Investigating Unconscious Race Bias and Bias Awareness Among Vascular Surgeons.

Background: Implicit bias can influence behavior and decision-making. In clinical settings, implicit bias may influence treatment decisions and contribute to health disparities. Given documented Black-White disparities in vascular care, the purpose of this study was to examine the prevalence and degree of unconscious bias and awareness of bias among vascular surgeons treating peripheral artery disease (PAD). Methods: The sampling frame included all vascular surgeons who participate in the Vascular Quality Initiative (VQI). Participants completed a survey which included demographic questions, the race implicit association test (IAT) to measure magnitude of unconscious bias, and six bias awareness questions to measure conscious bias. The magnitude of unconscious bias was no preference; or slight, moderate, or strong in the direction of pro-White or pro-Black. Data from participants were weighted to account for nonresponse bias and known differences in the characteristics of surgeons who chose to participate compared to the full registry. We stratified unconscious and conscious findings by physician race/ethnicity, physician sex, and years of experience. Finally, we examined the relationship between unconscious and conscious bias. Results: There were 2,512 surgeons in the VQI registry, 304 of whom completed the survey, including getting IAT results. Most participants (71.6%) showed a pro-White bias with 73.0% of this group in the moderate and strong categories. While 77.5% of respondents showed conscious awareness of bias, of those whose conscious results showed lack of awareness, 67.8% had moderate or strong bias, compared to 55.7% for those with awareness. Bias magnitude varied based on physician race/ethnicity and years of experience. Women were more likely than men to report awareness of biases and potential impact of bias on decision-making. Conclusions: Most people have some level of unconscious bias, developed from early life reinforcements, social stereotypes, and learned experiences. Regarding health disparities, however, these are important findings in a profession that takes care of patients with PAD due to heavy burden of comorbid conditions and high proportion of individuals from structurally vulnerable groups. Given the lack of association between unconscious and conscious awareness of biases, awareness may be an important first step in mitigation to minimize racial disparities in healthcare. CLINICAL PERSPECTIVE: What is new?: This is the first study to examine unconscious and conscious bias in vascular surgeons, an important population for treating peripheral artery disease which disproportionately affects structurally vulnerable groups.We found that the majority of vascular surgeons show a pro-White bias, there is a lack of association between unconscious bias and conscious awareness of bias, and those who do not report conscious awareness of bias may also show greater magnitude of unconscious bias.What are the clinical implications?: These findings offer important considerations for attentiveness to both unconscious biases and enhancement of awareness of the existence of biases among a surgery community that provides care to a diverse population of patients with PAD and disparities in health outcomes.Incorporating information on the awareness of biases and structural changes to facilitate behavior change based on these findings may be helpful within training programs for vascular surgeons.With awareness as an important first step in mitigation, cognizance of the existence of biases, as identified by this study, can aid in efforts to minimize racial disparities in health care.

Ultra-fine resolution of pre-saccadic attention in the fovea.

Microsaccades, the tiny gaze relocations that occurr during fixation, have been linked to covert attention deployed degrees away from the center of gaze. However, the link between attention and microsaccades is deeper in that it also unfolds at the foveal scale. Here, we have examined the spatial grain of pre-microsaccadic attention across the 1° foveola. Through the use of high-precision eye-tracking and gaze-contingent display system that achieves arcminute precision in gaze localization, we have shown that the spotlight of attention at this scale can reach a strikingly high resolution, in the order of 0.17°. Further, when a microsaccade occurs, vision is modulated in a peculiar way across the foveola; whereas fine spatial vision is enhanced at the microsaccade goal location, it drops at the very center of gaze, where acuity is normally highest. These results reveal the finesse of the visuomotor system and of the interplay between eye movements and attention.

Poster Session: Oculomotor influences on retinal input signals in myopia.

Studies of emmetropization have traditionally focused on the spatial characteristics of visual input signals. Yet the input to the retina is not a two-dimensional pattern but a temporally-varying luminance flow. The temporal structure of this flow is predominately determined by eye movements, as the human eyes move incessantly. Even when fixating on a single point, a persistent motion known as ocular drift reformats the luminance flow in a way that counterbalances the spectra of natural scenes. It is established that emmetropes are highly sensitive to these luminance modulations. However, their visual consequences in myopia and hyperopia are unknown. Here, we first review how the temporal-frequency distribution of retinal input signals varies with the amount of ocular drift. We then use a detailed optical/geometrical model of the eye to study how the eye movements jointly shape retinal input as a function of refraction. We show that, within the temporal range of sensitivity of the retina, the spatial frequency distribution of the input signals conveys signed information about defocus. Specifically, for a given degree of defocus, myopic retinas experience more power from low spatial frequency stimuli than hyperopic retinas. These redistribution of input power may have a consequence during eye growth supporting the proposal that eye movements should be taken into consideration in the process of emmetropization.

Poster Session: Fixational Eye Movements in Myopia.

During fixation, an incessant drift of the eye keeps the image impinging on the retina always in motion. Previous work indicated that luminance modulations from ocular drift serve important visual functions in emmetropes (Intoy & Rucci, 2020; Clark et al 2022). However, it remains unknown how ocular drift varies under myopia, a visual impairment commonly caused by eye elongation. We measured eye movements in 19 individuals with varying degrees of myopia (-0.25D to -6.5D) using a digital Dual-Purkinje Image eye-tracker, a recently developed system with sub-arcminute resolution. Subjects observed stimuli monocularly with vision corrected via a Badal optometer. They engaged in two high-acuity tasks: (a) resolution of a 20/20 line of an eye chart (5 evenly spaced tumbling E optotypes); and (b) a more natural task where subjects were presented with images of distant faces (1°) and asked to report the image's gaze direction. We show ocular drift characteristics differ in myopes relative to emmetropes. Drift was faster and less curved in myopic observers. On the retina, these changes result in luminance modulations that amplify low spatial frequencies at the expense of high spatial frequencies, so that high-frequency signals are effectively weaker in myopes These results are consistent with the proposal that fine spatial vision strongly relies on oculomotor-induced luminance modulations and emphasize the importance of considering fine eye movements in myopia.

High-resolution eye-tracking via digital imaging of Purkinje reflections.

Reliably measuring eye movements and determining where the observer looks are fundamental needs in vision science. A classical approach to achieve high-resolution oculomotor measurements is the so-called dual Purkinje image (DPI) method, a technique that relies on the relative motion of the reflections generated by two distinct surfaces in the eye, the cornea and the back of the lens. This technique has been traditionally implemented in fragile and difficult to operate analog devices, which have remained exclusive use of specialized oculomotor laboratories. Here we describe progress on the development of a digital DPI, a system that builds on recent advances in digital imaging to enable fast, highly precise eye-tracking without the complications of previous analog devices. This system integrates an optical setup with no moving components with a digital imaging module and dedicated software on a fast processing unit. Data from both artificial and human eyes demonstrate subarcminute resolution at 1 kHz. Furthermore, when coupled with previously developed gaze-contingent calibration methods, this system enables localization of the line of sight within a few arcminutes.

Cognitive influences on fixational eye movements.

We perceive the world based on visual information acquired via oculomotor control,1 an activity intertwined with ongoing cognitive processes.2,3,4 Cognitive influences have been primarily studied in the context of macroscopic movements, like saccades and smooth pursuits. However, our eyes are never still, even during periods of fixation. One of the fixational eye movements, ocular drifts, shifts the stimulus over hundreds of receptors on the retina, a motion that has been argued to enhance the processing of spatial detail by translating spatial into temporal information.5 Despite their apparent randomness, ocular drifts are under neural control.6,7,8 However little is known about the control of drift beyond the brainstem circuitry of the vestibulo-ocular reflex.9,10 Here, we investigated the cognitive control of ocular drifts with a letter discrimination task. The experiment was designed to reveal open-loop effects, i.e., cognitive oculomotor control driven by specific prior knowledge of the task, independent of incoming sensory information. Open-loop influences were isolated by randomly presenting pure noise fields (no letters) while subjects engaged in discriminating specific letter pairs. Our results show open-loop control of drift direction in human observers.

Pigmented Lesions of the Oral Cavity.

Pigmented lesions are a common finding in the oral cavity. Oral pigmented lesions may range from solitary to multiple, pinpoint to diffuse, and have a variety of clinical implications. Nearly all solitary pigmented lesions require a biopsy to rule out mucosal melanoma. Oral mucosal melanoma has a grim prognosis and early discovery is of utmost importance. Multiple pigmented lesions in the oral cavity may indicate a systemic condition about which the patient may not be aware. The presentation and management of these various lesions is the focus of this article.

Comparison of Delivery of Care Before and During COVID-19 Within an Academic Outpatient Psychiatry Practice.

Introduction: The COVID-19 pandemic has challenged outpatient mental health clinics. This article compares care delivery and patient characteristics before and during the COVID-19 pandemic in outpatient mental health clinics within an academic health system. Methods: A retrospective cohort study was conducted in patients who received outpatient psychiatric services at two clinics (A and B). The investigators compared care delivery with patients with mental health conditions prepandemic (January 1-December 31, 2019) and midpandemic (January 1-December 31, 2020) periods. Care delivery was defined as the number and type of new and return visits (telehealth and face-to-face visits), patients with recorded measurement-based care (MBC) outcomes, and communication capability between patients and providers. Results: During the prepandemic period, 6,984 patients were seen in Clinics A and B, resulting in 57,629 visits. In the midpandemic period, 7,110 patients were served, resulting in 61,766 total visits. Medication management visits increased from 2019 to 2020; number of visits with documented outcome measures increased by 90% in Clinic A and 15% in Clinic B. The number of MyChart messages per patient increased more than twofold during the midpandemic period. The number of new visits with primary diagnosis of anxiety disorders increased in CY2020 and the number of visits with primary diagnosis of major depressive/mood disorders decreased in CY2020. Payor mix did not vary between the two periods although there was variability between payor mix at the two primary clinic locations. Discussion: The study suggests that there was no detrimental impact on access to care between the prepandemic and midpandemic periods within the health system. Mental health visits while pivoting to telehealth increased during the midpandemic period. Transition to telepsychiatry improved the ability to administer and document MBC.

An Unexpected Finding on Chest Radiograph: Cavitating Pneumonia.

A pulmonary cavity is defined as a gas-filled space within a zone of pulmonary consolidation or within a mass or nodule. These cavities can be identified through imaging such as plain chest radiography and computed tomography. Pulmonary cavities arise from a variety of conditions that are infectious or noninfectious, leading to a broad range of differential diagnoses. One of the differential diagnoses is cavitary pneumonia, also referred to as necrotizing pneumonia; a rare complication related to community-acquired pneumonia. Infrequency of this complication can make this disease difficult to manage, leading to higher morbidity and mortality rates. This article provides an overview of a case of cavitary pneumonia that presented to an emergency department. This article discusses the history and physical, differential diagnoses/medical decision-making, management, and implications for the nurse practitioner for this patient.

Clinician assessment of blood alcohol levels among emergency department patients.

INTRODUCTION: Alcohol intoxication is a significant public health concern and is commonly seen among emergency department (ED) patients. This study was undertaken to identify the accuracy of clinician assessment of blood alcohol levels among emergency department patients. METHODS: This prospective survey study was conducted at a Level 1 Trauma Center. Eligible study participants included physicians, nurses, and medical students involved in the care of patients who had BAC. Clinicians estimated the BAC prior to results availability. RESULTS: Among 243 clinicians, the mean difference between the estimated BAC and actual BAC was 17.4 (95% CI: 4.7 to 30.1). Providers tended to overestimate the actual BAC level. The accuracy between roles (attendings, residents, RNs, students) was not significant (ANOVA p-value 0.90). Accuracy was not correlated with age of the patient (Pearson correlation 0.04, p-value 0.54). Accuracy was not associated with the patient's gender (Student's t-test two-tailed p-value 0.90), ethnicity (White versus all others, t-test p-value 0.31), nor insurance (government versus not government, t-test p-value 0.81). The average accuracy value was associated with mode of arrival (t-test p-value 0.003). The average accuracy for walk-in subjects was -14.9 (CI: -32.8 to 3.1) compared to ambulance arrivals 28.3 (CI: 12.7 to 44.0). Providers underestimated BAC for walk-ins and overestimated BAC for ambulance arrivals. Among 107 patients with a BAC of 0, clinician estimates ranged from 0 to 350. Clinicians estimated non-zero BAC levels in 17% of patients with BAC of 0 (N = 18). CONCLUSIONS: Clinicians' estimates of BAC were often inaccurate, and often overestimated the BAC.

Eye drift during fixation predicts visual acuity.

Visual acuity is commonly assumed to be determined by the eye optics and spatial sampling in the retina. Unlike a camera, however, the eyes are never stationary during the acquisition of visual information; a jittery motion known as ocular drift incessantly displaces stimuli over many photoreceptors. Previous studies have shown that acuity is impaired in the absence of retinal image motion caused by eye drift. However, the relation between individual drift characteristics and acuity remains unknown. Here, we show that a) healthy emmetropes exhibit a large variability in their amount of drift and that b) these differences profoundly affect the structure of spatiotemporal signals to the retina. We further show that c) the spectral distribution of the resulting luminance modulations strongly correlates with individual visual acuity and that d) natural intertrial fluctuations in the amount of drift modulate acuity. As a consequence, in healthy emmetropes, acuity can be predicted from the motor behavior elicited by a simple fixation task, without directly measuring it. These results shed new light on how oculomotor behavior contributes to fine spatial vision.

Penetrating trauma: Relationships to recreational drug and alcohol use.

INTRODUCTION: The incidence of alcohol and recreational drug use is increasing. The impact on penetrating trauma is unknown. This study was undertaken to identify the incidence of alcohol and recreational drug use prior to penetrating trauma, and to identify ISS and outcomes among patients with penetrating trauma. METHODS: In this retrospective study, eligible subjects included trauma patients age 18 and older, with major trauma (admitted or evaluated by the Trauma Team) from 2017 to 2021. A chart review was conducted to identify data including mechanism of injury, ISS, alcohol level, toxicologic testing, length of stay, and final disposition. RESULTS: Among 1270 adult subjects with penetrating trauma during 2017 through 2020, the majority were male (N = 1071; 84%), and African American (N = 679; 54.3%) or White (N = 537; 42.9%). Mechanisms of injury included gunshot wound (GSW) (N = 973; 76.6%) or stab wound (N = 297; 23.4%). Injury severity score (ISS) ranged from 1 to 75. Among 426 subjects (33.5%) tested for recreational drugs, 395 (93%) were positive for at least one substance. The most common recreational drugs identified included marijuana (N = 280; 65.7%), benzodiazepine ((N = 131;30.8%), alcohol ((N = 248; 25.3%), opiate ((N = 116; 27.2%), cocaine (N = 87; 20.4%), and amphetamine ((N = 84; 19.7%). Subjects with an ISS of 9 to 15 had higher odds of testing positive for opiates compared to subjects with an ISS of 1 to 3 (OR 2.3). Most patients were ultimately discharged home ((N = 912;71.8%) and a minority expired (N = 142; 11.2%). CONCLUSIONS: Positive screens for alcohol and recreational drugs were common among penetrating trauma patients in this setting. The most common identified recreational drugs included marijuana, benzodiazepine, opiates, alcohol, cocaine, and amphetamine.

A case of disseminated Lyme disease in a child with skin of color.

Disseminated Lyme disease requires treatment to prevent severe sequelae, particularly neurologic. We report here a case of disseminated Lyme disease in a patient with skin of color. Pediatric dermatologists must maintain a high clinical suspicion for Lyme disease and be aware of how typical cutaneous findings may appear differently in skin of color.

Pityriasis rosea after administration of Pfizer-BioNTech COVID-19 vaccine.

Pityriasis rosea (PR) is an acute papulosquamous cutaneous disorder that classically presents with a herald patch rapidly followed by a widespread rash along skin cleavage lines. Although the exact pathogenesis of PR is unknown, current evidence suggests that an inflammatory reaction due to a viral trigger may lead to the cutaneous manifestations. COVID-19 has been reported as one such viral trigger for PR. Previously, PR has been reported in temporal association with various viral inoculations. This article presents a case of PR in a 66-year-old black male 1 week after administration of the Pfizer-BioNTech COVID-19 vaccine.