Outcomes of a pilot virtual mentorship program for medical students interested in surgery.

BACKGROUND: Lack of mentorship may deter medical students who identify as underrepresented minorities (URM) from entering academic surgery. METHODS: 30 mentor-medical student pairs from the AWS 2020 virtual mentorship pilot-program were surveyed pre-and post-program to explore 1) feasibility of meetings, and, 2) program's perceived efficacy in fostering professional development skills. Participants responded using a 5-point Likert scale (1 = not at all; 5 = completely). Proportions of participants in each category were compared. RESULTS: Proportion of participants perceiving monthly meetings to be completely feasible did not differ from pre-to post-program surveys for mentees (75%(21/28) vs. 71%(12/17); p = 0.743) or mentors (71%(17/24) vs 71%(13/18); p = 1.00). Compared to pre-program responses, mentees endorsed "completely" (Likert scale 5) improving with regard to their elevator speech (p = 0.001), developing their curriculum vitae (p = 0.003), ability to network (p = 0.021), and acquiring skills for career advancement (p = 0.003). CONCLUSION: Virtual mentorship may be a feasible and effective means of increasing access to mentors for URM medical students.

Examination of Intersectionality and the Pipeline for Black Academic Surgeons.

IMPORTANCE: The lack of underrepresented in medicine physicians within US academic surgery continues, with Black surgeons representing a disproportionately low number. OBJECTIVE: To evaluate the trend of general surgery residency application, matriculation, and graduation rates for Black trainees compared with their racial and ethnic counterparts over time. DESIGN, SETTING, AND PARTICIPANTS: In this nationwide multicenter study, data from the Electronic Residency Application Service (ERAS) for the general surgery residency match and Graduate Medical Education (GME) surveys of graduating general surgery residents were retrospectively reviewed and stratified by race, ethnicity, and sex. Analyses consisted of descriptive statistics, time series plots, and simple linear regression for the rate of change over time. Medical students and general surgery residency trainees of Asian, Black, Hispanic or Latino of Spanish origin, White, and other races were included. Data for non-US citizens or nonpermanent residents were excluded. Data were collected from 2005 to 2018, and data were analyzed in March 2021. MAIN OUTCOMES AND MEASURES: Primary outcomes included the rates of application, matriculation, and graduation from general surgery residency programs. RESULTS: Over the study period, there were 71 687 applicants, 26 237 first-year matriculants, and 24 893 graduates. Of 71 687 applicants, 24 618 (34.3%) were women, 16 602 (23.2%) were Asian, 5968 (8.3%) were Black, 2455 (3.4%) were Latino, and 31 197 (43.5%) were White. Women applicants and graduates increased from 29.4% (1178 of 4003) to 37.1% (2293 of 6181) and 23.5% (463 of 1967) to 33.5% (719 of 2147), respectively. When stratified by race and ethnicity, applications from Black women increased from 2.2% (87 of 4003) to 3.5% (215 of 6181) (P < .001) while applications from Black men remained unchanged (3.7% [150 of 4003] to 4.6% [284 of 6181]). While the matriculation rate for Black women remained unchanged (2.4% [46 of 1919] to 2.3% [52 of 2264]), the matriculation rate for Black men significantly decreased (3.0% [57 of 1919] to 2.4% [54 of 2264]; P = .04). Among Black graduates, there was a significant decline in graduation for men (4.3% [85 of 1967] to 2.7% [57 of 2147]; P = .03) with the rate among women remaining unchanged (1.7% [33 of 1967] to 2.2% [47 of 2147]). CONCLUSIONS AND RELEVANCE: Findings of this study show that the underrepresentation of Black physicians at every stage in surgical training pipeline persists. Black men are especially affected. Identifying factors that address intersectionality and contribute to the successful recruitment and retention of Black trainees in general surgery residency is critical for achieving racial and ethnic as well as gender equity.

Pandanus nutshell generates a palaeoprecipitation record for human occupation at Madjedbebe, northern Australia.

Little is known about the Pleistocene climatic context of northern Australia at the time of early human settlement. Here we generate a palaeoprecipitation proxy using stable carbon isotope analysis of modern and archaeological pandanus nutshell from Madjedbebe, Australia's oldest known archaeological site. We document fluctuations in precipitation over the last 65,000 years and identify periods of lower precipitation during the penultimate and last glacial stages, Marine Isotope Stages 4 and 2. However, the lowest effective annual precipitation is recorded at the present time. Periods of lower precipitation, including the earliest phase of occupation, correspond with peaks in exotic stone raw materials and artefact discard at the site. This pattern is interpreted as suggesting increased group mobility and intensified use of the region during drier periods.

Protocol for the Yapatjarrathati project: a mixed-method implementation trial of a tiered assessment process for identifying fetal alcohol spectrum disorders in a remote Australian community.

BACKGROUND: Fetal alcohol spectrum disorder (FASD) is a highly prevalent neurodevelopmental disorder associated with prenatal alcohol exposure. Early identification can improve functioning for individuals and reduce costs to society. Gold standard methods of diagnosing FASD rely on specialists to deliver intensive, multidisciplinary assessments. While comprehensive, prevalence rates highlight that this assessment model cannot meet demand, nor is it feasible in remote areas where specialist services are lacking. This project aims to expand the capabilities of remote practitioners in north Queensland, Australia, where 23-94% of the community identify as First Nations people. Integrating cultural protocols with the implementation science theories of Knowledge-To-Action, Experience-Based Co-Design, and RE-AIM, remote practitioners with varying levels of experience will be trained in a co-designed, culturally appropriate, tiered neurodevelopmental assessment process that considers FASD as a potential outcome. This innovative assessment process can be shared between primary and tertiary health care settings, improving access to services for children and families. This project aims to demonstrate that neurodevelopmental assessments can be integrated seamlessly with established community practices and sustained through evidence-based workforce development strategies. METHODS: The Yapatjarrathati project (named by the local First Nations community and meaning 'to get well') is a mixed-method implementation trial of a tiered assessment process for identifying FASD within a remote Australian community. In collaboration with the community, we co-designed: (a) a culturally sensitive, tiered, neurodevelopmental assessment process for identifying FASD, and (b) training materials that up-skill remote practitioners with varying levels of expertise. Qualitative interviews for primary, secondary and end users will be undertaken to evaluate the implementation strategies. RE-AIM will be used to evaluate the reach, effectiveness, adoption, implementation and maintenance of the assessment and training process. DISCUSSION: Co-designed with the local community, integrated with cultural protocols, and based on implementation science theories, the assessment and training process from this project will have the potential to be scaled-up across other remote locations and trialed in urban settings. The Yapatjarrathati project is an important step towards increasing the availability of neurodevelopmental services across Australia and empowering remote practitioners to contribute to the FASD assessment process.

Laparoendoscopic single-site Heller myotomy with anterior fundoplication for achalasia.

BACKGROUND: Laparoendoscopic single-site (LESS) surgery is beginning to include advanced laparoscopic operations such as Heller myotomy with anterior fundoplication. However, the efficacy of LESS Heller myotomy has not been established. This study aimed to evaluate the authors' initial experience with LESS Heller myotomy for achalasia. METHODS: Transumbilical LESS Heller myotomy with concomitant anterior fundoplication for achalasia was undertaken for 66 patients after October 2007. Outcomes including operative time, complications, and length of hospital stay were recorded and compared with those for an earlier contiguous group of 66 consecutive patients undergoing conventional multi-incision laparoscopic Heller myotomy with anterior fundoplication. Symptoms before and after myotomy were scored by the patients using a Likert scale ranging from 0 (never/not severe) to 10 (always/very severe). Data were analyzed using the Mann-Whitney U test, the Wilcoxon matched-pairs test, and Fisher's exact test where appropriate. RESULTS: Patients undergoing LESS Heller myotomy were similar to those undergoing conventional laparoscopic Heller myotomy in gender, age, body mass index (BMI), blood loss, and length of hospital stay. However, the patients undergoing LESS Heller myotomies had operations of significantly longer duration (median, 117 vs. 93 min with the conventional laparoscopic approach) (p<0.003). For 11 patients (16%) undergoing LESS Heller myotomy, additional ports/incisions were required. No patients were converted to "open" operations, and no patients had procedure-specific complications. Symptom reduction was dramatic and satisfying after both LESS and conventional laparoscopic myotomy with fundoplication. The symptom reduction was similar with the two procedures. The LESS approach left no apparent umbilical scar. CONCLUSION: Heller myotomy with anterior fundoplication effectively treats achalasia. The findings showed LESS Heller myotomy with anterior fundoplication to be feasible, safe, and efficacious. Although the LESS approach increases operative time, it does not increase procedure-related morbidity or hospital length of stay and avoids apparent umbilical scarring. Laparoendoscopic single-site surgery represents a paradigm shift to more minimally invasive surgery and is applicable to advanced laparoscopic operations such as Heller myotomy and anterior fundoplication.

Oropharyngeal aspiration and pneumonia in children.

Oropharyngeal aspiration (OPA) of food and fluids is known to be associated with pneumonia in dysphagic children with neurological disease and direct causality is often assumed. However, little is known about the relationship between OPA and pneumonia in medically complex children when other possible risk factors for pneumonia are considered. We examined the association of World Health Organization (WHO)-defined pneumonia in a heterogeneous group of children with swallowing dysfunction identified by a videofluoroscopic swallow study (VFSS). A retrospective chart review of 150 children (aged 2 weeks to 20 years) was undertaken to determine the relationship between pneumonia and (i) type of swallowing dysfunction (including OPA), (ii) consistency of aspirated food/fluid, and (iii) other factors including multisystem involvement and age (1 year). In univariate analysis, the odds ratio (OR) for pneumonia was significantly increased in children with post-swallow residue (PSR) (OR 2.5) or aspiration on thin fluids (OR 2.4), but not with aspiration of thick fluids or purees. In multi-logistic regression, type of swallowing dysfunction or aspirated food/fluid were no longer significant. Instead, pneumonia was significantly associated with diagnosis of asthma (OR 13.25), Down syndrome (OR 22.10), gastroesophageal reflux disease (GERD) (OR 4.28), or history of LRTI (OR 8.28), moist cough (OR 9.17) or oxygen supplementation (OR 6.19). Children with multisystem involvement demonstrated a higher association with pneumonia, but no difference was found for age. We conclude that the impact of OPA on development of pneumonia is considerably reduced once other factors in children with multisystem involvement are taken into account.

A pilot study of cytokine levels and white blood cell counts in the diagnosis of necrotizing fasciitis.

STUDY OBJECTIVES: To characterize the early cytokine response of patients presenting to the emergency department with necrotizing fasciitis (NF) and to determine whether serum cytokine levels and white blood cell (WBC) counts may be useful in distinguishing NF from other severe soft-tissue infections. METHODS: White blood cell counts and cytokine levels (IL-1beta, IL-1Ra, IL-6, IL-8, IL-18, and IFN-gamma) were measured in patients presenting to the emergency department with severe soft-tissue infections and high suspicion of NF. Necrotizing fasciitis was confirmed intraoperatively and by surgical pathology. Cytokines were measured via the liquid-phase electrochemiluminescence method. RESULTS: Thirty-five patients were enrolled, 18 were diagnosed with NF, and 17 were diagnosed with cellulitis and/or abscess (CAB). On admission, patients with NF had significantly higher WBC counts and lower levels of interleukin 1beta (IL-1beta) compared with patients with CAB. There were no statistically significant differences in the levels of the other cytokines between the 2 groups. CONCLUSION: Patients with NF have higher WBC counts and lower IL-1beta levels compared with patients with CAB.

Decreased peritoneal macrophage NF-kappaB translocation to the nucleus in protein energy malnutrition--a role for the glucocorticoid response?

BACKGROUND & AIMS: Protein energy malnutrition (PEM) induces immune suppression leading to increased morbidity and mortality. The mechanism(s) underlying PEM-mediated immune suppression remain unclear. Plasma glucocorticoid levels are elevated in PEM and it has been postulated that these increased levels may mediate macrophage (MØ) dysfunction in PEM. We have previously shown that nuclear factor kappa B (NF-kappaB) activation in response to LPS stimulation is diminished in peritoneal macrophages (PMØs) from PEM mice. We hypothesized that decreased NF-kappaB activation in lipopolysaccharide (LPS)-stimulated PMØs in PEM is mediated through increased circulating glucocorticoid levels. METHODS: Mice were randomized to six groups of n = 15 each as follows: (1) control diet (24% casein) (C); (2) protein-free diet (PF); (3) mice with subcutaneously implanted corticosterone pellet on the control diet; (4) mice with subcutaneously implanted placebo pellet on the control diet; (5) adrenalectomized mice on the control diet; (6) adrenalectomized mice on the PF diet. Within each group, the mice were pair-fed for 7 days. At the end of the experimental time period, PMØs were harvested and NF-kappaB activation determined by electrophoretic mobility shift assay (EMSA). RESULTS: Elevated circulating glucocorticoids diminished NF-kappaB activation but adrenalectomy failed to restore this diminution in a murine model of PEM. CONCLUSION: NF-kappaB translocation to the nucleus in PEM is independent of elevated circulating glucocorticoid levels.