The Accreditation Council for Graduate Medical Education 20-Year Trends in Diversity, Equity, and Inclusion in the United States: How Does Neurological Surgery Compare?

BACKGROUND

Within the current medical workforce, diversity is limited among surgical specialties. However, diversity allows physicians to provide culturally competent care. This paper discusses the trends in racial, ethnic, and gender representation within different surgical subspecialties with an emphasis on neurosurgery over a 20-year time frame.

METHODS

A retrospective review of data collected by the Accreditation Council for Graduate Medical Education over the past twenty years, as reported in Journal of the American Medical Association, was conducted. Residents from 5 surgical specialties were evaluated based on gender, race, and ethnic identifications from 2002 to 2022. One-way analysis of variance was performed to compare the levels and retention rates of racial, ethnic, and gender diversity within these specialties.

RESULTS

Analysis of resident demographics of the 5 surgical specialties reveals an overall trend of increasing diversity over the study period. Over the past 20 years, neurosurgery had an overall increase in Asian (+5.1%), Hispanic (+3.0%), and female (+11.4%) residents, with a decrease in White residents by 2.1% and Black residents by 1.1%. Among the surgical specialties analyzed, otolaryngology had the greatest overall increase in minority residents. Notably, there has been an overall increase in female residents across all 5 surgical specialties, with the highest in otolaryngology (+20.3%) which was significantly more than neurosurgery (P < 0.001).

CONCLUSIONS

This chronological analysis spanning 20 years demonstrates that neurosurgery, like other specialties, has seen a growth in several racial and ethnic categories. Relative differences are notable in neurosurgery, including Black, Asian, Hispanic, and White ethnic categories, with growth in females, but at a significantly lesser pace than seen in otolaryngology and plastic surgery.

Cutaneous cryptococcosis in a diabetic renal transplant recipient

A diabetic renal transplant recipient with cellulitis caused by Cryptococcus neoformans, serotype A, is described. The diagnosis was based on the demonstration of capsulated, budding yeast cells in the aspirated material and tissue from the cellulitic lesion and isolation of the aetiological agent in culture. The isolate formed well-developed capsules in the brain tissue of experimentally infected mice and produced cherry-brown colonies on niger seed medium. The patient's serum was positive for cryptococcal antigen (titre 1 : 4) with no other evidence of systemic infection. He was successfully treated with AmBisome, followed by fluconazole, resulting in the complete resolution of cellulitis and disappearance of the cryptococcal antigen. This report underscores the fact that patients with cutaneous cryptococcosis should be thoroughly evaluated, as it may be the first manifestation of a systemic disease. Prompt diagnosis and treatment are important to improve survival.

Schistosoma mansoni antigens applicable to diagnosis of prepatent infections

Diagnosis of schistosomiasis still depends upon demonstration of eggs in excreta, by which time significant pathology may occur to the human host. This study was undertaken to identify Schistosoma mansoni antigen(s) to be exploited in serodiagnosis of prepatent and/or acute infections. Immunoglobulin G and M responses of inbred and outbed mice to Schistosoma mansoni whole adult worm antigen were monitored in immunoblots using sera obtained at sequential times from mice infected with either 600 or 100 Schistosoma mansoni cercariae each. Regardless of the initial infection dose, immunoblot reactions to two doublets, 31/32 and 34/35 kDa appeared as early as two and three weeks post infection respectively and reactions to 38 and 70 kDa antigens appeared after five weeks infection. Antigens 31/32 and 38 induced both IgG and IgM responses whereas 34/35 and 70 predominantly induced IgG response. Homologues of these four antigens equally reactive with serum of infected mice were also demonstrated in Schistosoma haematobium, worms. Examination of sera from 25 patients suffering from acute Schistosoma mansoni, two suffering from Schistosoma haematobium and 16 patients suffering from infections with other parasite species confirmed the potential of 31/32, 34/35 and 38 kDa antigens in the specific diagnosis of prepatent and acute schistosomal infections but showed cross-reactivity of the 70 kDa antigen.

Immune response to Shigella sonnei in U.S. Marines

Pre- and postdeployment serum samples obtained from U.S. marines in Operations Desert Shield and Desert Storm were tested for antibodies to Shigella sonnei. High predeployment levels of immunoglobulin A (IgA) and/or IgG antibodies to S. sonnei lipopolysaccharide antigen in serum and seroconversions were accompanied by higher IgA and/or IgG antibody response to Shigella invasion plasmids (Ipa). The results suggest exposure to S. sonnei in predeployment troops and frequent exposure to this bacterial agent during deployment.

Restriction fragment length polymorphism of flagellin genes of Campylobacter jejuni and/or C. coli isolates from Egypt

The conservation of flagellin genes from thermophilic Campylobacter spp. strains isolated in Egypt was evaluated by a restriction fragment length polymorphism (RFLP) assay. The flaA and flaB genes were amplified from 59 independent clinical isolates and digested with EcoRI and PstI, and the resulting patterns were compared with each other and with previously described RFLP groups. The results indicate that the isolates fell into 14 groups for flaA and 11 groups for flaB, 9 of which have been described, and that considerable genetic variability exists among isolates belonging to the same LIO serogroup. In most cases, the flaB gene displayed the same RFLP pattern as that of the flaA gene of the same strain, although some variability was observed. The data suggest that more variability of flagellin genes exists within the LIO serogroups common to Campylobacter field isolates from Egypt than has previously been reported for North American isolates.

Simultaneous radio-isotopic study of both fibrinogen and platelets in hepatic schistosomiasis

Simultaneous platelet and fibrinogen survival and turnover were studied using selenomethionine (75Se) in early and late groups of schistosomal hepatic fibrosis (SHF) and in a control group. In the control group, the mean platelet survival was 11.66 +/- 1.59 days and mean platelet turnover was 20,230 +/- 5090 platelets/microliter/day. Mean fibrinogen survival was 7.3 +/- 0.60 days and fibrinogen turnover was 0.35 +/- 0.04 mg/ml/day. In the early schistosomal group, platelet survival was shortened with an increased turnover rate and normal platelet count. The presence of a structurally abnormal fibrinogen molecule in the early group may have resulted in its shortened survival, that was compensated by the liver through increasing the turnover rate. In the late group, platelet survival was shortened with no significant increase of fibrinogen turnover, while fibrinogen concentration remained normal, suggesting the presence of extrahepatic sites of fibrinogen synthesis.

Effect of zinc supplementation on S. mansoni-infected hamsters

Golden hamsters were used to determine whether intraperitoneal Zn supplementation can improve the outcome of infection with Schistosoma mansoni. The animals were divided into two groups; one received an initial intraperitoneal dose of Zn chloride (0.75 mg 100 g body wt.-1) followed by booster doses (0.25 mg 100 g body wt.-1) twice weekly for four weeks, the other group received no Zn supplement. After one week, when the initial and one booster doses were given, half of the animals in each group were exposed to S. mansoni cercariae for two hours using body immersion technique. After five weeks (one week after the final Zn supplement) the animals were killed, their worm burdens determined and their livers, kidneys, spleens, hearts and sera examined. There was a significant reduction in total worm counts in the Zn supplemented group (P less than 0.05). Also, Zn supplementation of infected animals protected them against the hepatomegaly which is very often associated with schistosomiasis. Spleen weight and Zn uptake were highest in the infected Zn supplemented group, indicating that this organ requires larger amounts of Zn to perform its various Zn-dependent immunological functions. The data suggest that Zn may enhance the ability of the body organs to resist some of the harmful effects of schistosomal infection.

The interaction of zinc and vitamin A in human schistosomiasis

Levels of vitamin A and components of its transport protein complex, retinol binding protein and prealbumin, as well as zinc and its major binding proteins albumin and alpha 2-macroglobulin were measured in plasma of ninety-one male Egyptian patients with active schistosomal infection and thirty-two healthy adult males. Patients were divided into four groups: Group I had active schistosomiasis without associated complications; Group II had schistosomiasis complicated by colonic polyposis; Group III had advanced schistosomiasis, hepatosplenomegaly and/or ascites; and Group IV had chronic salmonella septicaemia in addition to schistosomiasis. Results showed that all patient groups had subnormal levels of plasma vitamin A, retinol binding protein, prealbumin, zinc and albumin (P less than 0.005 for all parameters) but elevated alpha 2-macroglobulin (P less than 0.001) when compared to the control group. Alterations in the vitamin A transport proteins increased with schistosomal complications and were closely correlated to changes in vitamin A (P less than 0.005), but alterations of albumin and alpha 2-macroglobulin were less consistent and did not correlate with changes in zinc levels. There was a highly significant correlation, however, between plasma zinc concentrations and those of vitamin A, retinol binding protein and prealbumin (P less than 0.001 for all correlations) in all groups of patients as well as the control group. These findings indicate that the binding and transport proteins of both zinc and vitamin A were adversely affected by schistosomiasis and its various complications. Deficiencies of both zinc and vitamin A seem to be interrelated in this disease and the vitamin A transport system may be largely dependent on zinc status.

The relationship between serum carnitine levels and the nutritional status of patients with schistosomiasis

Serum carnitine levels were investigated in a group of normal adults and two groups of patients with active schistosomiasis who also showed signs of malnutrition and vitamin deficiency. The first group consisted of 16 patients with Schistosoma mansoni and/or Schistosoma haematobium infection. They received an adequate diet supplemented with vitamin and iron therapy and received no treatment for their parasitic infection till their hemoglobin levels were restored to normal. The second group consisted of 12 patients with schistosomiasis as well as intestinal polyposis. They received the same diet as the first group but because of their poor condition were immediately treated for parasitic infection. Results showed that both groups of patients had subnormal levels of serum carnitine with the polyps patients (Group II) having a significantly lower level than patients with simple schistosomiasis (Group I). After nutritional repletion a significant increase was observed in the carnitine levels of most patients in group I indicating a relationship between the nutritional status of the patients and their serum carnitine levels. The patients with polyps also showed considerably increased carnitine levels after treatment and dietary repletion. The usefulness of serum carnitine measurement as an index of protein malnutrition in man is discussed.

Effect of hashish on brain gamma aminobutyric acid system, blood fibrinolytic activity and glucose and some serum enzymes in the rat

Adult male rats were exposed to Hashish smoke for 15 min. Certain biochemical parameters were determined. This treatment did not change the brain glutamic acid level, whereas it significantly decreased brain gamma aminobutyric acid level. There was a significant increase in the activity of the brain enzyme forming gamma aminobutyric acid, namely glutamate decarboxylase, as well as in that enzyme metabolizing gamma aminobutyric acid, namely aminobutyrate aminotransferase. However, the increase was much more marked in the case of aminobutyrate aminotransferase, a finding that might explain the decrease observed in brain gamma aminobutyric acid upon exposure to Hashish. Blood glucose and fibrinolytic activity were significantly increased. It was concluded that these changes might be due to an adrenaline releasing effect of Hashish smoke inhalation. Serum lactate dehydrogenase and serum glutamate oxalacetate transaminase activities were significantly increased, whereas serum glutamate pyruvate transaminase activity was unaffected. From these data it was suggested that the source of leakage of these enzyme activities into the blood is probably the skeletal muscles rather than the liver.

In vitro uptake of labeled amino acids by red blood cells of children with protein-calorie malnutrition

The in vitro uptake of 14C-glycine, 14C-leucine and 35S-methionine by red blood cells as well as the red blood cells and plasma amino acid patterns were studied in 20 children with protein-calorie malnutrition. Blood samples were obtained from each patient on admission, following clinical recovery and, when possible, several months later. Amino acid uptake as well as levels of red blood cells and plasma amino acids are quantitatively changed in protein-calorie malnutrition. Significantly increased uptake of 14C-glycine but decreased uptake of 14C-leucine and 35S-methionine were observed in patients on admission. Following clinical recovery the uptake values of all three amino acids were markedly reduced to levels significantly below normal. Several months later values for glycine and leucine uptake were found to be normal. No significant correlation, however, was found between glycine, leucine, or methionine uptake values and concentrations of these amino groups in RBCs or plasma of patients. It is concluded that the elevations observed in red blood cell amino acids of protein-calorie malnutrition patients are not purely a result of increased amino acid uptake of RBCs and that normalization of both amino acid uptake values and their concentrations in RBCs require longer than the treatment period.