Percutaneous thrombolysis via cholecystostomy catheter to dissolve biliary clots causing obstructive jaundice.

Haemobilia, or bleeding within the biliary tree, is rare. It can cause biliary obstruction secondary to blood clots. A comorbid 87-year-old was admitted to hospital with acute cholecystitis, choledocholithiasis, and an Escherichia coli bacteremia. He had a partial pancreatectomy and gastrojejunostomy 35 years prior for severe pancreatitis. He was treated with antibiotics and a percutaneous cholecystostomy. He developed atrial fibrillation and was subsequently commenced on warfarin. He re-presented 5 days after discharge with abdominal pain and fevers. Liver function tests revealed cholestasis and a supratherapeutic international normalised ratio. Imaging showed cholecystitis, biliary obstruction, and extensive biliary blood clots. He improved with antibiotics, vitamin K, and alteplase flushes through the percutaneous cholecystostomy. Repeat cholangiogram demonstrated dissolution of the biliary clots. Due to altered anatomy and comorbidities, alteplase flushes were utilized to relieve this patient's biliary obstruction. Thrombolytics may assist in treating biliary clots when first-line options are not possible or favourable.

Evaluation of an Integrated Intervention to Address Clinical Care and Social Needs Among Patients with Type 2 Diabetes.

BACKGROUND: The Providence Diabetes Collective Impact Initiative (DCII) was designed to address the clinical challenges of type 2 diabetes and the social determinants of health (SDoH) challenges that exacerbate disease impact. OBJECTIVE: We assessed the impact of the DCII, a multifaceted intervention approach to diabetes treatment that employed both clinical and SDoH strategies, on access to medical and social services. DESIGN: The evaluation employed a cohort design and used an adjusted difference-in-difference model to compare treatment and control groups. PARTICIPANTS: Our study population consisted of 1220 people (740 treatment, 480 control), aged 18-65 years old with a pre-existing type 2 diabetes diagnosis who visited one of the seven Providence clinics (three treatment and four control) in the tri-county area of Portland, Oregon, between August 2019 and November 2020. INTERVENTIONS: The DCII threaded together clinical approaches such as outreach, standardized protocols, and diabetes self-management education and SDoH strategies including social needs screening, referral to a community resource desk, and social needs support (e.g., transportation) to create a comprehensive, multi-sector intervention. MAIN MEASURES: Outcome measures included SDoH screens, diabetes education participation, HbA1c, blood pressure, and virtual and in-person primary care utilization, as well as inpatient and emergency department hospitalization. KEY RESULTS: Compared to patients at the control clinics, patients at DCII clinics saw an increase in diabetes education (15.5%, p<0.001), were modestly more likely to receive SDoH screening (4.4%, p<0.087), and had an increase in the average number of virtual primary care visits of 0.35 per member, per year (p<0.001). No differences in HbA1c, blood pressure, or hospitalization were observed. CONCLUSIONS: DCII participation was associated with improvements in diabetes education use, SDoH screening, and some measures of care utilization.

Hospital-Based, Community Teaching Kitchen Integrates Diabetes Education, Culinary Medicine, and Food Assistance: Case Study During the COVID-19 Pandemic.

BACKGROUND: Recent USDA Economic Research Service Population Survey cites a stabilization of food insecurity overall in the USA between 2019 and 2020, but Black, Hispanic, and all households with children cited increases - underscoring that the COVID-19 pandemic caused severe disruptions to food insecurity for historically disenfranchised populations. AIM: Describe lessons learned, considerations, and recommendations from the experience of a community teaching kitchen (CTK) in addressing food insecurity and chronic disease management among patients during the COVID-19 pandemic. SETTING: The Providence CTK is co-located at Providence Milwaukie Hospital in Portland, Oregon. PARTICIPANTS: Providence CTK serves patients who report a higher prevalence of food insecurity and multiple chronic conditions. PROGRAM DESCRIPTION: Providence CTK has five components: chronic disease self-management education, culinary nutrition education, patient navigation, a medical referral-based food pantry (Family Market), and an immersive training environment. PROGRAM EVALUATION: CTK staff highlight that they provided food and education support when it was needed most, leveraged existing partnerships and staffing to sustain operations and Family Market accessibility, shifted delivery of educational services based-on billing and virtual service considerations, and repurposed roles to support evolving needs. DISCUSSION: The Providence CTK case study provides a blueprint for how healthcare organizations could design a model of culinary nutrition education that is immersive, empowering, and inclusive.

Open splenic artery aneurysm repair in a patient with previous laparoscopic sleeve gastrectomy.

We present the case of a female patient in her 40s who underwent a splenic artery aneurysm (SAA) repair following a previous laparoscopic sleeve gastrectomy (SG). We aim to discuss the management approach to SAAs and considerations in the setting of previous bariatric surgery.The patient consented to this case report. We include preoperative and postoperative radiological images and intraoperative images.While pseudoaneurysms following bariatric surgery have been reported, we present a case of a likely true SAA following SG. Our experience may assist others who come across similar cases in the future.

Science of the Van Allen Probes Science Operations Centers.

The Van Allen Probes mission operations materialized through a distributed model in which operational responsibility was divided between the Mission Operations Center (MOC) and separate instrument specific SOCs. The sole MOC handled all aspects of telemetering and receiving tasks as well as certain scientifically relevant ancillary tasks. Each instrument science team developed individual instrument specific SOCs proficient in unique capabilities in support of science data acquisition, data processing, instrument performance, and tools for the instrument team scientists. In parallel activities, project scientists took on the task of providing a significant modeling tool base usable by the instrument science teams and the larger scientific community. With a mission as complex as Van Allen Probes, scientific inquiry occurred due to constant and significant collaboration between the SOCs and in concert with the project science team. Planned cross-instrument coordinated observations resulted in critical discoveries during the seven-year mission. Instrument cross-calibration activities elucidated a more seamless set of data products. Specific topics include post-launch changes and enhancements to the SOCs, discussion of coordination activities between the SOCs, SOC specific analysis software, modeling software provided by the Van Allen Probes project, and a section on lessons learned. One of the most significant lessons learned was the importance of the original decision to implement individual team SOCs providing timely and well-documented instrument data for the NASA Van Allen Probes Mission scientists and the larger magnetospheric and radiation belt scientific community.

Gender equality in the 21st century: Overcoming barriers to women's leadership in global health.

PURPOSE: The purpose of this manuscript is to provide an overview of the significant role that women play in providing global health care, barriers encountered to achieving gender equality in global health leadership, and to propose key recommendations for advancing gender equality in global health decision-making through the integration of gender mainstreaming, gender-based analysis, and gender transformative leadership (GTL) approaches. METHOD: Data were evaluated to determine the participation rate of women in global health care and social sector roles in comparison to men. Gender equality data from the United Nations, World Health Organization, Organization for Economic Co-operation and Development, International Labour Organization, and other resources were analyzed to assess the impact of the coronavirus disease 2019 pandemic on gender equality with an emphasis on women in global health leadership positions, the health care and social sector, and gender equality measures for girls and women throughout the world. The literature was examined to identify persistent barriers to gender equality in global health leadership positions. Additionally, a review of the literature was conducted to identify key strategies and recommendations for achieving gender equality in global health decision-making; integrating gender mainstreaming; conducting gender-based analysis; and adopting GTL programs, incentives, and policies to advance gender equality in global health organizations. FINDINGS: Women represent 70% of the health and social care sector global workforce but only 25% of senior global health leadership roles. Since 2018, there has been a lack of meaningful change in the gender equality policy arenas at global health organizations that has led to significant increases in women serving in global leadership decision-making senior positions. During the pandemic in 2020, there were nearly 100 open vacancies-one-quarter of CEO and board chair positions-at global health organizations, but none were filled by women. Women disproportionately provide caregiving and unpaid care work, and the pandemic has increased this burden with women spending 15 hours a week more on domestic labor than men. A lack of uniform, state-sponsored paid parental leave and support for childcare, eldercare, and caregiving, which is overwhelmingly assumed by women, serve as major barriers to gender parity in global health leadership and the career advancement of women. CONCLUSION: The pandemic has adversely impacted women in global health care and social sector roles. During the pandemic, there has been a widening of the gender pay gap, a lack of gains for women in global health leadership positions, an increase in caregiving responsibilities for women, and more women and girls have been pushed back into extreme poverty than men and boys. Globally, there is still resistance to women serving in senior leadership roles, and social and cultural norms, gender stereotypes, and restrictions on women's rights are deeply intertwined with barriers that reinforce gender inequality in global health leadership. To ensure comprehensive human rights and that equitable workforce opportunities are available, the concept of gender equality must be expanded within the global health community to consistently include not only women and girls and men and boys, but also persons who identify as nonbinary and gender nonconforming. Efforts to eliminate remnants of systemic and structural gender discrimination must also incorporate gender mainstreaming, gender-based analysis, and gender transformative approaches to achieve gender equality throughout global health systems and organizations.

Anti-racism structures in academic dentistry: Supporting underrepresented racially/ethnically diverse faculty.

OBJECTIVES: The purpose of this paper is to describe the racialized barriers to recruiting and retaining historically underrepresented racially/ethnically diverse (HURE) faculty at U.S. dental schools and the linkages of these barriers to structural racism to assist dental schools in eliminating these hurdles through an antiracism framework. METHODS: Data is used to describe the trends in the racial/ethnic composition of dental school faculty and the parity gaps by race/ethnicity between dentists and the U.S. POPULATION: Literature on the recruitment and retention of faculty of color at higher education institutions is reviewed to identify challenges and best practices. Barriers to the full participation of HURE faculty, outlined in the American Dental Education Association's Faculty Diversity Toolkit, are also identified. Research on antiracism frameworks is also investigated to denote their uses and key components. RESULTS: There is a critical shortage of HURE faculty at dental schools and active HURE dentists in the U.S. A history of racism and its legacy reinforce biases, stereotypes, and power structures that harm HURE faculty at U.S. dental schools. An anti-racism framework is needed to holistically eliminate inequities and racialized policies and practices that persists as barriers for HURE faculty. CONCLUSIONS: Increasing the representation of HURE dentists in the workforce and dental school faculty requires a major disruption to culture and institutional practices that mask centuries of structural racism embedded within complex academic systems. Dental schools must use antiracism models to create strategic initiatives that support a humanistic, equitable, and antiracism environment where HURE faculty can thrive.

ADEA Faculty Diversity Toolkit: A Comprehensive Approach to Improving Diversity and Inclusion in Dental Education.

Population demographic shifts in the United States and Canada have led to an increasingly diverse postsecondary student population. However, the largely homogenous dental faculty in the United States and Canada does not reflect the rapidly changing student body and the diverse patient population academic dentistry has been called to serve. Therefore, recruitment and retention of diverse dental faculty in dental education must be a priority. Substantial evidence also indicates improved outcomes for faculty, students, and institutions when faculty diversity on campus is increased. Beyond the positive impact faculty diversity can deliver to the learning and working environments of an academic institution, a variety of regulatory bodies mandate good faith efforts to maintain a diverse faculty, including the Commission on Dental Accreditation (CODA) standards for dental schools and dental therapy education programs. To assist its member institutions with answering the call for improved faculty diversity, the American Dental Education Association (ADEA) worked with its members to develop the ADEA Faculty Diversity Toolkit (ADEA FDT), a landmark evidence-based resource designed to assist dental education with the design and implementation of faculty recruitment and retention initiatives that can be tailored to their unique needs. This article provides an overview of the changing landscape of the United States and Canadian populations, shares the historic homogeneity of dental education faculty, provides an overview of some of the benefits associated with faculty diversity and highlights the challenges and barriers related to recruiting and retaining diverse faculty. Most importantly, it introduces the ADEA FDT and the need for dental schools and allied dental programs to use the Toolkit as a proactive resource in increasing and maintaining faculty diversity. Furthermore, it provides an overview of how to utilize and adapt the highlighted best practices and model programs to improve faculty diversity on their campuses.

Lithium-Induced Neurotoxicity: A Case Study.

BACKGROUND: In patients presenting with neurological deficits, identifying the cause can be challenging. METHODS: This case study discusses a condition that is not commonly seen. DISCUSSION: Although lithium toxicity syndrome is not as familiar as other causes of neurological issues, this should be considered for any patient who presents with unexplained neurological deficits and a history of taking this medication. CONCLUSION: If toxicity is not recognized early, the patient can be left with irreversible neurological symptoms, also known as syndrome of irreversible lithium-effectuated neurotoxicity, which impacts quality of life or can even cause death.

Mental health first aid training for nursing students: a protocol for a pragmatic randomised controlled trial in a large university.

BACKGROUND: The impact of mental health problems and disorders in Australia is significant. Mental health problems often start early and disproportionately affect young people. Poor adolescent mental health can predict educational achievement at school and educational and occupational attainment in adulthood. Many young people attend higher education and have been found to experience a range of mental health issues. The university setting therefore presents a unique opportunity to trial interventions to reduce the burden of mental health problems. Mental Health First Aid (MHFA) aims to train participants to recognise symptoms of mental health problems and assist an individual who may be experiencing a mental health crisis. Training nursing students in MHFA may increase mental health literacy and decrease stigma in the student population. This paper presents a protocol for a trial to examine the efficacy of the MHFA training for students studying nursing at a large university in Perth, Western Australia. METHODS/DESIGN: This randomised controlled trial will follow the CONSORT guidelines. Participants will be randomly allocated to the intervention group (receiving a MHFA training course comprising two face to face 6.5 hour sessions run over two days during the intervention period) or a waitlisted control group (not receiving MHFA training during the study). The source population will be undergraduate nursing students at a large university located in Perth, Western Australia. Efficacy of the MHFA training will be assessed by following the intention-to-treat principle and repeated measures analysis. DISCUSSION: Given the known burden of mental health disorders among student populations, it is important universities consider effective strategies to address mental health issues. Providing MHFA training to students offers the advantage of increasing mental health literacy, among the student population. Further, students trained in MHFA are likely to utilise these skills in the broader community, when they graduate to the workforce. It is anticipated that this trial will demonstrate the scalability of MHFA in the university environment for pre-service nurses and that implementation of MHFA courses, with comprehensive evaluation, could yield positive improvements in the mental health literacy amongst this target group as well as other tertiary student groups. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12614000861651 .

Simulation of the response of the inner hair cell stereocilia bundle to an acoustical stimulus.

Mammalian hearing relies on a cochlear hydrodynamic sensor embodied in the inner hair cell stereocilia bundle. It is presumed that acoustical stimuli induce a fluid shear-driven motion between the tectorial membrane and the reticular lamina to deflect the bundle. It is hypothesized that ion channels are opened by molecular gates that sense tension in tip-links, which connect adjacent stepped rows of stereocilia. Yet almost nothing is known about how the fluid and bundle interact. Here we show using our microfluidics model how each row of stereocilia and their associated tip links and gates move in response to an acoustical input that induces an orbital motion of the reticular lamina. The model confirms the crucial role of the positioning of the tectorial membrane in hearing, and explains how this membrane amplifies and synchronizes the timing of peak tension in the tip links. Both stereocilia rotation and length change are needed for synchronization of peak tip link tension. Stereocilia length change occurs in response to accelerations perpendicular to the oscillatory fluid shear flow. Simulations indicate that nanovortices form between rows to facilitate diffusion of ions into channels, showing how nature has devised a way to solve the diffusive mixing problem that persists in engineered microfluidic devices.

Pipeline programs in the health professions, part 1: preserving diversity and reducing health disparities.

BACKGROUND: Racial and ethnic minorities are underrepresented in the health professions. Affirmative action and educational pipeline programs play a vital role in increasing the diversity of health professions, addressing educational opportunity gaps, and reducing health disparities. Part 1 of this 2-part series discusses the need for educational pipeline programs to assist underrepresented minorities (URMs) in entering the health professions and the importance of these programs in developing a cadre of diverse providers to reduce health care inequality. METHODS: Part 1 presents an overview of diversity in the medical and health care workforce, educational enrichment programs, key components of successful pipeline programs, and notable pipeline examples for underrepresented students at the University of Nebraska Medical Center. Recommendations for improving and developing pipeline programs are also included. Part 2 reviews affirmative action case law and legislation along with recommendations for maintaining and reviewing diversity pipeline programs in light of recent anti-affirmative action challenges. CONCLUSION: Pipeline programs are an important strategy for addressing the shortage of URMs in the health professions. Anti-affirmative action initiatives threaten the existence of these student preparation programs and the ability of our nation to produce physicians of color and other health care providers who are more likely to serve in underrepresented communities and work to reduce related health disparities. Programs at universities and academic medical centers must develop innovative partnerships with underserved communities, adopt strategies that demonstrate a strong commitment to increasing racial and ethnic minorities in the health professions, and develop viable funding mechanisms to support diversity enrichment programs.

Pipeline programs in the health professions, part 2: the impact of recent legal challenges to affirmative action.

BACKGROUND: Despite recent challenges to educational pipeline programs, these academic enrichment programs are still an integral component in diversifying the health professions and reducing health disparities. This is part 2 of a 2-part series on the role of pipeline programs in increasing the number of racial and ethnic minorities in the health professions and addressing related health disparities. Part 1 of this series looked at the role of pipeline programs in achieving a diverse health professional workforce and provided strategies to expand pipeline programs. METHODS: This paper presents an historical overview of affirmative action case law, anti-affirmative action legislation, and race-conscious and race-neutral admission programs in education. Additionally, part 2 reviews current legal theory and related law that impact the diversity and cultural competence pipeline programming at higher-education institutions. Finally, based on recommendations from a review of legal and other literature, the authors offer recommendations for reviewing and preserving diverse pipeline programs for health professional schools. CONCLUSION: Affirmative action is an essential legal means to ensure the diversity-related educational programs in the health profession educational programs. Anti-affirmative action legislation and state-sponsored antiaffirmative voter initiatives have the potential to limit the number of underrepresented minorities in the health professions and create even greater opportunity gaps and educational disparities. Therefore, we must shift the paradigm and reframe the dialogue involving affirmative action and move from debate to a collaborative discussion in order to address the historical and contemporary disparities that make affirmative action necessary today.