Equity, diversity, and inclusion in academic American otolaryngology faculty: an elusive dream.

We analyze gender and racial disparities in academic otolaryngology from 2007 to 2018 in the United States (US). A cross-sectional retrospective analysis was done using data from the American Association of Medical Colleges. The distribution of gender and race, academic ranks, tenure tracks, and degrees was reported. The total number of otolaryngologists increased from 1,490 to 2,239, where 53 percent were females. All races experienced an increase; however, Whites and Asians had a greater increase compared to Black and Hispanics. Regarding percentages at different ranks, White were the majority (>50 percent) in every category. As for tenure, the general trend was a decrease in the total number of tenured physicians from 327 in 2007 to 318 in 2018, where Black, Hispanic, and Asian tenured physicians increased, while White tenured physicians decreased. White male otolaryngologists were the majority for every subgroup (>60 percent), whereas Black faculty made up less than 1 percent of tenured category. Female representation gradually increased for all levels of tenure. As for all degrees, Whites were the majority for all levels of education (>60 percent). There were some improvements in the representations for the females in all and Asians on the tenure track. However, progress for the URM remains an elusive dream.

Curriculum mapping as a tool to facilitate curriculum development: a new School of Medicine experience.

BACKGROUND: Every curriculum needs to be reviewed, implemented and evaluated; it must also comply with the regulatory standards. This report demonstrates the value of curriculum mapping (CM), which shows the spatial relationships of a curriculum, in developing and managing an integrated medical curriculum. METHODS: A new medical school developed a clinical presentation driven integrated curriculum that incorporates the active-learning pedagogical practices of many educational institutions worldwide while adhering to the mandated requirements of the accreditation bodies. A centralized CM process was run in parallel as the curriculum was being developed. A searchable database, created after the CM data was uploaded into an electronic curriculum management system, was used to ensure placing, integrating, evaluating and revising the curricular content appropriately. RESULTS: CM facilitated in a) appraising the content integration, b) identifying gaps and redundancies, c) linking learning outcomes across all educational levels (i.e. session to course to program), c) organizing the teaching schedules, instruction methods, and assessment tools and d) documenting compliance with accreditation standards. CONCLUSIONS: CM is an essential tool to develop, review, improve and refine any integrated curriculum however complex. Our experience, with appropriate modifications, should help other medical schools efficiently manage their curricula and fulfill the accreditation requirements at the same time.

Major dietary patterns and risk of acute myocardial infarction in young, urban Pakistani population.

OBJECTIVE: To investigate the role of dietary intake in the development of premature acute myocardial infarction (AMI) in a hospital-based Pakistani population in Karachi. METHODS: In a case control study, 203 consecutive patients (146 males and 57 females) with their first AMI and age below 45 years were enrolled with informed consent. Similarly, 205 gender and age matched (within 3 years) healthy adults were also included as controls. Dietary intake of both cases and controls was assessed by using a simple 14-item food frequency questionnaire. Using factor analysis, 3 major dietary patterns- prudent dietary pattern, combination dietary pattern and western dietary pattern were identified. Fasting plasma/serum of both cases and controls were analyzed for homocysteine, folate, vitamin B12, blood Pb, ferritin, cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides. ANOVA and conditional logistic regression were used to predict the association of dietary patterns with AMI. RESULTS: Consumption of prudent diet, characterized by high consumption of legumes, vegetables, wheat, chicken and fruits, is protective against the risk of premature AMI. Moderate to high consumption of combination diet, characterized by high intake of eggs, fish, fruits, juices and coffee was associated with decreased risk of AMI. No association was observed between western diet, characterized by high intake of meat, fish and tea with milk and risk of AMI. CONCLUSIONS: Consumption of a prudent dietary pattern and a combination dietary pattern is protective against the risk of AMI in a Pakistani population.

Implications of Ramadan Fasting in the Setting of Gastrointestinal Disorders.

Intermittent fasting is an increasingly popular dieting technique with many well-studied benefits, such as permitting weight loss in obese patients, lowering low-density lipoprotein cholesterol (LDL-C) levels and triglyceride levels, and optimizing circadian rhythms. A special type of intermittent fasting occurs during Ramadan, when Muslims worldwide fast daily from dawn to sunset for a month. Ramadan fasting has demonstrated several health benefits, including improving the gut microbiome, modifying gut hormone levels, and lowering proinflammatory markers such as cytokines and blood lipids. Although fasting has many health benefits, fasting during Ramadan may aggravate chronic medical conditions. We aim to review the literature devoted to Ramadan fasting and its effects on Muslim patients with gastrointestinal (GI) disorders, such as Inflammatory bowel disease (IBD), peptic ulcer disease (PUD), upper GI bleeding (UGIB), gastroesophageal reflux disease (GERD), and liver conditions. We will discuss recommendations for diet and medication compliance during Ramadan in the recommended pre-Ramadan counseling sessions. In this study, we used PubMed to research journals using the key terms "Ramadan," "intermittent fasting," and "gastrointestinal diseases." The current literature studying the impact of Ramadan on gastrointestinal disorders shows that patients with IBD have a minimal risk of disease exacerbation, although older men with ulcerative colitis (UC) were more prone to exacerbation during fasting. Patients with duodenal ulcers were at a higher risk of hemorrhage after Ramadan fasting. Although with mixed results, studies show patients with liver disease demonstrated improvements in liver enzymes, cholesterol, and bilirubin after Ramadan. Physicians should offer pre-Ramadan counseling to educate patients on the risks of fasting and encourage shared decision-making. To facilitate more definitive discussions between the physician and a Muslim patient, clinicians should seek a deeper understanding of how Ramadan fasting affects certain health conditions and offer accommodations, such as diet and medication adjustments.

Retrospective assessment of metabolic syndrome components in early adult life on vegetarian dietary status.

Background: Metabolic syndrome (MetS) encompasses several clinical presentations that include truncal obesity and insulin resistance at its core. MetS afflicts 23% of the adult US population, increasing their risk of diabetes and cardiovascular disease. Many studies have indicated the importance of a vegetarian diet in improving overall health and more specifically MetS components. Unfortunately, these findings have been inconsistent and cannot be extended to examine effects on MetS incidence in the younger adult population. Objective: This study aimed to conduct a retrospective analysis of a vegetarian vs. non-vegetarian dietary status in young adults (age 18-24) based on MetS components in later adulthood (age 20-30). This study focuses on elucidating any relationship between a vegetarian diet and MetS components of central obesity, hypertension, and hyperlipidemia. Methods: Waves 3 and 4 data were acquired from AddHealth. One-to-one propensity score matched vegetarians to non-vegetarians in a cohort of 535 women and 159 men. Logistical regression assessed the relationship between vegetarian status and MetS components, including truncal obesity (cm), hypertension (normal, pre-HT, HT1, and HT2), and hyperlipidemia (high and low). Results MetS components from ages 20 to 30 are not associated with vegetarian dietary status. Truncal obesity [N = 694; M = 92.82 cm; OR 0.999; p = 0.893; 95% CI (0.980, 1.017)]; hypertension [N = 694; OR 0.949; p = 0.638; 95% CI (0.764, 1.179)]; hyperlipidemia [N = 694; OR 0.840; p = 0.581; 95% CI (0.453, 1.559)]. Conclusion: Current study results were consistent with previous findings suggesting that consumption of a vegetarian diet cannot be directly linked to MetS outcomes. However, further investigation should be completed as MetS is a risk factor for several chronic diseases.

Gender of Department Chair and Paid Parental Leave Benefits in Academic Radiology Residency Programs.

RATIONALE AND OBJECTIVES: Residency training often overlaps with prime childbearing years, yet variability in availability and duration of parental leave in residency can complicate the decision to become parents. Gender disparities in attitudes towards parenthood in residency is well recognized, with females generally reporting more concerns surrounding prolonged training, hindrance of future career plans, and negative perception from peers. However, gender of the department chair has not yet been examined as a factor influencing parental leave policies for residents in Radiology. MATERIALS AND METHODS: The gender of the department chair and parental leave policies for residents in 209 ACGME accredited diagnostic radiology programs across the United States were procured from their websites. These programs were stratified into 6 geographical regions to identify regional differences. Chi-squared analyses were used to compare availability of paid parental benefits with the gender of department chairs. RESULTS: Seventy-seven percent of diagnostic radiology program department chairs were male. 34 of 49 programs (69%) with female department chairs advertised paid parental benefits, compared to 61 of 160 programs (38%) chaired by males (P < 0.001). When stratified by region, this gender difference remained statistically significant in the mid-Atlantic and New England. CONCLUSION: Female gender of the department chair was associated with the increased availability of paid parental leave benefits for residents, yet females hold fewer academic leadership positions than males. Future discussions regarding parental leave policies for residents will have to consider the unique challenges in residency such as length of training and burden on coresidents.

Origin, Impact, and Solutions for Lifestyle-Related Chronic Diseases in Samoa and American Samoa.

Samoa and American Samoa are two island groups in the South Pacific inundated with the physiological consequences of swift westernization of diet and lifestyle. These polities face the singular theme of lifestyle-related problems seen in other countries. This paper aims to discuss the current demographics in Samoa and American Samoa and examine the origin and impact of lifestyle-related chronic diseases within a subset of its populace. This review will highlight the prominent nutrition transition that these polities have undergone in their development and examine the pathogenesis and pathophysiology of lifestyle-related diseases, primarily type 2 diabetes and obesity, in the context of a prominent cultural shift. Samoa and American Samoa face a litany of public health concerns as a result of the rising prevalence of lifestyle-related chronic diseases and the persistent threat of obesity. Lifestyle medicine is proposed as the optimal treatment solution for the currently devastating disease states and is adapted to the vibrant agricultural resources and healing roots of the Samoan culture.

Dietary patterns are associated with hyperhomocysteinemia in an urban Pakistani population.

Little attention has been given to the association of dietary patterns with plasma homocysteine. Our objective in this study was to identify major dietary patterns and investigate their association with plasma homocysteine. In a cross-sectional survey, 872 healthy adults (355 males, 517 females; aged 18-60 y) were enrolled from an urban population in Karachi. Dietary intake was assessed by a FFQ. We used factor analysis to define major dietary patterns. Fasting concentrations of plasma or serum homocysteine, folate, pyridoxal-phosphate (PLP; coenzyme form of vitamin B-6), and vitamin B-12 were measured. Three major dietary patterns were identified and labeled as "prudent diet," "high animal-protein diet," and "high plant-protein diet." We observed a protective effect of the prudent dietary pattern for the highest quartile of intake compared with the lowest quartile of hyperhomocysteinemia when the model was adjusted for age, gender, household income, BMI, tobacco chewing, and smoking [OR = 0.52 (95% CI = 0.30-0.90); P = 0.01]. The high plant-protein diet pattern was inversely related to hyperhomocysteinemia, with a higher intake being protective. Compared with the 1st quartile, the adjusted OR was 0.42 (95% CI = 0.25-0.69; P = 0.001) for the 4th quartile. The high animal-protein diet was positively associated with hyperhomocysteinemia, with participants in the highest quartile of intake having the greatest increase in risk [OR = 2.10 (95% CI = 1.22-3.60); P = 0.007]. Plasma homocysteine concentrations appeared to be correlated more with circulating folate (r = -0.25; P < 0.001) than with PLP (r = -0.02; P = 0.663) or vitamin B-12 (r = -0.16; P < 0.001). A diet rich in fruits and uncooked vegetables decreased the risk of hyperhomocysteinemia, whereas diets rich in red meat, chicken, and tea with milk were positively associated with hyperhomocysteinemia.

High plasma homocysteine increases risk of metabolic syndrome in 6 to 8 year old children in rural Nepal.

Little attention has been given to the association of plasma homocysteine (Hcy) and metabolic syndrome (MetS) in children. We have evaluated the risk of MetS with plasma Hcy in a cohort of 6 to 8 year old rural Nepalese children, born to mothers who had participated in an antenatal micronutrient supplementation trial. We assessed Hcy in plasma from a random selection of n = 1000 children and determined the relationship of elevated Hcy (>12.0 µmol/L) to MetS (defined as the presence of any three of the following: abdominal adiposity (waist circumference ≥ 85th percentile of the study population), high plasma glucose (≥ 85th percentile), high systolic or diastolic blood pressure (≥ 90th percentile of reference population), triglyceride ≥ 1.7 mmol/L and high density lipoprotein < 0.9 mmol/L.) and its components. There was an increased risk of low high-density lipoproteins (HDL), [odds ratios (OR) = 1.77, 95% confidence intervals (CI) = 1.08-2.88; p = 0.020], high blood pressure [OR = 1.60, 95% CI = 1.10-2.46; p = 0.015] and high body mass index (BMI) [OR = 1.98, 95% CI = 1.33-2.96; p = 0.001] with elevated Hcy. We observed an increased risk of MetS (OR = 1.75, 95% CI = 1.06-2.90; p = 0.029) with elevated Hcy in age and gender-adjusted logistic regression models. High plasma Hcy is associated with increased risk of MetS and may have implications for chronic disease later in life.

Smokeless tobacco use: a risk factor for hyperhomocysteinemia in a Pakistani population.

BACKGROUND: Smokeless tobacco (ST) use is highly prevalent in the South Asian populations. While there have been a number of reports on association of ST consumption with cancer, very few studies have been conducted to investigate its relationship with cardiovascular disease. Hyperhomocysteinemia is a well-recognized risk factor for cardiovascular disease; however, its association with ST use has never been investigated. The objective of this study was to evaluate the relationship of ST use with hyperhomocysteinemia in an urban Pakistani population. METHODOLOGY/PRINCIPAL FINDINGS: In a cross-sectional study for assessment of risks of hyperhomocysteinemia, 872 healthy adults (355 males and 517 females of age range 18-60 years) were recruited from a low-income population in Karachi, Pakistan. A detailed questionnaire was administered which included information about smoking, non-smoking, use of ST alone (chewing as well as sniffing) and use of ST with betel nuts. Fasting serum/plasma levels of homocysteine, folate, vitamin B12 and pyridoxal phosphate (PLP; a coenzymic form of vitamin B6) were analyzed. In this population, 43.4% males and 15.5% females were found to be regular users of ST products. Laborers and vendors were the major ST consumers. Smoking was not found to be associated with plasma/serum concentrations of homocysteine, folate, vitamin B12 and PLP. However, homocysteine concentrations in the group which consumed ST alone and the group which consumed ST along with betel nut were significantly higher compared to the non-user group (17.7±7.5 µmol/L, 25.48 µmol/L vs. 11.95 µmol/L, respectively; p<0.01). Odds ratio for the association of hyperhomocysteinemia (>15 µmol/L) was 11-fold higher in the ST-consumer group compared to the non-user group, [OR (95%CI)  = 11.34 (7.58-16.96); p<0.001], when the model was adjusted for age, gender, folate and vitamin B12 status. CONCLUSION: This study shows a positive association between ST consumption and hyperhomocysteinemia in a low-income urban Pakistani population.

Association of body iron status with the risk of premature acute myocardial infarction in a Pakistani population.

BACKGROUND: Coronary artery disease is very common in Pakistani population. Some of the studies carried out on Western populations have shown a relationship between body iron status as determined by the ratio of concentrations of serum soluble transferrin receptor (sTfR) to ferritin and the risk of acute myocardial infarction (AMI). In order to investigate whether increased body iron status has any relationship with the risk of premature AMI in Pakistani population, a case-control study was carried out. METHODOLOGY/PRINCIPAL FINDINGS: In this case-control study, 203 consecutive AMI patients [146 males and 57 females; age range 18-45 years] admitted to the National Institute for Cardiovascular Diseases, Karachi, were enrolled with informed consent. In addition, 205 healthy controls whose gender and age (within 3 years) matched the patients, and who had a similar socio-economic background were recruited. Fasting venous blood was obtained and assessed for plasma/serum folate, vitamin B12, homocysteine, total cholesterol, triglycerides, LDL-cholesterol, HDL-cholesterol, sTfR and ferritin and blood lead. It was found that serum concentration of ferritin and blood lead levels were significantly higher in AMI patients compared to their age and gender-matched healthy controls (p value <0.05), while the concentrations of vitamin B12 and HDL-cholesterol were significantly lower in AMI patients compared to controls (p value <0.01). The ratio of sTfR to ferritin was significantly lower in AMI patients compared to controls [mean ± SD/median (IQR) values 84.7 ± 295/28.9 (38.4) vs 255 ± 836/49.4 (83.8), respectively; p value <0.001]. Compared with the highest quartile of sTfR/ferritin (low body iron status), the OR for the risk of AMI was 3.29(95% CI, 1.54-7.03) for the lowest quartile (quartile 1) when the model was adjusted for vitamin B12 and HDL-cholesterol (p value for trend <0.01). CONCLUSIONS/SIGNIFICANCE: This study shows a positive association between total body iron status and risk of premature AMI in a Pakistani population.

Polymorphisms in MTHFR, MS and CBS genes and homocysteine levels in a Pakistani population.

BACKGROUND: Hyperhomocysteinemia (>15 µmol/L) is highly prevalent in South Asian populations including Pakistan. In order to investigate the genetic determinants of this condition, we studied 6 polymorphisms in genes of 3 enzymes--methylenetetrahydrofolate reductase (MTHFR; C677T; A1298C), methionine synthase (MS; A2756G), cystathionine-ß-synthase (CBS; T833C/844ins68, G919A) involved in homocysteine metabolism and investigated their interactions with nutritional and environmental factors in a Pakistani population. METHODOLOGY/PRINCIPAL FINDINGS: In a cross-sectional survey, 872 healthy adults (355 males and 517 females; age 18-60 years) were recruited from a low-income urban population in Karachi. Fasting venous blood was obtained and assessed for plasma/serum homocysteine; folate, vitamin B12, pyridoxal phosphate and blood lead. DNA was isolated and genotyping was performed by PCR-RFLP (restriction-fragment-length-polymorphism) based assays. The average changes in homocysteine levels for MTHFR 677CT and TT genotypes were positive [ß(SE ß), 2.01(0.63) and 16.19(1.8) µmol/L, respectively]. Contrary to MTHFR C677T polymorphism, the average changes in plasma homocysteine levels for MS 2756AG and GG variants were negative [ß(SE ß), -0.56(0.58) and -0.83(0.99) µmol/L, respectively]. The average change occurring for CBS 844ins68 heterozygous genotype (ancestral/insertion) was -1.88(0.81) µmol/L. The combined effect of MTHFR C677T, MS A2756G and CBS 844ins68 genotypes for plasma homocysteine levels was additive (p value <0.001). Odds of having hyperhomocysteinemia with MTHFR 677TT genotype was 10-fold compared to MTHFR 677CC genotype [OR (95%CI); 10.17(3.6-28.67)]. Protective effect towards hyperhomocysteinemia was observed with heterozygous (ancestral/insertion) genotype of CBS 844ins68 compared to homozygous ancestral type [OR (95% CI); 0.58 (0.34-0.99)]. Individuals with MTHFR 677CT or TT genotypes were at a greater risk of hyperhomocysteinemia in folate and vitamin B12 deficiencies and high blood lead (p value <0.05) level. CONCLUSIONS: Gene polymorphism (especially MTHFR C677T transition), folate and vitamin B12 deficiencies, male gender and high blood lead level appear to be contributing towards the development of hyperhomocysteinemia in a Pakistani population.

Association of blood lead (Pb) and plasma homocysteine: a cross sectional survey in Karachi, Pakistan.

BACKGROUND: High blood lead (Pb) and hyperhomocysteinemia have been found to be associated with cardiovascular disease (CVD). Mean blood Pb and mean plasma homocysteine levels have been reported to be high in Pakistani population. The objective of the present study was to assess the relationship of blood Pb to the risk of hyperhomocysteinemia in a low income urban population of Karachi, Pakistan. METHODOLOGY/PRINCIPAL FINDINGS: In a cross sectional survey, 872 healthy adults (355 males, 517 females; age 18-60 years) were recruited from a low income urban population of Karachi. Fasting venous blood was obtained and assessed for blood Pb and plasma/serum homocysteine, folate, pyridoxal phosphate (PLP, a coenzymic form of vitamin B6) and vitamin B12. The study population had median (IQR) blood Pb of 10.82 microg/dL (8.29-13.60). Prevalence of high blood Pb (levels>10 microg/dL) was higher in males compared to females (62.5% males vs 56% females; p value=0.05). Mean+/-SD/median (IQR) value of plasma homocysteine was significantly higher in the highest quartile of blood Pb compared to the lowest quartile 16.13+/-11.2 micromol/L vs 13.28+/-9.7micromol/L/13.15 (10.33-17.81) micromol/L vs 11.09 (8.65 14.31) micromol/L (p value<0.001). Daily consumption of fruit juice had a positive influence on both levels of plasma homocysteine and blood Pb. Compared with the lowest quartile of blood Pb, the OR for hyperhomocysteinemia was 1.69 (95% CI, 1.00 to 2.85) for the fourth quartile when the model was adjusted for age, gender, folate and vitamin B12. CONCLUSIONS/SIGNIFICANCE: This study showed a relationship between blood Pb and hyperhomocysteinemia in a general population of Karachi, Pakistan. The harmful effect of Pb on cardiovascular system could be due to its association with hyperhomocysteinemia.