Decoding the Reference Letter: Strategies to Reduce Unintentional Gender Bias in Letters of Recommendation.

Introduction: There is a growing body of literature on gender bias in letters of recommendation (LORs) in academic medicine and the negative effect of bias on promotion and career advancement. Thus, increasing knowledge about gender bias and developing skills to mitigate it is important for advancing gender equity in medicine. This workshop aims to provide participants with knowledge about linguistic bias (focused on gender), how to recognize it, and strategies to apply to mitigate it when writing LORs. Methods: We developed an interactive 60-minute workshop for faculty and graduate medical education program directors consisting of didactics, reflection exercises, and group activities. We used a postworkshop survey to evaluate the effectiveness of the workshop. Descriptive statistics were used to analyze Likert-scale questions and a thematic content analysis for open-ended prompts. Results: We presented the workshop four times (two local and two national conferences) with one in-person and one virtual format for each. There were 50 participants who completed a postworkshop survey out of 74 total participants (68% response rate). Ninety-nine percent of participants felt the workshop met its educational objectives, and 100% felt it was a valuable use of their time. Major themes described for intended behavior change included utilization of the gender bias calculator, mindful use and balance of agentic versus communal traits, closer attention to letter length, and dissemination of this knowledge to colleagues. Discussion: This workshop was an effective method for helping participants recognize gender bias when writing LORs and learn strategies to mitigate it.

High Variability in the Duration of Chest Compression Interruption is Associated With Poor Outcomes in Pediatric Extracorporeal Cardiopulmonary Resuscitation.

OBJECTIVES: To determine the association between chest compression interruption (CCI) patterns and outcomes in pediatric patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR). DESIGN: Cardiopulmonary resuscitation (CPR) data were collected using defibrillator-electrode and bedside monitor waveforms from pediatric ECPR cases between 2013 and 2021. Duration and variability of CCI during cannulation for ECPR was determined and compared with survival to discharge using Fishers exact test and logistic regressions with cluster-robust se s for adjusted analyses. SETTING: Quaternary care children's hospital. PATIENTS: Pediatric patients undergoing ECPR. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 41 ECPR events, median age was 0.7 years (Q1, Q3: 0.1, 5.4), 37% (15/41) survived to hospital discharge with 73% (11/15) of survivors having a favorable neurologic outcome. Median duration of CPR from start of ECPR cannulation procedure to initiation of extracorporeal membrane oxygenation (ECMO) flow was 21 minutes (18, 30). Median duration of no-flow times associated with CCI during ECMO cannulation was 11 seconds (5, 28). Following planned adjustment for known confounders, survival to discharge was inversely associated with maximum duration of CCI (odds ratio [OR] 0.91 [0.86-0.95], p = 0.04) as well as the variability in the CCI duration (OR 0.96 [0.93-0.99], p = 0.04). Cases with both above-average CCI duration and higher CCI variability ( sd > 30 s) were associated with lowest survival (12% vs. 54%, p = 0.009). Interaction modeling suggests that lower variability in CCI is associated with improved survival, especially in cases where average CCI durations are higher. CONCLUSIONS: Shorter duration of CCI and lower variability in CCI during cannulation for ECPR were associated with survival following refractory pediatric cardiac arrest.

Infant in extremis: respiratory failure secondary to lower airway infantile hemangioma.

BACKGROUND: Infantile hemangiomas (IHs) are vascular tumors that commonly affect infants and usually regress spontaneously or can be easily treated as an outpatient with topical beta-blockers. However, IHs that present in the airway may cause life-threatening symptoms due to airway obstruction or risk of bleeding. Here we present the first documented case of an infant with rapid deterioration and acute respiratory failure secondary to a lower airway hemangioma. CASE PRESENTATION: This 3-month-old male initially presented in respiratory distress with symptoms consistent with a viral respiratory infection, however showed no clinical improvement with standard therapies. An urgent CT scan revealed a mass occluding the right mainstem bronchus. Upon transfer to a tertiary care facility, he developed acute respiratory failure requiring emergent intubation and single lung ventilation. The availability of multiple subspecialists allowed for stabilization of a critically ill child, expedited diagnosis, and ultimately initiation of life-saving treatment with beta blockers. After 17 total hospital days, he was extubated successfully and discharged home in good condition. CONCLUSIONS: While IH is a rare cause of infantile respiratory distress, we present multiple pearls for the general pediatrician for management of IHs of the airway.

A Scoping Review and Appraisal of Extracorporeal Membrane Oxygenation Education Literature.

Background: Despite a recent rise in publications describing extracorporeal membrane oxygenation (ECMO) education, the scope and quality of ECMO educational research and curricular assessments have not previously been evaluated. Objective: The purposes of this study are 1) to categorize published ECMO educational scholarship according to Bloom's educational domains, learner groups, and content delivery methods; 2) to assess ECMO educational scholarship quality; and 3) to identify areas of focus for future curricular development and educational research. Methods: A multidisciplinary research team conducted a scoping review of ECMO literature published between January 2009 and October 2021 using established frameworks. The Medical Education Research Study Quality Instrument (MERSQI) was applied to assess quality. Results: A total of 1,028 references were retrieved; 36 were selected for review. ECMO education studies frequently targeted the cognitive domain (78%), with 17% of studies targeting the psychomotor domain alone and 33% of studies targeting combinations of the cognitive, psychomotor, and affective domains. Thirty-three studies qualified for MERSQI scoring, with a median score of 11 (interquartile range, 4; possible range, 5-18). Simulation-based training was used in 97%, with 50% of studies targeting physicians and one other discipline. Conclusion: ECMO education frequently incorporates simulation and spans all domains of Bloom's taxonomy. Overall, MERSQI scores for ECMO education studies are similar to those for other simulation-based medical education studies. However, developing assessment tools with multisource validity evidence and conducting multienvironment studies would strengthen future work. The creation of a collaborative ECMO educational network would increase standardization and reproducibility in ECMO training, ultimately improving patient outcomes.

Maintaining Social Distancing: Video and Just-in-Time In Situ Simulation During the COVID-19 Pandemic.

SUMMARY STATEMENT: Respiratory failure and cardiopulmonary arrest in patients with SARS-CoV-2 infection require life-saving procedures that aerosolize virus and increase risk of transmission. To educate faculty, trainees, and staff on safe practices, a video with embedded questions was created demonstrating intubation and cardiopulmonary resuscitation in pediatric SARS-CoV-2+ patients. Just-in-time in situ simulations of these scenarios were also carried out while adhering to isolation and social distancing protocols. We demonstrated that use of simulation to train physicians and staff during the COVID-19 pandemic is possible and effective in improving confidence in performance of the procedures.

Evaluation of Three Postal Invitational Strategies to Increase Survey Response Rates in a Combat-Injured U.S. Military Population: Findings From the Wounded Warrior Recovery Project.

The survival rate of those injured in combat in overseas contingency operations is higher than in previous conflicts. There is a need to assess the long-term psychosocial and quality of life outcomes of those injured in combat, yet surveying this population presents inherent challenges. As part of a large-scale, longitudinal examination of patient-reported outcomes of service members injured on deployment, the present manuscript evaluated the effectiveness of three postal strategies on response rates: (1) mailing a study prenotification postcard, (2) mailing the survey invitation in a larger envelope, and (3) including a small cash preincentive ($2). Evaluation of these strategies yielded mixed results in this population. Neither the prenotification postcard nor inclusion of a $2 cash preincentive significantly increased response rates. However, use of a larger envelope to mail the survey invitation significantly increased the response rate by 53.1%. Researchers interested in collecting patient-reported outcomes among military populations, including those with combat-related injuries, may find that increasing the visibility of recruitment materials is more effective for improving response rates than attempting to cognitively prime or offer prospective participants preincentives.

Preliminary study of hearing protection and non-impact, blast-induced concussion in US military personnel.

PRIMARY OBJECTIVE: To examine the relationship between hearing protection and non-impact, blast-induced concussion in US military personnel. RESEARCH DESIGN: Retrospective cohort study. METHODS AND PROCEDURES: A total of 501 US service members from the Expeditionary Medical Encounter Database with hearing protection status reported either 'worn' or 'not worn' were eligible for analysis. Clinical records were reviewed for concussion diagnoses. Univariate and multiple logistic regressions were performed. MAIN OUTCOMES AND RESULTS: Overall, 270 (53.9%) service members sustained non-impact, blast-induced concussion and 231 (46.1%) sustained other blast injuries. Only 39.6% (107 of 270) of service members with concussion wore hearing protection at the point of injury compared with 61.0% (141 of 231) of those with other injuries (p < 0.001). After adjusting for covariates, service members wearing hearing protection had significantly lower odds of concussion compared with those not wearing hearing protection (odds ratio = 0.42, 95% confidence interval = 0.29-0.62). CONCLUSIONS: To our knowledge, this preliminary study is the first to demonstrate that hearing protection is associated with lower odds of non-impact, blast-induced concussion. The benefits of using hearing protection in terms of force readiness could be significant since many service members wounded in recent conflicts were diagnosed with concussion.

Tympanoplasty following Blast Injury.

Objectives To assess outcomes following tympanoplasty for blast-induced tympanic membrane perforations in a military population. Study Design Case series with chart review. Setting Tertiary care medical centers. Subjects and Methods Military personnel (N = 254) undergoing tympanoplasty for blast-related tympanic membrane perforations sustained between April 2005 and July 2014 were identified from the Expeditionary Medical Encounter Database. Descriptive statistics were obtained regarding demographics, primary and revision surgery success rates, hearing status pre- and postsurgery, and frequency of ossicular reconstruction. Rates of successful perforation closure were assessed against perforation size and character (central vs marginal) and time to surgery. Rates and types of complications were additionally explored. Results There were a total of 352 operations among 254 subjects, with an 82.1% rate of successful closure following primary surgery. For successful primary tympanoplasty, the mean improvement in pure tone average was 11.7 ± 12.1 dB. Ossiculoplasty was performed in 9.1% (32 of 352) of cases. There was no significant relationship between successful perforation closure and perforation size, perforation character, or time between injury and surgery. Cholesteatoma complicated 4.3% (15 of 352) of cases. A significant relationship was identified between risk of cholesteatoma development and increasing perforation size and marginal perforations. Conclusion Tympanoplasty success rates for blast-induced tympanic membrane perforations are lower than for other common injury mechanisms. Due to appreciable rates of postoperative cholesteatoma development, close clinical surveillance is recommended.

mTOR Inhibition by Everolimus Does Not Impair Closure of Punch Biopsy Wounds in Renal Transplant Patients.

BACKGROUND: Mammalian target of rapamycin (mTOR) inhibitors are approved to prevent allograft rejection and control malignancy. Unfortunately, they are associated with adverse effects, such as wound healing complications that detract from more extensive use. There is a lack of prospective wound healing studies to monitor patients treated with mTOR inhibitors, such as everolimus or sirolimus, especially in nondiabetics. METHODS: Patients receiving everolimus with standard immunosuppressant therapy or standard immunosuppressant therapy without everolimus were administered 3-mm skin biopsy punch wounds in the left scapular region. Homeostatic gene expression was examined in the skin obtained from the biopsy and wound surface area was examined on day 7. Peripheral blood mononuclear cells were examined for cytokine production. RESULTS: There are no significant changes in autophagy related 13, epidermal growth factor, insulin-like growth factor binding protein 3, IL-2, kruppel-like factor 4, and TGFB1 gene expression in the skin suggesting that there is little impact of everolimus on these genes within nonwounded skin. Peripheral blood T cells are more sensitive to cell death in everolimus-treated patients, but they retain the ability to produce proinflammatory cytokines required for efficient wound repair. Importantly, there is no delay in the closure of biopsy wounds in patients receiving everolimus as compared to those not receiving mTOR inhibition. CONCLUSIONS: Everolimus treatment is not associated with impaired closure of skin biopsy wounds in kidney transplant recipients. These data highlight the importance of exploring whether larger surgical wounds would show a similar result and how other factors, such as diabetes, impact wound healing complications associated with mTOR suppression.

Bilateral Dilated Nonreactive Pupils in a Neonate After Surgery.

Fixed and dilated pupils are disturbing when encountered during a physical examination in the pediatric intensive care unit, particularly when sedation or neuromuscular blockade confounds the neurologic examination. Rocuronium, a nondepolarizing neuromuscular drug, does not cross the blood-brain barrier and is not considered a causative agent for fixed mydriasis. We report a case of bilateral fixed and dilated pupils in a 1-week-old low-birth-weight neonate, which we contend was secondary to centrally mediated neuromuscular blockade.

Post-traumatic Stress Disorder Among Navy Health Care Personnel Following Combat Deployment.

U.S. Navy health care personnel are exposed to an array of psychological stressors during combat deployment. This study compared rates of post-traumatic stress disorder (PTSD) among Navy health care personnel with nonhealth care personnel following single and repeated combat deployments. The study sample was identified from electronic records indicating deployment to Iraq, Kuwait, or Afghanistan, and included 3,416 heath care and 4,648 nonhealth care personnel. Health care personnel had higher PTSD rates and an increasing trend in PTSD rates across repeated deployments. After adjusting for combat exposure and other covariates, health care compared with nonhealth care personnel were more likely to be diagnosed with PTSD after one (odds ratio [OR] 2.02; 95% confidence interval [CI] 1.45-2.80), two (OR 2.27; 95% CI 1.26-4.08), and three deployments (OR 4.37; 95% CI 1.25-15.28). Exposure to wounded/dead friendly forces was associated with higher PTSD rates in health care personnel (OR 1.53; 95% CI 1.13-2.07). Health care personnel occupy a unique and essential role in current wartime operations, and are a high-risk group for PTSD. These findings suggest that further research is needed on the effects of caregiver stress, and refinements to postdeployment screening for health care personnel should be pursued.

Airway Management in Severe Combat Maxillofacial Trauma.

OBJECTIVES: Airway stabilization is critical in combat maxillofacial injury as normal anatomical landmarks can be obscured. The study objective was to characterize the epidemiology of airway management in maxillofacial trauma. STUDY DESIGN: Retrospective database analysis. SETTING: Military treatment facilities in Iraq and Afghanistan and stateside tertiary care centers. SUBJECTS: In total, 1345 military personnel with combat-related maxillofacial injuries sustained March 2004 to August 2010 were identified from the Expeditionary Medical Encounter Database using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. METHODS: Descriptive statistics, including basic demographics, injury severity, associated injuries, and airway interventions, were collected. A logistic regression was performed to determine factors associated with the need for tracheostomy. RESULTS: A total of 239 severe maxillofacial injuries were identified. The most common mechanism of injury was improvised explosive devices (66%), followed by gunshot wounds (8%), mortars (5%), and landmines (4%). Of the subjects, 51.4% required intubation on their initial presentation. Of tracheostomies, 30.4% were performed on initial presentation. Of those who underwent bronchoscopy, 65.2% had airway inhalation injury. There was a significant relationship between the presence of head and neck burn and association with airway inhalation injury (P < .0001). There was also a significant relationship between the severity of facial injury and the need for intubation (P = .002), as well as the presence of maxillofacial fracture and the need for tracheostomy (P = .0001). CONCLUSIONS: There is a high incidence of airway injury in combat maxillofacial trauma, which may be underestimated. Airway management in this population requires a high degree of suspicion and low threshold for airway stabilization.

Characteristics of maxillofacial injuries and safety of in-theater facial fracture repair in severe combat trauma.

The study objectives were to characterize maxillofacial injuries and assess the safety of in-theater facial fracture repair in U.S. military personnel with severe combat trauma from Iraq and Afghanistan. We performed a retrospective chart review of the Expeditionary Medical Encounter Database from 2004 to 2010. 1,345 military personnel with combat-related maxillofacial injuries were identified. Injury severity was quantified with the Abbreviated Injury Scale and Injury Severity Score. Service members with maxillofacial injury and severe combat trauma (Injury Severity Score ≥ 16) were included. The distribution of facial fractures, types, and outcomes of surgical repairs, incidence of traumatic brain injury, concomitant head and neck injuries, burn rate/severity, and rates of Acinetobacter baumannii colonization and surgical site infection were analyzed. The prevalence of maxillofacial injury in the Expeditionary Medical Encounter Database was 22.7%. The most common mechanism of injury was improvised explosive device (65.7%). Midface trauma and facial burns were common. Approximately 64% of the study sample sustained traumatic brain injury. Overall, 45.6% (109/239) had at least one facial bone fracture. Of those with facial fractures, 64.2% (n = 70) underwent surgical repair. None of the service members who underwent in-theater facial fracture repair developed A. baumannii facial wound infection or implant extrusion.

Obesity impairs γδ T cell homeostasis and antiviral function in humans.

Obese patients are susceptible to increased morbidity and mortality associated with infectious diseases such as influenza A virus. γδ T cells and memory αß T cells play key roles in reducing viral load by rapidly producing IFN-γ and lysing infected cells. In this article we analyze the impact of obesity on T lymphocyte antiviral immunity. Obese donors exhibit a reduction in γδ T cells in the peripheral blood. The severity of obesity negatively correlates with the number of γδ T cells. The remaining γδ T cells have a skewed maturation similar to that observed in aged populations. This skewed γδ T cell population exhibits a blunted antiviral IFN-γ response. Full γδ T cell function can be restored by potent stimulation with 1-Hydroxy-2-methyl-buten-4yl 4-diphosphate (HDMAPP), suggesting that γδ T cells retain the ability to produce IFN-γ. Additionally, γδ T cells from obese donors have reduced levels of IL-2Rα. IL-2 is able to restore γδ T cell antiviral cytokine production, which suggests that γδ T cells lack key T cell specific growth factor signals. These studies make the novel finding that the γδ T cell antiviral immune response to influenza is compromised by obesity. This has important implications for the development of therapeutic strategies to improve vaccination and antiviral responses in obese patients.

Glasgow Coma Scale scores, early opioids, and 4-year psychological outcomes among combat amputees.

Morphine and fentanyl are frequently used for analgesia after trauma, but there is debate over the advantages and disadvantages of these opioids. Among combat amputees, intravenous (IV) morphine (vs IV fentanyl) after injury was associated with reduced likelihood of posttraumatic stress disorder (PTSD). The previous results were based on military health diagnoses over 2 yr postinjury. The present study followed psychological diagnoses of patients with amputation for 4 yr using military and Department of Veterans Affairs health data. In-theater combat casualty records (n = 145) documented Glasgow Coma Scale (GCS) scores and/or morphine, fentanyl, or no opioid treatment within hours of injury. We found that (1) GCS scores were not significantly associated with PTSD; (2) longitudinal modeling using four (yearly) time points showed significantly reduced odds of PTSD for patients treated with morphine (vs fentanyl) across years (adjusted odds ratio = 0.40; 95% confidence interval = 0.17­0.94); (3) reduced PTSD prevalence for morphine (vs IV fentanyl; morphine = 25%, fentanyl = 59%, p < 0.05) was significant, specifically among patients with traumatic brain injury during the first 2 yr postinjury; and (4) PTSD prevalence, but not other disorders (e.g., mood), increased between year 1 (PTSD = 18%) and years 2 through 4 postinjury (PTSD range = 30%­32%).

Dwell time and psychological screening outcomes among military service members with multiple combat deployments.

Recent studies have found that longer dwell times, or the period of time between deployments, may be protective against combat-related psychological outcomes. The purpose of this study was to examine the association between dwell time and psychological morbidity, while accounting for combat exposure. U.S. Marines with two combat deployments between 2005 and 2008 were identified from electronic deployment records. Those who screened positive for post-traumatic stress disorder and depression, and who were referred for mental health services were identified from the Post-Deployment Health Assessment. For the final study sample of 3,512 Marines, dwell time was calculated as time between deployments, and was analyzed as a ratio over length of first deployment. After adjustment for all covariates, there was an interaction (p = 0.01) between dwell time and combat exposure on mental health referral outcome. For personnel with maximum reported combat exposure, longer dwell times were associated with a 49% to 92% reduced odds of mental health referral. Longer dwell times may be protective against combat-related psychological outcomes. Because multiple deployments are likely to be the norm in future military operations, regulating dwell time, particularly for those with greater risk of combat exposure, should continue to be explored.

A study protocol for tracking quality of life among U.S. service members wounded in Iraq and Afghanistan: the Wounded Warrior Recovery Project.

There is a need for more work to understand the quality of life (QOL) outcomes of survivors of Operations Enduring Freedom and Iraqi Freedom combat injury to improve care and treatment, and prevent poor physical, psychological, and social outcomes. We describe the study design and methods of the Wounded Warrior Recovery Project, a study supported by the Department of Defense that will track close to 10,000 military personnel wounded in Operations Enduring Freedom and Iraqi Freedom. The overall objective of the 6-year longitudinal study is to track changes in QOL and describe variations in those changes as they relate to sociodemographic factors, injury characteristics, service-related factors, clinical/diagnostic measures including traumatic brain injury and posttraumatic stress disorder, and medical procedures and services. The Wounded Warrior Recovery Project study will be among the first longitudinal population-based investigations of QOL outcomes after combat injury and will provide a basis upon which large-scale epidemiological studies can be conducted.

Blast-related ear injuries among U.S. military personnel.

Blast-related ear injuries are a concern during deployment because they can compromise a servicemember's situational awareness and adversely affect operational readiness. The objectives of this study were to describe blast-related ear injuries during Operation Iraqi Freedom, identify the effect of hearing protection worn at the point of injury, and explore hearing loss and tinnitus outcomes within one year after injury. The Expeditionary Medical Encounter Database was used to identify military personnel who survived blast-related injury, and it was linked with outpatient medical databases to obtain diagnoses of hearing loss and tinnitus. The prevalence of ear injuries was 30.7% (1,223 of 3,981). The most common ear injury diagnoses were "inner or middle ear injury involving tinnitus" and tympanic membrane (TM) rupture. Hearing protection reduced the odds of ear injury involving tinnitus. Personnel with TM rupture had higher odds of hearing loss (odds ratio [OR] = 6.65, 95% confidence interval [CI] = 5.04-8.78) and tinnitus outcomes (OR = 4.34, 95% CI = 3.12-6.04) than those without TM rupture. Ear injuries and hearing impairment are frequent consequences of blast exposure during combat deployment. Hearing protection is warranted for all servicemembers at risk of blast exposure.