Discrimination 911: A Novel Response Framework to Teach Bystanders to Become Upstanders When Facing Microaggressions.

PROBLEM: Microaggressions are pervasive in daily life, including in undergraduate and graduate medical education and across health care settings. The authors created a response framework (i.e., a series of algorithms) to help bystanders (i.e., health care team members) become upstanders when witnessing discrimination by the patient or patient's family toward colleagues at the bedside during patient care, Texas Children's Hospital, August 2020 to December 2021. APPROACH: Similar to a medical "code blue," microaggressions in the context of patient care are foreseeable yet unpredictable, emotionally jarring, and often high-stakes. Modeled after algorithms for medical resuscitations, the authors used existing literature to create a series of algorithms, called Discrimination 911, to teach individuals how to intervene as an upstander when witnessing instances of discrimination. The algorithms "diagnose" the discriminatory act, provide a process to respond with scripted language, and subsequently support a colleague who was targeted. The algorithms are accompanied by training on communication skills and diversity, equity, and inclusion principles via a 3-hour workshop that includes didactics and iterative role play. The algorithms were designed in the summer of 2020 and refined through pilot workshops throughout 2021. OUTCOMES: As of August 2022, 5 workshops have been conducted with 91 participants who also completed the post-workshop survey. Eighty (88%) participants reported witnessing discrimination from a patient or patient's family toward a health care professional, and 89 (98%) participants stated that they would use this training to make changes in their practice. NEXT STEPS: The next phase of the project will involve continued dissemination of the workshop and algorithms as well as developing a plan to obtain follow-up data in an incremental fashion to assess for behavior change. To reach this goal, the authors have considered changing the format of the training and are planning to train additional facilitators.

Bone marrow stromal cell-mediated tissue sparing enhances functional repair after spinal cord contusion in adult rats.

Bone marrow stromal cell (BMSC) transplantation has shown promise for repair of the spinal cord. We showed earlier that a BMSC transplant limits the loss of spinal nervous tissue after a contusive injury. Here, we addressed the premise that BMSC-mediated tissue sparing underlies functional recovery in adult rats after a contusion of the thoracic spinal cord. Our results reveal that after 2 months BMSCs had elicited a significant increase in spared tissue volumes and in blood vessel density in the contusion epicenter. A strong functional relationship existed between spared tissue volumes and blood vessel density. BMSC-transplanted rats exhibited significant improvements in motor, sensorimotor, and sensory functions, which were strongly correlated with spared tissue volumes. Retrograde tracing revealed that rats with BMSCs had twice as many descending brainstem neurons with an axon projecting beyond the contused spinal cord segment and these correlated strongly with the improved motor/sensorimotor functions but not sensory functions. Together, our data indicate that tissue sparing greatly contributes to BMSC-mediated functional repair after spinal cord contusion. The preservation/formation of blood vessels and sparing/regeneration of descending brainstem axons may be important mediators of the BMSC-mediated anatomical and functional improvements.

Positron emission tomography for serial imaging of the contused adult rat spinal cord.

We investigated whether small-animal positron emission tomography (PET) could be used in combination with computed tomography (CT) imaging techniques for longitudinal monitoring of the injured spinal cord. In adult female Sprague-Dawley rats (n = 6), the ninth thoracic (T9) spinal cord segment was exposed by laminectomy and subsequently contused using the Infinite Horizon impactor (Precision System and Instrumentation, Lexington, KY) at 225 kDyn. In control rats (n = 4), the T9 spinal cord was exposed by laminectomy but not contused. At 0.5 hours and 3, 7, and 21 days postinjury, 2-[(18)F]fluoro-2-deoxy-d-glucose ([(18)F]FDG) was given intravenously followed 1 hour later by sequential PET and CT. Regions of interest (ROIs) at T9 (contused) and T6 (uninjured) spinal cord segments were manually defined on CT images and aided by fiduciary markers superimposed onto the coregistered PET images. Monte Carlo simulation revealed that about 33% of the activity in the ROIs was due to spillover from adjacent hot areas. A simulation-based partial-volume compensation (PVC) method was developed and used to correct for this spillover effect. With PET-CT, combined with PVC, we were able to serially measure standardized uptake values of the T9 and T6 spinal cord segments and reveal small, but significant, differences. This approach may become a tool to assess the efficacy of spinal cord repair strategies.

Reducing macrophages to improve bone marrow stromal cell survival in the contused spinal cord.

We tested whether reducing macrophage infiltration would improve the survival of allogeneic bone marrow stromal cells (BMSC) transplanted in the contused adult rat thoracic spinal cord. Treatment with cyclosporine, minocycline, or methylprednisolone all resulted in a significant decrease in macrophage infiltration at 3 days postinjury. However, when BMSC were injected at that time point, survival 7 days later was similar between treatment groups and saline-injected controls. In fact, we found that the presence of BMSC resulted in a significant increase in macrophage infiltration into the contusion.

Bone marrow stromal cells elicit tissue sparing after acute but not delayed transplantation into the contused adult rat thoracic spinal cord.

Bone marrow stromal cells (BMSC) transplanted into the contused spinal cord may support repair by improving tissue sparing. We injected allogeneic BMSC into the moderately contused adult rat thoracic spinal cord at 15 min (acute) and at 3, 7, and 21 days (delayed) post-injury and quantified tissue sparing and BMSC survival up to 4 weeks post-transplantation. BMSC survival within the contusion at 7 days post-transplantation was significantly higher with an acute injection (32%) and 3-day delayed injection (52%) than with a 7- or 21-day delayed injection (9% both; p < 0.01). BMSC survival at 28 days post-transplantation was close to 0 in all paradigms, indicating rejection. In contused rats without a BMSC transplant (controls), the volume of spared tissue gradually decreased until 46% (p < 0.001) of the volume of a comparable uninjured spinal cord segment at 49 days post-injury. In rats with BMSC, injected at 15 min, 3, or 7 days post-injury, spared tissue volume was significantly higher in grafted rats than in control rats at the respective endpoints (i.e., 28, 31, and 35 days post-injury). Acute and 3-day delayed but not 7- and 21-day delayed injection of BMSC significantly improved tissue sparing, which was strongly correlated (r = 0.79-1.0) to BMSC survival in the first week after injection into the contusion. Our data showed that neuroprotective effects of BMSC transplanted into a moderate rat spinal cord contusion depend strongly on their survival during the first week post-injection. Acutely injected BMSC elicit more tissue sparing than delayed injected BMSC.