Barriers to Women Entering Surgical Careers: A Global Study into Medical Student Perceptions.

BACKGROUND: Barriers to female surgeons entering the field are well documented in Australia, the USA and the UK, but how generalizable these problems are to other regions remains unknown. METHODS: A cross-sectional survey was developed by the International Federation of Medical Students' Associations (IFMSA)'s Global Surgery Working Group assessing medical students' desire to pursue a surgical career at different stages of their medical degree. The questionnaire also included questions on students' perceptions of their education, resources and professional life. The survey was distributed via IFMSA mailing lists, conferences and social media. Univariate analysis was performed, and statistically significant exposures were added to a multivariate model. This model was then tested in male and female medical students, before a further subset analysis by country World Bank income strata. RESULTS: 639 medical students from 75 countries completed the survey. Mentorship [OR 3.42 (CI 2.29-5.12) p = 0.00], the acute element of the surgical specialties [OR 2.22 (CI 1.49-3.29) p = 0.00], academic competitiveness [OR 1.61 (CI 1.07-2.42) p = 0.02] and being from a high or upper-middle-income country (HIC and UMIC) [OR 1.56 (CI 1.021-2.369) p = 0.04] all increased likelihood to be considering a surgical career, whereas perceived access to postgraduate training [OR 0.63 (CI 0.417-0.943) p = 0.03], increased year of study [OR 0.68 (CI 0.57-0.81) p = 0.00] and perceived heavy workload [OR 0.47 (CI 0.31-0.73) p = 0.00] all decreased likelihood to consider a surgical career. Perceived quality of surgical teaching and quality of surgical services in country overall did not affect students' decision to pursue surgery. On subset analysis, perceived poor access to postgraduate training made women 60% less likely to consider a surgical career [OR 0.381 (CI 0.217-0.671) p = 0.00], whilst not showing an effect in the men [OR 1.13 (CI 0.61-2.12) p = 0.70. Concerns about high cost of training halve the likelihood of students from low and low-middle-income countries (LICs and LMICs) considering a surgical career [OR 0.45 (CI 0.25-0.82) p = 0.00] whilst not demonstrating a significant relationship in HIC or UMIC countries. Women from LICs and LMICs were 40% less likely to consider surgical careers than men, when controlling for other factors [OR 0.59 CI (0.342-1.01 p = 0.053]. CONCLUSION: Perceived poor access to postgraduate training and heavy workload dissuade students worldwide from considering surgical careers. Postgraduate training in particular appears to be most significant for women and cost of training an additional factor in both women and men from LMICs and LICs. Mentorship remains an important and modifiable factor in influencing student's decision to pursue surgery. Quality of surgical education showed no effect on student decision-making.

Evaluating the collection, comparability and findings of six global surgery indicators.

BACKGROUND: In 2015, six indicators were proposed to evaluate global progress towards access to safe, affordable and timely surgical and anaesthesia care. Although some have been adopted as core global health indicators, none has been evaluated systematically. The aims of this study were to assess the availability, comparability and utility of the indicators, and to present available data and updated estimates. METHODS: Nationally representative data were compiled for all World Health Organization (WHO) member states from 2010 to 2016 through contacts with official bodies and review of the published and grey literature, and available databases. Availability, comparability and utility were assessed for each indicator: access to timely essential surgery, specialist surgical workforce density, surgical volume, perioperative mortality, and protection against impoverishing and catastrophic expenditure. Where feasible, imputation models were developed to generate global estimates. RESULTS: Of all WHO member states, 19 had data on the proportion of the population within 2h of a surgical facility, 154 had data on workforce density, 72 reported number of procedures, and nine had perioperative mortality data, but none could report data on catastrophic or impoverishing expenditure. Comparability and utility were variable, and largely dependent on different definitions used. There were sufficient data to estimate that worldwide, in 2015, there were 2 038 947 (i.q.r. 1 884 916-2 281 776) surgeons, obstetricians and anaesthetists, and 266·1 (95 per cent c.i. 220·1 to 344·4) million operations performed. CONCLUSION: Surgical and anaesthesia indicators are increasingly being adopted by the global health community, but data availability remains low. Comparability and utility for all indicators require further resolution.

The amino-terminal transforming region of simian virus 40 large T and small t antigens functions as a J domain.

Simian virus 40 (SV40) encodes two proteins, large T antigen and small t antigen that contribute to virus-induced tumorigenesis. Both proteins act by targeting key cellular regulatory proteins and altering their function. Known targets of the 708-amino-acid large T antigen include the three members of the retinoblastoma protein family (pRb, p107, and p130), members of the CBP family of transcriptional adapter proteins (cap-binding protein [CBP], p300, and p400), and the tumor suppressor p53. Small t antigen alters the activity of phosphatase pp2A and transactivates the cyclin A promoter. The first 82 amino acids of large T antigen and small t antigen are identical, and genetic experiments suggest that an additional target(s) important for transformation interacts with these sequences. This region contains a motif similar to the J domain, a conserved sequence found in the DnaJ family of molecular chaperones. We show here that mutations within the J domain abrogate the ability of large T antigen to transform mammalian cells. To examine whether a purified 136-amino-acid fragment from the T antigen amino terminus acts as a DnaJ-like chaperone, we investigated whether this fragment stimulates the ATPase activity of two hsc70s and discovered that ATP hydrolysis is stimulated four- to ninefold. In addition, ATPase-defective mutants of full-length T antigen, as well as wild-type small t antigen, stimulated the ATPase activity of hsc70. T antigen derivatives were also able to release an unfolded polypeptide substrate from an hsc70, an activity common to DnaJ chaperones. Because the J domain of T antigen plays essential roles in viral DNA replication, transcriptional control, virion assembly, and tumorigenesis, we conclude that this region may chaperone the rearrangement of multiprotein complexes.

Computer-aided vs. tutor-delivered teaching of exposure therapy for phobia/panic: randomized controlled trial with pre-registration nursing students.

BACKGROUND: Exposure therapy is effective for phobic anxiety disorders (specific phobias, agoraphobia, social phobia) and panic disorder. Despite their high prevalence in the community, sufferers often get no treatment or if they do, it is usually after a long delay. This is largely due to the scarcity of healthcare professionals trained in exposure therapy, which is due, in part, to the high cost of training. Traditional teaching methods employed are labour intensive, being based mainly on role-play in small groups with feedback and coaching from experienced trainers. In an attempt to increase knowledge and skills in exposure therapy, there is now some interest in providing relevant teaching as part of pre-registration nurse education. Computers have been developed to teach terminology and simulate clinical scenarios for health professionals, and offer a potentially cost effective alternative to traditional teaching methods. OBJECTIVE: To test whether student nurses would learn about exposure therapy for phobia/panic as well by computer-aided self-instruction as by face-to-face teaching, and to compare the individual and combined effects of two educational methods, traditional face-to-face teaching comprising a presentation with discussion and questions/answers by a specialist cognitive behaviour nurse therapist, and a computer-aided self-instructional programme based on a self-help programme for patients with phobia/panic called FearFighter, on students' knowledge, skills and satisfaction. DESIGN: Randomised controlled trial, with a crossover, completed in 2 consecutive days over a period of 4h per day. PARTICIPANTS: Ninety-two mental health pre-registration nursing students, of mixed gender, age and ethnic origin, with no previous training in cognitive behaviour therapy studying at one UK university. RESULTS: The two teaching methods led to similar improvements in knowledge and skills, and to similar satisfaction, when used alone. Using them in tandem conferred no added benefit. Computer-aided self-instruction was more efficient as it saved teacher preparation and delivery time, and needed no specialist tutor. CONCLUSION: Computer-aided self-instruction saved almost all preparation time and delivery effort for the expert teacher. When added to past results in medical students, the present results in nurses justify the use of computer-aided self-instruction for learning about exposure therapy and phobia/panic and of research into its value for other areas of health education.

Relevant and Irrelevant Fear in Flooding - A Crossover Study of Phobic Patients - Republished Article.

This study investigated the role of relevant vs irrelevant fear cues in the flooding of phobic patients. Six specific phobics and 10 agoraphobics were treated in a balanced crossover design. Eight patients had eight sessions of imaginal flooding concerned with their phobias followed by eight imaginal sessions concerned with situations which are normally frightening to anybody. Another eight patients had the same two treatments in the reverse order. The combined effects of both treatments after 16 sessions resulted in significant improvement on clinical, attitudinal, and heart-rate measures. Improvement was maintained at six months follow-up. Eight sessions by each treatment alone also produced significant improvement on clinical and attitudinal measures. Irrelevant fear also produced significant improvement in heart-rate and skin-conductance measures. The two treatments did not differ significantly from each other in their effects, except that irrelevant fear produced significantly more improvement than did relevant flooding in subjective anxiety during phobic imagery. The two treatments had significantly different prognostic correlates. Heightened physiological activity at the start of treatment predicted a good outcome to relevant flooding but not to irrelevant fear. High subjective anxiety during imagery before treatment predicted poor outcome to irrelevant fear. High anxiety during treatment sessions predicted good outcome to irrelevant fear, but did not correlate with outcome to relevant flooding. The experience of relevant and irrelevant fear in fantasy reduced phobic anxiety and avoidance to a similar extent, but appeared to do so through different mechanisms. These mechanisms need not be mutually exclusive and might be additive.

Ligandin heterogeneity : evidence that the two non-identical subunits are the monomers of two distinct proteins.

Purified ligandin (Y-protein) a 46000-dalton protein, has been shown to consist of two subunit species (mol. wts. 22 000 and 24 000) on discontinuous polyacrylamide gel electrophoresis in sodium dodecyl sulphate. This technique was used to define further the nature of these subunits. The Y sulphobromophthalein-binding fraction of rat hepatic cytosol was shown to contain three major subunit bands designated subunit Ya, subunit Yb and subunit Yc in ascending order of size. Purified ligandin was found to comprise Ya and Yc subunit species, and also gave two bands on isoelectric focusing. The two subunit species in purified ligandin were partially separated by an additional purification step. Antiserum to ligandin reacted mono-specifically with the purified protein, as well as hepatic, renal and small intestinal mucosa cytosol, but gave lines of identity and partial identity with cytosol from testis, ovary and adrenal gland. The Y fraction of testis was found to contain only Yb and Yc species, while all three major bands were found in liver, kidney and small intestinal mucosa. Phenobarbital treatment increased the concentration of Ya and Yb in the liver, but had little effect on Yc. These findings suggest that the Ya and Yc ligandin subunits are the monomers of two proteins: YaYa and YcYc.

Feedback of true heart rate during exposure in vivo. Partial replication with methodological improvement.

Ten specific phobics improved during a mean of two sessions of experimental treatment by exposure in vivo in a balanced design. Short-term results replicated those of a previous study that self-control of heart rate with the aid of biofeedback significantly reduced heart rate during treatment, but this did not hasten reduction of subjective anxiety, nor of respiratory rate or skin conductance responses. An hour's pretreatment training in self-control of heart rate with the aid of feedback did not enhance the effect. Mere instructions to lower heart rate without feedback had a significant effect during treatment, but the addition of heart rate feedback to instructions significantly augmented the decline in heart rate.

Feedback of true heart rate during exposure in vivo.

Ten women with specific chronic animal phobias were treated by graded exposure in vivo in two to four two-hour treatment sessions. Sessions were divided into four balanced half-hour epochs, half with visual feedback of true heart rate plus instructions to lower heart rate during approach to phobic stimulus. All patients improved significantly from the start to end of sessions on heart rate and on subjective anxiety. Feedback of heart rate plus instructions to lower it substantially reduced heart rate during epochs of feedback, compared to non-feedback epochs without instructions, but this effect did not generalize to skin conductance or to subjective anxiety in our short-term experiment.

Social skills problems in neurotic outpatients. Social skills training with and without cognitive modification.

Twenty-two "socially dysfunctional" outpatients had 12 1 1/2-hour sessions of social skills training either alone or combined with cognitive modification (each, n = 11). Two raters who were blind to the treatment regimen significantly differentiated the two treatments, as judged from audiotapes of treatment sessions. Measurement was by an independent assessor in a structured interview, by self-monitoring of several activities and of anxiety felt during them, and by self-rated questionnaires. In each treatment regimen, patients' conditions improved significantly and equally on reported behavioral and cognitive measures both during and after treatment, and at six-month follow-up. Outcome did not differ significantly between the two treatment conditions at any time on any measure. Patients reported increased levels of social activities and less anxiety during these, less isolation, better relations with their colleagues at work, less depression, and loss of many irrational social beliefs. During multiple baseline monitoring for up to nine weeks, no improvement occurred. Performance of each social task or "target" increased significantly after training was begun for it, and subjective anxiety decreased similarly during social performance. Untreated targets improved much less, and more slowly. Social skills training was followed by lasting and worthwhile improvement that was not enhanced by the addition of cognitive modification.

Onset of panic disorder with agoraphobia. Toward an integrated model.

Of 57 patients with panic disorder with agoraphobia, more had their first panic in late spring and summer than in fall and winter, and in warm weather than in cold weather. In the month before the first panic 52% of the patients had prodromal depression or anxiety. Agoraphobic avoidance preceded the first panic in 23%, began within days after the first panic in 32% (without prodromal anxiety or depression in only 20%), and after more than one panic (1 week to 11 years later) in 41%. The site of the first panic was from the agoraphobic cluster (public places) in 81%, at work or school in 11%, and inside the home in 8%. Thirty-eight percent of patients were with a familiar adult at the time. Many features of the syndrome can be explained by an integrated model with several interacting factors contributing in varying degrees to the different routes by which it develops. To the learning and biological factors already suggested we add an evolutionary factor to explain why most first panics occur outside the home and mainly in public places. Certain extraterritorial cues constituting an agoraphobic cluster seem to be prepotent and prepared triggers or modifiers of fear during stress.

Double-blindness procedures, rater blindness, and ratings of outcome. Observations from a controlled trial.

BACKGROUND: We determined whether blindness in a double-blind randomized controlled trial of alprazolam and exposure therapies in patients with panic disorder and agoraphobia was maintained in assessors and patients, what were the factors related to "unblinding," and whether unblinding was associated with clinical outcome. METHOD: In 129 patients with panic disorder and agoraphobia who were randomized to alprazolam-exposure, placebo-exposure, alprazolam-relaxation, or placebo-relaxation conditions, blindness was tested at the end of treatment by the independent assessors' and patients' classification of the treatment condition. RESULTS: Assessors' classifications were correct in 82% of the alprazolam group and 78% of the placebo group; corresponding figures for patients' classifications were 73% and 70%, respectively. Factors associated with unblinding included drug side effects but not assessors' ratings of treatment outcome. CONCLUSION: Judgment of the validity of the outcome of a randomized controlled trial is easier if the report notes not only the use of a double-blindness procedure but also details how blind the raters remained and how any unblinding affected their ratings of clinical outcome.

Treatment of posttraumatic stress disorder by exposure and/or cognitive restructuring: a controlled study.

BACKGROUND: Unanswered questions from controlled studies of posttraumatic stress disorder concern the value of cognitive restructuring alone without prolonged exposure therapy and whether its combination with prolonged exposure is enhancing. METHODS: In a controlled study, 87 patients with posttraumatic stress disorder of at least 6 months' duration were randomly assigned to have 10 sessions of 1 of 4 treatments: prolonged exposure (imaginal and live) alone; cognitive restructuring alone; combined prolonged exposure and cognitive restructuring; or relaxation without prolonged exposure or cognitive restructuring. RESULTS: Integrity of audiotaped treatment sessions was satisfactory when rated by an assessor unaware of the treatment assignment. Seventy-seven patients completed treatment. The pattern of results was similar regardless of rater, statistical method, measure, occasion, and therapist. Exposure and cognitive restructuring, singly or combined, improved posttraumatic stress disorder markedly on a broad front. Gains continued to 6-month follow-up and were significantly greater than the moderate improvement from relaxation. CONCLUSION: Both prolonged exposure and cognitive restructuring were each therapeutic on their own, were not mutually enhancing when combined, and were each superior to relaxation.

Imipramine and brief therapists-aided exposure in agoraphobics having self-exposure homework.

Forty-five chronic agoraphobics were randomly assigned to treatment by placebo or imipramine in doses up to 200 mg/day for 28 weeks. All patients also had systematic self-exposure homework with an instruction manual. In addition, half of each drug group had therapist-aided exposure and half had therapist-aided relaxation, each totalling three hours. Patients in both drug groups improved substantially and maintained their gains for one year of follow-up. Imipramine had no significant therapeutic effect despite satisfactory plasma levels and significant drug side effects. Patients' low initial Hamilton depression scores might explain the absence of any drug effect. Antidepressants may be ineffective for agoraphobics who have normal mood. Brief therapist-aided exposure improved phobias and panics to a significant but limited extent, and is a useful adjuvant to self-exposure homework, which can be a powerful therapeutic agency by itself.

The prevalence and severity of microvascular complications in pancreatic diabetes and IDDM.

OBJECTIVE: To investigate and compare the prevalence, associations, and severity of retinopathy and nephropathy in patients with pancreatic diabetes (PD) and insulin-dependent diabetes mellitus (IDDM). RESEARCH DESIGN AND METHODS: Thirty patients with PD due to alcohol-induced chronic pancreatitis were matched for age, sex, and duration of diabetes with 30 patients with IDDM. Retinopathy was assessed by fluorescein angiography using the Wisconsin classification. Renal function was assessed by albumin excretion rates (AERs) in at least two timed overnight urine collections and glomerular filtration rates (GFRs) by single injection of 51Cr-EDTA. Microalbuminuria was defined as AER 20-200 micrograms/min and nephropathy as AER > 200 micrograms/min. RESULTS: Retinopathy was found in 33% of patients with PD and in 40% with IDDM. The spectrum of disease was similar in the two groups. The geometric mean of AER was 15 micrograms/min (range 1-1,541) in the PD group and 24 micrograms/min (2-2,288) in the IDDM group. Nephropathy was found in 7 PD and in 5 IDDM patients, and a reduced GFR was present in 8 (26%) and 4 (13%) of the two groups, respectively. Microalbuminuria occurred in 9 (33%) and hyperfiltration in 3 (10%) in each group. These differences were insignificant. Retinopathy correlated with AER in both groups. Retinopathy and AER correlated with duration of diabetes in the IDDM but not in the PD group. CONCLUSIONS: Microvascular complications are equally common and severe in PD and IDDM, and improved glycemic control should be the goal in both.

Learning and unlearning fear: a clinical and evolutionary perspective.

Many fears, phobias and rituals seem to arise from prepared phylogenetic mechanisms which favor old over new evolutionary dangers and affect the rules of aversive learning which govern the acquisition of fear. Recent developments in several forms of aversive learning (sensitization, conditioning, extinction, observational learning) can improve them as paradigms of the acquisition, spread and maintenance of normal and clinical fears. The most reliable treatment for phobias and rituals is exposure, whose effects closely parallel the habituation of normal defensive responses and the extinction of conditioned fear and avoidance in animals. Habituation during exposure is usually slow and step by step, and generalizes little, but once attained tends to endure. Conditioned fear extinction and fear habituation have similar courses and may depend on similar neural processes. To be reduced, avoidance has to be prevented or the safety intervals that it heralds must be given up. Some phobias may result less from enhanced acquisition than from insufficient exposure to attain habituation. Finally, the review discusses the limits of habituation and the instability of fear extinction in relation to the long-term efficacy of exposure therapy.

Advantages of bias and prejudice: an exploration of their neurocognitive templates.

Bias is common in mental-processing tasks as diverse as target recognition, heuristic estimation and social judgment. This paper holds that cognitive biases stem from the covert operation of neural modules, which evolved to subserve adaptive behavior. Such modules can be innate or forged early in development. Research shows links between (i) biases in cognitive tasks and (ii) neural devices, which may mediate them. Evidence is included from biases that arise spontaneously in artificial neural networks during recognition/decision tasks. Two linked propositions follow. First, there are continuities in biasing strategies across different levels of cognitive processing. Second, a proclivity for stereotyping and prejudice depends on the biased functions of lower-level neural modules that promote adaptations to social environments. The propositions rest on evidence of biological preparedness for stereotyping and of deficits in social judgment in patients with neurological lesions. To test such claims, research studies are suggested at the boundary of cognitive neuroscience and social psychology. Advantages of bias and prejudice as evolved tools may include their: (1) speeding of scrutiny and improving of target detection in changing or uncertain situations; (2) aiding of a rapid choice of practical short-term rather than optimal longer term plans; (3) allowing appraisal of a workable world by creating fairly stable categories; (4) motivating of exploration and completion of problem-solving which might otherwise be abandoned too early. The biological priming of social biases need not mean that they are immutable; understanding them could lead to better ways of controlling them.

Blood-injury phobia: a review.

Natural human uneasiness about blood, injury, or deformity sometimes becomes a specific phobia, which can lead to serious disability if vital medical procedures are refused. Blood-injury phobia usually starts in childhood and is often familial. Unlike other phobic cues, which cause persistent tachycardia, blood-injury phobic cues evoke an initial rise in heart rate followed by vasovagal bradycardia and, frequently, syncope. Although blood-injury phobia may have an evolutionary, genetic, and physiological basis, it can be treated effectively by exposure. The tendency to faint early in exposure therapy can be reduced by lying down, tensing the muscles, or inducing anger.

Behavioral aspects of panic disorder.

The behavioral approach to panic disorder distinguishes between agoraphobia and nonsituational panic and emphasizes the handicap to the patient caused by avoidance of agoraphobic situations. Agoraphobia is a more viable label than panic disorder. Behavioral treatment consists of delineating the patient's agoraphobic avoidance and panic profile and developing a self-exposure program to produce habituation. Systematic exposure to agoraphobic situations is usually of durable efficacy, and the treatment requires little time from clinicians. Antidepressant drugs, which do not interfere with exposure, are a useful addition when dysphoria is present, but they can have troublesome side effects.

The current status of behavioral psychotherapy: theory and practice.

Behavioral psychotherapy has become one of the definitive treatments available for the relief of psychiatric suffering. Although hardly a panacea for all ills, the behavioral approach is the treatment of choice for certain selected problems. Behavioral methods make their contribution in the context of general psychiatric management and often must be used in conjunction with other treatment. The theoretical and practical aspects of behavioral psychotherapy have changed a great deal over the past few years and continue to evolve rapidly. Although useful molecular theories are emerging to guide the discipline, no global theory is likely to be satisfactory in the foreseeable future.

Review of behavioral psychotherapy, I: Obsessive-compulsive disorders.

Obsessive-compulsive ritualizers have maintained their improvement after exposure in vivo for up to 3 years' follow-up in the United States, Britain, Greece, and Australia. Unlike exposure in vivo, relaxation is of little value. Early gains in treatment predict long-term outcome. Exposure therapy is usually on an outpatient basis and takes 1-30 sessions. Self-exposure homework is critical. Sessions at home are also required, together with relatives cooperating as exposure cotherapists. Some patients can treat themselves almost unaided, while others need extensive assistance. Clomipramine is helpful for ritualizers with coexisting depression, but depression tends to recur when clomipramine therapy is stopped.