An Organizational Commitment to Diversity, Equity, Inclusion, and Justice: A Multipronged Strategic Approach.

Cedars-Sinai is a sixth continuous Magnet organization in Southern California that embodies inclusive leadership in support of diversity, equity, inclusion, and justice (DEIJ) principles. The organization adheres to a strategic model prioritizing staff sense of belonging, empowerment, engagement, curiosity, and creativity. Employing inclusive leadership, we have implemented strong programs of professional development and continuous learning, innovation, and research. This leadership and these programs have fostered a culture of inquiry, support evidence-driven practice, quality improvement, and staff engagement. Our organization is committed to creating a caring and healing environment that promotes performance. We believe in practicing loving-kindness toward ourselves and others as a core value. Executive leadership support has been a key element in our successful implementation of DEIJ strategies, including employee resource groups, Shared Leadership Councils, transition to practice programs, health equity research, and innovative solutions. These strategies have been shown to yield a significant return on investment.

Surgeon Burnout and Usage of Personal Communication Devices: Examining the Technology "Empowerment/Enslavement Paradox".

INTRODUCTION: Access to patients' electronic medical records (EMRs) on personal communication devices (PCDs) is beneficial but can negatively impact surgeons. In a recent op-ed, Cohen et al. explored this technology "empowerment/enslavement paradox" and its potential effect on surgeon burnout. We examined if there is a relationship between accessing EMRs on PCDs and surgeon burnout. METHODS: This was a cohort study with retrospective and prospective arms. Trainees and attendings with a background in general surgery completed the Maslach Burnout Index for Medical Personnel, a validated survey scored on three areas of burnout (emotional exhaustion, depersonalization, and low personal accomplishment). Data on login frequency to EMRs on PCDs over the previous 6 mo were obtained. Pearson correlation coefficients were calculated to determine if burnout and login frequency were associated. RESULTS: There were 52 participants included. Residents were 61.5% (n = 32) of participants. The mean login frequency over 6 mo was 431.0 ± 323.9. The mean scores (out of 6) for emotional exhaustion, depersonalization, and personal accomplishment were 2.3 ± 1.1, 1.9 ± 1.2, and 4.9 ± 0.8, respectively. There was no correlation between burnout and logins. Residents had higher median depersonalization scores (2.3 versus 1.2, P = 0.03) and total logins (417.5 versus 210.0, P < 0.001) than attendings. Participants who overestimated logins had higher median emotional exhaustion and depersonalization scores than those who underestimated (2.6 versus 1.4, P = 0.03, and 2.4 versus 0.8, P = 0.003, respectively). CONCLUSIONS: Using EMRs on PCDs is common, but frequency of logins did not correlate with burnout scores in this study. However, perception of increased workload may contribute to experiencing burnout.

The Challenge of Advancing Health Equity During a Year of Pandemic and Crisis: Our Organization's Response.

Since its inception, Cedars-Sinai Health System has led with compassion to embody the principles of health equity and the fight against prejudice and racism. Founded in 1902 as Los Angeles' first Jewish hospital, Cedars-Sinai through the years has continued to serve the most vulnerable, disadvantaged, and marginalized communities. In this article, we share a part of our current journey toward advancing health equity during a challenging year of pandemic and crisis (2020-2021).

Calcium montmorillonite clay reduces AFB1 and FB1 biomarkers in rats exposed to single and co-exposures of aflatoxin and fumonisin.

Aflatoxins (AFs) and fumonisins (FBs) can co-contaminate foodstuffs and have been associated with hepatocellular and esophageal carcinomas in humans at high risk for exposure. One strategy to reduce exposure (and toxicity) from contaminated foodstuffs is the dietary inclusion of a montmorillonite clay (UPSN) that binds AFs and FBs in the gastrointestinal tract. In this study, the binding capacity of UPSN was evaluated for AFB1, FB1 and a combination thereof in Fischer 344 rats. Rats were pre-treated with different dietary levels of UPSN (0.25% or 2%) for 1 week. Rats were gavaged with a single dose of either 0.125 mg AFB1 or 25 mg FB1 per kg body weight and a combination thereof in the presence and absence of an aqueous solution of UPSN. The kinetics of mycotoxin excretion were monitored by analyzing serum AFB1 -albumin, urinary AF (AFM1) and FB1 biomarkers over a period of 72 h. UPSN decreased AFM1 excretion by 88-97%, indicating highly effective binding. FB1 excretion was reduced, to a lesser extent, ranging from 45% to 85%. When in combination, both AFB1 and FB1 binding occurred, but capacity was decreased by almost half. In the absence of UPSN, the combined AFB1 and FB1 treatment decreased the urinary biomarkers by 67% and 45% respectively, but increased levels of AFB1 -albumin, presumably by modulating its cytochrome metabolism. UPSN significantly reduced bioavailability of both AFB1 and FB1 when in combination; suggesting that it can be utilized to reduce levels below their respective thresholds for affecting adverse biological effects.

Common African cooking processes do not affect the aflatoxin binding efficacy of refined calcium montmorillonite clay.

Aflatoxins are common contaminants of staple crops, such as corn and groundnuts, and a significant cause of concern for food safety and public health in developing countries. Aflatoxin B1 (AFB1) has been implicated in the etiology of acute and chronic disease in humans and animals, including growth stunting, liver cancer and death. Cost effective and culturally acceptable intervention strategies for the reduction of dietary AFB1 exposure are of critical need in populations at high risk for aflatoxicosis. Fermented gruels consisting of cornmeal are a common source for such exposure and are consumed by both children and adults in many countries with a history of frequent, high-level aflatoxin exposure. One proposed method to reduce aflatoxins in the diet is to include a selective enterosorbent, Uniform Particle Size NovaSil (UPSN), as a food additive in contaminated foods. For UPSN to be effective in this capacity, it must be stable in complex, acidic mixtures that are often exposed to heat during the process of fermented gruel preparation. Therefore, the objective of the present study was to test the ability of UPSN to sorb aflatoxin while common cooking conditions were applied. The influence of fermentation, heat treatment, acidity, and processing time were investigated with and without UPSN. Analyses were performed using the field-practical Vicam assay with HPLC verification of trends. Our findings demonstrated that UPSN significantly reduced aflatoxin levels (47-100%) in cornmeal, regardless of processing conditions. Upon comparison of each element tested, time appeared to be the primary factor influencing UPSN efficacy. The greatest decreases in AFB1 were reported in samples allowed to incubate (with or without fermentation) for 72 hrs. This data suggests that addition of UPSN to staple corn ingredients likely to contain aflatoxins would be a sustainable approach to reduce exposure.

Reducing Blood Draws in Pediatric Patients With Solid Organ Injury Through Protocolized Transcutaneous Hemoglobin Monitoring.

BACKGROUND: Management of pediatric solid organ injuries continues to evolve, decreasing the need for serial hemoglobin measurements, repeat imaging, and operative intervention. Transcutaneous continuous hemoglobin monitoring (TCHM) has been shown to effectively monitor hemoglobin levels in children with solid organ trauma. METHODS: A 6-year, single-center, retrospective chart review was conducted of pediatric solid organ injury patients aged 30 days to <18 years admitted to a quaternary children's hospital following implementation of a highly protocolized TCHM system. A laboratory hemoglobin measurement was obtained at the time of diagnosis and additional measurements were determined based on injury grading. Adverse events were tracked and included: central or arterial line placement, blood product(s) administration, percutaneous embolization procedures, transfer to the pediatric ICU and operative intervention. RESULTS: A total of 97 patients met the inclusion criteria. Blood draws were significantly reduced following TCHM protocol implementation (3.0 [IQR 2.0-5.5] vs 2.0 [IQR 1.0-4.5], p 0.01) without a significant increase in blood product administration (p = 0.30), central or arterial line placement (p = 1), or operative intervention (p = 0.29). Length of stay was not impacted (p = 0.36). The rate of unplanned ICU transfers and percutaneous embolization procedures were too low for statistical evaluation. CONCLUSION: TCHM safely reduces the need for serial blood draws in pediatric trauma patients when utilized within a well-defined protocol for solid organ injury. Further studies are needed to evaluate the role of TCHM in shortening or eliminating hospital admission for low-grade solid organ injuries in children. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Single-center, retrospective chart review cohort study.

Implementing a virtual emergency department to avoid unnecessary emergency department presentations.

OBJECTIVE: EDs are necessary for urgent health concerns; however, many physical ED visits could be better treated in alternate settings. The present study aimed to describe the feasibility, acceptability and effectiveness of a Virtual ED to reduce unnecessary physical ED presentations at a large tertiary health service in Australia. METHODS: This observational study using the RE-AIM framework (Reach, Efficacy, Adoption, Implementation and Maintenance) evaluated the feasibility of a Virtual ED using routinely collected health service data and process-evaluation to assess intervention fidelity and adherence between April 2020 and 31 March 2022. The primary outcome for the present study was the feasibility of the Virtual ED model of care. RESULTS: The Virtual ED received 2080 direct calls for patients with a mean age of 50.3 years, with 70.4% managed in the Virtual ED alone and 29.6% referred for physical ED presentation. Of the 2080 direct referrals, 95.8% were potentially avoidable ED presentations. Of those referred, 28.3% required an admission. Of calls managed entirely by Virtual ED, 18 (1.2%) unexpectedly required a hospital admission within 48 h. General practitioner respondents rated the Virtual ED service as helpful to very helpful. The service had an average of 212 referrals per month, with a 65.2% average growth rate. The Virtual ED service was considered helpful and clinically appropriate, with a high level of ED avoidance. CONCLUSION: The Virtual ED prevented 70% of community triaged patients from presenting to the physical ED, with good uptake from all referrers, supporting the use of virtual care pathways in emergency care management.

Utility and costs of surveillance imaging for low- and very low-risk gastrointestinal stromal tumors.

BACKGROUND: There is limited evidence on the optimal surveillance approach in patients with low- and very low-risk gastrointestinal stromal tumors, resulting in inconsistent and arbitrary approaches to surveillance in this population. In this study, we reviewed our institutional approach to surveillance in patients with low- and very low-risk gastrointestinal stromal tumors and the costs associated with detecting recurrence. METHODS: We retrospectively reviewed consecutive adult patients treated for low- and very low-risk gastrointestinal stromal tumors at our institution from 2010 to 2019. Data collected included patient and tumor characteristics, surgical management, and postoperative follow-up. Surveillance-related expenses were calculated using estimates of average costs obtained from our institution. A cost analysis was performed to evaluate estimated yearly costs based on the surveillance strategy used. RESULTS: There were 60 patients included. The mean age at diagnosis was 63.9 (±12.5) years. The primary tumor was typically in the stomach (73%; n = 44). Computed tomography scan of the abdomen and pelvis with intravenous contrast was the most common surveillance modality (total = 226 scans). No recurrences were identified. Median follow-up duration was 49.0 (interquartile range = 19.5-61.5) months. The mean number of surveillance images per patient was 4 (±2.6). Surveillance imaging was obtained more frequently than just annually in 83% (n = 50) of patients, with an estimated yearly cost of $2,840.77 (interquartile range = $2,273.62-$3,895.92) and no detection of recurrence. CONCLUSION: In this study population, patients with low- and very low-risk gastrointestinal stromal tumors underwent frequent imaging studies for surveillance with little yield and at substantial cost. Further multi-institutional studies on practice patterns and outcomes of surveillance are warranted to better inform standardized surveillance recommendations.

Reduction in the urinary aflatoxin M1 biomarker as an early indicator of the efficacy of dietary interventions to reduce exposure to aflatoxins.

Aflatoxin B1 is a persistent public health issue in Ghana. Assessment of AFB1 intervention efficacy is currently dependent on long-term biomarkers. This study was designed to determine whether daily AFM1 biomarker levels could be utilized as an early detection method for intervention efficacy. Participants were treated with a refined calcium montmorillonite clay (UPSN) or a placebo (calcium carbonate) in a crossover study. Urine samples were assessed for AFM1 levels daily. UPSN treatment reduced AFM1 biomarkers by 55% compared to the placebo. This is the first study to show that daily urinary AFM1 levels can be used as a biomarker of internal aflatoxin B1 exposure in short-term intervention trials to determine efficacy.

Integrative toxicopathological evaluation of aflatoxin B1 exposure in F344 rats.

In this study, male F344 rats were orally exposed to a single dose of aflatoxin B1 (AFB1) at 0, 50, 250, or 1,000 µg/kg body weight (BW) or repeated dose of 0, 5, 10, 25, or 75 µg/kg BW for up to 5 weeks. Biochemical and histological changes were assessed together with the formation of AFB1-lysine adduct (AFB-Lys) and liver foci positive for placental form glutathione S transferase (GST-P⁺). In single-dose protocol, serum aspartate transaminase (AST), alanine transaminase (ALT), and alkaline phosphatase (ALP) showed dose-related elevation, with maximal changes observed (>100-fold) at day 3 after treatment. Animals that received 250 µg/kg AFB1 showed concurrent bile duct proliferation, necrosis, and GST-P⁺ hepatocytes at 3 day, followed by liver GST-P⁺ foci appearance at 1 week. In repeated-dose protocol, bile duct proliferation and liver GST-P⁺ foci co-occurred after 3-week exposure to 75 µg/kg AFB1, followed by proliferation foci formation after 4 week and dramatic ALT, AST, and CK elevations after 5 weeks. Liver GST-P⁺ foci were induced temporally and in a dose-related manner. Serum AFB-Lys increased temporally at low doses (5-25 µg/kg), and reached the maximum after 2-week exposure at 75 µg/kg. This integrative study demonstrated that liver GST-P⁺ cells and foci are sensitive biomarkers for AFB1 toxic effect and correlated with bile duct proliferation and biochemical alterations in F344 rats.

In vivo efficacy of ferrihydrite as an enterosorbent for arsenic: short-term evaluation in rodents.

The use of dietary adsorbents to reduce arsenic (As) exposure is innovative. Ferrihydrite successfully sorbs arsenite and asenate over a wide range of pH conditions and the As-ferrihydrite complexes are stable in gastrointestinal (GIT) models. Our objectives were to (1) compare structural characteristics (using x-ray diffraction and Fourier-transform infrared [FTIR] spectroscopy) and As binding affinities of industrially produced ferrihydrite (IDF) and lab-synthesized ferrihydrite and (2) evaluate the efficacy of the material displaying the best sorption capability as an As enterosorbent in a short-term mammalian model. Lab-synthesized ferrihydrite displayed superior binding affinity for both arsenate and arsenite in vitro, which led to its use in the in vivo portion of the study. Young Sprague-Dawley male rats were fed either a control diet or a 0.5% w/w ferrihydrite feed. After 1 wk of acclimation, rats were given 0.5 ml of 500 mg/L arsenate or arsenite via gavage with or without ferrihydrite. Rats were then transferred to metabolism cages, and urine collected after 24 and 48 h was analyzed for total As. Rats were evaluated daily for signs of morbidity and mortality for up to 1 wk. Ferrihydrite reduced mean urinary As levels by 74.9% and 43.6% after 24 h and 49.1% and 39.5% after 48 h for arsenite- and arsenate-treated groups, respectively. Importantly, treatment groups receiving ferrihydrite displayed no signs of As-related toxicity. All As reductions were statistically significant except for arsenate treatments at 24 h. Data suggest that, as an enterosorbent, ferrihydrite reduces bioavailability after As exposures.

Is the time and effort worth it? One library's evaluation of using social networking tools for outreach.

Librarians are using social networking sites as one means of sharing information and connecting with users from diverse groups. Usage statistics and other metrics compiled in 2011 for the library's Facebook page, representative library blogs, and the library YouTube channel were analyzed in an effort to understand how patrons use the library's social networking sites. Librarians also hoped to get a sense of these tools' effectiveness in reaching users at the point of need and engaging them in different ways.

A Study to Evaluate the Need for Comminution in the Preparation of Food Materials for Testing of Listeria monocytogenes, Staphylococcus Species, and Generic Escherichia coli.

BACKGROUND: Comminution reduces the sampling error arising from distributional heterogeneity of the target contaminant/target analyte in the material, facilitating the selection of a more representative test portion. A laboratory sampling method incorporating comminution prior to selection of the test portion (Sampling Method B) was compared to current sampling methods that used no comminution step (Sampling Method A). OBJECTIVE: This required the development of an efficient process for comminution of food samples prior to removal of the test portion for the detection and isolation of Listeria monocytogenes and the enumeration of Staphylococcus species and Escherichia coli. METHOD: From December 2016 to December 2017, 2742 tests were conducted on 778 unique food samples. For all food samples, a test portion (TPA) was first removed using Sampling Method A, and then the remainder of the material was comminuted and a second test portion (TPB) was removed using Sampling Method B and tested alongside the first portion. RESULTS: Across all food matrices and microbial targets, 17 additional targets were detected using only Sampling Method B, and positive detections of target analytes increased by 77% using Sampling Method B from the test portions taken using Sampling Method A. CONCLUSION: Utilizing a sample preparation method that includes a comminution step resulted in an increased number of pathogen detections. HIGHLIGHTS: The introduction of a comminution step in the preparation of food samples for detection of three common microbial contaminants resulted in an increase in the rate of detection of natural contaminates in a variety of ready to eat foods. An efficient aseptic process for commutation that can be adapted to a wide range of laboratory settings was identified.

Using parallelized incremental meta-docking can solve the conformational sampling issue when docking large ligands to proteins.

BACKGROUND: Docking large ligands, and especially peptides, to protein receptors is still considered a challenge in computational structural biology. Besides the issue of accurately scoring the binding modes of a protein-ligand complex produced by a molecular docking tool, the conformational sampling of a large ligand is also often considered a challenge because of its underlying combinatorial complexity. In this study, we evaluate the impact of using parallelized and incremental paradigms on the accuracy and performance of conformational sampling when docking large ligands. We use five datasets of protein-ligand complexes involving ligands that could not be accurately docked by classical protein-ligand docking tools in previous similar studies. RESULTS: Our computational evaluation shows that simply increasing the amount of conformational sampling performed by a protein-ligand docking tool, such as Vina, by running it for longer is rarely beneficial. Instead, it is more efficient and advantageous to run several short instances of this docking tool in parallel and group their results together, in a straightforward parallelized docking protocol. Even greater accuracy and efficiency are achieved by our parallelized incremental meta-docking tool, DINC, showing the additional benefits of its incremental paradigm. Using DINC, we could accurately reproduce the vast majority of the protein-ligand complexes we considered. CONCLUSIONS: Our study suggests that, even when trying to dock large ligands to proteins, the conformational sampling of the ligand should no longer be considered an issue, as simple docking protocols using existing tools can solve it. Therefore, scoring should currently be regarded as the biggest unmet challenge in molecular docking.