[The Lübeck Scale of Basic Mobility : Assessment of geriatric patients with severely impaired mobility]. / Die Lübecker Skala der Basis-Mobilität : Assessment schwer in ihrer Mobilität beeinträchtigter geriatrischer Patienten.

BACKGROUND: In the geriatric assessment of mobility, the timed up and go (TUG) test is often used; however, many inpatients are unable to master this test. The Lübeck Scale of Basic Mobility (LSBM) was developed as a performance test for this target group. OBJECTIVE: The study investigated the properties of the 7­task LSBM, which has a scaling at item level based on the 5­level assessment of impairments according to the ICF. MATERIAL AND METHODS: In 77 patients who had not mastered the TUG test at acute geriatric hospital admission, the LSBM was completed at intervals of 7-18 days (t0, t1), including one rating by 2 investigators. For convergent validity, the De Morton Mobility Index (DEMMI) was used. RESULTS: The LSBM score and DEMMI score were highly correlated (-0.880, p < 0.001). A floor effect did not occur with LSBM and occurred with DEMMI in 5 patients (6.5%). The predictive validity for predicting coping with TUG test at discharge based on the sum score at t0 was -0.577 for the LSBM, and 0.542 for the DEMMI (Spearman's correlation, p = 0.001). The interrater reliability of the LSBM was 0.983 (p < 0.001), the correlation between test and retest was 0.836 (p < 0.001) and the internal consistency via Cronbach's α was 0.876. The effect size as a measure of change sensitivity was Cohen's d 0.711. CONCLUSION: The LSBM facilitates treatment goal setting and allows standardized documentation of even small improvements and deteriorations in patients with reduced basic mobility.

Referral care for high-risk pregnant women in rural Rajasthan, India: a qualitative analysis of barriers and facilitators.

OBJECTIVE: To qualitatively assess the barriers and facilitators to uptake of referral services amongst high-risk pregnant women in rural Rajasthan. METHODS: A purposive sample of pregnant women with high-risk conditions requiring referral follow-up care (severe hypertension, moderate anemia, and severe anemia) were considered for inclusion. In-depth individual interviews were conducted in the local dialect, Mewari. Interviews were transcribed, coded, and organized for thematic generation as per the analytical framework described in the socio-ecological model. RESULTS: 19 high risk pregnant women of low socioeconomic backgrounds across 15 villages were interviewed. Barriers to referral care included lack of transportation, household responsibilities, and limited awareness, education, and social support. The most prominent barrier was lack of accompaniment to the referral center by a family member or health worker. Facilitators included available husbands, engaged heath workers, supportive neighbors, and other female family members who shared past experiences. CONCLUSIONS: Social support at the interpersonal and community level was key to overcoming referral care barriers faced by high-risk pregnant women in rural Rajasthan. Interventions that enhance social support may improve uptake of referral care services by high-risk pregnant women.

[Positioning the hand to act-Validation of the 8-point reaching range test]. / Die Hand positionieren, um zu agieren ­ Validierung des 8-Punkte-Greifraum-Tests.

BACKGROUND: The standardized geriatric assessment of the upper extremities is often limited to measurement of hand strength. The only other instrument mentioned in the S1 guidelines on level 2 geriatric assessment is the 20 cents test (20-C-T); however, in addition to strength and fine motor skills, successful hand placement is a prerequisite for self-care. OBJECTIVE: The 8­point reaching range test (8P-GRT) was developed for standardized separate testing of sides in a seated person concerning hand positioning relevant to daily living. The purpose of the study was to determine quality criteria of the 8P-GRT in geriatric hospital patients. MATERIAL AND METHODS: Between 31 July 2019 and 23 September 2019, a total of 82 inpatients were examined at the Hospital Red Cross Lübeck Geriatrics Center using the 8P-GRT, shoulder pain and disability index (SPADI), a questionnaire on self-care activities corresponding to the hand positions of the 8P-GRT, hand strength measurement and the 20-C­T. RESULTS: The interrater reliability was 0.99 and the retest reliability was 0.95 for the right side and 0.90 for the left side. On the individual level a ceiling effect (both sides score 8) occurred in 4.1% (n = 3) but no floor effect was observed. The internal consistency (Cronbach's alpha) of the two-factorial test according to factor analysis was 0.78 (right) and 0.76 (left). Each of the other tests correlated more closely with the 8P-GRT on the right side, whereby the correlation was highest with the abovenamed questionnaire (-0.72), followed by the SPADI (-0.60). CONCLUSION: A standardized survey of hand strength, fine motor skills and active positioning of the hand (e.g., 8P-GRT) synthesizes the main aspects of upper extremity functioning into an overall picture.

[Self-assessment of daily activities using the Duruöz Hand Index-Validation of the German translation]. / Selbstbeurteilung von Alltagsaktivitäten mittels Duruöz-Hand-Index ­ Validierung der deutschen Übersetzung.

BACKGROUND: Independence in activities of daily living depends to a large extent on the upper extremities; however, the instruments widely used in geriatrics to assess self-care abilities do not allow a focus on this body region. In order to map the fluctuating course of hand function-dependent daily living skills with a self-assessment instrument, rheumatologists have developed the Duruöz Hand Index (DHI). OBJECTIVE: The German translation authorized by Duruöz was tested for its applicability in the assessment of geriatric outpatient and day hospital patients and test quality criteria were determined. MATERIAL AND METHODS: Study participants completed the DHI three times. A postgraduate student blinded to the results performed an anamnesis and examination. The geriatric team made an inter-professional assessment of hand function-related daily living skills twice with at least 2­week intervals. RESULTS: Data collection was performed from 16 November 2016 to 27 April 2017 on 101 geriatric day hospital or outpatient patients. Retest reliability was high (0.937), as was internal consistency (Cronbach's α 0.949). Difficulty with activities of daily living correlated more closely with joint mobility (Keitel Index) and fine motor skills (20 cents test) than with hand strength. CONCLUSION: The DHI provides a survey of difficulties with activities of daily living that is focused on the upper extremities. Because about one in three patients required assistance (answering follow-up questions, reading aloud) despite the exclusion of patients with more severely impaired cognition and vision, the examiner should remain present.

Professional language use by alumni of the Harvard Medical School Medical Language Program.

BACKGROUND: Despite the growing number of patients with limited English proficiency in the United States, not all medical schools offer medical language courses to train future physicians in practicing language-concordant care. Little is known about the long-term use of non-English languages among physicians who took language courses in medical school. We conducted a cross-sectional study to characterize the professional language use of Harvard Medical School (HMS) alumni who took a medical language course at HMS and identify opportunities to improve the HMS Medical Language Program. METHODS: Between October and November 2019, we sent an electronic survey to 803 HMS alumni who took a medical language course at HMS between 1991 and 2019 and collected responses. The survey had questions about the language courses and language use in the professional setting. We analyzed the data using descriptive statistics and McNemar's test for comparing proportions with paired data. The study was determined not to constitute human subjects research. RESULTS: The response rate was 26% (206/803). More than half of respondents (n = 118, 57%) cited their desire to use the language in their future careers as the motivation for taking the language courses. Twenty-eight (14%) respondents indicated a change from not proficient before taking the course to proficient at the time of survey whereas only one (0.5%) respondent changed from proficient to not proficient (McNemar's p-value < 0.0001). Respondents (n = 113, 56%) reported that clinical electives abroad influenced their cultural understanding of the local in-country population and their language proficiency. Only 13% (n = 27) of respondents have worked in a setting that required formal assessments of non-English language proficiency. CONCLUSIONS: HMS alumni of the Medical Language Program reported improved language proficiency after the medical language courses' conclusion, suggesting that the courses may catalyze long-term language learning. We found that a majority of respondents reported that the medical language courses influenced their desire to work with individuals who spoke the language of the courses they took. Medical language courses may equip physicians to practice language-concordant care in their careers.

The power of language-concordant care: a call to action for medical schools.

We live in a world of incredible linguistic diversity; nearly 7000 languages are spoken globally and at least 350 are spoken in the United States. Language-concordant care enhances trust between patients and physicians, optimizes health outcomes, and advances health equity for diverse populations. However, historical and contemporary trauma have impaired trust between communities of color, including immigrants with limited English proficiency, and physicians in the U.S. Threats to informed consent among patients with limited English proficiency persist today. Language concordance has been shown to improve care and serves as a window to broader social determinants of health that disproportionately yield worse health outcomes among patients with limited English proficiency. Language concordance is also relevant for medical students engaged in health care around the world. Global health experiences among medical and dental students have quadrupled in the last 30 years. Yet, language proficiency and skills to address cultural aspects of clinical care, research and education are lacking in pre-departure trainings. We call on medical schools to increase opportunities for medical language courses and integrate them into the curriculum with evidence-based teaching strategies, content about health equity, and standardized language assessments. The languages offered should reflect the needs of the patient population both where the medical school is located and where the school is engaged globally. Key content areas should include how to conduct a history and physical exam; relevant health inequities that commonly affect patients who speak different languages; cultural sensitivity and humility, particularly around beliefs and practices that affect health and wellbeing; and how to work in language-discordant encounters with interpreters and other modalities. Rigorous language assessment is necessary to ensure equity in communication before allowing students or physicians to use their language skills in clinical encounters. Lastly, global health activities in medical schools should assess for language needs and competency prior to departure. By professionalizing language competency in medical schools, we can improve patients' trust in individual physicians and the profession as a whole; improve patient safety and health outcomes; and advance health equity for those we care for and collaborate with in the U.S. and around the world.

In Vitro Entero-Capillary Barrier Exhibits Altered Inflammatory and Exosomal Communication Pattern after Exposure to Silica Nanoparticles.

The intestinal microvasculature (iMV) plays multiple pathogenic roles during chronic inflammatory bowel disease (IBD). The iMV acts as a second line of defense and is, among other factors, crucial for the innate immunity in the gut. It is also the therapeutic location in IBD targeting aggravated leukocyte adhesion processes involving ICAM-1 and E-selectin. Specific targeting is stressed via nanoparticulate drug vehicles. Evaluating the iMV in enterocyte barrier models in vitro could shed light on inflammation and barrier-integrity processes during IBD. Therefore, we generated a barrier model by combining the enterocyte cell line Caco-2 with the microvascular endothelial cell line ISO-HAS-1 on opposite sides of a transwell filter-membrane under culture conditions which mimicked the physiological and inflamed conditions of IBD. The IBD model achieved a significant barrier-disruption, demonstrated via transepithelial-electrical resistance (TER), permeability-coefficient (Papp) and increase of sICAM sE-selectin and IL-8. In addition, the impact of a prospective model drug-vehicle (silica nanoparticles, aSNP) on ongoing inflammation was examined. A decrease of sICAM/sE-selectin was observed after aSNP-exposure to the inflamed endothelium. These findings correlated with a decreased secretion of ICAM/E-selectin bearing exosomes/microvesicles, as evaluated via ELISA. Our findings indicate that aSNP treatment of the inflamed endothelium during IBD may hamper exosomal/microvesicular systemic communication.

[The "Lübeck Worlds of Movement Model"-results of the effects evaluation]. / Das "Lübecker Modell Bewegungswelten" ­ Ergebnisse der Effektevaluation.

BACKGROUND: There are few standardized and evaluated intervention programs for elderly people in need of care that consider motor, cognitive and social aspects. Therefore, the "Lübeck Worlds of Movement Model" was developed by the Lübeck Geriatrics Research Group as a multidimensional standardized intervention program for continuous use in the nursing home. OBJECTIVES: The model was evaluated for its effects over the course of one year in the areas of self-care competence (primary endpoint), mobility, coordination, flexibility, strength, endurance, and cognition. The results are presented in this article. MATERIALS AND METHODS: The sample recruitment took place in 6 nursing homes in Kiel (control group) and 10 in Lübeck (intervention group). Care-dependent senior citizens from the neighborhood were also allowed to participate. Inclusion criteria were the ability to walk at least 6 m independently and the cognitive and sensory capacities to follow the group training. The evaluation study had 255 subjects. To verify the effects of the intervention, various tests were performed at baseline and after 3, 6, 9, and 12 months: Barthel Index, Timed Up and Go, 4­meter walk test, Romberg stand, one-leg stand, 20-Cents Test, 8­Point Reach Test, hand force, 5­Chair-Rise Test, 2­Minute Step Test, and Six-Item Screener. RESULTS: Comparison of the control group with the subjects who had participated in at least half of the training sessions (per-protocol analysis) showed the highest effect size in the multivariate analysis of variance after one year for the Barthel index, followed by the Timed Up and Go, cumulated over all times for the Romberg stand and 5­Chair-Rise Test. The maximum effect measured over the entire assessment occurred after 6 months (partial eta square ηp2 = 0.332). CONCLUSIONS: The model developed preventive effects on all investigated dimensions over the course of a year, but with differences in intensity and time of maximum effect. The motivation for long-term participation was high.

Human CD8+ T Cells Damage Noninfected Epithelial Cells during Influenza Virus Infection In Vitro.

During severe influenza A virus (IAV) infections, a large amount of damage to the pulmonary epithelium is the result of the antiviral immune response. Specifically, whilst CD8+ T cells are important for killing IAV-infected cells, during a severe IAV infection, they can damage uninfected epithelial cells. At present, the mechanisms by which this occurs are unclear. Here, we used a novel in vitro coculture model of human NCl-H441 cells and CD8+ T cells to provide a new insight into how CD8+ T cells may affect uninfected epithelial cells during severe IAV infections. Using this model, we show that human IAV-specific CD8+ T cells produce soluble factors that reduce the barrier integrity of noninfected epithelial cells (referred to as "bystander damage"). We show that this bystander damage is the result of a combination of TNF-α and IFN-γ. This bystander damage occurred in the absence of widespread epithelial cell death and was instead associated with decreased expression of epithelial cell ion channels and pumps. Together, these data suggest that ameliorating the function of epithelial cell ion channels and pumps may help reduce immunopathology during severe IAV infections.

Influenza virus damages the alveolar barrier by disrupting epithelial cell tight junctions.

A major cause of respiratory failure during influenza A virus (IAV) infection is damage to the epithelial-endothelial barrier of the pulmonary alveolus. Damage to this barrier results in flooding of the alveolar lumen with proteinaceous oedema fluid, erythrocytes and inflammatory cells. To date, the exact roles of pulmonary epithelial and endothelial cells in this process remain unclear.Here, we used an in vitro co-culture model to understand how IAV damages the pulmonary epithelial-endothelial barrier. Human epithelial cells were seeded on the upper half of a transwell membrane while human endothelial cells were seeded on the lower half. These cells were then grown in co-culture and IAV was added to the upper chamber.We showed that the addition of IAV (H1N1 and H5N1 subtypes) resulted in significant barrier damage. Interestingly, we found that, while endothelial cells mounted a pro-inflammatory/pro-coagulant response to a viral infection in the adjacent epithelial cells, damage to the alveolar epithelial-endothelial barrier occurred independently of endothelial cells. Rather, barrier damage was associated with disruption of tight junctions amongst epithelial cells, and specifically with loss of tight junction protein claudin-4.Taken together, these data suggest that maintaining epithelial cell integrity is key in reducing pulmonary oedema during IAV infection.

[Timed up and go test for fingers in the form of the 20 cents test. Psychometric criteria of a simple performance test of fine motor skills]. / "Timed up and go" für die Finger in Form des 20-Cents-Tests. Psychometrische Gütekriterien eines einfachen Feinmotorik-Performance-Tests.

BACKGROUND: Although many activities depend on intact fine motor skills no standardized assessment has been broadly established. The 20 cents test (20-C-T) was developed in 2009 and takes less than 5 mins. The quality criteria were investigated within the framework of this study. PATIENTS AND METHODS: A total of 300 geriatric patients participated in the study. The classification of occupational therapists based on standardized anamnesis and clinical examination served as the gold standard. Physiotherapists blinded to the study particulars applied the 20-C-T. RESULTS: Every fourth patient suffered from deficits in fine motor skills relevant to everyday life. The 20-C-T correlated with the clinical severity level and was also feasible for patients with intermediate impairment of cognition or vision. Handedness, age and sex were without significant influence. Intrarater and interrater reliability were good. CONCLUSION: Standardized testing of fine motor skills should be included in geriatric screening and basic assessment. The quality criteria of the 20-C-T show that it can be used for this purpose. Further diagnostic steps are recommended whenever a geriatric patient needs more than 40 s for the task.

"The Water in Which We Swim:" A Unique, Post-Clerkship Multidisciplinary Course.

OBJECTIVE: To improve patient outcomes and promote health equity, medical students must be taught not only biomedicine, but also the social sciences to understand the larger contexts in which patients live and health care operates. Yet, most undergraduate medical education does not explicitly cover these topics in a required, longitudinal curriculum. METHODS: In January 2015 at Harvard Medical School, we created a two-part sequence (pre- and post-clerkship) of required, 4-week multidisciplinary courses-"Essentials of the Profession I and II"-to fill this gap. "Essentials of the Profession II (EOP2)" is an advanced social sciences course anchored in patient narratives and the lived experiences of students and includes clinical epidemiology and population health, healthcare delivery and leadership, health policy, medical ethics and professionalism, and social medicine that engages students to conduct structural analyses to be effective healers, advocates, and leaders. RESULTS: Per student course evaluations, the overall course rating was 1.7 (SD 0.9, 1 = excellent and 5 = poor); its overall rating has improved over time; and it has scored well even when run virtually. It was rated highly in application of critical thinking, integration of the disciplines, and relevance for clinical work. Qualitative analyses of student responses revealed the following key course strengths: breadth of topics, teaching faculty and guest speakers, and small group discussions. The weaknesses included workload, lack of diversity of opinions, repetition, and time spent in lectures. CONCLUSIONS: We argue that EOP2 is "essential" for post-clerkship medical education. It offers an opportunity to re-ignite and enhance humanism and activism; remind students why they chose the medical profession; equip them with frameworks and toolkits to help them to overcome challenges; and devise solutions to improve health care and patient outcomes that are applicable to their future training and ongoing practice of medicine.

Actin-templated Structures: Nature's Way to Hierarchical Surface Patterns (Gecko's Setae as Case Study).

The hierarchical design of the toe pad surface in geckos and its reversible adhesiveness have inspired material scientists for many years. Micro- and nano-patterned surfaces with impressive adhesive performance have been developed to mimic gecko's properties. While the adhesive performance achieved in some examples has surpassed living counterparts, the durability of the fabricated surfaces is limited and the capability to self-renew and restore function-inherent to biological systems-is unimaginable. Here the morphogenesis of gecko setae using skin samples from the Bibron´s gecko (Chondrodactylus bibronii) is studied. Gecko setae develop as specialized apical differentiation structures at a distinct cell-cell layer interface within the skin epidermis. A primary role for F-actin and microtubules as templating structural elements is necessary for the development of setae's hierarchical morphology, and a stabilization role of keratins and corneus beta proteins is identified. Setae grow from single cells in a bottom layer protruding into four neighboring cells in the upper layer. The resulting multicellular junction can play a role during shedding by facilitating fracture of the cell-cell interface and release of the high aspect ratio setae. The results contribute to the understanding of setae regeneration and may inspire future concepts to bioengineer self-renewable patterned adhesive surfaces.

Interactions of silica nanoparticles with lung epithelial cells and the association to flotillins.

Amorphous silica nanoparticles (aSNPs) gain increasing popularity for industrial and therapeutic claims. The lung with its surface area of 100-140 m(2) displays an ideal target for therapeutic approaches, but it represents also a serious area of attack for harmful nanomaterials. The exact nature of the cytotoxic effects of NPs is still unknown. Furthermore, cellular pathways and the destiny of internalized NPs are still poorly understood. Therefore, we examined the cytotoxicity (MTS, LDH) and inflammatory responses (IL-8) for different-sized aSNPs (30, 70, 300 nm) on our lung epithelial cells line NCI H441 and endothelial cell line ISO-HAS-1. Additionally, colocalization studies have been conducted via immunofluorescence staining for flotillin-1- and flotillin-2-bearing endocytic vesicles. Subsequently, the relevance of flotillins concerning the viability of aSNP-exposed epithelial cells has been evaluated using flotillin-1/2 depleted cells (siRNA). This study reveals the relevance of the nanoparticle size regarding cytotoxicity (MTS, LDH) and inflammatory responses (IL-8), whereat the smaller the size of the nanoparticle is, the more harmful are the effects. All different aSNP sizes have been incorporated in flotillin-1- and flotillin-2-labelled vesicles in lung epithelial and endothelial cells, which display a marker for late endosomal or lysosomal structures and appear to exhibit a clathrin- or caveolae-independent mode of endocytosis. Flotillin-depleted H441 showed a clearly decreased uptake of aSNPs. Additionally, the viability of aSNP-exposed cells was reduced in these cells. These findings indicate a contribution of flotillins in as yet unknown (clathrin or caveolae-independent) endocytosis mechanisms and (or) endosomal storage.

Cytocompatibility Evaluation of PEG-Methylsulfone Hydrogels.

Methylsulfone derivatized poly(ethylene) glycol (PEG) macromers can be biofunctionalized with thiolated ligands and cross-linked with thiol-based cross-linkers to obtain bioactive PEG hydrogels for in situ cell encapsulation. Methylsulfonyl-thiol (MS-SH) reactions present several advantages for this purpose when compared to other thiol-based cross-linking systems. They proceed with adequate and tunable kinetics for encapsulation, they reach a high conversion degree with good selectivity, and they generate stable reaction products. Our previous work demonstrated the cytocompatibility of cross-linked PEG-MS/thiol hydrogels in contact with fibroblasts. However, the cytocompatibility of the in situ MS-SH cross-linking reaction itself, which generates methylsulfinic acid as byproduct at the cross-linked site, remains to be evaluated. These studies are necessary to evaluate the potential of these systems for in vivo applications. Here we perform an extensive cytocompatibility study of PEG hydrogels during in situ cross-linking by the methylsulfonyl-thiol reaction. We compare these results with maleimide-thiol cross-linked PEGs which are well established for cell culture and in vivo experiments and do not involve the release of a byproduct. We show that fibroblasts and endothelial cells remain viable after in situ polymerization of methylsulfonyl-thiol gels on the top of the cell layers. Cell viability seems better than after in situ cross-linking hydrogels with maleimide-thiol chemistry. The endothelial cell proinflammatory phenotype is low and similar to the one obtained by the maleimide-thiol reaction. Finally, no activation of monocytes is observed. All in all, these results demonstrate that the methylsulfonyl-thiol chemistry is cytocompatible and does not trigger high pro-inflammatory responses in endothelial cells and monocytes. These results make methylsulfonyl-thiol chemistries eligible for in vivo testing and eventually clinical application in the future.

Inflammatory and cytotoxic responses of an alveolar-capillary coculture model to silica nanoparticles: comparison with conventional monocultures.

BACKGROUND: To date silica nanoparticles (SNPs) play an important role in modern technology and nanomedicine. SNPs are present in various materials (tyres, electrical and thermal insulation material, photovoltaic facilities). They are also used in products that are directly exposed to humans such as cosmetics or toothpaste. For that reason it is of great concern to evaluate the possible hazards of these engineered particles for human health. Attention should primarily be focussed on SNP effects on biological barriers. Accidentally released SNP could, for example, encounter the alveolar-capillary barrier by inhalation. In this study we examined the inflammatory and cytotoxic responses of monodisperse amorphous silica nanoparticles (aSNPs) of 30 nm in size on an in vitro coculture model mimicking the alveolar-capillary barrier and compared these to conventional monocultures. METHODS: Thus, the epithelial cell line, H441, and the endothelial cell line, ISO-HAS-1, were used in monoculture and in coculture on opposite sides of a filter membrane. Cytotoxicity was evaluated by the MTS assay, detection of membrane integrity (LDH release), and TER (Transepithelial Electrical Resistance) measurement. Additionally, parameters of inflammation (sICAM-1, IL-6 and IL-8 release) and apoptosis markers were investigated. RESULTS: Regarding toxic effects (viability, membrane integrity, TER) the coculture model was less sensitive to apical aSNP exposure than the conventional monocultures of the appropriate cells. On the other hand, the in vitro coculture model responded with the release of inflammatory markers in a much more sensitive fashion than the conventional monoculture. At concentrations that were 10-100fold less than the toxic concentrations the apically exposed coculture showed a release of IL-6 and IL-8 to the basolateral side. This may mimic the early inflammatory events that take place in the pulmonary alveoli after aSNP inhalation. Furthermore, a number of apoptosis markers belonging to the intrinsic pathway were upregulated in the coculture following aSNP treatment. Analysis of the individual markers indicated that the cells suffered from DNA damage, hypoxia and ER-stress. CONCLUSION: We present evidence that our in vitro coculture model of the alveolar-capillary barrier is clearly advantageous compared to conventional monocultures in evaluating the extent of damage caused by hazardous material encountering the principle biological barrier in the lower respiratory tract.

The Women Before Me: My Journey Painting Honor Wall Portraits of Women Physicians.

In this article, the authors briefly review the history and status of institutional honor wall portraits at medical schools, and they highlight the implications of a lack of diversity in these portraits for current medical students and the academic medicine pipeline. The authors then describe how contemporary portrait artists have used art as a tool for advocacy. They detail the first author's empowering and intimate journey as a medical student as she identified, connected with, and painted a portrait gallery of some of her medical school's prominent alumnae of color. This unique effort highlighted the unsung accomplishments of these women physicians and served to combat the visual disparity in honor wall portraits on campus. The authors also outline the common barriers faced by the portrait subjects and the key validation they offered the first author, a fellow woman of color. The authors describe the historical and psychological significance of several artistic decisions made for these portraits in weighing the intersections of race, gender, and profession. They then emphasize the reciprocal nature of oil portraiture and how, through painting these women, the first author was able to better envision her community of mentors, deepen her commitment to diversity and inclusion, and strengthen her own career aspirations. These portraits will hang in the student center of Harvard Medical School and will serve as a lasting reminder to future trainees, especially women and people of color, that they belong in the halls of medicine.

The relevance of U.S. Ratification of the Convention on the Rights of the Child for Child Health: a matter of equity and social justice.

The United Nations Convention on the Rights of the Child (CRC) is a universally accepted tool to understand the social underpinnings of child health that medicine alone cannot address. Injustices plague U.S. society: Child poverty has been increasing since 2000, and the gap between the wealthiest and poorest is growing. Poverty is a toxic stress on child health and well-being. Three articles from the CRC help frame how to address this: nondiscrimination, the right to enjoy the highest attainable standard of health and access to health care, and the right to a standard of living adequate for complete development.

Perspectives and Solutions from Clinical Trainees and Mentors Regarding Ethical Challenges During Global Health Experiences.

Background: Clinical trainees face challenges throughout short-term experiences in global health (STEGH) that are not routinely addressed. Objectives: Describe common professional and ethical dilemmas faced by clinical trainees and identify gaps and solutions for pre, during, and post-STEGH training and mentoring. Methods: We conducted a mixed-methods study among trainees and mentors involved in global health. The study utilized focus groups with trainees (November-December 2015) and online surveys of trainees, in-country and stateside faculty mentors (October 2016-April 2017). Results: 85% (17/20) of students reported feeling prepared for their STEGH; however, 59% (23/39) of faculty felt students were unprepared. A majority of both students (90%) and faculty (77%) stated students would likely experience an ethical dilemma during STEGH. Major themes relating to meaningful global health work were elucidated: personal and inter-professional skills; interpersonal networks and collaboration; and awareness of power dynamics and bias. Conclusions: The most common challenges faced by trainees during STEGH related to leadership, bias, ethics and interprofessional collaboration. Redirecting trainee energies from a focus on 'doing' and deliverables to attitudes (e.g., humility, professionalism) that cultivate personal and professional growth will help create lifelong global health learners and leaders.