The University of South Dakota Physician Assistant Studies Program.

The University of South Dakota Physician Assistant Studies Program (USD PA Program) is in its 26th year of operation. The mission remains the same: to provide "a comprehensive primary care education that prepares graduates to deliver high-quality health care to meet the needs of patients in South Dakota and the surrounding region." The inaugural class graduated in 1995 making the class of 2018 our 24th. Graduates now number 462. The purpose of this article is to provide a brief historical background and to describe the evolution of the program and its contribution to the health care workforce of South Dakota and the region.

Spermatogonial quantity in human prepubertal testicular tissue collected for fertility preservation prior to potentially sterilizing therapy.

STUDY QUESTION: Does chemotherapy exposure (with or without alkylating agents) or primary diagnosis affect spermatogonial quantity in human prepubertal testicular tissue? SUMMARY ANSWER: Spermatogonial quantity is significantly reduced in testes of prepubertal boys treated with alkylating agent therapies or with hydroxyurea for sickle cell disease. WHAT IS KNOWN ALREADY: Cryopreservation of spermatogonial stem cells, followed by transplantation into the testis after treatment, is a proposed clinical option for fertility restoration in children. The key clinical consideration behind this approach is a sufficient quantity of healthy cryopreserved spermatogonia. However, since most boys with malignancies start therapy with agents that are not potentially sterilizing, they will have already received some chemotherapy before testicular tissue cryopreservation is considered. STUDY DESIGN, SIZE, DURATION: We examined histological sections of prepubertal testicular tissue to elucidate whether chemotherapy exposure or primary diagnosis affects spermatogonial quantity. Quantity of spermatogonia per transverse tubular cross-section (S/T) was assessed in relation to treatment characteristics and normative reference values in histological sections of paraffin embedded testicular tissue samples collected from 32 consecutive boy patients (aged 6.3 ± 3.8 [mean ± SD] years) between 2014 and 2017, as part of the NORDFERTIL study, and in 14 control samples (from boys aged 5.6 ± 5.0 [mean ± SD] years) from an internal biobank. PARTICIPANTS/MATERIALS, SETTING, METHODS: Prepubertal boys in Sweden, Finland and Iceland who were facing treatments associated with a very high risk of infertility, were offered the experimental procedure of testicular cryopreservation. Exclusion criteria were testicular volumes >10 ml and high bleeding or infection risk. There were 18 patients with a diagnosis of malignancy and 14 patients a non-malignant diagnosis. While 20 patients had the testicular biopsy performed 1-45 days after chemotherapy, 12 patients had not received any chemotherapy. In addition, 14 testicular tissue samples of patients with no reported testicular pathology, obtained from the internal biobank of the Department of Pathology at Karolinska University Hospital, were included as control samples in addition to reference values obtained from a recently published meta-analysis. The quantity of spermatogonia was assessed by both morphological and immunohistochemical analysis. MAIN RESULTS AND THE ROLE OF CHANCE: The main finding was a significant reduction in spermatogonial cell counts in boys treated with alkylating agents or with hydroxyurea for sickle cell disease. The mean S/T values in boys exposed to alkylating agents (0.2 ± 0.3, n = 6) or in boys with sickle cell disease and exposed to hydroxyurea (0.3 ± 0.6, n = 6) were significantly lower (P = 0.003 and P = 0.008, respectively) than in a group exposed to non-alkylating agents or in biobank control samples (1.7 ± 1.0, n = 8 and 4.1 ± 4.6, n = 14, respectively). The mean S/T values of the testicular tissue samples included in the biobank control group and the patient group exposed to non-alkylating agents were within recently published normative reference values. LIMITATIONS, REASONS FOR CAUTION: Normal testicular tissue samples included in this study were obtained from the internal biobank of Karolinska University Hospital. Samples were considered normal and included in the study if no testicular pathology was reported in the analysed samples. However, detailed information regarding previous medical treatments and testicular volumes of patients included in this biobank were not available. WIDER IMPLICATIONS OF THE FINDINGS: This study summarizes, for the first time, spermatogonial quantity in a prepubertal patient cohort just before and after potentially sterilizing treatments. Boys facing cancer and cytotoxic therapies are regarded as the major group who will benefit from novel fertility preservation techniques. There are no previous reports correlating spermatogonial quantity to cumulative exposure to alkylating agents and anthracyclines (non-alkylating agents) and no information about the timing of cytotoxic exposures among this particular patient cohort. For prepubertal boys in whom fertility preservation is indicated, testicular tissue should be obtained before initiation of chemotherapy with alkylating agents, whilst for those with sickle cell disease and treated with hydroxyurea, this approach to fertility preservation may not be feasible. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by grants from The Swedish Childhood Cancer Foundation (PR2016-0124; TJ2016-0093; PR2015-0073, TJ2015-0046) (J.-B.S. and K.J.), the Jane and Dan Olssons Foundation (2016-33) (J.-B.S.), the Finnish Cancer Society (K.J.), the Foundation for Paediatric Research (J.-B.S.), Kronprinsessan Lovisas Förening För Barnasjukvård/ Stiftelsen Axel Tielmans Minnesfond, Samariten Foundation (J.-B.S.), the Väre Foundation for Paediatric Cancer Research (K.J.) and the Swedish Research Council (2012-6352) (O.S.). R.T.M. was supported by a Wellcome Trust Fellowship (09822). J.P.A.-L. and M.K. were supported by the ITN Marie Curie program 'Growsperm' (EU-FP7-PEOPLE-2013-ITN 603568). The authors declare no conflicts of interest. TRIAL REGISTRATION NUMBER: N/A.

Community Health Centers in the Dakotas, 2018.

Community health centers (CHCs) are a critical component of the healthcare safety network. The modern era of CHCs began in the mid-1960s although their origin can be traced back as far as the first two decades of the 20th century. Over 24 million people receive their healthcare in CHCs. North and South Dakota are home to nine centers and provided care to nearly 110,000 medical and dental patients in 2017. All CHCs use a uniform data set to report annually on demographics, scope of practice, and clinical measures to assure that they remain true to their original mission to provide quality healthcare to the most vulnerable of our population.

Collaboration in Primary Care Through the Integration of Behavioral Health Professionals.

Rising costs, poorer outcomes, and dissatisfied patients have challenged medical systems to rethink their approach to health care delivery. Although up to 70 percent of primary care visits stem from psychosocial issues, behavioral health services have traditionally occurred in separate buildings and systems. In order to decrease barriers and meet patients' and providers' needs, primary care practices have begun integrating behavioral health professionals into their clinics. Various levels of integration exist, but the best models fully integrate behavioral health clinicians into primary care teams, allowing for seamless collaboration. Behavioral health professionals are able to support the treatment of a number of mental and physical health conditions, and can provide such services as part of regular primary care visits. Although a number of obstacles exist to developing and optimizing integrated behavioral health services, efforts are underway nationally to decrease barriers and support further training and implementation.

Foundations, Core Principles, Values, and Necessary Competencies of Interprofessional Team-Based Health Care.

Health care reform has focused on improving health care delivery, quality, and patient safety. An interprofessional, team-based approach to health care is considered by many experts to be essential to meeting these goals. The evidence for this is growing. Core principles for team-based care and the interprofessional competencies necessary for a team to function effectively have been identified and can be taught. Resources for interprofessional education, which must begin at the health professions student level, are available to academic institutions, healthcare systems, and professional organizations to prepare students and current health care professionals for this cultural change. Models of successful collaborative practices exist in many forms and will continue to evolve as our expertise in best practices for interprofessional education and practice advance.

The Impact of Maternal Diabetes, Obesity and Race on Infant Birth Weights in South Dakota.

INTRODUCTION: Maternal obesity, high gestational weight gain and diabetes mellitus during pregnancy are known risk factors that correlate with high infant birth weight and the mother's race. Previous studies have focused on low birth weight, prematurity and infant mortality. This study examined the interaction between race, maternal risk factors and high infant birth weights at the population level in South Dakota to identify factors contributing to the high Native American infant birth weights. We hypothesized that high infant birth weights were associated with maternal diabetes, obesity and high gestational weight gain, and that Native American infants' higher birth weights were related to the prevalence of diabetes and obesity. MATERIALS AND METHODS: De-identified birth certificate data was provided by the South Dakota Department of Health. We used data for live infant births to South Dakota resident mothers from 2006 through 2011. The mothers were categorized as Native American or white by the mother's self-reported primary race. Infants were excluded from the study population for missing data, birth weight less than 350 g or gestational age less than 24 weeks or greater than 45 weeks. The study population included 11,416 Native American infants and 59,263 white infants for a total study population of 70,679 infants. Maternal variables (race, pre-pregnancy weight and body mass index [BMI], gestational weight gain, pre-pregnancy diabetes mellitus [DM], gestational diabetes [GDM] and delivery BMI) and infant variables (gestational age and birth weight) were analyzed using SPSS software. RESULTS: The mean birth weight (BW) of Native American (NA) infants (3377 g) was significantly greater than the mean BW of white (W) infants (3315 g) even though NA infants had a younger mean gestational age (p = 0.006). More NA infants were categorized as high birth weight (HBW) (11.8 percent) than W infants (8.5 percent). Both DM and GDM were significantly more common among NA mothers. Infants of NA mothers with GDM had a higher mean BW than infants of W mothers with GDM. There were more overweight and obese NA mothers (p = 0.006). In each maternal BMI category, NA infants had a higher mean BW. Mean BW was even higher for infants born to mothers with excessive gestational weight gain (GWG) for their BMI. The infants with the highest mean BW were born to obese NA mothers with GDM and excessive GWG (3680 g). Multivariable linear regression showed that race was the most significant variable affecting infant BW (R2 = 0.57, F = 692). Pre-pregnancy BMI, GWG and excessive GWG were also significant. The most significant interaction variables were race and GDM and race and BMI. CONCLUSIONS: Native American race, gestational diabetes mellitus, overweight and obese BMI, and excessive gestational weight gain for BMI were the most significant maternal factors associated with high infant birth weight. Mothers with any one risk factor gave birth to heavier infants. Mothers with all risk factors had infants with the highest mean birth weights in South Dakota. This large population-based study provides evidence that Native American mothers in South Dakota with GDM, overweight or obese BMI and excessive GWG are more likely to give birth to high birth weight infants. At-risk mothers should be educated regarding the risks and potential complications of high birth weight infants.

So You Want To Be A Reviewer.

Peer review is a process for evaluating the quality of "work" of a scientist or professional as judged by others in the same or related field. In the context of the biomedical and health sciences, it primarily pertains to review of manuscripts submitted to journals for consideration of publication, abstracts for proposed presentations at professional meetings, and competitive research grant applications. Serving as a reviewer is a scholarly pursuit and a worthwhile endeavor, assuming it is approached in a conscientious, responsible manner. The purpose of this article is to define peer review and its various forms, suggest reasons for serving as a manuscript reviewer, discuss considerations prior to accepting a review assignment, and provide guidelines for the process.

So You Want To Be An Author: A Primer On Writing For Publication In The Medical Literature Part II: Manuscript Submission.

Completing a draft of a manuscript that demonstrates the impact of your research within the current literature is the first step toward publication. The next step involves a review process that will allow your peers to provide feedback on the written document, with the goal of improving the presentation of your work. To complete this process, an author will have to be willing to accept constructive criticism of his or her work, as presented, and to modify the manuscript based on the feedback received. This peer-review process will ultimately shape the final draft of your manuscript, and here we provide some points to consider as you navigate the submission and review process.

So You Want to be an Author: A Primer on Writing for Publication in the Medical Literature Part I: Manuscript Preparation.

Writing a manuscript on a topic in the medical sciences that gets accepted for publication is not always a guaranteed process. The goal of this article is to provide a description of some key points associated with preparing a manuscript. It has been written primarily for less experienced or aspiring authors, but it addresses points that are important for even well-established authors to consider. Although there may not be a direct path from scientific observation to published work, possessing the desire to publish and persevering throughout the process can ultimately lead to one's findings being both preserved in and contributing to the scientific literature. Although challenging, and at times frustrating, it is a rewarding endeavor.

Influence of Resident Physician "Moonlighting" Activities on Educational Experience and Practice Choice.

OBJECTIVES: Moonlighting by resident physicians, though a long-standing practice in the U.S., is a controversial topic. Conflicting claims of both detriment and benefit to resident education have been made. In this study, we sought to evaluate practicing family physicians' perceptions of the influence of moonlighting during their residency on their educational experience and selection of future practice site. METHODS: Graduates of two Midwestern family medicine residency programs in the U.S., one located in a metropolitan area of a populous state, one from a small city in a rural state, were surveyed via an internet survey tool as to their motivation for moonlighting, perceived educational effects--positive or negative--and its role in practice selection. RESULTS: Seventy-eight percent of respondents reported that they participated in moonlighting. Supplementation of income was the most commonly reported motivation (identified by 95.4 percent of respondents), followed closely by acquisition of additional clinical experience (87 percent). The majority perceived moonlighting as overall beneficial to residency program education (91.1 percent), beneficial in preparation for clinical practice (98.5 percent), and having a role in selection of future practice (89 percent). CONCLUSIONS: Practicing Midwestern family physicians perceive an important role for moonlighting in residents' clinical educational experiences and practice selection.

Student perceptions of their value to patient care.

PURPOSE: Engagement in meaningful activities is integral to professional identity formation, yet little has been reported in the medical education literature and no studies have focused on the medical student's perspective. This study sought to further define meaningful activities and value to patient care as perceived by third- and fourth-year medical students and to explore whether there was correlation with a sense of accomplishment. METHODS: The authors surveyed third- and fourth-year medical students of the University of South Dakota Sanford School of Medicine regarding their perceptions using the Engagement in Meaningful Activities Survey. Responses of the two groups were compared, and correlations between perceived outcomes and a sense of accomplishment were calculated. RESULTS: Both third- and fourth-year medical students perceived themselves to be of value to patients and attending physicians and of help to patients, attending physicians, and the patient care team, although in all cases the mean responses for fourth-year students trended higher. The correlation between these items and a sense of accomplishment was greater among fourth year students. CONCLUSION: Student perceptions of their value to the patient and patient care team begin to play a more prominent role as clinical experiences progress in parallel with their identify formation as physicians.

Low health literacy: a barrier to effective patient care.

BACKGROUND: Health literacy is defined in the U.S. Department of Health and Human Services initiative Healthy People 2010 as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions." It is estimated that 48.8 million Americans are functionally illiterate, making health literacy a major obstacle for providing health care. Although communicating with physicians is a small component of the tasks that are incorporated in a definition of health literacy, it remains the most important aspect of this concept contributing to personal health. METHODS: Primary care clinics within the Sioux Falls area were provided with both English and Spanish patient education brochures on communicating with physicians. A survey was then distributed to determine how low health literacy was affecting physician practices and what they were doing to remove the obstacles that health literacy presented. Physicians were asked to evaluate the multiple skills and competencies required by patients to access health care services and resources they use to assist patients. RESULTS: A total of 77 surveys were distributed. Twenty-two (28.6 percent) were returned. Of the physicians who returned the survey, the majority (77 percent) thought that low health literacy is a moderate obstacle in their practices. Several physicians stated that their offices had at least one method in place to assist those with low health literacy, but none of them were using a formal test of health literacy. Only six physicians could name a community resource to assist patients with low health literacy. CONCLUSION: Low health literacy is an unavoidable barrier to effective patient care for physicians across the country. If the full spectrum definition of health literacy is understood by physicians and carefully considered in the context of their own practices, it is likely they would come to the realization that health literacy is a greater obstacle to providing health care than they previously considered. In order to communicate more effectively and better serve our patients, we need to resist stereotyping patients when estimating (e.g., over estimating or under estimating) their health literacy. We also need to identify educational resources and methods of communication that will ease the burden of health illiteracy. With nearly half of patients having low health literacy nationwide, it is essential to understand health literacy and acknowledge this problem in all of our practices.

Extenuating circumstances. Student selection of case presentations for a required rural family medicine clerkship.

PURPOSE: The Fourth Year Rural Family Medicine Clerkship has been a required four-week clinical rotation at the Sanford School of Medicine of the University of South Dakota (SSOM) for more than 30 years. Among the clerkship requirements has been a graded, formal case presentation. The purpose of this study was to examine the case presentations selected by the medical students for this required component of the clerkship and to determine if this correlated with their overall clinical experiences. METHODS: Clinical diagnoses of patients selected by all students for their formal case presentations were recorded and compared with the overall clinical experiences as documented using the Student Patient Experience Log database. The frequency of multiple diagnosis cases was also determined. RESULTS: Although the large majority of clinical experiences occur in ambulatory settings during this clerkship, findings suggest students have a preference for presenting on patients who were hospitalized. This does not, however, indicate that students wish to necessarily present more complicated cases. In fact, the percentage of patients selected who had multiple diagnoses was much lower compared with their overall clinical experiences. CONCLUSIONS: The variety of clinical cases selected for presentation is different than the variety of overall clinical experiences. This suggests that some selection criteria are being used by students.

Biological manganese-dependent sulfide oxidation impacts elemental gradients in redox-stratified systems: indications from the Black Sea water column.

The reduction of manganese oxide with sulfide in aquatic redox-stratified systems was previously considered to be mainly chemical, but recent isolation of the Black Sea isolate Candidatus Sulfurimonas marisnigri strain SoZ1 suggests an important role for biological catalyzation. Here we provide evidence from laboratory experiments, field data, and modeling that the latter process has a strong impact on redox zonation in the Black Sea. High relative abundances of Sulfurimonas spp. across the redoxcline in the central western gyre of the Black Sea coincided with the high-level expression of both the sulfide:quinone oxidoreductase gene (sqr, up to 93% expressed by Sulfurimonas spp.) and other sulfur oxidation genes. The cell-specific rate of manganese-coupled sulfide oxidation by Ca. S. marisnigri SoZ1 determined experimentally was combined with the in situ abundance of Sulfurimonas spp. in a one-dimensional numerical model to calculate the vertical sulfide distribution. Abiotic sulfide oxidation was too slow to counterbalance the sulfide flux from euxinic water. We conclude that microbially catalyzed Mn-dependent sulfide oxidation influences the element cycles of Mn, S, C, and N and therefore the prevalence of other functional groups of prokaryotes (e.g., anammox bacteria) in a sulfide-free, anoxic redox zone.

Migration and asthma medication in international adoptees and immigrant families in Sweden.

BACKGROUND: Studies of asthma in migrant populations illustrate the effects of environmental changes. OBJECTIVE: In this register study we investigated the importance of exposure to a western lifestyle in different phases of development in Swedish residents with an origin in regions in the world where asthma usually is less prevalent. METHODS: The study population comprised 24,252 international adoptees, 47,986 foreign-born and 40,971 Swedish-born with foreign-born parents and 1,770,092 Swedish-born residents with Swedish-born parents (age 6-25 years). Purchased prescribed inhaled corticosteroids (ICS) during 2006 were used as an indicator of asthma. RESULTS: International adoptees and children born in Sweden by foreign-born parents had three- to fourfold higher rates of asthma medication compared with foreign-born children. The odds ratios (ORs) of asthma medication declined persistently with age at immigration. For adoptees the ORs compared with infant adoptees were 0.78 [95% confidence interval (CI) 0.71-0.85] for those adopted at 1-2 years, 0.51 (0.42-0.61) at 3-4 years and 0.35 (0.27-0.44) after 5 or more years of age. Corresponding ORs for foreign-born children with foreign-born parents immigrating at 0-4 years, at 5-9 years, at 10-14 years and at 15 years or more were 0.73 (0.63-0.86), 0.56 (CI 0.46-0.68) and 0.35 (CI 0.28-0.43), respectively. The ORs were only marginally affected by adjustment for region of birth and socio-economic indicators. CONCLUSIONS AND CLINICAL RELEVANCE: Age at immigration is a more important determinant of purchased ICS than population of origin. This indicates the importance of environmental factors for asthma in schoolchildren and young adults.

[Procedure guideline for sentinel lymph node diagnosis]. / Verfahrensanweisung für die nuklearmedizinische Wächter-Lymphknoten-Diagnostik.

The authors present a procedure guideline for scintigraphic detection of sentinel lymph nodes in malignant melanoma and other skin tumours, in breast cancer, in head and neck cancer, and in prostate and penile carcinoma. Important goals of sentinel lymph node scintigraphy comprise reduction of the extent of surgery, lower postoperative morbidity and optimization of histopathological examination focussing on relevant lymph nodes. Sentinel lymph node scintigraphy itself does not diagnose tumorous lymph node involvement and is not indicated when lymph node metastases have been definitely diagnosed before sentinel lymph node scintigraphy. Procedures are compiled with the aim to reliably localise sentinel lymph nodes with a high detection rate typically in early tumour stages. Radiation exposure is low so that pregnancy is not a contraindication for sentinel lymph node scintigraphy. Even with high volumes of scintigraphic sentinel lymph node procedures surgeons, theatre staff and pathologists receive a radiation exposure <1 mSv/year so that they do not require occupational radiation surveillance.

Prognostic value of daily cardiac surgery score (CASUS) and its derivatives in cardiac surgery patients.

BACKGROUND: We aimed to validate the usefulness of CASUS derivatives for cardiac surgery patients and their reliability for daily decision making. METHODS: We included, prospectively, the data of all adult cardiac surgery patients who had an ICU stay of at least 12 hours between 20 January 2003 and 14 October 2005 in the Department of Cardiothoracic Surgery of the University of Cologne, Germany. Data were collected until ICU discharge and included initial, maximum, mean, and total CASUS values. δ CASUS (difference from initial value) was calculated at 48 and 96 hours postoperatively. The predictive efficacy of the derivatives was tested with calibration and discrimination statistics. RESULTS: 2372 patients were included with a mean age of 66.2 ± 11.2 years. ICU mortality was 3.6 % (n =85). Mean ICU stay was 3.0 ± 6.1 days. The discrimination was very good for all derivatives (area under the curve ranged between 0.988 and 0.926). The calibration was also good except for the total CASUS, which showed a significant difference between the expected and observed mortality. Increased δ CASUS at 48 hours (1038 patients) and 96 hours (435 patients) correlated with an increase in mortality (23.1 % and 42.9 %, respectively), and conversely a decreased mortality rate was observed with decreasing values (1.9 % and 3.8 %, respectively). CONCLUSION: CASUS derivatives including δ CASUS have a good prognostic value for cardiac surgery patients with regard to the prediction of mortality and survival during ICU stay, with the exception of total CASUS which was not informative.

Extenuating circumstances: The University of South Dakota Physician Assistant Studies program.

During the course of graduating 15 classes of physician assistant students at The University of South Dakota much has evolved, yet our ultimate goal remains the same: To meet the needs of South Dakota and the region. The inaugural class graduated in 1995, making this year our 15th graduating class. The purpose of this article is to provide a brief historical background and to describe the evolution of the Physician Assistant Studies program.