Technical Challenges for Laryngeal Electromyography.

BACKGROUND/OBJECTIVE: Laryngeal electromyography (LEMG) is a useful diagnostic test in the evaluation of vocal fold paralysis (VFP). This study investigates factors that can make LEMG challenging to perform. METHODS: Patients with subacute unilateral VFP presented for LEMG were prospectively enrolled. Demographic data including BMI, previous neck surgery, and anatomic factors were collected. Patient-reported pain related to the procedure was recorded on a visual analogue scale (VAS). Electromyographer and otolaryngologist recorded a consensus rating of the perceived difficulty in performing the test and confidence in using the results for clinical decision-making. RESULTS: A total of 111 patients (56.8% female) were enrolled between August 2015 and August 2018. The mean age was 55 ± 14 years, and the average body mass index (BMI) was 28.5 ± 6.4. The mean patient-reported VAS score for pain was 35 ± 24. Notably, 31.2% of the tests were considered "very easy," 32.1% were considered "mildly challenging" and 23.9% and 12.8% were considered "moderately challenging" and "extremely challenging," respectively, by the clinicians. Common factors affecting LEMG difficulty included poorly palpable surface anatomy (50.5%) and patient intolerance (15.6%). Clinicians felt confident in 76.1% of the test findings. Bivariate analyses showed that prior neck surgery is associated with elevated VAS (p = 0.02), but clinician-perceived difficulty of performing the test is not associated with elevated VAS scores (p = 0.55). CONCLUSIONS: Majority of LEMG tests are well tolerated by patients. Physicians reported more confidence using LEMG for clinical decision-making when the test was easier to perform. Difficult surface anatomy and patient intolerance affects clinician confidence in integrating the test results with clinical care. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:831-834, 2024.

Envisioning the Future of Student Success: Report of the 2022-2023 AACP Student Affairs Standing Committee.

Over the past several years, traditional metrics have indicated declining student success within colleges and schools of pharmacy. Though students may be less well-prepared for professional school than in years past, once candidates are admitted to our institutions, we have a responsibility to effectively support their progression through the program. The 2022-2023 Student Affairs Committee was convened to evaluate and advance the construct of student success within Doctor of Pharmacy programs. The Student Affairs Committee was charged with identifying environmental factors affecting the ability of pharmacy students to be successful; determining how colleges and schools of pharmacy are currently meeting needs related to student progress; conducting a literature review to determine what academic support measures minimize attrition; and developing innovative suggestions and recommendations that better support student success. To accomplish this work, we conducted an extensive literature review and synthesis of evidence, engaged in professional networking across the Academy, and administered a wide-ranging student success survey to all colleges and schools of pharmacy. In this report, we explore the complex and interacting systems that affect learning behavior and academic success and offer a novel, comprehensive description of how the Academy is currently responding to challenges of academic and student success. Additionally, we envision the future of student success, offering 7 recommendations to the American Association of Colleges of Pharmacy and 5 suggestions to members of the Academy to advance this vision.

Investigating multigelator systems across multiple length scales.

Preparation of multicomponent systems provides a method for changing the properties of low molecular weight gelator (LMWG)-based systems. Here we have prepared a variety of multicomponent systems where both components are N-functionalised dipeptide-based LMWGs that may either co-assemble or self-sort when mixed. We exemplify how varying the concentration ratio of the two components can be used to tune the properties of the multicomponent systems pre-gelation, during gelation and in the gel state using viscosity and rheology measurements, circular dichroism, NMR and small angle neutron scattering. We also investigate the effect of changing the chirality of a single component on the properties of these systems. While predicting the outcome of multicomponent assembly is a challenge, the preparation of a variety of systems allows us to probe the factors affecting their design. This work provides insights into how the properties of multicomponent systems composed of two gelators with the same basic structural design can be tuned by varying the chirality and the concentration ratio of the two components and considering the behaviour of the two components when alone.

A mixed method analysis of student satisfaction with active learning techniques in an online graduate anatomy course: Consideration of demographics and previous course enrollment.

Online learning has become an essential part of mainstream higher education. With increasing enrollments in online anatomy courses, a better understanding of effective teaching techniques for the online learning environment is critical. Active learning has previously shown many benefits in face-to-face anatomy courses, including increases in student satisfaction. Currently, no research has measured student satisfaction with active learning techniques implemented in an online graduate anatomy course. This study compares student satisfaction across four different active learning techniques (jigsaw, team-learning module, concept mapping, and question constructing), with consideration of demographics and previous enrollment in anatomy and/or online courses. Survey questions consisted of Likert-style, multiple-choice, ranking, and open-ended questions that asked students to indicate their level of satisfaction with the active learning techniques. One hundred seventy Medical Science master's students completed the online anatomy course and all seven surveys. Results showed that students were significantly more satisfied with question constructing and jigsaw than with concept mapping and team-learning module. Additionally, historically excluded groups (underrepresented racial minorities) were generally more satisfied with active learning than non-minority groups. Age, gender, and previous experience with anatomy did not influence the level of satisfaction. However, students with a higher-grade point average (GPA), those with only a bachelor's degree, and those with no previous online course experience were more satisfied with active learning than students who had a lower GPA, those holding a graduate/professional degree, and those with previous online course experience. Cumulatively, these findings support the beneficial use of active learning in online anatomy courses.

Hierarchical Composite Self-Sorted Supramolecular Gel Noodles.

Multicomponent supramolecular systems can be used to achieve different properties and new behaviors compared to their corresponding single component systems. Here, a two-component system is used, showing that a non-gelling component modifies the assembly of the gelling component, allowing access to co-assembled structures that cannot be formed from the gelling component alone. The systems are characterized across multiple length scales, from the molecular level by NMR and CD spectroscopy to the microstructure level by SANS and finally to the material level using nanoindentation and rheology. By exploiting the enhanced mechanical properties achieved through addition of the second component, multicomponent noodles are formed with superior mechanical properties to those formed by the single-component system. Furthermore, the non-gelling component can be triggered to crystallize within the multicomponent noodles, allowing the preparation of new types of hierarchical composite noodles.

Exploring the mono-/bistability range of positively autoregulated signaling systems in the presence of competing transcription factor binding sites.

Binding of transcription factor (TF) proteins to regulatory DNA sites is key to accurate control of gene expression in response to environmental stimuli. Theoretical modeling of transcription regulation is often focused on a limited set of genes of interest, while binding of the TF to other genomic sites is seldom considered. The total number of TF binding sites (TFBSs) affects the availability of TF protein molecules and sequestration of a TF by TFBSs can promote bistability. For many signaling systems where a graded response is desirable for continuous control over the input range, biochemical parameters of the regulatory proteins need be tuned to avoid bistability. Here we analyze the mono-/bistable parameter range for positively autoregulated two-component systems (TCSs) in the presence of different numbers of competing TFBSs. TCS signaling, one of the major bacterial signaling strategies, couples signal perception with output responses via protein phosphorylation. For bistability, competition for TF proteins by TFBSs lowers the requirement for high fold change of the autoregulated transcription but demands high phosphorylation activities of TCS proteins. We show that bistability can be avoided with a low phosphorylation capacity of TCSs, a high TF affinity for the autoregulated promoter or a low fold change in signaling protein levels upon induction. These may represent general design rules for TCSs to ensure uniform graded responses. Examining the mono-/bistability parameter range allows qualitative prediction of steady-state responses, which are experimentally validated in the E. coli CusRS system.

Prospective, Multi-Center Study of the Anatomic Distribution of Recurrent Respiratory Papillomatosis.

OBJECTIVES/HYPOTHESIS: To create a model of the anatomic distribution, recurrence, and growth patterns of recurrent respiratory papillomatosis (RRP). STUDY DESIGN: Prospective, multi-institutional cohort study. METHODS: Adult patients with a diagnosis of RRP evaluated between August 1, 2018 and February 1, 2021 at six participating centers were invited to enroll. At each office or operating room encounter, laryngologists recorded the location and size of RRP lesions using a 22-region schematic. A generalized linear mixed effects model was used to compare region variations in lesion prevalence and recurrence. RESULTS: The cohort comprised 121 patients: 74% were male, 81% had been diagnosed with adult-onset RRP, and a plurality (34%) had undergone 0 to 3 RRP interventions prior to enrollment. Across the study period, the odds of a lesion occurring in the glottis was significantly higher (odds ratio [OR]: 26.51; 95% confidence interval [CI]: 11.76-59.75, P < .001) compared with all other areas of the larynx and trachea. Within the true vocal folds, the membranous vocal folds had significantly higher odds (OR: 6.16; 95% CI: 2.66-14.30, P < .001) of lesion occurrence compared to the cartilaginous vocal folds. Despite these strong trends in lesion distribution, there were no differences in the odds of lesion recurrence, growth, or in the time to recurrence, between anatomic subsites. CONCLUSIONS: RRP lesions are most likely to occur in the glottis, particularly the membranous vocal folds, compared with other regions of the larynx or trachea. However, all lesions demonstrate similar behavior with respect to recurrence, growth, and time to recurrence regardless of anatomic location. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:2403-2411, 2022.

Are Prerequisite Courses Barriers to Pharmacy Admission or the Keys to Student Success?

The variability and complexity of course prerequisites across colleges and schools of pharmacy can result in barriers to admission. While prerequisites play an important role in the admissions process and assuring student preparation, requiring excessive prerequisites can create unnecessary challenges for applicants. Prospective students may choose not to apply to a particular pharmacy school or even enter the profession because they cannot complete all course prerequisites in time to apply. Extraneous prerequisites can also contribute to the cost of education and educational indebtedness, which can more adversely affect minority and disadvantaged students. Pharmacy programs should carefully examine their course prerequisite requirements and consider new ways to measure preparedness to attract a diverse and competent pool of applicants to the profession while also being more competitive with other health professions programs.

Characterizing heat mitigation strategies utilized by beef processors in the United States.

During lairage at slaughter plants, cattle can be exposed to extreme heat conditions from pen densities and holding pen microclimates. While research outlining heat mitigation strategies used in other sectors of the beef supply chain is available, there is no published data on the use of heat mitigation strategies at slaughter plants. The objective of this study was to characterize short-term heat mitigation strategies used by commercial beef slaughter plants in the United States. Twenty-one beef slaughter plants, representing an estimated 60% of beef slaughter in the United States, were included in the study. All plants indicated use of at least one heat mitigation strategy, and five of them used more than one type. Sprinklers/misters were the most commonly used heat mitigation type (n = 17, 81%), and fans were the least common type (n = 4, 19%). Shade usage was present in several plants (n = 7, 33%), ranging from barn style roofs to shade cloths. Respondents indicated that they believed heat mitigation strategies provide benefits both to cattle well-being and meat quality outcomes. Future research should focus on the effectiveness of these techniques in improving animal well-being and quality outcomes in the slaughter plant environment and protocols for optimum implementation.

The Patient Experience: The Relationship Between Vocal Handicap, Congruency, Perceived Present Control, and Mood Across Four Voice Disorders.

The potential for negative sequalae in psychosocial well-being presents clinical importance to the assessment of voice disorders. Despite the impairment voice disorders cause in the psychosocial domain, the clinical assessment of these disorders relies heavily on visual perceptual judgments of the larynx, audio-perceptual, as well as acoustic and aerodynamic measures. While these measures aid in accurate diagnosis and are necessary for standard of care, they present little insight into the patient experience of having a voice disorder. DESIGN: Retrospective between-subject, non-experimental design. METHODS: Data from 335 patients from the University of Pittsburgh Voice Center were collected from scores of the Voice Handicap Index-10 (VHI-10) and two recent questionnaires, the Voice Present Perceived Control scale (VPPC), and the Vocal Congruency Scale (VCS). Examining how these voice-specific scales related to three mental health screeners for stress (Perceived Stress Scale-4), anxiety (Generalized Anxiety Disorder-7) and depression (Patient Health Questionnaire-9) were also examined. Patient diagnoses included primary muscle tension dysphonia (pMTD), unilateral vocal fold paralysis (UVFP), vocal fold atrophy, and mid membranous vocal fold lesions. RESULTS: There were significant differences in scores from the voice-specific scales between diagnostic groups with UVFP being the highest (worst) in VHI-10 and UVFP being the lowest (worst) in VCS compared to healthy controls. There was no significant difference in VPPC scores between diagnostic groups. Results showed statistically significant inverse relationships between the VHI-10 and the VPPC and between the VHI-10 and VCS for all diagnostic groups. A significant direct relationship was found between the VPPC and the VCS for patients diagnosed with MTD, UVFP and Lesions. In sum, patients with UVFP presented with the most frequent and sometimes strongest relationships between voice and mental health measures. DISCUSSION: This study marks an initial investigation into the nuanced patient experience of having a voice disorder. Three theoretically unrelated voice constructs: handicap, perceived control, and sense of self, were measured via self-report. Results from this study describe the patient experience correlating to these constructs with weak correlations to stress, anxiety, and depression. Findings also clearly suggest that patient experience varies among diagnostic groups, as well as varying constructs. Measures of multiple constructs of patient perception provide valuable insight into a patient's experience of their voice disorder, guidance on the direction of voice treatment, and justification for such treatments.

A balancing act in transcription regulation by response regulators: titration of transcription factor activity by decoy DNA binding sites.

Studies of transcription regulation are often focused on binding of transcription factors (TFs) to a small number of promoters of interest. It is often assumed that TFs are in great excess to their binding sites (TFBSs) and competition for TFs between DNA sites is seldom considered. With increasing evidence that TFBSs are exceedingly abundant for many TFs and significant variations in TF and TFBS numbers occur during growth, the interplay between a TF and all TFBSs should not be ignored. Here, we use additional decoy DNA sites to quantitatively analyze how the relative abundance of a TF to its TFBSs impacts the steady-state level and onset time of gene expression for the auto-activated Escherichia coli PhoB response regulator. We show that increasing numbers of decoy sites progressively delayed transcription activation and lowered promoter activities. Perturbation of transcription regulation by additional TFBSs did not require extreme numbers of decoys, suggesting that PhoB is approximately at capacity for its DNA sites. Addition of decoys also converted a graded response to a bi-modal response. We developed a binding competition model that captures the major features of experimental observations, providing a quantitative framework to assess how variations in TFs and TFBSs influence transcriptional responses.

Enhancement of the mechanical properties of lysine-containing peptide-based supramolecular hydrogels by chemical cross-linking.

Exposure of lysine-containing peptide-based gelators to the cross-linking agent glutaraldehyde allows tuning of gel mechanical properties. The effect of cross-linking depends on the position of the lysine residue in the peptide chain, the concentration of gelator and the conditions under which cross-linking takes place. Through control of these factors, cross-linking leads to increased gel strength.

Exploiting and controlling gel-to-crystal transitions in multicomponent supramolecular gels.

Multicomponent supramolecular gels provide opportunities to form materials that are not accessible when using the single components alone. Different scenarios are possible when mixing multiple components, from complete co-assembly (mixing of the components within the self-assembled structures formed) to complete self-sorting such that each structure contains only one of the components. Most examples of multicomponent gels that currently exist form stable gels. Here, we show that this can be used to control the mechanical properties of the gels, but what is probably most exciting is that we show that we can use a magnetic field to control the shape of the crystals. The gelling component aligns in a magnetic field and so results in anisotropic crystals being formed.

Understanding gel-to-crystal transitions in supramolecular gels.

Most supramolecular gels are stable or assumed to be stable over time, and aging effects are often not studied. However, some gels do show clear changes on aging, and a small number of systems exhibit gel-to-crystal transitions. In these cases, crystals form over time, typically at the expense of the network underpinning the gel; this leads to the gel falling apart. These systems are rare, and little is known about how these gel-to-crystal transitions occur. Here, we use a range of techniques to understand in detail a gel-to-crystal transition for a specific functionalised dipeptide based gelator. We show that the gel-to-crystal transition depends on the final pH of the medium which we control by varying the amount of glucon-δ-lactone (GdL) added. In the gel phase, at low concentrations of GdL, and at early time points with high concentrations of GdL, we are able to show the nanometre scale dimensions of the self-assembled fibre using SAXS; however there is no evidence of molecular ordering of the gel fibres in the WAXS. At low concentrations of GdL, these self-assembled fibres stiffen with time but do not crystallise over the timescale of the SAXS experiment. At high concentrations of GdL, the fibres are already stiffened, and then, as the pH drops further, give way to the presence of crystals which appear to grow preferentially along the direction of the fibre axis. We definitively show therefore that the gel and crystal phase are not the same. Our work shows that many assumptions in the literature are incorrect. Finally, we also show that the sample holder geometry is an important parameter for these experiments, with the rate of crystallisation depending on the holder in which the experiment is carried out.

Trends in Pharmacy College Admission Test Requirements and Utilization Across Colleges and Schools of Pharmacy.

Objective. To identify national trends among US pharmacy schools and colleges in their requirements for the Pharmacy College Admission Test (PCAT) and underlying rationales for not requiring pharmacy school applicants to take it.Methods. An electronic survey regarding the following was sent to all US pharmacy programs: current and future PCAT requirements for applicants, use of the PCAT or other means to assess applicants' written communication skills, use of unofficial PCAT scores, and, if applicable, the rationale for not requiring applicants to submit PCAT scores. Data analysis was performed using Excel.Results. One hundred five (73%) of 144 schools and colleges of pharmacy responded to the survey. Twelve institutions discontinued the PCAT requirement between the 2018-2019 and 2019-2020 admissions cycles. The most commonly selected reason for discontinuation was a desire to increase pharmacy applications by reducing admission barriers. Pharmacy schools nationwide had concerns regarding high PCAT registration fees. The majority of pharmacy programs that used PCAT scores in their application process indicated that they always, often, or sometimes invited applicants for an interview before they had received the applicant's official PCAT scores. The majority of pharmacy programs considered applicants' PCAT writing score in making their admissions decisions. Other methods used included onsite essays and personal statements.Conclusion. At the time of this study the majority of US pharmacy schools required applicants to submit the PCAT scores before being considered for admission to pharmacy school; however, the use of this examination has declined nationally.

A Pathway to Professional Identity Formation: Report of the 2020-2021 AACP Student Affairs Standing Committee.

EXECUTIVE SUMMARY Professional identity formation (PIF) involves internalizing and demonstrating the behavioral norms, standards, and values of a professional community, such that one comes to "think, act and feel" like a member of that community. Professional identity influences how a professional perceives, explains, presents and conducts themselves. This report of the 2020-2021 AACP Student Affairs Standing Committee (SAC) describes the benefits of a strong professional identity, including its importance in advancing practice transformation. Responding to a recommendation from the 2019-2020 SAC, this report presents an illustrative and interpretative schema as an initial step towards describing a pharmacist's identity. However, the profession must further elucidate a universal and distinctive pharmacist identity, in order to better support pharmacists and learners in explaining and presenting the pharmacist's scope of practice and opportunities for practice change. Additionally, the report outlines recommendations for integrating intentional professional identity formation within professional curricula at colleges and schools of pharmacy. Although there is no standardized, single way to facilitate PIF in students, the report explores possibilities for meeting the student support and faculty development needs of an emerging new emphasis on PIF within the Academy.

Vocal fold injection material does not preclude interpretation of laryngeal electromyography.

INTRODUCTION/AIMS: Temporary vocal fold injection (VFI) is a common treatment for acute and subacute vocal fold paralysis (VFP). Laryngeal electromyography (LEMG) is useful for diagnosing neurogenic causes of VFP. This study evaluated whether the presence of VFI material prevents interpretation of LEMG in patients with acute and subacute VFP. METHODS: Patients with acute and subacute unilateral VFP (onset ≤6 mo) who underwent temporary VFI within 3 mo preceding LEMG were evaluated. A matched control group that did not undergo VFI was also studied. The LEMG team (laryngologist and electromyographer) performed and interpreted LEMG using a pre-specified protocol, including qualitative and quantitative motor unit analysis. RESULTS: Eighteen patients with VFI underwent LEMG successfully with interpretation of spontaneous activity and motor unit recruitment. Fourteen patients were seen in follow-up to determine accuracy of established LEMG prognosis. Seven of seven subjects with poor LEMG prognosis did not recover vocal fold motion. Five of seven subjects with fair LEMG prognosis recovered vocal fold motion. Findings were similar for the control group. DISCUSSION: VFI augmentation material did not prevent interpretation of meaningful LEMG data in patients with acute and subacute VFP, and accurate prognoses of vocal fold motion recovery were established.

Abnormal Laryngeal Electromyography Findings in Asymptomatic Adults Across the Age Spectrum.

OBJECTIVES/HYPOTHESIS: Laryngeal electromyography (LEMG) is a diagnostic tool for patients with suspected neurogenic abnormalities of the larynx. LEMG is often used with the assumption that any abnormality is symptom-/disease-related. We sought to determine the prevalence of abnormal LEMG findings in a group of healthy asymptomatic adults across a large age spectrum. STUDY DESIGN: Open, prospective study, gender-match and age balanced by decade. METHODS: Forty-six healthy participants (age 20-78) underwent LEMG, including 178 muscles. Participants had no history of voice problems, normal VHI-10, and normal flexible laryngoscopy. Qualitative and quantitative LEMG (bilateral) were performed involving the thyroarytenoid-lateral cricoarytenoid muscle complex (TA-LCA) and cricothyroid (CT) muscles. LEMG parameters included evaluation for fibrillation potentials, sharp waves, reduced recruitment, polyphasic potentials, electrical synkinesis, and measurement of turns per second. RESULTS: Of participants, 4% had at least one abnormal qualitative finding (slightly reduced recruitment or two to three discrete polyphasic potentials). There were no findings of fibrillation potentials or sharp waves. There were no abnormal qualitative findings in the CT muscles tested. Of participants, 16% had at least one abnormal synkinesis finding. LEMG qualitative abnormalities and quantitative abnormalities do not appear to correlate with gender or age. CONCLUSION: Abnormal qualitative and quantitative LEMG findings were uncommon and minor in severity in our group of asymptomatic healthy adults. The likelihood of abnormal LEMG results in asymptomatic adults was 2.2% for qualitative findings, 9.3% for synkinesis, and 5.4% for turns/s. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2065-2069, 2021.

Nerve Injury During Ultrasound-Guided Thyroid Biopsy-A First Reported Complication of Permanent Vocal Fold Paralysis.

Needle biopsy is a well-established component in the evaluation of thyroid nodules. The biopsy is usually performed with an ultrasound guidance and consists of either fine-needle aspiration or core needle biopsy. Although these terms are often used interchangeably, their difference is important. To our knowledge, we discuss the first reported case of biopsy-proven laryngeal nerve injury and permanent vocal fold paralysis following ultrasound-guided core biopsy of the thyroid. We advocate this complication be discussed as part of the consent process.

Report of the 2019-2020 AACP Student Affairs Standing Committee.

The 2019-2020 Student Affairs Standing Committee addressed charges related to professional identity formation (PIF) in order to set direction and propose action steps consistent with Priority #3.4 of the AACP Strategic Plan, which states "Academic-practice partnerships and pharmacist-involved practice models that lead to the progress of Interprofessional Practice (IPP) are evident and promoted at all colleges and schools of pharmacy." To this end, the committee was charged to 1) outline key elements of PIF, 2) explore the relationship between formal curricular learning activities and co- or extra-curricular activities in supporting PIF, 3) determine the degree to which there is evidence that strong PIF is embedded in student pharmacists' educational experience, and 4) define strategies and draft an action plan for AACP's role in advancing efforts of schools to establish strong PIF in pharmacy graduates. This report describes work of the committee in exploring PIF and provides resources and background information relative to the charges. The committee offers several suggestions and recommendations for both immediate and long-term action by AACP and members to achieve goals related to integrating PIF into pharmacy education. The committee proposes a policy statement relative to the committee charges. Furthermore, the report calls upon the profession to develop a unified identity and incorporate support for PIF into pharmacy education, training, and practice.