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Martinez M, Arora V, Gonzalez CM, Dzeng E, Williams JS. Doubling Down on Diversity: Enhancing the Recruitment and Retention of Underrepresented Academic Physicians in a Post-affirmative Action Era. J Gen Intern Med 2024:10.1007/s11606-024-08741-7. [PMID: 38564161 DOI: 10.1007/s11606-024-08741-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Affiliation(s)
- Maylyn Martinez
- Section of Hospital Medicine, Biological Sciences Division, Department of Medicine, University of Chicago, Chicago, IL, USA.
| | - Vineet Arora
- Pritzker School of Medicine, The University of Chicago, Chicago, IL, USA
| | - Cristina M Gonzalez
- Institute for Excellence in Health Equity, New York University Grossman School of Medicine, New York, NY, USA
| | - Elizabeth Dzeng
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Joni S Williams
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Wauwatosa, WI, USA
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
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Gonzalez CM, Ark TK, Fisher MR, Marantz PR, Burgess DJ, Milan F, Samuel MT, Lypson ML, Rodriguez CJ, Kalet AL. Racial Implicit Bias and Communication Among Physicians in a Simulated Environment. JAMA Netw Open 2024; 7:e242181. [PMID: 38506811 PMCID: PMC10955368 DOI: 10.1001/jamanetworkopen.2024.2181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/31/2023] [Indexed: 03/21/2024] Open
Abstract
Importance Racial implicit bias can contribute to health disparities through its negative influence on physician communication with Black patients. Interventions for physicians to address racial implicit bias in their clinical encounters are limited by a lack of high-fidelity (realistic) simulations to provide opportunities for skill development and practice. Objective To describe the development and initial evaluation of a high-fidelity simulation of conditions under which physicians might be influenced by implicit racial bias. Design, Setting, and Participants This cross-sectional study, performed on an online platform from March 1 to September 30, 2022, recruited a convenience sample of physician volunteers to pilot an educational simulation. Exposures In the simulation exercise, physicians saw a 52-year-old male standardized patient (SP) (presenting as Black or White) seeking urgent care for epigastric pain, nausea, and vomiting. The case included cognitive stressors common to clinical environments, including clinical ambiguity, stress, time constraints, and interruptions. Physicians explained their diagnosis and treatment plan to the SP, wrote an assessment and management plan, completed surveys, and took the Race Implicit Association Test (IAT) and Race Medical Cooperativeness IAT. The SPs, blinded to the purpose of the study, assessed each physician's communication using skills checklists and global rating scales. Main Outcomes and Measures Association between physicians' IAT scores and SP race with SP ratings of communication skills. Results In 60 physicians (23 [38.3%] Asian, 4 [6.7%] Black, 23 [38.3%] White, and 10 [16.7%] other, including Latina/o/x, Middle Eastern, and multiracial; 31 [51.7%] female, 27 [45.0%] male, and 2 [3.3%] other), the interaction of physicians' Race IAT score and SP race was significant for overall communication (mean [SD] β = -1.29 [0.41]), all subdomains of communication (mean [SD] β = -1.17 [0.52] to -1.43 [0.59]), and overall global ratings (mean [SD] β = -1.09 [0.39]). Black SPs rated physicians lower on communication skills for a given pro-White Race IAT score than White SPs; White SP ratings increased as physicians' pro-White bias increased. Conclusions and Relevance In this cross-sectional study, a high-fidelity simulation calibrated with cognitive stressors common to clinical environments elicited the expected influence of racial implicit bias on physicians' communication skills. The outlined process and preliminary results can inform the development and evaluation of interventions that seek to address racial implicit bias in clinical encounters and improve physician communication with Black patients.
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Affiliation(s)
- Cristina M. Gonzalez
- Institute for Excellence in Health Equity, New York University Grossman School of Medicine, New York
- Department of Medicine, New York University Grossman School of Medicine, New York
- Department of Population Health, New York University Grossman School of Medicine, New York
| | | | - Marla R. Fisher
- Department of Psychiatry, Mount Sinai Morningside-West, New York, New York
| | - Paul R. Marantz
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Diana J. Burgess
- Department of Medicine, University of Minnesota, Minneapolis
- Center for Care Delivery and Outcomes Research in the Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Felise Milan
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | | | - Monica L. Lypson
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Carlos J. Rodriguez
- Department of Medicine and Epidemiology & Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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Hossain OB, Srikantha R, Ferguson N, Agalliu I, Gonzalez CM. Implicit Bias and Clinical Decision Making in Psoriasis Management Among Dermatology Residents: A Feasibility Study. J Drugs Dermatol 2024; 23:e73-e76. [PMID: 38306135 DOI: 10.36849/jdd.7499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
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Gonzalez CM, De Leon E. A Call to Promote Interventions for Increased Diversity in Health Professions Programs-Beyond Trends. JAMA Netw Open 2023; 6:e2347852. [PMID: 38153741 DOI: 10.1001/jamanetworkopen.2023.47852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Affiliation(s)
- Cristina M Gonzalez
- Institute for Excellence in Health Equity, New York University Grossman School of Medicine, New York
| | - Elaine De Leon
- Institute for Excellence in Health Equity, New York University Grossman School of Medicine, New York
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Adams JE, Williams R, Gillespie C, Minsky M, LaPook J, Greene R, Ravenell J, Dennehy J, Gonzalez CM. Using an Animated Film to Foster Understanding of and Engagement in Addressing Implicit Bias Through Empathy Across the Health Care Continuum. Acad Med 2023; 98:S169. [PMID: 37983411 DOI: 10.1097/acm.0000000000005389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Affiliation(s)
- Jennifer E Adams
- Author affiliations: J.E. Adams, C. Gillespie, M. Minsky, J. LaPook, Center for Empathy in Medicine, Institute for Innovations in Medical Education, NYU Grossman School of Medicine; R. Williams, J. Dennehy, C.M. Gonzalez, Institute for Excellence in Health Equity, NYU Langone Health; R. Greene, J. Ravenell, Office of Diversity Affairs, NYU Grossman School of Medicine
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Hassan IF, Gorski V, Sanderson D, Braganza S, Benfield N, Nadas M, Amursi E, Gonzalez CM. Consensus on Social Determinants of Health Knowledge Topics and Behavior Learning Goals Across Primary Care Residencies: Results of a Delphi Study. Acad Med 2023; 98:941-948. [PMID: 36917120 DOI: 10.1097/acm.0000000000005207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
PURPOSE Social determinants of health (SDH) are a substantial contributor to health outcomes and health inequities across populations. The Accreditation Council for Graduate Medical Education has called for the incorporation of SDH into graduate medical education (GME), yet there is no consensus on what SDH knowledge or skills residents in primary care specialties should have on completion of training. The aim of this study was to develop expert consensus on the most important SDH knowledge topics and behavior learning goals for residents in 4 primary care fields. METHOD The authors used a modified Delphi technique to develop consensus among experts in internal medicine, pediatrics, family medicine, and obstetrics and gynecology across the United States via a survey administered between February and October 2021. They conducted a literature review on SDH in GME to develop an initial set of topics and learning goals and recruited experts who published about SDH and GME or led an SDH curriculum in GME. Consensus was determined a priori as 80% agreement that a topic or learning goal was very or extremely important. RESULTS Forty-one experts participated in the first round of the survey and 33 participated in the second round (80% retention). Experts reached consensus on the importance of 22/51 (43%) topics and 18/47 (38%) learning goals. Topics reaching consensus emphasized structural forces, broad domains of SDH, resources for addressing SDH, and advocacy strategies and resources. Learning goals reaching consensus focused on individual- and interpersonal-level behaviors. CONCLUSIONS To the authors' knowledge, this study represents the first rigorous evaluation of expert consensus on SDH in GME across 4 primary care specialties. The results could inform curriculum development and implementation and program evaluation, residency program goals, and shared GME milestones. Among other things, future studies can assess expert consensus on SDH in GME across nonprimary care specialties.
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Affiliation(s)
- Iman F Hassan
- I.F. Hassan is assistant professor, Department of Medicine, Albert Einstein College of Medicine, New York, New York
| | - Victoria Gorski
- V. Gorski is associate professor, Department of Family and Social Medicine, Albert Einstein College of Medicine, New York, New York
| | - Dana Sanderson
- D. Sanderson is assistant professor, Departments of Pediatrics and Family and Social Medicine, Albert Einstein College of Medicine, New York, New York
| | - Sandra Braganza
- S. Braganza is associate professor, Departments of Pediatrics and Family and Social Medicine, Albert Einstein College of Medicine, New York, New York
| | - Nerys Benfield
- N. Benfield is associate professor, Department of Obstetrics, Gynecology, and Reproductive Studies, University of California, San Francisco, California
| | - Marisa Nadas
- M. Nadas is assistant professor, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, New York, New York
| | - Erka Amursi
- E. Amursi is former program coordinator, Department of Family and Social Medicine, Albert Einstein College of Medicine, New York, New York
| | - Cristina M Gonzalez
- C.M. Gonzalez is professor, Departments of Medicine and Population Health, New York University School of Medicine, New York, New York; ORCID: http://orcid.org/0000-0002-9779-6548
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Gonzalez CM, Onumah CM, Walker SA, Karp E, Schwartz R, Lypson ML. Implicit bias instruction across disciplines related to the social determinants of health: a scoping review. Adv Health Sci Educ Theory Pract 2023; 28:541-587. [PMID: 36534295 DOI: 10.1007/s10459-022-10168-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 09/27/2022] [Indexed: 05/11/2023]
Abstract
One criticism of published curricula addressing implicit bias is that few achieve skill development in implicit bias recognition and management (IBRM). To inform the development of skills-based curricula addressing IBRM, we conducted a scoping review of the literature inquiring, "What interventions exist focused on IBRM in professions related to social determinants of health: education, law, social work, and the health professions inclusive of nursing, allied health professions, and medicine?"Authors searched eight databases for articles published from 2000 to 2020. Included studies: (1) described interventions related to implicit bias; and (2) addressed knowledge, attitude and/or skills as outcomes. Excluded were interventions solely focused on reducing/neutralizing implicit bias. Article review for inclusion and data charting occurred independently and in duplicate. Investigators compared characteristics across studies; data charting focused on educational and assessment strategies. Fifty-one full-text articles for data charting and synthesis, with more than 6568 learners, were selected. Educational strategies included provocative/engagement triggers, the Implicit Association Test, reflection and discussion, and various active learning strategies. Most assessments were self-report, with fewer objective measures. Eighteen funded studies utilized federal, foundation, institutional, and private sources. This review adds to the literature by providing tangible examples of curricula to complement existing frameworks, and identifying opportunities for further research in innovative skills-based instruction, learner assessment, and development and validation of outcome metrics. Continued research addressing IBRM would enable learners to develop and practice skills to recognize and manage their implicit biases during clinical encounters, thereby advancing the goal of improved, equitable patient outcomes.
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Affiliation(s)
- Cristina M Gonzalez
- Institute for Excellence in Health Equity, New York University Grossman School of Medicine, New York, NY, USA.
| | - Chavon M Onumah
- Department of Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Sydney A Walker
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elisa Karp
- Department of Pediatrics, North Central Bronx Hospital, Bronx, NY, USA
| | | | - Monica L Lypson
- Columbia University Irving Medical Center, Columbia University Vagelos College of Physicians and Surgeons, New York, USA
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Macfie WG, Spilka MJ, Bartolomeo LA, Gonzalez CM, Strauss GP. Emotion regulation and social knowledge in youth at clinical high-risk for psychosis and outpatients with chronic schizophrenia: Associations with functional outcome and negative symptoms. Early Interv Psychiatry 2023; 17:21-28. [PMID: 35362242 PMCID: PMC10084209 DOI: 10.1111/eip.13287] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 01/17/2022] [Accepted: 03/13/2022] [Indexed: 01/21/2023]
Abstract
AIM Previous studies indicate that several aspects of social cognition are associated with poor social and vocational outcome in the chronic phase of psychosis. However, it is less clear whether specific aspects of social cognition are impaired in those at clinical high-risk (CHR) for psychosis and associated with functioning. The current study evaluated two understudied components of social cognition, emotion regulation knowledge and social knowledge, to determine whether CHR and chronic schizophrenia (SZ) samples demonstrated comparable magnitudes of impairment and associations with functioning. METHODS Two studies were conducted. Study 1 included n = 98 outpatients with chronic SZ and n = 88 demographically matched healthy controls (CN). Study 2 included 30 CHR and 30 matched CN participants. In both studies, participants completed the emotion management and social management subtests of the Mayer-Salovey-Caruso Emotional Intelligence Test to assess emotion regulation knowledge and social knowledge, respectively. A battery of clinical interviews was also administered, including measures of: role and social functioning, positive symptoms, negative symptoms, disorganization and general symptoms. RESULTS Individuals with SZ demonstrated lower emotion management and social management scores than CN participants. CHR demonstrated lower scores in social management than CN but did not display deficits in emotion management. In both studies, reduced social knowledge was associated with worse functioning and negative symptoms. CONCLUSIONS Findings indicate that deficits in social knowledge are transphasic across the SZ spectrum, and are associated with clinical functioning. Social knowledge may be a novel treatment target for psychosocial interventions.
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Affiliation(s)
- William G Macfie
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | - Michael J Spilka
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | - Lisa A Bartolomeo
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | | | - Gregory P Strauss
- Department of Psychology, University of Georgia, Athens, Georgia, USA
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Ark T, Fisher M, Milan F, Kalet AL, Marantz PR, Burgess D, Rodriguez CJ, Burd-Orama L, Samuel M, Gonzalez CM. Heartache or Bellyache? Epigastric Pain, Communication Skills, and Implicit Bias: Can We Uncover an Association in the Simulation Lab? Acad Med 2022; 97:S118. [PMID: 36419761 PMCID: PMC9614548 DOI: 10.1097/acm.0000000000004868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Tavinder Ark
- Author affiliations: T. Ark, A.L. Kalet, Medical College of Wisconsin; M. Fisher, F. Milan, P.R. Marantz, C.J. Rodriguez, L. Burd-Orama, C.M. Gonzalez, Albert Einstein College of Medicine; D. Burgess, University of Minnesota; M. Samuel, New York University Tisch School of the Arts
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Lypson ML, Gonzalez CM, Thompson PY. Repaving the Pathway to Prevent the Loss of Students With Marginalized Identities-Medical Student Attrition. JAMA Intern Med 2022; 182:924-925. [PMID: 35816356 DOI: 10.1001/jamainternmed.2022.2140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Monica L Lypson
- Columbia University Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Cristina M Gonzalez
- Weiler Division, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Paula Y Thompson
- Research, Innovation, Scholarship, Education (RISE), University of Michigan, Ann Arbor, Michigan
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Bennett K, Dillahunt-Aspillaga C, Lasley C, Trexler LC, Schmeeckle W, Walker-Egea C, Gonzalez CM, Trexler LE. Traumatic brain injury vocational rehabilitation counselor competencies: Implications for training and practice. JVR 2022. [DOI: 10.3233/jvr-221198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: The Administration for Community Living (ACL) TBI State Partnership Program grants support states by providing funding to build capacity and infrastructure to support and maintain a system of services and supports to maximize the independence, well-being, and health of persons with traumatic brain injury (TBI). A Transition and Employment (T&E) workgroup identified competencies needed by Vocational Rehabilitation Counselors (VRC) to support people with TBI to obtain and maintain employment. OBJECTIVE: To: (1) identify self-perceived VRC TBI competence and (2) inform individual state VR training activities and competency goals. METHODS: A self-assessment online survey was employed. RESULTS: A total of 269 VR professionals across four states completed the VRC Self-Assessment between December 2020 and February 2021. The T&E workgroup identified TBI competencies across four domains (1) brain injury medical and rehabilitation, (2) employment, (3) state and local systems, resources, and service coordination, and (4) national systems, research and best practice. The results by TBI competency and the overall score for all participants show that state and local systems, resources, and service coordination is the highest area of competency, placing them close to the proficient level of knowledge. CONCLUSIONS: Future VR education and training opportunities may be informed by the results of this study.
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Affiliation(s)
- Keri Bennett
- Program Director for Acquired Brain Injury, Nebraska VR, Nebraska Department of Education, Kearney, NE, USA
| | - Christina Dillahunt-Aspillaga
- Rehabilitation and Mental Health CounselingProgram, Child and Family Studies, University of South Florida, Tampa, FL, USA
| | - Carla Lasley
- Program Director of CommunityServices, Nebraska VR, Nebraska Department of Education, Lincoln, NE, USA
| | - Laura C. Trexler
- ACL Grant Clinical Program Manager, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | | | - Connie Walker-Egea
- Senior Social and Behavioral Researcher, Department of Child and Family Studies, College of Behavioral andCommunity Sciences, University of South Florida, Tampa, FL, USA
| | - Cristina M. Gonzalez
- Doctoral Student, Counseling and CounselorEducation, University of Florida, Gainesville, FL, USA
| | - Lance E. Trexler
- Consulting Rehabilitation Neuropsychologist, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
- Department of Physical Medicine andRehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
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Gonzalez CM, Lypson ML. Bricolage in medical education, an approach with potential to address complex problems. Med Educ 2022; 56:146-148. [PMID: 34902884 DOI: 10.1111/medu.14714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/01/2021] [Accepted: 12/09/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Cristina M Gonzalez
- Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY, USA
| | - Monica L Lypson
- Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
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Abstract
Implicit biases describe mental associations that affect our actions in an unconscious manner. We can hold certain implicit biases regarding members of certain social groups. Such biases can perpetuate health disparities by widening inequity and decreasing trust in both healthcare and medical education. Despite the widespread discourse about bias in medical education, teaching and learning about the topic should be informed by empirical research and best practice. In this paper, the authors provide a series of twelve tips for teaching implicit bias recognition and management in medical education. Each tip provides a specific and practical strategy that is theoretically and empirically developed through research and evaluation. Ultimately, these twelve tips can assist educators to incorporate implicit bias instruction across the continuum of medical education to improve inequity and advance justice.
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Affiliation(s)
- Cristina M Gonzalez
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - Monica L Lypson
- Department of Medicine, The George Washington University School of Medicine and Health Sciences, Washington D.C, USA
- Medicine and Learning health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Javeed Sukhera
- Departments of Psychiatry/Paediatrics and Scientist, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry Western University Canada, London, Canada
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Stephenson-Hunter C, Strelnick AH, Rodriguez N, Stumpf LA, Spano H, Gonzalez CM. Dreams Realized: A Long-Term Program Evaluation of Three Summer Diversity Pipeline Programs. Health Equity 2021; 5:512-520. [PMID: 34476324 PMCID: PMC8409231 DOI: 10.1089/heq.2020.0126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/20/2022] Open
Abstract
Purpose: Pipeline programs are a well-known approach to enhancing health care workforce diversity and reducing health disparities. Few evaluations of pipeline programs include long-term outcome; fewer still, if any explore perceptions of students after completing such programs, to elucidate factors that contribute to successful entry into the health professions. The authors conducted a program evaluation of three summer diversity pipeline programs in the Bronx, NY, investigating both long-term outcomes and participants' hindsight perspectives of the impact of these programs on their career trajectories. Methods: Investigators conducted a cross-sectional, long-term, mixed-methods survey study. The primary and secondary outcomes for the quantitative analysis were matriculation into biomedical programs to pursue MD or PhD degrees and Master's degrees, respectively, and associated demographic factors. Free-text questions explored the most valuable and influential components of the programs; responses were analyzed qualitatively. Results: Of 147 respondents, 107 (73%) were on-track or had entered a doctoral or master's program, achieving either the primary or secondary outcomes, respectively. Components cited as most valuable included clinical experience, mentorship, career exposure, and research opportunities. Three themes were identified from the free-text responses: (1) Dreams realized; (2) Professional identity formation; and (3) Addressing systemic inequities. Conclusions: These three pipeline programs achieved career outcomes similar to published data. Participants' insights highlight the value of relationships, direct exposure to the health professions, and the importance of such programs to address systemic barriers faced. Results can inform criteria both for participant selection, as well as benchmarks used to define individual and programmatic success.
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Affiliation(s)
- Cara Stephenson-Hunter
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - A Hal Strelnick
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Natalia Rodriguez
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Luciana A Stumpf
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Hope Spano
- Hispanic Center of Excellence's Summer Undergraduate Program, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Cristina M Gonzalez
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
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Gonzalez CM, Walker SA, Rodriguez N, Noah YS, Marantz PR. Implicit Bias Recognition and Management in Interpersonal Encounters and the Learning Environment: A Skills-Based Curriculum for Medical Students. MedEdPORTAL 2021; 17:11168. [PMID: 34277934 PMCID: PMC8275619 DOI: 10.15766/mep_2374-8265.11168] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 05/05/2021] [Indexed: 05/21/2023]
Abstract
Introduction Students desire instruction in skill development to address both their own implicit biases and bias perceived in the learning environment. Curricula to date achieve strategy identification through reflection and discussion but do not provide opportunity for personally relevant skill development and practice in implicit bias recognition and management. To address this gap, we developed and evaluated a skills-based elective in implicit bias recognition and management focused on learners' own interpersonal interactions, including patient encounters, and perceived bias in the learning environment. Method Fifteen first-year medical students completed the nine-session elective over three annual offerings. Each session lasted 1.5 hours. Curriculum development was informed by published frameworks and transformative learning theory. Direct observation of student performances in role-plays and other active learning exercises constituted the formative assessment. Program evaluation focused on the impact of instruction through pre- and posttests, along with analysis of notes taken by the investigative team, including notes on formative assessments. Results Students engaged with all aspects of instruction, including role-plays. Pretest/posttest results demonstrated increased self-reported knowledge and comfort in addressing perceived bias. Formative assessment demonstrated students' skill development in safely and respectfully addressing perceived bias in the learning environment without endangering their relationships with supervisors. Discussion Skills developed-addressing bias in interpersonal encounters and perceived bias in clinical and teaching encounters-are relevant to learners throughout their careers. This course is relevant to medical students and trainees at various experience levels and could serve as a template for novel, skills-based curricula across health professions.
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Affiliation(s)
- Cristina M. Gonzalez
- Professor, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center
| | - Sydney A. Walker
- Medical Student, Oregon Health & Science University School of Medicine
| | - Natalia Rodriguez
- Medical Student, Perelman School of Medicine at the University of Pennsylvania
| | | | - Paul R. Marantz
- Associate Dean for Clinical Research Education and Professor, Departments of Medicine and Epidemiology & Population Health, Albert Einstein College of Medicine
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Gonzalez CM, Nava S, List J, Liguori A, Marantz PR. How Assumptions and Preferences Can Affect Patient Care: An Introduction to Implicit Bias for First-Year Medical Students. MedEdPORTAL 2021; 17:11162. [PMID: 34263027 PMCID: PMC8236500 DOI: 10.15766/mep_2374-8265.11162] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 04/04/2021] [Indexed: 05/25/2023]
Abstract
INTRODUCTION Instruction in implicit bias is becoming prevalent across the spectrum of medical training. Little education exists for preclinical students, and guidance for faculty to facilitate such education is minimal. To address these gaps, we designed and delivered a single session for incoming first-year medical students and developed a facilitator training program. METHODS One faculty member delivered a 1-hour, multimedia, interactive lecture to all first-year medical students. Students subsequently met in small groups with trained facilitators. Activities included reflection, guided debriefing, and strategy identification to become aware of when they might be making an assumption causing them to jump to a conclusion about someone. The program evaluation consisted of aggregated student strategies and facilitator feedback during postsession debriefs, both analyzed through thematic analysis. RESULTS We delivered instruction to 1,098 students. Student strategies resulted in three themes: (1) humility, (2) reflection, and (3) partnering. The postsession debriefs uncovered opportunities to enhance the session. Lessons learned included presenting material to an entire class at once, allowing students to engage in dynamic discussion in the small groups, eliminating anonymous polling in the small groups, and highlighting management of implicit bias as essential to professional development. DISCUSSION Our instructional design enabled first-year medical students to identify at least one strategy to use when implicit biases are activated. The large-group session was deliverable by one faculty member, and volunteers successfully facilitated small-group sessions after only one training session, making this model a feasible innovation to reach an entire medical school class at the same time.
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Affiliation(s)
- Cristina M. Gonzalez
- Professor, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine
| | - Stephanie Nava
- Research Assistant, Department of Medicine, Albert Einstein College of Medicine
| | - Julie List
- Principal Associate, Department of Family and Social Medicine, Albert Einstein College of Medicine
| | - Alyssa Liguori
- Research Assistant, Department of Medicine, Albert Einstein College of Medicine
| | - Paul R. Marantz
- Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine; Professor, Department of Medicine, Albert Einstein College of Medicine; Associate Dean for Clinical Research Education, Albert Einstein College of Medicine
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Rodriguez N, Kintzer E, List J, Lypson M, Grochowalski JH, Marantz PR, Gonzalez CM. Implicit Bias Recognition and Management: Tailored Instruction for Faculty. J Natl Med Assoc 2021; 113:566-575. [PMID: 34140145 DOI: 10.1016/j.jnma.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/18/2021] [Accepted: 05/11/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Implicit bias instruction is becoming more prevalent across the continuum of medical education. Little guidance exists for faculty on recognizing and debriefing about implicit bias during routine clinical encounters. OBJECTIVE To assess the impact and feasibility of single seminars on implicit bias and the approach to its management in clinical settings. METHODS Between September 2016 and November 2017, the authors delivered five departmental/divisional grand rounds across three different academic medical centers in New York, USA. Instruction provided background information on implicit bias, highlighted its relevance to clinical care, and discussed proposed interventions. To evaluate the impact of instruction participants completed a twelve-item retrospective pre-intervention/post-intervention survey. Questions related to comfort and confidence in recognizing and managing implicit bias, debriefing with learners, and role-modeling behaviors. Participants identified strategies for recognizing and managing potentially biased events through free text prompts. Authors qualitatively analyzed participants' identified strategies. RESULTS We received 116 completed surveys from 203 participants (57% response rate). Participants self-reported confidence and comfort increased for all questions. Qualitative analysis resulted in three themes: looking inward, looking outward, and taking action at individual and institutional levels. CONCLUSION After a single session, respondents reported increased confidence and comfort with the topic. They identified strategies relevant to their professional contexts which can inform future skills-based interventions. For healthcare organizations responding to calls for implicit bias training, this approach has great promise. It is feasible and can reach a wide audience through usual grand rounds programming, serving as an effective early step in such training.
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Affiliation(s)
- Natalia Rodriguez
- Perelman School of Medicine, University of Pennsylvania, United States
| | - Emily Kintzer
- Department of Obstetrics and Gynecology, Montefiore Medical Center, United States
| | - Julie List
- Department of Family and Social Medicine, Albert Einstein College of Medicine, United States
| | - Monica Lypson
- F. Edward Hébert School of Medicine, George Washington University School of Medicine and Health Sciences, University of Michigan Medical School, Uniformed Services University of the Health Sciences, United States
| | | | - Paul R Marantz
- Department of Epidemiology & Population Health, Department of Medicine, Albert Einstein College of Medicine, United States
| | - Cristina M Gonzalez
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, United States.
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Gonzalez CM, Noah YS, Correa N, Archer-Dyer H, Weingarten-Arams J, Sukhera J. Qualitative analysis of medical student reflections on the implicit association test. Med Educ 2021; 55:741-748. [PMID: 33544914 PMCID: PMC8119345 DOI: 10.1111/medu.14468] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 01/29/2021] [Accepted: 02/02/2021] [Indexed: 05/25/2023]
Abstract
INTRODUCTION Health professions educators use the Implicit Association Test (IAT) to raise awareness of implicit bias in learners, often engendering strong emotional reactions. Once an emotional reaction ensues, the gap between learner reaction and strategy identification remains relatively underexplored. To better understand how learners may identify bias mitigation strategies, the authors explored perspectives of medical students during the clinical portion of their training to the experience of taking the IAT, and the resulting feedback. METHODS Medical students in Bronx, NY, USA, participated in one 90-minute session on implicit bias. The focus of analysis for this study is the post-session narrative assignment inviting them to take the race-based IAT and describe both their reaction to and the implications of their IAT results on their future work as physicians. The authors analysed 180 randomly selected de-identified essays completed from 2013 to 2019 using an approach informed by constructivist grounded theory methodology. RESULTS Medical students with clinical experience respond to the IAT through a continuum that includes their reactions to the IAT, acceptance of bias along with a struggle for strategy identification, and identification of a range of strategies to mitigate the impact of bias on clinical care. Results from the IAT invoked deep emotional reactions in students, and facilitated a questioning of previous assumptions, leading to paradigm shifts. An unexpected contrast to these deep and meaningful reflections was that students rarely chose to identify a strategy, and those that did provided strategies that were less nuanced. CONCLUSION Despite accepting implicit bias in themselves and desiring to provide unbiased care, students struggled to identify bias mitigation strategies, a crucial prerequisite to skill development. Educators should endeavour to expand instruction to bridge the chasm between students' acceptance of bias and skill development in management of bias to improve the outcomes of their clinical encounters.
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Affiliation(s)
- Cristina M Gonzalez
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Yuliana S Noah
- Department of Pediatrics, Jacobi Medical Center, Bronx, NY, USA
| | - Nereida Correa
- Department of Obstetrics and Gynecology, Albert Einstein College of Medicine and Jacobi Medical Center, Bronx, NY, USA
| | - Heather Archer-Dyer
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Javeed Sukhera
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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Raugh IM, James SH, Gonzalez CM, Chapman HC, Cohen AS, Kirkpatrick B, Strauss GP. Digital phenotyping adherence, feasibility, and tolerability in outpatients with schizophrenia. J Psychiatr Res 2021; 138:436-443. [PMID: 33964681 PMCID: PMC8192468 DOI: 10.1016/j.jpsychires.2021.04.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 04/19/2021] [Accepted: 04/25/2021] [Indexed: 11/25/2022]
Abstract
Digital phenotyping has potential for use as an objective and ecologically valid form of symptom assessment in clinical trials for schizophrenia. However, there are critical methodological factors that must be addressed before digital phenotyping can be used for this purpose. The current study evaluated levels of adherence, feasibility, and tolerability for active (i.e., signal and event contingent ecological momentary assessment surveys) and passive (i.e., geolocation, accelerometry, and ambulatory psychophysiology) digital phenotyping methods recorded from smartphone and smartband devices. Participants included outpatients diagnosed with schizophrenia (SZ: n = 54) and demographically matched healthy controls (CN: n = 55), who completed 6 days of digital phenotyping. Adherence was significantly lower in SZ than CN for active recordings, but not markedly different for passive recordings. Some forms of passive recordings had lower adherence (ambulatory psychophysiology) than others (accelerometry and geolocation). Active digital phenotyping adherence was predicted by higher psychosocial functioning, whereas passive digital phenotyping adherence was predicted by education, positive symptoms, negative symptoms, and psychosocial functioning in people with SZ. Both groups found digital phenotyping methods tolerable and feasibility was supported by low frequency of invalid responding, brief survey completion times, and similar impediments to study completion. Digital phenotyping methods can be completed by individuals with SZ with good adherence, feasibility, and tolerability. Recommendations are provided for using digital phenotyping methods in clinical trials for SZ.
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Affiliation(s)
- Ian M. Raugh
- Department of Psychology, University of Georgia, Athens, GA, USA
| | - Sydney H. James
- Department of Psychology, University of Georgia, Athens, GA, USA
| | | | | | - Alex S. Cohen
- Department of Psychology, Louisiana State University, Baton Rouge, LA, USA
| | - Brian Kirkpatrick
- Department of Psychiatry and Behavioral Sciences, University of Nevada, Reno School of Medicine, Reno, NV, USA
| | - Gregory P. Strauss
- Department of Psychology, University of Georgia, Athens, GA, USA,Correspondence concerning this article should be addressed to Gregory P. Strauss, Ph.D., . Phone: +1-706-542-0307. Fax: +1-706-542-3275. University of Georgia, Department of Psychology, 125 Baldwin St., Athens, GA 30602
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Gonzalez CM, Grochowalski JH, Garba RJ, Bonner S, Marantz PR. Validity evidence for a novel instrument assessing medical student attitudes toward instruction in implicit bias recognition and management. BMC Med Educ 2021; 21:205. [PMID: 33845830 PMCID: PMC8040240 DOI: 10.1186/s12909-021-02640-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 03/26/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Implicit bias instruction is becoming more prevalent in health professions education, with calls for skills-based curricula moving from awareness and recognition to management of implicit bias. Evidence suggests that health professionals and students learning about implicit bias ("learners") have varying attitudes about instruction in implicit bias, including the concept of implicit bias itself. Assessing learner attitudes could inform curriculum development and enable instructional designs that optimize learner engagement. To date, there are no instruments with evidence for construct validity that assess learner attitudes about implicit bias instruction and its relevance to clinical care. METHODS The authors developed a novel instrument, the Attitude Towards Implicit Bias Instrument (ATIBI) and gathered evidence for three types of construct validity- content, internal consistency, and relationship to other variables. RESULTS Authors utilized a modified Delphi technique with an interprofessional team of experts, as well as cognitive interviews with medical students leading to item refinement to improve content validity. Seven cohorts of medical students, N = 1072 completed the ATIBI. Psychometric analysis demonstrated high internal consistency (α = 0.90). Exploratory factor analysis resulted in five factors. Analysis of a subset of 100 medical students demonstrated a moderate correlation with similar instruments, the Integrative Medicine Attitude Questionnaire (r = 0.63, 95% CI: [0.59, 0.66]) and the Internal Motivation to Respond Without Prejudice Scale (r = 0.36, 95% CI: [0.32, 0.40]), providing evidence for convergent validity. Scores on our instrument had low correlation to the External Motivation to Respond Without Prejudice Scale (r = 0.15, 95% CI: [0.09, 0.19]) and the Groningen Reflection Ability Scale (r = 0.12, 95% CI: [0.06, 0.17]) providing evidence for discriminant validity. Analysis resulted in eighteen items in the final instrument; it is easy to administer, both on paper form and online. CONCLUSION The Attitudes Toward Implicit Bias Instrument is a novel instrument that produces reliable and valid scores and may be used to measure medical student attitudes related to implicit bias recognition and management, including attitudes toward acceptance of bias in oneself, implicit bias instruction, and its relevance to clinical care.
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Affiliation(s)
- Cristina M Gonzalez
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.
- Montefiore Medical Center- Weiler Division, 1825 Eastchester Road, DOM 2-76, Bronx, NY, 10461, USA.
| | | | | | - Shacelles Bonner
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Paul R Marantz
- Departments of Epidemiology and Population Health and Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
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Gonzalez CM, Walker SA, Rodriguez N, Karp E, Marantz PR. It Can Be Done! A Skills-Based Elective in Implicit Bias Recognition and Management for Preclinical Medical Students. Acad Med 2020; 95:S150-S155. [PMID: 32889927 PMCID: PMC7686093 DOI: 10.1097/acm.0000000000003697] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
PURPOSE Students perceive bias in learning environments. Curricula targeting implicit bias recognition and management increase student awareness and achieve strategy identification, but fall short of actual skill development to address bias. In light of this gap, the authors developed and evaluated a skills-based elective to recognize and manage implicit bias in the learning environment. METHOD Nine 1.5-hour sessions were delivered to 15 first-year medical students from 2017 to 2019. An evidence-based conceptual framework and transformative learning theory informed the instructional design; it incorporated active learning exercises. Skills assessment occurred through direct observation of student performances in role-play exercises. Using thematic analysis, the authors conducted a program evaluation based on focus groups with students and data from notes taken by the investigative team. RESULTS Students engaged with all aspects of instruction, including role-plays. Authors identified 3 themes from the program evaluation: (1) Student engagement can be enhanced, (2) Instruction is empowering, and (3) It (addressing bias in one's own and witnessed encounters) can be done! Analysis additionally highlighted opportunities for improvement and lessons learned. CONCLUSIONS This innovative course achieved skill development and practice for medical students in implicit bias recognition and management as it pertains to 3 facets of clinical care present at every stage of a health professional's career. These include interpersonal encounters, advocating for patients when bias is perceived in witnessed encounters with peers and supervisors, and addressing comments made by others within the learning environment. Outcomes could inform novel, skills-based curricula across the spectrum of health professions training and practice.
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Affiliation(s)
- Cristina M Gonzalez
- C.M. Gonzalez is professor of medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Sydney A Walker
- S.A. Walker is a medical student, Oregon Health and Sciences University School of Medicine, Portland, Oregon
| | - Natalia Rodriguez
- N. Rodriguez is a medical student, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elisa Karp
- E. Karp is a resident at Jacobi Medical Center, Bronx, New York
| | - Paul R Marantz
- P.R. Marantz is associate dean, Clinical Research Education, and professor, Department of Medicine and Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
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Byhoff E, Kangovi S, Berkowitz SA, DeCamp M, Dzeng E, Earnest M, Gonzalez CM, Hartigan S, Karani R, Memari M, Roy B, Schwartz MD, Volerman A, DeSalvo K. A Society of General Internal Medicine Position Statement on the Internists' Role in Social Determinants of Health. J Gen Intern Med 2020; 35:2721-2727. [PMID: 32519320 PMCID: PMC7459005 DOI: 10.1007/s11606-020-05934-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/18/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Elena Byhoff
- Department of Medicine, Institute for Clinical Research and Health Policy Studies Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA.
| | - Shreya Kangovi
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Seth A Berkowitz
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Matthew DeCamp
- Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Elizabeth Dzeng
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Mark Earnest
- Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Cristina M Gonzalez
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Sarah Hartigan
- Department of Medicine, Virginia Commonwealth University, Midlothian, VA, USA
| | - Reena Karani
- Department of Medicine, Medicine and Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Milad Memari
- Departments of Medical Education, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brita Roy
- Department of Medicine, Yale Medicine, New Haven, CT, USA
| | - Mark D Schwartz
- Departments of Population Health and of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Anna Volerman
- Department of Medicine, University of Chicago, Chicago, IL, USA
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Raugh IM, James SH, Gonzalez CM, Chapman HC, Cohen AS, Kirkpatrick B, Strauss GP. Geolocation as a Digital Phenotyping Measure of Negative Symptoms and Functional Outcome. Schizophr Bull 2020; 46:1596-1607. [PMID: 32851401 PMCID: PMC7751192 DOI: 10.1093/schbul/sbaa121] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Negative symptoms and functional outcome have traditionally been assessed using clinical rating scales, which rely on retrospective self-reports and have several inherent limitations that impact validity. These issues may be addressed with more objective digital phenotyping measures. In the current study, we evaluated the psychometric properties of a novel "passive" digital phenotyping method: geolocation. METHOD Participants included outpatients with schizophrenia or schizoaffective disorder (SZ: n = 44), outpatients with bipolar disorder (BD: n =19), and demographically matched healthy controls (CN: n = 42) who completed 6 days of "active" digital phenotyping assessments (eg, surveys) while geolocation was recorded. RESULTS Results indicated that SZ patients show less activity than CN and BD, particularly, in their travel from home. Geolocation variables demonstrated convergent validity by small to medium correlations with negative symptoms and functional outcome measured via clinical rating scales, as well as active digital phenotyping behavioral indices of avolition, asociality, and anhedonia. Discriminant validity was supported by low correlations with positive symptoms, depression, and anxiety. Reliability was supported by good internal consistency and moderate stability across days. CONCLUSIONS These findings provide preliminary support for the reliability and validity of geolocation as an objective measure of negative symptoms and functional outcome. Geolocation offers enhanced precision and the ability to take a "big data" approach that facilitates sophisticated computational models. Near-continuous recordings and large numbers of samples may make geolocation a novel outcome measure for clinical trials due to enhanced power to detect treatment effects.
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Affiliation(s)
- Ian M Raugh
- Department of Psychology, University of Georgia, Athens, GA
| | - Sydney H James
- Department of Psychology, University of Georgia, Athens, GA
| | | | | | - Alex S Cohen
- Department of Psychology, Louisiana State University, Baton Rouge, LA
| | - Brian Kirkpatrick
- Department of Psychiatry and Behavioral Sciences, University of Nevada, Reno School of Medicine, Reno, NV
| | - Gregory P Strauss
- Department of Psychology, University of Georgia, Athens, GA,To whom correspondence should be addressed; tel: +1-706-542-0307, fax: +1-706-542-3275, e-mail:
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Abstract
Implicit bias recognition and management curricula are offered as an increasingly popular solution to address health disparities and advance equity. Despite growth in the field, approaches to implicit bias instruction are varied and have mixed results. The concept of implicit bias recognition and management is relatively nascent, and discussions related to implicit bias have also evoked critique and controversy. In addition, challenges related to assessment, faculty development, and resistant learners are emerging in the literature. In this context, the authors have reframed implicit bias recognition and management curricula as unique forms of transformative learning that raise critical consciousness in both individuals and clinical learning environments. The authors have proposed transformative learning theory (TLT) as a guide for implementing educational strategies related to implicit bias in health professions. When viewed through the lens of TLT, curricula to recognize and manage implicit biases are positioned as a tool to advance social justice.
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Affiliation(s)
- Javeed Sukhera
- J. Sukhera is associate professor of psychiatry and pediatrics and scientist, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; ORCID: http://orcid.org/0000-0001-8146-4947. C.J. Watling is professor of clinical neurological sciences and oncology and associate dean for postgraduate medical education, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. C.M. Gonzalez is associate professor of medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York. At the time of writing, she was also a scholar, Macy Faculty Scholars Program, Josiah Macy Jr. Foundation, and Amos Medical Faculty Development Program, Robert Wood Johnson Foundation
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Abstract
Health and health care disparities are present in every medical specialty, and stem from multiple etiologies. Within health care itself, issues mostly arise within medical providers and across a system with an inequitable distribution of care and resources. One potential way to address disparities is to educate our workforce, to not only know about disparities but to also actively advocate for underresourced and marginalized patients. In this review, the authors describe efforts being conducted in graduate medical education and seek to elucidate some of the curricula currently being developed and implemented in rheumatology.
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Affiliation(s)
- Irene Blanco
- Department of Medicine - Rheumatology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Forchh 107N, Bronx, NY 10461, USA.
| | - Nevena Barjaktarovic
- Department of Medicine - Rheumatology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Forchh 107N, Bronx, NY 10461, USA
| | - Cristina M Gonzalez
- Department of Medicine - Hospital Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, 1825 Eastchester Road, DOM 2-76, Bronx, NY 10461, USA
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Abstract
INTRODUCTION Implicit bias is a growing area of interest among educators. Educational strategies used to elicit awareness of implicit biases commonly include the Implicit Association Test (IAT). Although the topic of implicit bias is gaining increased attention, emerging critique of the IAT suggests the need to subject its use to greater theoretical and empirical scrutiny. METHODS The authors employed a meta-narrative synthesis to review existing research on the use of the IAT in health professions education. Four databases were searched using key terms yielding 1151 titles. After title, abstract and full-text screening, 38 articles were chosen for inclusion. Coding and analysis of articles sought a meaningful synthesis of educational approaches relating to the IAT, and the assumptions and theoretical positions that informed these approaches. RESULTS Distinct, yet complementary, meta-narratives were found in the literature. The dominant perspective utilizes the IAT as a metric of implicit bias to evaluate the success of an educational activity. A contrasting narrative describes the IAT as a tool to promote awareness while triggering discussion and reflection. DISCUSSION Whether used as a tool to measure bias, raise awareness or trigger reflection, the use of the IAT provokes tension between distinct meta-narratives, posing a challenge to educators. Curriculum designers should consider the premise behind the IAT before using it, and be prepared to address potential reactions from learners such as defensiveness or criticism. Overall, findings suggest that educational approaches regarding implicit bias require critical reflexivity regarding assumptions, values and theoretical positioning related to the IAT.
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Affiliation(s)
- Javeed Sukhera
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Michael Wodzinski
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | | | - Cristina M Gonzalez
- Albert Einstein College of Medicine/Montefiore Medical Center, New York, USA
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Affiliation(s)
- Cristina M Gonzalez
- Albert Einstein College of Medicine, Bronx, NY, USA.,Montefiore Medical Center, Bronx, NY, USA
| | - Monica L Lypson
- Office of Academic Affiliations, Veterans Administration, Washington, DC, USA. .,George Washington University School of Medicine and Health Sciences, Washington, DC, USA. .,University of Michigan Medical School, Ann Arbor, MI, USA.
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Gonzalez CM, Garba RJ, Liguori A, Marantz PR, McKee MD, Lypson ML. How to Make or Break Implicit Bias Instruction: Implications for Curriculum Development. Acad Med 2018; 93:S74-S81. [PMID: 30365433 PMCID: PMC6211195 DOI: 10.1097/acm.0000000000002386] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
PURPOSE To analyze faculty experiences regarding facilitating discussions as part of the institution's curriculum on racial and ethnic implicit bias recognition and management. METHOD Between July 2014 and September 2016, the authors conducted 21 in-depth interviews with faculty who had experience teaching in implicit bias instruction or were interested in facilitating discussions related to implicit bias and the Implicit Association Test. Grounded theory methodology was used to analyze interview transcripts. RESULTS Participants identified challenges that affect their ability to facilitate instruction in implicit bias. Faculty described the influence of their own background and identities as well as the influence of institutional values on their ability to facilitate implicit bias discussions. They noted the impact of resistant learners and faculty during discussions and made suggestions for institutional measures including the need for implementation of formalized longitudinal implicit bias curricula and faculty development. CONCLUSIONS Faculty facilitating sessions on implicit bias must attend faculty development sessions to be equipped to deal with some of the challenges they may face. Buy-in from institutional leadership is essential for successful implementation of implicit bias teaching, and medical educators need to consider formalized longitudinal curricula addressing the recognition and management of implicit biases.
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Affiliation(s)
- Cristina M Gonzalez
- C.M. Gonzalez is associate professor of medicine, Albert Einstein College of Medicine, Bronx, New York, scholar, Macy Faculty Scholars Program, and former scholar, Robert Wood Johnson Foundation, Amos Medical Faculty Development Program. R.J. Garba is a doctoral candidate, Department of Educational Psychology, University of Texas at Austin, Austin, Texas. A. Liguori is research assistant, Albert Einstein College of Medicine, Bronx, New York. P.R. Marantz is associate dean for clinical education and professor, Departments of Medicine and Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York. M.D. McKee is codirector and professor, Division of Research, Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York. M.L. Lypson is director of medical and dental education, Office of Academic Affiliations, Department of Veterans Affairs, Washington, DC, clinical professor of medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, and adjunct clinical professor of medicine and learning health sciences, George Washington University, Washington, DC, and University of Michigan Medical School, Ann Arbor, Michigan
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Gonzalez CM, Deno ML, Kintzer E, Marantz PR, Lypson ML, McKee MD. Patient perspectives on racial and ethnic implicit bias in clinical encounters: Implications for curriculum development. Patient Educ Couns 2018; 101:1669-1675. [PMID: 29843933 PMCID: PMC7065496 DOI: 10.1016/j.pec.2018.05.016] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 05/06/2018] [Accepted: 05/19/2018] [Indexed: 05/19/2023]
Abstract
OBJECTIVE Patients describe feelings of bias and prejudice in clinical encounters; however, their perspectives on restoring the encounter once bias is perceived are not known. Implicit bias has emerged as a target for curricular interventions. In order to inform the design of novel patient-centered curricular interventions, this study explores patients' perceptions of bias, and suggestions for restoring relationships if bias is perceived. METHODS The authors conducted bilingual focus groups with purposive sampling of self-identified Black and Latino community members in the US. Data were analyzed using grounded theory. RESULTS Ten focus groups (in English (6) and Spanish (4)) with N = 74 participants occurred. Data analysis revealed multiple influences patients' perception of bias in their physician encounters. The theory emerging from the analysis suggests if bias is perceived, the outcome of the encounter can still be positive. A positive or negative outcome depends on whether the physician acknowledges this perceived bias or not, and his or her subsequent actions. CONCLUSIONS Participant lived experience and physician behaviors influence perceptions of bias, however clinical relationships can be restored following perceived bias. PRACTICE IMPLICATIONS Providers might benefit from skill development in the recognition and acknowledgement of perceived bias in order to restore patient-provider relationships.
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Affiliation(s)
- Cristina M Gonzalez
- Albert Einstein College of Medicine & Montefiore Medical Center, Montefiore Medical Center- Weiler Division, Bronx, 10461, USA.
| | - Maria L Deno
- Albert Einstein College of Medicine & Universidad Iberoamericana, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, 10461, USA.
| | | | - Paul R Marantz
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, 10461, USA.
| | - Monica L Lypson
- George Washington University School of Medicine and Health Sciences, University of Michigan Medical School & Office of Academic Affiliations, Department of Veterans Affairs, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - M Diane McKee
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, 10461, USA.
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Gonzalez CM, Fox AD, Marantz PR. The Evolution of an Elective in Health Disparities and Advocacy: Description of Instructional Strategies and Program Evaluation. Acad Med 2015. [PMID: 26222321 PMCID: PMC6949531 DOI: 10.1097/acm.0000000000000850] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
PROBLEM Health disparities remain pervasive in the United States. Training future physicians to address health disparities requires attention to both systemic and provider causes of disparities, but comprehensive curricula are lacking. APPROACH Albert Einstein College of Medicine in Bronx, New York, offers a 13-session health disparities elective to first-year medical students. The curriculum covers three main content areas: background, provider contributions to health disparities, and systemic contributions to health disparities (i.e., social determinants of health). Teaching methods included didactic and multimedia presentations, reflective discussions, and skill-building seminars (e.g., addressing subconscious assumptions and advocacy training).The authors evaluated the course in 2010-2013 by comparing students' summary scores for knowledge, attitudes, and self-reported confidence on pre- and postintervention tests. They investigated associations between students' sociodemographic characteristics and changes in summary scores. OUTCOMES Scores increased significantly in each domain: Mean knowledge scores increased from 63.6 (± 10.0), out of 100, to 76.4 (± 12.8); mean attitudes scores increased from 16.7 (± 1.9), out of 20, to 18.2 (± 1.1); mean confidence scores increased from 10.7 (± 1.5), out of 16, to 14.4 (± 1.7). Younger students (< 24) had greater changes in confidence than older students. Other sociodemographic characteristics were not associated with changes in any domain. NEXT STEPS Exposure to health disparities instruction is important for medical students. The authors' experience provides insights for incorporating such material into the compulsory curriculum. Future evaluation of outcomes from similar curricula should include measures of clinical behaviors (e.g., through clinical examinations).
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Affiliation(s)
- Cristina M Gonzalez
- C.M. Gonzalez is associate professor of clinical medicine, Department of Medicine, Division of Hospital Medicine, Albert Einstein College of Medicine, Bronx, New York. A.D. Fox is assistant professor, Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, New York. P.R. Marantz is professor, Department of Epidemiology and Population Health and Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, New York
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Gonzalez CM, Kim MY, Marantz PR. Implicit bias and its relation to health disparities: a teaching program and survey of medical students. Teach Learn Med 2014; 26:64-71. [PMID: 24405348 DOI: 10.1080/10401334.2013.857341] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
BACKGROUND The varying treatment of different patients by the same physician are referred to as within provider disparities. These differences can contribute to health disparities and are thought to be the result of implicit bias due to unintentional, unconscious assumptions. PURPOSES The purpose is to describe an educational intervention addressing both health disparities and physician implicit bias and the results of a subsequent survey exploring medical students' attitudes and beliefs toward subconscious bias and health disparities. METHODS A single session within a larger required course was devoted to health disparities and the physician's potential to contribute to health disparities through implicit bias. Following the session the students were anonymously surveyed on their Implicit Association Test (IAT) results, their attitudes and experiences regarding the fairness of the health care system, and the potential impact of their own implicit bias. The students were categorized based on whether they disagreed ("deniers") or agreed ("accepters") with the statement "Unconscious bias might affect some of my clinical decisions or behaviors." Data analysis focused specifically on factors associated with this perspective. RESULTS The survey response rate was at least 69%. Of the responders, 22% were "deniers" and 77% were "accepters." Demographics between the two groups were not significantly different. Deniers were significantly more likely than accepters to report IAT results with implicit preferences toward self, to believe the IAT is invalid, and to believe that doctors and the health system provide equal care to all and were less likely to report having directly observed inequitable care. CONCLUSIONS The recognition of bias cannot be taught in a single session. Our experience supports the value of teaching medical students to recognize their own implicit biases and develop skills to overcome them in each patient encounter, and in making this instruction part of the compulsory, longitudinal undergraduate medical curriculum.
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Affiliation(s)
- Cristina M Gonzalez
- a Department of Medicine , Albert Einstein College of Medicine/Montefiore Medical Center, Bronx , New York , New York , USA
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Wu HM, Stern LA, Chen JH, Huth M, Schwalb CH, Winhold M, Porrati F, Gonzalez CM, Timilsina R, Rack PD. Synthesis of nanowires via helium and neon focused ion beam induced deposition with the gas field ion microscope. Nanotechnology 2013; 24:175302. [PMID: 23548767 DOI: 10.1088/0957-4484/24/17/175302] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The ion beam induced nanoscale synthesis of platinum nanowires using the trimethyl (methylcyclopentadienyl)platinum(IV) (MeCpPt(IV)Me3) precursor is investigated using helium and neon ion beams in the gas field ion microscope. The He(+) beam induced deposition resembles material deposited by electron beam induced deposition with very small platinum nanocrystallites suspended in a carbonaceous matrix. The He(+) deposited material composition was estimated to be 16% Pt in a matrix of amorphous carbon with a large room-temperature resistivity (∼3.5 × 10(4)-2.2 × 10(5) μΩ cm) and temperature-dependent transport behavior consistent with a granular material in the weak intergrain tunnel coupling regime. The Ne(+) deposited material has comparable composition (17%), however a much lower room-temperature resistivity (∼600-3.0 × 10(3) μΩ cm) and temperature-dependent electrical behavior representative of strong intergrain coupling. The Ne(+) deposited nanostructure has larger platinum nanoparticles and is rationalized via Monte Carlo ion-solid simulations which show that the neon energy density deposited during growth is much larger due to the smaller ion range and is dominated by nuclear stopping relative to helium which has a larger range and is dominated by electronic stopping.
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Affiliation(s)
- H M Wu
- Ion Microscopy Innovation Center LLC, Carl Zeiss Microscopy, One Corporation Way, Peabody, MA 01960, USA
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Aristizábal BH, Gonzalez CM, Morales L, Abalos M, Abad E. Polychlorinated dibenzo-p-dioxin and dibenzofuran in urban air of an Andean city. Chemosphere 2011; 85:170-8. [PMID: 21745682 DOI: 10.1016/j.chemosphere.2011.06.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 04/20/2011] [Accepted: 06/01/2011] [Indexed: 05/21/2023]
Abstract
Particle-bound polychlorinated dibenzo-p-dioxins and polychlorinated dibenzofurans (PCDD/Fs) in ambient air were monitored together with particulate matter less than 10 μm (PM(10)) at three sampling sites of the Andean city of Manizales, Colombia; during September 2009 and July 2010. PCDD/Fs ambient air emissions ranged from 1 fg WHO-TEQ m(-3) to 52 fg WHO-TEQ m(-3) in particulate fraction. The PM(10) concentrations ranged from 23 μg m(-3) to 54 μg m(-3). Concentrations of PM(10) and PCDD/Fs in ambient air observed for Manizales - a medium sized city with a population of 380,000 - were comparable to concentrations in larger cities. The highest concentrations of PCDD/Fs and PM(10) found in this study were determined at the central zone of the city, characterized by public transportation density, where diesel as principal fuel is used. In addition, hypothetical gas fractions of PCDD/Fs were calculated from theoretical K(p) data. Congener profiles of PCDD/Fs exhibited ratios associated with different combustion sources at the different sampling locations, ranging from steel recycling to gasoline and diesel engines. Taking into account particle and gas hypothetical fraction of PCDD/Fs, Manizales exhibited values of PCDD/Fs equivalent to rural and urban-industrial sites in the southeast and center of the city respectively. Poor correlation of PCDDs with PM(10) (r=-0.55 and r=0.52) suggests ambient air PCDDs were derived from various combustion sources. Stronger correlation was observed of PCDFs with PM(10). Poor correlation between precipitation and reduced PM(10) concentration in ambient air (r=-0.45) suggested low PM(10) removal by rainfall.
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Affiliation(s)
- B H Aristizábal
- Universidad Nacional de Colombia Sede Manizales, Hydraulic Engineering and Environmental Research Group, Cra 27 64-60, Bloque H Palogrande, Manizales, Colombia.
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Abstract
BACKGROUND Educating medical students about health disparities may be one step in diminishing the disparities in health among different populations. According to adult learning theory, learners' opinions are vital to the development of future curricula. DESIGN Qualitative research using focus group methodology. OBJECTIVES Our objectives were to explore the content that learners value in a health disparities curriculum and how they would want such a curriculum to be taught. PARTICIPANTS Study participants were first year medical students with an interest in health disparities (n = 17). APPROACH Semi-structured interviews consisting of 12 predetermined questions, with follow-up and clarifying questions arising from the discussion. Using grounded theory, codes were initially developed by the team of investigators, applied, and validated through an iterative process. MAIN RESULTS The students perceived negative attitudes towards health disparities education as a potential barrier towards the development of a health disparities curriculum and proposed possible solutions. These solutions centered around the learning environment and skill building to combat health disparities. CONCLUSIONS While many of the students' opinions were corroborated in the literature, the most striking differences were their opinions on how to develop good attitudes among the student body. Given the impact of the provider on health disparities, how to develop such attitudes is an important area for further research.
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Affiliation(s)
- Cristina M Gonzalez
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
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Longart M, Chatani-Hinze M, Gonzalez CM, Vullhorst D, Buonanno A. Regulation of ErbB-4 endocytosis by neuregulin in GABAergic hippocampal interneurons. Brain Res Bull 2007; 73:210-9. [PMID: 17562386 PMCID: PMC1949418 DOI: 10.1016/j.brainresbull.2007.02.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Revised: 02/08/2007] [Accepted: 02/14/2007] [Indexed: 01/12/2023]
Abstract
Neuregulin (NRG)/ErbB receptor signaling pathways have recently been implicated in the reversal of long-term potentiation at hippocampal glutamatergic synapses. Moreover, polymorphisms in NRG-1 and ErbB-4 genes have been linked to an increased risk for developing schizophrenia. ErbB-4 is highly expressed at glutamatergic synapses where it binds to PSD-95 via its carboxyl terminal T-V-V sequence. Here we investigated the expression, localization and trafficking of ErbB-4 in cultured hippocampal neurons by immunocytochemistry, surface protein biotinylation, and live labeling of native receptors. We show that neuronal ErbB-4 is detected at its highest levels in GABAergic interneurons, as observed in vivo. ErbB-4 immunoreactivity precedes PSD-95 expression, with ErbB-4 cluster initially forming in the absence of, but later associating with, PSD-95-positive puncta. By surface protein biotinylation, the fraction of ErbB-4 receptors on the plasma membrane increases from 30% to 65% between 6 and 16 days in vitro (DIV). Interestingly, 30 min of NRG stimulation triggers measurable ErbB-4 receptor internalization at DIV 16, despite increased colocalization with PSD-95. We also investigated the role of TNFalpha-converting enzyme (TACE)-mediated receptor processing in regulating ErbB-4 surface expression. We found that the cleavage-resistant JM-b isoform accounts for 80% of all ErbB-4 transcripts in cultured hippocampal neurons. Receptor stimulation or treatment with phorbol esters does not induce detectable ErbB-4 processing, indicating that neurons mostly rely on endocytosis of the intact receptor to regulate ErbB-4 surface expression. These results enhance our understanding of the regulation of ErbB-4--mediated signaling at glutamatergic synapses.
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Affiliation(s)
- M Longart
- Section on Molecular Neurobiology, NICHD, Bethesda, MD 20892, USA.
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Abstract
The photochemistry, photophysical properties, and temperature dependence (25 to +65 °C) of fluorescence by quantum yields and excited singlet state lifetimes in acetonitrile have been examined for three sets of dialkylbenzene derivatives: Set 1 ortho-xylene (10), tetralin (11), and indan (12); Set 2 2,3-dimethylbenzonitrile (9-23), 5-cyanotetralin (T-23), and 4-cyanoindan (I-23); and Set 3 3,4-dimethylbenzonitrile (9-34), 6-cyanotetralin (T-34), and 5-cyanoindan (I-34). Phototransposition reactions occur for 10, 9-23, 9-34, and T-34. Fitting of the temperature-dependent fluorescence data to an Arrhenius expression gave A and Ea values for all substrates studied except I-23 and I-34. The fluorescence intensity of these two compounds was essentially independent of temperature. For the other compounds, the data revealed that the activation barrier separating the excited singlet state (S1) from the reactive intermediate, a prefulvene biradical, was the important one in determining the reaction efficiency. The dominant mode of decay of the reactive intermediate was internal return to the starting material. Moreover, the general observation was made that nitrile substitution ortho to one of the alkyl groups in these dialkylbenzene derivatives reduced the rate at which they were converted to the reactive intermediate and, therefore, also the efficiency of the phototransposition reactions.Key words: phototranspositions, substituted benzenes, temperature-dependent fluorescence, activation parameters.
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Abstract
Accidental extravasation of vesicant chemotherapy may cause important tissue injuries. Nowadays, the majority of authors propose topical dimethyl sulfoxide (DMSO), with or without local cooling, as the treatment of choise efor anthracyclines extravasation. No significant toxicity has been reported when DMSO is used as topical treatment. This report describes a case of local toxicity consisting of severe pain after its use in a pediatric patient. An illustration shows the extravasation area.
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Affiliation(s)
- M E Llinares
- Division of Hematology Oncology, Pediatric Department, University Hospital Virgen de la Arrixaca, Murcia, Spain
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Gonzalez CM, Matheus G, Solander S, Castillo M. Transient edema of the spinal cord as a result of spontaneous acute epidural hematoma in the thoracic spine. Emerg Radiol 2004; 11:53-5. [PMID: 15278698 DOI: 10.1007/s10140-004-0359-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2004] [Accepted: 04/15/2004] [Indexed: 10/26/2022]
Abstract
We present an unusual case of spontaneous epidural hemorrhage in the thoracic spine resulting in rapid onset of transient and extensive edema in the spinal cord. The patient presented with acute onset of midscapular back pain, bilateral lower extremity weakness, and bladder dysfunction. Repeat MRI 20 days after decompression of the hematoma showed residual hematoma and complete resolution of the spinal cord edema. The implications and differential diagnosis of spinal cord edema in this clinical setting are discussed.
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Affiliation(s)
- C M Gonzalez
- University of North Carolina School of Medicine, Department of Radiology, Chapel Hill, NC 27599, USA
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Affiliation(s)
- J N Rubenstein
- Feinberg School of Medicine, North-western University, Department of Urology, Chicago, IL, USA
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Podlasek CA, Gonzalez CM, Zelner DJ, Jiang HB, McKenna KE, McVary KT. Analysis of NOS isoform changes in a post radical prostatectomy model of erectile dysfunction. Int J Impot Res 2001; 13 Suppl 5:S1-15. [PMID: 11781741 DOI: 10.1038/sj.ijir.3900772] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Optimal treatment of erectile dysfunction (ED) following radical prostatectomy remains a subject of much controversy and is a significant concern for prostate cancer patients requiring surgical intervention. Neural stimulation involving nitric oxide synthase (NOS) is a crucial aspect of the normal erection process. In this study NOS isoform interaction was evaluated to improve our understanding of molecular changes pertaining to erection post radical prostatectomy. Bilateral cavernous nerve (CN) resected and control adult male Sprague-Dawley rats were killed 7, 14 and 21 days after injury. RT-PCR, in situ hybridization, Western blot and immunohistochemical analysis were used to evaluate changes in NOS isoform expression and distribution. NOS-I protein was dramatically decreased after CN injury while NOS-III and NOS-II remained unchanged. A profound decrease in smooth muscle and endothelium was observed in the corpora. To our knowledge this is the first report of differential altered NOS isoform protein abundance under conditions which mimic radical prostatectomy. These results show the importance of maintaining at least partial innervation of the penis after surgical intervention and that endothelial and smooth muscle changes resulting from loss of innervation may account for the ED observed in prostatectomy patients.
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Affiliation(s)
- C A Podlasek
- Department of Urology and Physiology, Northwestern University Medical School, Chicago, Illinois 60611, USA.
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Abstract
PURPOSE We retrospectively compared our initial experience with the hand-assisted and retroperitoneal laparoscopic nephrectomy techniques to determine if there are important differences between these approaches. PATIENTS AND METHODS Twenty-four laparoscopic cases consisting of 12 hand-assisted and 12 retroperitoneal nephrectomies were compared. All cases but one were radical nephrectomies with intact specimen extraction performed for suspected stage T1 neoplasms. Data were collected from medical records and a postoperative questionnaire. To determine if significant learning curves existed, the first six nephrectomies in each group were compared with the second six nephrectomies on the basis of operative criteria. The two groups did not differ significantly in age, body mass index, ASA rating, or number of previous abdominal operations. RESULTS Although the mean tumor volume was greater in the hand-assisted group than the retroperitoneal group, the difference did not quite reach statistical significance (91.19 v 24.7 cc3; P = 0.06). The mean operative time, estimated blood loss, narcotic use (milligrams of intravenous morphine equivalent), hours to oral intake, hospital stay, and estimated percent activity at 2 weeks for the hand-assisted group (238.33 min, 293.75 mL, 35.7 mg, 17.56 hours, 4.4 days, 74.75%, respectively) were not significantly different from the values in the retroperitoneal group (255.83 min, 141.67 mL, 24.5 mg, 22.36 hours, 3.6 days, 76.91%). We found no significant difference in the mean operative times for the first and second six cases in either group. CONCLUSION In the initial experience and comparison of hand-assisted and retroperitoneal laparoscopic nephrectomy, we found no significant differences in operative time, estimated blood loss, narcotic usage, hours to oral intake, hospital stay, or activity level at 2 weeks postoperatively. A randomized trial is under way at our institution.
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Affiliation(s)
- R A Batler
- Department of Urology, Northwestern University Medical School, Chicago, Illinois, USA
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Eggener SE, Hairston J, Rubenstein JN, Gonzalez CM. Bladder lipoma. J Urol 2001; 166:1395. [PMID: 11547089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Affiliation(s)
- S E Eggener
- Department of Urology, Northwestern University Medical School, Chicago, Illinois, USA
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Gonzalez CM, Case JR, Nadler RB. Glutaraldehyde cross-linked collagen occlusion of the ureteral orifices with percutaneous nephrostomy: a minimally invasive option for treatment refractory hemorrhagic cystitis. J Urol 2001; 166:977-8. [PMID: 11490259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Affiliation(s)
- C M Gonzalez
- Department of Urology, Northwestern University, Chicago, IL, USA
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Podlasek CA, Zelner DJ, Bervig TR, Gonzalez CM, McKenna KE, McVary KT. Characterization and localization of nitric oxide synthase isoforms in the BB/WOR diabetic rat. J Urol 2001; 166:746-55. [PMID: 11458128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
PURPOSE Erectile dysfunction is a common pathological development in individuals with diabetes mellitus. Nitric oxide synthase (NOS) is essential for regulation of normal penile erection and NOS protein activity has been shown to be altered with diabetes. Several different isoforms and subtypes of NOS exist. However, little is known about how the distribution and abundance of these isoforms are altered with diabetes. We characterized the distribution and abundance of NOS isoforms and explored how they are altered with diabetes and result in erectile failure. MATERIALS AND METHODS In situ hybridization and quantitative reverse transcriptase-polymerase chain reaction were done to measure the abundance and distribution of NOS-Ia, NOS-Ib, NOS-Ic, NOS-II and NOS-III in control and diabetic (BB/WOR) rats. Protein was localized by immunohistochemical analysis and alterations in protein abundance with diabetes were examined by Western blot analysis. RESULTS NOS-I, NOS-II and NOS-III were observed in the endothelium lining the cavernous spaces and in the epithelium of the urethra. NOS-I protein was also present in the nerves of control and diabetic penes. We observed an increase in NOS-II expression around the dorsal nerves of diabetic penes, a decrease in NOS-III expression in diabetic pelvic ganglia and a decrease in NOS-Ib expression in the diabetic penis. NOS-I protein abundance was significantly decreased in diabetic pelvic ganglia. CONCLUSIONS To our knowledge this is the first report of regional differences in the distribution of NOS-III in the urethra and altered NOS-Ib gene expression with diabetes.
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Affiliation(s)
- C A Podlasek
- Department of Urology and Physiology Northwestern University Medical School Chicago, Illinois, USA
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Abstract
PURPOSE We retrospectively examined the experience of novice laparoscopic surgeons performing hand-assisted laparoscopic radical nephrectomy. The purpose was to determine if urologists with minimal laparoscopic training could perform hand-assisted laparoscopic nephrectomies in a safe and efficient manner. MATERIALS AND METHODS The first six hand-assisted laparoscopic radical nephrectomies performed by four different urology residents at the Chicago Lakeside VA hospital were reviewed. The residents included three chief urology residents and one postgraduate year 3 urology resident. None of the residents had taken any laparoscopic course, and all had limited exposure to the hand-assisted technique. In all cases, the residents performed the entire operation. The patients were evaluated for operative time, tumor size, body mass index, and ASA score. RESULTS All six procedures were completed without conversion to the open technique. The average operating time was 215.8 minutes, and the time from incision to organ removal averaged 140.8 minutes. The average estimated blood loss was 166 mL. Complications included an intraoperative diaphragmatic injury (recognized and repaired laparoscopically) and one postoperative ileus. CONCLUSION Hand-assisted laparoscopic radical nephrectomy can be performed safely and efficiently by urologists with minimal laparoscopic experience.
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Affiliation(s)
- R A Batler
- Department of Urology, Northwestern University Medical School, Chicago, Illinois, USA
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Abstract
Bedside ureteral stenting, although a challenging technique, can be achieved with frequent success by using some simple endoscopic maneuvers. By understanding the relationship of the working port to the lens and light source, surgeons can supinate or pronate their wrist to cannulate the ureteral orifices with greater success.
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Affiliation(s)
- R A Batler
- Department of Urology, Northwestern University Medical School, Chicago, Illinois 60611, USA
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Williams JI, Weitman S, Gonzalez CM, Jundt CH, Marty J, Stringer SD, Holroyd KJ, Mclane MP, Chen Q, Zasloff M, Von Hoff DD. Squalamine treatment of human tumors in nu/nu mice enhances platinum-based chemotherapies. Clin Cancer Res 2001; 7:724-33. [PMID: 11297269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Squalamine, an antiangiogenic aminosterol, is presently undergoing Phase II clinical trials in cancer patients. To broaden our understanding of the clinical potential for squalamine, this agent was evaluated in nu/nu mouse xenograft models using the chemoresistant MV-522 human non-small cell lung carcinoma and the SD human neuroblastoma lines. Squalamine was studied alone and in combination with either cisplatin or paclitaxel plus carboplatin. Squalamine alone produced a modest MV-522 tumor growth inhibition (TGI) and yielded a TGI with cisplatin that was better than cisplatin alone. Squalamine also significantly enhanced the activity of paclitaxel/carboplatin combination therapy in the MV-522 tumor model. Squalamine similarly improved the effectiveness of cisplatin in producing TGI when screened against the SD human neuroblastoma xenograft. Xenograft tumor shrinkage was seen for the MV-522 tumor in combination treatments including squalamine, whereas no tumor shrinkage was seen when squalamine was omitted from the treatment regimen. To gain a greater understanding of the mechanism by which squalamine inhibited tumor growth in the xenograft studies, in vitro experiments were carried out with vascular endothelial growth factor-stimulated human umbilical vein endothelial cells in culture exposed to squalamine. Squalamine treatment was found to retard two cellular events necessary for angiogenesis, inducing disorganization of F-actin stress fibers and causing a concomitant reduction of detectable cell the surface molecular endothelial cadherin (VE-cadherin). We propose that the augmentation by squalamine of cytotoxicity from platinum-based therapies is attributable to interference by squalamine with the ability of stimuli to promote endothelial cell movement and cell-cell communication necessary for growth of new blood vessels in xenografts after chemotherapeutic injury to the tumor.
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Affiliation(s)
- J I Williams
- Magainin Pharmaceuticals Inc., Plymouth Meeting, Pennsylvania 19462, USA.
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Gonzalez CM, Batler RA, Schoor RA, Hairston JC, Nadler RB. A novel endoscopic approach towards resection of the distal ureter with surrounding bladder cuff during hand assisted laparoscopic nephroureterectomy. J Urol 2001; 165:483-5. [PMID: 11176401 DOI: 10.1097/00005392-200102000-00030] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- C M Gonzalez
- Department of Veterans Affairs, VA Lakeside Hospital and Department of Urology, Northwestern University Medical School, Chicago, Illinois, USA
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Gonzalez CM, Brannigan RE, Bervig T, Zelner D, Podlasek CA, McKenna KE, McVary KT. Protein and gene expression of nitric oxide synthase isoforms I and III in the rat penile shaft. J Androl 2001; 22:54-61. [PMID: 11191088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Nitric oxide synthase (NOS) plays a key role in penile smooth muscle relaxation through the regulation of nitric oxide (NO). NO is a major neurotransmitter in the autonomic nervous system, and alteration of its activity has been implicated in erectile dysfunction. The objectives of this study were twofold: 1) to demonstrate and localize the NOS protein isoforms I and III in the normal rat penis, and 2) to identify and quantitate NOS I and III gene expression in the normal rat penis. The gene and protein product of NOS isoforms I and III are expressed in rat penile tissue. Protein expression of NOS I was confined primarily to neuronal tissue, while NOS III protein expression was identified primarily in both cavernosal smooth muscle and endothelium. The presence of both NOS I and III was confirmed in the penile shaft by Western blot. Quantitation of NOS I and III gene expression by reverse transcription-polymerase chain reaction revealed NOS III to be more highly expressed than that of NOS I in the rat penile shaft. NOS I and III protein and gene products are both expressed in normal rat penile tissue. Protein expression is localized primarily to neuronal tissue for NOS I, whereas NOS III is localized primarily to cavernosal smooth muscle and endothelium. NOS III gene expression is greater than that of NOS I in the normal rat penile shaft. These findings support the possibility that penile erection is regulated by different NOS isoforms released from neural, endothelial, and smooth muscle sources.
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Affiliation(s)
- C M Gonzalez
- Department of Urology, Northwestern University Medical School, Chicago, Illinois 60611, USA
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Gonzalez CM, Griffey SM, Naydan DK, Flores E, Cepeda R, Cattaneo G, Madewell BR. Canine transmissible venereal tumour: a morphological and immunohistochemical study of 11 tumours in growth phase and during regression after chemotherapy. J Comp Pathol 2000; 122:241-8. [PMID: 10805977 DOI: 10.1053/jcpa.1999.0366] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Eleven dogs with canine transmissible venereal tumour (CTVT) were given vincristine sulphate chemotherapy to induce tumour regression. Biopsy specimens were collected from tumours during the growth phase, before chemotherapy, and again from the same dogs during the regression induced by chemotherapy. Laboratory assessment included cytology, histology, the number of tumour cells in relation to the number of intratumoral leucocytes, proliferative and apoptotic fractions of tumour cells, intratumoral vessel density, and fibrosis. The results revealed that during regression, tumour cell proliferation ceased, apoptosis increased, leucocytes increased (with increased proportion of T lymphocytes), tumour parenchyma collapsed around intratumoral vessels, and fibrosis increased. These results, which were similar to findings in dogs with spontaneous regression of CTVT, suggest that tumour immunity plays a role in tumour regression after modest chemotherapy.
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Affiliation(s)
- C M Gonzalez
- Facultad de Ciencias Veterinarias, Universidad de Chile, Santiago, Chile
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