Resident Recruitment in a New Era.

ABSTRACT: This chapter focuses on resident recruitment and recent US National Resident Matching Program changes and the impact in the evaluation and ranking of applicants within the specialty of anesthesiology. Recruitment challenges are examined as well as program strategies and potential future directions. Also discussed are DEI initiatives within the recruitment process.

Physician Unionization: Opportunities and Challenges for Anesthesiologists in the United States.

Physician unionization is gaining traction in the United States, with <10% of practicing physicians now members, up from historically weak support. Factors that drive interest in unions include a decreased number of independent practitioners, an increase in workloads, and the erosion of autonomy. Approximately 56% of anesthesiologists are considered employees and may be eligible for union membership. Physician unions may provide higher wages, better working conditions, and legal protection. However, they also raise concerns about patient care and professionalism. This article discusses the legal and regulatory framework governing the unionization of physicians, benefits, challenges, and potential future developments. Continued analysis and debate are necessary to determine the optimal role of physician unions in the health care industry.

Feasibility of wearable technology for 'real-world' gait analysis in children with Prader-Willi and Angelman syndromes.

BACKGROUND: Prader-Willi syndrome (PWS) and Angelman syndrome (AS) are neurodevelopmental disorders in need of innovative 'real-world' outcome measures to evaluate treatment effects. Instrumented gait analysis (IGA) using wearable technology offers a potentially feasible solution to measure "real-world' neurological and motor dysfunction in these groups. METHODS: Children (50% female; 6-16 years) diagnosed with PWS (n = 9) and AS (n = 5) completed 'real-world' IGA assessments using the Physilog®5 wearable. PWS participants completed a laboratory assessment and a 'real-world' long walk. The AS group completed 'real-world' caregiver-assisted assessments. Mean and variability results for stride time, cadence, stance percentage (%) and stride length were extracted and compared across three different data reduction protocols. RESULTS: The wearables approach was found to be feasible, with all participants able to complete at least one assessment. This study also demonstrated significant agreement, using Lin's concordance correlation coefficient (CCC), between laboratory and 'real-world' assessments in the PWS group for mean stride length, mean stance % and stance % CV (n = 7, CCC: 0.782-0.847, P = 0.011-0.009). CONCLUSION: 'Real-world' gait analysis using the Physilog®5 wearable was feasible to efficiently assess neurological and motor dysfunction in children affected with PWS and AS.

Therapeutic mammaplasty is a safe and effective alternative to mastectomy with or without immediate breast reconstruction.

BACKGROUND: Therapeutic mammaplasty (TM) may be an alternative to mastectomy, but few well designed studies have evaluated the success of this approach or compared the short-term outcomes of TM with mastectomy with or without immediate breast reconstruction (IBR). Data from the national iBRA-2 and TeaM studies were combined to compare the safety and short-term outcomes of TM and mastectomy with or without IBR. METHODS: The subgroup of patients in the TeaM study who underwent TM to avoid mastectomy were identified, and data on demographics, complications, oncology and adjuvant treatment were compared with those of patients undergoing mastectomy with or without IBR in the iBRA-2 study. The primary outcome was the percentage of successful breast-conserving procedures in the TM group. Secondary outcomes included postoperative complications and time to adjuvant therapy. RESULTS: A total of 2916 patients (TM 376; mastectomy 1532; mastectomy and IBR 1008) were included in the analysis. Patients undergoing TM were more likely to be obese and to have undergone bilateral surgery than those having IBR. However, patients undergoing mastectomy with or without IBR were more likely to experience complications than the TM group (TM: 79, 21·0 per cent; mastectomy: 570, 37·2 per cent; mastectomy and IBR: 359, 35·6 per cent; P < 0·001). Breast conservation was possible in 87·0 per cent of patients who had TM, and TM did not delay adjuvant treatment. CONCLUSION: TM may allow high-risk patients who would not be candidates for IBR to avoid mastectomy safely. Further work is needed to explore the comparative patient-reported and cosmetic outcomes of the different approaches, and to establish long-term oncological safety.

ANTECEDENTES: La mamoplastia terapéutica (therapeutic mammaplasty, TM) puede ser una alternativa a la mastectomía, pero hay pocos estudios bien diseñados que hayan evaluado el éxito de esta estrategia o hayan comparado los resultados a corto plazo de la TM con la mastectomía con o sin (+/-) reconstrucción mamaria inmediata (immediate breast reconstruction, IBR). Para comparar la seguridad y los resultados a corto plazo de la TM y la mastectomía +/- IBR se combinaron los datos de los estudios nacionales iBRA-2 y TeaM. MÉTODOS: En el estudio TeaM se identificó el subgrupo de pacientes al que se realizó una TM para evitar la mastectomía y se compararon los datos demográficos, las complicaciones, los resultados oncológicos y el tratamiento adyuvante con las pacientes sometidas a mastectomía +/- IBR del estudio iBRA-2. La variable principal fue el porcentaje de éxito de la cirugía conservadora de mama en el grupo TM. Las variables secundarias fueron las complicaciones postoperatorias y el intervalo de tiempo hasta el inicio del tratamiento adyuvante. RESULTADOS: Se incluyeron en el análisis 2.916 pacientes (TM n = 376; mastectomía n = 1.532; IBR n = 1.008). La TM era más frecuente en pacientes obesas o en las sometidas a cirugía bilateral en comparación con las pacientes con IBR. Sin embargo, las pacientes sometidas a una mastectomía +/- IBR tenían más probabilidades de desarrollar complicaciones que las del grupo TM (TM n = 79, 21,0%; mastectomía n = 570, 37,2%; mastectomía y IBR n = 359, 35,6%; P < 0,001). La conservación de la mama fue posible en el 87% de las pacientes con TM y el procedimiento no retrasó el inicio del tratamiento adyuvante. CONCLUSIÓN: La TM puede permitir que pacientes de alto riesgo que no serían candidatas a IBR eviten la mastectomía de una forma segura. Se necesitan más trabajos para comparar los resultados percibidos por las pacientes y los estéticos de las diferentes estrategias terapéuticas y establecer la seguridad oncológica a largo plazo.

Is there a safe and effective way to wean patients off long-term glucocorticoids?

Glucocorticoids are highly effective medicines in the treatment of inflammatory disorders. However they cause severe adverse reactions, particularly where taken at high doses systemically for prolonged periods. Systemic glucocorticoids are therefore given at dosage sufficient to control the disease, then withdrawn as fast as is possible to minimise dose- and time-related adverse drug reactions without losing disease control. Adverse withdrawal reactions present a major challenge in the withdrawal of long term glucocorticoids. Suppression of the hypothalamic-pituitary-adrenal (HPA) axis causes adrenal insufficiency, which is potentially life threatening and can become symptomatic as treatment is withdrawn. Adrenal insufficiency can be extremely difficult to differentiate from 'glucocorticoid withdrawal syndrome', where patients experience symptoms despite adequate adrenal function, and from psychological dependence. Long term systemic glucocorticoids should therefore be withdrawn slowly. The rate at which the dose is tapered should initially be determined by treatment requirements of the underlying disease. Once 'physiological' doses are reached, the rate of reduction is determined by rate of HPA recovery and need for exogenous glucocorticoid cover while endogenous secretion recovers. If symptoms prevent treatment withdrawal, HPA testing should be used to look for adrenal insufficiency. Patients with adrenal insufficiency require 'physiological' doses of glucocorticoids for adrenal replacement, which may be lifelong if the HPA axis fails to recover.

Metabolite collision cross section prediction without energy-minimized structures.

Matching experimental ion mobility-mass spectrometry data to computationally-generated collision cross section (CCS) values enables more confident metabolite identifications. Here, we show for the first time that accurately predicting CCS values with simple models for the largest library of metabolite cross sections is indeed possible, achieving a root mean square error of 7.0 Å2 (median error of ∼2%) using linear methods accesible to most researchers. A comparison on the performance of 2D vs. 3D molecular descriptors for the purposes of CCS prediction is also presented for the first time, enabling CCS prediction without a priori knowledge of the metabolite's energy-minimized structure.

Specific class of intrapartum antibiotics relates to maturation of the infant gut microbiota: a prospective cohort study.

OBJECTIVE: To evaluate the potential impact of intrapartum antibiotics, and their specific classes, on the infant gut microbiota in the first year of life. DESIGN: Prospective study of infants in the New Hampshire Birth Cohort Study (NHBCS). SETTINGS: Rural New Hampshire, USA. POPULATION OR SAMPLE: Two hundred and sixty-six full-term infants from the NHBCS. METHODS: Intrapartum antibiotic use during labour and delivery was abstracted from medical records. Faecal samples collected at 6 weeks and 1 year of age were characterised by 16S rRNA sequencing, and metagenomics analysis in a subset of samples. EXPOSURES: Maternal exposure to antibiotics during labour and delivery. MAIN OUTCOME MEASURE: Taxonomic and functional profiles of faecal samples. RESULTS: Infant exposure to intrapartum antibiotics, particularly to two or more antibiotic classes, was independently associated with lower microbial diversity scores as well as a unique bacterial community at 6 weeks (GUnifrac, P = 0.02). At 1 year, infants in the penicillin-only group had significantly lower α diversity scores than infants not exposed to intrapartum antibiotics. Within the first year of life, intrapartum exposure to penicillins was related to a significantly lower increase in several taxa including Bacteroides, use of cephalosporins was associated with a significantly lower rise over time in Bifidobacterium and infants in the multi-class group experienced a significantly higher increase in Veillonella dispar. CONCLUSIONS: Our findings suggest that intrapartum antibiotics alter the developmental trajectory of the infant gut microbiome, and specific antibiotic types may impact community composition, diversity and keystone immune training taxa. TWEETABLE ABSTRACT: Class of intrapartum antibiotics administered during delivery relates to maturation of infant gut microbiota.

Robotic transanal minimally invasive surgery - technical, oncological and patient outcomes from a single institution.

AIM: Robotic transanal minimally invasive surgery (R-TAMIS) is gaining traction around the globe as an alternative to laparoscopic conventional TAMIS for local excision of benign and early malignant rectal lesions. The aim was to analyse patient and oncological outcomes of R-TAMIS for consecutive cases in a single centre. METHODS: A prospective analysis of consecutive R-TAMIS procedures over a 12-month period was performed. Data were collated from hospital databases and theatre registers. RESULTS: Eleven patients (six men, five women), mean age 69.81 years (51-92 years), underwent R-TAMIS over 12 months utilizing a da Vinci Xi platform. The mean lesion size was 36 mm (20-60 mm) with a mean distance from the anal verge of 7.5 cm (3-14 cm). Five lesions were posterior in anatomical location, four anterior, one right lateral and one left lateral. All procedures were performed in the lithotomy position using a GelPOINT Path Platform. Mean operative time was 64 min (40-100 min). Complete resection was achieved in 10/11 patients with two patients being upgraded to a diagnosis of adenocarcinoma. Nine patients were diagnosed with dysplastic lesions. Four patients had a false positive diagnosis of an invasive tumour on MRI. Six patients required suturing for full-thickness resections. One patient had a postoperative bleed requiring repeat endoscopy and clipping. One patient (full-thickness resection of T3 tumour) proceeded to a formal resection without difficulty with no residual disease (T0N0, 0/22). One patient with a fully resected T2 tumour is undergoing a surveillance protocol. The mean length of stay was 1 day with two patients having a length of stay of 2 days and one patient of 4 days. CONCLUSION: R-TAMIS could potentially represent a safe novel approach for local resection of rectal lesions.

Clinical outcomes and inflammatory response to single-incision laparoscopic (SIL) colorectal surgery: a single-blinded randomized controlled pilot study.

AIM: Single-incision laparoscopic (SIL) surgery is expanding, but its benefits, efficacy and safety compared with conventional laparoscopic (CL) surgery remain unclear. This pilot study examined clinical outcomes and biochemical markers of inflammation for colorectal resections by SIL and CL in a randomized controlled pilot trial. METHOD: Fifty patients undergoing elective colorectal resection were randomized to either SIL or CL. Primary outcomes were operating time and length of stay (LoS); secondary outcomes included combined length of scars, pain scores, complications, Quality of Life EQ5D-VAS and the inflammatory markers interleukin-6 (IL-6), IL-8 and C-reactive protein (CRP) at baseline, 2, 6, 24 and 72 h. RESULTS: There was no difference in age, gender, body mass index, indications and site of surgery, American Society of Anesthesiologists grade or incidence of previous surgery between the groups. Except for one conversion from SIL to open surgery, surgery was completed as intended. No difference between SIL and CL was found for operating time [median 130 (72-220) vs 130 (90-317) min, respectively, P = 0.528], LoS [median 4 (3-8) vs 4 (2-19)days, P = 0.888] and time to first flatus [2 (1-4) vs 2 (1-5) days, P = 0.374]. The combined length of scars was significantly shorter for SIL [4 (2-18) vs 7 (5-8) cm, P < 0.001]; in each group, four postoperative complications occurred (16%). Postoperative pain scores were similar [mean 7.67 (interquartile range 4) vs 7.25 (interquartile range 3.75), P = 0.835] to day 3. EQ5D-VAS was no different for both groups at discharge [72.5 (40-90) vs 70 (30-100), P = 0.673] but slightly higher for CL at 3 months [79 (45-100) vs 90 (50-100), P = 0.033].The IL-6, IL-8 and CRP levels between both groups showed similar peaks and no significant differences. CONCLUSION: SIL colorectal surgery by experienced laparoscopic surgeons appears to be safe and equivalent to CL, with no discernible difference in its effect on the physiological response to surgical trauma.

Association between child marriage and institutional delivery care services use in Bangladesh: intersections between education and place of residence.

OBJECTIVES: To examine the association between child marriage and women's use of institutional delivery care services and whether education and place of residence moderate this association. STUDY DESIGN: The study used de-identified data from four rounds (2004, 2007, 2011, and 2014) of the Bangladesh Demographic and Health Survey (BDHS). The BDHS is a cross-sectional survey conducted every three years. The analysis was based on 16,099 ever-married women aged 15-49 years with at least one live birth in the three years before the survey. METHODS: The study used multivariable logistic regression models with interaction terms between age at marriage, education, and place of residence. Adjusted predicted probabilities of outcome variables were computed from interaction models. RESULTS: Child marriage is significantly associated with decreased use of institutional delivery care services. Compared to women who married at adult ages (≥18 years), women who married between ages of 12-14 years were the most disadvantaged in having delivered at a health facility (odds ratio [OR]: 0.62; 95% confidence interval [CI]: 0.51-0.74) and having a skilled attendant present (OR: 0.63; 95% CI: 0.53-0.75) at the birth of their last child. The analysis suggests that the effect of education on the use of institutional delivery care is stronger among women married at age 18 or older compared to women who married younger than age 18 years. Further, the joint effect of age at marriage and education is stronger for women living in urban than rural place of residence. CONCLUSIONS: Increasing the age at marriage and discouraging child marriage may be a fruitful way to improve mother and child health in Bangladesh. Encouraging girls to complete high school and pursue college education would also help decline the rate of child marriage and, in turn, benefit social mobility and health.

Current practice and short-term outcomes of therapeutic mammaplasty in the international TeaM multicentre prospective cohort study.

BACKGROUND: Therapeutic mammaplasty, which combines breast reduction and mastopexy techniques with tumour excision, may extend the boundaries of breast-conserving surgery and improve outcomes for patients, but current practice is unknown and high-quality outcome data are lacking. This prospective multicentre cohort study aimed to explore the practice and short-term outcomes of the technique. METHODS: Consecutive patients undergoing therapeutic mammaplasty at participating centres between 1 September 2016 and 30 June 2017 were recruited to the study. Demographic, preoperative, operative, oncological and complication data were collected. The primary outcome was unplanned reoperation for complications within 30 days of surgery. Secondary outcomes included re-excision rates and time to adjuvant therapy. RESULTS: Overall, 880 patients underwent 899 therapeutic mammaplasty procedures at 50 centres. The most common indications were avoidance of poor cosmetic outcomes associated with standard breast-conserving surgery (702 procedures, 78·1 per cent) or avoidance of mastectomy (379, 42·2 per cent). Wise-pattern skin incisions were the most common (429 of 899, 47·7 per cent), but a range of incisions and nipple-areola pedicles were used. Immediate contralateral symmetrization was performed in one-third of cases (284 of 880, 32·3 per cent). In total, 205 patients (23·3 per cent) developed a complication, but only 25 (2·8 per cent) required reoperation. Median postoperative lesion size was 24·5 (i.q.r. 16-38) mm. Incomplete excision was seen in 132 procedures (14·7 per cent), but completion mastectomy was required for only 51 lesions (5·7 per cent). Median time to adjuvant therapy was 54 (i.q.r. 42-66) days. CONCLUSION: Therapeutic mammaplasty is a safe and effective alternative to mastectomy or standard breast-conserving surgery. Further work is required to explore the impact of the technique on quality of life, and to establish cost-effectiveness.

Retinoic acid receptor signalling directly regulates osteoblast and adipocyte differentiation from mesenchymal progenitor cells.

Low and high serum retinol levels are associated with increased fracture risk and poor bone health. We recently showed retinoic acid receptors (RARs) are negative regulators of osteoclastogenesis. Here we show RARs are also negative regulators of osteoblast and adipocyte differentiation. The pan-RAR agonist, all-trans retinoic acid (ATRA), directly inhibited differentiation and mineralisation of early osteoprogenitors and impaired the differentiation of more mature osteoblast populations. In contrast, the pan-RAR antagonist, IRX4310, accelerated differentiation of early osteoprogenitors. These effects predominantly occurred via RARγ and were further enhanced by an RARα agonist or antagonist, respectively. RAR agonists similarly impaired adipogenesis in osteogenic cultures. RAR agonist treatment resulted in significant upregulation of the Wnt antagonist, Sfrp4. This accompanied reduced nuclear and cytosolic ß-catenin protein and reduced expression of the Wnt target gene Axin2, suggesting impaired Wnt/ß-catenin signalling. To determine the effect of RAR inhibition in post-natal mice, IRX4310 was administered to male mice for 10 days and bones were assessed by µCT. No change to trabecular bone volume was observed, however, radial bone growth was impaired. These studies show RARs directly influence osteoblast and adipocyte formation from mesenchymal cells, and inhibition of RAR signalling in vivo impairs radial bone growth in post-natal mice.

Crystal structure of a bicupin protein HutD involved in histidine utilization in Pseudomonas.

Cupins form one of the most functionally diverse superfamilies of proteins, with members performing a wide range of catalytic, non-catalytic, and regulatory functions. HutD is a predicted bicupin protein that is involved in histidine utilization (Hut) in Pseudomonas species. Previous genetic analyses have suggested that it limits the upper level of Hut pathway expression, but its mechanism of action is unknown. Here, we have determined the structure of PfluHutD at 1.74 Å resolution in several crystallization conditions, and identified N-formyl-l-glutamate (FG, a Hut pathway intermediate) as a potential ligand in vivo. Proteins 2017; 85:1580-1588. © 2017 Wiley Periodicals, Inc.

Randomised crossover trial of telemonitoring in chronic respiratory patients (TeleCRAFT trial).

DESIGN: Randomised crossover trial with 6 months of standard best practice clinical care (control group) and 6 months with the addition of telemonitoring. PARTICIPANTS: 68 patients with chronic lung disease (38 with COPD; 30 with chronic respiratory failure due to other causes), who had a hospital admission for an exacerbation within 6 months of randomisation and either used long-term oxygen therapy or had an arterial oxygen saturation (SpO2) of <90% on air during the previous admission. Individuals received telemonitoring (second-generation system) via broadband link to a hospital-based care team. OUTCOME MEASURES: Primary outcome measure was time to first hospital admission for an acute exacerbation. Secondary outcome measures were hospital admissions, general practitioner (GP) consultations and home visits by nurses, quality of life measured by EuroQol-5D and hospital anxiety and depression (HAD) scale, and self-efficacy score (Stanford). RESULTS: Median (IQR) number of days to first admission showed no difference between the two groups­77 (114) telemonitoring, 77.5 (61) control ( p=0.189). Hospital admission rate at 6 months increased (0.63 telemonitoring vs 0.32 control p=0.026). Home visits increased during telemonitoring; GP consultations were unchanged. Self-efficacy fell, while HAD depression score improved marginally during telemonitoring. CONCLUSIONS: Telemonitoring added to standard care did not alter time to next acute hospital admission, increased hospital admissions and home visits overall, and did not improve quality of life in chronic respiratory patients. TRIAL REGISTRATION NUMBER: NCT02180919 (ClinicalTrials.gov).

The effect of education plus access on perceived fruit and vegetable consumption in a rural African American community intervention.

African Americans have an increased risk of cardiovascular disease partly due to low fruit and vegetable consumption. This article reports the results of an intervention to provide nutrition education and access to fruits and vegetables through community gardens to change dietary behaviors among African Americans in rural Missouri. Cross-sectional surveys evaluated the intervention effect on blood pressure, body mass index (BMI), and perceived fruit and vegetable consumption in this quasi-experimental study with a comparison group. Hypertension (OR = 0.52, 95% CI: 0.38-0.71) and BMI (OR = 0.73, 95% CI: 0.52-1.02) were lower in the intervention county at mid-intervention. Participation in nutrition education (OR = 2.67, 95% CI: 1.63-4.40) and access to fruits and vegetables from a community garden (OR = 1.95, 95% CI: 1.20-3.15) were independently associated with perceived fruit and vegetable consumption. The strongest effect on perceived fruit and vegetable consumption occurred with high participation in nutrition education and access to community gardens (OR = 2.18, 95% CI: 1.24-3.81). Those with access but without education had a reduced likelihood of consuming recommended servings of fruits and vegetables (OR = 0.57, 95% CI: 0.34-0.95). Education plus access interventions may be best at increasing consumption of fruits and vegetables in a rural African American population.

Total Chemical Synthesis of an Orf Virus Protein, ORFV002, an Inhibitor of the Master Gene Regulator NF-κB.

ORFV002 is a novel orf viral protein (117 Aa) that inhibits nuclear events through the regulation of the transcriptional activity of NF-κB, a master regulator of human gene expression (Diel et al., J Virol 2011, 85, 264-275). It is identified as the first nuclear inhibitor of NF-κB produced by orf virus (ORFV) and no homologues in other genera of the Chordopoxvirinae subfamily have been reported to date (Diel et al., J Virol 2011, 85, 264-275). Our molecular structure predictions suggest that ORFV002 may mimic part of IκB, an inhibitor and natural human partner of NF-κB. Recent advances in total chemical synthesis of proteins have provided solutions in overcoming challenges of current recombinant methods of protein isolation for structure elucidation. Aided by Boc solid phase peptide synthesis and native chemical ligation, ORFV002 was successfully synthesized in multimilligram amounts in good yield and high purity.

Development of the Nursing Community Apgar Questionnaire (NCAQ): a rural nurse recruitment and retention tool.

INTRODUCTION: Health professional shortages are a significant issue throughout the USA, particularly in rural communities. Filling nurse vacancies is a costly concern for many critical access hospitals (CAH), which serve as the primary source of health care for rural communities. CAHs and rural communities have strengths and weaknesses that affect their recruitment and retention of rural nurses. The purpose of this study was to develop a tool that rural communities and CAHs can utilize to assess their strengths and weaknesses related to nurse recruitment and retention. METHODS: The Nursing Community Apgar Questionnaire (NCAQ) was developed based on an extensive literature review, visits to multiple rural sites, and consultations with rural nurses, rural nurse administrators and content experts. RESULTS: A quantitative interview tool consisting of 50 factors that affect rural nurse recruitment and retention was developed. The tool allows participants to rate each factor in terms of advantage and importance level. The tool also includes three open-ended questions for qualitative analysis. CONCLUSIONS: The NCAQ was designed to identify rural communities' and CAHs' strengths and challenges related to rural nurse recruitment and retention. The NCAQ will be piloted and a database developed for CAHs to compare their results with those in the database. Furthermore, the NCAQ results may be utilized to prioritize resource allocation and tailor rural nurse recruitment and retention efforts to highlight a community's strengths. The NCAQ will function as a useful real-time tool for CAHs looking to assess and improve their rural nurse recruitment and retention practices and compare their results with those of their peers. Longitudinal results will allow CAHs and their communities to evaluate their progress over time. As the database grows in size, state, regional, and national results can be compared, trends may be discovered and best practices identified.

AOA Critical Issues Symposium: Promoting Health Equity.

ABSTRACT: Promoting equitable health care is to ensure that everyone has access to high-quality medical services and appropriate treatment options. The definition of health equity often can be misinterpreted, and there are challenges in fully understanding the disparities and costs of health care and when measuring the outcomes of treatment. However, these topics play an important role in promoting health equity. The COVID-19 pandemic has made us more aware of profound health-care disparities and systemic racism, which, in turn, has prompted many academic medical centers and health-care systems to increase their efforts surrounding diversity, equity, and inclusion. Therefore, it is important to understand the problems that some patients have in accessing care, promote health care that is culturally competent, create policies and standard operating procedures (at the federal, state, regional, or institutional level), and be innovative to provide cost-effective care for the underserved population. All of these efforts can assist in promoting equitable care and thus result in a more just and healthier society.