"Make the Implicit Explicit": Measuring Perceptions of Gender Bias and Creating a Gender Bias Curriculum for Internal Medicine Residents.

BACKGROUND: Gender bias in clinical training has been well established; however, little is known about how perceptions differ between men and women. Furthermore, few curricular options have been developed to discuss gender bias. OBJECTIVE: To measure the prevalence of gender bias, examine qualitative differences between men and women, and create a gender bias curriculum for internal medicine residents. METHODS: We surveyed 114 residents (response rate of 53.5%) to identify the prevalence and types of gender bias experienced in training. We compared estimates between genders and organized qualitative results into shared themes. We then developed a curriculum to promote and normalize discussions of gender bias. RESULTS: Among surveyed residents, 61% reported personal experiences of gender bias during training, with 98% of women and 19% of men reporting experiences when stratified by gender. We identified two domains in which gender bias manifested: role misidentification and a difficult working environment. Residents identified action items that led to the development of a gender bias curriculum. The curriculum includes didactic conferences and training sessions, a microaggression response toolkit, dinners for men and women residents, participation in a WhatsApp support group, and participation in academic projects related to gender bias in training. CONCLUSION: We confirmed a wide prevalence of gender bias and developed a scalable curriculum for gender bias training. Future work should explore the long-term impacts of these interventions.

ED-based care coordination reduces costs for frequent ED users.

OBJECTIVES: We evaluated a pilot quality improvement intervention implemented in an urban academic medical center emergency department (ED) to improve care coordination and reduce ED visits and hospitalizations among frequent ED users. STUDY DESIGN: Randomized controlled trial. METHODS: We identified the most frequent ED users in both the 30 days prior to the intervention and the 12 months prior to the intervention. We randomized the top 72 patients to receive either our pilot intervention or usual care. The intervention consisted of a community health worker who assisted patients with navigating care and identifying unmet social needs and an ED-based clinical team that developed interdisciplinary acute care plans for eligible patients. After 7 months, we analyzed ED visits, hospitalizations, and costs for the intervention and control groups. RESULTS: We randomized 72 patients to the intervention (n = 36) and control (n = 36) groups. Patients randomized to the intervention group had 35% fewer ED visits (P = .10) and 31% fewer admissions from the ED (P = .20) compared with the control group. Average ED direct costs per patient were 15% lower and average inpatient direct costs per patient were 8% lower for intervention patients compared with control patients. CONCLUSIONS: ED-based care coordination is a promising approach to reduce ED use and hospitalizations among frequent ED users. Our program also demonstrated a decrease in costs per patient. Future efforts to promote population health and control costs may benefit from incorporating similar programs into acute care delivery systems.

The intersection of genetic and chemical genomic screens identifies GSK-3α as a target in human acute myeloid leukemia.

Acute myeloid leukemia (AML) is the most common form of acute leukemia in adults. Long-term survival of patients with AML has changed little over the past decade, necessitating the identification and validation of new AML targets. Integration of genomic approaches with small-molecule and genetically based high-throughput screening holds the promise of improved discovery of candidate targets for cancer therapy. Here, we identified a role for glycogen synthase kinase 3α (GSK-3α) in AML by performing 2 independent small-molecule library screens and an shRNA screen for perturbations that induced a differentiation expression signature in AML cells. GSK-3 is a serine-threonine kinase involved in diverse cellular processes, including differentiation, signal transduction, cell cycle regulation, and proliferation. We demonstrated that specific loss of GSK-3α induced differentiation in AML by multiple measurements, including induction of gene expression signatures, morphological changes, and cell surface markers consistent with myeloid maturation. GSK-3α-specific suppression also led to impaired growth and proliferation in vitro, induction of apoptosis, loss of colony formation in methylcellulose, and anti-AML activity in vivo. Although the role of GSK-3ß has been well studied in cancer development, these studies support a role for GSK-3α in AML.

Enhancing quality of primary care using an ambulatory ICU to achieve a patient- centered medical home.

RESEARCH OBJECTIVE: The Patient-Centered Medical Home (PCMH) has been advocated as a model to address the lack of coordination and continuity in the health system. However, implementation in practice has been slow and incompletely described. STUDY DESIGN: Patients referred into the program received intensive nurse follow-up focused on medication adherence, care coordination, and education. Patients graduate from the program when treatment goals are met. POPULATION STUDIED: The first 100 patients enrolled into the PCMH focused program of a primary care clinic in an urban, academic medical center. The main outcome measures are goal adherence and emergency room use. PRINCIPAL FINDINGS: Ninety percent of enrollees met the health goals set for them at enrollment. During their enrollment, 31.6% of patients with diabetes reduced and maintained their blood glucose readings; 24.6% of patients with hypertension reduced and maintained their blood pressure readings. Emergency department use in the time period following enrollment dropped 46.7%. CONCLUSIONS: The ambulatory intensive care unit program showed an improvement in health outcomes and health care use.This program also helps to move the practice toward PCMH by centralizing care through a primary care provider, enhancing access to care, and by focusing on the patient holistically through rapport with a nurse. IMPLICATIONS FOR POLICY, DELIVERY, OR PRACTICE: This care delivery method drives the clinic closer to the PCMH and toward the Accountable Care Organization (ACO) model.

Proteomic and genetic approaches identify Syk as an AML target.

Cell-based screening can facilitate the rapid identification of compounds inducing complex cellular phenotypes. Advancing a compound toward the clinic, however, generally requires the identification of precise mechanisms of action. We previously found that epidermal growth factor receptor (EGFR) inhibitors induce acute myeloid leukemia (AML) differentiation via a non-EGFR mechanism. In this report, we integrated proteomic and RNAi-based strategies to identify their off-target, anti-AML mechanism. These orthogonal approaches identified Syk as a target in AML. Genetic and pharmacological inactivation of Syk with a drug in clinical trial for other indications promoted differentiation of AML cells and attenuated leukemia growth in vivo. These results demonstrate the power of integrating diverse chemical, proteomic, and genomic screening approaches to identify therapeutic strategies for cancer.

Pancreatic adenocarcinoma in the pregnant patient: a case report and literature review.

Pancreatic cancer is the fifth most common cause of cancer-related death in the USA. However, the antepartum diagnosis of pancreatic adenocarcinoma in the pregnant patient is exceedingly rare, with only six cases previously reported in the literature. Optimizing both maternal and fetal health outcomes is particularly challenging when surgical procedures are necessary for staging and/or therapeutic purposes--as these interventions often pose significant risks to both the mother and the developing fetus. In this article, we report a case of pancreatic adenocarcinoma diagnosed during pregnancy and review the literature on the management issues confronted in this unique clinical situation.