Recent Publications by CFE Educators

Conventional oral contraceptive (OC) starting instructions require waiting until menses to begin the OC. The conventional approach requires detailed patient education about when to begin and also may require the use of less effective or less acceptable interim contraceptive protection until menses. At our urban family planning clinic, we routinely offer patients starting the OC the option of taking the first tablet sooner. We prospectively evaluated predictors of short-term OC continuation among 250 OC requestors who were offered several approaches to OC initiation. Telephone follow-up of 91% of participants showed that women who swallowed the first OC in the clinic were more likely to continue the OC until the second package than women who planned to start the OC later (adjusted OR 2.8, 95% C.I. 1.1-7.3). Other factors associated with short-term continuation were: partner's knowledge of planned OC use, older age, and participant's agreement that she would be very unhappy about becoming pregnant in the next 6 months.

OBJECTIVE

Over half of American medical schools are currently engaged in significant curricular reform. Traditionally, evaluation of the efficacy of educational changes has occurred well after the implementation of curricular reform, resulting in significant time elapsed before modification of goals and content can be accomplished. We were interested in establishing a process by which a new curriculum could be reviewed and refined before its actual introduction.

DESCRIPTION

The University of California, San Francisco (UCSF) School of Medicine embarked upon a new curriculum for the class entering in September 2001. Two separate committees coordinated plans for curricular change. The Essential Core Steering Committee was responsible for the first two years of training, and the Integrated Clinical Steering Committee guided the development of the third-and fourth-year curriculum. Both groups operated under guidelines of curricular reform, established by the School's Committee on Curriculum and Educational Policy, that emphasized integration of basic, clinical, and social sciences; longitudinal inclusion of themes such as behavior, culture, and ethics; use of clinical cases in teaching; and inclusion of small-group and problem-based learning. In early 2001, the deans of education and curricular affairs appointed an ad hoc committee to examine the status of the first-year curriculum, which had been entirely reformulated into a series of new multidisciplinary block courses. This ad hoc committee was composed of students and clinical faculty members who had not been substantially involved in the detailed planning of the blocks. The charge to the committee was to critique the progress of individual courses, and the first year as a whole, in meeting the goals outlined above, and to make recommendations for improving the preparation of students for the clinical years. To accomplish these goals, the committee reviewed background planning documents; interviewed each course director using a standardized set of questions; and examined course schedules, cases, and detailed learning objectives for particular sessions. In July 2001, the committee reported back to the deans with specific recommendations for coordinating the block courses, and about the success in creating integration and the overall balance of topics students would learn. Specific recommendations included increasing the use of pediatric and geriatric cases across courses, creating a case database, developing explicit plans to relocate uncovered material in the four-year curriculum, and bolstering participation of clinical faculty during the first-year blocks. These recommendations were then presented to and endorsed by the Essential Core Steering Committee, which implemented an action plan prior to the September 2001 start date.

DISCUSSION

This proactive approach to quality improvement added an evaluation point before the new curriculum was actually unveiled. The anticipatory planning process substantially aided the interdisciplinary developmental process, increased input into the first-year curriculum by clerkship directors, and identified problems that would have otherwise become apparent after implementation. We believe this model adds value to the curriculum planning process.

Basic fibroblast growth factor (bFGF) is a potent mitogenic factor for smooth muscle cells, myofibroblasts, and fibroblasts, proliferation of which is a hallmark of idiopathic pulmonary fibrosis (IPF) and lymphangioleiomyomatosis (LAM). Mast cells produce bFGF and have been associated with pulmonary fibrosis. We hypothesize that smooth muscle cell/myofibroblast-like cells will be spatially associated with bFGF-containing mast cells and that bFGF receptors will be expressed on the effector cells in IPF and LAM. We performed quantitative immunohistochemistry for bFGF, mast cell tryptase, smooth muscle actin for smooth muscle cell/myofibroblast-like cells, and fibroblast growth factor receptors (Flg, Bek) and measured collagen and elastic fiber in lung sections from IPF (n = 14), LAM (n = 9), and control lung (n = 10). IPF and LAM lung contained more smooth muscle cell/myofibroblast-like cells than did control lung. bFGF-containing mast cells were abundant both in IPF and LAM and were associated with collagen, elastic fibers, and smooth muscle cell/myofibroblast-like cells in IPF. Flg was expressed on epithelial cells, endothelial cells, smooth muscle cell/myofibroblast-like cells, and macrophages in IPF. In LAM, Flg was expressed on epithelial cells adjacent to smooth muscle cell/myofibroblast-like cell aggregates. Bek was expressed dominantly on smooth muscle cell/myofibroblast-like cells in LAM and on smooth muscle cell/myofibroblast-like cells as well as neutrophils in IPF. These data suggest that mast cell-derived bFGF might exert fibrogenic, proliferative effects on smooth muscle cell/myofibroblast-like cells through its receptors.

Triglyceride-rich lipoproteins (chylomicrons and very low-density lipoproteins) bind endotoxin (lipopolysaccharide [LPS]), forming lipoprotein-LPS complexes, and protect against endotoxic shock and death in rodent models of gram-negative sepsis. Hepatocytes play a central role in the protective process, as demonstrated by the increased uptake of chylomicron (CM)-bound LPS by these cells. We have previously reported that CM-LPS complexes inhibit nitric oxide (NO) production by hepatocytes as compared with LPS or CM alone. Herein, we report that CM-LPS selectively inhibits NF-kappaB in hepatocytes. Pretreating cultured primary hepatocyte spheroids with CM-bound LPS inhibited cytokine-induced NF-kappaB activation by approximately 60% vs. untreated control cells (P 0.03). The lipoprotein-mediated inhibition of NF-kappaB was non-toxic, selective, and associated with inhibition of IkappaB degredation. These data indicate that the mechanism by which CM protect against LPS involves inhibition of the hepatocellular response to proinflammatory stimulation and also support a role for triglyceride-rich lipoproteins as components of the innate host immune response to infection.

Idiopathic pulmonary fibrosis (IPF) is an insidious inflammatory fibroproliferative disease whose cause and course before diagnosis are unknown, and for which existing treatments are of limited benefit. The National Heart, Lung, and Blood Institute convened a working group to develop specific recommendations for future IPF research. Inflammatory and immune processes are involved in IPF pathogenesis, and current therapeutic strategies are aimed at suppressing the inflammation. Recent data suggest that the molecular processes underlying the fibrogenesis may provide new opportunities for therapeutic intervention. Specific areas of future research recommended by the working group include studies to elucidate the etiology of IPF, to develop novel diagnostic techniques and molecular diagnostics, to establish a program for identification of molecular targets for IPF treatment and identification and generation of agonists or antagonists that inhibit fibrogenesis, to foster investigations that couple the use of new technologies (e.g., laser capture microdissection, microarrays, and mass spectroscopic analysis of proteins) with data from the human genome project, to establish a national consortium of Clinical Centers of Excellence to conduct coordinated clinical and laboratory studies of well-characterized patients and patient-derived materials, and to stimulate research to develop animal models of persistent and progressive pulmonary fibrosis for evaluation of new intervention approaches.

The aim of this study was to elucidate the role of the neuromodulator substance P and its related tachykinin neurokinin A (NKA) in the homeostasis of respiratory activity. Respiratory activities, in form of fictive eupneic and sigh activities, were recorded extracellularly from the preBötzinger complex (PBC) in normoxic and anoxic conditions using medullary slice preparations. The effect of a blockade of endogenous substance P was assessed by an acute pharmacological blockade of the receptors with spantide in wild-type animals and by the use of preprotachykinin-A (PPT-A) mutants. These mutants lack from birth the PPT-A gene, which codes for the precursor of substance P and NKA. Spantide treatment reduced frequency (-37%, n = 9) and regularity (twofold) of eupneic-like respiratory activity under normoxic conditions, whereas in PPT-A mutants, eupneic-like activity was under normoxic conditions not significantly different from the wild-type mice (WT). The response to short anoxic episodes (5 min) was characterized in the WT by an increase in respiratory frequencies at the onset of anoxia (ratio anoxic/control frequency = 1.9 +/- 0.2, n = 18). This anoxic ratio was unaltered in the presence of spantide (ratio = 2.3 +/- 0.4, n = 8) but increased in the mutant (ratio = 4.1, n = 15). We conclude that endogenously released substance P is important for the maintenance of regular respiratory activity. Short-term blockade of substance P receptors decreases the frequency and regularity of rhythmic activity. Long-term deficiency in substance P leads to compensatory mechanisms that result in an apparently normal respiratory activity under normoxic conditions but a significantly altered response of the respiratory network during anoxia.

The recently described ligand-receptor pair, B7h-inducible costimulator (ICOS), is critical for germinal center formation and antibody responses. In contrast to the induced expression of the related costimulatory ligands B7.1 and B7.2, B7h is constitutively expressed on naive B cells and is surprisingly extinguished after antigen engagement and interleukin (IL)-4 cytokine signaling. Although signaling through both B cell receptor (BCR) and IL-4 receptor (R) converge on the extinction of B7h mRNA levels, BCR down-regulation occurs through Ca2+ mobilization, whereas IL-4R down-regulation occurs through a distinct Stat6-dependent pathway. During antigen-specific B cell activation, costimulation through CD40 signaling can reverse both BCR- and IL-4R-mediated B7h down-regulation. These data suggest that the CD40-CD40 ligand signaling pathway regulates B7h expression on activated B cells and may control whether antigen-activated B cells can express B7h and costimulate cognate antigen-activated T cells through ICOS.

Surfactant proteins A and D, collagen-like lectins (collectins), were first isolated from the lung. In the lung, SP-A and SP-D have roles in surfactant homeostasis and innate immunity. In this study we show that SP-A and SP-D mRNA can be detected in a significant number of non-pulmonary tissues but the proteins have a more limited distribution. SP-D protein was detected in lung, uterus, ovary, and lacrimal gland, whereas SP-A protein was detected only in the lung. The results suggest that SP-D participates in mucosal immunity throughout the body.