Resolving the Coronavirus Disease 2019 (COVID-19) pandemic is hamstrung by emerging Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) variants with the potential to evade both natural and vaccine-induced immunity. Variants occur naturally from replication errors by viral polymerases and escape variants arise when virus mutations allow evasion of recognition by the immune system or therapeutic treatment. The selective pressure of vaccines, innate immune responses, and clinical interventions fosters the emergence of mutations that confer the capacity to continue infecting new hosts , and madRapid characterization of variants for future viruses is therefore essential to an effective pandemic response. If we can predict and characterize VOCs before they arise, monoclonal antibodies and potential vaccine antigens could be developed to proactively neutralize these variants. Furthermore, better understanding of the molecular characteristics of each variant could guide more precise public health policies.Currently, variants are identified and functionally tested using a combination of viral sequencing, cell-based assays, protein engineering methods, and computational tools. Sequencing of viral genomes from infected hosts identifies mutations away from the earliest reported genome of the virus, called the reference genome, highlighting possible variants. After identifying these mutations, cell and protein-based assays are used in the lab to test whether these mutations enable escape from neutralizing antibodies, which are antibodies created by the immune system from previous infection or vaccination ,5. MutatAs methods for variant characterization become increasingly powerful, we have yet to see effective coordination of the research groups conducting these studies across disciplines. Although the United States spends billions of dollars annually on infectious disease research and development, including genomic surveillance for identifying variants , this inIn preparation for future pandemics, we propose establishing a consortium of research groups with expertise in both computational and experimental techniques to more exhaustively map the landscape of variants upon the emergence of a new virus and predict which variants are most likely to arise. This would enable a rigorous set of standard analyses for assessing potential VOCs, as well as allow for early design of vaccines with efficacy against the variants deemed most likely to arise. While this work is currently being done for SARS-CoV-2 at multiple universities, companies, and government agencies, we can use lessons from this pandemic to propose a more rapid and coordinated response for future emerging viruses. Below, we highlight recent technological advances in these fields. By combining existing technology and new technologies, we envision a collaboration of groups employing computational and experimental tools to quickly predict and characterize likely VOCs, which could be used to aid initial identification of neutralizing monoclonal antibodies and vaccine design when a new virus emerges and inform policy decisions as variants arise.An efficient approach to predict viral variants would be for the US to invest in a new system for predicting and testing likely VOCs immediately upon identification of a new virus. This workflow would be handled by experts in the individual technologies working collaboratively and sharing data in real time. While we propose technologies that already exist, they are implemented in different labs around the world with different levels of expertise, requiring communication, collaboration, and sharing of information. One delay in the US response is bringing together these experts, allowing access to clinical surveillance samples and coordinating efforts between labs in a meaningful manner. The current variant response approach in the US is reactive since these collaborations take time to develop after a new virus becomes a concern to public health, increase the administrative burden for hospitals and diagnostic laboratories who are already overstretched in a pandemic and have to ensure compliant sample handling and patient consent to surveillance studies, and could ultimately cost thousands of lives, billions of dollars, and extend a pandemic because the nascent collaboration is not fast enough to prevent the spread of new variants.Instead, this proposed workflow, described in Computational approaches can rapidly identify VOCs early in a pandemic, especially given the reduced need for time, resources, and safety regulations associated with many computational approaches. Computational tools are a necessity since there are approximately 20^n single coding mutations, let alone multiple mutations and indels. While experimental tools are still the gold standard, the best experimental approaches, including pooled screening experiments, would not be able to handle every possible mutation.We envision this coordinated response would be activated upon obtaining the genetic sequence for a new virus. With only the genome, computational tools such as BLAST  and otheOne notable recent study implemented a deep learning algorithm known as a language model to build a powerful predictor of variants . The modAnother promising computational technique for early interrogation and prediction of viral changes are models based on nucleotide composition. It is known that nucleotide and dinucleotide compositions of viruses evolve to match their host species to evade detection and subsequent clearance by cellular defense systems ,21. AccoD of interaction [Computational modeling of the structural effects of mutations is another approach that provides rapid molecular characterization of a large set of viral variants. For example, molecular dynamics (MD) simulations have characterized the change in binding affinity of the SARS-CoV-2 spike receptor-binding domain to the human entry receptor angiotensin converting enzyme 2 (ACE2) upon mutation , and in eraction , achievieraction  and the eraction  were avaAs the pandemic progresses and novel variants arise, their genomes will be collected into databases  and fed In sum, these computational methods provide an enormous opportunity to support efforts to predict and identify VOCs, traditionally driven by experimental techniques. For example, finding suitable animal models posed an initial challenge for studying SARS-CoV-2 because it was unable to infect mice due to differences in the ACE2 receptor protein used for viral entry. Computational techniques allow for molecular insight independent of the access to these and other resource-intensive experimental techniques. Furthermore, computational approaches offer the unique opportunity to integrate information on the virus sourced from many different types of analyses, such as incorporating observed VOC frequencies from genomic surveillance to refine the predictions made by the models, thus accounting for human-specific factors that are not captured by the molecular mechanisms that form the basis of the computational techniques. Importantly, incorporating continuous low-level surveillance in the proposed consortium model will allow continuous refinement of computational methods, across several families of viruses that occur seasonally. This could also help better model seasonal influenza strain development.Complementing the computational tools, lab-based technologies could simultaneously predict variants and feed additional information to the computational tools. The most straightforward approach to mapping the mutational landscape is to simply test each one in turn, using a technique known as deep mutational scanning or saturation mutagenesis. In a series of studies, the group of Dr. Jesse Bloom at the University of Washington used an exhaustive library of single nucleotide variants of the SARS-CoV-2 spike protein receptor-binding domain expressed on the surface of yeast to test for binding to the entry receptor ACE2 , for escTo map the escape landscape of a whole viral genome, laboratory researchers incubate the virus with cells and potential treatments to examine how the virus mutates to adapt to selective pressures . This apLab-based assays can also be performed to identify epitopes for vaccine targets that would be less prone to mutations by finding epitopes and antibodies that have high binding affinities across related viral species. Recently, Wang and colleagues identified the main antigens of the SARS-CoV-2 spike (S) protein targeted by the immune system, which were distinct from antigens that are more conserved between SARS-CoV-2 and SARS-CoV-1 . By elimTo implement this system, strong computational expertise, tools, and access to computing power are needed within the consortium so that results can be quickly utilized by all assays to predict variants and vaccine candidates. The consortium would be active at a “maintenance” level continuously, characterizing the yearly influenza pandemic as well as several cold virus strains, conducting surveillance and optimizing training algorithms on the emergence of variants. This could improve the influenza vaccine selection and our response to other seasonal pathogens. We could also learn a lot about virus surveillance, transmission and mutagenic behavior of viruses, potentially informing public health recommendations for nonpandemic viruses that still cause significant morbidity . A consortium conducting continuous low-level virus surveillance in the population could easily ramp up activities when a virus reaches Phase IV of WHO’s pandemic phase designation, which includes sustained human to human transmission. The sequence of this virus will be immediately fed into the computational models above  while simultaneously being used in the lab-based assays (by other labs in the consortium with appropriate biosafety labs and expertise), with results being shared automatically among all members. These results will be fed into a central database maintained by the consortium and distributed to each member to update their respective work. Ultimately, a list of most likely variants and potential phenotypes associated  will be output along with potential vaccine and therapeutic targets within a few weeks to months.There are examples of many successful consortia, including The Broad Institute’s Interdisciplinary Research Consortium, the Enzyme Function Initiative funded by the National Institute of General Medical Sciences, and many others. The Viral Hemorrhagic Fever Consortium (VHFC) is a great example of a nonprofit consortium starting from an initial grant, spanning multiple universities, countries, and agencies and has since expanded to include many additional partners. The majority of existing consortia focus on a single virus or group of viruses, while this consortium could be expanded to include a broad range of experts spanning all viral families. Using lessons learned from these successful consortia as well as best practices for governance, reward structures, and implementation of consortia ,45, we bThe ability to centralize consent forms, IRBs, and other documentation while gaining access to large data sets will entice many labs to join this consortium. This consortium would be formed with NIH support, which could help develop “blanket” IRBs and consent forms to increase sequencing of samples throughout future pandemics by clinical and diagnostic labs. By working with these labs, the consortium could facilitate increased sequencing, improving surveillance for VOCs while providing additional data for the computational models and increasing efficacy of the consortium. These computational methods were applied to SARS-CoV-2 even at the poor sequencing rates in the country, so the additional sequencing would not be critical, but would certainly help policy makers and the consortium.There are many documented benefits to collaborative research, and this consortium would improve access to different resources, increase professional networks, minimize burdens on individual labs, provide additional funding for labs, provide opportunities for publishing, and ultimately speed up research that has the potential to impact the entire world. However, the consortium needs to be managed and funded well, be ready to act when called upon, and established structures and workflows  need to be sufficiently robust to support a rapid expansion of activities in case of a pandemic. Best practices mentioned above and a significant amount of learnings from the COVID-19 pandemic can help implement a system that helps prepare for and mitigate future pandemics.Additionally, virology and basic biology expertise is required, especially related to the lab-based assays working with high containment pathogens at Biosafety Level 3. The verification experiments we propose would comprise in vivo lab technologies requiring a Biosafety Level 3 and use mainly pseudovirus assays to avoid working with dangerous live viruses. It is of utmost importance that more virulent virus strains are only generated using precautions such as pseudovirions and appropriate containment and that once the computational tools are trained to be highly predictive, safety measures against abuse are taken, and both details of the tools themselves and sequences of highly virulent proposed viruses are appropriately safeguarded together with NIH and other government institutions. However, if the consortium is successful in predicting early variants that are moderately efficient at evading selective pressure and this informs improved vaccine design with future variants in mind, the risk of developing a highly virulent strain is in practice significantly reduced. Allowing a virus to “fester” with only partially effective vaccines over long periods of time will increase risk for more virulent variants.Another important consideration for VOC prediction is the different selective pressures experienced by the virus in parallel as it infects different hosts. For example, variants of SARS-CoV-2 are thought to have arisen in farmed minks before transmitting back to humans in Denmark  and PolaAdditionally, computational modeling and prediction efforts separate from the broader workflow may be warranted: While the computational models described above showed success in separating viral sequences from different host species for both influenza viruses and coronaviruses , the abiThe vision we present for an ideal response to the identification and sequencing of a new virus is to maintain at a low level and in case of pandemic, rapidly deploy both a computational and a lab-based assay pipeline to predict and characterize the most likely VOCs, and define optimal monoclonal antibody and vaccine targets. While many of these technologies were created for previous viruses and pandemics, they have been updated and now include many more computational aspects because of SARS-CoV-2. We have highlighted many older and newer techniques that would benefit from integration in a consortium of experts that could be activated at a specific time after new a virus is identified. This coordinated approach would combine the power and speed of computational methods with the accuracy and translation of lab-based assays. By preemptively organizing this group around recurring influenza and other seasonal virus outbreaks, algorithms could be trained and workflows optimized for continuous low-level virus surveillance, allowing a rapid and efficient ramp-up during outbreaks that could become pandemics. A coordinated effort could predict VOCs early to aid vaccine design and guide public health policies. These candidate vaccines would have a greater likelihood of being able to prevent and treat variants that arise or even prevent variants from arising by squashing transmission early in a pandemic. This approach could also be used to design booster shots for a pandemic even after initial vaccines are available. Additionally, the characterization of each viral variant can also provide critical data to guide public health messaging as new variants do begin circulation. This broadly applicable workflow would ultimately cost a fraction of what the US is spending on infectious disease work in addition to saving lives during future outbreaks and generate unprecedented insight into virus transmission and evolution.


Historical context and converging market conditions present a unique opportunity to study the factors contributing to the formalization of foregut, or upper gastrointestinal, surgery as a new subspecialty in United States healthcare. The aim of this study was to examine the justifications of those pursuing the formalization of a foregut subspecialty and to extract lessons for healthcare leaders on the evolving relationships between competing providers. This was a qualitative, cross-sectional study consisting of interviews, secondary survey data, and observation of society meetings between October 2018 and June 2019. Thirty interviews with healthcare professionals were conducted, transcribed, and analyzed for themes using qualitative coding software. Themes were correlated with observational field notes and archival data and compared against established social theories on professions and medical specialization. Analysis revealed that traditionally competing surgeons and gastroenterologists articulate a professional need to qualify foregut surgical expertise based on superior knowledge and outcomes, to define the allocation of certain tasks and procedures, and to foster collaboration across specialties. Converging market conditions precipitate individual and organizational decisions to pursue formal specialization. Participants in the formalization of this subspecialty should consider the history of professional competition and turf wars to achieve meaningful collaboration. Advocacy for multi-specialty societies and organizational movements could be a model for reduced conflict in other specialties as well. Diseases of the foregut represent a large and growing burden in the United States (US) and a significant source of controversy among treating providers. The term “foregut” is typically used by clinicians to reference the beginning portions of the gastrointestinal tract, including the esophagus, stomach, and first portion of the small intestines. For example, one such disease, gastroesophageal reflux disease (GERD), affects an estimated 10–20% of the adult population in the US . Such diThe SAGES Manual of Foregut Surgery, with an online introduction describing its comprehensive review and expert commentary aimed “to clarify controversies in the field” , there was a huge patient volume that was in the midst of a workup and also needed follow up. So I inherited all of those patients.–R15Recent advancements in diagnostic and therapeutic technologies are identified as the major catalysts for maturation of the space and drivers for specialization. “Technology” is referenced by 36% of interviewees. Four new therapeutic procedures are mentioned by name 67 times in the interviews; robotic surgery is also mentioned by five interviewed surgeons.You need specialization because there are more tools. Both in the surgical arena with different anti-reflux procedures.–R2The described market conditions, as well as references to historical dynamics between surgeons and gastroenterologists, suggest a critical juncture in cross-disciplinary relations as these providers pursue the formation of this subspecialty.The results of this study indicate that converging market conditions have created volatility among professions, leading to formal jurisdictional claims by a cohort of physicians. Based on the themes analyzed, the surgeon specialists aim to protect the reputation of and to exert professional dominance over their evolving field by collaborating with a select group of their traditional competitors, with whom they identify as having common interests.Precipitous innovation in this disease space seems to motivate the self-described specialists to seek exclusive control over certain procedures, thereby enhancing their claims to superiority in this arena. This method of professional differentiation based on unique knowledge is a concept described by Andrew Abbott as “cognitive abstraction” in his discussion of professional competition . The secUsing superiority claims, these professionals seek formal, regulative distinction between foregut specialists and others. Intra-disciplinary competition, evidenced by use of terms like “dabblers” and references to inadequate training, seems a significant impetus for the creation of a new specialty society. The results from the AFS survey indicate that most members want a professional society to outline foregut credentials, perhaps a preemptive move to self-regulate and maintain collective autonomy  14]. Le. Le14]. The self-described foregut surgeons are, however, deploying bridging strategies with gastroenterologists in effort to exert some control over their environment . While iUnlike the jurisdictional contests typically discussed in the literature , 20, forThe interviewed surgeons are quick to distinguish their gastroenterological colleagues who have foregut interest from those who do not, elevating them to a similar professional status within the boundaries of the foregut subspecialty. In the absence of a formal “foregut” specialty in prior years, and few programs devoted to specific training, many interviewed surgeons and gastroenterologists have chosen this area of focus through evolving, real-world preference; a desire to protect its reputation may foster comradery amongst traditionally competing medical and surgical providers, rather than overt antagonism. The creation of multi-specialty Centers of Excellence exists as a concrete, team-based goal relying on group rather than individual performance to realize its full value in the market.The study results demonstrate some incongruity between a desire for collaboration and the bias against non-surgical colleagues. Of note, surgeon representation at the inaugural AFS meeting was nearly three times greater than that of gastroenterologists. A recent article published in a gastrointestinal journal, co-authored by a gastroenterologist and a surgeon, discusses that though technological advancements in both specialties have begun to “erode the traditional turf” between these two parties, differences persist in protocols, which feed an underlying competitive spirit . Shared Consistent with theories discussed above, precipitous innovation in this disease space seems to motivate the self-described specialists to seek exclusive control over new procedures, thereby enhancing their prior claims to superior knowledge. Prior alimentary turf losses to gastroenterologists with the advent of the endoscope, the historical reputation of foregut surgery, and recent, rapid innovation converge to create a critical moment in the foregut subspecialty, in which surgeons and gastroenterologists can influence the outcome of this movement by choosing to collaborate and overcome professional differences.Strengths of the study include the duration and quality of interviews obtained, which resulted in detailed transcripts for interpretation. Limitations of the study included its cross-sectional design, which may have resulted in bias particular to the types of providers most willing to discuss evolution in the space. It was more difficult to elicit interviews from providers that have not chosen to join the emerging society to gain their perspective on the changes, though a few are represented in the data. The study is further limited by its US focus; there is currently an international discussion around specialization, as evidenced in the literature and by the recent inaugural meeting of the European Foregut Society Meeting in Vienna, Austria . A largeSelf-identifying foregut surgeons collaborate across traditional competing specialties to establish professional dominance as sub-specialists in an increasingly focused US healthcare system. The manifested cross-disciplinary dialogue could advance quality improvement mechanisms and guideline alignment in this particular disease space nationally and internationally. Healthcare leaders pursuing the development of formal collaborative movements between these specialists, such as Esophageal Centers of Excellence or Heartburn Programs, should consider the social theory behind professional competition and historical outcomes of turf wars if they hope to achieve successful collaboration instead of further division between competing physicians.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(PDF)Click here for additional data file.


Boronia (Rutaceae) to characterize seasonal patterns in dormancy and fire-stimulated germination over a 2-year period and synthesized the observed patterns into a conceptual model of fire seasonality effects on germination. The timing and magnitude of seedling emergence was mediated by seasonal dormancy cycling and seasonal temperature cues, and their interactions with fire seasonality, the degree of soil heating expected during a fire, and the duration of imbibition. Primary dormancy was overcome within 4–10 months’ burial and cycled seasonally. Fire-associated heat and smoke stimulated germination once dormancy was alleviated, with both cues required in combination by some species. For some species, germination was restricted to summer temperatures , while others germinated over a broader seasonal range of temperatures but exhibited seasonal preferences through greater responses at warmer or cooler temperatures. The impacts of fires in different seasons on germination can vary in strength and direction, even between sympatric congeners, and are strongly influenced by moisture availability . Thus, fire seasonality and fire severity (via its effect on soil heating) are expected to significantly influence post-fire emergence patterns in these species and others with physiological dormancy, often leading to “germination interval squeeze.” Integration of these concepts into current fire management frameworks is urgently required to ensure best-practice conservation. This is especially pertinent given major, ongoing shifts in fire seasonality and rainfall patterns across the globe due to climate change and increasing anthropogenic ignitions.Fire seasonality (the time of year of fire occurrence) has important implications for a wide range of demographic processes in plants, including seedling recruitment. However, the underlying mechanisms of fire-driven recruitment of species with physiological seed dormancy remain poorly understood, limiting effective fire and conservation management, with insights hampered by common methodological practices and complex dormancy and germination requirements. We sought to identify the mechanisms that regulate germination of physiologically dormant species in nature and assess their sensitivity to changes in fire seasonality. We employed a combination of laboratory-based germination trials and burial-retrieval trials in natural populations of seven species of  SL101105). The regional climate is temperate with no dry season, according to the Köppen classification . RainfalBoronia were selected for study on the basis of their fecundity, overlap in flowering phenology, and populations within the study region that were large enough to provide the requisite quantities of seed. The study species are all shrubs from fire-prone heaths and woodlands and comprise a mixture of obligate seeders and resprouters, rare and common species, and different evolutionary lineages (sections) within the genus , B. fraseri, B. pinnata, B. serrulata] to 7 weeks  prior to the commencement of burial trials.Fruits are ballistic at maturity, so seeds were captured at dispersal using light-weight polypropylene bags tied around fruiting branches. Seeds were stored in the laboratory at ambient temperature (c. 20–25°C) for 4 weeks [B. thujona and four for all other species) were established in mid-summer (late January to early February) at the original seed collection site for each species and positioned up to 15 m apart amongst random stands of mature Boronia individuals. Replicate batches of seeds  were mixed with a spoonful of local topsoil that had been finely sifted to remove any pre-existing seeds. The seed/soil mixture was placed inside 10 cm lengths of nylon stocking and sealed with a knot at each end. This enabled free movement of soil moisture and limited the volume of soil to be searched during later seed recovery. Additional protection from disturbance by animals was provided by placing bags inside durable fiberglass pockets made of 2 mm insect mesh and measuring 5 cm × 10 cm. Replicate pockets were arranged in a contiguous grid and buried 1–2 cm below the soil surface followed by reinstatement of the surface litter.Replicate burial plots , random samples of bags were exhumed from replicate burial plots at the beginning of each season for up to 2 years . Retrievals of B. pinnata and B. thujona) were subjected to factorial combinations of smoke and seasonal temperatures only  measuring seasonal changes in the state of dormancy of buried seeds and (ii) predicting germination responses to fires in different seasons. Seeds buried for 4–13 months were subjected to factorial combinations of fire-associated heat (10 min exposure to 80°C), smoke (10 min exposure to aerosol smoke generated from burning vegetation), and seasonal incubation temperatures , following the methodology of res only . GerminaSeeds buried for 16–25 months were subjected to species-specific cue combinations that were found to maximize germination during their first year of burial . Treatmeminimum estimate of the proportion of seeds in a non-dormant state was inferred from the maximum germination response observed across all treatments  while dormancy remained high in other species until the second summer  or autumn   . Dormancs of 64% .Boronia species were characterized by pronounced reductions in dormancy alleviation in winter or winter-spring  with peak dormancy loss (maximum receptivity to germination cues) in spring-summer  and autumn (B. ledifolia) (B. anemonifolia (Section g-summer . These rdifolia) . A similonifolia ; howeverin situ—with longer wet intervals leading to marked increases in germination for all species, but not across all seasons for every species. Three section Boronia species  were able to germinate to appreciable levels (≥50%) in response to treatments representative of a fire within 3 weeks of incubation in at least one season ; however, treatments representing spring fires continued to result in negligible germination due to high seasonal dormancy  and greater time available for slower germination at certain seasonal temperatures to occur  which is expected to vary seasonally. This greatly increases the stochasticity of seedling recruitment of PD species in these ecosystems due to natural variability in post-fire rainfall and fire ignitions, with climate change and increasing anthropogenic ignitions introducing further complexity and variation via impacts on rainfall patterns and shifting fire seasonality.B. fraseri are most at risk due to reliance on post-fire seedling recruitment for population recovery and persistence. However, resprouters with variable capacity for post-fire vegetative recovery such as B. anemonifolia are also susceptible.Delayed or reduced germination is expected to occur following fires in one or more seasons for all seven species due to mismatches between their dormancy and germination phenology and the seasonal timing of fire. Effects are likely to be exacerbated where soil moisture availability is short-lived and/or delayed post-fire  or is required to maximize germination . Contrary to its well-established role in the germination of hard-seeded  species . However, for ecological studies that seek to understand and predict species responses in situ, data on temporal patterns—including the time to onset of germination and subsequent germination speed and synchrony—are crucial given that moisture and temperature conditions amenable to germination are temporally limited. As demonstrated here, the duration of imbibition has a profound effect on dormancy and germination responses, and studies with an ecological focus should ensure that the length of germination trials and the incubation periods for which results are reported are ecologically plausible, i.e., reflect the intervals and temperatures over which seeds in the upper layers of the soil are likely to remain continuously imbibed in the post-fire environment. Three months seems an appropriate maximum for most temperate fire-prone ecosystems; however, continuous periods of seed imbibition are likely to be much shorter than this in the absence of high or extended rainfall events, especially in warmer seasons. Further studies quantifying in situ variation in soil moisture availability in different seasons  and seasonal cycles in dormancy and germination responses.Greater use of seeds aged naturally ble ways , precludBurial trials over long durations are required to accurately characterize soil seed bank dynamics. We followed single cohorts of seeds for 2 years and observed variation in dormancy and germination responses to certain cue combinations between years in some species , 5. A loThis study has highlighted seasonal temperature requirements and seasonal patterns in dormancy cycling and moisture availability as key drivers of fire-stimulated germination of PD species in fire-prone ecosystems. The mechanistic models proposed here predict significant effects of fire seasonality, fire severity, and soil moisture duration on post-fire emergence patterns, including the increasing risk of “germination interval squeeze,” and call for a more sophisticated and wholistic approach to fire management that explicitly addresses these fire regime and environmental components in addition to the effects of fire frequency . This isThe models presented here require field validation and the demographic consequences of any realized delays or reductions in seedling emergence following out-of-season fires need to be evaluated in terms of growth, fecundity, and longevity of recruits. Evidence of adverse effects of delayed emergence on post-fire seedling establishment following unseasonal fires is beginning to emerge  but is cThe original contributions presented in the study are included in the article/BM conducted the field and experimental work, analyzed the data, and led the writing of the manuscript. All authors conceived the ideas, designed the research, contributed critically to the drafts, and gave final approval for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Fertility preservation is the process of saving gametes, embryos, gonadal tissues and/or gonadal cells for individuals who are at risk of infertility due to disease, medical treatments, age, genetics, or other circumstances. Adult patients have the options to preserve eggs, sperm, or embryos that can be used in the future to produce biologically related offspring with assisted reproductive technologies. These options are not available to all adults or to children who are not yet producing mature eggs or sperm. Gonadal cells/tissues have been frozen for several thousands of those patients worldwide with anticipation that new reproductive technologies will be available in the future. Therefore, the fertility preservation medical and research communities are obligated to responsibly develop next-generation reproductive technologies and translate them into clinical practice. We briefly describe standard options to preserve and restore fertility, but the emphasis of this review is on experimental options, including an assessment of readiness for translation to the human fertility clinic. Fertility preservation is indicated in patients with reproductive potential who are at risk of infertility  or reduced fertility (oligospermia or diminished ovarian reserve) due to their disease, gonadotoxic medical treatments, age, or other circumstances6. Patients at risk of infertility should be counseled about their risk and referred to reproductive specialists to discuss options for fertility preservation, which include both standard-of-care and experimental approaches11. We will briefly list the established standard-of-care fertility preservation options and describe in more detail experimental options to preserve and restore the fertility of women, men, girls, and boys who are at risk of infertility.Fertility preservation is a process to protect or preserve the ability of individuals to have their own biological children by freezing sperm, eggs, embryos, or gonadal tissues/cells6. Sperm cryopreservation is not possible for prepubertal patients who are not producing sperm or transgender females receiving medical treatments to suppress testosterone. The only option to preserve the reproductive potential of those patients who are not producing sperm is testicular tissue cryopreservation, which is investigational and should be done under approved protocols  with the potential to initiate spermatogenesis, the process that produces sperm. Those tissues can be thawed and digested with enzymes to produce a testicular cell suspension, which contains SSCs, and subsequently transplanted into the seminiferous tubules of the testes to regenerate spermatogenesis and potentially restore fertility. This technique was first described in mice by Brinster 44, including development of conditions that do not require supporting feeder cells46, which may be an important consideration for clinical application. SSC culture has been extended to rats, hamsters, and rabbits48, but extension to larger animal species has been a challenge and this is perhaps due to species-specific differences in SSC regulation51. Many laboratories have described protocols for human SSC culture68, but definitive evidence of long-term SSC expansion in higher primates is lacking, and no methods have been independently replicated among laboratories70. The slow cell cycle of SSCs in higher primates may partially explain the difficulty expanding those cells in culture71.The tissue biopsies from young patients are usually small and may not contain a sufficient number of SSCs to produce robust spermatogenesis after transplantation. Thus, it may be necessary to expand SSC numbers in culture before transplantation. SSC culture has been firmly established in rodentsDe novo testicular morphogenesis is another cell-based therapy to regenerate spermatogenesis from testicular cell suspensions. Testicular cell suspensions consist of germ cells and somatic cells such as Sertoli cells, Leydig cells, peritubular myoid cells, endothelial cells, immune cells, and fibroblasts. Testicular cell suspensions from neonatal or fetal animals can reorganize to form seminiferous tubule-like structures when put under the skin of immune-deficient mice (de novo testicular morphogenesis)75. De novo morphogenesis has been reported to produce elongated spermatids in pig and sheep75 and round spermatids that resulted in live-born offspring in mice73. There have been no reports of de novo testicular morphogenesis from human testis cells to date.78. Graft-derived sperm were competent to fertilize mouse eggs and produce healthy mouse offspring78.Testicular tissue grafting is an alternative to SSC transplantation. In this approach, SSCs are maintained in their cognate seminiferous tubule niches in intact pieces of testicular tissue. Homologous species testicular tissue grafting was pioneered in mice, demonstrating that immature mouse testicular tissues could be grafted under the back skin of recipient mice and matured to produce complete spermatogenesis82, including studies that demonstrated the production of sperm82 and a healthy baby82 from cryopreserved tissues. Therefore, autologous grafting of cryopreserved prepubertal testicular tissues is a mature technology that may be ready for translation to the human clinic.Four studies have reported autologous and/or homologous grafting of immature nonhuman primate testicular tissues86. Xenografting of immature human testicular tissues has failed to produce sperm to date92 and this approach may raise concerns about transmission of xenobiotics if used in the clinic. However, if proven effective, testicular tissue xenografting may be an approach to circumvent cancer contamination problems or for transgender individuals who will not go through male puberty and cannot mature testicular tissues inside their own bodies.Autologous testicular tissue grafting may not be appropriate for patients who harbor malignant cells in their testicular tissues  or transgender females who do not want to experience male puberty, including testosterone production that is required to mature testicular tissues and produce sperm. Xenografting of immature testicular tissues to an animal host may provide an alternative to produce sperm outside the patient’s body. Immature testicular tissues from pigs, goats, rabbits, hamsters, dogs, cats, horses, cattle, and monkeys have been grafted under the back skin of immune-deficient nude mice and matured to produce spermatids or sperm  of immature oocytes, in vitro growth of primordial/primary follicles, non-antral/small antral follicles, and artificial ovary, will also be reviewed in the following sections (in vitro gametes from pluripotent stem cells (In vitro gametes from pluripotent stem cells’).Standard-of-care fertility preservation options for women include (1) embryo cryopreservation, (2) mature oocyte cryopreservation, and (3) ovarian shielding or transposition in patients undergoing radiotherapy 2,12. Ovaconcerns 2,3,5,9,1sections . The expem cells  will be 102. Cryopreserved ovarian tissues can be reimplanted to the patients, either in the pelvic cavity or on the ovarian medulla (orthotopic transplantation) or outside the peritoneal cavity (heterotopic transplantation), if the risk of transferring cancer is low103. Orthotopic reimplantation of cryopreserved ovarian tissues performed in human patients restored ovarian function in more than 90% of cases105. The duration of ovarian activity ranged from 4 to 7 years after reimplantation106. The pregnancy rate is 18 to 35% of transplanted cases, and the live birth rate is 13.6 to 25% of transplanted cases109. The reimplantation outcome may be improved by enhancing graft revascularization by angiogenic and antiapoptotic factors3. Ovarian tissue transplantation is available at only a few centers worldwide. The hormonal and live birth outcomes from transplanted ovarian tissues are encouraging and may justify wider implementation in centers with the knowledge, expertise, and infrastructure to conduct the procedure safely and with the appropriate regulatory approval.Ovarian tissue cryopreservation is the only option for prepubertal female patients with cancer or for adult women with estrogen-sensitive cancer or those whose cancer treatment cannot be delayed111, such as patients with ovarian cancers, blood-borne malignancies, cancers with potential to metastasize to the ovaries, or a genetic predisposition to ovarian cancer112. In addition, ovarian tissue transplantation may not be appropriate for transgender males because of estrogen production associated with follicle development. IVM may allow maturing of unstimulated or minimally stimulated oocytes from antral/germinal vesicle follicles to fertilization-competent metaphase II oocytes in vitro114, hence decreasing the chance of reintroducing cancer115. Additionally, immature follicles can be collected with minimal or no ovarian stimulation which is beneficial in the cancer patients whose cancer is hormone-sensitive, patients who cannot delay chemotherapy, prepubertal patients who are not sexually mature, and patients with polycystic ovarian syndrome (PCOS) to avoid ovarian hyperstimulation syndrome116. Immature follicles can be harvested directly by aspiration from the ovary, in situ or after oophorectomy in patients with ovarian cancer, or during processing of ovarian cortex for ovarian tissue freezing120.Although the ovarian tissue cryopreservation coupled with transplantation is successful in humans, it may not be appropriate in cases where there is a risk of malignant contaminationin vitro fertilization (IVF)128.Obstetrics outcomes of IVM were reported among different disease status patients, such as PCOS or PCO-like patients, patients with cancer, or infertile women with no underlying diseases, regardless of whether they had been treated with a hormonal priming regimen prior to oocyte retrieval  activation of primordial follicles to small preantral follicles, (2) in vitro growth of small preantral follicles to antral follicles where cumulus–oocyte complexes (COCs) can be isolated for (3) IVM132.About 90% of the follicles in ovarian tissue biopsies are primordial follicles, which cannot survive or be matured when cultured under regular IVM conditionsIn vitro growth of primordial follicles was shown in mice to produce liveborn offspring134. In humans, culturing oocytes in situ with the ovarian tissue was shown to support primordial follicle activation followed by in vitro growth of small preantral follicles to antral follicles in which COCs can be used for IVM, resulting in metaphase II mature oocyte all in vitro136. These multistep culture techniques therefore may broaden the utility of cryopreserved ovarian tissue.142. This technique is another way of using cryopreserved ovarian tissue without reintroducing the whole tissue and potentially cancerous cells back to the patients.An alternative approach for the cases with a higher risk of transferring cancer is to extract primordial follicles from cryopreserved ovarian tissues, put them on a supporting scaffold, and graft back to the patients or immunocompromised mice. These techniques have been shown to produce offspring in mice and supported short-term growth of preantral follicles after xenografting of human primordial follicles into severe combined immunodeficient (SCID) mice145. However, despite the best intentions of patients, families, and medical professionals, fertility preservation can be difficult to accomplish in the compressed and stressful time frame between diagnosis and initiation of treatment149.Counseling, consenting, and freezing of gonadal tissues for fertility preservation should be carried out before treatment or early in treatment before the oogenic or spermatogenic potential of the ovaries or testes is permanently destroyed. Parenthood is important to cancer survivorsin vitro germ cells” or “in vitro gametogenesis”, but references are provided here. This field emerged from early observations that germ cells sometimes spontaneously arise from pluripotent embryonic stem cells (ESCs) or iPSCs in two-dimensional or three-dimensional cultures after removal of leukemia inhibitory factor (LIF) from the culture medium161. Those events were rare and stochastic. Studies on Bmp4-deficient embryos and cultures of mouse epiblasts or epiblast stem cells provided initial clues about early germ cell markers as well as growth factors, signaling pathways, and transcription factors that were important for germ cell specification169. That knowledge was subsequently exploited to induce germ cell differentiation from pluripotent cells, as described above.In the future, it may not be necessary to cryopreserve gonadal tissues before treatment because it will be possible to produce eggs, sperm, or their precursors from skin cells or other somatic cells of the body. In this short review, it is impossible to detail all of the outstanding studies that laid the foundation for the emerging discipline of “et al. provided the proof of principle for this approach in mice by demonstrating that ESCs or iPSCs could be differentiated into epiblast-like cells and then to PGCLCs that were transplanted to the ovaries or testes to produce eggs, sperm, and live offspring172. In subsequent studies, PGCLCs were differentiated to haploid eggs or spermatids entirely in vitro. The resulting eggs and sperm were fertilization-competent and produced offspring174. Germ cells have also been produced from monkey and human pluripotent stem cells179. Monkey and human PGCLCs are transplantable (produce clusters of spermatogonia or oogonia) but so far there is no evidence that they can differentiate to produce fertilization-competent gametes, in vivo or in vitro182. This may be more a reflection of experimental limitations than actual limitations of PGCLC developmental potential in higher primates.Hayashi 184. However, access to gonadal tissue freezing is limited primarily to academic centers and is performed under institutionally approved experimental protocols. A few centers are addressing the geographical access-to-care challenge by providing centralized tissue processing and freezing services. This allows patients to have surgery performed at their local institutions and have tissue express-shipped to a center with the infrastructure, expertise, and capacity to process, freeze, and store tissues186. Access to care is also limited because costs for these experimental fertility preservation options are typically paid out of pocket. The experimental designation is because there is limited evidence that cryopreserved immature gonadal tissues can be used for reproduction.Assisted reproductive technologies enable fertility preservation for adolescent or adult patients who are able to produce eggs or sperm. Gonadal tissue cryopreservation is an investigational option to preserve the reproductive potential of patients who cannot produce eggs or sperm. Gonadal tissue freezing has been performed for thousands of patients worldwide, demonstrating that the methods to obtain tissues are safe and feasible188. Those live birth outcomes prompted the American Society for Reproductive Medicine to recommend that the experimental label could be removed from ovarian tissue cryopreservation12, which may open the door to insurance coverage in some locations. Notably, however, it was not always possible to unequivocally document that pregnancies resulted from the transplanted tissue versus endogenous cells, and there is only one published report of a birth from ovarian tissue that was frozen during childhood189.This review describes several methods in the research pipeline to mature gonadal tissues by transplantation or by IVM to produce fertilization-competent eggs or sperm. Ovarian tissue transplantation was introduced to the clinic in 2004 and has led to over 130 live births to date82. There are no human live births from frozen/thawed testicular tissues, so the fertility restoration option remains experimental in the United States. Testicular tissues, in contrast to ovarian tissues that are cryopreserved for adult women and prepubertal girls, are cryopreserved almost exclusively for prepubertal boys. That means it could be many years before the first males return to use their cryopreserved testicular tissues. How many more years and how many births will be required to remove the experimental label from testicular tissue freezing? If a man produces sperm or offspring (or both) after autologous transplantation of SSCs, how will we know whether sperm were from transplanted or endogenous cells? The Danish experience may be instructive. In 1998, the Danish Minister of Health concluded that there were no restrictions on freezing ovarian tissues or testicular tissues as long as only autologous transplantation was considered. This liberal ruling placed gonadal tissue freezing in the context of normal medical practice183.SSC transplantation and testicular tissue grafting for males are mature technologies that may be ready for translation to the human clinicIn vitro germ cells or in vitro gametogenesis are emerging technologies that could eliminate the need to cryopreserve gonadal tissues prior to treatment. Pioneering results in mice are promising, but it is important to acknowledge that there has been limited independent replication of the original fertile outcomes174 in mice and, to our knowledge, no replication in higher animal models. Several labs have reported the production of transplantable PGCLCs from monkey or human pluripotent stem cells, but there is no evidence to date that those cells can produce functional gametes, in vivo or in vitro190. The gold standard to prove the gametogenic potential of PGCLCs is to demonstrate that PGCLC-derived gametes can fertilize and produce healthy offspring. Those endpoints are nearly inaccessible under current regulatory and funding restrictions for human embryo research in the US. Producing human embryos for research is illegal in our state (Pennsylvania). Circumstances in other states or countries may be more permissive191. Nonhuman primate studies are a good preclinical surrogate to establish safety and feasibility but are expensive and accessible to only a few researchers. Nonetheless, more basic and translational research, including research in higher primates, is needed to demonstrate the safety, feasibility, and reproducibility of in vitro germ cell technologies.In vitro germ cell technologies may also bring a higher regulatory burden. The US Food and Drug Administration guidance for transplantation of human cells, tissues, and cellular and tissue-based products (HCT/Ps) stipulates that HCT/Ps that meet specific criteria or fall within detailed exceptions do not require premarket review and approval. To qualify for exception, the HCT/Ps must be minimally manipulated, be intended for homologous use (same function), and be for autologous or reproductive use or both. The in vitro reprogramming and stepwise differentiation required to convert a somatic cell to a germ cell or gamete may exceed the definition of homologous use and minimal manipulation, thus requiring regulation as a drug, device and/or biological product.192. This review describes a next generation of reproductive technologies that may enable patients with the most difficult infertility diagnoses  to have biologically related children. Development of these technologies, like that of IVF, will require the coordinated efforts of researchers and physicians and must be deployed in a transparent manner with regulatory oversight and with input from key stakeholders.It is an exciting time in reproductive biology and reproductive medicine. The technology that produced the word’s first IVF baby, Louise Brown , has now produced millions of babies worldwide. Louise was possible because her mother could produce eggs and her father could produce sperm that were combined in the IVF laboratory of Drs. Steptoe (surgeon) and Edwards (researcher) at Oldham General Hospital in the UKin vitro fertilization; IVM, in vitro maturation; PCOS, polycystic ovarian syndrome; PGCLC, primordial germ cell-like cell; SSC, spermatogonial stem cellCOC, cumulus–oocyte complex; ESC, embryonic stem cell; HCT/P, human cells, tissues, and cellular and tissue-based products; iPSC, induced pluripotent stem cell; IVF,


Narrative analysis, creative writing, and interactive reflective writing have been identified as valuable for professional identity formation and resilience among medical and premedical students alike. This study proposes that medical student blogs are novel pedagogical tools for fostering peer-to-peer learning in academic medicine and are currently underutilized as a near-peer resource for premedical students to learn about the medical profession. To evaluate the pedagogical utility of medical student blogs for introducing core themes in the medical humanities, the authors conducted qualitative analysis of one hundred seventy-six reflective essays by baccalaureate premedical students written in response to medical student-authored narrative blog posts. Using an iterative thematic approach, the authors identified common patterns in the reflective essays, distilled major themes, coded the essays, and conducted narrative analysis through close reading. Qualitative analysis identified three core themes  and one overarching theme (near-peer affinities). The premedical students’ essays demonstrated significant self-reflection in response to near-peer works, discussed their perceptions of medical professionalism, and expressed concerns about their future progress through the medical education system. The essays consistently attributed the impact of the medical student narratives to the authors’ status as near-peers. The authors conclude that reading and engaging in reflective writing about near-peer blog posts encourages premedical students to develop an understanding of core concepts in the medical humanities and promotes their reflection on the profession of medicine. Thus, incorporating online blogs written by medical trainees as narrative works in medical humanities classrooms is a novel pedagogical method for fostering peer-to-peer learning in academic medicine. The emergence of the mobile, social web in the early 2000s fundamentally changed how students learn, from K-12 through continuing medical education . A prominent feature of this new pedagogical landscape is the growth of digitally-connected peer networks for sharing resources and information. Recent research has shown the value of blogs and social media for fostering peer-to-peer learning in academic medicine . As compared to teaching by senior clinical faculty, peer-to-peer and near-peer learning offer novel approaches to a range of objectives, including enhancing awareness of sociocultural context , improving clinical skills (Chou and Teherani 2017), increasing anatomical knowledge , and transitioning to clerkships . Within the traditionally hierarchical context of medical education, online peer communities can enable previously unheard voices, such as medical trainees, to gain expression (Eysenbach 2008). Further, research has demonstrated the value of studying online medical student communities on platforms such as WhatsApp to better understand the concerns of participants in real-time and in a social context (Coleman and O’Connor 2019).Research on peer learning through online communities builds on literature in the field of narrative medicine. The practices of studying and creating narratives  have been identified as valuable methods for fostering some of the Core Competencies for Entering Medical Students established by the Association of American Medical Colleges (AAMC), such as empathy and ethical responsibility . Baruch (2013) has argued that creative writing should be seen as a medical instrument that provides “tools for clinical excellence and empathy” (459). Wald and colleagues (2019) argue that interactive reflective writing can help develop professional identity and resilience in medical students, while Lamothe and colleagues (2014) suggest that this practice may be protective against burnout. In addition to its role in medical education, Kanter (2008) has demonstrated that the practice of narrative medicine can be successfully used with students in the baccalaureate premedical setting, which offers more time and space to develop independent, creative thinking skills as well as strong moral reasoning and a commitment to social justice.The availability of public blogs written by medical students as they reflect on their experiences in training provides a unique opportunity for premedical students to gain insight from near-peers about their intended profession and to hone the practice of reflective writing. Thus, extending foundational research in narrative medicine, this study hypothesized that medical student blogs present an underutilized opportunity for medical educators – and other students – to gain insights into the qualitative aspects of their experience. To test our hypothesis that near-peer narratives prompt valuable reflection on professional identity development and provide a novel means to introduce core medical humanities concepts to premedical undergraduates, we conducted a qualitative study that examined students’ responses to creative nonfiction narratives written by medical students for an online blog.in-Training (https://in-training.org/); these blog posts were later published as an edited collection by the same name (Major and Paul 2016). The authorship of the essays by near-peer medical students was not explicitly emphasized by the instructor. Students in the course were assigned seventeen short pieces (approximately five hundred words each) from in-Training alongside readings from widely used scholarly sources in the field of medical humanities, including anthologies edited by Cole et al. (2015) and Jones, Wear, and Friedman (2014), over the course of a fourteen-week semester . Study participants consisted of zero first-year students, twelve (20%) sophomores, twenty-two (37%) juniors, and twenty-six (44%) seniors. The majority of students  were Natural Sciences majors, followed by Social Sciences , Humanities , and Engineering . The numbers of majors do not add up to 100% due to the participation of students pursuing double majors. Students were assigned to read seventeen in-Training blog posts were selected by the premedical students for their reflective writing. Next, we sought to identify the predominant themes that emerged from the reflective essays. We began by reading through all of the essays to deductively identify a broad range of important themes. We identified approximately twenty to thirty initial themes and, on the basis of discussion, reached consensus about terminology that could be used to cluster and distill conceptually similar themes into three, comprehensive thematic categories: empathic conflict, bias in healthcare, and the humanity of medicine. We used these categories to code the dataset of 176 essays, with each essay coded by two reviewers. We collaboratively verified consistent application of codes through regular team meetings throughout our analysis. All of the coded essay segments were then subjected to narrative analysis by two members of the research team using close reading methods to explore the premedical students’ engagement with near-peer medical student writings, which revealed an additional, overarching theme: near-peer affinities.Our qualitative analysis was conducted in two stages. First, the research team identified which 1 In addition, a fourth, overarching theme of near-peer affinities appeared across all three of the major themes. We present the results of our narrative analysis of these themes below. Illustrative quotes from premedical student essays are referenced by the semester and year followed by the essay number . Selected quotations from student reflections are compiled in Table Evidence of the pedagogical value of integrating near-peer narratives into a baccalaureate medical humanities course emerged from deductive, iterative analysis of our dataset. The premedical students focused their reflective writings on three major themes: empathic conflict, bias in healthcare, and the “humanity of medicine” Pham 2012).012.1 In Jennifer’s internal struggle here is something that I’ve thought about a lot ever sinceI decided to become a pre-med. At first, I used to wonder how doctors can maintain such a stoic outlook in the face of some clearly emotional decisions. What is the point of a brusque doctor? Shouldn’t we show some empathy and compassion to the patient who’s suffering? Why should treatment only be about the biological symptoms? I thought there was genuinely something wrong about doctors who failed to show empathy and compassion to their patients. It was detrimental. However, when I think about it now, I can kind of see why doctors may attempt to put some objectivity and emotional distance between themselves and the patient. Doctors are human beings. If you had to face illness and death regularly and if you were continually emotionally affected by it, doing your job as a physician would become very difficult. Keeping that emotional distance is not a weakness; it’s almost a necessity that allows a physician to work to the best of his or her ability. (F17-31)In their essays, premedical students emphasized the theme of empathic conflict, focusing on the difficult balance between expressing emotion and empathy towards patients while maintaining an appropriate professional distance. Responses discussed how emotional expression enhanced the practice of medicine for both patients and physicians . Study participants reflected on the professional costs of empathic conflict and identified depersonalization, dehumanization, and emotional fatigue in the medical students’ blog posts . Students frequently reflected on the medical trainees’ challenge of balancing their emotional attachment to patients with a professionally appropriate empathetic response (F16-2), and expressed concern that achieving this balance would be challenging in their future careers . Several essays noted that emotional distancing was a defense mechanism  and that imposter syndrome was closely related to issues of empathic conflict and burnout . Students identified the importance of patient narratives in the practice of medicine , and discussed the role these narratives may play in protecting the empathic wellbeing of medical students . Several essays also revealed how the near-peer blog posts exposed the students’ own internal empathic conflicts or conflicts they had personally witnessed in their interactions with other patients or clinicians, and how reflecting on those narratives allowed them to process their own emotions and empathy .in-Training bloggers’ descriptions of the subtle yet insidious ways that medical institutions discriminate against people of color, vulnerable populations, and marginalized cultures. The premedical students examined how their own implicit biases might influence the way that they would practice medicine in the future , and some advocated for coursework and training emphasizing the sociocultural dimensions of health and medicine . Others called attention to the need for institutional spaces and protocols better designed to serve diverse patient populations . Many students also took a broad, sociopolitical perspective on bias in healthcare, noting how systemic racism influences American medical practice, despite popular conceptions of medicine as an objective science .[T]he real issue isn’t the individuals who stick out for committing crimes of racism, but the system that made their implicit biases. This is a really important turning point in my own thoughts about this issue. ... [H]armful biases happen in everyday situations and though they aren’t as obvious, they matter and lead to statistically significant outcomes. (F17-4)The fact that physicians constantly marginalize certain races (whether they are aware of it or not) when practicing motivates me to become more conscious of these acts when I go into the professional field. (S17-25)Premedical students’ writings demonstrated nuanced comprehension of the ways in which bias, whether overt, implicit, or structural, is present in medicine and reflected in their own personal experiences of and beliefs about race, discrimination, structural racism, and social justice . Their essays commented on the in-Training blogger Jimmy Tam Huy Pham, refer to as the “human side of medicine” (2012). Their essays highlighted the professional importance of listening to the patient’s narrative and seeing patients as more than diseases to be cured . Premedical students reflected on their personal understanding of what makes a successful physician, focusing on the importance of open communication between doctors and patients, respecting patient’s wishes, understanding how patients live with medical conditions, and providing comfort and care to patients and their families . Several premedical students discussed aspects of medicine beyond the biomedical sciences that they recognized as critical to patient care, including social determinants of health , socioeconomic disparities, and barriers to accessing care . Some premedical students also used their essays to call for improvements in medical education, including increased training in addressing the inequalities that exist in both society and medicine .We come into the field very excited in hopes [of] getting involved with unique medical interventions and grandiose ideas. Yet, some of the most important and impactful work we will end up doing is simple[:] comforting of patients or working with them and their families to guarantee care, comfort, and respect of patients’ wishes. (S18-42)When I volunteered in an emergency room, I witnessed the casual way in which patients who complained of pain were dismissed. I did not have access to medical records, but one patient I particularly remember was an older black lady who was crying because she was in pain. She said nobody had performed an examination on her, and when I asked a nurse, she waved me off, saying, “You get an eye for figuring out who’s faking it for drugs.” I was alarmed by this, but assumed she was correct, as I had almost no power in the situation. Whether or not this old woman was addicted to painkillers, wasn’t it the duty of medical professionals to trust her and give her the benefit of the doubt? When filtering through the hundreds of patients who are turned away for being fakers, isn’t it possible that a couple of them were telling the truth? (F16-33)Premedical students reflected on the medical student blog posts by discussing the complexity of the patient-physician relationship and expressing appreciation for what they, borrowing the phrase from in-Training authors, the essays in our dataset frequently linked the value of the blog posts to their status as narratives authored by near-peers. Representative quotations on near-peer affinities are displayed in Table The fact that I felt emotionally involved […] is a testament to the value of narratives. Narratives from medical students are particularly relevant to us pre-meds, because we can easily imagine ourselves in their shoes a few years in the future. (S17-4)in-Training my initial reaction was surprise at their raw nature. Although each short story or poem had a clear central argument transmitted through the emotional perspective of the medical student author, they lacked the literary style and techniques I have come to expect. At first, I felt disappointed by this fact, feeling that the lack of polish took away from the worth of the selections. However, after just a couple narratives, I came to appreciate how intimate this informal style of writing can be. Since the stories are not excessively formulated or contrived, thoughts and emotions behind their writing are allowed to shine through. (F16-1)While reading the selections from Our narrative analysis of the premedical students’ reflective essays also revealed unprompted expressions of near-peer affinities. Although students had not been instructed to reflect on the near-peer status of the in-Training to be significant in two ways. First, the core themes identified in the premedical student essays demonstrate engagement with landmark topics in the humanities education of medical trainees: empathic conflict, bias in healthcare, and the humanity of medicine. Second, the students frequently discussed the medical student blog posts through the lens of self-reflection, closely identifying with the near-peer bloggers’ experiences and considering how they would respond to the same situations. While the first finding confirms our hypothesis regarding the utility of near-peer narratives for introducing core concepts in the medical humanities and fostering self-reflection on the professional demands of a career in medicine, the second was an unexpected finding that further confirms the pedagogical value of integrating near-peer blogs in an undergraduate premedical humanities course. Both findings highlight the importance of writing personal narratives as medical students and reading those narratives as premedical students.Our analysis found the student responses to the near-peer medical student narratives from Our analysis of the “near-peer affinities” present in undergraduate premedical students’ reflective writing suggests that near-peer narratives expose premedical students to varied perspectives, which serves to strengthen and broaden their personal experiences from clinical shadowing or volunteering. The integration of near-peer narrative may play a significant role in cultivating premedical students’ professional identities by attending to the demands of the profession and the social contexts in which medicine is practiced. Through their reflections on near-peer writings, these students enter medical school having developed an appreciation for the humanistic aspects of medicine and an ability to reflect on the role and duties of the physician in society. Structured engagement with near-peer writings in the undergraduate medical humanities curriculum, our research suggests, can be particularly influential in premedical students’ professional identity development because it provides those who are contemplating a career in medicine the opportunity to learn from the collective experiences of medical trainees.For educators, providing curricular material that is more easily relatable to undergraduates presents an obvious advantage in maximizing student engagement. However, this should be balanced with recognition of the novice nature of many near-peer pieces, as several study participants mentioned that the quality of the writing was at times inferior to the other reading assignments in the curriculum that were written by more experienced authors. At the same time, by demonstrating their ability to critique the quality and purpose of the medical student posts, premedical students in our study demonstrated their willingness and ability to engage in key discourses within the medical humanities.Our finding that many study participants wrote self-reflective essays on the topic of empathic conflict is an important outcome of this study and reveals that premedical students can discuss challenges with empathy and emotional distancing through the lens of narrative medicine in the same way as medical students. By engaging with near-peer blog posts, premedical students recognized their vulnerability to empathic conflict and the challenges with emotional distancing, and how this conflict may affect their connections with future patients and with their own personal wellbeing, issues that are well-represented in the literature on this subject . Students also recognized that reflecting on the narratives themselves was cathartic and instrumental in their own professional development. Our analysis further revealed that study participants discussed both the positive and negative effects of medical students’ empathic engagement with patients and their stories and included nuanced perspectives on the structural causes of burnout, including depersonalization and imposter syndrome. Self-reflective writing normalizes discussion of empathic conflicts, which has been shown to be critical for building resilience and combating burnout in health professionals . Our finding that premedical students were able to recognize burnout among their near-peers, despite not experiencing burnout themselves, may have important educational implications in allowing them to better recognize and prevent burnout in themselves in the future (Jennings 2009).The social construction of race, racial health disparities, and the persistent legacy of racism in United States health systems are frequently explored topics within health humanities research, and efforts toward racial justice within health professions education is rooted in the health humanities: ethics, medical sociology, and the history of medicine . Students’ essays exploring racial bias in medicine, socioeconomic disparities limiting access to healthcare, and the linguistic or cultural barriers that impact patient-provider communication provide compelling evidence that premedical students’ reflections on near-peer writing can effectively encourage a deeper awareness of these topics and the development of cultural competence as defined by the AAMC. The students in our study exhibited a significant willingness to engage with near-peer writings on these complex issues rather than avoiding recognition of medicine’s imperfections, evidence of their growing “structural competence” on issues of systemic racism, per Petty and colleagues (2017). In their essays, students further reflected on how near-peer narratives resonated with their own or their loved ones’ experiences with bias in a healthcare setting and considered how their own implicit biases might impact their ability to provide care for their patients. We find, therefore, that reflecting on near-peer narratives provides a productive space for undergraduate premedical students’ personal and professional development even before entering formal medical education, especially as it pertains to implicit bias and structural racism.Our analysis finds that near-peer narratives are an effective means of encouraging students to relate to their patients as people, and not just as constellations of symptoms to be cured. Entering medical students are asked to appreciate that an individual’s health and well-being are determined by the intersection of biological, social, cultural, and psychological factors. Premedical students often shadow physicians, volunteer in clinical settings, or work in ancillary services as emergency medical technicians or scribes to develop this understanding . Our findings show that near-peer written works can serve as an additional avenue for premedical students to reflect on their personal experiences with patients in a nascent form of narrative medicine. Students described the complex social and cultural narratives of the patients whom they had met in their premedical experiences, and how reading the near-peer pieces taught them to reflect more critically on their encounters with patients and on the structural issues within medicine and health care that contributed to these illness narratives. The premedical students in our study also reflected on how they personally would approach the patient-physician interactions and challenges described by their medical student near-peers, which is a key critical thinking skill required of medical professionals. Through their reflections, premedical students contemplated the role and duties of the physician in today’s society, and how they will approach the intersection of biomedical sciences and the “human side of medicine” as they enter the medical field.in-Training narratives, our analysis revealed frequent reflection on the authors’ status as near-peers. These commentaries included both positive responses to reading near-peer works as well as discussions that were more critical of the quality of novice writers. Near-peer narratives are, by the students’ own estimation, accessible, engaging, and impactful introductions to foundational topics in the medical humanities. Student reflections address the pleasure of near-peer learning through narratives that were written by trainees close in academic level and age to undergraduate premedical students. Thus, we find that near-peer narratives published in online, open-access venues (e.g. blogs) serve as a crucial introduction and complement to more traditional academic prose published in peer-reviewed venues  for premedical students.Although students were not explicitly instructed to comment on the authorship of the in-Training were chosen for their value in premedical health humanities education and therefore are not representative of all possible near-peer creative nonfiction narratives or blogs, which may not have equal value in achieving the results described in this study.This study has several limitations. Research was conducted in only one institution, and while the study population was racially and socioeconomically diverse, it may not be statistically representative of all premedical students across United States universities and colleges. As a qualitative analysis of an educational intervention, the study method did not include randomization or a comparator group, raising the possibility of selection bias among study participants. The students who participated in the study were enrolled in a medical humanities course and are not necessarily representative of the general population of premedical students. Finally, readings from in-Training readings thus underscores the value of this pedagogical method. This study finds that near-peer learning through engagement with creative nonfiction published on a medical student blog allows for critical reflection on medical education from the profession’s future leaders. The ability to use near-peer narratives to facilitate empathic learning, facilitate resilience, and address bias in medicine is an opportunity that warrants further study and integration into existing premedical educational curricula.This study identifies a novel pedagogical method for introducing core topics in the medical humanities through the integration of an online near-peer narrative medicine blog to augment traditional medical humanities teachings for premedical students. The premedical student essays analyzed in our study demonstrated nuanced engagement with three core themes – empathic conflict, bias in medicine, and the human side of medicine – as well as strong affinities with near-peer authors. Our results demonstrate how reading and writing about near-peer narrative accounts of medical training can provide a unique and valuable perspective on the impact of patient encounters, particularly those involving vulnerable and marginalized populations, as they shape professional identity formation for premedical and medical students. Our qualitative assessment of student responses to the


SUDs) presents a major opportunity for mouse genetics. Inbred mouse strains exhibit substantial and heritable differences in their responses to drugs of abuse (DOA) and in many of the behaviors associated with susceptibility to SUD. Therefore, genetic discoveries emerging from analysis of murine genetic models can provide critically needed insight into the neurobiological effects of DOA, and they can reveal how genetic factors affect susceptibility drug addiction. There are already indications, emerging from our prior analyses of murine genetic models of responses related to SUDs that mouse genetic models of SUD can provide actionable information, which can lead to new approaches for alleviating SUDs. Lastly, we consider the features of murine genetic models that enable causative genetic factors to be successfully identified; and the methodologies that facilitate genetic discovery.The tremendous public health problem created by substance use disorders ( We believe that the relationship between murine models and human diseases  resembles that between a small Cessna airplane and a large 787 jet plane. You can learn most of what you need to know about the fundamental principles of aviation by studying the Cessna, but this will not enable you to pilot the 787. The 787 has many more capabilities, much more complex and computer-controlled systems, and multiple redundancies that are essential for its function than are contained within a Cessna. Nevertheless, you wouldn't be able to pilot a 787 without knowing the aviation principals that are learned by studying the Cessna. Similarly, studying the mouse has revealed the basic principles underlying many areas of human physiology and pathobiology. Within the neurobiology realm, many of the mechanisms and circuits utilized for learning, memory, cognition, and the effects that drugs have on these processes have been uncovered through analysis of mouse models. However, since laboratory mice function within a very limited behavioral domain and lack some of the neural pathways that regulate human behavior, many of the complex factors mediating human psychiatric diseases cannot be understood by analyzing rodent models. The aviation analogy is quite appropriate for SUDs. Rodent models are ideal for understanding DOA neurobiology and for providing information about how drug seeking behaviors are generated; but they provide a very poor substrate for investigating the impact of that socioeconomic and psychosocial factors have on triggering relapse. This is an important limitation since human drug addiction proceeds through a three-stage cycle whose intensity increases over time, and each stage results from DOA-induced changes in brain circuits –3. The fHere, we examine what we have learned from our prior analyses of murine genetic models of responses related to SUD. First, we discuss a murine genetic model of a drug-induced toxicity to indicate the different types of genetic factors that can be identified. We then we review the genetic factors identified from our prior analyses of murine genetic models of opiate responses. Lastly, we consider the features of murine models that enable causative genetic factors to be successfully identified; and the methodologies that can facilitate genetic discovery.(Abcb5) that caused susceptible strains to have higher brain haloperidol levels; and a genetic association study in a haloperidol-treated human cohort identified human ABCB5 alleles as susceptibility determinants for HIT  that impaired the biosynthesis of a protective metabolite (cysteamine)  CNS toxicity illustrates the potential outcomes that could emerge when evaluating murine genetic models of SUD because drug addiction (in many ways) is a toxicity caused by DOAs. Although haloperidol is an effective anti-psychotic agent, it causes a treatment-limiting side effect in most treated subjects, which is very debilitating Parkinsonian-like extrapyramidal symptoms. When we began our studies of haloperidol induced toxicity (HIT), genetic susceptibility factors for this toxicity were completely unknown. Therefore, we analyzed a murine genetic model of HIT where the inbred strains exhibited very large and reproducible differences in susceptibility to HIT. Our analysis revealed that susceptibility was quantitatively determined by two distinct genetic loci: one encoded a pharmacokinetic factor and the other a pharmacodynamic factor. The pharmacokinetic factor was allelic variation within a murine ABC-drug efflux transporter Abcb that cauteamine) . While dAbcb that cauteamine) . Thus, aLike haloperidol, murine opiate response models hold great promise for genetic discovery. The inbred strains exhibit very large and heritable differences in their responses to opiates, which include the development of opioid analgesia, tolerance, dependence, and hyperalgesia –10. We pInbred strains also exhibit substantial and heritable differences in their cocaine responses, which include the extent of cocaine-induced locomotor activation , 29, cocP-glycoprotein transporter (Abcb1b) contributed to inter-strain differences in this opiate response  as a genetic locus contributing to the inter-strain response difference. This response was markedly diminished in Adrb2 knockout mice and was reversed by administration of a commonly used Adrb2 antagonist, which suggested a novel strategy for reducing OIH (Netrin-1 receptor (Dcc) (multi-PDZ-domain protein (Mpdz that encodes MUPP1)  was analyzed, we discovered that genetic variation within the response . Analysicing OIH . We alsoor (Dcc)  and mults MUPP1)  also condcc encodes a receptor for an axonal guidance protein (netrin-1) that plays a role in synaptic plasticity in the adult brain  reduced NPOW [and opioid-induced hyperalgesia (OIH)] in a dose-dependent fashion; and ondansetron co-administration with morphine impaired the mCPP response, which indicated that ondansetron eliminated the reinforcing effects of morphine (p = 0.03) in the NPOW in the volunteers, and it decreased all 11 of the measured manifestations of opiate withdrawal. Since the ondansetron effect observed in mice translated to humans, it is likely of fundamental importance. In a separate study  also prevented NPOW symptoms in normal human subjects and that a pretreatment that combined palonosetron with a commonly used antihistamine (hydroxyzine) caused a 95% reduction (p = 0.014) in withdrawal manifestations. The effect of the combination pretreatment was significant even when compared with that of palonosetron alone (p = 0.012)  response after 4 days of morphine administration in 18 inbred strains . Allelicresponse . Consistmorphine . Thus, ote study , we demo= 0.012) . These rneonates , we are neonates , 62. Thi> 15) of inbred strains. When a small number of strains are evaluated, the actual extent of the phenotypic variation present in the mouse population is under-estimated  methods are used for their analysis. (i) The DOA response must be measured across a large number  Sistimated , 68; thestimated  and Collstimated  panels , can be analyzed to facilitate identification of causative genetic factors.While many different methods can be used to analyze GWAS data obtained from inbred stains, we have successfully used haplotype based computational genetic mapping (HBCGM) to identify murine genetic factors underlying 22 biomedical traits , 75–90. hijack” the neural circuits used for learning and memory  to GP.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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