Medical Education Unit publications

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A physical map of the chromosomal region determining O-antigen biosynthesis in Vibrio cholerae 01
(Elsevier, 1987) Ward, H.; Morelli, G.; Kamke, M.; Morona, R.; Yeadon, J.; Hackett, J.; Manning, P.
We have previously described the cosmid cloning of the genes determining the biosynthesis of the Inaba and Ogawa O-antigens of the lipopolysaccharides of Vibrio cholerae 01 (Manning et al., 1986). By Southern hybridization analysis of chromosomal and cosmid DNA, and heteroduplex analysis between the clones we have been able to precisely define the region of contiguous chromosomal DNA in the vicinity of the O-antigen-encoding region. These data and comparison of end points of clones and of deletion derivatives demonstrate that at least 16kb of a 19-kb SstI fragment is required to encode O-antigen biosynthesis. Expression of O-antigen is independent of the orientation of this SstI fragment with respect to cloning vectors suggesting that its regulatory region has been cloned intact. No detectable differences were observed in the restriction patterns of the Inaba and Ogawa coding regions implying that only minor changes are involved when serotype conversion (Inaba to Ogawa or vice versa) occurs. Bhaskaran [Ind. J. Med. Res. 47 (1959) 253-260] originally defined this region associated with O-antigen biosynthesis oag; however, to be consistent with other organisms [Hitchcock et al., J. Bacteriol. 166 (1986) 699-705], it is suggested this be changed to rfb.
Open Access
A shuttle vector which facilitates the expression of transfected genes in Trypanosoma cruzi and Leishmania
(Oxford University Press, 1992) Kelly, J.; Ward, H.; Miles, M.; Kendall, G.
A Trypanosoma cruzi expression vector has been constructed using sequences derived from the flanking regions of the glyceraldehyde 3-phosphate dehydrogenase (gGAPDH) genes. The neomycln phosphotransferase (neor) gene was incorporated as a selectable marker. Using electroporatlon we have introduced this vector into both T.cruzl and Leishmania cells and conferred G418 resistance. Transformation is mediated by large extrachromosomal circular elements composed of head-to-tail tandem repeats of the vector. The transformed phenotype is stable for at least 6 months in the absence of G418 and can be maintained during passage through the T.cruzl ifecycle. Foreign genes Inserted into an expression site within the vector (pTEX) can be expressed at high levels In transformed cells. To our knowledge this paper describes the first trypanosome shuttle vector and the first vector which functions in both trypanosomes and Leishmania.
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A ZEB1-miR-375-YAP1 pathway regulates epithelial plasticity in prostate cancer
(Nature Publishing Group, 2017) Selth, L.; Das, R.; Townley, S.; Coutinho, I.; Hanson, A.; Centenera, M.; Stylianou, N.; Sweeney, K.; Soekmadji, C.; Jovanovic, L.; Nelson, C.; Zoubeidi, A.; Butler, L.; Goodall, G.; Hollier, B.; Gregory, P.; Tilley, W.
MicroRNA-375 (miR-375) is frequently elevated in prostate tumors and cell-free fractions of patient blood, but its role in genesis and progression of prostate cancer is poorly understood. In this study, we demonstrated that miR-375 is inversely correlated with epithelial–mesenchymal transition signatures (EMT) in clinical samples and can drive mesenchymal–epithelial transition (MET) in model systems. Indeed, miR-375 potently inhibited invasion and migration of multiple prostate cancer lines. The transcription factor YAP1 was found to be a direct target of miR-375 in prostate cancer. Knockdown of YAP1 phenocopied miR-375 overexpression, and overexpression of YAP1 rescued anti-invasive effects mediated by miR-375. Furthermore, transcription of the miR-375 gene was shown to be directly repressed by the EMT transcription factor, ZEB1. Analysis of multiple patient cohorts provided evidence for this ZEB1-miR-375-YAP1 regulatory circuit in clinical samples. Despite its anti-invasive and anti-EMT capacities, plasma miR-375 was found to be correlated with circulating tumor cells in men with metastatic disease. Collectively, this study provides new insight into the function of miR-375 in prostate cancer, and more broadly identifies a novel pathway controlling epithelial plasticity and tumor cell invasion in this disease.
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Androgen and estrogen receptors in breast cancer coregulate human UDP-glucuronosyltransferases 2B15 and 2B17
(American Association for Cancer Research, 2016) Hu, D.; Selth, L.; Tarulli, G.; Meech, R.; Wijayakumara, D.; Chanawong, A.; Russell, R.; Caldas, C.; Robinson, J.; Carroll, J.; Tilley, W.; Mackenzie, P.; Hickey, T.
Glucuronidation is an enzymatic process that terminally inactivates steroid hormones, including estrogens and androgens, thereby influencing carcinogenesis in hormone-dependent cancers. While estrogens drive breast carcinogenesis via the estrogen receptor alpha (ERα), androgens play a critical role as prohormones for estrogen biosynthesis and ligands for the androgen receptor (AR). In this study, the expression and regulation of two androgen-inactivating enzymes, the UDP-glucuronosyltransferases UGT2B15 and UGT2B17, was assessed in breast cancer. In large clinical cohorts, high UGT2B15 and UGT2B17 levels positively influenced disease-specific survival in distinct molecular subgroups. Expression of these genes was highest in cases positive for ERα. In cell line models, ERα, AR, and the transcription factor FOXA1 cooperated to increase transcription via tandem binding events at their proximal promoters. ERα activity was dependent on FOXA1, facilitated by AR activation, and potently stimulated by estradiol as well as estrogenic metabolites of 5α-dihydrotestosterone. AR activity was mediated via binding to an estrogen receptor half-site 3′ to the FOXA1 and ERα-binding sites. Although AR and FOXA1 bound the UGT promoters in AR-positive/ERα-negative breast cancer cell lines, androgen treatment did not influence basal transcription levels. Ex vivo culture of human breast tissue and ERα+ tumors provided evidence for upregulation of UGT2B15 and UGT2B17 by estrogen or androgen treatment. ERα binding was evident at the promoters of these genes in a small cohort of primary tumors and distant metastases. Collectively, these data provide insight into sex steroid receptor-mediated regulation of androgen-inactivating enzymes in ERα+ breast cancer, which may have subtype-specific consequences for disease progression and outcomes.
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Assessment for learning
(Sense Publishers, 2012) Schuwirth, L.; Ward, H.; Heeneman, S.; Faculty of Health Sciences
Most students enter medical school with the intent to become a physician and work in patient care; and rightfully so because good patient care is important for society. But there is also a need in society for physicians or MDs with special abilities in conducting biomedical and clinical research. This special need was the reason why at the University of Maastricht a graduate-entry medical program was begun with an annual intake of 30 students. But it was not the only reason. Educational innovation and experimentation have become increasingly difficult due to the rapidly increasing enrolment in many medical programs. Our new program was therefore also started with the intent of enabling experimentation and innovation at the curriculum level.
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Brain responses to mechanical rectal stimuli in patients with faecal incontinence: an fMRI study
(Wiley, 2017) Mirbagheri, N.; Hatton, S.; Ng, K.; Lagopoulos, J.; GLADMAN, M.
AIM: Continence is dependent on anorectal/brain interactions. Consequently, aberrations of the brain-gut axis may be important in the pathophysiology of faecal incontinence (FI) in certain patients. The aim of this study was to assess the feasibility of recording brain responses to rectal mechanical stimuli in patients with FI using functional Magnetic Resonance Imaging (fMRI). METHOD: A prospective, cohort pilot study was performed to assess brain responses during rectal stimulation in 14 patients (4 male, mean [SD] age 62 [15] years). Blood oxygen level-dependent (BOLD) signals were measured by fMRI during rest and mechanical distension, involving random repetitions of isobaric phasic rectal distensions at fixed (15 & 45 mmHg) and variable (10% above sensory perception threshold) pressures. RESULTS: Increases in BOLD signals in response to high-pressure rectal distension (45mmHg) and maximum toleration were observed in the cingulate gyrus, thalamus, insular cortex, inferior frontal gyrus, cerebellum, caudate nucleus, supramarginal gyrus, putamen and amygdala. Additionally, activation of the supplementary motor cortex and caudate nucleus with inconsistent activity in the frontal lobe was observed. CONCLUSIONS: This study has demonstrated the feasibility of recording brain responses to rectal mechanical stimulation using fMRI in patients with FI, revealing activity in widespread areas of the brain involved in visceral sensory processing. The observed activity in the supplementary motor cortex and caudate nucleus, with relative paucity of activity in the frontal lobes, warrants investigation in future studies to determine whether aberrations in cerebral processing of rectal stimuli play a role in the pathogenesis of FI. This article is protected by copyright. All rights reserved.
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Clinical audit: recent practice in caring for patients with acute severe colitis compared with published guidelines - is there a problem?
(Blackwell Publishing Asia, 2013) Lim, A.; Grafton, R.; Hetzel, D.; Andrews, J.
Background
Acute severe colitis (ASC) is a serious condition with possible outcomes of emergency colectomy and mortality. Validated guidelines exist to help avoid these.
Aims
To examine local adherence to guidelines and identify (a) opportunities to improve care and (b) possible barriers to adherence.
Methods
Retrospective, hospital-wide audit of all patients with ASC during a 2-year period (2009-2010) at a major metropolitan hospital. Cases were identified by an electronic search of all discharges with International Classification of Diseases-10 codes for colitis, colectomy, ulcerative colitis or Crohn disease.
Results
Twenty-six patients had 30 ASC admissions (14 female). Most admissions were under gastroenterology (25), 4 (13%) were under general medicine and 1 was under general surgery. Only 8 patients' (26%) management (all under gastroenterology) included all major details: blood investigations, Clostridium difficile test, abdominal X-ray, colonic examination and venous thromboembolism prophylaxis. Only one patient had formal severity scoring on admission, and seven patients (24%) had descriptive severity recorded. On day 3, nine patients (30%) had some recorded severity assessment; however, no formal criteria were used. Four had colectomy, three during first admission and one on re-admission. Of these patients, three received cyclosporine prior to colectomy. The mean duration of admission was 10 days (standard deviation 10.54, range 1-61).
Conclusion
Opportunities to optimise care exist including formal severity assessments on days 1 and 3, better deep vein thrombosis/pulmonary embolism prophylaxis and prompt colonic examination. Admission under teams other than gastroenterology appeared to be a barrier to better care. Despite the low rate of ideal management, the colectomy rate was acceptably low at 20%.
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Cloning and analysis of the human complement factor H gene promoter
(Nature Publishing Group, 1997) Ward, H.; Higgs, N.; Blackmore, T.; Sadlon, T.
The 5' flanking region of human factor H was cloned using nested polymerase chain reaction (PCR) and the promoter finder method. A total of 1.2 kb has been sequenced and a number of putative regulatory elements identified including glucocorticoid response elements, cAMP responsive element, HTF-1, and acute phase signal sequences. A 717 b.p. fragment was cloned into a CAT reporter vector and transfected into HeLa cells. A series of truncations from the 5' end of this fragment were also cloned into the CAT vector. Analysis of CAT activity of the cell lysates showed that the region from -699 to +18 is likely to contain promoter elements for the factor H gene as it was able to drive transcription of the CAT gene.
Open Access
Comprehensive assessment of estrogen receptor beta antibodies in cancer cell line models and tissue reveals critical limitations in reagent specificity
(Elsevier, 2017) Nelson, A.; Groen, A.; Miller, J.; Warren, A.; Holmes, K.; Tarulli, G.; Tilley, W.; Katzenellenbogen, B.; Hawse, J.; Gnanapragasam, V.; Carroll, J.
Abstract not available
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Developing an interprofessional capability framework for teaching health care students in a primary health care setting
(Informa, 2013) Gum, L.; Lloyd, A.; Lawn, S.; Richards, J.; Lindemann, I.; Sweet, L.; Ward, H.; King, A.; Bramwell, D.
This article is based on a partnership between a primary health service and a university whose shared goal was to prepare students and graduates for interprofessional practice (IPP). This collaborative process led to the development of consensus on an interprofessional capability framework. An action research methodology was adopted to study the development and progress of the partnership between university and health service providers. The initial aim was to understand their perceptions of IPP. Following this, the findings and draft capabilities were presented back to the groups. Finalisation of the capabilities took place with shared discussion and debate on how to implement them in the primary care setting. Several ideas and strategies were generated as to how to prepare effective interprofessional learning experiences for students in both environments (university and primary health care setting). Extensive stakeholder consultation from healthcare providers and educators has produced a framework, which incorporates the shared views and understandings, and can therefore be widely used in both settings. Development of a framework of capabilities for IPP, through a collaborative process, is a useful strategy for achieving agreement. Such a framework can guide curriculum for use in university and health service settings to assist incorporation of interprofessional capabilities into students’ learning and practice.
Open Access
Educating for interprofessional practice: moving from knowing to being, is it the final piece of the puzzle?
(BioMed Central, 2017) Ward, H.; Gum, L.; Attrill, S.; Bramwell, D.; Lindemann, I.; Lawn, S.; Sweet, L.
Background: Professional socialisation and identity arise from interactions occurring within university-based interprofessional education, and workplace-based interprofessional practice experience. However, it is unclear how closely language and concepts of academic learning situations align with workplace contexts for interprofessional learning. This paper reports on a study that brought together university-based educators responsible for teaching health professional students and health service-based practitioners who supervise students in the field. Methods: Interviews and focus groups with university-based educators and health service-base practitioners were used to explore perceptions of capabilities required for interprofessional practice. The qualitative data were then examined to explore similarities and differences in the language used by these groups. Results: This analysis identified that there were language differences between the university-based educators and health service based practitioners involved in the project. The former demonstrated a curriculum lens, focusing on educational activities, student support and supervision. Conversely, health service-based practitioners presented a client-centred lens, with a focus on communication, professional disposition, attitude towards clients and co-workers, and authenticity of practice. Conclusions: Building on these insights, we theorise about the need for students to develop the self in order to be an interprofessional practitioner. The implications for health professional education in both university and workplace settings are explored.
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Exploration of the perceptions, barriers and drivers of pharmacogenomics practice among hospital pharmacists in Adelaide, South Australia
(Nature Publishing Group, 2014) Dias, M.; Ward, H.; Sorich, M.; McKinnon, R.; Faculty of Health Sciences
There is little literature regarding the barriers to the uptake of pharmacogenomics (PG) in pharmacy practice, especially with respect to Australia. To date, pharmacists have seldom been engaged in discussions of these issues. This study aimed to obtain an in-depth understanding of these barriers by interviewing pharmacists in Adelaide, South Australia. Ethics approved semistructured interviews were carried out with 21 public hospital pharmacists. Analysis of the data identified themes including: confidence to engage in PG, clinician acceptance of a pharmacist PG role, and the importance of timely and relevant PG education. Interviewees thought that pharmacists could have a greater participation in PG in the future, but they questioned whether this would be possible at the moment given, among other factors, existing time and work constraints
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Five-year experience with congenital cardiac surgery at National University Heart Centre, Singapore
(Singapore Medical Association, 2010) Kang, G. S.; Soh, Y. F.; Kofidis, T.; Lee, C. N.; Medicine Learning and Teaching Unit
Introduction: Surgical procedures performed for congenital heart disease are usually complex and variable. The aims of this paper were to analyse patient demographics in a centre that caters to congenital cardiac surgery, compare departmental standards to international centres, and investigate the relationship between patient volume and clinical outcome. Methods : A total of 163 patients who presented to the Cardiac, Thoracic and Vascular Surgery Depar tment of the National University Hospital, Singapore between 2002 and 2006 were identified and studied retrospectively. Patient demographics were analysed. The mortality rates and patient volume were compared with those observed at international centres. Results: The mean annual patient volume was 32.6 cases. The mean age of the patients was 15.7 years, with the oldest patient being 73 years old. 57.1 percent of the patients were Chinese, 23.3 percent were Malay and 19.6 percent were Indian and other races. Foreigners made up nearly half of the patient cohort (45.4 percent). Atrial septal defect was found to be the most common diagnosis (n is 64), with the secundum being most commonly involved (76.9 percent). The commonest postoperative morbidities encountered were arrhythmias and pleural effusions. Patient volume was not found to be a significant factor affecting clinical outcomes. Conclusion: With a growing population of adults with congenital heart disease and a significant number of foreign patients, improvements to our resources and infrastructure need to be considered in order to cope with the increasing demands. Despite having a low patient volume, the centre is still able to provide congenital heart surgery with good clinical outcomes that are comparable to those of international centres with similar or higher patient volumes.
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A further example of paired-teacher lecturing to link theory to practice
(Blackwell Publishing Ltd, 2005) Hudson, Nicky (Judith Nicoll); School of Population Health and Clinical Practice : Medical Learning and Teaching Unit
Open Access
Genomic agonism and phenotypic antagonism between estrogen and progesterone receptors in breast cancer
(American Association for the Advancement of Science, 2016) Singhal, H.; Greene, M.; Tarulli, G.; Zarnke, A.; Bourgo, R.; Laine, M.; Chang, Y.-F.; Ma, S.; Dembo, A.; Raj, G.; Hickey, T.; Tilley, W.; Greene, G.
The functional role of progesterone receptor (PR) and its impact on estrogen signaling in breast cancer remain controversial. In primary ER+ (estrogen receptor–positive)/PR+ human tumors, we report that PR reprograms estrogen signaling as a genomic agonist and a phenotypic antagonist. In isolation, estrogen and progestin act as genomic agonists by regulating the expression of common target genes in similar directions, but at different levels. Similarly, in isolation, progestin is also a weak phenotypic agonist of estrogen action. However, in the presence of both hormones, progestin behaves as a phenotypic estrogen antagonist. PR remodels nucleosomes to noncompetitively redirect ER genomic binding to distal enhancers enriched for BRCA1 binding motifs and sites that link PR and ER/PR complexes. When both hormones are present, progestin modulates estrogen action, such that responsive transcriptomes, cellular processes, and ER/PR recruitment to genomic sites correlate with those observed with PR alone, but not ER alone. Despite this overall correlation, the transcriptome patterns modulated by dual treatment are sufficiently different from individual treatments, such that antagonism of oncogenic processes is both predicted and observed. Combination therapies using the selective PR modulator/antagonist (SPRM) CDB4124 in combination with tamoxifen elicited 70% cytotoxic tumor regression of T47D tumor xenografts, whereas individual therapies inhibited tumor growth without net regression. Our findings demonstrate that PR redirects ER chromatin binding to antagonize estrogen signaling and that SPRMs can potentiate responses to antiestrogens, suggesting that cotargeting of ER and PR in ER+/PR+ breast cancers should be explored.
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Identification of a heparin binding domain in the seventh short consensus repeat of complement factor H
(American Association of Immunologists, 1996) Blackmore, T.; Sadlon, T.; Ward, H.; Lublin, D.; Gordon, D.
Surface polyanions such as sialic acid and heparin are thought to enhance the binding of complement factor H (fH) to C3b deposited on particles and cell surfaces, thereby reducing complement activation. fH contains 20 short consensus repeat (SCR) domains, and it has been proposed that SCR 13 contains a heparin binding site. We used recombinant proteins to determine the heparin binding site on fH. Full-length fH (H20) and truncated and SCR deletion mutant proteins were cloned and expressed in Chinese hamster ovary cells. Supernatants were applied to heparin-agarose affinity columns to determine their binding and elution profiles. Deletion of SCR 13 from H20 did not prevent heparin binding nor alter its salt elution profile, indicating that SCR 13 does not contain an essential heparin binding site. We found that SCR 7 contains a heparin binding site, as SCRs 1 through 7 were the smallest truncated proteins to bind heparin (89 ± 3%). Furthermore, deletion of SCR 7 from a protein containing SCRs 1 through 9 reduced heparin binding, whereas deletion of SCR 6 did not (17 ± 13 vs 81 ± 13%; p = 0.02). It is likely that other heparin binding sites exist within SCRs 10 through 20; an SCR 7 deletion mutant of H20 eluted earlier than H20, but still showed >99% binding to immobilized heparin. SCR 13 does not contain such a site because a double deletion of SCRs 7 and 13 from H20 showed >97% heparin binding and had an elution profile smilar to that of a single deletion of SCR 7.
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Identification of a second heparin binding domain in human complement factor H
(OXFORD UNIV PRESS, 1998) Blackmore, T.; Hellwage, J.; Sadlon, T.; Higgs, N.; Zipfel, P.; Ward, H.; Gordon, D.
Complement factor H (fH) regulates activation of the alternative pathway of C, reducing the amount of C3b deposited on sialic acid-rich surfaces. Heparin binding has been used as a model for examining the sialic acid- binding characteristics of fH. We have previously shown thai of the 20 short consensus repeat (SCR) modules of fH, SCR 7 contains an important heparin binding site, but other SCRs also play a role in heparin binding. To localize the other sites, we prepared recombinant truncated and SCR deletion mutants of fH and tested them by heparin-agarose affinity chromatography. The 5 C- terminal SCRs were found to contain a heparin binding site as an SCR 7 deletion mutant of the N terminal 15 SCRs did not bind heparin, but a construct consisting of SCRs 16-20 was shown to bind heparin. Double deletion of SCRs 7 and 20 fH abrogated binding to heparin, indicating that SCR 20 contains a heparin binding site. This finding was confirmed with the observation that attachment of SCR 20 to a group of nonbinding SCRs produced a heparin-binding protein. A protein consisting of SCRs 19 and 20 did not bind heparin, whereas SCRs 18-20 did, indicating that, although SCR 20 contains a heparin binding site, at least two nonspecific adjacent SCRs are required. fH-related protein-3 (FHR-3) possesses an SCR homologous to SCR 7 of fH and bound heparin, whereas FHR-4, which lacks such an SCR, did not. Thus, fH contains two separate heparin binding sites which are located in SCRs 7 and 20.
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Improved animal production by genetic engineering of ruminal bacteria
(AusBiotech, 1992) Brooker, J.; Thomson, A.; Ward, H.
Ruminant production is a major focus of Australian agriculture. The ability of ruminant animals such as sheep and cattle to make productive use of low quality plant materials depends on the activity and efficiency of the anaerobic microbial population that resides in the rumen. Factors that affect ruminant production include the ability of cellulolytic microorganisms to digest plant structural polysaccharides (primarily cellulose and hemicellulose), the capacity of microorganisms to metabolise and detoxify otherwise inhibitory plant products and the efficiency of nitrogen utilisation by ruminal organisms. This review will consider some current Australian research programs aimed at improving ruminant production efficiency by genetic engineering of ruminal bacteria.
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Integrating gender and culture into medical curricula: putting principles into practice
(Radcliffe Publishing Ltd., 2005) Lawless, A.; Tonkin, A.; Leaton, T.; Ozolins, I.; Medicine Learning and Teaching Unit
In a multicultural and diverse society with vast health disparities, facing rapid socio-economic and demographic change both in the community and within the medical profession, it is imperative that our medical education system addresses appropriately issues arising from this diversity. The educational task is not only to encourage the development of our medical students in their understandings of how human diversity affects the health of their patients, but also to help them understand how it affects their own development as individuals and health practitioners. For several years, and in particular since introducing its new curriculum, the University of Adelaide Medical School has been developing innovative appropriate methods to encourage adequate discussion and learning about human diversity by its undergraduates. This article describes some of the techniques used to introduce gender and cultural discourse into the medical curriculum, and the challenges faced by medical educators in their efforts.
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L-carnitine supplementation in the dialysis population: Are Australian patients missing out?
(Blackwell Publishing Asia, 2008) Reuter, S.; Faull, R.; Evans, A.
It has been widely established that patients with end-stage renal disease undergoing chronic haemodialysis therapy exhibit low endogenous levels of L-carnitine and elevated acylcarnitine levels; however, the clinical implication of this altered carnitine profile is not as clear. It has been suggested that these disturbances in carnitine homeostasis may be associated with a number of clinical problems common in this patient population, including erythropoietin-resistant anaemia, cardiac dysfunction, and dialytic complications such as hypotension, cramps and fatigue. In January 2003, the Centers for Medicare and Medicaid Services (USA) implemented coverage of intravenous L-carnitine for the treatment of erythropoietin-resistant anaemia and/or intradialytic hypotension in patients with low endogenous L-carnitine concentrations. It has been estimated that in the period of 1998-2003, 3.8-7.2% of all haemodialysis patients in the USA received at least one dose of L-carnitine, with 2.7-5.2% of patients receiving at least 3 months of supplementation for one or both of these conditions. The use of L-carnitine within Australia is virtually non-existent, which leads us to the question: Are Australian haemodialysis patients missing out? This review examines the previous research associated with L-carnitine administration to chronic dialysis patients for the treatment of anaemia, cardiac dysfunction, dyslipidaemia and/or dialytic symptoms, and discusses whether supplementation is warranted within the Australian setting.

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