From Eggshells to Action: A Qualitative Study of Faculty Experience Responding to Microaggressions Targeting Medical Students.

PURPOSE: Microaggressions targeting clinical learners cause harm and threaten learning. Clinical supervisors can be powerful allies by intervening when microaggressions occur. This study explored general and student-nominated skilled supervisors' perspectives on responding to microaggressions targeting clinical learners. METHOD: This single-institution, qualitative study within a constructivist paradigm explored faculty supervisor experiences with bystander response to microaggressions targeting learners. Clinical supervisors in medicine and surgery departments and those across departments nominated by students as skilled microaggression responders were invited to discuss microaggression scenarios targeting students in semistructured focus groups in the U.S. in 2020-2021. Investigators applied the framework method of thematic analysis to identify themes. RESULTS: Forty-two faculty (31 medicine and surgery ["general"], 11 "student-nominated" as skilled responders) joined 10 focus groups (6 "general," 3 "student-nominated," 1 mixed). Four themes characterized experiences responding to microaggressions targeting learners: bystander goals, noticing, acting, and continuous learning. Participants' response goals were protecting learners, safeguarding learning, and teaching microaggression response skills. Noticing was influenced by past experiences with microaggressions and acculturation to clinical environments. Bystander action stemmed from (1) microaggression type, (2) personal emotional vulnerability, (3) knowledge of student preferences for supervisor response, and (4) clinical and educational context. Bystander action was more common when participants regarded all microaggressions as harmful, understood student preferences for faculty response, expected to err (growth mindset), and framed microaggressions as opportunities for humble reflection, intellectual candor, and teaching. Microaggression response required continuous learning through informal and formal skills development. CONCLUSIONS: Complex factors govern faculty bystander response to microaggressions targeting clinical learners. Efforts to strengthen faculty bystander response should incorporate skill-building around preemptive discussions with learners and using intellectual candor to promote psychological safety, learning, and bystander action. Additional investigation is needed on how to incorporate these skills into team workflows and to assess outcomes of specific response strategies.

Management of opioid use disorder, opioid withdrawal, and opioid overdose prevention in hospitalized adults: A systematic review of existing guidelines.

BACKGROUND: Hospitalizations related to the consequences of opioid use are rising. National guidelines directing in-hospital opioid use disorder (OUD) management do not exist. OUD treatment guidelines intended for other treatment settings could inform in-hospital OUD management. OBJECTIVE: Evaluate the quality and content of existing guidelines for OUD treatment and management. DATA SOURCES: OVID MEDLINE, PubMed, Ovid PsychINFO, EBSCOhost CINHAL, ERCI Guidelines Trust, websites of relevant societies and advocacy organizations, and selected international search engines. STUDY SELECTION: Guidelines published between January 2010 to June 2020 addressing OUD treatment, opioid withdrawal management, opioid overdose prevention, and care transitions among adults. DATA EXTRACTION: We assessed quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. DATA SYNTHESIS: Nineteen guidelines met the selection criteria. Most recommendations were based on observational studies or expert consensus. Guidelines recommended the use of nonstigmatizing language among patients with OUD; to assess patients with unhealthy opioid use for OUD using the Diagnostic Statistical Manual of Diseases-5th Edition criteria; use of methadone or buprenorphine to treat OUD and opioid withdrawal; use of multimodal, nonopioid therapy, and when needed, short-acting opioid analgesics in addition to buprenorphine or methadone, for acute pain management; ensuring linkage to ongoing methadone or buprenorphine treatment; referring patients to psychosocial treatment; and ensuring access to naloxone for opioid overdose reversal. CONCLUSIONS: Included guidelines were informed by studies with various levels of rigor and quality. Future research should systematically study buprenorphine and methadone initiation and titration among people using fentanyl and people with pain, especially during hospitalization.

Elevations in Tumor Necrosis Factor Alpha and Interleukin 6 From Neuronal-Derived Extracellular Vesicles in Repeated Low-Level Blast Exposed Personnel.

Objective: The purpose of this pilot study was to determine if military service members with histories of hundreds to thousands of low-level blast exposures (i. e., experienced breachers) had different levels of serum and neuronal-derived extracellular vesicle (EV) concentrations of interleukin (IL)-6, IL-10, and tumor necrosis factor alpha (TNFα), compared to matched controls, and if these biomarkers related to neurobehavioral symptoms. Methods: Participants were experienced breachers (n = 20) and matched controls without blast exposures (n = 14). Neuronal-derived EVs were isolated from serum and identified with mouse anti-human CD171. Serum and neuronal-derived EVs were analyzed for IL-6, IL-10, and TNFα using an ultra-sensitive assay. Results: Serum TNFα concentrations were decreased in breachers when compared to control concentrations (p < 0.01). There were no differences in serum concentrations of IL-6, IL-10, or the IL-6/IL-10 ratio between breachers and controls (p's > 0.01). In neuronal-derived EVs, TNFα and IL-6 levels were increased in breachers compared to controls (p's < 0.01), and IL-10 levels were decreased in the breacher group compared to controls (p < 0.01). In breachers the IL-6/IL-10 ratio in neuronal-derived EVs was higher compared to controls, which correlated with higher total Rivermead Post-concussion Questionnaire (RPQ) scores (p's < 0.05). Conclusions: These findings suggest that exposure of personnel to high numbers of low-level blast over a career may result in enduring central inflammation that is associated with chronic neurological symptoms. The data also suggest that peripheral markers of inflammation are not necessarily adequate surrogates for central neuroinflammation.

Examining Risk of Speech-Language Disorders in Children With Cleft Lip.

ABSTRACT: Although it is well-established that children with cleft palate are at high risk for communication disorders, little is known about the speech-language profiles of children with cleft lip (with or without cleft alveolus), who do not have an overt cleft palate. The purpose of this study was to determine the prevalence of speech-language disorders in a consecutively evaluated group of children with cleft lip, with or without cleft alveolus (CL ±â€ŠA) from a single cleft lip and palate center in the United States. We also explored the types of speech and language disorders in this cohort and examined the impact of co-occurring syndromes and other diagnoses (eg, submucous cleft palate). Eighty-six children (58 males, 28 females) with CL ±â€ŠA, evaluated between the ages of 12 and 72 months, were included in the study. Forty children had cleft lip and alveolus; 46 children had isolated cleft lip. We examined the proportion of children with CL ±â€ŠA who received team care, speech-language evaluations, and audiograms, as well as the number of children with CL ±â€ŠA diagnosed with a communication disorder. Fifty-three percent (n = 46) of children with CL ±â€ŠA had received at least 1 speech-language evaluation. Approximately 40% of children with CL ±â€ŠA who underwent evaluation by a speech-language pathologist were diagnosed with some type of communication disorder. Nine children (21%) with CL ±â€ŠA displayed an articulation disorder and 12 (27%) presented with a language delay/disorder. Statistical analysis examined the potential impact of comorbid diagnoses such as submucous cleft palate and other congenital anomalies, and results were essentially unchanged. Results of this study are congruent with past reports suggesting children with CL ±â€ŠA have a higher risk of communication disorders than the general pediatric population. Surgeons should be aware of the growing body of evidence that children with CL ±â€ŠA benefit from cleft team care, which should include routine speech-language assessments starting at an early age to ensure identification of conditions warranting intervention.

Online Training to Improve Service Provider Implementation of Letter-Sound Correspondence Instruction for Individuals Who Use Augmentative and Alternative Communication.

PURPOSE: Service providers have limited training in adapting and implementing literacy instruction for individuals who use augmentative and alternative communication (AAC), and therefore, opportunities to participate in phonological-based literacy activities are minimal. An online training was developed to teach service providers how to implement a systematic lesson in letter-sound correspondence (LSC) instruction with high fidelity for individuals who use AAC. METHOD: The Active Implementation Framework was used to guide the investigation of implementation fidelity and intervention effectiveness after service provider completion of an online training in LSC instruction. Study 1 trained five speech-language pathologists, one paraeducator, and six special educators in schools (N = 12), and Study 2 trained four speech-language pathology master's students. Single case across participant methodology was used for both studies with an implementation fidelity checklist to measure changes in instructional behaviors. Additionally, social validity data from service providers were collected. Preliminary data on intervention effectiveness for individuals who use AAC were collected for three LSCs after service providers were trained. RESULTS: Prior to the online training, service providers implemented LSC instruction with low fidelity. After the training, 11 service providers in Study 1 and all four speech-pathology master's students in Study 2 demonstrated large gains in implementation fidelity. Eight of the nine individuals who use AAC demonstrated improvement in LSC. CONCLUSION: Access to the online training has the potential to change the implementation behavior of service providers and take steps toward closing the research-to-practice gap surrounding early phonological skill acquisition for individuals who use AAC. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.19400741.

Local Anesthesia Alone for Postaxial Polydactyly Surgery in Infants.

BACKGROUND: Surgical excision for postaxial polydactyly type B is advocated to avoid long-term complications. Excision with local anesthesia (LA) in infancy represents a safe and effective treatment for this condition, although general anesthesia (GA) is employed by many surgeons. We present a comparison of surgical outcomes, cost, and time between LA and GA to support widespread change in management. METHODS: A retrospective review of patients under 12 months of age undergoing surgical polydactyly excision by a single surgeon was performed. Anesthesia type, patient demographics, and complications were recorded. Comparisons were made between LA and GA groups on procedure cost, operating time, length of stay (LOS), and time from procedure end to discharge. Stepwise forward regression was used to identify the best model for predicting total costs. RESULTS: Ninety-one infants with a mean age of 3 months (±1.9) were examined; 51 (56%) underwent LA alone, 40 (44%) underwent GA. Mean operating time was 11.53 ± 4.36 minutes, with no difference observed between anesthesia groups (P = .39). LA infants had a significantly shorter LOS (2.5 vs 3.5 hours; P < .05), quicker postoperative discharge (32 vs 65 minutes, P < .05), and fewer overall expenses, 2803 vs 6067 U.S. dollars (USD), P < .05. Two minor surgical complications (1 in each group) were reported. CONCLUSIONS: This study demonstrates significantly decreased cost, LOS, and time to discharge using LA alone for surgical excision of postaxial polydactyly type B. Results suggest the approach is quick, economical, and avoids the risks of GA in early infancy.

Improving Psychosocial Risk Assessment and Service Provision for Craniofacial Team Patients: A Quality Improvement Project.

To improve psychosocial risk assessment and service provision for children with craniofacial conditions presenting for annual interdisciplinary team visits.Institute for Healthcare quality improvement model.U.S. pediatric academic medical center.Caregivers of children ages 0-17 years with craniofacial conditions presenting for 1692 team visits between August 2017 and July 2019.Key drivers included: (1) standardizing pre-visit triage processes; (2) administering the Psychosocial Assessment Tool-Craniofacial Version (PAT-CV); (3) utilizing PAT-CV scores in real time to add patients to psychosocial provider schedules; and (4) family education. Interventions included improving patient screening, increasing PAT-CV completion rate, altering clinic flow, providing patient and parent education about psychosocial services, and altering team member roles to fully integrate PAT-CV administration and scoring in the clinic.The primary outcome was the percentage of patients identified for psychosocial consultations via nurse triage, PAT-CV score, family or provider request who completed consultations. The secondary outcome was the percentage of patients completing needed psychosocial consultations based on elevated PAT-CV scores.Use of the PAT-CV resulted in an increase in the percentage of patients with elevated psychosocial risk who received a psychosocial consultation from 86.7% to 93.4%. The percentage of children receiving psychosocial consultation at their annual team visit due to elevated PAT-CV scores increased from 72% to 90%.Integrating a validated psychosocial risk screening instrument can improve risk identification and psychosocial consultation completion. A combination of risk screening approaches may be indicated to identify patients in need of psychosocial services.

No One Size Fits All: A Qualitative Study of Clerkship Medical Students' Perceptions of Ideal Supervisor Responses to Microaggressions.

PURPOSE: This study explores medical students' perspectives on the key features of ideal supervisor responses to microaggressions targeting clerkship medical students. METHOD: This single-institution, qualitative focus group study, based in an interpretivist paradigm, explored clerkship medical students' perceptions in the United States, 2020. During semistructured focus groups, participants discussed 4 microaggression scenarios. The authors employed the framework method of thematic analysis to identify considerations and characteristics of ideal supervisor responses and explored differences in ideal response across microaggression types. RESULTS: Thirty-nine students participated in 7 focus groups, lasting 80 to 92 minutes per group. Overall, students felt that supervisors' responsibility began before a microaggression occurred, through anticipatory discussions ("pre-brief") with all students to identify preferences. Students felt that effective bystander responses should acknowledge student preferences, patient context, interpersonal dynamics in the room, and the microaggression itself. Microassaults necessitated an immediate response. After a microaggression, students preferred a brief one-on-one check-in with the supervisor to discuss the most supportive next steps including whether further group discussion would be helpful. CONCLUSIONS: Students described that an ideal supervisor bystander response incorporates both student preferences and the microaggression context, which are best revealed through advanced discussion. The authors created the Bystander Microaggression Intervention Guide as a visual representation of the preferred bystander microaggression response based on students' discussions. Effective interventions promote educational safety and shift power dynamics to empower the student target.

Infant-Driven Feeding Systems: Do They "Normalize" the Feeding Experience of Infants With Cleft Palate?

OBJECTIVE: To examine feeding skills of infants with cleft palate with or without cleft lip (CP±L) using infant-driven feeding systems compared to healthy controls on standard bottles. DESIGN: Cross-sectional cohort. SETTING: Large pediatric academic medical center in the Midwestern United States. PARTICIPANTS: Infants with CP±L (n = 15) using the Dr. Brown's Specialty Feeding System and typically developing infants without CP±L (n = 15) using the Dr. Brown's Natural Flow Original or Options bottles. MAIN OUTCOME MEASURE(S): Bottle-feeding proficiency, duration, milk transfer, and signs of feeding difficulty. RESULTS: Five-minute feeding proficiency differed significantly between groups with the control group taking 44% of the feed compared to 15% for the CP±L group on level 1 (P < .001) and 21% on level 2 (P < .001) nipples. Proportion of milk transfer was 96% ± 7% for controls and 75% ± 24% for the CP±L group (P = .013). Feeding duration (minutes) differed between the control group (13 ± 3) and the CP±L groups on each nipple level (level 1: 29 ± 16; P = .003; level 2: 32 ± 11; P = .001). Milk transfer rate (mL/min) was 9 ± 3 for control infants compared to 3 ± 1 for infants with CP±L on level 1 (P < .001) and 5 ± 1 on level 2 (P = .007). Coughing occurred in 40% of infants with CP±L and 27% of controls. CONCLUSIONS: Even when using specialty bottles, infants with CP±L differ from noncleft infants in feeding proficiency, duration, and overall intake.

A Hand Call Curriculum for Plastic Surgery Residents.

BACKGROUND: The ability to diagnose and manage patients with acute hand injuries is an essential component of plastic surgery residency. This study proposes an innovative and feasible curriculum to improve hand surgery education for plastic surgery residents and ensure optimal care for patients with hand injuries. METHODS: A hand call curriculum for plastic surgery residents (n = 29) from two institutions was implemented from 2018 to 2020. In 2018 and 2019, a hand call boot camp was conducted, while additional curricular sessions for anatomy and didactic learning were added in 2019-2020. Pre and post test assessments, as well as confidence assessments were conducted in 2018 and 2019. RESULTS: In 2019, after having completed the boot camp, residents indicated significantly more confidence in identifying hand emergencies and formulating a basic treatment plan, including when to enlist help (P = 0.0313). Overall, residents in earlier years (PGY 1-3) demonstrated steeper changes in confidence and readiness to take hand call than those in more senior years (PGY 4-8). Knowledge test scores improved amongst residents in both PGY groups following boot camp in both 2018 and 2019. CONCLUSION: Findings from our study will be used to optimize the hand call curriculum following limitations with COVID-19 and consider wider implementation across other plastic surgery programs nationally.

Feeding and Growth in Infants With Cleft Lip and/or Palate: Relationships With Maternal Distress.

OBJECTIVE: To examine relationships between early feeding and growth and maternal distress in infants with and without cleft lip and/or palate (CL/P). DESIGN: Cross-sectional. SETTING: Pediatric academic medical center in the Midwestern United States. PARTICIPANTS: Mothers of infants 1 to 12 weeks old with CL/P (n = 30) and without CL/P (control group, n = 30) were recruited at craniofacial clinic or pediatrician appointments. MAIN OUTCOME MEASURE(S): Maternal responses on the Feeding/Swallowing Impact Survey (FS-IS), Parenting Stress Index, Fourth Edition, Short Form (PSI-4-SF), and Edinburgh Postnatal Depression Scale. Infant feeding history and growth measurements were obtained. RESULTS: Having an infant with CL/P revealed greater impact on maternal health-related quality of life due to feeding problems (F = 4.83, P = .03). Mothers of infants with CL/P reported average range Total Stress scores on the PSI-4-SF, which were higher than controls (F = 4.12, P = .05). Edinburgh Postnatal Depression Scale scores did not differ between groups. Compared to controls, infants with cleft palate had lower percentiles for weight (t = 4.13, P = .04) and length (t = 2.93, P = .01). Higher FS-IS scores were associated with longer feeding duration (r = 0.32, P = .01) and lower weight (r = -0.31, P = .02) and length (r = -0.32, P = .02). CONCLUSIONS: Despite receiving early team care and feeding interventions, mothers of infants with CL/P reported higher stress and more challenges with feeding and growth. Future studies should examine targeted psychosocial interventions to improve feeding and growth outcomes in infants with CL/P.

Functional and Structural Neuroimaging Correlates of Repetitive Low-Level Blast Exposure in Career Breachers.

Combat military and civilian law enforcement personnel may be exposed to repetitive low-intensity blast events during training and operations. Persons who use explosives to gain entry (i.e., breach) into buildings are known as "breachers" or dynamic entry personnel. Breachers operate under the guidance of established safety protocols, but despite these precautions, breachers who are exposed to low-level blast throughout their careers frequently report performance deficits and symptoms to healthcare providers. Although little is known about the etiology linking blast exposure to clinical symptoms in humans, animal studies demonstrate network-level changes in brain function, alterations in brain morphology, vascular and inflammatory changes, hearing loss, and even alterations in gene expression after repeated blast exposure. To explore whether similar effects occur in humans, we collected a comprehensive data battery from 20 experienced breachers exposed to blast throughout their careers and 14 military and law enforcement controls. This battery included neuropsychological assessments, blood biomarkers, and magnetic resonance imaging measures, including cortical thickness, diffusion tensor imaging of white matter, functional connectivity, and perfusion. To better understand the relationship between repetitive low-level blast exposure and behavioral and imaging differences in humans, we analyzed the data using similarity-driven multi-view linear reconstruction (SiMLR). SiMLR is specifically designed for multiple modality statistical integration using dimensionality-reduction techniques for studies with high-dimensional, yet sparse, data (i.e., low number of subjects and many data per subject). We identify significant group effects in these data spanning brain structure, function, and blood biomarkers.

Impact of Interdisciplinary Team Care for Children With 22q11.2 Deletion Syndrome.

OBJECTIVE: To evaluate disease-specific guideline adherence among children with 22q11.2 deletion syndrome receiving multidisciplinary team care through a 22q specialty clinic compared to children not receiving team care. DESIGN: Retrospective chart review; quality improvement project. SETTING: Tertiary care pediatric hospital. PATIENTS: One hundred eighty-nine patients with 22q11.2 deletion syndrome were categorized into those receiving team care and those not receiving team care. Guideline adherence was compared between the 2 groups. MAIN OUTCOME MEASURE(S): Percent adherence across 8 disease-specific guidelines. RESULTS: A Welch t test revealed mean adherence among patients receiving team care was significantly higher (83% vs 42%, P < .001) compared those not receiving team care. Among team patients with a single 22q Center visit, a paired samples t test showed that mean adherence increased from 63% before the clinic encounter to 86% six months after the encounter (P < .001). Some guidelines were more likely to be associated with provider nonadherence, whereas others were more likely to be associated with patient nonadherence. CONCLUSIONS: Multidisciplinary team care is associated with significantly higher guideline adherence in children with 22q11DS. Additional research is needed to investigate the effect of team care on long-term health outcomes in children with 22q11DS.

Clinical outcomes of isolated distal deep vein thrombosis versus proximal venous thromboembolism in cancer patients: The Cleveland Clinic experience.

BACKGROUND: Previous studies suggest isolated distal deep vein thrombosis (IDDVT) has a self-limited clinical course. However, these studies excluded cancer patients, who remain a high-risk population. In addition, studies to evaluate the long-term clinical outcomes of IDDVT in cancer patients have been limited. Here, we report outcomes from our experience in treating cancer-associated IDDVT versus proximal venous thromboembolism (VTE). METHODS: We prospectively evaluated a cohort of patients referred to our cancer-associated thrombosis clinic from August 2014 through May 2018. We compared clinical characteristics, anticoagulation prescription, VTE recurrence, overall survival, major bleeding, and subsequent hospital admission between cancer patients with IDDVT and proximal VTE. A propensity score matching method was used to reduce bias from confounding variables. RESULTS: Of 1100 patients referred to the clinic, 124 IDDVT and 178 proximal VTE events were analyzed. After propensity score matching, 96 patients were included in each cohort. There was no difference in the rate of recurrent VTE between cancer patients with proximal VTE vs IDDVT, with or without matching (matched: hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.31-1.92; P = .58). There was no difference in overall survival between cancer patients with proximal VTE vs. IDDVT with or without matching (matched: HR, 1.18; 95% CI, 0.77-1.82; P = .45). Furthermore, subsequent hospital admissions and major bleeding events were similar between patients with proximal VTE events versus IDDVT. CONCLUSIONS: Cancer patients with IDDVT have similar outcomes as their proximal counterparts, including rate of recurrence and overall survival. These findings suggest treatment of cancer-associated IDDVT should mirror treatment of proximal events.

Provisional best practices guidelines for the evaluation of bulbar dysfunction in amyotrophic lateral sclerosis.

INTRODUCTION: Universally established comprehensive clinical bulbar scales objectively assessing disease progression in amyotrophic lateral sclerosis (ALS) are currently lacking. The goal of this working group project is to design a best practice set of provisional bulbar ALS guidelines, available for immediate implementation within all ALS clinics. METHODS: ALS specialists across multiple related disciplines participated in a series of clinical bulbar symposia, intending to identify and summarize the currently accepted best practices for the assessment and management of bulbar dysfunction in ALS Results: Summary group recommendations for individual speech, Augmentative and Alternative Communication (AAC), and swallowing sections were achieved, focusing on the optimal proposed level of care within each domain. DISCUSSION: We have identified specific clinical recommendations for each of the 3 domains of bulbar functioning, available for incorporation within all ALS clinics. Future directions will be to establish a formal set of bulbar guidelines through a methodological and evidence-based approach. Muscle Nerve 59:531-531, 2019.

Best practices protocol for the evaluation of bulbar dysfunction: summary recommendations from the NEALS bulbar subcommittee symposium.

OBJECTIVE: The aim of this Symposium was to develop a consensus based, bulbar assessment protocol for implementation within NEALS clinics. METHODS: A one-day symposium, held in April 2017, was organized into Speech and Swallowing sections to establish summary recommendations for the assessment of bulbar dysfunction within each group. RESULTS: Summary recommendations included speech referrals and AAC evaluations at initial visit, CNS-BFS, maximum sustained phonation, and speaking rate. Dysarthria evaluation included the speech subsystem involvement of respiration, phonation, resonance, and articulation. Specific recommendations for swallowing were established for each of the following domains: dietary/oral intake, airway defense physiologic capacity, swallow safety screen, patient-reported swallow-related outcomes, oral sensorimotor exam, and pulmonary function. Practice parameters focused upon patient education and unresolved questions included the use of videofluoscopy, monitoring diet progression, and swallow safety screening. CONCLUSIONS: The working goal is to establish a clinical bulbar protocol, designed to be incorporated within ALS clinics and ultimately to formulate a best practice set of bulbar ALS guidelines, available for implementation throughout the international ALS community.