Adapting the forms of yesterday to the functions of today and the needs of tomorrow: a genealogical case study of clinical teaching units in Canada

Emergent discourses of social responsibility and accountability have in part fuelled the expansion of distributed medical education (DME). In addition to its potential for redressing physician maldistribution, DME has conferred multiple unexpected educational benefits. In several countries, its recent rise has occurred around the boundaries of traditional medical education practices. Canada has been no exception, with DME proliferating against a backdrop of its longstanding central node, the clinical teaching unit (CTU). The CTU first appeared just over 50 years ago with its position in Canadian health care largely taken-for-granted. Given the increasing prominence of DME, however, it is timely to reconsider what the place of tertiary centre-based practices such as the CTU might be in shifting medical education systems. From a genealogical perspective, it becomes clear that the CTU did not just “happen”. Rather, its creation was made possible by multiple interrelated cultural, social, and political changes in Canadian society that, while subtle, are powerfully influential. Making them visible offers a better opportunity to harmonize the benefits of longstanding entities such as the CTU with novel practices such as DME. In so doing, the medical education field may sidestep the pitfalls of investing significant resources that may only produce superficial changes while unwittingly obstructing deeper transformations and improvements. Although this work is refracted through a Canadian prism, reconceptualizing the overall design of medical education systems to take advantage of both tradition and innovation is a persistent challenge across the international spectrum, resistant to tests of time and constraints of context.     

Post‐Traumatic Headaches in Civilians and Military Personnel: A Comparative,Clinical Review

Post‐traumatic headache (PTH) is the most frequent symptom after traumatic brain injury (TBI). We review the epidemiology and characterization of PTH in military and civilian settings. PTH appears to be more likely to develop following mild TBI (concussion) compared with moderate or severe TBI. PTH often clinically resembles primary headache disorders, usually migraine. For migraine‐like PTH, individuals who had the most severe headache pain had the highest headache frequencies. Based on studies to date in both civilian and military settings, we recommend changes to the current definition of PTH. Anxiety disorders such as post‐traumatic stress disorder (PTSD) are frequently associated with TBI, especially in military populations and in combat settings. PTSD can complicate treatment of PTH as a comorbid condition of post‐concussion syndrome. PTH should not be treated as an isolated condition. Comorbid conditions such as PTSD and sleep disturbances also need to be treated. Double‐blind placebo‐controlled trials in PTH population are necessary to see whether similar phenotypes in the primary headache disorders and PTH will respond similarly to treatment. Until blinded treatment trials are completed, we suggest that, when possible, PTH be treated as one would treat the primary headache disorder(s) that the PTH most closely resembles.     

The prevalence of pain at pressure areas and pressure ulcers in hospitalised patients

Background

Patients with pressure ulcers (PUs) report that pain is their most distressing symptom, but there are few PU pain prevalence studies. We sought to estimate the prevalence of unattributed pressure area related pain (UPAR pain) which was defined as pain, soreness or discomfort reported by patients, on an “at risk” or PU skin site, reported at a patient level.

Methods

We undertook pain prevalence surveys in 2 large UK teaching hospital NHS Trusts (6 hospitals) and a district general hospital NHS Trust (3 hospitals) during their routine annual PU prevalence audits. The hospitals provide secondary and tertiary care beds in acute and elective surgery, trauma and orthopaedics, burns, medicine, elderly medicine, oncology and rehabilitation. Anonymised individual patient data were recorded by the ward nurse and PU prevalence team. The analysis of this prevalence survey included data summaries; no inferential statistical testing was planned or undertaken. Percentages were calculated using the total number of patients from the relevant population as the denominator (i.e. including all patients with missing data for that variable).

Results

A total of 3,397 patients in 9 acute hospitals were included in routine PU prevalence audits and, of these, 2010 (59.2%) patients participated in the pain prevalence study. UPAR pain prevalence was 16.3% (327/2010). 1769 patients had no PUs and of these 223 patients reported UPAR pain, a prevalence of 12.6%. Of the 241 people with pressure ulcers, 104 patients reported pain, a UPAR pain prevalence of 43.2% (104/241).

Conclusion

One in six people in acute hospitals experience UPAR pain on ‘at risk’ or PU skin sites; one in every 8 people without PUs and, more than 2 out of every five people with PUs. The results provide a clear indication that all patients should be asked if they have pain at pressure areas even when they do not have a PU.

     

Limiting dilution analysis of the human T cell response to mycobacterial antigens from BCG vaccinated individuals and leprosy patients.

The number of peripheral blood T lymphocytes responding to soluble mycobacterial antigens from Mycobacterium tuberculosis purified protein derivative (PPD) and M. leprae (MLS) was estimated by limiting dilution analysis. Antigen-induced lymphocyte activation was measured by means of [3H]TdR incorporation on day 10 of culture in the presence of suboptimal concentrations of interleukin 2 (IL-2). In the peripheral blood of BCG-vaccinated individuals from the UK, the frequency of T lymphocytes responding to PPD was 1.5 to 4 times greater than to MLS. Frequencies between 1/1970 and 1/13, 982 were observed in response to PPD and between 1/4097 and 1/24, 717 in response to MLS. A proportion of cells in the peripheral blood were also observed to respond to IL-2 only. The frequency of cells observed in limiting dilution analysis for PPD and MLS reflected the relative amounts of proliferation to these two antigens in bulk culture lymphocyte transformation tests. Use of PPD-specific T cell lines suggested that the responsiveness observed to M. leprae antigens in BCG-vaccinated individuals was due to cross-reactivity with antigens shared with M. bovis BCG. In tuberculoid leprosy, the frequency of peripheral blood T lymphocytes responding to M. leprae antigens was either greater than or similar to the frequency of T cells responding to PPD. In contrast, limiting dilution analysis of T lymphocytes from the peripheral blood of lepromatous leprosy patients revealed the complex regulatory heterogeneity of this group. In some patients M. leprae responsive T cells were detected in the presence of exogenous IL-2.     

CD4-positive/heat-stable antigen-positive thymocytes cause graft-versus-host disease across non-major histocompatibility complex incompatibilities

Single-positive thymocytes are the immediate precursors of peripheral recent thymic emigrants (RTE) which develop into mature peripheral T cells. The functional ability of RTE is unclear but their state of differentiation may be relevant to the development of tolerance to peripheral “self” antigens. Since RTE are difficult to analyze, precursor CD4⁺/8⁻ thymocytes were assessed in a model in vivo to determine their functional capability and their susceptibility to tolerance induction. The ability of both heat-stable antigen-positive (HSA⁺) (immature) and HSA⁻ (mature) single-positive thymocytes to cause graft-versus-host disease (GVHD) across non-major histocompatibility complex differences was examined. Both HSA⁻ and HSA⁺ CD4⁺/8⁻ thymocytes from C3H mice caused lethal GVHD in AKR recipients as did CD4⁺ peripheral T cells in controls. Further, neonatal C3H thymocytes also caused lethal GVHD in AKR recipients. Since CD4⁺/8⁻ thymocytes are the precursors of RTE, these results suggest that RTE are not susceptible to tolerance induction to “minor” antigens and may have a normal immune function in vivo. This would suggest that peripheral tolerance may be dependent upon the manner of antigen presentation rather than T cell maturity.     

High frequency of memory and effector gag specific cytotoxic T lymphocytes in HIV seropositive individuals

Human immunodeficiency virus type 1 (HIV-1) specific cytotoxic T lymphocytes (CTL) have been detected in most patients following infection. It has also been suggested that the specific CTL response, which may play an important role in delaying disease in infected humans, may decline during the course of disease progression. We have measured HIV peptide specific CTL precursor frequency by limiting dilution analysis in two healthy seropositive patients whose fresh peripheral blood mononuclear cells (PBM) specifically lysed MHC matched target cells (restricted by HLA B27 and B8 respectively). The frequency of HIV peptide specific CTL precursors is high (3 x 10(-3)-10(-4], but lower than estimates of circulating CTL with the same specific cytotoxic activity present directly in peripheral blood using the same sample (10(-2)-10(-3]. We suggest that this difference may result from terminal effector CTL differentiation in the T cell lineage. This implies that only a subset of CTL effectors have growth potential, whereas relatively higher levels of CTL with lytic activity can be detected in PBM of healthy HIV seropositive patients.     

Anti-SARS-CoV-2 activity of targeted kinase inhibitors: Repurposing clinically available drugs for COVID-19 therapy

Coronavirus disease 2019 (COVID-19) remains a major public health concern, and vaccine unavailability, hesitancy, or failure underscore the need for discovery of efficacious antiviral drug therapies. Numerous approved drugs target protein kinases associated with viral life cycle and symptoms of infection. Repurposing of kinase inhibitors is appealing as they have been vetted for safety and are more accessible for COVID-19 treatment. However, an understanding of drug mechanism is needed to improve our understanding of the factors involved in pathogenesis. We tested the in vitro activity of three kinase inhibitors against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), including inhibitors of AXL kinase, a host cell factor that contributes to successful SARS-CoV-2 infection. Using multiple cell-based assays and approaches, gilteritinib, nintedanib, and imatinib were thoroughly evaluated for activity against SARS-CoV-2 variants. Each drug exhibited antiviral activity, but with stark differences in potency, suggesting differences in host dependency for kinase targets. Importantly, for gilteritinib, the amount of compound needed to achieve 90% infection inhibition, at least in part involving blockade of spike protein-mediated viral entry and at concentrations not inducing phospholipidosis (PLD), approached a clinically achievable concentration. Knockout of AXL, a target of gilteritinib and nintedanib, impaired SARS-CoV-2 variant infectivity, supporting a role for AXL in SARS-CoV-2 infection and supporting further investigation of drug-mediated AXL inhibition as a COVID-19 treatment. This study supports further evaluation of AXL-targeting kinase inhibitors as potential antiviral agents and treatments for COVID-19. Additional mechanistic studies are needed to determine underlying differences in virus response.