Moral injury and the hidden curriculum in medical school: comparing the experiences of students underrepresented in medicine (URMs) and non-URMs.

Underrepresented students in medicine (URM) have more negative perceptions of the medical school learning environment (LE), a phenomenon that can contribute to higher rates of burnout and attrition in these populations. The hidden curriculum (HC)-defined as a set of values informally conveyed to learners through clinical role-modeling-is a LE socialization construct that has been critically examined for its role in shaping students' professional identities. Yet differences in how URMs and non-URMs experience the HC remain underexplored. The study used a pragmatic approach that drew on elements of grounded theory and employed both deductive and inductive reasoning. Investigators conducted qualitative, semi-structured interviews with a purposive sample of 13 URM and 21 non-URM participants at a Bronx, NY medical school. Interviews examined student experiences and reactions to the HC. Both cohorts witnessed patient disparagement and mistreatment. However, from these encounters, URM participants expressed more moral injury-the adverse emotional consequence of feeling pressured to accept ideologically incongruent values. URMs were also more likely to describe resisting the HC. Differences in group reactions appeared to arise from URMs' identity resonance with patients' lived experiences. Participants across cohorts emphasized increasing URM recruitment as one step toward mitigating these circumstances. URM participants experienced more distress and offered more resistance to the HC relative to non-URMs. The etiology of these differential reactions may stem from relative barriers in negotiating personal and professional identities. As such, URMs' perceptions of the LE may be adversely impacted given their more negative interactions with the HC.

A Sense of Belonging: Perceptions of the Medical School Learning Environment among URM and Non-URM Students.

Phenomenon: Improving the learning environment (LE), particularly for students underrepresented in medicine (URM), has become an important goal for institutions that provide undergraduate and graduate medical education. Until recently, research and intervention development have been limited by the lack of comprehensive theoretical frameworks. A multi-dimensional conceptual model of the medical school environment, developed by Gruppen and colleagues in 2019, provides a useful framework for guiding research and interventions in this area.Approach: Using Gruppen et al's model, this study investigated experiences of the LE from the perspectives of both URM and non-URM students at a medical school in New York City. In examining experiences of the organizational, social, and physical domains of the LE, we sought to explore the symbolic and experiential links across domains and identify concrete needs for improvement.Findings: Institutional structures and policies, features of the built environment, and social relationships that put learning first and generated a sense of community were highly valued. Although both URM and non-URM students shared many perceptions and experiences, URM students expressed heightened vulnerability to the experiences of devaluation and exclusion.Insights: All participants in the study greatly appreciated aspects of the LE that made them feel like valued members of the community. Medical schools should approach the task of improving the LE for URM students using a comprehensive, multi-dimensional approach.

Upregulation of Proinflammatory Bradykinin Peptides in Systemic Lupus Erythematosus and Rheumatoid Arthritis.

Our recent study has implicated bradykinin (BK) signaling as being of pathogenic importance in lupus. This study aims to investigate the biomarker potential of BK peptides, BK and BK-des-arg-9, in lupus and other rheumatic autoimmune diseases. Sera from systemic lupus erythematosus (SLE) patients and healthy subjects were screened for BK and BK-des-arg-9 by liquid chromatography-mass spectrometry metabolomics. Serum from 6-mo-old C57BL/6 mice and three murine lupus strains were also screened for the two peptides by metabolomics. Given the promising initial screening results, validation of these two peptides was next conducted using multiple reaction monitoring in larger patient cohorts. In initial metabolomics screening, BK-des-arg-9 was 22-fold higher in SLE serum and 106-fold higher in mouse lupus serum compared with healthy controls. In validation assays using multiple reaction monitoring and quadrupole time-of-flight mass spectrometry, BK and BK-des-arg-9 showed significant elevations in SLE serum compared with controls (p < 0.0001; area under the curve = 0.79-0.88), with a similar but less pronounced increase being noted in rheumatoid arthritis serum. Interestingly, increased renal SLE disease activity index in lupus patients was associated with reduced circulating BK-des-arg-9, and the reasons for this remain to be explored. To sum, increased conversion of BK to the proinflammatory metabolite BK-des-arg-9 appears to be a common theme in systemic rheumatic diseases. Besides serving as an early marker for systemic autoimmunity, independent studies also show that this metabolic axis may also be a pathogenic driver and therapeutic target in lupus.

Collaborative Robotic Assistant Platform for Endonasal Surgery: Preliminary In-Vitro Trials.

Endonasal surgery is a minimally invasive approach for the removal of pituitary tumors (sarcomas). In this type of procedure, the surgeon has to complete the surgical maneuvers for sarcoma resection with extreme precision, as there are many vital structures in this area. Therefore, the use of robots for this type of intervention could increase the success of the intervention by providing accurate movements. Research has focused on the development of teleoperated robots to handle a surgical instrument, including the use of virtual fixtures to delimit the working area. This paper aims to go a step further with a platform that includes a teleoperated robot and an autonomous robot dedicated to secondary tasks. In this way, the aim is to reduce the surgeon's workload so that he can concentrate on his main task. Thus, the article focuses on the description and implementation of a navigator that coordinates both robots via a force/position control. Finally, both the navigation and control scheme were validated by in-vitro tests.

Effect of vitrification of in vitro matured prepubertal goat oocytes on embryo development after parthenogenic activation and intracytoplasmic sperm injection.

This work studies the effect of vitrification of in vitro matured (IVM) prepubertal goat oocytes on: 1) oocyte damage assessed by reactive oxygen species (ROS) level and apoptosis and 2) embryo development after Intracytoplasmic sperm injection (ICSI) and Parthenogenic Activation (PA). Oocytes were IVM in supplemented TCM-199 for 22-24 h. Control group oocytes matured during 24 h were directly used for the analysis after IVM. Vitrified/warmed IVM-oocytes were vitrified after 22 h of IVM in 15% ethylene glycol (EG), 15% dimethyl sulfoxide (Me2SO) and 0.5 M sucrose and after subjected to warming procedure. Oocyte ROS level was measured by staining denuded IVM-oocytes with 10 µM 2'7' dichlorodihydrofluorescein diacetate. Apoptosis was analyzed by Annexin V (AV) Apoptosis Detection kit and Propidium iodide (PI) signal and oocytes were classified as: Live (AV- PI-), early apoptotic (AV+ PI-), dead non-apoptotic (AV- PI+) and necrotic (AV+ PI+). Developmental competence of vitrified/warmed oocytes was assessed by PA (5 min in 5 µM Ionomycin plus 4 h in 2 mM 6-Dimethylaminopurine), and by ICSI fertilization. Presumptive zygotes were in vitro cultured for 8 days in commercial media BO-IVC. Vitrified/warmed oocytes showed higher ROS levels (P < 0.0001), lower live oocytes (44 vs. 66%; P: 0.0025) and higher dead non-apoptotic oocytes (33 vs. 13% P: 0.023) compared to control. No differences were found on normal zygote formation (2 PN) (32 vs. 25%) or blastocyst development (0 vs. 4%) after ICSI fertilization. However, after PA, significant differences were found in cleavage rate (59 vs.78%; P < 0.0343) and blastocyst formation (1 vs. 25%; P < 0.0001). In conclusion, vitrification reduced oocyte competence by increasing dead oocytes and ROS levels.

Resveratrol supplementation during in vitro maturation improves embryo development of prepubertal goat oocytes selected by brilliant cresyl blue staining.

This study aimed to investigate the effect of resveratrol supplementation in maturation medium on the developmental ability and bioenergetic\oxidative status of prepubertal goat oocytes selected by brilliant cresyl blue (BCB). Oocytes collected from slaughterhouse-derived ovaries were selected by 13 µM BCB staining and classified as grown BCB+ and growing BCB- oocytes. All oocytes were matured in vitro in our conventional maturation medium and supplemented with 1 µM (BCB+R and BCB-R) and without (Control groups: BCB+C and BCB-C) resveratrol. After 24 h, IVM-oocytes were fertilized with fresh semen and presumptive zygotes were in vitro cultured for 8 days. Oocytes were assessed for blastocyst development and quality, mitochondrial activity and distribution, and levels of GSH, ROS, and ATP. BCB+R (28.3%) oocytes matured with resveratrol presented significantly higher blastocyst development than BCB+C (13.0%) and BCB- groups (BCB-R: 8.3% and BCB-C: 4.7%). Resveratrol improved blastocyst development of BCB-R oocytes at the same rate as BCB+C oocytes. No differences were observed in blastocyst quality among groups. GSH levels were significantly higher in resveratrol groups (BCB+R: 36554.6; BCB-R: 34946.7 pixels/oocyte) than in control groups (BCB+C: 27624.0; BCB-C: 27655.4 pixels/oocyte). No differences were found in mitochondrial activity, ROS level, and ATP content among the groups. Resveratrol-treated oocytes had a higher proportion of clustered active mitochondria in both BCB groups (BCB+R: 73.07%; BCB-R: 79.16%) than control groups (BCB+C: 19.35%; BCB-C: 40%). In conclusion, resveratrol increased blastocyst production from oocytes of prepubertal goats, particularly in better quality oocytes (BCB+).

Effects of melatonin on oocyte developmental competence and the role of melatonin receptor 1 in juvenile goats.

Melatonin enhances in vitro embryo development in several species by improving the oocyte developmental competence during in vitro maturation (IVM). Melatonin has a wide range of actions, from scavenging reactive oxygen species (ROS) to regulating gene expression, and it can also act by way of melatonin receptors. The aim of this study was to determine the mechanism of action of melatonin during the IVM of juvenile goat oocytes and the role of the membrane receptors. Melatonin receptor 1 was immunolocalized in cumulus cells and oocytes before and after 24 hr of IVM. The effect of melatonin on oocyte developmental competence was tested in three experimental IVM groups: (a) control, (b) 10-7  M melatonin, and (c) 10-7  M melatonin +10-7  M luzindole (an inhibitor of both melatonin receptors). After IVM oocytes were assessed for ROS levels, mitochondrial activity, adenosine 5'-triphosphate (ATP) concentration and relative gene expression (ACTB, SLC1A1, SOD1, GPx1, BAX, DNMT1, GCLC and GDF9). IVM-oocytes were in vitro fertilized and cultured under conventional conditions. Blastocyst rate and quality (differential cell count) were assessed at 8 days post-fertilization. Melatonin decreased ROS levels, increased mitochondrial activity and ATP content and increased blastocyst quality compared to control group (55.8 vs. 30.4 inner cell mass ICM, p < 0.05). There was no effect on the relative gene expression due to treatment with melatonin. In conclusion, we have showed that melatonin improves oocyte developmental competence in juvenile goats by reducing ROS levels and improving mitochondrial activity.

A Gesture Recognition Algorithm for Hand-Assisted Laparoscopic Surgery.

Minimally invasive surgery (MIS) techniques are growing in quantity and complexity to cover a wider range of interventions. More specifically, hand-assisted laparoscopic surgery (HALS) involves the use of one surgeon's hand inside the patient whereas the other one manages a single laparoscopic tool. In this scenario, those surgical procedures performed with an additional tool require the aid of an assistant. Furthermore, in the case of a human-robot assistant pairing a fluid communication is mandatory. This human-machine interaction must combine both explicit orders and implicit information from the surgical gestures. In this context, this paper focuses on the development of a hand gesture recognition system for HALS. The recognition is based on a hidden Markov model (HMM) algorithm with an improved automated training step, which can also learn during the online surgical procedure by means of a reinforcement learning process.

Beneficial effects of melatonin on in vitro embryo production from juvenile goat oocytes.

Melatonin is a universal antioxidant that improves in vitro embryo production in several species. The aims of this study were to determine the melatonin concentration in the ovarian follicular fluid (FF) of juvenile goats and the effect of melatonin during in vitro maturation (IVM) on embryo development. The FF melatonin concentration was 0.57--1.07×10-9 M, increasing with follicular diameter. Oocytes were matured, fertilised and cultured under conventional conditions. Blastocyst development, embryo quality and levels of reactive oxygen species (ROS) and reduced glutathione were assessed. In Experiment 1 different melatonin concentrations (10-3, 10-7, 10-9, 10-11 M) were added to the IVM medium, which contained cysteamine as antioxidant, and no differences were observed. In Experiment 2, melatonin (10-7 M) was tested in the presence or absence of cysteamine (experimental groups: melatonin, cysteamine, melatonin+cysteamine, non-antioxidant). The melatonin group presented a higher blastocyst rate than the non-antioxidant group (28.9 vs 11.7%; P<0.01) and a higher total cell number than the cysteamine group (225.1 vs 129.0; P<0.05). Oocytes from the melatonin and cysteamine groups had lower ROS levels than those from the non-antioxidant group. This study shows that melatonin is an interesting tool for improving oocyte competence in juvenile goats as it increases embryo production and quality.

Lymphoma risk in systemic lupus: effects of disease activity versus treatment.

OBJECTIVE: To examine disease activity versus treatment as lymphoma risk factors in systemic lupus erythematosus (SLE). METHODS: We performed case-cohort analyses within a multisite SLE cohort. Cancers were ascertained by regional registry linkages. Adjusted HRs for lymphoma were generated in regression models, for time-dependent exposures to immunomodulators (cyclophosphamide, azathioprine, methotrexate, mycophenolate, antimalarial drugs, glucocorticoids) demographics, calendar year, Sjogren's syndrome, SLE duration and disease activity. We used adjusted mean SLE Disease Activity Index scores (SLEDAI-2K) over time, and drugs were treated both categorically (ever/never) and as estimated cumulative doses. RESULTS: We studied 75 patients with lymphoma (72 non-Hodgkin, three Hodgkin) and 4961 cancer-free controls. Most lymphomas were of B-cell origin. As is seen in the general population, lymphoma risk in SLE was higher in male than female patients and increased with age. Lymphomas occurred a mean of 12.4 years (median 10.9) after SLE diagnosis. Unadjusted and adjusted analyses failed to show a clear association of disease activity with lymphoma risk. There was a suggestion of greater exposure to cyclophosphamide and to higher cumulative steroids in lymphoma cases than the cancer-free controls. CONCLUSIONS: In this large SLE sample, there was a suggestion of higher lymphoma risk with exposure to cyclophosphamide and high cumulative steroids. Disease activity itself was not clearly associated with lymphoma risk. Further work will focus on genetic profiles that might interact with medication exposure to influence lymphoma risk in SLE.

The Duero Diatom Index (DDI) for river water quality assessment in NW Spain: design and validation.

Diatom indices developed in certain geographic regions are frequently used elsewhere, despite the strong evidence that such metrics are less useful when applied in regions other than that where species-environment relationships were originally assessed, showing that species have particular autoecological requirements in different geographic areas. The goal of this study was to develop a new metric, the Duero Diatom Index (DDI), aimed at monitoring water quality in Duero basin watercourses (NW Spain). In summer 2008 and 2009, a total of 355 epilithic diatom samples were collected following standard protocols. The 2008 samples were used to develop the DDI, whereas the samples collected during 2009 were used in the index testing. Weighted averages method was used to derive the autoecological profiles of diatoms with respect to pH, conductivity, biological oxygen demand, ammonia, nitrates, and phosphates. The optimum and tolerance values for the measured environmental variables were determined for 137 taxa with abundances and frequencies of occurrence above 1%, and subsequent trophic indicator and sensitivity values were defined for the DDI. The correlation between the observed and the diatom-inferred nutrient concentrations was highest for phosphates (ρ (S) = 0.72). Significant statistical relationship were observed between DDI values and the chemistry-based General Quality Index values (p = 0.006) and the specific pollution index (SPI) diatom metric (p = 0.04). DDI has demonstrated a better correlation with water chemistry than SPI diatom metric.

SLE: serving the underserved in an academic medical center.

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disorder that can cause significant morbidity and mortality. SLE typically affects women during their childbearing years, and can disproportionately affect racial and ethnic minorities. Because this disease afflicts them at the height of their youth, patients often carry a large psychosocial burden. This is especially the case in groups that may have to grapple with other issues such as poverty, work disability, and lack of insurance. In this review we look at these issues, and how they affect patients at one major academic center in the Bronx, NY.

Comparison of Mathematics Problem-Solving Abilities in Autistic and Non-autistic Children: the Influence of Cognitive Profile.

This study examines relationships between mathematical problem-solving performance (in terms of strategies used and accuracy) and the main cognitive domains associated with mathematical learning (i.e. executive functions, verbal comprehension and social perception) of children with and without autism spectrum disorder (ASD and non-ASD resp.). The study involved 26 ASD and 26 non-ASD children without intellectual disabilities, between 6 and 12 years old, matched by sex, age and school (grade and classroom). The results show a higher percentage of ASD children with problem solving difficulties than non-ASD (57% vs. 23% resp.). Poor performing ASD children showed comparatively lower scores in inhibition, theory of mind and verbal comprehension. Implications for the design of mathematical interventions for ASD students are discussed.

COVID-19-associated inflammatory syndrome in an adult woman with unexplained multiple organ failure: staying vigilant for COVID-19 complications as the pandemic surges.

Since the emergence of SARS-CoV-2, clinicians have been challenged with a wide spectrum of disease severity. One of the serious complications associated with the virus is multisystem inflammatory syndrome in children (MIS-C). It is characterised by inflammation leading to organ damage, in the setting of positive SARS-CoV-2 infection. MIS-C is thought to be a postviral reaction where most children are negative on PCR testing but are positive for SARS-CoV-2 antibodies. The Centers for Disease Control and Prevention recently defined the same phenomenon occurring in adults as multisystem inflammatory syndrome in adults (MIS-A) and emphasised on the use of antibody testing in this population. Here we describe an adult woman with an exposure to SARS-CoV-2 who presented with unexplained organ failure and shock. Positive antibody testing was the only clue to the diagnosis of MIS-A. We stress the importance of SARS-CoV-2 antibody detection in order to identify these cases.

Teaching addition strategies to students with learning difficulties.

Background & aims: In recent years, there has been an increased interest in analyzing the mathematical performance of students with learning difficulties in order to provide them with teaching methods adapted to their needs. In particular, the importance of studying the type of informal strategy that students use when solving problems has been highlighted. Observing how these strategies emerge and develop in children with learning difficulties is crucial, as it allows us to understand how they develop a subsequent understanding of arithmetic operations. In this paper we study the effect of explicit instruction in addition strategies, focusing on the minimum addend strategy, and analyze the difficulties that arise during this process. Methods: An adapted multiple-probe design across students with a microgenetic approach was employed to assess the effectiveness of the teaching instruction and the acquisition of the minimum addend strategy while solving addition word problems. The participants were three primary-school children (two boys and one girl) with learning difficulties, one of them diagnosed with autism spectrum disorder. The instruction on the minimum addend strategy was sequenced into levels of abstraction based on the addends represented with and without manipulatives. Results: The results show that the three participants were able to acquire the minimum addend strategy and transfer it to two-step problems. They all showed difficulties during the instructional process, with quantity comparison difficulties predominating. The instruction provided to address these and other difficulties is detailed for each participant. Conclusions: The teaching of the minimum addend strategy has proven effective, and all three students acquired it throughout the instruction. The results concerning the student diagnosed with autism spectrum disorder are especially interesting given the lack of studies that focus on the strategies employed by students with this disorder to solve arithmetic problems. In this sense, the use of the microgenetic approach was especially useful to observe the type of spontaneous strategies used by this participant, and how they varied in response to the instruction. Implications: Each study participant faced different difficulties and needed different periods of time to assimilate the new strategy. Conclusions are drawn for educators to help children with learning difficulties advance to more sophisticated strategies, so they can acquire these and subsequent mathematical concepts.

Relationship Between Genetic Risk and Age of Diagnosis in Systemic Lupus Erythematosus.

OBJECTIVE: Specific risk alleles for childhood-onset systemic lupus erythematosus SLE (cSLE) vs adult-onset SLE (aSLE) patients have not been identified. The aims of this study were to determine if there is an association (1) between non-HLA-related genetic risk score (GRS) and age of SLE diagnosis, and (2) between HLA-related GRS and age of SLE diagnosis. METHODS: Genomic DNA was obtained from 2001 multiethnic patients and genotyped using the Immunochip. Following quality control, genetic risk counting (GRCS), weighted (GRWS), standardized counting (GRSCS), and standardized weighted (GRSWS) scores were calculated based on independent single-nucleotide polymorphisms from validated SLE loci. Scores were analyzed in a regression model and adjusted by sex and ancestral population. RESULTS: The analyzed cohort consisted of 1540 patients: 1351 females and 189 males (675 cSLE and 865 aSLE). There were significant negative associations between all non-HLA GRS and age of SLE diagnosis: P = 0.011 and r2 = 0.175 for GRWS; P = 0.008 and r2 = 0.178 for GRSCS; P = 0.002 and r2 = 0.176 for GRSWS (higher GRS correlated with lower age of diagnosis.) All HLA GRS showed significant positive associations with age of diagnosis: P = 0.049 and r2 = 0.176 for GRCS; P = 0.022 and r2 = 0.176 for GRWS; P = 0.022 and r2 = 0.176 for GRSCS; P = 0.011 and r2 = 0.177 for GRSWS (higher GRS correlated with higher age of diagnosis). CONCLUSION: Our data suggest that there is a linear relationship between genetic risk and age of SLE diagnosis and that HLA and non-HLA GRS are associated with age of diagnosis in opposite directions.

Addressing Health Disparities in Medical Education and Clinical Practice.

Health and health care disparities are present in every medical specialty, and stem from multiple etiologies. Within health care itself, issues mostly arise within medical providers and across a system with an inequitable distribution of care and resources. One potential way to address disparities is to educate our workforce, to not only know about disparities but to also actively advocate for underresourced and marginalized patients. In this review, the authors describe efforts being conducted in graduate medical education and seek to elucidate some of the curricula currently being developed and implemented in rheumatology.

Healthcare disparities in rheumatology: the role of education at a global level.

All fields of medicine are victim to health inequity worldwide, including rheumatology. While the health system is a key proponent to health access for all, other social determinants of health also impact world health. We describe herein the current state of global healthcare disparities in rheumatology and attempts at optimizing graduate medical education and resources for optimized healthcare, international research collaborations and a future of universal health equity. We performed a comprehensive search through Pubmed using the following keywords: healthcare disparities, medical education, access to care, community health.Key Points• Healthcare disparities are ubiquitous globally, including the field of rheumatology.• The heterogeneity of global healthcare disparities emphasizes the importance of addressing unmet needs at a regional level.• A standardized approach to incorporating healthcare disparities education in the medical field is lacking. Intervening at this level provides a foundation of increasing provider awareness of regional healthcare disparities so as to establish a framework of addressing such disparities in a culturally competent manner.

Effect of crocetin added to IVM medium for prepubertal goat oocytes on blastocyst outcomes after IVF, intracytoplasmic sperm injection and parthenogenetic activation.

Crocetin is an active constituent of saffron recently used as antioxidant for embryo culture. The aim of this study was to test the effect of crocetin added in the in vitro maturation (IVM) of prepubertal goat oocytes on the embryo development after in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI) and parthenogenetic activation (PA). Cumulus-oocyte complexes (COCs) were released from slaughterhouse ovaries of prepubertal goats and in vitro matured in supplemented TCM 199 medium during 24 h without (control group) and with crocetin. In Experiment 1, we evaluated the effect of the IVM supplementation with 0 µM (control), 0.5 µM, 1 µM and 2 µM of crocetin on the blastocyst development after IVF. No significant differences were obtained on blastocyst formation among groups (12, 7, 10, 11%; respectively). Although the blastocyst total cell number was higher in 1 µM crocetin group (150.7 cells) compared to the control (105.5), 0.5 µM (116.2) and 2 µM (93.7) crocetin groups, no significant differences were detected. In experiment 2, we assessed the effect of 1 µM crocetin supplementation in the IVM medium on the oocyte GSH level, ROS level and mitochondrial activity. ROS was significantly higher in the control than in the crocetin group (P < 0.05), but no differences in GSH level and mitochondrial activity were observed. In experiment 3, we evaluated the effect of 1 µM crocetin on the blastocyst development of oocytes after ICSI and PA. No statistical differences were found on blastocyst rate or cell number. However, compared with control, crocetin groups led to higher cleavage (59 vs. 67%, respectively, P = 0.09) and blastocyst rates (19 vs. 12%, respectively; P = 0.12) after ICSI. Although crocetin reduced ROS levels in prepubertal goat oocytes, it did not have a significant effect on oocyte embryo developmental competence.