Confronting implicit bias toward patients: a scoping review of post-graduate physician curricula.

BACKGROUND: Physicians' behavior may unknowingly be impacted by prejudice and thereby contribute to healthcare inequities. Despite increasingly robust data demonstrating physician implicit bias (The Office of Minority Health. Minority Population Profiles, 2021; COVID-19 Shines Light on Health Disparities, National Conference of State Legislatures 2021), the evidence behind how to change this with training programs remains unclear. This scoping review therefore reports on the implementation, outcomes, and characteristics of post-graduate physician implicit bias curricula. METHODS: The authors conducted a literature review using scoping review methodology. They searched 7 databases in February and November 2020 for English-language academic and gray literature on implicit bias curricula for physicians at all levels of post-graduate training. Ten reviewers screened studies for eligibility independently, then extracted data from these studies and compiled it into a chart and analytical summary. RESULTS: Of the 4,599 articles screened, this review identified 90 articles on implicit bias interventions for post-graduate physicians. Inductive data analysis revealed a spectrum of educational approaches, which were categorized int o 4 educational models called Competence, Skills-Based, Social Contact, and Critical Models. The most commonly reported strength was the interactive nature of the curricula (26%), and the most frequently identified challenges were related to time and resources available (53%). Half of the interventions discussed facilitator preparation, and the majority (62%) evaluated outcomes using pre and post self-assessments. CONCLUSIONS: This review provides a comprehensive synthesis of the literature on physician implicit bias curricula. It is our goal that this supports medical educators in applying and improving aspects of these interventions in their own programs.

Paradoxical effects of cigarette smoke and COPD on SARS-CoV-2 infection and disease.

BACKGROUND: How cigarette smoke (CS) and chronic obstructive pulmonary disease (COPD) affect severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection and severity is controversial. We investigated the effects of COPD and CS on the expression of SARS-CoV-2 entry receptor ACE2 in vivo in COPD patients and controls and in CS-exposed mice, and the effects of CS on SARS-CoV-2 infection in human bronchial epithelial cells in vitro. METHODS: We quantified: (1) pulmonary ACE2 protein levels by immunostaining and ELISA, and both ACE2 and/or TMPRSS2 mRNA levels by RT-qPCR in two independent human cohorts; and (2) pulmonary ACE2 protein levels by immunostaining and ELISA in C57BL/6 WT mice exposed to air or CS for up to 6 months. The effects of CS exposure on SARS-CoV-2 infection were evaluated after in vitro infection of Calu-3 cells and differentiated human bronchial epithelial cells (HBECs), respectively. RESULTS: ACE2 protein and mRNA levels were decreased in peripheral airways from COPD patients versus controls but similar in central airways. Mice exposed to CS had decreased ACE2 protein levels in their bronchial and alveolar epithelia versus air-exposed mice. CS treatment decreased viral replication in Calu-3 cells, as determined by immunofluorescence staining for replicative double-stranded RNA (dsRNA) and western blot for viral N protein. Acute CS exposure decreased in vitro SARS-CoV-2 replication in HBECs, as determined by plaque assay and RT-qPCR. CONCLUSIONS: ACE2 levels were decreased in both bronchial and alveolar epithelial cells from COPD patients versus controls, and from CS-exposed versus air-exposed mice. CS-pre-exposure potently inhibited SARS-CoV-2 replication in vitro. These findings urge to investigate further the controversial effects of CS and COPD on SARS-CoV-2 infection.

Paradoxical effects of cigarette smoke and COPD on SARS-CoV2 infection and disease.

INTRODUCTION: How cigarette smoke (CS) and chronic obstructive pulmonary disease (COPD) affect severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and severity is controversial. We investigated the protein and mRNA expression of SARS-CoV-2 entry receptor ACE2 and proteinase TMPRSS2 in lungs from COPD patients and controls, and lung tissue from mice exposed acutely and chronically to CS. Also, we investigated the effects of CS exposure on SARS-CoV-2 infection in human bronchial epithelial cells. METHODS: In Cohort 1, ACE2-positive cells were quantified by immunostaining in FFPE sections from both central and peripheral airways. In Cohort 2, we quantified pulmonary ACE2 protein levels by immunostaining and ELISA, and both ACE2 and TMPRSS2 mRNA levels by RT-qPCR. In C57BL/6 WT mice exposed to air or CS for up to 6 months, pulmonary ACE2 protein levels were quantified by triple immunofluorescence staining and ELISA. The effects of CS exposure on SARS-CoV-2 infection were evaluated after 72hr in vitro infection of Calu-3 cells. After SARS-CoV-2 infection, the cells were fixed for IF staining with dsRNA-specific J2 monoclonal Ab, and cell lysates were harvested for WB of viral nucleocapsid (N) protein. Supernatants (SN) and cytoplasmic lysates were obtained to measure ACE2 levels by ELISA. RESULTS: In both human cohorts, ACE2 protein and mRNA levels were decreased in peripheral airways from COPD patients versus both smoker and NS controls, but similar in central airways. TMPRSS2 levels were similar across groups. Mice exposed to CS had decreased ACE2 protein levels in their bronchial and alveolar epithelia versus air-exposed mice exposed to 3 and 6 months of CS. In Calu3 cells in vitro, CS-treatment abrogated infection to levels below the limit of detection. Similar results were seen with WB for viral N protein, showing peak viral protein synthesis at 72hr. CONCLUSIONS: ACE2 levels were decreased in both bronchial and alveolar epithelial cells from uninfected COPD patients versus controls, and from CS-exposed versus air-exposed mice. CS-pre-treatment did not affect ACE2 levels but potently inhibited SARS-CoV-2 replication in this in vitro model. These findings urge to further investigate the controversial effects of CS and COPD on SARS-CoV2 infection.

[Long gamma nail for the treatment of subtrochanteric fracture of the femur]. / Enclouage par clou gamma long dans les fractures sous-trochantériennes et trochantéro-diaphysaires du fémur de l'adulte.

PURPOSE OF THE STUDY: The standard gamma nail is commonly used for the treatment of trochanteric fractures but cannot be used if the fracture lies at the level of the distal locking. Theoretically, the long gamma nail would overcome this inconvenience and could be used for all cases of subtrochanteric and trochanteric-shaft fractures. MATERIAL AND METHODS: Clinical and radiological charts were established in 1990 for a multicentric study. The radiology work-up included an AP view of the pelvis and an oblique lateral view of the hip. Two classifications were used: Seinsheimer and Muller as modified by Nazarian. Three stages of fracture reduction were recorded: 1=anatomic reduction, 2=acceptable reduction, 3=poor reduction. From January 1995 to December 1999, 46 patients were treated with the long gamma nail. Twenty-four cases were excluded for various reasons (from which 3 early death). 22 remaining patients were followed for more than six months. Mean age was 68 years (range 42-96); there were six women and 16 men. Ten patients were traffic or work accident victims and 12 had had a home accident. RESULTS: Mean duration of surgery was 70 minutes. Three patients required revision surgery within a week of the initial osteosynthesis. Mean hemoglobin level before surgery was 12.9 g/dl; 8.9 g/dl during the first postoperative week. Mean hospital stay was 14 days. Weight-bearing with support was possible early after surgery in 16 patients who walked with crutches or a walker. Mean delay to weight-bearing was 11 days. At three months, all patients were using an aid for walking; at six months, four patients used a walker. Bone healing was achieved on the average at the twelfth week. Radiological reduction was anatomic in four, acceptable in three and poor in 15. DISCUSSION: We advocate the AO classification as it allows a structured analysis of all fractures within a unique system. We compared our results with nine series reported in the literature using other therapeutic methods (screw-plate, nail-plate, Ender nail). The operative time for the long gamma nail (70 min) was comparable with that for other surgical techniques. Treatment with the long gamma nail favors bone healing and limits the risk of infection. Radiological results in our series were poor, but there were no cases with nonunion and the morbidity was low.

The development of multiple domains of child and adolescent self-concept: a cohort sequential longitudinal design.

The development of child and adolescent self-concept was examined as a function of the self-concept domain, social/developmental/educational transitions, and gender. In two overlapping age cohorts of public school students (Ns = 936 and 984), five dimensions of self-concept were evaluated every 6 months in a manner that spanned grades 3 through 11 (representing the elementary, middle, and high school years). Domains of self-concept included academic competence, physical appearance, behavioral conduct, social acceptance, and sports competence. Structural equation modeling addressed questions about the stability of individual differences over time. Multilevel modeling addressed questions about mean-level changes in self-concept over time. Significant effects emerged with regard to gender, age, dimension of self-concept, and educational transition.

Structural differences in parent and child reports of children's symptoms of depression and anxiety.

Two cohorts of public elementary school children and their parents (assessed 3 years apart) completed child and parent forms of the Children's Depression Inventory (CDI) and the Revised Children's Manifest Anxiety Scale (RCMAS). Assessments were conducted twice, once during the fall (N = 562) and again during the spring (N = 630) of the 6th grade. Factor analyses revealed 3 factors for each measure. Two of the 3 parent CDI factors manifested some degree of congruence with their counterparts from the child CDI. Similarly, 2 of the 3 RCMAS factors were somewhat congruent across informant types. Differences between parent and child factor structures suggest that parents' and children's reports focus on somewhat different aspects of child psychopathology, and they can make qualitatively different contributions to the multiaxial assessment of children.

Are the discrepancies between self- and others' appraisals of competence predictive or reflective of depressive symptoms in children and adolescents: a longitudinal study, Part II.

Two cohorts of children and adolescents (who started 6th grade in 1993 and 1996), parents, teachers, and peers participated in a 4-wave, 2-year, longitudinal study of perceived competence and depressive symptoms. The authors assessed children's tendencies to underestimate their competence (discrepant self-appraisals) relative to the appraisals of significant others. We also assessed the degree to which self-appraisals reflected the evaluations of others (reflective self-appraisals). Domains of competence were academic competence, physical appearance, behavioral conduct, social acceptance, and athletic competence. Cross-sectional analyses indicated that depressive symptoms correlated with reflective and discrepant self-appraisals. Longitudinal analyses revealed that reflective and discrepant self-appraisals predicted subsequent depressive symptoms and that depressive symptoms predicted discrepant but not reflective self-appraisals. Clinical implications of the findings are discussed.

Self-perceived competence and the relation between life events and depressive symptoms in adolescence: mediator or moderator?

In a 2-wave longitudinal study, 9th-grade students (N = 468) completed self-report measures of stressful life events, depressive symptoms, and 5 domains of self-perceived competence (i.e., academic competence, social acceptance, physical appearance, behavioral conduct, and athletic competence). Teachers and peers also reported about the participants' depressive symptoms. In longitudinal analyses, negative (but not positive) events related to depressive symptoms. Results suggested that self-perceived competence served as a mediator (but not a moderator) of this relation. Negative events predicted changes in self-perceived competence. Self-perceived competence predicted changes in depressive symptoms. Also, the direct effect of negative events on depressive symptoms diminished after controlling for self-perceived competence.