The Physiologic Impact of Unilateral Recurrent Laryngeal Nerve (RLN) Lesion on Infant Oropharyngeal and Esophageal Performance.

Recurrent laryngeal nerve (RLN) injury in neonates, a complication of patent ductus arteriosus corrective surgery, leads to aspiration and swallowing complications. Severity of symptoms and prognosis for recovery are variable. We transected the RLN unilaterally in an infant mammalian animal model to characterize the degree and variability of dysphagia in a controlled experimental setting. We tested the hypotheses that (1) both airway protection and esophageal function would be compromised by lesion, (2) given our design, variability between multiple post-lesion trials would be minimal, and (3) variability among individuals would be minimal. Individuals' swallowing performance was assessed pre- and post-lesion using high speed VFSS. Aspiration was assessed using the Infant Mammalian Penetration-Aspiration Scale (IMPAS). Esophageal function was assessed using two measures devised for this study. Our results indicate that RLN lesion leads to increased frequency of aspiration, and increased esophageal dysfunction, with significant variation in these basic patterns at all levels. On average, aspiration worsened with time post-lesion. Within a single feeding sequence, the distribution of unsafe swallows varied. Individuals changed post-lesion either by increasing average IMPAS score, or by increasing variation in IMPAS score. Unilateral RLN transection resulted in dysphagia with both compromised airway protection and esophageal function. Despite consistent, experimentally controlled injury, significant variation in response to lesion remained. Aspiration following RLN lesion was due to more than unilateral vocal fold paralysis. We suggest that neurological variation underlies this pattern.

Enhancing an Experience-Based Patient-Initiated Mistreatment Training.

PROBLEM: Mistreatment of health care workers and learners by patients and their families is prevalent at all levels of training. This mistreatment has negative consequences and disproportionately affects women and historically marginalized and excluded groups. APPROACH: The authors designed and piloted a preliminary practice-based curriculum consisting of a discussion of literature, a framework for responding to mistreatment in the moment, and interactive simulated mistreatment encounters with trained patient actors. Feedback was generally positive, but participants consistently requested greater diversity in the representation of mistreatment. Using funds from the Josiah Macy Jr. Foundation Catalyst Award for Transformation in Graduate Medical Education, the authors expanded and improved the curriculum to meet the needs of a diverse population of learners. Effectiveness of the curriculum was measured using pre- and post-curriculum surveys. OUTCOMES: The curriculum was delivered over multiple sessions from January 2022 to March 2024 with grant-funded interventions starting in January 2024. Participants included medical students, house officers, and faculty, and 678 participants completed pre-curriculum surveys. Upon implementation of grant-funded interventions, post-curriculum surveys showed improvements in respondents' self-reported plan to use skills demonstrated in the session (4.76 to 4.85, P = .006) and plan to address mistreatment with their teams moving forward (4.75 to 4.81, P = .045). NEXT STEPS: All health care workers and learners deserve to feel safe, respected, and welcome in their work and in training. The foundation of this curriculum will support expansion to meet the needs of all patient-facing health care workers and learners at the pilot institution and beyond.

Infection associated acute interstitial nephritis; a case report.

BACKGROUND: Acute interstitial nephritis (AIN) is a clinico-pathological syndrome associated with a variety of infections, drugs, and sometimes with unknown causes. It is a common cause of acute kidney injury (AKI) and subsequent renal impairment, which often times is under-diagnosed. Infection-associated AIN occurs as a consequence of many systemic bacterial, viral, and parasitic infec-tions; however, its incidence has decreased significantly after the advent of antimicrobials. Infection-associated AIN presents with both oliguric or non-oliguric renal insufficiency, without the classical clinical triad of AIN (fever, rash, and arthralgia). In this scenario the renal function is usually reversible after the infection is treated. In most cases, patients with acute renal failure present with extra-renal manifestations typically detected in underlying infections. Renal biopsy serves as the most definitive test for both the diagnosis and prognosis of AIN. CASE PRESENTATION: In this paper, we will address one such case of biopsy-proven AIN. In this case, the patient presented with severe AKI induced by anaerobic streptococcus, leading to a periodontal abscess, which was successfully treated with corticosteroids and requiring renal replacement therapy (RRT). CONCLUSIONS: AIN should be considered in the differential for unexplained AKI. Initial management should include conservative therapy by withdrawing any suspected causative agent. Renal biopsy is needed for confirmation in cases where kidney function fails to improve within 5-7 days on conservative therapy. Risk of immunosuppression is very important to consider when giving steroids in patients with infection induced AIN, and steroids may have to be delayed until the active infection is completely controlled.

Central nervous system integration of sensorimotor signals in oral and pharyngeal structures: oropharyngeal kinematics response to recurrent laryngeal nerve lesion.

Safe, efficient liquid feeding in infant mammals requires the central coordination of oropharyngeal structures innervated by multiple cranial and spinal nerves. The importance of laryngeal sensation and central sensorimotor integration in this system is poorly understood. Recurrent laryngeal nerve lesion (RLN) results in increased aspiration, though the mechanism for this is unclear. This study aimed to determine the effect of unilateral RLN lesion on the motor coordination of infant liquid feeding. We hypothesized that 1) RLN lesion results in modified swallow kinematics, 2) postlesion oropharyngeal kinematics of unsafe swallows differ from those of safe swallows, and 3) nonswallowing phases of the feeding cycle show changed kinematics postlesion. We implanted radio opaque markers in infant pigs and filmed them pre- and postlesion with high-speed videofluoroscopy. Markers locations were digitized, and swallows were assessed for airway protection. RLN lesion resulted in modified kinematics of the tongue relative to the epiglottis in safe swallows. In lesioned animals, safe swallow kinematics differed from unsafe swallows. Unsafe swallow postlesion kinematics resembled prelesion safe swallows. The movement of the tongue was reduced in oral transport postlesion. Between different regions of the tongue, response to lesion was similar, and relative timing within the tongue was unchanged. RLN lesion has a pervasive effect on infant feeding kinematics, related to the efficiency of airway protection. The timing of tongue and hyolaryngeal kinematics in swallows is a crucial locus for swallow disruption. Laryngeal sensation is essential for the central coordination in feeding of oropharyngeal structures receiving motor inputs from different cranial nerves.