Once Upon a Microscopic Slide: The Story of Histology

For centuries, histology has maintained its remarkable place in the medical curriculum. However, its teaching has been influenced by the new technological advancement that has reshaped medicine teaching into a more modern student-friendly form. Since its inception in the 18th century, the discipline of histology has progressed hand in hand with the advancements in microscopy and microscopic technologies, including immunohistochemistry. In the traditional curriculum of USA medical schools, especially after the first Flexner’s report of 1910, histology was considered as very essential topic for a physician studying the “Art and Science” of medicine. In this era, the teaching relied more on the light microscope and to some extent on the electron microscope. However, the field nowadays, after the second Flexner’s report, which stressed the importance of integrating clinical topics in the curriculum, is shifting towards the use of more electronic resources for teaching. Such new resources rely on information technology and electronic imaging modalities which are considered to be more student-friendly, time efficient, consistent in conveying the images, promote self-learning and are less costly. In fact, in the last 25 years, most universities started relying on virtual microscopy with limited use of the light microscopy by the students. Such an approach facilitated curricular integration of histology into histopathology and provided the opportunity to promote self-learning and clinical relevance. In the era of competency-based curriculum, histology remains an essential and indispensable basic science in the integrated module

The Advancement of Postmortem Investigations in Sudden Cardiac Death

Sudden cardiac death (SCD) is a major public health issue accounting for 15–20% of all-cause deaths. Several pathologies have been associated with sudden cardiac arrest. Clinical autopsies have always contributed to invention of novel strategies for SCD prevention. One of the serious challenges that pathologists are facing is the significant decline of the overall autopsy rate. Many reasons have been associated with this change, most importantly, the evolution process in the postmortem investigation tools. However, cardiologists seem unsatisfied with the new non-invasive imaging techniques and still believe in the traditional autopsy as a gold standard in diagnosis of cardiovascular diseases. In this chapter, we focused on the importance of autopsy in the prevention of SCD by shedding a light on guidelines of minimum requirement for routine autopsy investigation of SCD (including macroscopic, histological, toxicological and molecular examination). We also gave insight into the new radiological techniques, their advantages and related diagnostic pitfalls as compared to that of conventional autopsy. Thus, providing a comprehensive understanding on the advancement of postmortem examination will help improve the minimum standards of routine autopsy practice, develop new guidelines for radiological examination and prevent the growing heterogeneity of the pathologies underlying SCD

The Experience of Non-Traditional Medical Students in the Clinical Setting

Purpose: To understand the experience of mature-aged medical students on clinical rotations. Background/Theoretical Framework: Although the mean age of first year medical students is 24, an increasing number of mature-aged students, defined as over age 30, are entering medical school. Most studies of mature-aged medical students have examined academic performance using quantitative research design. Few studies have employed qualitative methodology to determine the experience of mature-aged medical students, especially in the clinical setting. Methods: A recruitment e-mail was sent to all medical students enrolled in clinical rotations; first responders were interviewed until saturation in emerging themes was achieved. Interviews were conducted and recorded in a private office setting, then transcribed into a Word document. Five mature-aged students and four traditional students were interviewed. Using methodology for qualitative research described by Mustakas (1994), the investigators individually coded the transcripts to identify emerging themes. Coded themes underwent peer review, with triangulation of data collection, to determine main themes. Results: Three main themes emerged from our study. First, abundant life experience influences students perception of their role on clinical rotations. A mature student explained, ...having kids... being married and divorced... helps in connecting with patients. Previous work experience shapes expectations as a physician-in-training. While traditional students tend to be intimidated, mature students desire to take the initiative. Age plays a role in the students\u27 ability to relate to senior team members, as well as medical student colleagues. Traditional students note that mature students are more realistic due to their life experience in the workplace. Conclusion: Mature-aged students draw upon previous life experience, which shapes role expectations, as well as medical team dynamics. These differences may have implications in training the growing number of mature-aged medical students. A larger scale qualitative study including multiple medical school sites is being developed

Inflammatory bowel disease, colorectal cancer and type 2 diabetes mellitus: The links.

The co-occurrence of the three disease entities, inflammatory bowel disease (IBD), colorectal cancer (CRC), type 2diabetes mellitus (T2DM) along with inflammation and dismicrobism has been frequently reported. Some authors have even suggested that dysbiosis could be the link through a molecular crosstalk of multiple inflammatory loops including TGFβ, NFKB, TNFα and ROS among others. This review focuses on the inflammatory process along with the role of microbiota in the pathophysiology of the three diseases. The etiology of IBD is multifactorial, and like CRC and T2DM, it is associated with a widespread and sustained GI inflammation and dismicrobism, whereby an array of pro-inflammatory mediators and other related biomolecules are up-regulated, both locally and systematically. Such a persistent or an inadequately resolved chronic inflammation may be a causative agent, in the presence other factors, leading to several pathologies such as IBD, CRC and T2DM. TGFβ plays a crucial role in pancreatic β cell malfunctioning as glucotoxicity stimulates its signaling cascade through smad 3, IL-6 and epithelial to mesenchymal transition. Such a cascade could lead to macrophages and other cells recruitment, inflammation, then IBD and CRC. NFkB is also another key regulator in the crosstalk among the pathways leading to the three disease entities. It plays a major role in linking inflammation to cancer development through its ability to up regulate several inflammatory and tumor promoting cytokines like: IL-6, IL-1 α and TNF α, as well as genes like BCL2 and BCLXL. It activates JAK/STAT signaling network via STAT3 transcription factors and promotes epithelial to mesenchymal transition. It also increases the risk for T2DM in obese people. In brief, NFKB is a matchmaker between inflammation, IBD, cancer and diabetes. In addition, TNFα plays a pivotal role in systemic inflammation. It is increased in the mucosa of IBD patients and has a central role in its pathogenesis. It also activates other signaling pathways like NFKB and MAPK leading to CRC. It is also overexpressed in the adipose tissues of obese patients thus linking it to T2DM, chronic inflammation and consequently CRC. On the other hand, increasing evidence suggests that dysbiosis plays a role in initiating, maintaining and determining the severity of IBD. Actually, among its functions, it modulates genotoxic metabolites which are able to induce CRC, a fact proven to be sustained by stool transfer from patients with CRC. Probiotics, however, may actively prevent CRC as well as IBD and results in a significant decrease in fasting glycemia in T2DM patients. In conclusion, IBD, CRC and T2DM are commonly occurring interrelated clinical problems. They share a common basis influenced by an inflammatory process, an imbalance in intestinal microbiota, and a crosstalk between various signaling pathways. Would probiotics interrupt the crosstalk or orient it in the physiological direction

Anatomical Knowledge Retention in Changing Curricula

Traditionally anatomy is one of the first subjects taught in medical school. Practicing physicians have commented on medical students’ poor anatomical knowledge in surgically oriented clerkships. Literature also shows that correlating clinical and anatomical sciences throughout early medical education may improve anatomical knowledge retention. With major medical school curricular changes happening across the nation, more quantitative data confirming this correlation is needed. The medical curriculum at the George Washington University School of Medicine recently underwent reorganization, transforming an earlier discipline-based curriculum to that of an integrated system-based one. In order to determine whether reorganization has an effect on anatomical knowledge retention, comparisons of anatomical knowledge between classes in the different curricula were made. Students from the last class of the discipline-based curriculum and students from the first class of the new, integrated curriculum completed the same 27question test before beginning their general surgery and obstetrics and gynecology (OB/Gyn) rotations. Scores for specific anatomy categories related to general surgery and OB/Gyn were then analyzed and compared between classes. Comparing the scores from the 2013 and 2016 cohorts, there was an overall decrease in retention from 65.69% to 63.64% (Table 1). Item analysis per topic revealed a mean decrease in surgical anatomy and OB/Gyn anatomy retention of 2.53% and 1.58%, respectively. There was a 21.6% increase in inguinal canal anatomy retention and a 17.33% increase in appendix related questions. There was also a 12.02% decrease in fallopian tube anatomy retention. In conclusion, when comparing the 2013 to the 2016 data there were overall decreases in retention for the anatomy as it relates to general surgery and OB/Gyn; however improvements were noted for specific topic areas. These results suggest that the change in retention is apparent and multifactorial. The differences between surgical anatomy retention and OB/Gyn anatomy retention scores may be related to the way the subject matter was organized and presented, or how the anatomic foundational knowledge was integrated with its clinical relevance. Although integrative learning has been associated with better retention, more studies will have to be conducted to validate this statement. Finally, analyzing the subject matter, curriculum structure, clinical focus, and objectives should be evaluated moving forward

Nutrition in Medical Education: Where do we stand and what needs to be explored?

Introduction: Dietary interventions and nutrition care improve patient outcomes and reduce healthcare costs. Despite status as a necessary topic in medical school education, many U.S. medical schools do not adequately prepare future physicians for everyday nutritional challenges in clinical practice. There is immense research behind the necessity of nutrition education but little concerning the methods of implementing this change. The purpose of this work was to review the current innovations of nutrition curriculum in the literature and discuss future directions for our medical school. Method: A systematic search of scientific literature databases was performed to examine existing literature about the current state of nutrition curriculum and identify current methods of improving nutrition curriculum. A database search of the undergraduate GW SMHS curricula helped us map where nutrition is currently taught and look into ways to expand and integrate it. Results: Shortcomings in sufficient nutrition education result from lack of proficient faculty, low funding, and lack of established core curricula with guidelines and protocols. Additionally, international medical schools have recognized their deficiency in nutrition education compared to U.S. standards. U.S. institutions making headway in new nutrition education programs include The University of North Carolina, Chapel Hill, Boston University School of Medicine, Southern Illinois School of Medicine, University of Nevada School of Medicine, Northwestern University Feinberg School of Medicine, University of Colorado School of Medicine, Mercer University School of Medicine, and various institutions introducing “culinary medicine”. Successful nutrition integration should be spread longitudinally across all years with an emphasis on active-learning techniques over rote memorization. Creativity, chief support, an established taskforce, trained faculty, and evaluation methods are essential tools to enhance medical curriculum. Looking at GW SMHS curricula, nutrition is concentrated in the Pre-Clinical years with very little emphasis in the Clinical years, a common trend across most medical schools. Medical students may be more confident incorporating nutrition into patient care if nutrition were spread proportionally across all years to combine basic foundations with clinical application. Conclusion: Expanding nutrition curriculum at The George Washington University School of Medicine could involve utilizing the Nutrition in Medicine project developed by The University of North Carolina, Chapel Hill or bringing in internationally renowned chef José Andrés to expand on his previous culinary courses and incorporate nutrition fundamentals into the medical curriculum. Future directions need to evaluate existing programs, current initiatives, and their effectiveness in order to be able to improve programs across the continuum

The Use of Stem Cells in Burn Wound Healing: A Review

Burn wound healing involves a series of complex processes which are subject to intensive investigations to improve the outcomes, in particular, the healing time and the quality of the scar. Burn injuries, especially severe ones, are proving to have devastating effects on the affected patients. Stem cells have been recently applied in the field to promote superior healing of the wounds. Not only have stem cells been shown to promote better and faster healing of the burn wounds, but also they have decreased the inflammation levels with less scar progression and fibrosis. This review aims to highlight the beneficial therapeutic effect of stem cells in burn wound healing and to discuss the involved pathways and signaling molecules. The review covers various types of burn wound healing like skin and corneal burns, along with the alternative recent therapies being studied in the field of burn wound healing. The current reflection of the attitudes of people regarding the use of stem cells in burn wound healing is also stated

Further Expansion of Nested E-Modules to Address Anatomical Knowledge Retention in Medical Students entering the Obstetrics and Gynecology Clinical Rotation

Previous work has shown that a curriculum that included computer-based teaching modules (“e-modules”) improved retention of preclinical concepts of gross anatomy, as medical students transitioned to the third-year OBGYN clerkship. However, data showed that deficiencies still remained in areas not addressed by the curriculum. Two of these areas were microscopic anatomy and embryology, where retention scores were 4% and 38%, respectively (Jurjus et al., unpublished). Based on this research, an expanded series of e-modules will be created to target these anatomical topics that still require improvement, specifically in microscopic anatomy and embryology: 1) Ultrasound in Pregnancy using Embryological Knowledge 2) Pregnancy Timeline and the Embryo and 3) The Cervix in Health and Disease. The learning objectives correlate clinical medicine and anatomical categories. Once finalized, these e-modules will be live on the Himmelfarb Library website. By further expanding the number of e-modules available to students, we hope to improve retention of clinically relevant anatomical knowledge in adult learners. Funding: GW Office of the Vice Provost for Teaching and Learning, Spring 2013 Grants for High Impact Teaching and Learning Practices

Improving Anatomical Knowledge Through Interactive Modules on the OB/GYN Clinical Clerkship

The goal of this study is to evaluate the impact of a newly designed interactive method of teaching clinically relevant anatomy to medical students on the OB/GYN clerkship. A 20-question multiple-choice exam was administered to 143 consenting third-year medical students at the beginning and end of each OB/GYN rotation. Students participated in a skills lab with preparatory e-modules that linked anatomy to clinical applications during each rotation. Topics included perineal muscle anatomy (laceration), anterior abdominal wall anatomy (cesarean section), vulvovaginal and uterine anatomy (IUD), and pelvic organ, vasculature, and neural anatomy (hysterectomy). Mean scores improved significantly after the nesting of interactive modules, increasing from 55.1% to 67.4% (p\u3c0.001). In comparing mean scores from questions that were covered in the e-modules (intervention) and questions that were not covered in the e-modules (non-intervention), students improved significantly after receiving an intervention (9.4% difference; p\u3c0.001). Therefore, completing the clerkship without an intervention did not yield significant improvement in relevant anatomical knowledge, compared to intervention. Thus, nesting anatomical science into the clinical curriculum through preparatory e-modules and hands-on anatomy lab sessions may improve clinically-significant anatomy knowledge. This data may be used to increase longitudinal integration of the various disciplines across the undergraduate medical curriculum

Medical Students in Microscopic Anatomy and Pathology Laboratories: Design of an E-Learning Histology and Histopathology Atlas

Computer-assisted learning, also known as e-learning, has been successfully implemented to educate students in anatomical knowledge as well as transferable skills, such as critical analysis, teamwork, leadership and communication. E-learning allows students to self-teach material at their own paces and provides a platform for team-based laboratory approaches. Several institutions have already integrated histology and physiology in team based laboratory approaches, but integration of histology and pathology instruction has been done to a lesser extent. Our aim was to develop an e-learning atlas that integrates microanatomy and pathology laboratory for an interdisciplinary pre-clinical medical curriculum. A multidisciplinary team of teaching faculty and students developed an online atlas (microanatomyatlas.com) that includes a library of histology and histopathology images. Traditional laboratory manual instructions and study objectives were added onto the digital interface and made interactive by linking it to specific labeled images to allow for self- testing. Online clinical case studies involving a disease entity in a specific organ system were incorporated, which allows students to toggle between the normal as well as the pathological slides involving the disease as they apply their clinical reasoning skills to arrive at the correct diagnosis. We are collecting data on the number and frequency of students using the atlas. We are also administering a detailed survey to assess student satisfaction and learning. To assess the impact of this new teaching tool, a comparative study of two years of student performance and course evaluations between students who used the online atlas and students who did not use the online atlas in the pre-clinical medical curriculum will be conducted. Our preliminary data so far shows that student feedback has been positive and an e-learning atlas integrating microanatomy and pathology laboratory may be an essential tool that guides the studies and enhances the performance of students in an interdisciplinary pre-clinical medical curriculum. DISCLOSURES/ACKNOWLEDGEMENTS: American Educational Institute, University and Campus Management (AEIUCM) developed, designed, and maintains the online portal