Frailty is an independent predictor of postoperative rescue medication use after endoscopic sinus surgery.

INTRODUCTION: The modified five-item frailty index (mFI-5) is a validated risk stratification tool with the ability to predict adverse outcomes following surgery. In this study, we sought to use mFI-5 to assess the potential relationship between unhealthy aging and postoperative endoscopic sinus surgery (ESS) outcomes. METHODS: Patients who underwent sinus surgery at Vanderbilt between 2014 and 2018 were identified and assessed using the mFI-5, which is calculated based on the presence of five comorbidities: diabetes mellitus, hypertension requiring medication, chronic obstructive pulmonary disease, congestive heart failure, and non-independent functional status. Multivariate regression analyses were performed to quantify the association of mFI-5 score on need for rescue oral antibiotics, oral steroids, and antibiotic irrigations within 1 year following ESS, adjusting for relevant potential confounders. RESULTS: Four hundred and three patients met inclusion criteria.  Within 6 months of surgery, 312 (77%) required rescue antibiotics, 243 (60%) required oral corticosteroids (OCS), and 31 (8%) initiated antibiotic irrigations. Increasing mFI-5 scores were significantly associated with higher postoperative use of rescue antibiotics (p < 0.0001), OCS (p = 0.032), and antibiotic irrigation (p < 0.0001). Frailty scores remained as an independent predictor of these outcomes after adjustment for age, polyp status, preoperative sinonasal outcomes test (SNOT-22) score, and revision surgery status. CONCLUSIONS: Modified frailty scores may be a useful clinical tool to predict the need for postoperative rescue medication use after ESS.

The feasibility of a sleep education program for informal dementia care dyads: A pilot randomized controlled trial.

BACKGROUND: Untreated sleep problems in both persons living with dementia (PLWD) and their family care partners (CP) impact their health and quality of life. This pilot study tested a sleep intervention program for both dyad members. METHODS: Thirty dyads were randomized to a 5-session Care2Sleep intervention (n = 15 dyads) or an information-only control group (n = 15 dyads) delivered in-person or by video-telehealth by trained sleep educators. Care2Sleep is a manual-based program, incorporating key components of cognitive behavioral therapy for insomnia, daily light exposure and walking, and problem-solving for dementia-related behaviors. Adherence with Care2Sleep recommendations was assessed. Sleep outcomes included actigraphy-measured sleep efficiency (SE) and total wake time (TWT) for dyads, and the Pittsburgh Sleep Quality Index (PSQI) for CP. Other outcomes for CP included the Zarit Burden Interview (ZBI) and positive aspects of caregiving (PAC). Outcomes were measured at baseline, posttreatment, and 3-month follow-up. A 2 (group) by 3 (time) mixed model analysis of variance tested treatment effects. RESULTS: Study feasibility was demonstrated, with 13 dyads completing all five sessions of Care2Sleep program and 14 completing the control condition. In the Care2Sleep group, the dyads adhered to recommended sleep schedules of 76% for bedtime and 72% for get-up time for PLWD, and 69% for bedtime and 67% for get-up time for CP. There were several nonsignificant trends in outcomes from baseline to 3-month follow-up between the two groups. For example, SE increased by 3.2% more for PLWD and 3.2% more for CP with Care2Sleep versus control. TWT decreased by 14 min more for PLWD and 12 min more for CP with Care2Sleep versus control at the 3-month follow-up. CP in Care2Sleep also showed improvement in the PSQI, ZBI, and PAC scores. CONCLUSIONS: A dyadic approach to sleep improvement is feasible. Larger trials are needed to test effects of this intervention for PLWD and their family CP. CLINICALTRIALS: gov: NCT03455569.

Investigation of nasal epithelial cells as a surrogate for bronchial epithelial cells in the research of equine asthma.

Equine asthma, previously known as Recurrent Airway Obstruction (RAO) or Inflammatory Airway Disease (IAD), is an often-debilitating condition that may severely affect both performance and quality of life. Research is hindered by the low sample numbers of subjects recruited to studies, a consequence in part of the invasive nature of the sampling methods of bronchial brushing and biopsy. We present an alternative method of sampling equine airway epithelial cells, the 'nasal brush method' (NBM). Obtained by light brushing of the ventral meatus whilst the horse is under standing sedation, these cells express the same markers of differentiation as their deeper counterparts. Grown as 3-D spheroids or as air-liquid interface cultures, nasal epithelial cells are responsive to the inflammatory cytokine interleukin-13. This may be attenuated by modulation of the Notch signalling pathway using the gamma-secretase inhibitor Semagecestat; a previously unreported finding that cements the link between equine and human asthma research and strengthens the case for a One Health approach in researching asthma pathophysiology and therapeutic intervention.

Rowell Syndrome in a Middle-Aged Woman: A Case Report.

Rowell syndrome (RS) is characterized by the presentation of lupus erythematosus (LE) with erythema multiforme (EM)-like lesions. It is thought to display a characteristic serologic pattern consisting of a "speckled-type" antinuclear antibody (ANA), positive anti-Ro/SSA or anti-La/SSB, or positive rheumatoid factor (RF). We report the case of a patient with subacute cutaneous lupus erythematosus (SCLE) who presented with EM-like lesions responsive to oral corticosteroids.

Grit: what is it and why does it matter in medicine?

Grit refers to the combination of passion and perseverance for long-term goals. Grit has emerged as a recent topic of interest within the medical community. With ever-increasing rates of burnout and psychological distress, increasing attention has been directed towards modulatory or protective factors for these deleterious outcomes. Grit has been studied in regard to a variety of outcomes and variables in medicine. This article reviews the current literature on grit in medicine and summarises the current research on grit and performance metrics, personality characteristics, longitudinal progression, psychological well-being, diversity, equity and inclusion, burnout and residency attrition. While there is inconclusive evidence on the influence of grit on performance metrics in medicine, research consistently demonstrates a positive correlation between grit and psychological well-being and a negative correlation between grit and burnout. After discussing some of the inherent limitations of this type of research, this article suggests some possible implications and future areas for research and their potential role in cultivating psychologically healthy physicians and promoting successful careers in medicine.

Retired Orthopedic Surgeons' Reflections on Their Lives and Careers: A Cross-Sectional Study.

Background: Retired surgeons often have limited opportunities to disseminate their wisdom and expertise in a structured manner to their younger colleagues. In addition, when asked to reflect on their personal and professional lives, many physicians say they wish they had done something differently. The extent to which this is true of retired orthopedic surgeons is not known. Purpose: We sought to determine the percentage of retired orthopedic surgeons who say that they would like to have changed something in their life/career and delineate the most commonly desired changes. Methods: We conducted a cross-sectional study of retired orthopedic surgeons, by emailing a Qualtrics survey to 5864 emeritus members of the American Academy of Orthopaedic Surgeons (AAOS), with 1 initial email invitation in April 2021 followed by 2 reminders in May 2021. The survey employed a branching logic, with up to 16 questions designed to determine whether they would have done anything differently in their life/career. Results: The survey was completed by 1165 of 5864 emeritus AAOS members, for a response rate of nearly 20%. The 3 most represented surgical subspecialties were general orthopedics, adult reconstruction, and hand and upper extremity surgery. Respondents' average age was 74.9 years and age at retirement was 67.8 years; nearly half worked part-time before retiring. More than 80% of the participants said that they had retired at the appropriate time, and 28.5% said they wished they had done something differently. The wished-for changes most often noted were spending more time with family, spending more time on personal wellness, and selecting better practice partners. Conclusion: The results of our survey of retired orthopedic surgeons show that while most were satisfied with their lives and careers, some had regrets. These findings suggest that there may be factors in the work lives of current surgeons that could be altered to reduce regret. Further study is warranted.

Grit: what is it and why does it matter in medicine?

Grit refers to the combination of passion and perseverance for long-term goals. Grit has emerged as a recent topic of interest within the medical community. With ever-increasing rates of burnout and psychological distress, increasing attention has been directed towards modulatory or protective factors for these deleterious outcomes. Grit has been studied in regard to a variety of outcomes and variables in medicine. This article reviews the current literature on grit in medicine and summarises the current research on grit and performance metrics, personality characteristics, longitudinal progression, psychological well-being, diversity, equity and inclusion, burnout and residency attrition. While there is inconclusive evidence on the influence of grit on performance metrics in medicine, research consistently demonstrates a positive correlation between grit and psychological well-being and a negative correlation between grit and burnout. After discussing some of the inherent limitations of this type of research, this article suggests some possible implications and future areas for research and their potential role in cultivating psychologically healthy physicians and promoting successful careers in medicine.

The Relationships Between Grit, Burnout, and Demographic Characteristics in Medical Students.

Grit, a positive psychological trait comprised of perseverance and passion, has been correlated with physician burnout but has not been extensively studied among medical students. Identification of the relationship between grit and burnout as well as between burnout and other demographics could help to identify students at risk of burnout, while informing educational strategies to increase grit in the medical occupation. For this cross-sectional study, an online, email-based survey including demographic questions, the Maslach Burnout Inventory-Human Services (Medical Personnel) Survey, and the Short Grit Scale was distributed to an entire student body of allopathic medical students via a schoolwide listserv in 2019. The response rate was 39.6% (177/444). Negative correlations were displayed between grit and emotional exhaustion, depersonalization, and overall burnout. Positive correlation was demonstrated between grit and personal accomplishment. Male participants had higher depersonalization than female participants and fourth year medical students had higher depersonalization than other years of training. Fourth year medical students had higher personal accomplishment than other years of training and married students had higher personal accomplishment than those who had never been married. These findings are important not only for potential identification of students at risk of burnout, but also for development of strategies to bolster grit and mitigate distressing experiences in the medical occupation. Future studies are necessary to gauge how this relationship may evolve throughout a medical career.

Identifying gaps in clinical evaluation and treatment of sleep-disordered breathing in women veterans.

PURPOSE: Sleep-disordered breathing (SDB) is a common sleep disorder in veterans; however, limited research exists in women veterans. We sought to estimate patterns of care in terms of evaluation, diagnosis, and treatment among women veterans with factors associated with elevated SDB risk. METHODS: Within one VA healthcare system, women identified through electronic health record data as having one or more factors (e.g., age >50 years, hypertension) associated with SDB, completed telephone screening in preparation for an SDB treatment study and answered questions about prior care related to SDB diagnosis and treatment. RESULTS: Of 319 women, 111 (35%) reported having completed a diagnostic sleep study in the past, of whom 48 (43%) were diagnosed with SDB. Women who completed a diagnostic study were more likely to have hypertension or obesity. Those who were diagnosed with SDB based on the sleep study were more likely to have hypertension, diabetes, or be ≥50 years old. Of the 40 women who received treatment, 37 (93%) received positive airway pressure therapy. Only 9 (24%) had used positive airway pressure therapy in the prior week. Few women received other treatments such as oral appliances or surgery. CONCLUSIONS: Findings support the need for increased attention to identification and management of SDB in women veterans, especially those with conditions associated with elevated SDB risk.

Evaluation of a System for Real-Time Surveillance of Suicide in England.

Background: Access to timely data on suicide is crucial to support suicide prevention. A real-time suicide surveillance (RTSS) system enables public health teams and allied agencies to review information following suicides promptly and take action quickly. Aims: The aim of this paper was to report on an evaluation of an RTSS system in South Yorkshire, England. Method: The system was reviewed, and outcome data were analyzed for 2019 and 2020 based on recorded suspected suicides, a stakeholder focus group, evaluation of postvention bereavement service outcomes, and lessons learned. Results: The benefits of RTSS included rapid response to emerging trends, identifying clusters, effective bereavement support, information to inform measures to mitigate risk, and supporting evaluation of interventions. The challenges faced included limited resources, data quality, consistency across places, and linkages with coronial processes. Limitations: This was an evaluation of one RTSS system based on routinely collected data covering one area, South Yorkshire, and hence some data limitations, and direct comparison with other services or against a control group was not possible. Conclusion: The RTSS system has led to better support for suicidal people and a responsive, timely, and effective service for those bereaved by suicide, all of which are likely to lead to enhanced well-being and community resilience.

Nirmatrelvir-ritonavir use among adults hospitalized with COVID-19 during the Omicron phase of the COVID-19 pandemic, Canadian Nosocomial Infection Surveillance Program.

Background: Recent studies have demonstrated the effectiveness of nirmatrelvir-ritonavir in reducing the risk of progression to severe disease among outpatients with mild to moderate coronavirus disease 2019 (COVID-19); however, data are limited regarding the use and role of nirmatrelvir-ritonavir among hospitalized patients. This study describes the use and outcomes of nirmatrelvir-ritonavir among adults hospitalized with COVID-19 in a sentinel network of Canadian acute care hospitals during the Omicron variant phase of the pandemic. Methods: The Canadian Nosocomial Infection Surveillance Program conducts surveillance of hospitalized patients with COVID-19 in acute care hospitals across Canada. Demographic, clinical, treatment and 30-day outcome data were collected by chart review by trained infection control professionals using standardized questionnaires. Results: From January 1 to December 31, 2022, 13% (n=490/3,731) of adult patients (18 years of age and older) hospitalized with COVID-19 in 40 acute care hospitals received nirmatrelvir-ritonavir either at admission or during hospitalization. Most inpatients who received nirmatrelvir-ritonavir, 79% of whom were fully vaccinated, had at least one pre-existing comorbidity (97%) and were of advanced age (median=79 years). Few were admitted to an intensive care unit (2.3%) and among the 490 nirmatrelvir-ritonavir treated inpatients, there were 13 (2.7%) deaths attributable to COVID-19. Conclusion: These findings from a large sentinel network of Canadian acute-care hospitals suggest that nirmatrelvir-ritonavir is being used to treat adult COVID-19 patients at admission who are at risk of progression to severe disease or those who acquired COVID-19 in hospital. Additional research on the efficacy and indications for nirmatrelvir-ritonavir use in hospitalized patients is warranted to inform future policies and guidelines.

Coordination and Pilot Implementation of a Standardized Data Collection for Touching Hands.

PURPOSE: Touching Hands is an American Society for Surgery of the Hand program that provides hand surgeries to the world's underserved communities. The purpose of this study was to develop and implement a systematic data collection method for Touching Hands to assess patient outcomes, volunteer impact, alleviated disease burden, and cost-effectiveness. METHODS: Research electronic data capture (REDCap) was used as the secure software platform to facilitate data collection. The Quick Disabilities of the Arm, Shoulder and Hand questionnaire was used to assess pre-and postoperative patient-reported outcomes. The Maslach Burnout Inventory-Human Services (Medical Personnel) survey was administered to volunteers before and after the mission to measure impact on volunteers. Case information was collected to calculate disability-adjusted life years and cost-effectiveness. RESULTS: The data collection system was implemented in some capacity in 4 domestic and 3 international mission sites during 2020 and 2021. CONCLUSIONS: Substantial limitations exist for the implementation of a systematic data collection framework for Touching Hands and warrant further modification and optimization. CLINICAL RELEVANCE: A REDCap database can be used for standardized and centralized patient and volunteer data collection for Touching Hands missions.

Updates in the Diffuse Large B-Cell Lymphoma Treatment Landscape.

During JADPRO Live Virtual 2021, presenters discussed updates in the treatment of diffuse large B-cell lymphoma (DLBCL), including novel agents and chimeric antigen receptor (CAR) T-cell therapy, and how the treatment and management of patients with DLBCL has been affected by the COVID-19 pandemic.

Experiences of Sleep Problems Among Older Korean Immigrants.

Despite poor sleep among older adults, little is known about the sleep habits of older immigrants living in the United States. The current pragmatic qualitative descriptive study explored sleep among older Korean immigrants, using a focus group with six participants and individual phone interviews with 22 Korean immigrants aged ≥60 years. Transcripts were coded to identify underlying themes. Several thematic categories were identified under six domains: daytime function, getting ready for bed, falling asleep, awakenings during sleep, going back to sleep, and seeking advice from peers. Unhealthy sleep behaviors were found during daytime and bedtime, particularly among those who were retired/unemployed or living alone. Seeking advice from peers was common but none of the advice helped participants sleep. Sleep education programs in Korean-speaking communities can be used to target those who are socially isolated and may benefit older Korean immigrants with sleep difficulties. [Research in Gerontological Nursing, 15(4), 193-202.].

Usability and Acceptability of the QuestLeukemia Mobile Application: A Pilot Study for An Educational and Psychological Intervention for Children with Chronic Illnesses.

It is widely accepted that educational interventions benefit children with chronic diseases (disease awareness and autonomy) or those undergoing medical procedures (decreased anxiety and improved satisfaction). Hematopoietic cell transplantation (HCT) is an intensive procedure to treat life-threatening diseases but is associated with multiple adverse medical experiences. QuestLeukemia (QuestED, Durham, NC) is a mobile app designed to educate pediatric patients preparing for HCT through age-appropriate videos and quizzes. Here we describe the results of the initial pilot study assessing acceptability and feasibility of QuestLeukemia app. Eligible participants were selected from a convenience sample (inpatient HCT unit and outpatient clinic). Participants spent 30-60 min using the app then completed a survey assessing the app for usability, accessibility, and user satisfaction. Participants identified the app as a useful tool for gaining disease-related knowledge and reported greater autonomy over their disease process. On average, patients indicated that the app was easy to use (M = 4.93), enjoyable (M = 4.79), and comprehensive (M = 4.71). Parents followed similar trends of satisfaction with the app. Pediatric HCT providers likewise reported that the app was easy to use (M = 4.22), enjoyable (M = 4.85), and educationally comprehensive (M = 4.77). The QuestLeukemia mobile application prototype provides an easy, enjoyable, and educational tool for pediatric patients undergoing HCT. This application was well received by patients, parents, and providers. These findings will be used to design future iterations of the game in clinical care.

Reach and Effectiveness of Diabetes Self-Management Education and Support in a Network of Federally Qualified Health Centers.

Diabetes self-management education and support (DSMES) is an evidence-based intervention to improve diabetes-related outcomes. Access to DSMES is limited for diverse and low-income groups, despite greater need for services to address health disparities. Providing DSMES in federally qualified health centers (FQHCs) may increase reach for priority populations, and further study is needed to evaluate this delivery model. This report examines program effectiveness, including outcomes by race/ethnicity and Medicaid status, among 1,247 enrollees in FQHC-based DSMES. There was substantial glycated hemoglobin (A1c) improvement overall (-0.98%) among a diverse, majority-Medicaid population. However, Medicaid beneficiaries were approximately half as likely to attend as other enrollees (p<.001), while Latinx and non-Latinx Black participants attended fewer sessions (p=.008 and p=.040, respectively). Additionally, Medicaid beneficiaries experienced less A1c improvement than others (p=.040). Findings are promising that FQHC-based delivery can increase access to high-quality DSMES, although further effort appears needed to ensure optimal outcomes for all.

Associations of Self-Reported Sleep Quality with Demographic and Other Characteristics in Older Korean Immigrants.

Poor sleep is common among older adults, affecting a wide range of health outcomes. However, little is known about sleep issues among older Korean immigrants, the fastest growing Asian American subgroup in the United States. We aimed to explore multiple factors associated with sleep among this group. We analyzed cross-sectional survey data from 43 older immigrants living in two large Korean communities in Southern California. Perceived sleep quality was significantly associated with gender, living arrangement, employment status, mental health, and sleep-related beliefs (all p-values < 0.05). Living with someone and being employed for wages were significantly uniquely associated with better sleep quality, accounting for demographic and health-related factors (R2 = 51.8%, adjusted R2 = 38.7%, p = 0.002). These findings suggest a potential role of sociocultural factors on sleep. Further studies are needed to confirm these findings and to inform a sleep intervention program tailored to the characteristics of older Korean immigrants.

Development and evaluation of a bovine lung-on-chip (bLOC) to study bovine respiratory diseases.

Purpose: Current air-liquid interface (ALI) models of bovine proximal airways have their limitations. They do not simulate blood flow necessary to mimic systemic drug administration, and repeated sampling requires multiple, independent cultures. A bovine lung-on-chip (bLOC) would overcome these limitations, providing a convenient and cost-effective model for pharmacokinetic or pathogenicity studies. Methods: Bovine pulmonary arterial endothelial cells seeded into the endothelial channel of an Emulate Lung-Chip were interfaced with bovine bronchial epithelial cells in the epithelial channel. Cells were cultured at ALI for up to 21 days. Differentiation was assessed by mucin quantification, phase-contrast light microscopy and immunofluorescence of cell-specific markers in fixed cultures. Barrier integrity was determined by FITC-labelled dextran 3-5 kDa permeability. To evaluate the model, endothelial-epithelial transport of the antibiotic drug, danofloxacin, was followed using liquid chromatography-mass spectrometry, with the aim of replicating data previously determined in vivo. Results: bLOC cultures secreted quantifiable mucins, whilst cilia formation was evident in the epithelial channel. Barrier integrity of the model was demonstrated by resistance to FITC-Dextran 3-5 kDa permeation. Bronchial epithelial and endothelial cell-specific markers were observed. Close to plasma, representative PK data for danofloxacin was observed in the endothelial channel; however, danofloxacin in the epithelial channel was mostly below the limit of quantification. Conclusion: A co-culture model of the bovine proximal airway was successfully generated, with potential to replace in vivo experimentation. With further optimisation and characterisation, the bLOC may be suitable to perform drug pharmacokinetic studies for bovine respiratory disease (BRD), and other applications.

Is Grit Associated with Burnout and Well-being in Orthopaedic Resident and Faculty Physicians? A Multi-institution Longitudinal Study Across Training Levels.

BACKGROUND: Grit has been defined as "perseverance and passion for long-term goals" and is characterized by maintaining focus and motivation toward a challenging ambition despite setbacks. There are limited data on the impact of grit on burnout and psychologic well-being in orthopaedic surgery, as well as on which factors may be associated with these variables. QUESTIONS/PURPOSES: (1) Is grit inversely correlated with burnout in orthopaedic resident and faculty physicians? (2) Is grit positively correlated with psychologic well-being in orthopaedic resident and faculty physicians? (3) Which demographic characteristics are associated with grit in orthopaedic resident and faculty physicians? (4) Which demographic characteristics are associated with burnout and psychologic well-being in orthopaedic resident and faculty physicians? METHODS: This study was an institutional review board-approved interim analysis from the first year of a 5-year longitudinal study of grit, burnout, and psychologic well-being in order to assess baseline relationships between these variables before analyzing how they may change over time. Orthopaedic residents, fellows, and faculty from 14 academic medical centers were enrolled, and 30% (335 of 1129) responded. We analyzed for the potential of response bias and found no important differences between sites in low versus high response rates, nor between early and late responders. Participants completed an email-based survey consisting of the Duckworth Short Grit Scale, Maslach Burnout Inventory-Human Services (Medical Personnel) Survey, and Dupuy Psychological Well-being Index. The Short Grit Scale has been validated with regard to internal consistency, consensual and predictive validity, and test-retest stability. The Psychological Well-being Index has similarly been validated with regard to reliability, test-retest stability, and internal consistency, and the Maslach Burnout Inventory has been validated with regard to internal consistency, reliability, test-retest stability, and convergent validity. The survey also obtained basic demographic information such as survey participants' age, gender, race, ethnicity, marital status, current year of training or year in practice (as applicable), and region of practice. The studied population consisted of 166 faculty, 150 residents, and 19 fellows. Beyond the expected age differences between sub-populations, the fellow population had a higher proportion of women than the faculty and resident populations did. Pearson correlations and standardized ß coefficients were used to assess the relationships of grit, burnout, psychologic well-being, and continuous participant characteristics. RESULTS: We found moderate, negative relationships between grit and emotional exhaustion (r = -0.30; 95% CI -0.38 to -0.21; p < 0.001), depersonalization (r = -0.34; 95% CI -0.44 to -0.23; p < 0.001), and the overall burnout score (r = -0.39; 95% CI -0.48 to -0.31; p < 0.001). The results also showed a positive correlation between grit and personal accomplishment (r = 0.39; 95% CI 0.29 to 0.48; p < 0.001). We also found a moderate, positive relationship between grit and psychologic well-being (r = 0.39; 95% CI 0.30 to 0.49; p < 0.001). Orthopaedic surgeons with 21 years or more of practice had higher grit scores than physicians with 10 to 20 years of practice. Orthopaedic surgeons in practice for 21 years or more also had lower burnout scores than those in practice for 10 to 20 years. Married physicians had higher psychologic well-being than unmarried physicians did. CONCLUSION: Among orthopaedic residents, fellows, and faculty, grit is inversely related to burnout, with lower scores for emotional exhaustion and depersonalization and higher scores for personal accomplishment as grit increases. CLINICAL RELEVANCE: The results suggest that grit could be targeted as an intervention for reducing burnout and promoting psychologic well-being among orthopaedic surgeons. Other research has suggested that grit is influenced by internal characteristics, life experiences, and the external environment, suggesting that there is potential to increase one's grit. Residency programs and faculty development initiatives might consider measuring grit to assess for the risk of burnout, as well as offering curricula or training to promote this psychologic characteristic.