Stereotype Threat and Gender Bias in Internal Medicine Residency: It is Still Hard to be in Charge.

BACKGROUND: Despite similar numbers of women and men in internal medicine (IM) residency, women face unique challenges. Stereotype threat is hypothesized to contribute to underrepresentation of women in academic leadership, and exploring how it manifests in residency may provide insight into forces that perpetuate gender disparities. OBJECTIVE: To quantify the prevalence of stereotype threat in IM residency and explore experiences contributing to that stereotype threat. DESIGN: We used a mixed methods study design. First, we surveyed IM residents using the Stereotype Vulnerability Scale (SVS) to screen for stereotype threat. Second, we conducted focus groups with women who scored high on the SVS to understand experiences that led to stereotype threat. PARTICIPANTS: The survey was sent to all IM residents at University of California, San Francisco (UCSF), in September-November 2019. Focus groups were conducted at UCSF in Spring 2020. APPROACH: The survey included an adapted version of the SVS. For focus groups, we developed a focus group guide informed by literature on stereotype threat. We used a thematic approach to data analysis. The mixed methods design enabled us to draw metainferences by integrating the two data sources. KEY RESULTS: Survey response rate was 61% (110/181). Women were significantly more likely than men to have a score indicating stereotype threat vulnerability (77% vs 0%, p < 0.001). Four themes from focus groups characterized women's experiences of gender bias and stereotype threat: gender norm tension, microaggressions and sexual harassment, authority questioned, and support and allyship. CONCLUSIONS: Gender-based stereotype threat is highly prevalent among women IM residents. This phenomenon poses a threat to confidence and ability to execute patient care responsibilities, detracting from well-being and professional development. These findings indicate that, despite robust representation of women in IM training, further attention is needed to address gendered experiences and contributors to women's vulnerability to stereotype threat.

The Road Not Taken: Disconnection of a Human-Unique Cortical Pathway Underlying Naturalistic Social Perception in Schizophrenia.

Background: Efficient processing of complex and dynamic social scenes relies on intact connectivity of many underlying cortical areas and networks, but how connectivity anomalies affect the neural substrates of social perception remains unknown. Here we measured these relationships using functionally based localization of social perception areas, resting-state functional connectivity, and movie-watching data. Methods: In 42 participants with schizophrenia (SzPs) and 41 healthy control subjects, we measured the functional connectivity of areas localized by face-emotion processing, theory-of-mind (ToM), and attention tasks. We quantified the weighted shortest path length between visual and medial prefrontal ToM areas in both populations to assess the impact of these changes in functional connectivity on network structure. We then correlated connectivity along the shortest path in each group with movie-evoked activity in a key node of the ToM network (posterior temporoparietal junction [TPJp]). Results: SzPs had pronounced decreases in connectivity in TPJ/posterior superior temporal sulcus (TPJ-pSTS) areas involved in face-emotion processing (t81 = 4.4, p = .00002). In healthy control subjects, the shortest path connecting visual and medial prefrontal ToM areas passed through TPJ-pSTS, whereas in SzPs, the shortest path passed through the prefrontal cortex. While movie-evoked TPJp activity correlated with connectivity along the TPJ-pSTS pathway in both groups (r = 0.43, p = .002), it additionally correlated with connectivity along the prefrontal cortex pathway only in SzPs (rSzP = 0.56, p = .003). Conclusions: These results suggest that connectivity along the human-unique TPJ-pSTS pathway affects both the network architecture and functioning of areas involved in processing complex dynamic social scenes. These results demonstrate how focal connectivity anomalies can have widespread impacts across the cortex.

A Process Evaluation of Developing Older Adult Research Advisory Boards in Long-term Care Settings.

BACKGROUND: Enhancing the capacity of researchers, providers and older adults to collaborate in research is critical for promoting relevant, useful research findings. OBJECTIVES: The Sages in Every Setting project aimed to disseminate a flexible model for developing research advisory boards (RABs) comprised of older adults receiving long-term services and supports (LTSS) via partnerships between academic researchers and LTSS providers. METHODS: Process evaluation assessed the feasibility of using resources to develop RABs. Partners sought regular feedback from facilitators and RAB members, which was shared with the evaluator. The evaluator conducted regular debriefings with academic partners and observed some RAB meetings. LESSONS LEARNED: The development of RABs was impacted by pre-existing collaborations, characteristics of providers, flexible use of the resources, facilitator capacity, member capacity, and researcher capacity. CONCLUSIONS: Developing RABs was feasible. Long-term partnerships between research institutions and LTSS providers that serve diverse populations could improve successful dissemination of this model.

Exploring Corporate Stakeholders' Perspectives on Building Capacity for Employee Engagement in Workplace Wellness Initiatives.

Engaging employees with chronic conditions as partners in designing, implementing, and evaluating workplace wellness activities is a promising approach for optimizing the impact of workplace health promotion programs. Yet, there is a need for information on how employees are engaged in this process. We conducted a process evaluation of activities of the Patient-Centered Outcomes Research for Employees (PCORE) project formed around building capacity for employee engagement in wellness initiatives. Individual interviews were conducted with the 11 project stakeholders to explore perspectives of the project's participatory process and activities. Thematic categories emerging in the analysis were (1) Commitment and support, (2) Understanding purpose and roles, (3) Role of employees in wellness programming, and (4) Communication during meetings. This process evaluation provides insights from a model of stakeholder engagement in the corporate setting. Creating an environment that supports meaningfully engaging employees as partners in co-creating workplace wellness initiatives requires effectively addressing the unique aspects of the U.S. corporate culture such as the emphasis on productivity and the prevalent traditional top-down organizational structures.

Blood-based traumatic brain injury biomarkers - Clinical utilities and regulatory pathways in the United States, Europe and Canada.

INTRODUCTION: Traumatic brain injury (TBI) is a major global health issue, resulting in debilitating consequences to families, communities, and health-care systems. Prior research has found that biomarkers aid in the pathophysiological characterization and diagnosis of TBI. Significantly, the FDA has recently cleared both a bench-top assay and a rapid point-of-care assays of tandem biomarker (UCH-L1/GFAP)-based blood test to aid in the diagnosis mTBI patients. With the global necessity of TBI biomarkers research, several major consortium multicenter observational studies with biosample collection and biomarker analysis have been created in the USA, Europe, and Canada. As each geographical region regulates its data and findings, the International Initiative for Traumatic Brain Injury Research (InTBIR) was formed to facilitate data integration and dissemination across these consortia. AREAS COVERED: This paper covers heavily investigated TBI biomarkers and emerging non-protein markers. Finally, we analyze the regulatory pathways for converting promising TBI biomarkers into approved in-vitro diagnostic tests in the United States, European Union, and Canada. EXPERT OPINION: TBI biomarker research has significantly advanced in the last decade. The recent approval of an iSTAT point of care test to detect mild TBI has paved the way for future biomarker clearance and appropriate clinical use across the globe.

Pediatric Group Care: A Systematic Review.

OBJECTIVE: To describe characteristics and outcomes of Group Well-Child Care programs and provide recommendations for future research. METHODS: Informed by Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, an electronic references database, manual search of bibliographies and peer-reviewed journals, and general Internet search were conducted including research published up to July 2019. English language, peer-reviewed research, with provision of medical care were included. Studies without published outcomes, not specific to well-child care, or included only one visit were excluded. Nineteen articles met review criteria. Study quality was assessed using the Downs and Black tool for rigor. RESULTS: Programs typically included an individual medical examination, check-in, and group discussion. Demographics varied by race, ethnicity, age, income level, education and parity, though many were used specifically with underserved populations. Group size ranged from 3 to 10 and lasted an average of 1.5 h over a period of 6-24 months. Evidence suggests group well-child care is as effective as individual care with improvement noted for health-care utilization, weight outcomes, and more content covered. Design elements such as patient-led discussion, self-check-in, inclusion of other family members, and use of a variety of health care professionals and para-professionals may influence these outcomes. CONCLUSIONS: Group well-child care is useful in providing efficient and patient-centered care and shows promise for use in underserved populations. Future research should utilize more rigorous study design and include evaluations of program components and group processes to address implementation challenges and determine effectiveness.

Failure to engage the temporoparietal junction/posterior superior temporal sulcus predicts impaired naturalistic social cognition in schizophrenia.

Schizophrenia is associated with marked impairments in social cognition. However, the neural correlates of these deficits remain unclear. Here we use naturalistic stimuli to examine the role of the right temporoparietal junction/posterior superior temporal sulcus (TPJ-pSTS)-an integrative hub for the cortical networks pertinent to the understanding complex social situations-in social inference, a key component of social cognition, in schizophrenia. Twenty-seven schizophrenia participants and 21 healthy control subjects watched a clip of the film The Good, the Bad and the Ugly while high resolution multiband functional MRI images were collected. We used inter-subject correlation to measure the evoked activity, which we then compared to social cognition as measured by The Awareness of Social Inference Test (TASIT). We also compared between groups the TPJ-pSTS blood oxygen level-dependent activity (i) relationship with the motion content in the film; (ii) synchronization with other cortical areas involved in the viewing of the movie; and (iii) relationship with the frequency of saccades made during the movie. Activation deficits were greatest in middle TPJ (TPJm) and correlated significantly with impaired TASIT performance across groups. Follow-up analyses of the TPJ-pSTS revealed decreased synchronization with other cortical areas, decreased correlation with the motion content of the movie, and decreased correlation with the saccades made during the movie. The functional impairment of the TPJm, a hub area in the middle of the TPJ-pSTS, predicts deficits in social inference in schizophrenia participants by disrupting the integration of visual motion processing into the TPJ. This disrupted integration then affects the use of the TPJ to guide saccades during the visual scanning of the movie clip. These findings suggest that the TPJ may be a treatment target for improving deficits in a key component of social cognition in schizophrenia participants.

What you see is what you get: visual scanning failures of naturalistic social scenes in schizophrenia.

BACKGROUND: Impairments in social cognition contribute significantly to disability in schizophrenia patients (SzP). Perception of facial expressions is critical for social cognition. Intact perception requires an individual to visually scan a complex dynamic social scene for transiently moving facial expressions that may be relevant for understanding the scene. The relationship of visual scanning for these facial expressions and social cognition remains unknown. METHODS: In 39 SzP and 27 healthy controls (HC), we used eye-tracking to examine the relationship between performance on The Awareness of Social Inference Test (TASIT), which tests social cognition using naturalistic video clips of social situations, and visual scanning, measuring each individual's relative to the mean of HC. We then examined the relationship of visual scanning to the specific visual features (motion, contrast, luminance, faces) within the video clips. RESULTS: TASIT performance was significantly impaired in SzP for trials involving sarcasm (p < 10-5). Visual scanning was significantly more variable in SzP than HC (p < 10-6), and predicted TASIT performance in HC (p = 0.02) but not SzP (p = 0.91), differing significantly between groups (p = 0.04). During the visual scanning, SzP were less likely to be viewing faces (p = 0.0001) and less likely to saccade to facial motion in peripheral vision (p = 0.008). CONCLUSIONS: SzP show highly significant deficits in the use of visual scanning of naturalistic social scenes to inform social cognition. Alterations in visual scanning patterns may originate from impaired processing of facial motion within peripheral vision. Overall, these results highlight the utility of naturalistic stimuli in the study of social cognition deficits in schizophrenia.

Responding to COVID-19: Lessons Learned from a Senior Living and Social Service Organization.

This case study analyzes one senior living and social service organization's coronavirus (COVID-19) crisis response. We conducted interviews with n = 14 department managers to explore the organization's pivot to remote work and service provision. We used the Pearson and Mitroff Crisis Management Framework to organize themes. A pre-existing culture of teamwork, willingness to adapt and adopt new approaches, and responsiveness to new policies and procedures facilitated the COVID-19 crisis response. However, low levels of digital literacy among staff, decreased job satisfaction due to no face-to-face interaction between care recipient and service provider, and lack of proactive policies for crisis response, which decreased the speed of enacting remote service provision, were obstacles in effective crisis response. Lessons learned from this case study highlight the need for pre-emptive policy creation on remote service provision and work from home policies, as well as training considerations for senior living and social service organizations.

Pregnancy and Parenting Partners (P3): A Comprehensive Group-Based Prenatal, Postnatal, and Pediatric Care Program Serving Socially Disadvantaged Families.

Pregnancy and Parenting Partners (P3) is a group-based prenatal care program developed to provide access to comprehensive medical care, education, and social support during pregnancy and early parenting. P3 innovatively combines positive elements of existing evidence-based programs to address needs specific to socially disadvantaged women and their families.

The Bureau of Sages: Incorporating Older Adult Voice into Meaningful Research.

BACKGROUND: Older adults receiving long-term care are often excluded from the design, development, and implementation of health-related research. The project aimed to create, implement and evaluate a sustainable research advisory board consisting of researchers, clinicians, and older adults living at home or in a skilled nursing facility (SNF). METHODS: To initiate Bureau development, 15 older adults, researchers, and clinicians came together to engage in research. In meetings and retreats, stakeholders mutually developed group procedures, roles, and values. Process evaluation focused on stakeholder experiences, development of the Bureau, and its impact. RESULTS: Trained Sages were able to offer meaningful input to researchers and present their own proposal at a conference. Lessons learned centered around continuously seeking feedback from participants, emphasizing co-learning, adapting to virtual engagement, and remaining flexible in structure and content of meetings. CONCLUSIONS: Results can inform future development of research advisory boards of older adult populations.

Intention to Participate in Group Prenatal Care: Moving Beyond Yes or No.

Group prenatal care (GPNC) is an alternative model to traditional individual care and may improve public health outcomes. Prior studies suggest that interest in GPNC varies widely and few studies have examined characteristics predictive of interest in this model. The purpose of this study was to inform GPNC recruitment efforts by examining likelihood of participation delineated by characteristics and GPNC perceptions. Pregnant participants received information about GPNC then completed a survey measuring demographic, psychosocial, and reproductive characteristics, likelihood to participate in GPNC, and factors influencing selections. Respondents expressed varied levels of likelihood to participate in GPNC; 16.2% low likelihood, 44.9% moderate likelihood, and 38.9% high likelihood. Characteristics were similar between groups, and thus their use is not recommended when targeting recruitment efforts. Benefits outweighed barriers and threats for the high likelihood category, barriers and threats outweighed benefits for the low likelihood category, and benefits, barriers, and threats were balanced for the moderate likelihood category. Accurately assessing likelihood of participating in GPNC efficiently identifies individuals who are clearly either going to decline or participate, as well as promotes targeted recruitment efforts directed at those who are ambivalent. Understanding and addressing perceived benefits, barriers, and threats supports effective GPNC recruitment.

Validation of the MedUseQ: A Self-Administered Screener for Older Adults to Assess Medication Use Problems.

BACKGROUND: Older adults taking multiple prescription and nonprescription drugs are at risk for medication use problems, yet there are few brief, self-administered screening tools designed specifically for them. OBJECTIVE: The study objective was to develop and validate a patient-centered screener for community-dwelling older adults. METHODS: In phase 1, a convenience sample of 57 stakeholders (older adults, pharmacists, nurses, and physicians) participated in concept mapping, using Concept System® Global MAXTM, to identify items for a questionnaire. In phase 2, a 40-item questionnaire was tested with a convenience sample of 377 adults and a 24-item version was tested with 306 older adults, aged 55 and older, using Rasch methodology. In phase 3, stakeholder focus groups provided feedback on the format of questionnaire materials and recommended strategies for addressing problems. RESULTS: The concept map contained 72 statements organized into 6 conceptual clusters or domains. The 24-item screener was unidimensional. Cronbach's alpha was .87, person reliability was acceptable (.74), and item reliability was high (.96). CONCLUSION: The MedUseQ is a validated, patient-centered tool targeting older adults that can be used to assess a wide range of medication use problems in clinical and community settings and to identify areas for education, intervention, or further assessment.

Job Negotiations in Academic Medicine: Building a Competency-Based Roadmap for Residents and Fellows.

Negotiation skills are critical to career success, yet many physicians feel ill-equipped to negotiate for professional opportunities. Enhancing competencies in this arena may be especially critical for women and underrepresented minorities to reduce disparities in compensation and resources that begin upon entry into the workforce as junior faculty. This perspective offers a comprehensive overview of negotiation strategies and the job search process for individuals finishing medical training and seeking first-time employment. First, we extrapolate lessons from clinical medicine to provide a negotiation roadmap for residents and fellows. We use both a clinical and an employment scenario to illustrate the concept of principled negotiation in which negotiating partners elicit each other's values and interests and identify options for mutual gain. We then describe approaches to seeking and negotiating job opportunities and discuss typical timelines for these activities. We supply a list of professional needs to consider before a negotiation begins and introduce the concept of a best alternative to negotiated agreement to help ensure essential requirements are met in a final employment offer. Finally, we explore the utility of third-party assistance and published benchmarks and offer best practices for negotiating.

Reduced Functional Brain Activation and Connectivity During a Working Memory Task in Childhood-Onset Schizophrenia.

OBJECTIVE: Working memory (WM) deficits are consistently reported in schizophrenia and are related to poor functional outcomes. Functional magnetic resonance imaging studies of adult-onset schizophrenia have reported decreased functional activations and connectivity in the WM network, but no prior functional magnetic resonance imaging study has examined WM in childhood-onset schizophrenia (COS). The aim of this study was to examine the neural correlates of WM in COS. METHOD: Adult patients with COS (n = 32, 21.3 ± 1.1 years), nonpsychotic siblings of patients with COS (n = 30, 19.4 ± 0.8 years), and healthy controls (n = 39, 20.0 ± 0.7 years) completed 1- and 2-back WM tasks during 3-T functional magnetic resonance imaging. Functional activation and connectivity analyses were conducted. A separate group of 23 younger patients with COS (17.9 ± 7.4 years) could not perform the tasks after twice completing a standard training and are not included in this report. RESULTS: Patients with COS who were included scored significantly lower than controls on all tasks (p < .001). Patients with COS showed significantly lower activations in the dorsolateral prefrontal cortices, posterior parietal cortices, cerebellum, and caudate and decreased frontoparietal and corticostriatal functional connectivity compared with controls (p < .05, corrected). Siblings had functional activations and connectivity intermediate between those of patients and controls in a similar set of regions (p < .05, corrected). In patients, functional connectivity strength in the left frontoparietal network correlated positively with accuracy scores during the 1-back task (p = .0023, corrected). CONCLUSION: Decreased functional activation and connectivity in the WM network in COS supports pathophysiologic continuity with adult-onset schizophrenia. The low participation rate and accuracy of the patients highlights the disease severity of COS. Hypo-activations and hypo-connectivity were shared by siblings of patients with COS, suggesting COS as a potential endophenotype. CLINICAL TRIAL REGISTRATION INFORMATION: Evaluating Genetic Risk Factors for Childhood-Onset Schizophrenia; http://ClinicalTrials.gov;NCT00001198.

In situ generation, metabolism and immunomodulatory signaling actions of nitro-conjugated linoleic acid in a murine model of inflammation.

Conjugated linoleic acid (CLA) is a prime substrate for intra-gastric nitration giving rise to the formation of nitro-conjugated linoleic acid (NO2-CLA). Herein, NO2-CLA generation is demonstrated within the context of acute inflammatory responses both in vitro and in vivo. Macrophage activation resulted in dose- and time-dependent CLA nitration and also in the production of secondary electrophilic and non-electrophilic derivatives. Both exogenous NO2-CLA as well as that generated in situ, attenuated NF-κB-dependent gene expression, decreased pro-inflammatory cytokine production and up-regulated Nrf2-regulated proteins. Importantly, both CLA nitration and the corresponding downstream anti-inflammatory actions of NO2-CLA were recapitulated in a mouse peritonitis model where NO2-CLA administration decreased pro-inflammatory cytokines and inhibited leukocyte recruitment. Taken together, our results demonstrate that the formation of NO2-CLA has the potential to function as an adaptive response capable of not only modulating inflammation amplitude but also protecting neighboring tissues via the expression of Nrf2-dependent genes.