Divided infrastructure: legal exclusion and water inequality in an urban slum in Mumbai, India.

Inadequate water access is central to the experience of urban inequality across low- and middle-income countries and leads to adverse health and social outcomes. Previous literature on water inequality in Mumbai, India's second largest city, offers diverse explanations for water disparities between and within slums.(1) This study provides new insights on water disparities in Mumbai's slums by evaluating the influence of legal status on water access. We analyzed data from 593 households in Mandala, a slum with legally recognized (notified) and unrecognized (non-notified) neighborhoods. Relative to households in a notified neighborhood, households in a non-notified neighborhood suffered disadvantages in water infrastructure, accessibility, reliability, and spending. Non-notified households used significantly fewer liters per capita per day of water, even after controlling for religion and socioeconomic status. Our findings suggest that legal exclusion may be a central driver of water inequality. Extending legal recognition to excluded slum settlements, neighborhoods, and households could be a powerful intervention for reducing urban water inequality.

Autonomy and focus of attention in medical motor skills learning: a randomized experiment.

BACKGROUND: The 'OPTIMAL' (Optimizing Performance Through Intrinsic Motivation and Attention for Learning) theory of motor learning suggests that autonomy, external focus of attention, and perceived competence can improve learning of simple motor tasks. The authors hypothesized that enhanced (vs. routine) autonomy and external (vs. internal) focus of attention would improve first-try performance of two medical motor tasks. METHODS: The authors conducted a randomized two-by-two factorial design study with high school students as participants. Task instructions promoted either enhanced or routine autonomy, and either external or internal focus of attention. These conditions were replicated in a crossover design for two common medical tasks (chest compressions on a manikin and a Fundamentals of Laparoscopic Surgery peg transfer task). Primary outcomes were objective measures of task performance (chest compression deviation from target depth; peg transfer time with penalties for errors). Secondary outcomes included subjective perceptions of confidence, autonomy, and workload. RESULTS: One hundred thirty-three high school students participated in this study. The primary outcomes concerning enhanced vs. routine autonomy demonstrated no statistically significant difference in either task (chest compression depth deviation: difference -0.7 mm [score range 0 to 37.5 mm]; 95% confidence interval (CI95) -3.85, 2.41; p = .65; peg transfer penalized time: rate ratio 1.03; CI95 0.91, 1.31; p = .79). The authors likewise found no statistically significant difference for external vs. internal focus of attention (depth deviation: difference 1.1 mm; CI95 -2.04, 4.17; p = .50; penalized time: rate ratio 0.89; CI95 0.75, 1.13; p = .33). The authors found no statistically significant differences for either comparison in confidence, autonomy and workload (p > .09; differences ranged from -0.83 to 0.79 [scale range 0 to 10]). CONCLUSIONS: First-try performance of chest compressions and peg transfer by novice learners is not significantly affected by enhanced (vs. routine) autonomy or external (vs. internal) focus of attention.

LEGO®-based communication assessment in virtual general surgery residency interviews.

Purpose: Effective communication skills are a critical quality and skill that is highly sought after for surgeons which largely impacts patient outcomes. Residency programs design their interview processes to select the best candidates. LEGO®-based activities have been frequently used to enhance communication skills and team building. This study investigates the effectiveness and reliability of a novel LEGO®-based communication assessment in interviews for surgical residencies and the feasibility of implementing it in a virtual setting. Methods: This study conducted a retrospective analysis of a LEGO®-based communication assessment at the program's 2020/2021 residency interviews. Each applicant was assessed on a different model. The total scores were analyzed for consistency among raters and correlated to faculty interviews. Furthermore, the impact of the assessment structure, scoring criteria, and range of models' difficulties on the total scores were explored. Results: A total of 54 categorical and 55 preliminary applicants interviewed on 2 days. The assessment on different models and had no impact on applicants' total scores for either categorical and preliminary groups (p = 0.791 and 0.709, respectively). The communication components of the assessment showed high consistency between the raters. The two applicant groups displayed a statistically significant difference (p = 0.004) in the communication evaluation and model accuracy components. Total scores did not correlate with the faculty interviews of standardized questions in either group. Conclusion: This novel LEGO®-based communication assessment showed high reliability and promising results as a tool to assess communication and problem solving for residency interviews that can be readily implemented in a virtual setting. Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-022-00021-4.

Video feedback with error-focused or correct-focused examples in surgical skills distance learning: A randomized trial.

BACKGROUND: Although it seems natural that surgical trainees would learn from demonstrations of a correct performance, evidence outside of surgical education has suggested that error-focused examples may promote error detection and improved procedural task performance. We hypothesized that feedback through error-focused videos would improve procedural learning more than correct-focused videos. METHODS: We conducted a randomized controlled trial of video feedback comparing error-focused versus correct-focused examples. The participants were interviewees at our general surgery residency program in December 2020. All of the interviewees performed suturing and knot tying tasks on their interview day (baseline), with 70 common errors identified. For each error, we created an instructional feedback video in two formats: one video demonstrating the error and another demonstrating correct performance. The study participants received feedback videos based on baseline performance errors, with the format randomly assigned. Two blinded raters assessed the baseline and postintervention performances. RESULTS: Thirty-seven interviewees enrolled and 17 submitted postintervention videos. The postintervention mean performance scores were significantly higher (P = .02) in the error-focused than the correct-focused example group (suturing [maximum score 18]: 16.9 vs 13.9 [difference 2.9; 95% CI 0.7, 5.1]; knot-tying [maximum score 24]: 21.6 vs 17.8 [difference 3.8; 95% CI 0.5, 7.0]). We found no between-group differences in performance time ([error-focused versus correct-focused] suturing: 246 vs 256 s; knot-tying: 170 vs 138 s; P = .08). Mean satisfaction with feedback was similar between groups (error-focused: mean = 5.3 versus correct-focused: mean = 5.2, out of 7; P = .95). CONCLUSION: Feedback that highlights errors is associated with better learning of surgical skills than feedback demonstrating correct performance, confirming our hypothesis.

Video Commentary & Machine Learning: Tell Me What You See, I Tell You Who You Are.

BACKGROUND & OBJECTIVE: Teaching and assessment of complex problem solving are a challenge for medical education. Integrating Machine Learning (ML) into medical education has the potential to revolutionize teaching and assessment of these problem-solving processes. In order to demonstrate possible applications of ML to education, we sought to apply ML in the context of a structured Video Commentary (VC) assessment, using ML to predict residents' training level. SETTING: A secondary analysis of multi-institutional, IRB approved study. Participants had completed the VC assessment consisting of 13 short (20-40 seconds) operative video clips. They were scored in real-time using an extensive checklist by an experienced proctor in the assessment. A ML model was developed using TensorFlow and Keras. The individual scores of the 13 video clips from the VC assessment were used as the inputs for the ML model as well as for regression analysis. PARTICIPANTS: A total of 81 surgical residents of all postgraduate years (PGY) 1-5 from 7 institutions constituted the study sample. RESULTS: Scores from individual VC clips were strongly positively correlated with PGY level (p = 0.001). Some video clips were identified to be strongly correlated with a higher total score on the assessment; others had significant influence when used to predict trainees' PGY levels. Using a supervised machine learning model to predict trainees' PGY resulted in a 40% improvement over traditional statistical analysis. CONCLUSIONS: Performing better in a few select video clips was key to obtaining a higher total score but not necessarily foretelling of a higher PGY level. The use of the total score as a sole measure may fail to detect deeper relationships. Our ML model is a promising tool in gauging learners' levels on an assessment as extensive as VC. The model managed to approximate residents' PGY levels with a lower MAE than using traditional statistics. Further investigations with larger datasets are needed.

Conducting Virtual Simulated Skills Multiple Mini-Interviews for General Surgery Residency Interviews.

OBJECTIVE: We describe the feasibility of transitioning simulated skills assessments during general surgery interviews from an in-person to virtual format. DESIGN/SETTING: Technical and nontechnical skill multiple mini-interviews (MMIs) were performed virtually and assessed for 109 applicants during virtual general surgery interviews over 2 days at a tertiary academic medical center. RESULTS: We demonstrate the feasibility of virtually assessing general surgery residency applicants' technical and non-technical skills. Using a virtual MMI format during general surgery interviews, we assessed communication, emotional intelligence, anatomical knowledge, interpretation of medical tests, knot tying, and suturing. Four tasks (communication, emotional intelligence , anatomical knowledge, and interpretation of tests) were assessed synchronously by trained general surgery interns. Applicants submitted a recording of themselves performing knot tying and suturing tasks, which were asynchronously assessed after the interview day. Applicants rated the MMI experience highly (4.3/5) via postinterview day survey and the majority of applicants felt that station objectives were met in the virtual format. CONCLUSIONS: We report a successful experience implementing technical and nontechnical virtual MMIs with capacity for 120 applicants during general surgery residency interviews. In the midst of a COVID-19 pandemic, the ability to assess surgical leaners virtually is essential. Virtual skills assessments may provide a more comprehensive picture of applicants and enable residency programs to better assess residents when gathering in person is not feasible.

Inspiring Young Learners Toward a Career in Healthcare Using Simulation.

STATEMENT: To inspire young learners toward a career in healthcare and provide them opportunities to learn lifesaving skills, a hospital-based simulation center collaborated with a local middle school to develop a 88-minute simulation-based educational activity. The activity consisted of eight 10-minute stations on lifesaving and basic medical skills. One hundred fifty students participated. Evaluation surveys showed students favored stations with extensive hands-on activities and valued the opportunity to interact with health professionals. Students also reported more interest in science careers after the visit. This collaborative effort is time-efficient and low-budget simulation-based learning experience that had an immediate impact on middle school students.

What Are We REALLY Looking for in a Letter of Recommendation?

OBJECTIVES: The letter of recommendation (LOR) is an important component of a residency application. There is great subjectivity in the interpretation of a letter writer's narrative and many residencies have moved toward standardized LORs (sLOR). We aimed to scrutinize the importance afforded to specific content and applicant attributes in an LOR in hopes of decoding this time-honored process. DESIGN: A 35-question survey comprised of nonidentifying general questions, and participant evaluation of applicant characteristics and LOR phrases were administered (cross-sectional design). Evaluations were scored both objectively on a 10-point Likert scale and subjectively using a relative ranking. SETTING: Academic, tertiary care center with a large general surgery residency program (Mayo Clinic, Rochester, MN). PARTICIPANTS: Surgery attendings and general surgery residents (n = 122). RESULTS: Seventy-two attendings and 50 general surgery residents completed the survey. Faculty ranked strong work ethic/hard working (median rank = 1) and inquisitive/hungry learner (median rank = 3) as the top 2 attributes. "We will plan to recruit this candidate" (median rank = 1.5) and "I give my highest recommendation" (median rank = 2) were the top 2 phrases. Residents valued strong work ethic and collaborative/team player as the top 2 applicant attributes. Seventy-three percent of attendings and 82% of residents agreed that LOR allows the applicant pool to be divided into upper and lower halves. Only 17% of faculty and 18% of residents agreed that an LOR allowed candidate stratification into quartiles. CONCLUSIONS: Elaborating the most favorable applicant characteristics and highly regarded content in an LOR will help truly exceptional candidates obtain letters that make them stand out in the eyes of their evaluators. Since LORs are mostly considered to be able to stratify only upper and lower halves of the applicant pool, it is imperative to move toward LORs which portray superior applicant qualities, and can provide more objective evaluation of a candidate.

Consistent simulation of X- and Q-band EPR spectra of an unsymmetric dinuclear Mn2(II,III) complex.

Simulation of X- and Q-band electron paramagnetic resonance (EPR) spectra of an unsymmetric dinuclear [Mn(2)(II,III)L(mu-OAc)(2)]ClO(4) complex (1), (L is the dianion of 2-{[N,N-bis(2-pyridylmethyl)amino]methyl}-6-{[N-(3,5-di-tert-butyl-2-hydroxybenzyl)-N-(2-pyridylmethyl)amino]methyl}-4-methylphenol) was performed using one consistent set of simulation parameters. Rhombic g-tensors and hyperfine tensors were necessary to obtain satisfactory simulation of the EPR spectra. The anisotropy of the effective hyperfine tensors of each individual (55)Mn ion was further analyzed in terms of intrinsic hyperfine tensors. Detailed analysis shows that the hyperfine anisotropy of the Mn(III) ion is a result of the Jahn-Teller effect and thus an inherent character. In contrast, the anomalous hyperfine anisotropy of the Mn(II) ion is attributed as being transferred from the Mn(III) ion through the spin exchange interaction. The anisotropy parameter for the Mn(II) is deduced as D(II)=-1.26+/-0.2cm(-1). This is the first reported D(II) value for a Mn(II) ion in a weakly exchange coupled mixed-valence Mn(2)(II,III) complex with a bis-mu-acetato-bridge. The [see text] electronic configuration of the Mn(III) ion in 1 is revealed by the negative sign of its intrinsic hyperfine tensor anisotropy, Deltaa(III)=a(z)-a(x,y)=-46cm(-1). Lower spectral resolution of the Q-band EPR spectrum as compared to the X-band EPR spectrum is associated to large line width broadening of the x- and y-components in contrast to the z-component. The origins of the unequal distribution of line width between the z- and x-, y-components are discussed.

Decomposition of amino diazeniumdiolates (NONOates): molecular mechanisms.

Although diazeniumdiolates (X[N(O)NO](-)) are extensively used in biochemical, physiological, and pharmacological studies due to their ability to release NO and/or its congeneric nitroxyl, the mechanisms of these processes remain obscure. In this work, we used a combination of spectroscopic, kinetic, and computational techniques to arrive at a quantitatively consistent molecular mechanism for decomposition of amino diazeniumdiolates (amino NONOates: R2N[N(O)NO](-), where R=N(C2H5)2 (1), N(C3H4NH2)2 (2), or N(C2H4NH2)2 (3)). Decomposition of these NONOates is triggered by protonation of their [NN(O)NO](-) group with the apparent pKa and decomposition rate constants of 4.6 and 1 s(-1) for 1; 3.5 and 0.083 s(-1) for 2; and 3.8 and 0.0033 s(-1) for 3. Although protonation occurs mainly on the O atoms of the functional group, only the minor R2N(H)N(O)NO tautomer (population ~10(-7), for 1) undergoes the NN heterolytic bond cleavage (kd~10(7) s(-1) for 1) leading to amine and NO. Decompositions of protonated amino NONOates are strongly temperature-dependent; activation enthalpies are 20.4 and 19.4 kcal/mol for 1 and 2, respectively, which includes contributions from both the tautomerization and bond cleavage. The bond cleavage rates exhibit exceptional sensitivity to the nature of R substituents which strongly modulate activation entropy. At pH<2, decompositions of all three NONOates that have been investigated are subject to additional acid catalysis that occurs through di-protonation of the [NN(O)NO](-) group.

Syntheses, crystal structures, and spectroscopic and magnetic properties of [Mn2III(H2L1)(Cl4Cat)4.2H2O] and [Mn2III(H2L2)(Cl4Cat)4.2CH3CN.2H2O]infinity: temperature-dependent valence tautomerism in solution.

The synthesis, X-ray data, and electronic structures of two manganese(III) 1D polymers ligated by tetrachlorocatechol, [Mn(2)(III)(H(2)L(1))(Cl(4)Cat)(4).2H(2)O](infinity) (1) and [Mn(2)(III)(H(2)L(2))(Cl(4)Cat)(4).2CH(3)CN.2H(2)O](infinity) (2), are reported. The electronic structures of the complexes have been determined by UV-vis-near-IR, IR, electron paramagnetic resonance (EPR), and magnetic susceptibility measurements. Both 1 and 2 are air stable in the solid state and in solution, unlike most of the previously reported o-quinone-chelated transition-metal complexes. Electronic spectroscopy exhibits a strong near-IR band near 1900 nm for both, suggesting the presence of a mixed-valence semiquinone-catecholate oxidation state of the catechol ligands, Mn(2)(III)(Cl(4)Cat)(2)(Cl(4)SQ)(2), together with the pure catecholate forms. The presence of this isomer was further supported by EPR and magnetic susceptibility measurements. The complexes undergo intramolecular electron transfer (valence tautomerism) upon an increase of the temperature involving the equilibrium Mn(2)(III)(Cl(4)Cat)(2)(Cl(4)SQ)(2) <==> Mn(2)(II)(Cl(4)SQ)(4). This phenomenon is reversible and is studied in solution using UV-vis-near-IR spectroscopy.

Light induced manganese oxidation and long-lived charge separation in a Mn2II,II-RuII(bpy)3-acceptor triad.

The photoinduced electron-transfer reactions in a Mn2II,II-RuII-NDI triad (1) ([Mn2(bpmp)(OAc)2]+, bpmp = 2,6-bis[bis(2-pyridylmethyl)aminomethyl]-4-methylphenolate and OAc = acetate, RuII = tris-bipyridine ruthenium(II), and NDI = naphthalenediimide) have been studied by time-resolved optical and EPR spectroscopy. Complex 1 is the first synthetically linked electron donor-sensitizer-acceptor triad in which a manganese complex plays the role of the donor. EPR spectroscopy was used to directly demonstrate the light induced formation of both products: the oxidized manganese dimer complex (Mn2II,III) and the reduced naphthalenediimide (NDI*-) acceptor moieties, while optical spectroscopy was used to follow the kinetic evolution of the [Ru(bpy)3]2+ intermediate states and the NDI*- radical in a wide temperature range. The average lifetime of the NDI*- radical is ca. 600 micros at room temperature, which is at least 2 orders of magnitude longer than that for previously reported triads based on a [Ru(bpy)3]2+ photosensitizer. At 140 K, this intramolecular recombination was dramatically slowed, displaying a lifetime of 0.1-1 s, which is comparable to many of the naturally occurring charge-separated states in photosynthetic reaction centra. It was found that the long recombination lifetime could be explained by an unusually large reorganization energy (lambda approximately 2.0 eV), due to a large inner reorganization of the manganese complex. This makes the recombination reaction strongly activated despite the large driving force (Delta-G degrees = 1.07 eV). Thus, the intrinsic properties of the manganese complex are favorable for creating a long-lived charge separation in the "Marcus normal region" also when the charge separated state energy is high.

Slow magnetic relaxation in a mixed-valence Mn(II/III) Complex: [MnII2(bispicen)2(mu 3-Cl)2Mn(III)(Cl4Cat)2Mn(III)(Cl4Cat)2(H2O)2] infinity.

A layered mixed-valence manganese complex, [Mn(II)(2)(bispicen)(2)(mu(3)-Cl)(2)Mn(III)(Cl(4)Cat)(2)Mn(III)(Cl(4)Cat)(2)(H(2)O)(2)](infinity), is synthesized and characterized structurally. It displays a slow magnetic relaxation and hysteresis effect.

New route to the mixed valence semiquinone-catecholate based mononuclear FeIII and catecholate based dinuclear MnIII complexes: first experimental evidence of valence tautomerism in an iron complex.

The semiquinone-catecholate based mixed valence complex, [FeIII(bispicen)(Cl4Cat)(Cl4SQ)] x DMF (1), and catecholate based (H2bispictn)[Mn2III(Cl4Cat)4(DMF)2] (2) (bispicen = N,N'-bis(2-pyridylmethyl)-1,2-ethanediamine, bispictn = N,N'-bis(2-pyridylmethyl)-1,3-propanediamine, Cl4Cat = tetrachlorocatecholate dianion, and Cl4SQ = tetrachlorosemiquinone radical anion) were synthesized directly utilizing a facile route. Both the complexes have been characterized by single crystal X-ray diffraction study. The electronic structures have been elucidated by UV-vis-NIR absorption spectroscopy, cyclic voltammetry, EPR, and magnetic properties. The structural as well as spectroscopic features support the mixed valence tetrachlorosemiquinone-tetrachlorocatecholate charge distribution in 1. The ligand based mixed valence state was further confirmed by the presence of an intervalence charge transfer (IVCT) band in the 1900 nm region both in solution and in the solid. The intramolecular electron transfer, a phenomenon known as valence tautomerism (VT), has been followed by electronic absorption spectroscopy. For 1, the isomeric form [FeIII(bispicen)(Cl4Cat)(Cl4SQ)] is favored at low temperature, while at an elevated temperature, the [FeII(bispicen)(Cl4SQ)2] redox isomer dominates. Infrared as well as UV-vis-NIR spectral characterization for 2 suggest that the MnIII(Cat)2- moiety is admixed with its mixed valence semiquinone-catecholate isomer MnII(SQ)(Cat)-, and the electronic absorption spectrum is dominated by the mixed charged species. The origin of the intervalence charge transfer band in the 1900 nm range is associated with the mixed valence form, MnII(Cl4Cat)(Cl4SQ)-. The observation of VT in complex 1 is the first example where a mixed valence semiquinone-catecholate iron(III) complex undergoes intramolecular electron transfer similar to manganese and cobalt complexes.