revbrashematolhemoter.2015;37(1):63–66
Revista
Brasileira
de
Hematologia
e
Hemoterapia
Brazilian
Journal
of
Hematology
and
Hemotherapy
w w w . r b h h . o r g
Special
article
Motivating
medical
students
to
learn
basic
science
concepts
using
chronic
myeloid
leukemia
as
an
integration
theme
Sara
Teresinha
Olalla
Saad
∗,
Hernandes
Faustino
Carvalho
UniversidadeEstadualdeCampinas(UNICAMP),Campinas,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received11June2014 Accepted11August2014
Availableonline16December2014
Keywords:
Academicteaching Medicineeducation Cellbiology Translationcourse
a
b
s
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r
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c
t
Objective:Toreportontheuseofchronicmyeloidleukemiaasathemeofbasicclinical inte-grationforfirstyearmedicalstudentstomotivateandenablein-depthunderstandingofthe basicsciencesofthefuturephysician.
Methods:Duringthepastthirteenyearswehavereviewedandupdated thecurriculumof themedicalschooloftheUniversidadeEstadualdeCampinas.Themainobjectiveofthe newcurriculumistoteachthestudentshowtolearntolearn.Sincethen,acaseofchronic myeloid leukemiahas been introduced to first year medicalstudents and discussed in horizontalintegrationwithallthemestaughtduringamolecularandcellbiologycourse.Cell structureandcomponents,protein,chromosomes,geneorganization,proliferation,cellcycle, apoptosis,signalingandsoonareallthemesapproachedduringthiscourse.Attheendof everytopicapproached,thestudentsprepareinadvancethecorrespondingtopicofclinical caseschosenrandomlyduringtheclass,whicharethenpresentedbythem.Duringthefinal class,apaperregardingmutationsintheablgenethatcauseresistancetotyrosinekinase inhibitorsisdiscussed.Aftereachclass,threetestsaresolvedinaninteractiveevaluation.
Results:Thecoursehasbeensuccessfulsinceitsbeginning,13yearsago.Greatmotivationof thosewhoparticipatedinthecoursewasobserved.Therewerelessthan20%absencesinthe classes.Atleastthree(andasmanyasnine)studentseveryyearwereinterestedinstarting researchtraininginthefieldofhematology.Attheendofeachclass,aninteractiveevaluation wasperformedandmorethan70%oftheanswerswerecorrectineachevaluation.Moreover, forthefinalevaluation,thestudentssummarized,ina writtenreport,themolecularand therapeuticbasisofchronicmyeloidleukemia,withscoresrangingfrom0to10.Considering all13years,amedianof78%oftheclassscoredabove5(min74%–max85%),andamedian of67%scoredabove7.
Conclusion:Chronicmyeloidleukemiaisanexcellentexampleofadiseasethatcanbeused forclinicalbasicintegrationasthisdisorderinvolveswellknownprotein,cytogeneticandcell functionabnormalities,haswell-defineddiagnosticstrategiesandatargetorientedtherapy.
©2014Associac¸ãoBrasileiradeHematologia,HemoterapiaeTerapiaCelular.Publishedby ElsevierEditoraLtda.Allrightsreserved.
∗ Correspondingauthorat:HemocentroUnicamp,RuaCarlosChagas,480,CidadeUniversitáriaZeferinoVaz,13083-878Campinas,SP,
Brazil.
E-mailaddress:[email protected](S.T.O.Saad). http://dx.doi.org/10.1016/j.bjhh.2014.08.002
64
revbrashematolhemoter.2015;37(1):63–66Introduction
TheFacultyofMedicalSciencesoftheUniversidadeEstadual deCampinas(UNICAMP)isconsideredoneofthebest med-icalschoolsinBrazil and inLatinAmerica.LocatedinSão Paulostate, inCampinas, acity ofone millioninhabitants andcenterofatechnologicalareacomparabletotheSilicon ValleyinCalifornia,theschoolenrolls110studentsfromat least10000candidateseveryyearfromalloverthecountry. Thustheselectionprocessisdifficult;theexamsarevery rig-orous,andconsistofapproximatelyoneweekofevaluations ofchemistry,physics,biology,maths,Portuguese,literature, history,geographyandEnglish.
Theundergraduatemedicalcourseisnominallysixyears long withthefirst and secondyears beingpre-clinical and yearsfiveandsixaretraineeinternyears.
Since the creation of the medical school 45 years ago, thefirstyear curriculumcomprisesbiochemistry,histology, embryologyandanatomy.Thecoursesarebasedonlectures, laboratoryclassesandexaminations.Duringthepastthirteen yearswehavereviewedandupdatedthecurriculumto revi-talizethecourse.Themainobjectiveofthenewcurriculum wastoteachthestudentshowtolearntolearn.Horizontal andverticalintegrationareonefocusofthenewcurriculum asistheintegrationofbasicandclinicalcourses.
Inthenewcurriculum,themodule‘TheCell’isintroduced duringthefirsteightweeksofthecourse.Themoduleisgiven in168hwith75%inclassstudiesunderteacherguidanceand laboratoryactivities,includingbioinformatics,andlessthan 25%reservedforlectures.Wewouldliketoreportthestrategy usedtoapplythemodule‘TheCell’inordertomaintainthe principlesofthenewcurriculumandmotivatestudents.
The objective of this paper is to report on the use of chronicmyeloidleukemiaasathemeofbasicclinical inte-grationforfirstyearmedicalstudentstomotivateandenable in-depthunderstanding ofthe basicsciences ofthe future physician.
Method
Chronicmyeloidleukemiaisadiseaseofthehematopoietic stemcells,whichacquireareciprocaltranslocationbetween chromosomes 9 and 22 (Philadelphia chromosome). This translocationleadstoajuxtapositionoftheBCRgenetothe ABLgene.TheABLgeneisaproto-oncogene.This juxtapo-sition determines the activation ofABL, a tyrosine kinase involvedin theintracellular signaling which culminatesin increasedproliferationandreducedapoptosisoftheabnormal clone.1,2
(1) On the first day of this module, 1h is reserved for thestudentstointerviewapatient,curedofchronicmyeloid leukemiaafterbeingsubmittedtobonemarrow transplanta-tion.
The students have an opportunity to hear the patient, personalandfamilyinformation,thecomplaintswhich cul-minated in going to the doctor, and the patient’s feelings regarding the diagnosis and the evolution of the disorder beforeandafterthebonemarrowtransplantation.
APowerPointpresentationisthenshownsummarizingthe epidemiology,clinicalcharacteristics,etiologicfactorsofthis diseaseandfinally,abloodsmearofthepatientatdiagnosis andofanormalpersonisshownandthesignificant differ-encesinthenumbersofwhitecellsandplateletsisdiscussed. Thisincreasedamountofcellsisthencorrelatedwithspleen growthwhichthepatientshadmentionedastheinitial symp-tom,duringtheinterview.
Then,thestudentsaregiventheaddressofthepage con-taining the clinical case on the Internet so that they can prepare themselvesforthenext classes.TheInternetpage includes descriptions of techniques emphasizing recently acquired basicknowledge, andvideos showingthe separa-tionofproteins,Westernblottest,chromosomeanalysisby standard karyotypingand insitufluorescence hybridization (FISH),polymerasechainreaction(PCR),RNAquantification byreversetranscriptionPCR(RT-PCR),stemcellseparationand growth,andcolonyformation.
Attheendofeachbasictheme,theclinical caseis pre-sented by randomly chosen students coordinated by the teacherasfollows.
(2)Duringthepresentationoftheproteintheme,the stu-dents discussthe basis ofthe westernblot technique that identifiedanabnormalbandinthepatient.Apictureofthe Westernblotresultsisusedasanexample.Onlythe abnor-malband,presentinthepatientandabsentinthecontrol,is shown.
Butwhydoesthepatientpresentthisabnormalband?The answertothatquestionarisesduringthecourse.
The Western blot technique is also described and stu-dents watcha videoshowing theprocedure used tomake polyacrylamide gel, the application of the sample in the gel,themigrationoftheproteinsinthegel,theverification ofthese proteinsusingCoomassieblue stain,the transfer-ence oftheseproteinstonitrocellulosemembraneand the revelationoftheseproteinsusingaspecificantibodyanda sec-ondaryantibody.Both,thevideo(approximately15minlong) andabriefdescriptionofthetechniqueareavailableonthe internet.
(3) During the classes concerning chromosomes, gene organizationandtranscription,thestudentsdiscussthe cyto-geneticsofpatientswiththePhiladelphiachromosome.The traditionalcytogeneticsandFISHofthepatient,aswellasthe procedure toperformthesetechniquesare availableinthe Internetsite.
At this point we discuss the relationship between the abnormalband (previously showed)and this translocation. The students discuss the genes that are involved in the translocationandtherelationshipbetweenthesegenesand theabnormalprotein.
The implication of this translocation at the RNA level and the usefulness of this knowledge in the diagnosis of the translocationarealsostudied. RT-PCR,usedto demon-stratetheBCR-ABLtranscript,andtheimportanceofRT-PCR tofollowuppatientsafterbonemarrowtransplantationare discussed. RT-PCRproducts, beforeand afterbone marrow transplantation,areshown.Finally,studentsareableto asso-ciatetheabnormalproteintothecytogeneticsandRT-PCR.
revbrashematolhemoter.2015;37(1):63–66
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roleofABLinsignaltransduction,theBCR-ABL hyperphos-phorylationand itsinvolvementinthesignalingpathways, leadingtoanabnormalproliferation,apoptosisandcell adhe-sion. Therelationship between ABL and BCR-ABL Western blotsusingtheanti-phosphotyrosineantibodyisexplored.
At this point we revise all themes discussed and then decideuponthediagnosis.
Butwhatshouldthepatient’streatmentbe?Analternative, incasethereisacompatibledonor,couldbeabonemarrow transplantation.
(5)Howprecursor cells are obtainedisdiscussed inthe chapteroncellproliferationusingavideoshowingan aphere-sisdonorselectedforbonemarrowtransplantation.Thecells arethencultivatedinvitroinordertodemonstratethatthere areprecursorcellscapableofproliferationinresponseto stim-ulationusinggrowthfactors.Methylcelluloseplateprecursor colonies(BFU-EandCFU-GM)areshown,andtheprocedure and principle of the method are explained. The proteins involvedinthecellcyclearedescribed.
(6)Howanormalhematopoieticcelliscapableof differ-entiatingbymeansofaspecificstimulationisdemonstrated inthe chapteroncell differentiation.Thedifferentiationof hematopoietic cells after the addition of erythropoietin in a two-phase liquid culture of mononuclear cells obtained fromperipheralbloodfromthebonemarrowdonorisshown. Atthispoint,humoralandcellularcomponentsinvolvedin hematopoieticcelldifferentiationaredescribed.
(7)Apoptosis ofnormalhematopoieticcellsofapatient withleukemiaispresentedinthechapteronapoptosisusing photographs of the cells stained using hematoxylin–eosin. Apoptosisofleukemiccellsisdelayed.Theinfluenceofthe BCR-ABLproteinontheregulationoftheproteinsoftheBcl-2 familyanditsanti-apoptoticactionismentioned.
However, the first line treatment for chronic myeloid leukemiaisnotbonemarrowtransplantationbutanoral tyro-sinekinaseinhibitor.
(8)Thus,studentsdiscussthedevelopmentofchemicals whichmodify the structureofproteinsand that are capa-ble ofinhibiting the functions ofthese proteins. Thedrug imatinib,aswellasothertyrosinekinaseinhibitors,is men-tioned.ThesedrugsdephosphorylatethetyrosineoftheABL proteinandinhibitthedeleteriousfunctionoftheabnormal protein.Afiguredemonstratingthisfunctionisavailablein theinternetsite. Thetertiary structureoftheablgeneand thepocketwiththeimatinibchemicalisexplored.The stu-dentshavethe opportunity toread laymanarticleson the impactofthediscoveryofimatinibinthetreatmentofchronic myeloid leukemia.The aimof this last item is to demon-stratehowalltheknowledgetheyhaveacquiredinthebasic course has importance in the development of therapeutic strategies.
(9)Onthelastdayofthecourse,thestudentsdiscuss a paper,whichtheyhavepreviouslyread,publishedinBlood.3
Thearticle showsinvitroanalysisofcelllinestransformed with constructs of ABL mutations, which are present in patients resistant to imatinib treatment. The aim of this exerciseistoreviewwhatwastaughtduringthecourse,to consolidatethe knowledge acquired and toshow students howtoanalyzeapaperandbeuptodateinthefield.Itisalso importanttoanalyzemutationsinthesecondaryandtertiary
structureoftheABLproteinwhichblockthebindingofthe tyrosinekinaseinhibitor.
Results
Thecoursehasbeensuccessfulsincetheverybeginning,13 yearsago.Studentswhoparticipatedinthecoursehadgreat motivationandallwereveryenthusiastic.Lessthan20%of thestudentswereabsentfromclassesandatleastthree(and asmanyasnine)studentseveryyearwereinterestedin start-ing researchtraining inthe fieldofhematology.Attheend ofeach class,aninteractiveevaluationwasperformed and morethan70%oftheanswerswerecorrectateachevaluation. Moreover,fortheirfinalevaluation,thestudentssummarize inawrittenreport,the molecularandtherapeuticbasesof chronicmyeloidleukemia.Consideringall13years,amedian of78%oftheclassscoredabove5(min74%–max85%),anda medianof67%scoredabove7.
Discussion
Theaimof‘TheCell’courseistoprovideabasisto under-standthemainaspectsofnormalandabnormalmolecular andcellularfunctioningofdifferentsystems.
The clinical case, approached during the entire course, provides thestudent withthe opportunitytoacquirebasic andup-to-dateknowledgeregardingcellstructureand func-tion.Usingchronicmyeloidleukemiaasanintegrationtheme, studentslearnaboutcelldynamics,includingstructuraland biochemical aspectsof cell components, such as proteins, carbohydrates and lipids, biomembranes and organelles, receptors and signal transduction,chromatin and chromo-somes,generegulation,proliferationmechanisms,migration, adhesion,differentiationandcelldeathamongotherissues.It wasalsoimportanttopreparethestudenttounderstandthe diagnostic and therapeutictechniqueswhichhaverecently beendevelopedorwhichareyettobedevelopedaswellas toincorporatebasicscientificknowledgeinorderto articu-latediagnostic,therapeuticandprognosticpractice.Moreover, thepapergivesstudentstheopportunitytoanalyzescientific informationrelevanttoprofessionalpractice.
In conclusion,chronic myeloidleukemia isan excellent disease for clinical-basic integration as it comprises well knownprotein,cytogeneticandcellfunctionabnormalities, has well defineddiagnosis strategiesand a target oriented therapeutics.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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revbrashematolhemoter.2015;37(1):63–662.VanEttenRA,MauroM,RadichJP,GoldmanJM,SaglioG, JamiesonC,etal.Advancesinthebiologyandtherapyof chronicmyeloidleukemia:proceedingsfromthe6thPost-ASH InternationalChronicMyeloidLeukemiaand
MyeloproliferativeNeoplasmsWorkshop.LeukLymphoma. 2013;54(6):1151–8.
3.ChuS,XuH,ShahNP,SnyderDS,FormanSJ,SawyersCL,etal. DetectionofBCR-ABLkinasemutationsinCD34+cellsfrom
chronicmyelogenousleukemiapatientsincomplete
