Socioeconomic and racial disparities in source-apportioned PM2.5 levels across urban areas in the contiguous US, 2010

Fine particulate matter (PM2.5) air pollution exposure is associated with short and long-term health effects. Several studies found differences in PM2.5 exposure associated with neighborhood racial and socioeconomic composition. However, most focused on total PM2.5 mass rather than its chemical components and their sources. In this study, we describe the ZIP code characteristics that drive the disparities in exposure to PM2.5 chemical components attributed to source categories both nationally and regionally. We obtained annual mean predictions of PM2.5 and fourteen of its chemical components from spatiotemporal models and socioeconomic and racial predictor variables from the 2010 US Census, and the American Community Survey 5-year estimates. We used non-negative matrix factorization to attribute the chemical components to five source categories. We fit generalized nonlinear models to assess the associations between the neighborhood predictors and each PM2.5 source category in urban areas in the United States in 2010 (n=25,790 zip codes). We observed higher PM2.5 levels in ZIP codes with higher proportions of Black individuals and lower socioeconomic status. Racial exposure disparities were mainly attributed to Heavy Fuel, Oil and Industrial, Metal Processing Industry and Agricultural, and Motor Vehicle sources. Economic disparities were mainly attributed to Soil and Crustal Dust, Heavy Fuel Oil and Industrial, Metal Processing Industry and Agricultural, and Motor Vehicle sources. Upon further analysis through stratifying by regions within the United States, we found that the associations between ZIP code characteristics and source-attributed PM2.5 levels were generally greater in Western states. In conclusion, racial, socioeconomic, and geographic inequalities in exposure to PM2.5 and its components are driven by systematic differences in component sources that can inform air quality improvement strategies.

REBUILDING THE NURSING HOME WORKFORCE: A TIME FOR CHANGE

The COVID-19 pandemic magnified several long-standing problems in nursing homes, including issues within the nursing home workforce. Issues include staffing shortages, high turnover, low pay, inadequate training, poor treatment and limited access to resources. Research suggests that workforce issues of these kinds have the potential to significantly threaten and further increase disparities in the quality of care for nursing home residents. Thus, solutions are needed that ensures the nursing home workforce receives adequate investment so that these critical personnel are able to more effectively do the work that they do. In this presentation, workforce issues salient within the nursing home setting will be elaborated and potential solutions to mitigating these issues will be discussed.

Perspectives of Historically Black College and University Advisors to Premedical Students During the COVID-19 Pandemic: A Qualitative Study

IMPORTANCE

Black students remain underrepresented in medicine despite national efforts to increase diversity in the physician workforce. Historically Black College and University (HBCU) students play a vital role in increasing representation in the workforce. Currently, there is a paucity of literature understanding the impact of COVID-19 on premedical students from HBCUs. Understanding the adverse impact of the pandemic on HBCU students is essential to inform strategies that promote holistic medical school admissions and increased diversity, equity, and inclusion in the medical workforce.

OBJECTIVE

To explore premedical advisors' perspectives on the impact of the COVID-19 pandemic on HBCU premedical students pursuing admission to medical school.

DESIGN, SETTING, AND PARTICIPANTS

In this qualitative study, semistructured interviews of HBCU premedical advisors were performed from March 2020 to March 2021. One-on-one interviews were conducted with 21 advisors with a depth of experience as advisors, varied educational backgrounds, and diverse geographic representation. Data analysis was performed from March 2021 to December 2021.

MAIN OUTCOMES AND MEASURES

The experiences of HBCU premedical students during the COVID-19 pandemic from the perspective of the premedical advisor.

RESULTS

Among the 21 participants, 13 (62%) were female, 15 (71%) were Black or African American, 11 (52%) had a doctorate degree, and 7 (33%) had more than 10 years of experience as advisors. Participants described 3 major themes: (1) balancing academic responsibilities with family demands; (2) distraction, disruption, and isolation in the virtual learning environment; and (3) harmful impact of new stressors for HBCU applicants in the medical school admissions process.

CONCLUSIONS AND RELEVANCE

In this qualitative study of HBCU advisors to premedical students, advisors described how the COVID-19 pandemic adversely affected undergraduate HBCU premedical students; students faced family hardships, challenges with virtual learning, and uncertainty in the medical school admissions process. These findings suggest that medical schools should continue to create direct interventions to address the challenges that HBCU students faced during the height of the pandemic and as longitudinal consequences of the pandemic. Addressing these issues may improve physician workforce representation and promote more equitable patient care for underserved communities disproportionately affected by COVID-19 and other health disparities.

Evaluation of Racial and Ethnic Disparities in Cardiac Transplantation

Background Racial and ethnic disparities contribute to differences in access and outcomes for patients undergoing heart transplantation. We evaluated contemporary outcomes for heart transplantation stratified by race and ethnicity as well as the new 2018 allocation system. Methods and Results Adult heart recipients from 2011 to 2020 were identified in the United Network for Organ Sharing database and stratified into 3 groups: Black, Hispanic, and White. We analyzed recipient and donor characteristics, and outcomes. Among 32 353 patients (25% Black, 9% Hispanic, 66% White), Black and Hispanic patients were younger, more likely to be women and have diabetes mellitus or renal disease (all, P<0.05). Over the study period, the proportion of Black and Hispanic patients listed for transplant increased: 21.7% to 28.2% (P=0.003) and 7.7% to 9.0% (P=0.002), respectively. Compared with White patients, Black patients were less likely to undergo transplantation (adjusted hazard ratio [aHR], 0.87; CI, 0.84-0.90; P<0.001), but had a higher risk of post-transplant death (aHR, 1.14; CI, 1.04-1.24; P=0.004). There were no differences in transplantation likelihood or post-transplant mortality between Hispanic and White patients. Following the allocation system change, transplantation rates increased for all groups (P<0.05). However, Black patients still had a lower likelihood of transplantation than White patients (aHR, 0.90; CI, 0.79-0.99; P=0.024). Conclusions Although the proportion of Black and Hispanic patients listed for cardiac transplantation have increased, significant disparities remain. Compared with White patients, Black patients were less likely to be transplanted, even with the new allocation system, and had a higher risk of post-transplantation death.

Development and evaluation of a pilot overdose education and naloxone distribution program for hospitalized general medical patients

Background: Overdose education and naloxone distribution (OEND) to people at risk of witnessing or experiencing an opioid overdose has traditionally been provided through harm reduction agencies. Expanding OEND to inpatient general medical settings may reach at-risk individuals who do not access harm reduction services and have not been trained. An OEND program targeting inpatients was developed, piloted, and evaluated on 2 general medicine floors at Montefiore Medical Center, a large urban academic medical center in Bronx, New York. Methods: The planning committee consisted of 10 resident physicians and 2 faculty mentors. A consult service model was piloted, whereby the primary inpatient care team paged the consult team (consisting of rotating members from the planning committee) for any newly admitted patient who had used any opioid in the year prior to admission. Consult team members assessed patients for eligibility and provided OEND to eligible patients through a short video training. Upon completion, patients received a take-home naloxone kit. To evaluate the program, a retrospective chart review over the first year (April 2016 to March 2017) of the pilot was conducted. Results: Overall, consults on 80 patients were received. Of these, 74 were eligible and the consult team successfully trained 50 (68%). Current opioid analgesic use of ≥50 morphine milligram equivalents daily was the most common eligibility criterion met (38%). Twenty-four percent of patients were admitted for an opioid-related adverse event, the most common being opioid overdose (9%), then opioid withdrawal (8%), skin complication related to injecting (5%), and opioid intoxication (2%). Twenty-five percent had experienced an overdose, 35% had witnessed an overdose in their lifetime, and 83% had never received OEND previously. Conclusions: Integrating OEND into general inpatient medical care is possible and can reach high-risk patients who have not received OEND previously. Future research should identify the optimal way of implementing this service.

Southeast and East Asian American Medical Students’ Perceptions of Careers in Academic Medicine

The Asian race represents one of the fastest growing racial groups in the United States that have unique health-care issues and barriers to services. Despite being the second largest racial group among medical students, Asians represent a markedly smaller proportion of leadership. Greater inclusion may facilitate Asian-related curriculum content development, community-engaged research, and increased services for Asian communities. This article explores Southeast and East Asian American (AA) medical students’ perceptions of and challenges toward pursuing academic medicine careers. We collected quantitative and qualitative data among 138 participants. Factors that increased trainees’ interests include collaboration with others, teaching and research opportunities, and influential role models/mentors. Interventions identified to overcome perceived challenges include exposure to senior-level race-concordant role models and mentors, enhancement of communication skills, and informed career discussions between parents and trainees. Such interventions may engage more AA trainees into academia and facilitate their growth as leaders.

Attracting Diverse Talent to Academia

Women and underrepresented racial/ethnic minority faculty (URM) are critical to developing inclusive learning environments. Career counselors can benefit from understanding the factors influencing women’s and URMs’ interest in academic careers, as this population remains markedly underrepresented in academic medicine. A mixed methods study was conducted among medical students and residents yielding 643 survey and 121 focus group participants. Participants were diverse by gender and race/ethnicity. Themes included (a) factors influencing career interest, (b) influential others, (c) timing of career interest, and (d) career expectations. Findings show differences among women, URM, and dominant-identity groups. Implications include how career development programs and institutional diversity policies and practices should consider developing and offering activities that support (a) mentoring—especially for women trainees, (b) learning how to align academia and community engagement and scholarship—especially for URM trainees, and (c) senior leadership development support for women and URM trainees.

Introducing Trainees to Medical Education Activities and Opportunities for Educational Scholarship

INTRODUCTION

The growth of medical schools, faculty attrition, and reports of student disinterest in academia all stress the need to cultivate the next generation of academic physicians. Because medical educators serve as the largest segment of faculty, heightening diverse students' awareness of opportunities to engage in various educational roles and scholarship may help them consider future academic positions.

METHODS

We implemented a workshop utilizing didactics and a small-group case discussion to help students learn how to (1) define educational scholarship and portfolios, (2) recognize the value of educational scholarship, and (3) identify how to get started with educational scholarship.

RESULTS

One hundred and fifty-six learners participated in the workshop at 11 regional conferences. Of learners from conferences 1-6, 100% (69/69) responded to the statement "The workshop INCREASED my confidence in achieving the following - Performing educational scholarship." Among these learners, 39 (56.5%) strongly agreed and 20 (29.0%) agreed with this statement. Of learners from conferences 7-11, 98.9% (86/87) responded to the question "How much confidence do you have in your ability to succeed along a clinician-educator track and publish your education-related work?" Using a paired-samples t test, a statistically significant increase in learner confidence was noted (p < .01) before and after the workshop.

DISCUSSION

Diverse learners appreciated a heightened awareness of educational roles and scholarship, which may help them gain confidence, interest, and experience in becoming future medical educators.

Learning histology - dental and medical students' study strategies

PURPOSE

Histology, the science of cells and tissues at the microscopic level, is an integral component of most dental and medical curricula and is often taught using both traditional and novel computer-based didactic approaches. The purpose of this study was to analyse the strategies used by dental and medical students when studying this very visual and challenging subject.

METHODS

Data were collected from 75 dental and 143 medical students, who had almost identical histology learning resources at their disposal.

RESULTS

When compared with their medical counterparts, dental students view histology as a more difficult subject and as less relevant for their future career. Whereas dental students, who are required to attend class unlike medical students, made more use of in-classroom learning opportunities, they did not take as much advantage of out-of-classroom resources. In addition, dental students reported a significantly higher tendency than medical students to work together, rather than to study alone.

DISCUSSION

Small differences in the dental versus the medical learning environment associate with several observed differences in learning strategies that are adopted by dental and medical students.

CONCLUSIONS

These differences should be considered when teaching the subject of histology to dental or to medical students.

Development and implementation of novel community outreach methods in women's health issues: the National Centers of Excellence in Women's Health

Numerous outreach efforts have been employed to educate both lay and professional communities about many medical issues. As part of our contracts with the Public Health Service, Office of Women's Health, Department of Health and Human Services, the National Centers of Excellence (CoEs) in Women's Health have been charged with creating innovative and effective methods of educating these audiences about the major issues involved in women's health. This mission is particularly critical in the arena of women's health, as women are responsible for approximately 75% of the healthcare decisions made by and for American families, and past efforts to provide them with good, evidence-based information have been fraught with difficulties ranging from financial to cultural. We report herein some of our successful novel outreach efforts. A common thread throughout this account is that among the most successful of the outreach activities are those that involve or incorporate existing community groups committed to women's health.

Information technology and the National Centers of Excellence in Women's Health

Women are increasingly turning to the Internet for health information. The National Centers of Excellence in Women's Health (U.S. Dept. of Health and Human Services) have as one goal the use of information technology to improve care of women. Telemedicine, the Internet, and Resource Centers were used for patient consultation, patient support, support of women in academics, and clinician education regarding women's health. Access of the lay public to high-quality health information was achieved using the Internet as well as Resource Centers employing Internet educational modalities. Telemedicine, distance learning for clinicians and patient consultations for those far from medical care, has been used successfully. For clinicians, continuing medical education regarding women's health and calendars of opportunities for education in women's health were made available on-line. Creative new uses of information technology have been developed by the Centers of Excellence in Women's Health. These modalities may be adopted, tested, and adapted by others seeking to improve the care and health of women.

The Spacebridge to Russia Project: internet-based telemedicine

The National Aeronautics and Space Administration (NASA) has been a pioneer in telemedicine since the beginning of the human spaceflight program in the early 1960s. With the rapid evolution in computer technology and equally rapid development of computer networks, NASA and the Department of Surgery in Yale University's School of Medicine created a telemedicine testbed with the Russia Space Agency, the Spacebridge to Russia Project, using multimedia computers connected via the Internet. Clinical consultations were evaluated in a store-and-forward mode using a variety of electronic media, packaged as digital files, and transmitted using Internet and World Wide Web tools. These systems allow real-time Internet video teleconferencing between remotely located users over computer systems. This report describes the project and the evaluation methods utilized for monitoring effectiveness of the communications. The Spacebridge to Russia Project is a testbed for Internet-based telemedicine. The Internet and current computer technologies (hardware and software) make telemedicine readily accessible and affordable for most health care providers. Internet-based telemedicine is a communication tool that should become integral to global health care.

Telemedicine: delivering medical expertise across the state and around the world

Many aspects of medical care can now be delivered at a distance using telemedicine technology. Rapid video and computer-based communication of medical information makes it possible for a physician to "examine" a patient located in another city, to view highly detailed medical images, to consult with distant subspecialists, or to supervise complex medical procedures. This same technology can bring scattered health-care workers together for joint teaching conferences. The Yale Telemedicine Center has initiated a number of such programs ranging from providing consultations in real time to physicians in Saudi Arabia, to interpreting medical images across town or across the state. Telemedicine will become a powerful tool for managed health-care organizations which are responsible for the medical needs of widely distributed patients in a vertically integrated health-care delivery system. This paper reviews the evolution of telemedicine, its technical fundamentals, specific medical applications, and the activities of the Yale Telemedicine Center. Evolving uses for telemedicine in Connecticut are described.

Colorectal cancer presenting with a cutaneous metastatic lesion on the scalp

Cutaneous metastases occur rarely with colorectal adenocarcinoma, accounting for approximately 5 percent of all cutaneous metastases. Cutaneous metastases from colonic cancer are most often located on the abdominal skin. The case we describe here is unusual because colorectal adenocarcinoma rarely metastasizes to the scalp. A review of the English language literature revealed only six reported cases of cutaneous metastases from a colonic adenocarcinoma to the scalp.