Surgeon Understanding and Perceptions of Social Determinants of Health.

INTRODUCTION: Social determinants of health impact surgical outcomes. Characterization of surgeon understanding of social determinants of health is necessary prior to implementation of interventions to address patient needs. The study objective was to explore understanding, perceived importance, and practices regarding social determinants of health among surgeons. METHODS: Surgical residents and attending surgeons at a single academic medical center completed surveys regarding social determinants of health. We conducted semi-structured interviews to further explore understanding and perceived importance. A conceptual framework from the World Health Organization (WHO) Commission on Social Determinants of Health informed the thematic analysis. RESULTS: Survey response rate was 47.9% (n = 69, 44 residents [63.8%], 25 attendings [36.2%]). Respondents primarily reported good (n = 29, 42.0%) understanding of social determinants of health and perceived this understanding to be very important (n = 42, 60.9%). Documentation occurred seldom (n = 35, 50.7%), and referrals occurred seldom (n = 26, 37.7%) or never (n = 20, 29.0%). Residents reported a higher rate of prior training than attendings (95.5% versus 56.0%, P < 0.001). Ten interviews were conducted (six residents, four attendings). Residents demonstrated greater understanding of socioeconomic positions and hierarchies shaped by structural mechanisms than attendings. Both residents and attendings demonstrated understanding of intermediary determinants of health status and linked social determinants to impacting patients' health and well-being. Specific knowledge gaps were identified regarding underlying structural mechanisms including the social, economic, and political context that influence an individual's socioeconomic position. CONCLUSIONS: Self-reported understanding and importance of social determinants of health among surgeons were high. Interviews revealed gaps in understanding that may contribute to limited practices.

Disparities in Utilization of Same-Day Discharge Following Appendectomy in Children.

INTRODUCTION: Disparities in the delivery of pediatric surgical care exist for racial and ethnic minority groups. Utilization of same-day discharge (SDD) following appendectomy for acute, uncomplicated appendicitis is increasing; however, rates among diverse populations have not been explored to evaluate equitable care delivery and healthcare utilization. Our objective was to determine whether race and ethnicity are associated with rates of SDD and postdischarge healthcare utilization. We hypothesized that racial and ethnic minority groups would have lower rates of SDD. METHODS: This retrospective cohort study used data from the 2015-2019 American College of Surgeons National Surgical Quality Improvement Program-Pediatric clinical registry and included children who underwent appendectomy. Patients with complicated appendicitis were excluded. Primary exposure was racial or ethnic group. The primary outcome was SDD, and secondary outcomes included postdischarge emergency department visits and hospital readmissions. RESULTS: Of 37,579 simple appendicitis patients, SDD after appendectomy occurred in 10,012 (26.6%). On multivariable analysis, Black or African American race was associated with lower likelihood of SDD (adjusted odds ratio [aOR]: 0.85; 95% confidence interval [95% CI]:0.79-0.92; P < 0.0001). Hispanic ethnicity was associated with higher likelihood of SDD (aOR: 1.19; 95% CI: 1.12-1.25; P < 0.0001). Likelihood of postoperative emergency department visits was higher in Black or African American patients (aOR: 1.36; 95% CI: 1.14-1.62; P < 0.001) and Hispanic patients (aOR: 1.37; 95% CI: 1.12-1.58; P < 0.0001). Hospital readmission rates were similar across groups. CONCLUSIONS: Rates of SDD following appendectomy vary among racial and ethnic groups. Interventions to achieve equitable healthcare delivery including SDD after appendectomy are needed.

Effects of race and test preparation resources on standardized test scores, a pilot study.

BACKGROUND: Little research exists on the relationship between pre-examination resources, race, and standardized test outcomes. This study aimed to determine the effect of test preparation resources and race on test scores. METHODS: We surveyed medical students at an allopathic institution on the use of test preparation materials and their test scores. Students were grouped by self-identified race. Underrepresented in Medicine (URiM) students were defined as Black/African American (AA), Hispanic/Latino (HL), Native American (NA) and multiple races. Univariate analysis and linear regression were used for statistical analysis. RESULTS: 192 students completed the survey (response rate = 33%). URiM students reported more MCAT attempts than other students. No differences between scores existed between races. There was no association between scores and the use of test preparation resources. CONCLUSIONS: We found that URiM students took the MCAT more times than their peers; however, we found no racial/ethnic differences in examination preparation resources or scores.

Differential Gene Expression and Withanolides Biosynthesis During in vitro and ex vitro Growth of Withania somnifera (L.) Dunal.

Ashwagandha (Withania somnifera L. Dunal) is a medicinally important plant with withanolides as its major bioactive compounds, abundant in the roots and leaves. We examined the influence of plant growth regulators (PGRs) on direct organogenesis, adventitious root development, withanolide biosynthetic pathway gene expression, withanolide contents, and metabolites during vegetative and reproductive growth phases under in vitro and ex vitro conditions. The highest shooting responses were observed with 6-benzylaminopurine (BAP) (2.0 mg L-1) + Kinetin (KIN) (1.5 mg L-1) supplementation. Furthermore, BAP (2.0 mg L-1) + KIN (1.5 mg L-1) + gibberellic acid (GA3) (0.5 mg L-1) exhibited better elongation responses with in vitro flowering. Half-strength MS medium with indole-3-butyric acid (IBA) (1.5 mg L-1) exhibited the highest rooting responses and IBA (1.0 mg L-1) with highest fruits, and overall biomass. Higher contents of withaferin A (WFA) [∼8.2 mg g-1 dry weight (DW)] were detected in the reproductive phase, whereas substantially lower WFA contents (∼1.10 mg g-1 DW) were detected in the vegetative phase. Cycloartenol synthase (CAS) (P = 0.0025), sterol methyltransferase (SMT) (P = 0.0059), and 1-deoxy-D-xylulose-5-phosphate reductase (DXR) (P = 0.0375) genes resulted in a significant fold change in expression during the reproductive phase. The liquid chromatography-mass spectrometry (LC-MS) analysis revealed metabolites that were common (177) and distinct in reproductive (218) and vegetative (167) phases. Adventitious roots cultured using varying concentrations of indole-3-acetic acid (IAA) (0.5 mg L-1) + IBA (1.0 mg L-1) + GA3 (0.2 mg L-1) exhibited the highest biomass, and IAA (0.5 mg L-1) + IBA (1.0 mg L-1) exhibited the highest withanolides content. Overall, our findings demonstrate the peculiarity of withanolide biosynthesis during distinct growth phases, which is relevant for the large-scale production of withanolides.

Why the Utilization of Ready-to-Administer Syringes During High-Stress Situations Is More Important Than Ever.

The COVID-19 pandemic has led to a high-stress environment causing a significant impact on frontline workers, including pharmacists and nurses. In addition to the increased workload, scarcity of resources, and emotional challenges, the frontline health care workers are required to wear additional personal protective equipment that can further limit their range of movement and decrease efficiency. The potential for errors can increase in these types of high-stress situations. One way to reduce the risk of errors is to use manufacturer-prepared, ready-to-administer (RTA) prefilled syringes, when appropriate. The use of RTA prefilled syringes is supported by literature evidence, recommendations, and guidelines from various professional organizations and societies.

Neural mechanisms of contextual modulation in the retinal direction selective circuit.

Contextual modulation of neuronal responses by surrounding environments is a fundamental attribute of sensory processing. In the mammalian retina, responses of On-Off direction selective ganglion cells (DSGCs) are modulated by motion contexts. However, the underlying mechanisms are unknown. Here, we show that posterior-preferring DSGCs (pDSGCs) are sensitive to discontinuities of moving contours owing to contextually modulated cholinergic excitation from starburst amacrine cells (SACs). Using a combination of synapse-specific genetic manipulations, patch clamp electrophysiology and connectomic analysis, we identified distinct circuit motifs upstream of On and Off SACs that are required for the contextual modulation of pDSGC activity for bright and dark contrasts. Furthermore, our results reveal a class of wide-field amacrine cells (WACs) with straight, unbranching dendrites that function as "continuity detectors" of moving contours. Therefore, divergent circuit motifs in the On and Off pathways extend the information encoding of On-Off DSGCs beyond their direction selectivity during complex stimuli.

Complications in low-risk older adult trauma patients: A case-control study.

BACKGROUND: Although some geriatric trauma patients may be at low risk of complications, poor outcomes are pronounced if complications do occur. Prevention in this group decreases the risk of excess morbidity and mortality. METHODS: We performed a case-control study of trauma patients 65 years or older treated from January 2015 to August 2016 at a Level I trauma center with a Trauma Quality Improvement Program-predicted probability of complication of less than 20%. Cases had one of the following complications: unplanned admission to the intensive care unit (ICU), unplanned intubation, pneumonia, or unplanned return to the operating room. Two age-matched controls were randomly selected for each case. We collected information on comorbidities, home medications, and early medical care and calculated odds ratios using multivariable conditional logistic regression. RESULTS: Ninety-four patients experienced unplanned admission to ICU (n = 51), unplanned intubation (n = 14), pneumonia (n = 21), and unplanned return to the operating room (n = 8). The 188 controls were more frequently intubated and had higher median ISS but were otherwise similar to cases. The adjusted odds of complication were higher for patients on a home ß-blocker (adjusted odds ratio [aOR], 2.2; 95% confidence interval [CI], 1.2-4.0) and home anticoagulation (aOR, 2.2; 95% CI, 1.2-4.1). Patients with diabetes (aOR 2.0; 95% CI, 1.1-3.7) and dementia (aOR, 2.0; 95% CI, 1.0-4.3) also had higher odds of complication. The adjusted odds of complication for patients receiving geriatrics consultation was 0.4 (95% CI, 0.2-1.0; p = 0.05). Pain service consultation and indwelling pain catheter placement may be protective, but CIs included 1. There was no association between opiates, benzodiazepines, fluid administration, or blood products in the first 24 hours and odds of complication. CONCLUSIONS: Geriatrics consultation was associated with lower odds of unplanned admission to the ICU, unplanned intubation, pneumonia, and unplanned return to the operating room in low-risk older adult trauma patients. Pathways that support expanding comanagement strategies with geriatricians are needed. LEVEL OF EVIDENCE: Therapeutic/Care management, Level IV.