Sentara Rockingham Memorial Hospital Medical Center

The purpose of this study is to determine if speech-language pathologists' (SLP) ratings of palpated hyolaryngeal excursion (pHLE) during a clinical swallow evaluation (CSE) are predictive of spatial measures of hyolaryngeal excursion determined by instrumentation (iHLE). Adults between the ages of 18-99 were recruited with a physician referral to complete a CSE and videofluoroscopy swallow study. Four SLP investigators completed ratings of pHLE palpation during a CSE. Spatial measures of hyoid peak elevation were taken from videofluoroscopy swallow studies. Statistical analyses included multiple linear regression to determine the best-fitting model to predict iHLE from palpated ratings. Data from 77 volunteers (44 female, mean age 71.6) were used for statistical analyses. The linear regression model indicated three significant predictors of superior (upward) hyoid peak position, including palpation, bolus consistency, and the number of swallows. There were no significant predictors of anterior (forward) hyoid peak position from the tested factors. The emergence of these significant predictors suggests that palpation may provide insight into superior HLE movements during a CSE. Next steps will be to determine if palpation improves SLPs' diagnostic accuracy and clinical decision-making during swallow assessment without instrumentation.

Left ventricular (LV) thrombus is traditionally a contraindication to transcatheter aortic valve replacement due to embolic risk. Consequently, management of valvular cardiogenic shock complicated by LV thrombus identifies unique challenges that require innovative strategies. A 58-year-old woman with critical bioprosthetic aortic stenosis, cardiogenic shock, and large LV thrombus (2.8 × 2.6 cm) underwent successful valve-in-valve transcatheter aortic valve replacement after systemic fibrinolysis bridge therapy. Current guidelines contraindicate transcatheter aortic valve replacement in patients with LV thrombus. This case demonstrates the novel use of low-dose, slow infusion tissue plasminogen activator as a bridge therapy to enable life-saving intervention. Pulsed delivery of small doses of systemic fibrinolytic with hemodynamic and echocardiographic monitoring may be suitable as a bridge to definitive management in valvular shock patients with LV thrombus. Minimizing instrumentation during structural heart procedures complicated by LV thrombus is critical. Low-dose, slow-infusion fibrinolysis coupled with echocardiographic monitoring may serve as bridge therapy to urgent structural cardiology intervention in carefully selected patients with LV thrombus and cardiogenic shock.

Objectives Previous studies have shown that residents play an important role in the education of medical students in the clinical setting, but the busy environment of the emergency department (ED) poses a challenge to the effective teaching of medical students by emergency medicine (EM) residents. Tocombat this, this study relies on just-in-time teaching, which refers to the application of teaching efforts specific to a particular moment, in this case, a clinical case or procedure. Building on studies showing that just-in-time teaching can improve education despite time constraints, as well as data showing that practitioners and trainees increasingly use apps for diagnosis and education, the objective of this project was to determine whether a free open-access medical education (FOAM) smartphone application (app) is feasible and improves the quality and frequency of resident teaching of medical students in the emergency department. Methods We created a smartphone app-based teaching resource that was available to residents and students on shift. We taught residents and medical students how to integrate the app into their workflow. We performed an observational pre/post-studydesign by surveying residents' and students' pre- and post-teaching app introduction to determine self- and student-reported teaching frequency and quality. Outcome measures were self-reported teaching frequency and quality of teaching. Results Ten of 17 residents (59%) reported using the app at least once per shift. Among them, six of 10 (60%) reported that it increased their teaching frequency, and eight of 10 (80%) reported that it increased the quality of their teaching. There was an increase in the number of residents with positive perceptions of the availability of evidence-based teaching resources on the shift from pre-intervention (five residents) to post-intervention (14 residents, p = 0.01); however, we were otherwise unable to identify any significant differences in residents' or students' perceptions of teaching after implementation of our intervention. Conclusion Just-in-time teaching of medical students by residents using a smartphone app is feasible, as evidenced by the majority of resident respondents reporting that they used the teaching app at least once per shift. Residents reported an improvement in teaching frequency and quality. The study is limited by a small sample size and a single-site design with a pre/post design. Further studies with a focus on qualitative feedback and objective measures of learning are needed to assess whether there is an impact on medical student instruction by residents when using this app-based teaching resource.

Previously, externally placed vibratory laryngeal stimulation increased rates of swallowing in persons with and without dysphagia. This study examined the feasibility of using a vibratory device on the skin over the thyroid cartilage for home-based swallowing rehabilitation in long-standing dysphagia. Only participants with long-standing dysphagia (> 6 months) following cerebrovascular accident or head/neck cancer who had not previously benefited from dysphagia therapy participated. The device had two modes used daily for 90 days. In automatic mode, participants wore the device when awake, which vibrated for 4-8 s every 5 min to trigger a volitional swallow. In manual mode, participants practiced by activating vibration while swallowing rapidly. Study-related adverse events, such as pneumonia, and device-recorded adherence were tracked. Swallowing function on a modified barium swallow study was assessed at baseline and after 3 months of device use. Outcome measures included the Dysphagia Outcome and Severity Scale (DOSS), Penetration-Aspiration Scale (PAS), and swallowing timing measures. Participants' perceptions of the vibratory device and training were obtained. The intent to treat analysis showed seven of 11 participants completed the study, all with severe chronic dysphagia. Of those seven participants completing the study, two developed respiratory complications (possibly due to pneumonia) that cleared after antibiotic intervention. For prescribed practice trials, adherence was 80% or greater in four of seven participants (57%) whereas prescribed automatic stimulations were met in only two of seven participants (29%). Three participants (43%) had a modest benefit on DOSS. The time to vestibule closure after the bolus passed the ramus was reduced in five participants (71%) on the modified barium swallow study. Overall, the results have indicated that intensive home-based practice with stimulation may provide limited functional benefits in severe chronic dysphagia. https://doi.org/10.23641/asha.21498591.

Laparoscopic ventral hernia repair with intraperitoneal mesh remains an accepted and evidence-based technique for ventral/incisional hernia (VIH) repair. The robotic surgical platform has some potential advantages compared to traditional laparoscopic instrumentation for VIH repair including, but not limited to, additional degrees of motion, three-dimensional imaging, a stable operating construct, preferred ergonomics, and relative ease of intracorporeal suturing. This chapter will cover patient selection criteria and operative technique for robotic-assisted VIH repair with intraperitoneal mesh. Specifically, the chapter will detail the equipment and operating room setup, patient positioning, trocar placement, docking, dissection, defect closure, and mesh placement and fixation strategies for robotic-assisted VIH repair with intraperitoneal mesh.

Patra H. Reed, DNP, RN, CNML, is Sentara Blue Ridge Regional Director for Integrated Care Management at Sentara RMH Medical Center in Harrisonburg, VA. She received her DNP and BSN degrees from James Madison University and her MSN degree from the University of Virginia. Her 23 years of nursing experience include 15 years in case management and case management leadership. Patra helped in developing the Continuum Case Management role and the community health worker program at Sentara RMH Medical Center. She has also presented these programs at local, state, and national case management conferences. Linda J. Hulton, PhD, RN, is Professor of Nursing at James Madison University and Coordinator of the Doctor of Nursing Practice program. She received her BSN degree from Roberts Wesleyan College and her master's and PhD in nursing degree from the University of Virginia, with a specialty in Community Health. Her areas of research interest are adolescent health promotion and homeless populations. Past awards include the CISAT Distinguished Teacher from James Madison University, the Alger Family Endowment Award for Community Outreach, and the Provost Award for Excellence in Graduate Advising. In 2016, she received the Virginia Nurses Foundation Leadership in Excellence in Nursing Research Award. Address correspondence to Patra H. Reed, DNP, RN, CNML, Nursing Administration, Sentara RMH Medical Center, 2010 Health Campus Dr, Harrisonburg, VA 22801 ([email protected]). The authors report no conflicts of interest.

ABSTRACTThis article is a qualitative study exploring fear of crime within an Asian American community in the southern region of the United States. As more and more Asian Americans move to the South, they force preexisting communities to encounter a burst of unfamiliar populations. The new makeup of communities in the South has resulted in fear of crime among the more recent residents. In interviews with leaders of the Asian American community, four major themes of fears were identified: violence against businesses, crime against personal property, invisibility and marginalization, and discrimination of individuals.