Introduction: Research on disparities in health and health care has demonstrated that social, economic, and political factors are key drivers of poor health outcomes. Yet the role of such structural forces on health and health care has been incorporated unevenly into medical training. The framework of structural competency offers a paradigm for training health professionals to recognize and respond to the impact of upstream, structural factors on patient health and health care. Methods: We report on a brief, interprofessional structural competency curriculum implemented in 32 distinct instances between 2015 and 2017 throughout the San Francisco Bay Area. In consultation with medical and interprofessional education experts, we developed open-ended, written-response surveys to qualitatively evaluate this curriculum's impact on participants. Qualitative data from 15 iterations were analyzed via directed thematic analysis, coding language, and concepts to identify key themes. Results: Three core themes emerged from analysis of participants' comments. First, participants valued the curriculum's focus on the application of the structural competency framework in real-world clinical, community, and policy contexts. Second, participants with clinical experience (residents, fellows, and faculty) reported that the curriculum helped them reframe how they thought about patients. Third, participants reported feeling reconnected to their original motivations for entering the health professions. Discussion: This structural competency curriculum fills a gap in health professional education by equipping learners to understand and respond to the role that social, economic, and political structural factors play in patient and community health.

Sexual and gender minority (SGM) people—including members of the lesbian, gay, bisexual, transgender, and queer communities—are understudied and underrepresented in research. Current sexual orientation and gender identity (SOGI) questions do not sufficiently engage SGM people, and there is a critical gap in understanding how SOGI questions reduce inclusion and accurate empirical representation. We conducted a qualitative study to answer the question, “For SGM people, what are the major limitations with current SOGI questions?” Focus groups probed reactions to SOGI questions adapted from prior national surveys and clinical best practice guidelines. Questions were refined and presented in semi-structured cognitive interviews. Template analysis using a priori themes guided analysis. There were 74 participants: 55 in nine focus groups and 19 in cognitive interviews. Participants were diverse: 51.3% identified as gender minorities, 87.8% as sexual minorities, 8.1% as Hispanic/Latinx, 13.5% as Black or African-American, and 43.2% as Non-white. Two major themes emerged: (1) SOGI questions did not allow for identity fluidity and complexity, reducing inclusion and representation, and (2) SOGI question stems and answer choices were often not clear as to which SOGI dimension was being assessed. To our knowledge, this represents the largest body of qualitative data studying SGM perspectives when responding to SOGI questions. We present recommendations for future development and use of SOGI measures. Attention to these topics may improve meaningful participation of SGM people in research and implementation of such research within and for SGM communities.

Clozapine is an atypical antipsychotic with particular efficacy in schizophrenia, possibly related to potentiation of brain N-methyl-D-aspartate receptor (NMDAR) -mediated neurotransmission. NMDARs are regulated in vivo by glycine, which is regulated in turn by glycine transporters. The present study investigates transport processes regulating glycine uptake into rat brain synaptosomes, along with effects of clozapine on synaptosomal glycine transport. Amino-acid uptake of amino acids was assessed in rat brain P2 synaptosomal preparations using a radiotransport assay. Synaptosomal glycine transport was inhibited by a series of amino acids and by the selective System A antagonist MeAIB (2-methylaminoisobutyric acid). Clozapine inhibited transport of both glycine and MeAIB, but not other amino acids, at concentrations associated with preferential clinical response (0.5-1 lg/ml). By contrast, other antipsychotics studied were ineffective. The novel glycine transport inhibitor Further, in meta-analytic studies, clozapine effect sizes are approximately double those of other agents. 4,5 Several theories have been proposed to account for the unique clinical effects of clozapine. These include preferential binding to serotonin (5-HT2A) receptors, 6 D4 selectivity, 7 or weak binding to D2 receptors with fast dissociation kinetics.8 However, these theories propose to account only for the decreased risk of extrapyramidal side effects associated with clozapine and other atypical antipsychotics, not for its preferential efficacy. Other newer atypicals, including risperidone and olanzapine, each share at least some of the above properties with clozapine. While these agents, like clozapine, have reduced risk of EPS, they do not appear to share clozapine's differential therapeutic efficacy, particularly against negative symptoms. Clozapine treatment typically produces trough plasma levels in the range of 0.2-1.2 mg/ml during therapeutic treatment, 9 with preferential response to clozapine being associated with plasma concentrations of approximately 0.5 mg/ml or greater in both cross-sectional 10 and longitudinal 11 studies. Two active metabolites of clozapine, desmethyl clozapine and clozapine-N-oxide, have also been described and

Human life history contains a series of paradoxes not easily explained by classical life history theory. While overall reproductive output is higher than in related primates, juvenile growth is slower and age-specific reproductive rates decline faster with age. A simple energetic model would predict that growth and reproductive rates should be positively correlated and that reproductive effort should not decelerate with age. The pattern of negative correlations in humans suggests the presence of trade-offs among peak reproductive rate, childhood growth, and reproductive rate at older ages. To address this puzzle, we propose a synthesis of reproductive ecology and behavioral ecology focused on intra-and inter-somatic energy transfers. This integration includes three concepts: the mother as final common pathway through which energy must pass to result in offspring; a distinction between direct and indirect reproductive effort, proposing the latter as a novel net energy allocation category relative to growth and direct reproductive effort; and a pooled energy budget representing the energetic contributions and withdrawals of all members of a breeding community. Individuals at all reproductive life stages are considered in light of their contributions to the pooled energy budget.

Hurricane Sandy led to the closing of many major New York City public hospitals including their substance abuse clinics and methadone programs, and the displacement or relocation of thousands of opioid-dependent patients from treatment. The disaster provided a natural experiment that revealed the relative strengths and weaknesses of methadone treatment in comparison to physician office-based buprenorphine treatment for opioid dependence, two modalities of opioid maintenance with markedly different regulatory requirements and institutional procedures. To assess these two modalities of treatment under emergency conditions, semi-structured interviews about barriers to and facilitators of continuity of care for methadone and buprenorphine patients were conducted with 50 providers of opioid maintenance treatment. Major findings included that methadone programs presented more regulatory barriers for providers, difficulty with dose verification due to impaired communication, and an over reliance on emergency room dosing leading to unsafe or suboptimal dosing. Buprenorphine treatment presented fewer regulatory barriers, but buprenorphine providers had little to no cross-coverage options compared to methadone providers, who could refer to alternate methadone programs. The findings point to the need for well-defined emergency procedures with flexibility around regulations, the need for a central registry with patient dose information, as well as stronger professional networks and cross-coverage procedures. These interventions would improve day-to-day services for opioid-maintained patients as well as services under emergency conditions.