Laparoscopic-Simulator Box: a Simple Design for Surgical Residency Programs to Improve Trainees’ Laparoscopic Skills

Introduction: Since the introduction and evolution of laparoscopic surgery, there have been some concerns related to surgical training in this field. Laparoscopic box trainers and virtual simulators appear as useful devices which have been demonstrating effectiveness in learning surgical skills. However, these tools remain inaccessible for many centers around the world. Our intent is to share our experience in successful design to inspire others in surgical residency programs to build such boxes for training in laparoscopic techniques and also to encourage the use of simulators in educational centers. [See PDF for complete abstract]

Prioritizing Residents' Needs: On the Creation of a Residents as Teachers and Leaders Program

Introduction: Residents are responsible for the majority of medical student teaching and directly supervise, instruct, and evaluate students. Many organizations now recommend that residency training programs include venues specifically designed to develop resident teaching skills. [See PDF for abstract].

The relationship between rheumatoid arthritis and reproductive function

There is growing support for the theory that an interaction between the immune and reproductive/endocrine systems underlies the pathogenesis of autoimmune rheumatic diseases. Most of the recent evidence derives from studies of sex hormones and pregnancy in women with systemic lupus. Other than an ameliorative effect of pregnancy, little is known about reproductive factors in relation to rheumatoid arthritis. To elucidate the relationship, a population-based retrospective study was undertaken. Included were 378 female residents of Olmsted County, Minnesota diagnosed with rheumatoid arthritis between 1950 and 1982 (cases) and 325 arthritis-free, married female controls matched to the 324 married cases on birth-year, age at first marriage, and duration of Olmsted County residency. Information of reproductive factors was extracted from the medical records system maintained by the Mayo Clinic.^ Cases had lower fertility rates compared with the female population of Minnesota (rate ratio = 0.86, 95% confidence interval (CI)= 0.80-0.92). Fertility was significantly reduced even prior to the onset of rheumatoid factor positive arthritis. Restricting the comparison to married Olmsted County residents did not alter the results. Further adjustments for time not at risk of conception using survival analysis and proportional hazards modeling only intensified the fertility reduction in the married cases compared with controls. Nulligravidity was more common among cases than controls (odds ratio = 3.16, CI = 1.61-6.20). Independent of fertility, pregnancy had a protective effect against rheumatoid arthritis (odds ratio = 0.31, CI = 0.11-0.89), which was dramatically reversed in the 12 months postpartum (odds ratio = 4.67, CI = 1.50-14.47). Cases were younger at menopause than controls (p $<$ 0.01).^ Small but statistically insignificant associations were observed between rheumatoid arthritis and the following factors: increased frequency of complaints to a physician of infertility; increased frequency of spontaneous abortion, premature birth, and congenital malformations following arthritis onset; and increased prevalence of menopause at arthritis onset. Cases did not differ from controls on age at menarche, duration of pregnancy, or birth weight.^ The findings provide further support for the involvement of the reproductive/endocrine systems in the pathogenesis of autoimmune rheumatic disease. The search for biological mechanisms should be intensified. ^

The population health performance of medical students at two medical schools

Public Health and medicine are complimentary disciplines dedicated to the health and well-being of humankind. Worldwide, medical school accreditation bodies require the inclusion of population health in medical education. In 2003, the Institutes of Medicine (IOM) recommended that all medical students receive basic public health training in population-based prevention. The purpose of this study was to (1) examine the public health clinical performance of third-year medical students at two independent medical schools, (2) compare the public health clinical practice performance of the schools, and (3) identify underlying predictors of high and low public health clinical performance at one of the medical schools. ^ This study is unique in its analysis and report of observed medical student public health clinical practices. The cohort consisted of 751 third-year medical students who completed a required clinical performance exam using trained standardized patients. Medical student performance scores on 24 consensus public health items derived from nine patient cases were analyzed.^ The analysis showed nearly identical results for both medical schools at the 60%, 65%, and 70% pass rate. Students performed poorly on items associated with prevention, behavioral science, and surveillance. Factors associated with high student performance included being from an underrepresented minority, matching to a primary care residency, and high class ranking. A review of medical school curriculum at both schools revealed a lack of training in four public health domains. Nationally, 32% of medical students reported inadequate training in public health in the year 2006.^ These findings suggest more dedicated teaching time for public health domains is needed at the medical schools represented in this study. Finally, more research is needed to assess attainment of public health knowledge and skills for medical students nationwide if we are to meet the recommendations of the IOM. ^

An assessment of risk of osteogenic sarcoma from exposure to radium

The etiology of the vast majority of osteosarcoma deaths has not been explained. A possible explanation might be lifetime ingestion of radium from environmental sources which might give rise to differential risk. This study was an effort toward understanding the role of naturally occurring radium in the etiology of bone cancer. Furthermore, there was an interest in the interaction of between radionuclides and selenium; the latter believed to be a potential anticarcinogen.^ Two approaches were used to evaluate the association between environmental radium, selenium and osteogenic sarcoma: (1) spatial and temporal patterns of osteogenic sarcoma mortality in Texas were described for the period from 1969 to 1988; and (2) a case-control study was performed using 974 osteosarcoma deaths and category-matched controls selected from other deaths to evaluate the association between this disease and residency history as an indirect measure of radium and selenium exposures.^ Analyses and comparison of mortality in a population exposed to regions of elevated levels of radium 226,228 and elevated levels of selenium in drinking water with those in a matched control population have resulted in three observations: (1) there appeared to be a slight protective effect for residing in areas high in radium; (2) there were no significant differences between cases and controls when observed for length of residence or residence in urban/rural regions of high or low radium; and (3) although regions high in selenium appeared to have a decreased risk for bone cancer and urban areas in regions of elevated selenium showed an increased risk of bone cancer, these differences were not significant. ^

Is family medicine meeting the HIV/AIDS challenge? A national survey of family physicians' beliefs, clinical competence, and experience regarding HIV disease

A national sample of family physicians was surveyed to (1) assess family physicians' beliefs about the human immunodeficiency virus (HIV) and individuals at risk for infection, their clinical competence regarding HIV-related issues, and their experiences with HIV disease; (2) present conclusions to the American Academy of Family Physicians (AAFP) to effect the development of an early clinical care protocol and a continuing medical education curriculum; and (3) collect base-line data for use in the evaluation of an early clinical care protocol and a continuing medical education curriculum, in the case that such programs are developed and disseminated. After considering retired or deceased respondents, of the 2,660 physicians surveyed, 1,678 (63.7%) responded. The resulting sample was representative of the active members of the AAFP. About 77% of the respondents were unable to accurately identify the universal precautions for blood and body fluids to prevent occupational transmission of HIV or hepatitis B virus (HBV). Residency trained and board certified physicians expressed fewer "external constraints," such as fear of losing patients, obviating them from providing treatment to individuals with HIV disease (p =.004 and p $<$.001, respectively). These physicians also manifested fewer "internal constraints" to the provision of HIV treatment, such as fear of becoming infected (p $<$.001 and p =.012, respectively). Residency trained physicians also expressed a greater comfort with discussing sexually-related topics with their patients than did non-residency trained physicians (p $<$.001). There were 67.1% of the physicians surveyed who reported never providing treatment to an individual with HIV disease. Residency trained and board certified physicians expressed a greater likelihood to provide treatment to HIV-infected patients (p $<$.001) than non-residency trained and non-board certified physicians.^ Among the various primary care specialties, family medicine is especially vulnerable to the current challenges of HIV/AIDS. These challenges are augmented by the epidemiologic pattern that characterizes AIDS. For the past several years, we have seen AIDS in this country assume a similar pattern to that seen in most other countries; HIV is becoming increasingly prevalent in the heterosexual population as well as in locations removed from metropolitan centers. This current phase of the epidemic generates greater pressures upon primary care physicians, particularly family physicians, to become better acquainted with the means to provide early care to HIV/AIDS patients and to prevent HIV/AIDS among their patients. Family medicine is especially appropriate for providing care to HIV patients because family medicine involves treatment to all age groups and conditions; other primary care specialties focus on limited patient populations or specific conditions. Family physicians should be armed with the expertise to confront HIV/AIDS. However, family physicians' clinical competence and experience with HIV is not known. The data collected in this survey describes their competencies, attitudes, and experiences. ^

Women physicians' specialty choices

Three hypotheses have been offered to explain the historical specialty selection by women physicians. They are: (1) women choose the specialty for which the training requirements and working conditions interfere least with their commitments to marriage and children; (2) women tend to select the more "feminine" specialties such as pediatrics and psychiatry, and to avoid the "masculine" fields such as surgery; and (3) women have been deliberately excluded from male-dominated fields such as surgery. While the above hypotheses may be true to a greater or lesser degree, none of them has been adequately tested.^ The major study hypotheses are as follows: (1) female physicians' choice of specialty is influenced by the following reasons: (a) family responsibilities; (b) sex role expectations; and (c) sex discrimination; (2) female physicians' choice of specialty is also influenced by their age and ethnicity; and (3) the primary reasons for choosing a given specialty vary by type of specialty.^ The reasons for specialty selection will be explored based on a survey of women graduates of one of the oldest medical schools in the United States, The University of Texas Medical Branch (UTMB) in Galveston, Texas (n = 930). The survey response rate was 75.3% (700 respondents).^ The results for the first study hypothesis showed that fewer than 14% of the respondents agreed that sex role expectations, sex discrimination and family responsibilities played a role in their choice of specialty. Fifty nine percent of the respondents disagreed with the idea that sex role expectations influenced specialty selection and 64% disagreed that family responsibilities had an effect on the selection of their specialty. Around half (49%) were uncertain of the influence of sex discrimination. It was concluded that sex discrimination, sex role expectations and family responsibilities did not have a major impact on specialty selection.^ With respect to the second hypothesis, age was significant in Internal Medicine, Obstetrics/Gynecology and Psychiatry. Women physicians in Internal Medicine and Obstetrics/Gynecology were significantly younger (less than 45 years old) while physicians in Psychiatry were significantly older (45 years or older) than other specialties studied.^ The third hypothesis was confirmed: the reasons for choosing a given specialty varied by specialty.^ Respondents' comments written on the survey provided insight into other possible reasons for specialty selection including exploration of the role of mentoring and job satisfaction.^ The retrospective cross-sectional study design used in this study does not adequately capture the fact that different reasons may be given for the choice of specialty at different points in time, e.g., as the time of choosing a residency program versus several years into the future.^ In conclusion, approaches that explore the range of reasons that women elect to enter and stay within a given specialty must be explored to gain richer understanding of the complex and dynamic nature of women physicians' professional lives. (Abstract shortened by UMI.) ^

Cross-sectional study examining the role of acculturation in self-reported hypertension among Mexican Americans in Harris County, Texas

The objective of this secondary analysis was to examine the role of acculturation and self-reported hypertension in a Mexican-American cohort from Harris County, Texas. Specifically, we examined the acculturation measures of language-based Bidimensional Acculturation Scale (BAS), nativity, and length of United States (U.S) residency. Of 6,229 participants aged 40 and older, 38.0% self-reported hypertension at baseline. ^ Multiple logistic regression was used to estimate the prevalence odds ratios (pOR) for the association of each acculturation measure and hypertension while controlling for confounding. When adjusted for age, gender, body mass index, number of comorbidities, and family history of hypertension, U.S.-born participants were 1.37 times more likely to report having hypertension compared to Mexico-born participants (95% CI: 1.21, 1.55). Similarly, immigrants residing in the U.S. for more than 20 years had an adjusted pOR of 1.40 (95% CI: 1.16, 1.70) as compared to immigrants living in the U.S. for less than 10 years. ^ In conclusion, individuals who were born in the U.S. or emigrated to the U.S. over 20 years ago were more likely to report having hypertension compared to individuals born in Mexico or compared to those who emigrated more recently to the U.S. This study will contribute to the literature in demonstrating the need for more initiatives in prevention of cardiovascular disease, specifically hypertension, in the acculturating Mexican American population.^

Prevalence of HIV risk-related behaviors among undocumented Central American immigrant women in Houston, Texas, 2010

The primary aim of this dissertation research is to provide epidemiological data on HIV risk-related behaviors among undocumented Central American immigrant women living in Houston, Texas. Between February and May 2010, we used respondent driven sampling (RDS) to recruit 230 Guatemalan, Honduran, and El Salvadoran women, ages 18 to 50 years, living in Houston without a valid United States visa or residency papers. RDS is a probability-based sampling method that utilizes social networks to access members of hidden populations that lack a sampling frame. Participants completed an interview regarding their demographics, access to and utilization of healthcare services, HIV testing, and sexual behaviors. Data from this study were used 1) to describe the prevalence of sexual HIV risk-related behaviors among undocumented Central American immigrant women, comparing those who recently immigrated to the U.S. (within the past five years) to those with more established residency (of over five years); 2) to describe the prevalence of lifetime HIV testing and evaluate its associated factors in this target population; and 3) to describe the effectiveness of RDS to access members of this target population. ^ As described in Paper 1, there was a generally low prevalence of individual HIV risk-related behaviors (i.e., multiple, concurrent, convenience, and casual sexual partnerships) among the undocumented Central American immigrant women in this study. However, there was evidence of HIV risk due to unprotected sex with male partners who have concurrent sexual partnerships. We identified recent immigrants as the subpopulation at greatest risk, as they were significantly more likely than established immigrants to have multiple and/or concurrent sexual partners. As described in Paper 2, the lifetime prevalence of HIV testing was almost 70%. After adjusting for age, number of years living in the U.S., income security, and resource barriers, lifetime HIV testing was significantly associated with being from Honduras, having more than a sixth grade education, having a regular healthcare provider, and having knowledge of available healthcare resources. Finally, as described in Paper 3, RDS was an effective method for obtaining a diverse sample of Central American immigrant women in Houston. ^ This project is the first to use RDS to conduct an HIV behavioral survey among undocumented Central American immigrant women. Our results will inform the design of future research studies and the implementation of HIV prevention activities among undocumented Central American immigrants in the U.S.^

Evaluation of Knowledge Regarding Diagnostic Strategies for Genetic Diseases in Select Residents

Genetics education for physicians has been a popular publication topic in the United States and in Europe for over 20 years. Decreasing numbers of medical genetics professionals and an increasing volume of genetic information has created a dire need for increased genetics training in medical school and in clinical practice. This study aimed to assess how well pediatrics-focused primary care physicians apply their general genetics knowledge to clinical genetic testing using scenario-based questions. We chose to specifically focus on knowledge of the diagnostic applicability of Chromosomal Microarray (CMA) technology in pediatrics because of its recent recommendation by the International Standard Cytogenomic Array (ISCA) Consortium as a first-tier genetic test for individuals with developmental disabilities and/or congenital anomalies. Proficiency in ordering baseline genetic testing was evaluated for eighty-one respondents from four pediatrics-focused residencies (categorical pediatrics, pediatric neurology, internal medicine/pediatrics, and family practice) at two large residency programs in Houston, Texas. Similar to other studies, we found an overall deficit of genetic testing knowledge, especially among family practice residents. Interestingly, residents who elected to complete a genetics rotation in medical school scored significantly better than expected, as well as better than residents who did not elect to complete a genetics rotation. We suspect that the insufficient knowledge among physicians regarding a baseline genetics work-up is leading to redundant (i.e. concurrent karyotype and CMA) and incorrect (i.e. ordering CMA to detect achondroplasia) genetic testing and is contributing to rising health care costs in the United States. Our results provide specific teaching points upon which medical schools can focus education about clinical genetic testing and suggest that increased collaboration between primary care physicians and genetics professionals could benefit patient health care overall.