey self-identified as new entrants who had begun or resumed fishing in that time. Self-reported motivations to fish during the pandemic suggest that free time, importance to mental and physical health, and desires for self-sufficiency caused some anglers to fish more, whereas a lack of free time, poor or uncertain accessibility, and perceived risks caused some anglers to fish less. Respondents also expressed their desires for more clear and consistent communication about COVID-19 fishing restrictions from governments, and viewed angling as a safe pandemic activity. Information on recreational angler behaviours, motivations, and perspectives during the pandemic may prove valuable to fisheries managers and policy makers looking to optimize their strategies for confronting this and other similar crises.

Systematic Development of Patient Decision Aids: An Update from the IPDAS Collaboration

BACKGROUND

The 2013 update of the evidence informing the quality dimensions behind the International Patient Decision Aid Standards (IPDAS) offered a model process for developers of patient decision aids.

OBJECTIVE

To summarize and update the evidence used to inform the systematic development of patient decision aids from the IPDAS Collaboration.

METHODS

To provide further details about design and development methods, we summarized findings from a subgroup (n = 283 patient decision aid projects) in a recent systematic review of user involvement by Vaisson et al. Using a new measure of user-centeredness (UCD-11), we then rated the degree of user-centeredness reported in 66 articles describing patient decision aid development and citing the 2013 IPDAS update on systematic development. We contacted the 66 articles' authors to request their self-reports of UCD-11 items.

RESULTS

The 283 development processes varied substantially from minimal iteration cycles to more complex processes, with multiple iterations, needs assessments, and extensive involvement of end users. We summarized minimal, medium, and maximal processes from the data. Authors of 54 of 66 articles (82%) provided self-reported UCD-11 ratings. Self-reported scores were significantly higher than reviewer ratings (reviewers: mean [SD] = 6.45 [3.10]; authors: mean [SD] = 9.62 [1.16], P < 0.001).

CONCLUSIONS

Decision aid developers have embraced principles of user-centered design in the development of patient decision aids while also underreporting aspects of user involvement in publications about their tools. Templates may reduce the need for extensive development, and new approaches for rapid development of aids have been proposed when a more detailed approach is not feasible. We provide empirically derived benchmark processes and a reporting checklist to support developers in more fully describing their development processes.[Box: see text].

Health effects of climate change: an overview of systematic reviews

OBJECTIVES

We aimed to develop a systematic synthesis of systematic reviews of health impacts of climate change, by synthesising studies' characteristics, climate impacts, health outcomes and key findings.

DESIGN

We conducted an overview of systematic reviews of health impacts of climate change. We registered our review in PROSPERO (CRD42019145972). No ethical approval was required since we used secondary data. Additional data are not available.

DATA SOURCES

On 22 June 2019, we searched Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane and Web of Science.

ELIGIBILITY CRITERIA

We included systematic reviews that explored at least one health impact of climate change.

DATA EXTRACTION AND SYNTHESIS

We organised systematic reviews according to their key characteristics, including geographical regions, year of publication and authors' affiliations. We mapped the climate effects and health outcomes being studied and synthesised major findings. We used a modified version of A MeaSurement Tool to Assess systematic Reviews-2 (AMSTAR-2) to assess the quality of studies.

RESULTS

We included 94 systematic reviews. Most were published after 2015 and approximately one-fifth contained meta-analyses. Reviews synthesised evidence about five categories of climate impacts; the two most common were meteorological and extreme weather events. Reviews covered 10 health outcome categories; the 3 most common were (1) infectious diseases, (2) mortality and (3) respiratory, cardiovascular or neurological outcomes. Most reviews suggested a deleterious impact of climate change on multiple adverse health outcomes, although the majority also called for more research.

CONCLUSIONS

Most systematic reviews suggest that climate change is associated with worse human health. This study provides a comprehensive higher order summary of research on health impacts of climate change. Study limitations include possible missed relevant reviews, no meta-meta-analyses, and no assessment of overlap. Future research could explore the potential explanations between these associations to propose adaptation and mitigation strategies and could include broader sociopsychological health impacts of climate change.

New perspectives on PPAR, VDR and FXRα as new actors in testicular pathophysiology

The incidence of reproductive disorders is constantly increasing and affects 15% of couples, with male's abnormalities diagnosed in almost half of the cases. The male gonads exert two major functions of the testis with the productions of gametes (exocrine function) and of sexual hormones (endocrine function). In the last decades, next to steroid receptors such as estrogen and androgen receptors, the involvement of other members of the nuclear receptor superfamily have been described such as Steroidogenic factor-1 (SF-1), Nerve growth factor IB (NGFIB), Liver-X-Receptorα (LXRα) and Dosage-sensitive sex reversal, adrenal hypoplasia critical region, on chromosome X, gene 1 (DAX-1). The purpose of this review is to highlight the emerging roles of some members of the nuclear receptor superfamily among which the vitamin-D Receptor (VDR), Peroxisome Proliferator-Activated Receptor (PPAR), Farnesoid-X-Receptor-α (FXRα). We discuss how these receptors could participate to explain male fertility disorders; and their potential to be use as biomarkers or therapeutic targets for management of fertility disorders.

Performance of predictive tools to identify individuals at risk of non-traumatic fracture: a systematic review, meta-analysis, and meta-regression

There is no consensus on which tool is the most accurate to assess fracture risk. The results of this systematic review suggest that QFracture, Fracture Risk Assessment Tool (FRAX) with BMD, and Garvan with BMD are the tools with the best discriminative ability. More studies assessing the comparative performance of current tools are needed.

INTRODUCTION

Many tools exist to assess fracture risk. This review aims to determine which tools have the best predictive accuracy to identify individuals at high risk of non-traumatic fracture.

METHODS

Studies assessing the accuracy of tools for prediction of fracture were searched in MEDLINE, EMBASE, Evidence-Based Medicine Reviews, and Global Health. Studies were eligible if discrimination was assessed in a population independent of the derivation cohort. Meta-analyses and meta-regressions were performed on areas under the ROC curve (AUCs). Gender, mean age, age range, and study quality were used as adjustment variables.

RESULTS

We identified 53 validation studies assessing the discriminative ability of 14 tools. Given the small number of studies on some tools, only FRAX, Garvan, and QFracture were compared using meta-regression models. In the unadjusted analyses, QFracture had the best discriminative ability to predict hip fracture (AUC = 0.88). In the adjusted analysis, FRAX with BMD (AUC = 0.81) and Garvan with BMD (AUC = 0.79) had the highest AUCs. For prediction of major osteoporotic fracture, QFracture had the best discriminative ability (AUC = 0.77). For prediction of osteoporotic or any fracture, FRAX with BMD and Garvan with BMD had higher discriminative ability than their versions without BMD (FRAX: AUC = 0.72 vs 0.69, Garvan: AUC = 0.72 vs 0.65). A significant amount of heterogeneity was present in the analyses.

CONCLUSIONS

QFracture, FRAX with BMD, and Garvan with BMD have the highest discriminative performance for predicting fracture. Additional studies in which the performance of current tools is assessed in the same individuals may be performed to confirm this conclusion.

Denosumab compared to other treatments to prevent or treat osteoporosis in individuals at risk of fracture: a systematic review and meta-analysis

The aim of this review is to compare the efficacy and safety of denosumab over other treatments for osteoporosis. The results of this study suggest that the safety of denosumab and its efficacy in reducing fractures is not significantly different from bisphosphonates. Denosumab was, however, more effective in increasing bone mineral density.

INTRODUCTION

This study was conducted to compare the efficacy and safety of denosumab over other pharmacological treatments for osteoporosis in individuals at risk of fracture.

METHODS

Randomised controlled trials comparing denosumab with another pharmacological treatment for osteoporosis were searched in MEDLINE, EMBASE and CENTRAL. Identified articles were screened by two independent reviewers and assessed for inclusion. Data from included studies were extracted and meta-analyses were conducted using random effects models.

RESULTS

Nine studies including a total of 4890 postmenopausal women were identified. The follow-up period varied from 12 to 24 months. In all studies except one, the comparator treatment was a bisphosphonate. There was no statistically significant difference between patients receiving denosumab and those receiving a bisphosphonate in terms of fracture risk (RR[95 % CI] = 1.15 [0.84-1.58]), adverse events (RR[95 % CI] = 0.99 [0.96-1.02]) or deaths (OR[95 % CI] = 0.58 [0.12-2.71]). Withdrawals due to adverse events were less frequent in denosumab than in other treatment groups but the difference did not reach statistical significance (OR[95 % CI] = 0.68 [0.45-1.04]). The percent change in bone mineral density at the total hip, lumbar spine, femoral neck and one-third radius was significantly higher in participants who received denosumab (e.g. mean difference [95 % CI] at the total hip: 1.06 [0.86-1.25]).

CONCLUSIONS

These results suggest that, after 12 to 24 months, the safety and efficacy of denosumab for reducing fracture risk is not significantly different from bisphosphonates despite higher gains in bone mineral density. In a clinical setting, denosumab may demonstrate greater effectiveness.

The impact of educational interventions on modifiable risk factors for osteoporosis after a fragility fracture

The purpose of this study was to investigate the impact of two educational interventions on the intake of calcium and vitamin D supplements and modifiable risk factors for osteoporosis in women ≥50 years with a fragility fracture (FF). Within 6-8 months of fracture, women were randomized to one of three intervention groups: usual care (UC), written materials (WM), or videocassette and written materials (VC). The written materials for patients and their physician provided information on osteoporosis, FF, and available treatments; written materials for physician were provided through patients. The videocassette presented similar information as the written material, but in greater depth. Twelve months after randomization, the effectiveness of the interventions was assessed. The study cohort consisted of 1,175 women undiagnosed and untreated for osteoporosis. After 12 months, the mean intake of Ca supplements increased by 33, 93, and 91 mg/day for the UC, WM, and VC groups, respectively (p value, WM vs UC = 0.163; VC vs UC = 0.026); the corresponding mean increases for vitamin D were 58, 105, and 118 IU/day (p value, WM vs UC = 0.214; VC vs UC = 0.012). The proportion of women who increased their Ca and vitamin D intake by supplements was similar in all three groups. The intervention had a greater impact in those not taking supplements at randomization and had no impact on modifiable risk factors. In women without diagnosis and treatment for osteoporosis, the interventions seem effective at increasing the amounts of Ca and vitamin D supplements, but not effective at inciting more women to increase their consumption. Therefore, the clinical significance of the impact of the intervention is difficult to evaluate.

Locomotor rehabilitation in a complex virtual environment

Virtual reality (VR) technology offers a new and safe way to increase practice time and provide the varied environments and constraints needed to optimize locomotor training. Our specific objectives are (1) to create a virtual environment (VE) coupled with a self-paced treadmill for locomotor training; (2) to compare temporal and distance measurements of gait during treadmill walking while looking at different scenarios of VE; and (3) to develop a protocol optimized for the training of locomotor disorders after stroke. A motorized treadmill was mounted on a six-degree-of-freedom motion platform. VEs were created using commercial software (SoftImage) and projected on a large screen, while system control was administered through the CAREN software (Motek BV). The instantaneous treadmill speed and scene progression were servo-controlled. Preliminary results show that healthy subjects are able to have full control of their own walking speed both on the treadmill and within the virtual scene, while experiencing a strong sense of presence. A street crossing training protocol has been developed for locomotor training. It is expected that locomotor training with increasingly complex VEs will allow persons with stroke to increase progressively their locomotor capacity, as required and entrained by the VE.

The 26S proteasome system degrades the ERM transcription factor and regulates its transcription-enhancing activity

ERM is a member of the ETS transcription factor family. High levels of the corresponding mRNA are detected in a variety of human breast cancer cell lines, as well as in aggressive human breast tumors. As ERM protein is almost undetectable in these cells, high degradation of this transcription factor has been postulated. Here we have investigated whether ERM degradation might depend on the proteasome pathway. We show that endogenous and ectopically expressed ERM protein is short-lived protein and undergoes proteasome-dependent degradation. Deletion mutagenesis studies indicate that the 61 C-terminal amino acids of ERM are critical for its proteolysis and serve as a degradation signal. Although ERM conjugates with ubiquitin, this post-translational modification does not depend on the C-terminal domain. We have used an Ets-responsive ICAM-1 reporter plasmid to show that the ubiquitin-proteasome pathway can affect transcriptional function of ERM. Thus, ERM is subject to degradation via the 26S proteasome pathway, and this pathway probably plays an important role in regulating ERM transcriptional activity.

Discussion of lifestyle-related issues in family practice during visits with general medical examination as the main reason for encounter: an exploratory study of content and determinants

The aim of this study was to describe the frequency and content of discussions on lifestyle issues during an annual examination and to identify characteristics of patients, physicians, and visits associated with lifestyle discussions. Audio-recordings of the visits of 35 family physicians with 148 of their patients were analyzed. Bivariate descriptive and multivariate analyses were used. On average, the visits contained discussions of 3.6 different issues for a total time of 2.9 min. Of the 11 topics of interest, weight, diet and nutrition, physical activity, and tobacco use were the most frequently discussed. Consultation with a female physician and perception by the physician of a poorer patient mental health status were associated with the number of themes discussed and the duration of exchanges. Results suggest that although, discussions on lifestyle issues are frequently observed during these visits, they remain limited in scope. Physicians appear to concentrate their energy on targeted patients, and female doctors are more active in this domain.

The PEA3 group of ETS-related transcription factors. Role in breast cancer metastasis

The ets genes encode eukaryotic transcription factors that are involved in tumorigenesis and developmental processes. The signature of the Ets family is the ETS-domain, which binds to sites containing a central 5'-GGAA/T-3' motif. They can be sub-classified primarily because of the high amino acid conservation in their ETS-domains and, in addition, in the conservation of other domains generally characterized as transactivating. This is the case for the PEA3 group, which is currently made up of three members, PEA3/E1AF, ER81/ETV1 and ERM, which are more than 95% identical in the ETS-domain and more than 85% in the transactivation acidic domain. The members of the PEA3 group are activated through both the Ras-dependent and other kinase pathways, a function which emphasizes their involvement in several oncogenic mechanisms. The expression pattern of the three PEA3 group genes during mouse embryogenesis suggests that they are differentially regulated, probably to serve important functions such as tissue interaction. Although the target genes of these transcription factors are multiple, their most frequently studied role concerns their involvement in the metastatic process. In fact, PEA3 group members are over-expressed in metastatic human breast cancer cells and mouse mammary tumors, a feature which suggests a function of these transcription factors in mammary oncogenesis. Moreover, when they are ectopically over-expressed in non-metastatic breast cancer cells, these latter become metastatic with the activation of transcription of matrix metalloproteinases or adhesion molecules, such as ICAM-1.

Medical faculty as humanistic physicians and teachers: the perceptions of students at innovative and traditional medical schools

BACKGROUND AND OBJECTIVES

The training of caring physicians represents an important goal of medical education. Little is known however, on whether medical faculty constitute good role models for teaching humanistic skills to medical students. In this study, we examined to what extent medical students at innovative and traditional schools perceived their teachers as humanistic physicians and teachers. We also explored whether pre-clinical and clinical students shared the same perceptions.

METHODS

A mail survey was conducted in Canada of all second-year students and senior clerks at one innovative medical school (problem-based learning (PBL), patient-centred, community-oriented) and three traditional medical schools. Students were asked to what extent they agreed or disagreed that the majority of their teachers behaved as humanistic physicians and teachers; 10 statements were used. Overall, 65% of the 1039 students returned the questionnaire.

RESULTS

Over 25% of second-year students and 40% of senior clerks did not agree that their teachers behaved as humanistic caregivers with patients or were good role models in teaching the doctor-patient relationship. More than half of second-year students and senior clerks did not agree that their teachers valued human contact with them or were supportive of students who had difficulties. There were few differences in the way medical students at innovative and traditional schools perceived their teachers' humanistic qualities. At the pre-clinical level however, there were more students from the innovative school than from the traditional schools (around 60% vs. 40%, P < 0.005) who agreed that their teachers valued human contact with them and were supportive of students.

CONCLUSION

Our results indicate that the PBL curriculum fosters better teacher-student relationships during the pre-clinical years. They also suggest that an unacceptably large number of medical students are taught by physicians who seem to lack compassion and caring in their interactions with patients. This study questions the adequacy of medical faculty as role models for the acquisition of caring competence by medical students.

[Supporting the conjugal system during the perinatal period: an experience in participatory research]

This article presents the process and results of a participatory study intended to develop and evaluate preventive interventions for couples in the process of becoming new parents. A total of 21 participants, 4 physicians, 8 couples, and an investigator, studied the interventions using a research approach derived from a constructivist paradigm, the fourth generation evaluation. Employing a family intervention model, the nurse guided and contributed to the investigation. The results enabled physicians to refine their perinatal care and facilitated the couples' adjustment to the arrival of their first child. The interventions, the research process, and the use of a family nursing model are promising for nursing applications.

Clinical teachers as humanistic caregivers and educators: perceptions of senior clerks and second-year residents

BACKGROUND

The acquisition and nurturing of humanistic skills and attitudes constitute an important aim of medical education. In order to assess how conducive the physician-learning environment is to the acquisition of these skills, the authors determined the extent to which clinical teachers are perceived by their trainees as humanistic with patients and students, and they explored whether undergraduate and graduate students share the same perceptions.

METHODS

A mail survey was conducted in 1994/95 of all senior clerks and second-year residents at Laval University, University of Montreal and University of Sherbrooke medical schools. Of 774 trainees, 259 senior clerks and 238 second-year residents returned the questionnaire, for an overall response rate of 64%. Students' perceptions of their teachers were measured on a 6-point Likert scale applied to statements about teachers' attitudes toward the patient (5 items) and toward the student (5 items).

RESULTS

On average, only 46% of the senior clerks agreed that their teachers displayed the humanistic characteristics of interest. They were especially critical of their teachers' apparent lack of sensitivity, with as many as 3 out of 4 declaring that their teachers seemed to be unconcerned about how patients adapt psychologically to their illnesses (75% of clerks) and that their teachers did not try to understand students' difficulties (78%) or to support students who have difficulties (77%). Compared with the clerks, the second-year residents were significantly less critical, those with negative perceptions varying from 27% to 58%, 40% on average. Except for this difference, their pattern of responses from one item to another was similar.

INTERPRETATION

This study suggests the existence of a substantial gap between what medical trainees are expected to learn and what they actually experience over the course of their training. Because such a gap could represent a significant barrier to the acquisition of important skills, more and urgent research is needed to understand better the factors influencing students' perceptions.

Modulation of 17alpha-hydroxylase/17,20-lyase activity of guinea pig cytochrome P450c17 by site-directed mutagenesis

Microsomal cytochrome P450c17 (17a-hydroxylase/17,20-Lyase) catalyzes two reactions in the delta5 and delta4 pathways leading to the production of C19 steroids. Transient expression of human, bovine, porcine, rat, and mouse P450c17 cDNAs showed that the protein has 17alpha-hydroxylase and 17,20-Lyase activities, converting pregnenolone and progesterone into delta5- and delta4-Cl9 steroids, respectively, although the rat and mouse proteins have a preferential pathway toward the delta4 steroids. The guinea pig (gp) P450c17 shares 46% to 70% amino acid identity with the corresponding proteins of other species, and further characterization indicated that the guinea pig enzyme only converts progesterone to androstenedione. In this study, we have tried to identify amino acid(s) in the gpP450c17 that governs such a steroid specificity. Among the various mutants that we have created, change of the arginine (R) residue at position 200 to an asparagine (N) (R200N) in the gpP450c17 protein increased reactivity toward pregnenolone compared with the wild-type enzyme. Pregnenolone was converted into 17alpha-hydroxypregnenolone and dehydroepiandrosterone. However, this gain occurred at the expense of the 17,20-lyase activity toward 17alpha-hydroxyprogesterone. The R200N mutation in the gpP450c17 protein introduced a potential N-linked glycosylation site (200Asn-X-Thr202); however, substitution of the Thr202 residue by an asparagine (R200N/T202N), which abolishes the site, did not change the preference of the gpP450c17 mutant for pregnenolone. Furthermore, introduction of a putative glycosylation site at amino acid 185 in the gpP450c17 enzyme did not alter substrate specificity. The properties of the amino acid were also investigated, and neither the charge nor the size of the sidechain elicited change in the substrate specificity of gpP450c17. Thus, our results demonstrate that the mutation of arginine to asparagine at position 200 changes the substrate specificity of the gpP450c17 enzyme.

Regulation of cytochrome P450 cholesterol side-chain cleavage, 3 beta-hydroxysteroid dehydrogenase/delta 5-delta 4 isomerase type 1 and estradiol-17 beta-hydroxysteroid dehydrogenase mRNA levels by calcium in human choriocarcinoma JEG-3 cells

In human placenta the cytochrome P450 side-chain cleavage (P450scc) and 3 beta-hydroxysteroid dehydrogenase type 1 (3 beta-HSD-1) convert cholesterol and pregnenolone producing progesterone, whereas 17 beta-hydroxysteroid dehydrogenase type 1 (17 beta-HSD-1) mediates the interconversion of estrone and estradiol. We have examined the effects of calcium on phorbol ester- and cAMP-induced P450scc, 3 beta-HSD-1 and 17 beta-HSD-1 mRNAs in human JEG-3 cells. A23187 increased in a dose-dependent fashion in the 1.3 kb 17 beta-HSD-1 mRNA whereas a weaker increase followed by a gradual depletion effect of A23187 was observed on 3 beta-HSD-1 mRNA. No significant effect of A23187 on P450scc mRNA was observed. Using 0.50 microM of A23187 the induction of 3 beta-HSD-1 and 17 beta-HSD-1 mRNAs was maximum within about 6 h whereas P450scc mRNA levels stayed unaffected throughout the time-course period. The action of A23187 was synergistic on cAMP-stimulated 17 beta-HSD-1 mRNA levels, while in a dose-dependent manner A23187 progressively depleted 3 beta-HSD-1 and P450scc mRNA abundance probably by activation of a calcium-/calmodulin-dependent phosphodiesterase. On the phorbol 12-myristate, 13-acetate (PMA)-stimulated 3 beta-HSD-1, 17beta-HSD-1 and P450scc mRNA levels only the lowest concentration of A23187 potentialized the PMA effect on the 17 beta-HSD-1 mRNA levels. Using thapsigargin (TG), a cell-permeable sesquiterpene lactone that releases calcium by inhibiting sarco/endoplasmic reticular calcium-ATPase, our data indicated the presence in JEG-3 cells of TG-sensitive and TG-insensitive calcium-ATPases regulating 3 beta-HSD-1 and 17 beta-HSD-1 mRNA levels. These results emphasized the complexity of calcium contribution with the protein kinase A and C pathways in the regulation of P450scc, 3 beta-HSD-1 and 17 beta-HSD-1 mRNA levels. In addition, the different sensitivity of these genes to calcium suggest they could be activated by different subclasses of PKCs.

Expression of the genes for 3 beta-hydroxysteroid dehydrogenase type 1 and cytochrome P450scc during syncytium formation by human placental cytotrophoblast cells in culture and the regulation by progesterone and estradiol

We have investigated the expression of cholesterol side-chain cleavage cytochrome P450 (P450scc) and 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD) type 1 genes during human trophoblast differentiation in culture and the modulation of their steady-state mRNA levels by steroids. During the first 24 to 48 h after plating, mononucleated cells aggregated, forming colonies. After 60 h in culture, cell diameters were increased and nuclei appeared centrally distributed within large cells, consistent with syncytiotrophoblast formation. During these striking morphological changes in culture the expression and activity levels of 3 beta-HSD type 1 and P450scc increased significantly as isolated cytotrophoblasts progressed to a differentiated state, with P450scc and 3 beta-HSD type 1 mRNAs activities being more abundant in cells cultured for 48 to 72 h. In the same culture, however, the amount of 3 beta-HSD protein decreased during the first 12 to 24 h by 50% compared with freshly isolated trophoblasts but remained at these levels throughout the culture period. The specific activity of the 3 beta-HSD as determined with pregnenolone or dehydroepiandrosterone was similar but increased with time as syncytiotrophoblast was formed in vitro. These observations provide additional evidence that the expression of these two progesterone-synthesizing enzymes is coincident and that they reach their maximum steady-state mRNA levels at a time when syncytium formation occurs in vitro. Incubation of trophoblast cells with progesterone or estradiol increased the abundance of P450scc and 3 beta-HSD type 1 mRNAs but had no significant effect on the amount of 3 beta-HSD protein. These observations of the regulation of 3 beta-HSD type 1 mRNA levels by steroids suggest a complex relationship of the mechanisms regulating transcription/mRNA processing and transduction of the 3 beta-HSD type 1 gene.

Intracellular regulation of 17 beta-hydroxysteroid dehydrogenase type 2 catalytic activity in A431 cells

There is growing evidence that various isoforms of 17 beta-hydroxysteroid dehydrogenase (17-HSD) are regulated at the level of catalysis in intact cells. A number of investigators have proposed that the NAD(P)/NAD(P)H ratio may control the direction of reaction. In a previous study, we obtained evidence that A431 cells, derived from an epidermoid carcinoma of the vulva, are enriched in 17-HSD type 2, a membrane-bound isoform reactive with C18 and C19 17 beta-hydroxysteroids and 17-ketosteroids. The present investigation was undertaken to confirm the presence of 17-HSD type 2 in A431 cells and to assess intracellular regulation of 17-HSD at the level of catalysis by comparing the activity of homogenates and microsomes with that of cell monolayers. Northern blot analysis confirmed the presence of 17-HSD type 2 mRNA. Exposure of cells to epidermal growth factor resulted in an increase in type 2 mRNA and, for microsomes, increases in maximum velocity (Vmax) with no change in Michaelis constant (Km) for testosterone and androstenedione, resulting in equivalent increases in the Vmax/Km ratio consistent with the presence of a single enzyme. Initial velocity data and inhibition patterns were consistent with a highly ordered reaction sequence in vitro in which testosterone and androstenedione bind only to either an enzyme-NAD or an enzyme-NADH complex respectively. Microsomal dehydrogenase activity with testosterone was 2- to 3-fold higher than reductase activity with androstenedione. In contrast, although cell monolayers rapidly converted testosterone to androstenedione, reductase activity with androstenedione or dehydroepiandrosterone (DHEA) was barely detectable. lactate but not glucose, pyruvate or isocitrate stimulated the conversion of androstenedione to testosterone by monolayers, suggesting that cytoplasmic NADH may be the cofactor for 17-HSD type 2 reductase activity with androstenedione. However, exposure to lactate did not result in a significant change in the NAD/NADH ratio of cell monolayers. It appears that within A431 cells 17-HSD type 2 is regulated at the level of catalysis to function almost exclusively as a dehydrogenase. These findings give further support to the concept that 17-HSD type 2 functions in vivo principally as a dehydrogenase and that its role as a reductase in testosterone formation by either the delta 4 or delta 5 pathway is limited.

[Role models of residents graduating in family medicine and in different specialties in Quebec]

OBJECTIVE

To describe and compare the role models of Quebec residents graduating from French-language faculties of family medicine and from medical specialities.

DESIGN

Survey by mail.

PARTICIPANTS

Quebec residents graduating in family medicine (189), medical specialities (147), and surgical specialities (64) in 1990.

MAIN OUTCOME MEASURES

Number of models chosen, social, demographic, professional, and personal characteristics of primary role models, role models' influence on students.

RESULTS

Role models chosen by family medicine graduates more closely resemble those of their medical speciality colleagues than those of their surgical speciality colleagues. Family medicine graduates, particularly female graduates, have more difficulty choosing models. Their choices are based mainly on qualities that reflect a biopsychosocial approach to care and concern with the community aspects of medical practice.

CONCLUSION

Choosing role models is a complex process. Medical faculty in residency programs play an important role in the professional identity of future physicians.

Lessons for clinicians from physician-patient communication literature

Research about the communication between physicians and patients contains information that can help clinicians be better diagnosticians and achieve greater compliance and can lead to improved patient health and satisfaction. We present research results that can be useful for the physician in daily clinical practice.

Family physicians' involvement in two hospitals. Two different models of inpatient care

OBJECTIVE

To describe the roles of family physicians in two hospitals with different models of inpatient care.

DESIGN

Cross-sectional descriptive study of a random sample of 11528 patients admitted to two hospitals between 1985 and 1988.

SETTING

Two acute-care community hospitals in suburban Montreal, Que.

SUBJECTS

Family physicians providing inpatient care at the two hospitals.

MAIN OUTCOME MEASURE

How often family physicians were attending physicians (attending responsibility); what percentage of patients were visited by at least one family physician (case load); and what percentage of bedside visits were made by family physicians (workload).

RESULTS

In one hospital, where family physicians were actively promoted as primary care providers, they were frequently attending physicians, had heavier case loads, and made more patient visits. Also, they collaborated more often with specialists. In the other hospital, family physicians tended to care for specific populations of patients.

CONCLUSION

When hospitals promote different organizational models of medical care, family physicians' roles are affected.

Gene expression of 17 beta-hydroxysteroid dehydrogenase type 2 isozyme in primary cultures of human trophoblasts predicts different mechanisms regulating type 1 and type 2 enzymes

Two 17 beta-hydroxysteroid dehydrogenase (17 beta-HSD) genes, types 1 and 2, have been cloned. The two isozymes show a 30% sequence homology but differ markedly in their kinetic properties. To date, the steroidogenic capacity of the placenta has been associated with syncytium formation. In this study, we have investigated 17 beta-HSD type 1 and type 2 gene expression during trophoblast differentiation in culture. We observed that term placenta and fetal cotyledons contain large amounts of both messenger RNAs (mRNAs). In culture, the type 1 gene is expressed concurrent with syncytium formation. However, type 2 expression is barely detectable in freshly isolated cytotrophoblasts and undetectable in syncytiotrophoblasts. Incubation of trophoblasts with progesterone and estradiol increased type 1 mRNA but did not restore 17 beta-HSD type 2 expression. 17 beta-HSD activities with substrates that differentiate the type 1 and type 2 enzymes correlated with the gene expression results. Type 1 activity decreased in freshly isolated trophoblasts by 2-fold and remained at these levels throughout the culture period. However, when compared with levels measured in term microsomes, type 2 activity decreased by 20-fold in freshly isolated cells and decreased again in culture by 5-fold. The expression pattern of 17 beta-HSD type 1 and type 2 activity in trophoblasts in culture suggests differing mechanisms regulate type 1 and type 2 mRNA levels.

Studies of the guinea pig adrenal cytochrome P450c17 cDNA

Cytochrome P450c17 is a single enzyme that catalyzes two successive reactions within the delta 5 and delta 4 pathways. The proteins expressed with human, bovine, and rat cDNAs convert both pregnenolone and progesterone into delta 5-delta 4-C19 steroids, although the rat cDNA prefers the delta 4 pathway. Our results showed that the guinea pig adrenal possesses the enzymatic machinery to produce C19 steroids and suggest that the lyase activity plays a major role in regulating these syntheses. To obtain more information on the structure-function relationship we isolated a full-length cDNA clone encoding guinea pig P450c17. Northern blots of total RNA extracted from the testis, ovary, and adrenals of the guinea pig show that the P450c17 cDNA hybridized with a predicted 1.8-kb mRNA and with two other mRNAs of 3 and 4 kb. No signal other than the 1.8-kb mRNA was observed in the human adrenocortical NCI-H295 cells. Activation of the cAMP-dependent protein kinase A pathway increased the levels of the three mRNAs. Transfection of vectors expressing guinea pig P450c17 cDNA into nonsteroidogenic cells confers 17 alpha-hydroxylase and 17,20-lyase activities, showing that a single protein in the guinea pig supports both activities. However, the analysis of the enzymatic properties showed that the guinea pig P450c17 recombinant, in contrast to the human, supports hydroxylase and lyase activities only with delta 4 substrates. These results were further confirmed with isolated guinea pig adrenocortical cells. Our data demonstrate, first, that guinea pig P450c17 cDNA hybridizes with three different transcripts and second, that the expressed protein has characteristics associated exclusively with the guinea pig enzyme.

Molecular cloning and expression of guinea pig cytochrome P450c17 cDNA (steroid 17 alpha-hydroxylase/17,20 lyase): tissue distribution, regulation, and substrate specificity of the expressed enzyme

In mammalian and fish species, P450c17 mediates both 17 alpha-hydroxylase and 17,20-lyase activities in the synthesis of steroid hormones. Previous results have shown that among the adrenal steroid hydroxylase enzymes involved in adrenal C19 steroid and glucocorticoid synthesis, regulation of cytochrome P450c17 is of primary importance because it is localized at the key branch between glucocorticoid and C19 steroid synthesis. A cDNA library from guinea pig adrenal was constructed, and the complete 17 alpha-hydroxylase cytochrome P450 cDNA was isolated. The guinea pig P450c17 cDNA includes the full-length coding region (1,524 nucleotide), the complete 3' untranslated region (169 nucleotide), and 39 bases of the 5' untranslated region. Our clone shares most of the features of the other P450c17 cDNAs; however, in addition, we identified a novel conserved region of 18 amino acids located in exon I between residues 80 and 97. This region presents the highest percentage of identity among the other P450c17 enzymes and is positioned one helixturn upstream of the important Ser106 on the corresponding human form. On Northern blot, the cDNA hybridizes with a major 1.8-kb mRNA and with two other related P450c17 mRNA of about 3 and 4 kb. P450c17 mRNA is equally distributed in male and female gonads and adrenals. Characterization of the enzymatic activity shows that 17 alpha-hydroxylase and 17,20-lyase are carried by a single protein, but in homogenates 17,20-lyase activity is barely detectable. Moreover, we demonstrate in vitro and in vivo that the guinea pig enzyme preferentially has very high levels of 17 alpha-hydroxylase and 17,20-lyase activities only toward delta 4 steroids. Second-messenger cyclic adenosine monophosphate and adrenocorticotropin specifically increased the abundance of P450c17 mRNA levels in guinea pig adrenal cells.

Regulation of 3 beta-hydroxysteroid dehydrogenase and 17 beta-hydroxysteroid dehydrogenase messenger ribonucleic acid levels by cyclic adenosine 3',5'-monophosphate and phorbol myristate acetate in human choriocarcinoma cells

3 beta-Hydroxysteroid dehydrogenase (3 beta HSD) in human placenta converts 3 beta-hydroxy-5-ene steroids producing progesterone, whereas 17 beta-hydroxysteroid dehydrogenase (17 beta HSD) mediates the interconversion of estrone and estradiol. We first showed that the expression of type I 17 beta HSD (17 beta HSD-I) gene was undetectable in human JEG-3 cells. We then studied the effects of cAMP- and protein kinase-C-dependent pathways on the expression of 3 beta HSD-I and 17 beta HSD-II genes using an analog of cAMP [8-(4-chlorophenylthio)cAMP (8CPTcAMP)] and a protein kinase-C (PKC) activator, phorbol 12-myristate 13-acetate (PMA), in JEG-3 cells. Novel inhibitors of protein kinase-A (PKA) and PKC were also used. The 3 beta HSD cDNA probe hybridized to a single 1.7-kilobase (kb) 3 beta HSD mRNA species corresponding to the transcript of the 3 beta HSD-I gene. The 17 beta HSD cDNA probe hybridized to two 17 beta HSD transcripts of 1.3 and 2.2 kb. The 1.3-kb 17 beta HSD mRNA species was regulated, whereas the 2.2-kb species was constitutively expressed in JEG-3 cells. When JEG-3 cells were exposed to 8CPTcAMP or PMA, 3 beta HSD-I and 17 beta HSD-II gene transcriptions were increased in a dose- and time-dependent manner. Moreover, the combined effects of PMA and 8CPTcAMP on 3 beta HSD-I mRNA levels was additive and synergistic on 17 beta HSD-II mRNA levels. The mechanism by which cAMP activated accumulation of 3 beta HSD-I and 17 beta HSD-II mRNAs involved an activation of the cyclase. The effects of a cAMP-dependent kinase inhibitor and a diacylglycerol-dependent kinase inhibitor in JEG-3 cells indicated that cAMP acts on 3 beta HSD-I mRNA via a PKA-dependent mechanism, but on 17 beta HSD-II mRNA via another nonclassical cAMP-dependent mechanism. Finally, the effect of activation of both signaling pathways on expression of the 17 beta HSD-II gene as well as the effect of PMA on the 3 beta HSD-I gene did not require protein synthesis. These data provide strong evidence for the regulation of the 3 beta HSD-I and 17 beta HSD-II genes by cAMP and PKC and, thus, indicate an important endocrine and/or paracrine regulation of steroid hormone production in human placenta.

Effects of residency training in family medicine v. internship training on professional attitudes and practice patterns

OBJECTIVES

To determine whether the professional attitudes and practice patterns of physicians with residency training in family medicine differ from those of generalists with internship training.

DESIGN

Mail survey conducted in 1985-86.

SETTING

Province of Quebec.

PARTICIPANTS

A stratified random sample of French-speaking family and general practitioners who graduated after 1972 (325 physicians with residency training and 304 with internship training) (response rate 82%).

MAIN RESULTS

Physicians with residency training were 3 years younger on average than those with internship training, were more likely to be female (38% v. 18%, p less than 0.001) and were more likely to work on a salaried basis in CLSCs (public community health centres) (36% v. 14%, p less than 0.001). Even after these confounding factors were controlled for, physicians with residency training seemed to be more sensitive to the psychosocial aspects of patient care and tended to attach more importance to informing patients about useful materials and resources concerning their health problems. They were not, however, more likely to value health counselling or integrate it in medical practice.

CONCLUSION

Our findings provide some evidence that the new requirement that physicians complete a residency in family medicine to obtain medical licensure in general practice in Quebec may foster a more patient-centred approach to health care.

Attitudes of Students Entering Internships and Residencies in Family Medicine: Self-selection and patient, social, and multidisciplinary orientations

Does self-selection explain why residency-trained family physicians show a stronger patient, social, and multidisciplinary orientation than other physicians? Responses to a questionnaire mailed to 235 senior medical students entering internships or family medicine residencies showed significant differences only in multidisciplinary orientation. The study indirectly suggests that residency training does affect physicians' attitudes.

Influence of training in family medicine residency on physicians' attitudes toward comprehensive care

The authors assessed the influence of residency training in family medicine on physicians' attitudes toward comprehensive care by surveying a representative sample of Quebec family physicians. The sample consisted of 290 physicians trained in family medicine and 267 physicians trained in internship programs. Multivariate regression analysis was performed to measure the influence of training on physicians' attitudes independently of physicians' sociodemographic and practice characteristics. Graduates of family medicine had more positive attitudes than other generalists toward three aspects of comprehensive care, even after controlling for sociodemographic and practice characteristics.

Generalists trained in family medicine

Since their creation in the early 1970s, the residency programs in family medicine have attracted an increasing number of medical graduates. In Quebec, over 1000 general practitioners have received their primary-care training in these programs. In order to assess the potential impact of these new training programs, we surveyed the medical practice characteristics of a representative sample of general practitioners, 294 trained in family medicine and 442 trained in the traditional programs. Results showed that trainees in family medicine were more likely to join group practice, to work in rural areas, to deliver hospital care, to work on a salary basis in local community health centres, and to be involved in teaching and research. There were, however, no differences between the two groups of general practitioners in their interventions with patients, particularly with regard to health promotion, patient education, and humanization of care. Implications of these results are discussed.