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Introduction Cancer survivors experience an increased stress burden. Twenty-five percent (25%) of cancer survivors experience persistent depressive and anxiety symptoms and 40% are afflicted with chronic sleep problems. Analysis of this relationship between survivors’ mental health and sleep may elucidate components of stress burden in a particularly vulnerable population. This study examined the relationship between anxious and depressive symptoms and frequency predicting sleep patterns, comparing individuals with a cancer history versus those without. Methods Data emanated from the 2020 National Health Interview Survey dataset (n=31,568). Six percent (n=1936) of respondents reported a cancer history. The primary outcome was sleep duration, based on the average hours of sleep per night an individual reported over the past month, which was coded into “healthy” (7-8 hrs.) vs “unhealthy” (< 7 hrs. or > 9 hrs.) sleep. Level of anxiety and depression as well as frequency of reported symptoms were included in the models as predictors. Binary logistic regression models were performed to determine the discrete impact of depression and anxiety on sleep duration among individuals with and without a cancer history. Adjusted models included the demographic covariates of age, sex, education, household income, and race. Results In adjusted models, frequency of anxious feelings (OR = 1.19, p Conclusion Mental health and sleep are closely and bidirectionally connected in the general population, but among individuals with a history of cancer the link between level of depression and healthy sleep were not significant. Further research is needed to understand the complex relationship between mental health and sleep among people with a cancer history. Support (if any) K01HL135452, K07AG052685, R01AG072644, R01HL152453, R01MD007716, R01HL142066, R01AG067523, R01AG056031, and R01AG075007.

Introduction Asthma is one of the leading respiratory illnesses in the United States. African Americans/Blacks are particularly vulnerable to the long-term effects of this condition. In addition to general healthcare inequities, African Americans/Blacks may also have an increased vulnerability to the deleterious effects asthma may enact on health behaviors such as sleep. Comparison between races for how much asthma affects sleep health would be useful to address these vulnerabilities. Methods Analysis was performed on the 2020 National Health Interview Survey, the most recently collected data (n=31,568.) The sample was stratified to include only asthmatics using the survey variable that asked “Have you ever been diagnosed with asthma?” 8.6% of the sample reported having asthma (n=2123). Adjusted binary logistic regression was performed to determine how race predicts sleep health in this population. Covariates included age, sex, education, household income, and physical activity. “Healthy Sleep” was coded as self-reported 7-8 hours of sleep, and “Unhealthy Sleep” was coded as either less than 6 hours or more than 9 hours, as literature establishes short and long sleep have deleterious effects on health. “Race” was coded as White, Black, American Indian/Alaskan, or Asian. In the regression, White was used as the reference category. Results In the adjusted model for race predicting healthy sleep, only African-Americans/Blacks showed significance compared to other races. The model showed that Blacks who are asthmatic are 54% (p Conclusion These analyses show a pronounced connection between black racial status and unhealthy sleep amongst asthmatics. The results are in line with literature that demonstrates blacks sleep less in general and are more commonly afflicted with sleep conditions such as OSA, but there is a dearth of research examining how asthma affects sleep in this population. Further studies are needed to examine the underlying factors that may drive these vulnerabilities. Support (if any) K01HL135452, K07AG052685, R01AG072644, R01HL152453, R01MD007716, R01HL142066, R01AG067523, R01AG056031, and R01AG075007

Issue: Calls to change medical education have been frequent, persistent, and generally limited to alterations in content or structural re-organization. Self-imposed barriers have prevented adoption of more radical pedagogical approaches, so recent predictions of the 'inevitability' of medical education transitioning to online delivery seemed unlikely. Then in March 2020 the COVID-19 pandemic forced medical schools to overcome established barriers overnight and make the most rapid curricular shift in medical education's history. We share the collated reports of nine medical schools and postulate how recent responses may influence future medical education. Evidence: While extraneous pandemic-related factors make it impossible to scientifically distinguish the impact of the curricular changes, some themes emerged. The rapid transition to online delivery was made possible by all schools having learning management systems and key electronic resources already blended into their curricula; we were closer to online delivery than anticipated. Student engagement with online delivery varied with different pedagogies used and the importance of social learning and interaction along with autonomy in learning were apparent. These are factors known to enhance online learning, and the student-centered modalities (e.g. problem-based learning) that included them appeared to be more engaging. Assumptions that the new online environment would be easily adopted and embraced by 'technophilic' students did not always hold true. Achieving true distance medical education will take longer than this 'overnight' response, but adhering to best practices for online education may open a new realm of possibilities. Implications: While this experience did not confirm that online medical education is really 'inevitable,' it revealed that it is possible. Thoughtfully blending more online components into a medical curriculum will allow us to take advantage of this environment's strengths such as efficiency and the ability to support asynchronous and autonomous learning that engage and foster intrinsic learning in our students. While maintaining aspects of social interaction, online learning could enhance pre-clinical medical education by allowing integration and collaboration among classes of medical students, other health professionals, and even between medical schools. What remains to be seen is whether COVID-19 provided the experience, vision and courage for medical education to change, or whether the old barriers will rise again when the pandemic is over.

The COVID-19 pandemic has led to shifts in healthcare utilization for patients both with and without COVID-19. We aimed to determine how trends in neurology service admissions during the pandemic may aid in departmental planning by predicting future clinician staffing and other needs. We examined all admissions to the general neurology, stroke, and neurocritical care services from January 31 to May 16, 2020 at our tertiary-care hospital using an electronic health record query, comparing these to analogous data in 2019. We trended admission rates and projected future censuses using logarithmic regression, tracked changes in length of stay (LOS), and quantified shifts in presentations of specific diagnoses. Daily rates of admissions declined sharply during the week of March 13, 2020 (the week after pandemic status was declared by the World Health Organization). On the censoring date, we projected a return to pre-pandemic censuses in the week of June 21 and used this information to make decisions regarding neurology resident schedules. There was a trend toward increased LOS for general neurology and stroke patients between March 27 and April 9, 2020 compared to in 2019, with subsequent decline coinciding with early hospital initiatives. Since March 13, 2020, there has been a trend toward reduced presentations of ischemic stroke, suggesting a need for community education on stroke awareness. Characterizing early trends in neurology admissions may allow physician administrators to plan local and community-level responses to the pandemic.

Introduction Circadian disruptions are associated with increased risk for morbidity and mortality. However, it is unclear whether these associations vary by race/ethnicity. We aim to explore, 1) Examine whether rest-activity rhythm (RAR) patterns vary across race/ethnicity among a representative sample of the US adult population, and 2) Examine the interaction of race/ethnicity and sex in RAR patterns. Methods The study was based on the National Health and Nutrition Examination Survey (2013–2014) with data from participants who wore a physical activity monitor (PAM ActiGraph accelerometer model GT3X+) continuously for seven consecutive days. After excluding pregnant participants and those with sleep minutes < 120 and >1200, the analytic sample included was 4,722 adults. The cosinor method was used based on PAM minutes time-series data to RAR outcome variables: mesor, amplitude, acrophase. and robustness. The main predictor of interest was race/ethnicity (Asian, Black, Hispanic, multi/other, and White). A sex-race/ethnicity interaction was tested to assess if racial/ethnic differences in RAR patterns differ between males and females. Other covariates included were age, marital status education federal poverty level, and employment status. Eight adjusted Generalized linear models (GLM) : four with race/ethnicity as the main predictors and four multiplicative interaction models with the product term of race/ethnicity and sex. An adjusted Wald test was used to test for interaction. Results Compared with White adults, Hispanic adults had increased mesor levels (ß=0.10; 95% CI:0.07;0.13), increased RAR amplitude (ß=0.10; 95% CI:0.06;0.13), and increased robustness (ß=0.07; 95% CI:0.03;0.11) whereas Black adults had decreased amplitude (ß=-0.11; 95% CI:-0.16;-0.07) and decreased robustness ( (ß= -0.14; 95% CI:-0.20; -0.09) compared to White adults. Similarly, Asians had decreased amplitude (ß=-0.06; 95% CI:-0.10;-0.01) and decreased robustness (ß=-0.11; 95% CI:-0.16; -0.06). A significant sex-race/ethnicity interaction was found for amplitude F(4,12)=3.94;p=0.029 and robustness (4,12)=6.02;p< 0.001. Conclusion RAR is associated with race/ethnicity, and this association varies by sex. Notably, Hispanic adults had increased mesor, amplitude, and robustness compared to Whites. Conversely, Black and Asian populations shared decreased amplitude and robustness compared to Whites. Future studies may consider further investigation of circadian health by race/ethnicity and sex for community intervention. Support (if any) K01HL135452, K07AG052685, R01AG072644, R01HL152453, R01MD007716, R01HL142066, R01AG067523, R01AG056031, and R01AG075007

The current chapter provides a broad and in-depth overview of wearable and nonwearable sleep devices, specifically highlighting their (i) features (hardware and software), (ii) accuracy, reliability, and validity, and (iii) utility and applications in assessment, diagnosis, and management of sleep health parameters including sleep duration, quality, disorders, efficiency, sleep architecture, and sleep stages. We acknowledge and briefly discuss the debate as to whether wearables and nonwearables should be included in traditional sleep and circadian medicine/science. Our suggestion is that wearables and nonwearables must be incorporated in medicine to meet the demands of sleep healthcare delivery.

Introduction Blacks have a high burden of poor sleep health outcomes. Environmental determinants, such as green space or open environments, represent an underexplored contributor to sleep burden among Blacks. The extent these environmental factors affect sleep health outcomes within this population has not been adequately explored. To fill this gap in the literature, we investigated associations between environmental factors and sleep outcomes among Blacks in a large urban city. Objectives included (1) examine if zip-code derived open spaces (defined as proportion of open space in residential area,) green spaces (defined as open tree coverage of the ground) and blue spaces (proportion of water space) sleep apnea risk, and insomnia symptoms; (2) Examine if open, blue, and green spaces predict sleep outcomes independent of sex, age, and education level. Methods Our study used data from the Metabolic Syndrome Cohort Study (2009-2014), a studythat examined behavioral intervention methods to improve sleep apnea outcomes among Blacks. Sleep Apnea was assessed with the ARES (apnea risk) scale and insomnia status was collected through self-report (“Do you have difficulty staying/falling asleep or waking up?”) in a subset of 344 participants. Logistic regression analyses were performed to predict the effect green, blue, and open spaces had on sleep outcomes. To account for within zip-code correlation, mixed effects models (unadjusted and adjusted) account for sex, age, and education were considered. Results We found that none of the green, blue, or open space variables predicted sleep outcomes in the unadjusted model. In adjusted models, green space predicted sleep apnea risk scores, (OR=1.03, P Conclusion Our study examined the extent which green, blue, and open spaces predicted insomnia and sleep apnea in urban blacks. We found that only green spaces were associated with sleep apnea, and none of our environmental variables predicted insomnia. Given the large amount of literature detailing a complex and multifactorial process on how environment affects sleep outcomes, our findings suggest that the link between urban environments, green spaces, and sleep outcomes may not be as definitive as they seem. Further research should explore the differential effect environment has on diverse populations’ sleep outcomes. Support (If Any) NIH R01HL142066, R01HL095799, RO1MD004113, R01HL152453

Introduction One in three American adults are sleep deprived in the United States (US). Racial/ethnic minorities are more likely to experience shorter sleep duration than are whites. Light exposure is associated with sleep duration. However, whether this association is independent of individuals’ race/ethnicity has not been studied in a nationally representative sample of the US adult population. We examined associations between ambient light exposure and sleep duration and between race/ethnicity and sleep duration. We also assessed whether associations between light exposure and sleep duration are independent of participants’ race/ethnicity. Methods We used data from the National Health and Nutrition Examination Survey (n=4,277 adults; 2013-2014). Participants (≥ 18 years old) wore an actigraph that collected 24-hour sleep/wake and light data for 7 consecutive days. Objective measurements in our analyses included sleep duration (valid minutes) and light exposure (lux). To determine the associations between light exposure and sleep duration, a weighted mixed-effects linear model was estimated controlling for age, sex, family income to poverty ratio, education, employment, marital status, homeownership status, birthplace, household size, vitamin D, smoking, physical activity, sedentary lifestyle, health status, body mass index, depression, chronic conditions, and time in days. A product term between lux and race/ethnicity was included in a second regression model. Results Participants had a mean sleep duration of 468.2 minutes. On average, White adults had the longest sleep duration (mean=478.8), followed by other/multiple races (mean=458.6), Asians (mean=449.1); Blacks (mean=445.0), and Hispanics (mean=444.7). Overall, light exposure was negatively associated with sleep duration (= -0.08 lux; p Conclusion To our knowledge, this is the first study that used national data to assess racial/ethnic disparities in objectively measured light exposure. Future research is needed to shed more light on racial/ethnic disparities in the light-exposure-sleep-duration link. Support (If Any) R01HL142066, R01HL095799, RO1MD004113, R01HL152453, R25HL105444

Histone proteins are elevated in the circulation after traumatic injury owing to cellular lysis and release from neutrophils. Elevated circulating histones in trauma contribute to coagulopathy and mortality through a mechanism suspected to involve endothelial cell (EC) dysfunction. However, the functional consequences of histone exposure on intact blood vessels are unknown. Here, we sought to understand the effects of clinically relevant concentrations of histones on the endothelium in intact, resistance-sized, mesenteric arteries (MAs). EC Ca2+ was measured with high spatial and temporal resolution in MAs from mice selectively expressing the EC-specific, genetically encoded ratiometric Ca2+ indicator, Cx40-GCaMP-GR, and vessel diameter was measured by edge detection. Application of purified histone protein directly to the endothelium of en face mouse and human MA preparations produced large Ca2+ signals that spread within and between ECs. Surprisingly, luminal application of histones had no effect on the diameter of pressurized arteries. Instead, after prolonged exposure (30 min), it reduced dilations to endothelium-dependent vasodilators and ultimately caused death of ~25% of ECs, as evidenced by markedly elevated cytosolic Ca2+ levels (793 ± 75 nM) and uptake of propidium iodide. Removal of extracellular Ca2+ but not depletion of intracellular Ca2+ stores prevented histone-induced Ca2+ signals. Histone-induced signals were not suppressed by transient receptor potential vanilloid 4 (TRPV4) channel inhibition (100 nM GSK2193874) or genetic ablation of TRPV4 channels or Toll-like receptor receptors. These data demonstrate that histones are robust activators of noncanonical EC Ca2+ signaling, which cause vascular dysfunction through loss of endothelium-dependent dilation in resistance-sized MAs. NEW & NOTEWORTHY We describe the first use of the endothelial cell (EC)-specific, ratiometric, genetically encoded Ca2+ indicator, Cx40-GCaMP-GR, to study the effect of histone proteins on EC Ca2+ signaling. We found that histones induce an influx of Ca2+ in ECs that does not cause vasodilation but instead causes Ca2+ overload, EC death, and vascular dysfunction in the form of lost endothelium-dependent dilation.

In this current review, we describe the benefits of community-based and “precision and personalized population health” (P3H) approaches to assessing and addressing sleep health problems and sleep-related cardiovascular diseases (CVD) among vulnerable populations such as racial/ethnic minorities, the elderly, and the socioeconomically disadvantaged. Very few sleep health programs utilize a community-based or P3H approach, which may account for low estimates of sleep health problems, related CVD outcomes, and inadequate healthcare infrastructure to address sleep-related health outcomes at the community and population level. We describe community-based and P3H approaches and programs as solutions to accurately capture estimates of sleep health and reduce burden of sleep health problems and corollary CVD outcomes at the level of the community and population. Specifically, we describe seven critical steps needed to successfully implement a community-based and P3H approach to address sleep health problems. Community-based and P3H approaches are effective strategies to assessing and addressing sleep health problems and related health conditions.

Introduction The prevalence of vitamin D deficiency (VitD) in the United States is 41 percent, with the highest rate among Blacks 82 percent. Vitamin D deficiency has been linked to chronic diseases. The extent to which the association between light exposure and vitamin D serum levels can vary by individual’s race/ethnicity of which has not been studied at a national level. We aim to explore the associations of ambient light exposure between race/ethnicity and vitamin D. Methods The study used data from the National Health and Nutrition Examination Survey (2013-14). For detection of 25-hydroxyvitamin D3 and 25-hydroxyvitamin D2 nmol/L, ultra-high-performance liquid chromatography-tandem mass spectrometry was performed based on serum samples from adults aged ≥ 18 years. Light levels (lux) data were gathered using 24-hour actigraphic monitoring over /a 7day period. Weighted generalized linear models were fitted examining association between light exposure and VitD adjusting for age, sex, family income/poverty ratio, education, employment, house tenure, marital status, birthplace, number of people in household, smoking, physical activity, and sedentarity. To compare this association across race/ethnicity, a product term between lux and race/ethnicity was included in adjusted models. Results Among 4,251 participants, White adults had the highest levels of VitD (mean=76.0; se=1.3), then other/multiple races (mean=65.1; se=2.2), Asians (mean=62.5; se=1.4); Hispanics (mean=57.4 nmol/L; se=1.6), and Blacks (mean=50.1; se=1.4). Regression analysis revealed estimated mean VitD of 64.9 nmol/L and positive association between light exposure and VitD ( 0.020). Blacks had significantly lower VitD levels ( -19.3) followed by Asians (-12.1) and Hispanics (-12.6) (all p-values Conclusion To our knowledge, this is the first study showing associations between objectively measured light exposure and VitD serum levels using a large representative sample of the US population. Although the study revealed racial/ethnic disparities in VitD levels, light exposure was associated with VitD even when race/ethnicity was adjusted for in the model. Further research on racial/ethnic differences in VitD is warranted. Support (If Any) R01HL142066, R01HL095799, RO1MD004113, R01HL152453, R25HL105444

Introduction COVID-19 disrupted traditional research infrastructures and processes most notably in-person community recruitment, especially in underrepresented populations like racial ethnic minorities. To find creative and effective strategies, our group implemented and tested the efficacy of a culturally tailored community outreach plan (COP) developed during the US COVID-19 pandemic. Methods In February 2021, we developed an 11 step culturally-tailored community outreach program to support the implementation of three NIH funded community-based sleep studies. The following steps include: (1) description of the situation statement, 2) definition of goals, 3) engagement of audience/stakeholders, 4) tailoring message, 5) defining incentives, 6) choice of outreach methods, 7) identification of spokesperson, 8) choice of tools to assess progress, 9) identification of media outlets, 10) creation of study timeline, and 11) implementation of the plan. The studies leveraged several recruitment channels: 1) community settings (Place of worship, “community recruiter”, health fairs, word of mouth, & healthcare providers/doctors’ clinics), 2) online platforms (Facebook, Twitter, LinkedIn and Research Match), and 3) preexisting datasets in NYC. Results All three studies successfully met recruitment goals. ESSENTIAL [n= 224, 69% females, mean age= 36], MOSAIC [n=109, 61% females; mean age= 64] and Latinx/Hispanics: DORMIR[n=260, 61.3% of female; 32.4]. Among the three NYC cohorts, the most common recruitment channels were: preexisting datasets (74%), community settings (19%), & online platform (7%) for ESSENTIAL; preexisting datasets (85%) & community settings (15%) for MOSAIC, and (71.7%) online platform for DORMIR. However, the Miami cohorts came mostly from community settings 90% for Essential and 97% for MOSAIC. Conclusion Overall, the TSCS community outreach plan seems to be an effective tool to engage minoritized populations in greater NY and Miami. Our current field experience indicates that recruitment channels must be adapted to age, and community resources. Limited access to technology, particularly among older Blacks seem to be a major barrier for field staff to successfully engage the disenfranchised communities. Support (If Any) NIH R01HL142066-04; R01HL152453-01 R01HL142066, R01HL095799, RO1MD004113

Introduction Obesity rates among Hispanic (26%) and Black (22%) children are considerably higher compared to their white counterparts (14%), which evidence suggests may be attributable to biological, behavioral, and psychosocial factors affecting the family unit. Bio-behavioral factors in the household may affect child health behaviors, including sleep, a known predictor for obesity. Hispanic and Black children report shorter sleep duration, later bedtimes, and are often lacking in bedtime routines, compared to white children. Evidence suggests that early childhood routines are highly predictive of overweight status in children. Herein, we investigate whether bedtime routines are associated with the genetic allele for obesity in a racially diverse sample of children. Methods Data for the present analysis emanated from wave 5 (Year 9--2007–2010) cohort of the Fragile Families Child and Wellbeing Study dataset. During home visits, interviews with children’s mother and father during home visits, around the target child’s ninth birthday collected data on home routines and other parent-child relationship and school connectedness topics. Saliva samples were also collected at Year 9 to assess telomere length and DNA methylation levels and changes. The independent variable was regular bedtime routine, and biological variable for fat mass and obesity (rs9939609) was the dependent variable. Adjusted covariates included child’s age and BMI, and parent household income. Results Analysis of the final sample of 466 children showed 52% of the children were male and were 9 years old, on average; 35% were White, 46% Black, 20% Hispanic, 4% Asian and 5% other. The median family income was $42,500. The child’s sleep measures captured was ‘children have a regular bedtime routine’ was associated with (β = -0.137, p = 0.01) decrease in the odds of having the genetic allele for obesity. Conclusion Regular bedtime routines among 9-year old Black and Hispanic children may be associated with genetic alleles related to fat mass and obesity. Regular bedtime routines could aid in promoting healthy weight in children. Support (if any) NIH (T32HL129953, K07AG052685, R01MD007716, R01HL142066, K01HL135452, R01HL152453.

Introduction Literature shows that exercise moderates the relationship between sleep and emotional distress (ED.) However, it is unclear whether different types of exercise, such as aerobic and strengthening, affect this relationship differently. We investigated the moderating role of two types of exercise (aerobic and strengthening) regarding the relationship between ED and sleep. Methods Our analysis was based on data from 2018 National Health Interview Survey (NHIS), a nationally representative study in which 2,814 participants provided all data. Participants were asked 1) “how many days they woke up feeling rested over the past week”, 2) the Kessler 6 scale to determine ED (a score >13 indicates ED), and 3) the average frequency of strengthening or aerobic exercise per week. Logistic regression analyses were performed to determine if the reported days of waking up rested predicted level of ED. We then investigated whether strengthening or aerobic exercise differentially moderated this relationship. Covariates such as age and sex were adjusted in the logistic regression models. Logistic regression analyses were performed to determine if subjective reporting of restful sleep predicted level of ED. We investigated whether strengthening exercise or aerobic exercise differentially moderated this relationship. Covariates such as age and sex were adjusted in the logistic regression models. Results On average, participants reported 4.41 restful nights of sleep (SD =2.41), 3.43 strengthening activities (SD = 3.19,) and 8.47 aerobic activities a week (SD=5.91.) We found a significant association between days over the past week reporting waking up feeling rested and ED outcome according to K6, Χ2(1) = -741, p= Conclusion We found that restful sleep predicted reduction in ED scores. Aerobic exercise moderated this relationship, while strengthening exercise did not. Further research should investigate the longitudinal effects of exercise type on the relationship between restful sleep and ED. Support (if any) NIH (K07AG052685, R01MD007716, K01HL135452, R01HL152453)

Introduction Inadequate sleep has been found to be associated with poor mental health. This is especially true in low-income and minority populations, who are concentrated in cities. It is not understood to what degree living in a city vs. a rural environment affects sleep and resulting mental health outcomes. This study seeks to understand how living in an urban environment affects the relationship between inadequate sleep and mental health. Methods The study used data from the 2018 US Behavioral Risk Factor Surveillance System (BRFSS,) a nationwide health dataset collected by telephone. Respondents were classified as living in either an urban or rural environment based on their zip code. Respondents reported hours of sleep per night and mental health status. This study classified mental health status based on whether the respondent reported one or more incidences of poor mental health in the previous 30 days. Results After filtration, 348,540 respondents were split into urban and rural groups. Binary logistic regression was run in each group to compare how much living in an urban environment contributed to the relationship between sleep duration and mental health. Sleep in the analysis was found to significantly contribute to both models; urban X2(15, N=295,796) = 11,485.70, p Conclusion In urban and rural dwellers, sleep duration predicted poor mental health. Contrary to expectations, sleep was more strongly tied to mental health in rural than urban populations. This was true even after controlling for sex, income, and education level. Further research should seek to understand how environment affects sleep and mental health. Support This study was supported by funding from the NIH: R01MD007716, R01HL142066, R01AG056531, K01HL135452, and K07AG052685.

Introduction Adherence to OSA assessment and treatment is low among racial/ethnic minorities, particularly among blacks. Navigating patients along the continuum of care from assessment to treatment adherence requires motivation, social support, and self-efficacy. Previous studies indicate that community health educators can provide motivation, social support, and skills to patients to better navigate the complex OSA care continuum. However, recruiting, training, and implementing sleep health educators in clinical or research settings is complex. For the current study, we describe how we recruit, train, and implement sleep health educators in research and clinical settings and assess what makes a sleep health educator successful. Methods We recruited and trained twenty-five self-identified black sleep health educators for a randomized clinical trial (R01MD007716) focused on increasing OSA assessment and treatment adherence among blacks. During recruitment, we assessed key personality attributes that translate to being an effective sleep health educator, via behavioral and personality surveys, focused groups, and process forms filled out by educators. Sleep health educators underwent an 8-week training program on sleep health and motivational interviewing. In order to be certified, sleep health educators had to pass a written and scenario-based assessment. During the implementation phase of the trial, we assessed how many interviews each health educator conducted and whether individual characteristics were related to how many interviews. Results Of the trained educators, 80% were female, ranging from 25 to 58 years old. They all completed at least high school. All educators rated the program highly and were very satisfied with dispensing tailored sleep health education. Educators who displayed the highest knowledge about sleep health, provided frequent emotional and strategic support, committed to helping their assigned participants, and who rated their rapport highly with their assigned participants were most effective in getting their participant to adhere to OSA assessment and treatment. Conclusion Sleep health educators can be vital to increasing OSA assessment and treatment adherence among blacks. In order to ensure success, sleep health educators must undergo a thorough recruitment, training, and implementation and dissemination process. Support K01HL135452, R01MD007716, R01HL142066, K01HL135452,and K07AG052685

Introduction In two waves of data we collected in Brooklyn New York, we observed blacks were at high risk for obstructive sleep apnea (OSA). In the NIH-funded study ‘Metabolic Syndrome Outcome Study (MetSO), blacks enrolled from primary-care settings had a 59% risk of OSA. Similarly, blacks surveyed in churches and barbershops had a 43% risk of OSA. While these studies showed higher than expected risk as noted in the general population (29%), it remains uncertain how many of those blacks would be diagnosed with OSA in that population. The purpose of this study was to explore the rate of OSA using the WatchPat device in a community-based setting. Methods Data were collected from an NIH-funded study ‘Peer-Enhanced Education to Reduce Sleep Ethnic Disparities, designed to navigate blacks at risk of OSA to receive timely diagnosis and treatment using peer-delivered linguistically and culturally tailored sleep health education. Blacks were screened for OSA using the Apnea Risk Evaluation System (ARES) Questionnaire; a score ≥6 denoted moderate-high OSA risk. Individuals were asked to wear the WatchPAT 200 for one night during a week-long sleep assessment. WatchPat 200 measures SaO2 to determine respiratory-related arousals, defined as an Apnea-Hypopnea Index (AHI) ≥5, which is used to identify and diagnose OSA. We used SPSS 25.0 to perform logical regression analysis to assess associations between ARES and WatchPat AHI. Results A sample of 111 blacks provided valid ARES and WatchPat data for the present analyses. Of the sample, the mean age was 62.26 (SD=13.52 years; female = 55%); 49% reported annual income >20K and 79.5% reported a high school education. Moreover, 27% reported high blood pressure, 13%, diabetes, and 65% were overweight/obese. Multivariate-adjusted logical regression analyses indicated that blacks at risk for OSA were 66% more likely to receive an OSA diagnosis based on WatchPat AHI data (OR = 1.662, p < 0.01). The model adjusted for age, sex, income, and education. Conclusion The present study demonstrated that blacks at risk for OSA at the community level have a significant likelihood of receiving an OSA diagnosis using home-based recordings. Support NIH Support (T32HL129953, RO1MD007716, K01HL135452 and K07AG052685).

Introduction Hispanic and Black school-age children from low-income communities experience disproportionate rates of obesity (26% Hispanic, 22% Black) compared to their White counterparts (14%). Sleep patterns and circadian regulation of biological markers are associated with BMI status. However, little is known about racial and ethnic disparities in circadian regulation among children of color. These suggest that it is important to investigate biological markers that could help delineate associations between sleep-circadian regulation and obesity among children of color. Serotonin transporter gene, a neurotransmitter associated with circadian rhythm regulation, has emerged as an important biological variable. In this study, we investigated whether this factor could serve as a proxy for studying associations of circadian rhythm regulation with weight status in this diverse sample. Methods Statistical analysis included descriptive and linear regression analysis of the wave 5, Year 9 cohort of the Fragile Families Child and Wellbeing Study dataset. Interviews were conducted with the participant child around their ninth birthday for data collection on home routines and other parent relationship and school connectedness variables. Biological variables were derived from saliva samples at Year 9 to assess telomere length and DNA methylation levels and changes. Variables of interest included sleep duration, sleep timing, and biological variables 5httlpr (insomnia and sleep quality), skin 2 (serotonin transporter), telomere length (stress) and rs9939609 (fat mass and obesity), with BMI as the outcome. Results The final sample of 466 children comprised 52% male were 9 years old. Participants’ race was: 35% White, 46% Black, 20% Hispanic, 4% Asian and 5% other. Median family income was $42,500. Sleep duration obtained from these children was negatively associated with BMI (β = -0.245 with p=0.022). We found that gk5stin212 (serotonin transporter gene) was positively associated with BMI (β = 0.991, p = 0.009), while no significant associations was found for genetic variable gk5stin210. Conclusion Circadian rhythm dysregulation may serve as a biological mechanism driving overweight or obesity among minority children. Lifestyle and behavioral interventions aimed at the family unit may be needed to modify household and environmental factors that affect circadian regulation among children. Support (if any) NIH (T32HL129953), K07AG052685, R01MD007716, R01HL142066, K01HL135452, R01HL152453

Background There is debate regarding the appropriate use of transanal endoscopic microsurgery for rectal cancer. Objective This study analyzed our single-center experience with transanal endoscopic microsurgery for early rectal cancer. Design Medical charts of patients who underwent transanal endoscopic microsurgery were reviewed to determine lesion characteristics, as well as operative and treatment characteristics. Complications and recurrences were recorded. Settings The study was conducted at a single academic medical center. Patients Patients with early stage cancer (T1 or T2, N0, and M0) of the rectum were included. Main outcome measures Local and overall recurrence and disease-specific survival were measured. Results A total of 92 patients were analyzed. Median follow-up was 4.6 years. Negative margins were obtained in 98.9%. Length of stay was 1 day for 95.4% of patients. The complication rate was 10.9% (n = 10), including urinary retention at 4.3% (n = 4) and postoperative bleeding at 4.3% (n = 4). Preoperative staging included 54 at T1 (58.7%) and 38 at T2 (41.3%). Adjuvant therapy was recommended for all of the T2 and select T1 lesions with adverse features on histology. The final pathologic stages of tumors were ypT0 at 8.7% (n = 8), pT1 at 58.7% (n = 54), pT2 at 23.9% (n = 22), and ypT2 at 8.7% (n = 8). The 3-year local recurrence risk was 2.4% (SE = 1.7), and overall recurrence was 6.7% (SE = 2.9). There were no recurrences among patients with complete pathologic response to neoadjuvant therapy. Mean time to recurrence was 2.5 years (SD = 1.43). A total of 89.2% of patients with very low tumors underwent curative resection without a permanent stoma (33/37). The 3-year disease-specific survival rate was 98.6% (95% CI, 90.4%-99.8%), and overall survival rate was 89.4% (95% CI, 79.9%-94.6%). Limitations The study was limited by its single-center retrospective experience. Conclusions Transanal endoscopic microsurgery provides comparable oncologic outcomes to radical resection in properly selected patients with early rectal cancer. Sphincter preservation rates approach 90% even in patients with very distal rectal cancer.

Background Twitter has been recognized as an important source of organic sentiment and opinion. This study aimed to (1) characterize the content of tweets authored by the United States cancer patients; and (2) use patient tweets to compute the average happiness of cancer patients for each cancer diagnosis. Methods A large sample of English tweets from March 2014 through December 2014 was obtained from Twitter. Using regular expression software pattern matching, the tweets were filtered by cancer diagnosis. For each cancer-specific tweetset, individual patients were extracted, and the content of the tweet was categorized. The patients' Twitter identification numbers were used to gather all tweets for each patient, and happiness values for patient tweets were calculated using a quantitative hedonometric analysis. Results The most frequently tweeted cancers were breast (n = 15,421, 11% of total cancer tweets), lung (n = 2928, 2.0%), prostate (n = 1036, 0.7%), and colorectal (n = 773, 0.5%). Patient tweets pertained to the treatment course (n = 73, 26%), diagnosis (n = 65, 23%), and then surgery and/or biopsy (n = 42, 15%). Computed happiness values for each cancer diagnosis revealed higher average happiness values for thyroid (h_avg = 6.1625), breast (h_avg = 6.1485), and lymphoma (h_avg = 6.0977) cancers and lower average happiness values for pancreatic (h_avg = 5.8766), lung (h_avg = 5.8733), and kidney (h_avg = 5.8464) cancers. Conclusions The study confirms that patients are expressing themselves openly on social media about their illness and that unique cancer diagnoses are correlated with varying degrees of happiness. Twitter can be employed as a tool to identify patient needs and as a means to gauge the cancer patient experience.

The current chapter provides a broad and in-depth overview of the extant literature on the relationship between sleep health and diabetes and diabetes outcomes, such as glycemic control, insulin sensitivity, and hemoglobin A1c, just to name a few. Specifically, the chapter will highlight the relationship between widely studied sleep parameters such as duration, quality, sleep architecture (e.g., spindles, rapid eye movement sleep, and slow wave sleep), sleep disorders (e.g., insomnia and obstructive sleep apnea), circadian rhythm, and diabetes diagnosis and outcomes (i.e., glucose, insulin resistance, hemoglobin A1c). We also describe evidence indicating which sleep parameters are associated with reduced diabetes risk. To provide a comprehensive overview of the mechanisms and consequences of the sleep-diabetes association in this chapter, we review epidemiological, observational, clinical trials and experimental research [1] .

Introduction Although Hispanics experience a high level of shorter sleep duration (< 7 hrs./24 period), a clear mechanism or cause is lacking. Previous research indicate that emotional distress may explain the burden of shorter sleep among blacks. Applying these findings to Hispanics, we investigated whether emotional distress explains the burden of short sleep duration (< 7 hrs.) among Hispanics and if this relationship varies by sex Methods We used data from the 2018 National Health Interview Survey (NHIS) dataset, a nationally representative sample, in which only Hispanic ethnicity participants (N=3,091) were analyzed. Average sleep duration was self-reported and measured in hours. Emotional distress was measured using Kessler 6, which measures how an individual felt over the past 30 days: nervous, hopeless, restless/fidgety, depressed, effortful and worthless. To assess the association between short sleep duration and emotional distress, we performed Pearson correlation, hierarchical regression analyses, and stratified this relationship by sex to determine if this relationship differed between males and females, adjusting for covariates. Results Of the total sample of 3,091 Hispanics, 1,762 were female, and 1,329 were male. Sleep duration and emotional distress were negatively correlated among females (r = -.27, p Conclusion Our findings indicate that a negative sleep-ED relationship, suggesting that shorter sleep was predictive of higher levels of emotional distress among Hispanics and that this relationship is greater among Hispanic females, compared males. Support K01HL135452, R01MD007716, R01HL142066, and K07AG052685

Introduction Initial download and use of sleep tracking is very high, but prolonged use is very low. Poor prolonged use may be attributable to several factors such as engagement, functionality, aesthetics, information, and recommendation. We appraised these five factors in 16 consumer- and research/medical- grade digital sleep devices. Methods Three reviewers independently assessed 16 consumer- and medical-grade sleep digital devices using the Mobile Application Rating Scale (MARS) App quality ratings, which measures engagement (engagement, entertainment, interest, customization, interactivity, target group), functionality (functionality, performance, ease of use, navigation, gestural design), aesthetics (layout, graphics, visual appeal), information (Accuracy. Goals, Quality of information, Quantity of information, Visual information, Credibility, and Evidence base) and recommended on a Likert scale, with 1- Inadequate to 5 Excellent. Each subcategory is rated on a 1-5 Likert scale which is summed for each category: engagement (30), functionality (25), aesthetics (15), information (35) and recommended (yes or no). Results Devices that had the highest engagement score were Fitbit (27), Apple Watch (27), Garmin (27), and Dreem 2 headband (25.5). Apple Watch (30) had highest score; while Fitbit (13), Apple Watch (13), Garmin (13), Samsung Gear (13) had highest aesthetic score. While for information, ActiGraph (35), SOMNOwatch plus (35), CleveMed SleepView Monitor (35), CleveMed Sapphire PSG (35), SOMNOscreen plus (35), Nox T3 Sleep Monitor (35) and Nox A1 PSG System (35) had the highest ratings. The Dreem 2 headband has the potential induce prolong use among users with and without sleep disorders, based on high scores on engagement (25.5), Functionality (20.5), and Information (26.5). Conclusion Consumer- and research-grade digital devices that measure sleep have varying levels of engagement, functionality, aesthetics, information and recommendations to facilitate prolong use. Consumer grade devices had higher engagement, functionality and aesthetics scores, while research grade devices had higher information and recommendation scores. If consumer- and research-grade devices are to have prolonged use, standardization is needed across the five MARS components. Support K01HL135452, R01MD007716, R01HL142066, and K07AG052685

Introduction Emotional distress (ED) is associated with poor sleep. Research shows that minority populations experience greater vulnerabilities to both ED and poor sleep. Interventions such as relaxation training and behavioral therapy address this relationship but are not always successful. Research shows that physical activity (PA) is negatively associated with ED and positively associated with sleep duration. However, it is unclear whether PA attenuates the relationship between ED and sleep, and if this relationship differs by race/ethnicity. Methods We analyzed data from the 2005-2015 National Health Interview Survey (NHIS), a nationally representative dataset of 416,152 participants. ED, hours of PA per day, and average sleep duration were collected. Regression models with covariates (age, sex, employment status, BMI) were used to analyze the moderation effect of PA within sleep and ED. Regression models were stratified by race/ethnicity. Results 261,686 participants (45,926 blacks, 17.55%, and 215,760 whites, 82.45%) responded with the required variables for analysis. 63% of participants reported at least some physical activity. The results of the regression showed that a significant amount of variance in ED stemmed from sleep duration; F (7, 121088) = 1,619.72, p < 0.001. PA was found to have a significant main effect, t(121,088) = 9.01, p= Conclusion The present study found support for moderation of PA in the sleep-ED relationship. However, it found that blacks do not experience the same benefits of PA in this relationship as whites. Further research should be performed to understand the connection of PA to sleep duration and ED. Support This study was supported by funding from the NIH: R01MD007716, R01HL142066, R01AG056531, K01HL135452, and K07AG052685

Objective To assess postoperative opioid prescribing in response to state and organizational policy changes. Methods We used an observational study design at an academic medical center in the Northeast United States over a time during which there were two important influences: 1) implementation of state rules regarding opioid prescribing and 2) changes in organization policies reflecting evolving standards of care. Results were summarized at the surgical specialty and procedure level and compared between baseline (July–December 2016) and postrule (July–December 2017) periods. Results We analyzed data from 17,937 procedures from July 2016 to December 2017, two-thirds of which were outpatient. Schedule II opioids were prescribed in 61% of cases and no opioids at all in 28%. The median morphine milligram equivalent (MME) prescribed at discharge decreased 40%, from 113 MME in the baseline period to 68 MME in the postrule period. Decreases were seen across all the surgical specialties. Conclusions Postoperative opioid prescribing at the time of hospital discharge decreased between 2016 and 2017 in the setting of targeted and replicable state and health care organizational policies. Policy Implications Policies governing the use of opioids are an effective and adoptable approach to reducing opioid prescribing following surgery.

Background The number of deaths from prescription opioids in the US continues to increase and remains a major public health concern. Opioid-related deaths parallel prescribing trends, and postoperative opioids are a significant source of opioids in the community. Our objective was to identify opioid prescribing and use patterns after surgery to inform evidence-based practices. Study design Data from a 340-bed academic medical institution and its affiliated outpatient surgical facility included retrospective medical record data and prospective telephone questionnaire and medical record data. Retrospective data included patients discharged after 1 of 19 procedure types, from July 2015 to June 2016 (n = 10,112). Prospective data included a consecutive sample of general and orthopaedic surgery and urology patients undergoing 1 of 13 procedures, from July 2016 to February 2017 (n = 539). Primary outcomes were the quantity of opioid prescribed and used in morphine milligram equivalents (MME), and the proportion of patients receiving instructions on disposal and nonopioid strategies. Results In the retrospective dataset, 76% of patients received an opioid after surgery, and 87% of prescriptions were prescribed by residents or advanced practice providers. Median prescription size ranged from 0 to 503 MME, with wide interquartile ranges (IQR) for most procedures. In the prospective dataset, there were 359 participants (67% participation rate). Of these, 92% of patients received an opioid and the median proportion used was 27%, or 24 MME (IQR 0 to 96). Only 18% of patients received disposal instructions, while 84% of all patients received instructions on nonopioid strategies. Conclusions Median opioid use after surgery was 27% of the total prescribed, and only 18% of patients reported receiving disposal instructions. Significant variability in opioid prescribing and use after surgery warrants investigation into contributing factors.

Hemorrhoids are a common problem managed by the general surgeon and colon and rectal surgeon alike. Most patients are managed conservatively or with office-based procedures. A minority of patients will require operative intervention. There are certain populations of patients in whom the approach to management must be carefully considered and tailored. The management of hemorrhoids in patients with HIV/AIDs, portal hypertension, acute thrombosis, inflammatory bowel disease, or who are pregnant or anticoagulated will be discussed. Occasionally hemorrhoidectomy specimens harbor histologic surprises and this will be discussed briefly.

Abdominoperineal resection is the surgical standard for low rectal cancers when sphincter salvage is not possible, and has proven to be a life-saving procedure for patients who need it. Otherindications for abdominoperineal resection include inflammatory bowel disease (IBD), and salvage surgery for persistent or recurrentanal cancer [1]. An unhealed perineal wound after oncologic surgery was first described by Miles in 1908 and it remains an ongoing issue for patients to this day [2]. As surgical approaches have become more aggressive, i.e., extralevator abdominoperineal excision of the rectum to reduce positive circumferential margins, patients have become more susceptible to wound complications. The increased use of perioperative chemoradiation further impairs local healing. For these reasons the unhealed perineal wound is a common complication following proctectomy [3]. The presence of an unhealed perineal wound can delay adjuvant chemotherapy or radiation therapy. It can also result in severely diminished quality of life following the operation owing to frequent outpatient visits, prolonged hospital stays, frequent dressing changes, further operations, and increased healthcare costs [1, 4].

This study aimed to determine the diagnostic yield of colonoscopy 1 year after colorectal cancer (CRC) resection based on whether the index colonoscopy was performed by the operating surgeon. All patients undergoing surgery for colorectal cancer by two colon and rectal surgeons at a university hospital from 1991 to 2005 were identified from the tumor registry. Those patients with a complete preoperative colonoscopy by any physician and a 1-year follow-up examination by the operating surgeon were selected for the study population. Family history of colorectal cancer, tumor location, endoscopist, presence of synchronous neoplasms, and findings of 1-year colonoscopy were recorded. Fisher’s exact test was used to compare the probability of finding any adenoma, advanced adenoma, or invasive cancer based on the index endoscopist. Of the 719 patients who underwent resection during the study period, 432 met the inclusion criteria. The index colonoscopy for 117 of these patients (27.1%) was performed by one of the two surgeons. Overall, 10 patients (2.3%) had a “new” cancer diagnosed at 1 year, and 1 patient (0.2%) had a local recurrence. Patients whose index colonoscopy was performed by their operating surgeon appeared less likely to have an advanced lesion found at 1 year (5.1% vs 11.4%; p = 0.06). The index colonoscopy for 9 of the 10 of cancers found at 1 year was not performed by the operating surgeon. Colonoscopy 1 year after CRC resection is clearly justified. An index colonoscopy by the operating surgeon eliminates a “handoff” and may diminish the incidence of high-risk lesions at 1 year.

daughter, Rubina, has been complaining of fatigue and has felt warm to the touch. Taking the child to the nearest clinic would cost Afiya a day’s lost wages, round-trip bus fare, and clinic fees of Taka 200 (U.S. $3). Instead, Afiya and her husband use the family’s mobile phone to dial “7-8-9,” the Healthline hotline service set up by TRCL, Ltd., a telemedicine firm, and GrameenPhone, the country’s largest mobile network operator. The family quickly reaches Dr. Quadri at Healthline’s call center in Dhaka. After asking a few questions, Dr. Quadri tells her to give Rubina small regular doses of paracetamol, available at neighborhood shops. For the threeminute call, Afiya pays only Taka 15 (U.S. $0.21) from her family’s GrameenPhone prepaid talk-time balance. Afiya is not the only person seeking basic medical advice and information by calling a health hotline. Telephone-based nurse triage, primary care, and health information have been offered in developed countries since the late 1990’s, and

Die von Buess in den 80er Jahren des vorigen Jahrhunderts entwickelte transanale endoskopische Mikrochirurgie erfreut sich in den letzten Jahren zunehmender Beliebtheit. Bisher gibt es noch keine grosere Studie zum Vergleich der Effektivitat der transanalen endoskopischen Mikrochirurgie und der traditionellen transanalen Exzision. Zwischen 1990 und 2005 unterzogen sich 171 Patienten wegen rektaler Neoplasien einer traditionellen transanalen Exzision (n = 89) oder einem transanalen endoskopischen mikrochirurgischen Eingriff (n = 82). Die Krankenakten wurden ausgewertet, um Art der Operation, Resektionsrander, Praparatfragmentation, Komplikationen, Rezidive, Tumortyp, Krankheitsstadium und Grose zu bestimmen. Die Gruppen waren hinsichtlich Alter, Geschlecht, Tumortyp, Krankheitsstadium und Grose vergleichbar. Das mittlere Follow-up betrug 37 Monate. Es fand sich kein Unterschied bei der Komplikationsrate zwischen den Gruppen (transanale endoskopische Mikrochirurgie 15% vs. traditionelle transanale Exzision 17%; p = 0,69). Die transanale endoskopische Mikrochirurgie erbrachte im Vergleich zur transanalen Exzision mit hoherer Wahrscheinlichkeit tumorfreie Rander (90% vs. 71%; p = 0,001) sowie ein nicht fragmentiertes Praparat (94% vs. 65%, p < 0,001). Nach der transanalen endoskopischen Mikrochirurgie traten weniger haufig Rezidive auf als nach einer traditionellen transanalen Exzision (5% vs. 27%; p = 0,004). Die transanale endoskopische Mikrochirurgie ist die Methode der Wahl bei der lokalen Exzision rektaler Neoplasien.

Laparoscopic colectomy has a shorter length of stay and less analgesic requirements than its open counterpart. Studies have suggested a learning curve of 30 cases. It is uncertain whether surgeons in rural settings have the case volume to acquire and maintain the necessary skill set. The aim of this study was to analyze the volume of colon resections performed by surgeons in rural practice.We performed a retrospective cohort study of the laparoscopic and open partial colectomy case volumes of rural general surgeons seeking American Board of Surgery recertification in 2012. Results were stratified by large and small rural area.One hundred ninety-seven surgeons were classified as practicing in a rural setting (large rural-150, small rural-47). The median open partial colectomy frequency for large rural surgeons was 7 cases and 4 for small rural surgeons. Median annual partial laparoscopic colectomy volume was 1.0 for large rural surgeons and 0.0 for small rural surgeons. Approximately half of surgeons in both groups did not perform a laparoscopic partial colectomy.Industry and financial pressures to promote laparoscopic colectomy may not promote optimal patient outcomes in rural settings, as safety concerns may outweigh the modest benefits of the procedure. Although referral to remote high-volume centers could be advocated, the need for rural general surgeons to perform urgent colectomy for acute indications and the desire of many patients to have care close to home must also be considered.

Surgery clerkship students at our institution receive a standardized orientation covering objectives, requirements, grading, and expectations. Limited data exist regarding the student perceptions of this approach.Surveys were provided to students to rate the importance of orientation topics and their satisfaction with topic conclusion. Scores between student groupings over the clerkship year were analyzed with Student t tests and analysis of variance with Scheffe adjustments.Significant differences in the mean importance rating between topics exists (P.0001) as well as among satisfaction scores for topics (P.0005). Early clerkship students value course expectations higher than later students (P = .03). Early clerkship students want more time devoted to hospital tours and expectations compared with later students (31% vs 8%).Orientation needs for students change over the clerkship year. Beginning students prefer basic direction for time spent on the ward. Later students prefer information regarding shelf preparation. Surgery course directors can adapt the orientation based on the experience of clerkship students.

Background The frenetic pace of inpatient care on surgical services can create barriers to resident teaching of students. Students are often concerned that busy surgical residents will not be able to adequately evaluate their performance at the end of a clerkship. Objective To determine whether the addition of a resident preceptor would increase the satisfaction of students rotating through the general surgery portion of the required third-year surgery clerkship. Study Design Before implementing a resident preceptor model, third-year students rotating on general surgery were administered a 24-item web-based survey regarding their experience on the general surgery portion of the surgery clerkship. General surgery residents were similarly surveyed. A resident preceptor model was then introduced. Subsequent students and residents were surveyed. Presurveys and postsurveys were compared and mean responses analyzed. Results The addition of a resident preceptor made students more comfortable with asking residents questions (p = 0.02), increased the time students felt was available for developing relationships with residents (p = 0.03), and improved the feeling that residents would be able to accurately evaluate the student’s effectiveness as a team member (p = 0.05). The students felt resident teaching on afternoon rounds was increased with the resident preceptor model (p = 0.05). Residents reported spending more time teaching students on morning rounds (p = 0.03). Conclusions Implementation of a resident preceptor model resulted in significant improvement in medical students’ perceptions of resident teaching effectiveness and ability to accurately evaluate a student’s performance.

A comprehensive study of the kinetics and mechanism for the thermal reduction of NO2 by H2 has been carried out in the temperature range 602−954 K by pyrolysis/FTIR spectrometry employing different mixtures containing (1) NO2/Ar, (2) NO2/NO/Ar, (3) NO2/H2/Ar, (4) NO2/H2/CO/Ar, and (5) NO2/H2/CO/NO/Ar. The results of kinetic modeling for the data obtained from mixtures 1 and 2 gave the rate constant for the key reaction responsible for NO formation and NO2 decay, 2NO2 → 2NO + O2 (4): k4 = 4.16 × 1012 exp(−13 840/T) cm3/(mol s). Combination of our data with those of Rohrig et al. (ref 27) measured at high temperatures in shock waves led to k4 = (4.51 ± 0.15) × 1012 exp[-(13 890 ± 27)/T] cm3/(mol s) for 600 K < T < 1450 K. Kinetic modeling of the measured data from mixtures 3−5 indicated that the existing rate constant for H2 + NO2 → HONO + H (−1) was too large; on the other hand, our theoretically predicted rate constant, k-1 = (1.30 × 104)T2.76 exp(−14 980/T) cm3/(mol s), obtained by high-level ab initio ...

Background Survival in colon cancer is greater in those patients who have more lymph nodes identified at resection and may be due to stage migration, confounding by treatment, social, or clinical characteristics. Identifying factor(s) responsible for the effect may represent an opportunity to improve quality of care for patients with colon cancer by increasing node counts in specimens. Methods Cox proportional hazards models were created to analyze survival of 11,399 patients with stage I-III colon cancer from the Surveillance, Epidemiology and End Results (SEER)-Medicare database. The primary predictor variable was the number of lymph nodes identified. The models allowed adjustment for patient factors, use of chemotherapy, surgical specialty, and the average number of nodes identified by surgeon and hospital pathologist. Results The number of nodes identified was related to survival. Compared to those with less than 7 nodes, patients with 7 to 11 nodes had a 13% lesser risk of death (hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.76–0.99; P = .037). Patients with more than 12 nodes had a 17% lesser risk (HR, 0.83; 95% CI, 0.73–0.95; P = .005). Adjusting for selected patient demographic characteristics, receipt of chemotherapy, surgical specialty, and the average number of nodes identified per specimen by the surgeon or hospital did not significantly alter the relationship between number of nodes and survival. Conclusion These findings argue against understaging or confounding as the explanation for the inferior survival observed in patients with fewer nodes identified. National initiatives to increase the number of nodes identified in colon cancer specimens may not improve substantially the cancer-specific outcomes.

Transanal endoscopic microsurgery, developed by Buess in the 1980s, has become increasingly popular in recent years. No large studies have compared the effectiveness of transanal endoscopic microsurgery with traditional transanal excision. Between 1990 and 2005, 171 patients underwent traditional transanal excision (n = 89) or transanal endoscopic microsurgery (n = 82) for rectal neoplasms. Medical records were reviewed to determine type of surgery, resection margins, specimen fragmentation, complications, recurrence, lesion type, stage, and size. The groups were similar with respect to age, sex, lesion type, stage, and size. Mean follow-up was 37 months. There was no difference in the complication rate between the groups (transanal endoscopic microsurgery 15 percent vs. traditional transanal excision 17 percent, P = 0.69). Transanal endoscopic microsurgery was more likely to yield clear margins (90 vs. 71 percent, P = 0.001) and a nonfragmented specimen (94 vs. 65 percent, P

To describe the clinical progression of an adult patient with traumatic brain injury who survived propofol infusion syndrome.Case report.Tertiary care surgical intensive care unit.A 21-yr-old male with traumatic brain injury was administered high doses of propofol for sedation and intracranial pressure control combined with vasopressor therapy to maintain cerebral perfusion pressure60 mmHg. He developed a significant metabolic acidosis with a lactic acid level of 10.9 mmol/L.Exploratory laparotomy, discontinuation of propofol infusion.An exploratory abdominal laparotomy was negative for traumatic injury. During the procedure, the propofol infusion was considered a possible cause and was discontinued. On review, it became apparent that a combination of high-dose propofol and catecholamines were responsible for the lactic acidosis. An echocardiogram revealed severe left ventricular dysfunction and cardiomyopathy, which resolved within 19 days.High-dose propofol should be avoided and alternative agents should be instituted for sedation and intracranial pressure management. The use of catecholamine infusions to maintain cerebral perfusion pressure in the setting of a high-dose propofol infusion may be pharmacologically unsound and may be a triggering factor for propofol infusion syndrome. Identification of the syndrome and discontinuation of propofol resulted in complete reversal of symptoms in the case described.