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FELLOWSHIPS & OPPORTUNITIES for TRAINING
TRAINING PROGRAM AT
THE UNIVERSITY OF TEXAS BURN SERVICES (Click here for layman's version of this article) § Background Thermal injury remains a major medical problem in the United States and throughout most of the world. Although many advances have been made in reducing the high mortality associated with this injury, there are numerous unresolved questions concerning the nature of burn pathophysiology. If these questions could be answered, the cost of hospitalization and rehabilitation and the morbidity and mortality associated with this form of trauma would be markedly reduced. Basic researchers are currently answering many questions concerning the nature of the pathophysiology associated with thermal injury. However, to make this knowledge usable by the population of clinicians caring for burned patients in general, trained burn physicians must be available who have the ability to interpret these data and test them in a clinical settings. To accomplish this latter objective, clinical researchers must have the ability to communicate their findings in the traditional academic settings through oral presentations, poster displays, and in the preparation of manuscripts. The objective of this program is to train these individuals. The University of Texas Medical Branch has been training clinical researchers since the latter part of the 19th century. Following the second world war, a multi-disciplinary program for the care of burn patients, research into the nature of thermal injury, and the training of clinicians and researchers in the area of thermal trauma was developed. This program was greatly enhanced 26 years ago by the philanthropy of Shriners of North America through their decision to establish the first center of teaching burn care research in the Galveston medical complex. This program has been integrated into The University of Texas Medical Branch and today, encompasses a large interdisciplinary team including 17 faculty from the Department of Surgery, 5 from Anesthesiology, 2 from Internal Medicine, 4 from Physiology, 3 from Microbiology, 3 from Pathology, 1 from Pharmacology, 3 from Human Biological Chemistry and Genetics, 1 from Otolaryngology, and 2 from Pediatrics. This team conducts a multi-million dollar research program, which investigates thermal injury and other areas of related pathophysiology. An integral part of these clinical and research activities is a training program, which has involved medical students, Pre and Postdoctoral Fellows in the basic science disciplines, residents, house staff, Fellows, nurses, and the allied health personnel. In addition, numerous medical students have been involved in summer research projects and there is an on-campus program to stimulate the interest of minority students in academic careers related to medicine. These training activities are supported from a variety of sources that include research grants from the public health service by the State of Texas. Continued funding from this grant proposal will enable us to expand the training programs for postdoctoral individuals, especially those who are looking for an academic career in investigating areas that relate to thermal injury.
Goals and Rationale The goal of this program is to train physicians and scientists to accomplish research in the burn/trauma area. These individuals will have at least one year of postdoctoral training and upon completing our program, will return to finish their specialty training and become clinician investigators. We will hopefully select individuals in more advanced areas of training in order that their research experience will be fresh when they enter into their academic careers. It is hoped, however, the individuals who enter our program in the early part of their clinical training will continue their residencies.
Balance and Integration The basic science rationale for this training program is the need for individuals in burn/trauma care who are capable of interpreting basic information from the laboratory and applying it to clinical problems and clinical research. It is hoped that these findings will ultimately lead to the dissemination of new knowledge and procedures for the care of thermally injured patients.
Basic Didactic Core The core is made up of courses in various disciplines. These include statistics and scientific writing. There are additional short courses, which train the individual to perform computerized literature and word processing. These two courses are not mandatory because all students avail themselves of this service. There is a weekly lecture series in which the Fellow's present lectures on topics related to burn, sepsis, and trauma. At these presentations the faculty are in attendance to critique the candidates and help them in developing their skills as lecturers. There is also a bi-monthly scientific staff meeting for which there is mandatory attendance. At this meeting the operation of the various research programs is discussed and there is a presentation from the faculty and Fellows on their research efforts. The Fellows are encouraged to attend a morning conference, which covers most of the subject materials of the basic sciences as they pertain to critical care medicine. They meet four times a week for 45 minutes. Weekly Morbidity and Mortality Conference in Anesthesiology and Surgery, and Surgical Grand Rounds are held. All Fellows attend the weekly Fellow’s Conference with Drs. Herndon, Traber, Papaconstantinou, Townsend, Barrow, Wolfe, and Hawkins to present their week’s data and plan their next week’s program.
Didactic Program for the Cardiopulmonary Track Fellows in the cardiopulmonary track have daily lab rounds in the morning and evening. During rounds Dr. Traber reviews the progress of each ongoing experiment with the Fellows and technical personnel. There is a weekly luncheon meeting with Dr. Herndon and staff in which each Fellow summarizes the progress made in their research programs and plans made for presentations at national and international meetings, the preparation of manuscripts and new projects. There is a weekly Journal Club in which a Fellow presents a literature review of a specific area and current pertinent literature applicable to their particular research projects. These Journal Clubs also function to preview the contents and abstracts of forthcoming meetings, as well as to report important papers that the Fellows may have heard in attendance at national or international meetings. As the Fellows ready themselves for presentations at national meetings, presentations are made before the group. Thus the candidate who is presenting receives constructive criticism of their performance and the attending Fellows gain experience in critiquing the work of others, as well as learning how a presentation should be made. There are courses and seminars in the basic science departments at UTMB and several of the Fellows participate in them. There is a close relationship between mentor and trainee in all the programs. Thus, the activities of the candidates are constantly monitored. In addition, their progress is evaluated at the various weekly presentations. During these time periods, areas that need improvement are identified, important changes in the data are noted and interpreted, and modifications of the various protocols and/or presentations are made. As the Fellows become more experienced, they become more independent and begin to participate in the training of new Fellows by teaching techniques, showing them literature, asking questions and stimulating conversation.
Didactic Program for the Metabolism Segment The focus of research is the regulation of metabolism in human subjects. Emphasis is on the response to injury and sepsis, but a broader focus is taken in order to understand physiological control mechanisms of metabolic events. The experimental approach involves the use of stable isotopes and kinetic analysis to assess metabolism. This is generally not an area in which Postdoctoral Fellows have extensive experience. Consequently, the first few months involve training in basic aspects of stable isotope tracer methodology. Some sessions are didactic lectures on fundamental principles. These lectures are given in part of Dr. Chinkes. Also, each Fellow is assigned a topic to cover for one or two weeks, and the other faculty members active in the Metabolism Unit (Drs. Chinkes, Herndon, Zhang and Aarsland) also lead sessions. Other sessions focus more specifically on experiments in progress. Technical aspects of performing experiments, such as mixing isotope solutions, performing infusions, and determining metabolic rate, are generally learned from the other faculty members and Fellows in the program. Experience is also provided in analysis, although emphasis is not placed on this unless it is of specific interest to the Fellow. When Fellows have completed a two-year Fellowship in the program, they will be able to perform and interpret all aspects of stable isotopic tracer experiments. Drs. Aarsland, Zhang and Chinkes are involved with the Metabolism Unit projects on a daily basis, and spend a good deal of their time either performing experiments in the CRC or Shriners, or in the analytical lab. Fellows are involved in a project with at least one of these faculty members as a major collaborator. The broadening of the experience of a Research Fellow in the Metabolism Unit also stems from the numerous investigators who come for a few days to six months to work on specific projects with the group, or to learn some aspects of stable isotope analysis.
The strength of the Metabolism Program is two-fold: Experience is provided by direct and frequent interaction with a diversified faculty, including a mathematician; a biochemist; an anesthesiologist with advanced training in nutrition; an endocrinologist; and a pulmonary physician. In studies involving patients, Dr. Herndon (Surgery) interacts on a daily basis with the Fellows. Thus, we feel this is an ideal environment in which an individual wishing to establish a career that will include investigation of metabolic regulation in burn injury and sepsis can receive training.
Didactic Program for Wound Healing New Program in Wound Healing Wound Healing: Pathogenesis of soft and hard tissue injury and repair The didactic program in the wound healing track consists of a series of seminars on the various components of wound healing, i.e., the ubiquitous fibroblast, collagen metabolism, soluble mediators, growth factors, the complement cascade, etc. In the early segments, normal wound healing is stressed, and later, abnormal wound healing resulting in hypertrophic scar and keloid formation is reviewed. Other members of faculty participate in specific areas such as immunology, scanning, and electron microscopy, and the interaction of the clotting cascade with wound healing. Dr. Herndon directs each research project. However, the individual project might be a specific subset of the repair mechanism and the Fellow may work directly with Dr. McCauley, or jointly with other members of the program such as Dr. Jeschke or Dr. Traber. To learn the various techniques necessary to teach wound healing, the Fellows rotate into various core facilities for briefs periods of time. Since the wound-healing segment is rapidly growing, it will be possible for Fellows to work with new faculty being recruited for specific aspects of wound pathogenesis and repair, such as a molecular biologist, electrical engineer, and a biophysicist.
Electives In addition to these tracks the Fellows may elect course work from any of the graduate programs in the school of Biomedical Sciences. These Fellows are encouraged to participate in teaching medical students in their basic science laboratories. These performances are evaluated by faculty and assist the Fellows in learning new experimental techniques, as well as perfecting their abilities as teachers.
Opportunities for Collaborative Research with Other Labs In the development of the Fellows experimental protocol, they are encouraged by their mentors to pursue collaborative research ventures outside of their mentor’s laboratory. If the pilot studies identify the probability of a particular mediator being involved in a response, then the Fellow is encouraged to collaborate with an investigator who has the expertise in quantitation of such mediators and who has in-depth knowledge in that particular area. This expertise can be gleaned from a review of the credentials limited to faculty at our institution. Past Fellows have collaborated with investigators at University of California at Davis, the Thomas Jefferson College of Medicine in Philadelphia, the University of Ohio College of Medicine in Rootstown, Cetus Corporation in California, DuPont Chemical Company in Delaware, and the Ludwig Boltzmann Hospital for Traumatology in Vienna, Austria.
Interaction Among Trainees There are numerous opportunities for interaction among the trainees and the different programs as can be gathered from descriptions of the didactic sessions mandatory post-up at weekly conferences of all Fellows. In addition, there is a common study area for each of the programs. The study areas not only contain the Fellows from this proposed program, but others studying at the Hospital. These include individuals from all over the world. Consequently, there is an opportunity to gain some understanding of educational systems in medicine and techniques for research activities and funding from other countries. This interaction is indeed a special feature of the program, as is the close interaction of the mentor-fellow relationship and the established integrated interdisciplinary aspects of the system. In addition to the Postdoctoral Fellows working in the laboratory, there are also Predoctoral Fellows, mainly medical students working on various research projects, as well as residents who are in training. At the time that a Fellow is accepted into the program, the Fellow indicates his/her choice of a mentor. If his choice is agreeable, then the mentor usually assigns a project that is acceptable to the candidate. As the candidates gain more experience in the laboratory, they may select additional projects of their own volition.
PROGRAM FACULTY Dr.'s Zhang and Chinkes are actively involved in developing new stable isotopic tracer techniques for measuring metabolic processes, including the measurement of fractional synthesis and breakdown rates of tissue proteins (muscle and skin wound) and the measurement of DNA synthesis in skin wounds. These new methods are currently used in various research projects in this institute. Dr. Zhang's primary applied focus is the study of nutritional effects on wound healing using stable isotope tracer techniques. Dr. Aarsland in an expert in lipid metabolism and looks at the effects of treatment such as PPAR agonists and propranolol on ameliorating fatty liver in burn patients. Dr.'s Aarsland, Chinkes, and Zhang are actively working with Dr. Herndon on clinical trials to study the effects of anabolic agents on muscle wasting in burn patients. Dr. Traber’s efforts in researching the cardiopulmonary aspects of thermal injury are concentrated on determining the various lesions noted with inhalation injury, sepsis, and identification of the mediators which are responsible for them. There are also studies evaluating fluids shifts that occur during sepsis and following thermal injury. Dr. Traber currently uses an ovine model for these studies. This model is especially suited for the study of integrated Physiology. The studies all center around chronically instrumented animals. They are maintained in an investigative intensive care unit. There are two major thrusts to the research project: studies of the effects of inhalation injury and chronic sepsis on pulmonary microvascular function, and the changes in systemic organ flow and function with inhalation injury and sepsis. There is a special interest in evaluating the cerebral blood flow in sepsis. A close correlation exists with the Metabolism group since they have several ongoing projects evaluating metabolism in these animals. Dr. David Herndon has performed small animal and human studies investigating mediators of post-burn hypermetabolism and ovine studies investigating the pathogenesis of increased pulmonary microvascular permeability after smoke inhalation insults. He is also involved in the study of inhalation injury in patients, with special emphasis on the tracheobronchial changes which occur. He has accomplished studies which identified inhalation injury as a major contributor to mortality and morbidity in thermally injured individuals. He, likewise, has investigated the changes in immunological functions present in thermally injured individuals, and performed studies which examined the efficacy of various therapeutic modalities. These latter include investigations into the use of artificial skin, wound covering, and in vitro skin growth. Dr. Herndon has studied wound healing in the normal and contaminated state. He has defined the bacterial balance in wounds and demonstrated how bacteria interfere with normal wound healing. He has investigated the role of the various inflammatory mediators in the pathophysiology of both thermal and non-thermal wounds. Presently, he has in vitro and in vivo studies proceeding on various growth factors, and has established both small and large animal models to investigate their effects on wound healing and their control. The participating faculty offers research experience in integrally related areas. These include expertise in immunology, tissue culture and cell biology, pharmacology and endocrinology, and recombinant genetic technology.
Stronger Points of the Postdoctoral Teaching Program The excellent facilities at the Shriners Burns Hospital in Galveston and the generous support provided makes two years of training and research a truly effective and fruitful experience for the young doctors involved. Each has the opportunity for innovative thought input and originality in their projects. Doctors are closely associated with a faculty member noted for expertise in their field of research. The post-doctoral student is quickly indoctrinated in disgorging research protocols, collecting data, and presenting abstracts at national meetings. Within one year, the writing of full-length manuscripts is expected and at this time the writing of research grants is suggested. At the end of two rather busy years, many of these doctors are capable of conducting and supporting their own research programs. Scientific meetings and presentations within the Shriners Burns Hospital teaching structure supplement this intensive research training. At these gatherings, pertinent information presented in the literature is reviewed along with other basic science and clinical departments to further enrich their research efforts. The productivity and quality of research is evidence that this system works and is successful here at the Galveston Unit.
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