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INTRODUCTION: Human trafficking (HT) is a public health issue that adversely affects patients well-being. Despite the prevalence of trafficked persons in health care settings, a lack of educational modules exists for use in clinical contexts. We developed a 50-minute train-the-trainer module on HT. METHODS: After piloting the workshop for faculty, fellows, and residents (n = 19) at the Society for Academic Emergency Medicine (SAEM) national conference, we implemented it in medical students curricula during their emergency medicine clerkship at the University of Iowa (n = 162). We evaluated the worskhop by (a) a retrospective pre-post survey of self-reported ability to (1) define HT, (2) recognize high-risk signs, (3) manage situations with trafficked persons, and (4) teach others about HT, and (b) a 3-month follow-up survey to assess longitudinal behavior change. RESULTS: In both contexts, results demonstrated improvement across all learning outcomes (pre-post differences of 1.5, 1.3, 1.9, and 1.7 on a 4-point Likert-type scale for each learning objective above, respectively, at the SAEM conference and 1.2, 1.0, 1.3, and 1.3 at the University of Iowa; p < .001 for all). In the 3-month follow-up, we observed statistically significant changes in self-reported consideration of and teaching about HT during clinical encounters among learners who had previously never done either (p < .001 and p = .006, respectively). DISCUSSION: This train-the-trainer module is a brief and effective clinical tool for bedside teaching about HT, especially among people who have never previously considered HT in a clinical context.

OBJECTIVE: To describe health equity research priorities for health care delivery systems and delineate a research and action agenda that generates evidence-based solutions to persistent racial and ethnic inequities in health outcomes. DATA SOURCES AND STUDY SETTING: This project was conducted as a component of the Agency for Healthcare Research and Qualitys (AHRQ) stakeholder engaged process to develop an Equity Agenda and Action Plan to guide priority setting to advance health equity. Recommendations were developed and refined based on expert input, evidence review, and stakeholder engagement. Participating stakeholders included experts from academia, health care organizations, industry, and government. STUDY DESIGN: Expert group consensus, informed by stakeholder engagement and targeted evidence review. DATA COLLECTION/EXTRACTION METHODS: Priority themes were derived iteratively through (1) brainstorming and idea reduction, (2) targeted evidence review of candidate themes, (3) determination of preliminary themes; (4) input on preliminary themes from stakeholders attending AHRQs 2022 Health Equity Summit; and (5) and refinement of themes based on that input. The final set of research and action recommendations was determined by authors consensus. PRINCIPAL FINDINGS: Health care delivery systems have contributed to racial and ethnic disparities in health care. High quality research is needed to inform health care delivery systems approaches to undo systemic barriers and inequities. We identified six priority themes for research; (1) institutional leadership, culture, and workforce; (2) data-driven, culturally tailored care; (3) health equity targeted performance incentives; (4) health equity-informed approaches to health system consolidation and access; (5) whole person care; (6) and whole community investment. We also suggest cross-cutting themes regarding research workforce and research timelines. CONCLUSIONS: As the nations primary health services research agency, AHRQ can advance equitable delivery of health care by funding research and disseminating evidence to help transform the organization and delivery of health care.

BACKGROUND: Bladder cancer poses a significant public health burden, with high recurrence and progression rates in patients with non-muscle-invasive bladder cancer (NMIBC). Current treatment options include bladder-sparing therapies (BST) and radical cystectomy, both with associated risks and benefits. However, evidence supporting optimal management decisions for patients with recurrent high-grade NMIBC remains limited, leading to uncertainty for patients and clinicians. The CISTO (Comparison of Intravesical Therapy and Surgery as Treatment Options) Study aims to address this critical knowledge gap by comparing outcomes between patients undergoing BST and radical cystectomy. METHODS: The CISTO Study is a pragmatic, prospective observational cohort trial across 36 academic and community urology practices in the US. The study will enroll 572 patients with a diagnosis of recurrent high-grade NMIBC who select management with either BST or radical cystectomy. The primary outcome is health-related quality of life (QOL) at 12 months as measured with the EORTC-QLQ-C30. Secondary outcomes include bladder cancer-specific QOL, progression-free survival, cancer-specific survival, and financial toxicity. The study will also assess patient preferences for treatment outcomes. Statistical analyses will employ targeted maximum likelihood estimation (TMLE) to address treatment selection bias and confounding by indication. DISCUSSION: The CISTO Study is powered to detect clinically important differences in QOL and cancer-specific survival between the two treatment approaches. By including a diverse patient population, the study also aims to assess outcomes across the following patient characteristics: age, gender, race, burden of comorbid health conditions, cancer severity, caregiver status, social determinants of health, and rurality. Treatment outcomes may also vary by patient preferences, health literacy, and baseline QOL. The CISTO Study will fill a crucial evidence gap in the management of recurrent high-grade NMIBC, providing evidence-based guidance for patients and clinicians in choosing between BST and radical cystectomy. The CISTO study will provide an evidence-based approach to identifying the right treatment for the right patient at the right time in the challenging clinical setting of recurrent high-grade NMIBC. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03933826. Registered on May 1, 2019.

Biomaterials that can be reversibly stiffened and shaped could be useful in broad biomedical applications where form-fitting scaffolds are needed. Here we investigate the combination of strong non-linear elasticity in biopolymer networks with the reconfigurability of packed hydrogel particles within a composite biomaterial. By packing microgels into collagen-1 networks and characterizing their linear and non-linear material properties, we empirically determine a scaling relationship that describes the synergistic dependence of the material's linear elastic shear modulus on the concentration of both components. We perform high-strain rheological tests and find that the materials strain stiffen and also exhibit a form of programmability, where no applied stress is required to maintain stiffened states of deformation after large strains are applied. We demonstrate that this non-linear rheological behavior can be used to shape samples that do not spontaneously relax large-scale bends, holding their deformed shapes for days. Detailed analysis of the frequency-dependent rheology reveals an unexpected connection to the rheology of living cells, where models of soft glasses capture their low-frequency behaviors and polymer elasticity models capture their high-frequency behaviors.

Introduction Human trafficking (HT) is a public health issue that adversely affects patients’ well-being. Despite the prevalence of trafficked persons in health care settings, a lack of educational modules exists for use in clinical contexts. We developed a 50-minute train-the-trainer module on HT. Methods After piloting the workshop for faculty, fellows, and residents (n = 19) at the Society for Academic Emergency Medicine (SAEM) national conference, we implemented it in medical students’ curricula during their emergency medicine clerkship at the University of Iowa (n = 162). We evaluated the worskhop by (a) a retrospective pre-post survey of self-reported ability to (1) define HT, (2) recognize high-risk signs, (3) manage situations with trafficked persons, and (4) teach others about HT, and (b) a 3-month follow-up survey to assess longitudinal behavior change. Results In both contexts, results demonstrated improvement across all learning outcomes (pre-post differences of 1.5, 1.3, 1.9, and 1.7 on a 4-point Likert-type scale for each learning objective above, respectively, at the SAEM conference and 1.2, 1.0, 1.3, and 1.3 at the University of Iowa; p < .001 for all). In the 3-month follow-up, we observed statistically significant changes in self-reported consideration of and teaching about HT during clinical encounters among learners who had previously never done either (p < .001 and p = .006, respectively). Discussion This train-the-trainer module is a brief and effective clinical tool for bedside teaching about HT, especially among people who have never previously considered HT in a clinical context.

Abstract Objective To provide an analysis of complications following eustachian tube balloon dilation as well as their treatments and outcomes. Data Sources PubMed, Ovid Embase, and MAUDE Database. Review Methods A systematic approach following PRISMA guidelines was used to identify publications pertaining to balloon dilation of the eustachian tube from PubMed and Ovid Embase databases was used. Once these publications were critically reviewed, the primary outcome extracted were reported complications. Additional complications were collected in the Manufacturer and User Facility Device Experience (MAUDE) database using the product class “eustachian tube dilation device” and searching through relevant manufacturers. Complications and outcomes were compared between these sources. Results Fifty five full‐length manuscripts involving 7155 patients were included and 98 complications reported for a 1.4% complication rate. The most frequently reported adverse events were subcutaneous emphysema of the head and neck (19%), epistaxis (12%), and acute otitis media (11%). The MAUDE search returned 18 distinct patient entries, of which 12 (67%) reported complications. The most reported complications in the MAUDE database included subcutaneous emphysema (8, 67%) and pneumomediastinum (3, 25%). The most serious complication was a carotid artery dissection reported in one patient in the MAUDE database. Conclusion Eustachian tube dilation is rarely associated with complications, which nevertheless may lead to morbidity and medical emergencies. Patients and providers should recognize potential risks associated with this intervention as well as methods to manage complications.

The COVID-19 pandemic demanded significant sacrifices from medical learners. We examine the meaning of sacrifice and frame it as a “side effect” of being dedicated to the good of the patient. We contend that sacrifice has played a central role in medicine, even before the pandemic, for professionals and learners alike. We identify three limits to the role of sacrifice in medical education and practice to separate healthy from harmful experiences of sacrifice. Developing an understanding of sacrifice in medical education and practice can help trainees and clinicians know when to marshal resilient responses to healthy sacrifices and reject harmful sacrifices encountered. Maintaining this balance requires a broader reflection on the nature of medical schools and their ability to support virtuous professional identity formation.

Abstract Background Bladder cancer poses a significant public health burden, with high recurrence and progression rates in patients with non-muscle-invasive bladder cancer (NMIBC). Current treatment options include bladder-sparing therapies (BST) and radical cystectomy, both with associated risks and benefits. However, evidence supporting optimal management decisions for patients with recurrent high-grade NMIBC remains limited, leading to uncertainty for patients and clinicians. The CISTO (Comparison of Intravesical Therapy and Surgery as Treatment Options) Study aims to address this critical knowledge gap by comparing outcomes between patients undergoing BST and radical cystectomy. Methods The CISTO Study is a pragmatic, prospective observational cohort trial across 36 academic and community urology practices in the US. The study will enroll 572 patients with a diagnosis of recurrent high-grade NMIBC who select management with either BST or radical cystectomy. The primary outcome is health-related quality of life (QOL) at 12 months as measured with the EORTC-QLQ-C30. Secondary outcomes include bladder cancer-specific QOL, progression-free survival, cancer-specific survival, and financial toxicity. The study will also assess patient preferences for treatment outcomes. Statistical analyses will employ targeted maximum likelihood estimation (TMLE) to address treatment selection bias and confounding by indication. Discussion The CISTO Study is powered to detect clinically important differences in QOL and cancer-specific survival between the two treatment approaches. By including a diverse patient population, the study also aims to assess outcomes across the following patient characteristics: age, gender, race, burden of comorbid health conditions, cancer severity, caregiver status, social determinants of health, and rurality. Treatment outcomes may also vary by patient preferences, health literacy, and baseline QOL. The CISTO Study will fill a crucial evidence gap in the management of recurrent high-grade NMIBC, providing evidence-based guidance for patients and clinicians in choosing between BST and radical cystectomy. The CISTO study will provide an evidence-based approach to identifying the right treatment for the right patient at the right time in the challenging clinical setting of recurrent high-grade NMIBC. Trial registration ClinicalTrials.gov, NCT03933826. Registered on May 1, 2019.

Margot Kelly-Hedrick,1 Kaitlin M Stouffer,2 Elizabeth Benskin,3 Suzy Wolffe,3 Norah Wilson,4 Margaret S Chisolm5 1Duke University School of Medicine, Durham, NC, USA; 2Johns Hopkins University School of Medicine, Baltimore, MD, USA; 3Department of Education, The Baltimore Museum of Art, Baltimore, MD, USA; 4Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD, USA; 5Department of Psychiatry and Behavioral Services, and of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USACorrespondence: Margot Kelly-Hedrick, Duke University School of Medicine, DUMC 2927, 40 Duke Medicine Circle, Durham, NC, 27710, USA, Email margot.kellyhedrick@duke.eduIntroduction: Health professions educators are increasingly recognizing the fundamental role the arts and humanities play in professional identity formation; however, few reports exist of programs designed specifically for pre-health professional students.Methods: We designed and delivered four, 2.5-h sessions for pre-health professions students at a local museum in partnership with museum educators. Participants were invited to respond to a follow-up survey asking about their perceived insights from and importance of the session. We used descriptive statistics and thematic content analysis for quantitative and qualitative data, respectively.Results: Ten of the participants responded to the survey (n=10/23, response rate=43%) and all supported the integration of such an experience in their pre-health curriculum. The qualitative analysis of responses to the open-ended item about any insights gained from participation in the program revealed three themes: cultivation of the health professional, personal growth, and awareness and appreciation of multiple perspectives.Discussion: Participants who responded to our survey drew meaningful connections to the relevance of these sessions to their development as future professionals.Keywords: pre-health, pre-medical education, arts and humanities, art museum

ObjectivePatients with labor and sex trafficking experiences seek healthcare while and after being trafficked. Their trafficking experiences are often unrecognized by clinicians who lack a validated tool to systematically screen for trafficking. We aimed to derive and validate a brief, comprehensive trafficking screening tool for use in healthcare settings.MethodsPatients were randomly selected to participate in this prospective study based on time of arrival. Data collectors administered 5 dichotomous index questions and a reference standard trafficking assessment tool that requires 30 to 60 minutes to administer. Data collection was from June 2016 to January 2021. Data from patients in 5 New York City (NYC) emergency departments (EDs) were used for tool psychometric derivation, and data from patients in a Fort Worth ED were used for external validation. Clinically stable ED adults (aged ≥18 years) were eligible to participate. Candidate questions were selected from the Trafficking Victim Identification Tool (TVIT). The study outcome measurement was a determination of a participant having a lifetime experience of labor and/or sex trafficking based on the interpretation of the reference standard interview, the TVIT.ResultsOverall, 4127 ED patients were enrolled. In the derivation group, the reference standard identified 36 (1.1%) as positive for a labor and/or sex trafficking experience. In the validation group, 12 (1.4%) were positive by the reference standard. Rapid Appraisal for Trafficking (RAFT) is a new 4-item trafficking screening tool: in the derivation group, RAFT was 89% sensitive (95% confidence interval [CI], 79%-99%) and 74% specific (95% CI, 73%-76%) and in the external validation group, RAFT was 100% sensitive (95% CI, 100%-100%) and 61% specific (95% CI, 56%-65%).ConclusionsThe rapid, 4-item RAFT screening tool demonstrated good sensitivity compared with the existing, resource-intensive reference standard tool. RAFT may enhance the detection of human trafficking in EDs. Additional multicenter studies and research on RAFT's implementation are needed.

IntroductionPediatric sleep problems can be detected across racial/ethnic subpopulations in primary care settings. However, the electronic health record (EHR) data documentation that describes patients' sleep problems may be inherently biased due to both historical biases and informed presence. This study assessed racial/ethnic differences in natural language processing (NLP) training data (e.g., pediatric sleep-related keywords in primary care clinical notes) prior to model training.MethodsWe used a predefined keyword features set containing 178 Peds B-SATED keywords. We then queried all the clinical notes from patients seen in pediatric primary care between the ages of 5 and 18 from January 2018 to December 2021. A least absolute shrinkage and selection operator (LASSO) regression model was used to investigate whether there were racial/ethnic differences in the documentation of Peds B-SATED keywords. Then, mixed-effects logistic regression was used to determine whether the odds of the presence of global Peds B-SATED dimensions also differed across racial/ethnic subpopulations.ResultsUsing both LASSO and multilevel modeling approaches, the current study found that there were racial/ethnic differences in providers' documentation of Peds B-SATED keywords and global dimensions. In addition, the most frequently documented Peds B-SATED keyword rankings qualitatively differed across racial/ethnic subpopulations.ConclusionThis study revealed providers' differential patterns of documenting Peds B-SATED keywords and global dimensions that may account for the under-detection of pediatric sleep problems among racial/ethnic subpopulations. In research, these findings have important implications for the equitable clinical documentation of sleep problems in pediatric primary care settings and extend prior retrospective work in pediatric sleep specialty settings.

Abstract INTRODUCTION Hearing loss is highly prevalent among older adults and independently associated with cognitive decline. The Aging and Cognitive Health Evaluation in Elders (ACHIEVE) study is a multicenter randomized control trial (partially nested within the infrastructure of an observational cohort study, the Atherosclerosis Risk in Communities [ARIC] study) to determine the efficacy of best‐practice hearing treatment to reduce cognitive decline over 3 years. The goal of this paper is to describe the recruitment process and baseline results. METHODS Multiple strategies were used to recruit community‐dwelling 70–84‐year‐old participants with adult‐onset hearing loss who were free of substantial cognitive impairment from the parent ARIC study and de novo from the surrounding communities into the trial. Participants completed telephone screening, an in‐person hearing, vision, and cognitive screening, and a comprehensive hearing assessment to determine eligibility. RESULTS Over a 24‐month period, 3004 telephone screenings resulted in 2344 in‐person hearing, vision, and cognition screenings and 1294 comprehensive hearing screenings. Among 1102 eligible, 977 were randomized into the trial (median age = 76.4 years; 53.5% female; 87.8% White; 53.3% held a Bachelor's degree or higher). Participants recruited through the ARIC study were recruited much earlier and were less likely to report hearing loss interfered with their quality of life relative to participants recruited de novo from the community. Minor differences in baseline hearing or health characteristics were found by recruitment route (i.e., ARIC study or de novo) and by study site. DISCUSSION The ACHIEVE study successfully completed enrollment over 2 years that met originally projected rates of recruitment. Substantial operational and scientific efficiencies during study startup were achieved through embedding this trial within the infrastructure of a longstanding and well‐established observational study. Highlights The ACHIEVE study tests the effect of hearing intervention on cognitive decline. The study is partially nested within an existing cohort study. Over 2 years, 977 participants recruited and enrolled. Eligibility assessed by telephone and in‐person for hearing, vision, and cognitive screening. The ACHIEVE study findings will have significant public health implications.

ABSTRACTPurpose We implemented and evaluated a hybrid 4-week arts-based elective for clinical medical students to support flourishing.Materials and Methods Five students participated in early 2022. Twelve sessions occurred in-person at art museums and other cultural centers, and five occurred online. Sessions incorporated varied arts-based learning activities, including Visual Thinking Strategies, a jazz seminar, and a mask-making workshop. We evaluated the course via weekly reflective essays, interviews 6 weeks after the course, and pre-post surveys that included four scales with clinical relevance: capacity for wonder (CfW), tolerance for ambiguity (TFA), interpersonal reactivity index, and openness to diversity.Results Qualitatively, the course helped learners: 1) reconnect with individual characteristics and interests that had been neglected during medical education; 2) better appreciate others’ perspectives; 3) develop identities as physicians; and 4) engage in quiet reflection, renewing their sense of purpose. Quantitatively, pre-post mean totals increased for the CfW (32.0 [SD 6.8] vs 44.0 [SD 5.7], p=.006) and TFA scales (16.4 [SD 5.2] vs 24.2 [SD 6.9], p=.033).Conclusions This elective facilitated learners’ connecting with themselves, others, and their profession with improvement in clinically-relevant measures. This provides further evidence that arts-based education can foster professional identity formation and be transformative for students.

ABSTRACTBackground Professional identity formation is an important aspect of medical education that can be difficult to translate into formal curricula. The role of arts and humanities programs in fostering professional identity formation remains understudied. Analyzing learners’ written reflections, we explore the relationship between an arts-based course and themes of professional identity formation.Materials and methods Two cohorts of learners participated in a 5-day online course featuring visual arts-based group activities. Both cohorts responded to a prompt with written reflections at the beginning and end of the course. Using a thematic analysis method, we qualitatively analyzed one set of reflections from each cohort.Results Themes included the nature of the good life; fulfilling, purposeful work; entering the physician role; exploration of emotional experience; and personal growth. Reflections written at the end of the course engaged significantly with art – including literature, poetry, lyrics, and film. One student disclosed a mental illness in their reflection.Conclusions Our qualitative analysis of reflections written during a visual arts-based course found several themes related to professional identity formation. Such arts-based courses can also enrich learners’ reflections and provide a space for learners to be vulnerable.Practice Points (five short bullets conveying the main points) Arts-based courses can support learners’ professional identity formationReflection themes related to professional identity formation included entering the physician role, fulfilling clinical work, and personal growthAt the end of the course, learners’ reflections included significant engagement with artReflective writing in small, arts-based learning communities can provide space for learners to be vulnerableThe Role of Arts-Based Curricula in Professional Identity Formation: Results of A Qualitative Analysis of Learner’s Written Reflections

Study objectiveAmong a comprehensive range of frontline emergency department health care personnel, we assessed symptoms of anxiety and burnout, specific coronavirus disease 2019 (COVID-19) work-related stressors, and risk for post-traumatic stress disorder (PTSD). We also determined whether COVID-19 serologic testing of HCP decreased their self-reported anxiety.MethodsIn a prospective cohort study from May 13, 2020, to July 8, 2020, we used electronic surveys to capture participant self-reported symptoms before and after serologic testing for anti-SARS-CoV-2 immunoglobulin G antibodies. Participants were physicians, nurses, advanced practice providers, and nonclinical ED personnel at 20 geographically diverse United States EDs. We evaluated these domains: 1) the effects of the COVID-19 pandemic on overall stress and anxiety; 2) COVID-19-related work stressors; 3) burnout; and 4) PTSD risk (measured using the Primary Care-PTSD Screen for DSM-5, a 5-item screening instrument in which a score of ≥3 signifies high risk for PTSD). We also assessed perceptions of whether results of COVID-19 antibody testing decreased participants' self-reported anxiety.ResultsOf 1,606 participants, 100% and 88% responded to the baseline and follow-up surveys, respectively. At baseline, approximately half (46%) reported symptoms of emotional exhaustion and burnout from their work, and 308 (19.2%, 95% confidence interval [CI] 17.3% to 21.1%) respondents screened positive for increased PTSD risk. Female respondents were more likely than males to screen positive (odds ratio [OR] 2.03, 95% CI 1.49 to 2.78). Common concerns included exposing their family and the health of coworkers diagnosed with COVID-19. After receiving antibody test results, 54% (95% CI 51.8 to 56.7) somewhat agreed, agreed, or strongly agreed that knowledge of their immune status had decreased their anxiety. A positive serology result indicating prior SARS-CoV-2 infection was associated with a higher likelihood of reporting decreased anxiety (2.83, 95% CI 1.37 to 5.83).ConclusionSymptoms of anxiety and burnout were prevalent across the spectrum of ED staff during the COVID-19 pandemic. One-fifth of ED personnel appeared to be at risk for PTSD. Increased provision of serologic testing may help to mitigate anxiety.

Study objectiveWe determine the percentage of diagnosed and undiagnosed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among a sample of US emergency department (ED) health care personnel before July 2020.MethodsThis was a cross-sectional analysis of ED health care personnel in 20 geographically diverse university-affiliated EDs from May 13, to July 8, 2020, including case counts of prior laboratory-confirmed coronavirus disease 2019 (COVID-19) diagnoses among all ED health care personnel, and then point-in-time serology (with confirmatory testing) and reverse transcriptase-polymerase chain reaction testing in a sample of volunteers without a previous COVID-19 diagnosis. Health care staff were categorized as clinical (physicians, advanced practice providers, and nurses) and nonclinical (clerks, social workers, and case managers). Previously undiagnosed infection was based on positive SARS-CoV-2 serology or reverse transcriptase-polymerase chain reaction result among health care personnel without prior diagnosis.ResultsDiagnosed COVID-19 occurred in 2.8% of health care personnel (193/6,788), and the prevalence was similar for nonclinical and clinical staff (3.8% versus 2.7%; odds ratio 1.5; 95% confidence interval 0.7 to 3.2). Among 1,606 health care personnel without previously diagnosed COVID-19, 29 (1.8%) had evidence of current or past SARS-CoV-2 infection. Most (62%; 18/29) who were seropositive did not think they had been infected, 76% (19/25) recalled COVID-19-compatible symptoms, and 89% (17/19) continued to work while symptomatic. Accounting for both diagnosed and undiagnosed infections, 4.6% (95% confidence interval 2.8% to 7.5%) of ED health care personnel were estimated to have been infected with SARS-CoV-2, with 38% of those infections undiagnosed.ConclusionIn late spring and early summer 2020, the estimated prevalence of severe acute respiratory syndrome coronavirus 2 infection was 4.6%, and greater than one third of infections were undiagnosed. Undiagnosed SARS-CoV-2 infection may pose substantial risk for transmission to other staff and patients.