Repairing moral injury takes a team: what clinicians can learn from combat veterans.

Moral injury results from the violation of deeply held moral commitments leading to emotional and existential distress. The phenomenon was initially described by psychologists and psychiatrists associated with the US Departments of Defense and Veterans Affairs but has since been applied more broadly. Although its application to healthcare preceded COVID-19, healthcare professionals have taken greater interest in moral injury since the pandemic's advent. They have much to learn from combat veterans, who have substantial experience in identifying and addressing moral injury-particularly its social dimensions. Veterans recognise that complex social factors lead to moral injury, and therefore a community approach is necessary for healing. We argue that similar attention must be given in healthcare, where a team-oriented and multidimensional approach is essential both for ameliorating the suffering faced by health professionals and for addressing the underlying causes that give rise to moral injury.

"Ruptured selves: moral injury and wounded identity".

Moral injury is the trauma caused by violations of deeply held values and beliefs. This paper draws on relational philosophical anthropologies to develop the connection between moral injury and moral identity and to offer implications for moral repair, focusing particularly on healthcare professionals. We expound on the notion of moral identity as the relational and narrative constitution of the self. Moral identity is formed and forged in the context of communities and narrative and is necessary for providing a moral horizon against which to act. We then explore the relationship between moral injury and damaged moral identities. We describe how moral injury ruptures one's sense of self leading to moral disorientation. The article concludes with implications for moral repair. Since moral identity is relationally formed, moral repair is not primarily an individual task but requires the involvement of others to heal one's identity. The repair of moral injury requires the transformation of a moral identity in community.

Moral Injury in Health Care: Identification and Repair in the COVID-19 Era.

Frontline health-care workers experienced moral injury long before COVID-19, but the pandemic highlighted how pervasive and damaging this psychological harm can be. Moral injury occurs when individuals violate or witness violations of deeply held values and beliefs. We argue that a continuum exists between moral distress, moral injury, and burnout. Distinguishing these experiences highlights opportunities for intervention and moral repair, and may thwart progression to burnout.

Neurological Sequelae of COVID-19 in Rehabilitation Settings.

Neurological symptoms of post-acute sequelae of COVID-19 (PASC), also known as Long COVID, are recognized. Four neurological syndromes (transverse myelitis, ischemic stroke, headache, and Guillain-Barré syndrome) associated with PASC are reviewed here, with a particular focus on issues related to rehabilitation.

Cardiac sarcoidosis requiring ICD placement and immune thrombocytopenia following alemtuzumab treatment for multiple sclerosis.

Alemtuzumab, an effective disease-modifying therapy for multiple sclerosis, carries a significant risk of secondary autoimmunity. We present a case of cardiac sarcoidosis and immune thrombocytopenia diagnosed in an MS patient two years after completing alemtuzumab treatment. We hypothesize that alemtuzumab-induced changes to the T regulatory cell population may be implicated in the development of sarcoidosis in MS patients.

A New England COVID-19 Registry of Patients With CNS Demyelinating Disease: A Pilot Analysis.

BACKGROUND AND OBJECTIVES: We sought to define the risk of severe coronavirus disease 2019 (COVID-19) infection requiring hospitalization in patients with CNS demyelinating diseases such as MS and the factors that increase the risk for severe infection to guide decisions regarding patient care during the COVID-19 pandemic. METHODS: A pilot cohort of 91 patients with confirmed or suspected COVID-19 infection from the Northeastern United States was analyzed to characterize patient risk factors and factors associated with an increased severity of COVID-19 infection. Univariate analysis of variance was performed using the Mann-Whitney U test or analysis of variance for continuous variables and the χ2 or Fisher exact test for nominal variables. Univariate and stepwise multivariate logistic regression identified clinical characteristics or symptoms associated with hospitalization. RESULTS: Our cohort demonstrated a 27.5% hospitalization rate and a 4.4% case fatality rate. Performance on Timed 25-Foot Walk before COVID-19 infection, age, number of comorbidities, and presenting symptoms of nausea/vomiting and neurologic symptoms (e.g., paresthesia or weakness) were independent risk factors for hospitalization, whereas headache predicted a milder course without hospitalization. An absolute lymphocyte count was lower in hospitalized patients during COVID-19 infection. Use of disease-modifying therapy did not increase the risk of hospitalization but was associated with an increased need for respiratory support. DISCUSSION: The case fatality and hospitalization rates in our cohort were similar to those found in MS and general population COVID-19 cohorts within the region. Hospitalization was associated with increased disability, age, and comorbidities but not disease-modifying therapy use.

Multiple sclerosis relapse presenting as an acute cardiomyopathy.

Multiple sclerosis is increasingly being recognized in association with cardiovascular dysfunction, which can manifest with cardiomyopathy, pulmonary edema (Kaplan et al., 2015), orthostasis (Kaplan et al., 2015) and other complications. Takotsubo cardiomyopathy is a syndrome of acute-onset ventricular dysfunction in the absence of obstructive coronary artery disease, which on rare occasion has been observed in the setting of demyelinated plaques in the brainstem. We report on two cases of Takotsubo cardiomyopathy with medullary demyelination secondary to multiple sclerosis.

Moving Towards a Cure for MS: Increased Immunosuppression and Striving for No Evidence of Disease Activity (NEDA).

Multiple sclerosis (MS) is a chronic central nervous system demyelinating disease. The cause is unknown, but likely results from a combination of genetic predisposition and environmental exposures leading to autoimmune destruction of the brain and spinal cord. The most common phenotype of MS is relapsing-remitting (RRMS), characterized by episodes of neurological symptoms, typically lasting days to weeks, followed by symptom remission. After years of disease, the majority of RRMS cases transform into secondary progressive MS (SPMS), characterized by slowly worsening symptoms and progressive neurological disability, which may or may not be also accompanied by superimposed relapses. A third distinct phenotype, primary progressive MS (PPMS) is characterized by slowly worsening neurological symptoms and disability from disease onset, without clinical relapses.1 The first disease-modifying agent was approved by the FDA in 1993. There are now 14 FDA-approved disease-modifying therapies (DMTs) with almost all agents indicated for relapsing forms of MS. The medical management of multiple sclerosis has changed dramatically over the past decade as the number of available DMTs has increased (See Table 1). Most of the newer agents have been shown to decrease clinical relapse rates to a greater degree than the older agents. These DMTs frequently also decrease the rate of disability progression in MS. With the increased immunosuppression of the newer therapies comes the potential for more serious side effects. Balancing efficacy with potential adverse events is a primary consideration of patients and clinicians treating MS today. The potential for near complete control of the disease is becoming a reality in select cases, and a new goal of "no evidence of disease activity" (NEDA) may be supplanting the previous aim of relapse rate reduction.

Student and Faculty Reflections of the Hidden Curriculum.

The hidden curriculum, or the socialization process of medical training, plays a crucial role in the development of physicians, as they navigate the clinical learning environment. The purpose of this qualitative study was to examine medical faculty and students' perceptions of psychological, moral, and spiritual challenges during medical training in caring for critically ill patients. Focus groups were conducted with 25 Harvard Medical School (HMS) students, and interviews were conducted with 8 HMS faculty members. Five major themes emerged as important in shaping students' medical training experiences. First, students and faculty discussed the overall significance of the hidden curriculum in terms of the hierarchy of medicine, behavioral modeling, and the value placed on research versus clinical work. Second, respondents articulated values modeled in medicine. Third, students and faculty reflected on changes in student development during their training, particularly in terms of changes in empathy and compassion. Fourth, respondents discussed challenges faced in medical school including professional clinical education and the psychosocial aspects of medical training. Finally, students and faculty articulated a number of coping mechanisms to mitigate these challenges including reflection, prayer, repression, support systems, creative outlets, exercise, and separation from one's work. The results from this study suggest the significance of the hidden curriculum on medical students throughout their training, as they learn to navigate challenging and emotional experiences. Furthermore, these results emphasize an increased focus toward the effect of the hidden curriculum on students' development in medical school, particularly noting the ways in which self-reflection may benefit students.

Developing a Medical School Curriculum for Psychological, Moral, and Spiritual Wellness: Student and Faculty Perspectives.

CONTEXT: Although many studies have addressed the integration of a religion and/or spirituality curriculum into medical school training, few describe the process of curriculum development based on qualitative data from students and faculty. OBJECTIVES: The aim of this study is to explore the perspectives of medical students and chaplaincy trainees regarding the development of a curriculum to facilitate reflection on moral and spiritual dimensions of caring for the critically ill and to train students in self-care practices that promote professionalism. METHODS: Research staff conducted semiscripted and one-on-one interviews and focus groups. Respondents also completed a short and self-reported demographic questionnaire. Participants included 44 students and faculty members from Harvard Medical School and Harvard Divinity School, specifically senior medical students and divinity school students who have undergone chaplaincy training. RESULTS: Two major qualitative themes emerged: curriculum format and curriculum content. Inter-rater reliability was high (kappa = 0.75). With regard to curriculum format, most participants supported the curriculum being longitudinal, elective, and experiential. With regard to curriculum content, five subthemes emerged: personal religious and/or spiritual (R/S) growth, professional integration of R/S values, addressing patient needs, structural and/or institutional dynamics within the health care system, and controversial social issues. CONCLUSION: Qualitative findings of this study suggest that development of a future medical school curriculum on R/S and wellness should be elective, longitudinal, and experiential and should focus on the impact and integration of R/S values and self-care practices within self, care for patients, and the medical team. Future research is necessary to study the efficacy of these curricula once implemented.

Internal tremor in Parkinson's disease, multiple sclerosis, and essential tremor.

OBJECTIVE: Internal tremor (IT) is a poorly recognized symptom that has been described in Parkinson's disease (PD). Described as a feeling of tremor in the extremities or trunk without actual movement, ITs are not debilitating but can be bothersome to patients. The origin of the sensation is unknown., and ITs may be prevalent in other diseases than PD. The present study sought to expand knowledge about IT by confirming their presence in PD, and determining their prevalence in Multiple Sclerosis (MS), and Essential Tremor (ET). METHODS: A survey was developed in order to determine the prevalence of IT in PD, MS, and ET and to learn what associations with various disease characteristics were present. The survey was administered to 89 consecutive PD, 70 MS, and 11 ET patients. RESULTS: ITs were found to be a prevalent symptom in all three disorders (32.6% of PD, 35.9% of MS, and 54.5% of ET subjects reported experiencing ITs). ITs were found to be associated both with the subjects' perceived levels of anxiety and the presence of visible tremors. CONCLUSION: ITs appear to be a common symptom in all three disorders studied. These results need to be confirmed and compared to appropriate control populations.

The association between fatigue and apathy in patients with either Parkinson's disease or multiple sclerosis.

OBJECTIVE: Fatigue and apathy are common symptoms in both multiple sclerosis (MS) and Parkinson's disease (PD). Both symptoms are considered "amotivational"--fatigue is a lack of energy to start or complete an action and apathy is a loss of interest in activities. Whether the two symptoms are related to each other is not known. The present study sought to investigate the prevalence and severity of fatigue and apathy in MS and PD, and the relationship between the two. METHODS: The Fatigue Severity Scale (FSS) and the Apathy Scale (AS) were administered to 89 consecutive PD and 73 consecutive MS subjects. RESULTS: The mean FSS score for PD subjects was 4.46 and 5.01 for MS; the average total AS score for PD was 12.4 and 12.5 for MS. Using a cutoff of >4.0 on the FSS to assess fatigue, 64% of PD subjects and 74% of MS subjects suffered from severe fatigue. Using an AS cutoff score of >14.0 to determine apathy, 57% of PD subjects and 52% of MS subjects were apathetic. There was a significant correlation between FSS score and AS score in both disorders. FSS average scores and AS total scores were significantly correlated with motor severity in PD but not in MS. Duration of disease was not correlated with either scale scores in either disorder. DISCUSSION: Results confirm that AS and FSS are correlated with each other in both disorders and that MS subjects rate their fatigue significantly higher.

Religion, Spirituality, and the Hidden Curriculum: Medical Student and Faculty Reflections.

CONTEXT: Religion and spirituality play an important role in physicians' medical practice, but little research has examined their influence within the socialization of medical trainees and the hidden curriculum. OBJECTIVES: The objective is to explore the role of religion and spirituality as they intersect with aspects of medicine's hidden curriculum. METHODS: Semiscripted, one-on-one interviews and focus groups (n = 33 respondents) were conducted to assess Harvard Medical School student and faculty experiences of religion/spirituality and the professionalization process during medical training. Using grounded theory, theme extraction was performed with interdisciplinary input (medicine, sociology, and theology), yielding a high inter-rater reliability score (kappa = 0.75). RESULTS: Three domains emerged where religion and spirituality appear as a factor in medical training. First, religion/spirituality may present unique challenges and benefits in relation to the hidden curriculum. Religious/spiritual respondents more often reported to struggle with issues of personal identity, increased self-doubt, and perceived medical knowledge inadequacy. However, religious/spiritual participants less often described relationship conflicts within the medical team, work-life imbalance, and emotional stress arising from patient suffering. Second, religion/spirituality may influence coping strategies during encounters with patient suffering. Religious/spiritual trainees described using prayer, faith, and compassion as means for coping whereas nonreligious/nonspiritual trainees discussed compartmentalization and emotional repression. Third, levels of religion/spirituality appear to fluctuate in relation to medical training, with many trainees experiencing an increase in religiousness/spirituality during training. CONCLUSION: Religion/spirituality has a largely unstudied but possibly influential role in medical student socialization. Future study is needed to characterize its function within the hidden curriculum.

Sexually dimorphic effects of hippocampal cholinergic deafferentation in rats.

To determine whether the basal forebrain-hippocampal cholinergic system supports sexually dimorphic functionality, male and female Long-Evans rats were given either selective medial septum/vertical limb of the diagonal band (MS/VDB) cholinergic lesions using the neurotoxin 192 IgG-saporin or a control surgery and then postoperatively tested in a set of standard spatial learning tasks in the Morris water maze. Lesions were highly specific and effective as confirmed by both choline acetyltransferase/parvalbumin immunostaining and acetylcholinesterase histochemistry. Female controls performed worse than male controls in place learning and MS/VDB lesions failed to impair spatial learning in male rats, both consistent with previous findings. In female rats, MS/VDB cholinergic lesions facilitated spatial reference learning. A subsequent test of learning strategy in the water maze revealed a female bias for a response, relative to a spatial, strategy; MS/VDB cholinergic lesions enhanced the use of a spatial strategy in both sexes, but only significantly so in males. Together, these results indicate a sexually dimorphic function associated with MS/VDB-hippocampal cholinergic inputs. In female rats, these neurons appear to support sex-specific spatial learning processes.