Medical Schools as Racialized Organizations: How Race-Neutral Structures Sustain Racial Inequality in Medical Education-a Narrative Review.

In 2021, The American Association of Medical Colleges released a framework addressing structural racism in academic medicine, following the significant, nationwide Movement for Black Lives. The first step of this framework is to "begin self-reflection and educating ourselves." Indeed, ample evidence shows that medical schools have a long history of racially exclusionary practices. Drawing on racialized organizations theory from the field of sociology, we compile and examine scholarship on the role of race and racism in medical training, focusing on disparities in educational and career outcomes, experiences along racial lines in medical training, and long-term implications. From the entrance into medical school through the residency application process, organizational factors such as reliance on standardized tests to predict future success, a hostile learning climate, and racially biased performance metrics negatively impact the careers of trainees of color, particularly those underrepresented in medicine (URiM). Indeed, in addition to structural biases associated with otherwise "objective" metrics, there are racial disparities across subjective outcomes such as the language used in medical trainees' performance evaluations, even when adjusting for grades and board exam scores. These disadvantages contribute to URIM trainees' lower odds of matching, steering into less competitive and lucrative specialties, and burnout and attrition from academic careers. Additionally, hostile racial climates and less diverse medical schools negatively influence White trainees' interest in practicing in underserved communities, disproportionally racial and ethnic minorities. Trainees' mental health suffers along the way, as do medical schools' recruitment, retention, diversity, and inclusion efforts. Evidence shows that seemingly race-neutral processes and structures within medical education, in conjunction with individuals' biases and interpersonal discrimination, may reproduce and sustain racial inequality among medical trainees. Medical schools whose goals include training a more diverse physician workforce towards addressing racial health disparities require a new playbook.

Medical Schools as Racialized Organizations: A Primer.

The year 2020 saw the largest social movement in response to the police killings of Black people and anti-Black racism in U.S. history. As a result, medical schools and professional societies such as the American Medical Association and the Association of American Medical Colleges are reckoning with their role in perpetuating racial inequality and the impact of structural racism on medical training. Whether these efforts will translate into meaningful change has yet to be determined. Success depends on a deep understanding of the fundamental role racism plays in how medical schools function and an acknowledgment that current organizational structures and processes often serve to entrench, not dismantle, racial inequities. Drawing on racialized organizations theory from the field of sociology, this article gives an overview of scholarship on race and racism in medical training to demonstrate how seemingly race-neutral processes and structures within medical education, in conjunction with individuals' biases and interpersonal discrimination, serve to reproduce and sustain racial inequality. From entrance into medical school through the residency application process, organizational factors such as reliance on standardized tests to predict future success, a hostile learning climate, and racially biased performance metrics ultimately stunt the careers of trainees of color, particularly those from backgrounds underrepresented in medicine (URM). These compounding disadvantages contribute to URM trainees' lower matching odds, steering into less competitive and lucrative specialties, and burnout and attrition from academic careers. In their commitment against structural racism in medical training and academic medicine, medical schools and larger organizations like the Association of American Medical Colleges should prioritize interventions targeted at these structural barriers to achieve equity.

Surgical options for hallux rigidus: state of the art and review of the literature.

Hallux rigidus is a painful condition of the great toe characterized by restriction of the metatarsophalangeal range of motion and progressive osteophyte formation. Many etiologies have been postulated including excessive length of the first ray, trauma, abnormally elevated first metatarsal and a positive family history. However, most cases are likely idiopathic. Plain radiographs are used to grade the severity of hallux rigidus. The more comprehensive grading is represented by Coughlin and Shurnas' system that introduced a four-grade classification. When nonoperative treatment fails to provide relief, surgery should be performed. The goal of surgery is to relieve pain, maintain stability of the first metatarsophalangeal joint and improve function and quality of life. Operative treatments can be divided into joint sparing (e.g., cheilectomy with or without associated osteotomies) versus joint sacrificing (e.g., arthroplasty or arthrodesis). There are a variety of osteotomies available for treatment of hallux rigidus (phalanx and/or metatarsal osteotomies). Newer techniques of interpositional arthroplasty as well as new hemi-arthroplasty designs, including synthetic cartilage implants, offer promising options for preservation of motion. The choice of procedure is based on the condition of the joint, patient's goals and expectations of the surgical outcome, and patient's motivation. This article discusses various procedures along with clinical outcomes and complications. The advantages and disadvantages of each procedure are discussed.

Envisioning a radical futureImagination: A Manifesto Ruha Benjamin Norton, 2024. 192 pp.

A more inclusive society begins with imagining audacious alternatives to today's systems, argues a sociologist.

Police Violence in Health Care Settings in US Media Coverage.

Importance: Hospitals do not collect or share data tracking their policing and security activities despite their reliance on police and security personnel, including armed officers. Thus, little is known about how hospital security is associated with patient and staff safety. Objective: To examine the harms exerted by health care-affiliated police and security personnel. Design, Setting, and Participants: For this qualitative study, data were collected using a systematic Media Cloud search for US news media coverage from January 2011 to May 2022. A total of 18 987 articles on policing and hospitals were screened and a content and thematic analysis of articles that met the search criteria was conducted, which involved incidents that revealed harm to patients, patients' families, and staff. Data were analyzed from October 2022 to April 2023. Main Outcomes and Measures: Incident year, incident location (hospital name, city, state), survivor and victim characteristics (race and ethnicity, presence of mental illness), and a narrative description of the incident focusing on outcomes of harm exerted by police and security personnel in the health care setting. Results: A total of 48 unique stories across 25 US states were included. The median (range) year published was 2017 (2009-2022). Harms reported to have been perpetuated by health care-affiliated police and security personnel were identified within 5 domains from 48 unique incidents: (1) patients shot by police or security personnel (17 patients); (2) patients subject to excessive use of force (17 patients); (3) patients arrested (7 patients); (4) patients subject to sexual assault (2 patients); and (5) hospital personnel or those considered collateral damage shot, injured, or arrested (5 individuals). Most survivors and victims were Black, although the race and/or ethnicity of involved individuals was not routinely reported across the news stories. Mental illness was the most documented medical condition among patients injured or killed by health care-affiliated police and security personnel. Conclusions and Relevance: This qualitative study of US news media found that police and security personnel in hospitals were reported to have perpetuated harm via excessive force, sexual assaults, injuring patients and health care workers, and fatal shootings. Compounded by a lack of transparency and accountability mechanisms, this may represent an underrecognized manifestation of structural racism at the organizational level. Policy suggestions include introducing accountability measures, deescalation techniques, and removing arms from hospital security personnel to reduce harm and fulfill health care's healing mission.

Simultaneous multisegmental and multifocal corrections of complex lower limb deformities with a hexapod external fixator.

INTRODUCTION: External fixators are a part of the therapeutic arsenal used in the correction of complex pediatric lower limb deformities. These long iterative procedures, which are commonly performed over several months, strongly impact the lives of these children and their families. To reduce these drawbacks, we perform, whenever possible, a simultaneous multisegmental and/or multifocal correction of these deformities. HYPOTHESIS: Simultaneous multilevel correction of complex pediatric deformities using external fixators does not result in more complications than sequential corrections. MATERIALS AND METHODS: Sixteen patients were treated with this hexapod external fixator correction procedure. The mean age was 13.9 years. The corrections involved 12 femurs and 20 tibias, representing 53 osteotomies on 23 limbs. The quality of the correction was assessed by measuring the mechanical axis deviation (MAD), residual limb length discrepancy (RLLD) and a new, specifically defined, criterion called the "angular healing index" (AHI). Complications were assessed according to Lascombes' classification. RESULTS: The mean MAD went from 30 to 13.5 mm (P<.05) and the mean RLLD from 33.2 to 6.9 mm (P<.05). The mean AHI was 74.1 days/cm (16.7 to 319). The overall complication rate was 13/23 operated limbs or 56.5% (4.3% grade 1, 43.3% grade 2, 9.3% grade 3, and no grade 4). DISCUSSION: One-stage multilevel corrections of complex pediatric lower limb deformities represent a difficult technical challenge, and any reduction in treatment time must not adversely impact the quality of the results. The rate and severity of complications compared to monofocal/segmental procedures were no higher than that reported in the literature. This study demonstrated the feasibility of multisegmental and multifocal corrections, which reduced the total treatment duration compared to successive corrections, without adversely affecting the result or increasing the complication rate. LEVEL OF EVIDENCE: IV; retrospective study.

Ellis-van Creveld syndrome in adulthood: extending the clinical spectrum.

Ellis-van Creveld (EvC) syndrome is a rare autosomal recessive malformation disorder. Cardiac defects are observed in about 50% of EvC cases. Surgical data is lacking on the prognosis and life expectancy of EvC patients. Herein, we report the case of a 38-year-old man with EvC syndrome who underwent two surgical corrections for cardiac anomalies. This report supplements the available information on the clinical course of EvC syndrome in older patients.

Successful biventricular assistance after heart transplantation.

We present a successful use of biventricular pneumatic assistance during seven days allowing the recovery from a severe primary graft failure that occurred in the operating room. Suboptimal donors are associated with higher rates of immediate graft failure; however proper use of mechanical assistance can help to recover graft function.

[Initial experience with the Impella left ventricular assist device for postcardiotomy cardiogenic shock and unprotected left coronary artery angioplasty in patients with a low left ventricular ejection fraction]. / Experiencia inicial con la asistencia ventricular izquierda tipo "Impella" para el shock cardiogénico poscardiotomía y la angioplastia de tronco coronario izquierdo no protegido con baja fracción de eyección ventricular izquierda.

Low-output syndrome is one of the leading causes of death following open-heart surgery or high-risk angioplasty. Ventricular assist devices have been used to treat patients who suffer from postoperative cardiogenic shock despite use of an intraaortic balloon pump and maximum inotropic support. The Impella pump (Impella Cardiosystems AG, Aachen, Germany) is a newly introduced left ventricular assist device that has been shown to reduce infarct size and to accelerate recovery of stunned myocardium. We report our initial experience using the Impella device for the treatment of cardiogenic shock following cardiopulmonary bypass and for maintaining hemodynamic stability in high-surgical-risk patients undergoing unprotected left coronary artery angioplasty.

Constrictive pericarditis due to Coxiella burnetii.

Q fever is characterized by its clinical polymorphism. Cardiac involvement in acute Q fever is rare. We report a case of pleuro-pericarditis that rapidly evolved to pericardial constriction during an acute episode of Coxiella burnetii infection. Constrictive pericarditis was confirmed by hemodynamic measurements, echocardiography, and magnetic resonance. Indirect immunofluorescence assay revealed positive serology for acute Q fever. The patient underwent a successful pericardiectomy and was given antibiotics. The histopathologic study of the excised pericardium showed C. burnetii in a large cluster of organisms. After a 6-month follow-up period, the individual was asymptomatic.

Endovascular repair of concomitant celiac trunk and abdominal aortic aneurysms in a patient with Behçet's disease.

PURPOSE: To report endovascular repair of dual aneurysms in a patient with Behçet's disease. CASE REPORT: A 37-year-old man diagnosed 6 months prior with Behçet's disease presented with a pulsating abdominal mass. Computed tomography revealed a 70-mm-diameter pseudoaneurysm in the abdominal aorta and another (20 mm) in the celiac trunk 5 mm from the aorta. Staged endovascular repair began with the aortic aneurysm, which was excluded with a bifurcated 23 x 140-mm Excluder stent-graft. Three days later, 2 Jostent stent-grafts were placed in the celiac trunk, successfully excluding the lesion. Fifteen days later, the patient was discharged on a regimen of clopidogrel, cyclosporine, and warfarin. At 6 months, the CT scan showed good perfusion of the stent-grafts. CONCLUSIONS: Aneurysmal involvement of the celiac trunk in a patient with Behçet's disease is a rare pathology that appears amenable to stent-graft repair.

Experiencia inicial con la asistencia ventricular izquierda tipo «Impella» para el shock cardiogénico poscardiotomía y la angioplastia de tronco coronario izquierdo no protegido con baja fracción de eyección ventricular izquierda / Initial experience with the impella left ventricular assist device for postcardiotomy cardiogenic shock and unprotected left coronary artery angioplasty in patients with a low left ventricular ejection fraction

El síndrome de bajo gasto es una de las principales causas de muerte tras la cirugía cardiaca y la angioplastia de alto riesgo. Los dispositivos de asistencia ventricular se han utilizado para tratar a pacientes con bajo gasto postoperatorio a pesar del balón de contrapulsación intraaórtico y el apoyo inotrópico máximo. El Impella (Impella Cardiosystems AG, Aachen, Alemania) es un dispositivo de asistencia ventricular de reciente introducción que ha demostrado reducir el tamaño del infarto, así como acelerar la recuperación del miocardio aturdido. Describimos nuestra experiencia inicial con el Impella para el tratamiento del shock cardiogénico tras el bypass cardiopulmonar y para el mantenimiento de la estabilidad hemodinámica en pacientes con tronco coronario izquierdo no protegido de alto riesgo quirúrgico tratados con angioplastia (AU)

Low-output syndrome is one of the leading causes of death following open-heart surgery or high-risk angioplasty. Ventricular assist devices have been used to treat patients who suffer from postoperative cardiogenic shock despite use of an intraaortic balloon pump and maximum inotropic support. The Impella pump (Impella Cardiosystems AG, Aachen, Germany) is a newly introduced left ventricular assist device that has been shown to reduce infarct size and to accelerate recovery of stunned myocardium. We report our initial experience using the Impella device for the treatment of cardiogenic shock following cardiopulmonary bypass and for maintaining hemodynamic stability in high-surgical-risk patients undergoing unprotected left coronary artery angioplasty (AU)