Sexual and gender minority content in undergraduate medical education in the United States and Canada: current state and changes since 2011

PURPOSE

To characterize current lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI +) health-related undergraduate medical education (UME) curricular content and associated changes since a 2011 study and to determine the frequency and extent of institutional instruction in 17 LGBTQI + health-related topics, strategies for increasing LGBTQI + health-related content, and faculty development opportunities.

METHOD

Deans of medical education (or equivalent) at 214 allopathic or osteopathic medical schools in Canada and the United States were invited to complete a 36-question, Web-based questionnaire between June 2021 and September 2022. The main outcome measured was reported hours of LGBTQI + health-related curricular content.

RESULTS

Of 214 schools, 100 (46.7%) responded, of which 85 (85.0%) fully completed the questionnaire. Compared to 5 median hours dedicated to LGBTQI + health-related in a 2011 study, the 2022 median reported time was 11 h (interquartile range [IQR], 6-16 h, p < 0.0001). Two UME institutions (2.4%; 95% CI, 0.0%-5.8%) reported 0 h during the pre-clerkship phase; 21 institutions (24.7%; CI, 15.5%-33.9%) reported 0 h during the clerkship phase; and 1 institution (1.2%; CI, 0%-3.5%) reported 0 h across the curriculum. Median US allopathic clerkship hours were significantly different from US osteopathic clerkship hours (4 h [IQR, 1-6 h] versus 0 h [IQR, 0-0 h]; p = 0.01). Suggested strategies to increase content included more curricular material focusing on LGBTQI + health and health disparities at 55 schools (64.7%; CI, 54.6%-74.9%), more faculty willing and able to teach LGBTQI + -related content at 49 schools (57.7%; CI, 47.1%-68.2%), and more evidence-based research on LGBTQI + health and health disparities at 24 schools (28.2%; CI, 18.7%-37.8%).

CONCLUSION

Compared to a 2011 study, the median reported time dedicated to LGBTQI + health-related topics in 2022 increased across US and Canadian UME institutions, but the breadth, efficacy, or quality of instruction continued to vary substantially. Despite the increased hours, this still falls short of the number of hours based on recommended LGBTQI + health competencies from the Association of American Medical Colleges. While most deans of medical education reported their institutions' coverage of LGBTQI + health as 'fair,' 'good,' or 'very good,' there continues to be a call from UME leadership to increase curricular content. This requires dedicated training for faculty and students.

Preclinical efficacy of targeting epigenetic mechanisms in AML with 3q26 lesions and EVI1 overexpression

AML with chromosomal alterations involving 3q26 overexpresses the transcription factor (TF) EVI1, associated with therapy refractoriness and inferior overall survival in AML. Consistent with a CRISPR screen highlighting BRD4 dependency, treatment with BET inhibitor (BETi) repressed EVI1, LEF1, c-Myc, c-Myb, CDK4/6, and MCL1, and induced apoptosis of AML cells with 3q26 lesions. Tegavivint (TV, BC-2059), known to disrupt the binding of nuclear β-catenin and TCF7L2/LEF1 with TBL1, also inhibited co-localization of EVI1 with TBL1 and dose-dependently induced apoptosis in AML cell lines and patient-derived (PD) AML cells with 3q26.2 lesions. TV treatment repressed EVI1, attenuated enhancer activity at ERG, TCF7L2, GATA2 and MECOM loci, abolished interactions between MYC enhancers, repressing AML stemness while upregulating mRNA gene-sets of interferon/inflammatory response, TGF-β signaling and apoptosis-regulation. Co-treatment with TV and BETi or venetoclax induced synergistic in vitro lethality and reduced AML burden, improving survival of NSG mice harboring xenografts of AML with 3q26.2 lesions.

BRG1/BRM inhibitor targets AML stem cells and exerts superior preclinical efficacy combined with BET or Menin inhibitor

BRG1 (SMARCA4) and BRM (SMARCA2) are the mutually exclusive core ATPases of the chromatin remodeling BAF (BRG1/BRM-associated factor) complexes. They enable transcription factors/co-factors to access enhancers/promoter and modulate gene-expressions responsible for cell growth and differentiation of AML stem/progenitor cells. In AML with MLL1r (MLL1 rearrangement) or mutant (mt) NPM1, although Menin inhibitor (MI) treatment induces clinical remissions, most patients either fail to respond or relapse, some harboring Menin mutations. FHD-286 is an orally bioavailable, selective inhibitor of BRG1/BRM under clinical development in AML. Present studies show that FHD-286 induces differentiation and lethality in AML cells with MLL1r or mtNPM1, concomitantly causing perturbed chromatin accessibility and repression of c-Myc, PU.1 and CDK4/6. Co-treatment with FHD-286 and decitabine, BET inhibitor (BETi) or MI, or venetoclax synergistically induced in vitro lethality in AML cells with MLL1r or mtNPM1. In patient-derived xenograft (PDX) models of AML with MLL1r or mtNPM1, FHD-286 treatment reduced AML burden, improved survival, and attenuated AML-initiating potential of stem-progenitor cells. Compared to each drug, co-treatment with FHD-286 and BETi, MI, decitabine or venetoclax significantly reduced AML burden and improved survival, without inducing significant toxicity. These findings highlight the FHD-286-based combinations as promising therapy of AML with MLL1r or mtNPM1.

Efficacy of novel agents against cellular models of familial platelet disorder with myeloid malignancy (FPD-MM)

Germline, mono-allelic mutations in RUNX1 cause familial platelet disorder (RUNX1-FPD) that evolves into myeloid malignancy (FPD-MM): MDS or AML. FPD-MM commonly harbors co-mutations in the second RUNX1 allele and/or other epigenetic regulators. Here we utilized patient-derived (PD) FPD-MM cells and established the first FPD-MM AML cell line (GMR-AML1). GMR-AML1 cells exhibited active super-enhancers of MYB, MYC, BCL2 and CDK6, augmented expressions of c-Myc, c-Myb, EVI1 and PLK1 and surface markers of AML stem cells. In longitudinally studied bone marrow cells from a patient at FPD-MM vs RUNX1-FPD state, we confirmed increased chromatin accessibility and mRNA expressions of MYB, MECOM and BCL2 in FPD-MM cells. GMR-AML1 and PD FPD-MM cells were sensitive to homoharringtonine (HHT or omacetaxine) or mebendazole-induced lethality, associated with repression of c-Myc, EVI1, PLK1, CDK6 and MCL1. Co-treatment with MB and the PLK1 inhibitor volasertib exerted synergistic in vitro lethality in GMR-AML1 cells. In luciferase-expressing GMR-AML1 xenograft model, MB, omacetaxine or volasertib monotherapy, or co-treatment with MB and volasertib, significantly reduced AML burden and improved survival in the immune-depleted mice. These findings highlight the molecular features of FPD-MM progression and demonstrate HHT, MB and/or volasertib as effective agents against cellular models of FPD-MM.

Identifying Strategies for the Use of Gender and Sex Language in Clinical One-Liners

Purpose: The "one-liner," commonly used in clinical communications, summarizes a patient's identity, presenting condition, medical history, and clinical findings. Imprecise, inconsistent use of gender and sex information in one-liners threatens the provision of affirming care to transgender, nonbinary, gender-expansive, and intersex patients and may exacerbate health care disparities. This study aimed to generate guidance for communicating gender and sex information in one-liners. Methods: This is an explanatory sequential, equal status mixed methods study of transgender, nonbinary, gender-expansive, and intersex people and clinicians caring for this population. Survey participants rated one-liners on a five-point Likert-type scale of appropriateness, considering affirmation and clinical utility, and provided open-ended comments. We conducted two focus groups with survey respondents to explore survey results and performed a thematic analysis of survey comments and focus group transcripts. Results: Survey respondents included 57 clinicians and 80 nonclinicians. One-liners containing patient pronouns were rated most appropriate, and appropriate patient descriptors included self-described gender identity or gender-neutral terms. In scenarios where patient sex information was not pertinent to the chief concern (CC), one-liners containing no sex information were rated most appropriate. Four themes were identified: inclusion of sex information based on relevance to the CC, accurate patient representation, influence of clinical setting, and risk of harm from inaccurate one-liners. Conclusion: This study generated data to support the appropriate use of gender and sex language in one-liners. Clinicians, educators, and trainees may use these findings to compose one-liners that are affirming and clinically useful for patients of diverse gender and sex identities.

Training Health Center Staff in the Provision of Culturally Responsive Care for Sexual and Gender Minority Patients: Results of a Randomized Controlled Trial

Purpose: The study was designed to evaluate whether an educational intervention to train the health center (HC) staff to optimize care for sexual and gender minority (SGM) patients could improve documentation of sexual orientation and gender identity (SOGI) and increase preventive screenings. Methods: Twelve HCs were matched and randomized to either receive a tailored, multicomponent educational intervention or a 1-hour prerecorded webinar. Documentation of SGM status and clinical testing was measured through analysis of data that HCs report annually. Nonparametric statistics were used to assess associations between baseline HC characteristics and outcome measures. Results: The HCs were geographically, racially, and ethnically diverse. In all but one HC, <10% of the patients were identified as SGM. Intervention HCs underwent between 3 and 10 trainings, which were highly acceptable. In 2018, 9 of 12 HCs documented SO and 11 of 12 documented GI for at least 50% of their patients. Five of 6 intervention HCs increased SO documentation by 2020, compared to 3 of 6 control HCs (nonsignificant, NS). Five intervention HCs increased GI documentation, although generally by less than 10%, compared to 2 of the controls (NS). Intervention HCs tended to increase documentation of preventive services more than control HCs, but the changes were NS. Conclusions: An educational intervention designed to train the HC staff to provide culturally responsive services for SGM patients was found to be acceptable, with favorable, but nonsignificant changes. Further refinement of the intervention using a larger sample of HCs might demonstrate the effectiveness of this approach. Clinical trial registration #: NCT03554785.

The effect of mandatory post-call relief on sleep and wellness in ophthalmology residents

BACKGROUND

Multiple duty hour reforms have been implemented to optimize resident wellness through increasing opportunities for sleep recovery, but few studies have recorded objectively measured sleep or shown direct sleep and wellness benefits from such interventions. This study seeks to determine whether mandatory post-call relief policies with a partial night float system improved resident sleep, activity, and burnout among ophthalmology residents taking home call.

METHODS

We conducted a two group cohort study of ophthalmology residents at the University Washington comparing post graduate year-2 (PGY-2) resident sleep, activity, and burnout between the optional post-call relief group from July 1, 2017 to June 30, 2019 to the mandatory post-call relief group from July 1, 2019 to June 30, 2021.

RESULTS

Of twenty total residents participating in the survey portion, 18 residents participated in the sleep and activity tracking portion of the study, 9 in in the optional post-call relief cohort, and 9 in the mandatory post-call relief cohort. The mandatory post-call relief group recorded longer total sleep on call than the optional post-call relief group (p < 0.001). There was no difference in overnight sleep recorded on call (median 3.4 h), but residents recorded more time napping in the mandatory post-call relief cohort (p < 0.001). There was no significant difference between cohorts in amount of sleep while not on call. Residents in the mandatory post-call relief cohort recorded higher average daily steps, higher exercise time, and lower sedentary time than residents in the optional post-call relief cohort (p < 0.001). They also recorded lower median emotional exhaustion on the Maslach Burnout Inventory and lower stress in the Depression and Anxiety Stress Scale in the mandatory post-call relief cohort (p = 0.008).

CONCLUSIONS

Implementation of mandatory post-call relief policies with a partial night-float system among PGY-2 residents was associated with more post-call naps with more overall physical activity, lower emotional exhaustion scores, and lower stress scores, despite no changes to overnight sleep on call or total sleep. Although sample size limits interpretation of data, implementation of mandatory post call relief could be considered to improve post-call sleep in programs with home call.

Resident Sleep During Traditional Home Call Compared to Night Float

Purpose  This article aims to compare resident sleep while on night float with a traditional home call. Methods  We conducted a crossover observational study assessing sleep patterns of seven postgraduate year-2 ophthalmology residents at the University of Washington from 2019 to 2021 using the Fitbit Alta HR device. Overnight call was scheduled from 5 p.m. to 8 a.m. on weekdays, and 8 a.m. to 8 a.m. on weekends. The residency program implemented a partial night float rotation, during which two to three nights of consecutive call were assigned to a resident without other clinical duties. Sleep was recorded using the Fitbit Alta HR for residents while on a 5-week partial night float rotation, on 10-week home call rotations, with postcall relief, and for stretches of seven or more days without call responsibilities. Mixed model regression analysis was used to compare average sleep on home call, night float, and periods without call. Results  Sleep data were recorded for a total of 1,015 nights, including 503 nights on home call rotation and 230 nights on night float rotation. Residents slept more during periods away from call compared to either night float or home call rotations ( p  < 0.001). Residents experienced increased average overall sleep during 10-week rotations on night float compared to home call ( p  = 0.008). While there was no difference in overnight sleep on call between night float and home call ( p  = 0.701), residents experienced more sleep overall while on call on night float compared to home call due to more sleep being recorded during postcall naps ( p  = 0.016). Conclusion  Implementing a night float system can increase resident sleep by allowing for more sleep recovery during time away from clinical duties.

PrEP Echo: A National Interdisciplinary Telementoring Program for HIV Prevention Through Practice Transformation

HIV pre-exposure prophylaxis (PrEP) is highly effective, but PrEP use has been suboptimal. We describe a telementoring program for clinics in high-HIV burden areas, focusing on systems-level practice transformation and care for populations disproportionately affected by HIV. We developed and delivered a telementoring program for U.S. health centers. We analyzed participants' baseline and post-session surveys to ascertain experiences providing PrEP and caring for people disproportionately affected by HIV, comparing responses between medical and behavioral health clinicians. Forty-eight people from 16 health centers participated. Medical clinicians were more likely than behavioral health clinicians to care for people taking PrEP, but the groups did not differ in self-rated capacity to counsel about PrEP or care for populations disproportionately affected by HIV. Virtual training on practice transformation for PrEP, involving medical and behavioral health clinicians, is feasible and acceptable. PrEP training and delivery efforts should include behavioral health clinicians.

Targeting of epigenetic co-dependencies enhances anti-AML efficacy of Menin inhibitor in AML with MLL1-r or mutant NPM1

Monotherapy with Menin inhibitor (MI), e.g., SNDX-5613, induces clinical remissions in patients with relapsed/refractory AML harboring MLL1-r or mtNPM1, but most patients either fail to respond or eventually relapse. Utilizing single-cell RNA-Seq, ChiP-Seq, ATAC-Seq, RNA-Seq, RPPA, and mass cytometry (CyTOF) analyses, present pre-clinical studies elucidate gene-expression correlates of MI efficacy in AML cells harboring MLL1-r or mtNPM1. Notably, MI-mediated genome-wide, concordant, log2 fold-perturbations in ATAC-Seq and RNA-Seq peaks were observed at the loci of MLL-FP target genes, with upregulation of mRNAs associated with AML differentiation. MI treatment also reduced the number of AML cells expressing the stem/progenitor cell signature. A protein domain-focused CRISPR-Cas9 screen in MLL1-r AML cells identified targetable co-dependencies with MI treatment, including BRD4, EP300, MOZ and KDM1A. Consistent with this, in vitro co-treatment with MI and BET, MOZ, LSD1 or CBP/p300 inhibitor induced synergistic loss of viability of AML cells with MLL1-r or mtNPM1. Co-treatment with MI and BET or CBP/p300 inhibitor also exerted significantly superior in vivo efficacy in xenograft models of AML with MLL1-r. These findings highlight novel, MI-based combinations that could prevent escape of AML stem/progenitor cells following MI monotherapy, which is responsible for therapy-refractory AML relapse.

Abstract 1140: Pre-clinical efficacy of targeting BAF complexes through inhibition of the dual ATPases BRG1 and BRM by FHD-286 in cellular models of AML

ATP-dependent chromatin remodeling BAF (BRG1/BRM-associated factor) complexes bind and enable transcription factors (TFs) and co-factors to gain access to enhancer/promoter DNA and modulate transcription. In BAF complexes, The BRG1 (SMARCA4) or BRM (SMARCA2) is the core ATPase. AML stem/progenitor cells (LSCs) express and are dependent on BRG1/BRM activity to maintain their dysregulated epigenome/transcriptome, especially driven by mutations in epigenetic regulators and TFs. CRISPR-dependency DepMap also shows dependency on SMARCA4 in numerous AML cell lines. FHD-286 is a selective, oral inhibitor of BRG1/BRM in early clinical development as a therapy for AML. Our present studies demonstrate that exposure to FHD-286 (10 to 100 nM) for 7 days induces differentiation followed by loss of viability of AML cell lines and PD AML cells with MLL rearrangement (r), mutant (mt) NPM1 and chromosome 3q26 lesions (with EVI1 overexpression). Treatment with FHD-286 caused whole-genome, concordant, up- or down-regulations in ATAC-Seq peaks and RNA-Seq-determined mRNA expressions of specific loci, associated with significant reduction in the gene-sets of targets of MYC, mTORC1, E2F, Interferon-gamma, IL6-JAK-STAT3, as well as of inflammatory response and oxidative phosphorylation genes. QPCR analyses determined significant reduction in mRNA expression of MYC, SPI1 and BCL2 genes. Mass spectrometry on AML cell lysates treated with FHD-286 showed log2 fold-reductions in c-Myc, SPI1, MEF2C, KMT2C and CDK4 (in MOLM13) and in EVI1, c-Myb, CDK6 and c-Myc (in AML191) cells. Co-treatment with FHD-286 and venetoclax, decitabine or BET inhibitor (OTX015) exerted synergistic in vitro lethality against AML cell lines and PD AML cells, especially those expressing MLL-r, mtNPM1 or EVI1 (Delta synergy scores &gt; 5 by the ZIP method). Based on the known efficacy of the Menin inhibitor SNDX-50469, we also found that co-treatment with FHD-286 and SNDX-50469 was synergistically lethal against AML cell lines and PD AML cells with MLL-r or mtNPM1. Finally, in a luciferase-transduced, patient-derived xenograft (PDX) model of AML cells with MLL-AF9, FLT3, KMT2C/2D and NOTCH2 mutations, we determined that treatment with FHD-286 administered orally alone for 4 to 6 weeks was significantly effective in reducing AML burden and improving overall survival of the mice. Additionally, co-treatment with FHD-286 and venetoclax, decitabine or OTX015, as compared to each drug alone or vehicle control, significantly reduced AML burden and improved the overall survival of the NSG mice, without inducing significant toxicity. Taken together, these findings highlight the promise of FHD-286 treatment alone and in rational combinations in exerting significant anti-AML efficacy against cellular models of AML, especially those with MLL-r, mtNPM1 or chromosome 3q26 lesions and EVI1 overexpression.

Citation Format: Warren C. Fiskus, Jessica Piel, Murphy Hentemann, Christopher P. Mill, Christine E. Birdwell, Kaberi Das, John A. Davis, Tapan M. Kadia, Naval Daver, Sanam Loghavi, Courtney D. DiNardo, Kapil N. Bhalla. Pre-clinical efficacy of targeting BAF complexes through inhibition of the dual ATPases BRG1 and BRM by FHD-286 in cellular models of AML [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1140.

Abstract 4900: Preclinical efficacy of targeting epigenetic mechanisms in AML with 3q26 lesions and EVI1 overexpression

EVI1 gene is located at 3q26.2 in the MECOM locus and encodes for a zinc-finger transcription factor. Chromosome translocation t(3;3) or inv(3) at 3q26 repositions the enhancer (E) of the tumor suppressor GATA2 to induce EVI1 over-expression, while concomitantly repressing GATA2. EVI1 over-expression promotes self-renewal and blocks differentiation of leukemia stem-progenitor cells (LSCs) and causes therapy refractoriness and inferior overall survival in AML. Previous reports highlighted that targeting BRD4 with BET inhibitor (BETi) is active against AML cells with inv(3)/t(3;3). BETi treatment also represses EVI1 and its targets c-Myc and Bcl-xL. We recently reported that tegavivint (TV) (BC-2059), a disruptor of the nuclear TBL1/R1-β-catenin-TCF7L2 complex represses c-Myc, cyclin D1 and Survivin and inhibits growth and survival of AML LSCs. In present studies, a CRISPR screen in UCSD-AML1 cells (with 3q26 lesion and EVI1 overexpression) with gRNAs targeting epigenetic regulators highlighted BRD4 and p300 as dependencies. Treatment with BETi, e.g., OTX015, dose-dependently induced apoptosis of AML cell lines and patient-derived (PD) AML cells (AML191 and AML194) with inv(3) or t(3;3). OTX015 treatment repressed c-Myc, c-Myb, CDK4, MECOM, and MCL1, while inducing HEXIM1 and cleaved PARP levels. TV treatment also dose-dependently induced apoptosis in AML cell lines and PD AML cells with 3q26.2 lesions, associated with depletion of nuclear β-catenin, EVI1, TCF7L2, c-Myc, c-Myb, RUNX1, CEBPα, c-KIT, BCL2, Bcl-xL and MCL1, but increase in p21, CD11b, BIM and cleaved PARP levels. Hi-ChIP with H3K27Ac antibody demonstrated that TV treatment abolished chromatin loops between MYC and its Es within the super-E. RNA-Seq analysis showed negative enrichment (log2-fold) of gene sets of MYC, E2F and WNT targets, DNA replication/repair and reduction of the 17-gene stemness score. Confocal microscopy showed that TV treatment disrupted co-localization of EVI1 and β-catenin with TBL1, also confirmed by the Proximity Ligation Assay. CyTOF analysis confirmed that TV treatment reduced EVI1, c-Myc, RUNX1, β-catenin, Bcl-xL, BCL2, MCL1 and Ki67 but increased cleaved PARP levels in the phenotypically characterized LSCs (with high expression of CLEC12A, CD123, CD244 and CD99) harboring inv(3) with EVI1 overexpression. Co-treatment with OTX015 and TV or the p300 inhibitor GNE-049 synergistically induced in vitro apoptosis in the AML cell lines and the PD AML cells with 3q26.2 lesions. Notably, in the flank-implanted PDX of AML191 or tail-vein infused PDX of AML242 models in NSG mice, treatment with OTX015 and TV, compared to vehicle control or each drug alone, significantly reduced AML growth and improved survival, without any host toxicity. These findings highlight the promising pre-clinical efficacy of novel BETi-based combinations against AML models harboring 3q26 lesions and EVI1 overexpression.

Citation Format: Christine E. Birdwell, Warren C. Fiskus, Tapan M. Kadia, Christopher P. Mill, John A. Davis, Kaberi Das, Stephen Horrigan, Kapil N. Bhalla. Preclinical efficacy of targeting epigenetic mechanisms in AML with 3q26 lesions and EVI1 overexpression. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4900.

Causal linkage of presence of mutant NPM1 to efficacy of novel therapeutic agents against AML cells with mutant NPM1

In AML with NPM1 mutation causing cytoplasmic dislocation of NPM1, treatments with Menin inhibitor (MI) and standard AML chemotherapy yield complete remissions. However, the causal and mechanistic linkage of mtNPM1 to the efficacy of these agents has not been definitively established. Utilizing CRISPR-Cas9 editing to knockout (KO) or knock-in a copy of mtNPM1 in AML cells, present studies demonstrate that KO of mtNPM1 from AML cells abrogates sensitivity to MI, selinexor (exportin-1 inhibitor), and cytarabine. Conversely, the knock-in of a copy of mtNPM1 markedly sensitized AML cells to treatment with MI or cytarabine. Following AML therapy, most elderly patients with AML with mtNPM1 and co-mutations in FLT3 suffer AML relapse with poor outcomes, creating a need for novel effective therapies. Utilizing the RNA-Seq signature of CRISPR-edited AML cells with mtNPM1 KO, we interrogated the LINCS1000-CMap data set and found several pan-HDAC inhibitors and a WEE1 tyrosine kinase inhibitor among the top expression mimickers (EMs). Additionally, treatment with adavosertib (WEE1 inhibitor) or panobinostat (pan-HDAC inhibitor) exhibited synergistic in vitro lethal activity with MI against AML cells with mtNPM1. Treatment with adavosertib or panobinostat also reduced AML burden and improved survival in AML xenograft models sensitive or resistant to MI.

Field applications of zein as a precise nanoscale delivery system for methoxyfenozide

When insecticides are applied in the environment, much of the product does not reach the target pest. Biopolymeric nanoparticles as nanocarriers have the potential to improve insecticide efficacy by improving absorption, coverage, and permeability while protecting the insecticide active ingredient from abiotic conditions and extending efficacy through controlled release. We conducted a series of experiments using a biopolymeric nanoparticle synthesized from zein, a biodegradable maize protein, to compare efficacy of a nanodelivered hydrophobic insect growth regulator (methoxyfenozide) against a commercial formulation. Positively charged zein nanoparticles (empty and loaded with methoxyfenozide) were compared to the formulated product, Intrepid 2F, as a foliar spray in-field on soybean. Chrysodeixis includens (Walker) was used as a model and was fed sprayed soybean leaves to evaluate efficacy of the tested foliar products over time. A separate set of leaves was sampled to measure residue levels of methoxyfenozide (MFZ) over time following foliar application using QuEChERS extraction and high-resolution liquid chromatography-mass spectrometry. Regression analysis found no differences in mortality slopes between positively charged zein nanoparticles loaded with methoxyfenozide [(+)ZNP(MFZ)] and Intrepid 2F, suggesting comparable efficacy of the synthesized nanoparticles to a commercial product. Higher concentrations of MFZ were present in (+)ZNP(MFZ)-treated in leaf tissue at 3 d following spray when compared to Intrepid 2F. The multiyear study results demonstrate that nanoparticles loaded with MFZ are comparable to Intrepid 2F under field conditions, with potential short-term benefits.

The Clinical Microsystems Clerkship at University of California, San Francisco: Integrating Clinical Skills and Health Systems Improvement for Early Medical Students

PROBLEM

Medical educators recognize that partnering actively with health system leaders closes significant health care experience, quality, and outcomes gaps. Medical schools have explored innovations training physicians to care for both individual patients and populations while improving systems of care. Yet, early medical student education fails to include systems improvement as foundational skills. When health systems science is taught, it is often separated from core clinical skills.

APPROACH

The Clinical Microsystems Clerkship at the University of California, San Francisco School of Medicine, launched in 2016, integrates clinical skills training with health systems improvement from the start of medical school. Guided by communities of practice and workplace learning principles, it embeds first-year and second-year students in longitudinal clinical microsystems with physician coaches and interprofessional clinicians one day per week. Students learn medical history, physical examination, patient communication, interprofessional teamwork, and health systems improvement. Assessments include standardized patient examinations and improvement project reports. Program outcome measures include student satisfaction and attitudes, clinical skills performance, and evidence of systems improvement learning, including dissemination and scholarship.

OUTCOMES

Students reported high satisfaction (first-year, 4.10; second-year, 4.29, on a scale of 1-5) and value (4.14) in their development as physicians. Clinical skills assessment accuracy was high (70%-96%). Guided by interprofessional clinicians across 15 departments, students completed 258 improvement projects in 3 health systems (academic, safety net, Veterans Affairs). Sample projects reduced disparities in hypertension, improved opiate safety, and decreased readmissions. Graduating students reported both clinical skills and health systems knowledge as important to physician success, patient experience, and clinical outcomes (4.73). Most graduates discussed their projects in residency applications (85%) and disseminated related papers and presentations (54%).

NEXT STEPS

Integrating systems improvement, interprofessional teamwork, and clinical skills training can redefine early medical student education. Health system perspectives, long-term outcomes, and sustainability merit further exploration.

Pre-clerkship Teaching and Learning in the Virtual Learning Environment: Lessons Learned and Future Directions

In response to the COVID-19 pandemic, we developed and implemented a theory-informed process to adapt a comprehensive pre-clerkship medical school curriculum to run in the virtual learning environment utilizing sociocultural learning theory and cognitive load theory. Of 124 student respondents, 45% rated virtual learning as very or extremely effective, and 49% as moderately effective. Positive aspects of virtual learning included effectiveness of chat moderators, displaying pronouns on Zoom, active learning technology, and captioning and transcription. Negative aspects included access to technology and feeling isolated from community. Overall course ratings, examination performance, and work hours did not differ pre- and post-implementation.

Belowground Herbivory to Sweetpotato by Sweetpotato Weevil (Coleoptera: Brentidae) Alters Population Dynamics and Probing Behavior of Aboveground Herbivores

Aboveground and belowground herbivory can alter host quality and trophic interactions. However, little research has explored the impacts of belowground herbivory on plant virus epidemiology. To understand this interaction in sweetpotato, Ipomoea batatas L. (Lam), we studied the impact of herbivory by sweetpotato weevil, Cylas formicarius elegantulus (Summers), to storage roots on vector herbivore, Myzus persicae (Sulzer), the green peach aphid, and Aphis gossypii Glover, the cotton aphid, feeding behavior (M. persicae and A. gossypii) and population dynamics (M. persicae only as A. gossypii does not colonize sweetpotato). In addition, a nonvector herbivore, Chrysodeixis includens (Walker), the soybean looper, weight gain was included for comparison. Infestations of sweetpotato weevil in storage roots reduced C. includens weight gain and M. persicae intrinsic rate of increase (rm), net reproductive rate (Ro), and finite rate of increase (λ) on aboveground portions of the plant. In probing behaviors related to nonpersistent virus spread (30 min trials), M. persicae probed less often, took longer to reach the first pd (potential drop), had shorter II-3 (intracellular subphase sap ingestion) durations, and had fewer archlets on plants infested with C. formicarius elegantulus. Total phloem duration did not differ between treatments, indicating that the lowered performance of M. persicae on infested plants was not due to discrepancies in probing duration. Results were less clear for A. gossypii. Thus, in sweetpotato, belowground herbivory can alter plant virus vector abundance and behavior. Understanding the mechanisms underlying these changes in behavior could improve plant virus vector integrated pest management.

Abstract 2648: Novel combination therapies against AML with 3q26 lesions and EVI1 overexpression

The EVI1 gene is located on 3q26.2 and encodes a zinc fingers-containing transcription factor. Nuclear β-catenin-TBL1/R1-TCF7L2 axis activity and EVI1 expression characterize leukemia stem-progenitor cells, supporting their self-renewal and blocking differentiation. EVI1 is overexpressed in AML with chromosome translocation t(3;3) or inv(3) at 3q26, where the distal GATA2 hematopoietic enhancer is repositioned to induce EVI1 overexpression while repressing GATA2. EVI1 overexpression confers poor response to therapy and inferior relapse-free and overall survival in AML. Tegavivint (BC-2059, Iterion) targets TBL1/R1 and disrupts its binding to β-catenin and TCF7L2, repressing MYC, cyclin D1 and Survivin, leading to apoptosis of AML cells. Here, we determined that treatment with TV (10-100 nM) dose-dependently induced apoptosis in AML cell lines (UCSD-AML1, MUTZ3 and OCI-AML20) and patient-derived (PD) AML cells (AML191 and AML194) with 3q26.2 lesions with/without monosomy 7. This was associated with attenuation of protein levels of EVI1, TCF7L2, c-Myc, c-Myb, RUNX1, CEBPα, c-KIT, BCL2, Bcl-xL and MCL1, but upregulation of CD11b, BIM and cleaved PARP levels. Additionally, by reducing BRD4 occupancy at GATA2 enhancer and repressing EVI1, the pan-BET protein inhibitor OTX015 (100-1000 nM) also dose-dependently induced apoptosis of AML cell lines and PD AML cells with t(3:3)/inv(3). RNA-Seq and gene set enrichment analysis in AML cells showed that TV treatment caused log2 fold-enrichment of gene sets of inflammatory response, TNFα and interferon signaling, TGFβ and apoptosis signaling, but negative enrichment of gene sets of c-Myc, E2F, DNA replication/repair, as well as showed reduction in expression of WNT targets and 17-gene stemness score. Confocal microscopy showed that TV treatment disrupted co-localization EVI1 and β-catenin with TBL1, also confirmed by Proximity Ligation Assay. Mass cytometry (CyTOF) analysis confirmed that TV treatment attenuated EVI1, c-Myc, RUNX1, β-catenin, TBL1/R1, Bcl-xL, BCL2, MCL1 and Ki67 but augmented protein levels of APC and cleaved PARP in phenotypically characterized AML stem cells harboring t(3:3)/inv(3) and EVI1 overexpression (with high expression of CLEC12A, CD123, CD244, CD99). In vitro co-treatment with TV and BCL2 inhibitor venetoclax or OTX015 synergistically induced apoptosis (determined by SynergyFinder) of AML cell lines and the PD AML cells. In the tail-vein infused and engrafted PD AML191 cell model in NSG mice, treatment with TV and/or venetoclax or OTX015 for 6 weeks significantly reduced AML burden and improved overall survival of the NSG mice more than treatment with each drug alone or vehicle control, without any toxicity. These findings highlight that targeted inhibition of TBL1/R1-nuclear β-catenin-TCF7L2 axis combined with BET protein or BCL2 inhibition is effective therapy against AML models harboring 3q26 lesions and EVI1 overexpression.

Citation Format: Christine Birdwell, Warren C. Fiskus, Christopher P. Mill, John A. Davis, Qi Jin, Courtney D. DiNardo, Koichi Takahashi, Stephen Horrigan, Tapan M. Kadia, Naval Daver, Kapil N. Bhalla. Novel combination therapies against AML with 3q26 lesions and EVI1 overexpression [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2648.

Abstract 4030: Efficacy of novel combination therapy against AML cells with mutant NPM1

Cytoplasmic dislocation and loss of nucleolar localization of the chaperone protein NPM1c occurs in 30% of AML following a frame shift C-terminal mutation in exon 12 of NPM1 (creating NPM1c), which contributes to differentiation arrest, growth and survival of AML stem progenitor cells. In present studies, we determined that knock out (KO) of mutant (mt) NPM1 (NPM1c) in the AML OCI-AML3, utilizing targeted gRNA (compared to control) and CRISPR-Cas9, induced growth arrest, morphologic differentiation and loss of viability of the KO cells over 5 to 9 days. This was associated with depletion of protein levels of NPM1c, c-Myc, and MEIS1, but upregulation of PU.1, RUNX1, CD11b, p21 and NOXA levels. ChIP-Seq analysis with H3K27Ac antibody 5d after KO demonstrated reduced peak density at the super-enhancers of MYC, MEIS1, and HOXA9. RNA-Seq analysis showed negative enrichment of HALLMARK gene sets of mRNA expression of MEIS1/HOXA9, MYC targets, ribosome/translation and cell cycle. Compared to OCI-AML3 with NPM1c, OCI-AML3 with NPM1 KO exhibited abrogation of the Menin inhibitor SNDX-50469-induced differentiation and apoptosis. Additionally, NPM1 KO also significantly reduced sensitivity of OCI-AML3 cells to apoptosis induced by targeted agents previously shown to demonstrate efficacy against AML cells with NPM1c, including KPT-330 (XPO1 inhibitor), homoharringtonine (protein translation inhibitor), and anti-AML chemotherapeutic agents, including daunorubicin, cytarabine and etoposide. However, NPM1 KO sensitized OCI-AML3 cells to ATRA (all trans retinoic acid)-induced differentiation and loss of viability, which was associated with marked induction of p21 and CD11b. Utilizing RNA-Seq signature of NPM1c KO and interrogating the LINCS1000-CMap data set of gene expression signatures, we determined that among the top expression mimickers were several pan-HDAC inhibitors and a WEE1 kinase inhibitor. Treatment with adavosertib (WEE1 inhibitor, MK-1775) or romidepsin (HDAC inhibitor) dose-dependently induced apoptosis in OCI-AML3 cells, as well as in 5 samples of patient-derived (PD) AML cells with NPM1c. Moreover, co-treatment with adavosertib and romidepsin synergistically induced lethality in OCI-AML3 and PD AML cells with NPM1c. This was associated with marked reduction in protein expressions of c-Myc, c-Myb, MEIS1 and CDK4/6, but upregulation of TP53 and p21 levels. These findings highlight that presence of NPM1c mechanistically regulates the sensitivity of AML cells to Menin inhibitor, ATRA and anti-AML chemotherapeutic agents. They also identify the novel non-chemotherapy combination of pan-HDAC inhibitor and WEE1 inhibitor for its potential synergistic activity against AML with NPM1c.

Citation Format: Christopher P. Mill, Warren C. Fiskus, John A. Davis, Courtney D. DiNardo, Christine Birdwell, Qi Jin, Koichi Takahashi, Joseph D. Khoury, Kapil N. Bhalla. Efficacy of novel combination therapy against AML cells with mutant NPM1 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 4030.

Abstract 4028: Menin inhibitor-based combinations to improve efficacy and overcome resistance in AML

In MLL1 rearranged (MLL1r) AML (~10%), N-terminus of MLL1 gene is fused to the C-terminus of a fusion partner, e.g. AF9, AF4, ENL and ELL, creating MLL1 fusion protein (MLL-FP), which increases expression of leukemogenic HOXA9 and its co-factor MEIS1. In AML with mutant (mt) NPM1 (NPM1c), MLL1 is the main driver of HOXA9, MEIS1 and FLT3, promoting self-renewal and growth of AML stem-progenitor cells (LSCs). Treatment with Menin inhibitor (MI), SNDX-50469 or SNDX-5613, disrupts binding of Menin to its binding pocket in MLL1/2 and MLL1-FP, reducing expressions of their targets and inducing differentiation and apoptosis. In the phase I/II AUGMENT-101 clinical trial, SNDX-5613 monotherapy was well tolerated and achieved objective remissions in patients with previously treated relapsed/refractory AML harboring MLL1r or NPM1c. However, majority of patients either fail to respond or eventually relapse. A minority of MLL1r AML (~9%) also exhibit a co-mutation in TP53, which is known to confer therapy resistance and poor outcome in AML. This creates the need to develop MI-based synergistic combinations with superior efficacy against patient-derived (PD) AML cells harboring MLL-FP or NPM1c. Present studies found that, following MI treatment, CyTOF analysis of PD MLL1-r and NPM1c AML cells showed decline in protein levels of Menin, MEIS1, MEF2C, PBX3, FLT3, CDK6 and BCL2 in phenotypically characterized AML LSCs expressing CLEC12A, CD123, CD244 and CD99. Notably, in vitro co-treatment with SNDX-50469 in combination with venetoclax, OTX015 (pan-BET inhibitor) or abemaciclib (CDK6 inhibitor) induced synergistic (determined by SynergyFinder V2) loss of viability in AML cell lines (MV4-11, MOLM13 and OCI-AML3), as well as in MOLM13 cells with CRISPR-Cas9-mediated knock-in of mutant or allelic loss of TP53 and in PD AML cells with MLL-r or NPM1c, but not in normal CD34+ progenitor cells or AML cells lacking MLL-FP or NPM1c. A CRISPR screen with a validated, domain-specific gRNA library against chromatin regulators revealed BRD4, p300, MOZ and KDM1A as druggable co-dependencies with treatment with MI. Consistent with this, co-treatment with SNDX-50469 and OTX015, or the p300/CBP inhibitor GNE049 was synergistically lethal in vitro in AML cells with MLL1r or NPM1c, either sensitive to MI or tolerant-resistant (induced in vitro) to MI (MITR cells). Co-treatment with SNDX-5613 and venetoclax or OTX015 compared to each drug or vehicle control, administered orally for 3 to 4 weeks to NSG mice engrafted with either MOLM13-GFP/Luciferase xenograft or with PD NPM1c and mtFLT3 AML xenograft, caused significantly greater reduction in AML burden and increased overall survival without weight loss or other toxicities (p &lt; 0.005). These preclinical findings highlight novel MI-based combinations exhibiting superior in vitro and in vivo anti-AML efficacy against AML cells harboring MLL1-FP or NPM1c that are sensitive to MI or the MITR cells.

Citation Format: Warren C. Fiskus, Christopher P. Mill, Christine Birdwell, John A. Davis, Qi Jin, Tapan M. Kadia, Courtney D. DiNardo, Koichi Takahashi, Gerard M. McGeehan, Naval Daver, Kapil N. Bhalla. Menin inhibitor-based combinations to improve efficacy and overcome resistance in AML [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 4028.

Considerations and recommendations for assessment of plasma protein binding and drug-drug interactions for siRNA therapeutics

At the time of writing, although siRNA therapeutics are approved for human use, no official regulatory guidance specific to this modality is available. In the absence of guidance, preclinical development for siRNA followed a hybrid of the small molecule and biologics guidance documents. However, siRNA differs significantly from small molecules and protein-based biologics in its physicochemical, absorption, distribution, metabolism and excretion properties, and its mechanism of action. Consequently, certain reports typically included in filing packages for small molecule or biologics may benefit from adaption, or even omission, from an siRNA filing. In this white paper, members of the 'siRNA working group' in the IQ Consortium compile a list of reports included in approved siRNA filing packages and discuss the relevance of two in vitro reports-the plasma protein binding evaluation and the drug-drug interaction risk assessment-to support siRNA regulatory filings. Publicly available siRNA approval packages and the literature were systematically reviewed to examine the role of siRNA plasma protein binding and drug-drug interactions in understanding pharmacokinetic/pharmacodynamic relationships, safety and translation. The findings are summarized into two decision trees to help guide industry decide when in vitro siRNA plasma protein binding and drug-drug interaction studies are warranted.

We Have No Choice but to Transform: The Future of Medical Education After the COVID-19 Pandemic

Medical education exists to prepare the physician workforce that our nation needs, but the COVID-19 pandemic threatened to disrupt that mission. Likewise, the national increase in awareness of social justice gaps in our country pointed out significant gaps in health care, medicine, and our medical education ecosystem. Crises in all industries often present leaders with no choice but to transform-or to fail. In this perspective, the authors suggest that medical education is at such an inflection point and propose a transformational vision of the medical education ecosystem, followed by a 10-year, 10-point plan that focuses on building the workforce that will achieve that vision. Broad themes include adopting a national vision; enhancing medicine's role in social justice through broadened curricula and a focus on communities; establishing equity in learning and processes related to learning, including wellness in learners, as a baseline; and realizing the promise of competency-based, time-variable training. Ultimately, 2020 can be viewed as a strategic inflection point in medical education if those who lead and regulate it analyze and apply lessons learned from the pandemic and its associated syndemics.

Consensus-Driven Priorities for Firearm Injury Education Among Medical Professionals

PURPOSE

Firearm injury is a leading cause of morbidity and mortality in the United States. However, many medical professionals currently receive minimal or no education on firearm injury or its prevention. The authors sought to convene a diverse group of national experts in firearm injury epidemiology, injury prevention, and medical education to develop consensus on priorities to inform the creation of learning objectives and curricula for firearm injury education for medical professionals.

METHOD

In 2019, the authors convened an advisory group that was geographically, demographically, and professionally diverse, composed of 33 clinicians, researchers, and educators from across the United States. They used the nominal group technique to achieve consensus on priorities for health professions education on firearm injury. The process involved an initial idea-generating phase, followed by a round-robin sharing of ideas and further idea generation, facilitated discussion and clarification, and the ranking of ideas to generate a prioritized list.

RESULTS

This report provides the first national consensus guidelines on firearm injury education for medical professionals. These priorities include a set of crosscutting, basic, and advanced learning objectives applicable to all contexts of firearm injury and all medical disciplines, specialties, and levels of training. They focus on 7 contextual categories that had previously been identified in the literature: 1 category of general priorities applicable to all contexts and 6 categories of specific contexts, including intimate partner violence, mass violence, officer-involved shootings, peer (nonpartner) violence, suicide, and unintentional injury.

CONCLUSIONS

Robust, data- and consensus-driven priorities for health professions education on firearm injury create a pathway to clinician competence and self-efficacy. With an improved foundation for curriculum development and educational program-building, clinicians will be better informed to engage in a host of firearm injury prevention initiatives both at the bedside and in their communities.

Managing expansions in medical students' clinical placements caused by curricular transformation: perspectives from four medical schools

Many challenges could occur that result in the need to handle an increase in the number of medical student clinical placements, such as curricular transformations or viral pandemics, such as COVID 19. Here, we describe four different institutions' approaches to addressing the impact of curricular transformation on clerkships using an implementation science lens. Specifically, we explore four different approaches to managing the 'bulge' as classes overlap in clerkships Curriculum leaders at four medical schools report on managing the bulge of core clinical placements resulting from reducing the duration of the foundational sciences curriculum and calendar shifts for the respective clerkship curriculum. These changes, which occurred between 2014 and 2018, led to more students being enrolled in core clinical rotations at the same time than occurred previously. Schools provided respective metrics used to evaluate the effectiveness of their bulge management technique. These data typically included number of students affected in each phase of their curricular transformation, performance on standardized examinations, and student and faculty feedback. Not all data were available from all schools, as some schools are still working through their 'bulge' or are affected by COVID-19. There is much to be learned about managing curricular transformations. Working on such endeavors in a learning collaborative such as the AMA Accelerating Change in Medical Education Initiative provided support and insights about how to survive, thrive and identifying lessons learned during curricular transformation.

Readiness of US Federally Qualified Health Centers to Provide HIV Pre-exposure Prophylaxis

We report the results of a survey on HIV pre-exposure prophylaxis (PrEP) perceptions, capacity, and barriers at federally qualified health centers (FQHCs) in high–HIV burden jurisdictions in the United States. Health care workers at FQHCs identified multiple barriers to, and strategies for, improving PrEP implementation.

The role of diet quality and dietary patterns in predicting muscle mass and function in men over a 15-year period

A growing body of evidence suggests that diet quality may predict muscle health. This study found that a "Traditional" dietary pattern predicted greater muscle mass, and an anti-inflammatory diet predicted greater muscle mass and better muscle function over 15 years. These findings reinforce the importance of optimising dietary behaviours for healthy ageing.

INTRODUCTION

Research investigating the roles of individual nutrients in muscle health fails to account for the synergistic relationships between foods and nutrients. This study aimed to investigate the predictive value of diet quality and dietary patterns for muscle mass and function in men over a 15-year period.

METHODS

This longitudinal study was conducted in 522 men from the Geelong Osteoporosis Study with complete dietary and muscle mass or muscle function data at both baseline and 15-year follow-up assessments. Dietary exposures were extracted from food frequency questionnaires and included the Australian Recommended Food Score, the Dietary Inflammatory Index (DII®), and three a posteriori dietary patterns: Plant-focused, Western, and Traditional (Anglo-Australian). Outcome variables included dual-energy X-ray absorptiometry-derived skeletal muscle index (SMI) and muscle function measured with the timed up-and-go (TUG) test.

RESULTS

An anti-inflammatory diet and higher scores on a Traditional dietary pattern both predicted greater SMI ((B: -0.04 (95%CI -0.08, -0.00) kg/m²) and (B: 0.12 (95%CI 0.04, 0.20) kg/m²), respectively), while a pro-inflammatory diet predicted slower TUG (B: 0.11 (95%CI 0.001, 0.21) sec) over the 15-year follow-up period. These associations remained significant following adjustment for confounding variables. There were no associations observed for other dietary exposures.

CONCLUSION

A Traditional dietary pattern higher in vegetables, wholegrain cereals, and animal protein was associated with greater skeletal muscle mass, and an anti-inflammatory diet, also rich in vegetables, fruit, and wholegrain cereals, was associated with greater skeletal muscle mass and better muscle function over 15 years.

Anxiety, PTSD, and stressors in medical students during the initial peak of the COVID-19 pandemic

Purpose

To assess psychological effects of the initial peak phase of the COVID-19 pandemic on United States (US) medical students in clinical training to anticipate sequelae and prepare for future outbreaks.

Methods

Authors emailed a cross-sectional survey in April-May, 2020 to students in clinical training years at six US medical schools which included validated General Anxiety Disorder (GAD-7) and Primary Care-PTSD (PC-PTSD-5) screening tools, and asked students about pandemic-related stress and specific concerns. Authors used quantitative and thematic analysis to present results.

Results

Of 2511 eligible students, 741 responded (29.5%). Most students (84.1%) reported at least “somewhat” increased levels of stress and anxiety related to the pandemic. On the GAD-7, 34.3% showed mild, 16.1% moderate, and 9.5% severe anxiety symptoms, with 39.6% demonstrating no/minimal symptoms. One quarter (25.4%) screened positive for PTSD risk symptoms. Top concerns of students chosen from a pre-populated list included inadequate COVID-19 testing, undiagnosed or asymptomatic spread and racial or other disparities in the pandemic. In thematic analysis, students’ reactions to removal from clinical learning included: understanding the need to conserve PPE (32.2%), a desire to help (27.7%), worry over infectious risk to others (25.4%) and self (21.2%), and lost learning opportunities (22.5%). Female students were significantly more likely to report anxiety and PTSD risk symptoms. Asian students had a greater risk of moderate anxiety and those underrepresented in medicine (UIM) had greater risk of moderate and severe anxiety symptoms compared to white students.

Conclusions

During the initial peak phase of COVID-19, over 60% of US medical students screened positive for pandemic-related anxiety and one quarter were at risk for PTSD. Female and UIM students were significantly more affected. Medical schools should consider broad support of students, and targeted outreach to female and UIM students.

Characterizing Host Plant Resistance to Melanaphis sacchari (Hemiptera: Aphididae) in Selected Sorghum Plant Introductions

Since 2013 Melanaphis sacchari (Zehnter) (Hemiptera: Aphididae), the sugarcane aphid, has been a threat to sorghum production in the United States. The development of resistant sorghum hybrids has been one of the main management strategies. However, plant resistance can be overcome over time and new resistance genes need to be identified and introduced into adapted sorghum hybrids to secure sorghum production. Sorghum plant introduction (PI) genotypes were screened for resistance to M. sacchari through laboratory, greenhouse, and field assays. In addition, the feeding parameters of M. saccahri were analyzed and detailed in seven sorghum genotypes through EPG assays. Results showed sorghum genotypes PI 524770, PI 564163, and PI 643515 expressed resistance to M. sacchari consistently in laboratory, greenhouse, and field tests. EPG analysis suggested sorghum genotypes PI 524770 and PI 564163 express antibiosis to M. sacchari while PI 643515 expresses both antibiosis and antixenosis. Increasing the number of sorghum hybrids resistant to M. sacchari is key to improving integrated pest management of M. sacchari. By utilizing host plant resistance, sorghum producers can decrease insecticide applications while enhancing biological control.

Post-Clerkship Curricular Reform: Specialty-Specific Tracks and Entrustable Professional Activities to Guide the Transition to Residency

The development of core entrustable professional activities (EPA) for entering residency and Accreditation Council for Graduate Medical Education's milestones have spurred thinking about the fourth year of medical school as a transition to residency. In this monograph, we lay out our specialty focused post-clerkship curriculum and report learner and residency director perceptions over the first three years of implementation. Ongoing curricular monitoring has reinforced core principles but has also informed actionable quality improvement efforts. EPA-focused learning experiences, integration of specialty-specific milestones, addition of the feedforward process, and accessible mentorships have been key curricular elements to guide the transition to residency.

Office of Medical Education: Opportunities for Trainees to Engage and Lead in Curricular Innovation and Reform

INTRODUCTION

The AAMC prioritizes promoting a diverse and culturally competent workforce which is thought to have a positive impact on the health of people living in the US. There is a lack of diversity in the current landscape of academic medicine and strategies are needed to effect change. This module introduced undergraduate and graduate medical trainees to leadership skills and opportunities in curriculum innovation and reform by learning about and interacting with the office of medical education (OME) at their institutions.

METHODS

We implemented a workshop using small-group case discussions and didactics to help medical students and residents learn how to: (1) describe the structure and functions of an OME, (2) describe leadership competencies associated with various roles within the OME, and (3) identify opportunities for trainees to engage with the OME on curricular innovation and reform, especially advancing diversity and inclusion.

RESULTS

Across three sites, 45 learners completed partial or full workshop evaluations. Of learners, 22 (49%) were not knowledgeable and 13 (29%) were somewhat knowledgeable in identifying leadership opportunities for trainees to become engaged through the OME. There was a statistically significant increase in confidence after the workshop in "discussing an interdisciplinary approach to the creation of a medical education innovation," and, "assessing the need for curricula change." Over 90% of attendees agreed learning objectives were met.

DISCUSSION

This workshop succeeded in promoting awareness of the structure and function of OMEs and confidence in seeking opportunities to become engaged in medical education, especially in advancing diversity and inclusion.

Study of the X-ray radiation interaction with a multislit collimator for the creation of microbeams in radiation therapy

Microbeam radiation therapy (MRT) is a developing radiotherapy, based on the use of beams only a few tens of micrometres wide, generated by synchrotron X-ray sources. The spatial fractionation of the homogeneous beam into an array of microbeams is possible using a multislit collimator (MSC), i.e. a machined metal block with regular apertures. Dosimetry in MRT is challenging and previous works still show differences between calculated and experimental dose profiles of 10-30%, which are not acceptable for a clinical implementation of treatment. The interaction of the X-rays with the MSC may contribute to the observed discrepancies; the present study therefore investigates the dose contribution due to radiation interaction with the MSC inner walls and radiation leakage of the MSC. Dose distributions inside a water-equivalent phantom were evaluated for different field sizes and three typical spectra used for MRT studies at the European Synchrotron Biomedical beamline ID17. Film dosimetry was utilized to determine the contribution of radiation interaction with the MSC inner walls; Monte Carlo simulations were implemented to calculate the radiation leakage contribution. Both factors turned out to be relevant for the dose deposition, especially for small fields. Photons interacting with the MSC walls may bring up to 16% more dose in the valley regions, between the microbeams. Depending on the chosen spectrum, the radiation leakage close to the phantom surface can contribute up to 50% of the valley dose for a 5 mm × 5 mm field. The current study underlines that a detailed characterization of the MSC must be performed systematically and accurate MRT dosimetry protocols must include the contribution of radiation leakage and radiation interaction with the MSC in order to avoid significant errors in the dose evaluation at the micrometric scale.

Effects of the COVID-19 pandemic on medical students: a multicenter quantitative study

BACKGROUND

The COVID-19 pandemic disrupted the United States (US) medical education system with the necessary, yet unprecedented Association of American Medical Colleges (AAMC) national recommendation to pause all student clinical rotations with in-person patient care. This study is a quantitative analysis investigating the educational and psychological effects of the pandemic on US medical students and their reactions to the AAMC recommendation in order to inform medical education policy.

METHODS

The authors sent a cross-sectional survey via email to medical students in their clinical training years at six medical schools during the initial peak phase of the COVID-19 pandemic. Survey questions aimed to evaluate students' perceptions of COVID-19's impact on medical education; ethical obligations during a pandemic; infection risk; anxiety and burnout; willingness and needed preparations to return to clinical rotations.

RESULTS

Seven hundred forty-one (29.5%) students responded. Nearly all students (93.7%) were not involved in clinical rotations with in-person patient contact at the time the study was conducted. Reactions to being removed were mixed, with 75.8% feeling this was appropriate, 34.7% guilty, 33.5% disappointed, and 27.0% relieved. Most students (74.7%) agreed the pandemic had significantly disrupted their medical education, and believed they should continue with normal clinical rotations during this pandemic (61.3%). When asked if they would accept the risk of infection with COVID-19 if they returned to the clinical setting, 83.4% agreed. Students reported the pandemic had moderate effects on their stress and anxiety levels with 84.1% of respondents feeling at least somewhat anxious. Adequate personal protective equipment (PPE) (53.5%) was the most important factor to feel safe returning to clinical rotations, followed by adequate testing for infection (19.3%) and antibody testing (16.2%).

CONCLUSIONS

The COVID-19 pandemic disrupted the education of US medical students in their clinical training years. The majority of students wanted to return to clinical rotations and were willing to accept the risk of COVID-19 infection. Students were most concerned with having enough PPE if allowed to return to clinical activities.

BET proteolysis targeted chimera-based therapy of novel models of Richter Transformation-diffuse large B-cell lymphoma

Richter Transformation (RT) develops in CLL as an aggressive, therapy-resistant, diffuse large B cell lymphoma (RT-DLBCL), commonly clonally-related (CLR) to the concomitant CLL. Lack of available pre-clinical human models has hampered the development of novel therapies for RT-DLBCL. Here, we report the profiles of genetic alterations, chromatin accessibility and active enhancers, gene-expressions and anti-lymphoma drug-sensitivity of three newly established, patient-derived, xenograft (PDX) models of RT-DLBCLs, including CLR and clonally-unrelated (CLUR) to concomitant CLL. The CLR and CLUR RT-DLBCL cells display active enhancers, higher single-cell RNA-Seq-determined mRNA, and protein expressions of IRF4, TCF4, and BCL2, as well as increased sensitivity to BET protein inhibitors. CRISPR knockout of IRF4 attenuated c-Myc levels and increased sensitivity to a BET protein inhibitor. Co-treatment with BET inhibitor or BET-PROTAC and ibrutinib or venetoclax exerted synergistic in vitro lethality in the RT-DLBCL cells. Finally, as compared to each agent alone, combination therapy with BET-PROTAC and venetoclax significantly reduced lymphoma burden and improved survival of immune-depleted mice engrafted with CLR-RT-DLBCL. These findings highlight a novel, potentially effective therapy for RT-DLBCL.

Influence of Sorghum Cultivar, Nitrogen Fertilization, and Insecticides on Infestations of the Sugarcane Aphid (Hemiptera: Aphididae) in the Southern United States

The sugarcane aphid, Melanaphis sacchari Zehntner, is an economically damaging pest of sorghum, Sorghum bicolor (L.), across the southern United States. Field experiments investigated impacts of sorghum cultivar, nitrogen fertilization, and insecticides on M. sacchari infestations and sorghum yields in Louisiana and South Carolina in 2017 and 2018. In South Carolina, M. sacchari densities in unprotected plots peaked on 30-31 July of both years before declining by early- to mid-August. In Louisiana, infestations peaked on 26 and 12 July for 2017 and 2018, respectively, and declined by mid-August. Nitrogen fertilization influenced M. sacchari densities in Louisiana in 2018 with the highest-level infestations recorded from plots that received high N rates. Densities of M. sacchari on susceptible sorghum cultivar, DKS 38-88, were 1.5- to 2.3-fold greater than on DKS 37-07 in both years in Louisiana and in 2018 in South Carolina. Nitrogen fertilization was associated with improved sorghum yields in Louisiana experiments. Sorghum yields across experiments were 2- to 4-fold greater in plots protected with multiple insecticide applications than in unprotected plots. Yield from plots with insecticides sprayed once at currently used action thresholds differed from unprotected plots only in the 2018 Louisiana experiment. Results from these experiments indicate insecticidal protection of susceptible sorghum cultivars remains critical throughout much of the southern United States. Further research is needed to develop integrated management programs that incorporate fertilization manipulation, cultivar resistance, and insecticidal control.

Detailed Characterization of Melanaphis sacchari (Hemiptera: Aphididae) Feeding Behavior on Different Host Plants

Worldwide, Melanaphis sacchari Zehntner is reported on several plants in the family Poaceae, including important crops. In the United States, M. sacchari has been present primarily on sugarcane (Saccharum officinarum L.), but recently sorghum (Sorghum bicolor (L.) Moench) has become a main host. It is not clear how M. sacchari exploits sorghum or other plant species present in the Louisiana agro-ecoscape, but there is potential for these plants to be bridging hosts. Thus, this study determined the feeding behavior of M. sacchari on sorghum, rice, Oryza sativa (L.), sweetpotato, Ipomea batatas (L.), maize, Zea mays (L.), Johnsongrass, S. halepense (L.), and wheat Triticum aestivum (L.) using electrical penetration graphs. Melanaphis sacchari established sustained feeding on sorghum, Johnsongrass, wheat, and rice, only a negligent percentage on maize and no aphid fed on sweetpotato. Differences in Electrical Penetration Graph parameters among the plants in nonpenetrating total time and the lower number of probes, time to penetration initiation, proportion of individuals probing, number of probes shorter than 30 s, number of probes longer than 30 s but shorter than 3 min, pathway phase duration, and number of cell punctures during pathway phase, suggest epidermis and mesophyll factors affecting aphid feeding behavior. While the lack of differences in number of feeding occurrences, total time feeding, and number of sustained feeding occurrences shows that M. sacchari is able to feed on those plants, sieve element factors such as resistance or low nutritional quality prevent the growth of this population in field.

LGBTQ+ Health-a Novel Course for Undergraduate Students

The concept of providing focused, competency-based LGBTQ+ health education outside the setting of health professional programs, specifically for undergraduates, is quite uncharted. However, the issue at the core of our rationale is one shared by those with and without clinical exposure: how to best support the development of cultural competence in providers who are or will be caring for LGBTQ+ patients. Traditional health professional education programs have enacted a number of curricular initiatives in this regard, designed for advanced learners. By focusing specifically on the undifferentiated learner, we offer a new perspective on the timing of LGBTQ+ health-related education. Our course is not intended to supplant the critical learning and application that must occur in the clinic or hospital room. Rather, we present a framework for cultivating understanding of the healthcare issues faced by the LGBTQ+ community that may help a learner to acquire and apply skills subsequently with greater cultural competence.

National Findings from an LGBT Healthcare Organizational Needs Assessment

PURPOSE

LGBT populations require expanded access to healthcare that meets their unique needs. This article presents the primary findings of a training and technical assistance needs assessment conducted with healthcare organizations in geographically diverse areas of the United States to help determine gaps in LGBT health familiarity, preparedness, comfort, and practices.

METHODS

A total of 5980 staff members and 638 leaders from 18 healthcare organizations participated in online needs assessment surveys. Cross-sectional findings and significance were evaluated using descriptive statistics and two-sample t-tests.

RESULTS

Significantly more clinicians agreed that they were familiar with lesbian, gay, and bisexual health needs compared with being familiar with transgender health needs (81.7% vs. 68.3%, p = 0.005). The majority of clinicians rarely or never talked to their patients about sexual orientation (55.4%) or gender identity (71.9%), mostly due to believing that the topics were not relevant to care, concerns with making the patient uncomfortable or offending the patient, lack of experience, and not knowing the appropriate language for talking about the subjects. Nearly one-third of staff respondents did not know if sexual orientation or gender identity/expression was included in organizational nondiscrimination patient policies.

CONCLUSION

Although clinicians may self-report that they are familiar with LGBT health issues, gaps in practice and knowledge indicate the need for more training, especially in transgender health and in talking to patients about sexual orientation and gender identity. Healthcare organizations also need support in ensuring that their organizations create inclusive environments by educating staff and leadership on nondiscrimination policies.

Time Since First Acting on Same-Sex Attraction and Recreational Drug Use among Men Who Have Sex With Men (MSM): Is There an Effect of "Gay Age"?

BACKGROUND

Men who have sex with men (MSM) have higher rates of substance use compared to men who have sex with women. Among MSM, drug use is linked to higher-risk sexual behavior and acquisition of HIV and other sexually transmitted infections.

OBJECTIVES

We hypothesize that time since first acting on one's same sex attraction, or one's "gay age", could be predictive of drug using behavior.

METHODS

We examined this question among 176 MSM, aged 18-35, presenting at a public sexual health clinic. Behavioral data were captured using interviewer- and self-administered surveys and clinical data were extracted from medical records. We used modified Poisson regression to examine associations between gay age and recent recreational drug use, and separately, between gay age and recent marijuana use.

RESULTS

In total, 43% of participants reported recent marijuana use and 26% of participants reported recent use of other drugs. The associations between gay age and marijuana use and other drug use varied by HIV status. After adjustment for biological age, race, and education, a one-year increase in gay age was associated with significantly increased drug use among HIV-negative men (adjusted prevalence ratio (aPR): 1.08; 95% confidence interval (CI): 1.03-1.14), but we observed no association between gay age and drug use among HIV-positive men (aPR: 0.96, 95% CI: 0.86-1.07). Gay age was not associated with marijuana use in HIV-negative (aPR: 1.00, 95% CI: 0.95-1.04) or HIV-positive (aPR: 1.06, 95% CI: 0.98-1.14) men.

CONCLUSIONS

In summary, HIV-negative MSM who had experienced more time since first same-sex experience had significantly increased prevalence of recent drug use.

Infections and the relationship to treatment in neuromuscular autoimmunity

INTRODUCTION

This study aimed to identify infections in patients with myasthenia gravis, dermatomyositis, and chronic inflammatory demyelinating polyradiculoneuropathy, and to investigate the relationship between infection and immunomodulation.

METHODS

A retrospective chart review examined 631 patients with myasthenia gravis (n = 358), chronic inflammatory demyelinating polyradiculoneuropathy (n = 124), and dermatomyositis (n = 149) patients over a 10-year time period.

RESULTS

Infection rates were similar at approximately 19% in all 3 diseases. Of the infections in which a causative organism was identified, pneumonia, sepsis, and opportunistic infections were the leading diagnoses. A multivariate model demonstrated a significant association between infection and an increased dose of plasma exchange, mycophenolate mofetil, and corticosteroid therapy.

DISCUSSION

There are few large studies investigating rates of infections in patients with autoimmune neuromuscular disorders and the relationship to immunomodulation. This study not only demonstrates the remarkably similar infection rates across the 3 diseases studied, but also shows their relationship to commonly used immunotherapies. Muscle Nerve 57: 927-931, 2018.

Influence of Host Quality and Temperature on the Biology of Diaeretiella rapae (Hymenoptera: Braconidae, Aphidiinae)

Biological features of Diaeretiella rapae (McIntosh), an aphid parasitoid, are conditioned by temperature and host. However, studies of host quality changes due to temperature adaptability have not been performed previously. Therefore, this study evaluated the adaptability of Lipaphis pseudobrassicae (Davis) and Myzus persicae (Sulzer) to high temperature, high temperature effect on their quality as hosts for D. rapae, and on parasitoid's thermal threshold. Aphid development, survivorship, fecundity, and longevity were compared at 19 °C and 28 °C. Host quality in different temperatures was determined through evaluation of parasitoid biology. Thermal threshold of D. rapae was determined using development time data. At 28 °C, development time, rate of immature survival, and total fecundity rates were greater in L. pseudobrassicae than in M. persicae. Development time of D. rapae in L. pseudobrassicae was shorter than that in M. persicae at 28 °C and 31 °C for females and at 31 °C for males. The thermal threshold of D. rapae was 6.38 °C and 3.33 °C for females and 4.45 °C and 3.63 °C for males developed on L. pseudobrassicae and M. persicae, respectively. Diaeretiella rapae size gain was greater in L. pseudobrassicae than that in M. persicae at 25 °C and 28 °C. Lipaphis pseudobrassicae showed better adaptation than M. persicae to elevated temperatures, which resulted in a better quality host for D. rapae at temperatures of 28 °C and 31 °C and a higher lower thermal threshold when the parasitoid developed within L. pseudobrassicae. The host's adaptation to high temperatures is a determinant of host quality for the parasitoid at that same climatic condition.

Disseminated adenovirus infection causing severe ARDS

A previously healthy young man with a rare genetic condition presented with severe acute respiratory distress syndrome secondary to pneumonia with septic shock. He did not improve with conventional therapy for his known causal organism thus prompting further workup. He was found to be profoundly immunosuppressed raising our suspicion for atypical organisms. A bronchoalveolar lavage sample was positive via PCR for adenovirus which we suspect exacerbated a pre-existing bacterial pneumonia and led to a severe and non-responsive respiratory failure. His serum adenovirus load was markedly elevated. Treatment was started once the diagnosis of disseminated adenovirus infection was made; however, at that time patient was suffering from refractory hypoxaemia, respiratory acidosis, right heart failure and septic shock. Despite maximal supportive measures our patient ultimately expired over the course of 6 days.

Hg concentrations in fish from coastal waters of California and Western North America

The State of California conducted an extensive and systematic survey of mercury (Hg) in fish from the California coast in 2009 and 2010. The California survey sampled 3483 fish representing 46 species at 68 locations, and demonstrated that methylHg in fish presents a widespread exposure risk to fish consumers. Most of the locations sampled (37 of 68) had a species with an average concentration above 0.3μg/gwet weight (ww), and 10 locations an average above 1.0μg/gww. The recent and robust dataset from California provided a basis for a broader examination of spatial and temporal patterns in fish Hg in coastal waters of Western North America. There is a striking lack of data in publicly accessible databases on Hg and other contaminants in coastal fish. An assessment of the raw data from these databases suggested the presence of relatively high concentrations along the California coast and in Puget Sound, and relatively low concentrations along the coasts of Alaska and Oregon, and the outer coast of Washington. The dataset suggests that Hg concentrations of public health concern can be observed at any location on the coast of Western North America where long-lived predator species are sampled. Output from a linear mixed-effects model resembled the spatial pattern observed for the raw data and suggested, based on the limited dataset, a lack of trend in fish Hg over the nearly 30-year period covered by the dataset. Expanded and continued monitoring, accompanied by rigorous data management procedures, would be of great value in characterizing methylHg exposure, and tracking changes in contamination of coastal fish in response to possible increases in atmospheric Hg emissions in Asia, climate change, and terrestrial Hg control efforts in coastal watersheds.

Group Sex and Prevalent Sexually Transmitted Infections Among Men Who Have Sex with Men

We evaluated the direct relation between group sex and prevalent sexually transmitted infections (STI) in a cross-sectional study of men who have sex with men (MSM) presenting at an urban STI clinic in the Midwestern US. Among 231 men who enrolled and reported that they have sex with men, we collected behavioral data using a combination of interviewer and self-administered surveys and extracted STI data from electronic health records. We used modified Poisson regression to examine the unadjusted and adjusted associations between group sex participation and prevalent STI. One-quarter of participants (n = 58) reported group sex participation in the last 3 months. Eighteen percent of participants (n = 42) had gonorrhea and 19 % (n = 45) had chlamydial infection. Men who reported recent group sex were more likely to be HIV-positive, to report recent drug use, and to report unprotected receptive anal intercourse in the past 3 months. After adjustment for age, race, and recent drug use, recent participation in group sex was associated with prevalent gonorrhea infection (prevalence ratio [PR] = 2.11, 95 % confidence interval [CI] = [1.13, 3.95]) but not chlamydia infection (PR = 1.03, 95 % CI = [0.58, 1.84]). We performed a sensitivity analysis in which we also adjusted for unprotected receptive anal intercourse and the results were not substantively changed. In summary, participation in group sex in the past 3 months was associated with a more than twofold increased prevalence of gonorrhea, but not with chlamydia. These findings support group sex participation as a potential contributor to increased STI prevalence.

Partial Life History of Chrysodeixis includens (Lepidoptera: Noctuidae) on Summer Hosts

The soybean looper, Chrysodeixis includens (Walker) (Lepidoptera: Noctuidae), is a major defoliating pest of soybeans, Glycine max (L.) Merrill, in Louisiana. However, other alternate host crops in the agroecosystem have the potential to impact C. includens populations. Life table statistics of C. includens on four host plants were evaluated. C. includens larvae were fed leaves of three cotton Gossypium hirsutum L. cultivars 'DP 143 B2RF,' 'DP 174 RF,' and 'PHY 485 WRF'; cowpea Vigna unguiculata (L.) Walpers 'California Blackeye'; three soybean cultivars 'Lyon,' 'PI 227687,' and 'RC 4955'; and sweetpotato Ipomoea batatas (L.) Lamarck 'Evangeline.' All C. includens larvae reared on cotton cultivars DP 143 B2RF and PHY 485 WRF experienced 100% mortality during the first instar. Total developmental period of preadult C. includens was significantly shorter on cotton DP 174 RF and cowpea California Blackeye but longer on sweetpotato Evangeline. Sweetpotato Evangeline had the highest amount of leaf tissue consumed and soybean Lyon had the least. Pupal weight was highest when insects fed on cotton DP 174 RF and lowest on soybean PI 227687. Life table statistics showed that the highest intrinsic rate of increase and net reproductive rate were attained when insects were reared on cotton DP 174 RF and cowpea California Blackeye whilst the lowest were recorded on soybean PI 227687. This study provides valuable information on the role of alternative host crops on the partial life history of C. includens in Louisiana agroecosystems.