Is Access to Optimal Concussion Care for Pediatric Athletes Limited by Geography?

OBJECTIVE: To evaluate access to optimal concussion care based on a pediatric patients' geography; the hypothesis is that differential access across the Unites States exists. DESIGN: Employed a novel strategy using internet searches to find local care, mimicking what families might do in different parts of the country. SETTING: Virtual internet searches. PARTICIPANTS: Not applicable. INDEPENDENT VARIABLE: Various metropolitan and rural geographic regions within each state in the United States. MAIN OUTCOME MEASURES: Evaluate access (defined as distance to clinic and ability to see pediatric patients) and optimal care (defined as self-referral process and presence of multidisciplinary care). RESULTS: Search strategy yielded 490 results. Overall ∼60% were within 50 miles of searched locations with significant differences in access based on rural versus metropolitan areas (P < 0.0001); in rural areas, only ∼22% of results were within 50 miles. Only about one-third of the results (n = 157) saw pediatric patient with no differences between regions. There was significant regional and geographic variation for optimal care regarding both self-referral processes and access to multidisciplinary care. A diverse group of specialists was represented in search results for concussion care. CONCLUSIONS: Nationwide, there is an overall lack of access to multidisciplinary concussion care for pediatric patients. Additionally, those in rural communities face more limitations related to access to facilities with increased distances from closest clinic sites.

Burn and Trauma Burden and Screening for Interpersonal Violence During the COVID-19 Pandemic.

INTRODUCTION: Nationwide shelter-in-place (SIP) orders during the pandemic have had long-lasting effects, including increased rates of domestic violence and interpersonal violence. Screening for violence varies by institution, which tool is used, and when. Given increases in burn and trauma admissions over the course of the pandemic, we sought to examine trends at our institution during this time period to better guide care and anticipate system-level effects. METHODS: We performed a retrospective cohort study of pediatric burn and adult burn and trauma patients at our level 1 trauma/burn center between March-May 2019 and March-May 2020. Home safety screening was performed by nursing staff using a 1-part screening questionnaire. Patients presenting before March 15, 2020, were defined as "pre-SIP; " between March 16-May 19, 2020, were "during SIP; " and those after May 19, 2020, were designated as "post-SIP." Descriptive and chi-square statistics were used. Demographic, injury patterns, and screening information were collected. RESULTS: Blunt trauma comprised 60% of injuries, followed by burns (30%) then penetrating injury (7%). Over the entire time period analyzed, 1822 patients had documented home safety screening; ∼2% of patients screened reported a safety concern pre-SIP, compared to 3% of patients during SIP. There were higher rates of burns and penetrating injury during SIP compared to other periods (P ≤ 0.0001). Home safety screening rates were 94%-95% pre- and during SIP, but dropped to 85% post-SIP (P < 0.0001). Home safety concerns were reported almost 2% of the time pre-SIP and 3% during SIP (P = 0.016). CONCLUSIONS: We noted an increase in trauma and burns during and after SIP orders, consistent with the experiences of other institutions. Implementation of a nurse-driven screening process demonstrated high compliance with appropriate referrals. The burden of burn and traumatic injury remains significant, highlighting a need for continued psychosocial screening and the provision of psychosocial support resources in the acute trauma setting.

Professional identity formation for underrepresented in medicine learners.

Professional identity formation (PIF) is a dynamic developmental process by which individuals merge the knowledge and skills of clinical practice with the values and behaviors of their personal identity. For an individual physician, this process is a continuum which begins with their nascent interest in the field of medicine and extends through the end stages of a medical career. The impact of PIF has become a growing focus of medical education research in the last decade, and in that time, little attention has been paid to the influence underrepresented in medicine (UIM) identities may have on this fundamental process. Importantly, in discussions of how medical educators can support and encourage successful PIF, there is little discussion on the distinct challenges and different needs UIM learners may have. The purpose of this paper is to address the current literature around PIF for UIM trainees. This review explores various threats to identity formation, including identity fusion, stereotype threat, minority tax, implicit bias, and lack of mentorship. Evidence-based strategies to mitigate these challenges is also presented, including furthering institutional support for PIF, building the community of practice, supporting an inclusive environment, and developing PIF assessment tools. Through exploring these challenges and solutions, we are better able to address the needs of UIM trainees and physicians as they proceed in their PIF during their lifelong journey in medicine.

ESTABLISHING A LIVE CARTILAGE-ON-CARTILAGE INTERFACE FOR TRIBOLOGICAL TESTING.

Mechano-biochemical wear encompasses the tribological interplay between biological and mechanical mechanisms responsible for cartilage wear and degradation. The aim of this study was to develop and start validating a novel tribological testing system, which better resembles the natural joint environment through incorporating a live cartilage-on-cartilage articulating interface, joint specific kinematics, and the application of controlled mechanical stimuli for the measurement of biological responses in order to study the mechano-biochemical wear of cartilage. The study entailed two parts. In Part 1, the novel testing rig was used to compare two bearing systems: (a) cartilage articulating against cartilage (CoC) and (b) metal articulating against cartilage (MoC). The clinically relevant MoC, which is also a common tribological interface for evaluating cartilage wear, should produce more wear to agree with clinical observations. In Part II, the novel testing system was used to determine how wear is affected by tissue viability in live and dead CoC articulations. For both parts, bovine cartilage explants were harvested and tribologically tested for three consecutive days. Wear was defined as release of glycosaminoglycans into the media and as evaluation of the tissue structure. For Part I, we found that the live CoC articulation did not cause damage to the cartilage, to the extent of being comparable to the free swelling controls, whereas the MoC articulation caused decreased cell viability, extracellular matrix disruption, and increased wear when compared to CoC, and consistent with clinical data. These results provided confidence that this novel testing system will be adequate to screen new biomaterials for articulation against cartilage, such as in hemiarthroplasty. For Part II, the live and dead cartilage articulation yielded similar wear as determined by the release of proteoglycans and aggrecan fragments, suggesting that keeping the cartilage alive may not be essential for short term wear tests. However, the biosynthesis of glycosaminoglycans was significantly higher due to live CoC articulation than due to the corresponding live free swelling controls, indicating that articulation stimulated cell activity. Moving forward, the cell response to mechanical stimuli and the underlying mechano-biochemical wear mechanisms need to be further studied for a complete picture of tissue degradation.

Development of a Cartilage Shear-Damage Model to Investigate the Impact of Surface Injury on Chondrocytes and Extracellular Matrix Wear.

Background Many i n vitro damage models investigate progression of cartilage degradation after a supraphysiologic, compressive impact at the surface and do not model shear-induced damage processes. Models also neglect the response to uninterrupted tribological stress after damage. It was hypothesized that shear-induced removal of the superficial zone would accelerate matrix degradation when damage was followed by continued load and articulation. Methods Bovine cartilage underwent a 5-day test. Shear-damaged samples experienced 2 days of damage induction with articulation against polyethylene and then continued articulation against cartilage (CoC), articulation against metal (MoC), or rest as free-swelling control (FSC). Surface-intact samples were randomized to CoC, MoC, or FSC for the entire 5-day test. Samples were evaluated for chondrocyte viability, GAG (glycosaminoglycan) release (matrix wear surrogate), and histological integrity. Results Shear induction wore away the superficial zone. Damaged samples began continued articulation with collagen matrix disruption and increased cell death compared to intact samples. In spite of the damaged surface, these samples did not exhibit higher GAG release than intact samples articulating against the same counterface ( P = 0.782), contrary to our hypothesis. Differences in GAG release were found to be due to tribological testing against metal ( P = 0.003). Conclusion Shear-induced damage lowers chondrocyte viability and affects extracellular matrix integrity. Continued motion of either cartilage or metal against damaged surfaces did not increase wear compared with intact samples. We conjecture that favorable reorganization of the surface collagen fibers during articulation protected the underlying matrix. This finding suggests a potential window for clinical interventions to slow matrix degradation after traumatic incidents.

Understanding the Leaky Pipeline: Perceived Barriers to Pursuing a Career in Medicine or Dentistry Among Underrepresented-in-Medicine Undergraduate Students.

PURPOSE: Representation of persons from diverse backgrounds remains a persistent challenge for medicine and dentistry workforces. Past research has focused on quantifying factors such as markers of educational achievement to explain the difficulty of increasing diversity within the professions. There has been less effort toward understanding the perspectives of undergraduate students on the threshold of applying to medical/dental school about distinct barriers to pursuing a medical or dental career and continuing through the training pipeline. METHOD: In 2012 and 2013, the authors conducted a qualitative study of undergraduate students participating in the Tour for Diversity in Medicine, a program where minority physicians and dentists visit colleges with large fractions of minority students to encourage careers in the health professions. Focus groups were convened during the visits to examine perceived barriers to pursuing careers in medicine and dentistry and challenges identified through thematic content analysis. RESULTS: Eighty-two students participated in discussions at 11 colleges visited between September 2012 and February 2013. Students described challenges including inadequate institutional resources (e.g., sparse clinical opportunities), strained personal resources (e.g., conflict arising from familial pressure), inadequate guidance and mentoring to assist with key career decisions, and societal barriers. For participants, these challenges caused them to question the viability of persisting in the pipeline to a medical or dental career. CONCLUSIONS: Solving the issue of diversity in medicine and dentistry is multifaceted, but elucidated challenges from the undergraduate student perspective offer targeted areas where intervention may help remedy barriers and decrease pipeline leakiness.

Clustering context-specific gene regulatory networks.

Gene regulatory networks (GRNs) learned from high throughput genomic data are often hard to visualize due to the large number of nodes and edges involved, rendering them difficult to appreciate. This becomes an important issue when modular structures are inherent in the inferred networks, such as in the recently proposed context-specific GRNs.(12) In this study, we investigate the application of graph clustering techniques to discern modularity in such highly complex graphs, focusing on context-specific GRNs. Identified modules are then associated with a subset of samples and the key pathways enriched in the module. Specifically, we study the use of Markov clustering and spectral clustering on cancer datasets to yield evidence on the possible association amongst different tumor types. Two sets of gene expression profiling data were analyzed to reveal context-specificity as well as modularity in genomic regulations.

Context-specific gene regulations in cancer gene expression data.

Learning or inferring networks of genomic regulation specific to a cellular state, such as a subtype of tumor, can yield insight above and beyond that resulting from network-learning techniques which do not acknowledge the adaptive nature of the cellular system. In this study we show that Cellular Context Mining, which is based on a mathematical model of contextual genomic regulation, produces gene regulatory networks (GRNs) from steady-state expression microarray data which are specific to the varying cellular contexts hidden in the data; we show that these GRNs not only model gene interactions, but that they are also readily annotated with context-specific genomic information. We propose that these context-specific GRNs provide advantages over other techniques, such as clustering and Bayesian networks, when applied to gene expression data of cancer patients.

Redirection of biological heat from head to hands to support finger comfort in the cold.

INTRODUCTION: Maintaining hand comfort in the cold while sustaining optimal performance is still a challenge. There has been little research on the efficacy of transporting biological heat from the head to the hands to stabilize finger comfort, although there are notable temperature differences between these two areas in the cold. METHOD: A tubing bypass between the head and the hands was designed as an independent component in a liquid cooling/warming garment (LCWG). Seven subjects (four men, three women) were studied, comparing finger temperature (Tfing) change in two conditions: LCWG with additional bypass; and LCWG without bypass. The protocol consisted of three stages: 1) comfort stabilization, LCWG inlet water temperature 33 degrees C, water in loop in bypass condition 23 degrees C; 2) body cooling, LCWG inlet water temperature 20 degrees C; and 3) rewarming, LCWG inlet water temperature 45 degrees C. RESULTS: The time to reach the 25 degrees C Tfing discomfort criterion was significantly longer in the bypass condition (p < 0.01); Tfing was significantly higher at the same time point when Tfing of 25 degrees C was reached in the control condition (p < 0.01). CONCLUSION: The incorporation of a bypass transferring biological heat from a high to a low skin temperature area has potential to improve local finger comfort and thus increase the time personnel can work in cold environments.