In recent years, medical students have been assuming increasing control over their preclerkship education. According to a survey involving 13 099 US medical students, the percentage of second-year medical students who reported "almost never" attending lectures in person continued to increase, from 26.3% to 37.0% between 2018 and 2020. 1 Concurrently, medical school curricula evolved to promote learner autonomy. Apart and distinct from increased reliance on recorded rather than live lectures, the curricular events allocated to independent learning nearly doubled between 2013 and 2020, from an estimated 3.35% to 6.38%. 2 These trends are unlikely to abate anytime soon. Current medical students accomplish the bulk of their learning outside the classroom, a practice likely solidified by adaptations to the COVID-19 pandemic. As others have noted, the reconfiguration of the preclerkship component of medical education is all but inevitable. 3 In this Viewpoint, we highlight the growing role of medical students in shaping their own education and outline the measures required to ensure that the increase of medical student-directed learning remains aligned with the educational aims of the medical discipline.Since the advent of Accreditation Standard 6.3 of the Liaison Committee on Medical Education (LCME), medical schools have taken to emphasizing selfdirected learning to complement lecture and casebased instruction. The LCME standard in question requires the inclusion of unscheduled time and independent learning components "to allow medical students to develop the skills of lifelong learning." 4 The emphasis on self-directed learning aptly encourages a more active role for medical students in the educational experience. These changes, along with the pressures imposed by the numeric score reporting of the United States Medical Licensing Examination (USMLE) Step 1, led to the emergence of a parallel, medical studentdirected curriculum that is dominated by resources geared toward studying for the USMLE. 5 Contemporary medical students now navigate a vast sea of didactic resources wherein institution-specific materials constitute but one of many sources.
Women suffering from absolute uterine factor infertility (AUFI) had no hope of childbearing until clinical feasibility of uterus transplantation (UTx) was documented in 2014 with the birth of a healthy baby. This landmark accomplishment followed extensive foundational work with a wide range of animal species including higher primates. In the present review, we provide a summary of the animal research and describe the results of cases and clinical trials on UTx. Surgical advances for graft removal from live donors and transplantation to recipients are improving, with a recent trend away from laparotomy to robotic approaches, although challenges persist regarding optimum immunosuppressive therapies and tests for graft rejection. Because UTx does not involve transplantation of the Fallopian tubes, IVF is required as part of the UTx process. We provide a unique focus on the intersection between these two processes, with consideration of when oocyte retrieval should be performed, whether, and for whom, preimplantation genetic testing for aneuploidy should be used, whether oocytes or embryos should be frozen and when the first embryo transfer should be performed post-UTx. We also address the utility of an international society UTx (ISUTx) registry for assessing overall UTx success rates, complications, and live births. The long-term health outcomes of all parties involved—the uterus donor (if live donor), the recipient, her partner and any children born from the transplanted graft—are also reviewed. Unlike traditional solid organ transplantation procedures, UTx is not lifesaving, but is life-giving, although as with traditional types of transplantation, costs, and ethical considerations are inevitable. We discuss the likelihood that costs will decrease as efficiency and efficacy improve, and that ethical complexities for and against acceptability of the procedure sharpen the distinctions between genetic, gestational, and social parenthood. As more programs wish to offer the procedure, we suggest a scheme for setting up a UTx program as well as future directions of this rapidly evolving field. In our 2010 review, we described the future of clinical UTx based on development of the procedure in animal models. This Grand Theme Review offers a closing loop to this previous review of more than a decade ago. The clinical feasibility of UTx has now been proved. Advancements include widening the criteria for acceptance of donors and recipients, improving surgery, shortening time to pregnancy, and improving post-UTx management. Together, these improvements catalyze the transition of UTx from experimental into mainstream clinical practice. The procedure will then represent a realistic and accessible alternative to gestational surrogacy for the treatment of AUFI and should become part of the armamentarium of reproductive specialists worldwide.
Haitian, Chinese, Somali, Ethiopian, and Asian/Pacific Islander Perspectives on Research abstract Researchers often approach community-based organizations as an access point to engage underserved populations in studies. In this article, 5 representatives of community organizations present their perspectives on the complexity of researcher-community partnerships and the nuances of engaging Haitian, Ethiopian, Somali, Chinese, and Asian/Pacific Islander populations in research. Each representative presents recommendations for gaining trust and understanding within their communities and challenge researchers to move beyond seeking knowledge and into social action that improves the lives of their constituents. Pediatrics 2010;126:S137-S142
Cancer is an evolutionary process of somatic cellular selection. Genetic and epigenetic alterations in tumour cell populations generate the heritable variation on which natural selection can act. The multistep process of carcinogenesis can be rationalised as the acquisition of functional traits that enable incipient cancer cells to achieve replicative success and, eventually, immortality in a tumour microenvironment. Evolution explains why cancer exists, as it is a natural consequence of selection at the cellular level, despite being harmful at the organismic level. Evolution also explains why cancer therapy fails. Therapeutic intervention may eradicate many cancer cells, but this also inadvertently clears the ecological niche and positively selects for the expansion of resistant cells. New applications of evolutionary biology, ecological theory and multilevel selection theory are deepening our understanding of cancer progression. An evolutionary perspective of cancer also offers novel prevention and treatment strategies for cancer. Key Concepts Cancer is a process of somatic selection in which variant cells acquire fitness advantages in a tumour microenvironment. The hallmark capabilities of cancer cells can be understood as functional adaptations that confer a reproductive advantage over normal cells. Tumours are heterogeneous populations of cells. A high amount of cancer heterogeneity is associated with an increased rate of cancer progression and a negative prognostic factor for treatment. The tumour microenvironment plays a key role in cancer suppression. The availability of resources in a tumour microenvironment can influence cancer development, invasion and metastasis. Cancer is an example of natural selection acting in opposing directions at different levels of the biological hierarchy – an increased fitness of the cancer cell is correlated with a decreased fitness of the host organism. Evolutionary medicine offers reasons for why our bodies remain vulnerable to cancer despite years of evolving powerful mechanisms for suppressing the development of cancer. The application of evolutionary thinking to cancer biology is offering fresh insights on new therapeutic strategies.
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