Beyond the Basics: A Novel Approach to Integrating a Social Determinants of Health Curriculum into an Emergency Medicine Course

Background

Our aim was to implement and evaluate a novel social determinants of health (SDoH) curriculum into the required fourth-year emergency medicine (EM) course at the University of Vermont Larner College of Medicine with the goal to teach students how to assess and address SDoH in clinical practice. The objectives were as follows: 1. Assess the SDoH, risk factors, and barriers to healthcare facing patients from diverse socioeconomic and cultural backgrounds in the ED. 2. Examine how social work consult services operate in the ED setting and how to identify appropriate referrals, resources, and treatment plans for patients in the ED. 3. Examine and interpret the impact health disparities have on patients in the ED and develop potential solutions to reduce these disparities to improve health outcomes. 4. Analyze the experiences and lessons learned and use them to inform future patient interactions.

Curricular Design

The curriculum was developed by a workgroup that considered the following: scope; target learners; overall structure; instructional and delivery methods; and session scheduling. The curriculum consisted of four components that took place over the four-week EM course. Students completed a required end-of-course survey. Survey results underwent a mixed-methods analysis to assess student attitudes and the impact of the curriculum.

Impact/Effectiveness

We received a 78.7% (74/94) completion rate for the 2021-2022 academic year. Of all respondents, 92% (68/74) indicated that they would apply lessons learned from the SDoH components of the curriculum; 74% (54/74) rated the SDoH curriculum as good, very good, or excellent; and 81% (60/74) felt that the EM course increased their understanding of diversity, equity, and inclusion as it relates to the practice of medicine. The thematic analyses revealed four main themes: 1) general comments; 2) course design; 3) interprofessional collaboration; and 4) expanding the scope of the curriculum.

Conclusion

Social medicine integration into core EM courses is a generalizable approach to experiential and collaborative exposure to the social determinants of health. Of student respondents, 92% indicated they will use lessons learned from this curriculum in their future practice. This can improve the way future generations of physicians identify SDoH and address the social needs that affect their patients, thereby advancing and promoting health equity.

Gender-based Barriers in the Advancement of Women Leaders in Emergency Medicine: A Multi-institutional Qualitative Study

Introduction

Leadership positions occupied by women within academic emergency medicine have remained stagnant despite increasing numbers of women with faculty appointments. We distributed a multi-institutional survey to women faculty and residents to evaluate categorical characteristics contributing to success and differences between the two groups.

Methods

An institutional review board-approved electronic survey was distributed to women faculty and residents at eight institutions and were completed anonymously. We created survey questions to assess multiple categories: determination; resiliency; career support and obstacles; career aspiration; and gender discrimination. Most questions used a Likert five-point scale. Responses for each question and category were averaged and deemed significant if the average was greater than or equal to 4 in the affirmative, or less than or equal to 2 in the negative. We calculated proportions for binary questions.

Results

The overall response rate was 55.23% (95/172). The faculty response rate was 54.1% (59/109) and residents’ response rate was 57.1% (36/63). Significant levels of resiliency were reported, with a mean score of 4.02. Childbearing and rearing were not significant barriers overall but were more commonly reported as barriers for faculty over residents (P <0.001). Obstacles reported included a lack of confidence during work-related negotiations and insufficient research experience. Notably, 68.4% (65/95) of respondents experienced gender discrimination and 9.5% (9/95) reported at least one encounter of sexual assault by a colleague or supervisor during their career.

Conclusion

Targeted interventions to promote female leadership in academic emergency medicine include coaching on negotiation skills, improved resources and mentorship to support research, and enforcement of safe work environments. Female emergency physician resiliency is high and not a barrier to career advancement.

Expansion of laparoscopic cholecystectomy in a resource limited setting, Mongolia: a 9-year cross-sectional retrospective review

BACKGROUND

The benefits of laparoscopic cholecystectomy have been largely unavailable to most people in developing countries. Mongolia has an extremely high incidence of gallbladder disease. In 2005, only 2% of cholecystectomies were being done laparoscopically. Open cholecystectomies were associated with high rates of wound infections, complications, and increased recovery time. Because of the unacceptable complications associated with open cholecystectomies, and nearly 50% of the nomadic population needing faster post-operative recovery times, a national project for the development of laparoscopic surgery was organised. Multi-institutional collaboration between the Mongolia Health Sciences University, the Dr W C Swanson Family Foundation (SFF), the University of Utah, Intermountain Healthcare, and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) led to the promulgation of a formalised countrywide laparoscopic training programme during the past 9 years. This is a retrospective review of the transition from open to laparoscopic cholecystectomy throughout Mongolia.

METHODS

Demographic patient data, diagnosis, and operation preformed-laparoscopic versus open cholecystectomy, between January, 2005, and September, 2013, were collected and trends were analysed from seven regional diagnostic referral and treatment centres, and two tertiary academic medical centres from six of the 21 provinces (Aimags) throughout Mongolia. Data were analysed by individual training centre, by year, and then compared between rural and urban centres.

FINDINGS

Nearly 16 000 cholecystectomies were analysed and compared (4417 [28·2%] men; 11 244 [71·8%] women). Men and women underwent laparoscopic cholecystectomy with the same frequency (41·2% men, 43·2% women) and had similar age (men, mean 52·2 years [SD 14·8]; women, mean 49·4 years [SD 15·7]). By 2013, 62% of gallbladders were removed laparoscopically countrywide as opposed to only 2% in 2005. More than 315 Mongolian practitioners have received laparoscopic training in 19 of 21 Aimags. On average 60% of cholecystectomies are done laparoscopically in urban surgical centres, up from 2%, versus 55% in rural surgical centres, up from 0%, in 2005. Laparoscopic cholecystectomy surpassed open cholecystectomy as the primary method for gallbladder removal countrywide in 2011.

INTERPRETATION

By 2013, 62% of cholecystectomies countrywide were done laparoscopically, a great increase from 9 years ago. Despite being a resource limited country, the expansion of laparoscopic cholecystectomy has transformed the care of biliary tract disease in Mongolia.

FUNDING

The University of Utah Center for Global Surgery.

The yeast Na+/H+ exchanger Nhx1 is an N-linked glycoprotein. Topological implications

Nhx1, the endosomal Na(+)/H(+) exchanger of Saccharomyces cerevisiae represents the founding member of a newly emerging subfamily of intracellular Na(+)/H(+) exchangers. These proteins share significantly greater sequence homology to one another than to members of the mammalian Na(+)/H(+) exchanger (NHE) family encoding plasma membrane Na(+)/H(+) exchangers. Members of both subtypes are predicted to share a common organization, with an N-terminal transporter domain of transmembrane helices followed by a C-terminal hydrophilic tail. In the present study, we show that Nhx1 is an asparagine-linked glycoprotein and that the sites of glycosylation map to two residues within the C-terminal stretch of the polypeptide. This is the first evidence, to date, for glycosylation of the C-terminal region of any known NHE isoform. Importantly, the mapping of N-linked glycosylation to the C-terminal domain of Nhx1 is indicative of an unexpected membrane topology, particularly with regard to the orientation of the tail region. Although one recent study demonstrated that certain epitopes in the C-terminal domain of NHE3 were accessible from the exoplasmic side of the plasma membrane (Biemesderfer, D., DeGray, B., and Aronson, P. S. (1998) J. Biol. Chem. 273, 12391-12396), numerous other studies implicate a cytosolic disposition for the hydrophilic C-terminal tail of plasma membrane NHE isoforms. Our analysis of the glycosylation of Nhx1 is strongly indicative of residence of at least some portion of the hydrophilic tail domain within the endosomal lumen. These findings imply that the organization of the tail domain may be more complex than previously assumed.

Synthesis of an anti-methicillin-resistant Staphylococcus aureus (MRSA) carbapenem via stannatrane-mediated Stille coupling

[formula: see text] A short synthesis of carbapenem 1 is described. They key step involves the cross-coupling of an enol triflate with an amino-substituted sp3 carbon. This cross-couping, which allows the introduction of the complete side chain in one step, utilizes a stannatrane as the heteroalkyl transfer reagent.

Preparation of crystalline p-nitrobenzyl 2-formyl carbapenems by oxidative cleavage

Crystalline 1beta-methyl-2-formyl carbapenem pNB esters were prepared by osmium-mediated oxidative cleavage of the corresponding 2-vinyl derivatives. Reduction of the 2-formyl compounds gave the corresponding 2-hydroxymethyl derivatives, which are key intermediates for the anti-MRS carbapenem candidate (1).

One practitioner's perspective

Comments are provided from the perspective of a practitioner.

Luminal Ca2+ protects against thapsigargin inhibition in neuronal endoplasmic reticulum

Thapsigargin is a specific and potent inhibitor of sarco/endoplasmic reticulum Ca2+-ATPases. However, in whole rat brain microsomes, 1 microM thapsigargin had no significant effect on the 10-min time course of ATP-dependent Ca2+ uptake in the absence of the luminal Ca2+ chelator oxalate. In contrast, 50 mM oxalate resolved a thapsigargin-sensitive Ca2+ uptake rate (IC50 approximately 1 nM thapsigargin) five times that of a thapsigargin-insensitive rate. This remaining approximately 20% of the total ATP-dependent accumulation was insensitive to thapsigargin (up to 10 microM), slightly less sensitive to vanadate inhibition, and unresponsive to 5 microM inositol 1,4,5-trisphosphate or 10 mM caffeine. Measuring both 12-min Ca2+ uptake and initial Ca2+ uptake rates, the apparent thapsigargin sensitivity increased as oxalate concentrations increased from 10 to 50 mM, corresponding to a range of luminal free Ca2+ concentrations of approximately 300 down to 60 nM. Addition of oxalate during steady-state 45Ca accumulation rapidly resolved the aforementioned thapsigargin sensitivity. These results strongly suggest that luminal Ca2+ may protect a large portion of neuronal endoplasmic reticulum Ca2+ pumps against thapsigargin inhibition. Although high [Ca2+] has been previously shown to protect against thapsigargin inhibition in several reticular membrane preparations, our results suggest that luminal Ca2+ alone is responsible for mediating this effect in neurons.

Effects of the intraluminal Ca load on the kinetics of 45Ca uptake and efflux in brain microsomes

Effects of increasing intraluminal Ca ([Ca]i) on the kinetics of rat brain microsomal uptake and efflux are reported here. Isolated rat brain microsomes accumulated 45Ca in an extravesicular free Ca ([Ca]o)- and ATP-dependent manner. Increased microsomal Ca load resulted in a decreased initial rate of 45Ca uptake and an increased tau, time to reach 63% of steady-state accumulation. Isolated rate brain microsomes lost 45Ca in a temperature- and [Ca]i-dependent manner. Whether preloaded with tracer 45Ca and either < or = 0.5 or 25 microM [Ca]o, the time constant of efflux was larger at 4 degrees C as compared with 37 degrees C. Additionally, increased microsomal Ca load resulted in a decreased time constant of 45Ca efflux. This shorter efflux time constant cannot explain the effect of [Ca]i on tau during uptake which was in fact longer for preloaded microsomes. Rather, these data suggest that, as Ca accumulates into unloaded microsomes, a steadily increasing [Ca]i slows unidirectional Ca influx (presumably by inhibiting the endoplasmic reticulum Ca pump) and enhances unidirectional Ca efflux, and that these combined effects ultimately shorten the time needed to achieve steady-state luminal [Ca]i.

Combined use of stents and coils to treat experimental wide-necked carotid aneurysms: preliminary results

PURPOSE

To develop a new technique to treat wide-necked side-wall aneurysms, combining the implantation of intraarterial stents with the endosaccular placement of coils.

METHODS

Bilateral side-wall aneurysms were surgically created on the carotid arteries of four dogs. In each animal, Guglielmi detachable coils were introduced into one of the aneurysms after implantation of a balloon-expandable Strecker stent within the parent artery, adjacent to the aneurysm orifice. The contralateral aneurysms were treated with coils alone.

RESULTS

In two dogs, one of the stented and both nonstented aneurysms remained partially open for 4 weeks after subtotal packing with coils. In another two dogs, tight aneurysm packing with coils resulted in complete occlusion of all four aneurysms. Bulging of the coil mass resulted in 30% to 75% narrowing of the nonstented parent arteries. At 4 and 5 weeks, significant stenosis resulting from reactive hyperplasia was observed in all stented carotid arteries.

CONCLUSION

Based on these preliminary results, we conclude that Guglielmi detachable coils can be introduced into an aneurysm cavity through Strecker stents. The stents allow tighter packing of wide-necked aneurysms by preventing coils from migrating or bulging into the parent arteries.

Anxiety disorders among Mexican Americans and non-Hispanic whites in Los Angeles

This report from the Los Angeles site of the NIMH Epidemiologic Catchment Area study reveals significant ethnic and national origin differences in lifetime prevalence rates for three out of six specific, DSM-III-defined anxiety disorders. In the case of simple phobia, United States-born Mexican Americans report higher rates than native non-Hispanic whites or immigrant Mexican Americans, the latter two groups having similar rates. Mexican Americans born in the United States had higher rates of agoraphobia than immigrant Mexican Americans, and non-Hispanic whites reported higher lifetime rates of generalized anxiety disorder compared with both immigrant and native Mexican Americans. Neither ethnic nor national origin differences in lifetime prevalence rates were found for panic disorder, social phobia, and obsessive-compulsive disorder. Selective migration is postulated as a potential factor influencing prevalence differences between native and immigrant Mexican Americans.