Ask-Tell-Ask with Bidirectional Feedback Improves Feedback Culture.

OBJECTIVE: The authors sought to assess whether an Ask-Tell-Ask feedback model augmented with bidirectional feedback improves perception of feedback. METHODS: Implementation occurred on an inpatient psychiatry unit at University of North Carolina (UNC) Hospitals from July 2022 to June 2023 among attending and resident physicians and medical students. Attending physicians were educated on the Ask-Tell-Ask model and encouraged to hold weekly bidirectional feedback sessions with trainees. Surveys containing scales and free-text response were distributed by email before and after rotations to assess perception of feedback: if feedback was clearly stated, occurred on a predictable basis, included actionable goals, and fostered bidirectional feedback with attendings. For statistical analysis, survey responses were assigned numerical values of 1 (strongly disagree) to 5 (strongly agree). Differences between mean numerical correlates of responses from pre-rotation and post-rotation surveys were analyzed with unpaired t-tests; p < 0.05 indicated statistical significance. Authors independently developed themes from free-text responses, which were consolidated with themes developed by all authors. RESULTS: Mean ratings to survey items universally improved following the intervention; all p < 0.0001 and statistically significant. Pre-rotation, feedback culture was described as constrained, fraught, non-actionable, inconsistent, improving, and hierarchical. Post-rotation, the feedback culture within the UNC Department of Psychiatry was described as constructive, consistent, improving, strength-based, approachable, and nonhierarchical. CONCLUSIONS: An Ask-Tell-Ask feedback model with an added emphasis on giving and receiving feedback significantly improves perception of feedback and feedback culture.

Academic performance of students in an accelerated medical pathway.

Accelerated medical school curricula, such as three-year programs, have gained attention in recent years but studies evaluating their impact are still scarce. This study examines the Fully Integrated Readiness for Service Training (FIRST) program, a three-year accelerated pathway, to assess its impact on students' academic performance preparedness for residency. In this observational study, we compared the academic outcomes of FIRST program students to traditional four-year curriculum students from 2018 to 2023. We analyzed multiple metrics, including exam performance (United States Medical Licensing Examination Step scores, shelf exam scores, and pre-clinical course scores) and clinical performance scores during the application and individualization phases. Analysis of Variance was used to examine the effect of accelerated pathway program experience relative to traditional 4-year medical school curriculum on the learning outcomes. FIRST program students were on average 1.5 years younger upon graduation than their traditional peers. While FIRST program students scored slightly lower on Step 2 Clinical Knowledge (CK), they exhibited no significant differences in other exam scores or clinical performance relative to the traditional students. Notably, FIRST students achieved equivalent clinical performance ratings during critical clerkships and rotations. Our findings suggest that a three-year medical school curriculum can effectively prepare students for residency and produce graduates with comparable medical knowledge and clinical skills, offering potential benefits in terms of financial relief and personal well-being for medical students.

Survival of Filipino women with breast cancer in the United States.

BACKGROUND: The survival of women with early-stage breast cancer varies by racial group. Filipino women with breast cancer are an understudied group and are often combined with other Asian groups. We compared clinical presentations and survival rates for Filipino and White women with breast cancer diagnosed in the United States. METHODS: We conducted a retrospective cohort study of women with breast cancer diagnosed between 2004 and 2015 in the SEER18 registries database. We compared crude survival between Filipino and White women. We then calculated adjusted hazard ratios (HR) in a propensity-matched design using the Cox proportional hazards model. RESULTS: There were 10,834 Filipino (2.5%) and 414,618 White women (97.5%) with Stage I-IV breast cancer in the SEER database. The mean age at diagnosis was 57.5 years for Filipino women and 60.8 years for White women (p < 0.0001). Filipino women had more high-grade and larger tumors than White women and were more likely to have node-positive disease. Among women with Stage I-IIIC breast cancer, the crude 10-year breast cancer-specific survival rate was 91.0% for Filipino and 88.9% for White women (HR 0.81, 95% CI 0.74-0.88, p < 0.01). In a propensity-matched analysis, the HR was 0.73 (95% CI 0.66-0.81). The survival advantage for Filipino women was present in subgroups defined by age of diagnosis, nodal status, estrogen receptor status, and HER2 receptor status. CONCLUSION: In the United States, Filipino women often present with more advanced breast cancers than White women, but experience better breast cancer-specific survival.

A novel multiplex score to predict outcomes of partial nephrectomy for multiple tumors.

BACKGROUND: The RENAL nephrometry score (RNS) is widely used to describe renal mass complexity and inform patient counseling for partial nephrectomy (PN). However, in cases with multiple tumors, it is unknown which features drive perioperative outcomes. OBJECTIVE: To employ a novel scoring equation (multiplex score [MS]) derived from RNS to assess outcomes of multiplex PN at our institution. DESIGN, SETTING, AND PARTICIPANTS: A total of 62 consecutive multiplex PN (median (range) # tumors = 4(2-11), 65% robotic) were performed by a single surgeon. The MS was defined a priori as a weighted score derived from RNS (# low risk ([LR] lesions) + 2*(# intermediate risk [IR]) + 4*(# high risk [HR]) based on published complication rates. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: MS was dichotomized into favorable/unfavorable based on median score. Patient outcomes were maintained prospectively. MS was compared with other potential RNS derived scoring systems. RESULTS AND LIMITATION: A total of 249 tumors were scored. Median (range) MS was 6(range 2-20, IQR 3-8). Complications occurred in 10 patients (16.1%). Only 1 complication occurred in the favorable MS(<6) group, and MS was associated with perioperative complication (P = 0.02) and blood loss (P < .001). When compared to other potential scoring systems, MS had the best area under the curve (AUC) to predict operative complications (0.75). CONCLUSIONS: The novel MS was associated with complications and blood loss. This tool may facilitate standardized reporting of complexity for multiplex series, with special relevance for hereditary cancer syndromes. PATIENT SUMMARY: For patients who have one kidney tumor, there are established scoring systems to help patients and surgeons decide on the surgical plan. However currently, for patients with more than one renal tumor, there is no such scoring system. Here, we present the "Multiplex Score" to aid shared-decision-making in cases with more than one renal tumor.

Integrated Care Education for General Psychiatry Residents in the US: a Review of the Literature.

OBJECTIVE: The purpose of this review was to synthesize published literature describing integrated care education available to general psychiatry residents in the United States (US) in order to better understand curricular models and summarize curriculum barriers and facilitators. METHODS: The authors searched electronic databases for articles describing integrated care education for general psychiatry residents. Minimum inclusion criteria were focus on an ambulatory integrated care curriculum, description of the study population and training program, publication in English, and program location in the US. Data extracted included trainee, faculty, or collaborator evaluations, educational model, level of care integration, and barriers or facilitators to implementation. RESULTS: The literature search identified 18 articles describing curricula at 26 residency programs for inclusion. Most programs offered clinical and didactic curricula to advanced trainees across a variety of care integration levels. Common barriers included fiscal vulnerability and difficulties identifying team members or clarifying team member roles. Common facilitators included institutional and interdepartmental support, dedicated space, and faculty supervision. No statistical analysis was able to be performed due to study heterogeneity. CONCLUSIONS: This review found a relatively small number of articles written about integrated care education for psychiatry residents. Resident evaluation suggests this training is valuable regardless of curriculum structure, training years, or level of care integration. Dedicated funding, staff, and space were crucial for successful curricula. This review highlights a need for more rigorous research characterizing and evaluating integrated care education.

Impact of Mentoring on Academic Career Success for Women in Medicine: A Systematic Review.

PURPOSE: Research has shown that barriers to career success in academic medicine disproportionately affect women. These barriers include inadequate mentoring, which may perpetuate the underrepresentation of women in senior leadership positions. The purpose of this review was to summarize the qualitative and quantitative evidence of the impact of mentoring on women's career outcomes and to inform future interventions to support the promotion and retention of women in academic medicine. METHOD: The authors conducted a systematic review of original research published in English-language, peer-reviewed journals through March 20, 2020. Search terms related to mentorship, women, and academic medicine. The authors searched MEDLINE, Embase, Scopus, Current Contents Connect via Web of Science, Cochrane Library, and PsycINFO. They excluded studies not specifically addressing women and those without gender-stratified outcomes. They extracted and analyzed the following data: study design, population, sample size, response rate, participant age, percentage of women, mentoring prevalence, and outcomes. RESULTS: Of 2,439 citations identified, 91 studies met the inclusion criteria, including 65 quantitative and 26 qualitative studies. Mentoring was associated with objective and subjective measures of career success. Women perceived mentorship to be more valuable to their career development yet were more likely to report having no mentor. Additionally, women were more likely to report lower levels of research productivity, less career satisfaction, and greater barriers to promotion. Qualitative results indicated that women had less access to informal mentoring and family responsibilities had a greater effect on their career outcomes. Professional networking, female mentors, and relational aspects of mentoring were common themes. CONCLUSIONS: This review examined gender disparities in mentoring and the impact on research productivity, promotion success, and career satisfaction for women in academic medicine. Institution-supported mentoring programs are needed to facilitate identification of appropriate mentors and promotion of a more equitable academic career environment for women.

Reoperative Partial Nephrectomy-Does Previous Surgical Footprint Impact Outcomes?

PURPOSE: Historically, open techniques have been favored over minimally invasive approaches for complex surgeries. We aimed to identify differences in perioperative outcomes, surgical footprints, and complication rates in patients undergoing either open or robotic reoperative partial nephrectomy. MATERIALS AND METHODS: A retrospective review of patients undergoing reoperative partial nephrectomy was performed. Patients were assigned to cohorts based on current and prior surgical approaches: open after open, open after minimally invasive surgery, robotic after open, and robotic after minimally invasive surgery cohorts. Perioperative outcomes were compared among cohorts. Factors contributing to complications were assessed. RESULTS: A total of 192 patients underwent reoperative partial nephrectomy, including 103 in the open after open, 10 in the open after minimally invasive surgery, 47 in the robotic after open, and 32 in the robotic after minimally invasive surgery cohorts. The overall and major complication (grade ≥3) rates were 65% and 19%, respectively. The number of blood transfusions, overall complications, and major complications were significantly lower in robotic compared to open surgical cohorts. On multivariate analysis, the robotic approach was protective against major complications (OR 0.3, p=0.02) and estimated blood loss was predictive (OR 1.03, p=0.004). Prior surgical approach was not predictive for major complications. CONCLUSIONS: Reoperative partial nephrectomy is feasible using both open and robotic approaches. While the robotic approach was independently associated with fewer major complications, prior approach was not, implying that prior surgical approaches are less important to perioperative outcomes and in contributing to the overall surgical footprint.

Inhibition of a tonic inhibitory conductance in mouse hippocampal neurones by negative allosteric modulators of α5 subunit-containing γ-aminobutyric acid type A receptors: implications for treating cognitive deficits.

BACKGROUND: Multiple cognitive and psychiatric disorders are associated with an increased tonic inhibitory conductance that is generated by α5 subunit-containing γ-aminobutyric acid type A (α5 GABAA) receptors. Negative allosteric modulators that inhibit α5 GABAA receptors (α5-NAMs) are being developed as treatments for these disorders. The effects of α5-NAMs have been studied on recombinant GABAA receptors expressed in non-neuronal cells; however, no study has compared drug effects on the tonic conductance generated by native GABAA receptors in neurones, which was the goal of this study. METHODS: The effects of five α5-NAMs (basmisanil, Ono-160, L-655,708, α5IA, and MRK-016) on tonic current evoked by a low concentration of GABA were studied using whole-cell recordings in cultured mouse hippocampal neurones. Drug effects on current evoked by a saturating concentration of GABA and on miniature inhibitory postsynaptic currents (mIPSCs) were also examined. RESULTS: The α5-NAMs caused a concentration-dependent decrease in tonic current. The potencies varied as the inhibitory concentration for 50% inhibition (IC50) of basmisanil (127 nM) was significantly higher than those of the other compounds (0.4-0.8 nM). In contrast, the maximal efficacies of the drugs were similar (35.5-51.3% inhibition). The α5-NAMs did not modify current evoked by a saturating GABA concentration or mIPSCs. CONCLUSIONS: Basmisanil was markedly less potent than the other α5-NAMs, an unexpected result based on studies of recombinant α5 GABAA receptors. Studying the effects of α5 GABAA receptor-selective drugs on the tonic inhibitory current in neurones could inform the selection of compounds for future clinical trials.

Dissecting the role of TRPV1 in detecting multiple trigeminal irritants in three behavioral assays for sensory irritation.

Polymodal neurons of the trigeminal nerve innervate the nasal cavity, nasopharynx, oral cavity and cornea. Trigeminal nociceptive fibers express a diverse collection of receptors and are stimulated by a wide variety of chemicals. However, the mechanism of stimulation is known only for relatively few of these compounds. Capsaicin, for example, activates transient receptor potential vanilloid 1 (TRPV1) channels. In the present study, wildtype (C57Bl/6J) and TRPV1 knockout mice were tested in three behavioral assays for irritation to determine if TRPV1 is necessary to detect trigeminal irritants in addition to capsaicin. In one assay mice were presented with a chemical via a cotton swab and their response scored on a 5 level scale. In another assay, a modified two bottle preference test, which avoids the confound of mixing irritants with the animal's drinking water, was used to assess aversion. In the final assay, an air dilution olfactometer was used to administer volatile compounds to mice restrained in a double-chambered plethysmograph where respiratory reflexes were monitored. TRPV1 knockouts showed deficiencies in the detection of benzaldehyde, cyclohexanone and eugenol in at least one assay. However, cyclohexanone was the only substance tested that appears to act solely through TRPV1.

Magno and parvo stimuli affect illusory directional hearing in normal and dyslexic readers.

In an experimental paradigm adapted from Hari (1995), forty observers listened via headphones to 8 binaural clicks: 4 left-ear leading followed by 4 right-ear leading with either 38 or 140 ms interstimulus intervals (ISIs). Concurrently, they viewed either foveal or peripheral visual stimuli designed to activate either the parvocellular or magnocellular pathway. They then reported the perceived location of each click-pair. Our results replicated Hari's finding that observers mistake the perceived location of short ISI click-pairs more often than long. That is, when ISIs were short, the sounds seemed to play across the inside of the head in a phenomenon called illusory directional hearing. However, when click-pairs were accompanied by peripheral visual stimuli that activated the magnocellular pathway, observers were more accurate than when there were no visual stimuli. Conversely, parvocellular-activating foveal visual stimuli produced more illusory hearing than when there were no visual stimuli. These findings suggest that activating the slow sustained parvocellular system may result in a longer processing window. Thirty dyslexic observers who repeated the experimental paradigm had an even longer processing window than control observers indicating that dyslexics may have a magnocellular system deficit.

A first principles study of water dissociation on small copper clusters.

Water dissociation on copper is one of the rate-limiting steps in the water-gas-shift (WGS) reaction. Copper atoms dispersed evenly from freshly made catalyst segregate to form clusters under the WGS operating conditions. Using density functional theory, we have examined water adsorption and dissociation on the smallest stable 3-dimensional copper cluster, Cu(7). Water molecules are adsorbed on the cluster sequentially until full saturation at which no direct water-copper contact is sterically possible. The adsorption is driven mainly by the overlap between the p-orbital of O atom occupied by the lone pair and the 3d-orbitals of copper, from which a fractional charge is promoted to the 4s-orbital to accommodate the charge transfer from water. Water dissociation on the Cu(7) cluster was investigated at both low and high water coverage. It was found that water dissociation into OH and H is exothermic but is inherently a high temperature process at low coverage. At high coverage, the reaction becomes more exothermic with fast kinetics. In both cases, water can catalyze the reaction. It was found that direct dissociation of the OH species is endothermic with a significantly higher barrier at both low and high coverage. However, the OH species can readily react with another adjacent hydroxyl group to form an O adatom and water molecule. Our studies indicate that the basic chemical properties of water dissociative chemisorption may not change significantly with the size of small copper clusters. Similarities between water dissociation on copper clusters and on copper crystalline surfaces are discussed.

Atomoxetine changes rat's HR response to stress from tachycardia to bradycardia via alterations in autonomic function.

Atomoxetine is a central norepinephrine reuptake inhibitor used to treat attention deficit hyperactivity disorder. We tested the effects of atomoxetine upon the heart rate (HR) and mean arterial blood pressure (mBP) response to aversive conditioning. In Protocol 1 the mBP and HR responses to a stress (15s tone followed by shock) were tested in 8 Sprague-Dawley rats given saline pretreatment for 3 days; the rats' responses were then tested for 3 additional days following atomoxetine (1mg/kg, sc). Atomoxetine decreased (p<0.05) baseline mBP from 128+/-11 mm Hg (mean+/-SD) to 117+/-19 mm Hg; baseline HR slowed from 380+/-23 bpm to 351+/-21 bpm. The mBP increase to acute stress was similar after saline vs. after drug, but the peak was attained more slowly. After atomoxetine HR tended to slow during stress rather than accelerate. In Protocol 2 the cardiovascular responses were tested (n=6) for 3 days post-saline and for 3 days after a higher dose of atomoxetine (2mg/kg, sc). The average HR acceleration during the last 10s of the stress after saline (+7.5+/-14.7 bpm) was replaced by a HR slowing (-6.2+/-10.5 bpm). We conclude that drug treatment (a) decreases baseline sympathetic tone and/or elevates cardiac parasympathetic tone; (b) slows sympathetic arousal to acute stress without changing its magnitude; and, (c) enables the emergence of elevated parasympathetic tone during the stress. These autonomic consequences are consistent with atomoxetine's anxiolytic and transient sedative effects.

A maximum likelihood approach for image registration using control point and intensity.

Registration of multidate or multisensor images is an essential process in many image processing applications including remote sensing, medical image analysis, and computer vision. Control point (CP) and intensity are the two basic features used separately for image registration in the literature. In this paper, an exact maximum likelihood (EML) registration method, which combines both CP and intensity, is proposed for image alignment. The EML registration method maximizes the likelihood function based CP and intensity to estimate the registration parameters, including affine transformation and CP coordinates. The explicit formulas of the Cramer-Rao bound (CRB) are also derived for the proposed EML and conventional image registration algorithms. The performances of these image registration techniques are evaluated with the CRBs.