Analysis of Pediatric Clinical Practice Guideline Authors by Gender, Race, and Ethnicity.

Background and Objectives: Clinical practice guidelines (CPGs) have significantly influenced medical practice worldwide. Nevertheless, the authorship of CPGs produced by several medical societies has not been representative of the field and population they address, as women and individuals from racial and ethnic minority groups have been underrepresented as authors. We hypothesized that women and individuals from minoritized racial and ethnic groups would also be underrepresented as authors of CPGs produced by the American Academy of Pediatrics (AAP). Methods: In this cross-sectional study, the gender, race, and ethnic composition of authors and subcommittee participants of AAP-produced CPGs published from January 2010 through May 2023 were analyzed and compared to the 2010 and 2021 U.S. population and 2010 and 2022 U.S. medical school pediatric faculty. Results: Women (39.7%, 127/320 of all positions, and 42.5%, 85/200 of named author positions) and women physicians (35.2%, 101/287 of all positions, and 36.4%, 64/176 of named author positions) were significantly underrepresented-while men and men physicians were significantly overrepresented-from their respective composition in the U.S. Census and pediatric faculty. Women and women physicians from all racial and ethnic groups and men and men physicians from minority racial and ethnic groups were significantly underrepresented-from their respective composition in the U.S. Census and pediatric faculty. No Black man was identified as an author. Conclusions: Medical societies that produce CPGs should be cognizant of these inequities and ensure appropriate authorship diversity.

Gender Representation of Editors at Journals Affiliated with Major U.S. Medical Societies.

Objectives: To assess the gender composition of upper-level specialty-specific editor positions among United States (U.S.) medical society-affiliated journals and to evaluate the equitable inclusion of women and women physicians. Materials and Methods: The gender composition of upper-level (e.g., editor-in-chief, deputy) specialty-specific editor positions among 39 U.S. medical society-affiliated journals as of January 5, 2023, was analyzed. Editor positions below the level of associate editor were excluded. Parity (50:50 representation) and equity (compared with the proportion of practicing physicians in each medical specialty) benchmarks were utilized to determine if women are underrepresented in editor positions. Results: A total of 862 editor positions among 39 journals were assessed. Women held 32.9% (284/862) of positions (95% confidence interval [CI]: 29.9%-36.2%), significantly less than expected based on the U.S. population (p < 0.001). Physicians comprised 90.8% (783/862) of positions, of whom 30.4% (238/783) were women physicians (95% CI: 27.3%-33.7%), significantly less than expected (p < 0.001). Thirty-three (84.6%, 95% CI: 70.3%-92.8%) journals were below parity for women overall, whereas 34 (87.2%, 95% CI: 73.3%-94.4%) were below parity for women physicians. Fourteen (35.9%, 95% CI: 22.7%-51.6%) journals were below equity for women physicians. Notably, 13 (33.3%, 95% CI: 20.6%-49.0%) journals were below both parity and equity for women overall and women physicians. Conclusions: This study reveals mixed results in the equitable inclusion of women in editor positions of journals affiliated with U.S. medical societies. Despite the equitable inclusion of women in editorial roles being a remediable issue, approximately one third of journals affiliated with major U.S. medical societies remain inequitable.

Creation of a High-Fidelity, Low-Cost, Intraosseous Line Placement Task Trainer via 3D Printing.

The description of procedural task trainers includes their use as a training tool to hone technical skills through repetition and rehearsal of procedures in a safe environment before ultimately performing the procedure on a patient. Many procedural task trainers available to date suffer from several drawbacks, including unrealistic anatomy and the tendency to develop user-created 'landmarks' after the trainer tissue undergoes repeated manipulations, potentially leading to inappropriate psychomotor skill development. To ameliorate these drawbacks, a process was created to produce a high-fidelity procedural task trainer, created from anatomy obtained from computed tomography (CT) scans, that utilize ubiquitous three-dimensional (3D) printing technology and off-the-shelf commodity supplies. This method includes creating a 3D printed tissue mold capturing the tissue structure surrounding the skeletal element of interest to encase the bony skeletal structure suspended within the tissue, which is also 3D printed. A tissue medium mixture, which approximates tissue in both high-fidelity geometry and tissue density, is then poured into a mold and allowed to set. After a task trainer has been used to practice a procedure, such as intraosseous line placement, the tissue media, molds, and bones are reclaimable and may be reused to create a fresh task trainer, free of puncture sites and manipulation defects, for use in subsequent training sessions.

Gender equity in ergonomics: does muscle effort in laparoscopic surgery differ between men and women?

BACKGROUND: Women surgeons may experience more ergonomic challenges while performing surgery. We aimed to assess ergonomics between men and women surgeons. METHODS: Laparoscopic surgeons from a single institution were enrolled. Demographics and intraoperative data were collected. Muscle groups were evaluated objectively using surface electromyography (EMG; TrignoTM, Delsys, Inc., Natick, MA), and comprised upper trapezius (UT), anterior deltoid, flexor carpi radialis (FCR), and extensor digitorum (ED). Comparisons were made between women (W) and men (M) for each muscle group, assessing maximal voluntary contraction (MVC) and median frequency (MDF). The Piper Fatigue Scale-12 (PFS-12) was used to assess self-perceived fatigue. Statistical analyses were performed using SPSS v26.0, α = 0.05. RESULTS: 18 surgeries were recorded (W:8, M:10). Women had higher activation of UT (32% vs 23%, p < 0.001), FCR (33% vs 16%, p < 0.001), and ED (13% vs 10%, p < 0.001), and increased effort of ED (90.4 ± 18.13 Hz vs 99.1 ± 17.82 Hz). Comparisons were made between W and M for each muscle group, assessing MVC and MDF. CONCLUSIONS: After controlling for surgeon's height and duration of surgery, an increase in muscle activation was seen for women laparoscopic surgeons. Since poor ergonomics could be a major cause of work-related injuries, we must understand differences in ergonomics between men and women and evaluate which factors impact these variations.

Fertility and Reproductive Health in Women Physicians.

Background: Our aim was to evaluate trends of childbearing during medical training, evaluate issues of infertility, and measure institutionalized barriers to childbearing among women physicians. Materials and Methods: Attendees of a national women physician's leadership conference (Brave Enough Women Physicians Continuing Medical Education Conference) were surveyed during the conference using Qualtrics© (2019 Qualtrics, Provo, UT), in September 2019. Survey data included demographics, training level, and medical specialty. Data related to reproductive health factors, pregnancy status and history, current number of children, medical history related to pregnancy, breastfeeding history, institutional family planning support, and use of previous fertility treatments were collected. Descriptive analyses were done using IBM SPSS v26.0. Results: Three hundred seventy-seven survey participants were included in the study. 10.6% of respondents reported at least one pregnancy during medical school, versus 78.8% as a practicing physician. Of the participants, 25.8% reported having taken off 1 month or less of clinical duties after giving birth, 39.4% reported that their job prevented breastfeeding for the desired length of time, and 52.2% reported significant workplace limitations to breastfeeding. Of them, 25.5% reported having had fertility issues in the past. Fertility drugs (72.9%) was the most common fertility treatment method used, followed by fertility tracking (54.2%). Demands of training (72.9%) and long work hours (61.5%) were the most cited factors in delaying having children as reported by women physicians. Conclusions: This study reported several barriers related to fertility, family planning, and reproductive health among women physicians. Our results highlight the need for a paradigm shift in fertility awareness and institutional support for childbearing during medical training, postgraduate training programs, and in practice for women in medicine.

Minimally invasive approach to hiatal hernia repair is superior to open, even in the emergent setting: a large national database analysis.

BACKGROUND: We aimed to examine the outcomes and utilization of different hiatal hernia repair (HHR) approaches in elective and emergent/urgent settings. METHODS: Vizient 2015-2017 database was queried for adult patients who underwent HHR. Patients were grouped into open (OHHR), laparoscopic (LHHR), or robotic-assisted (RHHR), and further stratified by elective or urgent status and severity of illness at admission. Surgical outcomes and costs were compared across all groups. Statistical analysis were done using SPSS v.25.0. RESULTS: 9171 adults were included (OHHR N = 1534;LHHR N = 6796;RHHR N = 841). LHHR was the most utilized approach (74.1%), followed by OHRR (16.7%) and RHHR (9.2%). OHHR was employed three times as frequently in U settings, compared to elective. Overall, OHHR had longer mean length of stay (LOS; 9.41 vs. < 4 days) and higher postoperative complication rates (8.8% vs < 3.8%), mortality (2.7% vs < 0.5%) and mean direct cost ($27,842 vs < $10,407), when compared to both LHHR and RHHR, all p < 0.05. Analysis of mild to severely ill elective cases demonstrated LHHR and RHHR to be better than OHHR regarding complications (p < 0.05), cost (p < 0.001) and LOS (p < 0.013); there were insufficient extremely ill elective patients for meaningful analysis. In the urgent setting, minimally invasive approaches predominate, overtaken by OHHR only for the extremely ill. Despite the urgent setting, for mild-moderately ill patients, OHHR was statistically inferior to both LHHR and RHHR for LOS (p = 0.002, p < 0.0001) and cost (p = 0.0133, p < 0.001). In severe-extremely ill patients, despite being more utilized, OHHR was not superior to LHHR; in fact, complication, cost, and mortality trends (all p > 0.05) favored LHHR. CONCLUSION: Our analysis demonstrated LHHR to currently be the most employed approach overall. LHHR and RHHR were associated with lower cost, decreased LOS, complications, and mortality compared to OHHR, in all but the sickest of patients. Patients should be offered minimally invasive HHR, even in urgent/emergent settings, if technically feasible.

Citizenship Tasks and Women Physicians: Additional Woman Tax in Academic Medicine?

Background: Our aim was to evaluate differences in reported citizenship tasks among women physicians due to personal or demographic factors and time spent performing those tasks for work. Materials and Methods: Attendees of a national women physician's leadership conference (Brave Enough Women Physicians Continuing Medical Education Conference) replied to a survey using Qualtrics© (2019 Qualtrics, Provo, UT), in September 2019. Data collected included age, race, ethnicity, training level, medical practice, specialty, current annual total compensation, educational debt, and number of children. We asked about employment-related citizenship tasks, including time spent on those activities, and perceived obligation to volunteer for citizenship tasks. Descriptive and impact of demographic factors on those opinions were evaluated using IBM SPSS v26.0. Results: Three hundred eighty-nine women physicians replied. When compared with their younger counterparts, women physicians older than 49 years stated they feel obligated to volunteer for these tasks because of their gender (p = 0.049), and were less likely able to decide which citizenship tasks they were assigned to (p = 0.021). Furthermore, a higher proportion of women of color physicians perceived race as a factor in feeling obligated to volunteer for work-related citizenship tasks, when compared with White women physicians (p < 0.001). Additionally, nearly 50% of women physicians reported spending more time on citizenship tasks than their male counterparts. Conclusion: Our findings suggest that gender, race, and age may play a role in the decision of women physicians to participate in work-related citizenship tasks. To our knowledge, this is the first study to report on work-related citizenship tasks as described by women physicians. Still, an in-depth assessment on the role citizenship tasks play in the culture of healthcare is warranted.

Current state of robotic use in inguinal hernia repair: a survey of minimally invasive hernia surgeons.

Little is known about how robot technology is employed by surgeons in minimally invasive surgery (MIS). We evaluated the needs of established robotic surgeons and of those who are new to this technology. A survey was designed and sent electronically to MIS surgeons. Questions included fellowship training, area of expertise, experience with robotic simulation and in clinical use, mentorship, likelihood of switching to a different approach, and expectations for the robot. Descriptive analysis was conducted using STATA/MP 15.1. 189 interviewees self-identified as hernia surgeons. 73.8% had additional fellowship, with majority practicing for 3-6 years (54%). Nearly 40% were MIS surgeons (N = 73), followed by general surgery (34.4%), and bariatrics (13.8%). 146 interviewees (77.7%) have used the daVinci® in clinical scenarios. Among robotic surgeons, majority were performing less than ten robotic cases per month. Inguinal hernia repairs were the leading procedures (49%), followed by foregut-related (19.5%), and colorectal-related surgeries (17.5%). Nearly 40% of surgeons stated inguinal hernia repairs to be the most often performed procedure using the robot. Nearly 40% of open and laparoscopic hernia surgeons are willing to adopt robotic-assisted procedures for their inguinal hernia repairs. Level 1 evidence (47.9%) and cost (24.1%) were the most pressing needs for robotic research. Majority of interviewees have used the daVinci® in clinical settings. Hernia repair remains the primary application of the robot in general surgery, among specialized surgeons. Over 40% of hernia surgeons are interested in switching to robotic technology over its open or laparoscopic counterparts.

Outcomes and impact of laparoscopic inguinal hernia repair versus open inguinal hernia repair on healthcare spending and employee absenteeism.

BACKGROUND: This study compares the impact of open (OIHR) versus laparoscopic (LIHR) inguinal hernia repair on healthcare spending and postoperative outcomes. METHODS: The TRUVEN database was queried using ICD9 procedure codes for open, laparoscopic, and robotic-assisted IHR, from 2012 to 2013. Patients > 18 years of age and continuously enrolled for 12 months postoperatively were included. Demographics, patient comorbidities, postoperative complications, pain medication use, length of hospital stay, missed work hours, postoperative visits, and overall expenditure were collected, and assessed at time of surgery and at 30-, 60-, 90-, 180-, and 365-days postoperatively. Statistical analysis was conducted using SAS, with α = 0.05. RESULTS: 66,116 patients were included (LIHR: N = 23,010; OIHR: N = 43,106). Robotic-assisted procedures were excluded due to small sample size (N = 61). The largest demographic was males between 55 and 64 years. LIHR had fewer surgical wound complications than OIHR (LIHR: 0.3%; OIHR: 0.5%, p = 0.007), less utilization of pain medication (LIHR: 23.3%; OIHR: 28.5%; p < 0.001), and fewer outpatient visits. In the 90-day postoperative period, LIHR had significantly fewer missed work hours (LIHR: 12.1 ± 23.2 h; OIHR: 12.9 ± 26.7 h, p = 0.023). LIHR had higher postoperative urinary complications (LIHR: 0.2%; OIHR: 0.1%; p < 0.001), consistent with the current literature. LIHR expenditures ($15,030 ± $25,906) were higher than OIHR ($13,303 ± 32,014), p < 0.001. CONCLUSIONS: The results highlight the benefits of laparoscopic repair with regard to surgical wound complications, postoperative pain, outpatient visits, and missed work hours. These improved outcomes with respect to overall healthcare spending and employee absenteeism support the paradigm shift toward laparoscopic inguinal hernia repairs, in spite of higher overall expenditures.

Updates on Monogenic Obesity in a Multifactorial Disease.

Obesity is a worldwide epidemic with rates nearly doubling over the last 30 years. Despite increasing prevalence, the multifactorial pathogenesis of obesity continues to be widely misunderstood. Investigating genetic drivers in the development of obesity is an important area of focus, as genetics move to the forefront of medicine and personalized treatment evolves. Thus, this narrative review focused on four genes which have genome-wide association study-documented links to obesity and obesity syndromes. We explored their involvement in the predisposition, progression, and prognosis of obesity. Leptin, leptin receptor, pro-opiomelanocortin, and melanocortin 4 receptor are our four genes of interest, and herein we elaborated on the current literature, pathogenesis, and available treatments for patients with these specific genetic mutations.

A pictorial presentation of 3. 0 Chicago Classification for esophageal motility disorders / Apresentação em imagens da Classificação de Chicago versão 3. 0 das doenças da motilidade esofagiana

ABSTRACT High resolution manometry changed several esophageal motility paradigms. The 3.0 Chicago Classification defined manometric criteria for named esophageal motility disorders. We present a pictorial atlas of motility disorders. Achalasia types, esophagogastric junction obstruction, absent contractility, distal esophageal spasm, hypercontractile esophagus (jackhammer), ineffective esophageal motility, and fragmented peristalsis are depicted with high-resolution manometry plots.

RESUMO A manometria de alta resolução mudou vários paradigmas da motilidade digestiva. A Classificação de Chicago, na versão 3.0, definiu critérios manométricos para as doenças da motilidade esofagiana. O presente artigo é um atlas das dismotilidades descritas. Tipos de acalásia, obstrução ao nível da junção esofagogástrica, contrações ausentes, espasmo esofagiano distal, esôfago hipercontrátil, motilidade esofagiana ineficaz e peristalse fragmentada são mostradas em traçados de manometria de alta resolução.

A pictorial presentation of 3.0 Chicago Classification for esophageal motility disorders.

High resolution manometry changed several esophageal motility paradigms. The 3.0 Chicago Classification defined manometric criteria for named esophageal motility disorders. We present a pictorial atlas of motility disorders. Achalasia types, esophagogastric junction obstruction, absent contractility, distal esophageal spasm, hypercontractile esophagus (jackhammer), ineffective esophageal motility, and fragmented peristalsis are depicted with high-resolution manometry plots. RESUMO A manometria de alta resolução mudou vários paradigmas da motilidade digestiva. A Classificação de Chicago, na versão 3.0, definiu critérios manométricos para as doenças da motilidade esofagiana. O presente artigo é um atlas das dismotilidades descritas. Tipos de acalásia, obstrução ao nível da junção esofagogástrica, contrações ausentes, espasmo esofagiano distal, esôfago hipercontrátil, motilidade esofagiana ineficaz e peristalse fragmentada são mostradas em traçados de manometria de alta resolução.

Ação da melatonina no tecido cartilaginoso / The role of melatonin on cartilaginous tissue

Os autores fazem uma revisão que mostra a ação da melatonina sobre o tecido cartilaginoso. Referem sua estrutura química, seu local de síntese, seus receptores e sua ação. Relatam que os níveis baixos da mela to nina na menopausa poderiam ser um importante fator no desenvolvimento e na manutenção da osteoporose, visto que em ratas a sua reposição leva a um aumento da densidade mineral óssea e da espessura da cartilagem articular. Sugerem uma possível ação benéfica da melatonina na proteção das lesões da cartilagem articular, o que poderia estar relacionado ao bloqueio do estresse oxidativo, uma vez que produtos desse estresse, com resíduos de tiro sina, são observados no tecido cartilaginoso com doenças de degradação articular. Sugerem que a melatonina aumenta a síntese de matriz cartilaginosa. Esses fatos indicam que a mela to nina pode ser benéfica para o tecido cartilaginoso, uma vez que há uma redução da secreção do hormônio da melatonina, com o avançar da idade, o qual está relacionado ao aumento da incidência de osteoartrite.

The authors write a review showing the action of melatonin on the cartilaginous tissue and relate its chemical structure, site of synthesis, and receptors. They report that low levels of melatonin in menopause may be an important factor in the pathogenesis of osteoporosis, since its replacement in rats leads to an increase in bone mineral density and the thickness of articular cartilage. It is also suggested a possible beneficial effect of melatonin in the prevention of articular cartilage lesions, which could be related to the blockade of oxidative stress, since products of this stress, in addition to tyrosine residues, are observed in the cartilage tissue degradation in joint diseases. Furthermore, it is related that melatonin enhances cartilage matrix synthesis. These facts indicate that melatonin may be beneficial to the integrity of cartilaginous tissue, since there is a reduced secretion of melatonin with advancing age, which is related to increased incidence of osteoarthritis.