Becoming a Co-Survivor-Reflections From the ICU.

This essay describes what the author learned from being in the intensive care unit with her father during multiple cardiac arrests and surgery.

Restorative Justice for Survivors of Sexual Violence Experienced in Adulthood: A Scoping Review.

Sexual violence (SV) is a widespread human rights issue. Survivors of SV often experience profound dehumanization and poor health outcomes when their trauma is not properly addressed, rendering it critical that they are honored and empowered within subsequent processes of healing and seeking justice. With adjudication through the criminal legal system largely underutilized due to retraumatization, scrutiny from law enforcement professionals, and high rates of case closure, restorative justice (RJ) has emerged as a promising option for survivors to repair harm and experience accountability. Little is known, however, regarding the best practices for its use in cases of SV. To meet this need, a scoping review was conducted to identify the best practices for the implementation of RJ after instances of SV experienced in adulthood. Following the search methodology outlined by the JBI Manual for Evidence Synthesis for scoping reviews, 15 articles met search criteria, including four empirical studies and 11 nonempirical research materials spanning five academic disciplines. Best practices and structures for RJ were subsequently identified, including key phases for appropriate implementation. This review can be used to create increasingly productive RJ processes for SV survivors, which is particularly important for those coming from marginalized communities facing structural inequities, as well as survivors on university campuses. As researchers, we have the power to use science to propel society toward the creation of more efficacious healing spaces for survivors of SV, and optimizing safe RJ processes plays a key role in bringing this to fruition.

Trauma-Informed Care Curricula for the Health Professions: A Scoping Review of Best Practices for Design, Implementation, and Evaluation.

PURPOSE: Trauma-exposed persons often experience difficulties accessing medical care, remaining engaged in treatment plans, and feeling psychologically safe when receiving care. Trauma-informed care (TIC) is an established framework for health care professionals, but best practices for TIC education remain unclear. To remedy this, the authors conducted a multidisciplinary scoping literature review to discern best practices for the design, implementation, and evaluation of TIC curricula for health care professionals. METHOD: The research team searched Ovid MEDLINE, Cochrane Library, Elsevier's Scopus, Elsevier's Embase, Web of Science, and the PTSDpubs database from the database inception date until May 14, 2021. Worldwide English language studies on previously implemented TIC curricula for trainees or professionals in health care were included in this review. RESULTS: Fifty-five studies met the inclusion criteria, with medicine being the most common discipline represented. The most prevalent learning objectives were cultivating skills in screening for trauma and responding to subsequent disclosures (41 studies [74.5%]), defining trauma (34 studies [61.8%]), and understanding trauma's impact on health (33 studies [60.0%]). Fifty-one of the studies included curricular evaluations, with the most common survey items being confidence in TIC skills (38 studies [74.5%]), training content knowledge assessment (25 studies [49.0%]), participant demographic characteristics (21 studies [41.2%]), and attitudes regarding the importance of TIC (19 studies [37.3%]). CONCLUSIONS: Future curricula should be rooted in cultural humility and an understanding of the impacts of marginalization and oppression on individual and collective experiences of trauma. Moreover, curricula are needed for clinicians in more diverse specialties and across different cadres of care teams. Additional considerations include mandated reporting, medical record documentation, and vicarious trauma experienced by health care professionals.

Navigating Cardiology's Leaky Pipeline.

This essay describes the author's experience of gender-based discouragement as a woman medical student.

Pushing for the same thing on the same set of tracks: a qualitative study exploring the anti-trafficking response in Bihar and Uttar Pradesh.

BACKGROUND: Human trafficking is a critical public health issue particularly pervasive in the Indian states of Bihar and Uttar Pradesh (UP), which share a border with Nepal. Many NGOs are participating in prevention, protection, prosecution, and capacity building initiatives. The aim of this study was to identify factors hindering and enhancing the efficacy of anti-trafficking programs in the region. METHODS: A qualitative study was conducted using semi-structured interviews and focus groups with key stakeholders in Bihar, Uttar Pradesh, and Nepal. RESULTS: Thematic analysis revealed that the barriers hindering the anti-trafficking movement include police corruption, insufficient enforcement of national law, discrimination toward trafficking victims, inadequate funding, and lack of government involvement. Recommendations for overcoming these barriers were through empowering survivors and increasing cooperation, coordination, and communications between NGOs and the government. CONCLUSIONS: In mitigating these barriers and increasing survivor autonomy, anti-trafficking interventions have the opportunity to create individualized environments for those with an experience of trafficking to thrive. Ultimately, elevating community accountability, honoring individual autonomy, and recognizing the value of the persons with a lived experience of trafficking are critical as we continue to use a public health lens in the fight against human trafficking and for human rights.

Trauma Recovery Is Cultural: Understanding Shared and Different Healing Themes in Irish and American Survivors of Gender-based Violence.

Little research has focused on the trauma healing processes of survivors of gender-based violence (GBV) worldwide. Even less research has utilized cross-cultural comparison to understand shared or culturally-distinct healing goals, creating a gap in understanding how to provide adequate, culturally relevant, and trauma-informed care to survivors. The purpose of this study was to cross-culturally compare shared healing influences and themes of the trauma recovery process in samples of Irish and American female survivors of GBV. To gather healing data, an ethnographic narrative interview was used with 19 American and 12 Irish female survivors who self-identified as having experienced GBV. Thematic analysis was used to examine and compare desired healing outcomes, focusing on the definitions, influences, and meanings of healing experiences. Our analysis revealed shared healing objectives of reconnecting to the self, others, and the world. Within reconnecting with the self, shared themes included regaining control and feelings of competency. Within reconnecting to others, shared themes included building and maintaining relationships, living one's life authentically, and feeling heard and understood. Within reconnecting to the world, shared themes included feelings of serenity, finding fulfillment, and having hope for a brighter future. Although these themes were shared, the way they manifested in each culture was often different. A vital component of the healing dynamic in the Irish sample was survivors' mothering responsibilities and feelings of unconditional devotion to their children. Conversely, the American sample focused on personal growth and resolving feelings of weakness. This information reveals shared as well as cultural nuances of important healing objectives following GBV. The present study's results can be used to create culturally sensitive and relevent healing spaces for survivors. These results can also inform intervention and messaging strategies aimed at promoting healing in these populations.

Silently Screaming in the Dark: Gender-Based Dynamics of Distress in Japanese Migrants.

Prior literature has shown the female Japanese population experiences higher susceptibility to mental health disorders. The causal influences of help-seeking for distressed women were investigated through analysis of 24 interviews of Japanese immigrant women in the Detroit Metropolitan Area. The Clinical Ethnographic Narrative Interview (CENI) was utilized as the interviewing technique, investigating Japanese culture as a determinant of personal wellness. This study was a grounded theory examination of the interactions among gender, social context, cultural displacement, and a causal model for Japanese women's distress experiences. The resulting theoretical model revealed the familial and social dynamics traditional to Japanese culture developed feelings of poor self-worth common amongst study participants. This negative perception of self was exacerbated by gendered challenges of expatriation and intense pressures within this region's Japanese migrant community. These findings show the need for increased contact with at-risk populations to understand their causal models and help-seeking behaviors and expectations.

Developing leadership as a trainee- opportunities, barriers and potential improvements.

The General Medical Council explicitly state that doctors completing training should demonstrate capabilities in leadership and teamwork.1 However, most trainees receive little formal training in leadership. In March 2017, at the Faculty of Medical Leadership and Management (FMLM) Northern Ireland Regional Conference, a workshop on developing leadership skills as a trainee was hosted and the views of doctors in training regarding current opportunities, potential barriers and improvements were sought. In Northern Ireland presently there are a number of opportunities available for trainees to gain experience in leadership - both by learning through observation and learning through experience. These range from informal activities which do not require significant time commitment to focused, immersive leadership experiences such as ADEPT (Achieve Develop Explore Programme for Trainees)2, and the Royal College of Physicians' Chief Registrar scheme.3 Several barriers to developing leadership have been identified, including limited understanding of what constitutes leadership, a lack of senior support and little formal recognition for trainees leading teams. Time pressures, frequently rotating jobs, limited resources and difficulty upscaling can also undermine the sustainability of improvement and other leadership projects. Incorporating awareness of and training in leadership skills, as well as greater engagement with senior leaders and managers, at an early stage in training could promote understanding and encourage trainees. Formalising leadership roles within training posts may improve experience. Deaneries and Trusts can also enable leadership opportunities by facilitating study leave, raising awareness amongst supervisors, and providing career enhancing incentives for interested trainees.

A Multicenter Analysis of Factors Associated With Apixaban-Related Bleeding in Hospitalized Patients With End-Stage Renal Disease on Hemodialysis.

BACKGROUND: In 2014, the United States Food and Drug Administration approved a labeling change for apixaban to include recommendations for patients with severe renal impairment and patients with end-stage renal disease (ESRD) on hemodialysis (HD), though these recommendations are largely based on pharmacokinetic and pharmacodynamic data. OBJECTIVE: Identify variables associated with bleeding events in hospitalized patients with ESRD on HD receiving apixaban. METHODS: This retrospective, multicenter cohort study evaluated hospitalized patients with ESRD on HD receiving apixaban from January 1, 2013, through March 31, 2016. Correlational analysis and logistic regression were completed to identify factors associated with bleeding. RESULTS: A total of 114 adults were included in the analysis. The median length of stay (LOS) was 6.2 (interquartile range = 3.8-11.9) days and bleeding events occurred in a total of 17 patients (15%). A weak correlation was identified for higher cumulative apixaban exposure, increased number of HD sessions while receiving apixaban, and increased hospital LOS ( P < 0.05; correlation coefficient < 0.40). When controlling for confounders, logistic regression revealed that composite bleeding events were independently increased by continuation of outpatient apixaban (odds ratio = 13.07; 95% CI = 1.54-110.54; P = 0.018), increased total daily dose of apixaban (odds ratio = 1.72; 95% CI = 1.20 to 2.48; P = 0.003), and total HD sessions while receiving apixaban (odds ratio = 2.04; 95% CI = 1.06-3.92; P = 0.033). CONCLUSION: The association between these factors and increased bleeding should prompt concern for long-term anticoagulation with apixaban in patients with ESRD receiving chronic HD.

Frequency of cytokine gene promoter polymorphisms in the Northern Ireland cystic fibrosis population.

It has been postulated that cytokine allele frequencies are gender and perhaps geographically-specific. Cytokine release is crucial in the regulation of the type and magnitude of the immune response. This study observed no differences in the frequency of cytokine promoter polymorphisms associated with variant levels of expression in patients with CF and a non-CF population of Northern Ireland.

Association of improved pulmonary phenotype in Irish cystic fibrosis patients with a 3' enhancer polymorphism in alpha-1-antitrypsin.

Modifier genes other than CFTR are thought to influence lung disease phenotype in cystic fibrosis (CF). In this study, we investigated the relationship between a polymorphism (1237 G --> A) in the 3' enhancer region of the alpha-1-antitrypsin (AAT) gene and pulmonary disease severity in 320 CF patients recruited from two independent adult referral centers in Ireland, and evaluated the in vivo effect of the polymorphism on AAT levels during acute infection. When corrected for confounding variables, the polymorphism was found to make a small but significant contribution to variance in percent predicted forced expired volume in 1 sec (FEV1) (1.1%, P = 0.05), with possession of the A allele being associated with better pulmonary function (AA/AG genotype: percent predicted FEV1, 70.8 +/- 3.9; GG genotype: percent predicted FEV1, 62.0 +/- 1.4). As would be expected of a modifier effect, the influence of the polymorphism was more marked in patient groups traditionally associated with more severe lung disease, contributing 3.2% (P = 0.033) to the variance in percent predicted FEV1 in patients homozygous for DF508, 3.3% (P = 0.007) to those infected with Pseudomonas aeruginosa, and 3% (P = 0.024) in female patients. In each instance, a positive association between possession of the A variant and higher percent predicted FEV1 was observed. We did not, however, find any evidence that possession of the A allele effected upregulation of AAT during acute infection in vivo. This lack of a demonstrable functional effect in vivo suggests that the polymorphism is a marker for a modifying effect on pulmonary phenotype in the Irish CF population by a mechanism that is yet to be explained.