Student, Staff and Faculty Experience with a Medical School Racial and Sociopolitical Trauma Protocol: A Mixed Methods Study.

Problem: Medical students experience racial and sociopolitical trauma that disrupts their learning and wellbeing. Intervention: University of California, San Francisco (UCSF) School of Medicine students advocated for a systems approach to responding to traumatic events. Students partnered with educators to introduce an innovative protocol that affords short-term flexibility in curricular expectations (e.g., defer attendance, assignments, assessments) to empower students to rest, gather, or pursue community advocacy work. This study explored students' protocol utilization and student, staff, and faculty experience with its implementation. Context: UCSF is a public medical school with a diverse student body. Students raised the need to acknowledge the effects of trauma on their learning and wellbeing. Consequently, students and educators created the UCSF Racial and Sociopolitical Trauma protocol ('protocol') to allow students time-limited flexibility around academic obligations following events anticipated to inflict trauma on a school community level. The protocol affords students space to process events and engage with affected communities while ensuring all students achieve school competencies and graduation requirements. Impact: We conducted a two-phase mixed methods study: (1) retrospective analysis of quantitative data on students' protocol use and (2) focus groups with students, staff, and faculty. We used descriptive statistics to summarize students' protocol use to adjust attendance, assignment submission, and assessments and thematic analysis of focus group data. Across eight protocol activations June 2020 - November 2021, 357 of 664 (54%) students used it for 501 curricular activities: 56% (n = 198) for attendance, 71% (n = 252) for assignments, and 14% (n = 51) for assessments. When deciding to utilize the protocol, student focus group participants considered sources of restoration; impact on their curricular/patient responsibilities; and their identities. The protocol symbolized an institutional value system that made students feel affirmed and staff and faculty proud. Staff and faculty initially faced implementation challenges with questions around how to apply the protocol to curricular components and how it would affect their roles; however, these questions became clearer with each protocol activation. Questions remain regarding how the protocol can be best adapted for the clerkship setting. Lessons Learned: High protocol usage and focus group data confirmed that students found value in the protocol, and staff and faculty felt invested in the protocol mission. This student-initiated intervention supports a cultural shift beyond diversity toward trauma-informed medical education. Partnership among learners and educators can contribute to transforming learning and healthcare environments by enacting systems and structures that enable all learners to thrive.

Correction to: Imaging features of immune-mediated genitourinary disease.

The authors regret that they neglected to cite their conference report on the technical part of a 'preliminary study' presented at, and published in, the Biomedical Sciences and Engineering Conference (BSEC), 2010, May 25-26 (Fully automated segmentation and characterization of the dendritic trees of retinal horizontal neurons -DOI: 10.1109/BSEC.2010.5510843 ), as it related to the larger dataset presented as validation of the method in the Neurochemical Research article (Automated Tracing of Horizontal Neuron Processes During Retinal Development- Neurochem Res. 2011 Apr;36(4):583-93). This resulted in the lack of transparency on the re-use and duplication of introductory text, which should have been cited. No figures or tables were reproduced, but rather larger confirmatory data and different set of results were reported. Appropriate authors were cited in both papers.

Twelve tips for responding to microaggressions and overt discrimination: When the patient offends the learner.

Microaggressions and expressions of overt discrimination negatively affect the experience of medical trainees at all levels. Mistreatment of trainees, including abusive and discriminatory behavior by patients and families, occurs commonly and is receiving increased attention in both the medical literature and popular press. Heightened awareness of the problem has sparked a call to engage in substantive conversations about bias in health professions education. The emphasis on direct observation in medical education makes the bedside a common setting for educators to witness these behaviors firsthand. Many educators are committed to developing a positive climate for learners but lack the training and skills to facilitate discussions about discrimination. As a result, these difficult but important conversations may not occur. The authors present a three-phase approach to responding to microaggressions and discrimination toward trainees from patients, and offer a communication toolkit that frontline medical educators can use in their daily practice.

Computational analysis of signaling patterns in single cells.

Signaling proteins are flexible in both form and function. They can bind to multiple molecular partners and integrate diverse types of cellular information. When imaged by time-lapse microscopy, many signaling proteins show complex patterns of activity or localization that vary from cell to cell. This heterogeneity is so prevalent that it has spurred the development of new computational strategies to analyze single-cell signaling patterns. A collective observation from these analyses is that cells appear less heterogeneous when their responses are normalized to, or synchronized with, other single-cell measurements. In many cases, these transformed signaling patterns show distinct dynamical trends that correspond with predictable phenotypic outcomes. When signaling mechanisms are unclear, computational models can suggest putative molecular interactions that are experimentally testable. Thus, computational analysis of single-cell signaling has not only provided new ways to quantify the responses of individual cells, but has helped resolve longstanding questions surrounding many well-studied human signaling proteins including NF-κB, p53, ERK1/2, and CDK2. A number of specific challenges lie ahead for single-cell analysis such as quantifying the contribution of non-cell autonomous signaling as well as the characterization of protein signaling dynamics in vivo.

Retinoblastoma (Rb) regulates laminar dendritic arbor reorganization in retinal horizontal neurons.

Neuronal differentiation with respect to the acquisition of synaptic competence needs to be regulated precisely during neurogenesis to ensure proper formation of circuits at the right place and time in development. This regulation is particularly important for synaptic triads among photoreceptors, horizontal cells (HCs), and bipolar cells in the retina, because HCs are among the first cell types produced during development, and bipolar cells are among the last. HCs undergo a dramatic transition from vertically oriented neurites that form columnar arbors to overlapping laminar dendritic arbors with differentiation. However, how this process is regulated and coordinated with differentiation of photoreceptors and bipolar cells remains unknown. Previous studies have suggested that the retinoblastoma (Rb) tumor suppressor gene may play a role in horizontal cell differentiation and synaptogenesis. By combining genetic mosaic analysis of individual synaptic triads with neuroanatomic analyses and multiphoton live imaging of developing HCs, we found that Rb plays a cell-autonomous role in the reorganization of horizontal cell neurites as they differentiate. Aberrant vertical processes in Rb-deficient HCs form ectopic synapses with rods in the outer nuclear layer but lack bipolar dendrites. Although previous reports indicate that photoreceptor abnormalities can trigger formation of ectopic synapses, our studies now demonstrate that defects in a postsynaptic partner contribute to the formation of ectopic photoreceptor synapses in the mammalian retina.

Peer Support Ambassadors: A Program to Advance a Supportive and Inclusive Clinical Learning Environment.

ABSTRACT: Peer support is beneficial to physicians in distress, but few institutions have created formal programs that train residents and fellows to effectively support their peers. Existing curricula also do not address the differential experience of residents from historically excluded groups, who are more likely to experience distressing mistreatment and discrimination in the clinical learning environment. The Graduate Medical Education (GME) Peer Support Ambassador (PSA) Program aimed to address this gap by: (1) offering peer support skills and trauma-informed care training to a diverse cohort of resident leaders representing a range of specialties, (2) deploying these leaders to support their peers, and (3) facilitating opportunities for participants to train other residents in these skills. In the PSA program's inaugural year, 10 residents were trained in fundamentals of peer support, trauma-informed care, and the restorative mindset. The training increased participants' confidence and skills in these areas, increased their understanding of when to refer a co-resident for additional levels of support, and their awareness of resources for mental health care and addressing mistreatment and discrimination. Beyond the skills training, the program broadened participants' perspectives about other residents' experiences and helped them feel more connected to residents in other specialties. Opportunities to improve the PSA program include creating more opportunities for program participants to connect between sessions and after the training, publicizing the program more effectively to residents experiencing distress, and training a larger number of residents in peer support skills.

The Impact of Patient-Physician Racial and Gender Concordance on Patient Satisfaction with Outpatient Clinic Visits.

BACKGROUND: Patient and provider race and gender concordance (patient and physician identify as the same race/ethnicity or gender) may impact patient experience and satisfaction. OBJECTIVE: We sought to examine how patient and physician racial and gender concordance effect patient satisfaction with outpatient clinical encounters. Furthermore, we examined factors that changed satisfaction among concordant and discordant dyads. DESIGN: Consumer Assessment of Healthcare Provider and Systems (CAHPS) Patient Satisfaction Survey Scores were collected from outpatient clinical encounters between January 2017 and January 2019 at the University of California, San Francisco. PARTICIPANTS: Patients who were seen in the eligible time period, who voluntarily provided physician satisfaction scores. Providers with fewer than 30 reviews and encounters with missing data were excluded. MAIN MEASURES: Primary outcome was rate of top satisfaction score. The provider score (1-10 scale) was dichotomized as "top score (9-10)" and "low scores (<9)." KEY RESULTS: A total of 77,543 evaluations met inclusion criteria. Most patients identified as White (73.5%) and female (55.4%) with a median age of 60 (IQR 45, 70). Compared to White patients, Asian patients were less likely to give a top score even when controlling for racial concordance (OR: 0.67; CI 0.63-0.714). Telehealth was associated with increased odds of a top score relative to in-person visits (OR 1.25; CI 1.07-1.48). The odds of a top score decreased by 11% in racially discordant dyads. CONCLUSIONS: Racial concordance, particularly among older, White, male patients, is a nonmodifiable predictor of patient satisfaction. Physicians of color are at a disadvantage, as they receive lower patient satisfaction scores, even in race concordant pairs, with Asian physicians seeing Asian patients receiving the lowest scores. Patient satisfaction data is likely an inappropriate means of determining physician incentives as such may perpetuate racial and gender disadvantages.

The General Surgery Residency Experience: A Multicenter Study of Differences in Wellbeing by Race/Ethnicity.

Objectives: We explored differences by race/ethnicity in regard to several factors that reflect or impact wellbeing. Background: Physician wellbeing has critical ramifications for the US healthcare system, affecting clinical outcomes, patient experience, and healthcare economics. Within surgery, literature examining the association between race/ethnicity and wellbeing has been limited and inconclusive. Methods: Residents at 16 academic General Surgery training programs completed an online questionnaire. Racial/ethnic identity, gender identity, post-graduate year (PGY) level, and gap years were self-reported. Differences by race/ethnicity in flourishing (global wellbeing) as well as factors reflecting resilience (mindfulness, personal accomplishment, workplace support, workplace control) and risk (depression, emotional exhaustion, depersonalization, stress, anxiety, workplace demand) were assessed. Results: Of 300 respondents (response rate 34%), 179 (60%) were non-male, 123 (41%) were residents of color (ROC), and 53 (18%) were from racial/ethnic groups that are underrepresented in medicine (UIM). Relative to White residents, ROC have significantly lower flourishing and higher anxiety, and these remain significant when adjusting for gender, PGY level, and gap years. Relative to residents overrepresented in medicine (OIM), UIM residents have significantly lower emotional exhaustion and depersonalization after adjusting for gender, PGY level and gap years. Conclusions: Disparities in resident wellbeing based on race/ethnicity and UIM/OIM status exist. However, the experience of ROC is not homogeneous. As part of the transformative process to address systemic racism, eliminate disparities in surgical training, and reconceptualize wellbeing as a fundamental asset for optimal surgeon performance, further understanding the specific contributors and detractors of wellbeing among different individuals and groups is critical.

Neogenin mediates the action of repulsive guidance molecule.

Repulsive guidance molecule (RGM) is a recently identified protein implicated in both axonal guidance and neural tube closure. The avoidance of chick RGM in the posterior optic tectum by growing temporal, but not nasal, retinal ganglion cell axons is thought to contribute to visual map formation. In contrast to ephrins, semaphorins, netrins and slits, no receptor mechanism for RGM action has been defined. Here, an expression cloning strategy identified neogenin as a binding site for RGM, with a sub-nanomolar affinity. Consistent with selective axonal responsiveness to RGM, neogenin is expressed in a gradient across the chick retina. Neogenin is known to be one of several netrin-binding proteins but only neogenin interacts with RGM. The avoidance of RGM by temporal retinal axons is blocked by the anti-neogenin antibody and the soluble neogenin ectodomain. Dorsal root ganglion axons are unresponsive to RGM but are converted to a responsive state by neogenin expression. Thus, neogenin functions as an RGM receptor.

Automated tracing of horizontal neuron processes during retinal development.

In the developing mammalian retina, horizontal neurons undergo a dramatic reorganization of their processes shortly after they migrate to their appropriate laminar position. This is an important process because it is now understood that the apical processes are important for establishing the regular mosaic of horizontal cells in the retina and proper reorganization during lamination is required for synaptogenesis with photoreceptors and bipolar neurons. However, this process is difficult to study because the analysis of horizontal neuron anatomy is labor intensive and time-consuming. In this paper, we present a computational method for automatically tracing the three-dimensional (3-D) dendritic structure of horizontal retinal neurons in two-photon laser scanning microscope (TPLSM) imagery. Our method is based on 3-D skeletonization and is thus able to preserve the complex structure of the dendritic arbor of these cells. We demonstrate the effectiveness of our approach by comparing our tracing results against two sets of semi-automated traces over a set of 10 horizontal neurons ranging in age from P1 to P5. We observe an average agreement level of 81% between our automated trace and the manual traces. This automated method will serve as an important starting point for further refinement and optimization.

Start the Way You Want to Finish: An Intensive Diversity, Equity, Inclusion Orientation Curriculum in Undergraduate Medical Education.

PROBLEM: Medical students often feel unprepared to care for patients whose cultural backgrounds differ from their own. Programs in medical schools have begun to address health: inequities; however, interventions vary in intensity, effectiveness, and student experience. INTERVENTION: The authors describe an intensive 2-day diversity, equity, and inclusion curriculum for medical students in their orientation week prior to starting formal classes. Rather than using solely a knowledge-based "cultural competence" or a reflective "cultural humility" approach, an experiential curriculum was employed that links directly to fundamental communication skills vital to interactions with patients and teams, and critically important to addressing interpersonal disparities. Specifically, personal narratives were incorporated to promote individuation and decrease implicit bias, relationship-centered skills practice to improve communication across differences, and mindfulness skills to help respond to bias when it occurs. Brief didactics highlighting student and faculty narratives of difference were followed by small group sessions run by faculty trained to facilitate sessions on equity and inclusion. CONTEXT: Orientation week for matriculating first-year students at a US medical school. IMPACT: Matriculating students highly regarded an innovative 2-day diversity, equity, and inclusion orientation curriculum that emphasized significant relationship-building with peers, in addition to core concepts and skills in diversity, equity, and inclusion. LESSONS LEARNED: This orientation represented an important primer to concepts, skills, and literature that reinforce the necessity of training in diversity, equity, and inclusion. The design team found that intensive faculty development and incorporating diversity concepts into fundamental communication skills training were necessary to perpetuate this learning. Two areas of further work emerged: (1) the emphasis on addressing racism and racial equity as paradigmatic belies further essential understanding of intersectionality, and (2) uncomfortable conversations about privilege and marginalization arose, requiring expert facilitation.

Student-Led Efforts to Advance Anti-Racist Medical Education.

Over the past decade, medical schools across the United States have increasingly dedicated resources to advancing racial and social justice, such as by supporting diversity and inclusion efforts and by incorporating social medicine into the traditional medical curricula. While these changes are promising, the academic medicine community must apply an anti-racist lens to every aspect of medical education to equip trainees to recognize and address structural inequities. Notably, organizing and scholarly work led by medical students has been critical in advancing anti-racist curricula. In this article, the authors illustrate how student activism has reshaped medical education by highlighting examples of student-led efforts to advance anti-racist curricula at Harvard Medical School (HMS) and at the University of California, San Francisco (UCSF) School of Medicine. HMS students collaborated with faculty to address aspects of existing clinical practice that perpetuate racism, such as the racial correction factor in determining kidney function. They also responded to the existing curricula by noting missed opportunities to discuss structural racism, and they planned supplemental sessions to address these gaps. At UCSF, students identified specific avenues to improve the rigor of social medicine courses and developed new curricula to equip students with skills to confront and work to dismantle racism. The authors describe how HMS students, in an effort to improve the learning environment, developed a workshop to assist students in navigating microaggressions and discrimination in the clinical setting. At UCSF, students partnered with faculty and administration to advocate pass/fail grading for clerkships after university data revealed racial disparities in students' clerkship assessments. In reviewing these examples of students' advocacy to improve their own curricula and learning environments, the authors aim to provide support for students and faculty pursuing anti-racist curricular changes at their own institutions.

Quantitative NMR-Based Metabolomics on Tissue Biomarkers and Its Translation into In Vivo Magnetic Resonance Spectroscopy.

Nuclear magnetic resonance (NMR) spectroscopy is an established analytical platform for analyzing metabolic profiles of cells, tissues, and body fluids. There are several advantages in introducing an NMR-based study design into metabolomics studies, including a fast and comprehensive detection, characterization, and quantification of dozens of endogenous metabolites in a single NMR spectrum. Quantitative proton 1H-NMR is the most useful NMR-based platform for metabolomics. The frozen tissues can be analyzed noninvasively using a high-resolution magic angle spinning (HR-MAS) 1H-NMR spectroscopy; or several extraction techniques can be applied to detect additional metabolites using a conventional liquid-based NMR technique. In this chapter, we report on tissue collection, handling, extraction methods, and 1H-NMR acquisition protocols developed in the past decades for a precise and quantitative NMR-metabolomics approach. The NMR acquisition protocols (both HR-MAS and conventional 1H-NMR spectroscopy) and spectral analysis steps are also presented. Since NMR can be applied "in vivo" using horizontal bore MRI scanners, several in vivo sequences for localized 1H-MRS (magnetic resonance spectroscopy) are presented which can be directly applied for noninvasive detection of brain metabolites.

PET imaging of brain macrophages using the peripheral benzodiazepine receptor in a macaque model of neuroAIDS.

HIV infection in humans and simian immunodeficiency virus (SIV) infection in macaques result in encephalitis in approximately one-quarter of infected individuals and is characterized by infiltration of the brain with infected and activated macrophages. 1-(2-chlorphenyl)-N-methyl-N-(1-methylpropyl)-3-isoquinoline-carboxamide (PK11195) is a ligand specific for the peripheral benzodiazepine receptor abundant on macrophages and is expressed in low levels in the noninfected brain. We hypothesized that positron-emission tomography (PET) with the carbon-11-labeled, R-enantiomer form of PK11195 ([(11)C](R)-PK11195) could image brain macrophages and hence the development of encephalitis in vivo. [(11)C](R)-PK11195 binding was assessed in the brain using PET in 11 SIV infected macaques, six of which showed increased binding in vivo. Postmortem examination of the brain in these six macaques demonstrated encephalitis, while macaques that did not show an increase in [(11)C](R)-PK11195 binding did not develop SIV encephalitis. Brain tissue from SIV encephalitic macaques also showed increased [(3)H](R)-PK11195 binding compared with binding in nonencephalitic macaques. Increased PK11195 binding in vivo and in postmortem brain tissue correlated with abundance of macrophages but not astrocytes. Our results suggest that PET [(11)C](R)-PK11195 imaging can detect the presence of macrophages in SIV encephalitis in vivo and may be useful to predict the development of HIV encephalitis and in studies of the pathogenesis and treatment of HIV dementia.

Musculoskeletal injuries in tennis.

Tennis is popular in the United States, with millions participating in the sport. Unlike many other sports, young, middle-aged, and elderly persons are actively playing tennis. Most injuries that are seen are secondary to overuse. Faulty stroke mechanics are often involved in the development of specific injuries seen in tennis players. Fortunately, most injuries respond to conservative treatment and do not require surgery. Most players are able to return to their previous level of activity after appropriate treatment.

Sodium MR imaging of acute and subacute stroke for assessment of tissue viability.

Sodium MR imaging at 3.0 T provides high-quality images in acceptable acquisition times that allow assessment of tissue viability as defined by maintenance of sodium ion homeostasis. This application is made feasible for clinical stroke evaluation by an efficient projection pulse sequence with extremely short echo time values. This twisted projection imaging provides high signal-to-noise images at adequate resolution (5 x 5 x 5 mm(3)) in less than 10 minutes at 3.0 T. The images are quantified as tissue sodium concentration (TSC) maps that can be interpreted directly in terms of tissue viability. With infarction, baseline TSC values of less than 45 mmol/L increase at variable rates to approximately 70 mmol/L, allowing monitoring of the progression of stroke pathophysiology.