Rural Surgery Training Programs in the United States: A Review of the Literature

RURAL SURGERY TRAINING PROGRAMS IN THE UNITED STATES: A REVIEW OF THE LITERATURE Abstract: Rural surgery training programs have been developed to train general surgeons for community and rural service. There are 10 rural surgery training programs in the United States. Rural surgery training began in 1974 in LaCrosse, Wisconsin to prepare general surgery residents for rural service. There is a national shortage of general surgeons which translates into a deficit of surgeons in rural areas. The terms “general surgeon” and “rural surgeon” are not synonymous as rural surgery is more extensive, more broad-based and more subspecialty with more trauma, burn care and wound care and far more endoscopic and laparoscopic procedures. There are many advantages to rural general surgery training programs. A well-trained rural surgeon with OB/GYN experience can handle 66% of all inpatient operations in a rural hospital. Rural surgery programs have been developed to address the above problems and attract graduating general surgeons to communities and rural areas. These programs have had high general surgery practice and high rural placement. Selection of appropriate campus, hospital and attending staff is critical for the educational experience to be maximal. Attending surgeons need to be general surgeons, rural surgeons and subspecialty surgeons. The American College of Surgeons (ACS) has developed the Advisory Council for Rural Surgery (ACRS). The ACRS has developed a repository of rural training experiences and training sites. There are five different types of training experience ranging from rotations to dedicated tracks to fellowships. Rural surgery training programs are a mechanism to attract more medical students to general surgery residencies, more graduating chief general surgery residents to private practice in community and rural areas, improve the case numbers and confidence of graduating surgery residents, and improve the quality of surgical care in this country

Evidence for a Black Hole and Accretion Disk in the LINER NGC 4203

We present spectroscopic observations from the Hubble Space Telescope that reveal for the first time the presence of a broad pedestal of Balmer-line emission in the LINER galaxy NGC 4203. The emission-line profile is suggestive of a relativistic accretion disk, and is reminiscent of double-peaked transient Balmer emission observed in a handful of other LINERs. The very broad line emission thus constitutes clear qualitative evidence for a black hole, and spatially resolved narrow-line emission in NGC 4203 can be used to constrain its mass, with M_BH less than 6 x 10^6 solar masses at 99.7% confidence. This value implies a ratio of black-hole mass to bulge mass of less than approximately 7 x 10^-4 in NGC 4203, which is less by a factor of ~3 - 9 than the mean ratio obtained for other galaxies. The availability of an independent constraint on central black-hole mass makes NGC4203 an important testbed for probing the physics of weak active galactic nuclei. Assuming M_BH near the detection limit, the ratio of observed luminosity to the Eddington luminosity is approximately 10^-4. This value is consistent with advection-dominated accretion, and hence with scenarios in which an ion torus irradiates an outer accretion disk that produces the observed double-peaked line emission. Follow-up observations will make it possible to improve the black-hole mass estimate and study variability in the nuclear emission.Comment: 10 pages (LaTeX, AASTeX v4.0), 2 postscript figures, accepted for publication in The Astrophysical Journal Letter

Effects of tissue hydration on nanoscale structural morphology and mechanics of individual Type I collagen fibrils in the Brtl mouse model of Osteogenesis Imperfecta

Type I collagen is the most abundant protein in mammals, and is a vital part of the extracellular matrix for numerous tissues. Despite collagen’s importance, little is known about its nanoscale morphology in tissues and how morphology relates to mechanical function. This study probes nanoscale structure and mechanical properties of collagen as a function of disease in native hydrated tendons. Wild type tendon and tendon from the Brtl/+ mouse model of Osteogenesis Imperfecta were investigated. An atomic force microscope (AFM) was used to image and indent minimally-processed collagen fibrils in hydrated and dehydrated conditions. AFM was used because of the ability to keep biological tissues as close to their native in situ conditions as possible. The study demonstrated phenotypic difference in Brtl/+ fibril morphology and mechanics in hydrated tendon which became more compelling upon dehydration. Dried tendons had a significant downward shift in fibril D- periodic spacing versus a shift up in wet tendons. Nanoscale changes in morphology in dry samples were accompanied by significant increases in modulus and adhesion force and decreased indentation depth. A minimal mechanical phenotype existed in hydrated samples, possibly due to water masking structural defects within the diseased fibrils. This study demonstrates that collagen nanoscale morphology and mechanics are impacted in Brtl/+ tendons, and that the phenotype can be modulated by the presence or absence of water. Dehydration causes artifacts in biological samples which require water and this factor must be considered for studies at any length scale in collagen-based tissues, especially when characterizing disease- induced differences

Nanoscale Morphology of Type I Collagen is Altered in the Brtl Mouse Model of Osteogenesis Imperfecta

Bone has a complex hierarchical structure that has evolved to serve structural and metabolic roles in the body. Due to the complexity of bone structure and the number of diseases which affect the ultrastructural constituents of bone, it is important to develop quantitative methods to assess bone nanoscale properties. Autosomal dominant Osteogenesis Imperfecta results predominantly from glycine substitutions (80%) and splice site mutations (20%) in the genes encoding the α1 or α2 chains of Type I collagen. Genotype-phenotype correlations using over 830 collagen mutations have revealed that lethal mutations are located in regions crucial for collagen-ligand binding in the matrix. However, few of these correlations have been extended to collagen structure in bone. Here, an atomic force microscopy-based approach was used to image and quantitatively analyze the Dperiodic spacing of Type I collagen fibrils in femora from heterozygous (Brtl/+) mice (α1(I)G349C), compared to wild type (WT) littermates. This disease system has a well-defined change in the col1α1 allele, leading to a well characterized alteration in collagen protein structure, which are directly related to altered Type I collagen nanoscale morphology, as measured by the Dperiodic spacing. In Brtl/+ bone, the D-periodic spacing shows significantly greater variability on average and along the length of the bone compared to WT, although the average spacing was unchanged. Brtl/+ bone also had a significant difference in the population distribution of collagen D-period spacings. These changes may be due to the mutant collagen structure, or to the heterogeneity of collagen monomers in the Brtl/+ matrix. These observations at the nanoscale level provide insight into the structural basis for changes present in bone composition, geometry and mechanical integrity in Brtl/+ bones. Further studies are necessary to link these morphological observations to nanoscale mechanical integrity

Mechanical Effects of Fine-Wire Climbing on the Hindlimb Skeleton of Mice

poster abstractHigh-impact exercise (running/jumping) can stimulate multiple anabolic responses (increased trabecular bone volume, BV/TV) in the skeleton, but is also linked to an increased incidence of skeletal fracture. Thus, it is not an appropriate treatment for patients with elevated fracture risks. However, multi-directional offaxis mechanical loading can also elicit anabolic responses, even when magnitudes are relatively low. This represents a potential alternative to high-impact exercise for improving skeletal mechanical properties. To test this hypothesis, we raised twelve weanling female C57BL/6 mice to 4 months of age in custom enclosures that prevent (control) or require (experimental) manual and pedal grasping while balancing and climbing above narrow wire substrates. At sacrifice, we measured whole mouse bone density (DEXA) and performed architectural (μCT) and mechanical (4-pt bending) analyses of the femur and tibia. Body mass was similar between groups, although exercised mice were leaner (-35% fat mass). Bone mineral density was also similar, while bone mineral content was increased (+7%) in the exercised mice. Femoral midshaft polar moment of inertia was similar between groups, but exercised mice had lower BV/TV (-46%) of the distal femur and greater trabecular spacing (+21%). Exercised femora showed more total displacement (+58%) and post yield displacement (+115%) in bending than controls, and increased material toughness (+40%). Patterns were similar for the tibia. Mechanical data are consistent with high-impact exercise studies, but architectural data are not. Together they suggest that our exercise model may improve bone mechanical properties by redistributing mineral within the skeleton, and not by increasing net bone formation

Closing the Gap between Methodologists and End-Users: R as a Computational Back-End

The R environment provides a natural platform for developing new statistical methods due to the mathematical expressiveness of the language, the large number of existing libraries, and the active developer community. One drawback to R, however, is the learning curve; programming is a deterrent to non-technical users, who typically prefer graphical user interfaces (GUIs) to command line environments. Thus, while statisticians develop new methods in R, practitioners are often behind in terms of the statistical techniques they use as they rely on GUI applications. Meta-analysis is an instructive example; cutting-edge meta-analysis methods are often ignored by the overwhelming majority of practitioners, in part because they have no easy way of applying them. This paper proposes a strategy to close the gap between the statistical state-of-the-science and what is applied in practice. We present open-source meta-analysis software that uses R as the underlying statistical engine, and Python for the GUI. We present a framework that allows methodologists to implement new methods in R that are then automatically integrated into the GUI for use by end-users, so long as the programmer conforms to our interface. Such an approach allows an intuitive interface for non-technical users while leveraging the latest advanced statistical methods implemented by methodologists

SuperMassive Black Holes in Bulges

We present spatially extended gas kinematics at parsec-scale resolution for the nuclear regions of four nearby disk galaxies, and model them as rotation of a gas disk in the joint potential of the stellar bulge and a putative central black hole. The targets were selected from a larger set of long-slit spectra obtained with the Hubble Space Telescope as part of the Survey of Nearby Nuclei with STIS (SUNNS). They represents the 4 galaxies (of 24) that display symmetric gas velocity curves consistent with a rotating disk. We derive the stellar mass distribution from the STIS acquisition images adopting the stellar mass-to-light ratio normalized so as to match ground-based velocity dispersion measurements over a large aperture. Subsequently, we constrain the mass of a putative black hole by matching the gas rotation curve, following two distinct approaches. In the most general case we explore all the possible disk orientations, alternatively we constrain the gas disk orientation from the dust-lane morphology at similar radii. In the latter case the kinematic data indicate the presence of a central black hole for three of the four objects, with masses of 10^7 - 10^8 solar masses, representing up to 0.025 % of the host bulge mass. For one object (NGC2787) the kinematic data alone provide clear evidence for the presence of a central black hole even without external constraints on the disk orientation. These results illustrate directly the need to determine black-hole masses by differing methods for a large number of objects, demonstrate that the variance in black hole/bulge mass is much larger than previously claimed, and reinforce the recent finding that the black-hole mass is tightly correlated with the bulge stellar velocity dispersion.Comment: 26 pages, 11 Postscript figures, accepted for publication on Ap

Loss of Nmp4 optimizes osteogenic metabolism and secretion to enhance bone quality

A goal of osteoporosis therapy is to restore lost bone with structurally sound tissue. Mice lacking the transcription factor Nuclear Matrix Protein 4 (Nmp4, Zfp384, Ciz, ZNF384) respond to several classes of osteoporosis drugs with enhanced bone formation compared to wild type (WT) animals. Nmp4-/- mesenchymal stem/progenitor cells (MSPCs) exhibit an accelerated and enhanced mineralization during osteoblast differentiation. To address the mechanisms underlying this hyper-anabolic phenotype, we carried out RNA-sequencing and molecular and cellular analyses of WT and Nmp4-/- MSPCs during osteogenesis to define pathways and mechanisms associated with elevated matrix production. We determined that Nmp4 has a broad impact on the transcriptome during osteogenic differentiation, contributing to the expression of over 5,000 genes. Phenotypic anchoring of transcriptional data was performed for the hypothesis-testing arm through analysis of cell metabolism, protein synthesis and secretion, and bone material properties. Mechanistic studies confirmed that Nmp4-/- MSPCs exhibited an enhanced capacity for glycolytic conversion- a key step in bone anabolism. Nmp4-/- cells showed elevated collagen translation and secretion. Expression of matrix genes that contribute to bone material-level mechanical properties were elevated in Nmp4-/- cells, an observation that was supported by biomechanical testing of bone samples from Nmp4-/- and WT mice. We conclude that loss of Nmp4 increases the magnitude of glycolysis upon the metabolic switch, which fuels the conversion of the osteoblast into a super-secretor of matrix resulting in more bone with improvements in intrinsic quality

Multilingual Simplification of Medical Texts

Automated text simplification aims to produce simple versions of complex texts. This task is especially useful in the medical domain, where the latest medical findings are typically communicated via complex and technical articles. This creates barriers for laypeople seeking access to up-to-date medical findings, consequently impeding progress on health literacy. Most existing work on medical text simplification has focused on monolingual settings, with the result that such evidence would be available only in just one language (most often, English). This work addresses this limitation via multilingual simplification, i.e., directly simplifying complex texts into simplified texts in multiple languages. We introduce MultiCochrane, the first sentence-aligned multilingual text simplification dataset for the medical domain in four languages: English, Spanish, French, and Farsi. We evaluate fine-tuned and zero-shot models across these languages, with extensive human assessments and analyses. Although models can now generate viable simplified texts, we identify outstanding challenges that this dataset might be used to address

A cluster randomized controlled trial of a modified vaccination clinical reminder for primary care providers

Objective: Adult vaccination rates in the United States fall short of national goals, and rates are particularly low for Black Americans. We tested a provider-focused vaccination uptake intervention: a modified electronic health record clinical reminder that bundled together three adult vaccination reminders, presented patient vaccination history, and included talking points for providers to address vaccine hesitancy. Method: Primary care teams at the Atlanta Veterans Affairs Medical Center, who saw 28,941 patients during this period, were randomly assigned to receive either the modified clinical reminder (N = 44 teams) or the status quo (N = 40 teams). Results: Uptake of influenza and other adult vaccinations was 1.6 percentage points higher in the intervention group, which was not statistically significant (CI = [-1.3, 4.4], p = 0.28). The intervention had similar effects on Black and White patients and did not reduce the disparity in vaccination rates between these groups. Conclusion: Provider-focused interventions are a promising way to address vaccine hesitancy, but they may need to be more intensive than a modified clinical reminder to have appreciable effects on vaccination uptake