From Eggshells to Action: A Qualitative Study of Faculty Experience Responding to Microaggressions Targeting Medical Students.

PURPOSE: Microaggressions targeting clinical learners cause harm and threaten learning. Clinical supervisors can be powerful allies by intervening when microaggressions occur. This study explored general and student-nominated skilled supervisors' perspectives on responding to microaggressions targeting clinical learners. METHOD: This single-institution, qualitative study within a constructivist paradigm explored faculty supervisor experiences with bystander response to microaggressions targeting learners. Clinical supervisors in medicine and surgery departments and those across departments nominated by students as skilled microaggression responders were invited to discuss microaggression scenarios targeting students in semistructured focus groups in the U.S. in 2020-2021. Investigators applied the framework method of thematic analysis to identify themes. RESULTS: Forty-two faculty (31 medicine and surgery ["general"], 11 "student-nominated" as skilled responders) joined 10 focus groups (6 "general," 3 "student-nominated," 1 mixed). Four themes characterized experiences responding to microaggressions targeting learners: bystander goals, noticing, acting, and continuous learning. Participants' response goals were protecting learners, safeguarding learning, and teaching microaggression response skills. Noticing was influenced by past experiences with microaggressions and acculturation to clinical environments. Bystander action stemmed from (1) microaggression type, (2) personal emotional vulnerability, (3) knowledge of student preferences for supervisor response, and (4) clinical and educational context. Bystander action was more common when participants regarded all microaggressions as harmful, understood student preferences for faculty response, expected to err (growth mindset), and framed microaggressions as opportunities for humble reflection, intellectual candor, and teaching. Microaggression response required continuous learning through informal and formal skills development. CONCLUSIONS: Complex factors govern faculty bystander response to microaggressions targeting clinical learners. Efforts to strengthen faculty bystander response should incorporate skill-building around preemptive discussions with learners and using intellectual candor to promote psychological safety, learning, and bystander action. Additional investigation is needed on how to incorporate these skills into team workflows and to assess outcomes of specific response strategies.

Improving chronic kidney disease detection and treatment in the United States: the chronic kidney disease cascade of care (C3) study protocol.

BACKGROUND: There are major gaps in the implementation of guideline-concordant care for persons with chronic kidney disease (CKD). The CKD Cascade of Care (C3) initiative seeks to improve CKD care by improving detection and treatment of CKD in primary care. METHODS: C3 is a multi-modal initiative deployed in three major academic medical centers within the Department of Veterans Affairs (VA) Health Care System: San Francisco VA, San Diego VA, and Houston VA. The main objective of the first phase of C3 described in this protocol is to establish the infrastructure for universal CKD detection among primary care patients at high-risk for CKD with a triple-marker screen comprising cystatin C, creatinine, and albuminuria. Across the three sites, a comprehensive educational intervention and the integration of primary care-based clinical champions will be employed with the goal of improving CKD detection and treatment. The San Francisco VA will also implement a practice-facilitation intervention leveraging telehealth and health informatics tools and capabilities for enhanced CKD detection. Parallel formative evaluation across the three sites will assess the feasibility and acceptability of integrating cystatin C as part of routine CKD detection in primary care practice. The effectiveness of the interventions will be assessed using a pre-post observational design for change in the proportion of patients tested annually for CKD. Secondary outcomes will assess change in the initiation of cardio-kidney protective therapies and in nephrology referrals of high-risk patients. DISCUSSION: The first phase of C3 is a multi-facility multi-modal initiative that aims to improve CKD care by implementing a triple-marker screen for enhanced CKD detection in primary care.

Palliative radiotherapy in cancers of female genital tract: Outcomes and prognostic factors.

BACKGROUND AND PURPOSE: Metastatic and incurable cancers of the gynaecological tract (FGTC) represent a major global health burden. Systemic treatment has modest efficacy and radiotherapy is often used for local symptoms. This study combines experience from two large UK centres in palliative radiotherapy for gynaecological cancers. MATERIALS AND METHODS: Pooled data from two major centres was analysed. Advanced FGTC patients who received at least one fraction of palliative radiotherapy to the pelvis between 2013 and 2018 were included. Data collected included demographic and tumour details, radiotherapy dose fractionation and details of previous and subsequent treatment. Response was defined in terms of toxicity, symptomatic response and survival. Comorbidities were recorded using a modified ACE 27 score which is adjusted for the presence of uncontrolled FGTC in all the patients. RESULTS: A total of 184 patients were included for treatment response and toxicity; survival data was available for 165 patients. Subjective response in pre-radiotherapy symptoms was documented in 80.4%. Grade 3 or worse gastrointestinal, urinary and other (vomiting, fatigue, pain) toxicity incidence was 2.2%, 3.8%, and 2.7% respectively. No statistically significant correlation between the prescribed EQD210 and symptom control or toxicity was seen. 1 year overall survival was 25.1% (median 5.9 months). Absent distant metastases, completion of the intended course of radiotherapy, response to radiotherapy, and receipt of further lines of treatment were independent prognostic factors. CONCLUSION: Palliative radiotherapy is effective for symptoms of advanced FGTC with low toxicity. The absence of a dose response argues for short low dose palliative radiotherapy schedules to be used.

Survival Outcomes After High-dose Chemotherapy and Stem Cell Transplantation in the Salvage Setting for Relapsed or Refractory Germ Cell Cancers.

BACKGROUND/AIM: High-dose chemotherapy (HDCT) and stem cell transplantation (SCT) have been established as the standard of care in patients with relapsed germ cell tumours (GCTs). We evaluated the safety, efficacy and tolerability of HDCT/ SCT in patients with relapsed GCTs. PATIENTS AND METHODS: Twenty-eight patients with relapsed GCTs, treated with HDCT, were included in this study. The conditioning regime was carboplatin, etoposide, cyclophosphamide and paclitaxel. Clinical, radiological imaging and tumour markers determined treatment outcomes. RESULTS: Median age was 35 years (range=21-57 years) with 26 males and 2 females. Median time to first relapse was 6 months. Median time to progression after 2nd line chemotherapy was 17.3 months. Fourteen patients hadMedian survival was 62 months and 16 patients (57%) are in clinical follow-up with surveillance. CONCLUSION: In relapsed GCT patients, median survival may exceed 5 years post-HDCT and SCT.

Tumor budding - A promising prognostic histopathological parameter in oral squamous cell carcinoma - A comparative immunohistochemical study.

INTRODUCTION: The majority of the head and neck squamous cell carcinomas (HNSCC) occur in the oral cavity. Even with advances in cancer therapy only minor improvements in the survival of HNSCC patients have taken place and approximately 350,000 patients die annually of HNSCC worldwide. Tumor budding (TB) is a novel and promising histo-morphological parameter that has been studied in many cancers. The presence of TB is associated with lymph node and distant metastasis as well as poor survival, independently of the applied scoring system. The depth of tumor invasion (D) measured from the surface of the tumor to the deepest point of invasion is also an important prognostic parameter for oral squamous cell carcinoma (OSCC) with a cutoff point of 4 mm. Both taken together constitute BD model and it has also been found to be an independent prognostic factor for patients with OSCC. Therefore, it would be highly beneficial to evaluate TB and BD model in routine histopathological reporting. AIMS AND OBJECTIVES: This study aims to compare the detection of TB in hematoxylin-eosin and pan-cytokeratin stained immune-histochemical sections of OSCC and also to evaluate whether BD score can serve as a reliable prognostic indicator for OSCC. METHODOLOGY: A total of 30 formalin-fixed, paraffin-embedded tissue blocks of clinically and histopathologically diagnosed cases of OSCC were retrieved. One section was stained with hematoxylin and eosin and the other was processed for pancytokeratin immunohistochemistry to evaluate tumor buds. Depth of invasion (D) was also evaluated to achieve the BD score. RESULTS: Statistical significance (P < 0.001) was noted between TB score evaluated in hematoxylin and eosin (H&E) and pancytokeratin stained sections. There was no statistical significance between age, gender, site of lesion, clinical staging, survival and BD score. CONCLUSION: Immunohistochemical analysis of TB is superior to H&E staining in detection of tumor buds at the tumor invasive front.

A Randomized Controlled Feasibility Trial in Behavioral Weight Management for Underserved Postpartum African American Women: The RENEW Study.

We aimed to test the feasibility of an in-person behavioral weight-loss intervention for underserved postpartum African American women with overweight or obesity in an urban hospital setting. Participants were randomized to an intervention of a culturally tailored adaptation of the Diabetes Prevention Program or usual care. The primary outcome was program satisfaction. Women who completed the intervention reported higher levels of satisfaction with the program, despite low attendance rates at group meetings. The intervention was not feasible because of these low rates of attendance and high rates of attrition after randomization. Offering the program electronically and off-site for convenience and more psychosocial support for postpartum women with obesity may improve feasibility.

The addition of whole-body magnetic resonance imaging to body computerised tomography alters treatment decisions in patients with metastatic breast cancer.

AIM: Accurate evaluation of distribution of disease and response to systemic anti-cancer therapy (SACT) is important in the optimal management of metastatic breast cancer. Whole-body magnetic resonance imaging (WB-MRI) has increased accuracy over computerised tomography of the chest, abdomen and pelvis (CT-CAP) for detecting liver and bone disease, but its effect on patient management is largely unexplored. This study investigates the effects of using WB-MRI alongside CT-CAP on SACT decisions in standard clinical practice for patients with metastatic breast cancer. METHODS: Metastatic breast cancer patients who had undergone WB-MRI within 14 d of CT-CAP were studied. Data on distribution and extent of disease and SACT response assessment from original WB-MRI and CT-CAP reports were compared. Contemporaneous medical records provided data on therapy decisions at each time point. RESULTS: Analyses were performed on 210 pairs of WB-MRI and CT-CAP in 101 patients. In 53.3% of episodes, WB-MRI reported additional sites of disease not reported on CT-CAP. Differences in SACT assessment were found in 28.0% of episodes, most commonly due to progressive disease (PD) on WB-MRI being reported as stable disease on CT-CAP (18.9%). Discordant SACT assessments were less common in first-line SACT than in subsequent lines of SACT (15.0% versus 41.6%; p = 0.0102). In 34.7% of episodes when SACT was changed, PD had been reported on WB-MRI only. CONCLUSIONS: SACT decisions in routine practice were altered by the use of WB-MRI. Further research is required to investigate whether earlier identification of PD by WB-MRI leads to improved patient outcomes.

Laparoscopic-assisted Ventral Hernia Repair: Primary Fascial Repair with Polyester Mesh versus Polyester Mesh Alone.

Laparoscopic-assisted ventral hernia repair (LAVHR) with mesh is well established as the preferred technique for hernia repair. We sought to determine whether primary fascial closure and/or overlap of the mesh reduced recurrence and/or complications. We conducted a retrospective review on 57 LAVHR patients using polyester composite mesh between August 2010 and July 2013. They were divided into mesh-only (nonclosure) and primary fascial closure with mesh (closure) groups. Patient demographics, prior surgical history, mesh overlap, complications, and recurrence rates were compared. Thirty-nine (68%) of 57 patients were in the closure group and 18 (32%) in the nonclosure group. Mean defect sizes were 15.5 and 22.5 cm(2), respectively. Participants were followed for a mean of 1.3 years [standard deviation (SD) = 0.7]. Recurrence rates were 2/39 (5.1%) in the closure group and 1/18 (5.6%) in the nonclosure group (P = 0.947). There were no major postoperative complications in the nonclosure group. The closure group experienced four (10.3%) complications. This was not a statistically significant difference (P = 0.159). The median mesh-to-hernia ratio for all repairs was 15.2 (surface area) and 3.9 (diameter). Median length of stay was 14.5 hours (1.7-99.3) for patients with nonclosure and 11.9 hours (6.9-90.3 hours) for patients with closure (P = 0.625). In conclusion, this is one of the largest series of LAVHR exclusively using polyester dual-sided mesh. Our recurrence rate was about 5 per cent. Significant mesh overlap is needed to achieve such low recurrence rates. Primary closure of hernias seems less important than adequate mesh overlap in preventing recurrence after LAVHR.

Prevalence of fungal hyphae in potentially malignant lesions and conditions-does its occurrence play a role in epithelial dysplasia?

BACKGROUND: Oral cancer is a major public health problem in India. A key factor that has led to lack of improvement in prognosis of oral cancer over the years, is delay in diagnosis and treatment. In many instances, a significant proportion of oral squamous cell carcinomas develop from premalignant lesions and conditions. Identification of such lesions and conditions is very important in order to prevent malignant transformation. The role of fungal infections has been studied and holds promise as an indicator to predict malignant transformation. So we designed a study to analyze the prevalence of fungal hyphae in biopsies of patients with clinically diagnosed cases of premalignant lesions and conditions. AIMS AND OBJECTIVES: To determine and compare the prevalence of fungal hyphae in biopsies of patients with clinically diagnosed cases of potentially malignant lesions and conditions and to assess the possible association between the degree of epithelial dysplasia and presence or absence of fungal hyphae. MATERIALS AND METHODS: Clinically suspected and histopathologically diagnosed 70 cases of potentially malignant lesions and conditions (29 leukoplakia, 16 submucous fibrosis and 25 lichen planus) made up the study group. Three tissue sections (5µm) of each were stained with hematoxylin and eosin (H and E), periodic acid-Schiff's reagent (PAS) and Grocott's methenamine silver (GMS) and evaluated for fungal hyphae. The data collected was statistically analyzed by using Chi-square test and Statistical Package for Social Sciences (SPSS) software. RESULTS: The estimated prevalence of fungal hyphae in cases with or without dysplasia in leukoplakia was 41.4%, lichen planus 36% and submucous fibrosis 25%. There was a significant association between degree of epithelial dysplasia with presence or absence of fungal hyphae in all the study groups. CONCLUSION: Presence of fungal hyphae in potentially malignant lesions and conditions may prove to be a useful indicator in predicting malignant transformation.

A study of salivary lactate dehydrogenase isoenzyme levels in patients with oral leukoplakia and squamous cell carcinoma by gel electrophoresis method.

CONTEXT: The enzyme lactate dehydrogenase (LDH), which is found in almost all the cells of body tissues, can be separated into five fractions and the isoenzyme pattern is believed to vary according to the metabolic requirement of each tissue. LDH concentration in saliva, as an expression of cellular necrosis, could be considered to be a specific indicator for oral lesions that affect the integrity of the oral mucosa. AIM: The present study was designed to evaluate salivary LDH isoenzyme pattern in oral leukoplakia (OL) and oral squamous cell carcinoma (OSCC) and to correlate between LDH isoenzyme levels and histopathologic grading in selected cases of OL and OSCC. MATERIALS AND METHODS: Clinically diagnosed 30 cases each of OL and OSCC were selected for the study and 30 healthy individuals of comparable age served as control. Unstimulated whole saliva was aseptically collected and was processed immediately for LDH isoenzymes measurement by agarose gel electrophoresis. Biopsy specimen obtained was processed and stained by hematoxylin and eosin. Sections of OL and OSCC cases were scrutinized histopathologically and appropriately graded for epithelial dysplasia and differentiation of carcinoma respectively. STATISTICAL ANALYSIS USED: Two sample t test for testing the significance of difference between two group means was used. RESULTS AND CONCLUSION: The present salivary analysis for LDH isoenzyme reveals an overall increased salivary LDH isoenzyme level in OL and OSCC cases and a significant correlation between levels of salivary LDH isoenzymes and histopathologic grades of dysplasia in OL and OSCC. Salivary analysis of LDH will definitely provide the clinician and/or the patient himself with an efficient, non invasive and friendly new tool for diagnosis and monitoring of oral precancer and cancer.

Ultrasonography - A diagnostic modality for oral and maxillofacial diseases.

BACKGROUND: Many diseases present themselves in oral and maxillofacial regions and various modalities may be applied for their diagnosis, including intraoral and panoramic radiography, ultrasonography (USG), computer tomography, magnetic resonance imaging, and nuclear medicine methods such as positron emission tomography. Of these modalities, USG is easy to-use for the detection of non-invasive and soft tissue related diseases in oral and maxillofacial regions. USG plays an important role in analyzing normal and abnormal structures. In particular, in oral and maxillofacial regions, the USG may be clinically applied to evaluate lymph nodes, subcutaneous, and oral cavity-related diseases. AIMS: The aim was to correlate the findings of USG and histopathology for the diagnosis of oral and maxillofacial pathology and to evaluate whether USG can be used as an adjunct in diagnosing oral and maxillofacial pathology. MATERIALS AND METHODS: A total of 10 clinically diagnosed patients with intraoral cancerous growths, swellings in maxillary and neck region were included in this study. Incision biopsy was obtained for confirming provisional clinical diagnosis. The selected cases were advised USG. All patients were then posted either for hemi-glossectomy, hemi-mandibulectomy, and partial maxillectomy with or without radical neck dissection. STATISTICAL ANALYSIS: Student's t-test and coefficient of correlation was used to statistically analyze significant relationship of both the methods. RESULT: In all 10 cases, USG correlated well with histopathology findings, it could also delineate tumor extent and measure tumor thickness. CONCLUSION: USG is an excellent method for the diagnosis of soft tissue lesions and can be used as an adjunct in diagnosing oral and maxillofacial pathology.

A histochemical study of tissue eosinophilia in oral squamous cell carcinoma using Congo red staining.

BACKGROUND: Tumor associated tissue eosinophilia is believed to play a significant role in the biological behavior of the carcinoma. Eosinophil infiltrate in association with the head and neck squamous cell carcinoma (SCC) have been reviewed from time-to-time. The significance of such an association has been variably thought to be either a potential diagnostic tool for stromal invasion or as a prognostic indicator. We aimed to evaluate the efficacy of Congo red staining to differentiate eosinophils in the inflammatory infiltrate in oral squamous cell carcinoma (OSCC) and whether this eosinophilia is associated with the histologic grading in OSCC. MATERIALS AND METHODS: The eosinophil infiltration in hematoxylin and eosin (H and E) and Congo red stained sections of 50 biopsies of OSCC were examined. The eosinophil distribution was quantitatively evaluated in both sections as either diffuse or focal and scored as mild, moderate and severe grades. The average number of eosinophils obtained in OSCC stained by H and E and Congo red were then statistically compared by univariate analysis carried out using Student's t-test. P < 0.01 was used to determine the statistical significance. RESULTS: In the OSCC, the eosinophil infiltration was seen in 43 out of 50 (86%) cases. The elevation of eosinophil count was more diffuse than focal (36 vs. 7 [83.72 vs. 16.27%]). The staining efficacy of Congo red stain over H and E stain to differentiate eosinophils was excellent and found to be statistically significant (P < 0.01). No significant correlation was found with the eosinophil infiltration and the histologic grades of OSCC. CONCLUSION: Our study showed a strong infiltration of eosinophils in OSCC though no significant correlation was found with the eosinophil infiltration and the histologic grades of OSCC. Congo red staining showed a high sensitivity in staining eosinophils over routine H and E. This staining technique could therefore provide an adjunct to routine H and E in evaluating eosinophils in dysplasia and OSCC cases.

Lung microbiology and exacerbations in COPD.

Chronic obstructive pulmonary disease (COPD) is the most common chronic respiratory condition in adults and is characterized by progressive airflow limitation that is not fully reversible. The main etiological agents linked with COPD are cigarette smoking and biomass exposure but respiratory infection is believed to play a major role in the pathogenesis of both stable COPD and in acute exacerbations. Acute exacerbations are associated with more rapid decline in lung function and impaired quality of life and are the major causes of morbidity and mortality in COPD. Preventing exacerbations is a major therapeutic goal but currently available treatments for exacerbations are not very effective. Historically, bacteria were considered the main infective cause of exacerbations but with the development of new diagnostic techniques, respiratory viruses are also frequently detected in COPD exacerbations. This article aims to provide a state-of-the art review of current knowledge regarding the role of infection in COPD, highlight the areas of ongoing debate and controversy, and outline emerging technologies and therapies that will influence future diagnostic and therapeutic pathways in COPD.

Viruses exacerbating chronic pulmonary disease: the role of immune modulation.

Chronic pulmonary diseases are a major cause of morbidity and mortality and their impact is expected to increase in the future. Respiratory viruses are the most common cause of acute respiratory infections and it is increasingly recognized that respiratory viruses are a major cause of acute exacerbations of chronic pulmonary diseases such as asthma, chronic obstructive pulmonary disease and cystic fibrosis. There is now increasing evidence that the host response to virus infection is dysregulated in these diseases and a better understanding of the mechanisms of abnormal immune responses has the potential to lead to the development of new therapies for virus-induced exacerbations. The aim of this article is to review the current knowledge regarding the role of viruses and immune modulation in chronic pulmonary diseases and discuss avenues for future research and therapeutic implications.

Gorlin-Goltz syndrome.

Gorlin-Goltz syndrome is an uncommon autosomal dominant inherited disorder, which is characterized by multiple odontogenic Keratocysts and basal cell carcinomas, skeletal, dental, ophthalmic, and neurological abnormalities, intracranial ectopic calcifications of the falx cerebri, and facial dysmorphism. Pathogenesis of the syndrome is attributed to abnormalities in the long arm of chromosome 9 (q22.3-q31) and loss or mutations of human patched gene (PTCH1 gene). Diagnosis is based upon established major and minor clinical and radiological criteria and ideally confirmed by deoxyribo nucleic acid analysis. We report a case of a 9-year-old girl presenting with three major and one minor feature of Gorlin-Goltz syndrome. Radiologic findings of the syndrome are easily identifiable on Orthopantomogram, chest X-ray, and Computed tomography scans. These investigations prompt an early verification of the disease, which is very important to prevent recurrence and better survival rates from the coexistent diseases.

A study to evaluate the efficacy of xylene-free hematoxylin and eosin staining procedure as compared to the conventional hematoxylin and eosin staining: An experimental study.

CONTEXT: Use of diluted dish washing solution (DWS) has been experimented successfully as a substitute for xylene to deparaffinize tissue sections during hematoxylin and eosin (H and E) staining. AIMS: (1) Test the hypothesis that xylene- and methanol-free sections (XMF) deparaffinized with diluted DWS are better than or at par with conventional H and E sections. (2) To compare the efficacy of xylene-free sections with the conventional H and E sections. SETTINGS AND DESIGN: Single blinded experimental study. MATERIALS AND METHODS: Sixty paraffin blocks were considered. One section was stained with conventional H and E method (Group A) and the other with XMF H and E (Group B). Slides were scored for parameters; nuclear staining, cytoplasmic staining (adequate = score1, inadequate = score0), uniformity, clarity, crispness (present = score1, absent = score0). Score >/= 2 was inadequate for diagnosis and 3-5 was adequate for diagnosis. STATISTICAL ANALYSIS USED: Z test. RESULTS: Adequate nuclear staining, 96.66% sections in group A and 98.33% in Group B (Z = 0.59, P>0.05); adequate cytoplasmic staining, 93.33% in group A and 83.33% in Group B (Z = 1.97, P<0.05); uniform staining, 70% in group A, 50% in group B (Z = 1.94, P<0.05), clarity present in 85% of group A, 88.33% of group B sections (Z = 0.27, P>0.05), crisp staining in 76.66% in group A and 83.33% in Group B (Z = 1.98, P<0.05), 88.33% Group A sections stained adequately for diagnosis as compared with 90% in Group B (Z = 0.17, P>0.05). CONCLUSION: Xylene- and methanol-free H and E staining is a better alternative to the conventional H and E staining procedure.

Human immunodeficiency virus type 1 RNA in breast-milk components.

We conducted the present study to determine which of the 4 components of breast milk (whole milk, skim milk, lipid layer, and breast-milk cells) had the highest sensitivity and concentration of human immunodeficiency virus (HIV) type 1 RNA burden and to determine biological correlates to these factors. The probability of detection of HIV (sensitivity) and the concentration of HIV-1 RNA were both associated with the choice of milk component, CD4(+) cell count, concentration of blood serum HIV-1 RNA, and the presence of breast inflammation. Whole milk demonstrated higher sensitivity and mean concentration than any other single component. Sensitivity was enhanced by analyzing all 4 components of breast milk.